Jillian Horton is a Canadian internist and writer. Her memoirs, We Are All Perfectly Fine, will be published next year.
As the COVID-19 crisis deepens around the world, I’ve noticed some graphics and dashboards using a subheading: situational awareness. The term has visceral significance to anyone who works in health care or the airline industry, because situational awareness can mean the difference between life and death.
Those of us who are interested in metacognition – how we think – tend to conceive of situational awareness as a learned ability to notice and interpret what is happening around us so we are prepared for what might happen next. Critically, it also allows us to anticipate and navigate common thinking and behaviour traps. The latter is especially important because our situational awareness in emergencies can be unduly influenced by the behaviour – including the under-reactivity – of those around us.
What is situational awareness? Often, it’s more helpful to begin by describing what happens when it is absent. Here’s a tragic example. A healthy child is admitted to a hospital for an elective procedure. The child stops producing urine and soon his blood pressure is unmeasurable. The staff insist he is fine and that the machines are all malfunctioning. Instead of giving large volumes of fluid and sending him to intensive care, they scour the hospital for “working” blood pressure machines. While they are looking, the child suffers a cardiac arrest due to shock, and dies.
Or here’s an example from the aviation world. A pair of commercial pilots are nearing the last leg of flight. They talk nonchalantly about ice on the wings, a potential sign of serious trouble. As they prepare to land, the aircraft experiences an aerodynamic stall. Two pieces of safety equipment activate, but both pilots respond incorrectly to the automated cues. All 49 passengers are killed when the plane slams into the ground.
Why did that young boy and those passengers die? Because the people in charge lacked situational awareness. They did not recognize or label their experiences as an emergency and, as a result, were unprepared for the consequences.
Sadly, when it comes to the COVID-19 pandemic, leaders around the world are falling into this same trap – and so are citizens.
Why are our brains so vulnerable to this phenomenon? Some of the answer is rooted in our wiring. Our behavioural responses are both learned and dependent on our environment, and when we encounter unfamiliar situations we often revert to a default setting: looking at what others are doing. This concept is known as social proof. We’re aware of the pandemic, but because people around us aren’t wearing masks, we’re tricked into thinking that what they’re doing must be right.
This problem is compounded by the fact that our perceptions can also be heavily influenced by what we want to be true – a cognitive misstep known as affective error. It’s less psychologically disturbing to conceive of a broken blood pressure machine than a child who is critically ill, or a bit of ice on the wings as a meaningless nuisance instead of a potentially life-threatening development. When I’m teaching medical learners about situational awareness, my focus is often on helping them realize how easily influenced our perceptions are by both of these things: how others behave and what we want to be true.
But here’s one of the hardest things about situational awareness: It requires vigilance, and vigilance takes energy. We’re all tired of the constant psychological assault on our sense of safety right now. So it’s tempting to downgrade our original assessments of the threat, perhaps even to question the experts who are telling us to be worried.
This ability to recognize our knowledge limits is another aspect of situational awareness, by the way, so we don’t waste precious time challenging those who best understand what is likely to happen next.
A recent study showed that even though our numbers haven’t worsened dramatically, Canadians are more worried about catching COVID-19 than we were in the middle of April. Initially, this made me hopeful that we were developing more situational awareness about the pandemic in general. But recent clusters of cases in many provinces have me worried that we are losing that awareness, a shift that may cost us dearly.
In my clinical life, it’s not uncommon that I meet a patient for the first time and have to tell them that they have widespread, incurable cancer. They say to me, incredulous: How did this happen so quickly? My sorrowful answer is always the same: This did not happen quickly. It started with a mutation in a single cell. That cell doubled, and then those cells doubled. Eventually, that patient had symptoms – warning signs – that they often didn’t recognize or ignored out of fear or denial or an inability to access care. And then there came a tipping point – but it was never all at once. That’s why one of my axioms as a clinician is: Most disasters happen slowly.
I don’t want us to be tricked into the false belief that the situation in Canada isn’t critical, because it could deteriorate in the blink of an eye. So I want to teach you four behaviour-altering words that can activate the skills that ultimately allow doctors, nurses and pilots to override the false messages our brains send us, allowing us to save lives.
And here they are: This is an emergency.
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