Alarm Fatigue: Correlative Applications to Gun-Related Self Defense
by Kjell Rosenberg MD, Rangemaster and NRA Instructor
People often ask me if doing anesthesia is dangerous. The answer is, “yes, but also very safe.”
How are both of those things true? Because we know the dangers are there and we set monitors up to watch our patients very closely. Our constant vigilance and technical skill decrease the risk tremendously.
In my second profession as a firearms/self-defense instructor there is, rightly, a significant amount of emphasis placed on situational awareness and mindset. The act of shooting is a very small percentage of an effective self-protection strategy. The greatest portion of learning to become something other than a victim is intellectual and psychological.
Despite the copious sources explaining and coaching situational awareness there seems to be an enormous disparity between the preaching and the righteousness of the congregation. Most people do not seem to pay attention to their surroundings. Conversely, some people are hyper-vigilant to the point of finding themselves the butt of “that (tacticool) guy” jokes. Often in instructor development courses, the comment is made, “if the student doesn’t learn, it’s a failure on the part of the instructor.” While I think that statement requires a healthy dose of qualification to it, there is some significant truth there.
It is difficult to compile statistical analysis of reality-based events that occur as a result of situational awareness since the control group creates a null event result. I have developed a theory which I call the Untrained Defender Paradox which essentially states that the majority of successful civilian gun defenses (ranging in numbers up to 3 million per the CDC)(1) are accomplished by the un- or insufficiently trained. This is partly because the trained combatant is able to avoid the situation through awareness, verbal judo, or other de-escalation techniques. Marc MacYoung states this similarly in his book In the Name of Self-Defense: What it costs. When it’s Worth It.(2) The targeted demographic in this paper is therefore the training but not yet expert individual.
We as trained self-defenders are confident that situational awareness is a key principle but know that there are still daily events of awareness failure among gun owners. It would seem that as a community we have a system failure. In order to solve this problem, it is important that we take a systems-based approach. The problem could be caused by a lack of interest in education, lack of educational sources available, poorly presented (instructor-based) information, or failure of the information to produce adequate results. I believe that all of these possible causes and more play into it, but I am focusing on just one piece of the pie in this article: failure to apply human psychology and limitations to data in the partially trained or not yet expert gun owner demographic.
In our training program at Condition Red Response, we combine the concepts of Col. Jeff Cooper’s color-coded mindset system(3) with Boyd’s Observe, Orient, Decide, Act (OODA) loop(4), and human response time or “reactionary gap.” Human response time is often taught in self-defense and shooting schools in conjunction with Dennis Tueller’s principle(5) in what is popularly (but incorrectly) known as a “Tueller drill.” Officer Tueller’s principle is perhaps one of the most misinterpreted and misapplied pieces of genius in self-defense training. It can, however, be used to great effect if properly applied as “alarm criteria” which we will get to shortly.
Since our audience is made up of those who seek out training and are interested in becoming an effective self-protector, I choose to focus on how to help those people better understand and apply the principles of situational awareness and therefore achieve violence avoidance. I propose that this demographic is most likely to be in, or attempt to be in, prolonged states of hyper-awareness (condition orange) and therefore fall victim to lapses rather than to knowledge deficits. Furthermore, I suggest that these lapses are less likely to represent a general attitude of carelessness, but rather what is known in the medical industry as “alarm fatigue.”
I will first describe the usefulness of understanding the concepts in the above paragraphs. We will then discuss the recognition of patterns that should precipitate a mindset change from “paying attention” to “hypervigilance.” Secondarily, I propose that setting appropriate alarm settings on our mindset conditions can allow us to remain in condition yellow for a higher percentage of the time while being appropriately switched on when we need to be.
Rather than thinking of a person as a threat or non-threat upfront, let’s refer to anyone who enters the area of operations of our senses (or monitors) simply as a stimulus. Further, lets define areas of high risk where a self-defender is likely to have heightened awareness or vigilance. John Correia at Active Self-Protection has created an enormous body of work depicting the dangers of the “transitional space.”(6) A transitional space is a location in which strangers are in constant flux and this flux is considered normal social practice. This includes spaces such as gas stations, parking lots, etc. Marc MacYoung refers to certain areas as “fringe” areas. These are areas which separate safer areas from distinctly unsafe areas. Both of these socio-geographical archetypes are high risk areas for the unaware since they are highly desirable areas for the criminal element to operate within.
The Tueller Principle is the result of data acquisition that indicates the average adult can cross 21 feet in approximately 1.5 seconds. From Officer Tueller’s work it can be implied or extrapolated that at certain distances, you have a certain amount of time to react and act. The implication being that it is vital for you to know what you can and cannot physically perform in that time –which is likely much less than you expect it to be. In the case of Tueller, the stimulus was a man charging with a contact weapon while an officer attempted to draw and get hits on target.
Master Instructor Tom Givens(7) instructs students that big box store parking lots are one of the most dangerous places to be caught unaware. This is because a big box store parking lot is both a transitional and a fringe space. Let us then do a mental exercise in which a stimulus has been introduced to our senses in just such a location and our mind enters Boyd’s OODA loop. First, we Observe the stimulus – usually by sight, but the sound of gunfire or yelling could easily be our introduction to an occurrence requiring our immediate attention. Next, we Orient to the stimulus, meaning that we try to make sense of it before we Decide what to do. Finally, we Act on the decision we made based on our observation and extrapolation of the data. All of this takes a certain amount of time to achieve, which is known as “the reactionary gap.” Depending on our distance from the stimulus, or our line of site, our reactionary gap may be sufficient or insufficient to act before we are acted upon. The goal of achieving situational awareness and the direct application of the Tueller principle is to Observe, Orient, and Decide well enough in advance that our Action is sufficient to protect ourselves whether by fight or by flight.
With those definitions in place it is now time to discuss alarm fatigue. Alarm fatigue is the idea that a human cannot – or will not – remain vigilant for long periods of time while alarms are buzzing. The alarms will be turned off or tuned out. The obvious danger of this is found in the children’s story about the boy who cried wolf. The story of villagers ignoring the cry of “wolf” after repeatedly responding to a null event is over simplified and almost silly but this occurs in a very real way and leaves us vulnerable to the proverbial wolf when we least expect it – despite the fact that our senses or “monitors” are actively warning us about a threat. In the medical industry, there have been several such deaths attributed to alarm fatigue.(8,9)
The answer to alarm fatigue is to set the alarm limits or settings to trip the alarm only when certain criteria are met. For example, if I am setting an alarm based on heart rate during surgery I could choose to make the low heart rate alarm 70 because the patient has a base heart rate of 75. However, the criteria need to be specific (the ability of an alarm to be meaningful to the current problem) and sensitive (the ability of an alarm to pick up a stimulus) enough that they do not repeatedly ring when the patient is not in danger, but loose enough to catch the majority of clinical signs of deterioration. With a low alarm setting of 70 and a baseline heart rate of 75, once the patient goes under anesthesia and their heart slows down, my alarm will be ringing for the entire case. But when I look at the monitor, I see a heart rate of 65 which is clearly within the acceptable range. How long before I either turn the alarm off or simply ignore it?
Similarly, our situational awareness criteria need to be calibrated to recognize actual threats and not key on every stimulus that enters our sensual area of operations or we will become both neurotic and lackadaisical about paying attention.
Some of the things we do as anesthesiologists are lessons learned from the airline industry.(10) We have checklists and develop patterns and habits in the way we prepare for a case, monitor a case, and respond to untoward events. As self-defenders, we can create similar habits which take the hypervigilance out of the equation and replace it with a “normal way of doing things” that mimics the checklists and setting of alarm criteria in an operating room. In his book “Be Your Own Bodyguard,”(11) Nick Hughes goes into detail about many of the habits we can develop. My point here is not to reinvent the work that experts like Nick and Marc have written about extensively, but to tie it all together and explain how using appropriate alarm criteria combined with checklists can help us prevent disaster.
In the self-defense world, stimuli meeting criteria of both sensitivity and specificity could be referred to in terms of “pre-attack indicators.” There are many pre-attack indicators which have been well described by experts like Greg Ellifritz(12) and others I have mentioned above, so I am not going to list them in detail. Categorically, they contain things such as furtive movements, deceptions, distractions, and more. In context to our discussion today, using knowledge of pre-violence indicators would be our alarm limits. Consider the following example:
You arrive at Bigboxstore and park your car. From this point on if we follow traditional mindset conditions you should be in condition orange, or at the very least a deep yellow. What I am suggesting as a replacement of the current paradigm is to be as aware and paying attention as you would be in condition yellow, BUT you will have set specific and sensitive alarms that will move you into a condition orange as necessary. These triggers might be anything from noticing odd behavior, a shady character who is a little too interested in you, etc. Nothing that requires action at this point, but something that definitely requires the heightened awareness of condition orange.
As you are casually taking note of your surroundings, a young man hops out of a car. This is a normal event in a transitional space and does not require an upgrade in mindset. Our awareness in this example is sensitive but not specific. However, this young man is wearing a light jacket on a hot summer day and pulls the hood up on his jacket as he exits his vehicle.
That action should warrant a trip of your specificity alarm. Initiation of condition orange should follow. There are potentially legitimate reasons why that young man might be dressed suspiciously. That’s why we stay in orange and don’t progress to red. However, the alarm criteria were met and now we need to pay attention to it. Imagine how quickly our awareness would diminish, however, if we stay in condition orange because we see a potential threat in every person, and yet a threat never materializes. Pretty soon we will start thinking we are paranoid and let down our guard altogether; it’s human nature.
Those who have mastered the skill sets above and written books about them have already consciously or subconsciously adopted this practice. I believe that utilizing what I am calling the “Alarm Fatigue Prevention Model of Situational Awareness” is a mid to advanced level skill set. Thus, we should not, as instructors, be encouraging novice self-protectors to downgrade their mind set conditions when they are in transitional and fringe spaces, but rather helping them refine the skills until adequate.
A 24/7/365 attempt at condition orange awareness will ultimately decrease your awareness as your brain tells you that you are crying wolf. Having appropriately set alarm triggers will help to attain the necessary vigilance when mandated, but decrease jumping at shadows and prevent alarm fatigue. In order for our students to set appropriate alarms, they must first learn what the indications are, be practiced enough to know what their own reactionary gap is, be honest about what their own physical skill set is, and know what their line in the sand is for flight vs fight. The concepts associated with situational awareness are strongly correlated between constant monitoring of our changing environment and medical personnel who are subject to the constant whine and beep of alarms during patient care. The potential pitfalls, such as alarm fatigue, that have been proven in the medical community will prove true in personal protection as well unless monitoring is done in a manner that is appropriate to each situation and stimulus.
1 Hsieh, P. (2018, April 30). That Time The CDC Asked About Defensive Gun Uses. Retrieved from https://www.forbes.com/sites/paulhsieh/2018/04/30/that-time-the-cdc-asked-about-defensive-gun-uses/#37a43 532299a
2 MacYoung, M. (2014). In the name of self-defense: What it costs and when its worth it. Place of publication not identified: NNSD Press.
3 Cooper, J. (1989). Principles of personal defense. Boulder, Col.: Paladin Press. 4 Mulder, P. (2017). OODA Loop. Retrieved [insert date] from ToolsHero: https://www.toolshero.com/decision-making/ooda-loop/
5 VirTra. (2018, December 19). 21-Foot Principle Clarified by Dennis Tueller and Ken Wallentine. Retrieved from https://www.youtube.com/watch?v=dEjxg1m3ORU&feature=youtu.be
6 Correia, J. (2018, December 04). Awareness Is Essential Especially In Transitional Spaces | Active Self Protection. Retrieved from https://www.youtube.com/watch?v=n30JqcFh33k&feature=youtu.be
7 Givens, T. (2019, January 27). Instructor Development course. Lecture presented at Instructor Development course in Florida, Homestead.
8 Peltor, M., Drew B. Harm From Alarm Fatigue. (n.d.). Retrieved from https://psnet.ahrq.gov/webmm/case/362/harm-from-alarm-fatigue
9 Andreas H. Taenzer, Joshua B. Pyke, Susan P. McGrath; A Review of Current and Emerging Approaches to Address Failure-to-Rescue. Anesthesiology2011;115(2):421-431. doi: 10.1097/ALN.0b013e318219d633. Rayo MF, Moffatt-Bruce SD
10 Toff, N. (2010). Human factors in anaesthesia: Lessons from aviation. British Journal of Anaesthesia,105(1), 21-25. doi:10.1093/bja/aeq127
11 Hughes, N. (2017) How To Be Your Own Bodyguard Nicholas Hughes
12 Ellifritz, G. How to Spot a Bad Guy- A Comprehensive Look at Body Language and Pre-Assault Indicators. (2019, January 25). Retrieved from
Cooper, J. (1989). Principles of personal defense. Boulder, Col.: Paladin Press.
Ellifritz, G. How to Spot a Bad Guy- A Comprehensive Look at Body Language and Pre-Assault Indicators. (2019, January 25). Retrieved from
Correia, J. (2018, December 04). Awareness Is Essential Especially In Transitional Spaces | Active Self Protection. Retrieved from https://www.youtube.com/watch?v=n30JqcFh33k&feature=youtu.be
Givens, T. (2019, January 27). Instructor Development course. Lecture presented at Instructor Development course in Florida, Homestead.
Hsieh, P. (2018, April 30). That Time The CDC Asked About Defensive Gun Uses. Retrieved from https://www.forbes.com/sites/paulhsieh/2018/04/30/that-time-the-cdc-asked-about-defensiv e-gun-uses/#37a43532299a
Hughes, N. (2017) How To Be Your Own Bodyguard Nicholas Hughes
MacYoung, M. (2014). In the name of self-defense: What it costs and when its worth it. Place of publication not identified: NNSD Press.
Mulder, P. (2017). OODA Loop. Retrieved [insert date] from ToolsHero: https://www.toolshero.com/decision-making/ooda-loop/
Michele M. Pelter, RN, PhD, and Barbara J. Drew, RN, PhD, Harm From Alarm Fatigue. (n.d.). Retrieved from https://psnet.ahrq.gov/webmm/case/362/harm-from-alarm-fatigue
Andreas H. Taenzer, Joshua B. Pyke, Susan P. McGrath; A Review of Current and Emerging Approaches to Address Failure-to-Rescue. Anesthesiology2011;115(2):421-431. doi: 10.1097/ALN.0b013e318219d633. Rayo MF, Moffatt-Bruce SD
Toff, N. (2010). Human factors in anaesthesia: Lessons from aviation. British Journal of Anaesthesia,105(1), 21-25. doi:10.1093/bja/aeq127
VirTra. (2018, December 19). 21-Foot Principle Clarified by Dennis Tueller and Ken Wallentine. Retrieved from https://www.youtube.com/watch?v=dEjxg1m3ORU&feature=youtu.be
This first appeared in The Havok Journal May 10, 2019.
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