Before I was a trauma surgeon, before I was a military officer, before I had any idea what a combat hospital looked like from the inside, I was a firefighter in the Ohio Valley. I started as a volunteer and eventually moved into a professional role. It was physically demanding work, unpredictable work, and it taught me things about myself and about teams that medical school reinforced but could not have created.
I have thought about that period more as I get older. Not with nostalgia, though there is some of that. More with recognition. The patterns I depended on through 40 years of trauma surgery and eight combat deployments were laid down earlier than I usually acknowledge when I talk about my career. They started with the fire service.
What You Learn Before the Call Comes In
Firefighting taught me that the quality of your performance in an emergency is almost entirely determined by what you did before the emergency began. By the time a structure fire is fully involved and you are making entry decisions, there is no time to recall procedures you did not already own. The knowledge has to be automatic. The team communication has to be practiced. The trust between crew members has to be established.
That sounds obvious when stated plainly. In practice, it is the thing that most people underinvest in. We prepare for emergencies in theory while living as though emergencies will give us time to organize ourselves. They do not. A burning building does not wait for you to find your footing. A trauma patient in hemorrhagic shock does not wait for you to remember the protocol. The firefighter who hesitates at a threshold because preparation was incomplete does not get a second attempt at that moment.
The habit of preparation I carry into everything I do, including the work I am focused on now in emergency preparedness in Cincinnati, started at a fire station in the Ohio Valley. It was not optional there. It became structural in how I think.
The Team Is the Unit, Not the Individual
Fire service is not a solo endeavor. You enter structures with a partner. You maintain communication with the crew outside. You trust that the person covering your exit is where they are supposed to be because your life depends on it. That interdependence is not an organizational preference. It is a survival requirement.
In medicine, particularly in academic medical settings, there is a strong cultural emphasis on individual expertise and individual accountability. Both matter. But the fireground taught me something that was easy to lose track of in those settings: the outcome in any true emergency belongs to the team, not to any single person within it. The surgeon who performs brilliantly while the team around them is underprepared, miscommunicating, or not trusted to act independently will produce worse outcomes than a slightly less technically skilled surgeon operating inside a well-coordinated team.
That understanding shaped how I built and led teams throughout my career, from the operating rooms at the University of Cincinnati to the combat hospitals in Bagram and Tikrit. The CCATT program I helped develop was built on this principle: a small, tightly coordinated team with clear roles and practiced communication outperforms a larger, loosely organized group with better individual credentials. Every time.
Reading What Is Not Being Said
Situational awareness is a concept that gets discussed extensively in both fire service and emergency medicine. In practice, it means maintaining an accurate picture of what is happening around you, not just the immediate task in front of you, while that task is demanding your full attention. It is a skill that develops slowly, through exposure and feedback, and that degrades quickly when the environment is novel or when stress is high enough to narrow focus.
Firefighters develop this skill in a specific way. A crew leader reading a fire reads dozens of signals simultaneously: the color and movement of smoke, the sound of structural stress, the behavior of the fire visible through windows, the time elapsed since entry, the crew members’ body language and communication patterns. None of these signals is individually decisive. Together, they form a picture that informs decisions that have to be made quickly and cannot be fully explained in the moment.
Medicine required exactly the same skill, operating in different physical environments with different signals. The patient whose vital signs look stable but whose level of engagement is subtly declining. The operating room where the mood has shifted in a way that precedes a problem. The team member who is technically compliant but whose confidence has gone somewhere. These observations matter. Training yourself to make them, rather than relying on the most salient signal in front of you, is one of the most useful things any person in a high-stakes role can develop.
The Discipline of Controlled Urgency
One of the things that surprises people unfamiliar with emergency work is how calm experienced responders tend to be. They expect urgency to produce visible stress. In reality, the opposite is true at the highest levels of performance. Experienced firefighters and experienced trauma surgeons share a quality that looks like calm but is better described as controlled urgency: full investment in the task, maximum efficiency of movement, and emotional regulation that keeps judgment functional rather than reactive.
That quality is not innate. It is trained. The fire service trains it through repetition in controlled environments that gradually increase in complexity and ambiguity until the stress response is managed rather than suppressed. You learn that you can function well under conditions that initially felt overwhelming. That learning compounds. By the time you encounter the genuinely extraordinary situation, you have a reference point for having performed well under pressure before.
I have written about how unrecognized resistances accumulate to halt progress, and the controlled urgency principle addresses one of the most common forms of that resistance: the avoidance of discomfort that keeps people from developing the capacity they need. You cannot train composure in comfort. You have to practice exposure, repeatedly, with good feedback, until the capacity builds.
What Carries Forward
I moved from the fire service into medicine and eventually into military medicine because the problems I wanted to work on were there. The environment changed completely. The underlying principles did not.
Prepare thoroughly before the moment of need. Build and trust the team rather than relying on individual brilliance. Read the environment continuously, not just the task in front of you. Train composure through graduated exposure rather than hoping it arrives when needed.
None of these principles is exclusive to firefighting or to trauma surgery. They apply to any role where performance under pressure matters and where the consequences of failure are real. The fire service gave me those principles early, in an environment where learning them was not optional. I am grateful for that. It was the foundation that everything else was built on.
