The tie-break ladder: which lens fires first
A seven-rung vertical ladder read top to bottom, each rung carrying a framework name and a one-word test, with a dashed arrow that enters at rung one and exits sideways at the first rung that separates the options, plus a small bypass loop around rung one labeled PULSELESS, COMPRESSIONS FIRST.
THE TIE-BREAK LADDER
The frameworks you memorized are not a menu. They are a ladder, and each rung only gets a turn when the rung above it cannot tell the four options apart. This single idea converts priority from a feeling into a procedure, and it is why two candidates can both know Maslow and only one of them can use it.
Panel 1 · Rungs one to three
- Rung 1, airway, breathing, circulation. Test: is anyone failing to move air or blood. The arrest exception: once the patient is pulseless, current American Heart Association sequencing puts chest compressions before airway, so a code stem is answered by circulation first. That exception applies to the pulseless patient and to nobody else.
- Rung 2, acute over chronic. Test: is this new. A new deficit outranks an old one at the same apparent severity, because nobody has evaluated the new one yet.
- Rung 3, unstable over stable. Test: is this trending. Stability is about direction, not about how abnormal a single value looks.
Panel 2 · Rungs four to six
- Rung 4, unexpected over expected. Test: does this finding fit the diagnosis, the procedure, and the day. Expected findings already carry a plan. Unexpected ones do not.
- Rung 5, safety and risk reduction. Test: can this room injure this person in the next few minutes. This rung decides between two stable patients when one of them is in an environment that can hurt them.
- Rung 6, Maslow. Test: which need sits lower on the hierarchy. Physiologic needs, then safety and security, then love and belonging, then esteem, then self-actualization. This rung fires only when nobody is physiologically threatened, which is rarer than the exam-prep folklore suggests.
Panel 3 · Rung seven, least restrictive
When the tie is about how to keep someone safe rather than whom to see, choose the least restrictive option that still maintains safety. Reorientation, a lowered bed, a bed alarm, and a room near the nurses' station come before a sitter. A sitter comes before a restraint. A restraint requires a provider order that is time limited and re-evaluated in person, and it is never ordered as needed.
Watch outa rung never skipped is a rung never reached. Do not reach for Maslow while an oxygen saturation is falling.
Margin notework down, never sideways.
Takeawaythe correct answer is always the highest rung that still discriminates between the options.
→ BOOK 04 · P11 for restraint documentation and monitoring requirements.