Resus Room Management Wed, 19 Mar 2014 23:57:03 +0000 en-US hourly 1 Aviation vs Emergency Medicine 4 – Combat vs Commercial vs ED Wed, 19 Mar 2014 23:57:03 +0000 I’m currently at the SMACCGold conference, and there is an exciting amount of discussion about human factors in resuscitation. Karim Brohi showed a great video of the resuscitation of a critically injured motorcyclist in the UK, which was a great demonstration that the best resuscitations are quiet, calm and co-ordinated.  And we were lucky enough to see Deniz Tek, ex-Radiobirdman frontman/military pilot, and current practicing Emergency Physician. He spoke about the analogies between skills required in ED resususcitations and combat aviation.  This was a popular session, and let’s face it, who doesn’t like Top Gun (and Radiobirdman)?

However I’m still skeptical about the comparisons being drawn between aviation and emergency medicine, in particular the combat aviation model.  I have a rudimentary knowledge of aviation training from having friends who are commercial and military pilots. What strikes me about this, apart from the obvious workplace differences of the cockpit vs the resus room, is the selection processes, training and assessment, as well as the context of the overall culture of the industry, with standardised language, clear hierarchies and chains of command, and the strong culture of teamwork (especially in the military), which is totally lacking in healthcare.

I’m also disturbed by the use of language like “fight”, “own” and “combat” that some people are attaching to resus care. To me there is a strong undercurrent of testosterone driven machismo in this language, which I think is really unhelpful in an industry where at least 50% of our workforce is female.  Let’s face it, most doctors (and nurses) are lovers not fighters.  There is also a huge difference in the underlying culture of combat aviation compared to medicine: they are training to not hesitate to kill another person when under extreme physical and psychological stress, with active threats to their own life, and the lives of potentially thousands of colleagues on the line (for example an aircraft carrier) if they falter.  If I falter, one patient dies, I and all of my colleagues andI go home at the end the of the shift.

So here’s a video of an Airbus A-380, the world’s largest passenger jet, coming in to land at San Francisco. Compare this to your usual in-charge shift in a tertiary ED.


I don’t know about you, but I can’t see a single similarity between this and what I do at work. Not one. The environment is incredibly quiet. There is zero interruption. There is a small, static group of people. The language is short, sharp and concise using standardised terminology. There are clear operating procedures being followed. And everyone’s polite to each other! The pilot’s have also spent 100% of their shift in the single room of the cockpit, with the same equipment that they have trained with in multi-million dollar simulators and flown with for hundreds of hours, which doesn’t change. In ED, we are constantly interrupted, in multiple ways, every few minutes, for 10 hours straight. Our environment is insanely noisy. We have to work in resus, cubicles, corridors, fast-track, the waiting room, the ambulance bay, helipad, procedure rooms, and in some hospitals we have to go to codes on the wards and in theatre. Equipment varies hugely between all of these areas, and is frequently not re-stocked, requiring us to go hunting around, rummaging through trolleys and cupboards to find the basics that we need to do our job. We frequently have to improvise, or “Macgyver” solutions from equipment, using it for purposes it was not intended for. And we have to do this with a constantly fluctuating, very large group of staff.

So this got me thinking about combat aviation, which is being held up as a better model, as commercial aviation is clearly has little or no relevance to what we do.  I wanted to know about the training military pilots undergo, and how this translates to their practice. So I found this great video from the New Zealand Air Force. It’s pretty simplistic, and New Zealand is not renowned for it’s high-level military expertise, but I think you’ll see that even in a low-level military operation, the differences to ED training and work are striking.


Points I took away from this are:

Selection Process
Combat Aviation
Screening includes aptitude tests, interviews, selection board interviews, psychologists heavily involved.  Trainees are specifically screened and selected for leadership, a proactive attitude and positive approaches to problem solving

Emergency Medicine
No real screening for entering ED training. Anyone can sign up. No formal criteria are used to select candidates. Personality pathology is commonplace.

Leadership training
Combat Aviation
Comprehensive program of leadership, management and teamwork training

Emergency Medicine
Absolutely zero training in leadership, management or teamwork

Team-mate Familiarity
Combat Aviation
Trainees live, eat, study, train, socialise and work together for months on end.

Emergency Medicine
Team mates have often never met, they may have met and not remember names, and frequently have zero awareness of each others skill sets or personality traits.

Combat Aviation
Strong sense of responsibility for rest of crew.  Mutual understanding and being able to work together are high priorities

Emergency Medicine
Sense of responsibility for crew is not possible to establish when team members constantly change.  Team members work in silos, mutual understanding is never discussed openly as a priority.

Combat Aviation
An in-dpeth, formal, standardised briefing occurs before every flight

Emergency Medicine
Pre-shift briefing is never done.

Combat Aviation
Frequent standardised, objective knowledge/skill assessment via regular written and practical testing with clear goals.

Emergency Medicine
No testing at all during career except two, large, high-stakes exams separated by several years. Informal “supervision” occurs daily, but is of extremely variable quality. Often “good performers” are ignored/given no feedback.

Combat Aviation

Competency must be demonstrated in high-fidelity simulation before being allowed into more sophisticated aircraft

Emergency Medicine
Access to simulation training is rare and variable in quality, and highly dependent on location of training. Possible to complete all training with minimal/no simulation based assessment.

Standardised Language
Combat Aviation
Communication is highly standardised, concise and brief.

Emergency Medicine
There is no standardisation of our communication. Misunderstanding is common due to use of acronyms and colloquialisms.

Combat Aviation
Highly male dominated. Vast majority of the flying workforce is young adult, physically and psychologically robust males.

Emergency Medicine
Workforce is nearly 50% female. Age range varies from mid 20’s to 60’s. Wide range of cultural backgrounds. Two separate industries (medical and nursing) that don’t study or train together are expected to function together.

So no disrespect to Deniz.  I think if you are trained in a military mindset, then using some of the skills you’ve learned that may help you run a resus better is fine. But suggesting that we can somehow take those skills and drop them onto an ED workforce, which is full of a totally heterogenous population of staff, with heterogenous training, and the extreme workplace, cultural, and ethos differences outlined above, is not only unhelpful, but is simply not possible.

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Flash teams in the ED resus room Wed, 04 Sep 2013 01:07:28 +0000 I’ve written previously of my skepticism for the word “team” in relation to the groups of strangers who congregate in  ED resus rooms.  Since then I’ve been trawling through the literature to find the best available evidence on how to teach human factors and non-technical skills, in particular team leading and teamwork skills to people in this setting. This post is the first in a series of articles looking at this concept in detail.

A huge downfall of most of the literature on training healthcare “teams” is that they focus on stable teams. Groups of people who often know each other, or who have worked together previously. Another big problem is the lack of a clear definition of the word “team” for researchers in this area.

A recent article by West and Lyubovnikova [1] tackles the terminology of teams and teamwork. Whilst it is a review article, they describe “pseudo-teams”, (or groups who do not have “real team” characteristics), as those teams which have little requirement to interact or communicate, whose objectives are not shared, and who rarely meet to reflect on performance.  This description partly covers ED resuscitation teams. What is accurate and applicable to the aforementioned teams I work with, is that “pseudo-teams” report higher rates of errors, incidents and near-misses, they experience more harassment, bullying and abuse from other staff and patients, an report higher levels of stress and lower levels of well-being. Clearly the pseudo-team characteristics should be avoided in teamwork training.

In a separate article [2], they describe further the characteristics of “real teams”, “pseudo teams”, and they also quote the phrase “flash teams”, which I believe more accurately describes the groups that congregate in ED resuscitation settings. Flash teams are teams in which membership turns over quickly, with “peripheral” individuals (for example the ICU, Anaesthetic and Surgical team members) coming and going, whilst “core” team members (for example the Emergency department medical and nursing staff) are more likely to remain constant.  They also go on in this article to describe how widespread, poorly defined use of the term “team” and “teamwork” in the literature by researchers who have adopted a more managerial definition of teams (ie any group of people that interact or work together, no matter how loosely), has made researching teams with a clear and precise approach, especially dynamic teams, very difficult.

Tannenbaum et al [3] coined the phrase “flash teams”. They highlight that in many industries including healthcare, dynamic composition, membership fluidity, reconfiguring temporary teams and belonging to multiple teams all have pros and cons for the function of the team, yet there is very little research to date into these dynamic teams. Their comprehensive review covers in detail many of the characteristics, problems and benefits of dynamic teams.  Based on their analysis, they suggest the following recommendations for team-based practice with dynamic teams:

  • The need to provide those who choose and allocate team members with criteria to optimise team formation by ensuring members are qualified to participate, and can work well together.
  • Creation of role clarity, and guidance for team leaders to how to create a sense of team identity.
  • Transportable teamwork competencies: ie skills that can be used in any of an individuals team assignments – however these may need to be organisation (eg hospital) specific.
  • “Quick-start” protocols and “join-in-progress” protocols that allow teams to form quickly, and to ensure new members that join an already  functioning team are brought up to speed quickly and seamlessly.
  • Explicit identification of the obligations of people with specific, high-value skills so as to avoid overloading them.
  • Defined team member number and skill mix for handover and transition periods, as well as a defined handover processes.
  • Evaluation and review of the process.

So here we have the building blocks for an educational program to teach teamwork with dynamic or “flash” healthcare teams, and these may help with setting learning objectives for anyone who is trying to do teamwork training in this area.  These concepts will be applied to our scenario teaching and simulation sessions on the upcoming Emergency Trauma Management Course, so if you’re interested in seeing these concepts applied to trauma resuscitations, click here for more details and to register for a course!

For anyone interested in reading more on this topic, Scott Tannenbaum and Eduardo Salas are luminaries in the field of simulation and teamwork training, and I recommend their extensive catalogue of papers, in particular those by Salas as a starting point.


  1. West MA, Lyubovnikova J. Illusions of team working in health care. J Health Organ Manag. 2013;27(1):134-142
  2. West MA, Lyubovnikova J. Real Teams or Pseudo Teams? The Changing Landscape Needs a Better Map. Industrial and Organizational Psychology. 2012;5:25–55
  3. Tannenbaum SI, Mathieu JE, Salas E, Cohen D. Teams Are Changing: Are Research and Practice Evolving Fast Enough? Industrial and Organizational Psychology. 2012;5:2–24
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Aviation vs Emergency Medicine Part 3 – Supervision & Training Sun, 04 Aug 2013 11:15:51 +0000 I’m not normally a nervous flyer. I was born overseas, and had lived on 4 continents by the age of 7, and took yearly trips from Australia to the USA to visit family throughout the 80’s and 90’s (in the old days when it took 4 stops and 40 hours to get from Melbourne to Houston).  That’s a lot of flights.  I currently rely on interstate locum work for a living, so I fly interstate at least once a month.  My favourite TV show however is Air Crash Investigation, so I think a lot about what’s happening on the aircraft, every time I fly.

I took a recent interstate flight on a Dash-8 (with propellers, not jet engines) for a locum stint. It involved flying over a decent stretch of water, on a cold, windy afternoon, in winter.  The flight was delayed 2 hours, “due to late arrival of the incoming aircraft”, and while we were boarding there was an engineer in the tiny cockpit with the pilot & co-pilot, playing with various switches, and frequently referring to a clip-board.  It was pretty obvious there was some sort of technical or mechanical issue with the aircraft.  Dash-8’s are workhorses of the sky, and from what I can gather, are fairly reliable. This one however was many years old, and looked worn, and tired.  As the engineer left the plane, I noticed that the co-pilot was a young woman, who looked to be in her mid 20’s, and didn’t seem to have many stripes on her epaulets.  She looked about the same age as many of the RMO’s and Registrars at work. The pilot was a classic middle-aged clean-cut pilot type, with a calm, experienced voice on the PA as we taxied out, and he apologised for the late departure.


A Dash-8 similar to the one I flew in (this one is much newer!)
Image courtesy of:

As we took off, I did notice that the floor was vibrating so much I couldn’t leave my feet down, the frequency of vibration was incredible, and I had to put my feet on my bag.  It made me wonder about various screws and rivets in the airframe being shaken loose.  There were quite a few bumps on the way over, and as we approached the destination, a small rural airport located right on the coast, we took an unusual route, going over the nearby main town, then back out to sea (which made me wonder if we were going to ditch in the ocean), before sharply banking to line up with the airport, and as I looked out the window I could just see the runway off to our right, disappearing below a blanket of very, very low cloud…  In my mind the following holes in a large piece of Swiss cheese were re-arranging themselves into a nice orderly line…

1)    Flight delayed 2 hours, now an early evening flight – late, tired pilots
2)    Co-pilot quite junior
3)    Old, rickety aircraft which required engineer attention prior to take-off
4)    Bad weather –  windy & bumpy, with a light rain
5)    Bad visibility – very, very low cloud, dusk approaching
6)    Rural airport with unknown emergency preparedness.

As we lined up to land, the way the plane banked felt very sudden and sharp, and the straighten up was quite abrupt too, and as I looked downward to the frothy ocean below, we seemed quite low, rather lower than I’d been on that approach before, it felt like we were barely 100 metres off the water. And I knew from the weather forecast it was about 6 degrees outside. Water temperature – arctic.  And by the jerky, almost over-corrected movements of the aircraft, I convinced myself we were in the hands of the young co-pilot for the landing.  Butterflies-in-the-stomach started, life jacket position reviewed, exits checked, seatbelt tightened, brace position visualised, and I wondered how long I could last in the freezing choppy ocean before the rescuers in this notoriously sleepy part of the world got moving.  As we hit the runway with a thud and a bounce, and the brakes got slammed on, I did feel a wave of relief.  I’d live to catch the same flight home in a few days time.

As we disembarked and my feet touched reassuringly onto terra firma, it made me stop and think about that young co-pilot, and the difference between her supervision during that landing, (which in the end was fine, we all lived), with an experienced pilot right next to her, with no-one interrupting, there to provide individual, real-time instruction and backup, and the way I was supervised during my emergency medicine training.

I could count on one hand the number of one-on-one patient interactions I had where it was just me and the Consultant in the room with no interruptions, no-one else there to distract us, and where I received personalised teaching from them.  More than 99.99% of my patient interaction during my training involved me seeing the patient alone, and reporting back to a Consultant at the desk.  No-one listening to my history taking.  No-one checking my examination technique. I was shown a lumbar puncture and central line insertion once each on a live patient before being let loose by myself (the old see one, do one, teach one). No supervision.  No decent feedback. No simulation.  And that was on day shifts. On nights one was truly “flying solo”. No backup, no-one to jump in when things got bumpy.  This training was “character building”, (ie idiotically stressful) but the main effect was that my peers and I learned our medicine in the “you’re doing it on your own, and if you fuck it up, you’re on your own, so you better not fuck it up” school.  Which is great for making you focus on the task at hand, but given that all educational theory is wishy-washy at best, I think this theory ranks near the bottom for educational utility. Would they let that young co-pilot fly in low, to a poor visibility runway, on a windy evening at dusk, in a rickety old aircraft with recent mechanical issues into to that bad weather, having never done it supervised nor in a simulator, on her own? I doubt it.

I remember complaining about this once to a Consultant who was rostered on as the “clinical education Consultant” – a job where they were meant to directly supervise and teach Registrars and not see patients – and her response was “well, you seemed quite capable, so I was happy for you to just carry on”! Meaning the only feedback I was getting day to day was “keep doing what you’re doing, on your own, and we’ll only step in if we think you’re doing something wrong”. Yet another awesome educational theory from doctors who know nothing about education.

Imagine this in pilot training. “As long as the aircraft stays in the air, keep doing what you’re doing, and it’s up to you to go home and read some books about flying so you know what to do, and we’ll only step in and teach you something if you really lose control or crash.  Oh, and if you do crash, you alone will wear the blame…”

Other medical specialties such as Surgical training (or any other specialty that involves being in the operating theatre – where you get extended one-on-one interaction with your boss), or even Psychiatry training, where you get weekly “supervision”, which is one-on-one time with a Consultant, are far ahead of us at the subtle as well as the literal or direct transfer of knowledge and experience that comes from close supervision.

Emergency medicine can never hope to achieve this degree of supervision with the way we’ve let administrators structure our workplace.  The demands on the system and the sheer volume of patients won’t allow it either. But next time your Registrar (Resident for the Americans) is having trouble with a patient, don’t just tell them what to do from the desk. Take 5 minutes to go in and see the patient with them, and get them to show you how they approached it.   If they’re doing it right, tell them. If they’re doing it wrong, don’t criticise, teach.  If they’re really struggling, show them the right way, and follow up with some feedback and discussion in a few days to ensure that it sunk in. Not only will you actually make a real difference to their learning, but hopefully they will role model that behaviour when they’re a Consultant.

For those health professionals that live in Australia and are truly interested in learning to teach, not just doing what you think is “good teaching” (because I can guarantee, you’re not half as a good a teacher as you think you are), I can highly recommend the following courses:

Graduate Certificate in Health Professional Education

Graduate Certificate in Clinical Simulation

I’m currently half-way through the latter course, and it has been a real eye opener into how little doctors know about teaching. Both cover educational theories and methods from a healthcare perspective in detail, and I’m stunned that we as a profession have allowed people with no educational skill or qualifications (ie practically all of our colleagues) to “teach” us for so long.  I’d encourage anyone who is seriously interested in gaining some formal teaching qualifications to check theses courses out, take some educational initiative, and you, your colleagues and your patients will be better off for it.

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Aviation vs Emergency Medicine – Part 2 – Stats Wed, 05 Jun 2013 08:44:16 +0000 I couldn’t put this better myself, so I’m poaching a post written by someone called Jeff Terry. Now I have no idea who Jeff Terry is, and I am very hesitant to post a link to a site emblazoned with the logo of a company that makes dishwashers, but also makes huge profits from military contracts, so take it with a double shot of 3% Saline.

Regardless, this very succinct summary gives some perspective to the ongoing aviation vs medicine debate with regard to patient safety, complete with reference to the omnipresnent Captain Sullenberger.

Let me know what you think. Do the stats sway your opinion? Can we really use aviation as a model for patient safety?



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Resus Time Out Checklist – V2.0 Sat, 13 Apr 2013 06:53:05 +0000 Having done a bit of reading about checklist design, and the challenge-response style, I’ve reconfigured the resus time out checklist.  I was actually working on this the other night after finished a late shift up in Darwin, and was on-call for the ED overnight. Sure enough I was asleep for about an hour when the phone rang at 03:15am. Groan…. “Two patients from a high-speed MVA, one was ejected and is agitated and combative, I think we’ll need to tube him” said the Registrar.

15 minutes later I enter the resus room to hear the words “pass me the bougie” from the head of the bed.  I’d missed the party, and the tube went in uneventfully.  As soon as this happened though, I stood back to watch what the assembled and very capable senior  ED, Surgical, Anaesthetic and ICU Registrars and nursing staff would do.  In true night-shift fashion, everyone started doing their own thing! The tasks they were doing weren’t wrong, but they lacked direction or focus, and there were a couple of glaring omissions. I’m sure if I suddenly blindfolded them all and asked what each of the other people in the room were doing, they’d have had no idea. Which of course is completely normal for people who are operating in a state that’s been proven to be the same as working when you’re drunk.

“Perfect time for the checklist” I thought, so I made the time out announcement, and ran through it.

The effect it had was interesting, and very productive. Some of the positive effects included:

  • Everyone stopped, which allowed everyone to catch up on where we were up to
  • It provided clear points for the scribe nurse to document, and double check those that she’d already written
  • I could see that the A/B/C structure was familiar, and it was evident that this was an easy sequence for the group to follow

Potential omissions/errors/efficiency points that were picked up included:

  • Sedation and paralytics were drawn up and administered immediately – these had not been pre-prepared prior to intubation
  • A bite block was inserted
  • The switchover from bagging circuit to the ventilator occurred sooner, freeing up the Anaesthetic Reg to obtain the 2nd IV access
  • 2nd IV access established, as the patient had been too combative to get two in before intubation
  • Blood gas checked & signed
  • Two registrars fixated on establishing an arterial line were (after two unsuccessful attempts) diverted to preparing staff, equipment & drugs for transport to CT
  • Prior to departure disposition direct to ICU from CT was arranged (which changed to theatre once the scan was done – see below)
  • It also gave me something to focus on, as I was exhausted having already worked a busy 11-hour shift, and having been woken so soon after entering deep sleep (a well-recognised mechanism for maximal brain scrambling).

Overall I really felt that use of the checklist provided a clear structure for the group to work within, and made the resus process more orderly, calm, and definitely more efficient.  Instead of performing time-consuming or unnecessary tasks, or falling into “night shift attention drift”, we managed to get the essentials done, and get the patient out of the ED in well under 30 minutes from my arrival.   About the only negative effect was that we got the patient stabilised, ready for transport and out the door so quickly, that the ED Reg hadn’t written any notes! Perhaps a sub-heading for version 3.0 could be “DOCUMENTATION”

Anyway, here’s the checklist: Resus Time Out Checklist: Version 2.0

And in this case, the sooner we got this patient out of ED, the better.
Yep, two separate extradurals, with midline shift.  Time really was of the essence.

extradural_1 extradural_2

As usual, comments are welcome.  Feel free to download, copy, modify and adjust as you see fit. It’s still a work in progress, so any suggestions are welcome.

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BBC Horizon & Kevin Fong Explore Human Factors in Healthcare Sun, 24 Mar 2013 11:41:39 +0000 Although titled “How to Avoid Mistakes in Surgery”, which may lead some medical viewers to dismiss it as unrelated to their specialty, the BBC Horizons program last week aired a fascinating episode, hosted by Dr Kevin Fong, a well-known Anaesthetic/ICU Consultant turned TV presenter from England, whose credits include such shows as Extreme A&E.  In this episode Kevin cuts to the heart of some of the issues we are discussing on RRM, and I’d urge you all to watch it.


Not sure how long this YouTube link will last, and please note, this show is only available (legally) via the BBC iPlayer on the BBC website, which restricts access to UK viewers only. To get around this, you may need to use a VPN service such as Unblock-us, as well as settings from some of the free VPN providers such as topukvpn or getukvpn or bestukvpn. NB: We don’t condone the use of these services or accept any liability for problems with your computer should you choose to use them!

In case the YouTube links craps itself, or gets taken down, or you don’t have time to watch it – here’s my point-form synopsis of the show:

Kevin utilises the now famous Elaine Bromley case as a striking example of loss of situational awareness.  Staff were so focused on establishing an oral airway they overlooked other options. If you’re unaware of this case, I suggest you watch the following video:


In a nutshell: We are wired up to fail, and we have a finite ability to cope with complex information.

It has nothing to do with intelligence, but it’s about accepting limitations & designing strategies that allow you to cope.

Kevin then used examples from other high performance industries to demonstrate the fallibility of the human mind under pressure

Fire Crews
Firefighters face the constant challenge of activities of search & rescue vs monitoring the constant threat of a rapidly changing environment

It is very hard to focus on lifesaving rescue tasks whilst maintaining awareness of the situation around you.

Sounds easy in theory, in real life, it’s extremely difficult

The utility of challenge-response checklists were demonstrated in a commercial aircraft simulator. (If only we could get that sort of training in medicine… Sigh).

Rationale for use of checklists in aviation:
Even smart people need reminders!
The human brain is frail & we all have bad days!!

He then interviewed Atul Gawande – Author of The Checklist Manifesto: How to Get Things Right

Atul believes that often knowledge is not the problem, it’s the execution or lack thereof that causes problems in surgery, and checklists can help with the execution of essential tasks.

Use of the WHO Surgical checklist which he helped develop led to an 18-47% reduction in complications in surgery, across 1st world, 3rd world and even military applications. Their utility in surgical settings is now beyond question.

Teamwork & Handover
Alan Goldman, (Coronary ICU Consultant at the world famous Great Ormond Street Children’s Hospital) instituted a 3-phase process for transfer of paeds cardiac surgery patients from theatre to ICU. This meant tasks were allocated, checklists completed, and practice became standardized, leading to fewer errors.

To develop this handover process, F1 Pit Crews were analysed:
In Formula-1 racing, the pit crews have the following characteristics
Each individual has a very specific, small task (Task allocation)
Situational awareness
Contingencies with a definitive plan

This left me wondering whether this sort of standardisation can ever really work in the ED, with the constant variation in staffing, environment, patients and acuity that we experience. I think not.

Some of the benefits of simulation were demonstrated, with footage of a real anaesthetic crisis being run in sim-mode with an unfortunate Registrar bearing the brunt of a very difficult case and surgeon!

But what about unpredictable, sudden emergencies?
Well, it’s CRM to the rescue, of course!
Captain Chesley “Sully” Sullenberger, the pilot from Flight 1549 (which famously landed in the Hudson River after a bird-strike), who has become an advocate of CRM in medicine, was interviewed:

“Over many decades, thousands of people have in aviation have worked very hard to create a robust, resilient safety system in which we operate, which formed the firm foundation on which we could innovate, improvise”

He highlighted some of the characterstics of CRM:
Shared sense of responsibility
Flattened hierarchy
Open channels of communication

“We have teams trained in the consistent application of best practice, with well learned, well defined roles & responsibilities to each other & to the passengers”.

“We took what we did know & applied it to a new situation to solve the problem”

Kevin’s response to this: “Standardise until you absolutely have to improvise”

Error Correction:
He then travelled to the US to meet a Professor of Psychophysiology, Jason Moser, an expert in error processing in the brain. This is where the show got interesting for me:

He showed how the more positive your attitude is to error, the shorter the time there is before you realize & correct your error. Interestingly, 100% of the time when your brain is in this positive, error-correct mode, you will not make a mistake with the next decision.

In a crisis, being positive about errors is essential. If you have a negative response/attitude to error, (for example, you’re afraid of being criticised, reprimanded or even sued, which is a very common perception of error in medicine), not only do you take longer to correct them, you make more of them.

Learning from mistakes is something that runs deep in the DNA of the airline industry. Every pilot is brought up with a POSITIVE attitude to errors. Error is not only accepted, it is expected.  He describes this as a “search for progress”, which is in stark contrast to the medical industry, which has an ingrained culture of blame.

Human error is always going to be with us, but it’s how we deal with it that’s important

Overall I think this was a great show that highlighted many of the problems, and the underlying psychology behind them in the medical world. The final commentary about attitude to error and safety cultures, to me, were the most useful points in the show, which if anything highlights the gaping chasm between medicine and aviation from the CRM/RRM perspective. I find it frustrating that Captain Sullenberger would reiterate exactly what I’ve been on about, that “over many decades, thousands of people have in aviation have worked very hard to create a robust, resilient safety system in which we operate”, when in medicine, over many decades, thousands of lawyers and hospital administrators have sought to hang individual doctors out to dry, to sue them personally for millions of dollars and create a paranoid culture of individual responsibility and blame that flies in the face of the aviation model, where any error in medicine is seen as a grave individual mistake that should be punished. On top of this we have a work environment, (including such simple things as poor rostering, hospital overcrowding and constant interruption), especially in Emergency Medicine, that not only exposes us to error, but guarantees it. “Safety”, whilst now being recognised as important, is not a concept I’ve encountered any formal sense, in any training, or any “culture”, in any public hospital I’ve worked at in nearly 15 years as a doctor. We do not have “teams trained in the consistent application of best practice, with well learned, well defined roles & responsibilities”, and I wonder if we ever really can. A noble ideal for sure, but all the checklists, CRM and simulation in the world isn’t going to work until we change the culture.

What do you think? Can we change the culture of blame in medicine and become more like aviation?






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Tearing down the silos in Critical Care Medicine Sun, 10 Mar 2013 21:52:44 +0000 After a rousing start from Scott Weingart at SMACC2013, John Myburgh, Intensivist from StGeorge in Sydney raised the issue of “silos” in Critical Care Medicine.  Why do we still see ourselves as such distinct specialties, who “play on different teams”, who are antagonistic, who often lose the focus of the patient as the most important thing in the resus room? What do you think of “silos”, and how can we all learn to work better together for the best outcome for the patient. Should we all just be called “Resuscitationists” as Scott suggested?

Leave your comments below…



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Process Communication Model: Surgeons trying to communicate better?! Fri, 08 Mar 2013 09:37:08 +0000 The Royal Australasian College of Surgeons, via their Professional Development area are running a course that can only benefit, well, all of us!  The Process Communication Model course involves reflecting on one’s own communication style, analysing your colleagues as well as your own communication styles under stress, and aims provide attendees with skills to better manage conflict.

“About time!” I hear you say.  Surgeons have long been ridiculed for their poor communication, and we have all been in trauma resuscitations, in theatre , in a cubicle with a patient or on the end of the phone with a surgeon who has communicated poorly, which invariably leads to heightened levels of distress for those on the receiving end.

Without knowing the full details of the course (or the company that runs it), I would still suggest that any effort to raise situational awareness, and awareness of others’ needs, to better manage conflict and improve communication should be applauded.

It still bothers me that as a profession we are still operating in “silos”, where different specialties take up different causes (or courses) in the name of improving non-technical skills, (eg ACME, CCrISP, PCM, ATTT, EMAC),when in fact we could all benefit from one unified process and language.  Should RRM fulfil this role? Are we doomed to fail by approaching stressful medical situations with different perspectives, different priorities, and different training? Or is something better than nothing?

I don’t think there’s any evidence that medical short courses of any kind improve anything, but at least the surgeons have recognised that communication is a problem, and are making a serious, concerted effort to address it.

Here’s one surgeons appraisal of the course. For him it was life-changing.

What do you think? Leave a comment below.

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Vortex – Cognitive Aid for Unanticipated Difficult Airways Wed, 20 Feb 2013 02:20:59 +0000 Peter Fritz and Nick Chrimes from Melbourne have just released a groundbreaking new concept in airway management.  Utilising a cognitive aid as opposed to a traditional flowchart algorithm, and a short checklist, the Vortex approach to unanticipated difficult airway management is designed to be easy to remember and implement, to be used by any critical care specialty, and to provide a much easier to remember method to manage this traditionally high stress situation.  As Peter said to me, “3 year old could look at it, walk away and draw it”.  From an RRM perspective, the Vortex approach gives you a single image to picture in your mind rather than multiple steps in an algorithm (much easier to visualise when the pressure and distraction of a difficult airway presents itself), it facilitates group communication, it enables the group to offer alternative suggestions to the airway doctor, and it uses a checklist for optimization methods.


Having only just been released, the concept is already gaining massive traction, with the guys being interviewed on Minh Le Cong’s hugely popular PHARM Podcast.  They have also started their own site, (in direct antagonism of my dislike for the word “crisis”!), Clinical Crisis Education which has links to CrisisPoint, a discussion area for critical care and resus issues, and their main Vortex site.


In my humble opinion the Vortex is much easier to remember than a flowchart, it changes the focus from “get the tube in” to “get the alveoli oxygenated”, it makes you consider a surgical airway from the very start, and it also includes the “green zone” – a type of Resus Time Out – which is when oxygenation has been achieved, regardless of the method, thereby allowing the team to stop, re-consider their options and make a safe plan, rather than ploughing on with repeated attempts at airway instrumentation.

I think the Vortex approach to the unanticipated difficult airway is great, and will surely make what was renowned as one of the more stressful experiences you can have in medicine easier to manage.  You can follow Pete (@pzfritz) and Nick (@nicholaschrimes) on Twitter, and there are plans afoot to make the Vortex widely available, with online and face-to-face teaching.

What do you think of the Vortex? Is a cognitive aid better than a flowchart? Are there other parts of resus you could use them in?

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The Resus “Time Out!” Tue, 12 Feb 2013 23:42:30 +0000 “Time Outs” have been used in the operating theatre for many years. They are designed as an error reduction method, whereby everyone in the theatre stops what they are doing whilst a checklist is run through, ensuring that the correct procedure is being carried out, on the correct patient, by the correct people with the correct equipment.

Checklists like this have been shown to reduce error rates in surgical cases, so I’ve wondered for a while if a resus time out could be implemented for a similar purpose.  Obviously stopping during CPR to do a checklist is not feasible, but at certain times during a resus it may be possible to at least pause, do a stocktake, run through a brief checklist to ensure critical steps have not been overlooked, and to communicate the forward plan to the team.

Checklists are making their way into critical care medicine, for example there are now different intubation checklists available to assist with planning for, and executing intubation. You can see examples of these here, here, here and here.

Cliff Reid talked about the Resus Room Safety Officer in a recent post on, which is more of a real-time, dynamic concept, whereby a nominated staff member, separate to the team leader, oversees the resus with a checklist that ensures critical elements are not missed. I wonder if a “time out” approach may be utilized to stop, focus everyone’s attention, ensuring that critical steps have not been missed and to ensure that the group is aware of the current status of the patient and the forward plan.  A downside of a time-out is that there may not be an appropriate time for everyone to stop and listen, and getting everyone’s attention could be hard, however they manage to stop surgeons in their tracks in theatre with time-outs, and once established in the culture of your resus room, it may not be as hard.

Here’s a very basic example of a resus time-out checklist, designed to ensure the really critical steps are covered. It doesn’t go into specifics, but acts more as a prompt, which allows staff to use their experience to make specific choices about how they like to do things.

Resus Time Out Checklist

It only takes 1-2 minutes to run through this list, and it could be done at set times, such as post intubation, upon return of spontaneous circulation, or prior to transfer to ICU, Theatre or Radiology.

This is a simplified form of resuscitation decision support.  Computerised decision support algorithms have been implemented at major trauma centers such as the Alfred Hospital in Melbourne, which uses software created by the Trauma Reception and Resuscitation project,  This system was designed based on data showing that most errors in trauma resus were simple errors of omission, rather than active mistakes made by clinicans.  Obviously the infrastructure required to implement this sort if system is out of reach of most public hospitals in Australia, but a more simple, human operated checklist system may still help reduce error in resus.

What do you think about resus time outs? Do you think it’s feasible, or would it just add more confusion to an already busy environment? Feel free to comment on, make suggestions, add or delete items from the checklist, it’s a version 1.0 draft that I’d like your comments on.

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