Part 1 – Crew Resource Management
Has this ever happened to you: You’re the new person starting your first day at a service with a seasoned Paramedic. You get your first call of the day, hop in the passenger seat and as the ambulance proceeds onto the roadway you reach over and “attempt” to turn the lights and siren on. Your hand does not get far because your partner swats it away, gives you “the look” then tells you to never touch the controls in his ambulance again. Thinking this was isolated to inside his ambulance, you find out this behavior extended to patient care too. It was only your second call when you noticed he drew up a wrong medication dosage. When you discreetly mentioned it to him, again you got “the look.” This was followed up by a “if you want to keep working here” lecture afterwards. Sound familiar?
This type of interpersonal dynamics is not the norm in EMS, although it would be hard pressed to say it does not happen either. All it takes is one time to harm a patient or get into a crash because you did not speak up and your career will be short lived. Count on it.
History of a Culture of Safety in Aviation
Not too many years ago commercial aviation had its challenges when post-crash investigations began noticing a common problem of poor communication in the cockpit. They believed that the authoritarian cockpit culture started the chain of events that lead to many crashes. This culture discouraged co-pilots to question the captains if they observed them making mistakes. It was not until after the 1977 Tenerife runway crash of two 747s that killed 585 people, the cockpit culture was addressed.
After the Tenerife crash, the National Transportation Safety Board began making recommendations based on research by NASA that addressed this concern. Soon airlines were adapting new training procedures called Cockpit Crew Resource Management or CRM. This new procedure focused on crew communication, decision making and leadership, which would eventually lead to a much safer operation of the aircraft.
So how does this work? One of the first steps is fostering a culture in an organization where authority can be respectfully questioned. Additionally, crews are encouraged to self-report when they made mistakes without fear of reprisal from leadership. If this is beginning to sound like Just Culture you are exactly right. The roots of Just Culture had its start in aviation.
How Does Crew Resource Management Work?
In public safety there have been a long and traditional hierarchies, which questioning authority is frowned upon. Although when it comes to safety, the proper crew resource management training can overcome this concern. Let us take a look on how this can work. Todd Bishop1 who is a crew resource management expert has developed a five-step process of inquiry and advocacy which easily crosses over to EMS.
1 – Opening or attention getter – Address the individual: “Hey Chief,” or “Captain Smith,” or “Bob,” or whatever name or title will get the person’s attention.
2 – State your concern – Express your analysis of the situation in a direct manner while owning your emotions about it. “I’m concerned that we may not have enough fuel to fly around this storm system,” or “I’m worried that the roof might collapse.”
3 – State the problem as you see it – “we’re showing only 40 minutes of fuel left,” or “This building has a lightweight steel truss roof, and we may have fire extension into the roof structure.”
4 – State a solution – “Let’s divert to another airport and refuel,” or “I think we should pull some tiles and take a look with the thermal imaging camera before we commit crews inside.”
5 – Obtain agreement (or buy-in) – “Does that sound good to you, Captain?”
Healthcare is also adapting crew resource management in patient safety strategies. The agency for Healthcare Quality and Research (AHRQ) provides this training for healthcare organizations. You may have heard of or been trained in Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), which has statistically shown to increase patient safety. All these programs must be deep rooted or what I call “hard wired” in a culture of safety to be successful. If not, these strategies can fail.
What Would Crew Resource Management Look Like in EMS?
As an ambulance safety consultant, I am always looking for new tactics and strategies to enhance the safe operation of the vehicle. As a firm believer that whoever is driving the ambulance does just that, drive. When both crew members are up front, the right seat person has an important safety responsibility. Think of the distractions that occur up front; Radio operation, MDT, siren (mode) operation and non-essential communication. Leave these tasks to the person who is not driving the ambulance. As for non-essential communication, there is another aviation safety strategy called silent cockpit. For commercial pilots this occurs below a certain altitude where the two pilots must keep their conversation limited to the safe operation of the aircraft.
In EMS, that could apply to emergent driving. I have several clients that employ this strategy and the feedback has been positive. In some of my lectures, I show several dash camera videos where I emphasize the importance of crew resource management in emergent driving. One is an ambulance in emergent mode approaching an intersection while the driver is on the phone texting. Just before the intersection, his partner sees a car approaching from his side and starts yelling at the driver. Fortunately, they avoid a crash as the driver is heard saying “didn’t see them,” which his partner replies “really!” In another video, an ambulance is in emergent mode while the two crew members are singing to the radio, one playing the air guitar when they crossed the center line and are side swiped a truck trailer.
Take Your Safety Strategy to the Next Level
For the most part, good common sense and adherence to policies can certainly reduce risky safety behavior. For those who want to take it to the next level with proven results, look at how you can take away some useful safety strategies from the aviation industry.
- International Association of Fire Chiefs (2003). “Crew Resource Management: A positive change for the fire service”(PDF). Archived from the original(PDF) on 4 December 2010. Retrieved 6 September2010
Part 2 – Checklists
In 1935, a fatal airplane crash changed the aviation safety world. It was at Wright Field near Dayton, Ohio, when the Boeing aircraft manufacturer and the U.S. Army Air Corps met to introduce the B-17 bomber. Two Air Corps pilots, a Boeing Chief Test Pilot and mechanic boarded the aircraft for a brief demonstration flight for many high-ranking officials watching from the ground. Of interesting note was the fact that Boeing did not want to take any chances of the aircraft having problems, hence the addition of the Boeing personnel that accompanied the pilots. Shortly after becoming airborne and beginning its climb, the aircraft stalled and crashed in a field.
Two on board lost their lives. The co-pilot survived, and his interview by the investigators proved to be the key in determining the cause of the crash. The investigators found that a critical pre-takeoff omission in the flight control had caused the aircraft to crash. It was further determined that technology on board this new type of aircraft was too complex for pilots to remember not what to do, but in the correct order to safely fly the aircraft. To address these issues, Boeing introduced a mandatory new tool for all pilots to use: a checklist. Since that day in 1935, pilots all over the world have been using checklists as a mandatory safety component that has proven to reduce crashes.
How Checklists Are Used in EMS Today
Today the checklist has expanded well beyond aviation and is commonly found in many different industries. The simple reason is it works is because it prevents lapses in memory in critical phases of certain high-risk job tasks. So, can checklists have a home in EMS? Most certainly!
I will focus on two patient safety concerns in EMS: Medication errors and stretcher incidents. I recently had the opportunity to view a couple of excellent videos produced by some of our colleagues. One was by Sedgwick County EMS in Wichita, Kansas. In these videos they simulate the administration of fentanyl for chest discomfort, one with no errors found and the other with a dosage error. What was interesting is they had a timer on the no error video, so you see how long the cross-check was taking. It was a professional exchange between the clinicians, and looking at it from a patient perspective, must have been reassuring that safety and quality was a priority.
In another video produced by Jones & Bartlett Learning, the clinicians are administering aspirin to a patient. Again, a timer is used during the med check exchange between the clinicians and the patient. Certainly, time well spent to confirm the right medication is administered.
For stretcher safety, I found another video from Jones & Bartlett Learning in which cross-checks are used during the loading and unloading of the stretcher. It was a simple exchange between the clinicians that ensured all critical safety steps were in place before moving on to the next stretcher operation step. It was obvious that if the cross-check was done correctly, the exposure of risk to the clinicians and the patient was significantly reduced.
How Else Could We Use Checklists in EMS?
While watching the exchanges in the videos above I kept asking myself how these cross-checks would be accepted by todays EMS providers. It is a totally different approach to safety that may take some time getting used to. Organizations that are deep rooted in a culture of safety should have little problem implementing checklists, while others may face challenges from staff. Proper education, medical direction oversight, and a good understanding of how and when to use checklists will be helpful.
An excellent book on this topic is The Checklist Manifesto – How to Get Things Right by ATUL Gawande M.D. The author shares his riveting story as a surgeon and some life and death cases that could have been fatal to the patient if it was not for a surgical checklist. In his book, Gawande explains what checklists can and cannot do. He walks through a simplified and common-sense approach that has proven itself time and time again in numerous industries. If you are contemplating checklists in your organization, I highly recommend this book.
About the Author
David R. McGowan
David McGowan, ASHM, has more than 35 years of experience in EMS serving as a clinician and administrator for fire and hospital-based services. He is an accomplished administrator in Operations, Communications, Marketing, Business Development and Systems Quality. McGowan is recognized nationally for his expertise in ambulance safety programs. He has had many speaking engagements at national EMS conferences and has authored numerous publications and papers. McGowan provides expert consultation for ambulance operators, manufacturers, educational institutions, government agencies and legal firms.
Mr. McGowan is highly regarded as an expert in safe ambulance operations with clients ranging from small to very large operations. His client list is a “who’s who” of Emergency Medical Services, not only here in the US but in Europe as well.
Before joining ACETECH, Mr. McGowan was employed by ZOLL Road Safety where he provided his clients with best practices in ambulance safety. His vast experience in EMS and vehicle telematics provides a unique approach to develop and enhance safety solutions.
Find out more about ACETECH here and how we can help improve the safety of your fleet.