What EMS can learn from the airline industry
Crew resource management, quick reference handbooks and fatigue management strategies can improve patient care and enhance safety
It may surprise you that flying a 30 ton airliner and working on an ambulance have many similarities. Both industries require decisions under pressure, teamwork, clear communication and resource management.
One of the first things a pilot will learn in training is “aviate, navigate, communicate.” No matter what situation or emergency comes up, fly the airplane first. Make sure the plane is stabilized before addressing any failures. Perhaps the most famous example of failure to fly the airplane was Eastern Air Lines Flight 401. In this accident, the flight crew were distracted, dealing with a burnt-out lightbulb. The flight crew failed to recognize the airplane was slowly descending and eventually crashed into the Florida Everglades. Make sure the airplane is going in the direction you want it to, before you address the issues at hand.
In EMT training, we learned early to always first address “airway, breathing, circulation.” We can sometimes get distracted by larger, more obvious traumatic injuries or symptoms and fail to assess the ABCs. Let’s assume we have a scenario where a pedestrian was hit by a car and presents with an open tibia fracture. Naturally, our eyes will likely see this first and instinctively want to address it. However, we may fail to realize that the patient is having uneven chest rise and dyspnea, possibly suggesting a pneumothorax. Any compromise to the ABCs will cause a fatality quicker than any other injury.
Let’s switch back to the cockpit of the airliner. You’ve just taken off when suddenly a master warning comes on and you hear over the speaker “engine fire.” Of course, you will be startled when you see the warning and it takes a lot of training and discipline to temporarily ignore the alert and fly the plane. Every flight instructor will tell you to just sit back and wait until you get the aircraft stabilized. Flying an airplane into a telephone tower near the departure will kill you much faster than that engine on fire. It may seem like an obvious point, but when that stressful moment hits, you need to always remember to address those fundamental lifesaving elements.
At many airlines, the top line of the emergency checklist usually reads “Fly the airplane.” I once heard of a great example of this principle being used in EMS. During the start of the opioid epidemic, many services were administering naloxone and reactively waiting for respiratory rates to increase. One service decided to tape their naloxone spray to the BVM as a reminder that while naloxone may help reverse the overdose, assisting ventilations will certainly address the root problem.
Checklists/Quick Reference Handbooks
For every flight, there are nine different checklists I have to complete between pushing back at the gate and returning after landing. Prior to a checklist being complete, we do what's called a “flow.” The flow is a memorized pattern of steps that configure the airplane for a particular phase of flight. After the flow is done, the other crew member calls for the checklist which verifies everything has been done correctly. A phrase pilots know too often is “checklists are written in blood.” There are numerous incidents/ accidents attributed to either a checklist not being followed or incorrectly written.
In 1988, a Delta Air Lines Boeing 727 crashed shortly after takeoff. One of the causes of the crash was that the flaps were not extended prior to take off. Flaps assist in the airplane’s takeoff performance and without the correct setting, the plane may not be able to climb safely from the runway. You may ask yourself, how does a professional flight crew forget to do such a critical thing like lower the landing gear or set the flaps? While it may seem like a simple situation, hindsight is always 20-20. Distractions or out-of-the-ordinary circumstances can result in missed checklist items. Checklists are the last line of defense to ensure all the critical items are accomplished. Pilots are taught that any interruption of the checklist requires a redo.
There are many sequences and procedures in EMS that require certain steps to be done in a correct order. Chances are you have done a few of them. An example many operators use includes “the five rights of medication.” Prior to administering medication, there is a list of five things we check. During ambulance checkout, our service uses a digital checklist to make sure all the required items are onboard. Nothing would be more unprofessional than showing up to a cardiac arrest to find the AED battery is dead.
On board every jet aircraft is a manual/card called “The Quick Reference Handbook” or commonly called “QRH.” The QRH contains a step-by-step checklist that deals with a specific emergency. It is laid out in an easy to navigate format. In the case of an engine fire, after verifying the plane is in a safe trajectory, the pilot would say, “QRH, engine fire.” The co-pilot would pull out the book and follow the steps.
When a patient is unable to maintain their airway, you decide to intubate. A seasoned medic will likely have this procedure memorized. Yet, medical errors still happen. Between 2000 and 2008, a John Hopkin’s Study showed that 250,000 deaths were attributed to medical errors. While human error does not account for all of these deaths, we can help to reduce the fatalities associated by the use of improper procedures. So, if our medic is about to perform this intubation – why not ask the other EMT to pull out the “Medic Reference Handbook” and read/confirm the steps. The less you have to rely on memory, the better.
Learn more: In praise of the checklist for error prevention
Crew Resource Management (CRM)
In 1978, a United Airlines jet was circling over Portland, Oregon, troubleshooting a landing gear problem. They circled for over an hour, burning all their reserve fuel and ended up crashing due to fuel starvation. While the other pilots informed the captain of the deteriorating fuel situation, the captain failed to recognize and act on the situation. This was a monumental moment in the airline industry. After this accident, airlines moved away from the a captain is all-powerful mentality to inviting other members to voice their concerns. This lesson taught us that no matter how experienced you are, people make mistakes.
It’s OK to make mistakes, but it’s not OK to ignore them. When flying an airliner, the captain and the first officer become a team. In order to have an effective team, we need to communicate. Every time I change the path of an aircraft, I confirm it with the other pilot. Open communication acts as a barrier against mistakes. When coming in to land, only one pilot physically lands the airplane, while the other monitors speed, altitude, configuration, etc. Sometimes, the pilot landing can get fixated on one detail and fail to recognize another, e.g., that the speed is decaying. It’s the other pilot’s responsibility to speak up and say “airspeed low.” This is not taken as a criticism of the landing pilot, but a joint responsibility for safety.
EMS organizations also have to ensure a culture is created where people can freely express concerns and work as a team. Part of CRM is knowing how to delegate responsibilities. A message often conveyed to new airline pilots is “expand your team.” When dealing with a chaotic situation, both pilots and EMTs can get very task saturated. Instead of trying to multitask multiple issues, think of other agencies that can assist.
When an emergency happens in flight, we have resources such as dispatchers, air traffic controllers, flight attendants and off-duty pilots all at our disposal. Instead of trying to do everything, I can ask them to work for me. If I need weather information, runway data or rescue equipment, I’ll simply ask ATC to coordinate that for me while I deal with the emergency on hand. I want almost all my focus to be inside the cockpit – not on minor distractions.
If you are on scene, providing patient care, do not hesitate to bring additional resources. You will be able to operate more efficiently and provide better patient care by removing distractions such as crowd control, traffic flow, extrication, etc.
Training, training and more training
Every year, all airline pilots are required to go back to the simulators to practice emergency procedures and other non-standard operations. In addition, many airlines have quarterly eLearning modules that cover topics such as aircraft systems, weather, airport ops, company procedures, etc. Pilots are also required to maintain currency in the number of landing and instrument approaches they conduct. But currency and proficiency are two separate issues.
Many EMS services require monthly continuing education requirements as a means to maintain certification. Depending on the type of service, some rescue crews don’t use some pieces of equipment for long periods of time.
Most pilots will never experience an engine failure in their careers. This doesn’t give us an excuse to not be prepared. Each year, pilots get a new scenario to deal with to make sure they are fully capable to handle any emergencies. Training teams in EMS services can create new scenarios with the goal of practicing with different pieces of equipment or apparatus. Scenario-based training is an excellent way to remain competent in our skills. Perhaps the most valuable part of the training is the debrief.
In flight simulators, instructors have the ability to replay the flight with data and provide insight as to how the lesson went and what improvements could be made. In EMS, you can designate an observer to watch the drill to provide some highlights or suggestions.
One of my first days of Airline training, the instructor told us very bluntly, “no one should die because you were too tired to fly.” Studies have shown that flying fatigued has the same effect as drunk driving. The danger with fatigue is that small errors can start to accumulate before the crew may notice. Federal law dictates how much a pilot can fly and there is an entire department at the airline monitoring our duty/flight time to ensure we don’t exceed our limits.
Even if we haven’t exceeded our legal limit but feel that we are too fatigued to fly, airlines have a “call in honest” policy. We will be removed from flying or delayed at the hotel if we do not feel adequately rested for the flight.
Pilots and first responders both work 24/7 and often start/stop work at odd hours. To mitigate the effects of fatigue, EMS organizations should provide areas for crews to nap/ rest and offer other ways to combat acute fatigue, such as workout spaces or caffeine stations. Below many major airports, airlines have crew lounges set up where crew members can nap, relax, drink coffee and, in some airports, workout. The nature of EMS and flying does not make us immune to fatigue, but there is a way to mitigate it. EMS supervisors should also be cognizant of how much their members work and offer education on how to avoid chronic fatigue.
Most people know that airplanes contain a black box which records data of the aircraft used in the investigation of an accident. However, the latest trend in safety is to be proactive rather than reactive. Airlines routinely download this data and run reports on safety trends at the airline. This process is called “Flight Operational Quality Assurance” (FOQA). The data is analyzed by a special team called gatekeepers, who will reach out to the crew in a non-punitive way to ensure they remedy any issues.
QA is a very powerful tool. For example, let's say an airline noticed airplanes were landing 10 knots faster than usual at a particular airport. The increased landing speed can increase the risk of the airplane over running the runway. Through the analysis process, the airline can see if the problem was caused by training, procedure, air traffic control, environmental reasons, etc. At the airline I work for, we get monthly newsletters highlighting the safety trends and some potential ways to mitigate these issues.
QA teams in both EMS and aviation have the ability to boost safety and make sure that teams are correctly following set guidelines. Sometimes people are following procedures, but the procedure could be incorrect, outdated, confusing, etc. QA is the only way to catch these errors and continuously improve the operation. QA members need to constantly exercise data discretion and emphasize to members that the data cannot be used for disciplinary action.
Hopefully by now you have seen how the structure of the airline industry can assist the EMS community in providing the best outcomes for patients. Many of the lessons learned in aviation are a result of accidents or incidents – some of which were very avoidable. So next time you board a flight, take a second and think about the careful coordination being done up front and think to yourself, how can we adopt this philosophy?