Implementing crew resource management tactics in emergency medicine

CRM strategies include a consensus among crew members and confirmed communications that make tasks more efficient

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By Stephen Norcup

Imagine for a minute that you’re a pilot. It’s 1977, and you’re about to fly a flagship Pan Am 747 from Los Angeles to a beautiful island off the west coast of Africa. Along with the other pilot and flight engineer, there’s 13 flight attendants looking after 380 passengers in the back.

You take off, stop in New York City for fuel, then take off again towards another continent. It’s been a long day, and as you near the islands, you’re told that you will need to land somewhere else. You learn that someone set off a bomb at the airport you were heading towards. You’re directed to land at Los Rodeos Airport on the island of Tenerife until they clean things up and reopen the airport. After landing at the alternate location, your original destination opens back up, but you’re stuck waiting for another 747 to receive fuel. With planes parked all over the airport, your only option is to wait until both aircrafts are able to take off.

The principles of CRM can be incorporated into the patient hand-off process in the emergency department with cooperation from the crews as well as the providers in the hospital.
The principles of CRM can be incorporated into the patient hand-off process in the emergency department with cooperation from the crews as well as the providers in the hospital. (Photo/Wikimedia Commons)

The 747, now fully fueled, taxis down the runway in front of you and quickly disappears into a fast-moving storm. You’re told to follow them and take the third left. There are no signs, visibility is nearly zero, it’s raining, you are trying to navigate unfamiliar territory and the radio is chattering away in the background. The plane that was in front of you has reversed its flight and is heading towards you at full throttle.

Ultimately, in this nightmare scenario, the 747s collided and caught fire, killing 583 people in one of the deadliest aviation accidents in history at what is now called Tenerife North Airport. There were many factors that contributed to this accident, however, it’s widely agreed that this event was the watershed moment for the science and culture of crew resource management (CRM).

In its early years, aviation culture placed the final authority of aircraft operations with the pilot in command, and subordinates often felt apprehensive about contradicting an order. In the Tenerife airport disaster, the pilot of the aircraft that took off without authorization was a highly decorated and respected training pilot with significant tenure in the organization. Non-standard language was used by both the flight crew and air traffic controller, and there was significant radio traffic which blocked portions of transmissions. The tenured pilot was anxious to leave, and started to takeoff without agreement from the entire crew.

What strategies are included in CRM?

This type of oversight drives one of the primary principles of CRM, which is agreement within the entire team, as opposed to decisions made by the senior member of the crew. While, ultimately, responsibility still lies with that senior member, they are encouraged to listen to input from others. Furthermore, in a go-no-go situation, a go decision is not made without a consensus. A common way to express this concept is “Three to go, one to say no.”

A second pillar of CRM lies in communications. All communications involve a component of positive feedback that the information has been received by the recipient. A common aviation example of this is a challenge and response checklist. One crew member will read a checklist item to the other, such as, “check altimeter,” while the second crew member makes a conscious choice to look at the altimeter and then confirm that he has done so with a response of “altimeter checked.” The two crew members can often work through a complex series of checks and actions quickly with a high degree of accuracy by working together to complete the list.

Applying CRM to healthcare

CRM is now being applied in ICU settings. While the scale of caring for patients is often smaller when comparing the application of CRM to healthcare instead of aviation, a lack of clear and concise communication can still have devastating consequences. Generally speaking, literature shows that implementing CRM in conjunction with programs that encourage interdisciplinary cooperation leads to better patient outcomes.

Not all CRM needs to be a formalized challenge and response checklist. One of the things I most enjoy about working with a regular partner is the amount of nonverbal communication that can take place. My favorite example of this is during stretcher lifts, which can often be accomplished with eye contact and a nod from one partner to another. These are subtle ways that we already employ and can capitalize on CRM in regular practice in EMS.

Another interesting, yet anecdotal, example of CRM is from the U.S. Coast Guard aircrews in the wake of Hurricane Katrina. Crews were assembled with available personnel who had not worked with each other previously, but, due to standardized protocols amongst flight crews, they were able to complete countless hoist rescues without incident.

Asking questions establishes firm CRM procedures

I have always been very blunt in acknowledging when I don't know an answer, while priding myself in knowing where to find the information in those situations. Sometimes the people around you, regardless of background, skill set or certification level, do have the answers. To extend this to healthcare, keep in mind that the “crew” may not be limited to who rode with you on the ambulance. Where a patient's wellbeing is concerned, that crew may include family members, other healthcare providers and the team at the hospital who will be receiving the patient. While it’s not practical to have all of them available in the midst of a call, try and consider the impacts your care has on their role in the patient's overall outcome.

Furthermore, it’s okay to ask questions. In emergency medicine, we are given the task of mitigating a lot of uncontrollable circumstances. While you should be knowledgeable about a wide swath of medicine, there is no expectation to be a subject matter expert on every disease process. Take pride in being able to intubate in a ditch, and be humble enough to ask for some input on a complex medical patient with significant comorbidities.

Support those who voice their opinions in a constructive manner

There’s a time and a place to express disagreements, which can be a skill in and of itself; however, expressing concerns over crew safety and patient care in a polite and professional manner should be an accepted aspect of the culture in your organization. I also feel there should be bonus points if an alternative solution is provided.

When other crew members voice a concern or alternative plan and you are the one responsible for making the decision, acknowledge the concern and incorporate it to the best of your abilities. Depending on the situation, this can be difficult to navigate, however, situations where a consensus is needed should be specified in advance.

Involve your healthcare system in the CRM process

Do you have a fantastic working relationship with the hospitals where you take patients? How about with your medical director? Some of us can answer this question with a resounding yes, and others, not so much.

Change can come from all sorts of places, and an interesting way to incorporate CRM into the hospital could begin in the emergency department. I know at times, I have felt like the information I provided to the receiving facility fell on deaf ears. The principles of CRM can be incorporated into the patient hand-off process in the emergency department with cooperation from the crews as well as the providers in the hospital. This can help improve patient outcomes by both making sure information provided by the crew is accurately documented, and, if implemented well, could also help improve the crew’s perception of the patient hand-off process by making them feel like their voices have been heard.

CRM implementation will not happen overnight

CRM is as much of a cultural change as it is an operational change. Training can demonstrate the basic principles and some tactics involved in the practice of CRM, but, at its core, CRM is about respecting the strengths of those around you, regardless of where they fit into the hierarchy in which you work.

Change can be difficult in organizations of any size. CRM principal implementation in your organization will not happen overnight, and also won’t happen without a buy-in from stakeholders at all levels. A good way to start is by simply introducing the concepts and making everyone aware of them. In some situations, this may be enough to see a change. Once the fundamentals have been introduced, look at ways the principles can be incorporated through more casual means, such as informal procedures or undocumented processes which take place.

It’s often said that respect is earned and not given. In the case of CRM, we seek to engrain respect, although it may not have been “earned” in the eyes of those who are being asked to give it. While this may seem like a monumental task, mandating respect will never lead to a positive outcome. Education and demonstration of the skills and value that each player brings to the table can often lead to significant adoption of these principles.

About the author

Stephen Norcup is a paramedic with Munhall (Pa.) Area Pre-Hospital Services; and director, clinical operations, Forest Devices, Pittsburgh, Pa.

This article, originally published on Sept. 7, 2018, has been updated

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