Aviation vs Emergency Medicine 4 – Combat vs Commercial vs ED

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.

“CRM”
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.

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

Emergency Medicine
Pre-shift briefing is never done.

Testing
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.

Simulation
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.

Workforce
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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