Aviation vs Emergency Medicine: CRM Smackdown

Comparisons between aviation and medicine are commonplace, and have made their way into the medical literature, forming the basis for the attempts at application of CRM in medical settings. Whilst there are some common elements, such as being responsible for peoples lives in an error prone environment, CRM is an industry specific concept that has developed over many decades, and is based on very specific studies of aviation behaviour, and crash/near miss investigation. Some argue that the basic elements of what causes human error, which is another aspect of CRM, are universally applicable, and therefore CRM is an appropriate model on which to base recommendations for medical “crisis” situations. Whilst there are some elements that are ubiquitous, such as attentional resolution, I feel strongly that the differences in working environment, job specific tasks, and causes of error vary so much, not only between aviation and medicine, but also between medical specialties, that ED Resuscitation needs its own defining set of behaviours and job specific tasks to manage resus well, and prevent error.

AviatvsMed

I spoke with an experienced ex-RAAF pilot, and current First Officer for a major Australian Airline, Mitchell Roggenkamp, (see Bio below) and we teased out the differences between aviation and Emergency Medicine with regard to CRM, safety and error potential. Here’s a list of what we came up with. I think you’ll see the aviation industry is well ahead of us with clearly defined job-specific tasks and procedures that improve safety.

(I’ll go into the universal human error concepts in another post, where we can talk about Swiss Cheese, Invisible Gorillas and the like, but for now, lets pull apart the aviation-medicine connection, and see what we can make of it).

DIFFERENCES BETWEEN AVIATION AND EMERGENCY MEDICINE WITH REGARD TO CRM:

PREPARATION
Aviation
At pre-flight briefing, (of predictable duration and long enough to complete all tasks), Captain establishes communication style, engages other cockpit crew and goes through flight plan in detail. This establishes leadership style and focuses group on task and is an opportunity for asking questions and clarifying ambiguous points in an un-rushed setting.

Emergency Medicine
Pre-arrival briefing of whole treatment group often impossible.  Limited notification/planning time (often only a few minutes) the norm, and group members arrive/leave as needed throughout treatment phase, meaning leadership difficult to establish. Treatment plan established, implemented & altered “on the run”.

ENVIRONMENT:
Aviation
Cockpit staff number and skill mix pre-determined, predictable and non-variable. Determined by make/model of aircraft. No intrusions by 3rd parties into cockpit, especially in a crisis.

Emergency Medicine
Resus staff numbers and skill mix highly variable, unpredictable, and dependent on hospital size, rostering, time of day & other unpredictable variables. Non-ED staff who attend to “assist” frequently cause interruption, fragmentation, dilution of leadership and distraction, with a raised potential for conflict.

CHECKLISTS:
Aviation
All staff read from the same checklists in a crisis.

Emergency Medicine
Use of checklists is not prevalent. Staff tend to rely on highly variable individual knowledge/habits in crisis.

Aviation
Aircraft won’t leave gate until all staff on board, checklists complete, Captain satisfied that staffing, equipment and weather are satisfactory.

Emergency Medicine
Care must proceed regardless of staffing, skill mix, cubicle or equipment availability.

STANDARD OPERATING PROCEDURES:
Aviation
Prioritisation determined by Standard Operating Procedures and checklists supplied by airline company, and aircraft manufacturer, as well as homogenous pilot training. Reasons for deviations must be justified. Can assume that other staff will always operate as per SOP’s.

Emergency Medicine
Common medical knowledge and resuscitation principles shared, but cases too variable to apply Standard Operating Procedures. Prioritisation decisions made by negotiation between parties, individual knowledge & skill varies by specialty, age/experience & individual interest.

“TEAMWORK”/CRM
Aviation
Studies show crews that have flown together, even once, perform better. It is common for crews to have not flown together previously, however because staff may not practice together, they get regular, standardized crisis management training/simulation provided by airline, and other elements such as pre-flight briefing also enhance teamwork.

Emergency Medicine
Staff rarely if ever work in same group in resus. Crisis training is completely up to the individual. Individuals participate in non-standardised, different crisis management training, bringing differing opinions to the situation. Lack of elements such as predictable pre-arrival briefing make forming a cohesive group difficult.

Aviation
CRM training proven to be less effective if not performed regularly and reinforced, hence regular simulation/reinforcement training provided by airlines.

Emergency Medicine
CRM training/simulation not widespread in medical industry (although this is changing). If individually sought, formal followup/reinforcement training is rarely/never provided.

Aviation
CRM Proven to work if certain industry enforced standards adhered to (ie regular practice/reinforcement, adherence to Standard Operating Procedures)

Emergency Medicine
No practically applicable strategy (ie methods/strategies for heterogenous groups of strangers to perform well at first meeting) exists to improve performance/safety in resuscitation settings.

ASSUMED SKILL LEVEL:
Aviation
Rank generally implies clearly defined knowledge and skill level, which allow for safe assumptions to be made about individual ability. Can assume that different crew members of same rank/position will perform similarly. (ie regardless of who individual is – especially in a crisis – tasks will be performed the same).

Emergency Medicine
Can only make limited assumptions about individual ability/skill level/knowledge based on rank/specialty. Individuals of same rank, including Consultants, often have different skill sets. Assumptions of skill/knowledge level based on rank/specialty may lead to dangerous over or underestimation of individual ability.

Aviation
Pilots not allowed into cockpit until specifically oriented, simulator trained and certified in that make/model of aircraft.

Emergency Medicine
Doctors gain resuscitation experience with an apprentice model, and graded exposure over many years, with no formal certification apart from generic medical short courses. Passing a short course, or a specialty exam does not guarantee resuscitation management skill.

CHAIN OF COMMAND
Aviation
No ambiguity in chain of command.

Emergency Medicine
Despite the idealised “Team Leader” concept, chain of command frequently unclear and fluid, ED will often defer to more senior/skilled non-ED clinicians, or make joint decisions.

FATIGUE
Aviation
Fatigue management strictly regulated and enforced.  At start of duty, crew well-rested & alert. Breaks/rest periods guaranteed & enforced.

Emergency Medicine
Medical staff work regardless of fatigue. Breaks are not part of culture, are rarely taken, and are not guaranteed or enforced.

SAFETY CULTURE:
Aviation
Safety Concept: Multiple levels of redundancy/backup: including checklists, hardware, automated computer software, multiple levels of “on-call” assistance (eg Air Traffic Control, Duty Captain and Maintenance Engineers).

Emergency Medicine
Few if any redundancies built in to system. Single equipment failure or knowledge gap can spell disaster, or requires on the spot, impromptu, “make-do” solution. Usually only one (if any) level of “on-call” assistance/backup.

 

So there you go, some differences between aviation and Emergency Medicine from the perspective of CRM and safety.  In future posts we’ll go into how we can learn from these differences, to improve systems and behaviours in ED resuscitations.

Do you think the differences between aviation and Emergency Medicine are relevant?  How would you use this information to improve your resuscitations? Leave us a comment below!

References:

Crew Resource Management, Second Edition by Barbara G. Kanki, Robert L. Helmreich and Jose Anca (Elsevier, 2010)

Attentional Resolution, He et al, Trends in Cognitive Sciences, Vol 1, No 3, June 1997

First Officer Mitchell Roggenkamp – Personal Communication:
Mitch has been flying aircraft for 22 years. After joining the RAAF from school, he flew transport and training aircraft in diverse roles such as the Roulettes formation aerobatics team and as the RAAF’s first C-17 Globemaster flying instructor. He has flown within Australia and also around the world, seeing active service in East Timor and the Middle East. He is now an airline pilot with a major Australian airline flying both domestically and overseas. Mitch has extensive experience in teaching crew resource management and aviation human factors and has been directly involved in aviation safety programs for the last ten years. He currently facilitates human factors training and oversees aviation safety management systems for the Australian Defence Force as a Reservist.

Event

Mitchell at the controls of a C-17 Globemaster

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