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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

8 Responses to Aviation vs Emergency Medicine: CRM Smackdown

  1. Tim Leeuwenburg January 2, 2013 at 9:01 pm #

    An oldie, but a goodie

    Not mine I hasten to add, but worth a re-read

    Biggles FRCA

    http://ki-docs.com/2011/11/19/anaesthesia-aviation/

    Bottomline – an aircraft is designed to fly. The human body…not so.

  2. Marc Livolsi March 11, 2013 at 5:45 am #

    This is a good “state of the industry” assessment. I think your next challenge is to follow on and identify those areas where aviation-style CRM is difficult to apply (done) and examine ways in which they can be addressed to promote a better use of a safety system. We in aviation came from the dark ages as well, and a lot had to change, but there’s clearly room to improve in Medicine.

    Also, while your focus is primarily emergency medicine here, what percentage of medical error-induced trauma or death results from what should have been routine? In the case of a routine procedure, isn’t the situation much more analogous to a scheduled flight? Should this not lend itself better to the kind of human-factors solutions that have proven so effective in aviation? Along that line, perhaps airline CRM is the wrong place to look for the ER crew. Aviation does have SAR, EMS, and Law Enforcement operations that, while admittedly being far less safe than commercial aviation, have developed training and procedures to address their risks. These operations represent a much closer parallel to the ER, and share many similar dynamics.

    Even in aviation, we have a long way to go to eradicate human error. That, however, is insufficient reason to not try!

  3. Todd Fraser March 12, 2013 at 1:33 pm #

    Hi Andy

    Great topic, and very worthy of discussion

    I take issue though – you’ve focussed on the differences and not the similarities, and you’ve focussed on what we do NOW, and not on what we SHOULD do.

    While many events in ICU-ED practice require urgent attention, there is still time for team organisation. A pre-intubation briefing is a good example of this and is analogous to that in aviation.

    Checklists have been widely adopted in aviation with considerable success. Their use is not solely in the time-rich situation you described. The use of these checklists in a critical emergency situation were widely commended in the landing of a commercial aircraft on the Hudson River with the loss of no lives.

    The points you raise regarding working in specific teams, a lack of standardised practice, the failure to regularly reinforce simulation and training, the absence of rigorous orientation, a seriously deficient fatigue policy and the lack of redundancies in the system HIGHLIGHT why we should make the comparisons. They are not barriers to implementing the learnings of aviation CRM, they are the REASONS why we should implement them.

    I think you’ll find that the behaviours and mindsets are incredibly similar – but the context is different. We do not need to reinvent the wheel, just make it work for our terrain.

  4. Andy Buck March 13, 2013 at 2:47 pm #

    Thanks Todd
    The whole point of the RRM site is to generate this sort of discussion. I think the notion of “reinventing the wheel” oversimplifies the matter, and implies that we don’t need to really analyse our own industry that closely. We don’t know what the specific errors and behaviours are that lead to harm, negative outcomes and conflict in the various resus specialties. CRM is based on decades of analysis by thousands of people, of hundreds of airline crashes and near misses, which has led to the derivation of a set of specific skills, tasks and behaviours that apply directly to that industry, and which are constantly reviewed and updated based on new information, from that industry.

    Apart from being “high stress”, involving people’s “lives being at risk”, and some basic human factors issues like “situational awareness” (which apply to everyday things, from driving cars to playing amateur sport), I’ve yet to hear or read a convincing description of the similarities between aviation and medicine. Most articles on this subject use opinion based statements at the beginning to justify why CRM is like medicine, rather than actual evidence.

    Carne et al, in a recent, extensive, detailed review article which strongly implies CRM should be used in Emergency Medicine, illustrates this point: “Although the environments of aviation and health care differ, it is likely that the practice of these behaviours will improve the management of crises, both medical and departmental, with a resultant increase in patient safety” (Emergency Medicine Australasia (2012) 24, 7–13). This is pure opinion and nothing else. The first reference in this article, which they use to illustrate some similarities between aviation, medicine, business and defence, is from an article on CRM in Anaesthesiology! Not Emergency Medicine!

    Just because people who fly different types of aircraft can use the same CRM training, it doesn’t by inference mean that because most resus occurs in a hospital, the skills required for resus in ED and resus in ICU/OT/wards are the same. This is presumptious, and I think a bit lazy on behalf our industry that we are so unwilling to really look at what makes us make mistakes.

    There is some evidence about what the causes of errors in trauma resus are (references can be found here: http://www.trrproject.com/proven_results.htm ) but until we have studied it in more detail, I don’t think we should succumb to the temptation to try and overlay the specifics of CRM onto a different industry, the similarities of which, until studied and published, are a matter of opinion, and nothing more.

  5. Andy Buck March 13, 2013 at 5:08 pm #

    And this just in, from one of the champions of aviation safety:

    http://magazine.nationalpatientsafetyfoundation.org/blog/lessons-learned-from-aviation/

    The only similarities Captain Sulley has come up with are that aviation and healthcare are both “high-risk, complex, evidence-based domains that require high-level human performance”. This generalisation does nothing to address the specifics of healthcare, let alone individual specialties. He then goes on in quite emotive, alarmist language to compare “preventable deaths” in healthcare settings to huge numbers of planes crashing every week, with loads of people dying and no-one being alarmed. I’m sorry, but anyone who has worked in healthcare and has seen what leads to adverse patient outcomes will know that it is just insane to compare a single plane crash, that occurs during one flight, between takeoff and landing, to a patient journey through a hospital where the factors that lead to an adverse outcome can be so multitudinous, over so many weeks or months, involving so many people, so many system, human, technological, patient, and other factors that comparisons are impossible.

    Whilst I don’t disagree that these numbers are of concern, and that something needs to be done, I’m not sure the solution he suggests, a single overseeing body that investigates every single event, is the answer. A good idea on paper, the logistics of implementing something like this, even in a small country like Australia, are unfathomable. The political bureaucracy alone would make it impossible, let alone the cost, especially in a cash-strapped public health system such as ours.

    A noble idea from a highly experienced aviation master, but an impractical solution to a complex problem in an unrelated industry.

  6. Todd Fraser March 16, 2013 at 9:04 pm #

    Thanks Andy, you make very interesting and sensible points.

    While I don’t disagree that it would be nice to have a more thorough understanding of the issues as they relate to healthcare, you’re talking a decade long period of research. What I’m arguing is that we should not idly sit by and watch more patients be harmed unnecessarily while we wait for data that may or may not ever by published. Its worth remembering that when the principles of CRM and competency-based training were introduced to aviation, there was no outcome data to support it.

    I think you underestimate the body of coronial data that supports its implementation. You don’t have to hang around in too many debriefs of patient misadventures and root cause analyses to figure out that the same principles are at the heart of health care incidents – failure of communication, failure to take leadership roles, failure of global awareness, failure to seek help, failure to implement documented management protocols…

    I’m not arguing that aircraft CRM should be taught to health care professionals, but it isn’t anyway. Its taught as healthcare based simulations and the lessons are applied in that context.

    I don’t think we need wait until there is an RCT to test these theories. There is only so much that EBM can tell us. Where possible we should use it. The rest of the time, we should use common sense.

  7. Amit Maini March 18, 2013 at 1:04 am #

    The basic principle of Crew Resource Management (CRM) is that communication & co-ordination behaviours between crew members are identifiable, and amenable to specific teaching, as well as being applicable to high risk environments. The emergency department may be one such environment (on the surface).

    One of the major issues with this is that these behaviours & processes are not currently practiced reliably & regularly, unless there have been active efforts to create specific training and reinforcement of such behaviours. To date, I have not worked in such a department (I have worked in a variety of emergency departments in the UK, Australia, as well as significant observation time in the US).

    It isn’t just inter-hospital differences, but differences between specialties in the same hospital that can lead to problems / errors / undesirable outcomes. In the aviation industry, often pilots will be working together for the first time, along with other members of the crew, yet they speak the same core language of aviation, and can function effectively, in a very tightly controlled / regulated environment. This is not the case in the emergency department resuscitation room, where several specialties are brought together, each with a different perspective (based on different specialty specific training) and set of priorities in any given resuscitation situation.

    One potential way to mitigate this might be to introduce “cross training” where each team member is trained in the duties of his / her team mates. This may be particularly effective in hospitals, given the high turnover in staff.

    There is no doubt that some general principles of aviation CRM may be extrapolated to other high risk environments such as the resuscitation room, but regardless of what we SHOULD be doing, our model of training does not lend itself well to this approach currently (for a variety of reasons).

  8. Derek Louey April 8, 2014 at 8:22 pm #

    SIMILIARITIES BETWEEN AVIATION AND EMERGENCY MEDICINE WITH REGARD TO CRM:

    PREPARATION
    Orientation for new staff and pre-shift briefing that junior staff should be prompted to seek consultation early with senior members

    ENVIRONMENT
    
Train regular staff in SOPs so that newcomers quickly accustomed to pattern of behaviours

    CHECKLISTS
    Train in the use of checklists for
    a) time-critical decision making e.g. airway check lists, 4Hs and 4Ts for ACLS
    b) safe disposition e.g. transfer of stablepatient to ward bed

    STANDARD OPERATING PROCEDURES:

    Encourage use of well-written clinical guidelines e.g. antibiotic use with clear exclusion criteria that necessitates senior input for exceptions

    “TEAMWORK”/CRM
    Improve multi-disciplinary collaboration e.g trauma meetings, simulation practise

    ASSUMED SKILL LEVEL:

    Use visible methods of rank identification e.g. ‘Team leader’ stickers in resuscitation, ‘ICU MET doctor’
    Encourage use of log books and proofs of competencies

    FATIGUE
    ‘Safe-hours’ programs

    SAFETY CULTURE:
    Establish Clinical Governance, audits and quality improvement programs
     

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