UNLIKE KERMIT I HAVE NO DISCLOSURES aprt from the fact that I have a management role.
Title reference bellweather paper Institute of Medicine in US in 2000 “To Err is Human” 60,000 and 100,000 deaths per year atribuatble to medical error in the US- twice as many as die on the roads. event rates closer to Bungee jumping and MB RACING. Within medicine, Critical Care is the highest risk medical domain. Medicine and especially CCM has looked longingly at aviation for ways to improve our performance and safety.
Comparison really is worse than you can imagine. Aviation and particularly commercial aviation has reached such a high level of safety (1 accident per 5 million flights)in 1st world airlines that it is now far more dangerous to drive to the airport than fly.
As a physician working on a medical helicopter doing prehospital and retrieval medicine I have my own very direct motiviation to look over the shoulder of our pilots and their systems and to look at aviation more generally to see how they achieve safety. EMS helicopter work is several orders of magnitude less safe than commercial aviation but I have been very impressed with how safety is managed particularly from a systems prespective and how safety is pursued actively as a priority for the organisations.
Aviation’s first lesson for medicine was that humans and human errors were the cause of most accidents. Today every simulation centre runs a medical CRM Course focussing on Communications/Team interactions/ leadership. Aviation meanwhile has moved on and calls all of this stuff - Non-technical factors but has moved to a model which focuses on Error trapping and Defence in Depth against hazards. There is no question that CRM is an important part of physician training (how to work together effectively in teams) But IS it the key to safety or are there other lessons to learn?
Has CRM training been the key to aviation safety - it is interesting to note that as a percentage the human element has remained a key cause of accidents despite several decades of aviation CRM training.
The dramatic changes in safety would seem much more to do with technical improvements in aviation - The evolution of new and safer aircraft. The absolute accident rates for each generation of aircraft has been very dramatic and perhaps explains some of the big improvements.
But is the analogy between medicine and aviation reasonable? It is readily apparent to most of us that the analogy between a team of clinicians resuscitating a criically ill OR DYING patient and a pilot sitting in a cockpit flying a preplanned route in a commerical aircraftare really stretching the boundaries of credulity. Planes were designed from the ground up to fly and NOT TO CRASH - They are now Highly automated and regulated. Redundancy is designed in from the start - multiple engines separate redundant hydraulics, electrics, Terrain and traffic avoidance systems, multiple backups for all critical systems. Critical care is well different.
In fact the pilots now do so little on a typical commercial jet that they fall asleep - sometimes twice. The better analagy might be the clinician doing resuscitation compared with a pilot managing a palne in a steep dive with 2 engines on fire and all the alarms going off at once with conflicting messages.
Doubt they would be so safe if this was their regular workplace.
BUT there is no getting round that aviation has succeeded where we still flounder... There is no question in my mind that we still have a lot to learn from aviation and the systems it have developed to ensure safety. The most important tool they have access to reamains the dream for all of us in critical care..... THE BLACK BOX.
But where to start -PERHAPS AT THE HIGHEST RISK PROCEDURES. Landings are obviously the most dangerous time for aircraft. If we look at the factors identified from accident investigations to develop safety during landings we might find some fertile ground. The magic of the black box and a well resourced accident investigation infrastructure have examined closely the reasons why landings are the most hazardous time for planes and this is the type of list they come up with. It is not one thing but a range of factors that need to be explored both specific to the procedure and those that are systematic. Everything from -
But lets get back to medicine for a sec. Our role at Greater Sydney Area HEMS is to take critical care to the patient as soon as possible whether that be on the edge of a cliff, side of the road, in a small hospital or a patient who needs ECMO. Sick patients are sick patients. Good critical Care is Good critical Care WHEREVER YOU HAPPEN TO BE. What is unique about Prehospital and Retrieval Medicine is not the pathologies we need to treat or the interventions we administer but the challenge of the environment in which we perform them.
Safe and effective advanced airway interventions are a defining feature of critical care medicine. There are questions in the literature about whether this can be delivered safely and effectively in-hospital never mind prehospital. First attempt intubation rates as low as 37% have been described for PICU intubations and even in ED settings a recent article by colleagues at RNSH ED with a more comparable patient group had first attempt success in 83% . Prehospital RSIs almost all have C-cpine immobilisation often have facial trauma and blood or vomitus in the airway and can be some of the most challenging airways.
There are particular challenges in delivering high levle critical care to the scene of a patient and this raises the stakes of safety.
In our service we also do prehospital winch access which is brings its own challenges - one of our doctors winching down gets in a little spin. She might need a little moment before she is ready to do a safe RSI.
The transport environement of a helicopter is obviosly challgening with lots of noise, vibration and but the most challenging of all is avoiding looking out at the view as you fly in over Sydney at Sunset
There is NO DOUBT IN MANY OF OURS MINDS THAT THE CALLENGES OF THESE ENVIRONEMNTS AND THE SPECIFIC TRAINING REQUIRED TO PERFORM HIGH LEVEL CRITICAL CARE OUT OF HOSPITAL MEANS THAT IT IS HIGH TIME FOR A DISCRETE SUBSECIALITY OF PRHOSPITAL AND RETRIEVAL MEDICINE. THE FIRST STEPS HAVE BEEN TAKEN IN THE UK WITH THE INTERCOLLEGIATE BOARD FOR TRAINING IN PRE-HOSPITAL MEDICINE AND THE FIRST BABY STEPS HAVE BEEN TAKEN IN AUSTRALIA AS WELL... WATCH THIS SPACE
So what do we need to do safe RSI in the prehospital environment ? Do we need some sort of Magyver, Chuck Norris hybrid? The Real Lesson from Aviation Safety is that it is NOT the individual that matters - it is the systems.
Just after I started 5yrs ago shortly after the service started - there was a sentinel event An experienced paramedic and doctor were tasked to a paediatric head injured patient. It was accepted at that time, as it had for several decades, that each doctor might have a different approach, choice of drugs, equipment, different backup plan. The paramedics barely knew what was coming next. On this occasion a child with a signficant head injury was administered drugs for intubation before the paramedic preparing equipment was ready or aware. There was a lot of blood in the airway and suction wasn’t immediately avaialbe. The child desaturated signficiantly during the multiple attempts at intubation whilst the team scrambled to catch up with events. They finally got a tube in so the intubation was “successful” but the desaturation was likely to have had a detrimental effect on the outcome of this severly head injured child
An experienced doctor and paramedic performing a complex task had a critical EVENT. I discussed how aviation ensures safety during high risk procdures such as landing.
How can we learn Lessons from the Air for Prehospital RSI ?
We can use the same process to identify Systematic and Procdural Factors in prehospital RSI to target We have implemented these in our service to improve and enure safety in this high risk procedure.
Then we scoured the literature and social media resources for the essential concepts required for safe prehospital anaesthesia to build broad consensus about the key elements. We produced an evidence based RSI Manual which describes our simplified and standardised approach and implemented it as the standard for all clinicians in our service. This is exactly the same way that aviation has achieved safety through high levels of standardisation amongst a range of pilots.
Operating procedures are an essential tool in aviation and have been a key component in developing safety wthin the medical aspects of our organisation.. Our Operating Procedures are published Open source on our Website for others to use freely, in the spirit of FOAM Ed. As you can might imagine there was some resistance from some of our doctors and paramedics to being told how to do their job but this has faded and they have become widely accepted and some of the critics are the stongest advocates Locally developed evidence based Standard Operating Procedures are the bridge between best practice as described by the published peer-reviewed literature as well as On-line Resources and blogs and really are the key to high quality care.
Patient PREPARATION is the key to airway management. Rather than hope our staff keep up with the literature we define what is required for safe prehospital anaesthesia - Where possible the team needs to adapt their environment to ensure the patient is off the ground on a stretcher with 360 degree access, Neck in neutral position with an occipital pad, collar open manual immobilisation in place ELM and bougie used routinely Preoxygenation with NP and ADO.
Redundancy in medical equipment - having spares and backups can gernerally be taken for granted in most in -hospital settings but needs to be designed into the world I work. Has anyone in the audience ever done an RSI where the cannula tissued following administration of induction agents but before the paralytic? A simple failure in this element can lead to a real disaster particularly in the prehospital setting. So we ensure we have redundancy in IV access, Suction, O2, laryngoscopes, tubes and ETCO2.
To reduce cognitive saturation at critical points in reuscitation we use challenge and response checklists for all RSIs. Initially we developed an equipment dump silhouette but now use purpose built pack with the equipment setup pre-prepared. Checklists have become an essential safety tool for us just as they are for aviation. The idea of checklists are slowly moving through medicine.
Choice and DOSE of induction agents can have great bearing on HD safety of RSI - we have used Ketamine for the last 5yrs - which we feel is much safer in patients with occult haemorrhagic shock following blunt trauma. PEDRAWN KETAMINE reduces risks of MEDICATION ERROR and encourages compliance
How do pilots practise rare and unusual events such as engine failures - the same way we do through simulation and this has been taken up avidly by medicine. How do we develop human factors - training in our envirnment.
YOU CAN’T START TEACHING THESE ELEMENTS TOO EARLY - THIS IS MY 18MTH OLD DAUGHTER LEARNING THE ICEPICK GRIP Aviation works on the concept of contingencies - a pilot will have an “alternate”, enough fuel to reach a different airport in case of inability to land, which will be briefed to the whole team. Likewise during RSI we formally brief our back-up plan prior to induction.
EVERY laryngoscopy must have a backup plan AND oxygenation strategy
You can only manage what you measure - We established an Airway Registry around 5yrs ago as part of our borader clinical data collection - intially this was paper but has been electronic for the last 4yrs. IT is an essential component to measure and assess compliance with our SOP and our perfmormance. We have rolled this out to most of the state and SA and Qld services are considering adopting it. Toby Fogg who works with us has developed a variation of this registry for ED practice and has done a great job promoting it.
A safety system needs a high level of governance and overview and we have evolved a very comprehensive clinical governance system inclduing: Daily Review of all missions by the Senior Retrieval Consultant 24hr follow of all patients with the receiving hospitals Daily “Coffee and Cases” team discussions Fortnightly Clinical Governance Days with case presentations Monthly M&M and Airway Audit against clinical KPIS Clinical Currencies for RSI, advanced airway equipment
So after all of that - how are we going? Our most important clinical KPI is FIRST LOOK SUCCESS RATE for prehospital RSI. Bear in mind this is FIRST LOOK not FIRST attempt which can refer to attempt at tube passage. Over the last 4yrs with 380 prehospital RSIs Overall success rate o ver 99% with our physicians attaining successful intubation on first look in over 91% of cases .
So what about the future - to develop furhter we need the equivalaent of the BLACK BOX Some organisations already routinely film their resuscitations in hospital but this is much harder in the prehospital setting. Small high resolution wearable cameras are now making it possible to film every prehospital resuscitation. A new gernation of monitors can stream data to base from the scene or store large amounts of important data which will enable us to know what went well and what didnt in a whole new way.
SO THE LESSON OF AVIATION IS THAT ITS NOT ABOUT THE INDIVIDUAL ITS SYSTEMS THAT ENSURE SAFETY
If you have any other questions - you know where to find us.
Habig: To Air is Human
“To Air is Human”
Lessons From The Air Karel Habig