Medical error…an unbelievable story

This past year (2012) was apparently aviation’s safest year ever!

I’m not sure the same can be said for medicine. I don’t know if we have similar global data as aviation but my guess is that we haven’t made the impressive strides our pilot friends have made.  While considerable efforts are being made to improve patient safety, medical errors continue and often despite identified solutions.

I wanted to share this amazing & shocking video (see below), narrated by Martin Bromiley who is the husband of a woman (Elaine Bromiley) who died as a result of medical error during a routine surgery in the UK (around 2007). Martin is a commercial pilot and using his experience with crisis resource management, teamwork and critical decision making he sought to determine what factors lead to his wife’s death. More impressively, he developed efforts and programs within the NHS based around human factors.  Listening to Martin speak is quite remarkable and for a man who has suffered a such devastating loss, he has made an amazing effort to make medicine safer. His efforts should be congratulated and shared. Watching this video provides powerful evidence that educators must incorporate simulation that elicits stress among the participants. In medicine, we should practice scenarios where clinicians must function and make decisions in a high-stress environment. This must be implemented with caution however, as there is some emerging evidence (and another study) that when stress levels are too high, trainees may experience cognitive overload that actually inhibits learning.

Helicopter Underwater Escape Training (HUET) course

It’s been a busy week so I’ve been a bit delayed getting up this post.

Our choppers at the base are extremely well maintained by a whole crew of super experienced staff, but regardless, there remains the possibility that we’ll “ditch” into the water during a flight. Ideally this occurs in a “controlled” manner but it’s possible that it happens suddenly. This unlikely occurrence has been the impetus for the HUET course that’s occurred at the base for the past 20 years. This course really highlights lots of stuff we can be doing in medicine – practicing rarely performed, high-stakes procedures in a simulated setting. The concept is fantastic and what’s great is that not only do we discuss what to do, we actually go out and practice.

We just finished up a really solid day at the base where we completed our Helicopter Underwater Escape Training (HUET) course. There was a combination of flight crewman, pilots, physicians, paramedics and surf rescue guards who all came together for an excellent day of training.

We started off the day with a full review of our lifejackets, seat belts and exit from the chopper.

Letting off flares over the bay

Then we headed out to the pier where we channelled our inner caveman, got to play with fire and let off  a bunch flares (ones usually kept in our life vests). I think there’s a genetic element (left over from the prehsitoric era) that provides us with great satisfaction from setting off fire into the air and watching fireworks launch into the air. Nothing quite like challenging your manhood with “my flare went further than yours”.

We then headed up to the local dive pool to practice our underwater escape plans. The Trust has a great training apparatus – a mini chopper known as the “dunker”! This thing functions as a practice model for escaping as the chopper is flipped upside down. As it was described in our course, we have to wait at least 7 seconds once we hit before we escape. By then all the chopper blades will have stopped and it will be safer to exit. This simulation process helps you gain appreciate for the complete clusterf*#)@ that it would be if the helicopter crashed into the water. While we couldn’t recreate the likely injuries you’d suffer, the gasoline in the water, the inability to see, the hectic ocean swells, we were at least able to go through the motions of our exit plans. When my wife asked, “how was your day?”, I started explaining what we were up to.  Judging by her reaction on my training for a possible helicopter crash, it appears that such things are best left on the list “things not to tell your wife”.

We had 4 divers in the water watching us as we got dunked under and to help us escape if we ended up down too long.

Two crewman getting the dunker back to “right side up” for another simulation

Imagine being in a set of rapids, hanging upside down without an idea of which way is up and completely disoriented while not being able to breath. This is exactly what we went through today…except in real life we’d then probably have to get to the surface (some 30-50m away). There’s little around to help you navigate except the simple technique of opening the door first then seat belt (otherwise you can float away and have no idea of your bearings).

This was a fascinating experience that helped emphasize the importance of in-situ training. When experiences are vastly different than what we’re used to, we must engage this environment and practice in a foreign situation.

A nice side-profile of the dunker! What a sweet ride!

I’ve included a video of the dunker, so that it can be observed in action! You’ll see the two that were belted in, pop up right at the end of the clip! Another successful escape!

http://youtu.be/OF1NuZFJZIk

Crew (or crisis) resource management…a must for medicine

While CRM (or crew resource management) is well described in the aviation literature, it’s not nearly as well known within medicine. Interestingly, it applies extremely well since we (medical professionals) work in teams and often in high-stress situations where decisions involve life and death.

Graphic illustrating that pilot responsibilities increase near landing and subsequent reduction in the safety margin. Similar patterns occur in medicine when we approach critical events…though without CRM training, these high risk periods may not be managed as effectively as possible

This past week I completed a CRM course with fellow physicians, paramedics and pilots through the ARHT. I wanted to share with you a recent publication by one of my supervisors here in Auckland, and a staff physician I work with back home in Toronto.

Chris Hicks and Chris Denny recently published their findings from a study of CRM instruction implementation among emergency medicine residents. It’s difficult to believe that we continue to train and do simulation without some emphasis on CRM. It’s well documented (as I’ve mentioned in a previous post) that stress affects decision making (often negatively) and also adversely affects team communication. So why don’t we train to improve this?

This study examined EM residents in their clinical & team leadership performance before and after a CRM training day. Findings suggest that participant attitudes were positive towards the impact of CRM on team work and error reduction. In addition, while it didn’t reach statistical significance, post course nontechnical skills (leadership, communication, problem solving, etc.) improved after well designed CRM instruction.  Further study is required to assess what impact such training has on trainee performance but the findings are important. As trainees/staff become more experienced, the likelihood that they’ll make one serious error is less likely, but serious errors still occur. Most often, these errors occur as a result of multiple smaller (“less significant”) errors that compound and subsequently affected by poor communication, leadership and team work. As educators, we need to work help trainees understand where teams break down under stress and plan to correct this.

Crew Resource Management…and a shocking video of Airbus’ first attempt at automated pilot technology

We just had a great session today with the pilots about crew resource management (or crisis resource management) which essentially is a way of thinking about a high stakes environment, who’s involved and how to manage the factors involved. Often this includes human factors and the goal is to reduce threats & errors.

It’s fascinating to hear from the aviation guys about their progress since we have so much to learn still in medicine. They were asking us if we have anything like “standard operating procedures” or protocols to follow for our acutely sick patients. We replied that we didn’t. We have general algorithms in our minds that we’ve committed to memory but it’s rare for someone to be actually going through a checklist in a crisis situation. The pilots were surprised to learn that we didn’t rely on such protocols or tools. There’s growing discussion about this in medicine in the literature and a recent book “Checklist manifesto” by Atul Gawande have started to address these concepts.

We watched this fascinating but shocking video of the first automated pilot program in an Airbus attempting to land. This is a key example of the value of human input despite the inevitability of human error in any task, as it’s been stated previously, “To err is human” but we just need to learn to manage these incidents.