The book “Why Hospitals Should Fly” misses a big part of what makes emergency medicine unique.
When I went through orientation at my latest hospital, there was a lot of talk about building a culture of patient safety and emphasis on how the organization wanted to reach that goal. As part of that effort, we were all asked to read the book Why Hospitals Should Fly.
Now, I’ve been an Air Force officer for over a decade. I’m a graduate of the U.S. Air Force Academy. I was weaned on aviation metaphors and the culture of safety that protects our aircraft. I eagerly started into the book. I only made it a few pages before I threw it down in disgust.
Why does that book annoy me so much? People aren’t planes, and trying to equate a machine to a complex biological system with free will is disingenuous at best. Many techniques that we borrow from the aviation industry are good steps toward safety, but checklists and call backs won’t fix safety in medicine. There are key provisions that we allow pilots that we do not allow physicians, and that omission undermines all of our safety.
I’ve flown a few planes in my time, but I’m a terrible pilot and should remain in the passenger seat for all of our sakes. However, I still remember the bold faces and check lists. I am familiar with a lot of the procedures that keep even incompetent pilots like me safe. By contrast, I’m a damn good doctor. I’ll tell you the difference in how those two roles function.
- We don’t get to preplan our missions – Pilots carefully preplan every mission they take. They calculate fuel, weight, distance, weather, a million variables. They are able to control for all of those things, and if things don’t look right, they stop the planning process and the mission is scrubbed. How often do we get to work to be told the CT scanner is down? Or that we’re out of saline? I had one memorable day that we ran out of all morphine, fentanyl, and hydromorphone in the hospital. The logistics folks suggested I use meperidine. I closed the ER to all ambulance traffic until they were able to find an alternative, and the C suite lost their mind. Would you ask a pilot to fly if the ground crew was out of hydraulic fluid for the plane? Of course not. That would be dangerous. We deal with supply shortages and maintenance failures every day, and are expected to safely make do without.
- We can’t insist on perfect staffing – Every member of the flight crew has a specific function. Large aircraft have pilots, copilots, navigators, flight engineers, load masters, and multiple other essential personnel. If one of them is missing, the plane doesn’t take off. How many people have had a flight delayed because the airline was waiting on a crew member? Lots. How many times does your ER or hospital function with less than full staffing? Mine does it daily, because we don’t have enough nurses to safely staff our ER. Planes don’t take off without a full crew, because that would be dangerous.
- Medicine is too complex for pre-flight checklists – Have you ever tried to land a septic 90 year old? How about bring a 25 week precipitous delivery with no prenatal care down on a correct glide path? Medicine doesn’t follow these neat rules. We have guidelines but the infinite variability of biologic systems makes it impossible to have a set plan of care predetermined for every situation. The septic 90 year old and the precip 25 weeker would never pass the preflight inspection. No pilot in her right mind would take off with the kind of odds stacked against her with some of these high risk presentations. However, especially in emergency medicine, we’re handed these mid-air inflight emergencies that are in progress and have to try to safely navigate them down. We don’t have a choice in the takeoff, but we’re still expected to land safely every time.
- Docs don’t get to focus on one patient at a time – Pilots are responsible for one plane at a time. They have other people who help them avoid others who are also flying in the area; they are called air traffic controllers. While I’m on shift, I will have anywhere between a dozen and 30 individual flights take off and land, with no one to help me run interference. Some of these are short puddle jumps, and some are epic journeys with bad weather, dangerous approaches, and difficult landings. When an inflight emergency occurs, all other flights are diverted, and full support is given to the emergency to get them landed safely as soon as possible. There is no mechanism to support this in modern emergency departments. In fact, I usually get a nasty comment from the next patient because they had to wait so long.
- We can’t abort the mission – In the end, the pilot has the ultimate safety tool. It’s called the safety of flight rule. A pilot can ground a mission for any reason if he has a valid concern that something may endanger the safety of flight. The pilot is the final ultimate authority on if that aircraft takes off, and the aviation industry honors that responsibility by giving him the authority to intervene if something threatens that aircraft. Can you think of a shift that you took over a department that you would have called a safety of flight risk and aborted the mission?
- Our mistakes don’t make headlines . . . and that might be a problem – Physicians and pilots hold lives in their hands every day. When a pilot makes an error that kills people, they usually do it in a spectacular manner which is splashed across headlines for weeks. Physicians and hospitals allow many smaller errors to occur, and statistically cause many more deaths than commercial and military aviation every day. The medical errors are not as sensationalized, because we usually only kill one person at a time. However, the cumulative weight of these errors could fill two 777 jumbo jets per day. Some researchers into patient safety estimate that medical errors contribute to 210,000 deaths per year, or roughly 575 patients per day across the US.
Patients are not planes. Our jobs are exponentially more difficult because of the variability of human physiology. Please don’t tell me if we would all just be more like pilots, we would stop hurting people. However, there are lessons from aviation that we can, and should take to heart. We need no fault incident analysis and we need standards for minimum staffing, supply, and maintenance standards so that we can hold our hospitals accountable. Fatigue management systems should not just consist of more caffeine, but rather comprehensive change to staffing and shift design to safeguard our patients. When we are handed mid-air catastrophes, we need support to deconflict other flights and help us land safely. Finally, we need to empower physicians to raise safety of flight concerns when patients are being endangered by conditions in our hospitals, and instead of crucifying doctors who raise these issues, they need to be rewarded for being patient safety advocates.
Two Boeing 777 planes a day is a lot to crash. If we were afforded some of the protections built into the aviation community, we could make significant strides in patient safety.
Three legitimate Lessons Emergency Medicine Should Learn from Aviation
- Sleep is sacred – Sleep is a sacred right for pilots. Pilots must have protected rest time, called crew rest, before they are allowed to take the controls. If you look at requirements set out by the Air Force, they require 10 hours of restful activity in the 12 hours prior to flight. Then, depending on how many pilots there are staffed on the flight, they may only fly 12-16 hours before they must sleep again. Commercial aviation is limited to 30 flying hours in any 7 day period. Those numbers seem almost laughable when we debate duty hours restrictions for residents. We allow doctors to almost triple what we allow pilots, and we not only allow it, we expect it. The FAA has a long paper that talks about the effect of fatigue on safety and flight performance. The house of medicine should do a little research and see what aviation already knows about sleep and safety.
- When mistakes happen, look for solutions, not scapegoats – When an aircraft mishap happens, there is a board from the FAA who investigates every bit of the incident. Pilots, ground crew, maintainers, flight attendants; they all get drug testing, interviews to account for days before the incident, examinations of flight logs, maintenance logs, every record available, plus flight data recorders and in person interviews. This is all done in a non-partisan non blaming way to find all of the errors that led to the incident. In medicine, we call this many names: standard of care review, root cause analysis, morbidity and mortality conference, witch hunt. Medicine has much to learn from the impartial aviation investigations that aren’t looking for someone to blame, but are instead looking for the factors that allowed an incident to happen. They start out with the assumption that everyone is smart and qualified for their job, and look for factors that degraded that ability. In medicine, it seems that we assume someone is incompetent and look to prove that. Much of this is our own fault; we need to get better as physicians in advocating for a non judgmental process for looking into medical errors to identify systems issues, including things like fatigue management, substance use, cognitive fatigue and overload, crowding, supply and maintenance issues, and staffing.
- Find better ways to assess patient satisfaction – The last time I flew, I received a text message with a survey while I was waiting for my luggage. It was about five questions long, and they asked me while I still remembered everything about my flight. I would argue this is better methodology than Press Ganey. They asked about the gate agents, the flight attendants, the baggage service. There was not a single question about whether or not the pilot was nice to me, or if I felt like he cared if I liked the inflight snack. The pilot’s job is to get the plane to its destination safely. Period. My job as a physician is to get people safely through their illness, but I often tell them things they don’t like. I tell a woman she’s lost her early pregnancy. I tell a chronic pain patient that he nearly died because of his opiate pain medication, and that I will not be giving him more. I tell smokers to put down their cigarettes. I tell people with viruses that I’m not treating them with antibiotics. I can do that all in a nice manner, but sometimes those messages are not pleasant nor well received. That does not mean that I have failed my primary job of getting a patient through their illnesses safely; in fact, it reinforces that goal. But it doesn’t make patients happy.
Thank you for your article. I greatly appreciate your insight as a former pilot in healthcare. I believe strongly that we can decrease medical error toll equivalent to two Boeing 777’s on a daily basis. I believe one of the biggest keys is to improve team communication and better orchestrate each event as they occur because we rarely take these high risk patient events one at a time. Technology is beginning to impact this area as long as healthcare will be open to change.
Torres has said it all very eloquently!
If you are, by your own admission, an “incompetent” pilot then perhaps you are not in the best position to make an informed critique? While I agree with a goodly portion of your piece, I must also strongly disagree with some of it. For example, planning, checklists and abortion (for want of a better term!) can all be used in medicine and elements of them have routinely been done so for decades, but only in a more formal, systematic way in more recent times.
If a patient who requires RSI comes into your ED I would sure hope you are doing a team-briefing (this might take, for example, as short as 30 seconds), using a checklist and having a backup plan (or, what to do if you decide to abort because, for example, this bloke is an unknown Grade 4 view). I also presume your surgeons are using the WHO checklist, and they are likely even making backup plans to, for example, abort a laparoscopic cholecystectomy and convert it to an open procedure if required. You will probably find in your hospital ICU the staff are using a standard plan-and-checklist approach for central venous access to avoid CLAB.
Medicine and aviation are not the same of course, however they do have much the same element of risk and much (but not all) of the same elements of SMS / TEM / CRM can be adopted.
BAv (Man – Massey) NZCPL(A)-IR(T) BHSc-MBChB I (Auckland)
This is a well written article and makes good points. Pilot competency is not the issue, rather its is the question of how we coordinate with the members of the hospital staff that makes things work or go awry.
There is no doubt that checklists, which we prefer to call protocols, in our hospitals have made a lot of procedures much safer for our patients. And, just as the pilot in the author’s examples, a good physician has the clinical expertise and judgement to know when to take a step back, reevaluate and choose another course of action.
However, even as a person who has never flown an airplane, it is clear that there is not a parallel between the preflight and in-flight activities done by a group of aircraft specialists who work as an integrated group, and a physician working in an ER. Yes, there are many people who are involved in the care of a single patient, but they tend to function more as individuals that the men and women who carry out a flight mission. I’m certain that you can think of other examples, but just to list one, how many times does a radiologist ask for additional tests that do not add to a diagnosis. I have had patients who have been sent for a sonogram, only to be told by the person who reads it that a CT is needed, and then be told by the person who reads the CT that a sonogram is needed.
This lack of coordination is where the differences begin to appear. And, how often have you come back to see a patient and found your orders changed by another physician who failed to contact you to discuss the changes? We do not do things perfectly in medical practice, but we can learn from others how to improve that we do.
Thanks for your comments! I’m afraid I perhaps did not communicate as clearly as I had hoped. I agree that checklists, closed loop communication, and crew resource management are powerful tools for safety in both aviation and medicine. I have been teased about how I run my codes in my “command voice” now that I’m on the civilian side; those old habits of military communication are deeply ingrained.
My point in this piece was not that we should abandon those. However, those tools do not address many of the complexities of medicine, and saying that the only reason we are not more safe in medicine is the lack of checklists is disingenuous.
My comments about being able to abort a “mission” was more to discuss that many of our issues are already in flight; for example, I would never choose to do a precipitous delivery or peri-mortem c section in my ER, but I didn’t have the choice to decline to take those patients. Certainly, in RSI, procedural sedation, and every chance that I have, backup planning and canceling the procedure if possible is integral to my “flight plan.”
I think we absolutely agree, but I fear my writing skills are the weak link in this communication.
Absolutely brilliant article.
100% agree with it.
Sadly it is likely that only EM docs (EPs in US) will fully understand what you are talking about and agree with your analysis though because some others have no insight in our job nor been in the position to make do with what is available in majority of EDs (ERs if you wish).
Half agree with your post. Cos in theory, you should be able to get more support from other depts in the hospital for cases you cannot handle or for more staffing (can deploy more doctors or nurses from other areas).
In reality, it rarely happens and you just struggle on your own. But just saying that people at the top might not see the problems you mentioned because they see that in theory, all your problems have simple solutions.