Ep 3 - CRM with Captain Mike Schuster

• Aspects of CRM
  • Making a welcoming environment, so that others feel they can speak up
  • CRM is not about being perfect. It’s about identifying and mitigating the times of increased risk of making mistakes and identifying why a particular mistake was made.
• The perceived tension between performance and “soft skills” (CRM)
  • Some people view these non-technical skills as costing time and money and not contributing to patient safety or as detracting from efficiency. The reality is that good CRM skills make teams more efficient. Additionally, we are no longer in a stage in medicine where we can say that leadership or non-technical skills don’t matter. We have plenty of evidence that failures of leadership have directly resulted in bad outcomes (morbidity and mortality).
  • Additionally, CRM skills improve the working environment for all, which leads to the preservation of healthcare workers and mitigates burnout.
• The origins of CRM
  • CRM developed in aviation because of a data-driven approach where successive accident investigations determined that the majority of aviation accidents were caused by human error (team performance) rather than mechanical failure, as had happened in the past.
  • In medicine, we can safely assume the same trend, but as a profession that purports to follow the evidence, we should investigate and build a dataset on which to make these kinds of decisions. This could look like the aviation-style medicine incident investigation systems that exist in the UK and Norway and could use systems like audio and video recording of operating rooms, ICUs, and resuscitation bays. It would also likely require a change to legislation to protect that data from being used in litigation, as currently exists for aviation black boxes.
• The evolution of CRM in aviation
  • from elective courses to mandatory SOPs to the point where even if a pilot completed the tasks technically correct, but exhibited poor CRM skills, they would fail their flight test.
• “Anticipation builds vigilance; vigilance aids recognition; recognition leads to recovery.”
• CRM & Error Management
  • In aviation, CRM treats errors as inevitable events to be managed, not moral failures.
  • Error prevention: reduces the chance of making an error in the first place. Usually through human factors engineering and improving working conditions. The focus is here, which involves planning, discipline, and preparation. (e.g. aircraft design, fatigue risk management, rules around how much additional fuel must be onboard, use of checklists to avoid memory errors).
  • Error trapping: catching the error before there is any effect. This is often about vigilance and teamwork. (e.g. crosschecking, callouts, assertiveness to encourage speaking up)
  • Error mitigation: to limit the severity of outcomes. This is about resilience and recovery. (e.g. unstable approach leads to missed approach. Short on fuel > divert to alternate.)
  • Error chains: a single error rarely, if ever, causes a major accident. It is untrapped, unmitigated error chains that result in accidents.
  • In clinical medicine we see this often: errors are inevitable (ask any clinician), harm is not.
• Medical examples of error management:
  • Error prevention: pre-printed order sets, standardize drug trays, avoiding look-alike drugs.
  • Error trapping: Surgical “time-out” checklists before skin incision, closed-loop communication during resuscitation.
  • Error mitigation: iatrogenic opioid overdose that was recognized and naloxone is given.
• Acceptable delays to ensure appropriate margins of safety
  • There are occasions in medicine and aviation where one group of professionals needs to push back on the production pressure to perform tasks appropriately in order to ensure safety. Both professions must understand that certain delays are required, however, the degree to which this happens is not consistent around the world. Mike gave the example of arriving early to train a new pilot and occasionally needing to close the cockpit door after saying the flight crew needed ten minutes. Amir and Adam gave anesthesia examples where they had to delay the OR in order to prevent or trap errors (additional airway equipment, provide preoperative medications). 
• CRM is alive and well in medicine, but we must meeting people where they are at
  • In this episode, there were many examples where medical teams are performing good CRM, particularly Threat and Error Management through the use of briefings. Mike mentioned the public health example of meeting people where they are. We should acknowledge that a lot of CRM strategies and skills exist in modern medicine, but much of it is not formalized.
• CRM as an inclusive tool to improve team performance
  • CRM by its nature of improving team performance has its foundation on clear communication from all team members. While it used to be called Cockpit Resource Management, it changed to become Crew Resource Management to emphasize the inclusion of flight attendants, ground personnel, air traffic controllers, etc. Many errors have been prevented or trapped by ancillary personnel speaking up.
• Escalation of Language of Concern
  • In order to encourage everyone to speak up, formalized escalation of language models exist. In aviation this is the PACE model:
    • Probing: “I’ve never seen [x] done before. Can you tell me why you’re doing it this way?”
    • Alert: “The oxygen saturation is 90%.”
    • Challenge: “The oxygen saturation is critically low, we need to move to BiPAP.”
    • Emergency: “This is an emergency. Dr. [x] will perform a cricothyroidotomy.”
  • In an emergency, you can start ‘higher up’ on the PACE ladder, as appropriate, but starting lower is less aggressive and can prevent conflict.
• Instrumentation to avoid fixation-induced loss of situational awareness 
  • Cockpit instrumentation is being redesign to account for the fact that hearing is one of the first things to go in a high cognitive load. Rather than just the aural announcements of “terrain, terrain”, the words are being displayed in red letter on the displays in front of the pilots.
• Cognitive load in training: much of what we can process related to cognitive load. As novice become experts, they can deal with greater and greater cognitive loads before becoming task saturated. This is well-recognized in pilot training.
• Line Oriented Safety Audits (LOSA) 
  • Trained observers in the cockpit observe and report on real-world operations. In this way, an accurate analysis of company-specific operations can occur. These observe comment on both salutary solutions and errors which can then be fed-back to trainers and risk management.
  • Theoretically, there is no reason such a system could not exist in medicine. In such a system, trained people would observe physicians and provide information solely for the purpose of improving safety, rather than any punitive action.
• Use people’s first names as opposed to their title, when it is critical to get their attention.

Who can do what tomorrow

1. Policy / government / regulator: Canada could have an aviation-style investigation board for medical incidents, as the UK and Norway currently have. This would be a non-punitive investigation conducted by a knowledgeable independent board to determine the causes and contributing factors of specific medical incidents. The report would be anonymized and publicly available and would include recommendations for practitioners, training institutions, medical device manufacturers, and regulators.
2. Hospitals / heads of department: We saw in aviation how CRM was a data-driven response in the 1970’s and onward to team performance becoming the predominant reason for aviation accidents. We don’t have the same quality of evidence in medicine, however, we need not wait for the government or regulator to mandate the technology that would lead to this data becoming available. The technology exists for audio and video recording (“black boxes”) of the OR, ICU, and resuscitation bays of emergency departments. Individual hospitals or departments could run a pilot program (ensuring that such information is prevented from being used in litigation by invoking current quality of care investigation legislation). Much like Tommy Douglas’s creation of publicly-funded healthcare in Saskatchewan, which was later expended to cover all of Canada, any hospital that begins such an endeavour may be credited with pushing the entire profession in this direction.
3. Residency program directors: while modules on human factors are a good start, we can look to the evolution of CRM in aviation and see that formalized CRM training with high-fidelity simulation is the gold standard. For those that are already doing this, Mike’s comments about the field of aviation ideally incorporating CRM into earlier stages of pilot training can be instructive for the medical field.

Other Resources: United Flight 232 - Captain Al Haynes (YouTube)

Next episode: Escalating Language of Concern with Dr

Some of the links in these show notes are Amazon affiliate links. As an Amazon Associate, we may earn from qualifying purchases, at no additional cost to you. Currently, we receive no outside funding, so we thank you for supporting the podcast, again at no additional cost to you.

Transcript

SPEAKER_00 0:04

In our business, the least risky thing to do is never fly an airplane. That's how we get to risk zero, which is not practical. So we try to manage risk to an acceptable level. Passengers do select their flights based on cost, among other things, but how do we come up with a balance? I know we're focusing on human factors today, but it all rolls together.

SPEAKER_03 0:22

Welcome to another episode of the Medical Safety Podcast. This is a place where we discuss how to improve the safety of our healthcare system through the integration of human factors into system safety, including medical incident investigation and proactive safety measures. In the first episode of the series, we discussed the Elaine Bromley case, where a healthy 37-year-old woman underwent attempted elective sinus surgery and died after a can't intubate, can't oxygenate situation, where the medical team were unable to establish an airway for over 20 minutes. Her husband, Martin Bromley, a UK airline pilot, commissioned, anonymized, and published a report of the circumstances of her death so that others could learn from it. In particular, he called out the fact that human factors, which are widely taught and used in the analysis of aviation accidents, are not being sufficiently discussed in medicine. In this episode, we'll hear from Captain Mike Schuster, a Canadian airline captain and aviation safety expert. We will discuss the origins of CRM in aviation as well as the challenges of implementing it.

SPEAKER_01 1:19

Captain Mike Schuster is a highly experienced airline pilot and flight instructor who has been flying for over 25 years. During his career, he has held various positions and responsibilities, including chief flying instructor and director of flight operations. He has qualified on multiple aircraft types ranging from smaller private aircraft up to the Airbus A321. In addition to providing classroom simulator and in-flight instruction in the airline environment, Mike has also written many technical operational manuals for aviation companies. He regularly contributes articles to aviation safety publications, including Transport Canada's Aviation Safety Magazine. He has received acclaim as a top 10 under 40 aerospace professional early in his career from Wings Magazine, twice received a special recognition from the David Charles Abramson Memorial Flight Instructor Safety Award, and most recently was the recipient of the 2022 Transport Canada Aviation Society Award for exceptional contribution and dedication to aviation safety. Captain Schuster holds the highest level of flight instructor qualification available and is one of only two people in Canada qualified to renew flight instructor qualifications via professional development programs through his company, Aviation Solutions, where he is the chief instructor and principal consultant. Mike has presented to aviation safety professionals from around the world at the Transportation Safety Board's annual air safety investigators workshop, and most recently was the keynote speaker at Transport Canada's Flight Training Aviation Safety Conference in Ottawa. It is our pleasure to welcome him here to the Medical Safety Podcast. Thanks very much, Shellman. It's a pleasure to be here with you. Captain Mike Schuster, can you tell us about how you got started in aviation?

SPEAKER_00 3:05

Absolutely. I think my first memory, because I grew up in an aviation family, was probably about eight years old on a plane down to Florida. And I remember thinking to myself at that point in time, when I grow up, I want to be the person flying the plane, taking all the families down to Disney World. And like a lot of people, high school rolls around, you get different interests, start out doing something completely different in university, and then realized, no, I want to fly airplanes. And that's when I got back into that neck of the woods and underwent all of my initial training and then got into the industry from there.

SPEAKER_01 3:35

So that's a pretty clear story as to how you got started in aviation. But what led to your involvement in aviation safety and human factors?

SPEAKER_00 3:44

I find the human factors and safety management systems and threat and error management and all the things I know we're going to talk about today, like super fascinating. And it really started not as much when I first got licensed and became a flight instructor. And at that point, you're essentially an apprentice flight instructor. And once you accumulate a certain amount of experience and recommendations of other pilots going through, you can work your way through the system. And once I eventually reached that upper tier, became a chief flight instructor and was then running the flight school and mentoring and supervising the new instructors, that's when I really realized even in the flight school environment, we have so many like new pilots coming in. Sometimes there's technical errors that are made, like they don't know how to operate a piece of equipment or something that gets forgotten. But a lot of times it could come back to some sort of human factors in there. Did we communicate that to the pilot that was involved in the incident? Were the standard procedures written correctly? And I was just very big on a non-punitive system. Come talk to me, come talk to whoever, or submit an anonymous report. And we want to address the root cause so it doesn't happen again. And only by sheer luck did I eventually realize, oh, this is really fitting in nice with a more formal CRM that I hadn't been exposed to before. And then it just really snowballed from there as far as the interest and how effective it can be in the safety

Involvement in CRM

SPEAKER_00 4:59

side of things.

SPEAKER_01 5:00

Most people find almost a backdoor into CRM where they see something that resonates with that thought or feel, and then they hear about this formal structure and they kind of tie them together. Do you have any concrete examples that you can share? Is there a personal experience that sends out that you're like, wow, this really crystallized the connection for you?

SPEAKER_00 5:16

It's I think way, way back, I could think of a winter's day, and this is at a flight school where you're dealing with those two seat, four-seat airplanes, the smaller types of airplanes, and students coming in. And we had one student in particular, and she was a little bit older and had come from the trucking and transportation background and was doing this for her own recreational purposes to get a pilot's license. And we were always very good in the winter at looking at the runway conditions. Are there the runway dry or wet or contaminated with snow or ice or whatever the case is? The runways were looking good. We had sent her out for her solo flight without a flight instructor. And on the taxi out, there was quite a bit of wind, and it actually spun the airplane. You think of a light two-seat airplane, spun it 180 degrees just on the taxiway, which is one of those pieces of pavement that takes you between the parking area and the runways. And so, of course, she was quite upset by that, came back, didn't really want to talk about it because her cultural experience, based on factors like age, workplace, and probably some other things was well, you don't admit to doing something wrong, something bad happened, that's the end of it. Whereas we are coming from this was a bad thing, no one got hurt, which is good. The airplane's fine, which is good. How do we prevent it from happening again? And ultimately, we found, oh, we can actually get reports for all the surfaces, all those different taxiways as well. We didn't realize we had access to them. We had to organize that with the airport authority that actually grades those surfaces. But if we didn't have the info about what happened, why it happened, what the fault was, we wouldn't have been able to then make that correction. And so you can see right there the human factor side of things. If you don't have the cultural background to want to get into situational awareness, communication, and decision making, then you can't make those links.

SPEAKER_03 7:02

And just to clarify that, Mike, this was at a flight school that you were, I believe at the time, the chief flight instructor. Is that right?

SPEAKER_00 7:10

That's correct, Adam.

SPEAKER_03 7:11

Just uh not to toot your own horn, so I think I'll do it for you, which is that there are some flight instructors or some chief flight instructors that perhaps wouldn't have inquired so much into that. They would have said, I guess we just will be on the lookout for when things are really icy and maybe send them on dual only or have an instructor on board or perhaps do things differently without saying, let's actually dig a little deeper here. Let's actually ask what exactly it was that happened, and then let's see what better information that we can get, and then we can conduct that root cause analysis, and then we can hopefully solve that problem, at least at an institutional level.

SPEAKER_00 7:46

Absolutely. And it's I'm sure we'll talk about it more later on, but what we call the five whys, right? We ask why at least five times, it usually drives down to the root cause. And a lot of times we see with companies that are not mature yet, they do exactly what Adam has just described versus let's find the root cause and address that instead of just a sort of a surface issue.

SPEAKER_01 8:07

Mike, what does your day-to-day work look like now?

SPEAKER_00 8:10

There's a huge variety, all depends on the day. Some days it'll be a lot of people be familiar with them. It's a work from Homer in the office doing some research and developing presentations and new materials, or it's going in to the office to teach or to instruct simulator sessions. So for those that might not be familiar, if you think about an amusement park, they have those simulator rides like star tours and things like that. It's that's where the technology came from, was from the aviation side of things. So you have these simulators, $5 million, $25 million a piece, and everything inside is straight out of the actual aircraft. And so we put the pilots in there and we give them all the bad things that could happen, right? It could be something very extreme like a fire that does not extinguish. It could be more routine things like winter operations, like the snowstorm we recently had in Toronto, or low fog, poor visibility days. So, in either case, whether it's teaching the similarity or teaching in the classroom, prepping the night before for an hour or two, making sure you know everything that you're gonna have to go over and doing those. And then, of course, the third one is actually going into go flying, which is always the really fun days. And since we're talking about CRM, it really is incredible. I was actually thinking this morning about all the times we actually use CRM throughout the day before we even get that thing in the air. Because you arrive at work, I usually get there about an hour and a half before the flight departs. You're pulling up your flight planning because the dispatch department has generated that for you. And then you're going over it with your other colleagues in the flight deck. So your first officer, your captain, your relief pilot, or augment pilot if you're doing a longer flight. And

CRM before the aircraft gets in the air

SPEAKER_00 9:38

you're really building that CRM, you're building a team, right? Very quickly, which is probably something that happens on the medical side of things too, depending on the environment. We're coming in and it's nice to meet you for the first time. But because we have a set of standard operating procedures, we know exactly what we need to do to get this aircraft in the air. But you still have to really set the tone for the CRM, right? That welcoming environment. Let's talk about this flight planning, let's talk about this weather, let's talk about any defects on the aircraft about that together. And then if we need to, we're gonna loop in the dispatcher who created the flight plan, right? So you can see how this kind of web forms. Then you get down to the gate, you say hello to the gate agents because you're trying to get a feel for is this flight been delayed for hours? What's the mood of the passengers? Do we need to address anything with the passengers first? So now you're putting your gate agents in a position where they're feeling open to communicating with you as compared to just walking past them onto the aircraft. You run into a similar situation then with your cabin crew and you meet your flight attendants and you do a crew briefing there. And beyond just this is how long the flight's going to be at this altitude, and this is the turbulence level and that sort of thing. Again, building that open environment. And it's not just feel free to give us a call if there's a concern. It's the expectation is if you see anything unusual, you will give us a call, right? And let us know what's going on. So we kind of set that tone. And then you're doing a welcome on board announcement for the passengers. And again, setting the tone for the flight, welcoming and letting them know about anything that might be concerning. There's turbulence that you're not going to be able to avoid. And you haven't even got the airplane in the air yet. So there's a really a lot of CRM aspects before we even get started. But at that point, we basically get the aircraft pre-flighted, exterior inspection, program the computers, set all the systems, and then we're underway from there. And that could be a quick get what we call a turn somewhere. So we might go out to Halifax and back to Toronto, or for some of the flights, it's a much longer flight, could be eight hours, and you're spending the night somewhere else.

SPEAKER_03 11:28

You mentioned setting the tone several times with your dispatcher, for example, with your flight crew, with your gate agents, with your cabin crew. And I know you mentioned that part of that is the making this a welcome environment so that they will bring concerns to you so that they feel able to do those things. Is there another element to this where you're bringing up this in on this particular flight, for example, the there might be certain threats like we have inclement weather, we have this, we have that. Can you talk a little bit about that? Is that part of this briefing or does that come later on? And how much does that play into it?

SPEAKER_00 11:57

Yeah, that'll be a good one. A really good point, Adam. So when we are doing the crew brief with the flight attendants in particular, because the pilots have all the technical knowledge to read the documentation, know what's happening with respect to weather, turbulence, and so on. But the coordination with the cabin crew. Let's say we're going to go do a four-hour flight. So that's going to take us down to somewhere in the Caribbean, like a punticana type thing, would be that range. And we might say, Leaving Toronto, we are expecting light turbulence for the first half hour during the climb. And then we're expecting it to be smooth for an hour, and then we're expecting moderate turbulence where we don't want you to be doing your food service. Now they know, okay, I have this window after a half hour, and then another 60 minutes. I got a 60-minute window in there where we're going to try and do that food service. And if there's times where it's going to be a little more turbulent, you want seatbelts on, things like that, so that everyone's safe. Everyone knows what the plan is.

SPEAKER_01 12:52

I'm actually very curious. Like it sounds to me like you started your pilot training or your flight training, and then over time you developed kind of this safety expertise, this like CRM lens. So, what do you think has actually changed in your individual work as you become either more aware of these issues or integrating them more into your day-to-day routine, in addition to actually becoming a formal instructor on this topic?

SPEAKER_00 13:21

Yeah, it's one where everyone, I think, as they go through their career, like any career, right, you start to pick up additional skills, whether technical skills, non-technical skills, and so on. But as an industry, we really start to to make a move and it's a big ship to turn sometimes. But when we start getting through sort of the history of CRM and what's happened over the last 50 years with it, you just start getting here's new information, here's new research, this is the way that we're going to do it now. And so one of the big changes that occurred was when we do training, whether it's in an aircraft or whether it's in a simulator or even scenario-based training in a classroom, looking at, okay, you made this mistake. Why did you make that mistake? Or this looks like a technical error on the surface, but let's dig down as to why that technical error occurred. And we actually get the flight crew now debriefing themselves in more of a facilitated debrief until they work down to, oh, here is the human factors that were involved, as compared to this is on the surface just a technical error.

SPEAKER_01 14:20

I

Common objections to aviation as an analogy to medicine

SPEAKER_01 14:21

really like your comment on aviation being a big ship to turn because I think that's something we can really describe to in medicine. It feels like medicine is an enormous ship to turn that takes an infinite amount of resources or something along those lines. So, what do you say to people who might roll their eyes or resist or reject this kind of training because, in their view, this isn't applicable to the field of medicine or it's not analogous to aviation?

SPEAKER_03 14:41

Are you okay if I jump in here? Yeah, go for it. I'm having a foot in sort of aviation and medicine. What I'll do is I'll take a leaf out of my sort of law background and tell you the kinds of objections that I've seen from doctors, if that's okay with both of you. And then by all means, just jump in at the end and we'll roll in your comments. I see a number of different things. And I see people who say medicine isn't like aviation because in aviation things rarely break or go wrong. And when they do, it's a huge deal. And this was actually a comment that was said to me in an operating room in Toronto a few years ago when the person didn't know that I used to work as a professional pilot. And then other things that I hear, medicine is not like aviation because the human body is vastly more complex than a machine, it's nature, and that's infinitely more complex. And then the other thing I hear is aviation can afford certain safety measures because ultimately it just passes that cost on to the flying public. But in Canada, it's publicly funded, and we just can't afford those things. That you just can't make medicine infinitely more expensive. And so if I take those point by point there, if we start with the first one, the idea that medicine isn't like aviation because in aviation things rarely break. This was said after in the operating room the Cottery machine had broken down and the scrub nurses had said, Oh, well, things rarely break, but this is a huge deal. And in aviation, this would be a massive deal, and things don't really break in aviation. And I actually spoke up at the time and said, actually, there's something called a minimum equipment list on board any of the commercial airplanes that you're used to flying on. And it literally spells out how many things on an airplane can be broken or non-operative at a certain point and still operate that flight safely. And so many of the airplanes that we're used to flying are incredibly well maintained, but they're also quite old. They might be decades old, for example. And so it's not uncommon that certain pieces of equipment, whether it's pieces of the navigation equipment, communications equipment, monitoring systems, just may not be operable. And so that's why they came up with this idea of a minimum equipment list. And we have to figure out whether or not we can still safely fly, and there are standards associated with that. I think the reason that that nurse and these people in the operating room had that impression is aviation's a bit of a victim of its own success. We know that it's the safest mode of transportation, and it's a little bit like 911. A few years ago, there was an article that had come out saying that no one knows the non-emergency numbers anymore for fire or police or things like that. And I think actually the police officer that was actually giving this press conference when asked what is the non-emergency number, they didn't have it at the tip of their mind as we all have for 911. In aviation, we only hear about the serious in big accidents. It doesn't mean that everything necessarily works. I'm going to move on to the second one. When people say medicine is not like aviation because the human body is vastly more complex than because it's nature, one of the biggest threats to aviation is weather. Storms, lightning, hail, downbursts, fire on board. You know, that is nature. How can anyone say that one part of nature is more complex than anything else? And as you pointed out earlier, that we do have medical incidents on board as well, and we have to factor in how do we manage those medical incidents. And as we're exploring in the podcast, the majority of aviation accidents have an element of human factors, which we're going to define later on, but it's literally how we interact with each other, the aircraft, the environment, and that psychology is just as complex as anything else. Moving on to the last one, which is that aviation can afford certain safety measures because ultimately it passes that cost on to the flying public, whereas in Canada, medicine is publicly funded. Publicly funded doesn't mean cheap. We decide what is and isn't worth paying for. We would never say that an autoclave, which is used to disinfect things that have been used, we'd never say that that piece of equipment is too expensive. And sometimes we pay millions of dollars for surgical machines that don't necessarily have proven benefit. We have a system that pays far more for reactive treatments like trauma care than for proactive or preventative safety measures like helmets and things like that to prevent traumatic brain injuries, in large part because it's incredibly difficult, and this is uh an issue that comes with a lot of safety initiatives. It's very difficult to quantify the amount of money or lives, et cetera, saved because of events that never really occur. Anyway, those are some of the thoughts. Those are the three most common things that I see. What do you think, Mike?

SPEAKER_00 18:41

I think you've hit a lot of really good nails on the head there, Adam. If I were to add a just to flush out a little of what you were mentioning, we in aviation had to go from this mindset from everything is aircraft handling to more of these soft skills, right? So now we actually evaluate flight management skills, even for those what we call private pilots, that basic recreational type level of pilot. They need to demonstrate good decision-making skills, situational awareness, communication, workload management. And this one thing we're trying to do now is under this threat and error management model, formalize those a bit more and drive that back to that initial stage of training. I'd say with respect to aircraft defects, yes, there's lots of things that pop up. You're on an aircraft that has a million parts on it, things are not going to work. It comes back to risk management. So if the table tray on seat 12 Delta is broken off, maintenance could come in, remove it so there's no sharp edges, and we can take the airplane flying. You're never in a perfect aircraft. This then applies, as Adam said, to things like navigation, communication, other aircraft systems, but it's all based on redundancy of systems, in interoperability of systems. So there is actually risk management that goes into it. And when we talk about nothing bad ever happens, we're not, thankfully, and as Adam says, a victim of our own success, crashing airliners all the time because that's what makes the news. If we had the same accident rates today that we had in the 1960s, you would see a major aircraft haul loss every week. So we've been doing very good on that front. And how do we get there? What's available publicly in Canada is something called Cadors. It's the Civil Aviation Daily Occurrence Reporting System. And I pulled them up a little bit earlier today just to see how many come up in a day. And you usually see 50 to 100 publicly reported uh occurrences a day. They're not necessarily safety related, they're just irregularities in operation. But once you have the data, you can then address that. So for example, an aircraft comes into land at an airport and they choose to conduct a missed approach, they go around, come back for another attempt, which is a really good thing. Because if the aircraft is coming in and it's at an incorrect speed, descent rate, you have wildlife move onto the runway, things like that, of course we want you to not land. We're going to go around, address it, come back again. But if we start seeing a trend of why does this one airport have so many of these go-arounds, which are a normal thing, now we can address what are the factors at that airport. And that is just the public version, right? Each operator, each airline, air taxi, they have these safety management systems that are confidential, right? But super routine. So if you you look at any of those, they're getting, again, dozens of proactive hazard reports. This looks like it could be an issue, and we try to identify those things proactively versus reactive. So things go wrong dozens of times a day, you just don't see them in the news, right? So that's something to keep in mind, as well as I'm sure it is the case in your line of work as well. As Adam alluded to, medical incidents on board. Now we're dealing with all the same. Is normally it's not to the level you'd see it in the emergency department, but you have strokes, you have heart attacks, you have all these things happening on board. Now you're in a noisy environment at a high altitude without all the resources of an emergency room. And you may or may not have medical volunteer help on board. And now you're also having to balance the safety of the other 200 passengers. You can't just say We're going to land this airplane at the nearest airport because that may not have a long enough runway, or it may not have stairs that are tall enough to get up to your particular type of aircraft to get that patient off anyway. So you're dealing with now your dispatch, your cabin crew, your medical help on board, you may be contacting a third party, such as Medlink, which has emergency room doctors available for phone patches to the flight crew, and you're trying to balance all these things out. So it can get quite complex in that sense. And as with respect to cost, in our business, the least risky thing to do is never fly an airplane. Right? That's how we get to risk zero, which is not practical. So we try to manage risk to an acceptable level. Passengers do select their flights based on cost, among other things. So there is a competitive element. You can't do everything to the absolute highest level. But how do we come up with a balance here, right? So these safety management systems, I know we're focusing on human factors today, but it all rolls together. A safety management system actually balances the frequency or the risk of occurrence, the severity if it does happen, and what the cost of mitigation is. And they look at that not just in direct cost, but also indirect cost. Right. And so maybe that that aircraft is down for a period of time if it gets hit by a catering truck. Not only are you taking that aircraft out of service, but now you're losing revenue from people on accounts or cancel flights, you're paying out passenger protection money, you're dealing with insurance. The folks that you're paying in your operation to deal with this, maintenance and so on, now that's more of an expense. So we like to think of safety as an investment when it's done through a more formal system. Because those indirect costs are often about six times the cost of the actual incident itself. I'm sure you gentlemen can come up with some sort of parallels for medical or malpractice or anything like that. But the most egregious one I've ever seen is if you were to think back to 2010 when BP had that oil spill in the Gulf of Mexico, their indirect costs were 100 times the cost of the oil rig itself. And so that's what we're trying to do is also manage all these other aspects.

SPEAKER_03 24:06

Amir,

The perceived tension between safety and efficiency

SPEAKER_03 24:07

I know what Mike and I have talked a little bit about this. You and I have talked a little bit in other episodes about this. Are there other objections that you hear to this kind of either the analogy between aviation and medicine or the kind of rolling of the eyes or the resistance to this? Are there other things that you think that we haven't captured in this?

SPEAKER_01 24:24

Yeah, I think so. Particularly to Mike's point about these skills being tested. It was kind of the first thing you said in that little like segment there about we got to really look at people's ability to manage leadership and in troubleshoot scenarios and have these quote unquote soft skills or not technical skills per se in terms of flying the airplane that are really important. And I'm gonna try to answer your question by providing an example and then having you kind of discuss about that. The response in medicine is like it doesn't really matter. Like if someone is dying and you can save their life, who cares about your leadership skills? It only really matters if things go poorly, right? Like, who cares about your ability to manage a team or do crisis research management? Like, that's not really an outcome we care about. I think Adam and I can speak about surgeons or other medical staff that we worked with who have challenging personalities to deal with and who really don't see the value of you know navigating a team optimally, all they care about is the productions. How many knees can I replace in a day? How many hips can I get in a day? How fast is my OR time? You know what I mean? And so I guess the question I have or the counter-argument I have is someone in medicine who's hearing about these things for the first time can say, yeah, that sounds all well and nice when things go poorly, but at the end of the day, you know, if things are suboptimal and I have to add so much more time to everything I do, you know, I'm gonna be dinged on that repeatedly versus this one in a million case that I'm gonna save and, you know, maybe make a marginal difference in a person's life for the team dynamic.

SPEAKER_03 25:44

That's it's an interesting point. It sounds like what you're saying is the star performer who happens to be rough around the edges, if you will, someone who says, I don't have to be on top or be all warm and fuzzy or any of those things because I'm an above-average whatever happens to be surgeon, and my day-to-day outcomes over time mean that it's acceptable to act in this way. And I think certainly we've seen that kind of conduct.

SPEAKER_01 26:08

I'll go a step further, Adam, and say that I'm not necessarily paid for being a nice or courteous doctor or a doctor who can like lead the team very well. I'm paid for my performance index. With the example of the airplane pilot, I can imagine the parallel being if it takes me an extra 15, 20, 30 minutes to integrate all these skills and do it all nicely, whereas I can just bypass them and then land the plane safely 30 minutes sooner, isn't that better for everyone? Isn't that where the incentive structure is leading to?

SPEAKER_03 26:31

Yeah, it's an interesting concept. In aviation, we talk about on-time performance and there are costs associated with not being on time and so on. You are at the end of the day a scheduled air carrier, for example, and that matters to a lot of people. And people aren't going to fly on your airline, for example. If you can't land the airplane on time consistently, it's a big deal. I'm sure Mike can speak a little bit more to this. But I think we've seen this in a lot of other industries, which is the star performer who says essentially, my work speaks for itself, and I may be rough around the edges, but I get the job done essentially. And my response would be a few different things. First and foremost would be that's fine when everything is going right. We want people that can do their job well. We want people who can be efficient, who can make efficient use of OR time and efficient use in throughput if we talk about the emergency department or ICU or any of those other critical care cases, and technical proficiency matters, absolutely. I don't think anyone's saying it doesn't matter. What I think most of the people now would be saying is it does matter the kind of person that you are, because now we have the data to say that bad outcomes are in part contributed to by the kind of leadership style that we have. And we know that people are going to have emergencies, people are going to have resuscitations, people you're going to have to lead teams. Your job as a physician is not to be a proceduralist, just your job is to lead teams. And if you can't do so effectively, you're not a good physician. And that's not me saying that. That's the Royal College, for example, that's the College of Physicians and Surgeons in the various provinces and jurisdictions that we have in Canada. That's a medical boards the world over because that's the model that medicine has changed to. The

Silos in aviation and medicine

SPEAKER_03 28:11

other thing that I'll say is I think a lot depends on when we talk about preventing harm, this isn't about just being efficient or technically good at placing a chest tube or intubation or what have you. This is also about preventing harm to the individual patient. And we can refer to the Elaine Bromley case as an example where leadership mattered and someone died as a result of things that went awry. But also when we say preventing harm, I think it's time that we looked at preventing harm to the rest of your colleagues. When we have resuscitation that doesn't go well, we all know that the burnout rates, the depression and suicide rates in medicine are higher for most places than the average population, than other places and so on. And how we deal with medical error, how we deal with resuscitations, and how we deal with our colleagues matters greatly when it comes to those things. And we need to start looking at our nursing colleagues, our allied health colleagues, our physician colleagues as resources. And when we look at a macro level at what the pressure has been since COVID and even before COVID, we're seeing people leave medicine, leave nursing, leave these other professions, and society then does not have that safety net to fall back on. And I think those are some of the very many reasons why we need to be considering how you interact with people, how you lead a team, and how you integrate CRM, which we want to talk about today, not just your technical proficiency.

SPEAKER_00 29:35

Adam, if I may, it almost sounds like you're describing silos, which is something in our industry we had to break down years ago. It used to be maintenance does their thing, flight ops does their thing, in-flight service or flight attendants do their thing. And it sounds like you may have a doctor that can execute a particular surgery or a particular procedure. And correct me if I'm wrong, but you submit the billing code and you're on to the next patient. With that being said, if those CRM skills aren't there, what happens downstream with the follow-up care? Was there a follow-up instruction that was missed because it wasn't communicated to the other staff? Or does that person come back with an infection later on or other things that aren't in my silo because now I've submitted that billing code and I'm on to the next patient? So there may be an aspect of patient care that could improve there, but that's more of a question to you, gentlemen.

SPEAKER_03 30:22

I think siloing is a really good way to put that because it was a phenomenon that I had experienced when I was a medical student and later on a resident, where in the surgical in the OR, for example, it I got the sense that, as you said, maintenance does this and the flight crew do this and the cabin crew do this and air traffic control does that. I got the sense that anesthesia is responsible for this and surgery is responsible for that, and nursing is responsible for this, and the hospital is responsible for that, and the people involved are really concerned about their own performance. As opposed to in some ORs, it seems they're responsible for the overall outcome for the patient. What they're looking for is the patient experience and the overall how do we get this patient safely home and back into their everyday lives. And I can tell you that it really depends on the surgical team that's at play. And yeah, siloing is the way that is what I would describe that.

SPEAKER_00 31:15

And not to say that you can't have each group with their own procedures and responsibilities, but this the interaction between those groups, breaking down the silo.

SPEAKER_01 31:25

I'll go a step further. And I know Adam's gonna I I can predict Adam's reaction to this before I say it. There's this and I want to hear your your thoughts on this, Mike. So there's this refrain that frequently hear from physicians regarding ordering tests and doing more investigations saying something along the lines of, if I order this test, it's my responsibility to follow up. The medical legal structure is such that whoever initiates the investigation for a problem is ultimately responsible for whatever bad outcomes may occur as a result of that, to some extent. Let me give you an example. Someone comes into the emergency department and they have vague symptoms, headache, fatigue, et cetera, et cetera. Some emergency physicians are very loath to order up complicated tests that require a lot of back and forth because the institution they exist with within the emergency department isn't very conducive to getting results back to them in a timely manner. But ultimately they're held responsible for if there's an adverse event that occurs that could have been prevented by these things. Very common example, someone comes in with a headache. You ordered a CT scan, you know, initially it's benign. They may have recommendations to follow up in six months' time. And you say, go and see your family doctor for this. And I've asked a number of preceptors or colleagues, why don't you just order the CT scan now? Right? Like that'll actually close the loop. You'll actually get all this information as recommended. And the response is, I don't want to be responsible. I don't know what I'm gonna do in six months' time, right? Like, I don't know if I'm gonna be here to pick up these results, I don't know where they're gonna get to, they may get lost, and ultimately I end up holding the bag. This to me is an example of siloing that I think is very applicable. Instead of focusing on, you know, uh addressing the overall issue, which is this patient's health, right? We're we're stuck in like, hey, what do I have to bring to this situation? And and a lot of people say, well, my job is just to address the acute issue, and everything else is kind of gone beyond that point. There are numerous examples in multiple fields, but you know, when when I heard the term siloing, when I heard that, that's really what I thought of.

Who's responsible vs who has the resources

SPEAKER_03 33:11

Amir, how many times have you seen this? I was a medical student, and no, I think I was a resident, I'm sorry, because I had the ability to actually order these tests. Somebody comes in complaining of certain symptoms, and it immediately brings to mind this person had been out of the country, they were a young person, and uh clearly I looked at this and I said, okay, well, I ordered HIV and hepatitis B and other STI serology blood tests to rule out STIs that are not gonna come back for several days, if not a few weeks. And the preceptor uh had pulled me aside and said, Hey, listen, what you did was textbook, it's what we're supposed to do, but you're gonna start really ticking people off if you do this. And I had asked why, and he had said, because those that blood brook's not gonna come back for quite a while. I'm not gonna be on shift. These are they're under they're ordered under me. I am now responsible for those investigations and then the follow-up, and who knows whether we can find this patient and so on. And if I can't, that's on me. And it's just the way that our system is not set up for that. It's an emergency department, it's not a family doctor's office, etc. etc. And so it's one of those examples where the system isn't set up necessarily to support the patient.

SPEAKER_00 34:14

Very interesting. If I could jump in with just something tangential to what Amir said about that word responsibility, because that's one that comes up sometimes in CRM. And earlier on in the CRM days, some of the pushback you might hear was, I'm the captain, I'm responsible. Yes, you are responsible. So the pilot in command of the aircraft, which we commonly call the captain, is the responsible person, right? The buck stops there. From the moment you release that brake to go off the gate until the moment you set that brake and shut the engines down, you are fully responsible. What CRM does is it gives you more tools to get out of your crew, to get out of your other resources, air traffic control, maintenance department, everyone else, to make sure that you are as successful as you can be in that role of responsibility. I just want to clarify that point that you always still have that one ultimate responsible party and the weights on them, but the CRM is there to help them be as effective as possible in that

The origins of CRM in aviation

SPEAKER_00 35:08

role.

SPEAKER_01 35:08

Mike, you you're obviously very well versed in this, you're very, very well experienced, but can you give us an overview of really what CRM is and why it came to be taught in aviation?

SPEAKER_00 35:19

For sure. It it's a really big topic, obviously. I'll try to keep it somewhat simple here, but if you think back, we've been flying airplanes for what, 123 years now. I see Adam nodding. And they weren't always that reliable. I mentioned earlier on if we kept the same safety record from the 60s, we'd be losing a major international airline flight like every week. And so no one really paid much attention to human factors because as a percentage of the accidents back in the 60s, 70s, for example. Like two-thirds of accidents or more, this thing mechanically failed. So that's where the focus was. And then as aviation evolved, the engineers got a better idea of what they were doing, maintenance got a better idea how to maintain the aircraft, that went down. So as a percentage of the accidents, even though the accidents were going down overall, the human factors as the primary cause started to become, oh, here's 75% of accidents are being caused by human factors. So let's put our focus there, right? How do we address this? And that's where we started to get more of this training in what we call soft skills, or essentially the human factors. Because pilots were crashing essentially perfectly serviceable aircraft into the ground. And there's a few examples that we can come up with there. There were really three or four big ones when we start talking about maybe history of CRM a bit more and the different generations and evolutions of that. But they came up with this concept of how do we take our human selves and properly integrate us with the machines. So something we call the shell model is dealing with software, hardware, liveware, which is us the humans, the environment that we're operating in. And when you look at aircraft manufacturers now, they have whole departments that look in the design of the aircraft, the flight deck, the ergonomics, where are we going to put warning lights and things like that to make sure that we can address this? And I don't want to use a lot of really old examples throughout because someone's our listeners will remember. And if you think back to US Air 1549, that was the one that had the bird strike, both engines failed, and they were leaving LaGuardia, New York, and they glided into the Hudson River. That airplane was not flyable, it had no engines, it was a glider. But zero fatalities. And this is the idea behind the CRM is when we get to train things like decision-making, situational awareness, workload management, communication. Now Captain Sullenberger and his first officer Jeff Skiles, they had the ideal outcome in that situation. And yes, they had to manually glide an airplane, but it never would have been successful without the CRM skills behind it. And so it's important to note too that you don't just have it or not have it. These are skills that can be trained, right? We can give a course on effective communication, we can give a course on different decision-making models. And that's a big difference that's happened now. If you used to get hired at an air carrier, you might get half a day of quote unquote CRM training, and then it became a day. And much as I mentioned earlier with the training being integrated throughout, if you get hired at an air carrier and they say, let's do a two-week ground school before we even touch the airplane, instead of that half day or one day, you're now looking at probably two days worth of modules, but they're all spaced out so that they're scenario-based and relevant to the accident example that you're looking at, and so on. So we can actually train the skills. So that's a big difference there as well.

SPEAKER_03 38:57

So, Mike, I think this is important, but in aviation, we often take it for granted. How did we know that the failure of some of these accidents that we talked about in the past were related to human performance or human factors? How did we know that?

SPEAKER_00 39:10

So a few things came into play, and one big one is technology, right? Technology drives us. So we got flight data recorders, cockpit voice recorders, as the quality of those improved over the years, that's where we started to actually be able to, as safety investigators, go back and look at actually what happened and track those things down. When you look at independent investigation agencies such as the Transportation Safety Board in Canada, when they go in, for example, you had the Endeavor Air, it was the Delta Connection flight last winter in Toronto, the one that landed hard, the wing ripped off, they rolled upside down. So when the TSB went in there, they bring into their field phase, and then when they do their follow-up phases as well, experts in operations, in maintenance, and engineering and human performance, right? So they have a specific team dedicated to that. And that we don't have all the details on that one yet, but if I go back to Asiana 214, this was a one folks will probably remember a few years back as well. It was a Boeing 777 landing in San Francisco, and they ended up crashing into the seawall prior to the runway. And what happened in that case was they had an incorrect auto-thrust autopilot mode engaged. This is something we call mode confusion. And when you look at a broader spectrum of accidents, particularly in smaller airplanes, because there's less standardization of some of this equipment, mode confusion normally lands within the top three root causes of these accidents. And essentially what happened was the aircraft was not maintaining a sufficient amount of speed. You need speed to keep an airplane in the air, because it's the airflow going over the wings that gives it the lift. You can get that two ways. You can either add more thrust to make it move through the air faster, or you pitch the nose up. That increases the angle of attack, basically the angle that the wing is meeting the air at. Either of those things will give you lift. But if the thrust is rolling back unintentionally, you just keep pitching that nose up up and eventually it can't give you any more lift. And that's when they started to sink down and crash short of the runway. Going back through not just the technical aspect of why was in that mode. Because we could just say wrong mode, done. We go to mode confusion, we listen to the cockpit voice recorder, and then you can also start getting into culture.

Medicine's blame culture

SPEAKER_00 41:16

And I both of you gentlemen mentioned this a little bit earlier as well. The culture in different operating rooms, for example, different airlines around the world are going to have a different culture, right? And so are we going to interject? Are we going to be assertive? Are we going to sit back and just watch and hope that the other people fix it? Or if I interject, am I interjecting too late? Again, we don't want to just take that surface response. We want to dig deep. And it is those independent agencies that can then access CVRs and FDRs that then do that work to drive down to the root cause. And a big part of that, beyond the technology, is the legislation. All right. The Transportation Safety Board Act in Canada, the TSB does not report to a government department. It does not report to Transport Canada, for instance. It reports directly to Parliament, not even the government of the day. That gives them a lot of independence to make their recommendations and make their findings. And then they can get that out. And that same act is the one that protects the security of the C VR and the FDR. They cannot be just released to the public. You can't just be like, here's the C VR audio recording. They can do a transcript. Right. And with that level of protection, now all of a sudden the people in the system are more willing to participate in it because they're protected by the legislation, if that makes sense, right? So they're more apt to again participate in the investigations, which is not the case all over the world, right? There's other countries where if you have an accident, let's go arrest the pilots and we must blame someone for this. And so we have to be aware of those sort of things as well. But the TSB for decades now, they have never written in a report in the last probably 20 years. The pilot failed to insert whatever. That's not a term they use anymore because it's such a complex series of factors that lead into it, right? Sorry for the long answer, but technology, but also a lot of the protections that are baked into the legislation.

SPEAKER_01 43:06

I really like the last point that you said where there was a loss or a move away from framing the pilot fail to XYZ. I think what resonates with me is that in medicine, I perceive there to be a high culture of blame when things go wrong. There's always someone to be held to account for an adverse event because it feels like the stakes are really high. And it is sometimes hard, I find, at least, to communicate to patients and say, like, we appreciate that there's a bad outcome. Sometimes systems are really complicated, and it's not the failure of any one individual. It's a systems-based failure, but it's very hard to come to someone who's had a very challenging or adverse or negative experience and say, this is long and complicated. You cannot just look one person in the eye and take out your frustration, anger at them. It is a large system that we acknowledge had many people playing in, and maybe some people function suboptimally, but it's not the fault of any one individual. I think that's very empowering to hear, but I struggle seeing how that moves into medicine and having patients, people, the general public. buy into that as a mentality they can accept.

SPEAKER_00 44:04

It's a wider culture that you're dealing with. And even just within aviation, there is a huge period of time where it is stretched because those first accidents in early prior to early CRM in the 1970s, it was your punishment for this is we've taken away your pilot's license, you'll never fly again. Whereas now it's let's put this into a safety management system. Let's look at all these causes as you just identified Amir and we're going to fix the system, which is harder to do in a broad sense with the public.

SPEAKER_03 44:31

I think what both of you are getting at is a philosophical difference driven by a number of different factors. So in my mind, one of the reasons that medicine and I agree with you Amir is very blame centric is I don't think we really want to dig too deep because we'll find the cracks in the system. In some cases that might be very expensive to fix. And it's a lot easier to blame the last person that touched the patient, the people at the sharp end, the doctors, the nurses and so on, whoever pushed the last medication or that did the last intervention or what have you. Because for any number of these reasons we've talked about there is this well some of these things are probably tractable. We don't have the data on which we can confidently say what percentage is human factors related. We don't have the technology that Mike alluded to we just don't have the data confidently say well if we fix the system we might be able to prevent this these these number of deaths and so on. And so when we look at the culture for example it's self-reinforcing. So Mike in his very eloquent answer there's a lot to unpack there. Mike mentioned technology about cockpit voice reporters and flight data recorders. We looked at the legislation we don't have similar legislation. We have some legislation that protects certain investigations but we don't have nearly the level of protection that you see for some of these things in aviation. The culture which is informed by the things that we've already talked about the laws that we have there a lot of those will feed into that and so when we look at this there's a lot of reasons why medicine is still blame centered. And I think a good part of that is simply the fact that we don't have the infrastructure for the investigations that are currently conducted in aviation. We don't have the data that might drive that policy change that would allow for that infrastructure. And so it is then becomes self-reinforcing. So we decide that well the last person that touched the patient, what if we just punish them and maybe they won't do that again as opposed to thinking well okay this happened now there is an acceptance in aviation that if this happened to this very experienced airline crew not captain, not first officer but the airline crew as a whole this can probably happen to other people and so therefore let's actually have a look at how we can make the system as a whole safer. And that's not an inquiry that often happens in medicine.

SPEAKER_00 46:53

Good thoughts Adam I think it's fair

Evolution of CRM in aviation (data-driven, voluntary course, then mandatory SOPs)

SPEAKER_00 46:56

there are struggles in implementing CRM besides the ones that you talked about besides the initial kind of buy-in was this a linear process was there regression you know what are the ups and downs what are the fluctuations and and lastly how do we know CRM is kind of effective at this point yeah a few really good points to unpack there Amir it's never really with anything a completely linear process but it really started with I think Adiv had mentioned earlier the United 173 troubleshooting a landing gear issue to the point that you run out of fuel right and effective communication from that crew in the back united lost 2860 just prior to that they crashed a perfectly good airplane into terrain because of an electrical issue that they were working on. Eastern Air 401 a light bulb for the landing gear the green light wasn't working until eventually the autopilot clicked off no one noticed it just descended into the ground and then we had KLM at Pan Am in Tenerife with the worst aviation disaster in history where we were dealing with captains that weren't listening to the crews, right? So it drove this early phase in 1979 and United came up with this first program. They called it CLR, command leadership and resource management, which eventually merged into the concept of CRM that we know today. But it was supported by NASA for example because NASA knew the importance of crew dynamics prior to this. And even though some pilots at the time were pushing back for the reasons you Adam identified earlier with some doctors as an example it was still really endorsed by example out by the Airline Pilots Association, the biggest pilots association in the world they currently have 95% of all the Unionized Canadian pilots within their fold right and they're like give us the resources can more because more than being just a union they're really a flight safety organization first. They wanted their pilots to have the tools so they were able to push forward with it. The pilots tend to be evidence based thinkers on the whole right so they got as many people online with the the evidence and then they started to actually see the accident rates go down. And once that happened then they started to take CRM at the airline level and move it into standard operating procedures. So this is no longer just a voluntary course you can come take it's now something you're going to be evaluated on constantly. So pilots are in for check rides in the simulator every six months and that includes all the bad things that could happen. But it used to just be you didn't crash so you passed. But now if they see hey your flight management skills you're were weak your CRM skills you don't pass anymore. So that was what kind of got the last of the holdbacks moved up so they went carrot for about a dozen years before they brought the stick into it. And then when we talk about the linear process seems like things are going great but what ended up happening there when we started to get into that sort of same phase is we went from cockpit resource management to crew resource management. And that meant that we're going to include the flight attendants, the dispatchers, the ground handlers, all these people as we've been discussing today. But it very much got into this focus on our personality types and our behaviors and it started to drift away from the core focus of flight management, fly the airplane. Right. So that was one of those nonlinear areas where it had to come back and start looking at we're all going to make errors right we the error is human. We need to accept that and that's really where the concept of threat and error management then started to come from because if we focus on managing errors that's one thing that's great. Let's take it to the next level with TEM threat and error management and say what threats are bringing us or coming at us so that we can deal with those before we even make the mistakes, right? It's

United Flight 232 - Captain Al Haynes

SPEAKER_00 50:33

been ups and downs and there's been changes along the way, but we often look back to Sioux City in 1989. That was United 232 which folks may have heard about this was Captain Al Haynes and he was one of the pilots who went through that initial CLR program at the time with United he was one of those trijets that has an engine back on the tail that had a massive failure ripped apart all sorts of hydraulics and electrics the plane was for all intents and purposes uncontrollable. They could only steer by bringing up more thrust on one engine than the other under each wing to turn this thing and the first one of the first things he did was that we have a very experienced Czech pilot riding in the back as a passenger get him up here and he added a third person to the two person crew and unfortunately if you go look at the video like it was still a pretty we'll call it a hard landing I mean the the thing broke apart but more than half the passengers survived in a completely unflyable airplane. So it's had its successes it's had its challenges and we make our way through to where we are today.

SPEAKER_03 51:30

Mike you mentioned United 232 I had the absolute privilege of hearing Captain Al Haynes speak earlier in my career and it was something absolutely beautiful to see and credited as you said CLR, the initial lines version of CRM uh with his ability to his and his crew's ability to be able to successfully save many lives in that crash landing as it was. And one of the things he had said was you know he said I said one of the stupidest things ever which was my airplane which is how you take control from one pilot to the other which was a joke because it was nobody's airplane. No one could fly that airplane it was not an airplane that was flyable as you said. And so he had a lot of humor in how he delivered his presentations and there's some really good YouTube videos I know of the accident itself but you may be able to see Captain Al Haynes actually talk about it. We'll try and put that in the show notes as well. You mentioned a few different things in there I really liked hyped about the evolution of CRM which we'll ask you a little more about as it comes up but one thing that really struck me was you said it was a data driven and still is a data driven enterprise. And so we had this idea of well we have all this technology we've managed to now figure out that human factors are playing an outsized role in these accidents that people are crashing perfectly good airplanes. And so we need to do an intervention the intervention that they came up with was CLR or CRM, the early stages of CRM. And then they followed the data from there where they said well the accident rate is going down and now when we look at a more granular aspect to it the reasons the root causes of these accidents are changing and they decided to change the intervention as the data directed them to and so as you said it is a data driven exercise.

Can we really say that we practice evidence-based medicine if we don’t gather the evidence for interventions like CRM?

SPEAKER_03 53:09

And so in my mind one of the things about this is we really need to know the data in medicine in order to drive this forward in order to change the culture as we've seen and other things. And it's not like the technology doesn't exist. It's not like we couldn't theoretically put in cockpit voice recorders or audio video recording in operating rooms as we've talked about. It's not like they go up and fly and crash into mountains like airplanes do. But there are good reasons why we don't yet have that technology implemented and part of it has to do with your earlier answer as to well what's the culture of aviation and how is it informed by the laws that exist and how is it informed by the protection that exists? And do we still have a blame culture and so on. And I don't think the answer is in any one of these things. I think it's in changing all of it. I think it starts with policymakers and it may start with even individual institutions who decide for example to say well this technology exists we're going to for example implement this as a pilot project in one operating room or one resuscitation bay in an emergency department and we are going to protect that with the existing legislation that exists for quality of care reviews that does protect these things from staying out of the courtroom and seeing how it goes. I mean if we look at healthcare writ large in Canada that's what Tommy Douglas did back, you know, way back when this was not a Canada wide Canada's going to have socialized healthcare this was a single province that then said we're going to try this and this is how it grew from there. So I think there's a whole lot to unpack there but I really wanted to highlight this data driven aspect to it. Amir, any thoughts?

SPEAKER_01 54:35

I think that's very important language that I think we need to commend Mike for using the fact that he's saying things like evidence-based and the fact that he's saying you know people tried it saw benefit and then it was more widely adopted I think keeping that in mind as we approach that into medicine to say we're a scientific field. We actually should be experimenting and implementing these things and seeing what the outcomes are, right? Like if we're going to wear the hat of being clinician scientists and being people who are evidence based, we have to be able to put this into practice regardless of how it is like that's inherent to our philosophy. The part that you just said I think was great.

SPEAKER_03 55:07

You said we're a scientific field. We should follow the evidence and it's very true we love to say oh well we practice evidence-based medicine can we honestly say that if we don't gather the evidence like this I think it's a really important point.

SPEAKER_01 55:21

We talked about the early implementations of CRM and the different generations and how it started with like a couple of modules or a half day course and then it moved into standard operating procedures. Mike can you give us a kind of brief overview of where we are now what the focus is now you mentioned terms like threat and error management.

SPEAKER_00 55:37

Can you give us a little bit more details as to that transition and how long that took absolutely so that first portion came out in 1979 was when that first CLR version came out and then as we have been discussing for the last bit the various iterations through it. And once we get to that acceptance of errors let's get back to error management a lot of the other things we were looking at were important but we've mastered them let's continue to move on a very quick example if I may is going to be cockpit authority gradient is what we call it. And as you can imagine back in the 50s you're in this post-war environment most of your civil aviators were coming out of the military where you're dealing with ranks and decision making and orders and that sort of thing, right? You'd have this very high cockpit authority gradient where the captain is way up here, your first officer is down here and at that point you probably still had a navigator, maybe even a radio operator in this hierarchical structure. The complete opposite and I have seen it in training sometimes as an instructor is if you get a weaker captain and a very assertive, knowledgeable first officer, you almost get an inverse authority gradient, which is just as dangerous. You want to develop the CRM to the point where you have a shallow authority gradient where everyone's comfortable participating. They're going to be assertive but we understand as we mentioned responsibility ultimately ends with one person, right? That they're still on the top of that. And so we really addressed that going through the 80s and the 90s and then we got back to this 1999 this fifth generation as we refer to it where we're getting back to errors. But then as we got into 2007 some more studies were done and realized how about we just stop making the errors in the first place right there it's going to happen but let's reduce the number of them and that's what threat and error management is. So what is a threat? A threat is something that comes at the crew. All right so that could be weather there's a thunderstorm or a snowy runway or air traffic control has given you an incorrect clearance your fueler didn't put the right amount of fuel on the airplane there's a flock of birds coming at you anything that comes at you is a threat. And the difference between that and an error is something we do internally. So we make a mistake. I'll give you an example momentarily on that but that's the difference between a threat and an error coming at the crew versus something the crew does. So what's a mitigation?

“Anticipation builds vigilance, vigilance aids recognition, recognition leads to recovery.”

SPEAKER_00 57:53

We want to do in my business a lot of threat mitigation. So we try to think about the threats ahead of time and come up with mitigations for them. And a lot of them are in the standard operating procedure because there's they're so common they're so routine we are going to do this as a mitigation. But then it's the day I think about the big snowstorm we had last week just because that's when we're recording and you have reduced visibility I was talking to one of my friends he was flying that day he was taxing an airplane and all of a sudden they just come up on another one stopped in front of them. It's like driving in fog, right? It was just like boom right there. But it was okay because they were taxiing slower than normal because they knew they had reduced visibility. So when they're on the gate they're talking about that they're talking about the snow is falling we have to de-ice the airplane and I'm sure a lot of your listeners are familiar with being on aircraft in the wintertime you go to what we call the de-ice pad, they spray fluid on the airplane gets the snow off prevents new snow from adhering makes it safe to take off again. But the snow is so heavy that day rather than that fluid working for the next hour it might only work for 15 minutes. So now they're trying to mitigate that threat by timing up their taxi to the runway, which means you need to loop in air traffic control, right? So we're always looking at threats and then mitigations for them. The idea is if we anticipate what the threats are, it builds our vigilance towards those. And if we're being vigilant, it aids in recognizing when that is happening. And if we recognize it, we're a whole lot more likely to recover. So I think that's a big takeaway right anticipation builds vigilance. Vigilance aids recognition recognition leads to recovery. So what

Avoiding, trapping, and mitigating errors

SPEAKER_00 59:23

am I when I say let's avoid things in the first place. We have regulations that say you need a certain amount of fuel on board the aircraft and different companies will have more restrictive internal requirements. But avoidance is catching the problem before it can exist. So if we're going to fly somewhere we have to have this much fuel plus a certain buffer. Fabulous that's good avoidance. But let's say that fueler was told the incorrect amount of fuel to put on the aircraft or they type in a six instead of an eight or whatever right human errors we know errors will happen. We have to accept that how do I identify the fact that instead of having eight tons of fuel I only have six tons because the six and the eight look like very similar digits on that screen. We use the checklist right we have a checklist in place. I know something Adam and I have talked in the past before about getting checklists in in into medicine for example we see the error that's made we make the adjustment we've just used our CRM skills to stop it. We call for more fuel. So there's avoidance there's trapping and then finally the mitigation because if I was laxodasial we've mentioned earlier about on time performance if I'm rushing through because I need to get this done and I say don't worry about the checklist I try doing it for memory and I don't pay attention to that amount of fuel now I'm in the air and now I'm doing a mitigation I have to deal with it right we didn't avoid it. We didn't trap it now I need to divert to land to a different airport that's closer to us so I don't run out of fuel. But that's

Time, no time, or limited time situations

SPEAKER_00 1:00:41

kind of the steps of avoid trap and mitigate and you can see how those good procedures those skills the diligence and not being overly concerned with the time take the time to do things correctly is really what drives that of course the challenges if you're in a no time situation. Because I just described one on the ramp we got time lots of time. If you want to come back to no time I'll talk about that too later.

SPEAKER_01 1:01:02

You hit a point that I scribbled down like three times that underlined and I find that um captures the sense of competing priorities when you have things like time pressures when you have things like crew pressures when you have things like personal pressures that make it hard to manage these things. You mentioned this kind of no time situation. And in medicine it feels like a lot of things we do are in no time situations or minimal time situations. Is CRM designed for competing priorities when things go catastrophically wrong as you say when we're in the air and we have less fuel than we thought we did.

SPEAKER_00 1:01:35

Absolutely so it comes down to step one recognizing is this time no time or limited time and if it's limited how much time do we have and a lot of air crews now when something abnormal happens they start the timer you you guys probably know about the concept of time compression where you don't feel the actual length of time. And by having that number on a chronometer right in front of you really helps you manage that situation. In particular if you're looking at an individual that might be upgrading from a first officer position to a captain position. At that point in their career they're very good at flying the airplane we're looking at CRM skills we're looking like decision making skills workload management skills. What tasks can I shed that are not critical right now so as an example you're doing your takeoff a flock of birds hits one engine gets caught on fire you have to climb away from the airport safely get above the train and then you run the standard procedure and the fire does not extinguish so now we have what we refer to as an uncontained or uncontrolled engine fire. Statistically because I know we've talked about evidence based already you have 17 minutes to get that airplane on the ground before it becomes catastrophic and you have parts melted off the airplane smoke inhalation in the cabin all that sort of thing. If you do all the procedures we are supposed to do with respect to CRM and briefing your flight attendants and making a public address and all these things that's going to take about 30 minutes. You won't be able to become a captain if you just follow the script as normal. If you start shedding too many tasks and trying to come into the airport too early you end up high fast off center line you overshoot actually adds more time because you're coming back around again. So what we're looking for as aviation instructors and evaluators is that the the captains are able to assess the amount of time that they have and appropriately task shed to hit just the most critical points in that situation. And that's not something that happens overnight to some extent you have it or you don't but it's also the studying right it's the what ifs it's the sitting at home and saying okay what if this were to happen? It's sitting in an eight hour flight of cruise and saying what if this happened to us right now and over a career building up the that ability till you can hit that final sort of level in the career pyramid and become an airline captain.

On time performance in ORs

SPEAKER_01 1:03:52

I'm going to paint you an example of something that happened to me recently and I want to hear your thoughts coming from the CRM lens. In Ontario healthcare one of the important metrics is what time is the patient in the operating room at the beginning of the day? What time do we actually cut skin? And there's a huge pressure to get patients in rooms to actually cut skin at a given point in time. A lot of funding for hospitals is tagged to that or I should say for operating rooms is tagged to that. Sometimes you'll have this situation where you know you're individually running late or it takes more time to see the patient or there's more charts to review or whatever the case may be. And I know in my routine I like to go into the operating room before the patient is there to ensure that my checklist is done personally, that I've gone through and I can touch all the things I need to touch, set up everything I need to do without any external pressures. I find it very difficult to do that once the patient has been brought into the room. And it's very hard to kind of be in this space where you say don't bring patients into the room until I've gone through my checklist because then people will say well our funding is dinged can't you just do them in the space you know what difference does it make if a patient and and Adam was with me in a case the other day where there was a piece of equipment that I would have liked to have ready and I'm sure if the patient was not in the room by the time I got there, I would have been able to do it. But I couldn't because the performance pressures were high. I'm hoping you can speak to not necessarily you know giving us an overall critique of medicine or addressing this one policy individual, but here this um anecdote that I provide for me, lack and we this is a disaster waiting to happen. And I don't know if your response is just adapt and get better at this Amir because you know that this is going to happen or if you have some other CRM educational perspective that you can bring to the table and address this issue.

SPEAKER_00 1:05:17

I'll sort of answer the anecdote with an anecdote if I can this has gone on forever in aviation right that pressure to be out on time. And we have a very clear priority and it's an SOP it's written down every company out there they're going to say safety is your first priority then on-time performance and efficiency and then customer service or some companies will switch number two and three and how they want to work that that's fine but safety is always number one. So I had a vice president at a previous company I worked at who said yeah no your gate agents are always asking you ready to push ready to push because they're going to be the ones to answer for well why was this plane getting laid off the gate right um you're you're you're going to have the ground crew coming in ready to close the door ready to close the door and sometimes it's just I've I've turned around and I've said, we're going to need 10 minutes. And I close the flight deck door. And then they know because sometimes it's not that they're trying to put the pressure on us. They just want to make sure that we know that they are ready and it's not their quote unquote fault. So we actually have in in the industry uh what we call delay codes. And the delay is actually assigned and attributable to one of something like 98 different subtopics.

SPEAKER_02 1:06:24

We have that, we have that no, oh, that was a that was an anesthesia delay. That was a surgical delay. Yeah, yeah.

SPEAKER_00 1:06:37

And we don't take that parking brake off until we're 100% satisfied that flight will be carried out safely with required tasks complete. And we are always more than happy to take a quote unquote pilot delay if there's a reason for it. So if I'm working with a brand new pilot at the company and it's their first day out flying airplanes, we'll show up a little bit early, we'll do everything we can, but we're probably going to be a little bit late off the gate. And I just let you know systems control know this is going to be a pilot delay. It's for training purposes. And they can look at this later and say, well, that's a valid and important delay that was safety related. All is good. And culturally, very interesting. Uh one of my colleagues mentioned he had done that with a pilot that had come from an overseas airline, and this uh new hire pilot just stared at him for a second and said, We can do that because there was no way in the Middle East that was going to be an acceptable practice.

SPEAKER_03 1:07:30

I feel that very much. I think what Amir's getting at is this happens not infrequently, where, and I'll just speak from my own experience, which is lately I've been, perhaps because we're starting up this podcast, much more diligent with my sort of briefing checklists. And when somebody comes into the operating room, we always make sure that we've got the right patient in the right room, we're doing the right surgery, and that everything's in the room and so on. And there are many different ways. We're gonna have a whole episode, I'm sure, about surgical safe checklists and all of these sorts of things. But one of the things I've been doing is, you know, as Amir mentioned before, is all my equipment set up? Am I prepared to do this? But also, did the pre-op nurses, and this just happened to me yesterday, day before, where we had a new pre-op nurse who just did not give the pre-operative medications that were supposed to be given. And the nurses had actually asked me to bring the patient just outside the operating room, and they're asking me to do a little bit more because we all work as a team and they were very busy doing their things. And so I'd already brought the patient in. Well, we I had to call over. There was a new nurse, we got the medication to the patient, you know, all of these sorts of things. It tends to fall to anesthesia, at least that's my experience of it, where the medications need to be given. Have we done the pregnancy check for a woman of childbearing age, for example? Have we done all these things? And then, for example, I ask at the very end of my sign-in, the surgeon talks about their surgical factors. I talk about my anesthesia factors. I then turn to the nurses and I will say nursing and equipment. And some of the nurses will say, Yeah, yeah, yeah. And and I'll turn to them, I'll say, You're okay with the sterility. We have all the pieces of equipment in the room that we need. Oh, well, we have everything but X. And if I hadn't done that extra step, that very often comes in. And sometimes they just don't have it in the room. And that may be fine if we have three of them in the hospital. But if we only have one of those, well, no, we're not, I'm not gonna anesthesize the patient until this happens. And I do think it's one of those things where really it comes down to anesthesia very often with this, and it there's a lot of pressure on the individual practitioner to hold up the entire operating room to say, well, we're not gonna go ahead yet because we need X or Y, or something, something done, and it might have been somebody's and so on. I think it's a it's a big problem.

SPEAKER_00 1:09:29

It's such an important point, and you're dealing, I feel, in a bit of a smaller environment where like the people under the pressure are directly interacting with you. Whereas I can sometimes be like, well, close that bulletproof door and get everybody away from me. So the airplane I fly, we can hold 200 passengers on that aircraft. And when I make a decision of, well, this isn't working to my satisfaction, I can deal with it at the destination or I can deal with it here. And I know that 35 of them are trying to get on a cruise ship today. Another 40 of them are going to the soccer final. The people that you don't even know, they're going to go visit someone in a hospital who's on their deathbeds, right? You don't know what's going on back there. But not only are you affecting 200 people with that decision, all of them their families and connections as well. And that's a lot of pressure when you're trying to make that safety-related decision. It's really something that sometimes we just have to set aside and say, what do I need to do right now?

SPEAKER_03 1:10:24

I don't think it's unique to their profession. I think you're 100% right. I just wish I had that proof door that you have, you know. So,

CRM as improving efficiency rather than costing time, money

SPEAKER_03 1:10:29

Mike, you mentioned there are six generations of CRM, which I think just is the point that we're 50 years deep into CRM and aviation, and we went from flattening the hierarchy and uh having increased input from a variety of flight crew members to then going to, well, let's uh trap errors to let's actually prevent errors with threat and error management. Now that's our sixth generation threat and error management. I think there's a few things I wanted to just unpack or at least point out some similarities in medicine. And I think the first one is I feel like there's a bit of pushback in medicine to this idea of we're gonna bring CRM from aviation for a number of reasons, either stated or unscathed idea that, well, medicine is, you know, one of the oldest professions in the world and we do things right most of the time. And we don't need somebody else, especially some airline captain, to come in and tell us how to do our jobs because we've been doing them for a while. And uh I think part of it is it almost think we're being scolded, like, oh, if you just were better at your job, physicians, nurses, whoever, then we wouldn't need to have somebody else come in and tell you how to do these things. It almost feels like you're being scolded. Um, and I think that gets back to the idea that we sometimes look at these interventions, whether we call it crisis resource management or whether we call it something else, as physical cost in terms of money, as downside, all downside, we don't think of the upside as cost in terms of time. These briefings are gonna take me a lot of time. I don't have time to do all these things. I already have a number of other things. These checklists are gonna take a lot of time. What we don't talk about is, and perhaps again it gets back to an idea that we don't have the data and we should go and get the data, but we don't talk about how CRM can improve efficiency, how it can improve teamwork, how it can improve outcomes for patients, how it can improve team satisfaction, how it can improve retention, how it can solve a lot of these other problems. We talk about maybe that these interventions might prevent one of these rare occurrences, um, but we don't talk about a lot of those other things. And then when I get back to this idea of threatener management, um, just literally yesterday I'll talk about something. We do these briefings sometimes. I will say that we're not nearly as good in aviation about having it incredibly formalized, but that's my point. A lot of very good practitioners will incorporate what we see in threat and error management, but we don't call it that. It's not so formalized. For example, we did a briefing. I had about six patients, and we talked about each of those patients with the nurses that were gonna work in that operating room, with the surgeon, with the anaesthetist, with everybody that was gonna be in there, and we said, okay, we've got patient A, B, C, D. And the surgeon talked about all of the surgical factors, and then I mentioned all of the anesthetic factors, and then nurses talked about their parts to it. And one of the things was the second patient of the day had a proven incredibly difficult airway that they had had their neck excised from skin cancer, and they previously had been intubated by an anesthesiologist who wrote them a letter saying that they were in incredibly difficult intubation. And this was something where we could do a spinal on this particular patient, which is where we numb them up from the belly button down, and then we can provide them sedation and so on. And that was incredibly important because I did not want to go anywhere near that scary airway. I wanted my emergency equipment in case it was needed, but I really needed to get that spinal. And later on, when we actually went to go do the case, which had talked about all of this, I couldn't get the spinal. Perhaps if I really stuck at it, maybe I could have, but I had attempted a couple of attempts and it just wasn't going my way. And one of the nurses, one of the experienced nurses, had said, Oh, so-and-so, who is the chief of anesthesia in this hospital, is available. They're doing a clinic someplace else. And I had said, Yes, please, would you please go get them? And this more experienced colleague came in. And it wasn't an easy spinal. I had to check my ego, but my ego was also a little bit satisfied by finding out that this person had a little bit of difficulty with it. But ultimately, they were more skilled and they were able to put this spinal in, which was of great benefit to the patient, to everyone in the room. And ultimately it was what really ended up working. But

Meeting people where they are at in terms of implementing CRM in medicine

SPEAKER_03 1:14:15

to me, if we look at this from this threat and error management lens, that briefing took place. We identified this as a threat that was going to happen. And ultimately, we, through good CRM, although not necessarily formalized, had a very good outcome for this patient. And so I think sometimes we look at these things and say, well, we're doing some of these things. And we're going to look at throughout this podcast about a lot of different ways about the healthcare system, how we have elements of CRM, we have elements of good in incident investigation, we have some elements of proactive measures, but perhaps not nearly as formalized as in aviation.

SPEAKER_00 1:14:51

I think you hit a really good point there. I can quote, you know, public health from the last four years. It's meet people where they're at. And when we try taking TEM back to the initial phases of pilot training and those and flight instructors that aren't familiar yet, like, oh, we do a bunch of this already. It's just not formalized. And that can be a really good way to help people get into it. And with respect to the time, one of the big differences from when Adam and I used to fly together is those checklists have gotten shorter and shorter, right? Not to be morbid, but we've basically taken the aviation ones now and said, if it's something that won't kill us, take it off the checklist because they were getting too long. That helps address that concern. And similarly, the TEM briefs, we used to brief a lot of things. We're gonna go fly an approach and it's foggy and there's low cloud. We're reading all this stuff off of these published maps, these approach plates. We don't do that anymore because we're all professionals that we can read the chart. We spend our time now just saying, what are the threats today? How are we gonna mitigate those? And that's helped with the time concerns as well.

SPEAKER_03 1:15:52

That's great because I remember thinking you and I had a conversation about 10 years ago where we were talking about, well, where should medicine perhaps start with CRM? My thinking was, well, we should go back to the first principles. And your idea, which I'm coming around to, is well, we don't need to repeat takes in the things that we've learned from. We can start with the more advanced CRM. We're all professionals, and we can start from here, and that'll actually probably go a long way. And I really like the idea of the fact that we do a bunch of this already, and as you said, meeting people where they're at. So, Mike, I think it's important to note that even after CRM was implemented in aviation, there were accidents where ground crew and others, for example, got killed. And only then did they change the name from Cockpit Resource Management to Crew Resource Management, or at least around that time to emphasize the inclusion of all potential resources, such as flight attendants, ground crew, air traffic control. And we hope there are a lot of people that are gonna be listening to this podcast. It might just be the three of us. I have no idea. But more than just doctors and nurses are gonna be listening to this. And it's important that should we try this, that we need to realize that we're gonna be incorporating more than doctors and nurses. There are gonna be a whole bunch of people that are involved. And the accident that stands out for me that I learned in my initial training was a 1995 accident called Royal Air Morocco. It's a 747 that was parked in Montreal in a de-icing pad. And the crew had heard the French term over the radio for what they thought was de-icing terminated. They thought that it was de-icing had been completed, and they started to taxi and they had knocked over some cherry pickers that had the de-icing crew on it, and people died. Three people died in that particular one, two vehicle drivers sustained minor injuries. But around that time, we changed it from cockpit resource management to crew resource management. Part of the idea being that you have more than just the people in the cockpit. They could have asked the flight attendants what's going on back there. They could have used their other resources. And I'm sure you have better examples than the one that I'm thinking of. But what can you tell us about this change from cockpit to crew resource management and the idea that it's including more than just the people that are on the flight deck?

SPEAKER_00 1:17:52

Well, it comes down to the silos we had mentioned earlier, right? Why are we training just at the time four pilots and three pilots and a lot of times just two pilots in this silo? Right? Because those aren't the only resources that I'm using. We're talking about CRM as you utilizing all the various human and technical resources that we have available to us. Not everyone in the industry gets formal CRM training. The pilots get it, the flight attendants get it to some extent because they are on board working with us. What we see more of is uh the assertiveness training. And a very common example would be the ground crew or aircraft fueler coming up to the flight deck and saying, Hey, yeah, it looks like there's a dent on this part of the airplane. And that happens, right? And it may have already been inspected and written up and fine, but if no one kind of says, that doesn't look right, let me bring it to their attention. And I've certainly had fuelers that have seen something that said, That I don't normally see this on this type of airplane. It might be nothing, right? It might be routine or it might be something that's on that minimum equipment list that we had discussed earlier. And the biggest thing that we can then do is to reinforce it's okay, this is what it is, but I really appreciate you bringing that to our attention. And if you see it again, always come up. We'd rather it not be anything than to not know about it. And that culture and that positive reinforcement.

SPEAKER_03 1:19:11

So I was in the operating room just the other day, and we were doing a hip operation, and one of the nurses happened to mention the patients' feet were quite dusky, indicating that they had just poor circulation overall. And it was a really good indicator of their overall health status, which matters to me as the anaestys greatly. And not everyone would have necessarily pointed that out or said anything. Some people do it because we want to make sure that no one thinks that the surgical team was responsible for this injury or that something had happened that it wasn't this way. They want to document that it was this way prior to the surgery and so on. But it was a really key piece of information and it comes back to the idea that we are doing a lot of these things, but in a less formal way. And I like the idea that you had said that we are really talking about assertiveness and we are really talking about using all of the resources.

Escalation of language of concern: “PACE Model”

SPEAKER_01 1:19:58

I have no better way of coming up with the segue than than Mike. But what we've seen in our previous episodes where we've talked about airplane crashes, there's some people who've started that discussion, but not necessarily have been received properly. You know, the example I think about is the United Flight 173, where the plane ran out of fuel and crashed. Although you had someone in the cockpit actually speak up and say something. Can you talk to us more about kind of like, you know, besides just saying, oh, I'm glad you mentioned that, how do people feel empowered to further act when they feel like they're not being received?

SPEAKER_00 1:20:28

That's a fabulous question. And we we see that with um another accident for a few years ago with the first air accident, which was I think one of the ones that Adam initially recognized, hey, let's get Mike on and we'll talk a little bit. But when you have someone trying to say something, but it's not coming through, and it's the same one that you just mentioned in your example, Amir. So it's become a real trend over time. And again, some of it can be addressed through through SOP. So for example, if a passenger or a flight attendant says, Hey, these wings look like they have ice on them, and maybe it's warm enough that it's just water, but airplanes don't fly well with ice and snow on them. It actually says, and some companies, their standard operating procedure, you shall go look and you shall give feedback to the person who raised the concern. So they actually force the respondent to to get involved. So it's something called grad of uh graded assertiveness. It's this pace model that stands for probe, alert, challenge, and emergency. And so this is something that we train now so that folks have the ability to jump in and have a bit of a template for it. And the idea is that it respects authority, and most of the time you're in this probing stage where you come across as being inquisitive, right? We don't have to jump to these higher levels. And people on the most part love to explain why they're doing something. They're the master if they are in charge of the situation. And that can be as simple as, well, I'm new on this airplane, I'm just wondering why did you make that choice for auto brake selection? So auto brake, I pick because it's not technical, but basically you break an airplane like a car, right? You put pressure on the pedals. But to make it smoother for the aircraft, which results in less maintenance, it's more predictable for the pilots because they know where they're gonna exit the runway, on which exit, and it's more comfortable for the passengers because it's a smooth braking motion. And it might be a setting of one through five or low, medium, or maximum, or whatever the case is. But if they're looking at it and say, Oh, well, okay, near the airplane, why did you choose low? And they might have a really good reason for it. It could be I'm gonna use up more runway, but it's 35 degrees outside. So when we land, the brake's gonna be too hot for us to then go do a takeoff in 45 minutes time. So as we balance safety and economy, oh, okay, that's great, because someone might have just said I always use the highest setting. So that's a probe. It comes across very inquisitive. And then you can escalate from that, and it's based on time, which we've discussed a lot about time, no time situations already, and the level of risk that's associated. So sometimes if I don't really see a high level of risk here, I don't have to jump in and how much time there is. In this auto brake example, if this is back in cruise, maybe it could have a high risk. Now all of a sudden the runway is covered in snow. What I need more braking action. But I'm gonna land in an hour and we're still briefing it. So I can pick it up at the probe phase, even though it might be considered high risk. Then alerting, this is more of making a bit more of a statement. It's a little more assertive. And then you get into the challenge where it's this is what's going on. I need you to do this, or this will happen. Right? So we're giving people those resources to get there, then ultimately that kind of emergency step at the end, where in our world the term I have control. So if we think of training new pilots back on a two-seat airplane, this happens all the time as they're learning to land. Everything looks really, really good. And then in that last moment before touchdown, they make a major error, and your risk level is going to go to an unacceptable level. Well, we jump right in there. I have control. As the captain, I take control, I fix the flight path of the airplane. Right. Um and this can be done again as a first officer to a captain, or we have pilot flying and pilot monitoring. Pilot flying seems very obvious, they're the one controlling the aircraft, but the pilot monitoring is the one doing all the other work. They're dealing with radios, they're manipulating the flight control surfaces at the direction of the pilot flying. And they are monitoring that pilot flying for any errors that they may be making, so we can trap those errors. So um the process of pace, it helps people to have a bit of a template to follow. So if I can give you one example of the escalation through it, let's say we're coming into an airport, and it might be surprising to some people, we do have speed limits. So within 10 miles of an airport, I cannot go more than 200 knots. Nontical miles an hour, it's about 380 kilometers an hour. We all know this is a rule all over the world. But that probe phase of Hey, what uh what speed were you planning to uh fly for approach? Oh, I'm gonna fly it at 160 knots. Okay, great. So I have a plan, then that alert is Hey, we're 11 miles from the airport, because I see they're still doing 240 knots. And that alert we're at eleven miles should be enough to bring their attention to it. But what happens is sometimes we get task saturated, our situational awareness may not match the situational awareness of others, and we know that one of the first things to go when we do get overloaded is hearing. The vision stays, but hearing actually starts to cut out. So now we're at 10 miles.

SPEAKER_03 1:25:34

Right?

SPEAKER_00 1:25:34

I say we're at 10 miles. I need you to slow to 200 knots now. I've made a very clear challenge. And then if they don't do it, then we get into this, okay, I have control because at this point you are clearly incapacitated because you're not responding to me anymore. Your task saturated, your workload's gone up. So being able to recognize that is the big part of it as well.

SPEAKER_03 1:25:57

You brought up some really interesting points there, uh, Mike, and listeners will know that in previous episodes we talked about the Elaine Bromley case, as we talked about at the top of this broadcast, where they ran into this can't intubate, can't oxygenate situation. They lost track of time, they had this fixation-induced loss of situation awareness. They fixated on trying to get a tube in the trachea as opposed to other ways that they could deliver oxygen. The nurses came in, one of them brought the front-of-neck access kit, which was the move that should have been done, and announced it to the room, but received no response. And I think it just dovetails really nicely with this idea of two things. One is that the nurses later on in the investigation mentioned that they knew exactly what needed to happen, which was that front-of-neck access, but they didn't have the language or the tools to really bring that to the physician's attention. And this PACE model is one of the best ways that we know to do that. And there are other models, and we're gonna look at this in a medical context in the next episode or one of the next episodes with Dr. Katie Lynn, who's gonna come on and talk with us about that. But had they had this PACE, I think that would have been one thing. And we've also talked about the fact that this isn't just something that one person can necessarily implement. Of course, it's a tool that you can use, but we also need to know that people are gonna be supported, that there is a hierarchy here, and that nurses need to be able to feel comfortable on an institutional level, that they're not gonna face discipline and so on. And this is part and parcel of bringing true crisis resource management into medicine. They talked about not having the language for that, but you also mentioned the fact that you said a few keywords in there that I just want to highlight. One of them is tasked saturation leading to time compression, and the fact that one of the first things that goes is hearing. It is entirely possible that they just did not hear the nurses because of the phenomenon that was going on, as we saw in the aircraft accident where they didn't hear the altitude alert chime indicating that the autopilot had kicked off and that plane that ultimately crashed into the Florida Everglades. So these are phenomenon that we know happen and may have played a factor there.

SPEAKER_00 1:28:03

So thanks for bringing those things over and if I may just quickly mention Adam, um really really good point you brought up there, because think as you described that situation, line of sight is really big. So in my environment, I don't see the person sitting beside me unless I turn and look at their face. So sometimes it's very hard to get feedback on are they task saturated? And I have certainly seen in the training environment where that airplane can be yelling all sorts of warnings and I see that tunnel vision. And that's why the aircraft manufacturers, because they know audio is the first thing to disappear, is now the primary instrument that we look at, which is the one right in front of us, they're putting the big red words right on there. Because they know that hearing disappears so quickly when someone does get away from you give an example of that mic because I'm not can you give us an example?

SPEAKER_03 1:28:49

Let's say it was Eastern Airlines 401 or any of these other ones. So what kind of red lettering would we be seeing and what instrument are we talking about for those that are familiar with aviation?

SPEAKER_00 1:28:58

So for my pilots out there, your primary flight display and your attitude indicator, which is essentially showing you the horizon outside when you're in cloud you can't see anything outside. That's the main instrument that you're looking at. And we have had now for many many years these call-outs about terrain pull up obstacle ahead all these audio alerts and now what they're doing is red lettering right on there. The latest example I saw is Airbus has their new runway overrun system. So that would have been one where Air France had overrun in Toronto back in I believe 2004. They touched down too far down the runway at too high a speed the runway was wet and they slid off the end into the Etobicoke and the airplane was destroyed in fire. And so in addition now to it just verbally saying things like long landing as an audio, it will actually say runway too short in red letters right on the PFD so that the pilots will see that. So that's where they're kind of making some advances on that front. And I can imagine in an operating theater because that's obviously not my area but when you have a situation as Adam describes you're probably all looking in the same place. Are we looking at our our colleague look at their face are they overloaded? We try to think of in my world situational awareness as a flashlight beam and you talk about the stress response curve and the right amount of stress gives you the highest level of performance. You're understressed, you're not paying attention right this is for us cruise flight over the Atlantic somewhere and I'm like which cruise ship is down there? What am I gonna have for lunch? Right? But then you have a fire or some big thing that's when that beam of the flashlight narrows so tight that now you're actually missing important bits that are around it, which sort of is what I think Adam described there with that situation. So if we get people to the right amount of stress and that beam at the right size, now all of a sudden they're gonna improve the situational awareness and we think of the Venn diagram and all the people in the flight deck plus air traffic control plus the cabin or as Adam described the nurses, the doctors where now the situational awareness, the Venn diagram, all those overlap, now we're gonna get some better outcomes but we can't get there if we don't understand the human factors behind it.

SPEAKER_01 1:31:02

Sorry are you saying that as the degree of stress increases we actually increase our performance become more responsive to stimuli whatever become more attentive but then it falls off after a certain degree of stress. Is that correct?

SPEAKER_00 1:31:14

That is absolutely correct and then that's going to depend on each individual as well. You see this a lot in training right if you take someone that has two hours in an airplane and you're doing their very very initial training you can only put so much stress onto them with the exercises you're training. Whereas you take someone who has 10,000 hours in an airplane you can start giving them multiple failures at once and they have no problem managing it. And so that's what we're looking for in our colleagues is where they're at on that curve.

SPEAKER_03 1:31:40

It's an interesting point Mike because we see this in related terms that I don't even think we sometimes don't even have the language in medicine to really talk about this. One of the things you said earlier in the podcast was this idea of mode confusion and I thought oh my goodness we don't even have that concept in anesthesia at least not that I've seen this idea that well maybe my ventilator is in the wrong mode maybe my anesthetic machine is in the wrong mode. And you just had this fluency with this term that accurately described in a succinct way a whole host of situations. I think it's exactly this idea and sometimes we talk about related terms like cognitive load and I think if you asked a physician colleagues that worked in acute care settings they would say well my cognitive load was high and therefore these are the decisions that I made or these are the errors that I made and so on. And so we definitely see this cognitive loading as a similarly related term to this stress response. I do think it is interesting and I think one of the real values potentially one of the real benefits of incorporating a more formalized crisis resource management in medicine as we see in aviation is this idea that we would all have the tools we would have an increased number of tools and we would all have the same language with which we could talk about these things.

SPEAKER_00 1:32:47

If I may very quickly I'm just giving a shout out to Dr. Helmrich so he was the director at the Human Factors Research Project at the University of Texas. It ran from 82 to 2008 and that's where a lot of this came from so when we talk about data and these common terms what they were able to do was take the data, do the studies and then IATA which is International Air Transport Association so all your big airlines in the world, they did these line oriented safety audits so they'll have someone sit in a third flight deck seat behind the pilots and actually look for these errors and threats and what was captured and not captured. And all that data went back down to Texas and that's really where they started to not work through even just all the different generations but this last generation of threat and error management. So that's really where we get a lot of these these terms and things from a lot of really good work was done down there.

SPEAKER_03 1:33:36

I think for the most part funded by the Federal Aviation Administration in the US I love LOSA, the line-oriented safety audit and in medicine in the safety literature, we talk a lot about safety one versus safety two safety one being this idea that, well, here's what we're doing wrong that we need to fix and safety two being a lot of the here's what goes right and how we improve these outcomes and how we build on what we're already doing that's right. And I think LOSA is just one of those key tools that we could absolutely be doing. I can imagine a situation where we have essentially audits very similar to how they have in the airline world where you have that third pilot that's sitting there or at least that trained observer anyway that observes all these things. And I remember one of the key things for one airline that you and I used to teach way back when was somebody from their flight training days had this knee board, which is exactly what it sounds a little clipboard that sits on your knee that a lot of flight instructors would use from their small aircraft flying days that this was a first officer on a large airline that just brought their knee board along and it made the cockpit organization at the time when they used paper a lot more just a lot easier. And it was one of those things that they identified that we could potentially use to mitigate other errors and so on. And so I can imagine a situation in an operating room where someone is now observing me providing anesthetic after anesthetic and finding that these are the things that that might be going well that we could do or later on I could say oh well Amir's doing this that I'm not doing that well that would be really good to do.

SPEAKER_01 1:34:59

Yeah I wanted to go back because you know before we get too off I really like the discussion about it's going to ties back into pace. I really like the discussion about pace. I like bringing it back to the Elaine Bromley case. But I guess my question that I have for you Mike is like when you frame this pace language it was in the context of two people who are relatively equal in skill or technical proficiency but how does this actually apply when people aren't like if I'm doing um like if a surgeon is operating in the operating room and someone else identifies that a potential error they can't necessarily go and scrub in and grab the surgeon's hand and take over right like the example you gave is you have two people of fairly equal skill doing a technical task perhaps but what do you do if if if you don't have that can you go back and just round that out for us that one becomes a little more challenging and to be honest it's not our world that we're we're dealing with very regularly.

SPEAKER_00 1:35:47

The closest example I would have would again someone's coming in and making that assertive statement whether it be uh a cabin crew a ground handler and saying something doesn't look right and and us taking the time to reinforce that hey thanks for coming but this is the reason why it is okay if they're coming in and again depends where it is on the model because if it's that probing if it's just I haven't seen someone do that incision that way before why do you like to do it that way? Right? That could be a very inquisitive non-threatening kind of come in and that might prompt us to be like oh well I always do this when I do this type of thing but we're doing this type of thing today. That can be a place to come in if it really becomes an immediate safety issue the one is stop like something's not right. Let's just take a quick time out here.

SPEAKER_03 1:36:31

It's interesting because we don't have a lot of the formalized assertiveness tools that you guys have in aviation but I see a lot of medical learners and I think it's really important that we point out that medical students and residents while they don't have the same degree of training that staff physicians have they're incredibly smart and motivated people and sometimes out of self-preservation sometimes just because they are trying to learn they will often couch a lot of their inquisition as for my own learning could you explain why X or Z or X, Y, or Z and for example, you know, oh I haven't seen this kind of incision before can you tell me why you decided to do that or what have you is often how I see a lot of medical students and learners because they will assume that it's because they're there's a knowledge deficit on their part but it may in fact be that they have the right idea about something and they don't know necessarily how to bring it up or they don't feel safe in doing so because they're the low person on that hierarchy.

Use first names rather than titles to get someone’s attention

SPEAKER_00 1:37:26

One sort of aspect is if you reach that challenge stage because when you look at some of the examples you'll see it written as captain or doctor, right? It says get the attention of the individual the best way to get someone's attention is use their full first name. Because that is one of the first words they learned as a kid is what would say all the time to get their attention and even if you know the hearing is cut out because of task saturation they might not hear their title they will hear their first name it's a good point.

SPEAKER_03 1:37:57

I make sure when I'm briefing an airway especially if I'm training somebody I'll say because often they're emergency medicine residents that are coming for some airway experience and I will say okay you've been in let's say four operating rooms this morning alone do you know who this person is that is assisting you with this airway do you know their first name and they'll often say well no I don't do they know your first name and I'll say I'm Adam don't call me Dr. Shahade if we're the I'm trying to put the patient to sleep and you need my attention I'm Adam you're whoever and you're whoever and now we know each other's names and I can't tell you how much m easier it facilitates the idea of in an emergency setting I need this piece of equipment I need that. I think it's super super important.

SPEAKER_01 1:38:33

We're gonna slowly wrap up here but before we do that Amir is there anything that you wanted to ask Mike before we start to wrap up the conversation what advice would you give to like the medical community as a whole whether that be you know legislatures individuals physicians practice like what what can we be doing on the CRM front to improve CRM in medicine?

SPEAKER_00 1:38:54

Sure I'll try to keep it reasonably timed for you. One is just be aware that CRM isn't just aviation. I had the pleasure of getting off a cruise ship a few weeks ago watched your presentation from the executive officer and one of the terms that came up bridge resource management and it's just what it sounds like the shipping industry's taking this on. Oil and gas high risk industry they use it nuclear power generation they use CRM and SMS right so it's not just an aviation thing. Know your people know their background Adam had mentioned just the introductions and their names sometimes people come in with an amazing background that you're unaware of because maybe their official qualification level is a little bit lower or vice versa what can we get them involved with how much stock am I putting into what they're saying there that's a pretty big one as well. And work on the premise that errors happen, we're all human they're gonna happen you can't get rid of them. We got to accept it once it's accepted then we can move into this non-punitive or this just culture where people feel safe, free to share lessons learned then the systems can be improved and that's to the benefit of everyone right because you learn about individually what you could improve. The system gets fixed so a lot of other people don't make the same mistakes that improves your patient care or your output or whatever you're looking for right and then we start to reduce the number of errors in the first place.

SPEAKER_03 1:40:14

I gotta say Mike we really appreciate you coming on I didn't think this was going to happen but I've really changed my perspective from the idea of oh we need CRM in medicine to I think we should identify that we're doing a lot of the things already about CRM but it's practitioner dependent it's institution dependent it's jurisdiction dependent and we could really be doing in my mind a better job of formalizing a lot of this on a number of different levels. At an institution level hospitals other places where we do especially critical care things can implement different technologies they could also start a more formalized investigation in driving a lot of the data here on a policy level whether it's a province or even a country we could start by saying okay well we should have as they do in the UK and in Norway a more formalized incident investigation where they have an aviation style accident investigation. And then again the data would then drive the further inquiry into doing a lot of these other things. And then if you happen to let's say run residency programs, you could have instead of just the modules that people talked about, a much more formalized curriculum when it comes to baking in a lot of these crisis resource management principles in there. And now we talk about competency based medicine or competency based education theoretically we could one day be seeing the evaluation of crisis resource management skills into residencies. And just as we don't allow pilots to graduate or to become type certified or licensed or what have you without demonstrating good pilot decision making, workload management, communication skills, all the things that you've talked about, just as we don't allow that in aviation one day that might be the case in medicine as well. So we really appreciate that it's a big big topic we're going to have to have you come back at some point and and talk about a number of different things here. So thanks very much.

SPEAKER_00 1:42:11

Oh it's been my absolute pleasure to join you gentlemen and uh hope everyone's able to take something away from that thank you.

SPEAKER_03 1:42:17

If

If Mike could change one thing in aviation, it would be to bring these CRM/TEM concepts earlier into pilot training

SPEAKER_03 1:42:18

you could change one thing about the system that you work in what would it be and why?

SPEAKER_00 1:42:21

I would really like to see more focus on the human factors, the CRM, the TEM earlier on in a pilot's career back when they're a student because we're so focused on I need you to technically handle the airplane and then what happens is then those flight instructors work for smaller air carriers, eventually an airline and then they're loving their life there and they've learned all the wonderful TEM elements. And one of the things we're trying to do at my company as we recertify flight instructors through different professional development methods is to bring a lot of that TEM back down to that initial phase of training and really use that as a bigger foundation.

SPEAKER_01 1:42:55

I think that's really applicable to our world in medicine because I feel like these things mentioned early on in your medical career but you're so inundated with as you said the technical stuff whether it be the knowledge of medicine or whatever, having a more longitudinal focus on these things rather than just having a one-off lecture or showing the applicability as time goes on and revisiting it at different stages of training is something we can bring in and hearing you say that it's important I think is a fairly good ringing endorsement for doing that.

SPEAKER_03 1:43:26

Okay so in some of the next episodes we're gonna talk to Dr. Katie Lynn who's a critical care air transport physician stroke attending and emergency physician from Calgary she'll share some of her research into the escalation of language where there is a safety concern during resuscitation which was the focus of her Masters of Public Health where she earned from Harvard. We're definitely going to be talking again to Captain Mike Schuster but we'll do what we usually do around here which is we talk about a safety intervention worth mentioning and we'll talk about CRM in this case as a philosophy which does not require as we mentioned this institutional support. Of course it would be benefited by that but you can institute that as an individual practitioner whether or not you're a doctor, a nurse or another member who works in healthcare the who can do what tomorrow we talked about medical schools incorporating CRM or threatener management as a formalized curriculum, hospitals what they can do we already talked about department heads we talked about individual practitioners.

SPEAKER_01 1:44:23

Anything else to add on that point about who can do what mayor I think from an individual perspective I'm gonna start trying to implement Mike's suggestion about the PACE language and not only am I going to use it for myself but the staff I work with at all levels to to be more facile and implement that. You know it's all one thing for us to talk about it and get it out to our audience but I think it's also a different thing for us to actually bring it to the places that we work with and use this as a learning point for myself, Adam and whoever I'm missing. So I'm gonna take that away and start for lack of a better word teaching or educating people I work with that that's a tool and that I'm receptive to that because like Mike said in the beginning like the culture starts with us and we have to be open and willing to listen and what better way to do that than bring it to the table and and see people and lead by example okay and at this point we just try and make random recommendations or functions um do you have anything that uh you've been doing in personal life that uh you might want to just recommend people check out has nothing to do necessarily with medicine or aviation or anything like that I've been getting out a lot more.

SPEAKER_00 1:45:17

It was very easy for a few years there after the 2020 to be like well turn on the Netflix but rediscovering theater and live music and productions and that sort of thing. So it's it's nice to get out and see other people and really take in live entertainment.

SPEAKER_01 1:45:31

Excellent Amir I echo kind of Mike's point and say instead of just getting out into the world actually go outside. I know I've said this before but I know it's winter just bundle up get outside enjoy the sun when it's actually sunny it feels great. And as a pediatrician I worked with before said no such thing as bad weather only bad clothes as we head into a cold week here in southern Ontario I want to really echo that point and encourage everyone to bundle up but go outside and enjoy your time out there.

SPEAKER_03 1:45:58

You guys both kind of stole mine there so I'm gonna just gonna piggyback on that if you really prepare for it you can go there. My daughter was just on a big ski trip and let me tell you she bundled up it was about minus 30 Celsius it was extremely cold and windy but let me tell you she had the absolute time of her life. So just to piggyback off of that take your dog to a dog park go skiing do something out in nature there's actually a lot of really good literature that actually suggests that if we get a couple hours in nature every week that our moods are better. Okay and so that's it for this episode of the Medical T podcast for our guest Captain Mike Schuster I'm Adam Shahada and I'm Dr. Amir Hammond and as one TV doctor said what you have to say it's a beautiful day to save lives. Please consider following us on Twitter, Facebook Instagram TikTok we are looking for an intern to help do research and make show notes for the show as well as a producer to help with technical aspects such as mixing and editing as this podcast currently receives no outside funding these would start as volunteer positions but you never know what might happen in the future if people are interested and donate maybe it becomes a funded position this would be a great opportunity for medical students, residents, anyone interested in patient safety, critical care, anesthesia or even aviation. If you are a fan of the show please consider going to wherever you got this podcast and leaving us a positive rating it really helps people find the show. If you are interested in becoming a supporter of the show please consider going to patreon.com where you can become a patron of the show. Even if it's just a dollar or two, it makes a big difference and we really appreciate it. Remember lives are not just saved in the resuscitation bay countless more lives are saved by the diseases and errors that are prevented and by the work done by scientists, labs, clinicians and professionals like you working to make every day safer than the last. Thanks very much.

SPEAKER_00 1:47:47

And so here's the big question is how good is the pit for accuracy? That's my only reference to emergency medicine.

SPEAKER_01 1:47:54

One of my colleagues he's American and he worked in the US medical system for a long time he worked in Long Island especially in the emergency department and he's like yeah some of it is a little dramatized but he's like the volume of patients like the administrative burden where you have administrators come down in the middle of your shift be like where are your performance metrics?

SPEAKER_03 1:48:10

He's like I had flashbacks and his wife is like yeah we can't watch the show anymore like it's it's truly a traumatizing experience they left because they were getting burnt out and like we're triggered watching the show it's so funny because season two opens up with them doing something with a sim mannequin and I'm like oh that's Tersata point they need magnesium sulfate and then that was like the next line and I'm like okay all right interesting interesting they're really going for it it's good it's good yeah