Crew Resource Management and EMS

   In the late 1980s, there was a series of airline accidents caused by strings of errors and critical breaks in communication between crew members. In one example, a landing gear malfunction caused the crew to focus on the mechanical problem and getting the cabin crew and passengers ready for a possible gear-up landing. The cabin crew was supposed to advise the captain when they were ready, but due to a communication breakdown never did. The plane ran out of fuel only a few miles from the airport as the pilot waited for the cabin crew to report that they were ready.

   Does this type of thing happen in EMS? Many times we might get our attention diverted to a piece of equipment that is not working properly and inadvertently skip priorities like scene safety or airway management. Medication errors are all too easy to make, both in the field and at the hospital. Often, we call medications by one name, yet they are labeled something different. We are all familiar with the name Benadryl, but it may be labeled in your drug box as diphenhydramine.

   We must understand that we will always have practitioners with different levels of experience helping us, and they might never have been trained in doing what we ask them to do. Do you store your bag of normal saline in the same compartment as the bag of lidocaine premix? If so, it would be easy to grab the wrong bag and give a bolus of lidocaine instead of saline! Sure, we need to verify the type of fluid given to a patient prior to starting the IV connections, but a little human-factors error trapping can prevent this kind of potentially fatal mistake.

   The person in charge of the scene has a different level of experience than other crew members, but should not talk over the heads of colleagues. Sometimes we inadvertently punish each other by using terms that are simply not understood with people who are reluctant to ask for clarification. Good Crew Resource Management (CRM)--an airline practice many have applied to benefit EMS operations--would be to ask if you don't understand.

CRM vs. Healthcare

   Preventable accidents were the basis for developing CRM. Actually, it was originally called Cockpit Resource Management and concentrated on coordination within the flight deck only. This was found to be lacking, as the cabin and ground crews are just as important in the process of flying safely.

   Does this concept fit with EMS? Yes and no. Airline staff operate as crews: There is a flight deck crew, a cabin crew and a ground crew all working at the same time. The closest we in EMS come to a common term is healthcare providers. This includes all the paramedics, EMTs, dispatchers, first responders, firefighters and even the staff at the emergency department. The term healthcare provider certainly does not evoke a mental picture of teamwork or a crew working together. This is a problem.

   In EMS, it is not just the paramedic and EMT who are important to the CRM process. Good resource management involves family members at the scene, fire and police personnel who may have responded, dispatchers, medical control and ED staff, to name a few.

   So where do we start? Well, at the beginning of the shift or flight you need to set the tone for the work day. If I have not worked with a person before, I will ask them about their background and experience and tell them a little about myself. I tell them I make mistakes from time to time, and if they are uncomfortable with something or don't understand what we are doing, to simply ask.

   If I am not in charge, the same process applies. If the person in charge does not mention these things, I do. I ask a new partner if they have anything specific they like to do on calls. Some paramedics like to carry the equipment into the house to the patient, while others prefer minimal equipment be brought in and most procedures performed in the back of the ambulance. Neither way is wrong, but asking gives me a better understanding of what to expect.

   As we go along on the call, I will update my partner on what we have, or think we have, and open the door for him to provide any information pertinent to the situation. This is actually a very critical step. For example, in an airplane I might say, "Crew, we have an engine failure on No. 2. We are going to climb to a safe altitude and then run the checklist." The other crew members may have seen the hydraulic and electrical failures but not noticed the engine failure. They were thinking only of resetting the generator and turning on the backup hydraulic pump instead of the engine not producing thrust.

   You may have been called out to a heart attack, but after arrival on scene discovered what you thought was an aortic dissection instead. This involves a completely different treatment--which leaves the rest of the crew, the family and firefighters thinking you're doing a terrible job treating the heart attack. I would like a large-bore IV on the scale of a 14-gauge, and my partner thinks that is way overboard and painful for a person with a heart attack. What should I have said, and what should my partner say to clarify? Right now we don't seem to be on the same page.

   One of the key components of CRM is recognizing that you should provide others with information, and solicit it from them as well. For example, while running a cardiac arrest, the lead paramedic says, "Everyone shut up, I need to concentrate." From a CRM perspective, this would be totally wrong. Perhaps the EMT or firefighter has a list of the patient's medications that hints at hypoglycemia as the cause of their cardiac arrest. You can calm the scene without shutting down all communication.

   Perhaps it's better to say, "The patient is pulseless and apneic, and we want good CPR and ventilations. Let's keep the voice level at a normal volume, please. Does anyone have any information as to the cause of the arrest?"

   There are a few phrases in the cockpit (and an ambulance) that are absolute red flags and demand the captain's (paramedic's) immediate attention:

• "I have no idea what you are asking me to do."
• "Is this legal?"
• "I am totally lost."
• "Who's in charge?"

   What do you do when you hear something like this? The person in charge needs to recognize that there is a problem and clearly state both the situation (e.g., possible heart attack, three trauma victims, etc.) and a plan of action with priorities. Finally, they must provide specific assignments for team members:

   "We have three trauma patients. The male in the driver's seat is our top priority for treatment and transport, and all need to be trauma packaged. The second unit to arrive will take the passengers in the backseat, who have minor injuries. Both of you guys bring the trauma equipment for three patients. Let's work together, and if you see something that concerns you, speak up. Questions?"

   Have you ever been on an EMS call and, in bringing the cot into the house, been told by your partner, "We need to hurry." You probably complied, but didn't have a clue why. What you may have missed was that the patient, by his signs and symptoms, may have had something like an aortic dissection. By not knowing, you might have handled the patient more roughly, for the sake of that requested speed, than you would have otherwise.

   One of the greatest fears in the beginning of CRM was that the airline captain would lose his command authority. This turned out not to be the case. In a medical emergency, the other responders want leadership and direction. If you are in charge, give it to them. This might include correcting others' mistakes. People get excited at cardiac arrests and might be doing the ventilations or compressions too fast. This can be corrected without abusing the person. At the moment, you might not have time to explain all the reasons why, but you must follow up later with an explanation.

   Frequent recaps of where you are, what you've done and what's next are critical to the process. These allow people to error-trap things that should have been done. If a person is gasping for breath and can only speak in two-word sentences, I will start the B of breathing with oxygen via a nonrebreather mask. A pulse oximeter is not high on my list of things to do for this call at this moment. The O2 needs to go first. On other calls, getting a room-air O2 saturation is appropriate. Could I have overlooked the pulse oximeter completely as I worked to perform the other procedures? Of course--I am human.

   What about afterward? Recap the call and discuss it openly! After an EMS call or a flight from JFK to Europe or Asia, I talk with the other crew members about what we did well and what we could have done better. If there is something you'd prefer other crew member did differently, this is the time to mention it. This will open the atmosphere for discussion and bring problems folks might not have been aware of into the open.

   Dick Blanchet, BS, MBA, has worked as a paramedic for Abbott EMS in St. Louis, MO, and Illinois for more than 20 years. He is also an airline captain on a Boeing 747 with more than 17,000 flight hours.