Applying Crew Resource Management in EMS: An Interview With Capt. Sully

Capt. Chesley B. “Sully” Sullenberger is a speaker, retired airline pilot and accident investigator. He is the founder and CEO of Safety Reliability Methods, Inc., a company dedicated to management, safety, performance and reliability consulting. He is also the CBS News Aviation and Safety Expert and has authored two books, Highest Duty: My Search for What Really Matters and Making a Difference: Stories of Vision and Courage from America’s Leaders.

Despite these accolades, Sullenberger is probably best known as the captain of US Airways Flight 1549, which in 2009 successfully landed in the Hudson River following a bird strike and subsequent engine failure, an event that has come to be known as the “Miracle on the Hudson.”

Capt. Sully gained great fame for his part in that event, but not without a twist of irony: Much of the media hype focused on the actions of this one man—but in reality, it was an amazing demonstration of how technical expertise and nontechnical skills can come together through a relationship characterized by the concept of crew resource management (CRM).

As a pioneer of CRM in the aviation industry, Capt. Sully was quick to share credit with the other individuals who influenced the outcome of this event and acknowledged that CRM contributed to the remarkable performance of his crew. Having focused a great deal of my own scholarly efforts on the study of CRM, I reached out to Capt. Sully to get his perspective on the application of CRM in EMS and its potential for improving performance in our profession.

Defining Crew Resource Management

Carhart: There have been countless derivations of the original CRM model and even several definitions of CRM, but throughout my research and writing on the topic, I have come to my own hybrid definition:

Crew resource management is a team-oriented concept of error management that originated in the aviation industry and has since been adopted in other dynamic, high-risk and high-stress environments.^1–3 This system is based on the goal of improving safety through acknowledgment of human contributions to error and the implementation of effective strategies for resource utilization.^1,4,5 CRM training is intended to foster the development of social, interpersonal and cognitive (i.e., nontechnical) skills, which can be used together with technical (i.e., procedural) skills to address the deleterious effects of such factors as stress, emotion and fatigue on human performance.

Would you agree with that definition? If not, how might it differ from your own?

Sullenberger: Exactly, exactly. I’m sort of the poster child for all the things that you’re talking about. What happened that day was no accident. It was the combination of literally 40 years of effort and study, thinking about these important concepts and then trying to hone my skills—both technical and human—every day on every flight, to build a team, to create a shared sense of responsibility for the outcome.

I should say upfront that I’m not your run-of-the-mill airline pilot. I was a fighter pilot, Air Force Academy graduate, safety committee volunteer and accident investigator for the pilot’s union on major transportation accidents at my airline 25 years ago. I’ve done much more than just fly. I actually helped develop the first CRM course at my airline back in the ’80s and taught the very first course in beta form at my airline. I’m a lifelong learner, continuously striving for excellence, understanding that “just good enough” is never good enough. It’s not.

What we’ve essentially done in aviation is observe attitudes and behaviors, the way people interact when they’re doing their very best—the best captains and the best crews—and we cataloged them. Then we taught everyone else to be almost as good as the best by giving them this very structured, well-defined, well-understood aviation vocabulary, where a single word can be rich with meaning. We had to first create a team of experts and then create an expert team; those are different skills, but they’re critical skills so that we’re not acting as individuals, we’re acting in concert. We’re coordinating individual efforts toward common goals.

By giving everyone a paradigm of how to relate to each other, how to handle situations, how to handle any emergency in an airplane, even if it was one we’d never specifically trained for, then based upon learning lessons from historic accidents, we not only understand the “what” and the “how” but the “why” of what we do. That knowledge of the “why” is so important. It helps motivate us, why it’s important to do these things and how many people died to give us that knowledge.

It also helps us to set clear priorities in unfamiliar terrain, things we never specially trained for. That’s literally what we did: We forced calm on ourselves, that kind of practiced, professional calm in this situation, because I could feel my blood pressure and pulse shoot up, and I got tunnel vision because of the sudden stress. Especially after almost 30 years of routine airline flying, where we try so hard to never be surprised by anything. Then we were suddenly confronted by this challenge of a lifetime. We had 208 seconds to solve something we’d never done before and get it right the first time. It wasn’t actually calm, it was having the discipline to compartmentalize and focus on the task at hand despite all the stress.

At the end, even though it was emotionally difficult to hear the engines spool down and the terrible noises coming from the engines as they were being damaged, and then the silence of the thrust loss, I was very proud of how good we sounded. I’ve read the transcripts of many accident flights, and so many of them sound rushed or confused or overwhelmed, quite frankly. Ours didn’t. We sounded organized. We sounded like we were working the problem, and I was very proud of what we were able to accomplish.

The Role of Checklists in Crew Resource Management

Carhart: Pilots routinely utilize checklists for a variety of procedures, but EMS providers seem to have a negative perception of checklists. They seem to be viewed as a weakness or a crutch we don’t need. I agree we should have expertise to perform without them, but as aviation has shown, they are essential tools. What are your thoughts on this apparent opposition to the routine use of checklists in EMS?

Sullenberger: I think it’s wrong. We’ve been using checklists in aviation since 1935. Checklists are a simple, inexpensive intervention that can formalize best practices when used properly—with leadership, team skills and in the appropriate culture. Those are all big caveats. I think one of the reasons checklists haven’t been adopted more widely and the beneficial aspects haven’t been realized in medicine is that in medicine, quite frankly, in many areas the leadership, team skills and effective culture do not exist.

It’s not the list itself that’s so effective. The list is simply a way to focus individual intention toward group goals. It’s a way of formalizing best practices. It’s a way of literally getting everyone on the same page. It’s a way of making sure you can take all the things we’ve learned in journal articles and put them in a useful form in five or maybe seven steps that can, when used consistently, lead to substantially better outcomes, whether it’s a central line insertion or something else.

There are certain steps that, when followed religiously, will lead to a 40% reduction in harm, for example. But it takes all the human skills that go along with the effective use of it to really make it successful, and I think those are the key parts that are missing in medicine and why it has not been adopted. It goes back to “I have to do everything by memory and be the fountain of all knowledge, and I can’t show any weakness or appear not to know everything I need to know”—that machismo bullshit doesn’t serve us well.

What I tell professionals, whether they’re nuclear power control room operators, financial risk managers, airline pilots or medical professionals, is that if you think you must appear to be infallible, if you think you must be a solo act, if you think you cannot let anyone assist you or correct your mistakes or point out to you something you didn’t notice that’s important, then ultimately, given enough time, given enough trials or challenges, you will fail. It’s inevitable. And when you fail, you may fail spectacularly.

The way to avoid that is to flatten the hierarchy to an appropriate level, to open channels of communication, to solicit input, time permitting, to share information, to manage your workload, to make better decisions. It’s these human skills that allow that to happen. Then the checklist isn’t a crutch. It isn’t for the weak and lame, for those who haven’t done their homework. It’s a way of getting right, every single time, something that needs to be done right every single time. We shouldn’t rely on our memories alone. We should make the routine easy. We should let the crises be hard. And using the checklist and doing it the right way every flight, every day or every run, it’s what we owe to our passengers, it’s what we owe to our patients.

What’s interesting to note in our event was that within about two seconds of the thrust loss, I had taken by memory the first two important remedial actions that we were not required to have committed to memory as a boldface memory item. But because of my in-depth study of the systems of the airplane, because of my knowledge of my machine, I knew we would eventually get to them on this checklist, which encompassed three pages and was designed to be used at 35,000 feet, where you had nearly half an hour complete it.

I announced to Jeff [First Officer Jeff Skiles] what I was doing. I said, “Ignition start. I’m starting the APU [auxiliary power unit],” and then I said, “My aircraft.” He said, “Your aircraft.” I said, “Get the QRH [quick-reference handbook], loss of thrust on both engines.” It turns out that checklist was not a perfect fit for our situation, but it was the most applicable one we had. We had to take an imperfect intervention and adapt it to fit our situation. Again, on the fly, never having specifically trained for that scenario.

Carhart: That’s probably a reality with any checklist designed for a specific situation, but it can at least be a starting point.

Sullenberger: Yes, it’s a place to start. You see, the way I describe this is, we didn’t have time in those 208 seconds, from when we hit the birds and lost thrust until we touched the surface of the earth. We didn’t have time to reinvent the wheel, but because for 40-plus years before we had built our teams, taught captains how to be leaders, created this structured aviation vocabulary, we had well-defined roles and responsibilities.

We had begun in our simulators to not assume there would be a perfect checklist that was a fit for every situation and to not assume that when you finished the checklist you’d have solved all the problems. We’ve taught ourselves to learn how to adapt, so we didn’t have to put the entire wheel in place, we just had to put the last three or four spokes into place, and that’s all we had time for. It was important that we had done all this preparation individually and as a profession for decades before that allowed us to have such an amazingly good outcome in such a high-stress, high-workload, time-compressed situation.

Using Simulation to Improve Safety

Carhart: How important is simulation in achieving those goals?

Sullenberger: It’s critically important. One of the many challenges in airline flying is how safe it’s become. It’s become ultrasafe. It’s become extraordinarily routine. In fact, it’s possible for an airline pilot now to go through an entire 30-year career and never experience in-flight the failure of even a single engine. It’s critically important that without that kind of real-world chance to practice, you have to do it someplace else.
Simulation is critical in medicine and aviation. It’s also critical not just to master your craft, but to master yourself and understand and control your own response. You miss things. You can’t have the awareness you need, but with practice and exposure…focusing on the fundamentals, the results will follow, but it takes preparation, exposure and practice.

When you’re practicing dogfighting in jet fighters, like I used to do, at first you can’t remember anything that happened—which way you turned, what next maneuver the opponent took. With practice you can begin to be aware of and remember and deconstruct the engagement after the flight and debriefing. At first you’re overwhelmed, but after a while you can be aware of more things until finally you can remember everything that happened pretty accurately. That’s the level of situational awareness you have to have.

Benefits of Crew Resource Management in EMS

Carhart: My dissertation focused on the use of CRM training to reduce medical errors in a simulated prehospital environment, and I found the participants who took part in that training demonstrated improved scores for teamwork, task management and decision making. But there was not a statistically significant difference in the number of medical errors committed between the participants who had the training and those who did not.

In 2014 Irish researcher Angela O’Dea and her colleagues published a meta-analysis that looked at CRM training in acute care settings and reported that despite the findings of behavioral changes produced from CRM training, it has yet to translate into actual improvement of clinical outcomes.2 You can argue that aviation experienced great success with CRM because pilots are invested in the reality that if the plane goes down, they go down. Medical providers don’t necessarily suffer the effects of the error they commit. We still have this great challenge ahead of us, but obviously there have been behavioral changes documented and observed from this process. What is your outlook on the potential of CRM to improve performance in the prehospital environment? Do you think it has the potential to make a difference in clinical outcomes, even though we’ve yet to actually capture it?

Sullenberger: Absolutely. There are many reasons we haven’t yet. I think in some domains, and medicine is probably one, it requires top-down leadership—psychological buy-in from the top of the organization all the way to the bottom—and it requires bottom-up engagement from the front-line workforce. I also think there’s not enough effective team training and not individual training on CRM-type skills. They don’t get enough simulation, role-playing and practice reinforcement.

I think the financial incentives are not aligned for quality and safety in medicine. I think for all these reasons, the essential elements that need to be present for CRM to take root and to flourish do not exist. You could have the most robust plant or seed and water it, but if the soil isn’t good enough, if it’s too much in shade, whatever, if all the other conditions aren’t there, it won’t flourish. I think that’s what we’re seeing now in medicine.

References

1. Helmreich RL, Merritt AC, Wilhelm JA. The evolution of crew resource management training in commercial aviation. Int J Aviat Psychol, 1999; 9(1): 19–32.

2. O’Dea A, O’Connor P, Keogh I. A meta-analysis of the effectiveness of crew resource management training in acute care domains. Postgrad Med J, 2014 Dec; 90(1,070): 699–708.

3. Oriol MD. Crew resource management: Applications in healthcare organizations. J Nurs Adm, 2006 Sep; 36(9): 402–6.

4. Carhart E. Effects of crew resource management training on medical errors in a simulated prehospital environment. Dissertation, Nova Southeastern University, 2012. Available from: ProQuest Dissertations and Theses database, UMI No. 3534980.

5. International Association of Fire Chiefs. Crew Resource Management: A Positive Change for the Fire Service, www.iafc.org/files/1SAFEhealthSHS/pubs_CRMmanual.pdf.

Suggested Reading

Carhart E. Origins and Applications of Crew Resource Management: The Role of CRM in EMS. EMS Reference, https://emsreference.com/articles/article/origins-and-application-crew-resource-management.

Elliot Carhart, EdD, RRT, NRP, is the EMS performance and research coordinator for Pinellas County EMS & Fire Administration in Largo, FL, an associate professor of emergency services at Jefferson College of Health Sciences in Roanoke, VA, and a member of the EMS World editorial advisory board. Contact him at researchmedic@icloud.com.