Your Captain Speaking: Memory Fails, But a Checklist Is Forever

Back in 1935 Boeing unveiled a state-of-the-art airplane. It was stunningly ahead of its time. It was a magnificent design, in perfect working order. The test pilots who were to fly the new B-299 were highly trained and experienced.¹ 

With a large audience watching its initial flight at Ohio’s Wright-Patterson Air Force Base, the pilots added power for takeoff, became airborne, and then crashed after climbing only a few hundred feet, killing two of the five-member crew. Airborne for only seconds—how could this happen? Did their mistake have an application to EMS? 

At the time the B-299 (later known as the B-17 Flying Fortress) was a very complex airplane compared to other airplanes. The pilots were some of the best in the world, yet they made a basic mistake: A control lock on the yoke had not been removed before the flight, and they could not move any control surface. That basic mistake cost lives.

As EMTs and paramedics we also work in complex environments. The wide range of illnesses, injuries, medications, procedures, and equipment we see and employ is simply astonishing. Be honest with yourself—have you ever put oxygen on a patient but somehow didn’t notice it wasn’t flowing? Maybe the oxygen tank was empty or not turned on, and pressure in the line made you think it was on? It’s a mistake I’ve made! (I changed by starting at the tank, turning it on, setting a flow on the regulator, connecting the mask/cannula, checking it for flow, then putting it on the patient—a flow pattern.)

The Boeing crash was a big turning point in aviation: In response Boeing developed the “humble checklist.”² Before that, checklists were not used. Why not? Many times in human activities, if a mistake is made, the proposed solution is simply, “They need more training.” It’s a reflexive reaction, but it’s not the answer for either aviation or EMS nowadays. 

After the crash, Boeing knew more training was not the solution. These guys were the best there was. So they developed a written checklist. But just giving people a checklist will not work; it’s been tried and failed: “I know what I’m doing. I don’t need a checklist.” However, if we look at complex situations where the cost of mistakes is high, the results are apparent.

A simple example is infections due to catheters in a hospital setting. At one time infections were thought to be unavoidable, even though people died from them. A checklist was developed for inserting IVs, but it ran into problems. Some of the equipment needed—such as the IV, tape, gloves, gowns, alcohol wipes, betadine, a sink to wash your hands, etc.—were not in a central location, so some steps were skipped. Nothing got better. But when these logistics were resolved and the people involved were shown how and why there was a checklist, the results were simply amazing: “Within three months after implementation, the median rate of infection was 0, a rate sustained throughout the remaining 15 months of follow-up.”³ They dropped their infection rate to zero for the remaining 15 months of the study!

How about a vehicle checklist that includes checking the ambulance’s tire pressure? We can agree that having the correct tire pressure is important, but what if when you run the checklist, there’s no tire gauge to be found? Rather than wasting time looking for one, you might skip it and go on to the next item. That’s a checklist failure due to organizational reasons.

The next time you fly on an airline, would you prefer the pilots perform the landing checklist by memory? Skip it altogether? They look capable. After all, it only has three items: speed brakes armed, landing gear down, and flaps. 

But this is not how pilots do it. One pilot reads the checklist from a card, and the other responds with the settings. Challenge and response. I have never called “landing checklist” and had the other pilot recite it by memory. They always refer directly to the checklist.

That is the culture in aviation today. Did it take time to develop? Certainly. Writing a checklist is a balance between too little, too much, and the wrong stuff. Running a checklist takes learning and discipline. What happens if you’re interrupted in the middle of a checklist? Picking up from where you left off seems right but has long history of tragedy. Instead you start it all over again. It takes an understanding that even though you’re good at what you do, memory can fail at the worse times. 

References

1. Aviation Safety Network. ASN Wikibase Occurrence #83555, https://aviation-safety.net/wikibase/wiki.php?id=83555.

2. Temple K. The Checklist: A Global Tool That Works. Infection Control Today, https://www.infectioncontroltoday.com/articles/2014/03/the-checklist-a-global-tool-that-works.aspx.

3. Pronovost P, Needham D, Berenholtz S, et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. N Engl J Med, 2006; 355: 2,725–32.

Capt. Dick Blanchet (ret.), BS, MBA, worked as a paramedic for Abbott EMS in St. Louis, Mo., and Illinois for more than 22 years. He was also a captain with Atlas Air for 22 years and a USAF pilot for 22 years.