Your Captain Speaking: Take It From the Top

I’m on scene with one of those patients and families where, whenever I ask a question, a minimum of three people give conflicting answers, and arguments result. The family is well meaning but is driving me nuts! Thankfully my partner, Becca, has a steady, patient, and calm demeanor. 

ABCD runs through my head: airway, breathing, circulation, do something!—an old-school mnemonic for sure. We have the information we need (we think) to give the patient the proper medication. Our organization utilizes a medication checklist protocol I’ve come to appreciate. I say to Becca, “Let’s run the medication checklist for D50.”

More and more evidence shows how the simple and consistent use of a checklist for routine matters can greatly reduce errors and omissions. One of the best sources on this is The Checklist Manifesto: How to Get Things Right by Atul Gawande, MD.¹ After reading that book it is easy to understand the importance of checklists in the medical field. But there is one point not discussed in the book: interruptions.

Back to our scene. Per the written checklist we have confirmed several items: correct patient, correct indications, correct method of delivery (IV, PO, IM, etc.), correct medication and expiration date. Just as I’m about to respond to an item, a family member grabs me by the shoulder to remind me that we need to “Do something!”

“Yes, thank you. Becca, let’s continue the checklist where we dropped off.” This is a terrible mistake on my part! Fortunately Becca knows better, and knows what to do next and why. 

For the past 50 years, since I started in aviation, it’s been standard to use checklists. It is also a standard that when you are interrupted, you have two choices:

• Restart the checklist from the beginning; 
• Ignore the interruption until the checklist is complete.

Nowhere in this list is the option to continue the checklist where you dropped off. Pilots know that attempting this will often result in picking the wrong place to restart and skipping a step. Often this is a critical step. 

We tried other approaches in aviation. We tried putting our thumb on the last item and going back to that. It didn’t work. First, it leaves you with just one hand, and sure enough, you’re going to need both. Second, thumbs seem to have feet and can move on the page. We tried using a grease pencil to tick off each item as we completed it. It was just a mess. It took both hands, and few people cleaned up the checklist when they were done, so they were grease-pencil messes too. Steps were missed that turned out to be critical.

Here’s the solution: Announce the title of the checklist and start from the top. “Medication checklist D50.” This does several things. First, it affirms we’re running the correct checklist! It is better to be a little slow with the correct checklist than do the wrong checklist really fast. The announcement also denotes we’re starting over from the top, which is what I should have said! After the call I’ll tell Becca that was perfect. We’ll quickly revisit the items we’ve done without the risk of skipping one or more.

Ignoring the interruption is often a good choice. For example, Becca is on the fourth item in the checklist when her radio crackles with a question about our off time. We just continue with the checklist as it never happened. Some interruptions must be attended to; for instance the family members demanding answers need to be addressed. Ignoring them will result in more challenges. If the scene is no longer safe, attend to that change. 

How do we know that the checklist is complete? Again take the lead from aviation: At the end of the procedure, verbalize the name of the checklist and the word “complete.” In this case, “Medication checklist D50 complete.” There is an argument in the aviation community whether the correct word to use is “complete” or “completed.” To me it seems to miss the bigger point. Bigger fish to fry.

Anyone who works in EMS knows we must deal with interruptions and distractions. Staying on track is important, but so is recognizing changes in the patient or environment. 

In this particular example, a very critical step in giving D50 is to verify that the IV is flowing freely. It was when the IV was started, but that was several minutes and numerous interruptions ago. By starting over at the top of the checklist, we may have avoided a very serious error. 

Take an example from Becca: If you’re interrupted while doing a checklist, run it from the top and don’t try to remember where you left off. It’s a proven concept. There’ no need to reinvent the wheel.

Reference

1. Gawande A. The Checklist Manifesto: How to Get Things Right. Metropolitan Books, 2009.

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 with more than 21,000 flight hours.