Crew Resource Management Module

Transcription

1 Crew Resource Management Module Knowledge Objectives: CRM At the end of this module the student should: Understand the origin and progression of CRM as it relates to medicine Be aware of areas of pre-hospital care where CRM is especially important Be able to give examples of good CRM in pre-hospital care Be able to list the key components of good CRM Case Study Air Florida Flight 90 was scheduled to leave Washington National Airport at 14:15 EST for a flight to Fort Lauderdale International Airport, Florida. A heavy snow fall and freezing temperatures had delayed the departure of the flight. Once departure had been rescheduled, the aircraft was de-iced and secured, the jet way was retracted and the crew received push-back clearance. A combination of ice, snow, and glycol on the ramp prevented the tug, which was not equipped with chains, from moving the aircraft. The flight crew, contrary to flight manual guidance, attempted to use reverse thrust to move the aircraft from the ramp. This caused snow to be blown up from the ground and settle on the aircraft. This manoeuvre was unsuccessful and eventually a replacement tug with chains was able to move the plane from its ramp. With the snow and ice that had settled on the plane the crew, again contrary to flight manual guidance, attempted to de-ice the aircraft by intentionally positioning it near the exhaust of the aircraft ahead in line (a New York Air DC-9). This may have worsened the adherence of ice on the wing s leading edges and may have led to the blocking of the engine s Pt2 probes. At 15:57:42, after the New York Air aircraft was cleared for takeoff, the captain and first officer completed the pre-takeoff checklist. Takeoff clearance was received at 15:58. During takeoff the first officer expressed concern that something was 'not right' to the captain, in spite of this the captain took no action to reject the takeoff. The aircraft accelerated at a lower-than-normal rate during takeoff. It required 45 seconds and nearly 5,400 feet of runway to reach lift-off speed, 15 seconds and nearly 2,000 feet more than normal. The aircraft s stall warning activated almost immediately after takeoff and the aircraft failed to accelerate after the initial climb. At about 16.01, the aircraft struck the heavily congested northbound span of the 14th Street Bridge and plunged into the ice-covered Potomac River. When the aircraft struck the bridge, it hit six occupied cars and a truck before tearing away a 41-foot section of the bridge wall and 97 feet of the bridge railings. Seventy-four of the 79 people on the plane were killed. Four persons in vehicles on the bridge were killed and four were injured, one seriously. The plane was completely destroyed.

2 BACKGROUND The investigation following the crash described in the case study above identified a serious of human errors that contributed to the crash. The report highlighted the failure of the pilot to respond to the crew s concerns about the de-icing procedure. This incident led to a number of reforms in pilot training regulations. It became a widely used case study for air crews and was one of several high profile aviation incidents that lead to the development of CRM as a concept. CRM initially stood for Cockpit Resource Management. The concept developed in the aviation industry as air accident investigations began to analyse newly-installed flight data recorders and cockpit voice recorders. These devices revealed that many accidents are caused by the inability of crews to respond appropriately to the unexpected situation in which they find themselves. Poor communication coupled with a loss of situational awareness would lead to a breakdown in teamwork leading to bad decision making and ultimately resulting in catastrophe. Emergencies faced by aviation crews that call for such rapid decision making in quickly evolving and sometimes unpredictable situations can be compared to some medical emergencies. This is particularly relevant for teams working in pre-hospital care. Over time the concept of CRM has progressed and is now understood to stand for Crew Resource Management incorporating not just the cockpit but the whole aviation team. CRM is now increasingly used in medical training and is widely regarded to be crucial in the preparation of London s Air Ambulance doctors and paramedics who frequently encounter emotive and highpressure medical emergencies, often in an unpredictable environment and with an unfamiliar team. ORGANISATIONAL CRM Effective CRM is implemented and endorsed at management level and plays an integral part in the daily operation of the organisation and in its quality management and governance systems. Good CRM includes the establishment of a positive safety culture, risk mitigation with identification of system weaknesses in areas of high risk, and training and fatigue management. All staff are empowered to voice any concerns relating to any aspect of their work. The lowest-paid worker must feel that he or she has just as much right to raise safety issues as the highest paid manager.

3 PERSONAL CRM Ultimately it is the individuals within the organisation that must take responsibility for practicing good CRM. Understanding some of the lessons of CRM helps to improve communication, work efficiently and safely, and ultimately increase the likelihood of coping and making safe decisions in stressful situations. Personal CRM concepts Bandwidth Bandwidth is a metaphor that can be used to describe the total cognitive processing potential of an individual. Bandwidth is the capacity of an individual to perform multiple tasks simultaneously. Tasks that take up bandwidth include practical procedures or motor tasks (more bandwidth is taken up with increasingly complex or unfamiliar tasks), listening to somebody speaking or processing multiple pieces of information in order to reach a decision. Our bandwidth is affected by our level of concentration. The more we are able to concentrate, the greater our bandwidth. Conversely, the more stressed we become the less able we are to concentrate, and our bandwidth shrinks. As our bandwidth becomes overloaded the more stressed we become and this becomes a vicious circle. Once our bandwidth is saturated we cannot take in any new information or take on any new tasks. A common early sign of bandwidth saturation is the inability of the person to process things that are being said to them and this is perceived as not listening to advice by those around. It is important for us to recognise bandwidth saturation in ourselves and our colleagues because at this point, decision-making is critically impaired. In the pre-hospital environment, a key skill is to recognise those who have spare bandwidth and those who are displaying signs of bandwidth saturation. Complex and important tasks can be given to the person with the greatest free bandwidth, and steps can be taken to help those who are already working at their peak intensity.

4 What to do if your bandwidth is overloaded 1. Stay cool under pressure The less stressed we are the greater our bandwidth. The LAA teams are exposed to major trauma and emotive scenes on a regular basis and this intensive exposure and experience can help crews cope. 2. Pattern processing Unfamiliar tasks are inherently more stressful that familiar tasks that are more routine to perform. LAA teams are exposed to major trauma on a daily basis and skill sets are learned and become more familiar. LAA training scenarios replicate the pressures of real scenes so that patterns and skills can be learned in a relatively safe environment. Refer to: Bredmose et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2010, 18:13 for a description of LAA simulation training and the zone. 3. Load sharing Load sharing is a critical skill to acquire to ensure pre-hospital scenes are managed quickly and safely. Efficient scene management involves delegation of tasks, direction of simultaneous activity, and reacting to colleagues needs as their bandwidth becomes saturated. By sharing the load, decision-making is improved. Person to person communication Communication is one of the crucial components of safe medical practice, particularly in the prehospital environments when working with a range of emergency service personnel. Clear and concise instructions using names can cut through a busy scene and ensure that tasks are completed. Individuals who are bandwidth-saturated may not be able to process spoken instructions. It is important to recognise this and take steps to offload their stress. Identify these individuals, use their name, make physical contact and give them simple instructions to complete a task that they are more comfortable performing. Asking for instructions to be repeated back or asking the individual to report back when they have completed a task can help to ensure that communication is properly passed and understood.

5 Situational awareness Situation awareness involves being aware of what is happening around you to understand how information, events, and your own actions will impact your goals and objectives, both now and in the near future. Lacking situational awareness has been identified as one of the primary factors in accidents that are attributable to human error. Situational awareness is therefore critical in environments where information flow can be quite high and poor decisions may lead to serious consequences. In the pre-hospital environment, good situational awareness is possible by taking a complete overview of the scene, preventing bandwidth saturation, and the avoidance of becoming taskfocused (see below). The processing of all of this information, whilst maintaining the ability to make good decisions allows the correct plan to be formulated and executed first time, and this ultimately benefits the patient. Actions can be taken safely, the next few steps are anticipated, and the scene can be driven towards an appropriate goal. Ultimately good situational awareness means that the patient receives the treatment they need in the most effective and efficient manner. Task focus Task focus is when an individual becomes focused entirely on one task. That one task may occupy the whole of that individual s bandwidth and situational awareness is lost. By focusing on only one task the practitioner is more likely to be successful and quicker, but it is impossible for a team leader to become task focused and maintain overall control of the scene. Good team leaders will always allocate tasks to team members while trying to stand back themselves to keep an eye on the bigger picture. Some tasks, such as the delivery of an emergency anaesthetic, require the LAA team to become temporarily task focused. If the team is briefed well prior to this task, situational awareness can be maintained because everything stops until this critical task is completed. Flattened Hierarchy Flattened hierarchy is a very important concept within good CRM. It is the empowerment of every member of the team to both participate in and question decision making. It depends on junior team members feeling able to speak up and senior team members being receptive to both ideas and constructive criticism. There are numerous well documented of catastrophe during or leading up to which junior team members had either mentioned worries and were ignored or had noticed that something was not right but did not feel confident to enough to mention it to senior colleagues.

6 CONCLUSION Case Study United Airlines Flight 232 was a scheduled flight between Denver and Philadelphia. On 19 July 1989, the flight suffered an uncontained failure of its number 2 engine which destroyed all three of the aircraft's hydraulic systems. With no controls working except the power levers for the two remaining engines, it broke up during an emergency landing on the runway at Sioux City, Iowa, killing 110 of its 285 passengers and one of the 11 crew members. Owing to the skill of the crew and a DC-10 instructor pilot, 175 passengers and 10 crew members survived the crash....the preparation that paid off for the crew was something called Cockpit Resource Management. Up until 1980, we kind of worked on the concept that the captain was THE authority on the aircraft. What he said goes. And we lost a few airplanes because of that. Sometimes the captain isn't as smart as we thought he was. And we would listen to him, and do what he said, and we wouldn't know what he's talking about. We had 103 years of flying experience there in the cockpit on that day, trying to get that airplane on the ground, not one minute of which had any of us actually practiced for this kind of emergency. So why would I know more about getting that airplane on the ground under those conditions than the other three. So if I hadn't used CRM, if we had not let everybody put their input in, it's a cinch we wouldn't have made it. Capt. Al Haynes The event described above is used within the aviation community as a textbook example of successful CRM. All the resources available on board the plane were effectively utilised during the emergency to help limit the impact of the disaster. Crew resource management is now considered to be an essential component of training at London s Air Ambulance. Medical decision making is often based on facts, and medical procedures are performed on the basis of the technical ability that all our clinicians have. It is CRM that forms the backbone to our interactions on scene and ultimately dictates our ability to provide excellent trauma care to our seriously injured patients in high pressure situations.