Patient Safety Scenario #12: CRM Means Listening to the Entire Team
Captain Rick Saber at the controls. He is a leader in the field of aviation safety and how “crew resource management” made aviation safer.
This essay is the twelfth installment of the monthly Patient Safety essays, produced by the Patient Safety Subcommittee of the Ethics and Professionalism Committee. The essays are written in the spirit of the aviation industry’s “Black Box Thinking” in order to inform and improve our medical safety record. To read earlier essays and learn how to contribute, please click here.
A comparison of safety in aviation and medicine is frightening: aviation disasters are investigated, written up, and every pilot has access to the lessons learned. In medicine, medical errors are investigated, written up, and buried so deeply that no one learns anything. Each surgeon has to repeat every error on their own. On their own patients. This is why now in aviation there is one accident every 2.4 million flights, and why medical errors kill between 44,000 and 98,000 patients per year, according to two good studies reported in the Institute of Medicine report of 1999, To Err is Human. This is the equivalent of crashing a 747 every other day. Would you be willing to fly if this was aviation’s safety record? Yet according to several studies, this is our safety record in medicine. Aviation learned the lesson of Crew Resource Managment in 1979; medicine is just beginning to learn it. In this spirit, the Patient Safety Subcommittee offers this series of essays to the membership.
Nelson, MD Chair, Patient Safety Subcommittee
Scott Lifchez, MD Co-Chair, Ethics and Professionalism Committee
Julie Adams, MD Co-Chair, Ethics and Professionalism Committee
Note: The Patient Safety Subcommittee actively solicits scenarios that might be appropriate for future articles. Please send them to: email@example.com
The planned surgery was a fairly simple LRTI in a 55-year-old office worker, and the surgeon was quite confident it would go well. Although newly minted, he had graduated from a prestigious medical school, a top residency, and a coveted fellowship with a former ASSH president. He knew all the obscure trivia that showed up in the exams, from sonic hedgehog’s effect on the apical ectodermal ridge to the treatment for malignant hyperthermia (dantrolene sodium). He was confident the case would go well.
He had learned from his mentors the proper surgical technique, and the proper surgical attitude. He was there to do the surgery, the anesthesiologist was there to do the anesthesia, and the nurses were there to get the room ready, handle the paperwork, etc. He had learned as a resident that the surgeon was in charge, the “captain of the ship,” and he had survived residency because he kept his head low and protected his chin. When the faculty wanted his opinion, they would ask for it, but otherwise he was to keep his opinions to himself. Now that he was the surgeon, he was in charge, and everyone in the room knew it, knew their role in his room, and to keep their opinions to themselves.
The patient was brought into the room, the nurse did the timeout, and the patient was moved to the OR table. He was a bit cold, so the circulator covered him with a warm blanket. The anesthesiologist started to put the patient to sleep. The patient was shivering a bit. The anesthesiologist was having some trouble getting the airway in, due to jaw spasm, and was focused on the airway. The surgeon waited on the sidelines, anxious to get the case started. The circulator, watching the patient shiver, thought that the shivering did not look normal. She thought about it for a moment. She had seen a lot of shivering due to cold ORs in her career, and this just did not look like that. She then spoke to the anesthesiologist, wondering out loud if malignant hyperthermia could start like this. The anesthesiologist was concentrating on the problem of the airway and ignored the nurse. The surgeon felt this was a stupid observation: it was obvious that the patient was shivering because he was cold. His temperature on the monitor: it was on the low side of normal, and that proved it. Hyperthermia was manifested by a high temperature; it was almost a “duh!” that this could not be hyperthermia. The nurse’s question, he thought, was pretty stupid. The nurse noted that the shaking was increasing, and she made sure the restraining safety belt was in place and secure. The surgeon, wanting to get the case going, left the room to start to scrub. The nurse looked on the monitor and noted the CO2 was rising. She again mentioned to the anesthesiologist that this might be malignant hyperthermia, but he was too busy struggling with the airway to listen. When the CO2 rose a bit more and the O2 dropped, she felt that she must take some precautionary measures. She opened the doorway and called down the hallway for help. A tech looked up, and she said, “Possible malignant hyperthermia, I am not sure, but get me a basin of ice, and rush it!” Another nurse overheard her and asked if she needed help. She said, “Yes! Tell the front desk we might have a malignant hyperthermia case in here! Get some more ice.” She turned back to the room. The hand surgeon was just standing there, waiting to be gowned and gloved. The scrub had heard the nurse ask for help, so he had broken scrub. He did not know what malignant hyperthermia was, but he had learned in his career to pay attention to experienced nurses. He verified that the front desk had been alerted, and then moved to assist the anesthesiologist, who by this time recognized that an emergency was present. The patient was tachycardic and the tension in the room mounted. The anesthesiologist could not get the laryngeal mask airway in the proper position due to jaw spasm so he was reaching for the succinylcholine. The circulator noted that the patient was no longer cold, but was 37.5 C. That was a big change in a short time! Ice was brought into the room by two of the staff, and circulator asked if she could start to put the ice around the patient. The surgeon, bewildered, just stood there. The anesthesiologist, bagging the patient with mask ventilation, told the circulator to go ahead and put the ice around the patient to cool him down. The circulator pulled off the blanket but kept the safety straps in place, and together with the scrub put ice and wet towels around the patient. Other staff were streaming in the door, bringing in more ice, and they placed it around the patient. The anesthesiologist had gotten the airway in, was now hyperventilating the patient to blow off the CO2 and called for the malignant hyperthermia crash cart. Almost before he had asked for it, the staff who had first heard the alert wheeled the crash cart in and handed the dantrolene sodium to the anesthesiologist. The surgeon just stood there.
The right answer on the exam was dantrolene sodium. The right answer in the room was to listen to the nurse.
She was as dedicated to her profession as the surgeon was to his, and had 20 years of experience. How was the surgeon to know the nurse went through a malignant hyperthermia simulation every year, knew the early and intermediate as well as late signs of hyperthermia, and was ready to act? All he knew was “dantrolene sodium” on the exam.
The aviation industry learned in 1979 that the captain may be in charge of the ship, but he is not infallible. An analysis of human factors in aviation, based on more than 60 accidents and 7000 incident reports, showed that many times the captain was making an error, the crew knew that he was making an error, but either because they did not speak up or did not speak up effectively, everyone aboard died. (1). This led to the concept of Crew Resource Management, CRM (2). This operational guideline states that the captain is required to pay attention and evaluate the input from his crew, and his crew have not only the right, but the obligation, to speak up when they see a problem. The captain is still the “captain of the ship,” but in order to make the best decisions, they need to use all the resources available to them, including their crew’s dedication, training, and experience. Since 1982, CRM has been standard operating procedure in both civilian and military aviation.
40 years later, surgeons are just becoming aware of the importance of CRM. In this series, we have examined both good examples of CRM in the operating room (3), and poor CRM in the operating room (4). In this scenario, although the surgeon could certainly get the right answer on the exam, he did not know that one of the early signs of malignant hyperthermia is muscle rigidity or shaking (5). Intermediate signs are a rising CO2, a falling O2, and a rapid change in temperature. If the patient starts out cold, the rising temperature may be normal or not very high. Despite the name malignant hyperthermia, a high temperature may never occur, or may be a late sign. It can also be a “too late” sign: clinical suspicion should start before there is a high temperature and treatment needs to be initiated quickly. It turns out that, in this case, the nurse was the first person to be suspicious for malignant hyperthermia. The surgeon’s mind was concentrated on the details of getting the case started and the anesthesiologist was temporarily distracted by the “cannot intubate, cannot ventilate” problem. The nurse, who was concentrating on the patient and did not have to deal with all the issues that the surgeon and the anesthesiologist were dealing with, happened to notice the abnormal shivering. She had been trained in the early signs of malignant hyperthermia. Also, because the OR team regularly did simulation exercises in managing malignant hyperthermia, the nurse knew exactly what to do. It is not a question of who is the “best person on the team.” We all know that no matter how talented a basketball team can be, if one of them is a “ball hog,” the team is not likely to win many games. It is not a question of who is the best person on the team, it is a question of what each team member can contribute to the ultimate goal. When the surgeon behaves as if they are the only one on the team, there will never be a team. And you cannot win without a team.
Everyone in the room is your resource. You are the “captain of the ship,” and ultimately must make most of the decisions. However, it is a significant error to ignore the dedication, training, and experience of your team in the room, as the aviation industry learned four decades years ago.
(1) John Lauber, 1979. Resource Management on the Flight Deck. Proceedings of a NASA/Industry Workshop, San Francisco. Https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/19800013796.pdf