Crew Resource Management and EMS

Similarities between EMS and the airline industry may make Crew Resource Management a useful error-prevention tool in the prehospital setting


   In the late 1980s, there was a series of airline accidents caused by strings of errors and critical breaks in communication between crew members. In one example, a landing gear malfunction caused the crew to focus on the mechanical problem and getting the cabin crew and passengers ready for a possible gear-up landing. The cabin crew was supposed to advise the captain when they were ready, but due to a communication breakdown never did. The plane ran out of fuel only a few miles from the airport as the pilot waited for the cabin crew to report that they were ready.

   Does this type of thing happen in EMS? Many times we might get our attention diverted to a piece of equipment that is not working properly and inadvertently skip priorities like scene safety or airway management. Medication errors are all too easy to make, both in the field and at the hospital. Often, we call medications by one name, yet they are labeled something different. We are all familiar with the name Benadryl, but it may be labeled in your drug box as diphenhydramine.

   We must understand that we will always have practitioners with different levels of experience helping us, and they might never have been trained in doing what we ask them to do. Do you store your bag of normal saline in the same compartment as the bag of lidocaine premix? If so, it would be easy to grab the wrong bag and give a bolus of lidocaine instead of saline! Sure, we need to verify the type of fluid given to a patient prior to starting the IV connections, but a little human-factors error trapping can prevent this kind of potentially fatal mistake.

   The person in charge of the scene has a different level of experience than other crew members, but should not talk over the heads of colleagues. Sometimes we inadvertently punish each other by using terms that are simply not understood with people who are reluctant to ask for clarification. Good Crew Resource Management (CRM)--an airline practice many have applied to benefit EMS operations--would be to ask if you don't understand.

CRM vs. Healthcare

   Preventable accidents were the basis for developing CRM. Actually, it was originally called Cockpit Resource Management and concentrated on coordination within the flight deck only. This was found to be lacking, as the cabin and ground crews are just as important in the process of flying safely.

   Does this concept fit with EMS? Yes and no. Airline staff operate as crews: There is a flight deck crew, a cabin crew and a ground crew all working at the same time. The closest we in EMS come to a common term is healthcare providers. This includes all the paramedics, EMTs, dispatchers, first responders, firefighters and even the staff at the emergency department. The term healthcare provider certainly does not evoke a mental picture of teamwork or a crew working together. This is a problem.

   In EMS, it is not just the paramedic and EMT who are important to the CRM process. Good resource management involves family members at the scene, fire and police personnel who may have responded, dispatchers, medical control and ED staff, to name a few.

   So where do we start? Well, at the beginning of the shift or flight you need to set the tone for the work day. If I have not worked with a person before, I will ask them about their background and experience and tell them a little about myself. I tell them I make mistakes from time to time, and if they are uncomfortable with something or don't understand what we are doing, to simply ask.

   If I am not in charge, the same process applies. If the person in charge does not mention these things, I do. I ask a new partner if they have anything specific they like to do on calls. Some paramedics like to carry the equipment into the house to the patient, while others prefer minimal equipment be brought in and most procedures performed in the back of the ambulance. Neither way is wrong, but asking gives me a better understanding of what to expect.

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