The Midlife Medic: Making a List and Checking It Twice
The first ACLS megacode I was ever subjected to was in 1989, during paramedic didactic. It was one of the final milestones before graduation to clinical rotations, and it was a deal breaker. Waiting in the atrium, we would be called one by one into the lecture hall. Pale faces and tears were present both going in and coming out.
Inside, at the front of the lecture hall, was a table with a manikin and equipment. (If anyone is curious, using paramedic carbon dating, it was a LifePak 5). In the front row sat the primary instructors along with the medical director of the program. An assistant stood quietly next to a huge empty blackboard, chalk at the ready to scribe whatever was going to happen. After some small talk, which did nothing to ease my sense of terror, Dr. Imbesi began the scenario. A male in his 20s, in cardiac arrest…go time.
Twenty minutes later the equipment was torn apart, my face was flushed and sweaty, and the “patient” was still dead. The chalkboard behind me was full of the shorthand the scribe used as I exhausted my algorithms, calling out steps and dosages faster than she could write. Months of training and memorization were spewed out on that board. This was early-generation ACLS; errors were not an option.
Neither were checklists.
EMS was not an open-book test. Not knowing your dosages cold was a direct reflection of your overall ability. If you didn’t know your ABCs, chances were good you wouldn’t get the card that let you practice in the field.
We are a field that speaks in acronyms and is driven by algorithms. At some point in our early evolution, our culture decided that rote memorization could somehow make up for the dearth of didactic knowledge we were sent into the trenches with.
Medicine is not a series of “if, then” statements. There are too many variables to allow for guarantees. Critical thinking and the establishment of differentials often occurs only when we’ve discovered all the information that happens outside of the expected outcome.
We know better now. We know there is room for both, and the combination of the two provides for successful outcomes and a better quality of care. One need look no further than the aviation industry to see what crew resource management (CRM) has done to reduce errors and improve the standard of safety for all involved. One of the primary tools at the heart of CRM is the use of protocols—the checklist.
The poster child for CRM is retired airline pilot Capt. Chesley B. “Sully” Sullenberger, best known as the pilot of US Airways Flight 1549, the “Miracle on the Hudson.” Sullenberger attributes the success of that fateful landing to deeply ingrained culture that resulted from the longstanding implementation of CRM in aviation. In a 2016 interview, he explained that checklists remain invaluable, a simple inexpensive tool that can reduce errors and promote effective team function.
“It’s not the list itself that’s so effective,” Sullenberger says. “The list is simply a way to focus individual intention toward group goals. It’s a way of formalizing best practices. It’s a way of literally getting everyone on the same page.”1
They say there is no substitute for experience. There are plenty of substitutes for memorization; most of them include making mistakes. (Or in my case, it’s ’80s song lyrics.) Why as a culture do we continue to insist on rigid memorization of protocols without additional methods to integrate this information into a usable skill set?
Consistent utilization of an accurate and up-to-date checklist reinforces that organic learning and helps develop that procedural memory that will enhance practical application in critical situations.
Checklists and references used during critical procedures should not be considered a demonstration of fallibility. As surgeon and Harvard professor Atul Gawande says, “Checklists, smartphone apps, or other interventions are penicillin-like in their lifesaving potential.”2 He believes much of our reluctance to use checklists has to do with the drive to be heroes, to be active in the role of saving a life. All the “routine” patients who don’t die escape our notice as a result.
Our culture should move away from the idea that checklists are a crutch or an indication of inability. We should foster the idea that they will enhance our performance, making it consistent, measurable, and safer for practitioner and patient alike.
Fostering the implementation of CRM may not help your crews land an airplane on a semi-frozen river, but it may just give them the ability to function more successfully and with less psychological impact the next time they are handed a dying child. Like Captain Sully, when they have just 208 seconds to come up with a plan, they will have an array of solid tools and backgrounds to facilitate what’s already in their heads.
1. Carhart E. Applying crew resource management in EMS: An interview with Capt. Sully. EMS World, https://www.emsworld.com/article/12268152.
2. Powell A. Checklists are boring, but death is worse. Harvard Gazette, https://news.harvard.edu/gazette/story/2017/10/checklists-are-boring-but-death-is-worse.
Tracey Loscar, BA, NRP, FP-C, is a battalion chief for Matanuska-Susitna (Mat-Su) Borough EMS in Wasilla, Alaska. Her adventures started on the East Coast, where she spent 27 years serving as a paramedic, educator and supervisor in Newark, NJ. She is a member of the EMS World editorial advisory board. Contact her at email@example.com or www.taloscar.com.
After many years in aviation, I find your article spot on. Checklist usage does not come easy and are difficult to write, but once understood are a great tool. A checklist that works for one organization may not for another. A checklist for one airline will not be the same in another airline even though the airplanes are exactly the same. The same will be true for EMS. And for what it's worth, I also recall the Lifepak 5. Nicely written.
Someone recommended an excellent book on keeping a check list. Ironically, it’s based around experiences by a NYC surgeon and very relatable to our industry. The book introduction begins with a story concerning a PT with a stab wound in the ER. I found it to be an excellent read. The book is, ‘The Check List Manifesto’ by Atul Gawande. Note: Not sure if this article is coincidental or just serendipity, but it just so happens, for several years, I’ve been working on an EMS check-list app! It’s in its early-adopter stage of development and not quite ready for prime time. But, so far, so good! Lt. John Skolits –EMT.