The human factor

LIKE most people associated with the emergency services I can never really anticipate what the day ahead has in store. All I can do is turn up in the morning and try to prepare myself as best as I can and hope that when I leave work in the evening the preparations have been up to the challenges I have faced during the shift.

And so it is one dull spring morning on our HEMS (Helicopter Emergency Medical Services) helicopter. Kit check complete, aircraft serviceable, crew qualifications in date and the weather checked. Oh yes the weather, not a great day with worse on the way. Well it is spring, after all.

It’s mid-morning when the phone rings. We are tasked to a car-vs-van RTA (road traffic accident), some 40 miles to the northwest, with no other details. As soon as we lift we encounter the deteriorating weather conditions forecast earlier. The issue is the lowering cloud base. We are heading towards a mountainous area and so the direct route is not an option.

We soon encounter worse than expected weather and find ourselves struggling to find a route through the valleys. It looks unlikely we will be able to make it to the incident but our deliberations are interrupted by a radio call from ambulance control. Fully expecting to receive a stand-down the news is not good. Apparently there are two fatalities, a woman and a child and CPR is on-going on another child. The nearest road crew is still 15 minutes away.

Absolute limits

The nature of the casualty should never be a factor in how we operate the aircraft. However, it is hard not to feel pressured by the fact a young child clearly desperately needs medical intervention. We fly on the absolute limits of our rules while constantly updating what our escape plan would be. We finally clear the worst of the weather, in no small part due to the brilliant map reading and navigation skills of the paramedic in the front of the aircraft, and it looks like we will now make it to the incident. We discuss several plans of action for when we arrive.

On arrival however, the first problem is finding a place to land. The incident is on a road running through a forest and landing on the road is the only option. However, traffic is blocking the road on both sides of the incident. Only by communicating through the police helicopter that had just arrived are we able to get the police on the ground to move the traffic and create a large enough space for us to land. As soon as the aircraft is on the ground both paramedics deplane and I remain rotors running. They soon return with a small child on a stretcher. On entering the aircraft and connecting to the intercom system the first thing I hear is “she’s not breathing” and the second is “we’re not strapping in, GO”.

The few minutes I had spent on the ground had been enough to tell me I did not have enough fuel to return the way I had come. The only option is to climb up into cloud and route to an airport near the hospital and carry out an instrument approach. Fuel is still going to be tight but the air traffic controllers clear all other traffic out of the way and give us priority. Having talked to ambulance control we are met by a medical team as we land at base. The decision is taken to carry out an RSI (rapid sequence intubation) in our hangar before onward transport to the nearby children’s hospital. At this point the prognosis does not look good. We carry out a hot debrief involving pilots, paramedics and police from both helicopters and doctors from the medical team. In the end we agree that given all of the circumstances on the day this child has just been given the very best of chances.

Managing the team

In fact a few days later we find out the child is making a remarkable recovery. What went right for us? Clearly, the skill of the paramedics and doctors played a critical part. However, there is no doubt that the human factors training we all received had a huge impact on the outcome of this job. In aviation this training is called CRM (crew resource management) but in the medical world it is now generally referred to as TRM or team resource management.

But is TRM truly relevant in medicine? Well if you take the basic premise that by default, human beings are predisposed to making mistakes and that the principal of CRM/TRM is to understand human behaviour in order to reduce or mitigate the mistakes we make then, yes, TRM is very relevant.

The Department of Health report, An organisation with a memory, states that research-based estimates suggest that in NHS hospitals alone adverse events in which harm is caused to patients occur in around 10 per cent of admissions or at a rate of over 850,000 a year and cost the service an estimated £2 billion a year in additional hospital stays alone, not taking account of the wider human or economic costs. Many of these adverse events are caused by human error. Therefore, any programme that can potentially reduce these errors must be looked at seriously.

Lesson from aviation

One of the main issues medicine faces is how to effectively introduce TRM and here it is helpful to look at the aviation experience. Aviation has been held up as one of the gold standard industries with regard to the study of human factors and the implementation of an effective programme of teaching. CRM has indeed been very successful but how it has been implemented in aviation has contributed to its success. First of all CRM is mandatory in civil and military aviation. Crew members have to undertake induction courses and annual recurrent training. In addition, the CRM aspects of carrying out crew duties are now also assessed on an annual basis. This assessment of ‘non-technical skills’, as the CRM aspects are called, can lead to removal from duty if the appropriate standard is not met.

Another crucial aspect of CRM training in aviation is that all CRM trainers have to have formal instructor qualifications. These qualifications are approved and audited by the Civil Aviation Authority. CRM instructors are required to instruct on at least three courses per year and every third year one of the courses they teach has to be assessed by an examiner. In this way instructor standards can be monitored and maintained.

It is important though that the aviation model is not followed blindly. The study of human factors consists of a wide and diverse range of subjects, and while an understanding of all the subjects is a requirement, some aspects of human factors are more relevant to some industries than others. What is required is for a training organisation to have an in depth look at the department or organisation that requires the training and tailor that training to their specific needs.

It should also be understood that it has taken since the mid-90s to get to the level of human factors understanding that we have in aviation now. Today all new entrants to aviation are exposed to human factors training at a very early stage of their careers. As well as introducing TRM into hospital departments today, I would advocate incorporating the study of TRM in medical undergraduate studies.

There is absolutely no doubt that an understanding of human factors and using procedures based on human factors error management will reduce the number of harmful errors made within an organisation. This can mean financial savings and reduced stress levels among well-intentioned workers. But most importantly, in the medical world, patient safety will improve and lives will be saved.

Captain Andy Rooney is a HEMS pilot with 16 years previous military experience. In addition, he is a director of DART Training Solutions, a company that provides TRM courses exclusively to medical clients. Contact: darttrm@gmail.com