A routine training mission of a three-ship formation of F-16s to drop live ammunition came to an abrupt end. An inexperienced wingman pilot missed key radio calls during our first dive to the drop zone and a “knock it off” call was made by the flight lead, so we returned to base ending the mission prematurely. This call halts any in-flight maneuvers and the jets ascend or descend to briefed deconflicting altitudes when flight safety is compromised. An emphasis is made during pre-flight briefings that there is no rank in the cockpit, meaning that any aircrew of any rank or position can call “knock it off” if flight safety is compromised. Task saturation is defined as having too much work without enough time, tools, or resources to accomplish the task, causing a degradation in performance. Often the first clue that someone is task saturated is when they miss radio transmissions or communications. This also resonates true in the operating theater.
“It is also important to realize that when you are task saturated, situational awareness is diminished and one may need to ask for help.”
I have often heard the comparisons between aviation and anesthesiology, which reverberates with me as I recently transitioned from the United States Air Force as a flight surgeon for a fighter jet squadron to an anesthesiology resident. Such parallels were emphasized after the 1999 publication by the Institute of Medicine of To Err is Human: Building a Safer Health System, which reported that 98,000 people die each year as a result of medical errors in the United States (To Err is Human: Building a Safer Health System. 2000). Health care administrators and medical boards looked to the airline industry to improve patient safety and outcomes. Health care checklists, simulation training, and the investigation and reporting of incidents, as well as overall organizational structure in health care all stem from aviation models. The Joint Commission found that 56% of intraoperative and postoperative complications are due to communication failures (Can J Anaesth 2019;66:1251-60). The incorporation of effective communication strategies developed in aviation can be implemented to improve safety in the perioperative environment.
It was found that over 70% of airline accidents from 1959-1989 were the result of human factors, including poor interpersonal communication (Crew Resource Management. 2010). Cultural norms of perceived hierarchies among crewmembers, such as deferring to the captain's authority and not raising safety concerns in an assertive manner, resulted in mishaps. Crew resource management (CRM) was developed to optimize performance and decrease human error, transitioning from an individual effort to team concept. CRM is composed of situational awareness, communication skills, team work, task allocation, and decision-making, which are all interrelated to communication.
Effective communication requires information sent from one person to be perceived and understood by the receiving person; with information transfer, errors occur in both hearing and speaking. Precise and unambiguous communication is the foundation of effective teamwork (Can J Anaesth 2019;66:1251-60). The use of closed loop communication and crosschecking of information, with readback and confirmation, have been shown to improve safety in aviation, the military, and simulated health care studies (Can J Anaesth 2019;66:1251-60). Not surprisingly, teams that work together routinely can better anticipate each other's actions and are more comfortable questioning unsafe actions, resulting in better outcomes (Crew Resource Management. 2010). When this is not possible, planning and role delegation prior to surgery during a timeout or pre-briefing builds rapport and ensures collaborative decision-making. The surgical team may also be surprised to learn that your actual name is not “anesthesia.”
The ability to effectively and succinctly communicate in the OR requires situational awareness. Situational awareness is defined as the perception of the elements in the environment within a volume of time and space, and the comprehension of their meaning and the projection of their status in the near future. More simply, situational awareness is being aware of one's surroundings. Clearly, this is of the utmost importance to an anesthesiologist. For example, discussion of anesthetic plans for upcoming patients may be appropriate during low workload or low stress times, but not during critical phases of surgery, where communication should be limited to essential information. It is also important to realize that when you are task saturated, situational awareness is diminished and one may need to ask for help.
Anesthesiologists are natural leaders in the OR tasked to ensure the patient's safety during the perioperative period while simultaneously monitoring multiple aspects of patient care. During chaotic times in the OR, it can be challenging to speak up assertively as a resident anesthesiologist to voice safety concerns. As we all know, something as simple as a poorly functioning I.V. can result in catastrophic consequences. Furthermore, knowing when to call “knock it off” and when to ask for help is integral to preventing errors and improving outcomes. In moments like these, I try to remember there is no rank in the OR and we all have the common goal of patient safety.
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