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Should Real Airway Experts Use Checklists?

The smaccGOLD debate ‘should real airway experts use checklists‘ in March 2014 between RFDS powerhouse Dr Minh le Cong (against) and myself (in favour) started some nine months prior to the actual event, with an almost daily exchange of trash talk on the topic via the wonderful medium of Twitter.


Twitter trash talk between Minh & myself got heated on occasions. Not quite Bruce Lee vs Chuck Norrris, but close…


You can download a PDF of my argument PRO checklists here.

It’s no secret that I am a fan of checklists and cognitive aids – not just for ‘occasional intubators’ but across the board, even for those with significant expertise. Minh on the other hand was determined to argue the counterpoint and expose some of the flaws and fallacies surrounding checklist use.

“quality care, out there”

The debate takes place at smaccGOLD – a critical care conference open to intensivists, emergency physicians, rural clinicians, paramedics, nurses, students – indeed, anyone interested in the delivery of “quality care, out there”. With this maxim in mind, we are all looking for things that will make a difference during critical procedures – whether this be relatively new concepts like use of apnoeic diffusion oxygenation in RSI, developing robust airway equipment and algorithms for airway management…I believe that use of checklists in a crisis helps deliver quality care.

There are arguments for and against checklists in medicine sensu lato, not just airway management. This post is a summary of checklists relevant to their use wherever airways are managed (hence not just Operating Theatre, but also to ICU, ED and prehospital). Checklists aren’t just for routine – they should be used in crisis management – whether this is emergency RSI, dealing with unexpected hypoxia, a rare emergency such as MH or similar.

The main benefits for use of a checklist regardless of experience include:

  • Reduced task fixation & improve situational awareness
  • Reduced cognitive overload
  • Reduced stress
  • Defined team member roles
  • Improved team function
  • Improved team communication
  • Team understanding of potential complications and what they will be expected to do
  • Use can make crisis management & high-stakes procedures such as RSI smoother and quicker(when well practiced at using the checklist)

The argument is that in sick patients, unfamiliar environments, etc we are very prone to task fixation and loss of situational awareness.  The adrenaline rush pushes us to get on with it, when often time is not actually so critical that we can’t pause for 30-60 seconds and have a quick brief.

Minh however doggedly argues the opposite, pointing out that checklists per se do not bring about quality – it requires team buy in and awareness of their limitations. Using a checklist as a ‘tick and flick’ exercise, or inappropriate use of a checklist are all real caveats.


Screen Shot 2014-03-09 at 1.47.28 pm


So what actually IS a checklist?

Clinicians have been using checklists since medical school – we are all familiar with the usual deluge of mnemonics , acronyms, algorithms and assorted prompts. Newer formats such as The Vortex are being used increasingly in crisis management, not as a ‘recipe’ but as cognitive aids in a crisis.

Some scorn checklists and other cognitive aids as ‘a crutch for the novice’, ‘cookbook medicine’ or as nothing other than ‘cheat sheets for novices’. Perjorative terms, often used by experts. After all, the expert doesn’t need help…or do they?

Humans make mistakes, especially when tired, when distracted or interrupted…or in a crisis when under cognitive load. Moreover, the expert does not function as an individual – he or she is part of a team, and members may have varying levels of expertise. We know this from the extensive human factors work, championed in healthcare (and anaesthesia has lead the way) by people such as David Gaba or Martin Bromiley.

In the true sense of the word, a checklist is exactly that – a list against which a check (or tick) is placed, to confirm an action has been completed. However it is not just learners who benefit – the true power of a checklist is to establish routine and so allow cognitive offloading by experts in an emergency, as well as to strengthen team performance and establish shared mental models.

“effective CLs are more about helping reduce cognitive overload and error reduction, not purely about the manual procedure”

@HawkMoonHEMS Dr Brian Burns, FACEM & Retrieval Physician

One of the best forms of checklist is a two-person challenge-response format. This obviates the temptation to ‘skim’ items on a checklist and places responsibility for reading the items with the assistant, not the operator. I think that this sort of challenge-response checklist is the most useful in crisis management – but in order to be effective, must be embedded into routine practice and adopted by teams with institutional support.

“a check of what has been DONE by experts, not a HOW TO for novices”

Delving a little deeper, the literature describes FOUR main types of checklist (Winters et al, 2009) which differ in terms of number of operators and the extent to which information is verified :

  • static parallel : usually completed by a single operator and executed in the form of a series of ‘read-do’ tasks. The anaesthetic machine check is a good example, as is restocking of equipment
  • static sequential with verification : this involves a challenge-response, with one operator reading a series of items for verification of completion or normality by another. The central line checklist in ICU is such an example as is an RSI challenge-response checklist
  • static sequential with verification and confirmation : these are used more in team-based settings, with sets of tasks completed by different team members. A designated person reads the items (challenge) and each responsible party verifies the completion of a specific task. The WHO Surgical Checklist is such an example, with separate activities for scrub, surgical and anaesthetic teams
  • dynamic : these typically use a flowchart to guide complex decision-making. There may be multiple options to choose from and the team must decide optimal course – in essence, an algorithm. The UK’s Difficult Airway Society algorithms & Australian Resuscitation Council ACLS algorithms are such examples.

Of course it’s not just in medicine that we use a checklist – we write a shopping list before visiting the supermarket and most of us will perform some sort of mental checklist before leaving for work (have I got my car keys? My wallet? My sunglasses? Is today even a work day?). Humans use cognitive aids most days. Why would we abandon them at work?


That’s not to say that one needs a checklist for everything. For some reason, Minh seemed obsessed with the idea of using a checklist before intercourse. Whilst this is clearly a ‘tightly coupled’ procedure, I think Minh was missing the point. To paraphrase Weingart, sex – like resus – is one of those times when “slow is smooth, and smooth is good”.


Well then, what is a REAL airway expert?

Yeah, yeah – you want me to say that it’s an anaesthetist. Except of course it’s not – airways are also managed outside of the elective operating theatre setting by non-anaesthetists. Real airway doctors can be found in the Emergency Department, in the Intensive Care Unit, in the Pre-Hospital & Retrieval environment – as well as in the operating theatre. It goes without saying that even an experienced anaesthetist, with decades of training and experience in routine anaesthesia, may struggle when faced with a soiled airway at the roadside, with unfamiliar kit and a lack of trained assistance. Expertise in one area, even airway management in the OT, may not translate into another arena such as the ED.

"Smoke me a kipper, I'll be back by breakfast" - the idea of the expert as an individual 'ace' is obsolete
“Smoke me a kipper, I’ll be back by breakfast”
– the idea of the expert as an individual ‘ace’ is obsolete

So ‘real’ airway experts are drawn from the ranks of anaesthetists, emergency physicians, intensivists, & rural doctors. Heck, they may not be doctors – we have excellent intensive care paramedics working in various systems. Ambulance Victoria relies on MICA paramedics to deliver prehospital RSI; the South Australian medSTAR service has retrieval practitioners, drawn from ranks of doctors, nurses, paramedics. The skill set defines the job, not the initial qualification. And all are striving for mastery, whatever our heritage…

Medicine is truly an apprenticeship. We move through the classic stages of skills-acquisition as described by Dreyfus & Dreyfus (2005), each seeking to achieve mastery in our field.


Classic Model of Skills Acquisition (Dreyfus & Dreyfus, 2005) Not everyone transitions to expert stage; many are doomed to confuse competence with expertise
Classic Model of Skills Acquisition (Dreyfus & Dreyfus, 2005)
Not everyone transitions to expert stage; many are doomed to confuse proficiency with expertise; few reach true mastery.

The concept of “it takes 10,000 hours of training to be an expert” from Ericsson is often banded about – with the generalisation that it takes 10 years or so to accrue this experience. Sadly many do not reach the desired level – many repeat one year of experience ten times, rather than deliberately train and gain mastery. Moreover, for the ‘expert’ in emergency medicine or intensive care, airway management makes up just one component of practice. Does expertise in one area of medicine necessarily translate to expertise in procedures such as intubation? Even once ‘expert’ status is achieved, there is a real risk of ‘skill fade’ – a recent observational study of endotracheal intubation in a tertiary ED suggested that emergency physicians may only perform this skill as little as three times per week, due to requirements to supervise trainees and allow them to acquire skills (Fogg et al 2012).

“Half of all experts are below average”

Even within the ranks of anaesthetists, performance will follow a Gaussian distribution, with half ‘below average’ when compared to peers. Expertise in the calm ordered environment of the Operating Theatre may not translate to the chaotic environment of an emergency airway in unfamiliar settings.

Truly expertise is a relative concept.

Hang on, this is all getting a bit Zen isn’t it?

Well, possibly. The path to mastery is something we all strive for – but as time goes on, many clinicians become comfortable at the ‘competent-proficient’ stage. They are considered technically capable, they are able to make a (good)-living doing what they have trained to do. To strive for expertise and mastery requires a lot more effort for seemingly less reward.

The danger is that once you are at the ‘proficient’ stage, you may feel that there is no need for cognitive aids. You are on top of things at work, you manage things adroitly…and then you are thrown a curve ball. An unexpected crisis. Something you have read about, perhaps even drilled for, in the comfort of a sim lab or one of the many continuing-professional development courses…but sadly your proficiency in everyday practice does not translate into expertise in a crisis. How can it? True crises are relatively infrequent. How many have managed malignant hyperthermia? A true CICO requiring surgical airway? Intraoperative anaesthetic machine failure?

The anaesthetic error in the sad case of Elaine Bromiley is but one example of this. Here experts in their field were overwhelmed by the situation (CICO) and failed to make appropriate decisions despite having the requisite skills. If you aren’t familiar with this story, take time now to review the video :

"in aviation we know that 75% of error is caused by human factors. In healthcare, we don't know. Is it 75% as well? Is it 85%? Is it 55%? No one really knows ... I would argue that the actual statistic is irrelevant ... a large proportion of accidents will be caused by human factors, the lessons learned from other industries apply to healthcare"

Martin Bromiley, Airline Pilot & Human Factors Expert

There are many more examples of error leading to catastrophe in airway management, despite the presence of experts. Hence there has been a huge emphasis on training in human factors for crisis management in medicine – mostly lead by anaesthetists but seeping across into other clinical disciplines as the years go on. We can all learn from this.

Error in Medicine

We need to be very clear – error in medicine occurs despite the presence of experts & their expertise.

If you read nothing else, read McIlvaine (2006) on ‘Human error and its impact on anesthesiology’ – a gentle introduction to understanding how we err and use of tools to mitigate against the inevitable.

Catastrophe can occur because of a major error – failing to check the correct site for surgery; accidentally injecting a cytotoxic intrathecally; awareness under anaesthesia due to forgetting to replenish the vaporiser; failure to monitor ETCO2 in the ICU to confirm ongoing ETT placement.

Harm can happen because of equipment failure or because of a seemingly trivial mistake – forgetting to have suction available during RSI, or not having a syringe available to inflate ETT pilot cuff. Not having drugs available in a crisis. Assuming that assistant is familiar with contents of difficult airway trolley.

These are all anathema to experts – who would be so foolish as to perform RSI without suction? Without checking the ET cuff? With an assistant who is not equally ‘expert’? Yet in analysis of medical procedures, mistakes & omissions are noted in a similar percentage as in aviation – 75%. Thankfully humans are adaptable and able to compensate; for most cases (eg: RSI in the OT for an elective, fasted patient) no harm will occur. Similarly minor mistakes may not amount to much, given levels of redundancy. But for the trauma patient with critical hypoxaemia, shock, MILS limiting optimal positioning and in the presence of a soiled airway, such omissions are less-forgiving.

“It may take many minor “holes in the swiss cheese” to line up to cause catastrophe. If only 9/10 holes line up, the operator will end the day in blissful ignorance of the near disaster as if 0/10 errors occurred. It’s the final hole that gets you”

But hang on – surely the expert is immune to error? I’ve already alluded to the problems of ‘expert’ status – it’s a relative concept, subject to problems of skill fade, of poor translation between areas of expertise or in dealing with relatively infrequent events…and of variation within a cohort.

OK, perhaps checklists are OK for routine procedures

– but surely there is no time to use one in a crisis?

The literature is fairly robust on use of checklists for routine procedures – the anaesthetic machine check, the WHO surgical checklist, central line checklists etc. But what about in a crisis? Surely we can rely upon the expert to manage the situation? Sadly not. Human factors research shows that humans can only manage to retrieve seven +/- 2 pieces of information from our memory with relative accuracy. During a complex procedure, with additional elements of stress or fatigue, memory becomes increasingly unreliable. Worse still, as the number of tasks we simultaneously manage exceeds three, we show significant decline in the accuracy and speed of handling problems. Even worse still, under stress we show increased skill degradation. Listen to Cliff Reid and Scott Weingart talk about the impact of stress and the concept of stress inoculation.

A checklist can help compensate for this, allowing “cognitive offloading” and empowering others (the non-expert team member) to ensure that procedures are followed.

Minimising error is especially important in ‘tightly-coupled’ processes – technical procedures where omission of a single step can lead to failure. Airway management is one example – one cannot afford to be distracted during RSI by another task, as the patient will be at risk. Conversely interruption during a pre-anaesthetic consultation is less serious – and may even be welcomed.

Certain procedures – such as RSI – are ‘tightly-coupled’ with little margin for error

Rather than expect perfection in the human operators, we need to make sure there are effective systems in place – acknowledging that error is inevitable in any system. A comparison is usually made between medicine and other fields – most notably aviation and the nuclear industry. Characteristics of these industries is the requirement for high degrees of safety despite the technically complex nature of tasks. Similar concepts abound in the manufacturing industry, where efforts are made to minimise variability and defects in products – the ‘Sigma Six’ process aims to shift defects to six standard deviations from mean – or 3.4 errors/million (99.99966% error free).








I don’t know if achieving a 0.00033% error rate in medicine is achievable – but there is no doubt that conscientious clinicians will strive for perfection – whilst acknowledging that no system involving humans is perfect. Most importantly, even experts will make mistakes – and expertise in one situation does not translate to another. Put simply – an experienced and expert anaesthetist will encounter catastrophe relatively infrequently – hence their expertise in ‘routine’ airway management may not translate to the same in a crisis. How could it? It is difficult for to gain expertise in infrequent events.

Anaesthesia & Aviation – caution with analogy

Human factors experts talk about creating opening up of communication, of team training and use of cognitive aids to minimise error. One of my bugbears is that anaesthesia is often compared to aviation. True, pilots are highly skilled professionals and use checklists bin acknowledgment of the fact that mistakes can happen even when performing routine tasks due to inherent complexity (read about the origin of checklists in aviation here). I think most of us would hesitate to get onboard an aircraft if we knew that the pilot had omitted to use a pre-flight checklist and instead relied upon ‘experiential expertise’ as sole safety check.

The standard argument is that ‘pilots use checklists’ and so should we

Some argue that in a crisis there is not time to use a checklist – the landing of US Flight 1549 on the Hudson River by Captain Cheslea ‘Sully’ Sullenberger after an unprecedented complete engine failure due to birdstrike immediately after takeoff is a case in point. Nevertheless, the pilots used their checklists even though they KNEW there was insufficient time to complete it – falling back on routine allowed them to rapidly confirm crucial procedures performed and come up with a novel solution to the problem. This is expertise – high-level problem solving in a crisis – and it relies upon the routine use of procedures such as checklists to help cognitively offload and so allow such improvisation.

“standardise until you absolutely have to improvise”

Dr Kevin Fong in “How to Avoid Mistakes in Surgery” – BBC Horizon

Of course anaesthesia is nothing like aviation. For a start, aircraft are designed to fly. And it’s not the norm for an aircraft to be on fire and hurtling towards the ground, whilst the Chief Engineer attempts to repair holes in the fuel pump – which is the analogy of a patient in haemorrhagic shock, needing an RSI for theatre as the surgeons attempt to ‘find the bleeding, stop the bleeding’.

There is a classic article written by Grant Hutchinson in 1998, originally published in ‘Today’s Anaesthetist’ and reproduced via this link. It is well-worth a read if you had any doubts about comparisons between aviation & anaesthesia.

As time moves on, lessons learned from aviation are being supplanted by those learned from the human factors industry and within anaesthesia itself. Training in “crisis resource management” has been practiced since 1990 (Gaba, 2010) – and it is not always appropriate to seek answers from the aviation field, when healthcare differs fundamentally.

If you really want to piss off a surgeon, remind them :

anaesthetists fly the plane …

…whilst surgeons serve the drinks & do the in-flight entertainment


Not that lessons from aviation are all bad – emphasis on human factors and team training is generally considered a good thing in clinical education via crisis simulation. But of course the clinical team is NOTHING like the highly-trained team on an aircraft or in a nuclear power plant. Rather the ‘team’ in an airway crisis in the ED is often comprised of disparate individuals who may have unknown skills mix and have probably never trained before (the exception of course being small rural EDs and of course highly-trained prehospital teams who ‘train hard, fight easy’). These are best considered as ‘flash teams’ – and it is obvious that although ostensibly a ‘team’ the rate of error in achieving a highly technical task amongst a ‘flash team’ is higher than in a team that has trained together.

Tannenbaum et al. describe the concept of “flash teams”

One of the ways to help mitigate against the vagaries of performance within a ‘flash team’ is to incorporate protocols that allow teams to form quickly – rapid identification of role clarity, use of a ‘shared mental model’ (the C-ABC approach). Checklists during critical procedures such as RSI can be considered as ‘join-in-progress’ protocols that allow individuals to function as a team – independent of the operator’s expertise.

Thus error is seen as inevitable in any system and may occur independently of expertise. Changes in systems, in addition to individual expertise, is the way forward to minimise error and reduce patient harm, particularly in technical & tightly-coupled processes. Cognitive aids (such as The Vortex) and use of checklists for critical procedures (surgery, RSI) have much to offer – even to experts.

Checklists in Medicine

Unless you have been living under a rock, it is highly likely that you have at least heard about Atul Gawande and his book ‘The Checklist Manifesto’. With any luck you will have read this and his other books – ‘Complications’ and ‘Better’. Gawande writes eloquently on the path to expertise, the need to see improvements in quality and the problems that clinicians face when things do not go wrong. He articulates clearly the difficulties of tightly-coupled processes in clinical practice, along with the inherent instability in dynamic systems such as the human body and disease.

The three books read as a series : ‘Complications‘ (published 2002) describes the problems we face in medicine and difficulties to achieve excellence. ‘Better‘ (published 2007) describes the qualities for success in medicine – diligence, doing the ‘right thing’ and ingenuity’. ‘The Checklist Manifesto‘ (published 2009) describes the importance of pre-planning and how simple interventions at an organisational level may help overcome predictable error.

Gawande’s work has lead to the widespread implementation of the WHO Surgical Checklist, reported to reduce surgical error (such as wrong-site surgery or retained instruments) by as much as 30% – see for more details.


There have been criticisms of the WHO Checklist – there are reports in the UK’s NHS of the checklist being introduced ‘top down’ with no local change champion, resulting in lack of institutional ‘buy in’ from team members. I have certainly witnessed the checklist completed as an aside AFTER induction – or the checklist being performed by part of the team (typically scrub & scout nurse) without the participation of either surgeon or members of the anaesthetic team. Moreover they can fail – as discussed by active twitter-contributer Dr Helgi Johanssen (@traumagasdoc) in this podcast.

WHO Checklist MUST take place without interruption, involve all team members and take place before the procedure – not aside as ‘additional paperwork’
Screen Shot 2013-12-25 at 3.08.30 pm
The WHO Surgical Checklist – widely adopted – is designed to be adapted to local circumstances – this is the Aus/NZ version


There have been other successes in checklist implementation – Provonost describes reductions in complications from central line insertion by introduction of a simple checklist to reduce central-line associated infection.

A recent (this week) paper in the NEJM describes NO improvement in outcomes when comparing checklist use before/after implementation (Urbach et al “Implementation of surgical checklists in Ontario, Canada” N Engl J Med 2014 370 : 1029-38). However, an accompanying editorial points out that the checklist was NOT USED in many cases, and cites other examples where checklist implementation takes time – it is probably that benefits will be proven with a longer period of study and ensuring that the checklist is used (Leape, L. 2014 The Checklist Conundrum NEJM 2014). As Gawande says “the checklist won’t work if you don’t use it”

The question is as to whether use of checklists is really needed by experts dealing with complex, non-routine events such as airway crisis management. 


The smaccGOLD debate :

‘Real Airway Experts Use Checklists’


Given the proven value of checklists in routine and yet tightly-coupled procedures such as surgery and central line insertion, should their use become standard in airway management, even by experts?

Arguments in Favour

Expertise is a hard area to define. Whilst the assumption that Fellowship or Board Certification in Anaesthesia means that one is an ‘expert’, even anaesthesia is a broad church. The wise anaesthetist knows that he/she may have strengths as well as weaknesses – and whilst airway management is a core skill, during times of cognitive overload even the most seasoned veteran may struggle. Moreover, the management of an airway procedure (let’s say RSI) or of a crisis (let’s say intra-operative hypotension) requires more than just the individual’s skills – success or failure requires a complex interplay of expertise, coupled with teamwork and equipment. Even the best airway doctor can fail if his/her assistant is unable to assist or if a vital piece of equipment is lacking. These are not theoretical concerns. In one study, anaesthetists were reported to make mistakes in nearly 50 % of mistakes even during a ‘core skills’ such as RSI – thankfully suck mistakes are small and usually compensated for by redundancy in systems and the fact that error (eg: failing to check suction available) may be undetected in a routine RSI that goes well.

First up, who is an expert? Monash anaesthetist Nicholas Chrimes suggested via Twitter that we consider this to be “anyone qualified to independently perform advanced airway management, regardless of specialty” – this including anaesthetists, intensivists, emergency physicians, pre-hospitalists and paramedics – even those country doctors. At 3am in an ED, the only available ‘expert’ for a crisis is going to be one of the ED/ICU/anaes registrars…not the anaesthetic consultant. Ditto in a small rural town, the country doctor or paramedic will be the designated ‘expert’.

(i) being expert is not enough

Regardless of the ‘label’, assuming the operator is qualified to independently practice, I argue that expert status is insufficient. Understanding dual-process decision-making shows us that experts tend to practice via so-called “system I” – experience and intuition, whereas novices tend to use more “system II” – rule-based heuristics. This can lead to the phenomenon of ‘strong but wrong’  decisions…countered by introducing cognitive checkpoints – such as checklists.

Experts tend to operate in routine, borne by years of experience. I interviewed Dr Helgi Johannsen (@traumagasdoc) for a podcast on wrong-site surgery (an example where use of the WHO checklist failed) and this naturally lead to a discussion of checklists in crisis management and high-stakes procedures such as RSI. Helgi made it clear that he does NOT use a checklist – as he operates in a theatre environment with ‘one set way’. Even if moving into a different environment (such as the ED) for an RSI, Helgi admits he would bring his ODP (a trained theatre assistant) with him from the OT to that environment.

Yet not all of us have that luxury. Moving from a routine, practiced over years of experience, to an unfamiliar environment, with new personnel, probable changes in equipment and a dynamic situation (invariably a crisis – hence the need for expertise) places extra demands, such as stress & cognitive overload, unclear authority gradients, complex human factors interplay. As cognitive demand increases, performance decreases with concomitant loss of situational awareness, task-fixation etc – the perfect storm for error. Add in the common strains of working in a medical environment (often being hungry, angry, late or tired) and error is almost inevitable. That’s just part of being human…

Checklists can help – not as a recipe or cookbook for novices, but as an adjunct to the expert to ensure key stages or information have not been omitted. They function as a check of what has been done, not a ‘how to do it’.

Being expert is NOT enough! Using a checklist is an additional line of defence against latent error.

(ii) a “team of experts” is not an “expert team”

Even assuming our expert is in tip-top form, able to superhumanly overcome the demands of cognitive load under stress (perhaps through stress-inoculation training)…he or she is only as good as the team around them.

Checklists help to democratise knowledge and establish a shared mental model of what is going on. The pre-RSI checklist is a good example – taking 60 seconds to run through the checklist during preoxygenation not only ensures that all equipment and planning is in place, it also sets the scene for crisis management in case of difficulty. Again, checklists are there to help the team ‘check done’ not tell the expert ‘how to do’.

(iii) checklists are for crises as well as routine

Books, journal articles and lay media have popularised the value of checklists for routine procedures – the WHO Safe Surgery Checklist from Gawande and colleagues as well as the central-line checklist from Provonost are the usual cited examples. Critics will tell you that checklists are fine for routine – but not for crisis management.

This is, of course hocum. Since the 1990s, anaesthetists have been implementing training in crisis resource management, leading to development of crisis algorithms & checklists. More recently the NAP4 study from the UK suggested implementation of checklists into practice. Aids such as Borshoff’s Anaesthetic Crisis Manual and crisis cards such as those for malignant hyperthermia, local anaesthetic systemic toxicity, CICO, anaphylaxis etc are enthusiastically adopted in theatre by anaesthetists. Is there evidence? Well, like aviation, anaesthesia is prepared to implement safety measures borne through accumulated wisdom – lessons learned through tragic human loss. Anaesthetists accept the use of such cognitive aids in crisis management, despite ‘expert’ status. Is anyone going to do a randomised-controlled trial of checklist use vs non-use in a crisis? Probably not. Should we use them? Probably yes.

Critics also state that use of a checklist in a crisis will cause delay and that sometimes you ‘just have to act’. Indeed. But if you break this down, it should be clear by now that routine use of a checklist helps establish a team with shared mental model and ability to flatten authority gradients…and if a crisis evolves, all the necessary steps have been considered and are in place. Moreover, during a crisis the impact of stress and cognitive overload can lead to ‘strong but wrong’ decisions by experts using ‘system I’ decision-making – having a reader run through checklist can act as a cognitive waypoint, ensuring alternative options have been considered and acting as an adjunct to the expert.

Critics often point to examples from aviation – either QF32 or US Airways Flight 1549. In the former, QF32 (an Airbus A-380) was on climb-out from Singapore to Sydney, then suffered an “uncontained turbine failure” causes multiple other failures. Using their own human instincts and decisions allowed the crew to override the numerous automated error messages. Does this mean that ‘expertise’ wins out over checklists? Not at all – having a routine – whetehr this be SOPs or checklists – allowed the QF32 team to make decisions even under pressure. In aviation parlance, they were able to aviate-navigate-communicate. Ditto in the case of Capt Sully Sullenberger and crew – loss of both engines after a birdstrike from New York to Charlotte, NC allowed only 208 seconds from crisis to landing – in this case on the Hudson River. There is no checklist for loss of both engines on climb-out – nor was there time to execute the checklists for power loss at higher altitude – nevertheless, the First Officer commenced a checklist and the use of routine allowed the pilot and team to function.

large_hudson river us airways flight splash landing

As Sullenberger says :

“My pulse shot up. My blood pressure shot up. My perceptual field narrowed because of the stress. And I had to really actively compartmentalize and focus and force that distraction away, and just concentrate on the task at hand. So I forced calm on my myself and then I imposed order on the situation”

This illustrates the impact of stress on performance – moving into the zone of raised HR and impairment of cognitive skills, with risk of loss of situational awareness and task saturation. Compartmentalising the problem allowed a solution – in this case, I believe regular use of checklists (as well as team training and crisis management) allowed the expert pilot to realise standard options are exhausted and to improvise.

Regular training, standardisation and checklists to ensure task completion allow us to develop both individual and team cognitive resilience. 

There is published evidence that use of a checklist for out-of-theatre RSI both reduces error and takes no longer than non-use (“Checklist for emergency induction of anaesthesia in critical care” Babolhavaeji, F. et al, Anaesthesia 2013 68 655-661)

Screen Shot 2014-03-09 at 9.38.22 am

(iv) There is evidence for beneficial use of checklists

This leads on from the above. Critics say that there is no evidence for checklists and that as such they should not be adopted. Most of the work comes from simulation…but as mentioned previously, there is no reason NOT to extrapolate from simulation, given the known problems of under-reporting of error in healthcare and the relative infrequency of crisis during training and subsequent professional career.

Stiegler et al (2012) highlight cognitive errors in as many as 50% of simulated anaesthetic crises – a sobering fact. Moving on from demonstrating error alone in simulated crisis management, Arriaga et al (2013) demonstrate an almost 75% reduction in error rate during simulated surgical crises when comparing management with checklists (6%) vs without (23%). 97% of clinicians involved in this trial expressed a preference for checklist use.

“If I were having an operation & experienced this intraoperative emergency, I would want the checklist to be used” 

One of the key recommendations from the UK’s NAP4 study was for use of an intubation checklist to be used alongside capnography in all remote site emergency airway management situations involving critically ill patients, as they have been shown to significantly reduce complication rates (Wijesuriya & Brand, 2014). Learning from NAP4, the recent introduction of a package of RSI checklist in all out-of-theatre intubations in a UK NHS trust lead to improved confidence in managing such situations and has been enthusiastically adopted locally, with suggestions to implement across other institutions.

There is recent evidence for a 50% reduction in the risk of desaturation for children undergoing RSI in a paediatric emergency department. That is impressive. Here’s the checklist user by Kerrey et al in the USA to reduce error in paediatric RSI :

Screen Shot 2014-03-11 at 7.16.29 pm

In Australia, the Royal North Shore Hospital ED published an important piece of work highlighting the performance of ED RSI in their institution. It makes for sobering reading, highlighting problems of skill fade, infrequent use of a bougie and complications in 29%. Kudos to the authors for publishing and more importantly, for using this audit to drive change in their institution and elsewhere. Fogg and colleagues have established an updated RSI checklist and are calling for other to join the audit of ED RSI via

Implementing change in medicine takes time. Yet high-performance teams such retrieval services are also enthusiastic early adopters of checklists – they understand the impact of human factors on crisis management, and even despite regular training will adopt cognitive aids and check tools into daily routine because of perceived benefits. And you think you are too cool or too good to need a checklist et these guys do? Come on!

Even Minh agrees – he is on the record talking at SMACC 2013 about “Airway Clean Kills(slideset available here).  Intubation offers you many ways to kill your patient.  Checklists can help avoid some of them as usually Minh espouses…


Slide from “Airway Clean Kills” by Dr Minh Le Cong, SMACC2013

Anaesthetist Dr Mark Knights, whose team in Wales, UK demonstrated less error and no delay in use of an RSI checklist, puts this well :

We do a lot of things in medicine that are costly and the evidence of benefit is marginal.  A lot of the more recent improvements in critical care are about doing the simple things well (ie care bundles for ventilation, central venous catheters, etc.) We do know that poorly conducted airway management causes significant morbidity and mortality and that there is particular risk of this in ED/ICU.  (NAP4).  Using a checklist is simple, free and should  improve the standard of intubations (we have shown that it does in simulations).  To quote Atul Gawande “Better is possible.  It does not take genius. It takes diligence”

Arguments Against Checklists

We have covered (and debunked) some of these above. Anaesthesia has been embracing lessons of crisis resource management for almost 25 years, with development of guidelines, algorithms, crisis action cards and checklists as a result. Whilst the weight of evidence for checklists has been demonstrated in routine procedures (elective surgery, central line insertion), there is emerging evidence that checklist use not only reduces error, but also does not cause delay in a crisis. Indeed, regular use may enhance performance in a crisis.

Much of this work has come from simulation – necessary given the problems of error reporting and relative infrequency of crises – but savvy experts who understand the limitations of crisis management even by experts are adopting checklists into their practice, guided by evidence from audit and the emerging evidence of benefit.

Of course checklists are not a panacea for all ill. Merely having a checklist won’t ward off disaster. Neither is a crisis the ideal time to implement a checklist – they need practice, buy-in from team members and regular rehearsal. They need to kept simple and only used for high-risk, tightly-coupled procedures where omission of steps can lead to disaster. Checklist fatigue is a real danger, as is the ‘tick and flick’ mentality of filling in boxes or ‘just another piece of paper’.

Ideal checklists should be kept as a laminated sheet for reference, not for filling in. The items are read as a challenge-response to enable the expert and team to avoid cognitive error in a crisis.

Design is key – a poorly designed or inappropriate checklist is worse than useless. They need to be relevant, simple and adapted to local use.

Have a look at some of the examples below and see if they fulfil the criteria.


Introducing The Vortex

The Vortex is a cognitive tool that we demonstrated in the Airway Workshop. I’ve seen it used effectively on the ETMcourse and seeing it in use by experts and novices alike is one of those ‘lightbulb’ moments of clarity. It neatly simplifies previously complex airway management algorithms into a “high stakes cognitive aid” – simple enough to be recalled in a crisis and flexible enough to be used in any context.

If you missed the workshop, check out The Vortex via There is a neat video demonstrating the ‘read aloud’ manner of a sensible and well-designed checklist in a crisis.


@NicholasChrimes “#Vortex is a checklist. Prompts the enactment of training in crisis”


@NicholasChrimes “#Vortex – It’s a novel checklist, for broad strategies not exhaustive, designed for real time crisis Mx”



Nick was kind enough to email me some ‘ammo’ in the argument PRO checklists – particularly poignant as he knows how much Minh loves The Vortex approach (as do I) :

“the Vortex is essentially an innovative graphic representation of a simple checklist for 4 airway techniques & 5 categories of optimisation manoeuvre. The graphic representation allows it to also convey additional elements of urgency (in the funnel) & safety (in the green zone) as well as facilitating use by the whole team”

So – it’s a checklist & cognitive aid – one which Minh endorses. Game – Set – Match.


Here are more examples of checklists used by airway experts :














From Bangor, Wales (authors of study demonstrating use of checklist did not delay intubation and reduced error rates in out-of-theatre airway management). Click to read their presentation via slideshare.

RNSH Checklist

Checklist from from the Royal North Shore Hospital ED via – see also commentary from Cliff Reid at


The above checklist is from George Douros of Austin Health (Victoria, Australia) and is discussed over in an article at It’s simple and well laid out.

Another RSI checklist

This example is from Yen Chow in Thunder Bay (Ontario, Canada). He’s a co-author on Minh’s excellent site and posts on PHARM about the benefits of checklists here. Check it out.

Click link below to download

Remembering that a true checklist is a “check of what has been done” not a “how to do it read-do”, I use the above in my ED and prehospital bag – works really well as a challenge-response checklist in the final minute before intubation and has the added bonus of a ‘kit dump’ to help layout kit – especially useful if enlisting helpers who may be unfamiliar with the kit.

 This has been modified from similar checklist mats used by retrieval services in Australia and the UK. This and a smaller ‘checklist action card’ is available for download and adaptation from the anaesthesia resources section of the site, along with an ED/Theatre Crisis Checklists pdf for iPad.


The above modification of an RSI kit dump and checklist is courtesy of Dr John Hinds from Eire – the essential item is in bottom right corner, concerning cricoid pressure….

Obs RSI checklist


Scott Weingart has weighed in on checklists – his version is above and can be downloaded here. I think one has to weigh up the pros of being all inclusive vs ease-of use.

With this in mind, I reckon the BEST checklists are those that are simple, easy to follow and limited to just key items. They should read as checks, not ‘to do’, although the latter blurs the line between checklists proper and cognitive aids or more complex crisis algorithms.


The above ‘checklist for checklists‘ is from – an excellent site which discusses checklist design and implementation.

Of course, checklists are not a panacea for all – they are but one extra layer of defence against error. Checklist implementation requires appropriate leadership, training and organisational change and must take place against a background of embracing human factors into a safety culture. This is discussed more in the book ‘Beyond the Checklist‘. In case you were dead set against checklists – don’t worry, the patients will be doing it for you – here is a checklist for patients to assess the teamwork & safety of their clinicians!

Beyond the CL

As EM IM Doc states in the “Ch…ch…ch…check it out; ED RSI Checklists” blog post – to create a practical checklist, consider the following:

  • Design each item to address a specific, actionable, critical safety step
  • Make it short and easily understandable
  • Utilize natural breaks in work-flow
  • Build it in to your process and delegate a team member
  • Review, Revise and Refine

The last word (for now) should go to Atul Gawande – writing in the Incidental Economist “When Checklists Work & When They Don’t“, he comments on checklists and their naysayers, saying “there is one thing we know for sure: if you don’t use it, it doesn’t work

 In Summary – Real Airway Experts use Checklists


Theatre checklists


Recommended Books

“An astronauts guide to life on earth” Chris Hadfield 2013 Macmillan

“Better – a surgeon’s notes on performance” Atul Gawande 2008 Profile Books

“Beyond the Checklist – what else healthcare can learn from aviation teamwork & safety” Suzanne Gordon, Patrick Mendenhall & Bonnie Blair O’Connor 2013 Cornell University Press

“Complications – a surgeon’s notes on an imperfect science” Atul Gawande 2002 Profile Books

“Crew resource management” barbara Kanki, Robert Helmreich & Jose Anca 2010 Academic Press

“The Checklist Manifesto – how to get things right” Atul Gawande 2010 Profile Books

“On Combat – the psychology & physiology of deadly conflict in war and in peace” Dave Grossman  2004 Warrior Science Publications

“Patient Safety” Charles Vincent 2010 BMJ Books

“Patient safety in emergency medicine” Pat Croskerry, Karen Cosby, Stephen Schenkel & Robert Wears 2009 Lippincott, Williams & Wilkins

Recommended Sites



CRISIS CHECKLISTS – via Brigham & Women’s Hospital projectcheck


EMERGENCY MANUALS – great list of refs at







In favour of checklists :

Arriaga A., Bader A., Wong J., Lipsitz S., Berry W., Ziewacz J., Hepner D., Boorman D., Pozner C., Smink D. & Gawande A. (2013) Simulation-based trial of surgical-crisis checklists The New England Journal of Medicine 2013 368 (3) : 246

Augoustides J., Atkins J. & Kofke W. (2013) Much ado about checklists: who says I need them and who moved my cheese 2013 Anesthesia & Analgesia 2013 117 (5) 1037

Babolhavaeji F., Rees I., Maloney D., Walker J. & Knights M. (2013) Checklist for emergency induction of anaesthesia in critical care Anaesthesia June 2013

Bates D. & Gawande A. (2000) Error in medicine: what have we learned? Annals Int Med (2000) 132 9 : 763

Braude D. (2008) Checklists : simple but overlooked solution to airway complexities Emergency Medicine News 2008 30 (5) 16

Dieckmann P. & Rall M. (2005) Safety culture and crisis resource management in airway management: General principles to enhance patient safety in critical airway situations Bailliere’s Best Practice in Clinical Anesthesiology 2005 19 (4) 539

Fogg T., Annesley N., Hitos K. & Vassiliadis J. (2012) Prospective observational study of the practice of endotracheal intubation in the emergency department of a tertiary hospital in Sydney, Australia EMJ 2012 24 617

Gaba D. (2010) Crisis resource management and teamwork training in anaesthesia British Journal of Anaesthesia 2010 105 (1) 3

Gaba D. (2013) Perioperative cognitive aids in anesthesia: what, who, how and why bother? Anesthesia & Analgesia 2013 117 (5) 1033

Goldhaber-Fiebert S. & Howard S. (2013) Implementing emergency manuals: can cognitive aids help translate best practice for patient care during acute events? 2013 Anesthesia & Analgesia 117 (5) 1149

Hales B., Terblanche M., Fowler R & Sibbald W. (2008) Development of medical checklists for improved quality of patient care Int J Quality in Health Care 2008 20 (1) 22

Hoffman L. (2013) Crisis checklists improve management of rarely occurring events Critical Care Alert 1st Sept 2013

Huang L., Kim R. & Berry W. (2013) Creating a culture of safety by using checklists AORN 97 (3) 365

Hunter D. & Finney S. (2012) Follow surgical checklists and take time out, especially in a crisis BMJ 2012 344 1136 d8194

Keane M. & Marshall S. (2010) Implementation of the World Health Organisation surgical checklist : implications for anaesthetists Anaesthesia & Intensive Care 2010 38 (2)

Kerrey, B.Y. et al (2013) Improving the safety of Rapid Sequence Intubation in a Pediatric Emergency Department. Abstract presented at American Academy of Pediatrics Conference, Orlando Oct 26-29 2013 Accessed 9 March 2014 via

Leape L. (2014) The Checklist Conundrum NEJM 2014 370 11 1064

Lichitor, L. (2012) Pilots use checklists. Why don’t anaesthesiologists do the same? – [accessed 2 Feb 2014]

Low D., Reed M., Geiduschek J. & Martin L. (2013) Striving for a zero-error patient surgical journey through adoption of aviation-style challenge and response flow checklists: a quality improvement project Pediatric Anesthesia 2013 571

Mackenzie R., French J., Lewis S. & Steel A. (2009) A pre-hospital emergency anaesthesia pre-procedure checklist SJTREM 2009 17 (supp 3) O26

Marshall S. (2013) The use of cognitive aids during emergencies in anaesthesia: a review of the literature Anesth Analg 2013 117 : 1162

McIlvaine W. (2006) Human error and its impact on anesthesiology Seminars in Anaesthesia, Perioperative Medicine & Pain 2006 25 : 172

Myburgh J., Chapman M., Szekely S. & Osborne G. (2005) Crisis management during anaesthesia: sepsis  Qual Saf Health Care 2005 14 e22

Mulroy M. (2013) Emergency manuals: the time has come Newsletter of the Anesthesia Patient Safety Foundation 2013 28 (1) 1

O’Leary, F., McGarvey K., Christoff A., Major J., Lockie F., Chayen G., Vassiliadis J. & Wharton S. (In Press) Identifying incidnets of suboptimal care during paediatric emergencies – an observational study utilising in situ and simulation centre scenarios Resuscitation (2013)

Pace G. &  Carmignani L. (2012) Checklists: are really necessary in the routinely clinical practice? Int. J. Surgery 10 (2012) : 169

Rall M. & Dieckmann P. (2005) Safety culture and crisis resource management in airway management: general principles to enhance patient safety in critical airway situations Clinical Anesthesiology 2005 19 (4) 539

Runciman W., Morris R., Watterson L., Williamson J. & Paix A. (2005) Crisis management during anaesthesia: cardiac arrest Qual Saf Health Care 2005 14 e4

Schmutz J. & Manser T. (2013) Do team processes really have an effect on clinical performance? A systematic literature review British Journal of Anaesthesia 2013 110 (4) 529

Sibbald M., de Bruin A.B.H. & van Merrienboer J.G. (2013) Checklists improve experts’ diagnostic decisions Medical Education 2013 47 301

Siriwardena A., Shaw D., Togher F., Davy, Z., Spaight A. & Dewey M. (2014) The effect of a national quality improvement collaborative on prehospital care for acute myocardial infarction and stroke in England Implementation Science 2014 9 : 17

Stiegler, M.P., Neelankavil J.P., Canales C. & Dhillon A. (2012) Cognitive errors detected in anaesthesiology: a literature review and pilot study British Journal of Anaesthesia 2012 108 (2): 229–35

Thomassen, O., Espeland A., Softeland E., Lossius H., Heltne J. & Brattebo G. (2011) Implementation of checklists in healthcare; learning from high-reliability organisations SJTREM 2011 19 53

Tobin, J., Grabinsky A., McCunn M., Pittet, J-F., Smith C., Murray M. & Varon A. (2013) A checklist for trauma and emergency anaesthesia Anesth Analg 117 (5) : 1178

Walker I., Reshamwalla S. & Wilson I. (2012) Surgical safety checklists: do they improve outcomes? British Journal Anaesthesia 2012 109 (1) 47

Weingart S. (2012) Podcast 92 – EMCrit intubation checklist [accessed 2 Feb 2014]

Winters B., Gurses A., Lehmann H., Sexton B., Rampersad C. & Provonost P. (2009) Clinical review: checklists – translating evidence into practice. Critical Care 2009 12 : 210

Wijesuriya J. & Brand, J. (2014) Improving the safety of remote site emergency airway management – Accessed 9th March 2014 via

Wittenberg M.D., Vaughan D.J.A. & Lucas D.N. (2013)  A novel airway checklist for obstetric general anaesthesia International journal of obstetric anesthesia 2013 22 (3) 264


Caveats re: checklists

Bosk C.L., Dixon-Woods, M., Goeschel C.A. & Provonost P. (2009) Reality check for checklists. Lancet 2009 374 444

Carthey J., Walker S., Deelchand V., Vincent C. & Griffiths W. (2011) Breaking the rules BMJ Sept 2011 343 621

Ko H., Turner T. & Finnigan M. (2011) Systematic review of safety checklists for use by medical care teams in acute hospital settings – limited evidence of effectiveness BioMedCentral – Health Sciences Research 2011 11 : 211

Maxfield D., Grenny J., Lavandero R. & Groah L. (2005) The silent treatment: why safety tools and checklists aren’t enough to save lives [accessed 3 Feb 2014]

Sparks E., Wehbe-Janek H., Johnson R, Smythe W. & Papaconstantinou H. (2013) Surgical safety checklist compliance: a job done poorly J Am Coll Surg 2013 1

Urbach et al (2014) “Implementation of surgical checklists in Ontario, Canada” N Engl J Med 2014 370 : 1029-38

Waehle H., Haugen A., Softeland E. & Hjalmhult E. (2012) Adjusting team involvement: a grounded theory study of challenges in utilizing a surgical safety checklist as experienced by nurses in the operating room BioMedCentral – Nursing 2012 11 : 16


General reading on error, distraction & crisis resource management :

Campbell G., Arfanis K. & Smith A. (2012) Distraction and interruption in anaesthetic practice British Journal of Anaesthesia 2012 109 (5) 707

Heard G (2005) Errors in anaesthesia – a human factors perspective Australian Anaesthesia 2005

Kahneman D. & Klein G. (2009) Conditions for intuitive expertise : a failure to disagree American Psychologist 2009 64 (6) 515

Marshall S (2010) Simulation-based education for building clinical teams J Emerg Trauma Shock 2010 3 (4) 360

Tannenbaum S., Mathieu J., Salas E. & Cohen D. (2012) Teams are changing : a research and practice evolving fast enough Industrial & Organisational Psychology 5 2




Abbreviated flight checklist

IVF checklist



Dr T is embarking on an intense 6 month programme of training prior to the debate with Dr le Cong
Dr T is embarking on an intense 6 month programme of training prior to the debate with Dr le Cong



Screen Shot 2013-12-25 at 2.27.34 pm




I KNEW IT ! Minh demonstrates the KIdocs version of kit dump - and RSI challenge-response checklist
I KNEW IT ! Minh demonstrates the KIdocs version of kit dump – and RSI challenge-response checklist



One of the criticisms of checklists is that there is “no evidence that they work”. As I keep suggesting to Minh, try jumping out of an aircraft without a parachute. There’s never been a randomised controlled trial on the effectiveness of parachutes.

Astute readers will be aware that absence of evidence doesn’t equate to evidence of absence, as the authors of this classic BMJ paper state :

“Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute”

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 More General Papers


Why Use Emergency Manuals: Evidence From Medicine

Babcock W. Resuscitation during Anesthesia. Anesth Analg 1924;3:208-13
Berkenstadt H, Ben-Menachem E, Dach R, Ezri T, Ziv A, Rubin O, Keidan I. Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises: results from the Israeli board of anesthesiologists. Anesth Analg 2012;115(5):1122-6
Berry WR. Cardiac resuscitation in the operating room: reflections on how we can do better. Can J Anaesth 2012;59:522-6
Gaba DM. Human error in dynamic medical domains. In:  Bogner MS, ed. Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc, 1995:197-224
Gaba DM. Human error in anesthesia mishaps. Int  Anesthesiol Clin 1989;27(3):137

Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, and mortality with major inpatient surgery in Medicare patients. Ann Surg 2009;250:1029-34    

Kurrek MM, Devitt JH, Cohen M. Cardiac arrest in the OR: how are our ACLS skills? Can J Anaesth 1998;45:130-2    

Lipman SS, Daniels KI, Carvalho B, Arafeh J, Harney K, Puck A, Cohen SE, Druzin M. Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises. Am J Obstet Gynecol 2010;203:179.e1-5

Semeraro F, Signore L, Cerchiari EL. Retention of CPR performance in anaesthetists. Resuscitation 2006;68:101-8    

Smith KK, Gilcreast D, Pierce K. Evaluation of staff’s retention of ACLS and BLS skills. Resuscitation 2008;78:59-65   

Stiegler MP, Neelankavil JP, Canales C, Dhillon A. Cognitive errors detected in anaesthesiology: a literature review and pilot study. Br J Anaesth 2012;108(2):229-35
Steigler MP, Ruskin KJ. Decision-making and safety in anesthesiology. Curr Opin Anaesthesiology 2012;25:724-9

Why use Emergency Manuals: Evidence from high-stakes industries, psychology, and human factors


Accident report: Loss of thrust in both engines after encountering a flock of birds and subsequent ditching on the Hudson River. National Transportation Safety Board. 2010

Aircraft Accident Report – United Airlines, Inc., McDonnell-Douglas DC-8-61, N8082U, Portland, Oregon, December 28, 1978. National Transportation Safety Board    

Psychology and Human Factors

Committee on Quality of Healthcare in America. To Err Is Human: Building A Safer Health System. Vol. 6. Kohn LT, Corrigan J, Donaldson MS, eds.Washington, D.C.: National Academy Press, 2000
Kahneman D, Klein G. Conditions for intuitive expertise: a failure to disagree. Am Psychol 2009;64(6):515
Klein G. Naturalistic decision making. Hum Factors 2008;50(3):456-60
Orasanu J, Connolly T. The reinvention of decision making. In: Klein GA, Orasanu J, Calderwood R, Zsambok CE, eds. Decision Making in Action: Models and Methods. Norwood, NJ: Ablex Publishing Co, 1993:3-20
Tversky A, Kahneman D. Judgement under uncertainty: heuristics and biases. Science 1974;85(41257):1124-31


Driskell JE, Salas E, Johnston J. Does stress lead to a loss of team perspective? Group Dynamics: Theory, Research, and Practice1999;3:291

Checklists and Cognitive Aids From Non-Emergency Settings in Medicine

Abbett SK, Yokoe DS, Lipsitz SR, Bader AM, Berry WR, Tamplin EM, Gawande AA. Proposed Checklist of Hospital Interventions to Decrease the Incidence of Healthcare-associated Clostridium Difficile Infection. Infection Control and Hospital Epidemiology. 2009;30(11):1062-9
Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004;32(10):2014-20

Birkmeyer JD. Strategies for improving surgical quality–checklists and beyond. N Engl J Med 2010;363:1963-5

Bould MD, Hayter MA, Campbell DM, Chandra DB, Joo HS, Naik VN. Cognitive aid for neonatal resuscitation: a prospective single-blinded randomized controlled trial. Br J Anaesth 2009;103(4):570-5
Dellinger RP, Vincent JL. The surviving sepsis campaign sepsis change bundles and clinical practice. Crit Care 2005;9(6):653-4

Gawande A. The checklist manifesto: how to get things right. 1st ed. New York: Metropolitan Books    

de Vries EN, Prins HA, Crolla RM, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 2010;363:1928-37    

Hales BM, Pronovost PJ. The checklist—a tool for error management and performance improvement. J Crit Care 2006;21(3):231-5
Hales B, Terblanche M, Fowler R, Sibbald W. Development of medical checklists for improved quality of patient care. Int J Qual Health Care 2008;20(1): 22-30

Haynes AB, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9    

Mills PD, DeRosier JM, Neily J, McKnight SD, Weeks WB, Bagian JP. A cognitive aid for cardiac arrest: you can’t use it if you don’t know about it. Jt Comm J Qual Saf 2004;30(9):488-96

Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010;304:1693-700    

Nelson KL, Shilkofski NA, Haggerty JA, Saliski M, Hunt EA. The use of cognitive AIDS during simulated pediatric cardiopulmonary arrests. Simul Healthc 2008;3(3):138-45
Semel ME, Resch S, Haynes AB, Funk LM, Bader A, Berry WR, Weiser TG, Gawande AA. Adopting A Surgical Safety Checklist Could Save Money And Improve The Quality of Care in US Hospitals. Health Affairs. 2010; 29(9): 1593-1599
Spector, J. M., Agrawal, P., Kodkany, B., Lipsitz, S., Lashoher, A., Dziekan, G., … & Gawande, A. (2012). Improving quality of care for maternal and newborn health: prospective pilot study of the WHO Safe Childbirth Checklist Program. PLoS One7(5), e35151

van Klei WA, Hoff RG, van Aarnhem EE, et al. Effects of the introduction of the WHO “Surgical Safety Checklist” on in-hospital mortality: a cohort study. Ann Surg 2012;255:44-9

Weiser, T. G., Haynes, A. B., Dziekan, G., Berry, W. R., Lipsitz, S. R., & Gawande, A. A. (2010). Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Annals of surgery251(5), 97

Checklists, Cognitive Aids, and Manuals in Operating Room Emergencies

Arriaga AF, Bader AM, Wong JM, Lipsitz SR, Berry WR, Ziewacz JE, Hepner DL, Boorman DJ, Pozner CN, Smink DS, Gawande AA. Simulation-Based Trial of Surgical-Crisis Checklists. New England Journal Of Medicine 2013;368:246-53
Augoustides, John G. T. MD, FASE, FAHA; Atkins, Joshua MD, PhD; Kofke, W. Andrew MD, MBA, FCCM. Much Ado About Checklists: Who Says I Need Them and Who Moved My Cheese?. Anesth Analg. 2013 November.

Burden AR, Carr ZJ, Staman GW, Littman JJ, Torjman MC. Does every code need a “reader?” improvement of rare event management with a cognitive aid “reader” during a simulated emergency: a pilot study. Simulation in Healthcare. 2012 Feb; 7: 1-9.

Gaba DM, Fish KJ, Howard SK. Crisis management in anesthesiology. New York: Churchill Livingstone; 1994    

Gaba DM. Perioperative cognitive AIDS in anesthesia: what, who, how, and why bother?. Anesth Analg. 2013 November.

Harrison TK, Manser T, Howard SK, Gaba DM. Use of cognitive aids in a simulated anesthetic crisis. Anesth Analg 2006;103:551-6    

Goldhaber-Fiebert SN, Howard SK. Implementing Emergency Manuals: Can Cognitive Aids Help Translate Best Practices for Patient Care During Acute Events?. Anesth Analg. 2013 Oct [E-pub ahead of print]
Marshall, Stuart. The Use of Cognitive Aids During Emergencies in Anesthesia: A Review of the Literature. Anesthesia and Analgesia (2013).
McEvoy MD, Smalley JC, Field LC, Furse CM, Rieke H. Use of cognitive aids significantly increases retention of skill for management of cardiac arrest. Abstract. American Society of Anesthesiologists Annual Meeting 2010
Moitra VK, Gabrielli A, Maccioli GA, O’Connor MF. Anesthesia advanced circulatory life support. Can J Anesth 2012; 59: 586-603
Mulroy, Michael. Emergency Manuals: The Time Has Come. Anesthesia Patient Safety Foundation; June 2013.
Nanji KC, Cooper JB. It is time to use checklists for anesthesia emergencies: simulation is the vehicle for testing and learning. Reg Anesth Pain Med. 2012 Jan-Feb; 37: 1-2
Neal JM, Mulroy MF, Weinberg GL et al. American Society of Regional Anesthesia and Pain Medicine Checklist for Managing Local Anesthetic Stystemic Toxicity: 2012 Version.  Reg Anesth Pain Med. 2012 Jan-Feb; 37: 16-8
Neal JM, Hsiung RL, Mulroy MF, Halpern BB, Dragnich AD, Slee AE. ASRA checklist improves trainee performance during a simulated episode of local anesthetic systemic toxicity. Reg Anesth Pain Med 2012;37(1):8-15
Neily J, DeRosier JM, Mills PD, Bishop MJ, Weeks WB, Bagian JT. Awareness and use of a cognitive aid for anesthesiology. Jt Comm J Qual Saf 2007;33(8):502-11
Podraza Stiegler, Marjorie and Sara Goldhaber-Fiebert. “Cognitive Errors and Cognitive Aids in Anesthesiology”. Patient Safety Newsletter. 77-5 May 2013: 10-12

Runciman WB, Webb RK, Klepper ID, Lee R, Williamson JA, Barker L. The Australian Incident Monitoring Study. Crisis management–validation of an algorithm by analysis of 2000 incident reports. Anaesth Intensive Care 1993;21:579-92    

Runciman WB, Merry AF. Crises in clinical care: an approach to management. Qual Saf Health Care 2005;14:156-63
Tobin, J. M., et al. A Checklist for Trauma and Emergency Anesthesia. Anesthesia and analgesia. 2013.
Ziewacz JE, Arriaga AF, Bader AM, et al. Crisis checklists for the operating room: development and pilot testing. J Am Coll Surg 2011;213:212-7 e10

Clinical Guidelines for Emergencies

Neal JM, Mulroy MF, Weinberg GL et al. American Society of Regional Anesthesia and Pain Medicine Checklist for Managing Local Anesthetic Stystemic Toxicity: 2012 Version.  Reg Anesth Pain Med. 2012 Jan-Feb; 37: 16-8
Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S729-67

Crew Resource Management, Team Training and Simulation-Based Training

Clancy CM, Tornberg DN. TeamSTEPPS: assuring optimal teamwork in clinical settings. Am J Med Qual 2007;22(3):214
Cooper JB. Are simulation and didactic crisis resource management (CRM) training synergistic? Qual Saf Health Care 2004;13:413-4
Dunn EJ, Mills PD, Neily J, Crittenden MD, Carmack AL, Bagian JP. Medical team training: applying crew resource management in the Veterans Health Administration. Jt Comm J Qual Patient Saf 2007;33(6):317-25
Gaba DM, Howard SK, Fish KJ Smith BE, Sowb YA. Simulation-based training in anesthesia crisis resource management (ACRM): a decade of experience.Simulation & Gaming 2001;32(2):175-93
Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents.Aviat Space Environ Med 1992;63(9):763­-70
Holzman RS, Cooper JB, Gaba DM, Philip JH, Small SD, Feinstein D. Anesthesia crisis resource management: real-life simulation training in operating room crises.J Clin Anesth 1995;7:675-87
McGaghie WC, Draycott TJ, Dunn WF, Lopez CM, Stefanidis D. Evaluating the impact of simulation on translational patient outcomes. Simul Healthc 2011;(6):S42-7
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Designing Checklists and Cognitive Aids

Weiser TG, Haynes AB, Lashoher A, Dziekan G, Boorman DJ, Berry WR, Gawande AA. Perspectives in quality: designing the WHO Surgical Safety Checklist. International Journal for Quality in Health Care. 2010;22(5):365-370


Be a ZERO, Not a HERO

DISCLAIMER : This post is about how medics interact within the various tribes. It is NOT about primary care vs teaching hospital, ED vs medics, surgeons vs anaesthetists. I’ve had some people comment on twitter that this is ‘about being a GP undermined by colleagues’. It’s not. It’s about clinicians, of whatever ilk, either undermining each other OR failing to work effectively within a team as too busy showing off how good they are. It’s a piece inspired by astronaut Chris Hadfield’s book and the concept of new team members being either a’plus one’, a ‘zero’ or a ‘minus one’. Now read on…

Medicine attracts bright people. I am constantly amazed at the smartness of some of my colleagues…and the ongoing exposure to brilliance via the FOAMed community. Not that you have to be smart to be a medic. Before medicine I trained as a research scientist, with undergraduate, Masters and PhD in an arcane area of immunology. But a life at the bench wasn’t for me – I enjoy interacting with people too much – hence the drift into medicine as a mature-age graduate. At medical school it struck me that medics were NOT particularly smart – the ability to absorb, memorise and regurgitate several phone books worth of information seemed to be the prerequisite, rather than original thinking. But insistence on high grades and academic excellence are just a cut-off to limit intake into the over-subscribed medical schools…and this encourages competition at a very early stage.

“Doctors are ingrained to compete – there is competition to get into medical school, competition for intern posts, competition for residency programmes, competition in Fellowship exams, competition for the desired consultant post…plus the inevitable competition between specialties”

Don’t get me wrong. I am all in favour of clinicians who are high-achievers and keen to move themselves to the right of the Gaussian distribution curve (mindful of the fact that 50% of all doctors are, by definition, below average). FOAMed helps us achieve that goal and strive to be better. For guys like myself in rural practice, than means to aim to bring “quality care, out there”.

But there is an ugly side to this competition. We all have tales of colleagues who have fallen by the wayside – whether through alcohol or drug addiction, failure of relationships, mental illness (including suicide). I am pretty sure that most of us have engaged in badmouthing colleagues, whether in the same discipline or in other specialties. Some of this is good-natured banter (think anaesthetists vs surgeons)…but it can become ugly, particularly when detracts from patient care or is a result of stressors perceived as being outside our control (bed pressure, busy workload etc). Both Dr Gerry Considine and myself have blogged about this from the perspective of rural practitioners – but it works both ways – primary care vs tertiary & vice versa as well as between in-hospital disciplines.

It never ceases to amaze me that medical training fails to expose junior doctors to primary care, given that this is where most patient encounters occur. And of course the bullshit perception of ‘just a GP’ continues to be promulgated within the tertiary centres leading to the comment ‘just a GP, not a specialist‘. Dr Penny Wilson blogs nicely on this. From my perspective, the more savvy tertiary colleagues turn pale when I suggest they sit in my shoes – they understand the skills needed to spot illness in undifferentiated primary care patients and would rather the security of preselected narrow-focus work.

“before you criticize a man, walk a mile in his shoes…then you will be a mile away from them & have their shoes”

I have certainly been guilty of critiquing colleagues without understanding their work. Before making the move to rural medicine I was a dual-trainee in EM & ICU. It was VERY easy to sit back and criticise the perceived failings of other doctors, especially as EM & ICU generally see a narrow selection of cases that have not been caught in primary care – blissfully ignorant of the wonderful “saves” out there. Add to this a complete lack of awareness of what different specialties actually do, and the system creates perfect conditions for disharmony. One of my shorthands as an ED reg over 10 years ago was ‘GPFI’ – GP is a ****ing idiot. My how we laughed. Now I am older and wiser.

A recent article in the NY Times captures this problem well, describing a paper in the Journal of Internal Medicine “Physicians Criticising Physicians to Patients” which has been re-tweeted by myself and others. The NY Times article on doctors badmouthing other doctors is worth a read.

“doctors will throw each other under the bus”

As a more grownup clinician in rural practice, a salutary experience for me was managing a patient presenting with acute-on-chronic back pain. I admitted him for analgesia..then 24 hrs later his BP dropped suddenly and the underlying sepsis from his epidural abscess declared itself – the source from an infection picked up a week or so prior whilst gardening. His retrieval & intensive care stay was prolonged and complicated, with devastating sequelae.

A single comment from an ICU nurse “you should sue your doctor for missing this” drove a three-year wedge between myself, the patient and family – very difficult in a small rural community, but eventually healed once the time course and decision-making had been explained. Systems failings (no ‘early warning’ notification, failure to appreciate significance of raised respiratory rate and falling urinary output so deterioration not communicated to doctor) all had their part to play, as did cognitive bias ‘just a flare of usual back pain’. But that chance comment from an ICU nurse undermined the therapeutic relationship.

That’s one example. I am sure you will all have similar stories. The ‘barndoor’ appendicitis referred to the medics as gastro by an ‘idiot ED reg’. The flail chest mismanaged as an infective exacerbation of COPD on the Care of the Elderly ward after a patient has fallen against bed rails. Mistakes happen, diagnoses are revised. But we are often quick to hang our colleagues out to dry with the benefit of the retrospectoscope.

Beware critique of others - but NEVER be afraid to apologise for an error
Beware critique of others – but NEVER be afraid to apologise for an error

The more medicine I do, the less certain I am. As a senior doctor I have more appreciation of the myriad presentations of disease, the understanding that patients don’t always ‘follow the textbook’. Contrast this to the cocksure certainty of a relatively junior doctor. The old adage rings true – “How do I avoid making mistakes? By getting experience! How to get that experience? By making mistakes!

FOAMed helps broaden that experience, sharing experiences and clinical discussions with colleagues worldwide. “Doing the simple things, well” is the essence of not just critical care, but all branches of medicine – particulalry in resource-limited rural Australia. Meticulous attention to obs (especially RR), use of bedside testing such as point-of-care lactate, having a heightened sense of “what if?” all contribute to better outcomes.

To be a ‘plus one’ a ‘zero’ or a ‘minus one’? Your choice…

All of which brings us full circle and (finally) to the purpose of this post. As ultra-competitive clinicians, trained to be better than our colleagues in order to progress in a system that seeks to limit entry at every waypoint, it is all to easy to fall into the trap of self-aggrandisement and for want of a better word “pissing on perceived competitors”. But does this REALLY help anyone? Of course not. we are all players in the healthcare team, yet it is almost de rigeur to criticise the perceived failings in other specialties without any understanding of what they do.

How then does a team function well when all the members are highly competitive? I’ve just finished reading Chris Hadfield’s book “An Astronaut’s Guide to Life on Earth“. It’s not a bad read, although I suspect is a springboard for former International Space Station Commander Hadfield’s retirement from the space programme into motivational speaking.

Hadfield talks about initial assessment of team members as ‘plus ones’, ‘zeroes’ and ‘minus ones’

Astronauts are all ‘plus ones’ – highly competitive, incredibly skilled across disciplines (he describes a typical day as performing ocular & cardiac ultrasound on fellow astronauts, fixing a malfunctioning toilet, playing Bowie’s ‘Space Oddity’ on guitar and Commanding the ISS). ‘Plus ones’ add value to the situation – they are leaders. Everyone wants to be the ‘plus one’ in a situation, in order to demonstrate their value to the team. That’s only natural when you are used to competing.

It should go without saying that there is no room in space (or in healthcare teams) for ‘minus ones’ – people who detract from the team plan. They cause problems, whether through laziness, inefficiency or lack of awareness.

But Hadfield outlines the BEST astronauts as the ‘zeroes’ – people whose input is neutral and doesn’t tip the balance one way or the other. Typically they quietly get on with the business of ‘making things happen’ – helping colleagues not for personal gain but because it helps the team overall. Reflective before acting. Competent information sponges.

In medicine we all strive to be ‘plus ones’, often by being the first to answer in a small group session, the first to critique patient management until the patient came under your brilliant care, or to blame ‘the GP’ or ‘those clowns in ED’ for dumping a patient on the already busy acute medical take. But declaring yourself as a ‘plus one’ in a situation almost guarantees that you will be perceived as a ‘minus one’ regardless of the skills you have. we see this when selecting instructors for EMST – we don’t want the flashy know-it-all, we are looking for the quiet, reflective achiever (the ‘zero’) who helps others become ‘plus ones’.

The take home message? I paraphrase from Commander Hadfield’s book :

When you have some skills but don’t fully understand your environment, there is no way you can be a ‘plus one’. At best, your can be a ‘zero’. But being a ‘zero’ is not a bad thing to be. You are competent enough not to create problems or make more work for everyone else. And you have to be competent, and prove to others that you are….

…even later, when you do understand the environment and can make an outstanding contribution, there’s considerable wisdom in practicing humility. If you really are a ‘plus one’, people will notice – and they’re more likely to give credit when you’re not trying to rub their noses in your greatness

Our environment as clinicians is the entire health care system. We occupy different ecological niches (with some amazing psychopathology between us) – primary care – emergency – surgery – medicine etc. yet we often have little understanding of what happens in other disciplines and are quick to critique. Even more so when all we see is other people’s mistakes (ED, ICU).

But unless you understand the nuances of another discipline, be slow to critique and quick to praise.

Be a ‘zero’ not a ‘hero’. Wise clinicians know this.



COMMENTS FROM TWITTER  – keep ’em coming or (better still) add a comment below :

@KangarooBeach Great stuff, spot on! The consultants I respect most: play zeroes, step up to heroes if need. Love the vid, @Cmdr_Hadfield !

Brilliant article from @KangarooBeach about badmouthing colleagues: Be a ZERO, Not a HERO

“Be a Zero, Not a Hero” Great stuff by the inimitable @KangarooBeach MT @emcrit: great read

Brilliant post from @KangarooBeach: Be a Zero, not a Hero.… #FOAMed

Such an excellent post Tim!!! Ironically a ‘plus one’ précis about some pervasive concepts 🙂 @KangarooBeach

Simon Carley @EMManchester

@AndyNeill @KangarooBeach Thanks for this piece – time to reset to 0

@KangarooBeach “Be a ZERO not a HERO” is a brilliantly written article, thank you. (def going to check out @Cmdr_Hadfield‘s book) #FOAMed

@KangarooBeach hey nice article on zero vs hero! maybe we can get @Cmdr_Hadfield to do a podcast about it?

@johnboy237: Follow this link ‘Be a ZERO not a HERO’ wonderful & truthful insight @KangarooBeach

@KangarooBeach @Cmdr_Hadfield Absolutely Tim! You enjoying the book too?

Andrew wrote: “Good one Tim, but would love to use GPFI on triage screen.”

Rural GP Anaesthetists – a ‘special needs’ mob?

As a rural doc I’m very lucky to have a job that is varied. I tell students and junior doctors that rural medicine offers all the stimulation and challenges of all the ‘best bits’ of medicine.

Currently I practice primary healthcare, emergency medicine and anaesthetics (I gave up obstetrics last year).

So this weekend just gone was a highlight – a chance to attend an annual GP-anaesthetics conference at one of the mainland tertiary hospitals. I’ve had this date ruled off in my diary for 12 months now…so you can imagine my disappointment when the ferry to/from Kangaroo Island sustained damage in the recent storms and the replacement therapy had to be hurriedly re-surveyed, launched and pressed into service. Needless to say all Rex flights were booked out days ahead and despite lots of people needing to get to/from KI, Rex declined to put on extra flights.

Noone can control the weather, but the lack of a contingency plan was disappointing. Not that Rex have a strong history of customer service…

Anyway, I missed the first day of the two day conference. But although I made it to the second, I was somewhat underwhelmed by what I did attend, cementing further my belief that there needs to be content tailored to the rural GPA delivered by people who ‘get’ rural medicine.

To backtrack, I went to my first rural GP-anaesthetist in NSW last year. It was really good, a day and a half of lectures, plus a half day in the sim lab doing emergency scenarios. But what struck me there was the disparity in equipment and resources available between city and rural anaesthetists…as well as between rural GPAs in different parts of the State. Lectures by some of the FANZCAs were all very interesting…but often they did not realise the conditions in which rural GPAs work (isolated, minimal equipment, no backup, cash-starved). At the same time I was getting increasingly inspired by blogs such as,, and LifeInTheFastLane – all of which seemed highly relevant to my practice.

So I resolved to look at some quality improvement in my own practice on my return to SA, mindful of the fact that it made sense to have commonalities in equipment and protocols available to rural anaesthetic providers. Setting up a GoogleDocs survey was relatively easy, and I was gratified to get a 2/3 response rate from rural GP-anaesthetists around Australia on my topic of difficult airway equipment availability. I’ll be talking about this at the Fremantle Rural Medicine Australia conference and my paper should be out in the Oct-Dec volume of Rural & Remote Health. Stay tuned…

So, a year down the track I had really high hopes of further upskilling in SA. Whilst most of the content was good, there was an alarming propensity of some lectures to cover topics like cell salvage, lab-markers in major transfusion and the like – all very interesting, but not translatable to the rural practice environment where such resources aren’t available. Questions on topics such as delayed sequence intubation and whole blood live donor panels were unfamiliar ground for the FANZCA experts, although very pertinent to many of the rural doctors.

Small group sessions made up for it, with hands on experience and chances for case discussion.

But a common theme amongst the people I spoke to was that city anaesthetists task with lecturing had very little idea of the resource limitations in country areas. The vast majority of us don’t have remifentanil..or desflurane..or BIS…or access to FFP/cryo/platelets…or labs..or $15K videolaryngoscopes. The FANZCAs who visit rural hospitals, whether for elective lists or retrieval, did at least have an idea of our circumstances Yand ‘special needs’

So, what does the rural GPA really need?

– lectures from experienced anaesthetists? Hell yes.
– small group sessions and case discussions? Even better.
– topics targetted to the audience and suggestions for improvement. Absolutely!

…and to top it off, perhaps consideration be given to sharing the knowledge base by holding two sessions per year (allows more docs to attend…as if one doc is at the conference, the other needs to be oncall)

…and even better, consider delivering content in rural areas by taking some of the ideas on the road.

The other thing that concerns me is the lack of communication between rural docs. Locally the RDASA has a ‘rural anaesthetists’ email group, but it has been inactive for a few years. It seems that many of us have the same issues with respect to equipment procurement, training and upskilling – yet operate in silos. Moreover there is little ‘top-down’ direction – certainly I have no sense of direction from the ‘Country Health SA Anaesthetic Consultant’ and it would be nice to see some more dynamism.

Maybe next year will be better…I’m going to keep pushing the barrel for local delivery of leading edge concepts in EM/anaesthesia that are rurally relevant for myself and other doctors.

Email me if you have any thoughts on this.

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