Who needs checklists?

“Good evening ladies and gentleman, this is your Captain speaking. We’re just getting ready for take off. My name is Captain Courageous and the First Officer today is Mr Jones. We’ve never actually worked together before but you’ll be pleased to know that we’ve nodded briefly at each other as we boarded the aircraft – so if there is an inflight emergency I am sure we’ll muddle along somehow….

If you heard this from your airline pilot, you’d be clamouring for the exit. Yet this is pretty much how a lot of the dynamics of the Operating Theatre work – separate teams : Surgical, Anaesthetic and Scout, all with own hierarchies and team members…but no structured communication.

It never ceased to amaze me as an Anaesthetic Reg how little communication there can be on an operating list. It wasn’t uncommon for the surgeon to arrive after induction (albeit having confirmed he/she was in the building)…but no discussion of the surgical plan. Then halfway through the case comes a muttered call of ‘Is the heparin in yet?‘ Heparin? Heck, I didn’t know it was needed!

Of course experience and working together allow a lot of anticipation of each other’s moves. But the theatre team is a dynamic and it makes far more sense to use a structured approach to plan BEFORE the operation.

The WHO Surgical Checklist goes some way towards this (I must admit that we don’t use it locally, using the less inclusive ‘surgical time out procedure’). Atul Gawande has written on this and you can hear his TEDx talk here.

However a recent report from the UK suggests that ‘never events’ such as wrong site surgery have occurred despite the WHO Surgical Checklist being used. An author on Doctors.net.uk writes of the absurd farce of the surgical checklist being used – but not understood by a tick-box mentality :

“Has everyone been introduced by name and role?” General muttering. Surgeon looks testy.

“Is anaesthesia stable?” A: No.

[At this point the checklist should stop and resources should be diverted to assisting the anaesthetist to stabilise the situation. The TSW ticked “No” and kept ploughing on]

“Has the correct site been marked?” A: No.

[TSW ticks no, continues]

“Critical or unexpected steps, blood loss, anticipated duration?” Surgeon doesn’t answer. I say “the operation”.

[TSW writes that down]

Blood loss?” The surgeon says “Most of it”

[TSW writes that down too]

“Patient’s ASA grade?” I say: nine

[TSW duly records]

“Antibiotic prophylaxis?” A: goldfish

[no recognition seen)

“VTE?” “Leeches.”

[No response]

Ludicrous. Check boxes ticked – but functionally useless as a safety device.

The point is, a checklist is no good unless there is training in it’s use. Ditto other cognitive aids such as DAS algorithms, RSI kit dump or The Vortex. Otherwise people will ‘use’ the checklist but with no understanding of what it entails.

In my example above, of the very casual airline pilot before takeoff, draws the usual analogy between anaesthesia and aviation (for another analogy see the infamous ‘Biggles FRCA‘). Outside of the Operating Theatre, crisis management in ICU, ED or prehospital are more akin to combat aviation – requiring a structured approach but less time to plan.

Scott Weingart has posted on this with the excellent ‘Combat Aviation & Emergency Medicine‘ podcast – please, no homoerotic Top Gun gags – Scott doesn’t swing that way….and the podcast is an excellent resource (although at SMACC13 I thought I heard Weingart mutter to Cliff Reid “you can be my wingman anytime“. We’ll have to wait for the SMACC13 audio transcripts to be certain…)

For the rural doctor, I reckon we need to ‘fight hard, train easy’. Thankfully our teams are small and we know each other well, so there is usually a tacit understanding of what is about to happen. But even so I am making it a habit to run through my anaesthetic plan with the anaesthetic nurse before every case,including Plans A-B-C-D in case of airway difficulty. As it stands, the Surgical Time Out is used, but we would be wise to adopt the WHO Checklist with it’s extra steps and inclusion of anaesthetic team.

Cognitive aids such as this are useful – but there must be a culture of their use across the board.

It can be hard, particularly as a rural GP because we are ‘visiting medical officers’ with no power to influence change within the organisation. Responsibility for nurse training rests with the Hospital…and our interactions are typically on a fee-for-service basis with no remuneration for team training.

Outside of the individual hospital, use of cognitive aids across the breadth of rural practitioners will help as doctors move from site-to-site (especially locums). So again a ‘top down’ approach from our glorious clinical leaders at Country Health SA would be appreciated.

We’ll explore some of these cognitive tools at the Rural Doctor Masterclass in November 2013 – most of this will be familiar turf to the FOAMed cogniscenti, but still offer a chance for hands-on deployment with a series of challenging scenarios. And for those new to FOAMed, the Rural Doctors Masterclass should help elevate the standard above usual EMST-APLS-REST courses…

So – are you a checklist user? Or is this ‘cookbook medicine’?

Either way, what use is a checklist if there is not a culture of safety around it?

Comments welcomed…



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