Aviation Checklists in the Operating Room

Imagine you’re a physician walking through the halls of your hospital. You come across a nurse ordering pizza for her colleagues over the phone. Just as she’s about to hang up and put the phone down, she hears something and raises the handset back up to her ears, just catching the person on the other end reading back her order to make sure it’s correct. Two days later, walking down the same aisle, you see the nurse on the phone receiving medication orders from your colleague. She writes down the order and at the end, she says, “Alright, doc. I’ll get that done.” and hangs up the phone to finish her work.

While this situation seems absurd, John Nance, the author of Why Hospitals Should Fly, recounts this exact exchange in his interview with Proto Magazine. As a pilot since the 1960s, flying for the Air Force and for commercial airlines, his work in connecting the disciplines of aviation and medicine were instrumental in paving the way for Gawande to write his own book, The Checklist Manifesto. While Nance’s work attempts to convince hospital administrators, Gawande takes a different approach in order to help those actually in the medical field to recognize their own humanity.

Physicians, and particularly surgeons, often think of themselves as the infallible commanders of the medical world. The “Miracle on the Hudson” is an excellent case study in team dynamics, and Gawande contrasts how aviators and surgeons deal with unexpected problems. Captain Sullenberger and First Officer Skiles had never worked together prior to that fateful flight. Yet, in the face of a dire situation, they were able to work as a seamless team to address every issue that arose. That seamlessness was no coincidence. Before every flight, the pilots brief each other as to what their specific roles are: who is the pilot in command, who will handle radio communication, etc. The checklist that they followed to ensure that everything was taken care of before the start of the flight was instrumental in the successful outcome of the flight, despite the flock of geese that knocked out both of their engines.

One of the key takeaways can be beautifully summarized by this, “The fear people have about the idea of adherence to protocol is rigidity. They imagine mindless automatons, heads down in a checklist, incapable of looking out their windshield and coping with the real world in front of them. But what you find, when a checklist is well made, is exactly the opposite. The checklist gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with… and lets it rise above to focus on the hard stuff.”

Gawande masterfully weaves this thread of “immense complexity” through anecdote after anecdote describing a diverse set of disciplines where checklists have made an impact. Importantly, he doesn’t forget to mention that checklists are simply tools – they can’t replace a surgeon after all.

Gawande opens the first chapter by contrasting the “dry prose of a medical journal article” with the miracle it describes. Immediately, he builds credibility by reassuring the reader that this book isn’t that. Rather, it shows exactly how he approaches the rest of the book. His linguistic style shows no signs of purple prose. Rather, he seems approachable and conversational in tone. It seems like he’s talking directly to you and just telling a story.

Gawande’s argument that the point of checklists is to help reduce cognitive strain resonates with me. Whenever someone asks how hard it is to fly a plane, I respond by saying that flying the plane is the easiest part of being a pilot. The hard part comes actually from doing all of the other things that the pilot needs to do, while flying the plane.

I remember one particular flight with my instructor that I think readily  illustrates the value of a checklist. My instructor asked me what I would do should the radios fail in mid flight. Immediately I begin to go through all of the possible modes of failure of the onboard radios in mind. I begin to panic. What would I do if the radios failed? The obvious thing to do, I say, is to check if we’re transmitting and receiving on the correct frequency. It could have somehow been changed accidentally. He says that it looks good – nothing amiss there. I ask if there are any other electrical issues; are other instruments behaving strangely? No, he replies, just the radios. I tell him that I would reset the electrical system anyway just to make sure. I think to myself, is anything wrong with the antenna? Did it shear off as a result of high winds or a rock during our takeoff roll? Not likely; we probably would have noticed earlier if that was the problem. I move on to explaining that we should squawk 7600 on our transponder to let air traffic control know that we have radio issues and have lost communication. I glance down at the paper below me, frantically looking for the light gun signals. That’s how the tower can communicate to aircraft without two-way radios. But no one bothers learning these anymore, not when modern electronics have become so reliable. I don’t find them, and so I sheepishly tell my instructor that I’ve forgotten what the light gun signals mean. He laughs it off and asks me, “Did you check if you’re headset is still plugged in? It might have come loose from the turbulence and bumpy ride we had earlier!”

That’s what a checklist is for. It’s so that we don’t overlook the stupid little things like checking if our headset has become unplugged from the intercoms. It’s so that we can focus on flying the plane. When you learn to be a pilot, you’re not learning how to fly a plane. Rather, you’re learning how to deal with the plane when things go completely wrong — and things do go wrong. Likewise, surgery itself isn’t too difficult. However, the training of a surgeon is to know how to deal with everything when it goes wrong.

Most people don’t realize just how easy it is to actually get lost. I was flying back towards Mansfield after a cross country flight to Keene, New Hampshire. Before I left, I noted that a Temporary Flight Restriction would be in effect surrounding Gillette Stadium around the time I would be flying back. I called ATC to ask them if the TFR was currently active, and after a brief pause to double check, they let me know that it was indeed active. In order to avoid the airspace, I flew a couple miles further south than the direct path, not even that far, but just enough to skirt around the edge. That little change completely threw off my sense of direction. I now had no idea what I was looking at and I couldn’t see where the airport was. I had a GPS, so I wasn’t too nervous, but in that moment I realized that without my tools, I would have no idea where I was. I searched outside to see if I could spot 290 snaking its way around. After a few minutes of flying straight ahead and double checking with the GPS, I finally found it. I knew that if I continued following the highway southwest, I would eventually come up to the airport, which just happens to be right off the highway and next to a lake on the other side. Airports tend to look like large clearings in the normally wooded landscape of Massachusetts.

As a pilot, being able to see the value of checklists firsthand is an invaluable convincer to support the use of checklists wherever possible.

While the overt premise of the book appears to be exalting the value of the checklist through anecdote after anecdote, the true reason that this book succeeds is through the masterful use of the connecting thread that ties those anecdotes together and shows how so many diverse disciplines, all with the commonality of immense complexity can greatly benefit from a well designed checklist. Gawande’s poignant reminders serve to show that surgeons, although in a role apt to believe in their infallibility, can also make mistakes and likewise benefit from a checklist to help guide them.