{"id":337,"date":"2019-08-29T11:17:11","date_gmt":"2019-08-29T15:17:11","guid":{"rendered":"http:\/\/www.sahilnawab.com\/blog\/?p=337"},"modified":"2019-08-29T11:17:13","modified_gmt":"2019-08-29T15:17:13","slug":"aviation-checklists-in-the-operating-room","status":"publish","type":"post","link":"http:\/\/www.sahilnawab.com\/blog\/aviation-checklists-in-the-operating-room\/","title":{"rendered":"Aviation Checklists in the Operating Room"},"content":{"rendered":"\n

Imagine you\u2019re 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\u2019s 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\u2019s 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, \u201cAlright, doc. I\u2019ll get that done.\u201d and hangs up the phone to finish her work.<\/p>\n\n\n\n

While this situation seems absurd, John Nance, the author of Why Hospitals Should Fly<\/em>, 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<\/em>. While Nance\u2019s work attempts to convince hospital administrators, Gawande takes a different approach in order to help those actually in<\/em> the medical field to recognize their own humanity.<\/p>\n\n\n\n

Physicians, and particularly surgeons, often think of themselves as the infallible commanders of the medical world. The \u201cMiracle on the Hudson\u201d 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.<\/p>\n\n\n\n

One of the key takeaways can be beautifully summarized by this, \u201cThe 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\u2019t have to occupy itself with\u2026 and lets it rise above to focus on the hard stuff.\u201d<\/p>\n\n\n\n

Gawande masterfully weaves this thread of \u201cimmense complexity\u201d through anecdote after anecdote describing a diverse set of disciplines where checklists have made an impact. Importantly, he doesn\u2019t forget to mention that checklists are simply tools – they can\u2019t replace a surgeon after all.<\/p>\n\n\n\n

\"\"<\/figure>\n\n\n\n

Gawande opens the first chapter by contrasting the \u201cdry prose of a medical journal article\u201d with the miracle it describes. Immediately, he builds credibility by reassuring the reader that this book isn\u2019t 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\u2019s talking directly to you and just telling a story.<\/p>\n\n\n\n

Gawande\u2019s 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<\/em> flying the plane.<\/p>\n\n\n\n

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\u2019re 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\u2019s 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\u2019t find them, and so I sheepishly tell my instructor that I\u2019ve forgotten what the light gun signals mean. He laughs it off and asks me, \u201cDid you check if you\u2019re headset is still plugged in? It might have come loose from the turbulence and bumpy ride we had earlier!\u201d
<\/p>\n\n\n\n

That\u2019s what a checklist is for. It\u2019s so that we don\u2019t overlook the stupid little things like checking if our headset has become unplugged from the intercoms. It\u2019s so that we can focus on flying the plane. When you learn to be a pilot, you\u2019re not learning how to fly a plane. Rather, you\u2019re learning how to deal with the plane when things go completely wrong \u2014 and things do go wrong. Likewise, surgery itself isn\u2019t too difficult. However, the training of a surgeon is to know how to deal with everything when it goes wrong.<\/p>\n\n\n\n

Most people don\u2019t 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\u2019t see where the airport was. I had a GPS, so I wasn\u2019t 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.<\/p>\n\n\n\n

As a pilot, being able to see the value of checklists firsthand is an invaluable convincer to support the use of checklists wherever possible.<\/p>\n\n\n\n

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\u2019s 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.
<\/p>\n","protected":false},"excerpt":{"rendered":"

Imagine you\u2019re 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\u2019s 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 […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-337","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"aioseo_notices":[],"amp_enabled":true,"_links":{"self":[{"href":"http:\/\/www.sahilnawab.com\/blog\/wp-json\/wp\/v2\/posts\/337","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/www.sahilnawab.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/www.sahilnawab.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/www.sahilnawab.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/www.sahilnawab.com\/blog\/wp-json\/wp\/v2\/comments?post=337"}],"version-history":[{"count":2,"href":"http:\/\/www.sahilnawab.com\/blog\/wp-json\/wp\/v2\/posts\/337\/revisions"}],"predecessor-version":[{"id":340,"href":"http:\/\/www.sahilnawab.com\/blog\/wp-json\/wp\/v2\/posts\/337\/revisions\/340"}],"wp:attachment":[{"href":"http:\/\/www.sahilnawab.com\/blog\/wp-json\/wp\/v2\/media?parent=337"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/www.sahilnawab.com\/blog\/wp-json\/wp\/v2\/categories?post=337"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/www.sahilnawab.com\/blog\/wp-json\/wp\/v2\/tags?post=337"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}