The Power of CRM: Collective Situational Awareness

Blog by Paul LeSage
Author of ‘Crew Resource Management: Principles and Practice’

The trauma call was going smoothly. Emergency responders Kyla and Nick were communicating well with the paramedics, and the 46-year-old male patient had just been successfully intubated based on all clinical and technical indicators.

The veteran Nick asked Kyla if she wanted to take over care of the patient while he drove. Kyla felt confident, but wary. She would be in the back with a very senior fire medic named Jeff, who was known as a demanding, but excellent clinician. Giving Nick a nod yes, the care was verbally transferred and Kyla climbed into the back of the ambulance with Jeff for the 12-minute trip to the Trauma Center.

Within three minutes, the patient began bucking the ET tube, and Jeff, who was managing the patients airway, called Kyla to give 2.5 of Versed. As Kyla drew up the Versed, she became distracted by her hospital report. Pulling out one vial of Versed, she grabbed a 3cc syringe and pulled the entire 2 millimeters into the syringe.

Dropping that vial, she quickly grabbed a second one and drew up another 0.5 ml, wiped off the IV port, and pushed the meds. The patient quickly became quiet and stopped fighting the ET tube, and as she prepared to put the syringe into the sharps container Jeff blurted out, “How much Versed did you just give?”

“2.5, as you requested,” she stated, suddenly self conscious.

“2.5 milligrams, or 2.5 millimeters?” asked Jeff.

“Well, I guess I gave 2.5 millimeters,” Kyla said, suddenly realizing she gave several times the therapeutic dose.

When the agencies involved in this particular incident conducted an analysis of the events, there were several surprises.

In teaching Crew Resource Management (CRM), one of the most powerful lessons that can be communicated involves the responsibility that every team member has to speak up if they perceive a discontinuity in how events are unfolding.

Several studies have demonstrated that good teams are always striving for coherence, described as clear communication where everyone is on the same page.

An important component is the realization that every team member sees things a little differently. It turns out that regardless of the uniformity of your training and education, it’s our experiences that form the basis of our interpretations about how events unfold and what actions to take when compressed for time.

This means team members are constantly striving for common ground, which can be defined as those cues, signs, symptoms, and strategies that are easily agreed upon within the team. However, when we see a team member diverge from what we believe is appropriate, there is a sudden rift, or tear on the fabric of common ground. Often, our response is one of anger or frustration. Why can’t they see they are taking the wrong action? What is wrong with them?

Studies on human behavior demonstrate our level of assertiveness will be predicated on how comfortable we are within the team, how much perceived expertise the person making the decision has, whether they outrank us in the official agency hierarchy or by experience (novice vs. veteran), and our own intrinsic comfort with managing conflict.

Surprisingly, in a study of several hundred clinical, dispatch, and technical errors, more than 74 percent of the time a team member (or members) observed a problem or overt error at the moment it occurred. But unfortunately, no one spoke up to try and correct the situation. In CRM, we know this as there are two ways to say yes, and only one way to say no.

Essentially, if you say nothing, even when you suddenly lose common ground, you have said, Yes, I agree to the actions taken by a team member.

One goal of CRM is to help us overcome the barriers associated with speaking up, and learn how to intervene effectively, which involves respectful behavior and assertive engagement.

During the incident outlined above, the veteran medic Jeff realized that when he saw Kyla pull out a 3cc syringe, it bothered him. He had been taught to minimize just this type of error with Versed by using a one cc syringe. He wasn’t paying close attention when she drew up the Versed, and Kyla admitted that she lost concentration when distracted by the radio report.

Of several valuable findings, two stand out as being common in these types of incidents. One, medication, once given, cannot generally be withdrawn. Once in, it’s in. This means we must pay close attention, particularly if we are veteran operators, to every step of the administration process.

Clearly state doses out loud, use specific language, and repeat. Secondly, when there is a tear in the fabric of your common ground, you have a responsibility to speak up respectfully and assertively. When Jeff saw the 3cc syringe, he should have said something.

Remember the power of CRM is collective situational awareness and there are always two ways to say yes, and only one way to effectively say I disagree.

About the Author
Paul LeSage worked for 29 years at Tualatin Valley Fire & Rescue in Oregon, and for seven years at Life Flight in Portland, Ore. He retired as the Chief of Operations in January, 2010, and has more than 33 years of experience as a firefighter, paramedic, and flight paramedic. Paul has co-authored a popular new book on Crew Resource Management, along with several Fire and EMS Field Guides.

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