That's A Negative, Ghost Rider

A couple of months back I read the book "Outliers" by Malcolm Gladwell.

I have to say it didn't impress me as much as his book, "Blink", but there were a couple of interesting chapters. The one I found most fascinating was the one about Air Korea and their increasing number of deadly crashes. Forgive me if you've read it but I'll flesh it out a little for those who haven't...(and also forgive me/correct me if I recall some of this sloppily as I've already passed the book on to a friend and can't reference it now for complete accuracy).

In brief, Air Korea was having so many plane crashes that it was in danger of losing it's ability to fly in North American airspace and going under as an airline. Experts were brought in to look at why the crashes were happening. In reviewing the documented dialogue between pilots/flight engineers they found the language that was being used (both to air traffic controllers and colleagues) often did not convey the seriousness of problems early enough for them to be corrected. It was often vague or the seriousness of the situation was watered down.

Also compounding that, the deference that the 1st officer has toward the captain (as a cultural implication) does not really allow for him to a)take over the controls if the captain is screwing up or b) tell the captain that he is royally screwing up and get him to change his actions. Even in the face of imminent death these 1st mates could not or would not violate the cultural norms to do as they are instructed in emergency situations (i.e take over the controls if the captain is making a grave error). I have to say that reading the transcripts of the dialogue prior to the crashes was heart wrenching and fascinating.

So the company was re-vamped, retrained, and dissected to see how this behavior could be 'un-learned' when the pilots were at the controls. One of the changes that was implemented was that the crew were to address each other by first names, thus eliminating some of the power differential present in the language of titles. Once the 1st officers were trained to be assertive and see themselves on more equal footing with the captains, the company soared (literally and figuratively). The pilots were trained to communicate more effectively with all of the members of the team--the captains consulting with the flight engineers and first officers and vice versa.
Korean Air, as it is now called, is a top notch airline with a safety record better than most of the competition.

So this got me thinking about the dynamics that occur in health care. Pilot errors and physician errors (or health care related errors) are often compared. Pilots have very strict guidelines in terms of sleep and work related to job safety...most hospitals have nothing in place that is comparable for nurses and doctors. Look at the hours that residents pull!! Would a pilot ever have to be at the controls for an entire weekend on only a few hours of sleep here and there? Not on your life! (Ha!)

This thread then got me thinking about the 'safest' places I've ever worked. And by safest I mean...ER departments or outpost clinics that I felt their existed a harmony amongst the staff where one could ask questions, point out errors, admit to errors, ask for help, admit to being swamped, call attention to urgent needs...etc. versus places where none of the nurses would speak up if they didn't understand an order, or thought that maybe the physician was making a mistake, or noticed a patient deteriorating. Or where physicians would ask for input, feedback, collaboration from the rest of the staff (be it physios, R.T's, nurses, whatever).

Trust and mutual respect go an amazingly long way with regards to patient safety in my humble opinion. The more I reflected on examples of this the more glaringly obvious it was.

The parallels between the airline crew example and an ER department staff seemed pretty obvious. Right down to addressing one another by first names instead of titles.

I know these aren't new or groundbreaking thoughts on workplace dynamics in the ED but it got me thinking back to a post that Old MD Girl made on her blog* about being a doctor and being the "boss" of nurses.

Nurses (and other health professionals) certainly have a lot more respect in the workplace than they did 100 years ago when their duties included cleaning the doctors lounge and standing up whenever one walked in the room (I would have lasted about 5 mins as a nurse if I'd been born 120 years ago, BTW).

Today I see us as the 1st officers to a certain degree. I have had relationships with some docs where I have felt my opinion and input on a patient was seen as important information and I have worked with docs who made me feel like an annoying mosquito buzzing in their ear every time I opened my mouth.

I have had physician colleagues write "sedative analgesic" as an order and trust me enough to use my discretion with regards to what I am going to give a patient to make them relaxed and pain free. And I have worked with doctors who have angrily told me NOT to use the word "angina" when describing a patients symptoms to him because "angina" is a medical diagnosis and nurses do not make medical diagnoses. (Not even joking).

So what sort of utopian emergency department would it be if nurses and doctors could lose some of that power differential and see each other as colleagues instead of two very separate camps. I know that all work places are all about hierarchies and titles and posturing and inflated egos. But I have seen how these natural human tendencies can actually put patients lives in jeopardy and I think it is something worth reflecting (or ranting?) on a little.





*To my surprise I actually wasn't irked by this post. Overall I enjoy her blog and think that she has interesting and often funny anecdotes (which I can certainly relate to being 'old' myself).