From Aviation to Intubation; RSI Checklists for the Prehospital Environment

In 1935 the Army Air Corps introduced it’s first modern, four engine bomber, the Boeing B17. For pilots of the day, it was a tremendously large, complicated machine. During initial trials, two highly experienced pilots failed to perform a simple procedure, and during take off the pilots stalled the aircraft and plummeted to the ground, killing both pilots and injuring several bystanders. The Army, unwilling to give up on the aircraft began searching for solutions. They came to the realization that pilots were task overloaded, and it was completely unreasonable for them to be expected to memorize the complex procedures the aircraft required for operation. The answer they found was simple, a written checklist. After implantation of a simple, straightforward checklist Boeing flew 18 B17s for 1.8 million hours without a single error.

Since 1935, the checklist has become a standard in aviation worldwide. Every pilot is required to carry with them a checklist that covers everything from takeoff and landing to engine failure. The checklist has expanded in scope, moving from aviation to other high risk fields such as construction, engineering, and manufacturing, consistently showing improved worker and product safety. With in the past ten years the influence of checklists has expanded into the medical field first starting in operating rooms and gradually moving throughout the hospital environment, finally making it’s way into emergency medicine.

Every experienced, honest prehospital provider can give you a story about a call where it hit the fan and they or there colleague hit a wall. The signs are easily recognizable the sweating, shaky hands, the rushed work environment where mistakes can become inevitable. It has been well shown in psychology literature that under pressure, such as when working with the ill, high acuity, low frequency patients, cognitive ability is compromised resulting in unsafe practices and negative patient outcomes. Providers, when under high stress, make decision based on emotion, and fall back to there level of experience and training. High pressure decision making is inherently risky and in the prehospital setting we can take a step back and learn from the early pioneers of aviation.

The term checklist is inherently misleading, it implies a crutch, something that will take away from the provider’s clinical abilities. In reality each bullet challenges the provider, forcing them to come to a solution. It forces them to address patient safety, improving outcomes. Checklists are rapidly becoming standard of care in prehospital RSI. They have been shown to reduce adverse events in intubation. In properly trained providers, a checklist can be rapidly implemented, even in the most austere environment.

The challenges to implementing a checklist system is difficult, but not impossible. Implementation requires a philosophical shift at all levels of care. Providers must be accepting of the fact that they are not experts in RSI, and that they are fallible and prone to human error. They must submit to the fact that patient care comes first, and personal egos have no place in the clinical environment. They must also understand that the checklist is in no way insulting to there knowledge, but can be utilized to augment and improve there decision making process. Only when those issues are addressed can the next step in this system be implemented.

The checklist must be custom designed to fit the medical protocols implemented by medical direction, then approved. It must be implemented in a training environment prior to a full roll out. Weaknesses must be identified and eliminated. Full confidence must be gained through simulation. Providers must be exposed to the benefits of checklists first hand. Providers must have a full understanding of how, and in particular why this is being implemented. Buy in at all levels is essential.

A properly implemented RSI checklist will improve the provider’s cognitive abilities. It will act as a safety net, insuring all providers on scene understand and agree with the procedure and how it is being performed. The checklist will help enforce a rally point in resuscitation, where the team can come together and perform the procedure in a smooth, safe manner.

Trevor is a Paramedic in Connecticut, USA. He is a flight paramedic in the Army National Guard, and works ground based 911 and specialty care transport. He is also combat medic instructor specializing in simulation. You can follow him on twitter @TrevMedic.

Trevor C. O’Neill, FP-C, CCEMTP, NRP

Sources and further education;

Video demonstration of Syndney HEMS performing an RSI checklist

Another great Sydney HEMS video with some serious entertainment value

Scott Weingart talking intubation checklists on EMCrit

A brief ScanCrit article summarizing a small study

A small study looking at pediatric RSI in the ED utilizing checklists

UK HEMS Protocol

Queensland SPEEDBOMBS Checklist

Sydney HEMS Checklist

Project Checklist, A great resource for checklist development

The development of checklists in aviationScandanavian Journal of Trauma, Resuscitation and Emergency Medicine, Deployment of a standard operating procedure and checklist for rapid sequence induction in the critically ill patient; Journal review b17_flying_fortress_cockpit_by_paulweber-d51omh6