Why Checklists Are Your Friend

Written checklists aren’t common in EMS. When you’re on scene with a critical patient, who has time to refer to a checklist? Capt. Chesley “Sully” Sullenberger, who in 2009 landed an airliner on the Hudson River, showed that proper training and practice to proficiency can make the difference during an emergency. The resulting book and movie demonstrated that unless the crew reacted immediately, there was no way to recover the aircraft safely. His argument was supported with human-factors concepts.¹

There are lots of parallels between EMS and aviation from which EMS could learn. One of those is using checklists; this article explores their hows and whys. Just so you know, the use of normal and emergency checklists in aviation will never go away—we learned our lesson.

We are human and make mistakes. Sometimes we make the same ones over and over. In aviation we had to change and adapt. Flying became more complex, just like EMS. If we’ve had a good night’s sleep and are well-rested, alert, and had a good breakfast, and we’re being tested on cardiac arrest protocols, we are likely to do pretty well! If the tones drop for that same cardiac arrest just before the end of our 24-hour shift, our performance will be much worse. Our decision-making response times when we’re fatigued are in the same range as if we are under the influence—functionally drunk!² It’s easy to make errors.

Checklists are not chiseled in stone but change over time to meet evolving needs. At one time when starting CPR, the A of airway was always first. Now the order has changed.

Lots of places already ask you to do checklists. Likely the most common many EMTs use is when checking equipment at the beginning of a shift. Stroke checklists are familiar, but are they provided in a written format for quick referral? Acute chest pain is another common checklist. We evaluate the patient and report to the ED so they can mobilize the stroke or cardiac catherization teams. Are you doing this by (gulp) memory?

Flow vs. To-Do List

You might use a flow-style checklist to prepare your ambulance at the beginning of your shift. Under this model maybe you’d at the cabinet at the top, back left side and check its contents, then move to the next cabinet below that one and on to the right. This creates a flow pattern where all the cabinets are checked. The checklist might be referenced at the end of each cabinet check or after completion of the flow. When checking the outside the vehicle, start at the left front door (battery switch, fuel level, radio checks, etc.), then move to the hood to check the engine, then to the right side until you’ve fully circled the ambulance. For whatever reason, EMTs can be terrible about checking under the hood.

A to-do list is more applicable to things that are infrequently performed in critical situations. Many paramedics intermittently perform rapid sequence induction (RSI), a complex procedure where we can get things out of order, missing the correct drug dosages. Complex EMS procedures are often done in the worst possible locations, patient positions, lighting, and states of fatigue. These high-acuity, low-frequency events are really serious but don’t happen to us often—for instance, an active shooter.

Checklist on the Hudson

A checklist for high-acuity, low-frequency events has a direct parallel in aviation. If you think you just don’t have time to get out a checklist, change and adapt: Sullenberger lost both his engines after takeoff at LaGuardia on a bitter cold January day in New York but glided to a safe water landing on the Hudson River. He had only 213 seconds of flight time, yet Sully and his first officer together ran the correct checklist, flew the airplane, made critical decisions, and communicated with air-traffic control and the cabin crew. They knew how to run a checklist, however, so let’s go into that.

A critical element of crew resource management (CRM) is to call for the correct checklist. One EMS provider may be thinking a patient’s having a heart attack, while their partner is set on congestive heart failure. The leader announcing, “Let’s run the CHF checklist!” allows others to concur or challenge if they don’t think that’s the correct treatment (good CRM). Calling for the correct checklist is critical. One designated person will open the checklist and start at the top, and the other will respond. Aviation learned this the hard way: If you’re interrupted in the middle of the checklist—and there are always interruptions—you never attempt to pick up where you left off. Never! It’s been proven over and over again that people will return to the wrong place and miss items. Instead, you restart at the top and do it by the numbers. The last thing you say is, “CHF checklist complete.”

Sullenberger directed First Officer Jeff Skiles to run a checklist in a quick-reaction handbook. This is a standardized, printed, indexed book kept readily available. The pilots had never practiced that specific checklist together, and some steps specified the captain perform an action while others were done by the FO, who would read them aloud. In the CHF example, the EMT might be tasked to obtain and verify medication dosages (e.g., nitro, Lasix) while the paramedic confirms the dosage, indications, contraindications, and then administers. This prevents what emergency physician, David Tan, MD, would call a “pharmaceutical misadventure.”³ The administration of medications and associated errors is an area of EMS where we can make major improvements.

“Things that are normally easy are hard in combat. Things that are normally hard are impossible in combat.”

Not sure who said that first, but from personal experience, when you’re at hour 23 of your 24-hour shift, wet, cold, and with a critical patient, calculating a dopamine drip rate in your head is hard to impossible. Many paramedics use a pocket guide to help them. Let me be the first to tell you, it’s OK to refer to a checklist in front of the family and patient. You can just say, “We’re going to refer a checklist for this to make sure nothing is missed.”

Memory Recall Checklists

Here is an unsettled hot-button item among pilots: Should you be required to memorize the first several steps of immediate-action checklists, or is it OK have them readily available in a guide and not rely on memory? Years ago pilots had to memorize and were tested on “boldface checklists” they had to recite from memory—anywhere from 5–15 different procedures with 2–5 steps each. These were deemed time-critical, immediate-action items. The procedures are just as critical today, but when we looked at the real-world situations—listened to cockpit voice recorders, for example—we found lots of mistakes and hesitation when items were performed by memory.

To use immediate-action item checklists, one pilot flies the plane and handles the radio while the other pulls the laminated checklist from the glare shield. Normal checklists are generally on one side, immediate-action items on the other.

They announce the checklist title (as mentioned, a critical step), then read the actions, and the other pilot confirms. It’s a to-do list, not a flow-type checklist, but we’ve been trained for it. Before each flight, as part of our CRM briefing, we talk about how we’re going to handle any critical problems.

Checklist Override

There are times when a checklist doesn’t fit a situation, and you must adapt accordingly. Say you have a patient with chest pain. This patient shows classic AMI waveforms with signs/symptoms to match. A treatment flag pops into your head: Heart attacks are greeted by MONA: morphine, oxygen, nitroglycerin, and aspirin. While that’s not the normal order for administering these drugs, we would be nudged to do them by memory. If your checklist has you place oxygen, then nitroglycerin with the correct dosages, you could override the nitro if the patient is pale and only has a blood pressure of, say, 70 over nothing. The nitro will expand the vessels and reduce the blood pressure further—not good. Here override of the written chest pain checklist would be appropriate.

Times Are Changing

Airplanes are smarter now. Craft such as the C-130J, Boeing 747-8, and Airbus A380 all have their checklists electronically displayed on screens. Checklists may pop up if a malfunction is detected or they’re selected by the pilots. Both pilots can see the checklist at the same time (though one needs to be flying the plane, just as we would have one EMS provider looking at the patient).

Everyone looking at the checklist and no one looking at the patient is a big potential problem. Having more alarms sound in the back of an ambulance isn’t necessarily helpful. Each piece of equipment has its own beep, buzz, or horn, and many of you have heard a tone and wondered what was out of order, only to realize it was your phone. I’m guilty of that.

Will we someday have our EMS equipment integrated and not operating as totally separate items? Here’s how that would look: The patient’s heart just went into a-fib. The central monitor pops up with a checklist of the items in your a-fib protocol. Items that have already been accomplished and sensed by the central monitor, such as an IV started or an oxygen cannula with CO₂ detector, would show on the checklist as green and completed. Open items and decision branches are in white and not checked. Is the patient symptomatic? Choosing yes or no will lead you in the right direction. The paper QRH does the exact same thing, except it can’t sense if items have been completed. Will we go in this direction in EMS and emergency departments? There will be hurdles, but yes.

Documentation

Regardless if you complete your reports electronically or by hand, if you include that you referred to and performed a specific checklist for the presenting situation, it will strongly support your actions in any type of critical review, including by a jury. You performed the procedures specified, in order, by your medical control—that’s a pretty solid documentation point.

Conclusion

While the format and how they’re accessed will change, checklists are never going away. The simple reason for this is that they work. Talk to your supervisors and medical control. Ask them to comprehend the hard lessons learned in other industries, such as aviation, where we looked at the evidence and made corrections. We changed and adapted—you can too.

References

1. National Transportation Safety Board. Loss of Thrust in Both Engines, US Airways Flight 1549 Airbus Industrie A320-214, N106US, https://www.ntsb.gov/investigations/AccidentReports/Pages/AAR1003.aspx.

2. Williamson A, Feyer A. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication. Occup Environ Med, 2000 Oct; 57(10): 649–55.

3. David Tan, MD, is medical director at Abbott EMS in St. Louis and an assistant professor in the Division of Emergency Medicine at the Washington University School of Medicine.

Dick Blanchet (ret.), BS, MBA, worked as a paramedic for Abbott EMS in St. Louis, Mo., and Illinois for more than 22 years. He was also a captain with Atlas Air for 22 years and an Air Force pilot for 22 years.

Maj. Ben Blanchet, BS, MS, is a C-130J evaluator/instructor pilot in the U.S. Air Force with a cumulative 19 years in civil and military aviation. He is also a trained aviation safety program manager and mishap investigator.