The dangers of flying solo

Surgeons can learn a lot from pilots when it comes to avoiding disaster and making sure a team cross-checks its own work, regardless…

Surgeons can learn a lot from pilots when it comes to avoiding disaster and making sure a team cross-checks its own work, regardless of rank and ego, writes Gerry Byrne

It might seem logical for surgeons to study air disasters so they know how to treat serious injuries, but when pupils at the Royal College of Surgeons in Ireland (RCSI) do plane crashes, the lecture is given by a pilot, not a doctor. And he will focus on how the doomed pilots flew their aircraft, not on injured passengers.

Pilot error causes 70 per cent of modern plane crashes just as surgeon error is a not insignificant cause of death in hospitals.

Finding ways of preventing pilot errors is widely attributed to reversing aviation's death toll. Is it not time for medicine to do the same thing?

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A 1999 American study suggested that up to 98,000 US deaths annually were caused by medical error, far more than die in plane crashes, yet some leading surgeons have suggested the root causes might be broadly similar. Ireland may be no different. Take the case of James McCarthy of Turners Cross, Cork who watched his wife die in Cork University Hospital as staff dismissed her complaint as something less critical than the fatal perforated ulcer which killed her. Or Alan O'Gorman, a relatively healthy young man from Ratoath, Co Meath, whose entire stomach was removed in 2002 in St Vincent's Hospital after his test results were exchanged in error with those of a 70-year-old man with cancer. Or the hundreds of women who spent anxious months last year as scandals over misinterpreted mammograms erupted throughout the country.

"People say that there is very little comparison between a pilot and surgeon," says Prof Arthur Tanner, director of surgical affairs at RCSI. "Well I say there is. I believe we have learned a lot from the airlines."

Tanner is one of the leading Irish exponents of using air accidents as case studies to train safer surgeons. The good news for hard-pressed surgical students is that he doesn't want them to learn how to fly, just to be open to the fact that they can make mistakes and accept criticism for it.

In aviation they call it things like cockpit resource management and human factors. Get those two wrong on the flightdeck and the result can be something like the world's worst single air disaster, when two Boeing 747 "Jumbos" collided on the runway at Los Rodeos in the Canary Islands in March 1977 with the loss of 583 lives. A presentation on that accident, caused by an accumulation of human errors in cockpits and in the control tower, was given by a Swissair pilot to the RCSI.

Tanner could see chilling parallels between the two professions, and how they made mistakes by forgetting to constantly cross-check their decisions.

But the Los Rodeos disaster also pointed to another issue - fear of correcting one's superiors. Just as KLM Captain van Zanten commenced his fatal take-off roll, his relatively inexperienced co-pilot reminded him that he didn't have clearance to take off.

Sadly, he didn't push the issue because, perhaps, he was in awe of his far more experienced captain. And, when the slightly more critical flight engineer asked for confirmation that the runway was clear, Zanten dismissed his worries. In fact the fog-shrouded runway was not clear, and there was a Pan Am 747 lumbering down it towards them.

The co-pilot, who should have corrected his superior, or the engineer, who should have demanded more caution, could be equated to the theatre nurse nervous at speaking out when she spots the consultant or anaesthetist about to make a serious error, a not uncommon situation. Instead of gratitude from the surgeon, she may even fear a disciplinary hearing.

The aviation industry tackled pilot safety through greatly improved communications between pilots on the flightdeck and a growing system of checklists whereby even a junior pilot gets to challenge his boss on operational issues, even on such obvious things as if he had put the wheels down fully for landing.

First-time visitors to the flight deck are often surprised to see that modern pilots spend as much time hauling out clipboards and reading checklists to each other as they do wrestling with the controls. And, even though two highly experienced pilots may have operated from the same airport every day of their careers, they are still required to brief each other every time on exactly what they will do if they have to abort their take-off, or return to the airport in the case of an emergency.

Pilots also receive training in human factors through which they learn to accept criticism and corrections from each other, even from underlings. It also makes them aware of their frailty and propensity for making mistakes.

Apart from empowering the junior officer, the checklists also have the primary function of helping pilots remember critical tasks they might otherwise have ignored. This has echoes in the MD80 which ran off the end of the runway killing 11 on landing at Little Rock, Arkansas in 1999, where it emerged that the tired pilots hadn't been as diligent as they might have with the pre-landing checklist and hadn't set the spoilers to slow the plane on touchdown, among other things.

"We have also adopted a checklist approach in laboratory simulations of operations although it is not as complex as on an aircraft," says Tanner. "Nursing staff also have a checklist."

The RCSI checklist has 10 or so questions ranging from checking that the surgeon has received informed consent, that there has been proper preparation of the patient, the correct anaesthetic is to be used, and, in the surgical equivalent of the aborted take-off, who will do what in the event of anything going wrong. It even asks if the surgeon himself understands the procedure and that the correct part of the body is to be operated on.

Tanner says that he encourages would-be surgeons to allow junior members of the operating team to take on the job of running through the checklist, effectively checking up on their would-be superiors.

The pilot-inspired checklist system and human factors analysis is a recognised training tool in RCSI, in the College of Anaesthetists and in the College of Nursing, and some consultant surgeons have adopted it in their everyday theatre work.

Sadly, it is not required procedure in most Irish hospitals. Calls to the press officers of three major Dublin hospitals revealed that they were unaware of the process and said that in any event they do not mandate how individual surgeons manage their operations.

This hardly comes as a surprise to Tanner who says that it is unlikely to be more widespread until surgeons have to undergo professional re-validation under forthcoming new legislation. Surgeons are not yet subject to any automatic review of their proficiency from the day they graduate. Pilots, on the other hand, have their licences re-validated annually and must undergo re-training, or face the sack, if they fail their yearly tests.

Pilots must also undergo very public scrutiny as investigators probe their actions should anything go wrong, as the flight crew of the British Airways 777 which crash-landed at Heathrow recently realise only too well. Even a minor accident, where a light aircraft slightly damages its undercarriage but nobody is injured, demands an official Irish government report.

If a surgeon botches an operation, someone can be badly incapacitated for life or killed even, but it only becomes public if someone sues. Yet, while pilots learn safer flying from crash-investigation reports, surgeons have no way of learning from the mistakes of their colleagues; or even knowing that they took place in the first place.

Gerry Byrne is the author of Flight 427: Anatomy of an Air Disaster, published by Copernicus Books, New York