18 January 2009

Lessons from the Hudson

The likes of Richard Branson complain that hospitals get it wrong when pilots don't. There is nothing new about this. Pilots have check lists. It is widely believed that doctors and nurses should do the same. And it is happening. Protocols and tick boxes abound.

But pilots get it wrong too. Dr Grumble has sat on committees which have investigated certain aspects of safety in the air. He became closely involved with one particular accident when lives were lost. The pilot made mistakes. More than one. The aircraft should never have taken off because it was outside limits. But that had nothing to do with the accident. People make mistakes quite often. It does not always matter too much. Pilots make mistakes just as doctors do.

When Dr Grumble heard that the aeroplane which has recently ditched in the Hudson had some special button to press to stop the water coming in he commented to Mrs Grumble that he would be surprised if the pilot had remembered to press it. It might have been on some check list somewhere but did they have the ditching check list readily to hand?

Acute medicine is more like ditching than a normal landing. There are a lot of uncertainties. The right decision to make is often not obvious. And decisions may need to be made quickly. The right check list for each set of complex circumstances you may encounter does not exist and even if it did it would not be realistic to consult it in the time available. That's the reality.

Now when the aeroplane ditched in the Hudson, despite the circumstances, the first officer would dutifully have gone through a three page check list to ensure everything was in order for landing. There wouldn't have been much time to go through this check list and he would have had more important things to consider like trying to restart an engine or, preferably, two engines. It might not even have been the ditching check list. That's the trouble with check lists. You need the right one for the circumstances. In medicine that is not always realistic.

The orange arrow shows the ditch switch.

So did the pilots remember to press the wonderful button the designers of the aeroplane put in to ensure that the water was kept out? Dr Grumble was not surprised to hear on the grapevine that both pilots forgot. Their lives and that of their passengers might have depended on their pressing that button but Dr G is told they did not. It is not a criticism. It is a fact of human life. Dr Grumble has made mistakes. We all make mistakes. Protocols and ticking boxes may help but they can be more trouble than they are worth and when you are ditching they may be plain impracticable.

Just think how mad you would feel if you were the plane's designer. You fit a wonderful button to turn the aeroplane into a boat and the pilots forget to press the wretched thing. But it was predictable. Dr Grumble predicted it. Fortunately no harm came from this omission. But it might have been otherwise.


Anonymous said...

Absolutely, it 'may have been otherwise'.

Just as it 'may have been otherwise' that a friend of mine would not have had to spend days in an Intensive Care Unit all because a Doctor failed to diagnose his heart failure even when presented with some very obvious symptoms... ....and as did the GP he saw fail to recognise the signs of his cancer for 4 months...

Indeed, we all make mistakes. The trick is to learn from them.

Nick said...

I too heard that they didn't press the ditching button, that, on the Airbus aircraft, seal all the "holes" in the cabin to make it more water-tight!

However, I also heard that the plane went down so fast that they simply never got to the part in the checklist where the button is pressed - Airbus thought that most ditchings would occur from cruising altitude and there would be plenty of time to do a long checklist!

Anonymous said...


Anonymous said...

Interesting article on the BBC website today : http://news.bbc.co.uk/1/hi/health/7610645.stm

'The lessons pilots can teach surgeons'

Dr Grumble said...

Certain checking rituals such as counting swabs have always happened in the operating theatre but it seems that whether you are in the US or the third world there is room for considerable improvement.

Anonymous said...

The paper you link to was reported on by the BBC last week; and yes, it does seem that across the world there is room for considerable improvement.

As someone non-medical, I found it interesting how formalising various processes made such a significant difference to patient outcome. As so often in life, it's the small things that make a big difference.

Dr Grumble said...

Just as aircrew may forget to put the wheels down a surgical team may forget to give the prophylactic antibiotics. It really should not surprise us. Collectively lots of little slips may add up to an effect on overall patient outcome. That's what it seems anyway.