Checklists – Part 1

By Damjan Gaco, MD, ARHT HEMS Fellow


The origin story of checklists goes as follows: A pilot in the 1930’s stepped off a newly built bomber and said something along the lines of “that is too much plane for one person to handle”. In an ever more complicated world, those words echo true today – especially in the field of medicine. For example, the act of intubation carries many steps – all important: pre-treatment, induction, intubation, back-up plans, confirmation of tube placement, post-tube sedation, and post-intubation care. A post written two years ago by then Auckland HEMS Fellow Dr. Robert Gooch outlines this ever-complicated environment, and the ultimate goal of reducing burden on clinicians.

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Prehospital Emergency Checklists

Medical emergencies present a significant cognitive challenge to the clinician.  Multiple causes must be considered and rapidly managed; the consequences of missing a step can be catastrophic.  Emergencies in the prehospital setting present the clinician not only with limited time, but also limited space, equipment, and communication.

Aviators have made use of checklists for years to minimize the impact of cognitive errors.  Physicians have historically spurned checklists, usually citing their ability to remember an extensive and esoteric differential for just about any physiologic abnormality.  Most steps in crisis management, however, are simple enough to be easy to forget under pressure: it doesn’t matter if a clinician can calculate the patient’s shunt fraction if they’ve forgotten to check if the oxygen is connected.

Checklists have made their way into a few areas in medicine already.  Pre-op checklists have already significantly improved outcomes at minimal cost.1  Many centres use a checklist for RSI, and operating theatre emergency checklists appear beneficial in simulation trials.2,3 UK HEMS have produced a series of crash cards for emergency situations, but overall the use of emergency checklists in the prehospital setting seems quite limited.

We have produced a series of ‘challenge-response’ emergency checklists.  After an emergency is declared, a crew member will read each management step (the challenge) to the clinician, and the clinician will confirm its completion (the response).

Our aim is not to replace a clinician’s judgement, but to reduce the likelihood a management step is missed, and, more importantly, to reduce a clinician’s cognitive burden so challenging steps can be more efficiently completed.

Attached below is our Hypoxia emergency checklist.  We’re up to 15 emergency checklists and 4 checklists for standard procedures.  We’ve trialled them extensively in a simulated setting at the base, and they’re headed for operational use soon.  They’re going to appear in a hard copy format in the helicopter, as well as on the brand new Auckland HEMS app.

Hypoxia Checklist

The preliminary hard copy format:


In-situ checklist testing:


We’d love to hear comments and suggestions – we’re looking to improve these on an ongoing basis.  Post any thoughts below or email me directly at


1.  Haynes AB. Weiser TG. Berry WR. Lipsitz SR. Breizat AS. Dellinger EP. Herbosa T. Joseph S. Kibatala PL. Lapitan MCM. Merry AF. Moorthy K. Reznick RK. Taylor B. Gawande AA. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine. 2009 Jan 29; 360(5):491-9.

2.  Arriaga AF, Bader AM, Wong JM, Lipsitz SR, Berry WR, Ziewacz JE, Hepner DL, Boorman DJ, Pozner CN, Smink DS, Gawande AA. Simulation-Based Trial of Surgical-Crisis Checklists New England Journal Of Medicine 2013;368:246-53.

3.  Ziewacz JE, Arriaga AF, Bader AM, Berry WR, Edmondson L, Wong JM, Lipsitz SR, Hepner DL, Peyre S, Nelson S, Boorman DJ, Smink DS, Ashley SW, Gawande AA. Crisis Checklists for the Operating Room: Development and Pilot Testing Journal of the American College of Surgeons. Aug 2011; 213(2): 212-217.

Crisis Resource Management – from Academic Life in Emergency Medicine


From ALiEM:

CRM and SBT… just another set of acronyms in the world of medical education?  Don’t we already have enough??

Not quite!  Rather, Crisis Resource Management (CRM) is a complementary approach to Simulation Based Training (SBT). It can enhance current ongoing medical simulations or provide foundation for a vigorous curriculum when launching new simulation programs.


Crisis Resource Management is the ability to translate medical knowledge to real world actions, in the setting of an emergency.

Rather than a separate entity from medical simulation, CRM principles can be looked at as a way to focus and shape medical simulation curriculum and especially the objectives of each case to focus upon development of critical skill-sets that contribute to optimal team function and success during crisis.”

Read the rest HERE

Human factors in aviation errors – The Dirty Dozen


Following a spate of aviation accidents in the 1980’s and 1990’s, Transport Canada and the aviation industry came up with the aviation ‘Dirty Dozen’ – human factors in aviation maintenance that commonly lead to errors.

Consider these in the context of your prehospital or emergency service:



(thanks to Tim Leeuwenburg at for this one!)