“Total Immersion” Simulation…..!!

The Auckland Rescue Helicopter Trust (ARHT) works with multiple agencies, including NZ Defence, and has the good fortune from time to time to train alongside these groups.

On the 14th May we were invited to train in the ultimate in-situ simulation venue – the Royal New Zealand Navy Damage Control School with the RNZN Sea Safety Training Squadron. This involved fire training and vessel damage control (for this read blocking lots of holes letting water into a ship simulator…!)

Present were 5 ARHT crewman, our physical instructor, and several representatives from the New Zealand Police Search and Rescue unit.  I went along as the HEMS medic representative and to get an idea of how in-situ simulation is conducted in other services.  It was the epitome of a multidisciplinary team!

We started with the Fire-Fighting Training Unit (FFTU). After instruction of the use of the differing methods of fighting fires, donning fire-retardant suits, gloves and masks we firstly made up our own foam fire extinguishers, then used them on a gas fire. We also did the same on oil and diesel fires with fire blankets, CO2 extinguishers and lastly dry powder extinguishers.



We then moved on to the Damage Control Training Unit (DCTU).  After some brief instruction on ‘shoring up’ methods (how to block leaks in the ship), we moved into the unit for a tour before the real fun began. The DCTU is a faithful recreation of a section of a ship three decks high.  It is used to train Navy personnel in Damage Control (leak stopping and removal of flood water) and casualty evacuation. The DCTU uses hydraulics to simulate the rocking motion of a ship at sea; this enables students to experience the problems which can arise from the combination of motion and free surface water.

navy                                                               (The Simulator is is the background of this picture)

I was appointed team leader for my team of 7 – I was reliably assured this was due to me being small (5′), mouthy and Irish… It was a rather daunting prospect.  Even with the training and experience I have in a leadership capacity; I was now leading a team of people in something that I had no prior experience or knowledge of.  Add in the team-mix as described above, then lock us all in a confined space, with freezing cold water pouring (under massive pressure) in through multiple holes in the walls, roof and floor, plus darkness, smoke, noise and the motion of a rocking ship – doubly daunting…

Not surprisingly it was extremely difficult to keep overall situational awareness – I did most of the team leading being “hands –off”, but with my backside blocking a leak in the wall!  Despite this the team worked together brilliantly. We had allocated roles beforehand.  There was great use of closed loop communication, once a job was done those free returned to the team leader for further task allocation.  We managed to shore up all the major leaks in the engine room (where we started) then moved to help the second team out in the mess hall with further leaks.  We finished in waist deep water (waist deep if you were 6ft tall that is…!).

Escape was though an overhead hatch, weighed down by water from leaks in the decks overhead – again great teamwork was put to use getting the stronger team members up a rope ladder first to open the hatch against pressure and then help the rest up through the subsequent torrent of water.

There are cameras all through the DCTU – everything was filmed, the footage is then usually viewed in a de-briefing session following the scenario.  Unfortunately due to time constraints we didn’t manage to see the footage from our exercise.

A few colleagues were wondering what exactly an emergency medicine / HEMS doctor was doing on a Navy damage control exercise as (to quote) “it’s not something you’ll ever need to do… the ED is hardly going to sink…”.  However I feel there were multiple comparisons to this training and what we do every day in the workplace, be that in the ED or on the helicopter.  In-situ simulation aside, today proved an invaluable crisis resource management and team-building exercise for the ARHT group.  14 people from different services, with differing physical attributes and prior experience working together in a completely alien environment, doing something they have never done before…  It suddenly dawned on me this was no different to your usual gnarly trauma resuscitation crew on an ED night shift, except with maybe a few more lives at stake!

For more insight into how other high-performance services train to mitigate for the “fallibility of the human mind under great pressure” and how this can be translated into healthcare, see this post from the blog Resus Room Management. This has a link to the BBC Horizon documentary “How to avoid mistakes in Surgery” where Kevin Fong (a well-known Anaesthetist and Intensivist from the UK) explores human factors in medicine.

I would like to thank the instructors from the RNZN Sea Safety Training Squadron and also ARHT crewman Ati Wynyard for organising this very worthwhile training day.

Human factors in prehospital adverse events


In the last decade or so, hospital medicine has learned (often the hard way) the importance of recognising the impact that human factors have when dealing with illness or emergencies.

While there is ample literature regarding the importance of human factors on the purely ‘aviation’ side of aeromedical work, there is little information about the importance (or otherwise) in the ‘medical’ side of prehospital care. The differences in environment, staffing, skill mix, time course of the patient, and a comparative paucity of resources means that extrapolating the ‘ED human factors‘ approach to the prehospital setting may not automatically be valid.

A study by the Ambulance Service of New South Wales, published in EMJ in 2012, sought to look at how human factors contributed to adverse events in the prehospital setting. The study involved surveying qualified and trainee paramedics regarding jobs they had been involved in where an adverse event or ‘near-miss’ occurred. Data was gathered for 370 jobs. On average, there were 10 contributing factors for each adverse event (range 5-15) – a typical ‘Swiss Cheese Model‘.

Factors which significantly increased the likelihood of an adverse event occurring were:

  • deteriorating patient (most important risk factor)
  • uncertainty about a change in patient condition
  • panic
  • on initial presentation patient seemed well
  • adaptation from low to high severity case
  • uncertainty in diagnosis
  • presence of reduced LOC
  • uncertainty in diagnosis

The presence of these factors, particularly grouped together, made adverse events or ‘near-misses’ more likely to occur.

(do these look familiar to anyone? I reckon most ED adverse events/near misses would have these factors as major contributors too!)

One of the most important points made in the discussion was

“The recognition of deteriorating and confounding patients, the management of uncertainty and decision making with impaired data may be considered as constructs of clinical judgement. If this conjecture is correct, then this study concurs with prior work that identified clinical judgement as the key issue in prehospital patient safety.”

The sequence of events that led to an adverse event or near miss was felt to be:

disconcerting patient factors –> uncertainty –> omissions –> patient harm

So how does this relate to our service?

  • factors contributing to adverse events or ‘near-misses’ in the prehospital setting are, according to this study, probably very similar to those that operate in our more familiar hospital setting. While we need to adapt to the prehospital environment, a new paradigm of thinking abut prehospital risk management to avoid error is probably NOT necessary.
  • assuming clinical judgement is a major issue in preventing prehospital adverse events, we should (in theory) be in a good position to counter this – our paramedic/doctor combination gives us clinical judgement from senior clinicians from two complementary backgrounds. Hopefully we have the best of both worlds.
  • Our model of care (doctor/paramedic/medically-trained crewman) puts us in a (relatively) well-resourced position to deal with deteriorating patients.
  • With ‘on initial presentation patient seemed well‘ being a risk for adverse events – we must keep in mind that complacency can be our enemy. With current dispatching protocols for our team, many of the jobs we do are based on geography rather than patient acuity, and many of the patients we transport are not actually that sick. Being lulled into a false sense of security and underestimating a patient’s illness/trajectory may be a significant risk for us.

Full text pdf for this post is available here (secure area limited to ADHB staff only – ADHB has online subscription access to this journal through the Philson Library at the University of Auckland School of Medicine)

Application of the Crewman’s Dictionary

In view of our upcoming ‘Equipment Usability Testing’ session, the following was circulated amongst the Auckland HEMS staff:
I) Here is one approach to the assessment of the ergonomics of a space:
  1. Attention and alertness
  2. Safety-critical information
  3. Position, placement and orientation of equipment
  4. Proximity of task, equipment and materials
II) Another approach (International Workplace Studies Program @ Cornell) emphasizes:
  1. Functional coherence
  2. Facilitation of communication
  3. Facilitation of task accomplishment
  4. Adaptable space

The Auckland HEMS doctors are fortunate to work closely with the helicopter crewmen. One of the many important functions the crewmen serve is to keep the doctors on Planet Earth. With this in mind, Herby Barnes (Crew Chief/Q.A. Manager) has consulted the crewman’s dictionary and provided the following real-world translation of the points above:

Approach I)

1.     If you didnt hear me the first time then go back to bed
2.     A thumb does not mean you look good in that jumpsuit
3.     Are you sure you’re in the right seat ?
4.     If you cant reach it MOVE !!!
Approach II
1.   Yes I am bigger and heavier and sometimes I may need to crawl all over you, so please do not get caught under me, we dont want another patient. 
2.   If you’re not kissing the MIC to talk, hand gestures are preferable to eyes or facial expression.
3.   Do your job or get off the machine.
4.   A space to secure extra crap that may be required, or recovered from the scene.
Given how slow HEMS doctors are at learning any practical helicopter-related matters, Herby has started their training at age 8