Test pilots wanted! Auckland HEMS app goes live

We are delighted to announce the release of the Auckland HEMS mobile app!


ALERT! January 2015: Since the publication of this post the app has been updated, including the launch of the Auckland HEMS simulation-based prehospital care curriculum podcasts. You can read  about the latest additions by clicking HERE


This app is a work in progress, and will be a living, dynamic project.

photo 2

Auckland HEMS home screen

We are very keen to have feedback regarding app development and improvement from the prehospital, aeromedical, and emergency medicine communities.

At the heart of the app are the emergency situation checklists that have been developed by Dr Robert Gooch (Canadian Emergency Medicine trainee and recent Auckland HEMS Fellow) and Dr Chris Denny (Auckland HEMS Medical Director).

Auckland HEMS also gratefully acknowledges the efforts of the pilots, paramedics, and crewmen who took place in the simulation-based usability-testing of the checklists, the work of Atul Gawande, and the international HEMS fellowship for allowing Dr Gooch to complete this patient safety initiative.

emergency checklist menu

The app also contains other clinical and non-clinical resources.

How can we make it better? We would like to hear your thoughts.

Please use the feedback button in the app, or post comments below.

The app was developed using a platform called ibuildapp‘. This is a web-based subscription service that has the following features:

  • straightforward user interface to construct and test the app – if you can create a powerpoint presentation, you can build an app!
  • NO coding required
  • apps created are functional on both iOS and Android
  • immediate updating – alterations to the master version will appear on user’s versions the next time they open the app
  • low startup costs compared to having an app professionally coded

The monthly subscription cost to Auckland HEMS increases as more users download the app. As a result we have had to introduce a small charge for iOS users to offset our ongoing costs. Due to some inflexibility regarding price alterations on Google Play (and a failure to read the fine print!), the app will remain free for Android users – it’s your lucky day…

No individual will make a personal profit from this project; any income above our development and subscription costs will go towards further app development and other Auckland HEMS educational and training activities.


Our vision is to use a large team of ‘test pilots’ to make the app as effective as possible for clinical and operational use prior to creating a professionally coded ‘Auckland HEMS 2.0′.


A test pilot who WAS up for the challenge: Chuck Yeager and the Bell X1

A test pilot who WAS up for the challenge: Chuck Yeager and the Bell X1

Some improvement suggestions will be possible within the technical features of ‘ibuildapp’, but many will not, and these will be added to the future development list for version 2.0.


Click HERE for iOS users

Click HERE for Android users

Thank you for being a part of the Auckland HEMS team!

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 rgooch44@gmail.com


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.

Patient safety in helicopter emergency medical services (HEMS): The safety management system

“Insanity: doing the same thing over and over and expecting different results”. Albert Einstein.

You could be right in thinking that “safety crusaders” are the glass half empty type, right? Those that believe “what can go wrong, will go wrong” (Murphys Law).

I’m not a pessimist, but I do believe in being prepared for the potential for error, or for when things do genuinely go wrong.  We need to avoid Einstein’s insanity; repeating that same thing and expecting different results the next time (as the next time might be a catastrophic outcome).  As HEMS clinicians we have a responsibility to get our patients from the pre-hospital to the hospital environment without harm, to the best of our abilities.  A culture of safety and forethought, identifying and mitigating for potential hazards (threat and error management) is a prominent facet of our work.

Both Aviation and medicine involve teams of highly skilled people working together in a high-stakes environment involving people’s lives. The obvious major difference is human beings are not planes or computer controlled, and interactions with people are so multifaceted and the human body so complex, that events cannot always be predictable.  Therefore we need to mitigate somewhat for that unpredictability. (Perhaps introduce the concept of ‘Threat and error management?’)

Aviation has bred a culture of safety for many years now and, although a little way down the track, Medicine (especially Anaesthetic and Surgical services) has been learning from this and applying appropriately modified safety techniques including:

  • ·         Human Factors and (team) training
  • ·         Ergonomic design and usability testing
  • ·         Checklists
  • ·         Communication Techniques
  • ·         Pre-procedural briefings
  • ·         Simulation Training (muscle memory)
  • ·         Debriefing
  • ·         Error/Incident reporting

Auckland HEMS has, from the outset actively promoted the already robust culture of patient safety at ARHT. We have introduced RSI checklists, human factors training, dedicated medical simulation training and (thanks to generous funding from ARHT and ADHB) a now a fully functioning clinical simulation lab. Furthermore we now have access to a multidimensional computerised safety management system (SMS) which the ARHT has recently introduced.  Originally developed for aviation, the system contains enough flexibility to expand into the clinical role of the HEMS service. This includes safety and quality reports (which can be anonymous), inventory management (circulation, maintenance and ordering of drugs and equipment) and personnel currency – ensuring all crew take a personal responsibility in being “flight-ready”.  There is also scope for a clinical risk register, which we are currently developing.

This brings me on to the value and/or role of Safety Management Systems (SMS) from a clinical perspective:

Definition of an SMS from the Civil Aviation Authority NZ  is a “formal organisational framework to manage safety.  Under an SMS, organisations will need to have systems for

  • ·         Error, threat and hazard identification
  • ·         Risk management
  • ·         Safety targets
  • ·         Reporting processes
  • ·         Procedures for audit, investigations, remedial actions
  • ·         Safety education…

… and to be effective it must be part of everyday practice”.

All these facets have an application to clinical care, not just aviation. Although it is arguable that we do all of the above currently, a systems approach means that the formally isolated clinical components of risk, safety, and quality of care are brought together in everyday practice in an integrated manner. This approach requires a strong safety culture within an organisation together with consistent managerial support.  It also needs individual accountability and that personnel are empowered to speak out.  It is in this complex environment where the integration offered by an SMS comes into its own.

The system and practice of safety not only relies on people putting their hand up and reporting incidents, it is also dependent on the staff on the ground having access to outcomes, therefore facilitating behavioural and organisational change.  Auckland HEMS safety reports allow all operational crew to have visibility of current and past events, to read comments from  the experts’ on a real time forum, as well as the opportunity to comment themselves. This whole-crew approach enables transparency and has been invaluable in providing a 360 degree scrutiny of the incident from both a clinical and aviation perspective, as well as the potential for change, outcomes and trends in incidents.

In the initial stages encouraging reporting can be difficult:  apart from the medico-legal aspect other barriers to reporting can include:

  • ·         Time
  • ·         Personnel buy-in
  • ·         Lack of “champions” in the organisation
  • ·         The thought that it is “somebody else’s job”

Error, near misses and incident reporting has not translated as well into medicine as it has in aviation. Humans in general have an innate distrust of any Orwellian “Big Brother” watching their every move looking for mistakes. This also stems from a prominent medico-legal “blame” culture, which medicine has been slow in overcoming.  Patient safety depends on open disclosure of error or near misses, primarily to avoid the same happening to someone else. Open disclosure (naively) would be the ideal, however may never be feasible due to the potential for individual blame for system faults.

To quote the Institute of Healthcare Improvement (IHI) “the focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system”.

The next question: would it be feasible to introduce an integrated SMS into the healthcare setting? A one-stop systematic shop for inventory, maintenance of equipment, personnel, rostering (shift-work and fatigue), clinical risk registers and safety reporting – and making this part of everyday practice? This has been approached by Toney in his paper (free online access to PDF here.)

Finally I would be interested in finding out how other HEMS / EMS services have developed their clinical risk registers. Feel free to comment below.