AFPP February President Meassage
Posted: Sat, Jun 23rd 2018 at 17:26:37

The theatre ‘cockpit’ – lessons from aviation
Adrian Jones (left) and John Nolan

The successful performance of surgery requires the completion of a series of complex tasks by highly motivated individuals, operating as part of a cohesive team.
The same is true of the flight cockpit, with which parallels have increasingly been drawn, but transposing and utilising the vast experience that aviation can offer us requires a genuine understanding of the processes used and not simply a superficial adherence to box-ticking exercises and checklists.
As with flight, the surgical perioperative period can be divided into three phases consisting of the preparation, the operative procedure and the closure; corresponding with aviation's preflight checks and take-off, the flight phase itself and the preparation for, and completion of, the landing.
The 'pre-flight' phase for surgery should be carried out formally and without distraction as it offers a real opportunity to identify potential problems and avoid major error. The tone is set for the whole procedure and the various roles of all team members are defined. Any possible 'bad weather' and its potential effects are clarified and contingency arrangements can be confirmed.
Implementing the principles of 'crew resource management' at this stage empowers otherwise quiet individuals to speak up and voice anyconcerns that they may have, at any stage during the procedure.
Checklists can usefully be individualised by teams who understand the surgery being undertaken (making them 'aircraft specific') and they should be relevant and concise. Their primary role is to protect the patient (rather than the hospital) from harm and its consequences. They should represent the switching on of a heightened level of observation and awareness of all members of the team, a state which should then continue until the procedure has been completed.
Throughout the surgery, there are opportunities for staff to interrogatesystemsandprocessesthatappeartobefunctioning satisfactorily. We do this when we drive by checking our petrol gauge, rather than allowing the tank to run dry. Planes and our carsareservicedregularlywithpartsbeingrepairedorreplaced before being allowed to fail, in a way that surgical instruments and equipment often are not. Where possible, longer procedures should offer staff members the opportunity of rest periods so that they are able to remain attentive, focused and engaged whilst within the active operating environment.
In preparation for landing, the sterile flight cockpit is characterised by an intense focus on a small number of clearly defined and important tasks and noise levels are minimised. Air traffic will limit transmissions to avoid distracting pilots and the formal implementation of a similar discipline toward the end of surgery reduces the risk of retained instruments and swabs, and other never events. This is a critical time in the procedure and there should be no tolerance of distracting and potentially disruptive conversation during completion of the 'pre-landing' surgical checklist.
There are of course many differences between the operating theatre and flight cockpit, and the flight crew have an obvious vested interest in avoiding adverse events! For the theatre team, often exposed to complex procedures under increasingly difficult circumstances, it is an opportunity to exercise their true professionalism and nothing less is acceptable.
Norfolk and Norwich University Hospital NHS Foundation Trust
The authors have worked together on a weekly basis, as both colleagues and friends for over 23 years and these thoughts represent a distillation of a series of their more recent conversations.
Wishing you many successful and safe surgical pathways for 2018!
Adrian Jones Surgical Care Practitioner and President AfPP Email: president@afpp.org.uk
John Nolan Orthopaedic Surgeon and Pilot
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