About Emergency Protocols

Simple, Stepwise, Standardised, Safe
In medicine competence is often measured by the ability to remember. Doctors have been taught to manage emergencies independently, by calmly reciting steps that may be stumbled over in a crisis managed by a team.

Cognitive aids, such as checklists and emergency manuals, have been frowned upon as “cookbook” medicine that somehow simplifies treatment – as if that is a bad thing in an emergency. Of course cognitive aids are no substitute for clinical acumen, good training, hard-won experience, and rehearsal with simulators. But perhaps the real opposition is to changing the image of the doctor in an emergency, away from the swashbuckling hero and towards a more human, more fallible, more integrated team member.

Pilots, nuclear power plant operators and military commanders use cognitive aids because:

  • in a crisis memory worsens, cognition is overloaded, performance degrades, and distractions interrupt planned actions1, 2
  • relevant literature can be difficult to find, poorly structured, and excessively detailed
  • aviators have long demonstrated the safety benefits of a culture of teamwork ingrained with cognitive aids and crew resource management techniques3,4
  • expertise requires repeated practice, and no-one is an expert in every emergency.

Good evidence supports cognitive aids in simulated medical emergencies, and their adoption represents a cultural change whose time has come.5,6,7,8

Printed protocols are more accessible, user-friendly, familiar, robust and reliable than screen-based applications.

Emergency Protocols are standardised with common-sense definitions. A “difficult airway” is something that you predict. A “failed airway” is something that happens to you. The diagrams in the Ventilation protocol feature the ubiquitous Oxylog transport ventilator, the little orange workhorse of Australian retrieval medicine.

Emergency Protocols work best when doctors and nurses are familiar with the protocols and have trained with them in simulated emergencies.10 Assigning a reader is recommended11 as the reader can prompt the team and help avoid the task fixation common in medical emergencies.

Using cognitive aids the doctor, like the pilot, still “flies the plane” and makes the big decisions. But cognitive aids improve performance, safety and satisfaction, which is why they have been widely adopted across industries managing time-critical emergencies.

Emergency Protocols are developed and tested by a team of doctors, nurses, graphic designers, a senior commercial pilot and ex-military test pilot, and human factors practitioners. These protocols are constantly updated as expert opinion evolves. New guidelines are parsed, refined, integrated and iteratively tested. Drug doses are presented as the amount and concentration of the commonly available formulation, minimising calculation and confusion in emergency drug administration. Protocol steps are practical, such as checking oxygen connections for the hypoxic patient. There is no extraneous information to wade through. In an emergency you don’t need to know the level of evidence . . . just what to do next.

Emergency Protocols should be visible in every Emergency Department resuscitation bay, and on every crash cart in the hospital.
  1. Kuhlmann S, Piel M, Wolf OT. Impaired memory retrieval after psychsocial stress in healthy young men. J Neurosci. 2005; 25(11): 2977-2982.
  2. Roth EM, Mumaw RJ, Lewis PM. An empirical investigation of operator performance in cognitively demanding simulated emergencies. US Nuclear Regulatory Commission. 1994; NUREG/CR-6126.
  3. Meilinger PS. When the Fortress went down. Air Force Mag. 2004; 87(9): 78-82.
  4. Helmreich RL. On error management: lessons from aviation. BMJ. 2000; 320(7237): 81-785.
  1. Arriaga AF, Bader A, Wong JM, et al. Simulation-based trial of surgical-crisis checklists. NEJM. 2013; 368(3): 246-253.
  2. Harrison TK, Manser T, Howard SK, Gaba DM. Use of cognitive aids in a simulated anesthetic crisis. Anesth Analg. 2006; 103(3): 551-556.
  3. Ziewacz JE, Arriaga AF, Bader AM, et al. Crisis checklists for the operating room: development and pilot testing. J Am Coll Surg. 2011; 213(2): 212-217.
  4. Marshall SD. The use of cognitive aids during emergencies in anesthesia: a review of the Literature. Anesth Analg. 2013; 117(5): 1162-1171.
  1. Marshall SD, McIntosh C, Sanderson P, Kolawole H. The effects of a cognitive aid and its design on team performance during a simulated intraoperative anaphylaxis. (Awaiting publication, 2015).
  2. Goldhaber-Fiebert SN, Howard SK. Implementing emergency manuals: can cognitive aids help translate best practices for patient care during acute events? Anesth Analg. 2013; 117(5): 1149-1161.
  3. Burden, AR, Carr ZJ, Staman GW, Littman JJ, Torjman MC. Does every code need a “reader”? Simul Healthc. 2012; 7(1): 1-9.