Ajar On Final: Owning Failure

“I have control”

I felt the yoke stiffen in the Cessna as I pulled my feet from the pedals and allowed my instructor to take over the aircraft. I felt sweat beading on my forehead and my hands were clammy as we nosed onto the runway. My instructor laid a worn, laminated checklist in my lap as we came to a stop and I began the shutoff sequence. Removing his headset he looked over at me as the prop shuddered to a halt. The cockpit was silent.

“Were you going to get sucked out of the door?” He asked. I was silent.

“When you tried to close the door you rolled us over the grass, we would’ve nosed down into the ditch. Stick the landing, then shut the door.”

I was in the process of landing the aircraft. It was the thing I dreaded the most through aviation school. It has the most complexities and requires the most attention to detail. The aircraft is sluggish, you’re pushing stall speed and you’re very close to the ground. You can literally watch your margin for error narrow as you glide closer to the tarmac. I had just confirmed my plan to land and been given clearance by the airport tower. I had placed my flaps into the 80% position and was gauging my glide into the runway when I heard a pop. The metal door of the Cessna clicked open and was rapidly shaking. The door, now unlatched, was violently slamming in the wind. I leaned over, grabbing the plastic handle and slamming it shut. I returned to the console as my headset buzzed to life.

"I have control".

Unless you’ve been living under a rock I’m positive this is not the first comparison of aviation and medicine that you have seen before. It’s used because the parallels are unmistakable. There is an undeniable need to make critical decisions in a time-sensitive environment. The stakes are high regardless if you are landing an airplane or managing a sick patient. The decisions you make can mean the life of your patient…or your own life.

Where did I go wrong? The door was open mid-flight! The door was loud, shaking, and…it was supposed to be shut right? The door being open also posed almost no threat to life or limb. It was highly stimulating from a sensory perspective but was not a true threat. What was the threat? Me becoming unduly distracted by the door that wasn’t a risk. I was in the middle of a complex procedure that required my full attention.

A patient screaming at the top of their lungs. A forehead profusely bleeding after a fall. Multiple patients in a head-on collision. All highly stimulating, high-stress situations. Nothing I am writing here is new or controversial but it is my personal takeaway from a time I failed to pay attention to what matters.

Let’s look at the bleeding forehead. Your patient had lost their footing after standing up and heading to bed. They caught their fall and did not lose consciousness or hit their head hard. On the way down they had cut their forehead on the edge of the coffee table. A few 5x9s finally seem to be allowing clots to form. There is blood everywhere! The carpet, the sheets, and the patient are all soaked. This injury is loud, obnoxious, and stimulating. But...why did they lose their footing?

Put a 12 lead on your patient. Is that elevation? Put a blood pressure cuff on your patient…it’s low. You do this because you asked why they fell. “I felt dizzy when I stood up and my chest hurt.”

It is easy in those situations to become distracted by the glaringly obvious screaming at you. They’re tired? Of course they are tired! They fell and are bleeding all over. You can demonize all the blood as the entire reason you are there. And you can miss vital information in the process.

It’s raining outside and it's dark as you pull onto the scene. You grab your jump bag as you walk to the closest vehicle. The front of the sedan is crumpled and a female is crying in the driver's seat. You click on your flashlight and instantly assess that her leg is fractured. Her knee is bent, the skin is torn and she's screaming in pain. “My leg, it hurts so bad”, She yells as you begin to assess her. Fire has a c-collar in place and you begin to prep for extrication. The entire time all she can mention is how bad her leg hurts and well…it looks the part. You can’t wait to get IV access and pain management on-board. Your partner is trying to stabilize and splint the injury as you push another dose of Fentanyl. Absent-minded, you ask Fire to place her on a bp cuff and pulse oximeter.

We do full trauma scans for a reason. The leg is horrible to look at and is causing your patient immense, excruciating pain. Loud, obnoxious, and not life-threatening (usually). When you check your patient's abdomen you notice bruising in the right upper quadrant. You press and she winces slightly but is still focused on her leg. Your patient has a liver laceration. She is bleeding internally. Now that will kill her.

You can be distracted by obnoxious stimulation on scene all the time. The blood, the shattered knee, or even a patient’s reputation as a frequent flyer. All these factors can cloud out details that may be obvious in a vacuum.

I remember feeling particularly egotistical after I finished what was considered a difficult scenario during a job interview, only to discover I had drastically mismanaged a patient. I treated a distracting injury like a champ. I followed the protocol like I was reading the national registry skill chart. And I failed the scenario because I didn’t recognize a glaringly obvious symptom. So how do we distinguish between the loud and glaring voice that serves to distract and the silent, under the radar voice that kills? It has to do with a few factors.

An experienced pilot was much less likely to have made the mistake I made. My instructor acknowledged it instantly and took control of the aircraft. An experienced pilot is confident in his ability to land and recognizes the importance of following through with that action regardless if there is an open door or not. Their landing is muscle memory while mine required far more cognitive bandwidth.

Practice has been emphasized over and over in our line of work. We practice our skills, we practice our assessments. Every time we practice a skill or an assessment we create muscle memory. This pushes this action further down the queue of cognitive bandwidth. Cognitive bandwidth that is needed for critical thinking and analysis. The thought power needed to recognize that an injury is loud but not lethal. It leaves room for the voice telling us that we are most likely missing something.

Learn to accept failure. I could have blamed the door hinge. A neutral third party who simply happened to open with no malevolent intention. In the process, I would’ve starved myself of a chance to improve on a weak point. When we fail it is easy for us to point at extrinsic factors but there is almost always a way to view it internally…and to improve from it. The book Extreme Ownership by Jocko Willink and Leif Babin tackles this topic for leadership and business. It is just as appropriate during patient care.

It is important that we practice the skills we've been given. The value that they can present in the field can be the difference in life or death for our patients. The time we spend in the training room is not useless. The more we practice utilizing these tools, the more space we free up to keep our head on a swivel. That door was loud and scary but the true danger was in my becoming distracted. We have to learn to decipher the bark from the bite.

But, inevitably we will fail. It is important to recognize these times. When one arrives will you blame others and the situation around you and deny yourself the opportunity to grow? Or will you acknowledge where you went wrong and build a game plan to patch those holes and become a better provider? Remember, always land the plane before you shut the door.