All rights reserved to respective authors or parties. This is a compilation of various materials from various sources.

1. Crew Resource Management
December 2010
EMT-Basic Continuing Medical Education
Justin Feldstein, NREMT-B , AC for Training

2. Outline
• Identify common management and leadership
problems in EMS
• Introduce the concept of CRM and how it
applies to EMeRG
• Foster critical thinking skills that can be used
in emergency and non-emergency situations
• Apply concepts

3. What is Crew Resource Management
(CRM)?
CRM is a program designed to enhance the
effectiveness of given resources:
– Assertiveness
– Leadership
– Communication
– Attitude
– Situational Awareness

4. Foundations of CRM
• Developed in 1980 after a string of fatal airline
collisions
– Tenerife Airport Disaster in 1977: KLM Pilot asks
for take-off clearance from tower. KLM Pilot falsely
assumes clearance was granted and began take-
off without visual of clear runway. The co-pilot
was too intimated to speak up and state they were
not cleared for take-off. KLM aircraft and Pan am
aircraft collide resulting in 583 fatalities.

5. Tenerife

6. Hudson River Landing of United 1549
Chesley "Sully" Sullenberger
"has to go down *as+ the most successful ditching in aviation history.”- NTSB

7. Bottom Line
Simple communication errors or
misunderstandings, based on human error can
result in fatal consequences.
– Clear similarities to EMS
– Flight crew and EMS crew go from “standby” to
“activate” instantly
– Crew change all the time, need standardized
methods

8. Bayley, et al (2008)
Study of one- versus, two-paramedic treatment
scenarios in a simulated cardiac arrest
Findings: “...two paramedic crews were more error-
prone and did not perform most interventions
more rapidly with the exception of intubation.
These data do not support the proposition that
two paramedic crews provide higher quality
cardiac care than paramedic-EMT crews in a
simulated ventricular fibrillation arrest.”

9. Thoughts?
• Human factors!
• Good Communication and effective leadership
are much more important to patient care
outcomes that we think
– Too many leaders on this one?

10. Team Leadership
What characteristics can be identified in a
good leader?
• Decision making skills/Conflict Resolution
• Authority
• Mentoring
What kinds of traits are these?

11. Followership
• Respect authority • Learning attitude
• Personal Safety • Ego in check
• Crew Safety • Balance
• Accepts authority assertiveness/authority
• Knows authority limits • Accept orders
• Leader success • Demand clear tasks
• Good communication • Admit errors
skills • Provide feedback
• Adapt

12. Conflict Resolution
• Conflict will ALWAYS arise. Unavoidable fact of
life.
• Key is to resolve conflict quickly before it
escalates
• Must have legitimate avenue for followers to
present issues
• Avoid emotional involvement

14. Conflict Resolution Methods:
Crewmembers Questioning Authority
• Assertive Statement Method
– Used in non-life threatening conditions, “off-
scene”
– Time is no factor
– Diplomatic and respectful approach
• “This-is-Stupid” method (TIS)
– Reserved for high-risk, short on time scenarios
– Last tool in the toolbox
– Focuses on actions, not individuals

15. Crewmembers Questioning Authority:
Assertive Statement Method
Five Step Process to expressing a difference of
Opinion:
1. Opening/attention- say the person’s name
2. State concern/owned emotion- “I’m
uncomfortable with…”
3. State the problem as you see it- real or
perceived
4. Offer a solution- “I think we should…”
5. Obtain Agreement- “What do you think?”

16. Practice!
Example: Justin, I am nervous about
driving right now, I have an exam in
an hour that I didn’t study for. How
about we do it next shift? Is that
cool?

17. Crewmembers Questioning Authority:
“This is Stupid Model”
One step process to raise a red flag, making the leader
immediately reconsider a situation:
1. Develop a call sign: For example, “Red flag”
– Forceful method when tragedy is real
– Removes personal issues, focuses on event
Automatic Red Flags for supervisors:
"I have no idea what you are asking me to do.”
"Is this legal?”
"I am totally lost.”
"Who's in charge?” (CC/Field Sup.)

19. Practice!
Example: Justin! Red Light!
Response: Justin realizes he shouldn’t
give nitro to someone without asking
if they have taken ED meds in the last
48 hours

20. Communication
• Messages are transmitted and received
– Verbal: 7%
– Body Language 35%
– Vocal Tone 55%
• The tone YOU set projects onto your crew
– Everyone has bad days, but in EMS bad days can
kill people

21. Authority
Vested by legitimate power
– Title and responsibility of EMT, Crew Chief, Field
Supervisor, Assistant Coordinator, and Coordinator
– EMT-B License
– Rights and responsibilities
• Both must be balanced and attended to

22. Mentoring
Fundamental function of leadership position
– Goal: Develop and support prospective leaders
– Technical competence is essential component:
• Demonstrate skills and techniques
• Demonstrate professional standards and best practices
• Verbalize errors and limitations promptly
• Recommend solutions to enhance crew effectiveness
• Monitor and assess crew performance
• Motivate members, create bonds

23. Situational Awareness
• Evaluating high risk situations
• Recognizing changing conditions
• Recognizing your limitations
• Recognizing equipment limitations

24. Clues to a Declining Sense of
Awareness in EMS
• Failure to meet objectives or goals
• Use of undocumented procedures
• Unknowingly/unapproved deviation from
protocol
• No one paying attention to radios
• Not noticing “scene clues”
• Unresolved discrepancies
• The “Bad” feeling in your stomach

25. Activity #1: Human Knot
• Stand up, form a circle, shoulder-to-shoulder
• place a hand in the middle of the circle and
grasp another hand
• Put other hand in the middle, grasp a different
person's hand
• Do NOT let go
• Untangle yourselves without letting go of each
other’s hands

26. Activity #1 Debrief
• What did I make you do and why?
• What communication occurred?
– Was it concise
• Who became the leader, why?
• What challenges did you encounter?
• What if I said you couldn’t talk?

27. Stress vs. Performance

28. “The Hump”
If you are close to or about to cross “the
hump” you need to make a decision if you are
able to stay on shift
– Provider wellness is ALWAYS our first priority

29. Increasing/Maintaining Awareness
• Maintain Skill-set: CMEs, on-shift training
• Experience: Practice makes perfect
• Sleep!
– This presents a bit of a problem…we are in college
AND EMS
• Lifestyle choices
– Separate yourselves from EMeRG in your off time
• Avoid tunnel vision, snippets of everything going
on
• Delegate!

30. Bad Attitudes
• “I’m the Supervisor”
• “See that X, that’s where you sit”
• EMTs are not as good as medics
• You haven’t been doing this as long as me
• “This is not how we do it in X (Jersey)”

31. Attitudes and Antidotes
• Antiauthority: Don’t tell • Follow the rules, they
me! are usually right
• Impulsivity: Do • Not so fast, think first
something quickly • Taking chances is foolish
• Macho • I’m not helpless, I can
• Resignation: What’s the make a difference
use? • It could happen to me…
• Invulnerability: it won’t
happen to me!

32. Activity #2: Plane Crash
• Break up into groups of approx 10
• A small aircraft crashes in the shark infested waters of the
Pacific Ocean. There is damage to the aircraft on impact
with the water which causes the electronic systems within
to be damaged. The resulting radio failure means that no
may-day message can be sent. Of the sixteen passengers on
the plane there are nine survivors. The location of the crash
is approximately one and a half days from the nearest land.
The life raft on one side of the airplane can be used,
however there is only room for four persons in it.
• Your group must reach a decision as to which four persons
can enter the life raft. You have approximately 20 minutes
to reach this decision before the aircraft sinks.

33. Activity #2: Debrief
• How did you make your decisions?
– Any other motives? (ageism, racism, sexism)
• Who took charge? Why?
• What roles did group members adopt?
• What would you do next time?
• Did you identify and use all resources?
• Meet goals?
• What kinds of behavior helped or hindered the
group?
• There are no “right” answers (sorry)

34. Decision Making

35. J.S.T Ragman, Instructor Trainer, USAF
Each of us, regardless of time, experience,
qualification, rank or position, can still do
stupid things. Be humble.
A “fledgling” member of my crew makes the
call. Listen to everyone. Look beyond age,
experience, rank and qualifications

36. Decision Making
• Pre-requisite: Good situational awareness
• Evaluate Situation:
– What needs to be corrected?
– What resources do you have?
– How can the resources best be used?
• Consider consequences of all actions
• Make Decision, inform all involved
• Evaluate decision, repeat as necessary

37. D.E.C.I.D.E. Model
• Detect the need to make a decision
• Evaluate options
• Choose option that most appropriately meets
goals
• Implement
• Detect the consequences of implementation
• Evaluate the consequences

38. Example: D.E.C.I.D.E.
D: Something doesn’t seem right with this patient,
they seem “off”
E: Rapid transport or wait for medic (ETA 15 min.)?
C: Rapid transport: 2 min transport time
I: Transport priority, make hospital notification,
increase index of suspicion
D: Pt arrives at hospital
E: Seems like right decision, medic would have
taken too long

39. C.L.E.A.R Model
• Used for GROUP decisions only
– Clarify the Problem
– Look for and share information
– Evaluate different solutions
– Act on your decision
– Review performance

40. Factors that Affect DM Skills
• Physiological factors
• Confidence
• Feeling of “support”
• Cohesive work-team
• Personalities
• Did I mention sleep?
• What else?

41. Other EMS Specific DM Models
• BLS
• EMT Assessment Steps
• ACLS
• Triage
– All are algorithms that enable effective decision
making and treatment implementation under high
stress situations

42. Task Allocation in EMS
• Know your limits
– Backup?
• Know your crew’s limits
• Capitalize on strengths
• “seek” out experts
• One “bite” at a time

43. The Scenario
Dispatch: 0630 to 19th and E Sts. NW for MVC with
two vehicles involved, total of four patients.
Scene is safe. GWPD on scene. Windshield survey
reveals the following:
ATF:
• 50 yom
• 8 yom (entrapped)
• 35 yof
• 43 yof (DOA)

44. Your A GW-1 Crew
You have a crew of four:
• Yourself: EMT-II for 2 months, about to be FTO
• Driver: EMT for 1 ½ years, solid attendant
• Probationer: from NJ, firefighter I, extrication
experience, ICS 300
• Probationer: 2nd shift on EMeRG, fresh out of
Class

45. Walk me through it…
• What needs to be done?
• Who does what?
• What should YOU be thinking about?
• What is the plan?
Yourself: EMT-II for 2 months, about to
ATF: be FTO
• 50 yom Driver: EMT for 1 ½ years, solid
attendant
• 8 yom (entrapped) Probationer: from NJ, firefighter I,
• 35 yof extrication experience, ICS 300
Probationer: 2nd shift on EMeRG, fresh
• 43 yof (DOA) out of Class

46. The Scenario: The “Average” Call
Dispatch: 1230 Corcoran Hall 3rd Floor Chemistry
Lab for a seizure
Your Crew:
– YOU (EMT-II)
– Driver: New driver, been in EMS for 6 years
– Probationary: Fresh out of class
– EMT: Solid BLS skills

47. Planning
• What needs to get done?
• Who is the most appropriate person for the
job given the goals and resources?
Sometimes the best solution still doesn’t
accomplish the goal or follow the rules, your
JOB is to pick the BEST solution

48. En-Route Planning:
Tasks: Assigned to:
• Driving • Driver
• Radios/Communication • Driver
• Call oversight/ “IC” • Crew Chief
• Vitals • Probationary EMT
• Interim Chart • EMT
• Safety Officer • GWPD (if on-scene)
• Pt Interview/Assessment • Crew Chief
Effectively communicate roles PRIOR to arriving on-scene

49. On-Scene Delegation
• No luxury of “pre-planning”
– That’s why we TRAIN
• Tasks differ on every call, Must be adaptable
and flexible
• Constant re-evaluation of allocation of tasks
• Scene changes = reevaluate

50. Charlie Foxtrot
• Results from failure to delegate,
communicate, or technical error
– “to err is human”- Alexander Pope
• If leader is overwhelmed, crew is
overwhelmed
• Solution: Prioritize tasks and reallocate tasks,
what goes out the window?
• Fall back on what YOU know

51. Assertiveness
• One of the most LACKING skills among new
providers
– Middle ground of clinical behavior
– Best parts of aggressiveness without the negative
energy
– Best parts of introversion without loss-of-self
– An individuals opinion can be heard without
challenging authority
• It clarifies understanding or intent, INCREASING safety

52. Questions?

53. Resources
“Crew Resource Management”: John S.
Halbrook, BA, EMT-P, Pilot
“Crew Resource Management for the Fire
Service” IAFC
“One Paramedic or Two?... and the crash of
United 173” Chris Carlson, PhD. JEMS.