On my last day on the ICU rotation block, one of the patients went into an irregular heart rhythm called ventricular tachycardia. He was a 60-something year old guy with multiple medical problems and connected to a breathing machine. All of a sudden, he became unresponsive and hypotensive and had a heart rate of 150+ beats per minute. As we all rushed into the room, we systematically ran through the ACLS algorithm. We initially evaluated him, checked for pulses, started CPR, established the airway, monitored blood pressure, identified the rhythm, and gave a dose of treatment. We repeated the process until the patient was stable. It was efficient, it was effective, and most importantly it was routine. It was a checklist that was used around the world and saved many lives.
In this fantastic article, Atul Gawande describes a bomber airplane competition held by the US army in 1935. One particular plane, the Boeing Model 299, was introduced as the plane that could carry five times the amount of bombs while flying faster and farther than any other plane in the competition. There were high hopes for this plane to revolutionize the US airforce at the time. At its first flight, the Boeing 299 taxied onto the runway, took off without a problem and climbed to about three hundred feet. Then the plane stalled and crashed – killing three out of the five pilots.
After further investigation, the reason for the crash was deemed “pilot error.” The new plane was so complex that not even the best pilots could master it by memory. The solution was a checklist. They created a step by step checklist on takeoff, landing, flying, and taxiing. The pilots went on to fly 1.8 million miles with the Boeing 299 without an accident. The Boeing 299 was renamed the B-17, and with the B-17, the Americans were able to have an unfair advantage in World War II by destructively bombing Nazi Germany.
Checklists seemed to work for medicine as well. In this landmark study in 2006, ICU’s in Michigan found that by implementing checklists they were able to decrease infection rates by 66%. With the checklist, the average ICU in Michigan was outperforming the rest of the nation by at least 90%. After eighteen months, nearly two million dollars and at least 1500 lives were saved in Michigan by this simple checklist. What was the checklist? Before each central line procedure, the checklist composed of just hand washing, covering the patient, cleaning the area, and removing unnecessary lines. Really simple, even more so effective.
“Good checklists, on the other hand are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything–a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps–the ones that even the highly skilled professional using them could miss. Good checklists are, above all, practical.”
― Atul Gawande,
Checklists don’t need to be complicated at all. Actually, the simpler the checklist, the better. Checklists lessen our cognitive load by automating the simple tasks that need to be done. The army used the checklist to fly the B-17 safely and used their free minds to strategically bomb Nazi Germany. ICU’s in Michigan revolutionized medicine by creating a simple hand washing checklist before every complex procedure so the healthcare team can concentrate and save more lives. I helped save a life the other day by performing a routine checklist executed across the country. In each of these scenarios, simple things became automatic which allowed for more energy and creativity to be spent on the difficult things.
Here’s a simple checklist I go through everyday:
- Did I plan my day?
- Did I do the most important things first?
- Am I actively thinking about my goals?
- Am I taking regular breaks?
- Am I taking care of myself?
- Did I show gratitude to at least one person today?
- Did I review myself at the end of the day?
If no to any of the above, I usually go back and correct it or write in my personal journal on how I can correct it next time. Try this out and let me know what you think.
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