Cutting Off the Lizard’s Tail in Surgery

Dear Sir

We recently read with interest the article by Hickey et al. [1]. The aviation vs. surgery debate is currently framed on the understanding, and possibly replication, of flight team dynamics that led to the outstanding record of safety currently enjoyed by commercial aviation (fatal accident rate of 0.06 per million flights or one fatal accident for every 16 million flights, well beyond six sigma [2]).

An aspect that is perhaps not fully appreciated in the current debate is the role of air traffic management (ATM) and the way it operates and contributes to safety. ATM operators face the critical task of managing the course of multiple aircrafts within an assigned sector, with the primary objective of avoiding mid-air collisions. The pilots are therefore relieved from this critical task. ATM vigilance requires variable degrees of mental workload. Variables affecting the workload are well understood and include (1) routine actions (e.g. acknowledging aircraft entering and exiting the assigned air-space, issue course variations due to weather conditions or other phenomena), and (2) actions required to solve high-risk situations in which there is a potential risk of air collision; with the latter being the most dangerous in terms of outcome as well as the most resource-consuming for the operators. Sector capacities (i.e. maximum allowed number of aircraft passing through a sector per hour) are not enough to ensure a sector is safely managed. As a matter of fact, workload is not experienced per hour by controllers. On the contrary, high-workload peaks manifest themselves in much smaller time-frames. Defining a threshold for maximum ATM controller workload is therefore essential to avoid cognitive overload, degradation of performance and escalation of risk. A recent article by Yoram Obbens and Rob Bezemer [3] discussed the features of a new ATM Workload Model (WLM) currently used at the Amsterdam Schiphol airport in the Netherlands. Workload modeling (based on Instantaneous Self-Assessment scores) determines a universal maximum workload threshold for operators of the concerned air traffic sectors, thus allowing for better decision making at the management level (how to staff sectors, how to manage the overall division of the air space etc.). The benefits are better resource management, better traffic flow management, and improved safety.

A real-time workload monitoring of the surgeon and team members during complex procedural care would allow for better understanding of the complexities of the scenarios and thus provide a more solid ground for decisions concerning decisions regarding task prioritization [4,5]. Pilots, air traffic controllers and surgical teams all need to strategically re-organize their task-list during periods of high cognitive load in order to maintain peak performance. They should be able to treat tasks like elastic springs, reduce the essential ones to the bare minimum and completely omit those that they do not consider mission-critical, just as a lizard that ‘elects’ to lose its tail when feeling threatened. This “task shedding” would allow members of the surgical team to get the job done when the task load suddenly increases and minimize potential for harm. Surgical teams should be trained on how to make these decisions under stress, something that, as pointed by Hicks and al, is not currently part of the standard training. Tools like air traffic control workload model may provide valuable information on how to succeed in this quest.