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Becoming Self Aware: Human Factors and Expedition Medicine



What are Human Factors?

These are organisational, individual, environmental, and job characteristics that influence behaviour in ways that can impact safety…

Clinical Human Factors Group


Human factors are hugely significant within healthcare environments, whether this is during a crash call in resus, whilst out in the community or when working in an expedition setting.


In austere environments, the value of having an effective team cannot be underestimated. It is important on such trips, to have an insight into aspects of our own and other's psychology, and to appreciate some of our hardwired biases that can risk getting us into difficult situations in the first place.


The study of human factors has its roots in the aviation industy

Swiss Cheese


This Swiss Cheese effect is a well known theory to those studying risk and emphasises that when things go wrong, it is usually due to a catalogue of mistakes, rather than one individual factor or decision. Being able to recognise these potential issues pre-emptively is part of carrying out a risk assessment, whether this is in the workplace or out in the field. Of course it is impossible to plan for every eventuality but minimising risk and anticipating the severity of possible consequences is vital in environments where rescue may be hours or days away.


The Swiss Cheese model has had a lot of attention with respect to COVID-19 and the various safety measures that society has instigated with variable levels of success around the globe. If we look at the picture below, we can see why the rates in some countries are so radically different to others.


Image © New York Times

We can apply this same "layering" idea to a road traffic accident that could occur whilst travelling from the airport to the start of your expedition. Trauma, as a result of vehicle collisions, is one of the leading causes of morbidity and mortality overseas. As hinted at above, it is often not one factor that is responsible for these scenarios.


For example, let's say your flight was 4 hours late to arrive. The driver has been awake since 5am, working on other jobs, and it is now 8pm. You face a 4 hour drive to your camp. He is tired. You are tired. He needs to get you to your camp and then drive back to the city as he has another job early tomorrow morning. Therefore he is driving quicker than usual. You are tired so you attention to detail is maybe not how it would be usually and you don't notice that his tyres need replacing.


Your flight was delayed due to bad weather. In fact there has been unseasonably heavy rainfall for the past 2 weeks and the road is in a state of disrepair...


Half way into your journey you skid off the road. You get a tyre blowout. Branches smash the windscreen and you may potentially have multiple casualties.



Heuristic Traps


Do we have any control over situations like the hypothetical one discussed above? Are we another slice in the system? Interestingly within our own psychology there are traps that exist that predispose us to making these mistakes. These are known as "Heuristic Traps."




Alot of the theories surrounding this comes from the study of avalanche accidents. For an in depth look at this, check out this article by Ian McCammon. Ian opens the abstract of this article by stating:


Even though people are capable of making decisions in a thorough and methodical way, it appears that most of the time they don't.

Ian McCammon National Outdoor Leadership School Wyoming USA



McCammon goes on to explain: "In a typical day we make hundreds of decisions, both large and small, and we must make them efficiently. To balance our constant need to make good decisions against our need to make them quickly, we often use simple rules of thumb, or heuristics."


I will explore some of these below, based on the linked article, and I am sure we have all experienced these to a varying degree at some point:



Familiarity


Here we subconsciously use our past actions as proof that a particular behaviour is appropriate.


Example:

"I have worked as medic on Mt Kenya loads of times and no one suffered with altitude illness, so it will be fine this time."




Social Proof


The tendency to believe that a behaviour is correct because other people are also engaged in it.


Example:

"The weather looks a bit ropey but I have seen lots of people venturing up onto the mountain plateau so I will as well- it cant be that bad..."




Commitment


The commitment heuristic is the tendency to believe that a behaviour is correct to the extent that it is consistent with a prior commitment we have made.


Example:

"we were aiming to summit, and although we are setting a slower pace than anticipated, we can still make it there and back before it gets dark..."




Scarcity


We tend to distort the value of opportunities we perceive as being limited.


Example:

"we only have a 4 day window to summit Mt Toubkal and even though the weather is bad, we have spent alot of money on this trip, so we must persevere."




Expert Halo


The assumption that an expert understands, and has accounted for, risks and consequences, without questioning these assumptions.


Example:

"the leader seems well qualified and has done lots of trips to wilderness locations. I am not sure about this ledge we are going to traverse but he/she must know what they are doing..."



Having an appreciation of these subconscious processes can help us understand why we make certain decisions, even when the objective evidence might suggest these are unwise.


This is important to be aware of when working on expeditions, as the potential consequences of these wrong decisions can have significant consequences.



Teamwork makes the dream work


What about the role of other team members when it comes to human factors?

Image © lucidchart.com

Teams are complicated things! The picture above shows the classic Forming, Storming, Norming and Performing stages that typically occur when you put a group of people together in a team.



How can we make this process easier?


Having an awareness of the above process is helpful, and in reality different parts of the team are likely to be at different stages along this curve at different times. This can depend on multiple factors, including personality types, whether individuals have worked together before, and the context that a fledgling team find themselves in at this initial stage.


On expeditions, this forming stage may often start at the airport. Feelings of trepidation and anxiety may be experienced both by participants and within the expedition team. The desire to make a good impression, alongside fears of imposter syndrome and the need to integrate within the group can make this a stressful but also an exciting time.

One sensible way to address this can be through pre-expedition meet-ups, whether face to face, or virtually in our current lockdown environment.


Team building exercises, creating an open dialogue for communication and establishing ground rules can be helpful whilst planning and brainstorming proactively, rather than reactively, for possible worst case scenarios is also vital.



What about when team members disagree?



People disagree. This is part of what makes us different and helps enrich us as a species, however on expedition this can create tension within a fairly closed environment, particularly if it happens early on in a prolonged trip. How we respond in these situations can make or break the leadership team.


Having a daily debrief to prevent the build up of negative energy and resentment between team members can be a sensible and proactive strategy, and it can help apprehend potential issues before they develop further.


Sometimes arguments will happen despite our best intentions and emotions can run high. If the subject of debate is not time-critical, having the opportunity to press pause and reflect on the situation can be really valuable. Trying to understand and appreciate the other person's point of view, and the logic behind their concerns is important and may help you to come to a mutual understanding.


The most important aspect of any decision is safety, risk and potential consequences. If the argument relates to team safety, and puts the expedition members at risk, you may have to stand your ground and escalate the discussion to involve an off-site mediator, who has an operational oversight. Most expedition companies have an on-call point off contact that can act as a soundboard to discuss important medical or logistical decisions in cases such as this.



These services are sometimes outsourced to external organisations overnight and at weekends. As an expedition medic it is important to remember that you have both a clinical and public health role towards all aspects of the expedition, and you may have a different insight and set of operational paradigms compared to other team members. Being able to express this to the rest of the team is vital, and having simulated worst case scenario discussions, as a dry-run, pre-departure can be a useful strategy to practice this.



This blog has touched on some key aspects that will hopefully help you when out in the field but also when working back home in your day job! I hope it has been interesting...





In other news: have you listened to Season 2 of the Wilderness Medic Podcast?


Episode one is all about how to become a dive medic: to listen click here


You can also listen to all 10 episodes from Season 1 including "How get into Expedition Medicine," "Working in Refugee Camps," "Expedition Dentistry" and more!




© The Wilderness Medic 2020