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Which would you rather do: evaluate what went wrong in hindsight, or have a methodical way of evaluating variables to make a safer go/no-go decision before you depart to reduce the likelihood of having to answer what went wrong? Seems like a no-brainer, doesn't it? That's why in surgery, we always do a safety pause first. After the patient is anesthetized, the operative site is prepped, and the scalpel is in hand, we STOP! We PAUSE and ask! 

  • Is this the right patient?  
  • Is this the correct side? 
  • Have antibiotics been given? 
  • What procedure is to be done, and is it consistent with the consent form?  
  • Who else is present in the room? 
  • Are there any pertinent labs or medical conditions that should be discussed (e.g. blood glucose, hematocrit, coagulation status)? 
  • Is blood available?  
  • Is the equipment needed available and sterile? 

In theory all of these questions should have been answered in advance, but just to make sure one last time before the moment of no return, we PAUSE. Why? Because mistakes have been made and careful analysis has shown us that if we had paused in advance, we could have caught errors before they occurred. What starts out as a written checklist has become engrained in healthcare workers’ minds, and we run through this checklist out loud for every single procedure we perform.  

In the field of aviation, pilots have a series of checklists they perform before the actual takeoff. From walking around the plane and visually inspecting the fuselage, wings, engines, and landing gear, to testing the engines prior to takeoff. These checklists are typically verbally announced because they help to avoid errors that might have been overlooked, and those errors could have had disastrous consequences. 

The Swiss Cheese Model

 

James Reason originally described the The Swiss Cheese Model in his book Human Error. The basic concept is that in order to have a catastrophic error, the “holes” in multiple “slices of cheese” must line up to allow the event to occur. Each slice of cheese is a line of defense and an opportunity to stop the error. This model is helpful when reviewing bad outcomes and is commonly taught in a myriad of professions.  

 

 

For example, in reviewing the case of an avalanche victim who is caught on a 37 degree slope, after it has snowed 24 inches in 24 hours, on an unstable snowpack, with a severe avalanche rating, alone, without a beacon, at 3 P.M., in a snowstorm... We would look back at that situation and hopefully find comfort that, "I would never do that." But could you make those mistakes? And how many risk factors are required for the outcomes we all want to avoid? Swiss cheese has holes but they seldom line up. We all make mistakes, and frequently consciously accept one or two carefully measured risk factors. So why don't we have a checklist for our adventures? Some sports have an abbreviated checklist. For example, a beacon check for backcountry skiing. "On in the car; off in the bar." And we check each other’s transmit and receive functions. A put-in talk given by the guide is commonly given on a river trip. But are these pre-adventure considerations enough? In my opinion, they are NOT. We need to go further and verbalize our concerns to our teammates. It needn't take a lot of time but we need our own "safety pause."  

P.E.E.P.S

P – Person, as in your Heath and wellbeing

How are you and your fellow adventures doing today? Is everyone feeling strong? Is anyone feeling sick, dehydrated, etc.? Are you stressed or are you mentally prepared for the challenges proposed? Does everyone have the nutrition and hydration needed for the planned adventure?  

E – Environment and conditions

What is the temperature variability? If body temp is 37 degrees, is the air temperature the same? - 20? 40? What about the water temperature? What about the winds? For your kiting or sailing trip are they forecast to be steady at 15 knots? Or with gusts to 50 knots? Are conditions at the summit stable or is a front blowing in?

E – Equipment 

Is your equipment optimized? Are repairs needed or have they been completed? Is your rudder functioning? Are your kite lines frayed? Does your avalanche beacon work (we already do this in a beacon check)? Do you have your life jacket and is it on properly? Is your harness properly attached? Do you have enough warm clothes?  

P – Partner or team

Look around and partner up if necessary, especially if the group is large. Who can you be responsible for and who is responsible or can help you? Did the two strongest partners of the team pair with each other, leaving the weaker members to pair with each other? Or is there a better mix of strengths and weaknesses?

S – Scenario 

Consider verbally walking through one emergency situation. What do you do in an avalanche? What is the plan for a capsized boat? What is the plan on the ridge top when you hear lightning?  

Let’s take a closer look at an unfortunate event that occurred December 8, 2015, on Lake General Carrera in Chile. Doug Tompkins was kayaking that day with five friends in what started out as a beautiful, calm day (for a review of the events that transpired, see Jamie Lieberman’s article in Wilderness Medicine Magazine and this recap from National Geographic). 

Based on written reports and my interview with a surviving member of the party, it is interesting to look back at the sequence of events and consider whether reviewing PEEPS would have made a difference.  

P – Person

Let’s assume they were all doing well and feeling well. They were certainly a very experienced group. 

E – Environment

The lake was 38 degrees F. The air temperature was unknown. The water/body temperature spread was huge! The winds each day had been progressively higher, and the location is well known for sudden storms. By 10:30 A.M., the wind was kicking up 50 mph gusts and six-foot waves, coming from multiple directions. 

E – Equipment

Was everyone’s boat in optimal working order? There were reports of Tomkins’ boat rudder malfunctioning. Presumably, everyone would have made sure prior to departure, but perhaps a verbal reminder might have triggered another evaluation? And what about clothing, considering the environment? Only two of the six were wearing a wetsuit.    

P – Partner

This was a group traveling together. How was the decision made to separate and all head for shore? Was this planned in advance? Or did each kayaker fend for himself or herself?

S – Scenario

Of course the critical question here would be what to do if someone capsizes? Should all parties huddle together in the middle of the lake? Immediately tie off a boat and tow it in, requiring easily accessible rope?  

There are never simple answers to the above questions, but the point is to verbally run through a checklist.  

The reality is that most of us have some informal evaluation we each do in preparation for the adventures we undertake. The above checklist can truly be expanded, but right before you set off, a last minute out-loud checklist with all members verbally participating just might bring out a safety item that is critical. It works in medicine. It works in aviation. As they say, "the life you save just may be your own." So before your next adventure, make sure you check your PEEPS!