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Bingo, Other Parlor Games and Thinking Outside the Box

For pilots who fly airplanes over large open stretches of ocean, “Bingo” is not a parlor game but a dead serious safety concept.  “BINGO” defines an actual point in time and space beyond which the airplane is not able to bingo 1safely reach an airport.  It is determined by fuel load and burn, distance back to an appropriate airport, wind, weather and aircraft performance.  With these parameters a physical box is drawn on the map that has sides defined by these numbers and as long as the BINGO point is within the box, the aircraft is always able to reach an airport for a safe landing, even in the event of an emergency.

This concept of a safety box is a critical component of the “high reliability mindset”.  The principle of operating within the confines of a theoretical “box” that has specific safety boundaries and provides a safety net is based on James Reason’s reference to a “safety space” and offers a useful mental model of a three dimensional area within which safe surgical outcomes are most likely.

Knowing the borders of the box can be difficult for us in surgery as there are many variables to take into account.  The surgery safety box has sides defined by patient physiology, individual surgical skills and currency of the surgeon, surgical team training and human and environmental factors.  Prior posts in this blog have defined many of the factors that go into establishing the borders of this safety box.  It is always necessary to determine the borders of the box for every clinical encounter, know the borders, and know if/when you are outside these safety parameters.  To assure safe outcomes, surgeons must assess the clinical scenario to define this box and all team members must understand the safety boundaries as they exist in each clinical situation.  Safe surgical outcomes are most assured by staying inside the box, but sometimes emergency circumstances or changes in the patient’s condition force you outside the box.  Getting outside the box isn’t necessarily a disaster unless you take your patient outside the box and don’t know you are there, and thus fail to make plans to get back within the safety zone.  It would be like being inside the box on the map in the cockpit but loosing an engine – then everything changes in a hurry.

bingo 2This is a helpful analogy when we think about surgical plans for this safety box and safe flight planning for airplanes that have only two engines such as the huge 777, A330s and 767s.  These planes routinely fly across the Pacific to Australia and across the Atlantic to Europe and Africa.  The “BINGO” point must factor in a critical change in aircraft performance if there is a loss of one of the engines not unlike an abrupt change in the patient’s condition during surgery.  For good reasons, both the FAA and military aviation regulations are quite strict on these safety rules.  The FAA regulations fall under the acronym “ETOPS that stands for “Extended range Twin engine Operations”.  (Any time you have flown in a twin engine airplane over water you will notice “ETOPS” painted somewhere on the front of the plane signifying compliance with these regulations.)  This added analogy to ETOPS regulations enhances our safety concept in surgery as it contemplates those imponderable events that can radically alter a surgical procedure and that I have discussed previously in this blog (Defeating General von Clausewitz).   

Operating near the edges or even “outside the box” is sometimes required due to changes in the condition of surgical or trauma patients.  It is essential to understand when such events are occurring and make sure all team members are aware.  In the cockpit, military pilots will call out “5 minutes to BINGO”, not that that have all the numbers covered on their game card, but to remind all crew members that the airplane is getting near the “edge of the box” and it’s about time to turn around.  (Civilian airplanes are never allowed out of the box at all and are always within reach of an airport even with only one engine running.)  During these times at the edges of the safety zone, a heightened level of individual vigilance and team performance is needed to prevent complications as this is the time of greatest risk to the patient.  It is like our own surgical call-out of “5 minutes to BINGO”.  The recent trend towards damage control surgery especially in trauma surgery is a very positive safety step and reflects a kind of surgical “ETOPS”.  When the physiology of the patient deteriorates due to decreasing temperature, increase need to blood products, coagulopathy and hemodynamic instability you are outside the box, and to return to the safety confines the surgeon must abort the procedure, pack the bleeding sites and close the skin and transfer the patient to the ICU for resuscitation with the idea of coming back to the operating room under more favorable conditions.

The safety box model combines concepts of error avoidance by understanding circumstances when error is more likely to occur (i.e. outside the box) and strategies to manage these risks (get back inside the box).  The HRO mindset encompasses a global awareness of the total space of operations including a central “safety box” that is defined by the boundaries of safe operations.  When patient management is confined within this box the surgical team is able to minimize risks of adverse outcomes.  But the areas outside the box are also part of the surgical environment that the surgeon may find his patient.  This model predicts increasing risk of error when circumstances take the team and patient outside the central safety box with risk increasing incrementally the farther outside the boundaries of the central safety box.  Best outcomes in the care of our patients come with knowledge of the boundaries of the safety box, understanding risks of operating outside these boundaries, awareness of when the surgeon and patient are outside the safety box and a treatment strategy for returning inside the safety envelope.

The “high reliability mindset” ingrains in those of us who are adopters a sense of enhanced vigilance during such times when increased risk of error exists.  Just think of a critical surgical encounter like being in an airliner out over the middle of the Pacific and losing an engine.  Always know where the closest airport is and plan surgery so you can reach it for a safe landing.

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Posted in CRM, High Reliability Mindset, Patient Safety, SA.

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