Developing a Universal Framework for Communication During Intraoperative Crises: Lessons Learned from Aviation

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In their article on learning lessons from aviation, Bhangu et al. [1] recommend the inclusion of ‘‘surprise and startle’’ scenarios in surgical simulation training. We feel that, in addition to exposing trainees to the technical aspects of these scenarios, there is a need for a standardised communication framework during such events that surgeons universally can implement—a framework with similar intent to the WHO surgical safety checklist [2] but that provides an algorithm for how surgeons from any locality can express concern and communicate it to others on their team during high stress situations. The need for such a standardised language in aviation was exemplified by the experiences of Korean Air in the 1990s, when a series of flight crashes were attributed to a ‘‘mitigated speech’’ phenomenon, where there was a distinct lack of transparent, direct and effective communication both inter-cockpit (i.e. between the first pilot and the captain) and externally (with Air Traffic Control) due to cultural speech formalities [3]. In these cases, it was recognised that communication failure and not technical incompetence was the dominant factor leading to catastrophe. The introduction of a standardised language—in this case the use of a formalised English syntax over the more nuanced Korean language—helped combat cultural and hierarchical tensions within the cockpit as well as removing the language barrier when communicating externally. In situations of ‘‘surprise and startle’’ in the operating room, the use of a universally accepted code through which members of the surgical team can communicate, in English or otherwise, may similarly limit the impact of cultural and hierarchical constraints. This is particularly important given the diversification of the global surgical community and would be facilitated by the precedent already set by the WHO surgical checklist.