Eoin Walker – Advanced Paramedic Practitioner & Pre-Hospital Lead
Eoin has been a paramedic since 2004. He has worked for World Extreme Medicine as the pre-hospital lead for 10 years delivering education across the world from the jungles of Costa Rica to the deserts of Oman to the alpine mountains of Slovenia.
The first thing any expedition medic will tell you is that providing healthcare in environments where standard medical facilities are scarce, inaccessible, or fundamentally limited is challenging.
They will go on to tell you that this is compounded by changing weather conditions and variable geography. They will finally confess that the compounding effects of scarce resources and extremes of weather will give way to challenges in teamwork and performance.
One of the main adages that is always taught in World Extreme Medicine courses is that you may or may not have to deal with illness and injury on an expedition, but you will have to deal with team dynamics and human factors on an expedition, 100%, every time.
So, what are human factors and why are they so important?
The goal of human factors is to reduce human error, increase productivity, and enhance safety and comfort with a specific focus on the interaction between a human and the thing of interest (1). Human factors as defined by the human factors and ergonomic society are:
‘A body of knowledge about human abilities, human limitations, and other human characteristics that are relevant to design. Human factors engineering is the application of human factors information to the design of tools, machines, systems, tasks, jobs, and environments for safe, comfortable, and effective human use.’
Expedition Medicine by nature requires a unique adaptation of baseline medical skills, with large amounts of flexibility and teamwork. In the realm of expedition medicine, the importance of High-Performing Teams (HPT) cannot be overstated as they play a critical role in ensuring the safety, health, and well-being of individuals undertaking adventurous and often risky journeys.
When dissecting an HPT, they exhibit several key characteristics which unite them irrespective of changing conditions around them. First and foremost, these teams are comprised of leaders who lead with a high level of emotional intelligence, preparedness, shared situational awareness and a fundamental ability to communicate well.
Modelling these attributes often proliferates these qualities throughout the team. The adage of modelling the virtues you want to see in a team plays out. Versed with these qualities, the team can adapt to changing conditions to demonstrate resourcefulness and embrace the unpredictable nature of any expedition environment.
Human factors encompass the complex interplay between individuals and their surroundings, equipment, and fellow team members. The dynamic changes of the weather, fatigue, environment, hot/cold/wet can directly impact team dynamics.The key is identifying these potential red flags early in every day and interaction to mitigate any rapidly deteriorating interactions.
On a practical level, human factors training enables proactive risk mitigation strategies, reducing the likelihood of accidents or emergencies. Expedition environments demand adaptability and resilience. Human factors training prepares individuals to cope with unforeseen challenges and uncertainties.
Human factors training also involves reviewing and learning from past incidents or near misses. This reflective practice identifies areas for improvement, leading to changes in procedures and continuous enhancement of preparedness.
These three models that have weathered the test of time and still hold true. These are Tuckman’s five stages of teamwork (2), Goleman’s leadership styles (3), and the Swiss Cheese model of human factors (4), bearing in mind that these might even play out in a microcosm of a leadership team.
Tuckman’s five stages of team development:
Tuckman’s model describes the typical evolution of a team from its inception to dissolution (3), with each stage building on the prior ones to enable effective collaboration and performance.
Bruce Tuckman proposed that teams go through five distinct stages of development: forming, storming, norming, performing, and adjourning.
In the forming stage, team members come together and establish basic goals and procedures. Storming involves conflicts and power struggles as the team dynamics are worked out. Norming is when the team agrees on roles, responsibilities, and norms.
Performing is when the team reaches a mature level of task productivity and cohesion. Finally, adjourning is the stage when the team disbands after completing its mission.
Goleman’s 6 leadership styles:
Daniel Goleman identified six distinct leadership styles: coercive, authoritative, affiliative, democratic, pacesetting, and coaching.
The coercive style demands compliance through threats and discipline. Authoritative leaders mobilise people towards a vision. Affiliative leaders create emotional bonds and harmony.
Democratic leaders build consensus through participation. Pacesetting leaders expect excellence and self-direction. Finally, coaching leaders develop people for the future through mentoring and personalized feedback. According to Goleman, the best leaders switch flexibly among these styles as needed.
No single style is optimal, and leaders must adapt to the requirements of different situations and team maturity levels. WEM has identified that expedition medics may move through each trait (even through the passage of 24 hours), and they are not fixed paradigms.
Swiss Cheese Model
The Swiss Cheese Model was developed by James Reason in 2000 (4). It illustrates how failures can occur in complex systems despite defensive layers.
It compares human systems to stacks of Swiss cheese slices. The holes in the slices represent vulnerabilities in each layer of defence.
When the holes align momentarily, a hazard can pass through all defences, leading to an accident or failure. Each layer has weaknesses, yet acting together, they normally stop dangers. But unpredictable conditions can misalign holes in multiple layers, allowing a trajectory of accident opportunity.
The Swiss Cheese Model promotes viewing human systems as defensive layers with dynamic weaknesses. Understanding how holes can temporarily align despite safeguards is key to improving safety and reducing failure on any expedition. This is a fundamental part of WEMs philosophy!
Effective communication is paramount in expedition medicine, where team members must concisely convey vital information, especially in conditions of poor connectivity or language barriers.
World Extreme Medicine places a high regard for communication skills as the forerunner for comprehensive training in wilderness medicine, and the specific challenges associated with the expedition.
The fundamentals of effective communication often rely on active listening, closed-loop communication, sharing the plan and the default plan, and paying attention to the small details as well as the big ones.
This is a cornerstone of high-performing teams.
Trust and cohesion among team members are foundational, as individuals rely on one another for their safety and well-being.
Strong leadership, effective decision-making, and meticulous planning contribute to the success of high-performing teams.
Trust enables the openness, risk-taking, alignment, creativity, engagement, and efficiency required for teams to perform at their highest levels. Teams thrive when members trust each other’s abilities, integrity, and purpose (4).
As you can see from the diagram, trust is the foundation of any HPT and conversely an absence of this is the first red flag in any organisation.
Operating with limited medical supplies and equipment, these teams must be skilled at improvisation and adapting standard medical procedures to suit the available resources.
One of the biggest differentiators is access to monitoring in extreme environments and this is one of many factors that might limit the ceiling of care that is provided on expedition. This can also limit the retrospective governance of a case especially if there is an adverse patient outcome from an expedition.
HPT in expedition medicine is often involved in supporting specific expeditions, each with its own set of challenges. For example, medical teams at Everest Base Camp face the difficulties of high altitude, extreme cold, and altitude-related illnesses. Jungle expeditions present challenges such as tropical diseases, wildlife encounters, and specialised casevac conditions. Arctic and Antarctic expeditions involve dealing with extreme cold, isolation, and the risk of frostbite and hypothermia.
At its heart, human factors training is crucial for risk mitigation as well as risk mitigation of adverse team dynamics.
Expedition environments pose various hazards, and identifying potential risks associated with individual behaviours, decision-making processes, and team interactions is paramount for proactive risk mitigation. Expeditions often involve high-stakes decision-making, especially in rapidly changing conditions.
WEM trains participants in human factors to enhance effective decisions under stress, recognise cognitive biases, manage stress levels, and maintaining situational awareness. Conflict resolution is crucial in the demanding nature of expeditions. Human factors training provides conflict resolution skills, promoting open communication, empathy, and compromise to maintain a cohesive high performing team mentality.
A lesser taught piece of harmonious human factors is cultural and indigenous awareness. Understanding cultural differences, ensures respectful engagement and positive relationships with local populations. Language and means of communication are often the entry point into a culture and often can be a major factor within a casevac situation.
Think about the arduous 4-day trek through a jungle with a 25-year-old with a left tibia/fibula closed fracture. You finally make it to a road to muster onward pre-hospital care, but the ambulance crew don’t speak your language, in fact they won’t even let you onto the ambulance to accompany the patient you carefully and painfully carried through the jungle for the past four days.
You also can’t then communicate an effective handover of information which also can lead to risks in transition of care. All the above factors need to be planned for ahead of time or the holes in the Swiss Cheese start to rapidly align!
Fatigue and managing energy levels
Human factors training includes recognising signs of stress, fatigue, and other health issues, supporting proactive measures for overall well-being.
Fatigue poses a major risk on extended expeditions, the extreme physical exertion over weeks or months can lead to cumulative exhaustion and impaired judgment. Fatigue impedes decision-making, situational awareness, and risk assessment.
It can manifest as irritability, lack of motivation, and diminished cognitive performance. Managing fatigue requires planning rest cycles, enforcing sleep discipline, maintaining nutrition and hydration, monitoring physical and mental states, distributing workload, and avoiding unnecessary risks when energy is depleted.
Allowing sufficient recovery prevents overexertion and burnout. Remaining vigilant to fatigue and its effects is critical to safe expedition conduct as physical and mental capacities decline. Finally, learning from past incidents is an integral part of human factors training. This reflective practice identifies areas for improvement, leading to changes in procedures and continuous enhancement of preparedness.
World Extreme Medicine teach and advocate all the above within their Expedition & Wilderness Medicine Course, this unique course is both one of a kind but contains all the pearls of wisdom that you will encounter on expedition.
- “Home – the Human Factors and Ergonomics Society.” org, 2019, www.hfes.org/
- West Chester University. “Tuckman’s Stages of Group Development.” wcupa.edu, West Chester University, 28 Sept. 2022, www.wcupa.edu/coral/tuckmanStagesGroupDelvelopment.aspx#:~:text=These%20stages%20are%20commonly%20known.
- “MindTools | Home.” Www.mindtools.com, 2022, www.mindtools.com/as8cal8/six-emotional-leadership-styles
- The Decision Lab. “Swiss Cheese Model.” The Decision Lab, 2023, thedecisionlab.com/reference-guide/management/swiss-cheese-model.