Crew Resource Management: What EMS Can Learn From Pilots and a Comedy Show

There is a moment in every bad call where someone in the room knows something is wrong and does not say it.

The senior medic is committed to a working diagnosis. The crew is moving. The patient is deteriorating in a way that does not fit the story being told. A newer provider sees it. They glance at their partner. They say nothing.

That moment, repeated across thousands of calls a year, is what Crew Resource Management was built to fix. EMS has adopted CRM unevenly, and in many systems we are still behind where we should be.

I did not make this connection on my own. I made it studying for my FAA Part 107 certification. Part 107 is the rule that lets you fly a small unmanned aircraft commercially, and the study material spends a surprising amount of time on crew resource management principles. Even drone operations, where you are often working alone or with one visual observer, get CRM training baked into the curriculum. The FAA decided, somewhere along the line, that the human factors lessons learned from cockpit crashes apply to anyone operating an aircraft, including a 2-pound quadcopter being flown by one person and a spotter.

I sat with that for a while. If the FAA thinks CRM matters for two people flying a drone, what does that say about three people running a cardiac arrest? About a medic, an EMT, and four firefighters managing a critical patient in a small bedroom? About the entire structure of how we work calls?

That is the question this post is trying to answer.

Where CRM Came From

Crew Resource Management did not start in a hospital or an ambulance bay. It started in airline cockpits in the late 1970s, after a string of crashes where the aircraft was flyable, the weather was workable, and the crew was qualified, but everyone died anyway.

The 1978 United Airlines Flight 173 crash outside Portland is the case study every pilot learns. The flight engineer and first officer both knew the plane was running out of fuel. Both tried to tell the captain. Neither said it directly enough to override his focus on a landing gear problem. The aircraft ran dry and crashed in a wooded suburb. Ten people died.

The investigation did not blame the captain alone. The NTSB recommended that flight crews be indoctrinated in what was then called cockpit resource management, with particular emphasis on assertiveness training for junior crewmembers. NASA convened a workshop to develop the training concepts. United Airlines launched the industry's first formal CRM program in 1981. The FAA later required CRM training for all Part 121 air carriers, codified in 1995, and extended the requirement to Part 135 charter operators in 2011. Aviation fatality rates over the same period dropped substantially, and CRM is broadly credited as one of several contributing factors.

The core idea is unglamorous: the most senior person in the room is not always right, the most junior person in the room often sees the problem first, and the team needs structured language and explicit permission to surface concerns before the situation becomes unrecoverable.

Why EMS Has Been Slow to Adopt It

Medicine took the lesson seriously starting in the late 1990s. Operating rooms run pre-procedure timeouts now. ICUs run structured handoffs. Trauma teams use closed-loop communication. The literature on surgical CRM is thick.

EMS got the memo later, and unevenly. Some agencies have folded CRM principles into their TCCC and TECC training. Most have not. Field providers still operate in a culture where the senior medic on scene is presumed correct, where "speaking up" is treated as insubordination rather than a safety function, and where post-event reviews focus on what the patient did wrong rather than what the team did wrong.

Part of the problem is the structure of EMS work. A flight crew has hours together in a cockpit. An ambulance crew has whatever partner the schedule gave them, often someone they have worked with twice. The newer provider may not know the senior provider's last name. Building the trust required to say "I think you are wrong about this" is harder when you have not built any trust at all.

The other problem is ego. EMS attracts confident people, which is generally good, and then rewards confidence over accuracy, which is not. A provider who is wrong but loud often outranks a provider who is right but quiet. CRM is specifically designed to invert that.

Worth saying clearly: the rank dynamic in EMS is not just EMT versus paramedic. It shows up between a 20-year medic and a medic two years off their card. It shows up between a senior EMT who has been on the rig since the new hire was in middle school and a rookie EMT on day three of orientation. It shows up between a flight nurse and a ground medic on a shared scene. The pattern is experience versus inexperience, not certification level. The 20-year medic can be wrong about a working diagnosis in the same way a captain can be wrong about a fuel state. The two-year medic across from them sees it. The two-year medic has to be willing and able to say so.

The Nathan Fielder Detour

This is the part where the framing gets strange, but stay with it.

Nathan Fielder, the comedian behind the HBO series The Rehearsal, became inexplicably and seriously interested in airline safety culture. In the second season of the show, Fielder spends six episodes arguing that commercial aviation still has crashes because first officers cannot bring themselves to challenge captains forcefully enough. He builds elaborate simulations. He interviews real pilots. He gets his actual commercial pilot license to make the point. The show is funny. It is also, accidentally, one of the clearest pieces of CRM advocacy in popular media in the last decade.

His thesis, stripped of the comedy: the entire safety architecture of modern aviation depends on a 28-year-old first officer being willing to tell a 55-year-old captain "you are about to kill us." That sentence is hard to say. It does not get easier with rank or experience. The training has to be specific, the language has to be rehearsed, and the culture has to make it clear that saying it is the job, not an act of disrespect.

If you swap "first officer" for "less experienced provider" and "captain" for "the senior provider on the rig," the entire argument applies to EMS without modification. That senior provider might be a paramedic. They might be a 20-year EMT. They might be the flight nurse running the LZ. The certification on the patch is not the variable. The experience gap and the willingness to challenge it is.

The Structural Disadvantage Nobody Names

There is one more piece of this that gets glossed over, and it matters.

The fire service has a command structure built into every call. ICS is not optional. The first arriving officer establishes command, announces it on the radio, and assumes responsibility for scene organization. Every additional unit checks in, gets an assignment, and reports to a defined position in the structure. When a second alarm comes in, divisions and groups stand up. Accountability tags get tracked. The structure is taught at the recruit level, reinforced at every promotional rank, and drilled until it is automatic. A fire captain knows, before the apparatus rolls, what their role will be when they arrive.

EMS does not get this. A medic walks into a multi-patient scene, or a working code in a small bedroom with eight family members, or a motor vehicle collision with fire on scene and police running traffic, and is expected to organize the medical side of the operation in real time, with no formal command training, while also running the clinical care.

Paramedic education rarely teaches this in a practical, repeatable way. The curriculum covers anatomy, pharmacology, cardiology, trauma assessment, and protocols. Scene management gets touched on, but rarely in a way that prepares a medic to walk into a chaotic scene with five other responders, two of whom outrank them on the fire side, one of whom is a first responder bystander, and one of whom is a partner they have never worked with before. There is no standard module on "how to assign tasks to four people who do not work for you." There is no consistent practical exam on running a code with one trained partner, two firefighters of unknown skill, and a CPR-certified family member.

Medics are expected to figure it out. Most do, eventually, by surviving enough calls to build their own informal system. The good ones develop a presence and a shorthand that makes scenes work. The ones who do not develop it run scenes where things get missed, redundant tasks happen, and important tasks do not.

This is not a failing of medics. It is a failing of how the discipline is built. Aviation gave its captains command training. The fire service gave its officers ICS. EMS gave its medics a card and a protocol book and assumed scene leadership would emerge on its own.

CRM does not solve this entirely, but it is the closest thing the field currently has to a framework for it. Closed-loop communication, explicit role assignment, and the two-challenge rule all give a medic something to work with when they walk into a scene where they are nominally in charge of the medical side but have no formal authority over half the people on it. Without that framework, the medic is improvising. With it, at least the team has a shared language.

What CRM Looks Like in the Field

Functional CRM in EMS is not a checklist. It is a set of habits a crew builds together so that when the call goes sideways, the habits do the work.

A few of the load-bearing pieces:

Closed-loop communication. When the medic says "give 1 of epi," the partner repeats it back. "1 milligram epi, 1:10,000, going in now." Then confirms when it is done. This is not bureaucracy. It is the only reliable way to catch the moment where one person heard 1 mg of cardiac epi and the other heard 1 mg of the 1:1,000 concentration meant for IM use in anaphylaxis. Same number, very different drug. Closed-loop catches it.

Explicit role assignment on arrival. Who is running the call. Who is on airway. Who is on compressions. Who is talking to family. This gets said out loud, even if the crew has worked together for years, because the day you assume it is the day two people both think they are running airway and nobody is on compressions.

The two-challenge rule. If a crew member sees something they think is wrong, they are expected to raise it twice. If the lead does not address it, the crew member is expected to escalate, not defer. The rule exists to give junior providers permission to push past the initial brush-off.

Structured handoffs. SBAR or MIST or whatever your system uses, but the same format every time, so the receiving team knows where to listen for the piece they need. Improvised handoffs are where information dies.

The post-call debrief. Five minutes in the bay, before the next call. What did we do well. What did we miss. What would we do differently. Not a disciplinary process. A learning one. Run it after good calls too, because the lessons from a smooth call are the ones that prevent the next bad one.

None of this is technically difficult. All of it requires a culture where the crew has agreed, in advance, that this is how they operate.

The Hierarchy Problem

The hardest part of CRM, in aviation and in EMS, is not teaching the techniques. It is convincing the senior person in the room that the techniques apply to them.

Pilots resisted CRM for years. The senior captains who had flown without it for two decades took it as an insult, a suggestion that their judgment needed to be checked by a 26-year-old who had been flying jets for 18 months. The training programs that worked were the ones that made it explicit: this is not about your competence, this is about the fact that any human being, regardless of competence, has a worse day sometimes, and the system needs to catch that.

The same conversation has to happen in EMS, and it has to happen at every level of the seniority gradient. A 27-year medic with thousands of calls under their belt is not being insulted when a less experienced partner says "I think we should reconsider that airway plan." They are being protected. The system is doing what it was designed to do. The senior EMT being challenged by a rookie is in the same position. The flight crew being challenged by the ground medic is in the same position. The principle does not care about the patch.

The providers who get this are the ones whose crews catch their mistakes before the mistakes reach the patient. The ones who do not are the ones who eventually have a call go badly in a way that the QI committee cannot quite explain.

What to Actually Do With This

If you are running an agency, CRM is not a memo. It is a training investment, a debrief structure, and a willingness to take the side of the junior provider the first time a senior provider complains about being challenged on a call. The first complaint is the test. If the agency backs the senior provider, the program is dead. If the agency backs the process, the program survives.

If you are the senior provider on a crew, regardless of certification, the move is simpler. Tell your partners, out loud, that you want to be challenged. Tell them you would rather be wrong on the way to the hospital than wrong in the QI review. Mean it. Reward it the first time it happens, even if the challenge turns out to be unfounded, because the next challenge might be the one that catches something real.

If you are the newer provider on the crew, the move is harder. Learn the language. Learn what closed-loop communication sounds like. Learn what the two-challenge rule is. Use it. The first time is the hardest. It gets easier. The career you are protecting is partly your partner's, and partly the patient's, and partly your own.

The airlines figured this out after enough crashes. Medicine figured it out after enough sentinel events. EMS is figuring it out now, slowly, one agency at a time.

A comedian made a six-hour HBO series about it. The least we can do is run a debrief after the next bad call.