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Monday, December 18, 2006

Advice from a Pilot-Widower - Choosing your surgical team: An anesthesia error

Martin Bromiley is an airplane pilot, the father of two young children. His deceased wife Elaine had long suffered from chronic sinusitis, an inflammation of the nasal passages. Then, early in 2005, one of her eye sockets had become infected. The threat of permanent damage to the optic nerve led her surgeon to recommend a minor operation to straighten the inside of the nose - a possible contributory factor.

Unfortunately, during the operation, she was deprived of oxygen. It appears that moments after being sedated, Elaine's airway collapsed, preventing adequate levels of oxygen from reaching her brain. Though potentially an emergency, the event is a recognised risk during an anaesthetic and, as such, should be manageable. Surgeons and anaesthetists are drilled to follow a series of steps at this point - beginning with a non-invasive attempt to get the patient breathing normally, and ending, as a last resort, with an emergency surgical procedure. This is usually a tracheotomy - where the surgeon cuts through the windpipe, inserting a tube directly into the airway through the throat.

At first the drill was followed impeccably. But then a problem arose: the surgical team tried to get a tube into the airway to help Elaine breathe, but encountered some kind of blockage. According to the drill, this was the time to consider doing a tracheotomy. But the three physicians appear to have made the sort of human error that is horribly common in crisis situations. They became fixated on what they were doing. They also appear to have ignored the junior staff and remained intent on finding a way to insert a tube into the airway. More than a half hour passed before adequate oxygen levels to the brain were restored. Significant brain damage resulted, and she died less than two weeks later, soon after life support was withdrawn.

As a pilot, Martin Bromiley had received the standard training in open communication in the cockpit. Indeed, he is a specialist in this "Human Factors" field. He realizes that "Fixation is a normal reaction to stress. Human Factors training teaches people that it's normal to carry on trying to take the usual action, even when it's clearly not working. But at some point, a decision has to be made to break out of that pattern of behaviour. The way to ensure that happens is for all members of the team to see it as their duty to speak out to keep the patient safe." There was no comfort in knowing that two of the nurses knew how to save his wife's life. "What they didn't know - and what Human Factors [also called in the U.S., Crew Resource Management or Crisis Resource Management] would have taught them - is how to broach the subject with their bosses."

Lesson for Caregivers: Before surgery, verify that the surgical team has been trained so that the surgeon will open-mindedly consider urgent input from nurses and junior doctors. Do this in advance by asking the Risk Manager of the hospital whether the surgical team has been trained in Crisis Resource Management, Crew Resource Management or similar candid team communication techniques. If not, consider scheduling the surgery at a different hospital.

The whole story is told by blogger John Ray, and by Jane Feinmann in the newspaper article "Blunder that Killed my Wife."

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