Martin Bromiley's wife went into the hospital for minor surgery, but suffered catastrophic brain damage from being deprived of oxygen. The surgical team experienced difficulty in ventilating the anesthetized patient, then in intubating her. Instead of shifting focus to an emergency tracheotomy--a priority so obvious that even Bromiley immediately wondered why it had been overlooked--they seemingly lost track of time and spent 25 minutes intensely focused on repeating a failed procedure.
But when Bromiley was given the terrible news, his internal response was not furious rejection but recognition. An airline pilot, he was reminded of United Airlines Flight 173, whose pilots ran it out of gas and crashed while fixating on a malfunctioning landing gear light.
Perhaps because of Bromiley's deep empathy for the surgical team's shocking and deadly error, he found a way not only to spur a useful investigation of his wife's death but to put the experience to good use in the medical field. Medical workers respond well to his parallel experience with error fixation and other human foibles common to highly trained professional teams that face life-or-death emergencies. Teams of this kind need charismatic, self-confident leaders, but they also need trusting communication and a disaster routine that kicks in when priorities get lost, the brain fixates, and the internal time clock stops working: "Get that blood oxygenated one way or another within ten minutes" or "Fly the plane."