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."
5 comments:
All the competent master surgeons must have either retired or are reserved exclusively for the use of the political class. But that actually sounds like the US, rather than UK alone.
Error fixation is on the level of the guy trying to grapple in fencing, while getting kicked in the groin because he was at the wrong range.
That's less fixation on one's errors, and more like incompetence being unable to power out of the error.
Sometimes a good checklist is a great thing. Of course, you have to balance that with the bureaucratic impulse that can cause death, too: "He skipped three steps on the checklist and went right to the one that saved the plane. Crucify him!"
I'm reading The Checklist Manifesto, which is a book by a surgeon about the complexity faced by people in modern society and how a good checklist can help. I'm only a couple of chapters in, which has pretty solidly established how complex things are today. It's interesting so far.
A doctor friend (now deceased) used to say, "The first thing to do in any patient emergency is to take your own pulse." Checklists seem awfully rigid and silly, don't they? But there has to be some way to address the natural human tendency to forget the big picture in the absorbing interest of the small-picture puzzle. The dogged attempt to intubate and establish an airway against all odds was a complete waste of time if the doctors spent 25 minutes doing it, while the patient's brain died. If there were no alternative to achieve blood oxygenation, we could see it as fighting against all odds and refusing to give up the ship, but there's an alternative--the tracheotomy--which will remain a viable alternative only if the doctor switches over to it very quickly.
Sometimes apparently the doctors need someone in the room to announce loudly, "There's no more time to keeping trying to intubate. Here's a trach kit. We're out of time. Do the trach NOW. The intubation procedure isn't important any more."
It's not as though one of the possible good outcomes here was that a doctor exercised superhuman creativity and skill to complete the intubation at minute 25, in defiance of hidebound procedure. The whole point of the intubation was lost past about minute 10--just as the whole point of solving the mystery of the landing-gear lights was lost as soon as the aircraft ran out of fuel while still in the air.
One must first realize their weaknesses, and account for them, before moving ahead. It seems like a timer/stopwatch for situations like that in the operating room would be a really good idea. Patient goes into distress, first thing that should happen is for the surgeon to call to start the clock, and then for the nurse to make reminders of time passed every minute or two.
If I go in for surgery, I'm taking a sharpie and making it clear what's to be done and what's not so there are no mistakes! Best to be proactive.
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