Episode 6 - Patient Safety with Captain Martin Bromiley
Elaine Bromiley
Healthy 37 year old woman for elective sinus surgery in the UK in 2005
Can’t Intubate Can’t Oxygenate
Experienced anesthesiologist + another who joined when help was called for + a head and neck surgeon in the room + experienced OR nurses
Elaine’s oxygenation fell and the team could not get oxygen to her through intubation, face mask ventilation, or by using a laryngeal mask airway (LMA or rescue airway device)
Several minutes went by, meanwhile a nurse brought in a cricothyroidotomy kit for surgical Front of Neck Access (FONA). The nurse announced the kit’s presence to the operating theatre but received no response.
After 40 minutes (20 without sufficient oxygenation), an airway was established with an LMA.
A nurse had arranged for an ICU bed and returned to the OR to tell the team, but received a look from the physicians as if to say, “What’s wrong? You’re overreacting.”
Elaine was taken to the recovery room and the surgical team continued on with the rest of the patients on the list.
The nurses in the recovery room were concerned that Elaine may have been having seizures and called the anesthetist, but he was busy with a patient in the OR and could not attend.
Eventually, Elaine was transferred with an LMA (as opposed to a secured airway) to another hospital for ICU care.
Having confirmed an unrecoverable anoxic brain injury due to the lack of oxygen on induction of anesthesia, Elaine was removed from life-sustaining therapy and allowed to die naturally.
Martin Bromiley
Elaine’s husband, and father to their two young children, was also a UK airline pilot
He told the hospital that he would “wait for the report” which is what would have happened if Elaine had died on or near an airplane in the UK. The accident investigation board, an independent investigatory body, would have determined the causes and contributing factors and then published an anonymized report with recommendations on how to improve safety.
Mr. Bromiley was told that no such process existed in the UK and that “that would only happen if you sued us.”
Martin commissioned just such a report, anonymized it and published it “so others can learn”.
Importantly, Martin did not seek punishment. He specifically stated that the physicians and nurses that were in that room were intelligent, hard working, caring professionals. He did not blame them. He blamed the system, but the inquiry did not end there. The system can be changed but first we need to know what happened and why.
The report (see MSP Ep 1 - Elaine Bromiley)
Professional, third-party investigation may help
Avoid the fundamental attribution error in medicine, which suggests that when we see another’s actions, particularly errors, we attribute them to individual failings, but when we see our own, we see them as products of the environment or context.
By running similar can’t intubate, can’t oxygenate scenarios, it was seen that many anesthetists at the time, fell into the same patterns of behaviour that led to Elaine Bromiley’s death, so arguments that “I wouldn’t have done that” are not credible when put to the test.
Provide a “win-win-win”
Patients and loved ones win as they generally want to know what happened and how the system can learn to prevent it in the future;
Hospitals and healthcare systems win because safety is tangibly improved; and
Practitioners win by also becoming better, but also knowing that it wasn’t all on them. That the system failed and it was not a moral or individual failure on their part. This reduces moral injury and distress for the practitioner. In this way, we preserve a much needed resource in the healthcare professional, but also in the person who is less likely to self-harm.
Provide commentary about how the system as a whole, which includes the regulator, operates, as opposed to looking at one hospital or one profession.
Blame-culture in medicine
The blame-culture in medicine is so ingrained that some view physicians as more culpable than pilots given a similar set of circumstances (physicians taking care of Elaine Bromiley vs pilots in United Flight 173).
The idea that the physician has all the answers and can save the day all on their own is an outdated concept that has no place in modern team-based medicine.
Human factors are so called because they are a part of the human condition and they exist amongst all high-risk industries.
There are many ways of getting human factors training and investigation into medicine, but perhaps the most likely to be permanent is when the front-line professionals demand it.
In medicine, we need senior clinicians to describe times when they’ve made mistakes. Not things that were mostly someone else’s fault, but time when they made a serious error. This will allow more junior members to talk about these issues and that is the starting point for fixing these issues. Those clinicians that do this, will be remembered as it is rare these days.
Audio-Video Recordings (“Black Boxes”) in Healthcare
With much of society being recorded, patients are often surprised that we don’t audio and video record in resuscitation areas (ORs, ICUs, ED’s). One reason for this is the lack of specific legislation that exists for other industries (such as protects the black box recordings from being used in court). It is possible that current quality of care legislation can be invoked to protect such records should anyone want to start a pilot project, but certainly this is an area that needs to be explored before full implementation of nation-wide recorders would be likely. In the UK, the HSSIB has specific legislation protecting such recordings.
Making it easier to get it right and harder to get it wrong
In general, we need more interventions in healthcare that make it easier to get things right and harder to get things wrong. As Professor James Reason’s work shows, errors are a part of the human condition and while we cannot change the human condition, we can change our work environment.
The Health Services Safety Investigations Body
The HSSIB works a bit differently from the AAIB (the UK’s air accident investigatory body). While aviation investigations and reports focus on specific accidents, the HSSIB may start by looking at one incident, but generally looks at a number of similar incidents and publishes a report where all the incidents have a specific theme.
Independence of investigatory bodies from the regulator is of prime importance otherwise credibility is in question.
Learning from excellence
Medicine can export good ideas to other industries, such as “learning from excellence”. This means that we should be investigating notable times when things went right, so that we can improve our chances of success.
Justifying the costs of safety endeavours
It is impossible to measure harm that is prevented (because it is a non-event);
Society spends millions of dollars investigating aviation accidents where only a few people died. Why should it matter that someone died on an airplane vs in a hospital, if there is the potential to prevent their death?
We spend billions of dollars helping heal people after the healthcare system has harmed them and there can be considerable cost savings associated with improved systems safety.
Safety intervention worth mentioning
The YouTube videos Martin Bromiley produced to improve patient safety
Other resources
A Life In Error: From Little Slips to Big Disasters by James Reason
Royal College of Anesthetists (RoCA) NovPod - S2E11: Prevention and management of pain during caesarean section (with Susanna Stratford)
Random recommendations
Martin: Confessions of a Hornet Pilot by Tug Wilson
Adam: Project Hail Mary audiobook, movie or Artemis II lore
Amir: The Drama movie
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