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FORUMS
If fibre optic intubation was the norm and practiced regulary, then this would have been avoided.
The NHS do not drill this technique anough…and is the toy and luxury of the consultant.
Having a fibre scope to hand nowing where it is in the department, using the aintree catheter technique with the fibrescope, passing the catheter through the LMA under direct vision using the fibrescope at 4 mins, I am convinced her outcome would have been different moreover if she was pre-oxygenated for the period of time they teach the juniors…
If that failed mini tracheostomy high jet ventilation at 6-7 mins.
So what normally happens is this.
a senario in a busy list..
13,00 patient arrives in anaesthetic room.
13.02 check in patient, little chat apply monitoring leads if consultants allow, I find a few refuse to have them put on at all.
13.04 Cannula in.
13.06 anaesthetist induces with-out preoxygenation because they fear it might upset the patient. putting sensitivity before safety.
13.07 . Patient has LMA but anaesthetist did,nt wait long anough for the propofol and fentanyl to work, causes laryngospasm.,
13.08. more induction agent , repositions LMA, ventilates through LMA.
13.09. Takes out LMA ventilates via facemask.
13.09 No air entry…sats 70% sux is given.
13.10. Attempted intubation….failed oxygenation via mask…
13.12 bougey assisted intubation..cannot see cords
traumatises cords with repeated insertion.
13.13. back to mask and forced ventilation…call for help.
13.15 help arrives sats 40% or un readable….new consultant attempts intubation..
13.15. 7-8 mins after induction…NOW is the time for advanced airway intervention …..Fibre optics should now be available or mini tracheostomy thryro cricoid stab high jet ventilation in place.
Truamatised cords may make fibre optic intubation challenging
A size 6-6.5 tube needs to be available. High jet ventilator for mini trach…with correct attachments. This is only good for 30 mins max, as you will not allow for CO2 blow off with a mini trach in situe.
10 mins-15 mins he said consultants still intubating….was this with an LMA.
He says the airway was not secure. why not?
What were the Blood gases? were arterial blood gases carried out at all?
why no response to the offer of trachy at 15 mins?
I feel the human factor is this …
By failing to act decisively your ingoring the gravity of sprial you instigated, you are not confident that you may make things better, and at that moment in time you may think you may make things alot worse, hense failure to act. But with routine training you eliminate this lack of confidence to act without deliberation.
Simular prior bad experiences may also lead to hesitation, so will not being exposed to the senario to which you find yourself in.
Sticking to a technique you have used for years and not changing or updating practice wont help either. Lots of consultants do not want to take on board new techniques used by their colleagues.
Pride.
LMA itself is a major cause of laryngospasm if inserted without proper pretreatment…. after that attempt of intubation with ET tube gets difficult… and its quiet obvious… so be cautious with LMA.
Can not intubate can not ventilate …then nothing will pass cords untill patients been pharmaceutically relaxed..
non depolariser should only be given if you can ventilate.
Apart from fibre optic intubation, I definitely want to highlight that the AIRTRACK device should be utilized when in routine intubation difficulty.
Saw this video a while ago. Massive deviation from agreed protocol for CICV situation if you ask me. I disagree that fibre-optic intubation should have been attempted, it is not an emergency procedure. The DAS algorhythm advocates use of a fibre-optic scope only AFTER airway has been established, to permit endotracheal intubation. Cricothyroidotomy was warranted.
Hindsight is a wonderful thing and all the above comments reflect that…. I’m sure that many of us can suggest things that should/should’nt have been done in the situation…. what will definately help prevent these situations is the exact thing Martin Bromiley is doing… talking about it, reflecting on it and accepting that those of us who work in healthcare are human beings who make mistakes not because we are negligent but because we are HUMAN!
We get tunnel vision, we get arrogant we get side tracked! What we need to do is learn from other professions that the only way to reduce those human factors influencing events is by accepting they are there and putting mechanisms in place to prevent them causing tragedies like this!
The much derided(admit it we all sighed not ANOTHER piece of paperwork to fill in when it arrived!!) WHO surgical safety checklist is one small step towards this and I am absolutely positive that it will have the effect of advancing safety that is it’s aim…. but much more needs to be done!
Well done Martin Bromiley, your attitude and courageous behaviour after an event that would have moved most people to blind rage is absolutely going to help save the lives of others!!!
Thank you Jane! At last someone got the point. I was the executive producer for the film and had a ball making it with Martin. Going airside at Heathrow to film the cckpit sequence was the best.
The issue is not to get into a technical discussion of CICV. Also, don’t forget that the incident occurrred several years ago now. If you want a full account of the investigation into the precise events you can find it here: http://www.chfg.org/resources.htm
However, the point is that the anaesthetic staff were under extreme stress and completely lost situational awareness. Under stress the first sense to be lost is hearing (unlike induction of anaesthesia). Which is why the nurses were not heard. Also they became fixated on the solution.
Martin’s message is that we are all human and we can create a more resilient system if we acknowledge that fact and learn non-technical skills to improve team-working and communication. One of the keys to this is a flatter hierarchy in which all can speak up.
You might be pleased to know that Martin has remarried, but he is still very active in running the clinical human factors group in the UK (see link above). He also works full time as a pilot and as a trainer in human factors for bmi.
Thank you for your comments Hugh.
I see Elaine Bromiley’s family give full permission for the use of the investigation report for educational purposes so I will add it to the Human Factors Error Management page. http://theatreteam.co.uk/best-practice/human-error-management/
Please email me at admin@theatreteam.co.uk if there is anything else that you think would be of benefit to include there.
Liv
Hi
I am a lecturer at Malmoe School of Nursing in Sweden and use this video clip in my lectures to pre-graduate nurse students concerning safety in healthcare. It’s a valued contribution to the lecture as it helps the students understand patient safety and the importance of learning from mistakes to develop rather than blaming others.
thank you Katherine
It’s good to see that the film is helping educate healthcare staff in other parts of the world Katherine. Thanks for letting us know that you are using it in your school.