Medical Safety Podcast

Welcome to the Medical Safety Podcast where we aim to improve the safety of our healthcare system through the integration of human factors into medical incident investigation and proactive safety measures. This podcast is hosted by two Canadian anesthetists, Drs. Adam Shehata and Amir Hamid. In the inaugural episode, we take a look at the 2005 death of Elaine Bromiley and the lessons learned from it.Themes and episode timelineElaine Bromiley (4 min)Can’t Intubate, Can’t Oxygenate (5 min)In the recovery room (6 min)Elaine’s legacy in airway management (min)Commissioning the report (10 min)The report’s findings (12 min)Parallels to well-known aviation accidents (14 min)The Swiss Cheese model of organizational accidents (Professor James Reason) (17 min)Example of a surgeon who held the view of individual responsibility (blame-centric) and “You can’t fix stupid” (19 min)What do those affected by bad outcomes in medicine want to happen in the aftermath? (24 min)Show notesElaine BromileyHealthy 37 year old woman for elective sinus surgery in the UK in 2005Can’t Intubate Can’t OxygenateExperienced surgical teamElaine’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)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 BromileyElaine’s husband, and father to their two young children, was also a UK airline pilotHe 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 UKMartin commissioned just such a report “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. The system can be changed but first we need to know what happened and why.The reportA failure of leadership and communication which led to a fixation-induced loss of situational awarenessThe physicians became fixated on intubating to the exclusion of other possibilities of providing oxygen (such as FONA).They became so fixated that they did not respond to the nurses who later reported knowing what needed to happen but being unable to communicate it effectively.