Lessons from the Bromiley Case

In 2007, Martin Bromiley’s wife died due to medical error. The Bromiley case will be familiar to many of us. The lessons from this case can teach us stark lessons about our own leadership and teamwork. http://www.youtube.com/watch?v=JzlvgtPIof4 Martin’s story Martin and his wife, Elaine had two young children. Elaine went into hospital for a routine sinus operation and during anaesthetic induction, it all went horribly wrong. Her airway obstructed and the team was unable to gain a secure airway. For 20 minutes they attempted to achieve a stable airway, during which time her sats were around 40%. Although she survived, she sustained serious hypoxic brain injury and 13 days later her life support was turned off. Martin is an airline pilot with an interest in human factors and formed the Clinical Human Factors Group in 2007. Here are the key teamwork lessons from his wife, Elaine’s case. 1. Communication Communication between team members is crucial and in Elaine’s case, the communication process dried up completely. There were three senior and experienced doctors in the room – two anaesthetic consultants and an ENT consultant. They did not communicate with each other and nobody actually vocalised what was happening (i.e. this patient is in trouble, this is a ‘can’t intubate, can’t ventilate’ situation).The key in resus situations is to have clear communication. The other team members need to know what’s going on and this can help the team formulate a plan...
Source: Life in the Fast Lane - Category: Emergency Medicine Doctors Authors: Tags: Anaesthetics Emergency Medicine Featured Intensive Care airway crisis resource management elaine bromily lessons Martin Bromiley teamwork Source Type: blogs