Saving Lives Through Failure

November 17, 2011 by  
Filed under All Updates

Think about what you would do if faced with the following situation:

You sedate and paralyse a patient with severe injuries in order to intubate them. You are unable to intubate due to a poor view and massive orofacial haemorrhage. An iGel provides temporary oxygenation while you prepare for a surgical airway.

Your first surgical airway attempt fails due to insertion of the bougie through a false (too superficial) passage. You spot your mistake and re-do the procedure successfully with a deeper incision. The patient’s airway is secure and there is good oxygenation and ventilation.

You discover that a colleague has videoed the procedure on his iPhone. However he only captured the first, unsuccessful attempt. The patient is not identifiable in the close up video. It’s late at night and only he and you know of the existence of the video. He asks you what you want him to do with it.



Do you…

(a) Ask your colleague to delete the video?

(b) Watch the video with him and look for learning points, and then delete it?

(c) Ask him for a copy of it and request that he doesn’t show it to anyone else?

(d) Other course of action

Consider your course of action given this situation, and then click below to reveal what my colleague did recently in exactly the same scenario…


(d) He did something else entirely: he got a copy of the video, burned it onto a CD, and left it on his boss’s desk!

It takes a certain kind of practitioner to risk embarrassment and criticism in the pursuit of the greater educational good.

He had already ascertained what he would need to do differently next time, so had nothing personal to gain from his chosen action.

Instead, he believed that sharing the video would help prevent his colleagues from repeating the same mistake, and help his supervisors review their cricothyroidotomy training in order to better prepare their team for the procedure. Ultimately, this gesture was directed towards the good of our patients.

His actions may have saved more than one life that evening.

Comments

8 Responses to “Saving Lives Through Failure”

  1. Scott on November 17th, 2011 14:28

    Amazing! Only thing that would be even better is if you could make sure there is no patient identification at all in the video and then post it for all of us to learn from.

  2. Minh Le Cong on November 17th, 2011 15:42

    Cliff, I find this inspiring.
    its easy to not talk about failure and try to forget .
    thats human nature
    but if we are to progress emergency airway safety and quality, doctors need to feel able to report and discuss failure.
    And in a sensitive manner those lessons need to be disseminated.
    Projects like NAP4 try to do this and the ANZCA airway SIG have recommended there be a national system of data collection on airway failures so lessons can be learnt by all.
    but as doctors only we can foster the safety culture to allow this

  3. Cliff on November 17th, 2011 17:33

    Thanks guys. Glad you find it inspiring Minh – that’s the idea of this new blog category!

    I thought of that Scott – it can’t happen yet but I’ll work on it.

    Cheers

    Cliff

  4. Andy Buck on November 17th, 2011 18:10

    Nice one Cliff. Having been involved in a very similar case recently (thankfully not being recorded on video) with a near-fail surgical airway in a patient with laryngeal fracture and massive airway bleeding, the intensivist (who I deferred to on the grounds of experience) seriously struggled to site the airway despite multiple attempts. Despite being “trained” for this procedure I was thanking my lucky stars I wasn’t the one holding the mini-trach, and it was very educational seeing someone who’d done it before struggle with it. You can practice on as many mannequins and sheeps necks, and read as many books/watch as many schematic youtube videos as you like, but seeing and doing it in real life is a different ball game all together. Good on your colleague for sharing it, as it’s a rarely done, extremely stressful procedure. I support the comments above, it’d be great to get it online for the wider ED community.

  5. Malcolm on November 17th, 2011 20:18

    I agree, a brave action indeed and a thought provoking post. Even with retrospective consent to use the video for education, one has to be incredibly careful with such material: if it finds it’s way onto the open internet, you can never get it back and there are voyeurs out there from whom we must protect our patients. Some of them in the medical community.

    I don’t want to detract from the very positive message here – it’s all about good CRM or TRM or whatever you’d like to call it and this is an excellent example of a well functioning team in action.

    I’m trying together my head around the use of imagery for teaching and debriefing at the moment: the only conclusion I’ve reached so far is that ‘to film or not film’ is a question that should really be answered before going out on a job. Was the ‘filmer’ in this case asked to film / expected to film / asked not to film / or not discussed beforehand.

    Great team CRM and culture – think about photo/video SOP: my own is really out of date for today’s IT culture.

    Nice one Cliffie!

  6. Cliff on November 17th, 2011 21:50

    Thanks Malcolm. Can’t give too much detail here but all those points are regularly considered. Complex area and we recommend staying within local medical council / registration board guidance where it exists and above all protecting confidentiality. Some justify the use of photos/video in the critically ill patient too sick to consent as a QA tool or as part of the clinical record, but the bottom line is without consent you are on dodgy ground. No-one involved in education can doubt its power as a teaching tool. Many policies are out of date in the age of digital media. I completely agree with your comments on how careful you have to be. I even struggled with whether to publish the image of the CD!

  7. Minh Le Cong on November 17th, 2011 23:21

    I tend to agree with Malcolm. You have to be careful with media materials like this. Its challenging to know where to draw the line. Do you need consent to take a video of an airplane crashing and then deciding upon whether to distribute it to people who may actually be able to prevent the same thing happening?

    there are hundreds of videos online where clearly no consent was given. But that does not make it right or ethical.

    perhaps in a dedicated training forum where registered participants can learn and review from such material is appropriate but not openly on the net.

  8. Tim Leeuwenburg on November 19th, 2011 18:14

    Even a dedicated forum has its problems (Cliff will be familiar with doctors.net.uk or its Aussie cousin ausdoctors.net). Both as leaky as a sieve, sadly.