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.

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 oxygen saturations 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.

2. Have a plan

This team planned to start with a laryngeal mask but when this failed the only alternative considered was tracheal intubation. They did attempt to use different mask sizes for bagging, but other than that the attempts to intubate persisted for 25 minutes in spite of the sats being 40% throughout.

Before starting any procedure, there should be a clear plan. Never is this needed more so than when planning an intubation. Whatever the local difficult airway algorithm is – know it well. Again, vocalising is essential. Talk through the plan with the team before the procedure starts so everyone knows what will happen in the event of a crisis.

3. Listen to all the team members

In Elaine’s case, as well as the three doctors, there were three experienced nurses. Although the doctors did not appear to recognise the seriousness of the situation, the nurses did. During the resus, one of the nurses fetched a surgical airway kit and told the consultants that she had brought it in – but there was no response. One of the other nurses called for an ICU bed early on in the resus – when she told the consultants this they made her feel like she was overreacting (and she cancelled it). It transpired that the nursing staff didn’t know how to broach the subject with the doctors.

Every member of the team needs to be able to show assertiveness, particularly when they can recognise trouble and have suggestions for a solution.But more than that, there must be culture of listening. Every team member is valuable and may have something helpful to add. Questioning what is happening and suggesting possible options is an important part of any resus and is essential for good team work.

Everyone has a voice; everyone must be listened to.

4. Take control

In this case, the lead anaesthetist ‘lost control’ and there was no clear leadership. Someone must take charge of any resus situation. It is their job to share what is actually happening, keep an overview of the whole situation and plan for alternatives.

Without a good leader, there are just lots of people working independently to achieve their own goal.The leader is essential to ensure that all the other points above can actually benefit the team.

As Martin Bromiley identifies, ‘we are all wrong no matter how good we are’.

We need people around us to tell us.

Be open to suggestions. Listen to your team. Step up and lead.

References

• Mastering Intensive Care 021 with Martin Bromiley (LITFL)