How crises cause brain block
Our trio of writers – two doctors and an airline pilot – are co-founders of a business on a mission to improve patient outcomes by helping healthcare professionals understand why errors occur.
Analysis of a number of high-profile medical errors has demonstrated poor crisis management. In their fourth and last article in the series, John Reynard, Tim Kane and Peter Stevenson discuss the Elaine Bromiley case as a classic example of poor crisis management, and analyse it according to High Reliability Organisation (HRO) principles, focusing especially on our psychological response to a crisis.
An analysis of a large number of aviation disasters revealed that crises were not infrequently managed badly, even by highly experienced air crew.
The aviation industry realised that a systematic approach to crisis management had to be developed which involved training before the event and developing systems of managing a crisis in a better way once one had unfolded.
Aviation has led the way in practising common crises in a simulator – an environment where pilots can test their response to a crisis and then, critically, can practise in safety to get better at handling it.
The ergonomics – people’s efficiency in their working environment – of crisis management have been addressed by a number of industries.
Everyone will have experienced the unpleasant sensation caused by the surge of adrenaline rush, which, in turn, causes a rise in pulse and blood pressure. Less well known and understood is the cognitive response to a crisis, a response which can impair effective management of what is happening.
Forgetting important steps
The cognitive response to a crisis is described by some HROs, particularly in the US, as ‘tachypsychia’. The components of tachypsychia include:
Omitting vital actions and forgetting important steps;
Auditory exclusion – failing to hear verbal input from colleagues and equipment alarms;
Loss of time awareness;
Memory lapses;
Loss of situation awareness and fixation – too much focus on the wrong thing;
Communication failures;
Problems using the emergency equipment because of impaired motor skills and hand-eye co-ordination;
‘Visual exclusion’: tunnel vision.
Our psychology evolved to deal with predators – essentially lions and bears. It did not evolve to deal with an airway crisis because such problems only became relevant after the administration of the first anaesthetic in 1846 at the Massachusetts General Hospital.
Before then, there had been no need to understand or develop a better psychological response.
When faced with a predator, as a general rule, the best response is to turn, run or climb the nearest available tall tree: the so-called flight response. The fight response was an alternative but usually riskier strategy.
The response is automatic. No mental reasoning is required. An awareness of time and of what is going on in the peripheral visual field are not important and focusing on what other people might be saying is generally of little importance. Tachypsychia in such a situation is helpful and its evolution allowed us to succeed in evading predators.
Programmed to respond
Our psychological response to a crisis in an operating theatre derives from the same physiological system underlying the flight or fight response just described. In evolutionary terms, we are programmed to respond in the same way.
The problem with that same response in the example of the airway crisis is that these various components combine to impair our cognition during such crisis and hamper our ability to acquire information and analyse that information. Our ability to reason in an airway crisis is critical to its effectiveness management.
If we think this all sounds a bit theoretical and irrelevant to crisis analysis and management, then think again. Let us consider the case of Elaine Bromiley, a fit woman in her 30s undergoing an elective and minor ENT procedure from which she should have made a complete recovery [Bromiley 2015].
The experience of the team on the day could not have been better. The lead anaesthetist had over ten years’ experience at consultant level and was described by anaesthetic colleagues as diligent.
A second anaesthetist who attended the crisis had difficult airways skills. The consultant ENT surgeon had 30 years’ experience at consultant level. No team of doctors was better placed to insert a surgical airway.
Why then, faced with the crisis of ‘can’t intubate, can’t ventilate’, the correct management of which is a surgical airway, did they continue with attempts to intubate Elaine? Any of them could have easily done a cricothyroidotomy or tracheostomy.
Nurses knew
Even more remarkable, at least on first ‘analysis’, is that the nurses knew exactly what needed to be done – they prepared the tracheostomy equipment – but the doctors appeared not to listen to them.
Things went from bad to worse. Elaine’s oxygen saturations remained critically low for most of the crisis and she died a few days later – having been brain dead within the first 30 minutes – after never regaining consciousness.
When analysed according to HRO principles of accident causation, this is a classic case of three doctors experiencing the negative effects of tachypsychia on cognitive function.
All three doctors experienced loss of time awareness. They all had auditory exclusion – it wasn’t that they didn’t listen to the nurses, but rather that they didn’t hear the nurses.
They all lost awareness of the situation, thinking it was not as serious as it really was and became fixated on a single task – namely continued attempts at intubation. They had all developed ‘mind-lock’.
Loss of time awareness
All three doctors experienced loss of time awareness thinking they had only been trying to intubate Elaine for a few minutes, rather than 20 minutes.
The high level of mental concentration required to analyse and manage a complex problem slows down our mental metronome. Time passes very quickly when one is concentrating intently, as any surgeon can tell you during a long operation. When one looks at the clock, an hour can have passed in a what seems like a fleeting moment.
Mind-lock has been seen in many mismanaged crises in aviation and the nuclear power industry. It was a major component of the Three Mile Island nuclear disaster in 1979.
Roger Green, a leading aviation human factors expert in the 1980s, said that his analysis of aircraft accidents revealed many cases where pilots carried on with a flawed course of action while the aircraft’s warning systems were ‘screaming at them that they had got it wrong’ [BBC TV Horizon documentary: The Wrong Stuff, 1986].
The experience of mind-lock was eloquently described by another anaesthetist’s experience of an airway crisis – unrecognised oesophageal intubation – in the following way: ‘By that stage I had got myself into a mind-set I could not break’.
Once we understand the basic concept of tachypsychia and appreciate its impact on our cognition, a more sophisticated 21st century approach to crisis management can be developed.
Crucial to effective crisis management is the allocation of an individual to record time. This individual can be the team leader who calls out time every minute while directing the other team members.
Critically, that leader remains hands-off so he or she maintains an overview of the situation and does not become focused on technical tasks – intubation, a tracheostomy. The approach to trauma management, much of which can aptly be described as crisis management, adopted by the British and US armies at Camp Bastion is a good example of the hands-off approach to team leadership.
Speaking-up protocols
To allow individuals to speak up in a crisis when they have noticed something that concerns them, or simply to allow juniors to input their observations into crisis management, HROs have developed ‘stepped’ speaking-up protocols.
The Probe, Alert, Challenge, and Emergency system (PACE) is used globally by aircrew to express concern. ‘I need some clarity here’ is the opening phrase for the probe step.
‘I am uncomfortable about this’ is a phrase for the alert step. ‘You must listen’ is the opening phrase for the challenge. In 30 years of commercial airline flying by one of us, he has never had to advance beyond ‘I am uncomfortable about this’ – those words have great meaning.
Healthcare has a long way to go to improve crisis management and to allow juniors to speak up when concerned. But as with all of the concepts discussed in these four articles, much can be learnt by adopting techniques which are used by HROs.
John Reynard, Tim Kane, and Peter Stevenson are co-founders of Practical Patient Safety Solutions.
John Reynard (right) is a consultant urological surgeon and honorary senior lecturer in the Nuffield Department of Surgical Sciences at the University of Oxford. He is an honorary consultant urologist to The National Spinal Injuries Centre at Stoke Mandeville Hospital. He holds a masters degree in Medical Law and Ethics.
Peter Stevenson (left) has been an airline pilot and human factors instructor for over 30 years. He flies Airbus A330 airliners on inter continental routes for a major UK airline.
Tim Kane (right) is a consultant trauma and orthopaedic surgeon at Spire Portsmouth Hospital and the city’s Queen Alexandra Hospital.
Further reading
W.B. Runciman, A.F. Merry. Crises in clinical care: an approach to management, Qual Saf Health Care 2005;14: 156-1635
