Dr Mai O'Sullivan

Human Factors Surrounding a Successful Resuscitation

"On Christmas Eve the patient’s brother visited the ICU bearing good news; he was at home celebrating with his wife, a glass of wine in hand''

Last December, as a first year Specialist Registrar, I was involved in a successful resuscitation. This is a joyful but unremarkable occurrence in our chosen speciality. What makes this resuscitation remarkable, is that our team performed an emergency surgical cricothyroidotomy in the resuscitation room of an emergency department at 6am in a ‘Cannot Intubate, Cannot Oxygenate’ scenario. More remarkable still; our team was led by two first year registrars. Most remarkable of all; our patient survived, with no neurological deficit.

Human factors are commonly used to divide a negative outcome into its composite parts, to identify where the hole lay in a particular slice of swiss cheese. Allow me to take you through an imperfect process that resulted in a positive outcome.

The aviation industry describes a “dirty dozen”- that is twelve of the most common human error preconditions to accidents or incidents. They include lack of communication, distraction, lack of resources, stress, complacency, lack of teamwork, pressure, lack of awareness, lack of knowledge, fatigue, lack of assertiveness and norms. Humour me as I take you on a rapid journey through a selection of these factors and how we overcame them with a junior team in a small resuscitation bay.

Fatigue: At 6 o’clock in the morning, on hour 22 of a 24-hour shift, I was woken by a bleep from ED, groggy.

Lack of awareness: It was a request that I (the ICU registrar on call) transfer a patient with stridor, indicating partial upper airway obstruction, to another hospital for assessment by an ENT team.

Lack of knowledge: The team were unaware of the high risk of deterioration while in transit, resulting in complete airway obstruction. In the interest of patient safety, I declined to make the transfer, instead requesting that ENT attend our institution to assess the patient. The presumed diagnosis was a peritonsillar abscess with associated with trismus. Unfortunately, what had been deemed to be the patient’s ‘quinsy’ was his hard palate. He had a Mallampati score of 4. He had micrognathia. His BMI was 35.

Complacency: I arrived in resus, only to find it empty. The patient was still on the main floor of the emergency department. He had soft stridor, an increased work of breathing and was saturating 99% on room air. He was swiftly moved into the first resuscitation bay.

Lack of assertiveness: The patient had received steroids and antibiotics. I met the ED registrar, he like me, was in his first year. We started nebulised adrenaline, mostly to treat ourselves. While the nebuliser finished, we discussed hi-flow nasal oxygen. It was being assembled the way all things are at 6 o’clock in the morning: slowly. With the nebuliser completed, he began to desaturate. The stridor stopped. There was no sound to be heard as he went grey and lost consciousness.

Stress: The arrest call went out. Bag mask ventilation failed. Despite rocuronium, the patient’s mouth would not open. A blind nasal intubation failed. Bag mask ventilation failed again. We could not intubate. We could not oxygenate.

Communication: Was clear. Scalpel. Bougie. Size 6.0 cuffed tube. Please? I have discussed the events of this morning with a handful of colleagues. The most common question asked has been: was the decision to make the incision difficult? My answer: no. I had attended the CAI’s difficult airway course a month previously. They had drilled us on DAS guidelines, airway anatomy and various techniques to be used in this situation. I had performed a scalpel cricothyroidotomy twice before, albeit on a mannikin, so I knew the steps. The key learning point from that course was: irrespective of your level of training, if you have reached ‘Plan D’, you must execute ‘Plan D’. This gave me the confidence that I needed to proceed.

Teamwork: I do not remember that room in the first person. I remember it from the ceiling, floating, looking down. At the head of the bed were two “night sisters”, who had more clinical experience than I had years on this earth. One was performing a vigorous head-tilt and chin lift manoeuvre, the other was squeezing the bag of the c-circuit with all off her might, praying. The medical intern stood with a tray of emergency drugs in her hand, the names of which she had only ever read in medical school, awaiting instructions on which one, and how much to administer next. The medical registrar had a firm grip on the patient’s right wrist. He informed the room that the pulse was becoming faint. The ED clinical nurse manager announced the pulse oximeter’s reading of 35%. A low, slow, blub sound emitted by the monitor confirming her observation. The ED registrar and I were at the patient’s left side, not the side advised by any of the courses I have attended before or since, but the side that we found ourselves on. We had reached the dreaded ‘Plan D’: attempting a surgical cricothyroidotomy was the only option available. Our hands clammy, we made the leap of faith together.

His trachea was impalpable. An 8cm incision was made, followed by blunt dissection to the point where we could palpate tracheal rings. I say we because we were a team. We discussed each step aloud. I had full trust in him, and he in me. We were all we had. Senior help and surgeons were on the way, but there was no time to wait. At each step we paused and checked: Is that definitely cricothyroid membrane? Do you want to make the cut?

Distraction: Watching this unfamiliar scene unfold, our airway assistant dropped the bougie onto the floor. She did not notice.

Lack of resources: That was the only bougie available in resus. We soon learned that a size 6 cuffed ETT does not fit over an adult sized stylet.

Pressure: Despite this, the medical intern spotted the bougie on the floor.

Norms: Had evaporated, thankfully each member of our team stepped into the role required of them in that moment. Suddenly, normality returned. The ETT was railroaded. The bougie removed. The end-tidal CO2 trace appeared on the monitor. The ENT team arrived, followed by my consultant. An arterial line was inserted. The sun came up. The patient was transferred to theatre where a diagnosis of epiglottitis was made. ICU handover began. The call was over. We went home to our beds.

On Christmas Eve the patient’s brother visited the ICU bearing good news; he was at home celebrating with his wife, a glass of wine in hand.

This resuscitation is one that will stay with me for the rest of my life. I will never forget the face of the ED registrar who made it possible. Whose hands were one with mine as we battled through our worst nightmare together. The ‘dirty dozen’ of human factors may have been out in force that morning, but having an excellent teammate at my side (along with some well-timed mandatory training the previous month) meant that we overcame them to bring about a joyful and remarkable occurrence: a successful resuscitation.

The aviation industry describes a “dirty dozen”- that is twelve of the most common human error preconditions to accidents or incidents.