Applying the Airway Spider
Let’s analyse the things that went well:D = Design• Careful preoperative assessment by her anaesthetist.
• Anaesthetists involved were experienced consultants and well trained.
• Monitoring and equipment were in line with AAGBI national standards and a trained anaesthetic assistant was present.
• A second anaesthetist came to help immediately.
• Airway trolley with relevant equipment was readily available (the absence of an Aintree catheter was not thought to be relevant here).
Some other things did not go very well:N = Non-Technical Skills• Loss of situation awareness and fixation on intubation by the anaesthetists.
• The staff involved lost track of time: no one was keeping a log of events and noting the time as is now recommended.
• This case was an example of marked hierarchy within the theatre team, with the theatre nurse clearly aware that an emergency tracheostomy was required, and she even brought in a tracheostomy set (NB an ENT surgeon was present) but was told that it wasn’t needed. She didn’t feel she could speak up against that decision.
• Due to loss of situation awareness, staff were fixated on the act of intubation, and did not appear to consider the risk of hypoxic brain injury or the need for ICU care post event – even when one of the theatre nurses rang ICU to request a bed, she was told that it would not be needed.I = InvestigationAn investigation wasn’t planned as a routine procedure. Eventually, when Martin Bromiley asked for one, the then president of the AAGBI, Professor Harmer, volunteered to do one himself – and did an amazing job. He had no HFE training or access to a HFE investigative tool but he was independent, did an investigation covering all factors involved and wrote the report  in such a way that others could learn from the event rather than apportioning blame. He was ahead of his time!
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• Due to loss of situation awareness, 20 minutes passed with sub-optimal oxygenation and no prompt for eFONA.In the next step we will meet Dr Kelly again, as part of a panel of human factors experts sharing their top tips.
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