By Philip Neuwirth, BS, MICP, CCEMTP, FP-C

I tweeted a message recently that has received nearly 100 retweets which said, “Nobody dies from not being intubated; patients die from not being oxygenated and ventilated. First, learn the proper use of a bag valve mask!”

I sent this tweet to remind myself, my students and everyone who would read it that it’s easy to get tunnel vision during emergency situations and especially during a failed airway. I believe those imgres-1that use an RSI checklists are more prepared; the checklist should include time to verbalize out loud their airway plan, a backup plan and failed airway plan. And, not only verbalize, but have the equipment at the bedside to perform backup procedures. Verbalizing your airway plan also keeps you accountable to everyone else caring for the patient; whether you are in the back of an ambulance, an aircraft or the emergency department. The RSI checklist I use is posted above.

This evening, I was reminded by my colleague about a video on Youtube of a woman, wife, and mother who came to the hospital for “Just a Routine Operation” The video below is worth watching in its entirety. It, unfortunately, is a real life reenactment that people die from not being oxygenated and ventilated. The three anesthetists that eventually became involved in this case became so focused on securing this patient’s airway; they forgot to perform the most important skill; oxygenate and ventilate.

As a result of his wife’s death and personal experience, Martin Bromiley founded the Clinical Human Factors Group in 2007. This group brings together experts, clinicians, and enthusiasts who have an interest in placing the understanding of human factors at the heart of improving patient safety.

In Just A Routine Operation Martin talks about his experience of losing his wife during an apparently routine procedure and his hopes for making a change to practice in healthcare.

This film was produced by thinkpublic for the NHS Institute for Innovation and Improvement.

Please post your comments and click “Like” if you found this informative. The opinions and views are my own. Always follow your local protocols.

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