Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

What Does it Take to NOT Kill a Patient – Part IV

This is a review of bad outcomes by anaesthetists (anesthesiologists in the US), not paramedics, so we should expect that, because of much less experience, paramedics would have much worse outcomes in similar circumstances.

We need to learn from this.

You can’t ignore the impact of your own thinking, tuned to normal, routine success, and the impact of those around you when things turn nasty.[1]

But we do ignore the impact of our own thinking.

We ignore what we do not want to know.

Ignorance motivates us to avoid change.

Ignorance motivates us to avoid improvement.

Ignorance motivates us to harm our patients.

We expect success.

We plan for success.

When success does not happen, we blame the individual, rather than our culture of ignorance.

Failure to plan for failure. In some circumstances when airway management was unexpectedly difficult the response was unstructured. In these cases outcome was generally poor.[2]

Generally poor?

Hypoxia.

Ischemia.

Injury.

Infarction.

Death.

These are the poor outcomes that can result from failure to plan for failure.

We continue to harm patients by following protocols designed by administrators/bureaucrats to protect the organization from our patients.

We get away with this because we do not see the results.

NAP4 shows us some of those results.

NAP4 shows us some of the blood on the hands of the administrators/bureaucrats and on our own hands.

See also:

What Does it Take to NOT Kill a Patient – Part I – 4/03/2011

What Does it Take to NOT Kill a Patient – Part II – 4/04/2011

What Does it Take to NOT Kill a Patient – Part III – 5/20/2011

What Does it Take to NOT Kill a Patient – Part IV – 5/23/2011

What Does it Take to NOT Kill a Patient – Part V – 5/30/2011

From EMCrit –

EMCrit Podcast 47 – Failure to Plan for Failure: A Discussion of Airway Disasters – 5/09/2011

From Resus.Me –

Anaesthesia’s dirty laundry – let’s all learn from it – 4/03/2011

Footnotes:

[1] Major complications of airway management in the UK – 2011 NAP4
Royal College of Anaesthetists
Forward (page 7/54 – Section 1)
Page with link to various full text pdf versions of report, press release, executive summary, and full report.

[2] Major complications of airway management in the UK – 2011 NAP4
Royal College of Anaesthetists
Executive Summary (page 1/3)
Page with link to various full text pdf versions of report, press release, executive summary, and full report.

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