Just A Routine Operation

As a result of his 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

[@theenglandguy]

When he said "you will be pleased to know they all returned to work" about the staff that made the mistakes from which his wife suffered, is when I knew this man is a greater man than many. Learned a lot from this video, working in healthcare.

[@keith3289]

Great respect for Martin Bromiley's involvement in this video and his attitude towards the staff involved in the tragedy and their returning to work. Absolutely human factors are involved in a great number of incidents.

[@jackiemarini3203]

Before they said anything about the trac I said why don't they do it .This is so sad and wrong.🥺😓She had brain damage along time ago not long after they started .🙏🤍🙏

[@missy07yashy]

You would be pleased to know that schools are now using this story as apart of teaching material ... we're all learning from this

[@susansechtem8226]

+Honey Dee I'm training to be a paramedic, and we were told about your story as well. It was important to see the hazards of miscommunication and now pay closer attention to it...

[@talialxox]

Same here for Occupational Therapy!

[@gracea3671]

same here for Professional Communication Workshop

[@DrJM0]

Same, medical school

[@alinski112]

Yes, we did. Here in Germany, we use this video to educate paramedics. I watched this video today, and it's very helpful to lower the rank-thinking in general

[@hk3083]

In July 2016 I attended an ALS course and this video was shown. Needless to say we were all shocked. I am an agency nurse and I felt compelled to stand up and show courage if I ever encountered a situation like this, especially if I knew what to do. Truth be told, a couple of months later I WAS in a similar situation. It was a cardiac arrest on an ITU and it was pretty chaotic. Beside other issues the doctors failed to rule out all the 4 H's an 4 T's. Eventually I intervened, listened to her chest myself and diagnosed a Tension Pneumothorax. The Anaethetists ignored me and refused to insert a decompression needle, stating that they would need to wait for a Chest XRay (... ??!). Luckily the consultant arrived, and after relaying my assessment to him, he agreed and did not hesitate a second to put the needle straight into her chest. Shortly after she achieved ROSC. Without watching YOUR inspirational video I would have not had the courage to do this, but now I am glad as it possibly saved someone's life.

[@dolls2871]

wow,,,Thank goodness for your courage. you definitely saved a life. I am a final yr medical student myself, and what has been nailed into me from my med school is to listen to other healthcare professionals especially when they have concerns about a patient. In your case, its a bit worrying why the anaethetist would refuse to do a needle decompresson especially if querying tension pneumothorax....no waiting for xray for tension pneumothorak, u go in straight and relieve the tension to convert it to a open penumothorax then chest xray later. in my head, when i hear a nurse say, I have a bad feeling about this patient, something is wrong, it immediate rings alarm bells in my head cos 9 out 10, something ends up genuinely wrong with the patient and just a few minutes to check the patient out is what needs to be done........

[@sophiareiter2075]

I am so proud that you had the courage to do it! I study medicine and I know that nurses have way more expierence than I have so I will always listen to you. Very sad that many people died because doctors were to arrogant to listen to their nurses. Thanks for sharing your story

[@robynadams8]

Well done. Very brave!

[@mazvi8427]

I feel like it is due to power dynamics why some people dont speak up but we should always stand for the truth.

[@muhammadumair9074]

Great you saved a life

[@ChrisPollitt1]

I'm so sorry for your loss. I have learned from this video and other lectures on this case. As a Consultant Anesthetist, I will not forget.

[@lexaprobabes5947]

This is used to train student nurses here in Australia now. I'm so sorry for your loss, Martin. Your wife's story is being used to prevent things like this from happening again.

[@bjarnedreyer8401]

Itˋs also being used to train paramedics in Germany!

[@ephraimlion]

As a Dr, one thing I've learned to do under such circumstances is to zoom out mentally in such situations, calm down for a few seconds and ask myself what simple thing I could be doing wrong. It's simple to say this but if you find yourself under such situations, it's very easy to forget the basics.

[@davidpecora7750]

Thank you for sharing your terrible story. I am going to use this during airway training of other health care professionals.

[@doctorhaf]

Martin your ability to look for the learnings and not be punitive shows an admirable capacity for forgiveness. I am sorry for your loss and very grateful for your work. As a doctor in the NHS, we get put through a lot of mandatory training that is poorly designed and delivered and often repetitive (eg annual manual handling, infection control etc every time we rotate to a new hospital trust in August) - highly frustrating when you don’t have the luxury of time. I had seen “Human factors” courses advertised but did not know what that meant and steered clear thinking it would be more of the same. The case of Dr Hadiza Bawa-Garba has made me revisit this and I’ll be looking to get some training. Many thanks

[@emmah4887]

Thank you Martin for being so open and honest in sharing your very personal story. Our Medical School is also using your family's story so that we all may learn. Having just come from an anaesthetics rotation myself your story has had huge impact Thank you again for sharing

[@palladiumblue2539]

As I am about to start training in theatre as an anesthetic nurse, I was asked to watch this video by one of the anesthetists with whom I'll be working. He was a nurse before coming a doctor. Extremely thought provoking. Thank you for sharing your story.

[@lk4543]

I am a student nurse with an interest in theatre and this story is something that always appears in my mind.

[@danielQiura]

Assertiveness training to all carders of clinical staff will teach them how to speak up in such and similar situations. Confidently saying “ I am concerned; I am uncomfortable; this is a safety issue-stop.” Can make a big difference. We have a lot to learn from the aviation industry. Thank you for sharing.

[@talabaidas9025]

I respect this man who has turned a tragic situation into an essential lesson for all of us. We see this kind of mistake in healthcare regularly. I am personally touched by this story

[@mazvi8427]

This just shows you how there is a power dynamic between nurses and medical staff they didn't listen to the nurse when she was concerned. This shows you if you feel something Is not right you should comment and escalate it further.

[@stuartcross3910]

what an amazing man such a touching story

[@jennyhughes4474]

I must add this: it has been suggested for some time that one person must watch the clock and loudly tell all how many minutes have passed, at 4 minutes a tracheostomy should be done immediately. It makes my blood boil that the nurses knew instant action must be taken but the consultants refused to listen/believe/think/act. Consultants and all in anaesthesia must be taught to listen to juniors/nurses/ODPs and these latter MUST be allowed and encouraged to SHOUT. Anaesthesia training is not fit.

[@charliegoblin9680]

This was played during a lecture at Durham University for us first year medical students this afternoon.

[@abbie-eirian4876]

First year nurses watch this too!

[@unit0033]

student paramedics also watch this

[@kimt4512]

Its thanks to people like him and the aviation industry that has taught us in the medical field teaching tools like SIM and mannequin simulation for disastrous life and death situations. There is nothing like constant practice and re enactments of scenarios in training

[@helencee2838]

I'm watching this video as part of the learning materials for my nursing degree, and I find this especially enlightening. Thank you so much for sharing, and I'm deeply sorry for your loss

[@lindashillabeer4018]

This is a brilliant learning video. I am a nurse and it has made me think about getting some training in human factors. My husband is a retired pilot so I could really relate to their emergency training procedures. Thank you so much to Martin Bromley girl sharing his story and all his efforts to highlight the learning from thus very tragic event. Found the story in my nursing RCN journal.

[@pssrn42]

Deepest sympathies to the family and hopefully a lot will be learned from this.

[@hilde4225]

I'm so very sorry for your loss.. what a terrible story. Very good to see how you are holding up and sharing this story to teach medical students/staff. I am a medical student from the Netherlands and this video is used as part of our teaching material, hopefully this will never happen again in the future

[@lizsharma8867]

This is bar none one of most moving and thought provoking things I have watched in decades. Thank you. I'm committed to changing how I communicate and do my work.

[@Comcaldone]

This story is the reason why I consequently perform preoxygenation before every single general anesthesia also in young healthy patient. With that the oxygen level drops multiple minutes later and therefore giving you a relevant amount of time to solve the airway problem. Unfortunately correct preoxygenation is a standard many do not follow because most of the time they are to lazy or to arrogant 😢!

[@benjaminalacarne384]

Thank you so much for sharing this and for helping educate us to be better providers. Take home messages for me are: - A team of experts is not necessarily an expert team; - Concept of a 'Sterile Cabin' in aviation - Concept of a 'Walk Round' in aviation and; - The concept of Direct V Mitigated speech in the emergency situation (after Gladwell, 2008) We have a lot to learn from both tragic situations such as this and from other industries who have decades of experience in recognising the challenges of human communication and error in highly technical environments. It is also so humbling to learn of your endeavors in the face of this to devote to improving the way we do things.

[@jobinbaby4110]

I am so sorry for your loss Martin. May God be with you and your children. I am doing a nursing degree and your personal views have inspired me to make a difference.

[@EibaProductions]

In my medical university, this video is used to show us, how important human factors are in the health care environment.

[@victorJ2050]

Gave me goosebumps. I have worked in Anesthetics as a junior doctor for a 1 year. Our job was to check the drugs and equipments each morning and after the day ended. We would do the procedures under supervision. This situation is a nightmare for everyone. Terribly sorry for the loss. But the way you used your tragedy to bring improvement in healthcare is amazing.

[@etsout]

What a beautiful and tangible way to honor his wife.

[@daisyphipps3254]

Hello Martin, I have just watched your very powerful video as part of a module in my pre-registration nursing programme at the University of Lincoln. I have an aviation background as well. I was a cabin crew member for both British Midland and British Airways. I liken the two areas of business often. Good communication is key in both roles as a nurse and cabin crew. I take your point about the grey area of who should take responsibility. I remember a captain once said to me that cabin crew are the eyes and ears of the pilots, and I believe nurses are the same, because on a ward the nurses see patients more and can relay any changes. In this instance these nurses viewed your wife from a different angle looking at her as a whole, from a distance, their points of view should have been considered. Seniority can sometimes be seen as a barrier and I will definitely keep this scenario in my mind when I feel a situation warrants my assertiveness. Thank you so much for sharing your story and the commitment in continuing to break these barriers that do still exist. I hope good has come out from this tragic event.

[@shielapantrini1555]

I'm seeing this for the first time in preparation for becoming an instructor to instructors in a clinical setting - thank you for sharing your story and know I was listening!

[@mariuscoetzee425]

Good lesson for pathology laboratories also. ISO 15189:2012 standards for medical diagnostic laboratories are achieved more easily if everyone in the lab is fully conscious of the human factor and everyone has each others backs.

[@salome265]

For your knowledge, this video is shared for last year medical students in Sweden, to teach us the importance of CRM. Thank you Martin and family for making this.

[@rab333]

Martin thank you for sharing your story. So sad about the tragic death of your wife Elaine. I attended a SMART course yesterday as part of my job as a nurse in the recovery room. I have been made aware recently that despite excellent clinical training and skills developed there is an element that appears during a real life scenario. I am now aware this element is the human factor. Things will improve because of your story, and Elaines memory will live on and hopefully help to save many lives.

[@nolickspittle4753]

So often the nurses have a clearer perspective than the doctors, maybe because they are standing a little more distant from what is going on and get a clearer picture, maybe due to a certain sense of humility or maybe due to actual more experienced medical knowledge. Ask any nurse how many times they have "fought" and argued with doctors.

[@louisereed9615]

here i am doing my ALS for the second time and I was quite surprised i knew the answer - tracheostomy...through my tears I know that your story will save lives and is being used in all sorts of educational platforms...thank you for sharing...what an amazing dad and human being...words fail me

[@sampsonanya3990]

This is an incredible learning material for all, and is reproducible virtually in all human endeavors, I find this very useful. Many thanks to Martin Bromiley who turned this sad life experience to a blessing to all humanity. Generations to come will continue to learn from his experience.

[@michaelashafer3397]

Sadly this happens all too often. I recently lost my daughter in a same day surgical procedure and similarly, many professionals either became incapacitated by fear, arrogance or something else that allowed my daughter to remain on a table without a heartbeat for over 30 minutes before they realized they had punctured her heart and moved her to an OR. She was already brain dead and as a nurse, I was all too familiar with the chaos that no doubt occurred in that room. Tragedy that so affects a family that simply should not have happened. Thanks for making this video. I hope to do something similar to show another side of this issue.

[@zannatul23]

Really sorry for your loss. Your video are being used in our school and teaching us the importance of good communication and multidisciplinary approach in managing a critical patient promptly. Thank you

[@Wildgpd]

There is also the myth of experience... Had any of the physicians involved actually encountered a similar experience with their years of experience.... I think not; they probably never had encountered a situation where they required an emergency tracheostomy in an elective surgery before.

[@bee_waspee]

Thank you for your bravery and for channelling this awful mistake to help us learn. Lots of love to Victoria and Adam.

[@lucyjane3778]

Martin, I just want to commend you for your strength and wisdom. You made a brave & wise decision to pull a positive out of this and I am sorry at the massive cost it was to you and your family. My prayers are with you even today. I am an emergency nurse and understand the value of these lessons. This will save somebody's wife, husband, mother, child etc. Maybe the causes of human factors is all mentioned below in overworked and under funded but it should never cost a life. I'm sorry. God bless.

[@lisabennett1625]

Watching as part of suggested learning on Podiatry apprenticeship. Very difficult to watch and yet, so essential. True courage to share this message for our learning. Thank you Martin and sorry for your family's tragic loss. 🙏

[@shivanaramsingh6940]

Deeeppp condolensces to you!!! But thank you for reminding me and teaching me to listen, to be diligent , no matter how experienced you are. Im sorry, your wife died and you had to contribute to human betterment in this manner. Thank you a million times over. I will heed the advice.

[@imedicineman]

Thank you Martin for sharing this. I have further shared it with my healthcare colleagues. In 2005, we began teaching the principles of good team dynamics per the American Heart Association during resuscitations. I will use your video in my classes and truly believe it will make a difference in more positive outcomes.

[@naomikelly5861]

Thank you for sharing your story!

[@xXHPPXx]

Thank you for sharing! This video is part of med school in Germany now. I am sure many health care workers all across the world have lernt something from this.

[@jxc7226]

Was shown this in an ALS course last year, now I'm sharing it with my fellow medical course mates. You will be pleased to know that more will be learning from this mishap.

[@tsw686]

Watching this as a required part of my Nursing Dgree. Excited to know more and learn from this. All the best

[@paulinemartin7294]

Hello Martin, I have recently watched this video and others relating to this tragic event. It was presented to a number of healthcare professionals completing a leadership module within a post graduate degree. Whilst I no longer work in acute or emergency care, your message and teachings of clinical human actors will never leave me. It surprises me too that human factors was not part of clinical training. Thanks to you and your family it now is. I have now doubt that this has already changed the lives of patients and staff around the world. Sending you warm wishes. Thank you.

[@mariogamer02]

Watched this before a Human Factors training day - thank you Martin. I hope to learn more and spread the learning to make this focus in Human factors part of everyday practice.

[@twoleftfeet9626]

What a wonderful man. Used his personal tragedy for the very best outcomes for everyone in the future

[@jillsanko4106]

Will definitely add this to my IPE and IPE/ patient safety courses. Thank you for sharing this.

[@tessaraafat6288]

Selfless brave man

[@deliriumdoll]

So valuable. Thanks for making this available.

[@Sunnyday38]

Wow I wish there were more people like this guy. The world would be a better place.

[@wakawaka608]

referred here by the University of Dundee's medical education master program. Sir, you should be proud of how positively we learn from you.

[@DoctorKoco]

What a nightmare, on both sides. That's why it's so important that we are aware of what to do and listen to the best clue knowmatter where it comes from. Thank you for sharing

[@FreePeoplesMovement]

I'm watching this for a paramedic course

[@happichick73]

You are an Inspiration! Sorry for the tragic outcome, thanks for sharing your story...all the way through I was thinking "tracheostomy"!

[@julesr3066]

They just showed this in my law and ethics class. Difficult to watch. But necessary.

[@mahendraperera7688]

Difficult air way handling was one thing my anaesthesia tutor always stressed me on. However much we do, we never learn fully. Once I remember my teacher saying," If I were you, I would use a bougie for this patient". In this scenario, my opinion is that after the second failed intubation, I will definitely use the tracheostomy kit with the 30 yrs experienced ENT surgeon's expertise. What more to be shy than killing a human?

[@bearcat9183]

As a doctor, your wife’s tragedy will always remind us about the importance of situation awareness and assertiveness in dealing these situations Really sorry about your loss 😢

[@becomematrix]

“All experienced” killed his wife

[@nullusanxietas2379]

What a kind, brave person. I'd be full of rage and bitterness if that happened to a loved one. I know better know. Watching this as part of my course material for registered nursing. Thanks to Martin and Laerdal Medical for this great video. :) I hope his kids are doing okay.

[@simonmaverick9201]

There is no such thing as 'routine' surgery. Every patient is different, every medical team member has different approaches and, more importantly, every patient is an individual.

[@AaaaA-wr9md]

This video was played at an inter professional education session between healthcare students at Qatar university it was so beneficial.

[@schneggli1]

we also use this tragic story as teaching material here in Switzerland

[@sonianunez5811]

Thank you for sharing. Your story is saving a lot of lifes. I'm sorry for your lost.

[@kamanasubba]

Dear Martin, It was a really really tragic story where a husband lost his wife and those lovely kids their mother! So, sorry about your loss. Thank you ever so much for being an exceptional exemplary lead for Human Factors in Healthcare sector as well. I always find your video being played in almost every Human Factor workshops/conferences I attend in Healthcare organisations! Also, you have proved yourself to be a great Human- "all those people involved.... they returned back to work; that is what I exactly wanted" I am sure Elaine is so proud of you! Wish you and your children peace and happiness.

[@XxALRxX1995]

This is incredibly hard to watch, Mr. Bromiley is an incredible human for sharing his story and his work. Probably has saved many people from serious harm and even death. We are send to watch this video in our emergency medicine class on human error and good team communication. His work and story are used to train generations people going into medicine.

[@neilduffy7807]

Thanks for this video, i'm doing my nurse degree. your story and message will have saved many many lives and will do into the future. i was very touched by this video. Thank you very much.

[@hawthornroot]

nursing student here. reading a book from my class and it directed me here!

[@tolaosaji2469]

Thanks for sharing this. So sorry for your loss. i have learnt a lot from this video. it has impacted me and will definitely make a positive change in my practice.

[@arlenek4039]

Mr. Bromley your story is being shared in our graduate program with an assignment to watch your video. By sharing your story we can all learn from our errors.

[@tromboneJTS]

thank you for sharing your experiences. The situation you describe shows how nurses and other allied professionals tend to follow routines and guidelines, while physicians tend to improvise and devise their own solutions. When the tracheostomy kit arrived it was perhaps even arrogance which clouded the anaesthesiologist's judgement.

[@Sheba_316]

Arrogance, ego and hierarchy are contributing factors most of the time. Nurses are looked down on in many ways.

[@Partywevelyn]

this video is being used as learning material at USC, well done.

[@emmaphil123]

Been taught this in two separate university courses now. Excellent learning.

[@TheJohnnyb007]

What a sollid lesson!

[@mohamedhassanmahmoud6531]

Rest in Peace for your wife. Very Sad for you. Mohamed

[@maxineminton1459]

This was such an incredibly sad incident - Thank you for making positive changes for the future from this experience.

[@frocesterwindsors]

What an amazing and inspirational family.

[@danielir]

Watching this as a medical student ten years later

[@rachelgooden9981]

Awesome human being

[@jambawo]

Amazing and touching story

[@johnquick4880]

Thankyou for this upload, thoughts and prayers to her and her family, what a champ/ good sport the husband is. I as a student nurse find this very frustrating, how could a veteran healthcare team fail this patient. I gather it 1 of the many complex errors was a lack of a multi disciplinary team communication with 1 another. I will certainly take this story with much weight and am much appreciative.

[@farhanat.siddique2430]

I watched it from Karachi, Pakistan as part of my study at KCL London UK MSc Diabetes Care It's heart breaking as a nurse and human So many incidence happen unrevealed in Pakistan

[@toastedhippo]

This continues to be the single most important video/piece of education in healthcare from the last 50 years.

[@kpkbkpkb7768]

So sad to hear of your loss. I can't imagine the pain of raising your two kids without her. I do wonder what the root cause of the airway trouble was: Laryngospasm? Aspiration? Anatomical difficult airway (unrecognized)? Obstructive Sleep Apnea combined with other issues? In these instances, understanding cause is helpful to successful management. Nothing was mentioned about muscle relaxant medication so I wonder if any was used (assuming so). If this was a teaching facility, more misadventures can occur while trying to teach a junior, which makes rescue measures by the senior even harder/impossible. Perhaps the reserving of the ICU bed was more of a distraction (at the moment) than anything, causing frustration in the team. Low saturations after prolonged difficult intubation can be due to aspiration, a life threatening pneumonia, defined by stomach contents entering the lung tissue. Moments like those 35 minutes are when seconds count. In fact, all of anesthesia is about seconds, and, you are right, it's easy to lose track of how many seconds are passing. So many questions, not enough answers from this presentation.

[@timelessskinbeauty2117]

Thankyou and sorry for what you’ve experienced. Nurse studying in Australia graduating this year.

[@keithbrunt1427]

Just wanted to drop a note here to acknowledge that this video will be used in medical training at Dalhousie University as part of our critical thinking training workshop for first-year medical students.

[@dalicaminade3677]

Firstly, sorry for the loss of your wife.😢😔 Thank you very much for this eye opening and tremendous helpful, insightful, wisdomly video. Thanks be to God of the grace He had shown you that you then gave towards the people involved which in turn you encouraged them to be open to learning, vigilance and more education so we could all be prepared for unknown incidence as this and many more. God bless you and your family and that His presence in your life daily.🙏💕

[@TheResearcher-x3b]

This is an incredible lesson and this resonates the truth about how we work together as teams in any industry. If we listen to each other, and accept that someone else may have a different view that will only enhance what you are doing, we will have more success in all we do.

[@alskdudndjcndisksucbdj]

I'm a 3rd year undergraduate at the University of Sheffield studying BMedSci Health and Human Sciences. My aim is to become a researcher in health care. The story of this wife and mother, and the hundreds of stories where human factors have restricted communication will remain at the core of my professional venture. I am deeply sorry that such pain was caused, and I will remain eternally inspired to help in whatever way I can to help ensure people receive the care that was intended.

[@Flowerpower2407]

I would like to know what your upto nowadays

[@alskdudndjcndisksucbdj]

@@Flowerpower2407 I’m now a medical writer working to make sure that medical devices are safe and effective enough to stay on the market. As promised, patient protection is at the core of what I do! Thank you for your comment! :)

[@Christy79496]

Thank you Martin for sharing your story. I am learning this as a part of my nursing education & this has profoundly impacted me on many different levels. It has provided me with courage to speak up in situations where I may not be considered the most experienced or educated. No amount of pride is worth the price of our patients lives. Your forgiveness & desire for the clinicians in this story to continue to work and ensure this tragedy never happens again left me speechless. You are honouring your wife & teaching your children amazing values. I will make sure I never forget your story & share it where I can.

[@julielogan-n9b]

I am a CC nurse educator at a hospital in Florida. Do I have permission to use this video in a PowerPoint teaching new nurses entering the field?

[@hannahc4054]

Yet an other example of nurses knowing more than doctors. In situations like this it's important to listen to everyone.

[@VivekRajcoomar]

1 causes of mistakes due to "human factors"? Stress. Being overworked, having 9 dr's/nurses do the job of 10 (to save £), a rigid time limit per patient/procedure, targets, + financial incentives if met and a blind eye to any other costs/ corners cut in meeting them. How are we going to save £ in the NHS/ reduce its budget & public spending? By "reducing inefficiency" but unless careful, by increasing workload/stress & mistakes with will then be labeled as due to human factors instead of £.

[@mohsiddig135]

Much thanks for you and our thanks is extending to your doughtier, her life was the precious price to make me and my team more aware of non technical skills through her father video.This will help the people we taking care off, me and my team are providing medical service to high risk operation in desert for over 5k persons.