The Case of Elaine Bromiley
Elaine Bromiley, an otherwise well 37 year old woman, presented for routine sinus surgery in 2005 and died due to complications of an an unanticipated difficult airway. The case highlights how, despite the presence of skilled and diligent clinicians, human factors can adversely impact on patient care. The following free resources have been made available in order to increase awareness of the issues involved in cases such as these and potential strategies to address them.
In this podcast with Martin Bromiley & Nicholas Chrimes, they discuss human factors in healthcare and the rationale behind making the 2 new videos to supplement the original "Just A Routine Operation" documentary.
Just A Routine Operation
In this documentary, produced by thinkpublic for the NHS Institute for Innovation and Improvement, Martin Bromiley discusses the events surrounding the death of his wife. Martin's comments come not just from a personal perspective but from that of an airline pilot working in an industry which places a strong emphasis on the importance human factors engineering. Martin expresses the hope that changes can be brought about in the approach of healthcare to human factors. To further this goal Martin founded the Clinical Human Factors Group in 2007.
The Elaine Bromiley Case
This recreation, produced by Simpact with the support of Martin Bromiley, is primarily intended for the education of healthcare clinicians, particularly those involved in advanced airway management. By providing a more immersive, real-time version of events which includes some technical detail, the hope is that this video will increase the learning opportunities from the case by assisting airway clinicians to understand not just how these events could happen - but how they might happen to them.
The video was made in collaboration with the Australian Centre for Health Innovation and launched the Society for Airway Management meeting in Seattle on September 20th 2014.
It is important to recognise that many details of what transpired during this case are unknown. The depiction of unknown events has been based on the best estimate of expert clinicians. The scenario portrayed thus represents only one possible interpretation of the reported events and approximate timeline of the case. This video is not intended to depict the specific actions of particular individuals and whilst based on actual events, it is a work of fiction.
What If?
Teamwork in Emergency Airway Management
This video, produced by Simpact with the support of Martin Bromiley, portrays a scenario which deliberately resembles the circumstances of the Elaine Bromiley case, to illustrate the potential impact of various teamwork behaviours, cognitive tools and other interventions, including the Vortex Approach, in the management of an airway crisis.
It is not possible to know whether these strategies would have influenced the the course of events in the actual context of the Elaine Bromiley case. The intention is that this video be used to initiate discussion about approaches which might facilitate the efficient implementation of the technical aspects of difficult airway management, by optimising teamwork and situational awareness during an emergency.
This video was made with the support of the Australian Centre for Health Innovation and launched at "The Airway Meeting" run by Monash Anaesthesia on November 22nd 2014.
'The Elaine Bromiley Case' and 'What If?' videos are distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License which permits use without alteration for non-commercial purposes with acknowledgement of Simpact Pty Ltd as the creators and copyright holders of the work. No derivative works. For commercial use please contact Simpact.