I remember how I felt when. I first watched “Just a Routine Operation“, – the story of the events that led to the tragic death of Elaine Bromiley.
Elaine Bromiley went into hospital for a routine operation. Despite an appropriate pre-operative assessment, the anaesthetists tasked with intubating Elaine found themselves in a Can’t Intubate, Can’t Oxygenate scenario, though they failed to recognise it at the time. As they struggled to provide oxygenation, they lost sight of the bigger picture, and Elaine remained critically hypoxic. It wasn’t until over 20 minutes later that they managed to secure an airway and transfer her to the ICU, where she died 13 days later.
But we wouldn’t have known about any of this if it were not for the bravery of her husband, Martin Bromiley. An airline pilot by training, he knew all about the importance of human factors in critical scenarios. He knew about closed-loop communications with the sterile cockpit, about flattening the hierarchy and planning for problems. We, the doctors, didn’t.
To be truthful, I felt angry. I felt angry that we had failed Elaine and Martin. I felt angry that things I took for granted were not happening. And I felt angry that human factors awareness was not a part of our core curriculum.
I first met Ben McKenzie when I was working for Adult Retrieval Victoria. Having spent a lot of time at sea, I thought I might enjoy a stint travelling around the great state of Victoria in all manner of flying craft instead. Having just completed my Paediatric ED placement, I donned the navy flight suit and spent two weeks learning how to deal with every conceivable le in-flight emergency.
I left Adult Retrieval to pursue my Paediatric Emergency career, and I hadn’t thought of Ben for some time until I heard his son, Max, had passed away.
Max McKenzie was an otherwise healthy teenager but died from a hypoxic brain injury sustained during food anaphylaxis-related bronchospasm/asthma. He was talented, happy and loved, and his death was a tragedy causing unimaginable pain for his family and the broader community.
He died in Victoria, Australia, in 2021 after a period of prolonged brain injury sustained in a fully equipped metropolitan hospital.
When Max entered the healthcare system, he was alert and could ask for help.
Tragically, inadequate emergency health care resulted in Max sustaining an unsurvivable brain injury.
At the moment, I still feel I am on an island while everyone else is on the mainland going about their lives. I can see and appreciate them, but there is a barrier between our lives and everyone else’s. I have a lot of existential questions that I can’t answer (nobody can), and the only thing I can do to give Max’s death meaning is to save just one other family from going through this. Teaching and encouraging everyone to be the best emergency physicians they can be is the only thing that helps me try to connect with life and everyone on the mainland.
I’m not angry at the people who could have saved Max’s life. The thing that makes me most angry is the response to his death. I’m angry at the system for letting a culture develop where that kind of standard of emergency medicine is ok – we were told face-to-face that Max’s care was “best practice”.
It makes me angry that the hospital review found nothing wrong about taking 23 minutes to intubate the victim of an asthmatic arrest causing asystole. It’s longer than Max’s favourite TV show, Brooklyn 99.
For better or worse, the way we set the standards for emergency medicine is the way we teach each other, support each other, and push each other to be better—and there should be more of that.
Ben McKenzie
Ben McKenzie has made it his mission to ensure this does not happen again. To do that, he has created the AMAX4 algorithm—a best practice algorithm for Critical Care Clinicians to use in Anaphylaxis and Asthma resuscitation.
Please head over to the AMAX4 website to find out more.
