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The catastrophic outcomes that arise from failures in systems, planning and communication

During my training in Intensive Care Medicine, I was part of a team that treated a middle-aged man for cardiogenic shock. In the process of treating this man, the team was required to provide an emergency intubation for respiratory failure. A series of unfortunate events followed that resulted in an unrecognised oesophageal intubation. The man sustained a severe hypoxic brain injury from which he died about a week later.

A culmination of inter-hospital and intra-hospital system problems and failures in team planning and communication contributed to this man’s death.

Despite the post-event management and open disclosure being well executed, my colleagues and I suffered in our own ways as we worked out how to function under the burden of such a confronting situation. My responses to my first time in this situation were feelings of terror, shame, incompetence, self-loathing, despair and anger. In the subsequent weeks and months, I suffered flashbacks to these events. I felt like an abject failure and an incompetent doctor. I chose to share my experience and I spoke confidentially to colleagues, friends, family and professionals. It took a long time to process the chaos of that day.

The turning point for my recovery from this difficult time was when I actively chose to take this on as a learning experience.

I realised I needed to change the system to serve patients and healthcare staff better.

I chose to address the communication and technical factors in my practice that had contributed to this event. I also committed to honouring this man by teaching people about my experience. I do not want others to experience this, if possible. I discovered many others, including my clinical role models, had been through similar experiences. I gradually made my peace with that terrible situation. During the subsequent coronial hearing, I was well briefed by a compassionate legal team. I presented my evidence and had an opportunity to offer suggestions about how to prevent this happening again. I spoke with the bereaved family and my colleagues. The legal team organised another debriefing of the intensive care team after the hearing. We shared the experience again and we healed further.

This event has been a powerful driver of the development of my practice and teaching.

Personal reflections by Dr Cameron Knott, an Intensive Care Physician and a member of the AICG Course Advisory Committee.

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