Matthew Syed - Black Box Thinking: Why Most People Never Learn from Their Mistakes--But Some Do

O n March 29, 2005, Martin Bromiley woke up at 6:15 a.m. and made his way to the bedrooms of his two young children, Victoria and Adam, to get them ready for the day. It was a rainy spring morning, a few days after Easter, and the kids were in high spirits as they sprinted downstairs for breakfast. A few minutes later, they were joined by Elaine, their mother, who had snatched a few extra minutes in bed.

Elaine, a vivacious thirty-seven-year-old who had worked in the travel industry before becoming a full-time mother, had a big day ahead: she was due in the hospital. She had been suffering from sinus problems for a couple of years and had been advised that it would be sensible to have an operation to deal with the issue once and for all. Dont worry, the doctor had told her. The risks are tiny. It is a routine operation.

Elaine and Martin had been married for fifteen years. They met at a country dance through a close friend, had fallen in love, and eventually moved in together in a house in North Marston, a cozy village in the heart of rural Buckinghamshire, thirty miles northwest of London. Victoria had arrived in 1999 and Adam two years later, in 2001.

Life was, as for many young families, hectic, but it was also tremendous fun. They had been in an airplane for the first time as a family the previous Thursday and had gone to a friends wedding on the Saturday. Elaine wanted to get her operation out of the way so she could enjoy a few days break.

At 7:15 a.m., they left home. The kids chatted in the car as they made the short journey to the hospital. Martin and Elaine were relaxed about the operation. The ear, nose, and throat (ENT) surgeon, Dr. Edwards, had more than thirty years of experience, and was well regarded. The anesthetist, Dr. Anderton, had sixteen years of experience. The hospital had excellent facilities. All was set fair.

When they arrived they were shown to a room where Elaine was put into a blue gown for her operation. How do I look in this? she asked Adam, who giggled. Victoria climbed up onto the bed so that her mother could read to her. Martin smiled as he listened to a plot that was, by now, familiar. On the windowsill, Adam played with his toy cars.

At one point Dr. Anderton came in to ask a couple of standard questions. He was chatty and in fine humor. Like any good doctor, he understood the importance of setting a relaxed tone.

Just before 8:30 a.m., Jane, the head nurse, arrived to wheel Elaine into the operating room. Are you ready? she asked with a smile. Victoria and Adam walked alongside the gurney as it rolled down the corridor. They told their mother how much they were looking forward to seeing her in the afternoon, after the operation. As they reached a junction in the corridor, Martin ushered his children to the left as Elaine was wheeled to the right.

She leaned up, smiled, and cheerily said: Byeeee!

As Martin and the kids were walking into the parking garagethey were going to the supermarket to do the weekly shopping and buy a treat for Elaine (cookies)Elaines gurney was being wheeled into the pre-operating room. This room, adjacent to the operating room, is where last-minute checks are made and the general anesthetic administered.

Dr. Anderton was with her: a familiar and reassuring face. He inserted a straw-shaped tube called a cannula into a vein in the back of her hand, which would deliver the anesthetic directly into her bloodstream.

Nice and gently, Dr. Anderton said. Here you go... into a deep sleep. It was now 8:35 a.m.

Anesthetics are powerful drugs. They dont just send a patient to sleep; they also disable many of the bodys vital functions, which have to be managed artificially. Breathing is often assisted using a device called a laryngeal mask. This is an inflatable pouch that is inserted into the mouth and sits just above the airway. Oxygen is then pumped into the airway, and down into the lungs.

But there was a problem. Dr. Anderton couldnt get the mask into Elaines mouth: her jaw muscles had tightened, a familiar problem during anesthesia. He delivered an additional dose of drugs to loosen the muscles, then tried a couple of smaller laryngeal masks but, again, couldnt insert them.

At 8:37, two minutes after being put under, Elaine was beginning to turn blue. Her oxygen saturation had fallen to 75 percent (anything below 90 percent is significantly low). At 8:39 Dr. Anderton responded by trying an oxygen face mask, which sits over the mouth and nose. He still couldnt get air into her lungs.

At 8:41 he switched to a tried-and-tested technique called tracheal intubation. This is standard protocol when ventilation is proving impossible. He started by delivering a paralyzing agent into the bloodstream to completely disable the jaw muscles, allowing the mouth to be fully opened. He then used a laryngoscope to cast a light into the back of the mouth, helping him to place a tube directly into the airway.

But he hit another snag: he couldnt see the airway at the back of the throat. Normally, this is a neat, triangular hole, with the vocal cords to either side. It is usually quite easy to push the tube into the airway and get the patient breathing. With some patients, however, the airway is obscured by the soft palate of the mouth. You just cant see it. Dr. Anderton pushed on the tube again and again, hoping that he would find the target, but he couldnt get it in.

By 8:43 Elaines oxygen saturation had dropped to 40 percent. This was so low it represented the lower limit of the measuring device. The danger is that, without oxygen, the brain will swell, causing potentially serious damage. Elaines heart rate had also declined, first to 69 beats per minute, then 50. This indicated a lack of oxygen to the heart too.

The situation was becoming critical. Dr. Bannister, an anesthetist in the adjacent operating room, arrived to provide assistance. Soon Dr. Edwards, the ENT surgeon, had joined them too. Three nurses were on standby. The situation was not yet disastrous, but the margin for error had started to shrink. Every decision now had potentially life-and-death consequences.

Thankfully, there is a procedure that can be used in precisely this situation. It is called a tracheotomy. All the setbacks so far had been in trying to access Elaines airway via her mouth. A tracheotomy has one huge advantage: you dont go near the mouth. Instead, a hole is cut directly into the throat and a tube inserted into the windpipe.