Abstract
A 32-year-old trauma patient was admitted to the emergency department with severe head trauma, maxillofacial injuries, blunt thoracic trauma, an open fracture of the femur, and the suspicion of a contained subcapsular hematoma of the spleen. Following the initial work-up, the patient was transferred to the OR and was simultaneously operated on by trauma surgeons and maxillofacial surgeons. Twenty minutes after the incision, the patient developed increasingly high peak inspiratory pressures, the tidal volumes began to decrease, and the saturation dropped. The flow-volume curve on the monitor showed an incomplete expiratory phase; however, lung auscultation was normal. Suspecting bronchospasm, the anesthesiologist initiated broncholytic therapy which failed to improve the ventilatory parameters. At the anesthesiologist’s request, the surgeons explored the oral cavity and noticed that the endotracheal tube was kinked. After unkinking the tube, the peak pressure, tidal volumes, and saturation normalized.
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsPreview
Unable to display preview. Download preview PDF.
References
Atlee JL (2007) Complications in anesthesia. Saunders, Philadelpha
Badke-Schaub P (2002) Kritische Situationen als Analyseeinheit komplexer Handlungen [Critical situations as unit for analyzing complex actions]. In: Trimpop R, Zimolong B, Kalveram A (eds) Psychologie der Arbeitssicherheit und Gesundheit, Neue Welten – alte Welten [Psychology of work safety and health]. Asanger, Heidelberg, pp 137−142
Cook R, Woods D (2001) Operating at the sharp end: the complexity of human error. In: Salas E, Bowers C, Edens E (eds) Improving teamwork in organizations: applications of resource management training. Erlbaum, Mahwah, New Jersey, pp 255−310
Dörner D (1996) The Logic of failure. Recognizing and avoiding error in complex situations. Metropolitan Books, New York
Dörner D, Schaub H (1994) Errors in planning and decision-making and the nature of human information processing. Appl Psychol Int Rev 43:433−453
Frensch A, Funke J (eds) (1995) Complex problem-solving: the European Perspective. Erlbaum, Hillsdale, New Jersey
Gaba D (1992) Dynamic decision-making in anesthesiology: cognitive models and training approaches. In: Evans DA, Patel VL (eds) Advanced models of cognition for medical training and practice. Springer, Berlin Heidelberg New York, pp 123−148
Gaba DM, Fish KJ, Howard SK (1994) Crisis management in anesthesia. Churchill Livingstone, New York
Gravenstein N, Kirby RR (1995) Complications in anaesthesiology. Lippincott-Raven, Philadelphia
Kahneman D, Slovic P, Tversky A (1982) Judgment under uncertainty: heuristics and biases. Cambridge University Press, Cambridge
Klein G (1992) A recognition-primed decision (RPD) model of rapid decision-making. In: Klein G, Orasanu J, Calderwood R, Zsamboka E (eds) Decision-making in action: models and methods. Ablex, New Jersey, pp 138−47
Perrow C (1999) Normal accidents. Living with high-risk technologies. Princeton University Press, Princeton, New Jersey
Rasmussen J (1979) On the structure of knowledge: a morphology of mental models in a man−machine systems context. Technical Report Riso-M-2192. Riso National Laboratory, Roskilde, Denmark
Rasmussen J (1983) Skills, rules, knowledge: signals, signs and symbols and other distinctions in human performance models. IEEE Trans Systems, Man and Cybernetics, vol SMC-13, no. 3, pp 257−267
Rasmussen J (1987) Cognitive control and human error mechanisms. In: Rasmussen J, Duncan K, Leplat J (eds) New technology and human error. Wiley, Chichester, pp 53−61
Rasmussen J, Lind M (1981) Coping with complexity. Technical Report Riso-M-2293. Riso National Laboratory, Roskilde, Denmark
Reason J (1990) Human error. Cambridge University Press, Cambridge UK
Reason J (1997) Managing the risks of organizational accidents. Ashgate, Aldershot
Salas E, Dickinson TL, Converse SA, Tannenbaum SI (1992) Toward an understanding of team performance and training. In: Swezey RW, Salas E (eds) Teams: their training and performance. Ablex, Norwood, New Jersey, pp 3−30
Sterman JD (1994) Learning in and about complex systems. Syst Dyn Rev 10:291−330
Taylor TH, Major E (1987) Hazards and complications in anaesthesia. Churchill Livingstone, Edinburgh UK
Tversky A, Kahneman D (1974) Judgment under uncertainty: heuristics and biases. Science 185:1124−1131
Woods D (1988) Coping with complexity: the psychology of human behaviour in complex systems. In: Goodstein L, Andersen H, Olsen S (eds) Tasks, errors and mental models. Taylor Francis, London, pp 128−147
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2008 Springer-Verlag Berlin Heidelberg
About this chapter
Cite this chapter
(2008). The Challenge of Acute Healthcare. In: St. Pierre, M., Hofinger, G., Buerschaper, C. (eds) Crisis Management in Acute Care Settings. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-540-71062-2_2
Download citation
DOI: https://doi.org/10.1007/978-3-540-71062-2_2
Publisher Name: Springer, Berlin, Heidelberg
Print ISBN: 978-3-540-71061-5
Online ISBN: 978-3-540-71062-2
eBook Packages: MedicineMedicine (R0)