A lens for the case
Follow the oxygen.
Enter the case with one question: what is happening to oxygenation while the team works?
Room 01 // Human factors
When the task replaces the problem.
Elaine Bromiley entered hospital for planned sinus surgery in 2005. After induction of anaesthesia, her airway became difficult and her oxygen saturation fell. Experienced clinicians continued trying to manage and intubate the airway while severe hypoxaemia persisted.
The independent review describes a skilled team with the equipment it needed. It also records attention narrowing around repeated airway attempts. Nurses recognized the crisis, brought a surgical-airway set into the room, and voiced concern. That information did not become a shared decision to change course.
Everyone was working. The work no longer matched the most urgent problem.
Boundary: The review lets us examine attention, communication, leadership, and transition. It cannot tell us that one different action would certainly have changed the outcome.
The case film
Elaine Bromiley: The Essentials
As you watch, follow what the patient's oxygenation is doing while the team remains occupied with airway tasks.
Room 02 // The First Law
The First Law
Oxygenation is the mission.Everything else is tactics.
A tracheal tube can provide a reliable route for ventilation once it is in place. The attempt to place it consumes time, oxygen reserve, and attention. Those are different physiologic moments.
An intubation attempt cannot be allowed to hide failure to oxygenate. The team must be able to name the tactic, decide whether it is working, and recognize the finding that will end it.
The Difficult Airway Society's 2025 adult guideline prioritizes continuous oxygen delivery, maximizes the chance of successful intubation at the first attempt, confirms ventilation with waveform capnography, and moves through planned alternatives when a tactic fails.
The First Law is PAC's organizing principle for keeping the technique in proportion to the physiology.
Boundary: The exact device, sequence, and stopping point depend on the patient, setting, operator, and local protocol. Those decisions are developed in the Exhibits ahead.
References & further exploration →
- Clinical Human Factors Group. Elaine Bromiley’s story and the independent review.The family’s account and links to the review: explore the interaction of task fixation, communication, and the working system.
- Ahmad I, El-Boghdadly K, Iliff H, et al. Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults.
Gallery complete // Practice remains
See how the First Law gets lost.
Three short cases show how a tactic, a technical failure, or an unowned team priority can quietly displace oxygenation.
Practice Studio // Exhibit 01
See how the First Law gets lost.
The First Law is easy to agree with before the room becomes difficult. Open each case. Notice what pulls attention away from oxygenation. Then reveal the error.
Three clinical scenarios
What displaced oxygenation?
Tap once to open the case. Decide what went wrong. Tap again to reveal the error.
Swipe or use the arrows to move through the cases
You are finished when you can name what displaced oxygenation in each case before revealing the answer.
These cases teach recognition. They do not prescribe a patient-specific airway plan or establish clinical competence.If a case feels complicated, strip it back to one question: what is happening to oxygenation while the team remains busy?
Exit Passage
Carry the First Law forward.
The next Exhibit introduces a cognitive tool for recognizing failing oxygenation, organizing best effort, and moving before fixation takes hold.
Next Exhibit · Poster 110