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Message from the Chair: Missed Diagnosis

I’m the daughter of an aviator.

I spent hours as a child sitting with my dad on the hood of a ’65 Mustang watching planes take off and land at Minneapolis/St. Paul International Airport. A former Air Force instructor pilot and Northwest Airlines captain, he taught me early on how 450 tons of aluminum can become airborne (Newton’s Third Law) and other aerodynamic concepts like pitch, yaw, attitude, and angle-of-attack. I still love talking to my father about airplanes and, like cable news outlets, often turn to my own resident aviation expert whenever a commercial airliner goes down. He is nearly always spot on when he predicts a crash was due to pilot error. Though each accident may have different antecedents, the final, often fatal mistake usually boils down to a simple failure of the flight crew to “fly the airplane.”

The 2009 crash of Air France 447, an overnight flight from Rio de Janeiro to Paris, is a classic case study in pilot error. Over the Atlantic, three hours into a routine flight, the crew started receiving faulty airspeed readings while entering a thunderstorm. Onboard computers, recognizing the erroneous airspeed was inconsistent with all the other normally functioning flight indicators, kicked off the autopilot. Forced to fly manually and distracted by the faulty airspeed, the crew (incorrectly) pulled the nose up, slowing the plane down and precipitating a stall. This error was further compounded when, in a departure from standard cockpit procedure, the pilots failed to monitor and call out loud the plane’s altimeter readings (how far up in the air the plane is). Recovering from a stall is as instinctive to an aviator as putting one’s hands out to break a fall: point the nose down, build up air speed, restore lift to the wing (Bernoulli’s Principle), and pull out into level flight. The crew had at least two minutes during their free fall to safely execute this maneuver but lost situational awareness of where they were in the air. Trying to troubleshoot the various alarms, confused and panicked by conflicting information, the pilots of Air France 447 literally forgot to “fly the airplane.” In under four harrowing minutes, the Airbus 330 dropped 38,000 feet from the nighttime sky killing all 228 aboard.

This issue of the Digest is dedicated to missed diagnoses, the medical equivalent of “forgetting to fly the airplane.” By one estimate, failure to diagnose kills over 40,000 people annually in American ICUs alone.1 That’s the equivalent of three Air France crashes every week. Plaintiffs alleged a failure to diagnose in 13% of OMIC’s 4,500 closed claims. It’s not the “zebras” we overlook; retinal detachment, glaucoma, and intraocular foreign bodies are among the top diagnoses we miss. The same factors contributing to pilot error—conflicting information, distraction, lack of communication, departure from preferred practice patterns—are at work in our clinical environments. Like those Air France pilots who failed to execute a successful recovery from their stall, we ophthalmologists usually have all the clinical information we need to make the correct diagnosis, even when we fail to do so. Maintaining situational awareness in high stakes, high stress situations—Why is this patient deteriorating? What could I be missing?—helps us to better connect the dots. Now sit back, relax, and read on for tips to keep you and your passengers, I mean patients, safe.

  1. http://qualitysafety.bmj.com/content/early/2012/07/23/bmjqs-2012-000803.abstract
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