Use of an Emergency Manual During an Intraoperative Pulmonary Arterial Rupture, Hypoxemia, and Bradycardia

The use of an emergency manual can improve team performance on critical steps during crisis events. Measures of improved performance have so far been captured through survey and simulation data; however, real-life case studies showing successful use of the manuals are fewer in number. The case of a patient with an unexpected rupture of the pulmonary artery, hypoxemia, and bradycardia during a video-assisted thoracic surgery lobectomy is described here. Relevant sections of Stanford University Operating Room Emergency Manuals were activated immediately and used during the rescue. The team of surgeons, anesthesiologists, and nurses managed the crisis in an orderly, smooth, and efficient manner, and the patient recovered without any complication. The use of the emergency manual reinforced by regular simulation-based training benefited the team and ultimately, the patient’s safety.