Richard Smith: Flying a Jumbo jet and doing a kidney transplant for the first time: a parable

richard_smith_2014Recently a young friend flew a Jumbo jet across the Atlantic for the first time, reminding me of a contrasting story of another friend doing his first kidney transplant.

The airline industry, which has a remarkable record of safety and where safety really is the first priority, is often invoked in discussions about safety in healthcare, where 10% of patients admitted to hospital suffer injury and one in a hundred dies because of error, famously making hospital admission much more dangerous than bungy-jumping. The comparison mustn’t be taken too far because airline safety is concerned primarily with managing a (usually) predictable machine, whereas healthcare is primarily concerned with highly unpredictable people.

My pilot friend has been flying medium-sized planes in Europe for a couple of years, so when he switched to Jumbo jets his training was all in a simulator. For almost two months he was put through every set of circumstances. Then the came the day when he had to fly for real.

He didn’t sleep the night before and was consumed by both terror and excitement. Although it was his first flight piloting an actual plane it was his job to fly the plane during both take off and landing. He wasn’t, of course, alone: a captain trained to be a trainer and another first officer sat beside him. But you can imagine the excitement and terror he must have felt as he took 300 tons of aircraft and 300 people down the runway at 200 miles an hour and lifted the whole lot into the sky. The pulse of even an experienced pilot rises to 150 on take off.

We joked about the Captain announcing to the passengers: “Good morning everybody, this is Captain Haddock speaking. First officer Macbeth will be flying us across the Atlantic today, and I’m pleased to tell you that this is his first flight. So wish him well, and please give him a cheer as we approach the end of the runway. Fingers crossed everybody, here we go.”

My kidney transplant story is from long ago, from a world that I hope has vanished but fear has not entirely. My friend was an experienced urologist with many operations behind him, but he had never done a kidney transplant. He made this clear when he was appointed to an academic post and was assured that he would not be called on to do transplants until fully trained.

Two week after he started his new job he was called by the professor to do a transplant. The professor was in an important committee meeting and unable to do the operation himself.  My friend reminded the professor that he had never done a transplant.

“Oh, you’ll be fine,” said the professor, “You’ve lots of experience. It’s not that hard.” [Needless to say, I wasn’t part of this conversation, but I am imagining the professor’s words to tell the story.]

My friend resisted.

“Well, both the patient is anaesthetised, and they are ready to go. If you really don’t want to do it, call the theatre to wake the patient up.”

My friend thought of the patient, succumbed, and did the operation. The patient survived.

But the patient might well not have survived, whereas those flying the Atlantic can be almost certain of surviving, even when the plane is being flown by a pilot for the first time.

Richard Smith was the editor of The BMJ until 2004.