Intended for healthcare professionals

Observations Ethics Man

Preparing for when things go wrong

BMJ 2016; 354 doi: (Published 25 August 2016) Cite this as: BMJ 2016;354:i4627
  1. Daniel Sokol, medical ethicist and barrister
  1. 12 King’s Bench Walk, London
  1. Sokol{at}

What doctors can learn from astronauts

During his basic training as a fighter pilot, the astronaut Chris Hadfield was flying his jet in close formation, with jets immediately to his right and left, when he noticed a bee inside his helmet. Losing his cool would have endangered his life and those of his colleagues. Years later, in 2001, Hadfield was out on a space walk, holding on to the side of a spaceship travelling at more than 28 000 km an hour around the earth. He first lost his vision in one eye, and then the other. Again he kept calm. About 20 minutes later he recovered enough sight to complete the mission. He had been blinded by the anti-fog detergent used the evening before to clean his visor.

An even more perilous situation befell the Italian astronaut Luca Parmitano in July 2013. On a space walk Parmitano started feeling water on the back of his neck. The water gradually spread over his head into his ears, cutting off his ability to hear instructions, then into his eyes, blinding him, and into his nose, impeding his breathing. With considerable effort he managed to “feel” his way back into the spaceship. NASA’s report on the incident, which found that Parmitano’s spacesuit had leaked up to 1.5 L of water, noted that his “calm demeanor in the face of his helmet filling with water possibly saved his life.”1

In a TED talk in March 2014 Hadfield described his preparation for a space launch. He told the audience that in the first five shuttle launches the chances of a “catastrophic event” were one in nine. At the time of his launch in 1995 the odds of such an event were one in 35-40. He recounted mentally preparing for things going wrong during the launch, spotting which switches would need to be flicked for each eventuality. He then said, “In the astronaut business, we have a saying, which is: there is no problem so bad you can’t make it worse.”

Making a bad situation worse

The dictum applies in obvious ways to medicine. A surgeon reaches deep into the sylvian fissure of the brain in search of an unruptured aneurysm. Suddenly, it ruptures. The blood rushes up, flooding the operative site in high pressure arterial blood. The temptation is to panic. Yet, a few seconds of hesitation could make the difference between life and death. One error can lead to another, making a bad situation even worse.

With his characteristic honesty the neurosurgeon Henry Marsh described in his book Do No Harm how he once used a faulty applicator when clipping a cerebral aneurysm.2 The fault could have led to a tear of the aneurysm and a catastrophic haemorrhage. Marsh was so frustrated by the situation that he shouted, swore, and eventually threw the instrument across the room. This response would not attract praise from the astronaut community.

The dictum applies as well to ethical issues in medicine. A poorly handled conversation with a patient’s relative is left unresolved and escalates into a full blown complaint. A medical error is deliberately withheld from a patient, only to surface later, with serious consequences for the doctor. The failure to respond appropriately to an initial problem will often confirm the truth of the dictum.

Like an astronaut, the well prepared doctor will foresee what may go wrong and rehearse an appropriate response. What to do if the aneurysm bursts prematurely, the needle enters the wrong space, or a relative disagrees with your proposed plan? In an interview last January Hadfield said, “In my experience things hardly ever go perfectly. Stuff goes wrong. That’s just life. But we call that ‘going wrong.’ I think it’s just ‘going normal.’”3

“There’s no problem so bad you can’t make it worse”—Chris Hadfield


  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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