We congratulate Nathanson et al. for their timely editorial [1], and share their regret that lives continue to be lost to preventable errors. Twenty years ago, the death in similar circumstances of Elaine Bromiley led to the creation of the charity we now represent.

The reasons why skilled and conscientious practitioners make such errors are well-established. We know that human beings under stress are prone to ‘mind lock’ – rigid fixation on a diagnosis or course of action – and confirmation bias, where contradictory data (such as an abnormal capnography trace) are ignored, while corroborative information (such as breath sounds) is favoured. Sense of time dissipates and memory recall becomes difficult. These are fundamentally human responses and no amount of training will prevent them.

However, there is a common thread in all these tragedies, which is too often overlooked. In nearly all cases, senior colleagues arrived to assist within minutes, but these rescuers failed to cut through the ‘mind lock’ and followed the primary caregiver down the wrong, fatal, path. The role of rescuer is critically important but almost completely undefined. It is something few if any of us are formally trained in, yet it is in dire need of a formal, structured and, above all, standardised approach. In short, if we're going to train our way out of this problem, we need to train the rescuers.

Some of the attributes that make a good rescuer can be found in guidelines from the Association of Anaesthetists for implementing human factors in anaesthesia [2]. Much of it is counterintuitive (for example, the advice to stand back and analyse rather than pile in and do something) or counter-cultural (using checklists rather than relying on memory). Yet these seeds are sown on barren ground. How often does the Quick Reference Handbook sit on a shelf uselessly while a crisis is unfolding?

Specific rescuer training would reinforce these skills, while also achieving the aim of rehearsing rare scenarios, all of which is easily done in a simulator. Above all, such training should be standardised nationally, so that everyone involved in an incident, rescuer and rescuee, knows exactly how it will play out. This is a big challenge, but one that falls to our profession alone.

Finally, while we recognise the value of teams training together, the costs are enormous and insisting on this counsel of perfection too often leads to teams not training at all. Pilots are required to take a simulator assessment every 6 months, in which they rehearse their responses to rare emergencies in exactly the way envisaged by Nathanson et al., and they do so individually. Aircrews do not train as teams, yet no-one has died from an accident on a British commercial aircraft for 35 years.

Would that we could say the same for anaesthesia.

我们祝贺 Nathanson 等人的及时社论 [1]，并分享他们对可预防的错误继续失去生命的遗憾。20 年前，Elaine Bromiley 在类似情况下去世，导致了我们现在所代表的慈善机构的成立。

技术娴熟、尽职尽责的修行者犯这种错误的原因已经很清楚了。我们知道，在压力下的人类容易出现 “思维锁定”--僵化地关注诊断或行动方案--和确认偏差，即忽略矛盾的数据（如异常的二氧化碳图痕迹），而偏爱确凿信息（如呼吸音）。时间感消散，记忆回忆变得困难。这些从根本上说是人类的反应，再多的培训都无法阻止它们。

然而，所有这些悲剧都有一个共同点，但往往被忽视。在几乎所有情况下，高级同事都会在几分钟内赶到提供帮助，但这些救援人员未能打破“心灵锁”，并跟随主要护理人员走上了错误的、致命的道路。救援者的角色至关重要，但几乎完全没有定义。我们中很少有人接受过正式培训，但它迫切需要一种正式的、结构化的，最重要的是标准化的方法。简而言之，如果我们要通过培训来解决这个问题，我们需要培训救援人员。

在麻醉师协会 （Association of Anaesthetis） 关于在麻醉中实施人为因素的指南中，可以找到一些优秀施救者的特质 [2]。其中大部分是违反直觉的（例如，建议退后一步分析，而不是堆积起来做某事）或反文化的（使用清单而不是依赖记忆）。然而，这些种子却播种在贫瘠的土地上。当危机发生时，《快速参考手册》有多少次被无用地放在书架上？

特定的救援人员培训将加强这些技能，同时还可以实现排练罕见场景的目标，所有这些都可以在模拟器中轻松完成。最重要的是，此类培训应在全国范围内标准化，以便参与事件的每个人，无论是救援人员还是被救者，都确切地知道事故将如何发展。这是一个巨大的挑战，但仅限于我们的专业。

最后，虽然我们认识到团队一起训练的价值，但成本是巨大的，坚持这种完美的建议往往会导致团队根本不训练。飞行员需要每 6 个月进行一次模拟器评估，其中他们完全按照 Nathanson 等人设想的方式演练他们对罕见紧急情况的反应，并且他们单独进行。机组人员不进行团队训练，但 35 年来没有人死于英国商用飞机的事故。

如果我们能对麻醉说同样的话吗。