Of the research I’ve done, and the opinion pieces I’ve had published during my professional life, only one article seems to have had any lasting impact. It’s Biggles FRCA.
I wrote it on a whim one Sunday afternoon in 1998, and sent it off to a free magazine that was then being distributed to my profession in the UK, Today’s Anaesthetist. It saw print in the July/August edition that year. They spelled my name wrongly, and added a typo that changed the sense of one important sentence. I wasn’t particularly concerned—it was just a bit of whimsy, after all.
And then something odd happened. People laminated it and stuck it up on the wall of their common room. At meetings, colleagues were seeking me out to ask if I was the one who’d written Biggles FRCA. After a while, a plain text version showed up as an e-mail attachment that went the rounds intermittently. A bit later, people started to post it on their blogs—sometimes with appropriate attribution, sometimes not.
My little bit of whimsical fluff had turned into an Internet Phenomenon, albeit at a strictly homeopathic level. And it’s still out there, rattling endlessly around the blogosphere. It has even been cited in a scientific journal* and a textbook† (the latter being the only time I will ever appear in a reference list that also includes “Shakespeare W” and “Wodehouse PG”).
So I thought it was time to repossess it—which also gives me the chance to remove the accumulated typos, get my name spelled properly, and give due credit to its original publishers.
By way of explanation: Biggles is the pilot hero of a series of novels written by Captain W.E. Johns (you probably knew that); FRCA is the Fellowship of the Royal College of Anaesthetists, a postgraduate qualification that is a marker of due professional training for UK anaesthetists. The story came about because of a then-popular analogy (popular among anaesthetists, that is) comparing the process of anaesthetizing a patient for surgery with flying an aeroplane. Putting the patient to sleep was like the take-off, maintenance of anaesthesia during surgery was like level flight, waking the patient up was like the landing. Various allegedly informative parallels were drawn. Biggles FRCA found humour by taking that analogy and running with it, putting poor Biggles into the cockpit of an aeroplane that was behaving as if it were a patient undergoing surgery.
I should add a disclaimer, I suppose. I believe strongly that the aviation industry has many lessons to teach health-care practitioners. Aviation engineers and pilots have a deep understanding of the failure modes of complex systems operated by fallible humans, and have developed ways of minimizing the associated risks. And anaesthetists are nowadays working hard to learn from the aviation model. However, all that serious and important stuff is a world away from the rather simple-minded analogy I was poking fun at in Biggles FRCA.
So here it is—the full, corrected text appears below. For fun, I’ve also put it together in downloadable form as a pdf and in a couple of e-book formats. (And if you download one of the e-books, you also get the fine cover page featured at the top of this post!)
* Vickers MD. The psychology of human error. European Journal of Anaesthesiology 1999; 16: 578
† Nethercott D, The Fundamental Principles of Anaesthesia. In: Cottle D, Laha S, eds Anaesthetics for Junior Doctors and Allied Professionals: The Essential Guide. London: Radcliffe Publishing, 2013
First published in Today’s Anaesthetist Vol.13 No.4 July/August 1998
LORD, IF ONE MORE PERSON tells me that giving an anaesthetic is like flying a plane, I will swing for them, I really will.
Look. The whole point of a plane is that it is designed to fly, and if it’s not working properly then you don’t take it off the ground. Human beings, in contrast, are not designed to be anaesthetized, and are often not working properly when the occasion arises. They are also rather poorly provided with back-up systems and spares, and frequently have long histories of inadequate servicing.
So if giving an anaesthetic is like flying a plane, then this must be what flying a plane is like:
Captain James Bigglesworth DSO stepped out into the thin sunlight, and took a deep breath of the damp air. It was good to be alive. He was taking up a new crate today, and he relished the little knot of mixed tension and anticipation that always formed at the pit of his stomach under such circumstances. He strode briskly towards the hangar.
The Junior Engineer was waiting next to the aeroplane. He handed Biggles a single sheet of paper, on which he had scrawled a haphazard note of his work on the craft.
“Is this all?” asked Biggles. “Where is the service record?”
“It seems to be lost. The filing department say it’s maybe still at the previous airfield.”
“And the manual?”
The Junior Engineer looked startled. “I don’t think there is one. We thought you knew how to fly a plane.”
A cloud drifted slowly across the sunny sky of Biggles’ mind. He began his walk-round.
“Where’s this oil coming from?”
The Junior Engineer frowned seriously. “I don’t know.”
Biggles sighed. But he too, long ago, had once been a Junior Engineer. “Where do you think it might be coming from?”
“The engine?” hazarded the youth.
“Of course. So what’s the oil level in the engine?”
“I don’t know.”
“Have you checked the oil level?”
Biggles could feel his voice becoming a little tight, a little cold. “So could you check it now, please?”
“But you’re just going to take off. The Chief Engineer wants you to take off right away.”
“Not without an oil level. And this undercarriage strut is broken. And the port aileron is jamming intermittently.”
At that moment, the Chief Engineer arrived. “Biggles, old chap! Ready to take her up? Good man.”
“She’s not remotely airworthy. I need an oil level and some basic repairs.”
The Chief Engineer sighed. “What do you want an oil level for? You know it’s going to be low. We’ve got to get her into the air before we can control the leak. And that undercarriage and aileron aren’t going to get any better while we stand here. She needs to be in flight before I can properly assess them. Come on, old chap—the tower’s given us a slot in ten minutes’ time. If we don’t take off then, we’ll be waiting all day.” He eyed the plane despondently, and tapped a tyre with the toe of his boot. “And, frankly, I don’t think she’ll last much longer.”
Biggles rippled the muscles of his square jaw. The Bigglesworths had never balked at a challenge, but this … Well, there seemed to be no way out of it. He was going to have to take the old crate into the air, just as she stood. Deuced bad luck, of course, but no point in whining.
Twenty minutes later, they were aloft. The plane kept trying to fly in circles, and the engine temperature gauge was sitting firmly in the red. The Engineer was out on the cowling with a spanner.
“Just turn her off for a bit,” he bawled over the clattering roar of the sick engine.
Biggles was astonished. “What?”
“Turn off the engine. There’s nothing I can do about this leak until the engine’s stopped.”
Reluctantly, Biggles turned off the engine, and trimmed the aircraft for a shallow glide. The weight of the Engineer, out there on the nose, was not helping matters at all.
Four minutes passed in eerie silence, as the treetops swam up to meet them. “I’m going to need power again soon.” There was no response from the Engineer. Another thirty seconds passed. “I need power.” No answer. “I’m turning on now.” The engine roared, and the Engineer recoiled, cursing, in a cloud of black smoke.
“What’s your game, Biggles, old man? I almost had the bally thing fixed, and now we’ll need to start all over again!”
Biggles bit back an angry retort, and concentrated on guiding the crippled plane upwards. This time, now that he knew what was going on, they would start their glide from a lot higher.
After another protracted glide, the Engineer clambered back into the cockpit, beaming. “All fixed!”
Biggles tapped the oil pressure gauge. “Pressure’s not coming up,” he said.
“It will, it will,” said the Engineer breezily. “Don’t be such a fusspot. Now let’s get the aileron sorted.”
He crawled out onto the wing, and began to strike the recalcitrant aileron with a hammer. A minute later, the plane rolled violently to the right. Biggles struggled momentarily for control, his lips dry. By cracky, they’d almost lost it completely, there.
“Don’t do that!” he called hoarsely to the Engineer.
“Whatever you did, just then.”
“I wasn’t doing anything, old man.”
Almost at that moment the plane lurched again, more fiercely, and rolled through forty-five degrees. “That!” screamed Biggles, fighting the controls for his very life. “Don’t do that!”
“Fair enough,” said the Engineer, cheerily. A minute later he did it again, and the plane was inverted for ten long seconds before a sweating Biggles regained any vestige of control.
“Fixed! Undercarriage next!” called the Engineer, and clambered out of sight below the fuselage.
Ten minutes later, Biggles caught brief sight of a set of wheels dropping away earthwards. “Couldn’t save ’em,” said the Engineer when he regained the cockpit. “Better off without them, frankly.”
“I still have very little oil pressure,” said Biggles, worriedly.
The Engineer pursed his lips and tapped the pressure gauge reflectively. “Well, the leak’s fixed, old man. Must be something about the way you’re flying her.” He reached under his seat and pulled out a parachute. “Look, I’m most frightfully sorry about this, but the nice men from Sopwith are taking me out to dinner tonight, so I’ve got to dash. Be a brick, Biggles old fellow, and just put her down anywhere you like. I’ll cast an eye over her in the hangar tomorrow morning.”
And with that, he was gone.
Biggles thought longingly of his own parachute. But he couldn’t abandon the old girl now. It wasn’t her fault, after all. Black, oily smoke was already billowing out of the engine cowling, however—he needed to put her down soon. He began to peer around for a flat place to land and, almost immediately, he spotted a distant grassy field. He moved the controls a little so that he could take a closer look.
He flew around the field once, and it certainly looked flat enough. Oddly, someone had painted huge white letters across the level green grass—I C U, it read. He had no idea what that meant, but it seemed vaguely comforting, for some reason. The engine coughed once, and then stopped. He could see a fitful orange glow beneath the cowling. This rummy ICU field would just have to do, it seemed.
As he swung the ailing aircraft around to make his final approach, he realized that the field was just a little too short for comfort. He licked his lips, and prayed that there would be enough room.