Paralysed by indecision

One of the defining skills of being a doctor is the need to make decisions, sometimes with limited information and under significant time pressure.

As I’ve matured in my career, I’ve realised that most of what I was taught in medical school was just plain wrong.  The ongoing challenge has been to identify WHICh bits were wrong and to remain constantly up-to-date across my field of practice.  An oft quoted phrase is “the more medicine I do, the less certain I am!”

FOAMed (free open access medical education) has helped me in this regard, especially the use of SoMe to interact with colleagues around the globe, discuss common diagnostic challenges and learn from the global collective of engaged clinicians,

However success in tightly-coupled high stakes decision-making is not just about clinical knowledge.  It requires an understanding of error, of metacognition (thinking about ‘how we think’) of understanding performance under pressure and realising that guidelines and protocols aren’t always the solution.

Some recent examples – up in Cairns, discussing basic airway management on the ETMcourse and the old adage of ‘never insert a nasopharyngeal airway’ in suspected basal skull fracture came up.  Some of the more junior docs stated they’d NEVER inert an NPA in a base of skull or max-fax injury.  So I showed them a picture of a patient with horrendous maxillofacial injuries, likely BOS fracture based on mechanism…and two NPAs inserted.  The decision-making was that without it, we couldn’t preoxygenate to perform RSI.  How did we get to that course of action? By talking about it.  “This is massive maxillofacial injury – and he’s probably got a base of skull fracture. We both know that standard teaching is that we shouldn’t insert an NPA…but if we don’t we won’t be able to pre oxygenate this patient in any way.  So let’s pop in a Guedel, two NPAs and crank up the O2 whilst running through the RSI checklist.  Agreed? OK then...”

Similarly discussing the sad Zeke Upside case – a cardiac arrest management on the basketball pitch (see video below) and the clinicians conflict between ‘don’t move the patient – might have a C spine injury’) and the inherent need to consider CPR in this unresponsive young athlete who has collapsed on the court, witnessed, no contact with another player.

It’s excruciating to watch.

I won’t dissect the case in detail.  Suffice it to say that after the player collapses, an Automatic External Defibrillator is brought to the patient within 10 seconds…and remains unused.

The player is facedown.  The intervention we witness appears to be ‘bring towels’

I have compassion for the clinician.  It’s a tough call sometimes and one can almost feel the cognitive gears grating as competing management demands collide against each other.

I assume that the clinician was paralysed with indecision in the face of limited clinical information, a large crowd and conflicting guidelines i.e. “Don’t move the patient who may have a suspected C spine injury” vs “Is he breathing normally? If not, do we need to consider CPR?

A horrible position to be in.   But that’s what being a doctor requires.

Meanwhile there was an AED not 12 inches from the patient…and a whole basketball court of young fit athletes able to help perform CPR.

How could that happen?

I think the key here is that performance and resuscitation isn’t just about clinical knowledge.  It’s about having a cognitive mindset.  It’s understanding that your own performance will degrade under pressure and that you must realise that.  As such need to build in measures to allow extra safety – opening up communication, sharing the mental model, gaining 360 access, utilising tea members, sharing the load etc etc

Cliff Reid has been espousing the SELF-TEAM-ENVIRONMENT-PATIENT approach for some time and I’ve certainly used this in my teaching and to debrief after a resuscitation.

SELF – understand the effect of a sympathetic surge on own performance and consider ways to mitigate against it

TEAM – use closed loop communication, share the mental model (whiteboard), be clear on the next steps in the resuscitation and set goals with time frames

ENVIRONMENT – get 360 access, remove clutter, good lighting, optimise position for interventions

PATIENT – all those clinical guidelines, protocols and knowledge!

You can read more in Cliff’s recent blog post.  We also cover this sort of stuff in the ‘ETM course’ – particularly teaching generic transferrable resus room management skills and the use of closed loop communication and avoiding therapeutic inertia.

Imagine how much different the outcome in this care may have been if the internal monologue (surpassed through paralysis and indecision) was articulated:

He’s face down.  Did anyone witness a collision?  So he just collapsed?  Look, I’m obviously worried about a possible impact and cervical spine injury…but this could also be sudden cardiac arrest in a young adult – a channelopathy perhaps.  Its great that you’ve brought the defibrillator – so let’s roll him over, maintaining the spine in neutral alignment…then start CPR and get the AED on him.  We might be able to shock him before the paramedics arrive...”

Sounds easy, right?

But it’s not always.

The experienced clinicians will understand this.


Making things happen – Cliff Reid smacc2013 (video)

Analysing difficult resuscitation cases – (blog)

Lauria et al (2017) Psychological skills to Improve Emergency Care Providers’ Performance Under Stress

Leave a Reply

  1. Great post Tim. I wonder what wizardry they thought the Paramedics would use to resuscitate, package and transport this patient?