In anaesthesia, sitting at the point where the ideal meets reality, is compromise.

Compromise is the practical, real-world necessity that allows a health system to function in the face of competing demands. Every point of care in a hospital is a balance of compromises, frequently between safety and the many other flavours of medical quality.

For anaesthesiology the most common compromise is balancing safety with the quality of the patient experience: pain, distress, cost, delays, efficiency, levels of intervention, seniority of care… (Though let’s acknowledge, suffering injury because of a safety compromise is also a pretty poor patient experience.)

In a dynamic world of external stressors (<cough>pandemic<cough>) compromise becomes both more important and more fraught. How do we balance conflict between the needs and priorities of care? Compromises are then a pragmatic necessity, recognising the fractal complexity of patients and hospitals that the inherently reductive nature of best practice and theory struggles to accomodate.

A great example of this is found within the Zero Harm safety movement, aspiring to the worthy (though naive) goal of reducing healthcare staff & patient injury to zero. Zero Harm’s mistake is to build an entire ideology upon an unachievable goal, for as Thomas points out in 'The harms of promoting Zero Harm':

“...some harms are inevitable and impossible to eliminate.”
– Thomas (2020)

Zero Harm is itself a compromise, deprioritising other components of care in service to absolute safety. Only by recognising the natural compromises at every level of the health system can we make informed decisions about the risk-price we are willing to pay for compromise.

Many years ago as a junior resident, a senior colleague dropped some wisdom about compromise that sticks with me today. He made the observation in the setting of one of the commonest and discrete medical interventions: intravenous cannulation. Sometimes you have a cannula that is smaller or not flowing as well as you would prefer. Depending on the circumstance, this is often tolerable and we grudgingly accept it.

"But beware”, he said, “never allow more than one compromise.”

Although imperfect intravenous access may be a small compromise, it represents an increased-risk point of failure. Perhaps you now feel compelled to accept a ‘minor’ airway compromise (LMA over an ETT?), or a fasting compromise, or location, or the presence (or not) of a parent at induction? While each step may be justifiable, stacking compromises increases points of failure and risk in a non-linear way.

Stacked compromises increase risk geometrically.

Stacked compromises are fragile.

While there may be no true hard rules in anaesthesia, we need to appreciate that risk exists on a dynamic spectrum. The adolescent ideology of Zero Harm may have near Zero Place in anaesthesia, yet the primacy of risk management and harm minimisation always requires considering how our compromises interact and compound to alter the risk profile of the care we provide. Our goal in managing risk in complex systems should be to reduce risk where we can, and build resilience where we cannot.

You may still feel it necessary to stack your compromises, but by the Gods of Anaesthesia, if you do then you better make sure you know the price being paid – and who is ultimately paying it.