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Posts tagged Decision making.

Only one compromise

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.


Why were Anaesthetists so early on COVID?

On a Monday morning in March, an anaesthetist stood outside his children's inner Sydney school as a solitary protestor, asking parents to keep their children home if they could.

In the heady early days of the coronavirus pandemic, alarm was raised by a disparate mix of professionals: virologists and epidemiologists, journalists and technologists, and a range of frontline and critical care medical specialists exposed to the first COVID patients.

But as concern spread from the earliest hit countries to those threatened by their own surge, one specialty group was over-represented in public calls for early action: anaesthesia.

In Australia, medical anaesthetists from all states and territories spoke-up, not for health authorities and legislators, but for their communities. For a specialty most comfortable when not spoken of, suddenly anaesthetists were appearing in national newspapers, on radio, television, and even (very small) picket lines.

In Victoria, Dr Pieter Peach was a prominent early voice pushing for cancellation of Melbourne's Grand Prix. The Australian Society of Anaesthetist's fearless president Dr Suzi Nou guided the society's careful campaigns to prepare for the pandemic, pause elective surgery and then cautiously restart. In NSW, Dr Tanya Selak's advocacy was celebrated on Telstra's #saythanks billboard, while Rob picketed outside his children's school.

Like a warning telegram from 1940s London, the message scrawled on Rob's chest captured the zeitgeist of our specialty at the time:

"Lives depend on it. Government too slow to act."

Read on for why…

The Paradox of Avoidance

The cries of 'over-reaction' are as predictable as they are simplistic. Epidemiologists and pubic health experts knew they were coming, because avoiding a disaster brings little thanks.

As Australia emerges unevenly from its soft lockdown, anxious and still responding to COVID flares, it is the envy of much of the world. Alongside success achieved in places as varied as New Zealand, Vietnam, Taiwan, South Korea, Iceland and even austerity-inflicted Greece – the contrast with those that have suffered disastrous outcomes is obvious.

And yet the naysayers still question the painful necessity of the lockdowns, even as study after study demonstrates how the measures have avoided or delayed hundreds of millions of infections.

The United Kingdom, uniquely and even justifiably proud of its National Health System, first chose instead to ignore expert advice and offer up its venerated NHS as a funeral-pyre sacrifice to COVID and the gods of conservatism. Today more than 43,000 British are dead. (You know what would help NHS healthcare workers more than clapping? Earlier border closure and adequate access to PPE!)

Sweden pursued a Claytons lockdown founded on an ideological mix of misplaced intellectual-exceptionalism and responsibility-abdicating libertarianism (my eyes are rolling...). It has not gone well.

Despite making up less than 40% of the Nordic population, Sweden now accounts for five out of of six Nordic COVID deaths. Sweden has twice the population of neighbouring Norway but twenty-times the COVID mortality.

And then there is the Land of the Free, the United States. The wealthiest country on the planet, now the epicentre of the pandemic with well over 2 million infected and 120,000 deaths. A disaster due to a failure to act either early or decisively, a dash of magical thinking and an embarrassing absence of leadership.

It is disappointing that the main contribution the United States is currently making to the global COVID response is to serve as a warning to other nations.

The common theme among these failures is the inability to develop a rational response guided by expert advice. A virus does not care for your wishful thinking. A virus does not care for your political posturing, your dog-whistling or your belief in national uniqueness. A virus is the honey-badger of microbiology.

Which leads us back to the braying calls of 'over-reaction'. Whether former politicians, conservative economists, or performance artists playing opinion writers, they are all making the same mistake: misattributing causality and misunderstanding the purpose of modelling.

Read more on the paradox of avoidance...

Biased thinking in a time of COVID

The 2020 coronavirus pandemic for all it's horror and challenge, has highlighted certain uncomfortable truths about the human condition. One of these has been the impact of our cognitive short-comings: our difficulty understanding the non-linear and non-binary, and our susceptibility to cognitive biases.

Many of these problems led to missteps at the beginning of the pandemic response, and now early in the fight continue to impede our decisions. By better understanding these cognitive traps we can at least be more alert to our blind spots and alter our actions in response.

As early data seeped out of China in January, quickly followed by cases appearing in global travel hubs, many national governments along with their populations refused to acknowledge the pandemic threat. Even as Northern Italy's health system first bent then broke, surpassing China's own COVID death count a mere 47 days after Italy's first confirmed case, world governments continued to water-down the threat.

Read on about exponential growth and biased thinking...

Are there any truly universal anaesthesia rules?

It’s not uncommon to hear anaesthesiologists drop verbal markers of universal truths into their clinical utterances: always, every, never. Often it's the most banal practices ("always attach the cannula tegaderm so") that generate our greatest passions.

However there are few, if any, universalisms in anaesthesia. Almost every rule has caveats and exceptions, reflecting the shades-of-grey reality of patient needs and human physiology.

When clinicians decree something is always or never so, they are often confusing truth with convention. Sometimes confusing an absolute with what is instead dogma. A minority reveal the rigidity of their thinking, impeding rather than enhancing the performance of their practice.

Rules are still useful. They are important guardrails, a mental model to keep us on the road of safety unless there is very good reason to cautiously edge onto the gravely shoulder, or even turn down a completely new path. But always with the understanding of the compromise we have intentionally made, reminding us of the cost that may need to be paid.

Universal anaesthesia rules become a problem when we dogmatically extol them without understanding the foundations of why – or use them as a blunt tool to browbeat our colleagues and assistants.

Rules are shortcuts to express the tension between the benefits and risks of different anaesthetic decisions. All difficult airways in specialty exams might require mandatory awake fiberoptic intubation, but in a real world of patient refusals and modern airway toys & techniques, it is a more nuanced decision. In fact, patient refusal might be the closest we get to an absolute rule – but even this is a negotiable area of greys.

As a mental model for normalising risk, rules are an efficient way to communicate our prioritisation of the risk-benefit tension. A tool for education and standard setting, without requiring the immediate overhead of qualifying and rationalising.

First learn the rules. Then master the rules. And only then can you break the rules.

The danger comes when we confuse the mental model – the guardrails – for the reality. Misidentifying a tool to guide perception and practice, as something we mistakenly believe reality can be bent to. When we make this error, reality has a nasty habit of reasserting itself with unsentimental brutality.

I made my mistakes so you don’t have to. Don’t repeat my mistakes. Make your own mistakes. Make better mistakes.

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