Have you ever found yourself in a bit of a dilemma in a resuscitation as whether to perform a procedure? If you’re like me then you’ll be familiar with the sort of scenario below where the decision as to whether to proceed is seemingly unclear and inconsistent.
You are put on standby for a 6 year old child who has been hit at moderate speed by a car. She is cardiovascularly stable but is reported to be irritable and have an GCS of 13. It is reported that she appears to be an isolated head injury. You assemble your trauma team and brief them (using the zero point survey) that an RSI is a possibility here as the child will likely need a CT head and that may be difficult to achieve if she is irritable. Your team assembles and prepares for an RSI.
On arrival in the ED the crew report that she has settled on the way to hospital and she is now asleep on the stretcher. They think this is a result of the IV paracetamol that she received.
She is indeed sleeping and a gentle examination of her reveals no obvious life threatening injuries.
You decide to head off to CT un-intubated. You thank the anaesthetic team for coming down who start to pack up their kit.
At that point the monitor is transferred the bed and the cable brushes her face at which she wakes up. She rapidly becomes agitated and struggling on the stretcher. Clearly CT is now impossible.
You review the patient who is now being assessed/held from lots of different directions. You call back the anaesthetic team for an RSI. One of your colleagues administers a small amount of opiate having identified that she has a swollen tib/fib that might be broken.
As the anaesthetic team walk through the door they find your patient lying quietly, maintaining their airway and comfortable enough to go to scan.
You feel as though you’ve made 5 decisions in 15 minutes, still not left resus, asked for 2 RSIs, declined 2 RSIs, and perhaps tried to treat a headache with the anaesthetic team. You’re not feeling great, but is that really your fault?
I like to think of situations such as this is oscillatory decision making. There are two options that are possible (do or not do), and they both have consequences. Information pushing you towards one or the other options (the external influencers) come in at different times and with different factors/strengths/complexities. In many cases the information may be contradictory. All these matters lead to a high degree of complexity that is exacerbated by the nature of emergency medicine. Our speciality, and especially when we are working in the resus room requires us to make time critical decisions, but where the full picture is unknown or unseen. I refer to this as ‘Time Critical: Information Light’ decision making, and I think it’s a marker of our speciality and those who are expert at it.
Resus/Trauma patients also typically involve more than one speciality/professional team. It is not uncommon to find different views amongst these groups. As a TTL/RTL one of the key skills is bringing those different views together into one coherent and deliverable strategy for the patient. This is often further compounded by different seniorities of clinician arriving from the same team with a different view. For example a senior anaesthetist arrives to supervise their trainee, they reassess the patient and then inject a new option/plan into the case. This may potentially derail the previous plan taking the resuscitation in another direction. Their suggestion may be a great one, or it could be unhelpful, or perhaps it’s neutral, but consideration of the ‘new’ plan steals time from the patient journey (Ed – a historical example would be an anaesthetist arriving to support an RSI that was ready to go, we did not have their favoured laryngoscope in the department and so delayed until it arrived from theatre). I suspect all experienced RTL/TTLs will recognise the drip feed of opinions into a complex resus as new team members arrive. These need careful management as new suggestions are often helpful, but they may slow progression. From a patient’s perspective time is often very important as they move to definitive care (e.g. IR, surgery, cath lab). As a team leader one of the hardest things we do is balance time against refining the plan. In the resus room perfection may be the enemy of good, and finding that balance is difficult skill.
The problem with oscillatory decision making is that if it is allowed to continue then no decision at all is made and ‘decision paralysis’ occurs. Many of you will be familiar with this from observing teams in emergency medicine. A recent example was a trauma patient who was deemed too sick to go via CT, but the surgical team really wanted a CT before theatre. The patient’s clinical observations waxed and waned such that decisions went back and forth, and as a result no decision ever lasted long enough for actions to take place. Thus an unstable patient remained in the resus room 60 mins after arrival, with no CT, no surgery and no plan. If I’d have asked anyone in the room whether staying in resus was the best option for the patient, then no-one would agree with that, and yet……. Obviously such situations are less than ideal, but sadly it does happen.
in the Resus Room, the worst decision is usually the decision of indecision.St Emlyn
Let’s think about this graphically. The figure below shows how differential information can push a decision in different directions leading to swings in opinion until enough supportive information appears to push the decision in one direction and action takes place,
Strategies for managing oscillatory decision making.
- Recognise that it’s happening. This is certainly something that comes with experience, but even the most experienced clinicians sometimes need a nudge from a colleague. This is something we often notice when conducting peer review of TTL/RTLs, as the observer it’s easier to see the bigger picture and to identify oscillatory decision making and.or decision paralysis as the observer has better bandwidth to understand the bigger picture. It’s worth recognising that as TTL/RTL you might not spot this happening and that you must rely on your team. On several occasions over the years one of my team has stated ‘we just need to make a decision and act‘ , this has often the senior resus nurse who is not directly involved in patient care, but who is in more of a departmental/resus wide role. Such a phrase can be very powerful. Feel free to use it with colleagues, and more importantly, if you hear it said to you, then listen carefully and quickly review your actions. (Ed – note that if this ever happens to you be sure to thank the person who gave you a nudge as a way of promoting team work in the future).
- In time you might be able to predict situations when oscillatory decision making may be a problem and plan for them. This may be during your zero point survey time when preparing for patient arrival. If you can identify potential difficulties in advance then you may have time to put a mitigating strategy in place. This will most likely be similar to strategies 3 and 4 below.
- Identify key pieces of information that will secure a move in one direction or the other. This will vary depending on the situation but it might be something such as a blood test, radiograph or (more commonly) trends in clinical observations. State what these are and how they will be determined. For example ‘Review the GCS every 5 mins, if no improvement then we will….. ‘. Explicit statements like this, shared with the team are an effective way of ‘damping’ oscillations in the team decision making. They can help by reducing the urge to suddenly change direction (Ed – clearly there will be times when important new information requires an urgent change of direction, but this is not the case for everything).
- Use explicit time points and share with the team. For example state that we will review a decision at 5 minutes. For example stating that ‘ If the blood pressure has not changed or is worse at 17:10, we will proceed with peripheral noradrenaline. If improving then we will not we will not and and we will then move to……‘ will help your decision making process and also support your team in helping move things forward.
- There is great skill in balancing the need to make a decision (to be ‘decisive’) with the need (the very important need), to listen to, value and weight the opinions of the team. A high functioning team will encourage people to speak up and to put ideas into the mix in a supported way. Do not fall into the trap of thinking that the way to avoid oscillations is to have a limited and fixed view about what to do, and then to impose that on the team. Clearly that is not a strategy that we would support as it’s bad for the team, and thus bad for the patient.
- Debrief your decisions and your decision difficulties. When we debrief we try to not just focus on ‘what’ happened, but more on the ‘why’. Try and explore your decision making in chronological fashion, understanding how new information influenced your choices and how these ultimately relate to outcome. What information was helpful, what was contradictory and how did the various elements assist or hinder the team
Oscillatory decision making is one of several factors that can lead to decision paralysis and poor quality care in the emergency department. Understanding what it is in yourself and in other team members can help you identify it and mitigate against it.
TTL: Trauma Team Leader
RTL: Resuscitation Team Leader