Time Critical: Information Light decision making
A few years ago, we described the concept of being able to manage ‘Time Critical: Information Light’ and decision-making as one of the key attributes of working in emergency medicine. We illustrated this with the diagram below that illustrates that the earlier you see a patient in their illness, the more uncertainty there is, and as a result the greater chance for error and/or the wider diagnostic differential. The graphic and concept seems to have been widely shared and used by colleagues which I guess means that it strikes a chord with those of us who work with the most severely ill and injured patients.
The graphic illustrates that uncertainty usually diminishes over time, and this is a result of two factors
- The clinician has more information available as the result of imaging and other investigations becomes available. For example in a trauma patient there is far less uncertainty after the CT scan is performed than before.
- Secondly many conditions themselves eveolve to be more obvious over time. An example would be meningococcal septicaemia which may be tricky to diagnose in the early stages, but really easy after several hours when the characteristic rash becomes florid and the patient is seriously physiologically deranged.
Many emergency clinicians will have experienced the feeling (or more commonly the accusation) that they ‘got it wrong’ with a diagnosis, when in fact they were just dealing with an enormous amount of uncertainty at the time when they had to make a decision. When reviewing such cases we should do so on the basis of information available at the time, but as we know they are often viewed through the retrospectoscope. We can do better of course and one way to do this is to use the shadow boxing technique described by Gary Klein and exemplified by Scott Weingart on his podcast (see links at the end) where we use expert assessment as we talk through a case and based on the information available at the time the decisions were made. Interestingly when Scott does this he often talks about uncertainty and judgement as he goes along and I would recommend a listen to some of the cases as an example.
More recently I have started to use the triplet of ‘Time Critical: Information Light: High Consequence’, to describe some of the most difficult decisions we make in practice. A typical example where we are often challenged would be in the prehospital administration of blood products to trauma patients. That decision is difficult (and there is clear evidence that clinicians find this difficult), and the consequences may be profound, but is still a question that needs answering in the moment and without the ability to wait and see in many cases.
Goldilocks and the three procedures
Whilst the original concept was linked to diagnosis, similar themes exist regarding the uncertainty of performing a procedure in the resuscitation phase of the critically ill or injured. This brings us to the Goldilocks moment in healthcare.
Let’s take a procedure such as a thoracotomy for a central stabbing to the chest. You might already have a good idea of when you might proceed to a thoracotomy, but let’s explore that a little more and with some (somewhat absurd) extremes. We do know that timing is important, and we know that the patients who are likely to do best are those who have a single stab wound to the right ventricle. We also know that time is really important too. However, we also know that a thoracotomy is a huge procedure with significant consequences for the patient and for onlookers. So we really only want to do it to people who need it, and also for those who. arelikely to benefit from it (so not too late).
So let’s look at some options (yes some are absurd)
- We could perform a thoracotomy on all patients with a central stab wound at risk of cardiac tamponade. Everyone gets a thoracotomy, but most would not need it. We might save a few more cardiac stab wounds, but would surely harm (even kill) many more
- We could perform a thoracotomy on any patient with a central stab wound and a risk of tamponade as evidenced by a low BP
- We could perform a thoracotomy if peri-arrest
- We could perform a thoracotomy once the patient has arrested
- We could perform a thoracotomy only if tamponade is seen on ECHO
- We could perform a thoracotomy only if the patient is in VF/Asystole
- We could perform a thoracotomy only in the autopsy room
Clearly, some of these are silly, but they illustrate a rough continuum of risk of unnecessary harm balanced against the certainty of diagnosis. Or rather is it a question of certainty of diagnosis or assurance to the clinician? Arguably, and in my experience in several cases, it is the potential for loss of face that might prevent life-saving treatment from being given until the clinician is personally assured that they are definitely doing the right thing.
An example would be the trauma team standing around the unconscious patient with a central stab wound who has a BP of 40/20, saying that they cannot do the thoracotomy yet as the patient still has a waveform on the art line and is therefore not ‘really’ yet in cardiac arrest. I’m sure you can think of similarly absurd situations, and I’m sure you can find real-world examples, too, with other presentations and situations.
So how do we illustrate this in practice and how do we teach and learn how to do it better. The graphic below shows how going too early (too hot) is likely to lead to more harm as you will end up doing too many procedures to patients who don’t need it, or who may not benefit from it. Waiting too long (too cold) means that your patient has missed the optimal time for intervention and is therefore harmed (maybe dead) as they missed the optimal time to have the benefit of the procedure.
Your aim in life is to find the Goldilocks moment where you have enough certainty that the procedure is indicated, and at which the patient still has the potential for benefit. This concept will hopefully help you choose the right time, for the right procedure, for the right patient in order to proceed.
In general the procedures that we are referring to here are the HALO procedures in EM/PHEM, but the principles arguably apply to many other aspects of emergency care.
Editors note: If you don’t know the Goldilocks story, you can find more out here. We are obviously focusing on the famous concern about the temperature of the porridge (too hot, too cold, and just right), but we should not forget that the story is technically about a home invasion and wrecking of a perfectly respectable family of bears house!
Training for uncertainty
Can we train to be better at finding the Goldilocks moments for our patients? I think we can, but it undoubtedly takes time and effort. I am a great believer in peer review as a tool to develop excellence, but there are other things we can adopt. Examples are below.
- Mortality & Morbidity meetings. Remember that you should include positive outcome patients as well – the Awesome & Amazing concept
- Peer review. Direct observation or with a friend/mentor/coach you can really openly discuss cases with (and as a subgroup the concept of a failure friend)
- Shadow boxing cases . See EMCRIT for more on this
- Online discussions. Don’t fall foul of confidentiality arrangements, but I am aware of some fantastic case discussions that go on using social media tools within departments. Don’t get sacked by breaking the rules, but do chat to each other and share the learning love. Closed whatsapp groups, with suitably anonymised cases have been used for this purpose.
- Policies and protocols. These can be helpful, but we prefer the term CDSG. This stands for clinical decision support guideline as no policy/protocol will ever fir every patient and every circumstance. That said they can provide guidance in a tight spot and are often helpful in IFTT decisions (these are If This Then That decisions that you can read more about here).
- Vignettes and patient stories. Clinicians love stories and they are really powerful tools for learning. If you want to illustrate difficult decisions then write about them and share them with colleagues.
- A curious mind. Arguably the most important attribute of any clinician, and the number one attribute I look for in any colleague I work with. The fact that you are still reading means that you probably are one of us. The clinician who remains curious about what they do and why they do it will continue to get better and hopefully be the best that they can be.
Final thoughts
Great resuscitationists can make decisions in circumstances that are time-critical and information-light. They recognise that the optimal timing for many of the life-saving procedures that we undertake is difficult to judge. They understand that the quality of those decisions can be improved through training and review.
For those of us involved in training, the Goldilocks model may be a useful tool to explore decision making and hopefully improve the quality of our training for the next generation of resuscitationists.
References and further reading
- Klein G. Decision making in action: Models and methods. In: Klein G, Orasanu J, Calderwood R, Zsambok CE, editors. Decision Making in Action: Models and Methods. Norwood, NJ: Ablex Publishing Corporation; 1993. p. 11-29.
- Klein G. Streetlights and Shadows: Searching for the Keys to Adaptive Decision Making. Cambridge, MA: MIT Press; 2009.
- Simon Carley, “Training for HALO procedures. Part 1: Background and psychomotor skills. St Emlyn’s,” in St.Emlyn’s, April 2, 2023
- Simon Carley, “Training for HALO procedures. Part 2: Personal Preparation. St Emlyn’s,” in St.Emlyn’s, May 11, 2023
- Simon Carley, “Training for HALO procedures. Part 3: The Team.,” in St.Emlyn’s, July 29, 2023, https://www.stemlynsblog.org/training-for-halo-procedures-part-3-the-team-st-emlyns/.
- Scott Weingart, MD FCCM. EMCrit 314 – ShadowBoxing Case 1 – In the end, it’s always…. EMCrit Blog. Published on December 30, 2021. Accessed on August 1st 2024. Available at
- Simon Carley, “Decisions, oscillations and damping. St Emlyn’s,” in St.Emlyn’s, October 5, 2022
- Simon Carley, “Making good decisions in the ED. #RCEM15 #EuSEM15,” in St.Emlyn’s, October 13, 2015
- Simon Carley, “SMACC2019: The Power of Peer Review,” in St.Emlyn’s, May 30, 2019
- The Goldilocks principle.