Decision making in emergency situations under time pressure.

[alf5071h]

After an unexpected 3 days in ICU, I am seeking views on decision making in situations often described as requiring intuition, or naturalistic decision making. I stress that I am not seeking cause or blame, only to better understand the process of decision making and if there is anything which aviation might benefit from.

Background; a TURP procedure (senior gentleman’s hydraulic pipe clean out) with a local spinal anaesthetic. I have a history of (minor) irregular heart-beat (two crew flying restriction). After retirement this was treated with B blockers; more recently raised blood pressure (age 70). The surgeon and anesthetist noted these.

The procedure progressed normally, but apparently took longer than planned – more difficult / higher workload (largest [internal] organ seen so far this year). The operating team, doctors and two nurses, appeared to work in a very well-co-ordinated manner, without rush, and continued to do so as events unfolded.
After some time (towards the end ?) I reported increasing difficulty in breathing – heavy chest; there was minor, right sided chest pain, and shivers.
The anesthetist ordered a change in the drip feed apparently in response to a rapid change in blood pressure (decrease?); the surgeon announced ‘nearly finished’.
Suddenly I entered ‘shock’ feeling very cold shivers and with body tremor; oxygen was applied and drips changed.
The next events were very hazy; I was moved to the recovery room and the surgical team and others provided treatment. From very vague memories everything was orderly and co-ordinated; (memories include tunnel vision and ‘the bright white light’ – but I am convinced that these were real effects). From other reports I deduce that I have no recollection of the next 2-3 hrs in post op recovery.

After 24hr of basically ‘out of it’, I was able to understand most of the explanation. Either due to the unusual/unexpected length of the procedure, which involves continuous flushing fluid, or an unusual reaction to the fluid (aniline? vs saline) the body sodium level was diminished (lowest ever seen by the anesthetist); the result is a distinctly downhill trend and could ultimately lead to seizure. The recovery involves increasing the body fluid level (salts), but not too quickly as this could cause brain damage.
Thus the medical team were ‘between a rock and a hard place’.

My interests are in what conceptual aspects / processes of decision making would be considered in diagnosis and initial treatment, and in the critical time dependent recovery process. I have not as yet been able to discuss these details with the surgical team.

Situation awareness; identifying the situation did not seem to have been a problem. Presumably there are standard indicators, levels, rates of change, which would be ‘basic’ knowledge, and similarly a standard principle of treatment. However, the choice of action and recovery appears to depend far more on judgement. (My pre-op briefing from the anesthetist included his priority of providing oxygen to the brain; – risk mitigation?)
It is difficult to imagine any detailed procedure as actions depend on a rapidly changing situation (hopefully improving). Again I assume that there are key indicators, values, and rates of change, but which aspect or attribute might dominate, and when.

The extremes might be easier to understand; better the risk of brain damage vs seizure ?; or as recovery commences, change the rate of fluid increase with improvement, which for me apparently took several cycles over 48hrs. My background condition involving the risks from high blood pressure, conflicted with need to raise blood pressure, and risks from irregular heart rhythms (an indication of impending seizure ?) had to be considered. Fortunately neither of these played a part and continue to be well controlled / improved.

From the above, I identify situational aspects which might include the confluence of both known and unknown contributors, high workload, a sudden onset (surprise). For recognition, presumably key parameters and rates of change, with possibly varying priorities according to the changing situation; where all of the above contribute to decision making and judgement.
From a medical aspect I don’t need to know what these are; but if there is merit in this line of thought, then how might these parameters, and the processes involving their use, be identified, taught, practiced, memorised, etc, etc.

I am pleased to report progressing recovery in strength and activity, hopefully with normal cognition, and an improved, fully functional, hydraulic system.

[alf5071h]

Thanks to those who replied privately; also for ideas from other threads, which with some subject research has provided an acceptable view of the event and decision processes.

My initial view that the situation was ‘unusual’ or overly surprising was perhaps over stated. Events may have evolved quickly, but probably not in a way which the anaesthetist was ill prepared for. Thus with correct situation assessment (diagnosis), the remedial action followed a standard, intuitive course of action, the extent of which was moderated with continuing assessment.

As an analogy with aviation, it is like encountering wind-shear during an approach to land. The onset may be sudden and surprising, but with appropriate situation assessment, a trade-off between speed and flight path (altitude) should be intuitive; a basic attribute of flying. This requires managing speed to avoid a stall, and flight-path to avoid early ground contact – or even a crash. Thus there is a trade-off between parameters depending on the severity of the event and the margin from a critical parameter.
At higher altitudes, flight path can be traded to maintain speed, but nearer the ground, speed reduction is more likely to be traded for safe altitude, hopefully avoiding a limiting condition in either.
Extreme conditions require quick and accurate assessment and skilled management; there is an excellent example in Windshear Encounter. (www.scribd.com/doc/35984283/Windshear-Incident) This example also includes aspects of preparation (planning) and expertise which enabled recovery from a situation which for other than exceptional action may not have been possible.

Thus for the anaesthetist who encountered a situation perhaps more severe than any previously experienced, the quick recognition and treatment was still a relatively standard procedure. There was also advanced planning – pre op statement of priorities.
What is still unknown is how close this patient came to a ‘crash’ or a ‘stall’, nor if the minimum conditions reported by the anaesthetist were his personal limiting experience, or that of the profession in general; similar to differences of being a good pilot in windshear, and an exceptional one in a micro burst.