emDOCs Podcast – Episode 69: Decision Making in EM – Getting closer to better

Today on the emDOCs cast, Brit Long, MD (@long_brit) interviews Andrew Petrosoniak, MD, MSc, FRCPCP (@petrosoniak) on decision making in emergency medicine.

Andrew is a world-renowned leader in decision making and trauma. He is currently an EM attending physician, assistant professor at St. Michael’s Hospital, University of Toronto.

Episode 69: Decision Making in EM – Getting closer to better

Every day in emergency medicine, we are faced with decisions. In fact, as world-renowned decision-making researcher and emergency physician, Pat Croskerry notes “in few other workplace settings, and in no other area of medicine is decision density as high” as in emergency medicine.

We regularly face high degrees of uncertainty, with limited information and often in time-sensitive conditions. Virtually everything about the emergency department makes decision making more difficult and yet we must make many decisions every day, every hour, every minute while on shift.

Given that we’ll be required to make hundreds of decisions every shift, translating to millions of decisions over a lifetime in emergency medicine, it’s critical to understand how can we become better decision makers?

Here are 8 techniques to improve decision making both in life and on shift. They represent a culmination of ideas from experts, researchers and academics who study decision making.

1. Reduce decisions all together: This is not novel in emergency medicine. Decision making rules, scoring tools (e.g. Canadian CT head rules, NEXUS) all utilize this concept. Instead of asking whether this patient needs a CT, we have criteria that guide that decision. These criteria (developed from evidence) are established agnostic from the patient in front of us. This carries over to other parts of our lives too. Have you ever tried to eat healthier diet? It’s far easier at the beginning of the day than the end. Decision-making degrades over time as we fatigue. This is why Obama, Jobs and Zuckerberg wear the same thing every day. Rather than rely on will power, ensure the environment supports the goals.

How to apply in EM: Create rules for frequent or high-stakes decisions e.g. for blunt traumatic cardiac arrest I don’t proceed with a thoracotomy, only under rare circumstances (which I keep in mind) will I deviate. Have a pre-determined airway algorithm or decide which decision tools to use for diagnostic imaging. This reduces cognitive load and reallocates decision making power to other areas of work.

2. Sign post decision points: Set explicit parameters or targets to trigger an action e.g. at 80% we’ll halt attempts at intubation and re-oxygenate the patient. This reduces emotion that can be tied to making decisions under stress. This also promotes accountability and empowers other team members.

How to apply in EM: Outline explicitly key decision points during a resuscitation or during a shift. For example, after the next pulse check, if we do not have a survivable rhythm, then terminate resuscitation, otherwise we’ll continue with an arterial line, ongoing CPR and intubation.

3. Deliberately consider alternatives options: This is one of the biggest decision-making pitfalls. We often fail to consider alternatives. Using the heuristic, “is there any other option” even after you’ve listed a few forces creativity and may illuminate viable alternatives.

How to apply in EM: After creating a differential diagnosis for chest pain, ask “is there anything else this could be”? Getting in this habit will result in new options come to light

4. Assign probabilities to decisions: Virtually no outcome is certain. It’s not enough to simply say “its likely” or “its unlikely” since humans naturally assume that likely = WILL HAPPEN and unlikely = WON’T HAPPEN. By assigning a numeric probability this conveys uncertainty and consideration of alternatives.

How to apply in EM: If there’s 80% chance the patient has appendicitis, by definition there’s 20% chance it’s something else. This forces us to consider that alternative 20%. We can develop a plan in the event these alternatives occur ahead of time. This leads to decoupling of emotion from the decision, which is incredibly helpful. Rather than, “it’s near the end of my shift and I’m tired, maybe I’ll just send the patient home”, we can put plans in place for these alternatives.

5. Use one-line summaries: Sometimes we get bogged down in the details. Simplifying a situation with only the most pertinent information can make a decision easier. It does not mean it’s more accurate, but it clarifies the path in which we can feel comfortable.

How to apply in EM: For patients where we feel uncertain regarding next steps (e.g. disposition, imaging, etc.), take a step back and summarize the case in your head in 2-3 lines. A 35yr old male, with intermittent vertigo 10 days post chiropractic manipulation and a normal neuro exam. Now, it seems like < 10% chance of vertebral artery dissection but that 1-liner may just seem too high risk and we give ourselves permission to proceed with imaging.

6. Use a pre-mortem: Assume your decision or project has failed and come up with all the reasons why. Knowing these ahead of time can allow you to put into place mitigation strategies e.g. my next intubation results in being unable to secure the airway… why? And what steps can I take to manage this.

How to apply in EM: Imagine before beginning that the RSI fails and the patient has a significant desaturation. Now think about all the reasons why this might occur and develop tactics to protect against this. In addition, go through the CICO approach in case it’s required.

7. Debrief decisions: This can be done both individually and/or as a team. The context should be focused on the decision-making process and not just about the outcome. Both good outcomes and poor outcomes are worth reviewing, b/c sometimes good outcomes still result from bad decisions (& vice versa).

How to apply in EM: For example, let’s debrief the last intubation. Yes, it was successful, and that’s often where we stop. But dig deeper. Was the technique appropriate? Did we get lucky because we happened to get the tube as the patient hit 80% O2 saturation? Could we have optimized pre-oxygenation better and delayed the decision to intubate? Ask the hard questions that we often gloss over, especially when the outcome is preferred because the process may still be flawed.

8. Reflect on our emotional state during the decision: Every other skill we reflect on our practice, yet for some reason, in decision making, this is rare. Think about the last intubation. Was I stressed? Was I calm? What was my mindset? When we’re angry, we blame others. When we’re scared, we believe things are out of our control. Use a decision-making journal. This forces deliberate reflection on your state of mind and how your expectation/prediction matched the outcome.  This promotes learning and hopefully improved decision making over time.

How to apply in EM: Reflect on our last cricothyroidotomy or cardiac arrest. How were we feeling as a team? As an individual? Did we feel calm or stressed? Now that we’re removed from the situation, did that emotional state potentially impact our decision making?

Summary

There’s 8 techniques that we can apply on our next shift to optimize and improve our decision making. It’s not necessary to use all 8 all the time but rather these are tools that can be deployed under various situations. And most of all it’s important to remember this takes practice.

References

1. Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002;9(11):1184–204.
2. https://www.businessinsider.com/barack-obama-mark-zuckerberg-wear-the-same-outfit-2015-4