THE POWER OF THE DECISION
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Decisions on the battlefield are made under duress and experts are expected to make decisions quickly , aggressively and accurately . There is little to no time to plan or have philosophical discussions . The great Prussian Field Marshal Helmuth von Moltke the Elder , a contemporary of Clausewitz , is attributed with these words of wisdom , “ No plan survives first contact with the enemy .” To translate , even good plans fall into chaos , and you better have a backup plan plus a backup plan for the backup plan .
As I reflect on my training and practice in emergency medicine , the decisions my colleagues and I make each day seem quite similar to those made by battlefield commanders . Though we are in far less stressful situations , and we are likely not having to risk our own mortality to care for patients , our decisions must be made urgently when lives are on the line . The foundational aspects for those types of decisions still exist in the practice of medicine . The practice of emergency or acute care is one that values intuition , pattern recognition cultivated from experience and careful study , training and knowledge development . Decisions by physicians are expected to be made quickly , aggressively and accurately ; if not , the consequences could be very grave , leading to further deterioration in the patient ’ s condition .
Often critically ill patients present to the emergency department with limited history or information . Quite often we stand in front of an obtunded , altered patient and the only EMS history is “ found down .” Despite this , it is the expectation of our profession and specialty to stabilize this patient , control the airway and investigate the underlying cause . Missteps such as failing to identify hypoglycemia , hypothermia , sepsis , reversible drug intoxication , cardiac arrhythmia , electrolyte disturbance , intracranial hemorrhage or other conditions could have dire consequences . Inappropriate interventions could lead to irreparable harm . Our colleagues expect that when we call them to admit , we ’ ll have a provisional , working diagnosis , that we have effectively ruled in or ruled out the prime conditions on the differential . While we may not have the final diagnosis , it is the expectation that we have brought order to chaos .
The decision-making process for acute and emergency care focuses on rapid cognition , this is the power in our decisions . The training of an emergency physician and other acute care specialists involves the ability to collect immense amounts of data , but the expertise is sifting through this data to determine what is most pertinent , and what puzzle pieces are missing that are required to complete the puzzle . As a detective gathers and examines multitudes of minute details to find the perpetrator , so too does the physician process the limited information , filter the data and make treatment recommendations . We have to think fast then act fast , bolstered by the foundations of medical knowledge and experience , to handle rapidly deteriorating critically ill patients in both medical and trauma cases .
“ No plan survives first contact with the enemy .” While patients aren ’ t the enemy and we are trying to provide them with treatment and comfort , a well-prepared plan , no matter how expertly crafted can and will go awry . Murphy ’ s Law is often gospel , as “ Anything that can go wrong will go wrong .” It is a humbling reality . In resuscitation it is no different . When I find myself at the head of the bed preparing to intubate , I run my “ oh shit ” checklist with the multitude of back up plans . As an apostle of the Law of Murphy , in every intubation , I ensure that my video laryngoscope is working , I have a backup direct laryngoscope with a working bulb , a bougie , smaller endotracheal tubes , nasopharyngeal or oropharyngeal airways and bag-valve mask . If those don ’ t work , do I have supraglottic airways available ? Finally , to “ ward off the evil spirits ,” I have a scalpel in my back pocket , praying it never has to be employed . With every airway , I expect that my plan will not “ survive first contact ” and that I will have to quickly react and adapt to secure the patient ’ s airway .
The power of decision-making in emergency and acute care medicine is the ability to collect , process information and formulate decisions to accurately address acute medical conditions rapidly and effectively . These decisions are often made in situations that are high stakes and have a high level of uncertainty . These decisions have the potential to have a profound impact on patient outcomes . To be successful , the physician must possess the medical knowledge , expertise , clinical skills and ability to make swift and thoughtful decisions under pressure . This ability requires years to cultivate : the knowledge to be proficient in this type of decision-making requires hundreds and hundreds of patient encounters , with gradually increasing responsibility for care . Just like Col . Chamberlain on Little Round Top , a decision must be made , and it must be acted upon . Could this decision be flawed ? Absolutely , but reflect on the words of von Moltke , and be prepared to adjust , modify and rapidly change the course .
Dr . Kuzel is a Clinical Instructor of Emergency Medicine and Fellow of Hospital Administration and Clinical Operations at the University of Louisville School of Medicine . Dr . Kuzel also serves as the Assistant Medical Director for Bullitt County Emergency Medical Services and Medical Director for Flaherty Volunteer Fire Department in Meade County .
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