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Split Second Decisions

Some of the most important and consequential decisions we make about our patients have to be made in seconds.  Error theory teaches us that the less time we have to formulate and then carry out a critical plan of action, the greater the risk of error. As students of The High Reliability Mindset lets see what we can learn about the split second decision-making process that will help us minimize risks to our patients when there is little time to act.

bondsIt was clear and cool on the evening of Friday, September 17, 2004 in San Francisco.  During the home half of the third inning, Padre pitcher Jake Peavy threw a fastball to Giant’s slugger Barry Bonds who hit the ball 385 feet over the fence for his 700th career home run. Pretty good, even if it was aided by juicing on steroids.  Let’s consider some facts about how Bonds made the decision to swing away.  Home plate is 66’6” from the pitching rubber, Jake Peavy is 6’2” so the release point of the ball is about 55 feet from home plate, his fastball travels about 90 MPH or 132 ft/sec so it reached Bonds in 0.4 seconds.  Most baseball “physicists” believe that the batter sees the ball for the first time about 12 feet from the pitchers hand or about 40 feet from Bonds’ bat. So Bonds only had about 0.3 seconds to decide if and when to swing at the pitch.

During that brief moment in time, Bonds’ brain made the split second decision to swing away by comparing what he saw that night to what he had stored in his memory from thousands of other trips to the batters box.   This is what an expert brain has inside – the experiences of thousands of hours of practice.  From his experience, he knew what a ‘ball’ and a ‘strike’ looks like as the ball leaves the pitchers hand. His brain then decided (correctly) to swing at the pitch. It initiated nerve signals to his spine and told his arms and legs where and when they needed to be in three dimensions to swing the bat and finally follow the bat to the ball with his eyes for feedback and last moment adjustments.  The result of this complex process was home run number 700.

Quite a task!  How hard is this to do?  Very.  Ted Williams, who finished his baseball career with the highest lifetime batting average in baseball history (.344) and the highest single season batting average (.416) once said, “Hitting a big league fastball is the hardest thing a man can ever do”.  Really?  I’m not so sure I agree with that.  Statistically, baseball players actually get it wrong most of the time.  Consider Warren Spahn, who pitched in 608 games and won 356 of them (59%) – the best winning percent of any left-hander in baseball history – famously said, “Baseball is a game of failure.  Even the best batters succeed only 35% of the time; the two best pitchers in baseball history only succeed 60% of the time”.   Imagine if those were the outcomes for surgeons or pilots!

Let’s look at some facts about other split second decisions such as made by pilots and surgeons.  A Marine aviator is flying an F-18 on an air support mission a few thousand feet off the ground when a surface-to-air missile is fired at him f18from 1000 yards away.  Assume the pilot is traveling at around 575 mph and the average missile travels at 2400 m/sec,  the closing rate of the aircraft and the SAM is about 1½ miles per second.  The SAM will take about 0.2 seconds to reach the F-18 – one third less time than Barry Bonds had to hit his 700th home run.  During that brief time the pilot’s brain must carry out the same process that Bonds did and compare what he sees to what he has stored in his brain about the threat from all his thousands of flight hours and training.  His brain then had come up with the best way to avoid the missile and push his arms and legs on the flight controls away from the incoming threat based on comparing what he has practiced and stored in his memory to what he sees in front of him.  The decisions needed to avoid the missile must be made with a combination of motor and cognitive skills that are layered on top of the added stress of a potentially life ending threat that the pilot knows is coming his way. Bonds had it easy, at least he didn’t have his life on the line when he made his decisions to swing at the incoming fastball.

Let’s take a look at a Saturday night on the trauma service with this idea of the added stress of life and death on top of the need to make perfect split second decisions.  A young patient arrives with a gunshot wound to the chest with no blood pressure and just an agonal heart rate.  Even the youngest and healthiest trauma victim has only couple of minutes that they could survive with minimal cerebral blood flow. If circulation is not re-established and blood flow restarted to the body and brain quickly, death or at least permanent neurological deficits will ensue.  This process has d already started with the time used up in transport so the trauma team has almost no time to assess the problem, decide on a plan of action, implement it and begin to resuscitate the patient.  That our lives are not on the line when making these decisions is something we’ve discussed before on this blog (see “Surgeons Don’t Die”).  But that surgeons don’t die if we make a mistake like the F-18 pilot might doesn’t reduce the catecholamine rush of stress that can impair the decision making process.  The solution to this dilemma for practitioners of The High Reliability Mindset is to practice our skills so many times that during an actual emergency these catecholamine rushes do not impair our actions.

A decision to do an emergency left thoracotomy and then actually carry out all the complex actions necessary to perform the procedure is the only option to save the patient’s life.  The correct decision making process is similar and based on comparing the facts in front of the surgeon with knowledge that has been stored over years of training, simulation and practice.  To call up the steps to do the procedure also depends on multiple of past times that this procedure has been practiced and actually done. At the same time the trauma surgeons are starting the operation they must be directing all the team members to do their role, starting IV’s, sending blood to the lab, calling the OR to set up the room and orchestrate assistants to expose to the heart and aorta to control the hemorrhage.  Under enormous stress of life and death all these complex actions need to be done quickly, efficiently and correctly.   Quite a task.

Making decisions are extremely complex processes in our brains involving high levels of cognitive skills and rely on experience, subjective and objective data and appropriate weighting of probabilities and uncertainties. As healthcare experts, we are generally highly proficient decision makers. When there is lots of time, the process of is done using knowledge and weighted variable reasoning know as “Bayesian” analysis.  By consciously weighting each probability, the physician chooses the most likely solution from among a number of options.  But when time is limited, we use something psychologists call “heuristic reasoning” that describes a decision arrived at using a process of high-level trial and error rather than set-weighted rules. This type of decision making is used when the clinical circumstances do not lend themselves to extended thought processes.  Heuristic decisions generally involve quickly comparing what we see in front of us to what we have stored and have known to work in the past.  This is where the practice paradigm and the 10,000 hours of expertise outlined by Malcolm Gladwell have come from.  Heuristic decisions involve a great amount of risk taking in that the clinical situation may dictate an action before all information can be accumulated and accounts for the greater number of errors in emergency and trauma management.  Success is totally based on previous practice, drills and simulator training.

Understanding and optimizing the decision making process, how we recall stored knowledge and use it to choose the best clinical option especially under time compressed circumstances, are important safeguards that can be built into medical school and resident training to avoid errors.  As practitioners of The High Reliability Mindset, we need to have as much information up front in our brains for immediate access as quickly as possible.  There simply is not enough time to “search” for the right answer in a life-and-death emergency, the knowledge has to have been pre-stored, called up immediately and implemented to save lives.  It’s like that old joke about how you get to Carnegie Concert Hall?  Practice, Practice, Practice.

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Posted in High Reliability Mindset, Human Factors.

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