Losing Momentum

A dual qualified Emergency Physician and Intensivist once shared this interesting insight.  He observed that sometimes during a critical situation there are moments when it appears that no real progress is made even though it may be quietly evident to observers that there are options that are yet to be pursued or progress has stalled..

These occurrences typically occur in immature or improvised teams and are not always due to lack of clinical experience as in this cause of Just A Routine Operation

There are various reasons for this:

They have believe they have exhausted all the interventions that they are capable of  For example a junior doctor on the ward may have applied maximal medical treatment for a patient with acute asthma and despite escalating oxygen requirements, the patient remains hypoxic and progressively develops respiratory failure.  Intubation and mechanical ventilation is the next logical step but because this is beyond the scope of his ability or experience, he doesn’t contemplate that option nor appreciate who can provide it.  Meanwhile, the patient deteriorates until they arrest.  This is because they are:

Unable to characterise or articulate the critical issue There are multiple conditions that lead to a life-threatening situation.  Some of them are common and are readily identifiable.  In other situations, they remain uncertain or temporarily unknown.  Regardless, critical illness manifests itself within a limited range of pre-terminal scenarios.  Arrest or peri-arrest is invariably the consequence of persistent or progressive airway compromise, inability to maintain oxygenation, refractory hypotension, persistent lethal arrhythmias or a severe CNS insult.  Resuscitative interventions  ‘buy time’ for the clinician to come to a more definitive diagnosis and treatment plan.   But clinicians unaccustomed in providing these simple interventions are often pre-occupied with achieving a definitive diagnosis whilst leaving the critical issues partially attended.   When these cannot be adequate addressed, it is imperative that they are able to rapidly communicate their immediate concerns to those who can provide help.  Eventually further assistance will be required to define the ultimate problem and eventual solution e.g. CT, surgery etc but this is difficult if they are:

Uncertain about who can help  A Hospital MET in most centres can provide a huge safety net in managing the deteriorating patient.   Their chief function is in providing advanced interventions that temporarily stabilise the patient e.g. intubation, ventilation or pressor support followed by more specific treatments that may help reverse the disease process.   But in many circumstances further investigation is required and other specialists will need to be engaged to provide definitive care.   For example, circulatory compromise could be due to severe sepsis, cardiogenic shock or ongoing haemorrhage.  Interventions could include surgery for source control or interventional cardiology for coronary revascularisation.  In the case of haemorrhage, depending on the origin it would require a surgeon, interventional radiologist or gastroenterologist.  Knowing exactly which service to engage and the skills they provide can greatly facilitate the rapid treatment and disposition of these patients.

Diffusion of responsibility In a team environment which lacks strong leadership there is a temptation to assume someone else will assume the task of making major decisions, alterations in plans or be responsible for executing them.   This typically occurs when members are of similar abilities with no clear dominant figure.  It may even occur when all members are highly experienced (see above).   For whatever reason the result is a mutually deferential team that finds itself eventually incapable of making effective decisions or carrying out further actions .    One does not need to be the omniscient authority to assume the role of a leader but it is certainly important that someone can facilitate interaction, discuss possibilities and co-ordinate activities in a timely manner.

High authority gradients In a very hierarchal organisation, the cultural expectation is that leaders are expected to give instructions and sub-ordinates who dutifully follow them as best they can without question.  Problems may occur if the instructions are wrong or dangerous, or those required to perform them are inadequately equipped to do so.   The inability to question the leader, obtain assistance or admit failure may lead to poor outcomes.  Silently ignoring an ambiguous instruction can be as bad as following an incorrect one.     Effort has been particularly made in the aviation industry to encourage better communication through the Two Challenge Rule to encourage team members to flag the risk of imminent danger and ensure that the leader reflects on their decision or when further discussion or clarification should occur.

Present of team conflict and egos In a group where there are several dominant figures with conflicting but valid opinions, it is sometimes difficult to progress a specific plan.  Rather than attempting to reach a resolution they act to obstruct any alternatives.  The absence of any concrete decision may be detrimental to the patient.  Ultimately, the leader of the group needs to point out that the impasse is jeopardising the patient’s safety and that a compromise needs to be reached.  This may involve either a workable hybrid of different approaches or pursuing one provisional plan with the option of selecting an alternative if the first one fails.

Delays in execution Sometimes it becomes very clear to everyone what the next action is required but due to a lack of clear and directed communication they do not immediately occur e.g.  transfer to CT or the operating theatre.    In a busy resuscitation, it is easy to become pre-occupied with the immediate tasks and needs without anticipating the requirements of future actions.  To maintain this momentum, the leader must pre-warn team members  to begin making preparations for the next step.

Ultimately, the common theme in these scenarios is less related to clinician ability but impacted by the quality of communication that is able to characterise the issues, problems or blocks and articulate the plan of actions that need to be carried out.

Further reading: