Mind of the Resuscitationist – Errors of Commission and Omission

permission-to-act

I received an email from a friend and colleague on how to build mental toughness in our trainees. After hearing the case that spurred the question, I actually began to believe the problem is actually one of self-granted permission to act and the conflict between erros of commission and errors of omission.

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Comments

  1. John Conroy, EM PGY-3 says:

    So very true in medical education today. Not only true with dramatic procedures such as a pericardiocentesis, but also just the medical management of patients. The tasks we used to give med students we now give interns; the tasks we gave interns now belong to senior residents; so on with fellows, with attendings, then finally to subspecialty services. The only explanation I have found for this ascending responsibility drift is liability; the ominous threat of legal action should there be a complication.
    Great topic.
    Fix what is killing the patient first.

    • When I was a resident, I was able to intubate without an attending in the room. Now as an attending, in the current climate, that would be beyond unthinkable if one of my residents intubated while I was elsewhere in the dept.

  2. Mikael says:

    Well, from my point of view. That is being a resident in Sweden. Most of the time it is easier to be passive than active. And you sadly get in less truble for not doing.
    —Mikael Nöjd

    • yep!

      • caseyparker207 says:

        Scott – it is an interesting tension in the scenario you depict. On Omission vs Commission

        The junior medics would tend towards the error that “gets them into less trouble” whereas I am sure the patient would prefer the ‘error’ that leaves them with the “best possible outcome”
        I fear that the two are not always (or often ) the same thing.

        I think that is the crux of the problem here?
        Casey

  3. Andrew DeWolf says:

    Scott: First off, great topic! Look forward to the responses and further reflection from the greats on here. Wouldn’t let me open the link attached for recommended reading, says I need to have a name and password to your website? Any chance you could post it in another format, maybe a .pdf?

  4. thanks Scott. interesting discussion point. essentially a philosophical challenge. You might have even quoted Hamlet !

    I dont think its a binary equation. its not black and white. It depends. and we dont always get it right

    Hemingway once famously said “Its better to wade in and get hammered in the process”..he was a serial committer I hazard!

    Its really about the philosophy of ” Act and beg forgiveness” vs “First do no harm”

    Life teaches us the former, whereas medicine teaches us the latter.

    and you are right..its got nothing to do with mental toughness.

  5. DaveLilie says:

    Hi, first time contributor.

    Very interesting topic. We are trained to “first, do no harm.” This may weigh on our minds as we deliberate performing a procedure or intervention. I know it does mine. “Do” is an action word. If we are taking action and harm occurs, then WE have done harm. If inaction leads to harm, we* do not feel as guilty or as much a participant, even though we decided not to do the procedure. We were not the ones to pull the trigger. Some of us fall into a certain mentality of omission based on that word, “do.” This biases us toward inaction if the course of action is not clear.

    If we reference the sagely gods of rock and roll, Rush, we find “if we choose not to decide, we still have made a choice.” (http://www.azlyrics.com/lyrics/rush/freewill.html) In parallel thought, if we decide to do nothing, have we done something? That something being nothing. If so, we can argue by doing nothing, we have done harm. So, we can DO harm by doing something or doing nothing. What does “do” mean? But the doing something (intervention) requires more volition, thus more responsibility, than doing nothing.

    As an aside, this idea of our actions (not inactions) causing adverse outcomes is, I feel, why it is sometimes difficult to get family members to make a patient comfort care. The feel their doing something, in this case a decision to change code status, will be the cause of the death of their loved one. That is a responsibility they cannot burden.

    *By “we” I realize each of us is different but I am sure there are like minded thinkers out there for which as residents it is (was) not an issue permission for commission but, the commission itself. Now as an attending I wonder will my action harm the patient? That is one of my struggles as an attending, especially when a complication of that procedure rears its ugly head.

    In the case Dr. Weingart presented, probably little downside to evacuating the pericardium in coding patient. But there seem to be a hundred cases of more equivocal risk-benifit profiles for each of the cut-and-dried, nothing-to-lose cases.

    Sorry I was so long winded but I hope my ramblings have at least left you with a pleasant ear worm from Rush.

  6. I thought I would listen to something relaxing before going to bed, but no. O_o

    I see this the opposite way in EMS.

    Rather than being afraid to do something that is right, we are afraid to not do something – no matter how harmful that something is. Backboards (beloved of trauma surgeons trying to fit a curved back to a flat piece of rigid plastic and blaming EMS for the problems with this incoherent untested hypotheses) have been used for decades, because “What if we don’t do everything possible to the patient?” It’s Cricolol.

    Epinephrine for everyone who remains dead long enough to be sprinkled with the magic resuscitation sauce – Cricolol.

    Lasix for CHF, because if we don’t give everything in the protocol, we might deprive the patient of a chance to be harmed by the Cricolol.

    What I see is people routinely using the Yuppie Nuremberg Defense.

    Everyone’s got a mortgage to pay. [inner monologue] The Yuppie Nuremberg defense.

    https://en.wikiquote.org/wiki/Thank_You_for_Smoking

    If I don’t assault the patient with every available unstudied/poorly studied/dangerous treatment in the protocol, I will get in trouble.

    The problem seems to be a lack of confidence standing up to those who insist that something must be done because you could get in trouble for doing the right thing and a lack of confidence standing up to those who insist that something must not be done because you could get in trouble for doing the right thing.

    Is it better to harm the patient by doing too much vs, Is it better to harm the patient by doing too little? – This is the wrong question.

    Why don’t we understand enough about what we are doing to make reasonable decisions?

    A dead patient might benefit from a pericardiocentesis, while there is not much chance of harm to the dead patient.

    Where does the risk/benefit ratio lead us?

    We need to have a better understanding of what is appropriate risk management.

    I look at the question a different way. Better to ask for permission or for forgiveness?

    I choose to do what is right and ask for forgiveness later. I occasionally violate protocol, but I go to the doctor first and explain why I did what I did, then it is much more difficult for the protocol enforcement gnomes to punish me, because they are afraid to confront a doctor on a patient care issue. I have been fortunate that the physicians I have dealt with have understood my reasoning and did not see it as something to be punished.

    I have been told, You did the right thing, but don’t do it again.

    How is that a sane message? Why is doing what is right discouraged? What kind of care does this encourage?

    Is it that really any different for physicians?

    Consider this informed consent – I know that this is not likely to be beneficial for you, and may even be harmful for you, but this is to keep me from getting in trouble. That is not the kind of treatment we want to be maximally aggressive with. You do not practice kitchen sink medicine because you know that much of what you can do to the patient is likely to cause more harm than benefit.

    If I give a bunch of large doses of NTG to the CHF patient, I probably prevent the need for intubation, or compressions, but we are terrified that their blood pressure might crash because What if . . . ?

    The right thing is not action vs. inaction, but taking the responsibility for making a decision vs. just trying to follow the protocol, blend in with the herd, and hope that nobody notices that we don’t know enough to make a reasonable decision.

    First do no harm is a ridiculous way of phrasing an approach to medicine – It is impossible to treat a patient with something harmless. Nothing is harmless, but that does not mean that doing nothing is more harmless than doing something. Everything is harmful to some extent, but that does not mean that doing something is more harmful than doing nothing.

    There is a great article on the subject that should be read by everyone involved in patient care.

    A piece of my mind: the harm of “first, do no harm”.
    Shelton JD.
    JAMA. 2000 Dec 6;284(21):2687-8. No abstract available.
    PMID: 11105155 [PubMed - indexed for MEDLINE]

    http://www.ncbi.nlm.nih.gov/pubmed/11105155

    We should be trying to do as little net harm as possible, not pretend that we are doing the impossible (no harm).

    We do not know how to make difficult decisions, so we try to think like lawyers and decide what will get us in more trouble, rather than doing what is best for the patient. We have a legal system that uses intermittent punishment to encourage this form of superstition.

    Is doing something the same as using Cricolol?

    Are we doing/not doing something because it is the right thing to do or are we doing/not doing something because we are afraid of getting in trouble.

    When blood-letting was the standard of care, was maximally aggressive care the right approach?

    You wouldn’t have gotten in trouble for bleeding the patient, but it was not good patient care – even though blood-letting showed improvement in many surrogate endpoints.

    Physicians observed of old, and continued to observe for many centuries, the following facts concerning blood-letting.
    1. It gave relief to pain. . . . .
    2. It diminished swelling. . . . .
    3. It diminished local redness or congestion. . . . .
    4. For a short time after bleeding, either local or general, abnormal heat was sensibly diminished.
    5. After bleeding, spasms ceased, . . . .
    6. If the blood could be made to run, patients were roused up suddenly from the apparent death of coma. (This was puzzling to those who regarded spasm and paralysis as opposite states; but it showed the catholic applicability of the remedy.)
    7. Natural (wrongly termed ” accidental”) hacmorrhages were observed sometimes to end disease. . . . .
    8. . . . venesection would cause hamorrhages to cease.

    Blood-Letting
    Br Med J.
    1871 March 18; 1(533): 283–291.
    PMCID: PMC2260507

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2260507/

    The problem is not choosing action/inaction. The problem is not understanding how to make a difficult decision about what is best for the patient. The problem is a system which discourages doing what is best for the patient, or is at least perceived as discouraging doing what is best for the patient.

    Sorry for a rant longer than the podcast, but now I can try to sleep. This is a great topic that does not have easy answers.

    :-)

    • Love the comments Rogue! You and Seth below both mention the issues of over-treatment which is obviously a huge problem in EMS and the hospital. I was not quite touching on that problem so much as the decision to do the hard, big ticket items; the high stakes things. And then you got to EMS protocol violations, and that is the perfect example. Or even in protocol items where you need MedCon, but you can’t get them due to radio issues. Do you give the treatment anyway knowing the pt will get better from it or do nothing b/c you can’t get the order.

      • I was not quite touching on that problem so much as the decision to do the hard, big ticket items; the high stakes things.

        What about the simple big ticket items, such as intubation?

        Is the tough decision to wait and try something less aggressive or to intubate before the patient becomes unstable? Your discussion of this for DSI is something that is using aggressive intervention with ketamine that may lead to an improvement that would allow for aggressive withholding of intubation that, on further assessment, no longer seems to be in the patient’s best interest.

        The gold standard of airway management is the patient protecting his own stable airway.

        The most difficult part can be making the decision, rather than performing the procedure.

        Do you give the treatment anyway knowing the pt will get better from it or do nothing b/c you can’t get the order.

        The older I get, the more I am able to violate protocol with the doctor defending me. More emergency physicians have EMS backgrounds, so they have dealt with the same situations. Sometimes this is the reason they went to medical school.

        I tell the doctor what I have done and stick around to make sure that they have all of the information that they need. I think that this helps a lot, because most doctors realize that we can kill the patient with just about everything we carry, not just the treatments that require a “Mother-, may I?” call. The bigger concern is often for something that they do not know about. I also tell them what I did wrong, when I do something wrong. It is better to have the doctors and nurses aware of everything, than to protect my ego.

        I have known my current medical director for about 20 years, so there is familiarity with the way I do things.

        I will violate the protocol, rather than harm the patient. If that means that I lose my paramedic card to protect my patient, I can find other work. I cam’t guarantee a good outcome to anyone, but I can do the best I can with what I have.

        My protocols are written to be a ceiling, rather than a floor. They protect patients from some aggressive care, regardless of whether the aggressive care is appropriate. The system is designed to allow the uninvolved medical director to feel comfortable sleeping at night with no idea who the medics are, how good the medics are, what kind of decisions the medics make – unless quality control flags something for the medical director’s attention. Quality control is too often just a matter of looking for discrepancies between the protocol (textbook treatment for the uncomplicated patient) and the chart (narrative fiction).

        I have not always been so good at doing what is best for my patients, but I have learned from them.

        http://roguemedic.com/2008/05/burns-and-pain-and-little-kids/

        .

        • Amen! But then there could be the obvious discussion of the difference between an experienced, astute medic doing this vs. a potentially arrogant rookie–dunning-krugerr, etc.

          • Currently, some of the doctors have known me for about 20 years. That helps the communication, but I think that newer doctors have become much more willing to listen to paramedics and realize that treatments delivered outside of the hospital can be just as beneficial, or harmful, as treatments delivered inside the hospital.

            There also seems to be more of an understanding that, related to this podcast, that not doing something/ordering that something not be done, can be bad patient care.

            I think that what has worked in my favor (other than the good fortune of the doctors involved not being protocol fanatics) when I was brand new, was that the reasons I gave for what I did were always for the benefit of the patient and were logical.

            A literal interpretation of a poorly worded document (such as a poorly worded protocol) is not that much of a threat. Do we really want paramedics who do not think? My protocols have improved a lot. Unfortunately, my protocols still act as a ceiling to discourage good medics, rather than a floor to discourage bad medics. And there are still too many systems with very badly written protocols.

            .

  7. Julian says:

    Awesome topic, and I’m really looking forward to what comes out of it! As a med student, I feel that two things have really helped me start along the path of granting ‘self-permission’. One is educating myself on cognitive biases and human factors (kahneman/judgement in managerial decision making/less wrong sequences/HPMOR). I feel this helps a lot with respect to insight into these situations – identifying cognitive barriers and overcoming them.

    The second is #FOAMed, encouraging excellence (ie not copping out, an internal mental model where it is simply expected that pericardial effusion+tamponade = time for pericardiocentesis). I feel like a lot of this could easily be lost by being exposed to colleagues who don’t hold the same mental model and are more indecisive.

    As humans we are incredibly influenced by our surrounding community (such as in Asch’s conformity experiments). If our workplace has a general air of ‘ommiting’, we are likely to do the same. Maybe #FOAMed can provide an alternative community to ‘escape’ from the pressures of the one we are surrounded by at our workplaces – it could be used to practice ‘commiting’ medicine. However in this case the alternative community is mentally granting us permission, not ourselves, so not quite the same.

    Enough rambling from me.

    • We just need a little Cliff Reid bobble-head that you can put in the resus room that just says, “If you think it-do it. If you can think it-you can do it” on a loop.

  8. OK, this all get’s a bit philosophical – and indeed a bit circular…

    We do not rise to the level of our expectations. We fall to the level of our training.
    Archilochus, Greek Soldier-Poet, 650 BC

    The entire medical system is geared up to criticise mistakes, viz :

    “Did you hear what those dumb ass docs did in ED? Thank heaven we in ICU were able to save the patient!”
    “What about those rural docs? You can’t fix stupid!”

    The problem of course is that often trainees don’t know what they don’t know…and even if they DO know, they may be terrified of acting for fear of making a mistake and ‘getting it wrong’.

    It all comes back to training. Unless your training enables one to act, it is effectively useless.

    And it is OUR responsibility to enable trainees to make decisions. Their failure is OUR failure.

    I’d be interested to know how things are set up in many readers institutions….

    - what is the level of training does it encompass decision-making?
    - do you use sim?
    - does training happen according to a plan?
    - is it intentional?
    - is it documented and audited?
    - do your trainees understand what is expected of them?

    In short, do you expect them to rise to the occasion? When in fact, like the ancient Greeks (who knew a thing or two), this is a myth…

    …without the proper training, there is nothing to rise with.

    Good WEE!

  9. ie : train them in difficult decision-making, not just knowledge-base.

  10. Interesting talk, and clearly there are a lot of times where the bias is toward inaction. On the flip side, our system is clearly biased toward “doing something” on a bigger scale — rigorous workups for low risk chest pain, increasing use of CT, excessive coronary stents, and probably most importantly, the immense over-treatment at the end of life.

    I’m not sure where the divide is: overcommit on the big scale, but individuals without permission to act during resuscitation?

  11. Kyle M says:

    Great topic. Like others have said, it seems a bit ridiculous to say ‘first do no harm’, even though many seem to make it a mantra for med students like me to live by.

    I’d be curious to learn how the med-legal cases on each side of the argument tend to work out. Is care legally deemed inappropriate in cases where X was done and went south more/same/less often vs situations with omissions of active care?

    • Kyle, see Rick Body’s post linked now in the main post above for a discussion of the silliness of first, do not harm as an excuse

  12. caseyparker207 says:

    Hi Scott
    I wrote a really long reply – the thought…. ahhh bugger it – I’ll just do an audio rant: http://traffic.libsyn.com/broomedocs/Pearl_-_Schizo_mind.mp3

    Its all about Kenny rogers really!
    Casey

  13. you can see this thread has pulled out all the philosophical geeks with rants on the meaning of life , existential despair and medical futility with dashes of EBM religion.

    May I suggest getting back to reality and the case cited of two junior doctors dealing with a critical patient who eventually died of severe aortic dissection.

    In all probablity even if a pericardiocentesis was done and successful the patient had a significant risk of dying regardless.

    To say that these doctors failed to act is a gross assumption. You could equally argue they acted within their scope of practice and did what they thought was reasonable and more importantly what they thought they could live with afterwards!

    What this boils down to is your opinion vs someone elses. sure we are entitled to our opinions but like I said earlier, this is not a binary equation. its not black and white.

    This reminds me of a junior doctor who did a needle cric and saved a patients life. She had watched one of my videos on how to do it…then did it! When I asked her what made her do it..the simple answer was it had to be done, so it was!

    What made her act, and the two junior doctors with the dissection case, not act? clearly they are two different cases and the decision is dependent on the situation!

    Thats my whole point. dont be judgemental if you werent actually there!

    as for training, of course we should be training, that goes without saying. But lets get real..we cant train for everything! S hould I train to do a splenectomy on the kitchen table of a remote cAttle farm? Probably not!

    Let me offer a more pragmatic example

    TPA for Stroke lysis! Many neurologists and physicians around the world consider that if we failed to act, in offering TPA to an acute CVA patient, we would be making a SIN of OMISSION.
    Some EM. docs would however consider that to do so is in fact a SIN of COMMISSION!

    at the end of the day…it is a matter of opinion..is it not!? :-)

    • Yes, it is a matter of opinion.

      However, not all opinions are equally valid.

      That is where the evidence, the quality of the evidence, and the application of logic and experience come into play.

      We should take a skeptical approach to intervention.

      Medicine has a horrible history of encouraging intervention based on expert opinion, weak evidence, and unwarranted wishful thinking. This time it will be different!. As your tPA example highlights – we haven’t stopped counting the hits and ignoring (or making excuses for) the misses. A success rate of 2/11 is horrible, but that is the evidence for tPA.

      http://smartem.org/content/guideline-science-and-gap

      We like to think that we know what horrors will befall our patient if we do not intervene, but the more we learn, the more we realize we don’t know as much we think we do.

      http://www.ncbi.nlm.nih.gov/pubmed/20446970

      Shouldn’t we be skeptical of all opinions?

      .

      • Rogue, how is this in anyway relevant to the cited case at hand? What opinion is valid when you have someone dying of a pericardial tamponade from an aortic dissection? What would you have done if you were in the position those junior doctors encountered?

        • I hope that I did not give the impression that I was, in any way, addressing the specifics of this example. The example does not contain many specifics and I did not interpret it as intended to discuss specifics.

          I did interpret this case as a presentation of a general concept that is intended to generate an important discussion of the ways that we make decisions.

          .

  14. Hi Minh
    I would make it clear – I make no criticism of a specific doctor’s decision to act or not act. The problem as I see it is the failure to change gears (up or down) and provide the most appropriate level / degree of aggressive care.
    We should train Docs to recognise when they need to switch gears – or else you get inadequate Resus or on the otherside Overdiagnosis and innappropriate care.
    C

    • Thanks Casey. I appreciate your attempt to delineate the problem. I am not sure if you have proposed a solution..or even a list of options towards a solution…or even a hint of a suggestion as to a way possibly remotely forward towards a solution.

      I am even uncertain if what you describe is what these junior doctors faced? Do you really think it was a problem with being able to change gears? really?

  15. British Bloke in Aus says:

    I think we can over-analyse all this and I don’t think it’s about sins of omission or commission at all. I think it’s about having a supportive environment where people feel able to go out on a limb when necessary and understand that if things do go wrong they will be safe within an honest, no blame culture where such events are learning events, not a means to strike people down and humiliate them. Mental toughness? No, you don’t have to ‘do’ things to your trainees to foster the right spirit, just bring them up in the right overall culture.

    David

    • Obviously I agree with all that except for the mental toughness being a cultural assimilation situation. Yes if we chose to raise our trainees in constant austerity and punishment like the Spartans did, they may become tough by culture alone. The OBGyns in New York seem to have adopted this path. The trainees may be tough in the sense that they are generally mean and bitter, not what we are looking for. The special operations groups of the military also have a culture, but they take specific steps to breed the desired toughness in their recruits as well.

      David, it sounds like you would not look at mental toughness as a positive attribute. Does the specific term rankle you or do you genuinely believe that the idea is not useful in our specialty?

      • British Bloke in Aus says:

        Hi Scott,

        Sorry for not responding earlier, but I’ve been caught up. The term, ‘mental toughness’, doesn’t rankle, but equally I think it’s important to view it in its cultural context, that of US emergency medicine. To this foreigner, the US approach to emergency medicine can sometimes seem to have a bit of the ‘Seal Team Six’ about it: a macho, at times quasi-military air. The question you frame is fine and valid, but perhaps it is also culture-specific and maybe the term ‘mental toughness’ is not appropriate to other EM global cultures. Certainly, I find the concept alien and would prefer to talk solely in terms of how to foster a sense that there is permission to act in a given situation. Mental toughness doesn’t come into it, as far as I’m concerned, or at least the term means nothing to me.

        I think we often underestimate how our practice of medicine is culturally enjoined and varies so much around the globe. On the other hand, too, I am only a GP in Casey’s department here in Aus, much lower acuity and throughput than you deal with, so perhaps that also influences my view.

        Cheers,

        David

        • I think many of us in resuscitation actually wouldn’t mind a mindset comparison to special forces (excepting the macho of course, b/c we need tough women and men). This same attitude can’t be extended to non-critical care EM, just as you mention. Thanks so much for commenting.

          • British Bloke in Aus says:

            Maybe. I’d be interested to see if specialist ‘resuscitationists’ in other countries agreed with you. I suspect the special forces thing is more culture specific than a general phenomenon of ultra-acute emergency medicine which transcends cultural boundaries. Anyway, a moot point. Interesting podcast. Thanks.

  16. Kath Woolfield says:

    “I actually began to believe the problem is actually one of self-granted permission to act”
    I think you hit the nail on the head here Scott.
    As trainees we are so used to our consultants/attendings affirming or prompting our decision-making that when we are faced with the need to make an immediate decision to act without them, we can falter at the last step.

    The other part of it is the little niggle in the back of our minds that says we could be wrong. I know on night shift my thought processes can get a little muddled and it is easy to mistrust my first instinct. Hence errors of omission become default. Tim brought up a very pertinent point about fear of criticism. Trainees need permission to make mistakes. This is becoming increasingly difficult given we also believe in preventing all patient harm. I’m sure those trainees will never forget that patient’s name. If allowed, the lessons learned will undoubtedly save more lives than this one (arguably one with a very low chance of survival had the procedure been performed). The alternate is that they will feel like failures and lose what “mental toughness” they had.

    The way forward? Hard. I’m sure it comes with experience. I find verbalising the issues helps – suddenly the solution is obvious (and to everybody else in the room). Perhaps this is the real reason speaking to a senior about a case helps formulate a plan. Sims and mental preparation for these difficult cases is of course also very important.

    Finally, I believe good mentorship to discuss challenging cases and the decision-making processes that surround them is vital. As is the need for strong leadership qualities to be seen everyday in our bosses. We do (still) learn by example ;-)

  17. Great podcast, Scott – as usual! I think this is really interesting. Minh, I totally agree with your point about being judgemental and I think it’s really important that you made it. However, to be fair to Scott it would have been hard to make this podcast so interesting without giving it a clinical context – and the story does just that.

    In the worst scenarios, we all know that we can get into more trouble from acts of commission gone wrong. Look at the cases of doctors convicted of gross negligence manslaughter – they tend to be convicted for acts of commission (e.g. giving IV drugs intrathecally; giving unintentional lethal overdoses). No matter how hard we work to avoid it and no matter how good we are, all doctors miss diagnoses some times – that’s just reality. But if acts of omission were treated just as acts of commission are, the whole profession would be in trouble.

    We’re *afraid* of acts of commission – and fear is never a good emotion to have in clinical practice. It’s paralysing effects actually make us more likely to cause harm. That’s why I love #FOAMed, SMACC and approaches like those of Scott, Minh and Richard Levitan (call it a ‘challenging’ airway rather than a ‘difficult’ one). These things encourage us to enjoy our jobs. Don’t focus on the negatives – the targets, the pressures, the inevitability that things sometimes go wrong, the potential for litigation. If you focus on that, it will happen to you.

    Instead, enjoy your job. Enjoy the challenges. Focus on what really matters… *the health of the patient in front of you*.

    PS, as an interesting aside – notice how our paralysis with acts of commission probably doesn’t extend to diagnostic tests. D-dimer. CT scans. Troponin even. Doctors (generally speaking) aren’t afraid of those acts of commission… And they certainly have potential harms in the wrong hands.

    Rick

    • thanks Ric! Can you sing all that to a piano tune as well!
      Python was right all along…”Always look on the bright side of life..”

      seriously, well done for pointing towards a way forward that has humanistic pragmatism! Enjoy your job, focus on patient needs.

      I subscribe to that philosophy rather than mechanistic dogma, EBM religion and existential medical despair.

      Doctors are indoctrinated to fear. we are made to see ourselves as machines,computers, EBM scientists.
      We are not supersoldiers

      The art is lost to the science.

      Humanism is forsaken in the face of an irrepressible enemy, death.

      so thanks for sounding it out, Ric.

      I love those St EMlyns folk..when the zombie apocalypse occurs, they will be the..candle in the wind.

      • The great tragedy of Science — the slaying of a beautiful hypothesis by an ugly fact. – Thomas Henry Huxley.

        EBM helps us protect our patients from treatments that do not work.

        Using treatments that do not work on our patients expose our patients to risk for no benefit.

        EBM is Ethics-Based Medicine as well as Evidence-Based Medicine.

        .

        • Well then it’s ethical to give epi in cardiac arrest as per the two RCT for VSE !
          Checkmate

          • Please explain.

            • Are you suggesting that all epinephrine in cardiac arrest is effective?

              A specific cocktail that contained epinephrine as only one of three drugs has been shown to be effective.

              Are you suggesting that we should look for loopholes and that this is somehow the way EBM works?

              You finish with – Checkmate

              I am accustomed to seeing this in comments from vaccine denialists and other science denialists, Is that what you intend?

              In what way would your comment be a form of checkmate?

              I know you are capable of explaining much more clearly. I would rather respond to what you actually mean, than to something that is so vague as to have no meaning (are you going for nihilism?).

              We had a reasonable discussion of EBM as part of our conversation on the lack of evidence for epinephrine in cardiac arrest on your podcast –

              http://prehospitalmed.com/2012/05/20/pharm-podcast-012-epinephrine-and-ohca-with-paramedic-tim-noonan/

              .

  18. Eric Siegal says:

    Judging by the comments, you’ve obviously struck a nerve here.

    A wonderful surgeon once told me that a good surgeon knows when to operate, but a great surgeon knows when to NOT operate. Over the last 20 years, I’ve seen as many bad outcomes from omission as I have seen from commission, and wisdom lies in quickly weighing risks and benefits and acting accordingly. It’s a gross and dangerous oversimplification to make blanket statements about whether it is better to err towards action vs inaction.

    To be sure, the twin crusades for patient safety and resident work reduction have (in the US at least), created a suffocating blanket of supervision that is breeding a generation of physicians who can’t wipe their own butts without supervision. That should scare all of us. That said, we can’t return to (not so distant) days when residents had free reign to (mis)manage extraordinarily sick patients with little or no supervision. Again, it’s all about balance. In this case, we have to balance the immediate needs of the patient vs the imperative to ensure that the next generation of physicians is competent to take care of, well… us.

    • agree on both the surgeons comment and the residents–striking the balance has been ridiculously hard in my career as an educator

  19. RuralRN says:

    Thank you RougeMedic for giving me the courage to add my voice to this discussion. As an RN I am not sure that all of my opinions will relate to all of you, but I am a long time listener of the podcast and I have never heard Scott discuss an issue to which I have felt compelled to respond. I agree with you Scott, we are more likely to overDO the easy stuff and omit the hard stuff as a medical culture.

    Kidocs discusses the training process, including training good decision making, and training to DO and succeed instead of fear the results of a potential failure. I received my training (and I still practice) in a rural environment. While the doctors and nurses I work with may not be as specialized, the culture is generally open minded and more team oriented than the other (larger) facilities where I have worked. In large facilities there can be a idea that if you make a mistake of omission you can sweep it under the rug in the hustle and bustle; it may not be reviewed (unless someone with exceptional mental toughness gets a hold of the case:)). If you do nothing in my environment, it will be noticed. The result of this is a significant review process and the empowerment of nurses and doctors to DO and speak. It is helpful for us in the rural environment to think that it is ‘us or nothing.’ In essence, if there is a chance and I think I can do it, I will, as that is why the patient came to me.

    The real question is how do we train this into all of our care providers. I guess we have to give them the opportunity and create a culture which encourages risks and actions in a safe environment. My personal experience of indoctrination into the DO culture started on my first day of clinical. I had an NG tube shoved into my hand by an ED doc and she told me to put it in a patient that was losing consciousness. I told her I had never done it before and wasn’t trained and handed the tube back to her. She handed it back to me and said, “If you don’t do it, you’ll never learn. Do it now.” I wish I could write that woman a thank you letter because she gave me the mindset I needed to DO the right thing for the patient. I am not sure if that was what she thought she was teaching me, but that is what I took away, and it stuck with me ever since.

    Like RougeMedic discussed, as nurses we are taught to do “what is right for the patient.” But I feel many nurses probably frame this in a different way. What many of us hope to do is to rise to patient and family expectations. This requires understanding of the patient, family and their needs (something I realize is very difficult to ascertain in a busy ER). That is our biggest challenge, because it is different for each patient. Like RougeMedic, I have blown protocol and woken up doctors, who were not on call, in the middle of the night, to get what I felt was best for my patient. (People, unfortunately, are unpredictable, and sometimes they are only able to tell you what they really need after their blood pressure has stabilized :)

    That all being said, I am a big believer in protocols. Casey Parker talked about being able to flip the switch between urgent care, critical care and palliative modes, and most importantly, knowing when to do all of these. I agree that this is what we must train all medical practitioners to be able to do. I am sure all of us have saved a life we regretted and most of us have at least witnessed an aggressive treatment that killed or harmed a patient. I am still learning every day that we have to be ready and brave enough to DO, but aware enough to look at the patient or family before we start and quickly consider if it is appropriate.

    Thank you Scott, for bringing this subject to the table. I apologize for the long response.

    • love the long response. love that rogue has been rebranded as rouge. I spent the past year back at shock trauma, where the nurses are empowered at every level to call an attending if the fellow is not being maximally aggressive. If the attending doesn’t stand up, they call the physician-in-chief. The right RNs can be masterful guarantors of optimal care.

  20. Sorry to join the party a bit late…..

    As a trainee with only 6 months of training to go, I think Kath and Rick probably encapsulate it from where I am.

    There are times when it is hard to switch into Casey’s “surgical” mode because in the back (and front) of my mind is the subsequent conversation in a law court:

    - So, Dr C, have you ever done a pericardiocentesis/thoracotomy/perimortem C-section?
    - Erm, no.
    - And have you had training in cardiothoracic surgery/obstetrics/any kind of surgery?
    - Erm, no.
    - And did you discuss with a consultant before you did the procedure?
    - No, I felt it was too urgent.
    - And did you call a cardiothoracic surgeon/obstetrician?
    - My colleague was doing that as I did the procedure.
    - So did you not think it was appropriate to wait for the expert?
    - Erm, no, I felt it was too urgent.
    - And how many cases of this have you seen to give you the experience to judge the urgency?
    - Erm, none.
    - And what do you make of Professor Very-profitable-medicolegal-practice’s report that says that procedure should only be carried out by experts with credentialing?
    - Erm, I think he’s an idiot who has no understanding of emergency care *wakes in cold sweat*.

    I will always get into less trouble for doing nothing and arguing that the “something” was outwith my training and scope of practice than for doing something ad being perceived to f*** it up.

    Rubbish for the patients.

  21. PS – in direct reply to Rick – I AM afraid. Having had my life on hold for 18 months with the Damoclean sword of potential prosecution over my head made me afraid….. and I will probably stay that way. I doubt that I’m unusual in that respect amongst those who have been on the receiving end of the regulatory authorities :-(

  22. Pik Mukherji says:

    Interesting discussion- but IMO 2 separate discussions.

    I think “permission to act” is relevant to the case presented, and having a mental model of the procedure may give oneself “pre’ permission” to avoid unnecessary cognitive load when the time comes. Puts me in mind of Cliff Reid’s “Hero” talk and Rich Levitan’s “barriers to cut” in cric discussions.

    But errors of commission/omission are very different when discussing testing vs. procedures. Extra testing is somehow “safer” and extra procedures are “invasive” and “aggressive.”. So medicolegally folks seem to treat extra testing as “safe” while procedures are “dangerous.” Rewarded for errors of commission in workup but punished for committing procedure errors.

    Lots of folks have weighed in with “do no harm” vs. “intervene first, ask permission later.” I have a roughly equal # of critical situations in which I paused and waited with good outcomes, as the number where I plunged into an aggressive action. Judging whether to act or wait is the key and the hardest question to answer. Short answer? The sicker the pt., the more you should do.

    • absolutely right, Pik. This dealt purely with treatment, folks consistently err on the side of excess commission when it comes to testing in the US.

  23. Great podcast Scott. A bit on my background before my comments : after a 15-year career in EMS, I’m in the home stretch preparing to go to medical school, with the goal of returning to pre-hospital practice as an EMS Medical Director. The exact topic of this article and podcast plagues me daily as a Paramedic FTO in an urban setting with conservative protocols and a typical transport time of 30 minute transport times, where the paramedics actually get to practice medicine).

    I see a two part problem here: first, my primary system is one in which every employee gets sent to paramedic school within a year of hire, and one in which we simply don’t run enough *good* ALS calls to keep the skills of 120+ medics sharp. We have created a culture of watered-down paramedics who follow the paradigm set by the old-heads of “just throw them in the ambulance and get to them to the hospital”. The result is that we are breeding an entire culture of providers who are committing errors omission due to lack of confidence. Secondly, we practice “lawsuit avoidance” in this country more than we practice medicine… we have become so conservative in our treatments out of fear of malpractice suits that we are bordering on neglecting our patients. This is yet another trend which has started with physicians and has trickled out to pre-hospital providers, and our patients are the losers. We have created a culture where errors of omission are perfectly acceptable.

    I agree with you… if I’m going to get hammered for something, I would rather it be because I performed an aggressive treatment which I thought was warranted, rather than doing nothing. A recent example: a few weeks ago, I rolled into the ED with a trauma patient I had sedated, paralyzed and intubated, and had done a needle decompression. When I gave my report which included “and I darted his right side”, the trauma surgeon was absolutely INDIGNANT when she asked why I had darted him. I explained that he had a tension pneumo, which was met with a rude “WELL HOW DID YOU KNOW THAT?!” Fortunately for the patient I’m confident in my assessment and skills, and unfortunately for the trauma surgeon I’m not easily intimidated, and the CXR showed that the patient DID in fact have a hemo-pneumo on that side. Many physicians (not to mention paramedics) would have been terrified when challenged in such a manner, and as a result we have providers who are beaten into submission, tuck their tail, and begin to commit errors of omission because they’re not confident in their assessments and skills, and they’re afraid to be made to look foolish. Part of the issue here is the condescending attitude which comes from some physicians (although I will go on record to say this isn’t the case with all trauma surgeons, as when I transported patients to Parkland Hospital in Dallas, I never had this problem with a trauma surgeon).

    It’s an epidemic with many facets which, like many trends in medicine, starts with physicians, and trickles down to the providers they supervise, in my case, field medics. I’m constantly looking for answers when I see a problem, and unfortunately, I don’t see a clear-cut answer here. The best thing I can offer is for us to foster a culture where we praise positive actions, put egos aside, stress education and critical thinking, and use teachable moments for positive influence instead of using them to belittle providers.

  24. michael kroll says:

    hi scott
    it all depends – in a stable patient i will not do a procedure with a risk of harm unless i am 80 % sure it should be done (pareto analysis 80% rule). as the patient becomes more unstable my 80% starts dropping and i have less concern about potential harm. it also involves knowing what is the right thing vs being unsure as well as having the skill set to do it. all these variables play in my mind. we all make judgement calls that someone will question when things go wrong. in the end, if i know what i am doing, the right call will usually me made.
    (i first read about 80% rule in s schulichs book “get smarter”)

    • it’s a good heuristic. I guess by pure application of Pareto, it would actually be that we should only perform the 20% of treatments that have the most yield; and we would wind up with 80% of the beneficial outcomes. Still like the idea that you need to be 80% sure before acting. It is identical to the treatment threshold lines we use for deciding any intervention.

  25. justinhensleymd says:

    Where I find the biggest issue is not “do or not do”, it’s “do what is right, right now.” I’ve seen patients harmed by inappropriate medications or therapies in an attempt to “do something”, and then I’ve seen patients harmed by not doing a procedure that they need. So some of it comes just simply to having the knowledge to do the correct treatment. But some of it comes from from the ability, or lack thereof, to decide, and I agree that the medicine vs surgery analogy is very correct in this case.
    Agree with Casey in that there needs to be a switch that can be turned on, but I don’t have an answer for how to teach that in the 24 odd months my trainees are in the ED (and 12 months of offservice). Everything you do, you had to do a first time, and if it is a lifesaving procedure, you should be prepared to perform it.

  26. Great podcast, very thought-provoking.

    I put up a quick blog about this (http://www.pulmcrit.org/2014/06/errors-of-commission-vs-errors-of.html). I wrote the blog before reading all the comments in efforts to be original. The general concept ended up being similar to Casey Parker’s audio rant although rather than emphasizing distinct mindsets it places things along more of a continuum of aggressiveness vs. level of acuity.

  27. Great discussion. Grappled with this recently, and after much rumination am now in a place where next time I may l give my self more permission to act. A lot of these decisions live in the grey zone. My recent dilemma was whether to intubate a patient who gave every clue to being a very difficult airway on the floor (literally)in a department across the hall from my ED, or to grab them and run them over to my team and equipment (endtidal CO2,CMAC) which I Believed in that moment to be the best chance of success. had the mental block that I was less likely or couldn’t save her life on the,floor so moved her but likely sacrificed some critical minutes of less than optimal effective Ventilation and oxygenation. I established an airway in my. Resus bay but still lost the patient. Hats off ..to you medics,who do this on the,floor routinely, morbidly obese, no neck, no teeth, massive tongue. I was afraid if no view and no endtidal CO 2 available I might “do harm” but it cost some time to,get to the tools. Dunno. I was confident in my ability in my environment to take on a very difficult airway but let this be a barrier to my willingness to do what may have been needed but harder and riskier nor in a place of my comfort. In the end I may have mentally defeated myself. It is very likely to have been an unsuccessful resus anywhere. . . Anyone else go through this?

    • Hi Renee
      yes I have been in that situation before and yes I regretted moving the patient . having said that I think we will always be at risk of getting burnt by these situations. I dont think moving the patient to a better resus area if it cAn be done quickly is a bad idea. The problem is that it can take longer than we predict and the patient can deteriorate whilst nothing is being done during the move,

      I have tended now to start resuscitation with basic gear at the bedside and call for help and more gear to be brought to the bedside rather than try to move patient. I learnt this with my prehospital work…having said that even in prehospital it is still better to optimise your resus area and patient positioning. for example the common mistake is to leave a trauma patient lying on the ground and try to intubate at that level! the far better plan is to lift the patient onto an elevated platform or position for the intubation.

      • Renee–there is no right answer and you would beat yourself up either way. The ideal, as Minh says, is to bring the resus bay to the patient if the resources are there. Definitely grey zone!

  28. Very interesting indeed. First when you mention ” if someone would have said do it they would have” it remind me of :
    http://en.wikipedia.org/wiki/Milgram_experiment

    So i think the issue not so much an ethical one but our aversion to loss or been wrong. In her book:

    http://www.ted.com/talks/kathryn_schulz_on_being_wrong
    Discuss that subject. Our aversion to loss or been wrong sometime will make us be irrational. In nursing I notice a similar trend. We used to report safety issue via report that was more interesting in blaming someone then finding a solution. When they change that approach for finding a solution or prevention, more people filled those report. Society train us to have the right answer, no to be wrong but changing that mind set to try, be confident and learn from our mistake would make stronger clinician I believe. In my opinion it is even a generation issue. For example,in Quebec, Can. The school cannot fail a student in primary school. It would be to hard on their ego. I think it’s the opposite, we learn from mistake and failure, isn’t the beauty of simulation? Which bring us to a solution.
    When I preceptor a nurse I let them do mistake and ” struggle” with full assignment. But i am there to catch the mistake first, second to correct it. But the feeling they had of the possible impact of their decision remain. Then it come to be a good teacher, mentor….. been a sherpa. Sherpa in expedition carry the most of the load. Whit out them expedition wouldn’t be possible. But you still have to do the journey yourself. So we look to identify what can be done so this doesn’t happen. At the end isn’t an expert” someone that did all the mistake that is possible”?

    • RuralRN says:

      Thanks for speaking up MountianRN. I think you make some good points. I admit I have no knowledge of how physicians are trained. I received my training in a rural setting and I have worked here since I got out of school. There is no medical school in my state! However, I think we are seeing similar problems in new nurses. Being tentative, inexperienced and lacking knowledge are all expected when we are new at anything. I agree with the new push that critical thinking should be the focus of schooling, as it is the most important skill to our jobs. However, I am concerned that we are doing our new nurses a disservice by not allowing them opportunities to practice vital skills they will need in practice. Where I work we get twelve weeks to train a new graduate RN. Some of the new RNs I train have never put in an IV before, not even on another student in school. While some skills will be new, and most should be beginners at the ones they were trained to do in school, this seems like a disservice. If basic skills are not learned vital mental space is taken up worrying about these things, space that is needed for the critical thinking that we know is the key to good care.

      • RuralRn says:

        And I spelled Mountain wrong. Not a banner week for me in the spelling department.

      • Actual critical thinking is a skill that help in all area of life. Sadly it is not widely taught . Back in ancient Greece every citizen require to represent his own in front of others. They learn rhetoric, argumentation to do so. I believe, in nursing, learning those skills, dealing with difficult people, critical thinking and having not just teacher but mentor to built confidence would help alleviate. Becoming MacGyver of those situation. Like Minh mention on earlier post, we can train for every situation, but Mac with his swiss knife always manage to find a solution. Let’s be better at building a ” mental swiss” knife to future resuscitationist.

        • yes, as a society we have let these critical thinking skills slip. in fact any Socratic challenge is usually viewed as offensive, rather than an opportunity to defend thinking.

  29. I have had in my 36 year career many occasions where I had to give myself permission to do something in the absence of a doc. In these cases I could have lost my license, been reprimanded for out of scope of practice. But, I did it anyways and would do it again. I have been in many situations with junior residents and a patient spiralling down, and have taken over as a nurse and start active treatment, until a more senior resident arrived or a staff man arrived. I would alway take responsibility for my actions, and I would not make the junior resident feel stupid. I have had many nurse colloquies over the years tell me I am just looking for trouble. I am a critical care nurse since 1983, CCRT nurse for four years, presently a casual ER nurse in a rural setting semi retired. In many cases as a nurse I do not have permission to do things, and it is out of my scope of practice, but with my experience and knowledge base, I have found myself in situations where I know what to do, and it should be done. Very catch 22 position. I feel, that if I did not do the action, and a negative outcome occurred, if it went to court I would get into trouble there for not doing what I new, but it still not in my scope of practice. Giving yourself permission to act is not a nice feeling, you are afraid, you are second guessing yourself, but you do it at that moment in time because it is the right thing to do and worry about the consequences after.

  30. Tom Halliday says:

    As another Swedish doctor I have a different view from my friend Mikael. In anaesthetics/icu I will always be questioned if I don’t do things. I think it’s a bit different for the orthopods here (hi mikey welcome to us soon). My mentor says constantly that we should focus on doing the right things with our patients not on trying to avoid doing the wrong things. Also there’s not a snowflakes chance in hell of him coming in to stand by my side while I intubate, so a fair bit left before we are in the same position as the residents in the US. Great discussion!

  31. Great Wee that really hit home. As a resident, I love Shock Trauma for a plethora of reasons, but one definitely is like you said, they are not afraid to act and to do. They try everything for patient. That’s the type of physician I would want for my family or myself, so I feel its the kind of physician I want to become. We are all going to make errors, but I feel at least with an error of commission, you tried and were unsuccessful instead of omission, where you just didn’t even give the effort. I get really sad, when I see physicians give up without giving the full effort. How do you suggest finding a hospital to work in as an attending where they support the commission philosophy? Any hints on how you can find that out about a hospital ahead of time? Thanks for all your help :)

  32. PAUL BISHOP, PEDIATRIC/NEONATAL CRITICAL CARE PARAMEDIC says:

    Meanwhile, I can intubate all day long with no supervision or asking permission from anybody…

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