Speaker 1: Decisions range from gut instinct choices made in the blink of an eye to government and business policy judgements based on months of analytic research. Slow-moving decisions regarding policy, training, engineering choices and design are often significant for safety, but human performance and limitations are more apparent at the fast end of the spectrum, which is what we'll be focusing on. When things go wrong in healthcare, flawed decision-making is often to blame. This has led to research into the specific issue of healthcare decision-making. Decision-making can go wrong in several ways. The most obvious is when we choose the wrong option. We might also consider the options but fail to make a decision, make the correct decision but take too long over it, or miss the trigger to make a decision at all and continue with what we were doing, with adverse results. People make decisions in different ways to suit different situations. Several schemes have been proposed to classify these different ways. These schemes are somewhat arbitrary and are usually used to help describe the decision-making. Our emphasis here is on improving decision-making and that is reflected in the classification system we use. We divide decisions into automatic versus analytic and conscious versus unconscious. When choosing a new car, we might look at brochures, test-drive different models, discuss colours and any deals available, finally leading to a moment of decision. On the way to the dealership, the traffic lights go red, so we follow the rule to stop. However, if we are blocking the progress of a fire engine, we might judge that there is reason enough to break the rule on this occasion. If we then find the road ahead is blocked by a fallen tree and we know the area well, we could divert from the planned route, still arriving at the dealership more or less as planned. This thought process involves a pattern-matching automatic decision based on previous knowledge and experience. Analytic decisions are when we have the time and information needed to consider our options, gain further information as necessary and to reach a reasoned choice. Most of the research done on decision-making has involved experiments on college undergraduates, with carefully contrived analytic decision tasks. This led to a classical theory of specific steps we go through in decision-making. Several of the steps refer not to the decision itself, but to its associated situation awareness. The decision trigger is not actually part of decision-making, which is why it is zero. It is, however, part of situation awareness, which is covered in more detail in a separate module. We are not assessing the decision itself, but assessing its consequences and the time and resources that are available to make it. Assessment involves asking the right questions. A recurrent error in decision assessment relates to time. The natural tendency, particularly with inexperienced decision-makers, is to hurry to the first available option. Time is rarely that pressured, and for inexperienced staff it is usually better to prolong mental assessment at the expense of reduced time for action. The quality of decision-making depends on the accuracy of the information gathered at the assessment phase. Consider deciding whether to do an appendectomy operation or not. Information relevant to this decision includes a coated tongue, rebound peritonism, anorexia and tender lymph nodes in the groin. Less relevant information is hair colour, tendon reflexes and visual acuity. In the assessment phase of this decision, the surgeon prioritises by gathering the relevant information. This principle can be applied to analytic decisions in general. The best assessments involve identifying the most important features and specifically looking for them to ensure they are accurately registered. Another recurrent error in assessment is losing sight of the ultimate object of a decision. For example, are we trying to improve compliance with treatment or cure disease? The options check is a concept that we have introduced for this course and it is one of the more practical take-home messages. The check begins with a deliberate, conscious identification of the ultimate objective of the decision and the options in hand. Then it involves stepping back to see if there are further options that have not so far been considered. This is shown here. Other authors have described this process under various headings, including creative and adaptive decision-making. We include it because we want to encourage it rather than describe it. Option checking is at its best when no

Speaker 2: existing options look attractive. Orthopaedic surgeon Professor A. W. Wallace showed thorough and creative option checking when he was travelling from Hong Kong to London on an aeroplane. He was asked to care for a passenger who had developed chest pain who had been involved in a motorcycle accident before boarding the plane. The passenger rapidly became seriously unwell. A pneumothorax was suspected by the professor. This happens when a damaged lung leaks air into the pleural space between the chest wall and the lung. When the air becomes trapped, the lung collapses and threatens life. With minimal aids to diagnosis, the professor asked for a second opinion from a junior doctor, Dr. T. Wong, who was also on the plane. Dr. Wong agreed with the diagnosis. They then improvised a chest drain set using a urinary catheter, a coat hanger as a trocar, adhesive tape, oxygen tubing and a plastic bottle of mineral water as a water trap. They used five-star brandy as a disinfectant. The patient recovered. Once they had made the diagnosis, they initially

Speaker 1: had no acceptable options for treatment. They asked for advice from the ground about what equipment was on board, but none came. They considered a diversion, but time was too short. The catheter in the aircraft's medical kit would do for a drain, but it would let air into the chest as well as letting it out. Therefore, they needed a one-way valve system and they devised one from whatever was at hand. Their option-checking was prompted because there was no acceptable option to hand. This is often the case, as illustrated by the anonymous phrase, necessity is the mother of invention. Option-checking is a good habit to get into, even without such prompting. The principle tool of analytic decision-making is predicting the consequences of, or projecting the options. This involves looking at the predicted consequences of each option and comparing them before the best one is chosen. Slow strategic and policy decisions, such as do we merge these hospitals or do we add bariatrics to our general surgery service, are analytic and involve acquiring data over a substantial time. Their purpose is to provide projections for all options that are as accurate as possible. In medicine, many diagnosis, treatment and place of care decisions require careful appraisal, time and a search for information with the same intention, that is, accurate projection. The purpose of reviewing a decision is to revisit it in the light of updated information. This information is used for two things. Firstly, to suggest new options. A positive options check is an important part of review. Secondly, to update projections. The most obvious projection to update is the one for the chosen option, but other projections should also be updated.

Speaker 2: The constant stream of phone messages to Dr Brown's Android phone was irritating enough, but he also had a management team meeting at midday to prepare for and was very behind. There was one more hernia repair to go on a patient who was obese and would need intubating and might take ages to recover. The patient, weighing in at over 150 kilos, had been seen and pronounced fit and well by the registrar. At induction, the light bulb in the large laryngoscope failed. Then the replacement, which was a size smaller, did not give an adequate view. The patient's oxygen saturation fell rapidly and several attempts to intubate with various scopes and airway aids were equally unsuccessful. When he asked about fibre optic equipment, a device that is threaded through the airways to enable intubation under direct vision, he learned that it was in use, but should be available in 20 minutes. Time for taking stock. With a simple bag and face mask, a simple Goodell airway and two-handed ventilation, an oxygen saturation of 85% could be maintained. It was not brilliant, but neither was it lethal for the patient. The surgery was non-urgent and no drugs had been given that could not be rapidly reversed. Therefore, the patient was woken up, his drugs were reversed and he was half sat up to reduce the work of breathing. After a stormy few minutes, he was back in recovery, complaining bitterly that his surgery had not been done.

Speaker 1: This frustrating situation illustrates a continuous cycle of option checking, choosing and reviewing by Dr Brown. He was under time pressure but decided to go ahead with the operation anyway. He initially decided on conventional intubation. He chose the large laryngoscope, but the bulb failed. An options check led to the use of the second largest laryngoscope, but this too failed. Review showed falling saturation and an urgent need to gain airway control. Various airways were tried without success. The fibre optic option was identified and projected well. Then it failed too because it was not available. Dr Brown reviewed the situation again. With limited options, he realised he could keep oxygenation at a tolerable but not ideal level for enough time for the induction drugs to be reversed. He therefore cancelled the surgery and woke the patient up. The situation involved an unfortunate conspiracy of circumstances, but Dr Brown managed it successfully. For more information visit www.fema.gov