The human factor in critical decision making.

To the Editor:

Anaesthesiology is a specialty that has grown in popularity over the previous year due to the COVID-19 pandemic. Anaesthesia management in critical situations during the pandemic has showcased the flexibility of anaesthesiologists and also, perhaps, our little-known medical and human skills. Managing critical scenarios is challenging. Our development as clinicians able to work in any type of critical situation (pre- and intra-hospital) has been guided by scientific evidence and training. However, what happens when we have to deal with a hitherto unknown clinical problem? What happens when the number of intubated patients increases exponentially and ultimately exceeds the resources of the healthcare system? Our intention in this letter is to describe how the human factor can influence our decision-making process in critical scenarios.

During the first wave of the pandemic, a 70-year-old woman was admitted to the intensive care unit due to bilateral SARS-CoV-2 pneumonia that required immediate oral intubation and pronation. Nine days later, we performed blind percutaneous tracheotomy. Due to fear of infection and uncertainties at that time regarding the infectiousness of the virus, the procedure was not guided by fibreoptic bronchoscopy in order to avoid exposing the operators to the virus in an open airway. Several hours later, the patient presented thoracic and cervical subcutaneous emphysema with progressive desaturation, and was diagnosed with bilateral pneumothorax. Fibreoptic bronchoscopy revealed a tear in the pars membranosa and dissection of the pre-oesophageal space about 5 cm above the carina. Ventilation and respiratory parameters improved after the cannula had been replaced with a reinforced tube. Surgical repair was ruled out due to the patient’s age and the severity of her clinical condition, and she ultimately died due to respiratory complications 15 days after admission.

COVID-19 patients typically require prolonged weaning from mechanical ventilation, often requiring tracheotomy. In patients with COVID-19, this technique is particularly challenging to clinicians as it is an aerosol-generating procedure that can put them at risk of infection. Studies published so far have observed no difference between the percutaneous and surgical approach in terms of timing or infection of healthcare workers. Measures such as changing the ventilation mode from mechanical to spontaneous, administering muscle relaxants, or using closed suction systems to seal the bronchoscope can help reduce the spread of the virus3, 4, 5, 6, 7. Percutaneous tracheostomy is usually performed under fibreoptic bronchoscopy to guide insertion of the needle and ensure that the posterior wall of the trachea is not injured during dilation.

The COVID-19 pandemic has given us an opportunity to show our strengths and weaknesses, and we have encountered many cases such as the one reported here, although we usually prefer not to share them. We usually work following guidelines, but what happens when cannot rely on our training to guide our actions, and our work involves not only a risk for our patients, but also for ourselves? Can we act appropriately when we are forced to work under circumstances that have not been foreseen or rehearsed in even the worst contingency plans? At the beginning of the pandemic, the need to react rapidly to ever increasing healthcare demands forced us to rely on evidence from isolated case reports, small patient series, and/or low-quality studies. During the pandemic, our decision-making processes were undermined by the relentless pressure of caring for so many patients, by our own fears and instinct for self-preservation, and decades of evidence-based medicine were swept away and replaced by emergency-based medicine. Lack of evidence forms the basis of cognitive bias. Lack of evidence is the context, the setting; we act with this setting, and are therefore compelled to make decisions. Fear is an emotional reaction to our surroundings that strengthens our convictions and modifies our choices.

The COVID-19 pandemic has revealed how emotions can influence the decision-making process: fear leads to irrational thinking and misjudgement. Continuing education must be prioritized to prevent mistakes from being repeated. The safety of both patients and clinicians is mandatory; therefore, standard operating procedures should be followed in any emergency setting. COVID-19 has shown how cognitive bias makes us behave irrationally in an emergency situation, and that fear must always be taken into account in critical decision making.

Authors/collaborators

RB: supervised the data collection, took part in writing and preparing the manuscript.

FC: contributed significantly to the revision and design of the manuscript.

FL: contributed significantly to the revision and design of the manuscript.

AB: supervised the data collection, took part in writing and preparing the manuscript.

All authors have reviewed and approved the final document.