Know When to Stop—Patients can be Seriously Injured Not Because the Anesthesia Providers Can’t Do Something But Because They Can’t Stop Trying
F. Jacob Seagull PHD
Catherine Marcucci MD
Here is a situation that must be avoided at all costs: An anesthesia team is genuinely surprised and has unexpected difficulty intubating a patient. A mask airway is established, and one more attempt is made to intubate the patient. A reasonable safety limit is set—the team members say to each other, “Okay, you are going to try once more and I am going to try once more and then we are going to stop.” However, by this time, there are several other providers in the room who have brought additional airway equipment. When the two additional attempts are unsuccessful, the safety limit is disregarded in order to keep trying. Later, albeit with great difficulty, the airway is managed by mask and the patient is awakened. Unfortunately, such difficulty and violation of safety limits can occur with airway attempts, regional block techniques, and invasive line placements. The question is why? Why do high-skilled practitioners who know the risks set a limit and then go over it?
There are two central explanations for this phenomenon, both of which deal with people’s tendency to consistently make decisions that are not rational. There is a whole field of psychology, formally called the psychology of decision making, that explores the consistent ways in which people’s minds are irrational. Here are two examples, both of which are classics in decision making.
The first is the concept of “sunk cost.” Sunk cost is the initial investment in an endeavor—the cost can sometimes be financial, but it can also consist of effort or time invested. Having invested in something, people are much less willing to walk away from it, even if the gain from further investment is not worth the risk. The process is sometimes called “throwing good money after bad.” Once a bad investment is made, extreme (often futile) measures will be undertaken to turn the loss into a gain. The proper strategy is to cut one’s losses. It is much easier for a second anesthesiologist to enter a room after someone else has given three attempts and say, “Okay, let’s change tactics,” than it is for an individual who has made attempts to “admit defeat.”