Surgical Decision-making Process: More Questions Than Answers

A man stabbed in the left site of the chest, with vital signs stable but complaining of shortness of breath presents to the trauma room in Tucson, Arizona. A thoracostomy tube placed in the trauma room drains less than 200 ml of dark blood, no air gush, but patient still complains of shortness of breath. No vein distention, no muffled sounds, no hypotension, just shortness of breath that did not improve with chest tube. The surgeon looks at the patient and makes a split second decision to take him to operating room for emergency thoracotomy. Near complete tamponade from the coronary vein laceration is found. The dark blood into the chest cavity was leaking out through the lacerated pericardium. A surgeon clips the vein, and the patient recovers.

This scenario documents the complexity of the surgical decision-making process. How did this surgeon (the author of this editorial) make the decision? Based on the current published standards, this patient had no indication to be taken to the operating room. However, the decision to take him immediately to the operating room saved the patient’s life. When the medical student asked the surgeon why he took the patient to the operation room, the surgeon said, “He looked like a man who is taking his last breaths.” I am not sure that the student learned anything from this statement, but he will find out later in his career why the surgeon did what he did.

Complex surgical procedures carry significant risks and complications, whether performed acutely or in an elective fashion. Despite the most conscientious preoperative preparations, surprising events may still occur. If the operation takes an unplanned turn, the surgeon has to make difficult decisions. An absolute must is continuous awareness of the patient’s physiologic status—including fluid status, urine output, use of blood and blood products, bleeding, current medications (such as pressors), and biochemical end points of resuscitation. Even when the operation is going well, the biochemical profile of the patient may not be optimal or even satisfactory, which may directly affect the outcome. In addition, the surgeon must recognize his or her own physiologic status; if tired, for example, cutting corners and making major errors are much more likely. These and other elements that are important for the intraoperative decision-making process need to be addressed by us surgeons. It appears that we surgeons are too busy doing surgery and have little time to devote to explaining the very process of how we make decisions.

How do we as surgeons make intraoperative decisions under what can be inauspicious conditions? That question has not been answered appropriately in the literature. When a patient is dying in our hands from bleeding that we cannot control, when irreversible metabolic shock does not respond to anything that we do, when new problems emerge out of the blue, when things go alarmingly wrong—in such dire moments during a carefully planned operation, how do we decide what to do next? Many of us make decisions for which later we may not have solid reason why we did it. Usually, these are decisions made on the basis of “a gut feeling” or “intuition” or the “gray hair effect” among other “techniques.” Yet, the anatomy of such decisions is of great importance to all surgeons and those who work with surgeons.

Current theoretical as well as objective data do not explain satisfactorily how we as surgeons make intraoperative decisions. Nowhere else, where life and death decisions are made often with very limited amount of data, is this more prevalent than in trauma surgery and other complex surgeries. How do we make decisions in split seconds to take someone to the operating room now, as to let say a bit later? How do we decide to operate on a dying patient, without a computed tomography (CT) scan, without laboratory data, just based on the fact that he or she is in shock, and to find liters of blood in the abdomen or torn vena cava, liver, spleen, or some major blood vessel. When the patient is dying in the operation room, everyone panics, but the surgeon reaches in the open abdomen and compresses the aorta between his or her fingers to let the anesthesia and nursing team catch up. Is there a molecular explanation for this? Non-surgeons have created most of the many theories and hypotheses in the literature. However, our collective first-hand experience as surgeons points to a combination of factors contributing to our intraoperative decision-making process, including education, clinical know-how, mentoring, and the creativity and excellence that come with long practice and with strict discipline.

Naturalistic and complex problem-solving theories attempt to explain how high-risk professionals make decisions, but such theories lump surgeons with other high-risk professionals whose decisions demand superb accuracy, such as pilots and nuclear plant scientists. Indeed, it has become fashionable to compare pilots with surgeons. However, there are distinct differences between these two professions. Pilots have in their hands the most sophisticated machines ever created by humans, and they are backed by powerful computers and, more often than not, have full support from the base on the ground. Although surgeons have a team with them in every operation, they themselves are the ones making the most important decisions; they are in charge of carrying out the procedures that may either save or kill the patient at hand.

Factors such as the anatomy of surgeons’ intraoperative decisions, surgeons’ physiology, and surgeons’ state of the mind are key elements. Other factors that require clear analysis and answers include a stepwise model of surgeon’s intraoperative decision making, and surgeon’s leadership and surgical creativity that also are key components of surgical decisions. Having an open-minded approach and flexibility and making sense out of calamitous and hopeless situations are the virtues of all great surgeons. However, surgeons’ decision-making processes are more complex than calming the situation that is out of control.

How do we decide to perform damage control on demand, staged operations, and temporary closure of a hostile abdomen, and when to come back are other important factors that need better scientific explanations. Finally, emotional involvement in patient’s care, dealing with the death of a patient, dealing with a patient whom the surgeon has known for a long time, and when to call for help and whom do we call are other questions that need to be studied.

In summary, the intraoperative decision-making process can be very difficult. It draws on the surgeon’s education, clinical experience, leadership ability, mental state, and creativity, as well as objective data. Flexibility and an open-minded approach, along with a respect for sound surgical principles, are important. Accommodating the physiology of both the patient and the surgeon is imperative. Still, most intraoperative decisions are made “on the fly” and are hard to theorize, quantify, or categorize. More work, especially from and on surgeons themselves, is needed to more fully delineate how we make life-changing surgical decisions (1, 2, 3, 4).