nexus/sreweekly/markdown/464/05-surviving-cardiac-surgical-chaos.md

Surviving Cardiac Surgical Chaos

• 期号: SRE Weekly Issue #464（2025-02-16）
• 作者: Robert Poston, MD
• 链接: https://robpostonblog.wordpress.com/2025/02/04/dealing-with-chaos-during-cardiac-surgery/

简介

Normally, we rely on the thoughts, decisions, and actions of individuals to create resilizence in our sociotechnical systems, but in some time-critical situations, it can be best for one expert to call the shots.

正文

When done well, heart surgery is very reproducible. So much so, it gives us the feeling of déjà vu. Even though every case is on a different patient with unique pathology, there are similarities that give us that odd but comforting feeling we’ve been at this exact spot before. When an ideal case comes along that is challenging but not overwhelming, the team enters an enhanced state called “flow”. This pleasurable state enables heightened focus, improved decision making and greater teamwork. The experience of flow during a case is a major part of what makes cardiac surgery so rewarding, apart from the tremendous pride we feel from a good patient outcome.

In moments that are even more rare (but more frequent than anyone would prefer), the opposite happens. Just as the cardiac team is lulled into our routine of deja vu, something unexpected and horrible turns everything strange. A problem that is too big to see happens, replacing the feeling we have been here before with the terrorizing thought we have no idea where we are. Extreme levels of disagreement and uncertainty erupt about what to do. Our system that we rely on is thrown into chaos and rendered ineffective, at least temporarily. If unchecked, a contagious panic can set in and paralyze the team at the worst possible time, leaving us with no idea who can help. In stark contrast to the flow state, these moments are so devastating because of how horrible team members feel that go through it, apart from the guilt of a poor patient outcome. In only a few brief moments once or twice a year, the goals of the entire surgical program are threatened.

Disagreement and uncertainty are necessary parts of all creative activity. Cardiac surgical teams routinely navigate at the edge of chaos using small acts of improvisation and innovation in virtually every case. Part of the definition of a high performance team is the skill to tap into the strengths of chaos without succumbing to its dire downsides. The problem is when chaos gets out of control and leads to disaster.

The Mann Gulch tragedy is powerful metaphor of what can happen to cardiac surgical teams that live on the brink of combustion. The Mann Gulch forest fire in Montana in 1949 seemed harmless at first but then exploded after the winds shifted. A team of fifteen inexperienced smoke-jumpers parachuted in to contain the fire, but soon they were running for their lives. Their foreman, a man with 10 years of experience, recognized that they would not make it up the top of a steep ridge. He invented a solution known as an “escape fire” by setting fire to the grass directly in front of him as the larger flames approached. The escape fire spread quickly uphill and he stepped into the middle of the newly burnt area, calling for his crew to join him. The crew did not, and the fire raged past the foreman and overtook the crew. Only the foreman survived.

The foreman had not previously met his firefighting crew to establish his credibility prior to that fateful day. The entire crew ignored his lifesaving command not just because they didn’t get the reason for his escape fire. It was a breakdown in group psychological safety, starting with an initial crew member that chose to start running past the escape fire and up the hill. His act of panic spread contagiously throughout the others, causing them to act impulsively and run. With more time to reflect and rethink, it seems likely all would recognize how foolish it was for an inexperienced crew to ignore ther leader, the only firefighter who had lived through things like this before.

Examples of similar uncontrolled chaos happening during cardiac surgery include:

1. A patient with critical aortic valve stenosis is developing hemodynamic collapse with an unusual clinical presentation of rigors and chills. He needs rapid intervention, but experienced members of the OR team are worried about valve replacement in a setting suspicious for infection. Disagreement between moving ahead with emergent surgery vs a delay to analyze the situation further causes chaos.
2. A patient appears well paralyzed by standard parameters but shows signs of diaphragm movement in a part of a case where that can cause major injury to the patient and needs emergent administration of additional paralytics. Disagreement about the urgent downside of not giving paralytics and the actual risk for diaphragm movement at that moment created chaos.
3. An induction dose of propofol is given at a dose well below what would be expected to cause hemodynamic or respiratory problems yet suddenly develops a code blue and the team argues about the underlying cause. An ill-timed argument distracts from understanding and treating a code blue, triggering chaos.
4. A patient comes into the OR wide awake with an impella device and the arterial line shows no pulsatility. After induction of general anesthesia, the mean pressure and lack of pulse remain the same. Few in the OR have impella training and the rep is not in the room although everyone notices the surgeon addressing some kind of device malfunction (suction alarm at P2) and later directs the team to emergently crash on the bypass machine. Team members become confused why the critical decision was made to crash on bypass, which causes chaos.
5. A patient undergoing open mitral valve repair is on bypass and has the left atrium opened after a cross clamp is placed on the aorta. There is a large volume of dark blood noted in the left atrial operative field obstructing the view of the mitral. The surgeon and the perfusionist talk over each other at the exact moment when their communication needs to be highly collaborative, causing a moment of chaos.

Chaotic systems are susceptible to a phenomenon called the “butterfly effect”, famously described as the flap of a butterfly’s wings in the Amazon that leads to a tornado in Texas. This metaphor illustrates that initial conditions have a huge impact on the final outcome of a chaotic system. When either a forest fire or surgical case turns chaotic, team members improve their ‘initial conditions’ by subordinating any disagreements/alternative opinions to the judgment of the leader. Even a minor disagreement at the wrong moment can lead to contagious dissent, triggering bad decisions with no time to course correct. OR team members in a chaotic moment avoid this fate when they ‘lean on the surgeon’: listen closely, follow my direction and hold any disagreements until the moment resolves. A team whose surgeon has to repeat a command twice or yell over others during chaos is not creating the optimal ‘initial condition’. Its like a pilot that calls out “Mayday” but the air traffic controller chooses not to comply with clear communication protocols. Making it automatic to agree with my requests when in the thick of things is a failsafe way to contain chaos, allow the moment to pass and prevent things spiraling out of control.

I admit it. What I’m asking for is confusing. A high performing team is made up of members willing to speak up, act autonomously and think for themselves. A rule requiring automatic agreement seems to suggest the opposite. To clarify, assertiveness and autonomy are still critical during routine cardiac surgery, but just not during brief, low probablility/high consequence moments of chaos. Extreme disagreement and uncertainty during a cardiac surgical case signals that everyone should shift their mindset, put any disagreements away and limit communications to what is needed to support the lead surgeon. Any other communication plan during a moment of chaos risks breeding confusion, mistrust and harm. Your disciplined response to chaos will calm me down so we can save the patient. Once that happens, I ask you then to anticipate what will pull us back further from the edge of extreme chaos. At the point we fully resolve the moment of chaos, resuming assertive, coordinated and clear communication will get the patient out of the OR alive.

The reasoning behind this paradoxical rule is worth spelling out, because it is dramatically different than what we do during most other times in the OR.

1. Act first, ask questions later – Cardiac surgery sometimes requires taking action without all the desired amount of information because the results of your action provide invaluable information. In these situations, inaction risks confusion and letting a crisis overtake you. Extreme chaos pushes us even further towards taking action. Reflection follows. Inaction under a threat might seem safe but risks letting these moments spiral into a patient death. For a team that is completely lost, decisive action is the solution that buys you time to flesh out and rework your interpretations.

2. Centralize to decentralize – High performing teams balance individuality/autonomy and belonging/subordination. Autonomy is effective only when everyone has a clear understanding of my expectations on any given case. These expectations are analogous to the military doctrine of “commander’s intent” that empowers field officers to act autonomously while engaging the enemy. Our team is put at risk of not recovering from extreme chaos unless everyone understands my expectation that I as the leader will be fully in charge at that moment.

3. Believing is seeing – Normally, we ask team members to believe a plan only after having a chance to see what it is and provide feedback, in other words “seeing is believing”. Extreme chaos requires faith that an experienced surgeon is the only one with the skills, judgment and leadership to see the team through chaos; ‘believing is seeing’. Less experienced team members lack decision-making acumen and cannot process and react to the rapid influx of information fast enough, leading to inappropriate responses and poor situational awareness. These flaws interact in a vicious circle, creating dissention at the exact moment it is least tolerable. Chaos resolves by listening closely and heeding commands of the surgeon. He/she is best equipped to quickly recognize patterns, spot violations of expected patterns or piece together seemingly unrelated cues. Forgive me if I act terse in this moment–only an autocrat takes effective action within seconds.

4. Fly in formation – Psychological safety in routine situations means no hesitation to speak up if a team member suspects that the surgeon is about to do something wrong. Open debate occasionally diverts or distracts the team from the task at hand, but that is a risk worth taking. Normally. However, moments of extreme chaos are the glaring exception to this. Psychological safety in these brief moments is not acheived by individuals being assertive, but by sticking together in close communication. This team behavior mitigates the feeling of helplessness and maintains resilience during moments of chaos. The military recognizes the value of ‘staying in formation’ with their saying: “A thinking wingman is a liability”.

A high performance team recognizes that being engulfed within a moment of extreme chaos changes the rules of engagement. They are able to act before asking, centralize in order to decentralize, believe to see and fly in formation. Remaining psychologically safe during extreme chaos is not about the ability to speak up. Psychological safety in extremis is salvaged by a simple rule: lean on the surgeon. Loyalty to the rule saves the patient and the program.

Please don’t misinterpret my message. Autonomy and assertiveness are critical team skills during the course of routine cardiac surgery. It enables the type of team that does not suffer through episodes of extreme chaos very often. Indeed, chaos rarely happens in my OR; but it is not so rare that I can safely ignore the impact of this issue. Thinking back over the past several years, I estimate about one or two of these chaotic events happen per year, each lasting about 5-10 minutes. Despite a frequency as low as this, the stakes of these events could not be higher. Lives depend on how we perform as a team, both the unfortunate patient on the table that day and future ones as well.

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