Assessing risk and benefit in resuscitation

Pik Mukherji will change your mind on assessing risk and benefit in resuscitation. There is a bent towards action in the Emergency Department. This is for a few reasons. We are risk adverse – we do not want to miss the acutely sick patient. We do not want to miss the patient that “falls of the cliff”. In fact, as Pik discusses, in emergency medicine and critical care, training is focused on looking for the sharks, even when the waters appear friendly and calm. This is highlighted acutely well by Pik in a story about an elderly gentleman. The man presentedto the ED after a minor trauma. On history and examination there was nothing to find, apart from a minor scrape. Due to the risk adverse nature of the ED, the patient got a CT scan. It showed an acute subarachnoid haemorrhage. This meant he stayed in hospital for observation. The next day he fell off a bed being transported back to the scanner and disaster followed. On review, the original CT showed no abnormalities. This story highlights the risk of the devastating harm that can come to patients in the medical system. Every time a test is ordered there is risk of incidentalomas, biopsies, and repeat visits – to name a few. Pik wants to drive the message home - not every patient can be helped. Every patient can be hurt. Time and time again, doctors overestimate the benefits of their treatments and underestimate the harms. Even armed with this knowledge and knowing the guidelines does not seem to change behaviours. Pik demonstrates this fact with the live SMACC audience where he shows this “cover my backside” mentality in real time. Unnecessary testing and over cautious approaches flying in the face of the evidence. As health care professionals we are taught to “do”. We are programmed to act. The trouble is that sometimes the only person this is benefitting is the clinician. After all, we feel better having done something over nothing. Hippocrates was wrong! “Do no harm” is impossible. So, take a step outside of your comfort zone and try to do less.

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