Ok here goes - my first attempt at a Tweetorial - let me know what you think ... Intro to Decision Making in General - but maybe in Anaesthesia / Airway Management in particular ... @RCoANews @WeekesLauren @doctimcook @jopo899 @elboghdadly @sally_ghazali @GongGasGirl @dasairway
Decisions are complex and come in two broad categories; What would you do coming to this junction on a dark and stormy night requires a perceptual decision based on sensory data (not a lot of higher cognition) 
Who your favourite bond is, is a preferential decision - requiring much more higher cognition and deliberation, but much less sensory input (in case you're wondering, it's Timothy Dalton ... no question)
Between 6-10% of patients experience preventable harm and human factors and decision making are fequently implicated - 1 - Preventable Patient Harm across Health Care Services:A Systematic Review and Meta-analysis
This is born out in multiple studies - NCEPOD, Danish Airway Database and NAP4 included.
@AirwayMxAcademy and Bouman estimated that if all airway options were available, there are approx 1million combinations. Psychologist Barry Schwartz showed that increasing choice increases the burden of negative emotions
Decision making is poorly understand and multiple brain areas are involved, different facets dealt with by different areas, e.g. Anterior cingulate gyrus - uncertainty, Dorsal Anterior Cingulate Cortex – strategic thinking -
Sanfey, A. G. (2007). Decision Neuroscience:
Sanfey, A. G. (2007). Decision Neuroscience:
There are multiple models of how decisions are made, Bayesian now largely replaced with system 1 (intuitive) and 2 (analytical) a la Daniel Kahneman.
There are myriad factors that influence how we make decisions; environmental, personality (ambiguity tolerance being a big factor - approx 50% of personality variation is genetically based) and non-personality (gender, age, thirst/hunger, fatigue, stress level, experience).
Decision load is important. Wasink and Sobel J showed that an estimated 226.7 decisions are made daily on just food. Danziger et al S showed in Israeli parole hearings, unfavourable outcomes were more likely as hearing progressed, but favourability increased after rest/breaks
Decision making capability is like a battery, we have finite reserves and multiple sources of drain are present. We need to maximise out reserve by planning, treating physical/psychological fatigue AND sharing decision load where possible.
We are all subject to cognitive biases. Steigler et al highlighted the 9 most common in anaesthesia. Premature closure, Confirmation bias, Sunk costs, Commission bias, Omission bias, Anchoring, Overconfidence, Framing effect and Availability bias.
Metacognition - thinking about thinking can help eliminate biases. The Anterior Insular Cortex and Dorsal Anterior Cingulate Cortex appear to be key to this sort of strategic thinking.
Chew et al in Singapore suggested the TWED mnemonic to help with cognitive debiasing - Threat, What else, Evidence to confirm/disconfirm and Dispositional factors influencing decision (e.g. environment, hunger). Ultimately situational awareness is key,
Optimal situational awareness is when cognitive level meets task complexity. Johari and Cynefin windows can help make sense of a situation helps define what decisions we need to make by defining what is known/unknown, the kind of situation and the basis for how to proceed.
Multiple studies have shown that decision making in airway disasters is often poor and time-consuming. From @doctimcook's review in anaesthesia
How do we tackle decision inertia ? If you saw this you'd know what to do instinctively. Why is the same not true for airways ?
Prof Laurence Allison advocates a least worst goal directed decision making process, highlights failed management not the same as failure to attempt management. Decision-making shouldnt be complex, but requires frequent evaluation and re-evaluation.
My mnemonic is DCGARDEN - DEFINE problem, time frame, acceptable goals/limits, COLLECT data, GENERATE a handful of options, ASSESS options / evidence, REFLECT on potential outcomes / dispositional factors, DECIDE, EVALUATE decision and NEXT - - avoid inertia. End of thread.
