Controversy vs Non-Controversy in Emergency Medicine

This essay is inspired by a question raised in the FOAMed community, ‘Why are we always arguing about intubation? Why don’t we argue about lumbar puncture?’ Examining this question closely has implications for psychological safety, and for a general understanding of controversies (within and outside emergency medicine).

The controversial question is this: “A patient in the emergency department needs endotrachial intubation. Should the procedure be performed by the emergency department?” The non-controversial question is this: “A patient in the emergency department needs a lumbar puncture. Should the procedure be performed by the emergency department?” Firstly, is it a fair comparison? The answer is pretty firmly ‘yes’.

Both procedures (endotrachial intubation and lumbar puncture) can kill patients if something goes wrong; they are performed because they can be the only way to save someone’s life. They require high levels of skill, a challenging combination of force and delicate maneuvering. They hurt patients, and require an anaesthetic. It’s possible to think that you’ve done it correctly, when what you’ve actually done is to kill your patient. For both questions, there are smart people who say “Yes” and smart people who say “No”.

Applying my simple formula “Perceived threat fuels controversy” to those commonalities suggests that they should both be controversial. And yet, intubation is controversial, and lumbar puncture is not. The formula needs to be clarified: “The perceived threat of the conversation fuels controversy.” It’s not the threat of the procedure that makes it controversial, it’s the threat involved in talking about it.

There may be differences of opinion regarding lumbar puncture, but those differences are not perceived as threats. When it comes to intubation, differences of opinion are much likely to be a cause of fear.

The question of ‘who should do a lumbar puncture’ has as many answers as ‘who should do an intubation’, and every sensible opinion agrees on the principles:

  • There needs to be a strong reason for a risky procedure
  • The person performing the procedure must be appropriately trained. If inexperienced, they should also be supervised.
  • The more people who can perform a procedure (who do it often and for real), the stronger the profession is (better able to care for more patients)
  • Calling people in from other departments & sending patients to other departments both take time. Doing things here with the people who are already here saves time.

In any given hospital, the local practice will be self-reinforcing. If the emergency department doesn’t do the procedure, they won’t get the practice, and therefore can’t do the procedure. If they do the procedure, they’ll get the practice, and they’ll be able to do it.

And yet, there is a recurring professional debate about intubation, and no debate about lumbar puncture. Why is it so?

I suspect that the answer is this: If you need intubation, you typically have seconds (perhaps minutes) to live before you die. If you need a lumbar puncture, you have hours (perhaps days or weeks) to live before you die. If a patient needs a lumbar puncture, you can afford to spend a few minutes working out who the very best person is for the current situation. If a patient needs intubation, every second spent talking is a second that the patient spends dying. The question ‘who will intubate’ must be answered before the patient enters the emergency department; the question ‘who will puncture the spine’ can be answered after you decide to do it.

Therefore, someone who is used to having intubation done in the emergency department will be horrified at the prospect of delaying the procedure by sending the patient to ICU. Someone who is used to intubation being done only in ICU will be horrified at the prospect of the emergency department killing the patient via inexperience. Both of them know that when the patient can’t breathe, there will be no time for discussion; lives depend on getting the answer right in advance.

Ironically, the more important it is for us to reach an agreement, the more our emotions impede us from reaching an agreement. When you’re terrified that incompetent idiots will kill a patient they should have sent to ICU, or that incompetent bureaucrats will kill patients by insisting they be sent to ICU, it’s hard to take a step back and see that ‘local practices will be self-reinforcing’.

Of course, ‘local practices will be self-reinforcing’ isn’t truly an answer to the controversy. Those local practices will be shaped by a number of factors, including the kinds of diseases that are common in the local community, staffing levels, government policies, and personalities. “It’s right to do it this way because this is the way we do it” isn’t a well-considered or strongly defensible argument.

So, to generalize, controversies will persist when:

  • Both sides of the argument have a defensible point of view
  • The existence of an opposing view is perceived as threatening by (some of the) people on both sides of the argument
  • Both sides have a continuing supply of evidence to support their view

In the case of the intubation controversy, the threat posed by the opposing view is that a patient will be treated in the wrong place (leading to inexperience or delay, depending on which side you take) because an urgent decision is made by someone holding the opposing view.

In the case of the lumbar puncture non-controversy, we can be confident that when an emergency doctor decides that a lumbar puncture is needed, a process of ‘selecting someone to do the lumbar puncture’ will begin; that process will resolve quickly enough that the best person for the job will arrive in time to do the job before things get seriously worse.

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Nick Argall is an organization engineer, structuring activities to help businesses achieve their goals. nargall@gmail.com

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