Imagine that you are alone and walking in the woods on a beautiful sunny day.  Your map indicates that there is a lake off the trail you are taking so you decide to veer off the beaten path.  The weather is perfect with occasional bright beams of sunlight peaking through the dense forest.  There are no bugs or any other wildlife to bother you other than an amazing golden eagle flying in the trees above.  You continue to walk towards where you think the lake is while keeping your attention towards the incredible bird in the sky.  Eventually, it flies out of view.  Now you look down and start to realize that you are a considerable distance away from the trail you left and there is no lake in sight.  On your left and right, in front and behind, for as far as you can see are nothing but trees.  It is hard to recall exactly from which direction you have been walking.  You are undeniably lost in the woods.

An analogous situation can occur in the operating room.  Imagine a team that has just finished a challenging and well executed heart operation.  The case was full of crucial steps and key moments in which everyone had to be at maximal concentration in order to complete their tasks successfully.  Once the case is over, there is a tremendous relief among team members that things are done and the patient escaped without harm.  The circulating nurse calls the family members to let them know that things are going well and their relief is palpable.  The surgeon leaves the room and the anesthesiologist is getting their lines and tubes ready for transfer to the ICU.  Anyone present in this room would be reading the cues correctly to feel like they were in a beautiful sunny forest with no bugs where nothing bad could happen.  Then the arterial line shows a flat line.  The first and most obvious reaction is to think the arterial line is not working.  It is.  No reasonable explanations come to mind how such a sharp downward turn of events could happen.  At this moment, the entire team has become lost in the woods.

In both these scenarios, the culprit was losing situational awareness.  This means that perceptions about what was going on did not line up with reality.  The reality is that almost all major problems are preceded by warning signs.  If there was a lake just a few hundred yards off of the trail, it would not have been hard to find the way back.  But there was neither a lake where it was expected nor sufficient awareness of the direction that was being taken to be able to get back easily.  Similarly, if anyone in the operating room had provided a cue to the OR team that continued vigilance was still required after a complicated cardiac surgical case, then they would have picked up on several (probably not so subtle) signs that the patient was headed towards a crash.

Getting lost occurs the way that Ernest Hemingway describes going bankrupt: gradually, then suddenly (“A Sun Also Rises”).  The trick is to prevent problems or to steer things back on track during the gradual stage before its too late.  A more accurate map, GPS device and/or compass are to the hiker are what the blood gas, arterial pressure and PA catheter are to the team in the cardiac OR.  Perhaps more importantly is the right mindset.  It must be recognized that going off a trail and doing heart surgery always pose potential hazards.  These risks are constantly and dynamically changing over time, so it is really never appropriate to get the feeling that nothing bad could happen.  When used appropriately, the right tools and a focused mindset prevent 99% of the problems associated with situation awareness.

High reliability organizations (ie. the crews in nuclear power plants, airplanes and aircraft carriers) are faced with situations every day that despite everyone’s best efforts can suddenly get out of control. For these teams, 99% prevention is not enough.  Their survival depends on well-established plans for resolving the other 1% of the cases.  Fortunately, others have gotten lost in the woods and come up with effective strategies that can be learned.  Experienced hikers that get lost know to first stay calm and then look for high ground.  From that vantage point it is easier to pick up on important landmarks that let you know where you are.  If this is not helpful, a good general rule is to start moving downhill while keeping careful attention to the exact path that is taken.  Other people tend to live downhill and it saves energy compared to going uphill.

The surgical team in this situation stays calm by having clear protocols ahead of time for what to do and who is responsible for doing it.  Next, they look for “high ground” by articulating out loud all the data that is available to clarify the patient’s situation.  They walk downhill by agreeing to a tentative diagnosis about what happened even as further diagnostic testing is being obtained.  Finally, they carefully mark their trail by re-evaluating this diagnosis based on how the patient responds to specific treatments.  When the high ground doesn’t provide enough answers, staying frozen in your tracks is not usually an effective way to get out of trouble.  Often the only way to tell where you are is to start walking somewhere else.

One final piece of wisdom about these types of problems: it happens to everyone.  Sometimes heart surgical patients provide us with unavoidably ambiguous data.  What looks like a warning sign in retrospect after a bad event happens often appears at the time like yet another false positive that physicians deal with everyday.  We will never be able to prevent all harm caused by losing situational awareness.  However, we can strive to avoid the harm that is preventable.  It is human nature to resolve discrepancies between two conflicting pieces of data by discarding the one that does not support our preconceptions.  Once we recognize the natural cognitive flaw that causes this tendency, called confirmation bias, we are one step closer to preventing it from having undue influence. Less commonly, there are times that the group’s norms of behavior or rules for performance are broken and this triggered the problem.  Other times poor communication was the underlying issue.   The best teams commit to regular debriefings where they can be open and honest about rules that were broken or communication that broke down.  Only then can the surgical team be considered to be highly reliable.  That’s the type of team you would want to operate on your mother.