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ANNSURG-D-15-00685
RESPONSE Error Management in Emergency Surgery and Music: Fight, Flight, or Freeze Reply: hank you for the opportunity to reply to the remarks of Dr Coccolini and colleagues. It seems that my considerations about the relationship between jazz and surgical practice were not so clear as I thought.1 As underlined in the article, my main feeling is that in the era of evidence-based medicine and standardized surgical procedures, improvisation still plays an essential role. However, the quality of improvisation is conditioned by experience, knowledge, practice, curiosity, unconsciousness, and passion. Music, like surgery, is a way to communicate. Unfortunately, emergency surgery is not just something to talk about to impress the girls, and I do not believe that it is just a solo performance. On the contrary, the surgical performance in emergency surgery could be considered a short 16- or 32-bar solo, placed in the middle of a large band composition, in which the surgeon is only one of the involved players. When Dr Coccolini talks about out-of-tune instruments and out-of-time musicians, he seems to forget that it is sometimes the surgeon that is out of tune or out of time. In fact, most common error types were in clinical performance and involve primarily the therapeutic interventions (not only surgical) caused mostly by
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knowledge deficits.2 For example, the delayed control of abdominal or pelvic hemorrhage was one of the major errors contributing to potentially preventable trauma mortality.3 However, only about 5% of errors are potentially avoidable, and the majority of events happen during the initial assessment of patients after trauma, or in intensive care unit, when the role of the surgeon is limited. In the trauma patient tune, surgeons are rarely involved as leaders and their hard solo performance only few times is determinant, by itself, to the final outcome. In music as in surgery (especially in emergency surgery), leadership and team communication, rather than individual performance, still represents the most important factors for error prevention or mitigation. In front of a significant error, as it happens in front of a general emergency event or acute stress, individual responses can be divided into 3 groups4: - Ten percent to 15% of people will remain relatively calm. They will be able to collect their thoughts quickly, their awareness of the situation will be intact, and their judgment and reasoning abilities will remain relatively unimpaired. They will be able to assess the situation, make a plan, and put it into practice, acting as a leader. - Seventy-five percent will be stunned and bewildered, showing impaired reasoning and sluggish thinking. They will behave in a reflexive, almost automatic manner. However, they could follow a leader, if present.
- Ten percent to 15% will tend to freeze, showing a high degree of counterproductive behavior, such as uncontrolled weeping, confusion, screaming, and paralyzing anxiety. For these reasons, every emergency surgeon and every musician should hope, in front of an error during a challenging group performance or a hard solo, to be one who fights, or to quickly find a leader nearby.
Jacopo Martellucci, MD, PhD General, Emergency and Minimally Invasive Surgery Careggi University Hospital Florence, Italy [email protected]
REFERENCES 1. Martellucci J. Surgery and jazz: the art of improvisation in the evidence-based medicine era. Ann Surg. 2015;261:440–442. 2. Vioque SM, Kim PK, McMaster J, et al. Classifying errors in preventable and potentially preventable trauma deaths: a 9-year review using the Joint Commission’s standardized methodology. Am J Surg. 2014;208:187–194. 3. Gruen RL, Jurkovich GJ, McIntyre LK, et al. Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths. Ann Surg. 2006;244:371–380. 4. Leach J. Individual response. In: Survival Psychology. Basingstoke, England: Macmillan Press; 1994.
Disclosure: The author declares no conflicts of interest. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000001328
Annals of Surgery Volume XX, Number X, Month 2015
www.annalsofsurgery.com | 1
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ANNSURG-D-15-00685
RESPONSE Error Management in Emergency Surgery and Music: Fight, Flight, or Freeze Reply: hank you for the opportunity to reply to the remarks of Dr Coccolini and colleagues. It seems that my considerations about the relationship between jazz and surgical practice were not so clear as I thought.1 As underlined in the article, my main feeling is that in the era of evidence-based medicine and standardized surgical procedures, improvisation still plays an essential role. However, the quality of improvisation is conditioned by experience, knowledge, practice, curiosity, unconsciousness, and passion. Music, like surgery, is a way to communicate. Unfortunately, emergency surgery is not just something to talk about to impress the girls, and I do not believe that it is just a solo performance. On the contrary, the surgical performance in emergency surgery could be considered a short 16- or 32-bar solo, placed in the middle of a large band composition, in which the surgeon is only one of the involved players. When Dr Coccolini talks about out-of-tune instruments and out-of-time musicians, he seems to forget that it is sometimes the surgeon that is out of tune or out of time. In fact, most common error types were in clinical performance and involve primarily the therapeutic interventions (not only surgical) caused mostly by
T
TO
LETTER
knowledge deficits.2 For example, the delayed control of abdominal or pelvic hemorrhage was one of the major errors contributing to potentially preventable trauma mortality.3 However, only about 5% of errors are potentially avoidable, and the majority of events happen during the initial assessment of patients after trauma, or in intensive care unit, when the role of the surgeon is limited. In the trauma patient tune, surgeons are rarely involved as leaders and their hard solo performance only few times is determinant, by itself, to the final outcome. In music as in surgery (especially in emergency surgery), leadership and team communication, rather than individual performance, still represents the most important factors for error prevention or mitigation. In front of a significant error, as it happens in front of a general emergency event or acute stress, individual responses can be divided into 3 groups4: - Ten percent to 15% of people will remain relatively calm. They will be able to collect their thoughts quickly, their awareness of the situation will be intact, and their judgment and reasoning abilities will remain relatively unimpaired. They will be able to assess the situation, make a plan, and put it into practice, acting as a leader. - Seventy-five percent will be stunned and bewildered, showing impaired reasoning and sluggish thinking. They will behave in a reflexive, almost automatic manner. However, they could follow a leader, if present.
- Ten percent to 15% will tend to freeze, showing a high degree of counterproductive behavior, such as uncontrolled weeping, confusion, screaming, and paralyzing anxiety. For these reasons, every emergency surgeon and every musician should hope, in front of an error during a challenging group performance or a hard solo, to be one who fights, or to quickly find a leader nearby.
Jacopo Martellucci, MD, PhD General, Emergency and Minimally Invasive Surgery Careggi University Hospital Florence, Italy [email protected]
REFERENCES 1. Martellucci J. Surgery and jazz: the art of improvisation in the evidence-based medicine era. Ann Surg. 2015;261:440–442. 2. Vioque SM, Kim PK, McMaster J, et al. Classifying errors in preventable and potentially preventable trauma deaths: a 9-year review using the Joint Commission’s standardized methodology. Am J Surg. 2014;208:187–194. 3. Gruen RL, Jurkovich GJ, McIntyre LK, et al. Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths. Ann Surg. 2006;244:371–380. 4. Leach J. Individual response. In: Survival Psychology. Basingstoke, England: Macmillan Press; 1994.
Disclosure: The author declares no conflicts of interest. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000001328
Annals of Surgery Volume XX, Number X, Month 2015
www.annalsofsurgery.com | 1
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
