Head or Heart?

Timidity in the face of adversity is no virtue, but prudence is preferred to recklessness.

By David Brody, MD

(This article originally appeared in the September edition of the North Star Monthly.)

In aviation, as in life, and notably as in medicine too, there are circumstances in which we are faced with uncertainty – changing weather, a patient’s confusing presentation, a friend’s inscrutable moods – but action is required and we are forced to make a decision with incomplete knowledge. Perhaps this is even the rule. And in all such situations we are then faced with two competing positions that may not always align – what is most probable, and what we might prefer. How we navigate between these two poles can make all the difference.

I recently faced a dramatic and nearly catastrophic instance of the need for sound decision making as I was flying home from Laconia, New Hampshire. The weather on departure was essentially “blue skies” with occasional clouds, but as I headed north it became apparent there was a front moving in. From Laconia I will usually fly the direct line route over the White Mountains and across Franconia Notch, but as I got on course I could see a cloud cover settling over the mountains, so I decided to head west towards Lebanon with a plan to dogleg it up the Connecticut valley, following I-91 and the river at a lower altitude, and then on up to the airport in Lyndonville.

There was adequate clearance as I started heading up the valley at 3000 feet, but I could see the oncoming front to the west darkening and thickening, and soon realized that it was going to be a matter of timing – which would make it to the airport first, the plane or the weather. My GPS is able to give me not only the distance to my destination but also the time and I warily kept an eye on the diminishing gap: 40 miles, 25 minutes; 15 miles, 10 minutes; then, with Saint Johnsbury off my wing, 10 miles and 6 minutes. Surely I can find a way across only 6 minutes I assured myself. However, conditions were rapidly deteriorating, with blackening skies and diminishing visibility announcing the arrival of the front. And then: a sudden hammering jolt of turbulence, a pelting rain opened up, the visibility went from bad to poor, and I hit a stomach-turning downdraft which slammed me against my seatbelt and plunged me 200 feet. This was trouble. No more time for thoughts of Maybe I should divert — it was now or never. I did a one-eighty, reset my GPS, and after what seemed an interminable time, hoping the window of opportunity hadn’t closed on me, I managed to land safely at Dean Memorial airport in Haverhill.

In every encounter with a new patient there is a period of uncertainty, a gap between the presenting complaint and a diagnosis. Sometimes this is vanishingly small – the diagnosis of shingles, for example, can often be made at a glance from across the room – but in many instances there is a definite lag, and sometimes uncomfortably so. With that patient with chest pain – is it a heart attack, a pulmonary embolism, a pneumonia; or something as innocuous as a pulled muscle from too vigorous a sneeze? Or is it possibly one of those rare entities that one learns about in medical school but which the great majority of physicians will not see even once in their entire career? The physician craves certainty – once we have a diagnosis we know the specific treatment, and one of the supremely unsettling circumstances for the physician is to not know what’s going on – but the danger, especially in a difficult case, and even more especially should the patient become unstable, is that our wish for certainty can compete with the requirement for accuracy. We cannot allow our needs to divert from what will be best for the patient. We must train ourselves to not give in too early to certainty when legitimate grounds for uncertainty may still exist; to always question and double check our conclusions; and always be prepared to acknowledge that one may have been wrong and change course. These are marks of the mature clinical mind.

The physician is no God, nor is the pilot, and we are all subject to the all too human wish for certainty. What is it that allowed me to push on in my flight despite the obviously deteriorating weather conditions, to the point where there was serious doubt as to the outcome? Was the wish to avoid the inconvenience of having to figure out a way home from Haverhill worth risking my life (or that of others on the ground, God forbid)? Obviously no – and yet still I delayed. Denial? Wishful thinking? A naive determination to “complete the mission”? These are mental habits that need to be trained out, and fortunately I had sufficient study and training under my belt to recognize the threat, albeit uncomfortably late.

And what of the physician facing a complex and unstable patient? There are some things we can do even in the face of uncertainty – giving fluids to a patient with a rapidly dropping blood pressure for example – while we continue to sort out the case. But there are certain situations — an atypical presentation, say, or its being too early in the process for the usual findings to appear, or concomitant conditions obscuring vital clues — in which we need to press on despite the lack of clarity, patiently teasing apart the signs, assuring that each step forward is tested and reliable, all the while on guard to avoid being tempted into settling on a diagnosis prematurely.

In both instances the key is the ability to tolerate a degree of uncomfortable reality – in the one case the acknowledgement of an unpleasant truth, in the other the rejection of a false lead — while we patiently (but expeditiously) work the problem, unbiased by preference, and then make the call.

And then, as is said, bring that plane in for a landing.