Goals and Plans: Turning Points for Success

Abstract

A physician-in-training was confronted with a ventilatory problem in an intensive care patient. He interpreted the presenting constellation of symptoms (increased airway pressure, absent breath sounds over the right lung, and slowly decreasing saturation) as signs of a tension pneumothorax. Although there were several more differential diagnoses for this symptom constellation, and although the patient was in no immediate danger, the resident started to act on his first assumption. He neither searched for alternative causes for the clinical problem, nor did he request a second opinion. He performed a thoracostomy without supervision by an experienced colleague and did not adequately consider the possibility of a complication. When the complication occurred he did not recognize it for what it was: a punctured liver. The clinical course led to the patient’s cardiac arrest that required immediate cardiopulmonary resuscitation. Because of a massive volume replacement and red blood cells, CPR was successful. As a result of this massive transfusion, the pulmonary situation of the patient deteriorated and he developed full-blown Acute Respiratory Distress Syndrome. The real trigger for the situation, a blood clot in the right main bronchus, could have been removed bronchoscopically with very little risk to the patient. Because the resident prematurely formulated the goal “insert a chest tube” and because he subsequently planned and executed the insertion poorly, he put the patient’s life at risk. Setting goals and planning actions did not adequately take place.