The wait-and-see fallacy

We’ve all done it. You’re taking care of a critically ill patient. The basic supportive measures are in place, but you’ve got another trick up your sleeve—something bigger and more aggressive—something you think you may need to deploy, but aren’t yet sure. So you decide to wait, and watch, and monitor.

All very sensible. You wait. The patient gets worse. Finally, they reach your treatment threshold, you pull the proverbial trigger, and the big guns come into play.

Except that’s not quite how it works, is it? Because therapies aren’t actually guns, and they don’t fire instantaneously. Instead, you’re forced to stand there, “watching and wait” some more, as the wheels turn and inevitable delays occur. Orders are verified. Drugs are prepared. Machines are found, and discovered not to work, and fiddling is done, and replacements are located. Ducks are aligned, T’s are crossed, I’s are dotted. Finally, your “big gun” comes into play… only rather than hitting the stage with perfect timing, it’s hours late, far behind the proverbial 8-ball, and too slow to make a difference. Where did you go wrong?

How you think it works
How it really works

Why are scrambled eggs cooked to perfection in the pan, but overdone on the plate? Because time, illness, and eggs wait for nobody.

You went wrong by forgetting about the hidden gap between decision and implementation. It takes minutes to start a vasopressor that isn’t already at the bedside, not seconds. It takes hours to initiate hemodialysis, not minutes. It takes an unknowable (but probably prolonged) amount of time to recognize a floor patient is deteriorating, move them to the ICU, and intubate them. Inter-facility transfers, “emergency” surgery, obtaining vascular access… no matter how you imagine it, in reality, none of it will happen instantly. If you don’t include those delays in your clever planning, you’ll discover over and over that even though your decisions are timely, your treatments are not.

You can try to shorten the delays, of course. But they’ll always exist. Eventually, you’ll acknowledge the reality: in order to treat some patients in time, you’ll need to treat others too early. In other words, you’ll need to make the treatment decision before it’s obvious whether it will be necessary—because if you wait until it’s 100% clear, you’ll wait too long. Nothing happens instantly. Not in any world, or in any ICU.

Overtriage is a necessary evil in critical care. Don’t wait until the last minute. On time is too late.

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