CPM Summer 2019 - 4

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From the Editor

FIXATE ON REDUCING

D
Joseph F. Answine, MD, FASA
Central PA Medicine Editor-in-Chief

facebook.com/dauphincms

Dauphin@pamedsoc.org

Dauphin County Medical Society
777 East Park Drive, PO Box 8820
Harrisburg, PA 17105

Fixation Errors

r. Answine is concerned about his next patient; her history of asthma is significant
and he hears bilateral wheezing as he auscultates her lung fields with his stethoscope.
She requires emergency surgery for acute appendicitis so cancelling is not an option.
He knows it will be a struggle once under anesthesia and intubated. As he expected,
after induction of anesthesia and endotracheal intubation, ventilation is difficult, requiring
high inspiratory pressures and the end-tidal carbon dioxide (ETCO2) is minimal as per the
capnograph. He starts albuterol via the anesthesia circuit as the arterial oxygen saturation
(O2sat) begins to fall below 90%. Dr. Answine considers more albuterol and epinephrine as
Dr. Smith enters the room. She asks if appropriate placement of the endotracheal tube was
re-confirmed as the O2sat falls to 50%. Dr. Smith proceeds to actually confirm an esophageal
intubation, and replaces the endotracheal tube within the trachea. The ETCO2 returns and
the O2sat rises to 100%. The patient emerges from anesthesia after a successful appendectomy
without obvious sequela.

Dr. Answine is perplexed as he watches his last patient moan with confusion in the recovery
room. He contemplates giving reversal agents for the opioids and benzodiazepines as well as
physostigmine as a treatment for the emergence delirium. Nurse Jones eventually suggests
checking a finger stick glucose since the patient is on oral medications for type 2 diabetes.
Although Dr. Answine feels strongly about his diagnosis of emergence delirium secondary
to the anesthetic agents, he agrees to the test. The glucose level returns at 20 gm/dL and the
patient is immediately given glucose IV. The patient begins to become more coherent and
makes a full recovery as the serum glucose normalizes.
The "fictional" Dr. Answine in both cases suffered from "fixation error." Fixation error is
defined as "concentrating on a single aspect of a case or a diagnosis at the detriment of other
aspects or diagnoses." In English: "You are so sure of the reason for a problem that you refuse
to believe other possibilities even when it becomes obvious to others that you are wrong". The
literature describes three types; "this and only this," "anything but this," and "everything is just
fine." Fixation errors have also been called "anchoring errors" or "tunnel vision."
Fixation error has been described as a cause of many aviation disasters, but it is not uncommon in acute care medicine especially in the fast paced, ever changing world of anesthesiology.
Due to the power of our medications and the unstable nature of many of our patients, it can
have dire consequences.
In the February 2019 edition of the Anesthesia Patient Safety Foundation newsletter, an
article titled "On Reducing Fixation Errors" describes and discusses fixes for fixation errors. The
authors state that it is important to reduce the incidence of fixation error by having "awareness"
of the possibility of its occurrence. Simulation has played a key role in demonstrating the ease
with which fixation error can occur, as well as to aid in the practice of avoiding its occurrence.
It is important to "rule out the worst case scenario," "assume your first thought is wrong,"
"never assume artifact until other possibilities are ruled out," and "not to bias others with your
assumptions." Lastly and importantly, ASK FOR A SECOND OPINION!

Summer 2019 Central PA Medicine

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CPM Summer 2019

Table of Contents for the Digital Edition of CPM Summer 2019