Abdominal compartment syndrome
It was about 4 am, the patient came out of surgery for the second time that night. This patient was swollen, he had already had his whole blood volume (approximately 5 liters) replaced multiple times. One of the patient’s blood vessels had ruptured spontaneously. His body was swelling after getting so many fluids and blood products to fight against the constant loss of blood. His neck had grown in diameter, his face was slowly becoming distorted from what it had looked like earlier in the day, and his abdomen was becoming more firm. We knew that abdominal compartment syndrome was a risk at this point. This is where the contents of the abdomen swell, in this case due to fluid overload. The abdomen like other compartments of the body is like a meat casing. The contents can only swell to certain extent, contained by the casing until they start pushing on vital organs like the diaphragm and major veins that run from the abdomen back to the heart.
He kept bleeding. His blood pressure suddenly dropped and the next wave of fluids and blood products put him over the edge. It became difficult to ventilate the patient and his blood pressure kept dropping. Now it was 60/30 and still dropping. His abdomen was now rock hard. The trauma surgeon said, “Get me iodine and a scalpel now!” The abdominal contents had become so swollen they were now for sure pushing on the diaphragm and venous blood vessels returning to the heart, dropping the blood pressure. The situation was critical.
Immediately a small army of staff started running down the hall to get the supplies necessary to perform a bedside exploratory laparotomy, opening the abdomen. This is a procedure usually performed under highly sterile conditions. Now there was no choice; it had to be done in the ICU to allow the organs within to escape or “eviscerate” to relieve the pressure. The casing had become too tight, the swollen abdominal organs were not allowing the diaphragm to move or allow blood to return to the heart. We poured the iodine all over the stomach to sterilize the skin. As the surgeon began the procedure, he lost pulses and we began CPR, breaking the ribs to push the chest wall to squeeze the heart so blood can be pushed through circulation, to keep the brain and other vital organs alive.
The surgeon skillfully took the scalpel, opening the layers of skin to the abdomen even as the patient’s body was being rocked by the CPR. The abdominal contents spilled out under pressure, still connected to their vascular pedicles called the mesentery. After the abdominal contents were released there was a sudden gush of blood from the abdomen. This was a new location of bleeding. Likely due to the pressure exerted on the vessels during CPR. It was devastating, one of the vessels that had an aneurysm likely ruptured. The trauma surgeon remained unphased and reached in the abdomen with her hand and blocked the blood flow through abdominal aorta between her fingers, the main vessel leading to where the new bleeding was coming from. A Resuscitative endovascular balloon occlusion of the aorta (REBOA, Ree-Bow-ah) was called for and was accidentally dropped in the process of opening the device sterilly to hand off to the surgeon. The trauma surgeon understanding the severity of the situation said, “Pick it up off the floor and give me the device”. There was no time to find another one. This tool, once inflated, could block all blood flow through the abdominal aorta to keep the blood pressure elevated in the portion of the circuit that flows to the brain, keeping the patient alive. After the placement the patient’s exposed feet seemed to turn more pale.
The patient stayed alive and made it to the operating room in an attempt to repair the now multiple vasculature ruptures. The heart suddenly stopped showing a signal on the monitor. As a last ditch effort the surgeon took the scalpel to the left side of the rib cage opening the thoracic cavity to manually manipulate the heart and clamp off a higher portion of the aorta to keep as much blood circulating to the brain as possible. Very few survive at this point and this case was no exception.
So what does this have to do with anticipating and leading into the unknown? There are many take away lessons from this scenario, but the main idea is focused around the development of the compartment syndrome. All the tools for an exploratory laparotomy should have been set up and ready for the surgeon right at the patient’s bedside ahead of time.
Could we have anticipated that the equipment was going to be used and gathered the materials ahead of time? Yes, we could have. Applying the concept of risk management, anticipating multiple scenarios and then planning ahead should be done for many of life’s scenarios and could have helped us anticipate the need to gather supplies ahead of time.
Leading into the unknown
Leaders still have to make decisions when there are numerous unknowns and often you will not have complete information. You have to step outside the situation you are in and observe the big picture. Easier said than done. Once you’ve seen the big picture one way to move forward is to theorize multiple scenarios and make plans for each of the most likely scenarios.
This is a method of risk management that was part of one of the MBA classes that I took. For any project or scenario, it is highly beneficial to develop a risk register. A risk register is just listing out different possible scenarios that could happen, identifying how each situation will be recognized or “trigger points”, who’s responsible for the scenario should it come to be, and what the plan is. This basic exercise of planning ahead can even be applied to “black swan” types of events. You don’t necessarily need to know what the disaster might be, but it is important to have a plan and system in place to begin to address the scenario.
Below is an example of a risk register that goes through the risk category, risk description, probability of the risk, impace, risk value (from matrix), possible losses and costs, explanations, trigger points, and responsible stakeholder. This was straight from one of the MBA classes, and one of the books we utilized in this course was, “Identifying and Managing Project Risk: Essential Tools for Failure-Proofing Your Project”.
A great example of risk management can be found in scenario analysis as well as in pro-forma projections. A pro-forma is a financial projection tool used to estimate financial predictions. It looks at the best case, worst case and most likely scenarios to identify where the future is likely headed based on past data and “what-ifs”. This concept can and should be applied to our everyday lives. In fact, physicians are kind of doing this type of thinking through a process called the differential.
Example of a scenario analysis used for the ebola outbreak research
A differential is a form of risk management
When diagnosing patients, physicians create a differential, meaning a list of what the most likely diagnoses are based on the available data. They do this so that decisions are being made to make strategic decisions based on the multiple scenarios, so just in case it was the rare very dangerous differential, it was thought of and planned for ahead of time. This makes patient care more efficient, cost effective, and overall better for patient outcomes.
The same concept can be applied to your everyday life, business, and finances.
Looking at the current market situation. Before COVID-19, became identified as a pandemic the same concepts could have been applied. Smart investors can go through the risk management process thinking of what could possibly happen with the COVID virus as it was being described in China, and what could possibly happen. Now we know the outcome, but pretend that we didn’t.
Months before the pandemic took hold in the United States I listened to the, “We Study Billionaires” podcast discussing the potential threat that COVID could impose on the world. I was flying on a plane to an orthopedic trauma course in Phoenix, Arizona, and I heard this investor talking about the potential economic impact that COVID could have on the United States and world. The investor was essentially employing a risk management method. He was looking at the different scenarios that could take place and was making plans according to the potential outcomes.
A healthy amount of hindsight and self reflection is good, but don’t get discouraged
It is always easy to look back and say, “It was so obvious that COVID would cause a market crash”. Even outside of market investing, these risk management techniques can be applied ahead of time so that you don’t have to look back and say, “I wish I would have…” There are numerous historical projects that we studied in this context for the MBA class. One of them was the Panama Canal, I bet you didn’t know that multiple project managers attempted the canal prior to the attempt that was successful? Do you know how many lives that were lost due to disease and other economic waste there was that could have been prevented with sound risk management principles? Alot…
It is still unwise to time the market
Overall, I believe that it is unwise to try to time the market, but I believe that it may have been possible to hedge against the potential of a COVID crash by selling a percentage of equity as a back up plan in case the market crash did come. Really the most powerful method of weathering a bear market is through the timeless strategy of diversification (Amazon and other business sectors associated with the new normal of social distancing are now hitting record highs).
Unfortunately, I did not consciously apply this mental exercise of risk management, even for the sake of preparing my pantry and arming my family with at least a few masks. I did not sit down and write out the different scenarios and plan accordingly. Even if you were planning on staying the course and staying the course with your investments- which would have been the right answer for the majority of people- this method could have been applied to preparing the United States for its battle with COVID more thoroughly. Through optimizing supply chains, anticipating the need to recycle masks, materials, glide scopes…etc.
Apply the system
For the next time you hear about something new or for a new project, whether it is for company strategies, a new looming disaster like COVID, or even with the potential that one of your patients may be developing abdominal compartment syndrome… Sit down and go through a system to anticipate and make plans to address each potential outcome. It seems tedious, but the process will help be prepared so that you can make wise decisions and lead into the unknown.