Judgment in anesthesia, as in all of life, takes unusual forms. While you might think that drug selection/technique are the essence of anesthesia judgment, I believe after thirty years that these choices matter rather less than we think. I am reminded of old studies of psychotherapy that concluded that good therapeutic outcomes correlated with individual therapists more than theoretical "schools" of therapy; that talk therapy is personal. So, perhaps surprisingly, is anesthesia. In my memory, some of the most knowledgeable anesthesiologists were the least capable in the OR. Sometimes it was because they were crippled by their encyclopedic cognitive sets, and sometimes it was because they had no damn common sense. There are two countervailing aphorisms that apply in anesthesia, both taught to most anesthesia residents. First, "if you don't know where you are going, you'll probably end up somewhere else." You have to have a plan going into an anesthetic with a specific set of therapeutic goals and indications (where are you going and why are you going there). The second is "No plan survives first contact with the enemy." You've got to be willing to modify/abandon your first plan when circumstances don't support it. Let me give an example.
I am presented with a truly unfortunate hypotensive late middle aged patient with bad generalized vascular disease who requires anesthesia for an abdominal catastrophe; probably bowel infarct. He has suffered a stroke some years earlier and is institutionalized. He is aphasic, and does not follow commands, but is vigilant and appears scared. Per telephone conversation with daughter, a previous anesthetic one year earlier at another institution presented unclear airway difficulties ("they said they had trouble with the tube" - when will we ever get electronic records!?) Textbook plan A; awake fiberoptic intubation with mild sedation and appropriate limited topicalization. Start out. Midazolam. Clenched teeth; door shut tight. OK. Plan B; NG decompression, rapid sequence induction. Hmmm; succinylcholine contraindicated for peritonitis, but seems unwise to use rocuronium in case matters become ugly. Ditto more midazolam v etomidate. Sux it is. Reassuring words, 2 suckers, NG out, cricoid pressure, a touch of etomidate, 40 of sux. Mouth barely opens; skin/tmj contractures. No direct laryngoscopy here. Push on? Back out? Easy mask airway (don't like this, but a man's gotta do...) no regurgitation past cricoid. Plan C. Flexible fiberoptic/Ovassapian airway. Chin lift (assistant B) cricoid maintained (assistant A). Easy access, tube passes clean... Another victory for the home team. Elapsed time; about 6 minutes. Lowest sat; 96% Changes of plan- hmmm, two, I guess. Aspiration zero. Perspiration zero. Might it have gone different? Sure. If he'd refluxed, I would have fought it off, backed out and regrouped. Plan D? Awake cricothyrotomy or trach, maybe.
Lots of trade-offs. Flexibility (semper gumby!) calculated risks; if I couldn't fight off regurgitation and he had aspirated, I am a dog. He didn't. I'm not. Next time? Who knows? Ahhh, the joys of anesthesia combat. But, I digress (as usual).
A lot of the time, judgment involves a simple go/no go decision. Knowing when to cancel is important. Being able to articulate why you are canceling is vital; how will the patient benefit from surgical delay? Actually, being a politician too, I never cancel; I postpone. That helps clarify how delay will make things better, and it is my responsibility as a physician to define what our goal is in delay, to generate a plan to accomplish that goal, and to implement the plan. I am always willing (eager!) to take charge of the preoperative care once I have interviewed the patient; if the surgeon wants to do it herself, no problem, but I am always willing to put my money (time) where my mouth is. Anyway, that way I know I will get what I think the patient needs. Anybody who does the work knows that canceling requires conviction; there is generally tremendous momentum in the expectation of proceeding to surgery on the part of the patient and surgeon.
On the other hand, I am convinced that half the patients that "cheat" on their NPO instructions eat because they are afraid of just canceling surgery. I never "just do it under local" or any of that. If a patient can't comply with an NPO instruction, they won't comply with any other instructions, and they will put themselves at risk. Which brings me to another issue. We do not work for the patient; patients are not just clients.We as physicians and patients each have our role to play in a complex interaction. Because patients do not always play their part appropriately does not relieve us of the need to play our parts. Anesthesia and medicine are a calling. Just because a patient (and sometimes surgeon!) are willing to proceed despite an avoidable risk (like proceeding with an elective procedure on a full stomach) for convenience, does not absolve the anesthesiologist/physician of responsibility for the consequences of going along with it; so sayeth I.
How about the judgment regarding Your own fitness, doctor? Will you work with the flu or a fever? Will you work exhausted? Will you do a case beyond your current skills? When does "stretching" beyond your comfort zone become taking a chance? Every morning I wake up and do a "gut check." Most mornings that involves a brief instant of thankfulness as my feet hit the floor and I pad off to pee and brush my teeth. On rare days it's obvious I'm not fit (nausea, vertigo, vomiting...). Two decades ago, when my mom was dying, I asked myself the question "am I fit" every morning (my mom and I were close); but that's a story for a different day (perhaps...)
It's all about judgment; lines and tubes are easy. (after a while) Even when you know what to do, doing it can be hard (vigilance at 3AM? setting those alarm limits tight?)