I will never forget my first day in the pediatric intensive care unit (PICU). My first patient was a five year old boy named John, who was admitted the previous night after nearly drowning in a bathtub. At first glance, John was lying on his back, eyes closed, and his hospital gown had elephants on it. I felt like I was peeking into the bedroom of a sleeping child. By the bedside his mother held his hand and silently sobbed. As I looked around the PICU, I noticed other rooms similar to John’s: 24 glass boxes neatly arranged in a U-shape around the nurse’s station. Doctors recorded and interpreted patient data, looking for patterns of improvement or deterioration. The various monitor tones, ventilator breaths, computer keystrokes, and quiet conversations merged into an emotionless symphony.
When it was time for rounds, the discussion was unexpected. Our team focused on the hypothetical possibilities of every patient more than what was actually happening to them. The ICU physicians– who are supposed to be the best trained doctors in the hospital– seemed to be obsessed with what they didn’t know. They talked about arterial blood gases, acute respiratory distress syndrome, then played with the ventilator like a new video game. As a result, I spent most of my nights in the library learning how to interpret the endless data, wondering why we were collecting all these useless numbers if we weren’t going to act on them. Remember John? Over the next 3 days, his lungs improved and his breathing tube was removed. Even still, the ICU doctors obsessed over dangerous uncommon events that never happened. Could they not see John was improving? Their vigilance seemed out of proportion to the clinical situation.
On my 5th day, our team gathered in front of John’s room for our morning rounds. Just as I did on my first day, I peeked into his room. But this time, he woke up, rose to his feet, and walked energetically back and forth in his crib! When he came to the side of the crib facing the doorway, he looked at me with the silly, innocent smile of a happy, well-adjusted 5-year-old. Suddenly– in the midst of the countless vital signs and machinery that can make hospitals seem so grim– my eyebrows unfurled, my shoulders relaxed, and my pursed lips transformed into the kind of smile that makes the corners of your eyes wrinkle, then we began to laugh together! Years later, I finally understood why the ICU physicians’ embrace of uncertainty was the key to John’s survival.
After 4 years of undergraduate biochemistry, 4 years of medical school, and 4 years of anesthesiology residency I will complete a critical care fellowship at the Texas Heart Institute in Houston, TX. Anesthesiologists make excellent intensivists because we excel at managing multiple organ systems in real time, finding creative solutions in uncertain situations, and remaining calm during emergencies. In fact the intensive care unit was invented by an anesthesiologist! In Copenhagen, Denmark, 1952, Danish anesthesiologist Bjorn Ibsen applied operating room ventilation strategies to a ward of paralyzed polio patients. He decreased the death rate of bulbar polio –(which paralyzes the diaphragm)- from 90% to 25%.1
Several features make anesthesiology unique from other medical specialties. Our patient is always minutes away from death, with no time to consult other doctors when complications occur; we must tolerate long periods of uncertainty interrupted by short bursts of dangerous intensity; and events happen faster in the OR than any other place in medicine. Because of the speed and limited information available, anesthesiologists learned how to make smart decisions about unknown events that cause life-threatening conditions like bradycardia, hypoxia, and hypotension, among others. We specialize in the management of rapidly evolving, high-uncertainty, high-risk situations without a known solution. In other words, we figured out how to manage difficult situations we don’t understand.
We figured out how to save lives by abandoning a simple cause-and-effect view of reality, instead adopting a systems-based approach. Because we manage every organ system in the body– in real time– as they adapt to their internal changes and the changing surgical environment we view the operating room as a complex system. A complex system is an organic structure of components that communicate with one another and respond to changes in real time. Complex systems are all around us. Common examples include the human body, stock market, a class of 4th graders, or infamous Los Angeles traffic.
Conversely, simple systems –such as a math equation– are unchanging patterns describing part of a complex system. Simple systems are different from complex systems because they cannot react to predictions, they produce predictable results, and they follow the same rules regardless of size. The simple systems that form a complex system can describe individual parts of the complex system, but, the sum of the simple systems cannot predict the outcome of the complex system. This is because complex systems exhibit synergy; when interactions of individual components produce an effect greater than the sum of their separate effects. In other words, in a simple system 1+1=2, but in a complex system 1+1=3.
Complex systems exhibit synergy for three reasons: first, the components of a complex system can react to forecasts of its future (ex. Los Angeles drivers use apps to find the best way around traffic); second, the components can behave in unforeseen ways (ex. humans are free to choose their preferred driving route); third, the number of possible outcomes becomes unmanageably large as complex systems grow (ex. rush hour traffic). When complex systems have too much synergy they become random. Los Angeles traffic is so complex drivers experience seemingly random traffic jams at all hours of the day and night. Ask me how I know!
Think of a large complex system (ex. Los Angeles traffic) as a random event generator that produces events at a speed and intensity proportional to its complexity. A few events will cause positive changes (ex. parking spot becomes available at the exact moment you need it), most will cause no change (ex. rolling through a stop sign alone at night), and eventually one event will derail the entire system (ex. car accident on the I-405 freeway). Large complex systems are responsible for our political, economic, financial, and cultural institutions; however, the same complexity that makes them valuable also make them vulnerable to sudden, catastrophic, unpredictable events called Black Swans.
Black Swans are unpredictable, cataclysmic events retrospectively “obvious” due to psychological biases.2 They are named for the ancient metaphor, “rara avis”, which means “rare bird”, in Latin. The metaphor was originally used as a compliment, meaning “one-of-a-kind”. In Ancient Greece the expression evolved into “Black Swan” because, at that time, all known swans were white. Black swan meant “someone so exceptional they have never been seen before.” In 1697 black swans were discovered in Australia by Dutch explorer Willem de Vlamingh. The modern expression- popularized by Nassim Taleb in 2007- means “a major event that is unpredictable because it was beyond the scope of human knowledge when the event occurred”.3
Current examples of these events include the 9/11 terrorist attacks, the Sandy Hook Elementary shooting, and the COVID-19 outbreak. Historical examples include the stock market crash of 1929, World War II, and the sinking of the Titanic. Black Swan categories can be known ahead of time (ex. war, car accident, gun violence), but the event itself is unpredictable. They are unpredictable because over time, the synergy of a complex system grows in unexpected ways, and then evolves into an unforeseen event that crashes the system. Residents of Los Angeles cringe when we hear about a car accident on “the 405”. The only thing worse than one accident on the 405 is two accidents on the 405.
As the world’s financial, political, and economic systems grow in complexity, Black Swans will become more intense, and occur more often, because more complexity means more synergy, and synergistic interactions create Black Swans. For example, pandemics, like COVID-19, are a greater problem now than 150 years ago because our movement patterns are exponentially more complex. Like traffic, communicable diseases thrive on the number and variety of interactions between people for their evolution and propagation. In other words, as the complexity of human movement increases, the intensity and speed of pandemics will also increase. Our society is a car accelerating toward the edge of a cliff. So, what does this have to do with anesthesiology? Anesthesiologists already have a solution.
Foonotes
- The full story can be found in many places ranging from Wikipedia to academic journals. Two excellent summaries I found were “The physiologic challenges of the 1952 Copenhagen poliomyelitis epidemic and a renaissance in clinical respiratory physiology”, By Dr. John West and “The Doctor Who had to Innovate or Else”, By: Conor Friedersdorf.
- I highly recommend Nassim Taleb’s Incerto, a series of four books about luck, uncertainty, probability, opacity, human error, risk, disorder, and decision making. My “complex system” is synergy from his original research into the epistemological and mathematical origins of random events. My definition of a Black Swan is based on Part I of his book, “The Black Swan: The Impact of the Highly Improbable”. For the purpose of the introduction I include Taleb’s “grey swan” in my Black Swan definition. Chapter 1 will articulate the differences between them.
- I found a summary of Black Swan etymology at en.antiquitatem.com. The specific page is titled “The white blackbird and the black swan are a rare avis (rara avis)”, and the author is Antonio Marco Martinez, a retired professor of Latin. English explorers also brought black swans back to England from Australia, however, de Vlamingh is generally credited with their initial sighting. A summary of his discovery can be found at lifeonperth.com, a website about the history of Perth, Australia.
Airway, Bagel, Coffee 