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Free Solo – Does 4 hours zero margin for error seem a short time?

Second attempt. The first time the movie was showing my car had problems and I didn’t get away early enough and it was sold out. The second time it was equally sold out but I took a gamble. And standing opposite the ticket queue for 15 minutes paid off. I managed to get a ticket for the recently released National Geographic documentary ‘Free Solo’.  And if you have a few minutes, then go and watch the trailer (or have a look whether the movie is coming to a cinema near you) before you read on. The movie is absolutely awesome. Documentary makers Chai Vaarhelyi and Jimmy Chin follow rock climber Alex Honnold in his attempt to scale Yosemite’s biggest rock-face ‘El Capitan’: 900 meters of sheer vertical granite! The special thing is that Alex goes on his own, with no other climber, no ropes, using his bare hands only. Climbing this wall of rock with full kit is already a formidable challenge and the first team that made the ascent many years ago took over two weeks. To try this without any ropes, hooks or other safety equipment would seem reckless at best.

Alex prepares for the ascent for several years. He studies the rock, records each little hold and step and practices repeatedly the most complex parts of the route while wearing a harness. We are observing him doing devilishly difficult moves, falling repeatedly, starting again, again and again. And finally he feels he is ready. An early morning start, the drive to the face of ‘El Capitan’, and the climb begins. The cameras following him up the wall, capture the vertiginous views from the rock face into the valley. Breathtaking climbing even for those of us who are just watching. 900 meters of vertical climb with 1000s of moves and no margin for error. Absolutely no margin for error. None. Hanging on to little scabs of rock, only millimetres deep on often only a single finger and any wrong grip will lead to a fall down the rock and immediate death. Beyond the athletic achievement this is undoubtably an unbelievable achievement of keeping focus for the full four hours that the climb evenutally takes and not loosing grip or focus for a single second during this whole period.

The auditorium at Caernarfon’s Galeri is full to the last seat. Mostly young adults, a few children, many in outdoor clothes, many climbers, quite a few coleagues from my hospital. All of us in awe of the superior skills.

I am fascinated by the movie but equally baffled by my curiosity. Clearly hanging off any piece of rock that is more than five meters above ground only by the tip of a finger would not seem a good idea and not one that I would usually contemplate for myself. And most of the people in the auditorium that night would probably try some climbing, maybe even without ropes. But not THIS!

In the hospital environment where we are treating patients with more and more complex conditions using more and more complex treatments margins for error are getting equally smaller. They are not as small as the ones that Alex experienced but they are pretty small in many cases. We equally try to practice, but given the variation of risk we can often only practice principles, not the actual combination of problems that we will be seeing on the day. Most clinicians are aware of the risks of modern medicine and at system level we are trying to build better, safer systems that reduce the immediate impact of initially small errors. We are recording increasingly large numbers of data items to detect any deviance from projected pathways and we have undertaken first steps to create ‘redundancy’ – having several responders who can spot and fix errors as they occur.

One of thelearning from ‘Free Solo’ is the attitude of practicing difficult moves till errors become less and less likely and only starting complex procedures once fully prepared and well rested. The latter might to well out of our reach in healthcare for the foreseeable future given current constraints in resources, techniques of training and recruitment.

Risks in climbing are due to skill and endurance of the athlete and to variation of the environment: rock, weahter, wind, moisture. Most of the risks are known. Risk in healthcare feels much more unpredicatable but might be only so because we spend too little time to assess our environment: physiology, dynamics of change and resources.

Rockstar climbers are obviously taking big risks, but even thought this sounds paradoxical – they don’t usually get a thrill from the risk. They get a thrill from the skill. Alex has had brain scans to assess his response to scary images. And fascinatingly he is definitively not getting a thrill from hights. The special thing about climbers taking risks is that by enlarge they take risks after a lot of preparation, careful evaluation and only with their own lives. With some understanding of how this risk might affect those around them. There is no space in either healthcare or climbing for people who just want to feel a thrill from risk.

The key difference between risks in healthcare  and risks in climbing is that the risks that nurses, doctors and other professionals take nearly never affect their own lives, but always someone elses. And that other person, the patient, often does not know the risk. So before taking someone on ‘a risky climb’ –  we might want to speak to the owner of that risk and ask them whether they feel ready, understand the risks and want to come along. Without good ways to explain and quantify these risks and relate the experience that might actually be quite difficult.

What is an acceptable margin of error: for surgery, for a discharge decision?

What are good ways to relate risks and allow patients to assess them?

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