Mental Health, an oxymoron.

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If people were healthy they wouldn’t be mental…

Ok, before everyone gets offended by my dry and dark sense of humor, let us explore what mental health is or rather is not.

When I was at University in the USA, I was fortunate enough to study biological anthropology with one of the greatest minds of such of all time. One of the things he researched was tribal mental healthcare by South American tribal shamans compared to western psychology and psychiatry. His conclusions? What they do works way better. At least measured by number of relapses, length of disease, and severity of disease.

So aside from the liberal use of cocaine and amphetamine, what have they got that we haven’t got?

Social support.

For them, mental health and disease is a community problem. It is a strain on their local community resources to have non-productive people. So how do they do this? First they identify there is a problem, which due to the fact there is no stigma on mental disease, is not that hard to do. Somebody just cries out for help. The solution is then to have an exorcism. It is believed that it is evil spirits that are at play, and by getting rid of the evil spirits, it benefits not only the person, but the whole community. This is where some rituals, dancing, and of course some “uppers” come into play.

But it is after this that the brilliance of their treatment is observed. They often have a feast, and certainly a big party to celebrate making the afflicted better. Sounds too good to be true right? Except their party is based around the cause of the affliction. For example, if the person had no food, gifts of food are given. If the house was destroyed, the house is rebuilt. No job? What HR manager would not want somebody freshly demon free? A blessed person?

When you observe it through the lens of anthropology, and not religion, or even medicine, here is the basics: They recognize the problem. They motivate the person. They take decisive action to solve the problem.

But I am not here to advocate witchcraft and alternative medicine. (Although I think witchcraft is probably safer and more effective than alternative medicine) So permit me to look at it through the lens of modern Western Medicine?

Identifying the problem. Like any illness or disease, the earlier you identify a mental health issue, the earlier you can treat it, the earlier the treatment, usually the better the prognosis. We call that screening and secondary prevention.

Primary prevention is preventing the disease before it starts. But let’s face it, Western culture just isn’t interested in preventing mental diseases. So treatment it is…

Some people may have noticed that there is an increase in mental disease. Some would claim it was always there and it is just now being reported. As with many medical theories, the answer is probably somewhere closer to the middle.

You see in the past, Western cultures had greater social interaction and support. Whether in a small town or block of a big city, there was a concept of “community.” These people felt they were in life together, they supported each other, looked out for each other, they actually knew each other! Some people had mental diseases no doubt, perhaps less, perhaps the same, but the goal was to help these people within the community or if that wasn’t possible, send them off to a cage somewhere. Surprisingly, many of these people did remain in the community. There were not a lot of cages. That is exactly the goal of modern psychiatry, to help the crazy enough to let them return to productive and independent life. (Don’t get upset over my use of “crazy” either. I am crazy, I just accept and live with it.) This community easily identified problems and took decisive action.

Today though, in the West, there is very little community. It is all about the individual. Many people don’t even know their neighbors. Help them? Out of the question! It is better when you can pretend that only people far away need help and your Facebook selfie or a few bucks can completely change their life. (not possible, but it makes us feel good, like we are doing something) We are living in the time of “me and I.” As such, being “abnormal,” or in any way not super self-sustaining as everyone else carries with it a stigma. We must hide this “defect.” We should be ashamed… If you don’t feel that way yourself, you will be reminded by your peers. “Suck it up,” “everyone has problems,” “get over it.” They make it sound like problems are a choice.

I don’t choose to have problems I cannot fix. Do you choose problems you cannot fix? Who does?

When we have problems this creates stress. You know that old “fight or flight”, sympathetic, autonomous, nervous reaction… We usually think about this only from the acute point of view. But I think that is simply like thinking a myocardial infarction is an acute event, (It is really an acute exacerbation of a chronic disease) flawed at the very core of the theory. How many fire/ems providers break down on their first event ever? How many soldiers? Police officers? Doctors? Nurses? As far as my experience goes, not one. I have not even heard of one breaking down on their first exposure.

We are left with only one conclusion, mental illness is a chronic illness. That naturally means that like any chronic illness, a cure is unlikely. Treatment and palliation is probably the best we will be able to do.

From the physiologic point, we know that when one body system or function is not working properly, the other systems and functions alter themselves in order to compensate. The same can be seen with stress resulting in mental health issues. Under constant endorphin stimulation, other functions are affected, compensatory mechanisms from every system are engaged, I could list things like BNP, cortisol, and a host of other molecules to demonstrate my understanding of molecular physiology and pathophysiology, but I thought I would spare you the reading and just go right for the point, it will be a long enough post as it is. The end result, things are messed up. You heart, your kidneys, your liver, your brain. Emphasis on brain. Contrary to popular opinion, it is an organ, not just a magical consciousness. Like any other organ, it’s functions can be altered, broken. It is interesting that when a person’s heart is broken, or their intestines, they go to the doctor and nobody gives them a second thought, but when the brain is messed up, stigma follows. This is completely asinine.

So let’s talk about treatment? The first treatment any of us try for anything is to “tough it out.” You don’t go to the doctor the first time you sneeze or cough, or the first time a muscle or joint aches. You do not seek treatment the moment you feel stressed. These self-treatments we refer to as “coping mechanisms.” We all know there are destructive ones and constructive ones, and unfortunately, the destructive ones work better!

Think about it. Smoking didn’t carry a stigma until recently. In fact, nicotine is the only proven anxiolytic and antidepressant. Doctors used to give out prescriptions for smoking in order to relieve stress and depression! (That is kept on the down-low in more modern times) “High risk” sexual behaviors used to not only be acceptable, but even encouraged. “Comfort women,” “horizontal relaxation,” “make love not war” have been documented throughout history by every culture! There wasn’t always a war on drugs. THC, amphetamine, sleeping pills, alcohol, have all been/being used. In fact firemen and sailors used to be paid with alcohol.

I would point out that in the effort to not offend people trying to kill Western soldiers in wars in the Middle East, strict rules forbidding many of these destructive coping mechanisms were put in place at the same time increasing the chronic exposure to stress through extended and multiple deployments. But it is not limited to soldiers. Police Officers, firefighters, paramedics, nurses, and doctors also are in an environment of chronic stress and the negative coping mechanisms have been removed from them too. These civilians will not only be exposed to this stress longer than the average soldier is to combat, but as “representatives” of “the finest” of society, they are expected to live the ultimate puritan lifestyle.

So what should we do? Exercise? You mean between our 3 jobs, hours long commute, overtime, child care responsibilities, house cleaning, shopping, and figuring out our taxes? Perhaps we need to “make time” by working less? That relieves stress right up until it is time to pay the bills. Then it is even more stress. The same with extra time off.

Perhaps we should volunteer some time in order to use altruism to reduce our stress? Most of us do! If it was the magical cure, we wouldn’t be talking about this and there wouldn’t be websites and Facebook groups dedicated to mental health for medical, healthcare, and public safety providers!

Eat right? Well, I guess if you call Red Bull on your 20+ hours on duty “right” it might work, but comfort food is definitely verboten in healthy living. (My triple espresso latte coffee is not comfort food, it is the very liquid that keeps me going when my endorphin rush is wearing down and patient safety and health, or my own life depends on being mentally alert and physically capable.) Let’s call it a performance enhancing drug. I am not a pro-athlete, so it is not a problem.

Now I am not suggesting we shouldn’t do these things, we most certainly should! What I am doing is pointing out the reality of it all. Most of us don’t. Not for lack of wanting.

But lately it has come to my attention, we don’t have social support in the form of camaraderie anymore. When I was a firefighter, you could always count on other firefighters to not only notice something was wrong, but to help you make it right. It was similar as a paramedic, even in the hospital. We were the Emergency Department, an elite group unto ourselves. We strived to be the best of the best, whether it was taking care of chronic toe pain or multiple gunshot wounds. A team united in one goal and supporting and enabling each other to reach it. Police officers, Soldiers, Sailors, Marines all shared similar esprit de corps. Even if we could not relate or get support from society or family, there was always the co-worker, who we referred to as our brothers and sisters. (I’ll spare the incest jokes) But now, even that is breaking down. No more “all for one and one for all” but replaced with “All for me and more for me, not even sorry to hear about your loss.”

This alienation further drives the shame and need to hide mental diseases. It eliminates perhaps our most potent and effective treatments. It sure doesn’t pass the Shaman test.

So what do we do? Go to the doctor and get a pill to try and put our chemistry back in order? Give up that spare time we could be at the gym to get “professional” counseling? I laugh at those “professionals” anyway. Because as we all know, you can read about our lives as much as you want. Study it with the most perfect scientific clarity. But until you have lived it, you really don’t understand it. Whether you are a soldier, doctor, nurse, firefighter, etc. it holds true. There are a few of these professionals out there, but they are very few, and certainly no substitute for the social support from within our group.

Ultimately, I see stress as a cup. Some things add to make it full. Some things help it to empty. When it overflows, you have mental illness, emotional illness, personality disorder, physical sickness, and all manner of badness. If you are not helping empty somebody’s cup, you are helping to fill it. It is not possible for us to help everyone, but maybe we should make the effort for those closest to us? The cup is never empty, and the amount you must take out has to at least add to the amount you put in. Once you overflow, you need to take a lot out and clean up the mess. It may be from that point, you will never be the same again and it will take even more to help stop another overflow. Maybe it cannot be stopped again, only reduced in frequency or severity?

Mental illness is a real illness, no different from a stroke or cancer. It is much easier to prevent than treat. Social support is our best prevention and treatment. Identify people struggling around you. Help them before you are asked. If somebody calls out for help, do not ridicule or trivialize them. Help them. If for no other reason, so others will do the same for you! Attempt to use positive coping mechanisms, because surely if you can’t, negative ones will be your only other alternative.

Bottom line: “Never judge, always help.”                    

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Something that pains me.

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“Pain management” the very phrase stirs strong emotions. Everyone in medicine from patients, nursing aids, to CNA’s, nurses, rad techs, paramedics, and doctors (titles listed in order I could think of them, don’t get all crazy with some sort of order of preference) of all specialties.

                About the only things people agree on are a) something should be done about pain and b) nobody is doing the right thing.

                That is strikingly similar to the common conceptions of “Nobody works at work except me” and “Everybody is stupid except for me”.

                The first thing we must understand in controlling pain is that there are different types. The most common pain we think about is nociceptive pain. This is pain that from pain receptors. Like when you smash your finger in a door. However, this pain is not so simple. For example, the same nerve endings that register pain also register cold. Pain receptors, like the cardiac tissue that many emergency providers spent outrageous sums of time learning and professing about, also have action thresholds. This threshold is lowered by the kinin system as part of the inflammatory response. So what appeared as a simple statement on a single type of pain is actually not very simple at all.

                Additionally, there are other types of pain, such as neuropathic pain, when there is abnormality in pain reception and transmission. But perhaps something often over looked is ”remembered” or “anticipated” pain. This is equally a problem both in the acute presentation of pain as well as chronic presentation.

                There was once a theory (which has been completely debunked scientifically) that children would not remember pain.  Primates, who include humans, remember pain in order for self- preservation.  It is a biological survival function. It stops you from putting your hand on the hot stove “again” it causes fear which makes you afraid of the dog or all dogs, because you were once bitten. It is the reason kids don’t like to go to the doctor or dentist because every time they have in the past, pain was part of that experience. This biological programming does not completely go away in adults. But the important point is, you expect it to hurt, and that by itself can cause or amplify pain.

                Anyone who deals regularly with opioid pain medication understands resistance over time, down to the cellular mechanisms of reduced cell surface receptors because of intracellular cascades. (If you haven’t heard one of my lectures, biological processes have been conserved over centuries in all life forms, and so there are patterns which repeat in numerous forms. By understanding and recognizing these patterns, the practice of medicine is considerably simplified, and more effective.)  You can see a similar pattern to opioid resistance in insulin resistance, making the principles of one applicable to the other.

                Another important part of the background on pain is culture. In some cultures pain is a sign of weakness; in others people need permission to feel pain. On the opposite side of the scale, some cultures are very vocal about their pain; those outside of the culture have a very difficult and often biased acceptance of the person’s pain.

                The final piece of the puzzle is the social morals regarding the management of pain. This contributes into provider attitudes towards managing pain. Some providers cite legal responsibility, and I just call malarkey. In the US, abortion was once “illegal” but there were many providers who were putting medical care above the law, which is a time honored tradition in medicine. (whether we agree or not, is not relevant to this discussion) It is very popular in certain countries, such as the US and Poland, for providers to withhold or improperly manage pain based on their moral and sociological perceptions of chronic pain, drug abuse, and overall desirable mating characteristics of patients (see my previous post on this).

                In many countries, it is written and posted that patients have the right to have their pain managed. Whoever came up with this right needs to have a lawyer more clearly define “managed” as there is considerable confusion. Some will say “managed” doesn’t mean any pain, but an acceptable level of pain. Some will say it means it means no pain at all. I tend to interpret the spirit of this “right” to mean, every effort should be used to eliminate pain until the risk of therapy outweighs the benefit. Classic medical risk/reward analysis.

                However, the risks are not simply limited to biomarkers, parameters, patient satisfaction and safety. What I consider an acceptable risk, another provider would consider no risk, or even possibly wanton disregard for patient safety. (In my case, most likely the later.)

                But among other things, risk can be reduced both education and experience. People not experienced at managing pain, will be afraid not of managing pain, but of their unfamiliarity with the means to do it. Having the proper tools, or even more than one tool, readily available also helps.

                The purpose of anesthesia is stated in 3 criteria. 1) The patient does not feel pain. 2) The patient does not react to pain. 3) The patient does not remember pain. It doesn’t get much simpler than that. It means, no pain. We also define analgesia. There are several variations of the definition available, but I think this one,  from the freedictionary.com sums it up the best.  “A deadening or absence of the sense of pain without loss of consciousness.” Most of the other variations mention only the complete absence of pain while maintaining consciousness. But this definition is not the(a) theory like the purpose of anesthesia. It has very specific criteria.

                So does analgesia have the same theory as anesthesia? You bet it does! Don’t believe me, go to the dentist and ask him to drill away. It won’t take too long for you to decide you don’t want to feel that. Go and have your appendix removed or a fractured bone reset, decline anesthesia. Be a boss and simply tell the anesthesiologist, “No thanks, I got this…” The next time you have a headache, tough out the rest of your day at work. I also don’t want to hear any misogynous remarks about “walking off the pain,” or “manning up.”

                In medicine we often profess that the whole patient must be treated. It seems to mean in relation to pain too. You can’t just treat nociceptive pain and call that management. Because it means that all other pain was not treated. In modern times, especially in pediatrics, every effort is made to reduce remembered pain. Neuropathic pain is also its own monster.

                In the EMS world, an antagonist of mine is often quoted as saying “Extreme pain + 2mg of morphine= extreme pain.” That actually very accurately describes my thoughts on it as well. Most Emergency providers, whether in EMS, fire, or even the ED, don’t know that opioids come with a weight based dosage. (0.10-0.15 mg/kg for morphine) More practically 1mg/10 kg or 1.5mg/10 kg if it is really bad. You can look up the weight based dosages for whatever you like to use or is available to you. Some providers claim that bolus dosing is dangerous and should be avoided, and I tend to agree with them, but these weight based ranges are still a good indicator of how much you can expect to need in the end. In my experience using procedural sedation (conscious sedation) these are actually minimum doses that seem to work, under another dosing technique called “titrate to desired effect.”

                  However, for all this discussion on morphine, opioids only really work on nociceptive pain. Other medications and techniques are needed for the other types for total pain management. I have found using small doses of benzodiazepines in addition to opioids actually helps deal with the remembered pain too, especially in peds. We do not want children to be afraid to go to the doctor or hospital remembering it hurts. There are also pathophysiologic effects of pain. Some providers prefer ketamine. One of my best teachers in medical school was an anesthesiology professor who professed “There are many ways in anesthesia to achieve the same thing. It is impossible to know and be competent with them all, therefore, pick a few that you like, and stick with them.” The same pattern holds true in the pursuit of martial arts. Each style has hundreds of techniques and variations. If you are in a fight, standing around deciding which technique you want to use probably isn’t going to work so well if you plan to win. But I digress… There is more than one way to be effective. But you need more than one choice, because well… its medicine, and nothing works 100%.

                In practical terms for providers, pain usually comes in 3 kinds, chronic pain, acute pain, and irretractable pain. This is where I think all of the problems actually occur. 1st, people with no idea about pain control or practical pain control, make up restrictions based on fear and not reason. Call them joint commission, your medical director, professor, or whatever.  This comes in the form of ineffective drugs, dosing, and techniques. 2nd is provider accessibility. If controlling a patient’s pain creates pain for providers, they simply are going to find justifiable reasons not to. 3rd is the providers moral objections, you know, “the patient is a seeker,” “the patient is an addict,” “the patient is undesirable for X reason.”

                Let us look at these “undesirable” patients. Is being an addict a choice? Perhaps at first, when the need to seek pharmacological support to deal with socio-economic or psychological issues, is required.  At some point though, it becomes a physical dependence and at that point, medical palliation is required. I purposely do not call it medical care, because effective rehab and manipulating the environment that caused it is beyond the scope and ability medical provider.

                Going back again to my fire service roots, one of the things I learned in fire/arson investigation class was “bad things happen to bad people too.” In context, it was to point out not to automatically think a fire which involves a criminal or other morally objectionable person was the result of arson. In relation to pain, the same thing applies. An addict, seeker, chronic pain sufferer, etc., may really be in pain. But these conditions do not preclude them from the patient rights of having their pain managed. Some providers are adamant that the emergency system should not be involved in that.

                This begs the question, whose job is it? The logical answer would be a pain management specialist. However, there is a major question of access to these specialists. In the US, this access is limited by the ability to pay. In other countries it is limited first by the few pain specialists, and second by the inability to be productive or even maintain basic function while navigating a cumbersome system. Consequently, the common people dealing with pain are 1) The patient themselves, either by nonprescription medication or illegal means of obtaining drugs, whether sharing prescriptions, or more elicit means). 2)Primary care providers, whose knowledge, techniques, and time are limited, but none- the-less are morally, ethically, and in some cases legally burdened with a duty to act. 3) Emergency providers.

                I have had the experience of having a patient show up at a clinic I was at with an official US prescription bottle that looked more like a soda bottle than prescription bottle because of its size. It was an official prescription, with the prescribing doctor’s name, dosage, filling pharmacy, date filled and everything for morphine, 20mg, 3 times daily, 6 months supply. It was empty one month since it was last filled. For many years I have professed the physical exam and history of a patient is not a mystery to be solved. It is an interrogation and the desired outcome is confession. His initial story was the “pills were stolen.” Because you know, when you steal 450 pills of morphine, leaving the bottle behind makes it easier to get away and it takes longer for the patient to notice the pills are gone right? (I didn’t buy that story either) So I took him to my office and offered to do my best for him, but I wanted the truth. He then volunteered that he needed to take more than 3 a day to make the pain go away and that he had been having the same primary care provider treat him for years with this. I asked him what type of work he did, and he told me he was an aircraft mechanic! That takes the phrase “fly the friendly skies” to another level. I explained to him, that not only was I not going to refill his prescription, but that he could not continue to work in his current position. He then gave me a very sincere sob story about needing the money for family, etc. In the end, it was decided that he would return home without a prescription and look into temporary or permanent disability. I took it upon myself to call the doctor who prescribed it and ask him if he knew his patient was a civilian aircraft mechanic. (From his reaction I am guessing he didn’t) This doctor very humbly concluded qualifying the patient for disability would be a better plan.

                This experience aside, I have talked to a few primary care providers about pain control, and their almost universal response (imagine getting nearly the same response from multiple doctors) is “We have to do something, opioids are our best/cheapest option.” Stands to reason if the patient cannot have specialist treatment for whatever the reason, less effective treatment will be the only option. But this is not curative treatment, this is palliation.

                So that leaves the emergency system. Whether EMS, the fire department, or the emergency room. (A&E for the British friends) people with chronic pain and addiction use these resources for help. Just as for many other conditions, emergency is an extremely ineffective form of help. (One of the many reasons I am convinced Emergency Medicine should not really be a medical specialty, with no ill reflection on the ability of the many great doctors that “practice” it)Some emergency rooms have taken to posting signs stating they will deny patients effective pain treatment. Some believe that simply referring a patient to another doctor will suddenly solve all of the access issues around chronic pain management. Some actually profess they are not a drug supplier for the undesirable. But the bottom line of all of this is: They have chosen not only to deny patients their right to pain treatment, but to deny them any effective help at all.

                Generally in medicine when you cannot best treat the patient, you refer them. Understanding the access issues above, when was the last time you saw an emergency physician ask for an immediate consult from anesthesia or PM&R at even 1pm in the afternoon much less 3am? I have never.

                When an alcohol addict is admitted to the hospital, in order to treat their physical addiction, they are given either alcohol or benzodiazepines. When an addict of any drug requires surgery (not to be confused with elects surgery) in order to reduce complications both surgeons and anesthesiologists maintain their addiction.

                Taken as a whole that means your GP, your surgeon, and your anesthesiologist will not only treat your pain, but also palliate your addiction in the name of best and safest practice. The response from emergency? “Fuck you, undesirable, we aren’t doing shit for you or your addiction.”

                Not exactly altruism.

                Maybe “come back here when you are dying and I will make an effort for you then.” So much for prevention and promotion. Probably good they don’t say that to patients presenting with chest pain!

                People do not choose to become addicts anymore or different than they choose to have coronary artery disease. But yet one is treated much differently than the other?

                We have all heard the phrase “Primum non nocere,” many of us profess it. But never give a thought as to what it means. It doesn’t say “do not harm people with medical treatment or diagnostics.” The scope is much broader. One might even conclude it means do not harm patients by forcing them to palliate their addiction on the street, which is dangerous, unreliable, and criminal. (Forcing people to become a criminal is causing harm.) If they are arrested their social problems increase. If they are jailed, further health and safety is at risk. Do I really need to describe the dangers of criminal life on the street and the composition of the drugs found there?

                Has anyone considered that alienating and ostracizing people addicted to drugs, because of pain they really have or life they cannot cope with, actually promotes their dependence and lessens the chance they will seek help in the future?

                This all seems to me like one of the most simple aspects of medicine, relieving pain, is perhaps the single biggest failure of medical providers around the world.  Providers and institutions need to start getting their act together. If they are not going to actually help, they should start by first doing no harm. Keeping in mind bad things happen to bad people, but we should not be prejudiced towards them.            

The Appeal of “alternative medicine”

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Usually not a day goes by where I do not see a Facebook post or directly hear (Facebook is my primary form of communication) comments on anti-vaccination, both for and against, as well as homebirths, dieting, diet supplements, extraordinarily rare diseases and proof positive testimonials about how somebody’s grandmother cured them of incurable cancer with some Dr. Jeckle worthy concoction cooked up in her kitchen.

                So I decided to try to explain this popular acceptance and even preference using my knowledge of human behavior and patient care experience.

                One of the biggest problems in medicine today is the concept of “the ivory tower.” In the industry we sarcastically use this phrase to describe a tertiary care facility filled with the greatest minds and the latest technology. But I think it quite accurately describes all of medicine as the general public (aka patients) perceives it.

                From the perspective of my experience in US Emergency Medical Service (EMS), the paramedic is the only healthcare provider left that actually sees people in their native environment. While some doctors still do house calls, and home health nurses may rightfully claim some experience, only the paramedic will be there at 0’dark 30 on the average night and the only provider who will show up without prior planning and approval.

                In most modern nations, from the US, to Britain, and even Poland (anyone doubting if Poland is a first world nation should come and visit and I will put that debate to rest) the healthcare systems accidentally place the EMS provider in the position of being the most accessible. It is easy to contact EMS, they usually come within the hour, and it is a medical opinion without “bothering”, waiting for, or the cost of a doctor.

                In modern times, most “emergencies” are exacerbations of chronic disease or an acute on chronic condition. But how does this examination of EMS relate to “alternative” medicine?

                Simple, trust.

                As medical systems evolved, they got so complex that they are not understandable by people outside the system. People are faced with an insurmountable choice of who to call, where to go, and when. One of the most common questions I heard as a firefighter and paramedic was “Do I need to go and see a doctor?” Closely followed by “Do I really need to go to the emergency room?” I even have 1st hand stories of people coming to the station, stating they are not going to the hospital because they cannot afford it or have no way home, and could I please do what I could.

                On the list of most trusted professions, doctors and nurses have fallen out of favor compared to their pre-hospital counterparts. While everything from industry conspiracy theories, poor treatment by healthcare providers, and numerous other theories attempt to explain this, if we just use the theory of Occam’s razor, from the time we are little kids we are told: “Don’t talk to strangers”. Certainly don’t get into their car, go to their house, etc.

                Our Ivory towers have made us strangers.

                Furthermore, our behavior and lifestyle puts us absolutely out of touch with our patients. Let’s face it, we speak our own language. Whether I am talking to a doctor from Russia, Japan, Poland, France, The UK, Nigeria, Kosovo, or anywhere else that has a different language, we can exchange meaningful information about patients in the language of medicine.

                How do you feel when people are speaking a language you do not understand in front of you?

                At best unintentionally left out and at worst purposefully excluded. What’s more, unlike people speaking in a different language around you, medical providers are definitely talking about you!

                Aside from language, we fail to communicate in other forms. Our body language and tone of speech often conveys we do not really have time for patients or a desire to speak with certain ones. From both our familiarity of the system we see things like the patient sitting in the waiting room for 14 hours wondering how bad they were while we dismissed them as trivial in the first 10 seconds we talked to them to not knowing that after we draw your blood, it will take at least 45 minutes to even get results, perhaps longer to get around to them, and even longer to see other people more urgent before we get back to you.

                Moreover, we also have cultural exclusions. Many healthcare providers are not first generation college graduates or if they are, they have been away from “the normal people” for so long; they forgot what “normal people” know and don’t, what their concerns, and fears are. What they need from medicine, and in the worst case, belittle or negatively judge them for their lifestyle treating them accordingly. We don’t live in their communities; we don’t associate with them outside of work. We fail to understand what they want and need.

                As if that wasn’t enough, we go one further. Medicine and science are so advanced that the average person simply cannot understand it. We (at least I hope most of us) do understand at least enough to know when to refer somebody to another provider. Once we reach the level of “doctor” we understand a considerable bit of it. After all, we have spent nearly an equal amount studying just medicine as other have total education in all their lives! Oh, and we also work with it too. Nothing drives patients crazier when they pay to see a doctor and they have a problem so simple, that it really looks like we did nothing and didn’t even give them enough time to finish their story, much less address their concerns. In their eyes they paid us a lot for nothing!

                  We are worse than strangers, we are the arrogant witches and warlocks in the tower where you only go when everything else fails and there are no other options.

                All of this together creates a disconnect between people and medicine and like all things, where there is emptiness in life, something will fill the void. In the case of medicine, this void is filled by people who are less knowledgeable, more sure of themselves, (it seems the more you learn the less certain things become) and offer a definitive solution to the problems plaguing people.

                From  blogs and non-peer reviewed publications on the internet, to print, TV commercials, and even at the mall, these charlatans are readily available to people. For free. Like all people who know very little, they are very sure in what they do know. They present these headlines and incomplete snippets of information as often as possible. They completely buy into their own bullshit. They speak the language of the common person. They offer solutions (too good to be true).

                What are these solutions? Feel bad? Take this and feel good!  Do you need to see a doctor? No, just do this… Do you need to go to the doctor every month for a new prescription? Nope…just stop by the shop or we will send it in the mail. Just like snake oil sales, they can cure whatever ills you. Even if your only ill is concern.

                Look at the examples, anti-vaccers. They latch on to a few buzzwords or a handful of negative outcomes. They present this as the norm, or at least so common it should affect your decisions. After all, who are you going to believe? Somebody who is a parent like you or those greedy, conspiring, doctors and scientists (strangers in the ivory tower)?

                Even nurses get in on it. “Let me tell you what I have seen…” How can you explain what you haven’t seen? Just asking…

                Do I get vaccinated? Absolutely! Not with the flu shot I will admit, because the evidence seems to point out I do not have a high level of benefit. I make sure my daughter is vaccinated, with everything out there, on schedule. I encourage my wife to get anything that might benefit her. (They are in different risk/benefit categories than I am)

                Do I know there have been a handful of negative affects? Yes I do. Do I know that at any time something can go wrong? Yep, I know that too. It’s not even a choice between risk/reward. The risks so low and the reward so high, it is a no-brainer. But I have some benefits in making that decision that not everyone has which makes it so clear. For example, I have an advanced professional education. I work in the industry. I have access to the latest science (which costs well more than most people can afford, with some journal subscriptions upwards of $1000 a year), not just the stuff free on the internet from very professional looking, but highly questionable websites and adverts.

                You see the exact same thing with home-birthers. ( I think these people are a bit more sinister than anti-vaccers because they actually collect evidence and then selectively exclude anything that doesn’t support their case, where anti-vaccers simply have no evidence and are selling fear). The use of the scientific method for social or economic gain is well documented through the ages in a variety of issues, this is just one of the latest appearances.

                Do you need a doctor to have a baby? I am told “no.” but because of my personal experience of making it through a Fire/EMS career, medical school, medical practice, and internship time in OB/GYN, I have never seen an uncomplicated childbirth. In fact when my daughter was born, despite absolutely no indication through prenatal care and early labor there was a complication.p>

                I am compelled to point out the infant and maternal fatality rates during times and in places where medical care during birth is not available. Morbidity is also a major concern. As well, I would be remiss if I failed to point out that the medical discipline of anesthesiology was developed to ease the pain of women in labor by Dr. John Snow! (which is where the term “getting snowed” comes from)

                I will also point out that where medical care, pre, during, and post labor is greatest, they have measurably the best outcomes in all respects. (Including total medical costs) The US for-profit system is the only exception to cost benefit.

                There is also the biological reproductive strategy associated with various populations. Rats have lots of babies, because they have a high mortality rate prior to reaching the age of reproduction. So do fish. So do dogs. (We have all heard of the runt of the litter). Humans too, in some parts of the world, follow a similar reproductive biology. Out of 7 or 8 kids maybe 2-3 will survive to reproduce. This is a fact of life they live with. How many people in a modern country, where they might have 1 or 2 children per lifetime would accept a 70% child mortality rate? Are you willing to accept it? How about the financial costs and family stress associated with a severely disabled child? Obviously some do accept this, but very very few and in countries where there is social support systems for it.

                Some claim that surgical birth is overused in medicine. I tend to agree, but perhaps not for the reasons many people think. First, there are indications for a C-section. Only some of these are identified prior to labor. Many would not argue against them. Trial of natural labor and deciding on a C-section is tricky. If you decide early, you may over-triage people who ultimately could deliver without surgical intervention. But if you wait too long, you run the risk of mortality and long term disability. Prudence dictates you err on the side of caution. Consequently, many will have C-sections that were not required, but that is simply the perfection of hindsight.

                But this has profound effect on patients; surgery, scars, complications, costs, future pregnancy costs. It is a big concern for non-medical people.

                I have even been at the table for “elective” C-sections. Most notably after a vaginoplasty. (Yep you heard that right, plastic surgery to improve the look of the vagina in a female prior to childbirth.) Body image and sexual health occupy a larger role in modern society than in the past.

                But for all of the decisions with pregnancy; age to get pregnant, keep/not keep, abortion, types of childbirth, costs, etc. There is somebody there to tell people their experience and advert their “easy way” or justify their decisions. After all, in Western cultures women generally seek consensus, rather than correctness. (at least that is what the psychology of women professors I sat through thought, and it did seem to be true at the time) What better way to find consensus than to get as many women as possible to do what you already did?           

                4 pages on this already, wow!

                I could probably write another 4 or so pages on diet supplements, diets, and herbal remedies, but it really all boils down to the same things I already talked about, only the details change a little.

                So it seems, the more medical providers separate from the community, locking themselves in the ivory towers, and forcing patients to play the game their way or no way; the needs, desires, and opportunity to take advantage of the lay-person will only expand, and all of this nonsense will expand with it.

                The solution is really simple. Medical providers need to understand and be proactive in their communities, visibly and not just when people pay or become desperate for help. It seems to be working for paramedics. There are even parallels to the fire service and police officers. Some will argue that is public safety, not medical care, but I will leave you with this though:

                Medical providers draw their social and economic status from the values of their patients. If you alienate yourself from them, how does that work out in the end? Who and what will fill the gap?

McMedicine and science as a religion

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Does your doctor suck? Do you suck as a doctor? How do you know?

Well, the truth of the matter is it is simply a matter of opinion. I have been called “a brilliant doctor”, “singularly gifted”, “inspirational”, “hardcore”,”stupid”, “a menace to patients”, “cold” “heartless” and “asshole” and a few other good and bad adjectives.

So how do I go about deciding if I am a freedom fighter or a terrorist? (aka: which side am I really on?)

How do you decide if your doctor is good or bad? An important question, because it is your health and the health of your loved ones if you are wrong that is at stake.

There are really only 2 types of medicine. One is individualized care and the other is care by the numbers. I refer to this as “McMedicine” because it is no different than going to McDonalds and ordering a value meal off of the menu.

There is a lot to be said for McDonald’s way of doing things. They have analyzed every aspect of their operations, and can deliver a consistent product, everywhere they operate in the world.  Their food is roughly the same price. It always tastes like shit no matter which country you are in. But if you are feeling like 2 all “beef” (we won’t quibble about the definition of “beef” here) patties, special sauce, lettuce, cheese, pickles, onions, on a sesame seed bun, you have only to order a #1 value meal and your culinary cravings, or the lesser of all evils that you must eat, shall be met.

So too has modern medicine attempted to replicate this consistency. Unfortunately, there is only one thing stopping success…Patients… If you work in healthcare, you know from your very first biology class in high school, everybody is different. Not in the sociological or cultural sense so much, but physically. We use words like human locus antigens, DNA, cell surface receptors, blood groups, and more to describe these differences. From biology, through molecular biology, biochemistry, physiology, and pathophysiology, we learn that every person is different for years.

From the patient point of view, we have all experienced side effects of medications, foods that we don’t tolerate well. Different preferred climates, perhaps an itchy cast, or ugly scar.

We know people are different. But some (“I’ll be generous) doctors, insist on treating everyone the same! Why?

Well, one school of thought is, if we quantitatively analyze all manner of medicine, we will come up with the treatments that work for the most people the most often. Nobody is fool enough to think there is going to be a treatment that works for everybody all the time. Unfortunately, “the most” and “most often” rarely hits 30%. Which means it will not work 70% of the time. But since it is the “most” there will be a clinical guideline and your healthcare provider will try this first. Let’s call it a #1 value meal. You know exactly what you are getting, and it will be consistent no matter what provider you go to if they are practicing McMedicine.  

 

In the USA and moving to the British and Commonwealth countries is the fast food of medicine. The midlevel provider.  These providers have discovered that with the most minimum of medical education, coupled with some on-the-job training, they can deliver the exact same medicine with the exact same results as a doctor, these are essentially medical value meals.  Some may think this statement is a slight against these providers, but in fact, what it means is doctors are not any more capable or willing to provide anything better, so why should you pay more, wait longer, and all the other things associated with doctors to get the same thing? The answer is simple, you shouldn’t. Hell…I wouldn’t.

Now some doctors will put the blame on medical malpractice and the threat of getting sued. To which I am just going to call malarkey. According to the yearly Medscape article on malpractice, the doctors who get sued the most, by a vast majority, some 40x%, are primary care providers. The #1 reason is misdiagnosis. The number 2 reason is not apologizing for any “mistakes. Which might be logically surmised as the #1 value meal didn’t work for the patient, and the next attempt will be value meal #2. The next group who are sued the most often are gynecologists. These are doctors who actually have something to worry about… The reason they get sued is reported as parents want somebody to blame for their kid not turning out perfect. Vast arrays of laws have been enacted in favor of these “patients,” so you can reasonably understand the paranoia.  OB/Gyn and GP make up more than 70% of all medical lawsuits in the US. All other medical specialties fall between 1-4% respectively.

Because of this paranoia (often unfounded) by doctors, an idea has come about of “the standard of care.” The idea is if you follow the standard of care, you will be found not at fault because you did what another doctor would also do in the same situation. Which is an argument flawed at its core. That is claiming innocence for sucking because most people can be expected to suck. Yea… I am not buying that as what lawyers call an “affirmative defense.”

Still yet other providers practice what I call “the religion of science,” they believe that practicing McMedicine will provide the correct treatment more often than it fails to. Given the best guidelines barely meet the 30% criteria, it is clear that there will still be far more failures than successes, and we haven’t even talked about effectiveness of a given procedure or medication yet. (and we won’t today) The reason I compare this “science” to religion is because its practitioners do not use it as science (To observe in a standard way over time). They use it as religion (to explain the unknown, provide mental security, justify suffering, and explain death). By using scientific papers as a “bible” of sorts, they lose all concept (if they ever had any) that there are limitations to both the scientific method and to medical study. They are in practice not doctors or healthcare providers, but priests of their religion.

So what is the alternative?

It is called “individualized care”. The idea that everyone is different and each case should be examined on its own merits. Most people who wind up in court would like to think their case will be judged on its own merit. Most would seem to like their healthcare to be based off of their own case too.

Now let’s just be clear, even with individualized care, many patients will best be served by a medical value meal. Nobody disputes that. The trade-off though is that there will need to be more doctors. Simply because the time individualized care takes is greater than McMedicine. It requires both more effort and more knowledge on the part of doctors.

The current problems in medical training share blame for McMedicine. 1st, in many countries, the selection process is for those who excel at science, and whose people skills are somewhat lacking, which means you are making doctors out of people predisposed to McMedicine, quantitative thinkers. Another problem is the current residency training. Most doctors in training believe and hear regularly from their mentors, that there is a difference between scientific medicine and clinical medicine. They further expand upon this concept by claiming what is learned in residency is “real or practical” medicine and the things learned in medical school can simply be forgotten as unimportant and impractical.

Individualized care on the other hand requires both the school learning and practical learning to be reconciled together, as two sides of a coin.

If the Mentors of McMedicine cannot do it themselves, they cannot pass it on to their students. If they simply refuse to see its value and pass it on, patient care as a whole suffers as medical progress is stifled.

The hyper-specialization of medicine also promotes the practice of McMedicine. For if the patient does not fit into a specific set of parameters, a specific doctor will or will not see them. But what happens when a patient overlaps or does not fit into these parameters?

Any doctor worth their title and most non-doctors can tell you that a patient must be seen as a whole. But in McMedicine, nobody behaves that way and no doctor is responsible for the whole patient. After all, when will the GP step in and tell a surgeon that a given surgery is not in the best interest of a patient? Never… They just try to clean up any mess after.

I observe every day in clinical practice treatments that are enshrined in protocol and professional guideline. Diagnostics and treatments which do not meet the known basic scientific principles on which they supposedly work. But yet, they are prescribed anyway. Some patients get better in spite of this treatment. Some are not affected either way, and many are probably made worse.

I carry the banner for individualized care. My scientific research is based on discovering why things work. In my many professional presentations I profess we must always ask “why” especially in our treatments. “By what mechanisms do they work?” Usually when I suggest something I am seen as either hopelessly stupid or uneducated, or brilliant. There is no middle ground, and it is easy to predict what the reaction will be by the attitude of the provider. Generally the ones who perfected the system of McMedicine instead of the principles of medicine are quick to negatively criticize and vise versa.

Do you want McMedicine or individualized care?

Does your doctor suck or do you suck as a doctor?

Ultimately these are questions you must answer for yourself.    

Choose your death and call hospice.

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Generally it is acceptable to begin palliative care in people who have a terminal disease who will no longer benefit from “curative” medical interventions. The term “curative” as we all know is actually rather deceptive. After all, there are only a handful of diseases that can actually be “cured” and they most often relate to childhood cancers. The rest of medicine is designed to alter the physiologic processes of the body in order to help the organism (aka patient) compensate.

Originally, medicine was designed to help people maintain productivity. This was during a time when social safety nets basically did not exist. If you couldn’t grow or hunt your food, or do something in order to trade for it, you would simply die. Being productive was synonymous with life.

However, medical knowledge also was useful for palliating terminal patients; some on the battlefield and others in the civilian world. Recognizing the inevitability of the end, comfort care of the dying was simply the humane thing to do.

However, over the centuries, as people, medicine, and society evolved, so too has diseases that affect humans. The purpose of medicine is no longer to keep people productive, but to keep people living. As many of us witness daily, this is simply an impossible task. We are trained and encouraged to help people lead healthier lifestyles. Eat right, quit smoking, exercise, and all manner of non-medical intervention.

But how many patients actually choose to do this? An abysmally small percent… So facing death, which may not seem real until the active dying phase because of the actual amounts of time involved in chronic disease and the relatively painless symptoms, it seems patients have no interest in actually curing or putting off disease, but simply want to be defiant to the end.

This attitude, philosophy, mentality, whatever you want to call it is enshrined in American culture. Let’s face it, what America does for better or worse, the world usually copies.

“I have not yet begun to fight” was famously stated by John Paul Jones, an early American naval officer, in response to a British request to surrender after the initial stages of the engagement which left his American ship sinking. In the end, the American ship did sink, but after taking the British ship a prize, the Americans declared it a great victory. A great fight for sure (in the man vs. man sense) but arguably, pretty much a draw, after all, everyone lost a ship.

Has medicine become the same? Patients do not want to actively take care of their health, but instead wish to continue the lifestyle they have chosen as long as possible. In order to do this, they require pills, and surgery, and all manner of treatments forcing science to push the envelope further every day.

In essence, they know their ship is sinking, and they call the doctor and begin to fight; in the end, not seeking to win, but merely to stay afloat a bit longer.

Now it is obvious that circumstance often dictates this choice. After all, when your 10,000 calorie McDonald’s meal is only $5, but your 350 calorie Mediterranean salad is $10 and you have a limited amount of money, McDonald’s is the clear choice. (Starving isn’t healthy either.) Some can be blamed on education, tradition, culture, history, and a myriad of other factors.

But I am not here to explore healthy living or what can be done to help people be healthy. Other people get paid to do that. I am here to talk about a decision point.

I have only a handful of friends who are not healthcare providers. Even among friends that are healthcare providers of some type, only a small percentage are not some form of Critical (Acute) Care provider. (Emergency, Intensive Care, Surgery) We are simply not in the business of health promotion.

So at what point is further medical care futile? During the active dying phase after a resuscitation event or the end stage of a terminal cancer is a no-brainer. But what about the 50 year old morbidly obese patient, whose idea of productivity is making it to the fridge and back between TV commercials? What about the diabetic sitting in the ED bed eating cookies while waiting for lab results or the surgery patient for yet another amputation?

Most Critical Care providers I know do not want to be resuscitated, or only in under very select circumstances, usually revolving around a return to a comparable level of previous function. People not a part of this acute care lifestyle generally talk about a quick death being preferable to a prolonged one. But yet when they are told the foot has to come off, or the leg, they cry and ultimately acquiesce, all pretense of fighting spirit gone. Right up until after the surgery when the mental shock subsides, they retake up defiance with the mantra of “it’s over and I have nothing more to lose.”

So after a few years in the medical system, well before they get to these extreme points, why don’t we just say “you might go out with DKA, but you’ll be eating your burger right up until the end.” Maybe a catchy slogan, like “have some fries for your M-Is?”

Now I am not suggesting not treating people, quite the contrary. But I am asking when the determination of switching from “curative medicine” to palliation should be determined.

It extends beyond chronic diseases to other inflictions. For example, a popular topic among emergency providers is not providing opioids to addicts. What “curative” treatment do we offer? It certainly isn’t effective substance abuse treatment.  At what point do we decide in the battle of life, you lost, so let’s practice the time honored medical tradition of making your death as painless as possible?

I have given 2 examples, but I could go on and on. We cannot use medicine to give people the life we want them to have. We can only help them along in the life they do have. Otherwise I will please have a prescription for wealthy, sexy, and completely carefree. Furthermore, I don’t want to be the person in the nursing home all alone because I am so much a burden on my family they cannot possibly take care of me. I suspect many of you reading want the same. Why are we so quick to use medicine that will give that very drawn out end to others instead of telling them to live it up and helping them?

Wouldn’t helping them have the life they choose until the end, even if it was years less, medicine that would make people feel better? Hacking them to death a piece at a time or polypharm treatment until they are so sick they cannot function or even want to be around people because of the side effects doesn’t seem like “reasonable medical treatment” to me anymore. In fact, I am not even sure it was ever “reasonable,” but it sure made me feel good to do it to somebody else.     

Selecting patients you want to mate with…

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That was a rather provocative title wasn’t it?

I was marveling at the way some providers act in a contemptuous way towards their patients. You know; that patient who is a drunk, a drug addict, prostitute, or even a frequent flyer, etc.

In school many of us are told about paternalism as it relates to patient care. In the more modern world, it is commonly accepted that providers are not “above” a patient, but rather a partner, or as I like, a trusted friend and advisor.

So today I was trying to determine why providers judge their patients. Since I have some background in biological anthropology, I first decided to examine this issue as a matter of culture.

Culture is defined as: the ideas, customs, and social behavior of a particular people or society.

It occurred to me that medical providers usually have a different subculture than their patients, particularly along socio-economic lines. The lower the socio-economic class, the more medical help a person generally requires.

But this hypothesis proves to be a dead end. Providers don’t hate poor people. At least most of them don’t. Many providers also aspire to one day be a part of some medical mission to a less developed country in order to provide care. So the issue cannot be as simple as haves vs. have-nots.

I also noticed that this trend of contempt of patients is not unique to any country I have been to. It is a shared behavior. So I had to put my keen mind to the task and try and figure out what causes this…

Currently I am exploring the possibility it is a mating behavior. Perhaps these providers who always claimed to want to help people, a very common reason given for entering the medical or healthcare fields, are subconsciously seeing these undesirable patients simply as undesirable mating prospects? After all, who dreams of meeting the perfect alcoholic or addicted partner? The partner no matter what or how much you do for them simply continues to repeat the same destructive behavior or behavior of victimization?  Why are providers so fascinated and eager to go half way around the world to help the “less fortunate,” but find these same people absolutely appalling when in their home range?

The most obvious answer is: they don’t intend to bring their “underserved” patients back with them. The provider can walk away from the environment of the unfortunate. Why can they not walk away from the unfortunate where they live?

The answer to this I think is 2 fold. For one, some providers are in a specialty or agency where their primary role is to help these people. The Emergency Medical Services as well as a number of hospital based medical specialties find this to be their primary population. I would ask “who didn’t know that going in?” After all, the respectable family man or mother of 2.5 kids in the middle class, in their socially productive prime doesn’t usually require any of these services or providers. The second reason I think goes back to mating behavior. In a primate’s home range, they have ample food, shelter, and reproductive prospects.

Providers, being primates, do not seem to want these “undesirable patients” in their home range. They do not take their food or shelter from them. They do compete for mating prospects. In fact, many providers go as far as to punish, humiliate, not properly care for, or otherwise attempt to drive these patients away. A person certainly wouldn’t do that to somebody they wanted in their mating pool.

In a round-about way, this might be attributable to the lack of paternalism in modern medicine. The position of authority and social status as being “above” undesirable patients creates a separation in the reproductive pool. They are not in your mating pool, because you are clearly acknowledged as superior. You act it and they reciprocate this hierarchy. The modern concept of the patient as a friend puts them on an equal plane. They are for all intents and purposes the same as you. It can even be taken further by the concept of treating a patient as a customer. You are there to serve their demands. Now from a social standpoint you are not just equal, but inferior!

The British providers I know derogatorily refer to patients as “punters” which is their word for a person who hires prostitutes. In American parlance, if your patient is a John, what does that make you? It takes the idea and value of “patient satisfaction” to a completely different level. Should your patient satisfaction survey reflect poorly on you, it is likely you will be slapped around a little by your pimp (employer) until you start to “properly respect the wishes of your customers.”

There are several consequences to this. First, it leads to over or improper treatment for customer service. This increases medical costs. It may even play a part (this is a controversy not a fact) in problems like antibiotic resistance. It certainly degrades providers, which in turn leads to the behaviors of punishing or failing to properly care for the patients by mechanisms such as withholding treatment.

But this goes back to the issue of mating behavior as well. Most prostitutes do not see their John’s as partners they want to reproduce or have a relationship with, though they may pretend to and go through the motions. Just like modern healthcare providers and “undesirable patients.” They are simply not wanted in the mating pool.

Clearly something must be done for the benefit of the providers and the patients. But what?

The mindset of Critical Care

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I once saw a podcast where Dr. Thomas Scalia said: “Critical care is not a place, it is a mindset.” Prior to this, while I certainly subscribed to that mindset, I had never really thought about it in such terms.

Having started my career in the Fire and EMS service I have a diametrically opposed experience of the more traditional medical provider. The traditional education focuses on most common or “likely” diagnosis and treatments, followed by a career of working your way up to the most severe and complicated patient encounters. There is always somebody around to consult or call for help. Only in the most extreme circumstances are you left to your own devices. Even then, many times there is a set of instructions which clearly detail the steps to be taken for a specific patient population.

Critical Care is just the opposite. In the emergent setting, the patient could be anyone, have anything wrong with them, and communication or effective communication, may not even be possible. In the intensive care environment, the patient has multiple things wrong, all of which have complex interactions on other systems and functions, and often treatments that regularly conflict. In the surgical critical care environment, the patients are not prequalified, again could be anyone, with comorbid conditions, and require surgical intervention which is the very antithesis of how most surgeons are trained and prefer to operate.

The “mindset” of this environment necessitates first considering, diagnosing, and treating the worst case scenario. In both EMS and medicine. It is common to find the newest provider, without benefit of definitive help or counsel, deciding and acting in these extreme conditions.

This appeals to certain personality types. (You can pick your favorite description of the many available terms) But generally speaking, these people work hard and play hard, and in many cases are defined by their professional position. They also develop a “dark” sense of humor that makes them seem very cold and displeasurable for the uninitiated.

I must admit, sometimes I have very little tolerance for people who do not share the mindset, but I do try to remember their point of view.

The Critical Care mindset extends beyond this much further. Some have described providers as “cowboys who shoot from the hip.” I think that while this is what it appears like to the uninitiated, it isn’t very accurate.

One of my First teachers in the fire service once asked my class during a lecture, “Who read the chapter on rescue last night?” To which many people, myself included, raised our hands. He simply laughed and stated “The book tells you how to rescue people in the perfect circumstances. If the circumstances were perfect, nobody would need rescued…” That statement has had a profound effect on my career. It didn’t take long for me to discover how accurate that statement was. In the emergency environment, the protocols, treatments, etc. have to be tailored to the patient. The patient will almost never “fit” into the rules, and improvisation becomes the norm.

Said very well in one of my favorite movies “The code is more like guidelines, than actual rules.” But this is where the “cowboy” image loses its accuracy. In dealing with such patients, the mastery of the details of medicine is a must in order to be successful. The question of “why” is never answered to satisfaction, and constantly challenged. Without knowing why you are doing something, you will never know what to do. The constant learning required between patients along with the need to incorporate a broad based understanding when treating the patients creates more of a sniper-like precision than a wild shot from the hip. It has been my experience, the more you know and experience, the more accurate that “first shot” becomes every time.

It is also why it seems critical care practitioners are excellent “zebra hunters” (reference to the book “The House of God for those who have not heard the term) The knowledge of “why” permits more than accuracy in treatment, but also unmasks seemingly disconnected presentations.

So I think this insight should conclude my first blog post, it seems long and deep enough already and I should save something to write more on later, but I will leave with one final quote if you are deciding whether or not this form of medicine is for you, for the old hands to nod their heads to, and for those not in the club trying to grasp our madness.

Bilbo Baggins: “Can you promise that I will come back?”

Gandalf: “No…and if you do, you will not be the same…”