Chopin’s Piano

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The old city center of Krakow, Poland (Number 2 in my top 3 favorite places in the world) is surrounded by a series of parks. Actually, it is only one park, but it is transected by several major roads. In one of the divisions in a glass display is the wreckage of Chopin’s piano. This artifact was destroyed by Nazi soldiers during the invasion of Poland in WWII.

When I look at this display, I wonder what was going through the minds of the soldiers that did it. Chopin was recognized around the world as one of the greatest musicians of all time. Everyone was listening to and could recognize his music. It was perhaps “the song” of many couples. It put children to sleep (probably some adults too), and people lined up to hear him play his piano.

Those soldiers were in all likelihood not well educated nor cultured. Is that to say all German soldiers at the time were not? Certainly not. After all, it was the soldiers of the German high command that refused to destroy the city of Krakow because of its beauty and artistry. Somebody was smart enough to see the value in it, despite being told it was made by a lesser race. But these were not foot soldiers. They were generals.

A similar situation played out a couple of thousand years prior, when conquering Syracuse, Roman soldiers killed Archimedes, despite orders specifically not to. Perhaps because the soldier thought he was an educated arrogant asshole and he wanted to demonstrate how important a foot soldier really was? Archimedes is an extraordinarily important figure in history and modern medicine. The LVAD device is actually an Archimede’s screw. (which he developed to pump well water)

In all likelihood, these common foot soldiers did not know what they were looking at or what they were doing either. Though they probably believed they were in the right and acting in their best interests.

I started my blog mostly to write what I was thinking about medicine. It’s philosophy, things that could improve it. Parts of it I disagree with and potential solutions. A way to convey my introspections. Some of it was ranting. Simply because I am passionate about what I do, it is the defining factor of my life, and I don’t like to see it done poorly.

It was only by chance I wrote a peace on the failures of EMS providers and their implementation of EBM. I am not sorry for that piece, and I stand by what I said. I approved all the comments for posting, despite them being overwhelmingly negative. Strangely enough, despite these comments, the piece was an overwhelming success. Not only did it drive traffic to my blog beyond anything I could have ever imagined, it actually proved the point I was attempting to make.

In one of the earlier paragraphs, I specifically stated there would be a plethora of people who would vehemently deny the problem because they as individuals had an education. Either they didn’t read, didn’t understand, or somehow doubted my ability to predict a reaction that is no different from what has been happening for decades.

I was particularly entertained to the point of replying of the doctor who doubted I was a doctor because I was disparaging another healthcare provider. Because as we all know, (insert heavy sarcasm) doctors don’t regularly complain about nursing or any other healthcare provider. (I am not saying doctors should complain about nursing, but we would all be foolish to pretend it doesn’t happen.)

“We are part of the team,” was a common thread, more colorfully worded. I haven’t figured out which team yet, I am compelled to think that the water boy is part of the team, but I might supply some intriguing insight to this.

For mental security, most healthcare providers must believe what you are doing is helping. I have forgone mental security because the fact is some patients actually survived in spite of my efforts. You see, I worked on an ambulance when escalating doses of epinephrine was the standard of care. When CPR was stopped for undeterminable lengths in order to start an IV, drop a tube, check for pulses, or push a drug. My competency was judged by my peers on whether or not I could intubate, start an IV, push a tackle box full of medications (including multiple antiarrhythmics) into a patient, and declare them not only dead, but really most sincerely dead. (Be honest, how many of you recognized that from the Wizard of Oz?) Around 2005 we decided that maybe focusing more of quality CPR and less on those “life-saving medications” was important. There is but one logical conclusion, we weren’t helping, we were hurting. But I am ok with that. Why? Because every time I see a patient I promise myself to learn and do better. I spend my off time mostly learning to do better, holding all practices, both former and proposed under unrelenting scrutiny. From the system to the individual, nothing is sacred.

There is another fact US EMS providers overlook. They are not paid for their medical ability, they are paid to drive people to hospitals. If you don’t believe me, ask some of the operations directors about the specifics of billing. Consider why interfacility transport companies exist? Actually the whole US EMS system is purposefully designed with “go to the hospital” as the final pathway. There are some efforts to make an exception to this, but they are in relative infancy compared to other modern nations.

Speaking of which did you know that the requirements to be a paramedic in the US would not even qualify you to work on an ambulance in the entire rest of the civilized and most of the developing  world?

Not once did I criticize the desire of US EMS providers to help people. But that is different from ability to help people. It is very different from commitment to help people. Once again, I will point out there are individuals that may be committed, but the industry as a whole is actually committed to being as uncommitted as possible. After all, if you raise educational requirements, people will have to pay money to meet them. Volunteers might go away except for a few extremely dedicated people which already exist, and people may have to come to terms with the fact that maybe they, like me, were not helping people after all.

But instead of addressing these issues, the same arguments I have witnessed for decades play out the same way they always did. With responses that are so similar to those posted on the internet since it became publically available, (yea, I predate that too) that I actually think it is the same blowhards saying the same things everywhere with a predefined copy and paste hotkey.

Like the foot soldiers of yesterday, they plan to crush any opposition under their righteous force, with a mentality that reminds me of Alfred Lord Tennyson, “Ours not to reason why, ours but to do and die.”

Unfortunately, I have not seen a US EMS provider step up like the General who saved Krakow and in doing so declared it the seat of local power to preserve its beauty and cultural value. But you can clearly witness the comments of the foot soldiers of US EMS who would enthusiastically throw Chopin’s piano out of a window with their ignorance and zealotry. For this they want to be called and given the respect of professionals?

Here is one last fact of life, digging a ditch for 20 years doesn’t earn your right not to dig a ditch. Education is what gets you out of the ditch. Taking a stance against education because you are already good enough is so absurd it is laughable. As I pointed out with the flawed use of EBM, not being educated does not somehow make you capable to do what educated people do.

While I appreciate your passion on the matter, calling me an asshole, whether I am or not, doesn’t earn you any respect. It doesn’t make you more capable. It may make you feel like part of the tribe, which makes you feel like you belong to something. But look at it for what it really is Don Quixote, because that is exactly who you look like.

You may think pointing this out to you makes me an asshole, but I will leave you with this thought. I know and can manipulate your ignorance and passions with so little effort, that I could start a website playing to them, convince you to buy some worthless products, like a t-shirt, that praises your mentality, and use the proceeds to buy myself and family nice things.

The only reason I don’t is because I think somebody who would take advantage of you in such a way would be an arrogant asshole.

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Why US EMS will never get to sit at the adult table.

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Here is the bottom line, at the top of the page, they have too little education, do not understand science, and are too simple minded.

I was recently in a discussion with another doctor about using or adding anesthesiologists to emergency department resuscitation. It was an extremely good conversation, very civil, despite opposing ideas, and in the end, a very agreeable conclusion with each admitting that the other had some good points. But this was a conversation between physicians.

Enter in some cretin who is believed to be an EMT at some level. Yea I know that National Registry changed EMT-P to paramedic, but that is just lipstick on a pig. Paramedics are still trained like technicians. They still act like technicians, and worst of all, still think like technicians.

Right about now somebody chimes in with “our service…” and “not the people I know…” but I am just going to state the obvious for you. Your “service” is probably not as great as you think, because if it was, we would all know and have already have heard of it, because good services are so small in number anyone who has been around for 5 or more years knows them all.

The people you know are good… Ok, how many of them have even an associate’s education? The States that have made an associate’s degree the minimum as laudable, but they are few, if I count the 2 states I know of, 2 out of 50 is 4% of all states.

This is where somebody chimes in with a comment like “well we can give fentanyl and RSI. We have an advanced scope of practice.” Sad news friend, you have a medication you can administer and a technical procedure. That doesn’t make you advanced. Maybe you were even one of those services that “forced” your local hospital to institute the now questionable practice of hypothermia based on “science?” More sad news, you were duped.

The reason you do not succeed and are so easy to make a sucker out of is because you do not understand medical research. There is more to it than being able to read and convince yourself it is irrefutable data and no amount of opinion can dislodge it.

 You should do yourself a favor and go read some of the many websites on science based medicine compared to “evidence based medicine.” One of the things they all talk about it the serious (fatal) flaw in EBM. You see it most often in the form of a clinical study. “treatment X was tried N times on Population Z, and compared to Y. our conclusion is…” (let me fill in the blank) A. More study is needed. B. Our hypothesis is confirmed. This is where unsuspecting EMS providers seize this published document as evidence and the answer to all mysteries. But in this attempt to use the scientific method to answer all riddles, (The same exact behavior of religious people who spout their deity knows and controls all without fail.) simple minded EMS folk don’t want to believe that this evidence is actually pretty circumstantial. I have yet to see an EMS provider pick up a study they like and try to reproduce it. Well, you know, it takes time and money and effort, and…Education!

You see, EBM is a system. Like any system, there are those who have mastered the ability to use that system. It may seem innocuous. That everyone has the best intentions. But what intentions are those? Sell a product? Get your name on a published paper? Publish a paper in order to get/use grant money? Make a new breakthrough discovery and save the world? Change medical practice to what you believe is correct?

Permit me to pose another question? If it was possible to create and publish a study that showed what to do or what was best for patients in every conceivable situation, why would we need healthcare providers at all? It is 2014, kid sick? Just get out your smart phone and google up some answers! The evidence is clear and incontrovertible. You could solve your kid’s sickness yourself, effectively and accurately. Drug companies would love it, they could massively slash their R&D budgets because they would almost never make a mistake. A simple clinical study easily would demonstrate the value of their medicine. No doctors or pharmacists injecting their villainous “expert opinion” in on the true and benevolent god of EBM.

But here is the heresy called the truth. All medical publications are based on expert opinion. How they start is an expert gets an idea, we call it a hypothesis. Said expert got this idea because they need to publish/sell something, or because they believe in their position. So they decide to create a study. (For our purposes we will assume that this expert has every benevolent intention and is not corrupt in any way, intentional bias is very easy to insert into a “study” and also very easy, but time consuming to disprove and is a criminal act in many places.) So, our expert needs to do a few things. 1. They need to convince somebody to pay for this research. It takes peoples time, you use consumable resources, etc. So you have to present your idea in such a way it seems like it matters. (Even if it is ketchup flow rates) Having competed against others seeking these same resources and having won, you now get to decide how you are going to study this topic. 1st, it must be possible to study. Meaning the technology and materials need to exist. 2nd, you must be able to measure it, if you cannot you must devise a way (this is more expert opinion) to extrapolate such data from something you can measure. 3rd, and probably most important to the critical care environment, you must be able to do it within ethical and legal limitations.

That’s right, no double blind random placebo controlled studies on the validity of CPR. No prospective treatment studies on unconscious people who cannot be advised on and consent to the risks. No deviating from “the standards” or “commonly accepted” modalities of care. Sometimes you can get a waiver, but it is easier to walk on water and part seas. Those waivers are extraordinarily rare. Nazi Germany is the closest anyone has come to unbiased human experimentation. Have a look at some of those studies (and the pictures). EMS exists in this environment; direct correlation studies are simply inconsequential, ethically impossible, or expertly extrapolated. Sure you can do a retrospective chart review study. But in terms of accuracy, precision, and conclusions, they don’t really provide much. Since one of the limits of these studies is documentation, a lot is assumed, missing, inconsistent, or just outright made up. (In very “reasonable ways” like filling in blank spots in your spread sheet with average values from those you have or asking your stat software to do it for you.)

What all that means is that your all knowing all powerful Evidence Based study isn’t really all knowing or all powerful. That big giant hole is filled in by, wait for it… Expert opinion.

This is where I will talk about another major issue with EBM in general. The peer review and consensus. In my )expert)opinion peer review is absolutely a must for any study. It needs to start during the study, to look for unintentional bias and perhaps keep excitement under control and force you to constantly re-verify your findings. But when submitting for publication, your experiment is not repeated, some “experts” look over the work, make sure there are no glaring errors, and often ask you to answer a question, soften the language of your conclusions, or add or delete something they believe is important. Once you do this, you are published.

The system of EBM is easily corrupted by the exact same trick creationists use to insert the idea of intelligent design as scientifically credible for more “reasonable” purposes. Teach the controversy! You see, if I do not like something you have to say, I can immediately give credibility to my position, by demanding evidence from you. In many cases the evidence does not exist, and as we have seen here, because of things like ethics and the publication requirements, may never exist. Simply, if you cannot produce a published study, you must be wrong or your position has no credibility. On one of the SBM websites, this was very well illustrated by an example the author (I forget who, but it was all his/her idea) parodied called “stick in the eye to cure blindness treatment.” Many years ago, the (correction)BMJ published a similar example claiming “There is no randomly controlled, double blinded, evidence that parachutes work.” It is all simply expert opinion. If you track it down, it is quite funny to read.

Science based medicine in a nutshell. The long and short of it is, in order for a study to have credibility, in order to nullify the giant flaw in the EBM system, the basic science, biology, chemistry, physics, etc. must be viable. If these basic elements are unaccounted for or a study does not account for them, then that study is suspect.

I’ll tell you, as a researcher, this prospect is painful. You have to track down and read all kinds of publications totally unrelated to your specialty or research. A personal example is when I had to prove a molecule could physically fit through the space between glomerular cells. Eventually, I was able to establish this basic fact with credible research, but it took time and was definitely not fun.

Ask a homeopath to do something like that with eye of toad or whatever they are selling today. Does the molecule actually fit where it supposedly works? Do the chemical properties of the atoms permit bonding to their target? This is the basic science that proves the value of an evidence based study. It is why clinical studies without it are garbage, even if they enroll ½ the population of the entire earth and come out with numbers needed to treat and harm. It has to be accounted for at every level of measurement too. Not just atomically, or molecular receptor cite, as well as other basics like transport, volume of distribution, etc.

Most EMS providers simply don’t have the education, time, or resources to check that sort of stuff. They read a study, and assume this evidence has been met. Here is a hint, after I take the time and effort to research all that stuff, I write about it and cite it in the publication as evidence, so if you are not reading about it in the publication in front of you, it is because it has not been done.

EMS providers, especially ones who call themselves “advocates of evidence based medicine” really latch onto clinical studies. They are on every website demanding you cite proof that parachutes work in order to give credibility to their pathetic positions for stick in the eye treatment. They believe so desperately and completely in the all-knowing, all powerful deity of the published study, that they label anyone who does not share their acceptance of the one true faith as uninformed, unscientific, biased, and simply an unsubstantiated opinion. Yet they haven’t the education, resources, or experience, in research perhaps other than retrospective studies or reviews of research. (Among the lowest levels of publication, just above case report) They create websites and blogs (which are not peer reviewed) to pontificate their opinions citing this incomplete “research” and the masses of EMS buy into this dogma and call it “evidence” as clear to see, read, and accept as fact as the King James Bible or the Quran.

No critical care provider will ever be able in the Western and even Modern World to ethically and legally conduct definitive studies to treatments or diagnostics. All of that information is “expertly extrapolated.” EMS providers are simply not expert enough to do it. So you will repeat the cycle of backboards, fluid boluses, etc. with treatments and procedures that will one day ultimately be disproven because our knowledge of basic and clinical science changes with time. The “expert opinions” that brought you those treatments actually used EMB and studies to come up with them. They were not sitting around drawing on bar napkins when they decided a fractured spine should be stabilized. They had actual patients and created studies. Based on this “evidence” they instituted what they could demonstrate was best, based on what they knew. Today’s EMS providers vilify these people as just making shit up. (Expert opinion) Some of these people are still alive today. You can talk to them. Meet them. Ask them what evidence they used. They will tell you and show you. They are not meat headed villains. They spent their lives caring for people, not selling snake oil. 10 or 20 years from now, the evidence we create will be written off as expert opinion, unless we check our basic science credibility and publish studies based on it rather than random clinical trials. The dogma you buy into today based on “evidence” will one day be vilified and ridiculed as expert opinion. You can “teach the controversy” and demand evidence all you like. But you will never have the true answers.

Because of all of this, US EMS providers, and in fact many providers at all levels around the world, will never be more than sheep, singing the choruses created by the experts with more knowledge, while indisputably believing in their evidence, and labeling as a heretic anyone who cannot prove another god exists.

It is sort of ironic they use the same methods to attempt to discredit others that homeopaths and creationists use to discredit them. “Where is your evidence God did not create the earth in 6 days? You cannot cite one study as proof!”

EMS providers really sound that stupid when they do it too.            

“Surgeons are not technicians. Surgeons are doctors who also know how to operate.”

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Wise words from a world respected cardiac surgeon and intensivist. At least I like them.

Today I witnessed practitioners (they certainly didn’t earn the title doctor today) acting in a manner (I would not call it practicing medicine or helping people) that made me physically ill. It was worse than homeopathy, worse than witchcraft. It was blatant and unabashed nonfeasance.  Forget sued. People should be in jail.

I am currently delegated to “The Emergency Department.” I realize not everyone has my history or insight, but what I witnessed today made me physically ill and I powerlessly watched.

Here is what I saw.

Medics (aka non surgeon doctors) who would not perform simple manual skills on patients because they were considered “surgical skills” and deferred to consulting a surgeon. These included suture removal and incision and drainage of a grossly purulent abscess. When I offered to do it for them, I was told by my supervisor I am not a fully qualified specialist surgeon and therefore I cannot.

Surgery came down and declared this patient had too many medical issues to admit to surgery and therefore he would not provide further care to the patient. To say the treatment plan was conservative would be a gross understatement. It was outright neglectful.

When I raised my concerns I was then fed a line on how doctors are afraid of being sued and lack expertise in a range of common medical procedures and in the interest of the patient perform the absolute least amount of treatment and escalate accordingly. (In other words, not do shit, because I have no other conclusion that they really have no idea or experience what they are doing.)

So now that my rant is over, I am here to pontificate on the absolute asinine idea that non-surgeons cannot do manual procedures and surgeons cannot take on patients with medical complications.

In modern medicine, there cannot be a line between surgery and medicine. All of these people go to medical school. All of these people need to be signed off in medical on being capable to perform certain procedures. I know, because I went to the same school and was signed off.

Interventional radiology, Interventional cardiology, Neurology, these are all medical disciplines with surgical procedures. Anesthesiology and Intensive medicine have surgical skills. Even Internal medicine has surgical skills.

Conversely, surgeons qualify people for surgery. Surgeons write post operation orders. Both of these actions require medical knowledge. No small amount of it at that. If it didn’t they would still be barbers.

What is driving this idea a person can do one and not the other? The answer to that is simple.

Laziness. It is much easier to go to work every day and do a handful of things than it is to maintain knowledge and proficiency over many things. It is much easier to decide that particular thing you don’t want to do is not your job.

But patients don’t see it that way. Doctors who actually care about people don’t see it that way. People with even a modicum of integrity don’t see it that way. The job description of medicine and by extension all of healthcare is to help. (full stop)

Making excuses to do nothing is not helping anyone but yourself.

If I had a dollar for every time I heard a premed or medical student say they want to be a doctor to help people, I could work for free because I would be independently wealthy enough to do it.

Perhaps it is time to qualify that with some truth.

“I only want to help people if it is convenient, doesn’t require responsibility, takes very little effort, and pays well for doing absolutely the minimum possible.” That is what modern medicine really is. It doesn’t matter if you are in Poland or the USA. Just ask a dermatologist. It is all about minimal effort.

There are a handful of people I have met who are not like this. But are by far a very small minority.

When did this idea of doing nothing start? Where? How did it catch on?

Whether it is convenient or not, the foreseeable future of medicine is a combination of medical knowledge and surgical skill. More so everyday. To their extreme credit, specialized emergency doctors I know get this. They take it as a challenge to be met.

I must recognize and admit, my thoughts that EM should not be a specialty was biased because of the ability of a small number of outstanding non-EM providers I saw doing an admirable job in the ED and on ambulances.

For the rest of the quacks who make their patients suffer for their convenience, please do everyone a favor and go find some job with no responsibility or effort like working the grill at McDonalds.

If any lawyers need an expert witness to sue one of these charlatans, I am available for only the cost of transporting me to your court. (sorry, I am not wealthy enough to take a loss)

Touch your fucking patients. Help your Fucking patients. Earn the title and respect of being called “doctor.” At the very least, earn your pay cheque!

Your job is to help. Not talk about what you don’t or can’t do.

I am supervised by people who can’t do shit! Otherwise I am supervised by people who won’t do shit. I hold out hope for the former.

If you don’t know how. Ask, and I will teach you myself.

“Resuscitationist”?

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I saw this word on a Facebook page I was invited to this week. The idea is that it is an expert on resuscitation. (I did not come up with the term, I do not know who did.I would give them their due credit)

But what is an “expert at resuscitation?”

Early in my career I was taught “steps of resuscitation.” A list of things to do, in a particular order, that would permit you to drive a “live” patient to the hospital for another “initial step” which would be continued in the ICU, where “actual” resuscitation would take place.

                This was further taught and enforced when I was in paramedic school and early in my paramedic career, that “initial resuscitation,” was the defining skill set of a good or bad paramedic. Furthermore, it was emphasized we were doing everything that would be done in the Emergency Department. But we never directly admitted patients to the ICU, we always stopped in the ED.

                Survival rates were dismal.

                Recently there has been considerable press and focus on “pit crew” CPR, “quality” CPR, etc. Survival rates have gone up. Experienced experts and resuscitation scientists have been discovering and practicing resuscitation without “advanced procedures” which are recommended and advocated by guidelines from the AHA, ERC, ILCOR, and a few smaller ones.

                However, all providers are expected to know these guidelines, and people who do not spend their nights and weekends focusing on resuscitation science are still performing based on these guidelines. My colleagues and peers involved in resuscitation all sit around saying things like “no way would I follow that guideline because…”

                When I started pursuing my PhD, in my search for a mentor I was directed to a much respected clinician and scientist at my university. Because of my history and the fact I was not a physician specialist, it was suggested it would be more credible for me to do an academic PhD program in pathophysiology. Thus I started pursuing that route. When I got to the clinical research component, which was really basic science research in the clinical setting, it was discovered despite not being a physician, I really did have a lot of experience and knowledge and was very much an expert at resuscitation. So after just over a year of work, I went through a process to get permission to change to a clinical medicine PhD in intensive care. (It was not an easy process, but it worked out well for me) I was formally handed over to another mentor/promoter who is a neonatologist.

                Having taken and taught some Neonatal Resuscitation Provider courses as an “expert in resuscitation”, not particularly neonatal resuscitation, prior to medical school, I was fairly confident I had the topic in hand. I was very much mistaken. I read and learned things I had not even considered as part of resuscitation. Physiology, pathophysiology, homeostasis connections, basic science, I was initially overwhelmed and well and truly schooled.

                But when this influx of knowledge started to settle, I noticed some things that have made a considerable impact on my world of resuscitation. Not least of which is that neonatology is a fairly new specialty. Most practitioners admit not a lot of scientific knowledge exists for it, and as such, you can research things that would be absolutely forbidden to try in pediatric or adult resuscitation.

                When we are in basic biology in university, or even high school, we learn of life cycles. If you are reading this, you know the drill, larva stage, pupa stage, adult stage… Humans have a life cycle just like that! We give it different names, neonate, infant, toddler, adolescent, adult, but in one of nature’s conserved and enduring patterns, we are no different from other species. In anthropology, I was taught that there are certain characteristics unique to human birth and development because we evolved into a bipedal species, and certainly that information is relevant to both pediatric and neonatal resuscitation. (More to neonates actually)

                    But how this all ties together is: any research and consequent medical advances in resuscitation and breakthroughs can be expected  to come from neonatology. In fact, some advances currently introduced in both peds and adult resuscitation was transferred from neonatology. Limited use of oxygen therapy, the harm it causes, the mechanisms of those causes, and some potential treatments, mixed gas ventilation, and alveolar recruitment, were all neonatal discoveries.

                In any neonatology resuscitation class you take or book you read, you will see that medications are the last ditch effort at the smallest point of “the neonatal resuscitation triangle.” They have all but disappeared, being used only in very specific identified pathologies. Even predetermining futile resuscitation comes from neonatology. This too applies to peds. But not adults? I call malarkey!

                The inflammatory process, the focus of much research into shock and resuscitation, is being studied in neonates because of ethical restrictions in other populations.

                What have I learned? Too much to form a comprehensive list here. But advanced fluid balance, temperature regulation, subclinical detection of diseases, are a few that really stand out as being immediately applicable to other populations. Neonatology was also kind enough to confirm my hypothesis that in addition to the central circulatory organs of the brain, heart, and kidneys, other organ support such as the liver and gut are absolutely critical to resuscitation outcomes. Furthermore it has confirmed my other hypothesis that surgery and medicine must be combined, not separated by different specialties in resuscitation and severe disease processes. Moreover, I have confirmed there is no such thing as “initial resuscitation.” That is an idea for the convenience of providers, not best practice for patients. Any true hope of resuscitation will come from a continuum of resuscitative efforts, not independent skill sets. The ambulance and ED can no longer “do what they want” as biasedly confirmed by the clinical research which simply proves current practices should be paid for.

The only “initial resuscitation” is making sure there is an airway and CPR if needed and potentially beneficial. “The chain of survival” needs to be reworded from “early advanced care” to “early expert care.” Advanced or invasive skills are not enough. To adopt the term, resuscitationist.” Which is certainly a subset of intensive care, not emergency care based on the knowledge and principles.

                I think it is also time to start advocating more of a lifeline approach to resuscitation in the interim. Rather than answer questions on your own, perhaps phone an expert? Maybe even phone a friend? The ultimate goal would be to bring “initial resuscitation” providers up to the more advanced level with additional education and skills.(more on that later) Not just for cardiac arrest, but for all types of resuscitation. Also as I mentioned in another post, we must realign modern medical specialties to modern knowledge of disease and treatment. Antiquated specialty groups/training is not going to permit another recent buzzword I have learned, “science based medicine.”

 It might be time to write that book. The lecture circuit doesn’t seem to be working for me.

Playing to your audience, the performing art of education.

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I am supposed to be doing scientific work right now, but I am not. Sometimes I think I spend too much time with science and not enough time taking care of people. Part of that is because I am “the new guy” as far as the medical field is concerned. (Medicine just cannot get used to the idea of people doing other things, especially patient care related before you become a doctor) Consequently, I am never put to use in my full potential at work. It frustrates me to no end. Especially when I can predict mistakes that will be made and powerlessly watch them happen.

So how does this fit into education? Well that is actually rather simple. One of my more recent assignments at work was teaching English speaking students. Which works out well for me, because while I do understand Polish, it is a difficult language (so say the experts), and most often I sound like a window licking retard (I am sure somebody is taking up a collection to buy me a helmet). I am also allowed to call myself retarded and make fun of it. So no comments about how insensitive the Latin (and Italian) word for slow is. But when it comes to English and teaching, well… There is no stopping me.

I find it interesting that people who work at an academic medical center have difficulty teaching. It is not like they never do it. In fact, it would be more unusual on any given day not to have students. I have no idea why people who do not like to teach ever apply at these centers, but they seem to in abundance.

One of the things I often hear from my coworkers is that they are not teachers. There is no class on how to teach in medical school, there is no lecturing on teaching techniques or learning styles, but every doctor is a teacher. Just as every nurse is a teacher, and yes, even every paramedic is a teacher. After all, if you cannot teach, how do you get patients to follow advice and prescriptions? How do they learn how and when to properly take medication and use the medical devices given to them? How do you get them to “buy in” to their treatment plans? Whether you like it or not, you are a teacher. The only real question is “Are you a good witch or a bad witch?” I mean… “Are you a good teacher or a bad one?” What’s more, any “senior” provider, whether by years of service, title, or educational degree has a responsibility to teach their more junior colleagues, whether you are in an academic facility or not.

Apparently people like when I teach. (I admit to being a reluctant teacher, I started because of a challenge, not a desire) Sure there is the odd student, who simply doesn’t like me, and nothing I can do will ever change their mind, but for the most part, my reviews, whether from students in Poland, Ukraine, Romania, The USA, or Afghanistan, are very positive. But I am not here to boast, I am thinking about what makes an effective teacher.

Meyers-Briggs consistently labels me as an ENFJ, more commonly called “a teacher” but I prefer the less often descriptor of “champion.” While I am not entirely sold on the value of psychology, the description is uncannily accurate. But if you ask me what makes me an effective teacher, my answer is not some psychological predisposition, it is actually just remembering all the bad teachers I have had and not doing what they did. As I often do, I take things to the extreme and purposefully do the opposite of what they did. You will never see me talk for more than 45 minutes in an hour. I don’t read PowerPoints with “walls” of text. I like to show students I remember and identify what it was like to be a student. I like to incite their emotions because it is commonly known in educational circles that when people connect something with an emotion they better understand and remember it. The same fucking thing happens when you use swear words. I’ll bet of everything I wrote so far, your foremost thought right now is that I just dropped the F-bomb. Perhaps there is something to psychology. (When I used to read Firehouse magazine, in their classified section they always had an advert that was printed with red letters on a yellow background that said “I bet you read this first.” Despite trying for years, I could never not read it first.)

Back on point: I like to enable students. I like to have them feel like they are successful. Because like attracts like. I once saw a T-shirt that said “I am a bomb disposal technician, if you see me running, try to keep up.” But early in my fire service career, I was told by a great firefighter whom I looked at as perhaps one of my greatest mentors, “Never run on a scene. Calm inspires calm, panic inspires panic. If you want to bring order to the chaos, you must be the embodiment of order and control. Even if you do not know what to do next, you must always appear to without doubt.” I think the same applies to  teaching. If you show students (or patients) they can be successful, that they can do it, they usually go on to be even better than taking the industrial age approach of trying to motivate them by negative reinforcement. In fact, I noticed that that negative reinforcement mimics the exact same type of behavior as abusive spouses and parents. Nothing good can ever come from abuse. If it could, it would not be called abuse! So how does any teacher expect a positive outcome from abusing students? The only thing they learn is what to do to please the teacher. Things like abstract thinking and concept integration are totally lost. They don’t remember, I doubt they ever learn, what was taught. They learn and remember what it took to make the teacher happy.

You see the same thing in raising kids. Behavior that you want repeated needs to be recognized and rewarded immediately. Human kids are primates. Human adults are primates. One of the things I learned in anthropology is that all primates whether human, high order, or low order, all respond to the same stimuli in the exact same way. Speaking of anthropology, incidentally there is a lot of modern focus on role-playing and simulation in medical education and “play behavior” is the most effective educational behavior in all primate and many mammal populations. It would seem absolutely insane not to use the most effective method of teaching primates as often as possible.

If you are reading this, if you have not taught a class, you definitely experienced one where somebody talks at you for hours. I had a physiology and neuroscience professor in medical school who could lecture for 4 hours without taking a breath, much less a break. After about 20 minutes, I don’t remember anything that was said. (The more complicated and unfamiliar a topic, the more breaks you need to take.) Since she would call on students not paying attention to her often with impossible questions not even related to the topic, I perfected the ability to sleep with my eyes open resting my head on my arm in a way that made it look like I was hanging on every word. (But I was in a much nicer world than neuroscience.) So I like to engage people right from the start and I spare nobody. At some point everyone will be asked what they think, or to try to logically figure out the next step that I haven’t talked about yet.

One of the things I found enjoyable in my younger years was classical performing arts. (Band, acapella choir, classical dance, I have spent years doing them all) I still love them, but now I am a spectator, not a performer, except when I am teaching. Don’t judge, it is a captive, paying audience! I mention this because I meet a lot of doctors and teachers who are very introverted. Sometimes they just claim they don’t like public speaking. (I failed public speaking in high-school by the way, it wasn’t that I didn’t like it, I just like to pick what I am speaking about and generally prefer an audience that isn’t full of outright hostile bullies with a teacher hoping I will confess my deepest darkest secrets as a way to “get over the stage fright.” Again, bad teachers can teach you a lot about teaching too.)But medicine is just not a good fit for introverts, which is what most scientists are. It is a people person job. We take care of people! We do not practice medicine on textbooks, in secret dark back alley shops hoping nobody will see us. We aren’t judged by how well we cite statistics and guidelines. We are not sued because the patient was happy and thought we were their trusted friend. There is a lot to be learned from “showbiz” in teaching though. For example, a classically trained artist can perform in any environment, but you have to be very well established to improvise. Orators practice their speeches prior to giving them. We call this rehearsing. Even priests rehearse! Why do many teachers not rehearse? Are they all at the level of mastery of improvisation? I think not. Don’t forget some of us are though; I am quite capable to give a lecture or speech with less than 10 minutes’ notice and have a great many times. But for the most part, I rehearse. It really does help.

Also like show business, you need a good costume. Not only what you wear, but also the way you act and your body language. Just like the calm of being on scene, you must perform in a way that inspires students. Especially if you don’t like the topic you are teaching or the patient you are interacting with.

All of this is a lot of work. Most teachers know for every hour you spend in class, you spend several hours preparing and several hours after with other related activities. If they don’t know, they are about to find out.

My final thought for now is on the philosophy of the teacher. Also being involved in Japanese martial arts from time to time, I have learned and adopted the “sempai/kohei” philosophy, the experienced person who guides the less experienced person. Not the authoritarian tyrant that dictates to the unworthy student. (What the Russians call villnious nastavnik, the villainous schoolmaster, forgive my poor translation of the spelling. Go ahead and cue music Pink Floyd’s Another Brick in the Wall.)

So this is my thoughts today on teaching, while procrastinating from work I really need to get done today. OCD is not my mental disease. It’s not ADD either, I am just bored it seems like I just did the same thing last week. (Mostly because I did.)

Bottom line. If you work in medicine or healthcare, whether you like it or not, you are a teacher. You might not want to be one, you may not like doing it, but it doesn’t change the fact. You don’t have to want to be a great award winning teacher; just don’t do to your pupils what bad teachers did to you. Put on a show worth the price of admission, play to your audience. If your students are not paying attention or engaged and your patients don’t follow your advice, it is because your performance sucks.

Does medical specialization need to be revamped or abolished?

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There are all sorts of problems with primary care. General surgery is really just a training program, not a specialty. Truth be told, I am not even sure what the point of emergency medicine even is anymore.

So these last couple of days I have been off trying to survive an ulcer and find a primary care doc who actually understands more about medicine than simply handing out OTC meds regardless of history and despite my excessive distress prescribing pills for menstrual cramps for pain control. Basically these doctors are absolutely worthless. They follow guidelines like some bum on the street with no medical knowledge or patient care experience.

But in my anger and frustration, I remembered that is what primary care actually is! Antibiotics and referrals. None of them do anything except follow the least aggressive guidelines. It is what they are trained to do in residency. I would cut them some slack, but it is no wonder they get sued all the time. They deserve it.

Now that I have vented my anger with a harsh truth about primary care, I would like to explore the problem of “modern” medical specialties further.

One of the people I correspond with on an email list is a professor of cardiac surgery who also has his own cardiac intensive care unit. He likes to say “surgeons are not technicians, they are doctors who also know how to operate.” I like that, because I hope to “specialize” (if you can call it that) in surgery and intensive medicine. But taking a look at surgery as a profession, the first 2+ years of residency is basically like being a medical student. You do nothing, you learn nothing, it is completely a waste of time. If you eliminated it, you would actually start “learning surgery” about the 3rd year. Some have said there is education in watching, but from experience I can tell you, you can watch until you fall asleep at the table holding retractors (I did) or until your eyes bleed, but once you put a tool in your hand, everything you “knew” goes right out the window and you look like you never seen or heard of what happens in surgery before. (Even if you practiced the basics on everything from banana peels to cups, did that too.) When it is all over, you are a general surgeon. Aka, now you can actually do a specialty, because unless you work in an austere environment, there is no point on earth for a general surgeon.

What about primary care? It doesn’t really matter what country you are in, and I have been to a few, they do lots of the nothing I already described, if you have timely access or even access to them at all. In some countries like the USA, it has been made obvious that this is not a job that even requires a doctor. There are studies showing nurse practitioners and physician assistants do an equally effective job.  What then is the point of having a doctor? Just like general surgery, there is no point at all. You could eliminate GP from all of medicine and replace them with less educated people, who cost less money, who get the same results.

 Most of emergency medicine is not really an emergency. But it is not primary care either. The big problem with that is that it is ineffective at primary care, which as discussed, doesn’t require a doctor at all. So basically the whole emergency specialty and system revolves around not doing as effective a job as a “specialist” at anything they do. Sure they can reduce a fracture and put on a plaster splint like ortho, but they don’t follow up at all, despite many people using the emergency system for primary care. They might be expected to handle a “true emergency” except than the “initial resuscitation” techniques might make the patient totally unviable in the ICU. Having an MI, they will call somebody to help you. So basically they just do part of the job of primary care, which as we know, can be totally replaced with non-physicians.

I could go on and on. Trauma surgery? Yea, except more traumas can be treated non-operatively in 2014 than is actually operated on in the civilized world. Even those requiring operative therapy, might be better served by a vascular surgeon or interventional radiologist. Not to mention the fact that unlike military and 3rd world surgeons who practice “damage control surgery” on a regular basis, my general observation of surgeons who do not “specialize” in trauma, attempt to definitively repair people in one operation, and if they don’t survive, well… “It’s trauma and you can’t save everyone.”

Even intensive medicine doesn’t make a good specialty without another specialty first. For example, in neonatology and pediatrics, the knowledge of those disciplines actually determines which intensive therapies will be effective and when. An intensivist who is simply following a guideline or script for things like ventilation, nutrition, water balance, etc, isn’t going to have much success, at least not nearly the success of a specifically specialized pediatrician. My experience with internists trying to do intensive care just makes my head spin while I close my eyes and pretend to see, hear, and speak no evil. Ineffective treatments, under medication for pain, even in palliative care, I could go on for hours, I will sum up. They suck at it.

So we are left with only one logical conclusion. Modern medical specialties do not benefit patients. They benefit providers. They limit the knowledge required down to a mere fraction of medical knowledge. Great if you weren’t actually a complex organism with symbiotic organisms, but a single cell or organ with one or two pathological processes that have no effect on anything else.

Of course as a “specialist” you can charge more. But even with your “extreme” knowledge of a few things, you might be tempted to just mindlessly follow whatever scale or guidelines your fellow “specialists” (read narcissists) have agreed upon as being able to live with, not necessarily best. What’s more, most specialists do not actually talk with other specialists nor share research. They claim that magically what one specialty discovers has no bearing on their specialty because “it is not the same” or “they don’t understand what we do” or “we have a different environment.”

So what does that leave us with? Simple, medical practice that doesn’t benefit patients or keep up with modern medical treatments. Medicine that is confusing or inaccessible/navigatable by patients. No wonder homeopathy is making a comeback. No wonder physicians are not the most trusted profession anymore. No wonder they don’t vaccinate their kids because they doubt our “expert” knowledge.

Modern medicine is broken. The systems do not work well. The economics are totally off. The treatment plans aren’t effective. What are medics trying to do to fix all of it? Double down on what already isn’t working. It is a mess.

Solutions? No acceptable ones. Perhaps start by getting rid of residencies all together. All they seem to do is supply cheap labor to hospitals while reinforcing old treatments and stifling medical advancement and free thinking. At the very least it might be time to reduce the amount of residency time to the actual 1 – 2 years where something is actually learned. Realistically, if you can’t learn surgery in a couple of years, then nobody is, because like I said, the first 2 years are a waste of time easily replicated by a few hours a day on YouTube.

Perhaps we need to worry more about being doctors with a broad and in depth knowledge?

Perhaps we need to stop subdividing medicine into a few repetitive psychomotor tasks?

Lots of “maybes”, little chance for change, one ultimate fact; Medicine doesn’t work for people anymore.

And take special note. A majority of flaws I pointed out are in disciplines that are very dear to me. We must first admit there is a problem if we ever want to fix it.

Have you ever seen a CHF patient who is fluid overloaded and in shock?

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I have recently.

When I started writing this blog I thought I would stick with the philosophical aspects of medicine, but sometimes I feel compelled to speak out about poor medical care. I am especially apt to speak out when I kindly offer my observations and suggestions only to be called “stupid” by people who have mastered medical guidelines instead of medicine, and haven’t updated their practice since before I was born.

                So here is how it goes, patient is admitted to a monitored bed with CHF exacerbation. You don’t have to look too hard to see the edema nor do you need a stethoscope to hear his lung sounds. It seems rather simple, decide this patient has a fluid overload problem and begin treatment.

                We assume with treatment that works…But some have decided that furosemide is still in vogue because some guideline somewhere still lists it.

                For those of you who have been hanging out in Emergency Medicine of some form, you know this practice for acute exacerbation has been out of favor for the better part of a decade. This illustrates the critical problem of “specialists” not knowing why they are doing something AND not talking to other specialists.

                In medical science there is a secret code. The word “novel,” which is the code for “I actually understand pathophysiology and came up with a treatment based off of it instead of the expert opinion that no amount of scientific evidence will ever convince you to change your practice.”

                Now there are several “novel” ways of treating CHF patients. One of them involves renal replacement therapy, continuous or for a short period. Yet another that I recently explored is the use of hypertonic saline.

                This is where McMedicine falls apart. For the longest time it was believed restricting sodium intake was critical to success of managing a range of cardiovascular issues. A quick Pubmed search will reveal that most of the evidence produced after 1980 shows it doesn’t really make a difference. Further research might also lead you to the problems of hyponatremia in a majority of hospitalized patients and all the consequences arising from that. But if you are still practicing bloodletting and cautery, the idea of adding salt to this wound seems like madness or as I was accused of “stupidity.”

                But let me tell you something about the theory that has produced that. The story starts off with an extremely boring meeting, one where my mind was wandering through the various pathological mechanisms of the patients I was helping to care for. A few were CHF patients who were being diuresed with furosemide per the guidelines.

                A thought that struck me was that in the emergent setting, furosemide was removed from the guidelines because the problem with CHF isn’t actually water overload, it is water distribution.

                Under the concept of increased afterload, in CHF, blood “pools” in the vascular system. But there is also the consideration of inflammatory and kinin changes evoked by local ischemia, rendering the capillary beds permeable. You can find the exact same type of permeability in sepsis and anaphylaxis. The long and short of it is that the Starling’s forces cause a net movement of water out of the intravascular space and into the interstitial compartment.

                In a brief review of Starling’s forces, there is osmotic pressure and hydrostatic pressure. In the CHF patient there is an increase in hydrostatic pressure out of the vessels at the capillary. By adding furosemide, you eliminate electrolytes in the loop of Henle, and water follows. However, these electrolytes, particularly sodium, also normally increase intravascular osmotic pressure in the later part of the capillary and venous system. So when you reduce them, you would have less movement of water from the extravascular space into the vascular compartment. (General Chemistry 101, you don’t even need medical school) The net result is a decrease in fluid shift from the extravascular space into the vascular system. With so little fluid shift, the only logical explanation is water goes nowhere.

                So I started to ponder how to move water from the extravascular compartment to the intravascular compartment, and because many of these patients have diabetes, I instantly ruled out dextrose, glucose, and mannitol, as they are all sugars, even though mannitol is not absorbed. But I also hypothesized since it isn’t so great for cerebral edema, a systemic effect would not be likely anyway.

                The only logical conclusion I was left with was a hypertonic saline. I must qualify I was working on the assumption of 3% NACL. But after I proposed this and was very publically and ceremoniously degraded, I did the only thing a scientist can do… I looked it up on Pubmed expecting to find studies on why it didn’t work in order to postulate a new hypothesis for treatment.

                What I found was quite the opposite. Not only does it work, it works very well in all of the studies I found, including a handful of respected reviews. Not only does it work in CHF, but in a number of fluid balance pathologies, including shock states. I even learned the technique on how to do it. My hypothesis on 3% saline was grossly underpowered. But I would like to qualify I was thinking on using it as a more prolonged treatment than acute treatment.

                The technique is thus, using a bolus of 10-12% NACL, 40mg of furosemide is added to prevent renal reuptake of the sodium, ensuring sodium’s unopposed action as an osmotic diuretic. This salt bolus ensures increased intravascular osmotic pressure, pulling water into the vascular system. The furosemide prevents reabsorption, but the low dose ensures there is not a complete absence of reabsorption, furosemide does not inhibit sodium uptake in the proximal tubule. This has the side effect of insuring there is not “salt wasting” and consequent hyponatremia, which is an independent predictor of all-cause morbidity and mortality.

                It was a few days later when the particular patient that inspired this post was admitted and his McMedicine treatment started. While I was explaining the case to students, while going over obvious clinical findings, I pointed out, he had obvious gross dependent edema, difficulty breathing, low urine output which was dark yellow from his catheter, on the monitor his BP was 88/60, with a heart rate of 136. I didn’t have the benefit of a lactate measurement at the time, but clinically, he was full of water and in shock. I SWAGed what the American college of surgeons would describe as class I. (<15% total volume loss, and would be responsive to fluid therapy) He was not hemorrhaging, so clearly this was a “distributed shock.” I later did find lab values in his chart of increased lactate, decreased PH, and base deficit.

                Following the McMedicine guideline, this patient was medicated to a shock state! Some clinicians may dismiss this as early shock and not extremely significant, but I would like to point something out. (I know a considerable bit about shock, I spent years researching and writing my PhD on it) Cited in several texts, shock is the final common pathway before death. All diseases decompensate to shock. It affects every organ and system in the body, from the biochemical level to gross clinical level. It potentiates inflammatory response. While there are some demonstrated benefits to leaving patients in low levels of shock, I cannot think of any benefit of actually purposefully causing it. Even when managing traumatic brain injury or stroke, the purpose of therapy is to normalize pressure, not to reduce it to the point of negative fluid balance and impaired oxygen delivery! Inducing shock is not even done in diabetes insipidus.

                One of my university General Chemistry professors back in the States, Dr. Shupe, professed every class, it doesn’t matter how many PhDs come up with the most convoluted equations to explain the value of a chemical formula, if it doesn’t meet the basic fundamentals of the most basic scientific knowledge, the concept will always result in failure. In medicine and education it is often professed that if you do not understand the basic concepts, you can never work with advanced ones. But yet 90% of all clinical studies and clinical guidelines do not meet this basic burden! It is why I believe clinical studies, without basic laboratory studies that demonstrate that it does meet the basic science test are at best useless and at worst, harmful. Yet there is no shortage of medical doctors putting out hundreds of these studies a year. It is simply bad science and bad medicine.

                They defend this crap by calling the people who understand it “stupid.” These same people call the studies of other researches, particularly nurses, garbage because the experiments are inherently biased to prove what you are currently doing works. But what they are doing is absolutely no different!

                “Consensus” guidelines… Utterly useless… Consensus doesn’t make anyone right, it just makes them part of a herd.  Is a herd of medical providers hurting people right? You will have to decide that for yourself.

                In the meanwhile, I am going to continue to be stupid.