Within normal limits

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The more I am involved in the study of various biomarkers, the more convinced I become that they are not ever going to achieve what is hoped for them.

Some medical providers look at various biomarkers like blood pressure, lab values, and the like and determine the patient is sick or not based solely on whether or not the number is above or below “normal ranges.” Many very astute medical providers interpret how these numbers reflect what is going on in the body.

But I have been observing a phenomenon that medical scientists don’t really like to talk about; that their “novel” or “new” biomarker studies may very likely have an inherent bias. You see, when you study biomarkers in a population, you spend a lot of time observing those patients. You also get exposed to their cohort more. As any capable scientist will tell you, larger populations leads to more significant conclusions. As any clinician will tell you, there is no substitute for experience and number of patient contacts.

But this bias may have a positive effect on biomarkers for the purpose of patient care. Some of the researchers I have interacted with have studied their respective biomarker for years, sometimes decades. Anytime they publish a study on their effectiveness the results are usually positive for the marker. They often highly select patient populations to prove their point. Detractors often select the worst possible cohorts to raise questions of effectiveness.

But both of these parties seem to develop an exceptionally accurate intuition in identifying and treating their respective patients.

What is basically demonstrated is it is not the biomarker that is effective, it is the act of studying the biomarker that makes the clinical scientist a more effective clinician. In layman’s terms, it is the journey not the destination that is really important.

I was wondering if clinical trials share a similar bias.

If this is actually the case, neither diagnostics nor treatments will be better for “non-experts,” which is actually the point of trying to verify their usefulness.

Oh well, at least we can still use the studies to convince others to pay for various tests and treatments.

More on EMS and adult tables

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The other day I ran across an article that I not only had to share, but found it amazingly insightful. So much so I think it should be mandatory reading for every EMT and Paramedic student in the world.

Here is a link if you are wondering: http://thefederalist.com/2014/01/17/the-death-of-expertise/#.U3tejC7AdEo.facebook

A few weeks ago I posted an insight that some mistook as a rant on a self-purported EMT demanding I cite a study that anesthesiologists are better at resuscitation than EMTs. Anyone reading the comments can see that US EMS providers have certainly overstepped their expertise. I had to edit out some comments of people intentionally trying to impersonate others, especially me.

In the weeks since then while perhaps not what I think is my best post, it is certainly the most viewed. Normally about 25-30 people read my posts. But that one is seen by at least 5 people a day, and even hit the 5000 views mark.

This post isn’t meant to boast, in fact, there are other posts I would much rather people read, but I think it illustrates the point of the link I referenced perfectly.

You see, for many years I was involved in US EMS. I worked in almost every manner of it possible, in a number of states and countries. (I was never an air-med crew member and frankly, despite my earlier enthusiasm about it, I wouldn’t apply for one of those jobs today in any country)

Throughout my life I was always told I was very smart, on numerous occasions, too smart to work in the fire service or EMS. I really didn’t think I was smarter than anyone else, I just figured I worked hard and anyone who worked as hard as I did could do the same things, maybe even more things. One of my earliest mentors, and in fact I would say “heroes” liked to tell me “You can have anything you want as long as you work for it.” It turns out that was a lie, or most probably, not an accurate assessment of the truth.

You see no matter how “smart” or “experienced” or “capable” I was as a firefighter or EMS provider, I could never break through the barriers of being smart (which for a long time I was actually ashamed of) or more important to my career, having my opinion being seriously considered formally.

Many of the doctors I worked with informally accepted my opinion in private; a few even took credit for my moves. But ultimately I was told in order to really effect the changes I sought, I had to become a doctor. I hemmed and hawed over it for a few years until one day when working as an ER Tech, a doctor whom I greatly respected told me that one day he hoped to work for me. So I figured it was time to go to medical school. This was obviously a big step from my 750 hours of paramedic training. (I may have done some extra clinical time for my own enjoyment, but on paper, 750 hours) Having experience under my belt making diagnostic and treatment decisions in EMS, I found that in medical school I could worry less about certain aspects of “practice” and focus in on the material explaining “why” and all of the theory that I could reconcile with my experience to determine what works, what doesn’t, and what could be improved.

During this period of being a student, I actually got some doctors and even departments to change some practices. But mostly I was ignored as simply “another student.” I was told yet again, if I wanted to be taken seriously, I would need a PhD. So, I figured there was no point in procrastinating, and during my 5th year of med school, also started working full time on the requirements for my PhD. (I went to school in A European country where a medical degree takes 6 years and the requirements for a PhD are more demanding than in the US.)

Having finished all of this, and actually being taken seriously among experts as knowing something, I actually believed I was finally “an expert.” I put in the work, I got the papers, I had proven myself to other people who had proven they were experts.

So I was a little taken aback by people who had not worked as long (or as hard) as I did claiming either I didn’t know, or I didn’t cite a source for my statements. Despite accusations I didn’t give US EMS providers enough credit, I have come to discover I have given them too much. You see, I like to talk to people like they are my peers. As was eloquently said in the link above, experts have a certain level of understanding. They don’t have to prove every statement they make with a citation because there is a base level of understanding among experts.

The people demanding citations or even providing citations themselves for information that experts recognize as basic knowledge simply do not possess that basic knowledge themselves. They are imitating the methods of experts by citing things that are so painfully obvious and such a basic level of understanding, that most experts just accept the word of others who have demonstrated themselves as such. They erroneously believe this imitation makes them expert.

Now I am sure there will be some comments calling me an arrogant elitist asshole. But I have noticed something, which is why I was so taken with the article I posted in the beginning. This phenomenon is unique to the USA. It is only there I have experienced that people believe everyone is equally expert, despite limited or no formal education or training in a subject. They believe their skills at googling can make up for a lack of base knowledge and education. It is only in the US where every idiot is expert and every expert is an idiot. What’s more, this celebration of ignorance and lack of value on education is so pervasive that people are on the internet, TV, and print everyday suggesting education is a waste of money!

I know of no other people or place in the world where people view education and the educated in a negative way. Now while there is definitely some issue with the cost of education in the US, I ask myself, if it is so useless or invaluable, why do people in other nations give their very lives trying to get an education? Some will say that not every job requires an education. Certainly this is true. But I would point out every profession does. Even priests must have formal schooling.

When and how did being called “elite” become an insult? I do not see “regular” sailors calling US Navy SEALS “elitist” in a derogatory way. I do not see minor league athletes calling Olympians or Major League athletes “elitist” in a derogatory way. Instead they aspire to emulate and attain their level. Which is a completely different concept from “imitate.”

In my original EMS training, let’s not fool ourselves and call it education, it was taught and reinforced that a doctor was the high level expert. The one you were a representative of, to use an analogy, Darth Vader is the emissary of the emperor, and while extremely powerful and capable, was still the junior colleague. You see, just because you are part of the team doesn’t make you an equal player. Soldiers are all part of a team, they are not all equal players. Some are cannon fodder, some are generals. They do not have equal knowledge, training, or responsibility. They cannot step into any role in the army effectively, though it is much easier to move down and be successful than move up. For many years, and I accept equal guilt, US EMS providers saw anyone outside of the emergency medicine specialty as less capable as doctors or barely useful at all. There are even jokes about “what would you do if an “OB/Gyn showed up and offered to help at a car crash?” But really, an OB/Gyn is a surgeon, with training in general surgery. In fact, more training in general surgery than any US EMS provider has EMS training and they are a doctor to boot! Where did this hubris that they are not worthy to help come from? How does it apply to any doctor? I know a GP who spent most of his >15 year career in war medicine, is he not a capable doctor in an emergency? (He can be my doctor any day.)

I realize not all doctors are created equally, nor are they equally capable. But they are still experts at medicine. There are a lot of complaints by EMS providers doctors do not so enough to support or help them with everything from training to becoming a professional. But I offer this question. Why should we help? If I don’t tell you how great you are you call me names and try to defame me in clever ways like quoting me out of context and making up arguments I never stated. EMS providers do not recognize me as having any more expertise or knowledge than they do. In many eyes, I am not even an emergency doctor, so how could I possibly be of value?

Here is an expert insight my mom once told me.(In the western world females are taught from a young age to maintain relationships) “If you want somebody to be nice to you, you have to be nice to them.” If you do not respect my internationally accepted expertise, why should I accept yours? Simply because you can imitate an expert by citing a study for an argument so basic we could accept it as fact without a citation based on our detailed knowledge?

I submit, it is not US EMS that is in trouble, the article I linked demonstrates it is the whole country! Don’t believe me? Read the news. Measles outbreaks, articles on “don’t go to school it is a waste of money”. I don’t think it is possible for US citizens to vote to harm themselves any more than they already do at every level of society except the very top. I think you are all getting played; EMS is just a symptom of the disease.

soap box on fluid therapy.

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I was typing out a an opinion about modern antibiotic theory when I was interrupted by somebody suggesting that large and rapid fluid boluses should be used in shock secondary to surgical emergencies such as hemorrhage from acute pancreatitis or of course penetrating trauma.

I don’t know where these people have been for the last 10 or so years, but I am sure many of us old people can remember the days of large bore IVs and machines infusing liters of fluid (I have seen 14 before blood was even available) until the person died and the blood looked more like artificial fruit juice. Consequently some brilliant minds did some research and came to the conclusion this should not be done unless the patient is “seriously hypovolemic.” The idea of permissive hypotension was reborn. I say reborn because it was part of WWI trench warfare and the was practiced by doctors on all sides according to accounts I have read on French surgery. But the “serious hypovolemic” recommendation is flawed to the core! If you have that much loss, water will not help at all.

We know all about hematocrit and hemoglobin levels, oxygen transportation, fluid balance, ischemia secondary to edema, capillary permeability, and even clinical references like ATLS that maintain severe hemorrhage is either transiently or not affected by crystalloid/colloid, fluid infusion at all!

So why do we keep doing this? Why does suggested practice directly conflict with everything we know about what should and does work?

The reason can only be we are not performing these treatments for patients. We are performing them for ourselves. To make us feel and look like we are doing something, because we are faced with the truth that if we cannot make resuscitation into an algorithm, most really cannot do it. So they would basically do nothing, especially in the emergent setting, waiting for somebody who could really help to show up or deliver the patient to them. It creates a false sense of making a difference. This is reinforced in the attempt to “normalize” a set of quantitative values to target numbers. It is foolishness at its best. I could go to a cadaver lab right now, plug every hole in the vascular, infuse fluid to a 120/80 bp, and use a chemical slurry with a Ph of 7.34, but that corpse will not come back to life.

What is wrong with admitting you just can’t do anything? What is wrong with not making things more complicated for the people who can?

This madness must stop. There have been more advances in the last 20 years in medicine than in the entire history of medicine prior. I just cannot reconcile how doctors go on practicing techniques with absolutely flawed theories, which seems to be nothing more than dogma passed on verbally and with no basis in fact other than “that is what we have always done.” Really? You have always done something that doesn’t work and your solution is to keep on doing it?

There really isn’t much hope for mankind. If our ancestors were this lazy and stupid, none of us would be here today.

Is there anyone who actually thinks about what they are doing anymore instead of just following the script?

I need a raise and a better job.

Did I ever mention I don’t like ethics?

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Yesterday I had a meeting with the professor of intensive care (an anesthesiologist) at the regional trauma center. We were talking about our favorite topic, trauma. In particular we were discussing the clinical complications, treatments, and outcomes between blunt mechanism trauma patients and penetrating trauma patients along with the latest scientific literature. It was in all respects, a good day.

Today I am back to my normal role of staying out of the way in another service. But one of the things consuming my mind was the effectiveness of massive transfusion in penetrating trauma vs. the outright detrimental results of using it in patients suffering trauma from blunt mechanisms. One of the things that crossed my mind was “how different are the forces involved?” Understanding and promoting the idea of science based medicine, which stipulates potential clinical treatment must meet basic scientific concepts, I decided to start with physics.

The ideal man-killing gun caliber is 7.62mm. At least that is what weapon makers over time discovered. Using this premise I decided to figure out how much energy is involved in blunt trauma. With the help of some online calculators and basic physics, I determined that the average velocity of a 10 gram, 7.62mm projectile is 3,304.0Joules. Comparatively, a 75 kg person moving at 70mph striking a solid object is 36,721.4 joules. Greater than 10 times the energy!

Now it also occurred to me that the surface area of the force transfer along with the vectors of the force transfer in these 2 injury patterns are quite different,  and I attempted to math out just how different. Unfortunately, the resources I need are not available to do that right now. (all the docs in this department have to share 1 computer with internet, so I cannot monopolize it for my purposes) But I will get to it.

Now I started the painstaking task of accounting for all of the basic physiology and pathophysiology involved, as well as the various treatments, and it is a work in progress, but the most important “eureka moment” I had on the whole topic was that there is another injury that shares the exact same mechanisms as blunt trauma. That is a burn. High energy, large surface area.

So,  I hypothesize, the reason the outcomes of blunt trauma are so poor compared to penetrating trauma is because we attempt to use penetrating trauma treatments on a pathology of completely different mechanisms. Of course it doesn’t work. In the meanwhile, I am going to get back to figuring out how the principles of burn therapy can be applied to blunt trauma… I really don’t foresee ethical approval for an actual experiment on this one though.

I decided to map out some of what I thought were the most important factors. 1st, would be what I call primary ischemia, as far as I know, a term of my own making, but I could be ignorant to other people using it, which would correspond to a vascular inflow-outflow inadequacy. 2nd would be a corresponding inflammatory insult, as is always the case in both shock and trauma. 3rd would be what I describe as secondary ischemic injury, which is microvascular circulation compromise secondary to edema and disruption of the physiologic equilibrium of starlings forces. It has become another one of my rather complex maps. Certainly not fit for inclusion in a textbook. Of all the people who have ever tried or needed to prove something by a math equation, I certainly never considered myself as even remotely the person. I am definitely not capable of doing something like that by myself. I need a friend or coworker who is also an astrophysicist. They are generally good at complex multivariable mathematics…

“The only rules that really matter are these…”

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“What a man can do, and what a man can’t do”

 

A great and telling line from one of my favorite movies. It also pretty much describes my experience in austere/war medicine. In fact on my employment contract, it specifically stated “there is no scope of practice, job responsibilities include anything that needs doing.”

When I was actually doing it, and for now almost a year after, I have been asked to recount my Afghanistan stories more times than I can remember. I have given a presentation on it no less than 5 times. Every time somebody asks, I sigh and reluctantly give then an anecdote. Mostly because for me, it didn’t seem in any way out of the ordinary from anything else I have done in some form of emergency service or in any job in any industry I ever had. In fact, one of the most frequent questions I am asked is how does a person go from being a firefighter to a doctor and scientist? (It is important to qualify that most people where I live hold 1 job their entire lives and work in into an art of putting forth the most minimum effort to keep it.)

But all of these things tie together in a rather simple philosophy.  I would like to think I am something of a renaissance man. In a combination of being able bodied, I would like to think a bit intelligent, and through sheer force of will, the only impossible task is one that can never be done again. (I claim a few of these and many 1sts to my credit)  But ultimately, when somebody calls for help, no matter how cliché it sounds, I answer that call, and I believe in it. Over time my uniforms change, the tools change, the locations change, but the fundamental principle remains.

I started in the fire service at a time when it was not a particularly good time to. Firefighters were mostly regarded as a bunch of guys who sit around and do nothing all day. Especially in affluent suburbs, the fire department is actually more of a tax liability and burden than required public safety force. After all, these places rarely have fires and most people are fairly well taken care of medically so they don’t require a great amount of EMS. Usually the FD wasn’t so much an “all hazards” response agency, but more of a “we didn’t know who to call so the fire department seemed like the most appropriate choice.” Checking river levels, looking at downed power lines until the utility company came, playing ping pong, and pumping out flooded basements were a large part of the duties. In essence, we were trying to prove our value to the community. This was important because politicians in particular do not like to fund “invisible services” compared to a campaign photo project like a park or parade. Overt and covertly, we were faced with the reality that it was an honor to have our job, and we made no small effort in demonstrating we were happy, even honored to have it.

For a combination of reasons, many emergency/medical services, whether they be police, fire, EMS, or even doctors now seem as if they feel they are entitled to their position, prestige, and even pay. Whether they are a physician, paramedic, nurse, or whatever, they are quick to not only tell others what they believe their job should be, but strictly delineate the exact help/procedures they will render. Everything else is simply “not their job.”

One of the best things I ever got to do in my opinion was spend time on an inner city FD Rescue Squad. Depending on the source, you get some deviation in the definition, but perhaps my favorite, which I have no citation for, as it is lost to time, is: “Rescue: To set free from danger or imprisonment.”

While searching burning buildings and cutting people from cars may seem like “real rescue,” working in an emergency room, intensive care unit, or even surgery, is really the same thing. The same skills are used, and the same mindset applies. At least I apply them to it.

I wrote all of this because I think it is important background to what is really bugging me right now. That is doctors who don’t want to help people.

Many doctors are smart enough to know it is impossible to be knowledgeable, much less proficient in the totality of modern medicine. Even I have to admit that. But instead of being seen as a limitation to attempt to work towards minimizing, it is used as a crutch. “I don’t have to know more than a few things, because nobody can know it all.”

In every country I have actually laid hands on patients in, currently numbering 5 and counting, a large part of medical practice I have witnessed is doctors deciding whatever was wrong with the patient was not their job. It is so prolific, I currently meet medics who cannot/refuse to suture and actually consult surgery to remove sutures to surgeons who discharge patients with no referral or follow-up who have obvious infections and cardiac decompensations because they have concluded there is no treatment they can perform in the operating room. Sadly, this is not the exception, it is the norm. We make jokes about it. “How do you hide $100s from a…” “What do you call two orthopods looking at an EKG…” It’s not funny anymore. It is not even sad. It is outright appalling.

   One of the things I have noticed about patients as they struggle to navigate seemingly impossible access to the medical help they need, forget desire, need, is that they don’t identify with the self-imposed limits of various doctors. They go to the doctor for help, whether in a social system or a private system, they ultimately pay a lot for that help. Helping people is actually pretty simple. You either do, or you do not. When a doctor gives a referral, misdiagnoses a patient, doesn’t listen to a patient and ultimately creates a treatment plan of common guidelines that do not work for the individual, the patient perspective is the doctor was paid a lot, but did not help. Many doctors not only do not explain why they did or didn’t do something; they actively avoid non-therapeutically minded conversation, failing in not only their role as clinicians, but that of teachers too.

When you go to medical school you are not taught emergency medicine, nephrology, or surgery. You are taught basic information about all of them. Most medical residents erroneously believe what they learned in medical school has no bearing on actual medical practice. I take great issue with this. It is not that the information in school isn’t relevant; it is the practicing doctors either don’t understand its relevance or they seek to simplify their own practice and effort by ignoring it.

They cite reasons like getting sued, limited time, standards of care (aka: acceptable levels of sucking), limited knowledge or experience, and all manner of what ultimately are self-serving excuses for what they don’t want to do.

Coming full circle with the introduction to Afghanistan, it is only after much reflection that I find my experiences there are somehow more than another day at the office. From routine medical needs like chronic disease management, cold/flu, medication refills, to orthopedic injuries, industrial trauma, war trauma, to field surgeries and complicated childbirths, no patient goes to the ED who refers them to surgery, internal medicine, family practice, or Ob/Gyn. They go to the doctor, whose only options are to help or not help. Whether they can be treated and released, or have to be admitted to the ward or ICU, it is the responsibility of the same doctor from soup to nuts. Certainly I do not claim expertise at every aspect of medical practice, but I do know how and where to look for help, and at the end of the day, I am not only willing and able, but sign my name to “the best I could do”, no matter how good or bad. Not only is it an experience that sets me apart. I have discovered It is an experience many doctors cannot even imagine or even want.

Undoubtable it was my prior history in the fire service, EMS, and academic medical centers that gave me the knowledge, skills, and values to not only do something uncommon, but to actually be inspiring at it. So much so, I cannot seem to land a “normal” job anymore. Not only have I been offered more than 1 “austere” medical position, but it seems like that is the first and only position anyone wants me to do. At first I was quite insulted by this. Then I was depressed. But now I understand why. I still don’t like it and do not want to do it as a primary profession, but I understand. I want the surgery and ICU of the ivory tower of academic medicine, the tertiary facility where all the hardest cases eventually go. With the bells and whistles, resources, and seemingly limitless knowledge and expertise found there. After all, in austere medicine you do what you can or must. You are not pushing any envelopes. Even if you wanted to you would not have the resources. I am here to push the envelope. To do better than yesterday, everyday.

Ultimately the one lesson, piece of advice, words of wisdom, or whatever you want to call it, I would like other doctors to really latch onto is: Earn the honor of being the one people not only come to, but pay for help. It is neither a birthright nor a right of educational title. To paraphrase another quote from the Pirate movie, because patients go to see the “doctor” for help, who may or may not be a surgeon, intensivist, nephrologist, internist, or gynecologist.

“Are you a doctor or are you not?”

Because no matter what “special” title you identify with, everyone else stills sees you as and calls you “doctor,” which is not just a title or a job. It is a respected position of humanity in every culture in every language, and every country, since the inception of medicine. It is the person who helps. It is not the person who stands idly by or denies responsibility.      

On trauma

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One of my friends, who is also a paramedic among his other pursuits, asked me what EMS could do to take better care of trauma. He went on to cite a few skills that readily help, like splinting, hemorrhage control, and driving to a surgeon.

                Unfortunately, driving to a surgeon in the year 2014 is not the obvious answer anymore. The idea of trauma must be handled by a surgeon is historic only to the limited age of the trauma surgeon specialty. (1960’s-80’s) prior to that it was primarily the providence of both general surgeons and internists or as they called themselves, doctors. In fact prior to the acquisition of surgeons by medicine, the call was for “a doctor in the house” not “a surgeon in the house.”

                So how did this focus on surgery come to pass? Well, for starters surgeons cause trauma every day. Logically they should be expert about it. Unfortunately what is logical and what is practical are often opposed. The focus of the physiological effects of trauma are often lost in the act of qualifying patients for surgery, which includes determining if the pathology will be worse than the surgical operation. From the practical point it is not seen as a risk/benefit analysis, it is seen as a how bad is the pathology point of view.

                Another interesting point of that is the focus on inflammation and effects of trauma on the body. I mention inflammation specifically because not only does it have historical relevance to trauma, but it is also the focus of much of modern trauma research. When you open many surgical textbooks (I have read a couple) inflammation and particularly sepsis occupy a prominent role. In fact in one surgical textbook, sepsis is listed as a surgical disease! (Probably because historically, surgeons caused a lot of sepsis.) However, when you read in anesthesia and critical care texts, not only is the information on inflammation and sepsis often more detailed. (I can actually tell whether it was a surgeon or an anesthesiologist who wrote the chapter just by skimming it, because of the focus and detail from the respective specialist.)

                Because the days of exploratory laparotomies for every trauma patient are over and the obvious fact, often touted in countries where orthopedics are the lead in trauma care, most trauma is ortho in nature. (Bone and soft tissue) More so, the whole purpose of trauma care anywhere is to return victims to as normal as possible, and ortho does this far more and with far more intensity than any other surgical specialty.

                Modern trauma care can easily and usefully be divided into blunt and penetrating injuries. There is an interesting dichotomy to this I think. Minor and moderate blunt injuries have the best outcomes and severe blunt injury is almost futile to care for, where as minor and moderate penetrating injuries hardly require a surgeon, but severe ones are most amiable to surgical intervention and positive outcome from surgery. Simply, you probably will not require a surgeon for trauma, but if you do, only a surgeon will help.

                Another factor which is starting to remove the need for a surgeon in trauma is medical advancement. It used to be that things such as liver lacerations, splenic lacerations, and even pelvic fractures required open surgical hemorrhage control. While that is still true in some cases, low grade liver and splenic lacs can now be managed in the ICU without surgery, and these injuries including some vascular pelvic injuries can be managed by endovascular techniques, which is usually the realm of interventional radiology in many places and partially vascular surgery in some others.

                All of this has led to the question, who should ultimately manage trauma. Perhaps the most vocal proponent is emergency medicine. Certainly they are trained and have important skills to manage all forms of trauma. One of their most proud surgical skills is the emergent thoracotomy. However, while it certainly seems like a very effective skill, the opportunities to use it are limited to the most high volume centers. Many community EDs around the world I have seen are not even equipped to do it. But one of my early surgical mentors once pointed out during an ATLS class, “Once you open the chest, are you going to close it too?” While not an issue in the ACS level 1 academic trauma center, certainly it is an issue in the smaller emergency departments, which may not even have onsite surgical capability. Even if you do close it, how/where will this patient be managed “post op”?

                While certainly there is a place for this skill, other skills relating to life threatening trauma which might be used more often are absent, for example bilateral craniotomy for blunt head injury with increased ICP. A few years ago I took an informal poll on Facebook of physicians I knew who would even be willing to perform such a procedure. The only ones who voted in favor were surgeons. Almost all of the emergency physicians voted they would not perform such a skill, and only 2 opined they would be willing to use a “burr hole” which is less invasive and according to the studies I have read, not nearly as effective. I will also point out that I learned in my neurosurgery experience, that opening a skull is the most basic of all neuro operations, and usually done by first year neurosurg residents.

                As far as surgical skills go, most of them are actually pretty easy. No different from most psychomotor skills performed by paramedics. Certainly I think they are more exciting and it seems easy to be impressed by them. The real skill of a surgeon is deciding who would benefit from such interventions, and taking care of the patient before and after surgery and through rehab. (Which most have given up doing despite it still being a core part of surgical education.)

                So understanding all of this, the question remains what does the surgeon bring to trauma that others don’t? The role for ortho is obvious, they fix bones and other soft tissue related to motion in order to return to the pt to maximum function. But rarely are they emergently required. Vascular surgery has a role in severe penetrating trauma, and it is perhaps one of the few remaining “whole body” operators left in modern medicine, operating on vessels wherever they are found. General surgery can certainly be valuable in the remote or austere environment, but those opportunities are rare. Not to mention most of the injuries will be vascular in nature or relatively minor. In my experience in austere medicine, most injuries were ortho or minor and required only simple skills and aggressive “post surgical” treatment. (surgery in many cases was simple suturing, abscess drainage from infected wounds which were initially managed by non-physician providers, re-margining of disheased wounds, managing work/sports related injuries, and the occasional dislocation/fracture reduction and splinting before evacuating them to ortho) hardly the stuff of surgical legend. I will just give myself points and mention I was required to manage a complicated birth which thankfully was manageable with an episiotomy, because I was hoping to any higher power who might have influence that I was not going to be required to perform a field c-section with the limited equipment we had on site. But the fact is that lady would have been better served by an OB/Gyn, who are by definition, surgeons.

                EMS providers do not exist in some alternative world in trauma. Most of the injuries they see are isolated, often minor or moderate, and more rarely severe. There are some exceptions to this like those working in inner-cities, but even then, they see only a fraction of the patients the local trauma center does.

                This leads all providers to the “Oh my God! Oh no!” syndrome when they do see something that looks like surgical trauma. Most often it is not as exciting as they may anticipate. It is all about perspective. So let me offer some. When I teach all levels of providers from first responders to physicians, I show them a really great photo taken of a self-inflicted shotgun wound. (Taken by somebody that was not me, whose name I don’t know) The person is conscious and looks “fucked up”. I profess if the first thing that goes through your mind is “that guy is fucked up” you are most likely right. You don’t need to be a doctor to figure that one out. But when you have been around these patients for a long time, the definition of “fucked up” changes considerably. Most patients fall into the category of “yea, that looks worse than it is,” because not only have you seen it before, but your management is rather logical and routine, with commonly positive outcomes. Gunshots, stabbings, power tool accidents, and a host of others fall into this category. (I was actually formally written up and reprimanded at one of my EMS employers for “not sounding panicked enough when calling the hospital”, I did my paramedic clinical time and later came to work in one of the busiest trauma centers in the US, by the time I even finished paramedic school, trauma was not as exciting as it seemed in the past)

                One of the pitfalls of the inexperienced is estimated blood loss. Even people who spend a majority of time in the OR are notoriously poor estimators of blood loss. Even the best clinical techniques I have heard and use myself overestimate by a considerable margin. Even more problematic is using the commonly referred to ACS estimates of percentage blood loss for determining severity and they make no reference to individual patient response for preexisting disease, extremis of age, or any other obviously important factor. There is also considerable variance in the opinion on what “a lot of blood” is. For example, OB/Gyns during routine c-section estimate 300-400ml blood loss as “massive.” Ortho during knee replacements have a similar estimate after using power tools on the patient. As a proponent of vascular/cardio surgery though, I can tell you that is basically chump change. During aortic aneurysm repair, losing 1200ml of blood in a few minutes is not uncommon. Even a bypass or rupture of a femoral aneurysm may produce upwards of 800ml of loss. But with expert management by both anesthesia and surgery, many of these patients make a good recovery. This has direct implications on trauma care. First it demonstrates the need for early and aggressive treatments. Flavored water simply isn’t going to work when somebody loses >2000ml of blood. It is not even attempted. Another thing that is done is measuring inter-operative hemoglobin, hematocrit, and lactate levels to determine how individual patients are responding. One of my current mentors in surgery often likes to tease me about my interest in both surgery and intensive medicine by saying “Mike, you don’t need all those fancy machines and labs, if the drain is empty, the urine bag full, and the patient can tell you they are in pain, then the patient is stable.” While certainly true, it doesn’t tell you when they are unstable, or how much, which is really what determines treatment. (Yes, I am sure this professor of surgery is aware of that too, but it doesn’t stop him from teasing me.)

                One of the coolest pieces of equipment I get to play with is the bedside ABG machine. In about 2 minutes from putting in the sample, I get a host of useful information. The machine even self-calibrates and runs controls, who could ask for more? The reason this host of information is required is because no single indicator of shock is reliable. The goal then becomes to use a few to “triangulate” a reasonable estimate and act/adjust accordingly. I have no idea why EMS doesn’t use these machines. I can think of no other reason but cost. But the initial expense might save hundreds of thousands in the long run from over triage and unnecessary transport to “higher levels” of care, especially useful for providers without a lot of experience.

                    I speak a lot about hemorrhage (Haemorrhage for the British types, which is actually “hay-mor-hage” according to the rules, I am always fascinated by the random places Brits add an “A” and then don’t pronounce it) because it is the number one preventable cause of death in penetrating trauma. Some studies estimate as high as 40% of all preventable death. Direct pressure can control most bleeding, again studies and estimated as high as 90%. Even in vascular surgery, during procedures like carotid endarterectomies (where the carotid artery is purposefully and completely surgically transected), as well as all forms of open bypass, and aneurysm repair, direct pressure is the preferred method of bleeding control. I will also point out all vascular surgery patients are heparinized; which means direct pressure works to control major artery bleeding on heparinized patients every day and most often by without any adjunct. The second go to method is a form of chitin gauze in addition to direct pressure to locally counter the effects of the heparin. On minor vessels, including arteries, simple ligation and electro-cautery handles all of the work, but mostly for operative efficiency, not necessity. I recently opined EDs should have electro-cautery, this came from an experience where I was teaching a medical student the presentation and skills to identify and close hemorrhaging arteries in a trauma patient, and realized the device would have made minutes worth of work and materials only seconds with much less.

                The real key to hemorrhage control is access. In order to apply direct pressure you have to, well, be able to touch the place that needs pressure. While I like to think you have to be really bad ass to use a knife to stop bleeding, the truth is it is as simple as finding a leaky pipe in your house. You don’t use all kinds of chemicals and devices to find and stop a leaky pipe. You simply dig it up, destroying as little as possible on the way, and either replace or patch it. Again like many surgical skills, it is more of a matter of learning and practicing. The real trick is deciding when you need to vs. something like a tourniquet. (which is also used in surgery)

                A popular EMS mantra is “you should never stick anything inside a wound”. I am just going to call BS on this dogma. I stick things in wounds all day long; tools, gauze, fingers, sutures, synthetic plastic, sometimes metal and even a fair amount of water. The idea EMS cannot do something like pack a wound, is just self-limiting nonsense. But it makes a lot of money for medical gizmo manufacturers. Probably cheaper and easier just to teach medics how to effectively do it. Imagine a whole device industry that revolves around a totally unfounded self-limitation!

                Splinting is another “pre-hospital” technique of much renown. But it is highly underutilized. Not only for potential bone and soft tissue injury, it also can help control bleeding, wound healing, and pain control.

                Pain control is another monster in pre-hospital trauma. One of the limiting factors I am most often reminded of is “hemodynamic stability.” First it is almost laughable because blood pressure is a poor indicator of end tissue perfusion. let’s face it, BP is the measure of blood leaving the heart, not coming back, and the clinical sign of altered mental status will precede any significant drop in BP. Narrowing pulse pressure makes a quick and dirty estimate, but again, the problem must be profound to detect it. However, in any operation, whether general or regional anesthesia is used, some form of water is also used simultaneously to make up for vascular expansion and the drop in perfusion pressure from it, in this case not to deal with hemorrhage, but in container volume expansion. The goal of anesthesia is simple. Patient feels no pain, patient does not react to pain, and patient doesn’t remember pain. It is not “patient finds the pain level reasonable enough to tough out.”  Look at the management of severely burned patients. Even in the pre-hospital setting, RSI may be necessary simply to manage pain. What about local/regional anesthesia pre-hospital? Lidocaine is great on small wounds, digital blocks, and in fact any broken skin. Strangely enough most “sunburn” ointment is 0.5% lidocaine and it works great on not only sunburns but minor cuts and blisters.

                Speaking of burns, most burns, which are also trauma, do not require a burn center. Some people even get partial thickness (formerly called 2nd degree) sunburns and manage without a doctor or hospital at all. Silverdine cream (locally argosulfan) is a wonderful tool. (Also please recall not to include 1st degree burns as part of the overall estimate.)

                Ibuprofin is a wonderful tool for managing minor traumatic pain, both short and long term, especially in conjunction with something else. It even reduces the amount of other pain medication required. That whole bradykinin  pain threshold pathway… Even a single dose of steroid can have considerable effect on musculoskeletal pain. Those are often tools found in EMS, simply under-utilized.

                Perhaps the most important thing that can be done for trauma in the pre-hospital setting is not to send every patient to the highest level of care. Better would be the most appropriate level of care. It is often closer and cheaper, with no worse results. Airmed people especially hate this thinking. After all, they don’t often bring much in the way of actual treatment modalities to a scene. They even advertise speed. But the fact is once you close an open circuit rather than try to “resuscitate” and open circuit, then the amount of time you have increases greatly, by hours or days. You can even use a spineboard to indirectly apply pressure and control hemorrhage. (seen it many times)

                The best advice I could offer to EMS in terms of trauma care is simply, calm down. Look at what you are actually dealing with. A bleeding artery? Stop it from bleeding. A burn? Stop it from burning. Splint deformities, you don’t really need to know if there is a fracture to help. In fact, splinting soft tissue helps too! A freaked out patient in pain? Stop them from freaking out and being in pain. Try to use your tools to maximum effect, rather than trying to invent and have a tool for everything. Don’t worry about what “might happen”, plan for it. Get ahead of the pathology. Clean and explore the wound. Make seemingly complex problems simple tasks. For example an open fracture. That is usually not a dramatic bone sticking out, but a small wound with a retracted bone. Stop the bleeding, splint the site, relive pain, inspire calm, and drive to ortho. You don’t need a $20k helo ride. Mission accomplished.

                What really makes an expert in trauma is not their medical specialty, but the mindset and confidence in the way they handle it.                

“Train like you fight. Fight like you train.”

Standard

I have no idea who said this or when, but I think it is one of the smartest things ever said. I have had the honor and good fortune of being a paramedic in one of, if not the best EDs in the world. What makes it so? High quality equipment? Nope, we didn’t have that.  The best training possible? Sort of. Diversity? Yes. Teamwork? Yes. High volume of both high acuity and low acuity patients? For sure! But what really made it great were the people. Many of us are no longer there, a few still are. Most of us still keep in touch.  You see, all of these people were highly experienced at their job, genuinely cared about patients, even if they did sometimes bother us, but most importantly were passionate and wanted to be the best.  On more occasions in 4 years than I could possibly recall, we proved that a team is greater than the sum of its parts.

That could not be in greater contrast to where I work now. There is no team. Diversity is frowned upon or outright hated. 70% of providers I encounter are only concerned with money. Another 29% I have met are only concerned with doing the minimum they have to not to get fired. (Which believe me, is minimal).What’s worse is I only encounter the 1% on an irregular basis. It is not to say these people are bad at their jobs, they are actually very skilled. But there is a difference between doing a job and being great at it.

Some of it can be traced to the system, which is a copy of the German “Herr Dr. Professor,” system where the professor is God, and everyone else is basically nothing serving at God’s leisure. There is no independent thought, no reward for excellence, no pride from owning your job. Another problem is this is a former Soviet bloc country and many of the senior people grew up in communism. Unfortunately, they also have not grown from communism yet. Between the two, many hold as a value not standing out. Even more simply wait to be told what to do by the people who will never deviate from what they have done for 100 or so years.

So how did I end up here? Well, it’s actually pretty complicated, but I chose it on purpose. I am trying to do my best with it, but some days are harder than others. I often say any day I do not join the French Foreign Legion it is a successful day. I have even had days when I called one of their recruiters.

Today while at work in the ED, a real emergency patient was brought in. Apparently she was in the hospital for a specialty consult and she collapsed. She was rushed over and the biggest cluster fuck of resuscitation I ever witnessed ensued. There was nobody in charge, clearly nobody had any clue what to do, and I was told to stay out of the way because how could “the new guy” have any concept of what to do in a “real emergency.” When my shift ended for the day some hours later, the lady was still in the ED hooked up to a nonrebreather. Had not yet had a CT scan. No ultrasound. No blood gas. No Xray, and No Foley, the ED cannot do a urine toxicology screen, the hospital cannot do a toxicology screen at all I am told,   Was given some IV NSAID for pain, was semiconscious, had a neurology consult which was inconclusive, and a intensive care consult that said “reconsult after you get some information.” Despite arriving unconscious/unresponsive, providers of all types stood around staring at the lady in what resuscitation experts refer to as “the circle of death” diagnosing and treating her with “the stare of life.” It took a full 3 minutes before anyone decided it might be helpful to get a BP or hook her up to a monitor. It took another 5 minutes before anyone decided an IV might help. That’s when somebody had the idea to put her on the NRB. As she regained consciousness on her own, providers started disappearing until nobody was left except for the patient laying on her side semiconscious, the monitor beeping away, BP cuff still not attached, much less cycling, and me, wondering what if anything I could do for her without breaking the chain of command mandate of “stay out of the way.”

I sat for hours today comparing this nonsense to my time at Metro. Where this lady would have been taken to a resuscitation bay where, usually at least 1 paramedic, 1 emergency nurse, 1 or more emergency doctors, would control the airway by the fastest possible means, cut the patent’s cloths to ribbons, perform a full head to toe, front, and back physical exam, start 2 IVs, have a full set of vitals, a bedside ultrasound, 12 lead EKG on at least the left, maybe the right too, blood gases, a portable chest xray, stat laboratory results from every blood test that could be run, a foley catheter and urine toxicology screen, and be on their way for a Como-Gram (local term for a full body CT scan to include Head, Chest, Abd, and Pelvis, with contrast, reconstruction of the spine, and upon suspicion “supersized” to include the face and soft tissue of the neck.) In most cases the team was so proficient, communication was often silent except for the occasional warning of “X-ray” and the total time for all of this to happen, including the CT scan, was less than an hour. All except the CT scan in less than 15 minutes.

When I went to work in Afghanistan, as the “emergency” doc, I was paired with a Romanian EMS nurse. (Nurse who works on an ambulance in the same role as a medic) She was also a former scrub nurse. Despite being from different countries and speaking different languages, we worked together as seamlessly as the experts at Metro, usually performing every possible intervention, from controlling airway, cutting cloths, running the blood tests ourselves, and even the Xray which we shot ourselves, in under about 15 minutes average. We were a team and we were expert and passionate about being the best.

All of these expert tem members, from the US to Afghanistan, trained to be the best. Constantly. Many, including myself spend our off hours, teaching, and seeking out opportunities to be even better. We train like we fight, and we fight like we train.

I was told today that at the end of the month I must attend mandatory resuscitation training for 2 days. Honestly I have no idea who is teaching these classes or what their experience and capabilities are. My only hope is that they are at least passionate about what they are teaching and that they actually fight like they train.

I considered just contacting them, showing them my CV and credentials and asking for the professional courtesy of being “signed off” so I can go about my business of pursuing my passion at the level I am used to. But ultimately, I decided against this. I decided to put in the time because I will be in a class with my colleagues, who have never been a part of this before. I hope to encourage them to be passionate or at least train like they will fight. Because their day to fight is coming and I really don’t want them to replicate what I witnessed today.

It is easy to sit here and criticize and compare, quite another to step up and demonstrate and educate. At the very least, I hope they will at least see what resuscitation could look like. We shall see. I will probably just be vilified for showing off.