“The only rules that really matter are these…”


“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.      


4 thoughts on ““The only rules that really matter are these…”

  1. Jason

    Mike, I would argue that austere medicine is where you push the boundaries the most. Those hardest cases have to come from somewhere, and often that’s somewhere relatively austere. It’s why I chose community medicine: there aren’t specialists at my beck and call, and if something needs to be done, it’s all on me–not quite austere medicine, but definitely not ivory tower either. I’ve done things out here that the EM attendings at tertiary care centers would never do. So if anything, the front line is maybe where you ought to be. Hell, I think about half the things we know about ED US came from Everest base camp….

    • Jason, I think it depends on whether or not you are pushing boundaries of medical systems or boundaries of medicine. I think you are absolutely right though in terms of systems. I can’t think of even one service or department that would do many of the things done in austere medicine in even one day. But where I disagree is in really doing what has not been even attempted before. When I think of RRT, ECMO, even radiology on some days, I can’t help but wonder, “Imagine all the things we could do with all of this stuff!” But ultimately all those things are just tools. It is the people that really make a difference. Community medicine is just not my thing. There are song lyrics from the musical Oliver, “we love coughs and wheezes and diseases called “incurable.” I would much rather be trying to reattach somebody’s leg or put their brain back in their skull. Personal preferences I guess.

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