I am not comfortable.

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One of my friends was lamenting last night (well it was night for me, probably the middle of his day) that he wasn’t happy with the patient care he was witnessing at work. I can sympathize with him on this because it drives me crazy when I see it at work too.

I cannot speak for my friend, but I can tell you why it bothers me when I see poor patient care. First, I come from a family of soldiers and laborers. Predating the Napoleonic wars, fighting, mining, and factory work is what my relatives did. It is what my father did, my mother did, and I somehow escaped through great effort and sacrifice. But I wasn’t always free. I have done my fair share of manual labor, and one thing I know is that laborers who need to work to live and feed their families need to maintain their productivity. That productivity comes in many forms. It comes in the stereotypical male family figure whom goes to work every day, ignoring pain and sickness in order to earn money for their family. It comes in the form of single or working moms who not only have to care for family, but also have to work to earn a living. It comes in the form of the stay at home moms who basically do whatever needs to be done to keep their family functioning. It may be the grandparents who in their waning years are baby-sitting, lending a hand to parents who both have to work.

These people rely on their healthcare providers. They trust the judgment of healthcare providers, holding in esteem the knowledge, ability, and altruism and in all respects putting themselves and their families in such care. They believe in all respects that what providers do for and to them is for their benefit. Whether you are a doctor or a paramedic or a nurse or some position I am too lazy to type up, you receive not only money, but a special reverence in the eyes of everyone from the heads of state to the most low paid laborer.

Believe it or not, healthcare is not about providers. It is about patients. It is not an industry where you come in and do your manual part and go home. It is not simply a technical set of behaviors. One of my good friends and former coworkers is a CT tech. This sounds like a very technical job, but it isn’t immune from the concerns of the healthcare provider. You see, she is the one advocating not to use this radiological machine for the convenience of a doctor, but for the benefit of the patient. It is her that makes sure nobody overlooked your metformin prescription or contrast allergy. It is her who gets into “discussions” with people above her pay-grade over patient safety. Why? Because she cares about people. It is perfectly within her power to come in and simply and mindlessly press buttons. But to her credit and that of her profession, she doesn’t. There are many like her too.

Myself and my colleagues, no matter what their position, are part of medicine, and we believe in our hearts in the values and the mission. We live it. We expect the same from our colleagues.

Another thing that makes it hard for me to stomach poor care is because I am a “lead from the front” sort of guy. I like to be the one getting my hands dirty. I see my role as the guy who can always be found in the trenches, not directing from afar. If you ask around, I am pretty good at what I do too. It is hard to watch people who are not so skilled or caring.

Yet another thing that bothers me, because it conflicts with not only my own experience, but the ideals of my colleagues is the idea of providers who feel or act like patients are a nuisance who interrupt their day from being “easy” which they view as their right and privilege. I try to prove everyday on every patient I earn what I have. I even tell people, most notably at the formal PhD dinner I had recently which seemed to stun everyone, “the patients I see today, do not care what I did for the patient yesterday, so every new patient, every new day, is the day I will be measured. A first place finish yesterday doesn’t count for anything today.”

I like to be elite. To play for the best teams, to be the best of the best. I consider it a great honor to be the one people call for help and get paid to do it. I am very proud that I have earned that not only in the suburb of 24,000 I am originally from, but everywhere in the entire world I have taken care of patients. I have no use for mediocrity. I recognize not everyone is or can be a champion, and I am happy to help and teach anyone, but regardless of knowledge or ability, I expect them to care. I expect them to at least aspire to my ideals. I have very little time or tolerance for those who don’t.

One of the replies to my friend’s rant about substandard patient care, there was a reply that stated “the outcome didn’t change.” I can see how people who try to imitate professionals without understanding can latch on to a quantifiable metric like this. But I submit it is not just the goal, but the process that matters too. Here are a few examples. I took care of a patient who had a perianal tear and abscess. (It gets lonely in the desert.)The desired outcome was to check for extension, sew up the tear, and to treat and prevent further infection. Certainly I could have had a nurse or medic hold this guy down while I did what I had to do. But he very much appreciated being sedated for it. I can only imagine local anesthetic might not be enough to have your torn asshole probed, scrubbed, and sewn up. Another example was evacuating patients with bilateral femur fractures. (Usually secondary to an explosion) They really appreciate pain relief while they lay in bed. But they really appreciate a little more before they are moved over uneven ground in a truck and manhandled into an aircraft. (Many times an aircraft not designed as an air ambulance) I certainly could reduce a dislocation or fracture without medicating people and the outcome would be the same. But I submit, especially with kids, it is the process that counts.

I will right out confess, I am not always comfortable doing things I have never done before or doing things I don’t feel very confident doing. But when help is not available, I always remember that the whole patient care event is not about me. Strangely enough, I have discovered the only way to become comfortable doing something is to do it.

Medical knowledge and practice changes over time. Why would it be acceptable for providers not to change with it? Why do they insist patients need to “take it”? Why do they believe their comfort and insecurities take precedence over patient care? Would they want the same for themselves or their family?

Several months ago I was discussing with a friend the difference in teaching approaches of emergency medicine. He comes from an environment where “emergency” providers are the best of the best because they have to earn the right to take care of emergencies by taking care of hundreds of non-emergencies first. This is diametrically opposed to how I was taught, which was “here are the keys to the truck and drug box, best of luck.” I was asked what I thought was better. At the time I was of the mind both have merit. But looking back, I would answer differently. I would say the way I was taught. Because you cannot do something the second time until you have done it the first. I have also discovered emergency is like surgery. You can train and talk about it all you want. You can practice the skills in a teaching non-threatening environment. But when the real deal is dealt, when the tool is in your hand, and you call and take responsibility for the plays, it is an entirely different experience, things become much less certain, and the only thing that prepares you for it or makes it easier is doing it again.

At that moment, it is not about you. But you are involved all the same.

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Surgery 2.0

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Ok, so I stole the name from EMS 2.0…(Credit to whomever thought of it.)

In my journey through medicine, I continue to pursue my interest in trauma and emergency surgery. For the last 4 weeks I have been delegated to the cardiac surgery department. I have to say this is probably the best department I have been to in my whole time in Poland. Not just because they actually let me practice surgical skills, but because the people there are absolutely super human beings. (Perhaps a few think they are God, but we won’t quibble…) Really though, I found them to be strikingly humble for cardiac surgeons. During my time there though, I have noticed something about surgery.

Surgeons attempt to perfect the operations they do and have done yesterday, this is in contra to medicine where there is a constant effort to break new ground. (No wonder these people hardly ever get along) However, as surgeons are quickly discovering, this mentality is shutting them out of their future. You see it is medical disciplines that were first to adopt endovascular techniques. Surgeons have also perhaps mistakenly sought to improve their statistics by disqualifying people for surgery. As if that were not enough, surgeons have basically led the charge of hyperspecialization. No longer content with specializing in regions of the body, they have whittled themselves down to specific procedures on specific organs. What all this taken together means is that they are basically putting themselves out of a job.

The cardiac surgeons are acutely aware of this. They lament the short waiting lists to get cardiac surgery. They worry they will have trouble finding work. The problem is not new, but they are basically doubling down on the behavior that caused the problem. Notice I keep referring to cardiac surgery and not cardiothoracic surgery, because they have given up operations not specific to the heart and proximal aorta.

However, in one of my forest from the trees moments, I have noticed that there are really only a handful of surgical skills. The only real difference is where they are being applied. The fact is, you are either cutting something or sewing something. (Stapling counts as sewing) If you want to make this sound important you can call it “anastomosing.” I have read all of the literature on the idea of specialized surgeons reducing complications. But I sometimes wonder if it hasn’t become specialized to reduce an insignificant amount of complications or insignificant complications? The cost of training and supplying these hyperspecialized surgeons may far outpace the cost of complications.

I doubt that the respective medical disciplines are going to start turning over their endovascular procedures to surgeons to give them something to do. It may be the future of medicine is not only a combination of surgical skill and medical knowledge, but disease specific specialization?

One thing is for sure. Surgeons are definitely not on board with this future. It will be interesting to see how the future role of surgeons plays out.    

shopping for doctors

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Vacation! Day one. Today is the first day of my first ever 2 week-long vacation. I even get paid extra for taking 2 weeks off in a row. I have been a little slow on the writing for 2 reasons. 1) I have spent the last several weeks delegated to cardiac surgery, who have made sure that I was busy in the OR, mostly involved in venous harvesting all day, and 2) I have really been making an effort to reduce my exposure to the EMS world so I don’t actually have much to write about.

One of the things that is a cause of ongoing grief for me is antibiotic therapy. Rather the lack of antibiotic therapy among physicians who not only seem to have latched on to a fatally flawed theory of antibiotic resistance, but more importantly, because it seems to me most physicians simply do not understand the difference between acute infection, chronic infection, and an acute exacerbation of a chronic infection.

All 3 of these conditions have different findings and history, despite this, it seems most physicians only use the guidelines for acute infection and subsequently misdiagnose and do not treat the other two. While it is simply another example of the failure of McMedicine in action, it is one that stresses me.

When staring at a patient’s blood counts, in chronic infection and acute exacerbation of chronic infection, forget about seeing an elevated neutrophil count. You won’t. Sometimes you can see a middle or upper end of normal range neutrophil count, but mainly you see mid-range of normal to slightly elevated lymphocytes. Anyone who actually understands the immune system should not be surprised by this.

Another matter of misdiagnosing chronic infection is the absence of fever. Generalized fever is actually part of the initial inflammatory response. Why would anyone expect to find a generalized fever in a chronic infection? I don’t know. But I really wish more doctors (I expect less from other providers) would take some time to actually understand immune response and correlate it with patient findings when choosing therapies.

Just because a patient has WNL lab values does not mean they have a viral infection. Why is that so hard to figure out?

Moving right along to another topic that “emergency” workers seem to really not have caught onto is that “true emergencies” are actually pretty rare. The ability to effectively intervene in these “true emergencies “ is rarer still. But for some reason there is this complete denial of reality of emergency physicians and those working in emergency.

It really pains me when I hear emergency docs give people grief on how they should not have come to the emergency room because they don’t have an emergency. But it totally ignores the reasons many people go to the emergency room.

You see, no matter what country you go to, primary care operates on a totally outdated concept. That you will take time off of work or make an appointment to see a doctor some weeks in advance. This is completely unrealistic in the year 2014. First, the main purpose of medicine has always been to maintain individual and sociological productivity. In order to be productive, people need the doctor after normal business hours. Primary care providers see this as a burden that interferes with their life style. In doing so, they have basically made themselves irrelevant as physicians. They claim there is the alternative of “urgent care” but it has accessibility problems and suffers from the same inadequacies of emergency care, namely the lack of long term history and care. Also let’s face it, when you have a UTI, a sinus infection, an STD, or even pneumonia, waiting 2+ weeks for an appointment with a GP is just not realistic.

So people naturally gravitate where and when they can for care. That is the emergency system. Emergency workers might as well get used to it because it is not going to change. More than getting used to it, maybe they should make an effort to actually be good at it?

What a crazy concept, doctors who actually help people with their problems instead of endlessly referring them through unnavigable systems at a later date when they are sick now. You see that’s what GPs do.

Both of these topics together lead people to “doctor shop”, basically search for a doctor who will actually help with their problem. In the healthcare industry this is viewed in a very negative way. Most often it is labled as “drug seeking” behavior, even when it is for medications other than pain meds. It is in fact drug seeking, but I would say more accurately believing that drugs are the help sought.

It is all really a situation where nobody can win. Providers don’t get to do what they want. Patients don’t get help. Money trades hands and nobody is better off.

I would hope one day it will change. But reality is that it will not. This mentality is absolutely engrained in every medical system I have ever seen. I am opened to reasonable solutions. Even unreasonable ones. I have yet to figure out why despite the world being completely different in 2014 than it was even 10 years ago, medical providers still insist on working and acting like it is the 1800s. I am not even convinced people have the mental capability to change it.