Work in an environment incompatible with life, no experience required… Will train…

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I belong to a critical care email list. For some time now we have been following the Ebola outbreak in Africa. As of today the “official” death toll stands at almost 700, including 2 doctors, and another expected to die. (with an estimate only 25% infected are receiving medical treatment)

Reports from the area state that at least one of the doctors was infected outside the containment zone and it was attributed to a breach in containment procedures.
In the latest part of the conversation, it was postulated, “how many on the list have actual experience or even training on how to operate in an environment where isolation equipment levels above what is found in surgery or ICU was required.?” “How many of you even have such equipment available?”

Needless to say, there were not many of us. You see, hazardous materials training is part of being a firefighter. It also helps to be at a place that has the county hazmat truck as well as several passionate experts on the topic. But from EMS providers, nurses, doctors, etc, we talk about this stuff in school, but never actually even touch it, much less train on it.

We know the phrase “gloves on! Scene safe!” medical providers do not enter into dangerous situations they tell us in school. We talk about cold zones, warm zones, hot zones, decon, etc, but it is nothing but talk, and it is often taught by people who are just parroting what they were taught, but never actually experienced.
By now, you might have come to the conclusion “that is just a tragedy waiting to happen!”

You are wrong…

It has happened. It is happening. It will happen again. Several years ago, when I actually did public speaking for free, I gave a presentation at a university on Chemical, biological, and radiological emergencies. I even included photos of some of my former coworkers from an event I was part of. I have informally taught many of my EMS partners about seemingly obvious hazards like “don’t park the ambulance in the puddle of flammable liquids at the car accident we just responded to.”

As a plug to my Friend Kip, he started a training class on violence against healthcare providers called DT4EMS. In talking with him on the subject, he noticed that there is a culture of talking about provider violence and safety and people who haven’t experienced his course and material are not only untrained, but in some cases are getting “informal” training from people who have no Fucking idea what they are talking about (It’s my blog I can use any language I want). Those same people often have never had any experience in what they are talking about, no education on it, and never actually did the things they profess. (probably why many of them are not in jail to their benefit).

In my fire/EMS experience I have been a part of more than a few mass casualty incidents, including one internal hospital disaster in a major facility.

The biggest lesson I learned in all of them was: Whoever did the planning obviously didn’t know shit about it nor had any experience, because if they had been present even once, they would realize just how shitty their plan was. We ended operating on basically no plan at all many times, because the plan was completely untenable. Not only that all the fancy equipment they bought, that we never even touched before, was completely useless. In some cases it even inhibited our ability.

Another lesson I learned in these experiences is the whole idea of “hot, warm, cold zones” are not static. Just like in provider safety for violence, what was safe can become unsafe for reasons beyond recognition, planning, and control. Now like many “accidents” there are often several close calls before an actual incident takes place. Since I started talking about people killed by Ebola, what that means there were likely several instances of infection control breeches before somebody actually got infected, and died…

I was no there, so I don’t have anybody to ask: In surgery, the nursing staff, and usually all providers present, immediately identify and correct any perceived sterility breech. Was that common in the Ebola treatment facility? Was anyone supervising provider fatigue? How much training was provided in these operations prior to deploying volunteer healthcare providers? In the austere environment (I have experience there too) the techniques and procedures have to be modified for the environment. Was this done? How?

Back to the presentation I gave on hazardous materials for a minute, I actually have the 911 recording of an organophosphate poisoning which involved a specialized hazmat team which took place on exactly the same day as an organophosphate poisoning in a distant municipality that didn’t have trained or experienced providers. The end result, trained experienced providers handled the situation to a positive outcome for all. The B team had 96 of their own hospitalized after exposure and the initial patient still died. Some 500 off-duty healthcare workers had to be pressed into service to care for their injured coworkers. Fortunately, nobody outside of the initial patient died.

In healthcare we have classes like “Advanced Cardiac Life Support” and all sorts of other merit badge style courses. I estimate 70+% of all providers who take these courses (whether mandated or voluntarily) will never actually be present for an actual resuscitation in their work environment in their entire careers! They are forced to take them “just in case…” Having taught these classes for more than a decade, it has been my observation most of these professional healthcare providers who are not professional resuscitation providers have one goal in mind. To do a few simple tasks that are easy to remember while praying or wishing not that the patient lives, but that an expert comes to help them resuscitate the patient.

How much training have you had in person safety? How much training have you had in hazardous materials? How many times have you actually even seen or touched the equipment? Have you ever put on an SCBA? Do you even know what that acronym means?

How about a “Gumby suit?” Think you could start an IV in one? How about when you are hot, physically exhausted, and hungry? For days? How many of you have thought about rotating your working people or even yourself through rest/rehab periods? Ever have any training on mitigating a mass casualty incident or disaster? Any experience? Do you even know anyone with such?

Would you volunteer to go into an environment not compatible with life with no training or experience? You know, like a fire, chemical leak, underwater, space, or a place where a virus that kills more than 60% on the low end and 90% on the upper end of all those it infects?

As of this writing, at least one person who was infected with Ebola in the outbreak area air-traveled and died in another country. There are people in quarantine on 2 other continents who have flu-like symptoms after returning from the area by air.

I am not trying to spread panic about Ebola. I doubt it is coming here or will affect my life in any way in the near future. But I am writing this to point out a major deficit in medical and healthcare. Because while Ebola may not affect you or I, I have been to organophosphate events, chlorine spill events, fires, floods, tornados, and a few other environments incompatible with life. If you work in healthcare or medicine, I suspect one day you will very likely experience these or similar events and patients.

How does your plan look? Who made it? Ever practice it? Do you have the equipment you will need? Do you know how to use it? Do you even know where it is? Forget helping others, are you able to keep yourself from being a secondary victim?

You may never purposefully travel to a hostile environment on purpose. You may never volunteer to respond to a disaster. You may never resuscitate a patient or family member in your life or even witness one. I’ll bet you never asked to be assaulted by a patient at work either. But any of this could happen on any given day.

Perhaps we need to stop talking about it and actually prepare for it? What do you think?

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The statistical power of zero.

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Today I was going through the most recent literature on sepsis. I subscribe to Medscape emails for Surgery, Critical Care, Anesthesia, and Ob/Gyn; basically all of the disciplines that actually contribute to the type of medicine I would ultimately like to be in charge of. (A combination of surgery and intensive care for emergency patients if you did not see the connections).

The Medscape articles are usually not very good compared to many journals. They are more attention grabbing headlines, but as I was reading this one, I was actually more intrigued with what it didn’t say than what it did.

The study was in all respects not worth publishing or reading. 23 patients over more than 5 years, retrospective review. That might as well be an anecdote.
The conclusion was of course the obligatory “This might help but more study is needed.”

But as I was thinking this article was moments of my life I will never get back, I realized what was not written. There was a sound theory behind the treatment. I am not sure it was complete or accurate based on the limited info in the study. It focused more on coagulation than inflammation. As a retrospective review, they tried this on individuals they thought it might help.

If you read between the lines what you come up with is: “Our study sucks, it proves nothing, adds nothing, but demonstrates that some individuals are sometimes helped by theoretical treatments.”

But instead of latching onto that idea and writing it up as an opinion piece, the authors desperately tried to use the scientific method to give credibility to that argument (very ineffectively I might add).

As I keep professing, I know a thing or two about science. I know a thing or two about publishing studies. I may even know a little about medicine!

The medical community really needs to stop trying to fit the square peg in the round hole. We need to recognize we deal with diverse biological organisms, not simply mathematical reproducible physical properties. There are hundreds if not thousands of variables on a given patient. We need to start telling non-medical people this, not trying to deceitfully disguise it is our best scientific wild-assed guess (SWAG) to help people who do not fit into epidemiological guidelines. We need to finally realize that sometimes we might not know why a treatment worked for a given patient, but at the time it seemed like a good idea and it somehow worked.

This may sound like a call for “non-scientific” medicine and I guess in a way it is. Not because I am anti-science or something crazy like that, but because of the reality that we simply cannot produce good science on critically ill patients. In many cases, such patients will die or be permanently disabled under the best circumstances. In order to not write them off as “acceptable losses” we will have to attempt “heroic” measures from time to time. Not always, but perhaps more than we are accepting?

Otherwise, we are simply accepting the joke “the operation was successful, but the patient died.”

Maybe we really should start acknowledging and accepting that there is not going to be a preponderance of evidence for every patient or condition and start having meaningful discussions on practical ways to handle those situations rather than just writing them off as “unscientific”?

Physician Gestalt is not evil. It is and has been an obvious observation for a long time. Why do we continue to treat it as a shameful topic? When has not talking about something ever produced a desired or even positive outcome relating to it? That is exactly like trying to prevent teen pregnancy by not talking about sex.

Sometimes I think medicine is the only profession that constantly devalues its own expertise. That seems self-defeating to me. Why would anyone respect or pay you for being an expert when you constantly claim it is somehow wrong in medicine to possess knowledge or abilities that cannot be replicated by anyone able to read a scientific paper? If anyone could do it, why would we need doctors? If all doctors were equal, why is there any competition among them?

P.S. I didn’t forget to link the study I was talking about, I chose not to because it is a waste of time to read.

You killed the patient!

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Since this extremely well written article has been making the rounds, After a quick read, I thought I would offer some observations. Fair warning, I do not have access to the original paper right now. But I have corresponded with the author in the past and his assessment is usually as good as gold.

http://emsbasics.com/2014/07/19/murder-by-checklist/

There is actually so much to say about this article, it is hard to even begin. But I think it is fair to mention that what happened here is not only found in EMS, it is endemic in all of medicine and healthcare. I see it every day, in every (hospital) department I see; everywhere in the world I go.

It should really not be surprising to anyone. First, most doctors and many other healthcare providers are selected for their initial professional schooling by their past academic success. A large part of being successful in school is not mastering the material, it is mastering the system. Permit me to give a personal example on how this plays out?

On my first day of pathophysiology class in medical school the professor (a former emergency doctor who subsequently got a second specialty in pathology) held up a copy of “Pathological Basis of Disease.” She stated that anyone who really wanted to succeed in medicine should read it. SO logically I got myself a copy. It is a very detailed book, it was simply not possible for me to keep up with the class quizzes of covering one complete topic of patho a week. My quiz scores were often barely passing and I even failed a couple of them. But I had my eye set on the final; because in school, it is all about the final. I ended up with a B in the class, despite reading all 3049 pages of the Patho book. I was a bit disappointed to score lower than some of my friends who discovered reading the USMLE review guide was an easy A. To their credit they often tried to encourage me to give up my pursuit of knowledge for better grades. Some days I should have listened. Strangely enough, despite getting lower grades, I am usually the one who gets called for the consult and dish out information and insight which they usually take credit for on their patients.

I don’t regret it though. In fact after that year of school, I was convinced I needed more review because I could not remember it all. So I spent my summer vacation working and teaching in EMS and I read the book again. All 3049 pages.
I like big, thick, books, I have several I have read in their entirety. However, my ability on standardized tests is a bit wanting. I still place a much higher value on knowledge.

But getting back to the point, most providers made it through school identifying concepts. Not only that they did very well in school.

The first thing you hear in residency after you get out of school is “all of that book stuff doesn’t matter, now you will learn what you really need.” I heard this exact same thing when I got out of paramedic school. I have no doubt some of my nursing friends heard the same. However, it is not true, all that school stuff does make a difference. But you have to be taught how to apply it. When you are not, your practice turns into what was so eloquently described as “Murder by Checklist.”
Another thing that creates this situation is not recognizing the difference between a crutch and an excuse. There are all kinds of courses like ATLS, PHTLS, ACLS, PALS, NRP, and a host of others that were designed as crutches for non-experts. However, they are no longer seen as crutches, but as certifications of definitive knowledge. Many of these courses even state in the text they are not definitive knowledge, but that is just the obligatory warning label. A vast majority of people who take these classes actually believe they have learned all they need to know to expertly manage patients. As one of my marital arts teachers liked to say “I taught you everything you know, but not everything I know.” As an instructor for many of these courses, I really wish I could say that to everyone, but then I would get yelled at.

Think about it, I will use ATLS as an example because the first instructor I ever had for it stated as an opening “this class will not make you a trauma surgeon.” You would think it didn’t even need to be said. After all, if you could be a trauma surgeon after a 2 day class, who wouldn’t specialize in that? It sure beats years of other residencies.

But the same holds true for other providers. “In the PHTLS book it says…” “Back in the day when ACLS was hard…” We’ve all heard it. We have taught people all there is to taking care of patients is a formula. A check list. There are even efforts to introduce more checklists into medicine. This is often compared to the aviation industry. Unfortunately, check lists don’t work as well for biological organisms as they do for mechanical devices.

It is impossible to know all there is to know about all aspects of medicine. That is why we have specialists. But we must always remember the difference between having a crutch until we can get an expert and believing that crutch is all that needs to be known or done.

Furthermore, institutional practices and requirements meant to minimize errors if they are well designed rewards the use of check lists; of doing the same thing repetitively. Some even require it. I was at one institution that required a trial of peritoneal dialysis prior to hemodialysis on patients who were septic and had already had necrotic gut surgically removed. This was in order to be reimbursed by insurance! Think about that, a septic patient, the peritoneum surgically opened, and necrosis in the compartment, it meets all the major medical contraindications for the procedure! But the insurance company doesn’t care. It is cheaper and more than a few studies point out just as effective at filtration. (Even though not one of those studies enrolled a patient that met contraindications to the procedure.)
Finally, there is the fact we are not all created equal. We all don’t have the same education, we all don’t have the same ability. We all have good days and bad days. We all get fatigued, stressed, and hungry. Medicine is simply not like fast food. You don’t get the same thing from the same people or place every time. Because medical and healthcare education is designed to measure the minimum requirements, providers will never be equal. You know the joke, “What do you call the person who finishes last in medical school? Doctor.” Not everyone sees the bigger picture. Not everyone has the theoretical knowledge. Not everyone can apply it. Not everyone can improvise. In medicine or any other occupation. So, you get a checklist.

Now let’s examine trauma for a minute because it directly relates to this case? There are relatively few people in medicine who are interested in trauma. In fact almost nobody is. It doesn’t pay particularly well. The patients are not particularly desirable. It is a nights, holidays, weekends, job. Almost nothing goes as planned. Life/limb/death decisions must be made constantly, often with imperfect information. There is never the right or enough working equipment. It affects people between the ages of 1-44 primarily. (Most non-peds providers go crazy when they have to work with kids.) In the modern world, trauma care is localized, so most providers outside of specialists, will not see much of it, much less severe cases. They will not be attuned to the subtle signs and findings. Plus some things I probably forgot to mention.

I will pick on EMS a bit, because despite many EMS providers calling themselves “trauma junkies” they really don’t know shit about it. I must profess…Trauma affects every system of the body, not just the obviously affected tissues. It does things like change metabolism. It involves more than just the acute bleeding event. EMS providers spend almost no time learning about trauma. What they do learn is often outright harmful. What isn’t is no more detailed than what a boy scout learns. It should not be surprising when mistakes like this were made. It should be surprising when they are not!

I really can’t find any fault with the medics at all! “The operation was successful but the patient died.” They were doing exactly what they were trained, ordered, and authorized to do. I know they were not trained to identify and place indirect pressure to the aorta superior to the hemorrhage cite. From the account, I wonder why the on-scene physician did not accompany the medics to the hospital? He clearly had knowledge and skill which the medics could not replicate. Some have suggested the medics didn’t think. Of course they didn’t! Have you ever seen an interview with soldiers or firefighter or police officers that did something crazy that ended up being heroic? The reporter always asks “So what were you thinking?” to which the reply is “I wasn’t I was just doing what I was trained to do.” In a stressful situation, practiced training will supersede conscious or logical thought unless you are trained to think about the why to’s and where fore’s.

If you want to train people to do that, I am all for it. But it will take much more than is given now. I don’t see that happening.

Of course in the interest of full disclosure, this piece was written by the guy who was once formally written up for discipline for “Not sounding panicked enough when dealing with a critical trauma patient.”

90 day warning!

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Welcome back everyone; it has been a few weeks since my last post. I really did write 2 other posts, but ultimately was not satisfied with the short length or the content might be too soon after the incident to call out.
But I received an official email from the last state I am certified as a paramedic in that my paramedic credentials will officially expire in less than 90 days and I should take immediate actions to stop that from happening…
Not going to happen…
After reading the email, I took a trip down amnesia lane, remembering all the people, places, things I learned, and experiences from my Fire and EMS days. Some were good, others very bad, but ultimately, relegated to the annals of history.
When I started medical school, I had resolved to keep my medic credentials; mostly as a way to show off my street cred after becoming a medical director. “That’s not how it works in the field,” “You don’t understand what it is like,” and my all-time favorite “you are just a spoiled doctor who cannot function outside the confines of a hospital,” are things I heard from medics on an almost daily basis, before resolving that nothing I could do and no effort I would make would ever improve EMS.
It is not that I didn’t realize it earlier. My ambition of being an EMS medical director ended sometime around my second year of med school. Mostly because I was hit in the face with the dual reality that 1) medics as labor group (profession is too unbefitting) don’t actually want to improve and 2) Medical directors are largely irrelevant to EMS. In more advanced nations, paramedics are autonomous; medical “direction” is more of an expert opinion or phoning a friend. In the US, statewide protocols and being forced to write protocols to the absolute most mindless providers makes advancing the practice all but impossible. What is more now that I think about it is agencies don’t want to advance, and will replace a medical director who doesn’t “play ball” which completely emasculates the whole idea of a “director.”
But, as I said, I have worked with many great people and despite peer pressure and all evidence to the contrary, I thought my continued involvement would give something back to the people and experiences that gave me so much.
I have done what I could, it was a good run, and it is time to move on.
“Medical director of trauma, burn, and intensive care” sounds so much more appealing anyway.
Enough of my lamenting for one day, next post back to our regularly scheduled program of thoughts on medicine.