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.
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.”