“I am better than thou art now;

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I’m a fool, thou art nothing”
King Lear by William Shakespeare.

 

Today at work we were talking about well…Sanity…

 

With 5 deaths in 3 days and at least 2 more on the way this week, we had an interesting discussion on how no sane person would choose to work in the ICU. It was the very same conversation I once had at a fire department. Most creatures on Earth run away from death and fire, so there must be something a bit askew in regards our mental balance.

 

One of the doctors opined it is not that we are insane; it is that we are stupid. Most of us are trying to “help people” or at least we believe we are. But in exchange we trade our time, health, sanity, and are not economically better off than any other doctor. In fact, we are less well off than most. He further described we have bought into some sociological bullshit that our sacrifice actually means something.

 

While I sat there listening to him, I tried to come up with a million reasons why he was wrong. However, his argument as to why (I just summarized it here)was both logical and compelling.

 

One of the other doctors I have great respect for shared his opinion that our mission is completely flawed. We have the most expensive and capable equipment (even if it is not always top of the line or new). We take into account most of the patient, and even the needs of the family (opposed to single organs, systems, or diseases). But our mandate is to treat people with 3 or more organ systems failing who have a reversible condition.

 

What kind of nonsense is that? First of all, the molecules that lead to organ failure are an irreversible cascade! Medicine has not advanced to the level where we can interrupt this cascade. We certainly cannot reverse it. So many of our patients get a very expensive and emotionally trying run through of the guidelines while we try to think up heroic measure to help. In almost all cases we identify what might have helped the patient before they got to this state. We say/hear almost daily, “if only they would have done X 4 days ago.” It is almost like reliving my many arguments about EMS treatment guidelines, which can be summed up “please stop doing X, you are just making it harder down the line!”

 

In my lecture about first aid for the non-medical provider, I have a PowerPoint slide of a response I was on with a FD rescue company. The bullet points are: “It is better to have help and not need it, than need help and not have it! Call early, call often.”

 

Why isn’t this same concept used in medicine? Is it hubris? Ignorance? The desire not to be responsible? The desire to not look incompetent? Pissing around the corners of our little kingdoms in order to protect our turf?

 

Now that we have restated the problem probably for the millionth or so time, let’s look at what we know. 1) It is easier to prevent an emergency than to reverse one. There are some studies that show in hospital emergency response teams have no greater impact on survival to discharge when responding to a “code”. The solution is going to be to prevent the arrest. 2) There is not, nor will there be enough intensivists or emergency experts to put one on every hospital ward. This leaves us with only 2 options. A) Said experts will have to respond outside of their respective department or B) Said experts will have to routinely be outside of their department looking for “trouble” patients. Perhaps a bit of both might work better?

 

I have noticed that most specialists fall into a rut in terms of their diagnostics and treatment. In fact, I am convinced what “specialization” really is about is training in repetitive tasks rather than knowledge. Various critical care experts are trained and repetitively look at the whole patient. No other specialty actually does that. Even internal medicine subspecializes or deals only with chief complaints. However, defensive medicine of running every test imaginable is neither economical nor practical.

 

In one of the books I do editing for, the author very accurately and scientifically describes what he calls “the human animal” or “gut feeling”, and of course advocates “listen to your gut.” The summary of his writing is basically: we are bombarded with sensory input, the brain attempts to prioritize certain inputs in consciousness, and the focus of our perception is not our total perception. We must understand and train ourselves to recognize when there is more than meets the eye. The mesenteric nervous system may or not be involved to certain degrees.

 

Some patients providers know or have a strong indication are going to be train wrecks. They come in with multiple major pathologies. Their file is so large it lags every computer on the network when you open it. You have seen them so often you know their medical record number and wonder what of their many problems it is today.

               In the spirit of “call early, call often” it might work out if these patients triggered an automatic critical care consult? Perhaps not at the very moment of presentation, but in a timely manner. Within this population, certain patients would be flagged for closer observation, additional testing, and follow up during their hospitalization before needing admitted or transferred to an ICU or higher level facility. A similar problem in tertiary hospitals and outside hospitals is that once the problem is obvious, it is usually too late for the patient. A multi-disciplinary approach would probably be best. Especially where there are strict delineations of practice and authority. Some patients may even be pre-emptively transferred to the ICU.

 

We must also recognize futility earlier. “Reversible” is part of the ICU criteria. The contracted nursing home patient with pneumonia, previous stroke, and GCS <8 should not be a candidate for the ICU. This should be a palliative care consult or treatment plan. If IV antibiotics in the geriatric ward do not work, a vent in the ICU sure as hell won’t.

 

Obviously, there is a balance that needs to be made between admitting every patient to the ICU, dumping palliative care and otherwise futile patients in the ICU, and taking care of patients on medicine wards. The current way medical specialties are practiced does not lend to that balance. Certainly the practice of “punting” does not. But without some kind of change, the non-ICU services are not going to take care of people with more than 1 organ or pathology with any sort of efficiency. The practical and economic consequences of this are significant. Not to mention it makes the ICU not only undesirable from the standpoint of the amount of work to do, the constant futility and dealing with death and grieving family members will drive more practitioners away resulting in largely second rate care by any “band-aid” solutions that come along.

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Paramedic vs. Nurse. The doctor’s definitive edition.

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Last night and this morning my Facebook page exploded with articles about The California nurses’ unions and association opposition to a community paramedic program. Not surprisingly the EMS group thinkers got together and have a million reasons why nurses are wrong. The usual utterly misinformed statements appeared, “we don’t need a written order like nurses do”, “nurses cannot handle being on the front lines”, and even EMS leaders chimed in with “we have overlapping training so we can do nursing too; I have nurse friends that say so!”
For those of you who do not know about me what is important for this article is, I started my career as a firefighter who did not want to do EMS, ever. I was forced to become an EMT, I was forced to become a paramedic to work on the fire department. At no point in time did I ever want to do those things. What I wanted was to rescue people. I did however seem to possess a special talent for medicine which was noticed by my peers and superiors alike. After a couple years of being a paramedic I had a “eureka” moment. (My strictly EMS colleagues have said I had seen the light and repented.) Rescue is all about a patient. When it is not about a patient, it is no longer rescue, it is a recovery. You cannot possibly be expert at rescue unless you can take care of the person you are rescuing. (Some fire departments try to separate this into a team task in much the same way as surgery and anesthesia with varying degrees of success) My career has never been driven by what I should do. It has been driven by what I have had to do and what I want to do. After some years of being a paramedic I was encouraged to go to medical school, which I did; with the desire to be both a surgeon and intensivist. Much like rescue, I have discovered you cannot be truly great at trauma or resuscitation without the skills of both. You can get by, many places have a team approach with varying degrees of success, but my unrelenting goal is to be the very best. I take the time to explain all of this to qualify, having “worked my way up” from the bottom, I know, have seen, and have done every part of every step on the way. I have spent holidays, nights, weekends, and blood with every level of healthcare provider and allied health professional there is. I have not only friends, but the best friends anyone could ever hope for among all of them.

Therefore I state:

In the matter of community paramedic programs, I think community paramedicine is the future of EMS, whether any of us like it or not is inconsequential. Everyone knows it is better to prevent emergencies both for the potential patient and for the economics. There are so many calls for help all over the world, that no EMS agency in any country (I have cared for patients in 5 different ones) can possibly be successful as responding after the fact. There must be “preemption.”

Now then, having covered all of that, I agree with the position of the CA nursing bodies 100%. US paramedics are not ready or capable of taking up the role of community healthcare provider.

I must single out US paramedics because unlike their colleagues (“peer” is definitely not accurate) in the rest of the world, they are trained without being educated (to varying levels) and therefore cannot be effectively licensed as independent providers responsible for their own actions. Some states have taken to “licensing” paramedics but it is what my lawyer and paramedic friend Skip calls “differentiation without distinction.” US paramedics function under written standing orders. (You can see where the common paramedic argument of we don’t need a doctor’s permission is blatantly misinformed.) Part of making US paramedics ready is the ability to “cut the cord” and permit them to practice without a doctor ultimately being responsible for them. Doctors are not responsible for nurses like they are for medics. Nurses can practice nursing without the oversight of a doctor. US Medics cannot.

The next major hurdle is education. US paramedics as I have stated before do not possess the education required to be a healthcare provider, neither at home nor in the emergent setting. They have a rudimentary understanding of information that permits the use of various interventions under the orders of a physician. A fair few of them take it upon themselves to go beyond this, but that is the decision and ambition of individuals, not the industry as a whole. In most first world nations and many developing nations, a US paramedic does not have enough education to get reciprocity. This is not true of doctors and nurses. (and in some countries even chiropractors)

In order to become more than a technician, US paramedics must get a formal education. Society demands it, other healthcare professionals demand it, and the very act of taking care of patients demand it. It is more than just about money. US paramedics don’t know what they do not know. That is fine when all of your decisions end with “call medical control or drive to the hospital.” It is not ok when deciding who and when patients need to go where for further healthcare. There have been actual studies that show US paramedics cannot effectively decide who needs to be admitted to the hospital and who does not. That is a critical skill when it comes to taking care of people at home. It is perhaps the most critical skill. Another major part of healthcare education is learning the rare cases and “what if’s?” This is where nursing is actually weakest compared to medicine. But nursing is far ahead in this area compared to US medics. This is another essential skill for home healthcare. Finally one of the reasons “additional training” for paramedics is not adequate to set paramedics loose on home healthcare are the questions of how and why?

During my time as a doctor in Afghanistan I saw many patients who were in worse condition than was reasonable or severely mistreated by medics at remote locations who were given extra “training” and tried to care for the non-emergent patient. This is not a negative judgment about providers who were doing their best under the most extreme of conditions. This is acknowledging the fact that such a system does not effectively work. Giving patients ibuprofen until they have nephrotic syndrome in war is an accident and a risk of the environment. In the civilian world in a modern western country, it is criminal. That is but one example but I could write a book on the failures I have witnessed.

Some systems in the US have already instituted community paramedicine and are having success with it. So how does this affect my position and opinion?

All of the programs I have been familiarized with are not actually providing healthcare. They are filling a needed role for certain, and being successful and preventing the need for EMS and hospitalization by doing things that people without training could do, things that people without training do on a regular basis; things that some patients even do themselves. These paramedics are however doing these things for patients and family who are not doing them.

When you start talking about  addressing medical issues or seeking out care as opposed to routine tasks like taking a blood pressure, making sure people have medication or are taking as instructed, getting to dialysis or the doctor on time, you have entered a whole new world. Nurses are educated and must receive specialized training to do this. Medics taking what amounts to a few more hours of school reminiscent of a merit badge course like CCEMT, ACLS, etc, simply are not going to have all the information they need. In order to have any level of purposeful success and not just get lucky with the occasional tragedy, one must possess a basic underlying knowledge that they can apply to all aspects of patient care. This is the knowledge gained in degree programs like nursing and medicine. It takes years to effectively gain and understand that knowledge.

Permit me a personal example? When I was in medical school, one of the most respected anesthesiologists I ever met and whom I still hold in highest regard, flat out stated to our class during an operation “I could not pass medical school today.” He went on to explain to us that when he was in medical school (he is an old guy) biochemistry and molecular biology were not even considered science. They had no idea what it was or how it worked. Back in the day he knew “enough” to practice his specialty. He learned on the job as he went as he needed. His generation is almost gone from the earth.

Today, that level of knowledge with on-the-job training is inadequate; for doctors, for nurses, for paramedics in every country outside the US. Imitating what one sees (similar to US paramedics doing “research”) is not the same as knowing what one is doing. It is not acceptable in any industry. If a person was able to imitate all the skill requirements for a US Marine to pass basic training but does not actually enlist in the Corps or complete basic training is he permitted to function as a Marine? To call himself one? Obviously the answer is “no.” That is the exact same thing other healthcare providers are trying to tell paramedics. That is exactly why they rightfully oppose community paramedicine in this day and age. Until paramedics go through the same “enlistment” and “basic training” aka accredited official college or university which confers a degree attesting to having learned the basic material and met the minimum requirements to get their piece of paper, paramedics are imitating other healthcare providers like in my marine example above. They are expecting to essentially call themselves “marines” and function in the field without really doing it the official way. The internet today is full of examples of paramedics and even their leaders trying to justify this. Many have convinced themselves it is ok because they are somehow “special.” (I guess it could be called “special education”, but in the most derogatory way possible.)

I am not anti-medic, actually, myself and many would claim I am quite ready and able to help medics. US paramedics should be doing community medicine. They must be doing it in the future. But as the CA nurses pointed out, they are not ready yet. They do not have what it takes. But the only thing stopping them is their useless groupthink and lack of desire to do what it takes to be recognized as a peer of other healthcare providers. There are no secrets. It takes education. Everyone has been telling US medics that for decades. No exception will be made. Quit being laborers masquerading as healthcare professionals and then bitching when recognized healthcare professionals call you out on it or tell you that you don’t measure up. Quit telling yourselves that somehow you are special and do not have to do the same exact basic things everyone else did. I am tired of listening to all of the US EMS windbags. Step up and do what it takes or shut up and sit down. Then we will talk about money and respect and all of those other things. If I have done it, you can do it.

It is not nurses or firefighter or doctors holding back US EMS. The only thing holding US EMS providers back are themselves. Being great is like the ultimate Teflon. People can sling shit at you all day, but nothing sticks. With demonstrated capability, greatness stands on its own merit. Nobody can take it from you. Nobody can reasonably challenge you. Nobody can hold you back.

Smile, you’re on candid camera!

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A few minutes ago one of my friends shared a Facebook post about police officers wearing a camera on their person while working. It described how use of force went down 60% and complaints went down 88%.

My first thought on the matter was “this would probably be great in EMS!” For much the same reasons as the Police have benefitted.

But as I was pondering the idea further, I remember that in one of the ORs there is a camera set up in the surgical lamps. Multiple ORs have giant digital displays for CTs, angiographs, ultrasounds, laparoscopes, etc.

Why don’t all ORs have cameras? Why are DVD recordings of a patient’s surgery not included in their records like their radiology reports? Sure it may cost a bit more, but once you close somebody up, nobody will ever know again what was seen during the operation. Taking it one further, pathologists dictate their findings and observations as they do an exam. Why do surgeons not do this? Go one further and review these recordings in a debriefing. Professional athletes and racers watch video of their games and races. They watch other games they were not part of to analyze various aspects that might benefit them in the future.

I think there is a great opportunity with this technology that is being missed. What do you think?

I also think this is the shortest blog post I ever wrote.

Customer satisfaction survey

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Many years ago I was with a friend sitting in Taco Bell. We were talking about things we normally talked about at the time, video games, why girls didn’t like us, video games, roleplaying games, plans for taking over the world, etc. As we started to leave, we noticed a stop sign on the door. Underneath the word “Stop” is said “are you leaving fully satisfied, let us know, we are listening.” My mind being what it is thought this could be a really great thing to put on my bedroom door. (Not that there was ever anyone in my bedroom at the time who would offer a comment on it) But the marketing and public relations people over at Taco Bell seemed to think that actually asking people if they were happy and why or why not could improve their business. You see, knowledge is power. You can try to guess your customers, patients, John’s, punters, (whatever you want to call them) are happy or not and the reasons why. But seeing things from your own point of view will likely lead you to believe nothing is wrong or erroneously conclude what is wrong.

When I teach, at the end of every class, there is a survey. There are the obligatory bubbles to fill in of “fully satisfied” to “very unsatisfied” on the 1-5 scale. But more important I think are comments. I encourage people to comment. I am told soliciting comments weakens the value of the survey, but knowing you did something that made people very satisfied or very unsatisfied doesn’t actually clue you in on what you did well and should keep doing, or what you really don’t do well and should stop or improve.

Recently there is a lot of talk on customer satisfaction surveys in medicine. In every discussion is the obligatory mention that happy patients have worse outcomes according to some study or another. It basically uses the scientific method to create a study and enforce our point of view that we are right and therefore patients must be wrong. Unless of course they give good reviews, then we can just chalk that up as they “get it.”

Now in some countries, these surveys are mandatory. In some they are an optional effort to improve. But they usually have a bunch of questions that don’t really address patient concerns.

Because of my experience with this from teaching, I just outright solicit feedback. What did you like? What didn’t you like? What would you like to see changed? When I or my family go to the doctor (that’s right, I don’t take care of everything myself. That is like a lawyer representing himself with facts he believes are true and doesn’t actually know. Plus I don’t have all the equipment needed to take care of people properly at home.) I am sure to tell them what I liked and didn’t like. They don’t always appreciate it I am sure.

I have said it many times. I will say it again. Modern medical systems do not work for patients. Not because they wanted antibiotics and didn’t get them. Not because they had a treatment plan they found on WebMD and the doctor didn’t verify that they in fact have the most rare cancer known to man and are going to die in hours.

But here are a couple of observations of mine on what is not working for patients.

The medical system does not respect the patients’ time. It is a primary care provider who is constantly late, the surgeon who “get’s around” to talking to the family post operation, the call center that tells patients they can get an appointment for their UTI sometime next year, or that most services only operate on bankers’ hours when people who need care actually have to go to work or school.

As providers, we have all kinds of excuses. The paperwork needed done, there were “complications”, X amount of patients needed to be seen, etc. The fact is there are not enough doctors. The system needs to increase the amount of them. In fact, I know of absolutely no medical system in the entire world that has enough doctors, much less, too many. Bottom line, it doesn’t work for the patients.

Providers do not take the time to explain things. You see, we work in the system. For me it is like a second home. I know how long everything takes to do; I know who is on what list. I know the pathophysiology of diseases inside out. If I don’t know, I look it up, and then for at least a few days, I know. I know the guidelines. I know what diagnostic tests hurt and which ones don’t. I know why we are doing them and what I want to see or not see to help me make a decision on something. Patients don’t know any of that. They are lucky if they called the correct number to go to the correct provider. Even before we can “explain things” in their language, we need to tell them what to expect. Simple things like: “you are not about to die and the blood test results will take between 45 minutes and 2 hours, for reasons beyond our control.” “You will get an x-ray today, I do not know when. It could be in minutes or hours.” “I will tell you what I find out or know as soon as I find out.” “You are going to have to come back.” “This is not going to be better by tomorrow morning and you will miss work.” All of that information is needed or desired by patients before you start “speaking their language” when talking about their illness and treatment options.

I draw on my teaching experience when talking to patients. I know a major part of my job is teaching them. Have you ever been in a class where the teacher explains something for hours and despite everyone looking at each other with utter confusion, the teacher then asks “does everyone understand?” (Everyone nods yes) “Does anyone have any questions?” (Nobody has questions) Because nobody wants to look dumb? Because their brains are basically toast because it was too much info in too short of time? Because you are such a dull speaker nobody wants to listen to you another minute? For any number of reasons not mentioned here? So class breaks up and everyone leaves. The exact same thing applies to patients!

This was really driven home with me when I was working in an ED. A 13 year old boy had fractured his femur riding an ATV. He was lucky that was all, those things are death traps. He was being supervised by his grandfather and as the official supervising parent with the inability to contact other parents; an orthopedic surgeon offered him 3 treatment options. Said grandfather did not understand exactly what those options meant. So he asked. Our orthopod went on to describe plates held together by screws, pins inserted lengthwise through the bone, and listening to it being told in “common language” I laughed about how if we were outside the hospital, we would probably be tried for crimes against humanity for planning such things. In the end, grandpa was doing his best not to faint or vomit, he meekly managed “whatever you think is best doc.” This man did not understand the procedures. He had to be taught exactly what they were. He was totally lost on “growth plates” and “medullary canals” but when broken down into “we are going to screw a plate to his leg.” He understood perhaps more than he wanted. The orthopod was not “explaining” the procedure or treatment, he was teaching him what it was! Teaching and explaining are not the same thing.

I might be wrong! I tell that to every patient. I am giving you my very best opinion. Based on what I think. I tell them why I think so. I show them my evidence to support it. I explain what could be beyond my ability to predict or correlate. I tell them why I don’t do certain things. I make sure to remind them I cannot promise any outcome, but I will give them my very best effort. I tell them this because while every healthcare provider in the world may know these things, patients do not. They need to be taught how medicine works. What its limits are. That it is not McDonalds where you order off the menu and get exactly what you ask for.

It does take a few moments to do this, but I find that not only does it make the patient more at ease; it builds their confidence in me. It also reminds us both I am not all powerful and all knowing. We laughed when Donald Rumsfeld said it in a press conference, but there are known knowns (things we know we know), there are known unknowns (things we know we don’t know), and there are unknown unknowns (things we do not know we do not know).

Finally, I like to ask whether the patient understands, regardless of if they say “yes” or “no” I summarize it anyway, just like I do when I teach students. Then I ask what they liked, what they didn’t, what they would like to see different. I acknowledge their gripes, even if I have to admit to them there is nothing I can do to change it. I do what I can to adopt what they suggest will help; not only for them but for other patients.

Satisfaction surveys do not change how I practice. Issues are addressed with patients most of the time before they wind up on a survey. I also get a lot more and nicer compliments than many of my peers. Not because I am any more deserving of them, but because I use patient feedback to work for me. I understand that patient “needs” usually have nothing to do with medicine. Certainly they have illnesses, and those illnesses need treatment. But illness does not affect patients. What affects them are the consequences of the illness. How does the illness change their life, not just what symptoms does it cause.

Some will chalk this up as “good customer service” but I think it is actually more than that. I think it actually understanding what the patient is trying to say or ask. Giving the patient what they expect will never satisfy them. Their demands are unrealistic. We must teach them what to expect, making every effort to under-promise and over-deliver. Not only does that take the fear out of the satisfaction survey and make it something to look forward to. It provides more effective medical care.

No doctor should be focused on what they are not going to do or give to patients. They should be focused on what they are going to do or give them.

One more thing…Most patients really hate paternalism. Treating patients like that should be for an exceptional few, not as a rule for all.

The war on sepsis.

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A friend of mine posted this article:

http://www.psmag.com/navigation/health-and-behavior/alarmed-pediatric-emergency-care-u-s-85922/
It talks about the need for guidelines, checklists, various specialists, and simulation to improve medical care in the USA.

As we know though, despite all of these things, the US spends more on healthcare than any other country in the world. Several years ago the New England Journal of Medicine published a WHO study showing the USA was at best 42nd and at worst 47th in effectiveness of all the countries surveyed.

One of the things I noticed when I read the paper was that in order to fare worse, you had to go to Africa or any number of underdeveloped nations in the world.

With all sorts of specialties, technologies, guidelines, and checklists, the lack of effectiveness of US healthcare is often attributed to greed. But while reading this article, I am starting to have my doubts.

You see, in particular the UK, and more and more other countries are starting to follow the methods of the US healthcare system. While I have not seen any papers on effectiveness, many of the providers I talk to regularly seem to feel that the level of patient care and outcome where they are is noticeably decreasing.

The solutions seem to be basically doubling down on the same things that are already being done. More hyper-specialized medical practitioners, more expert consensus guidelines, checklists, simulators, and merit badge courses which must be regularly recertified.

I don’t harbor any doubt that these things have been, are, and can be beneficial. But what I have noticed is that these solutions were once adjuncts to good medicine, now they are the definition of good medicine. Like any crutch, it is just not as effective and an actual leg to stand on.
The first rule I ever learned in respect to resuscitation was “get ahead of the pathology.” In other words, anticipate and work to mitigate what happens next. I have noticed this takes a combination of experience and formal education. Basically learning what to expect when and then managing it before it becomes a critical issue.

Sun Tzu is credited with saying ““Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat.”

So here is how The Art of War applies to medicine…

Checklists, guidelines, protocols, merit badge courses, simulators, etc. are all tactics. They do not constitute a strategy and they are reactionary in every respect. “If/when you see X, then you do Y.”

Doctors for the most part practice reactionary medicine. A great example that I am proud to not be a part of is antibiotic therapy in women. You see, from experience, I know that when a female takes clindamycin they almost always get a major yeast infection. The same holds true when they are on multiple antibiotic therapy for actual or suspected STIs. So as part of my routine practice, I prescribe the fluconazole with the initial therapy with instructions to take it at least 3 days after the stopping of the antibiotics. Knowing what antibiotics do to upset the natural balance of microorganisms, I anticipate what pathology is next. I address it before it becomes a problem. Before the lady has to make another appointment and suffer to get relief. Some Gyns would suggest instead lactobacilli, but it takes time and doesn’t always work. I like to go right for the money shot. Patients seem to appreciate it.

The same is true in the ICU. You can wait until you see clinical signs of XYZ, but in many patients, my colleagues and myself can tell you it is simply a matter of when, not if. Sepsis in children is a great example. A septic child in decompensated shock can have a normal BP, a normal pulse, and a “normal” urine output. That is to say the volume of urine is normal. (The content is not) If you do not anticipate an abnormal content, there is no reason to test for it. Treatment can be delayed until the child crashes, which is usually when they start to actually “look bad.”(active dying in a child usually looks bad) Of course at this point resuscitation attempts are often futile.

Putting this in the context of the “outside facility” mentioned in the article, many outside providers are usually in deep before they realize a transfer to tertiary care is needed. At the same time, they are operating with the purpose not to need to refer every patient to tertiary care. They know the surviving sepsis guidelines. They know ACLS. They are skilled at following guidelines. They are likewise shocked when they don’t work. Some even protect their sanity by the idea “sometimes no matter what you do shit happens.” (Which is true, I just doubt as often as they accept.)

Medicine in general has a known strategy that is taught in every medical school I have ever heard of: Primary prevention, which is preventing the disease to begin with. Vaccinations, Well child checkups, industrial safety, public safety, are all examples of the strategy of primary prevention. Secondary prevention: Stopping the disease from getting progressing or slowing its progression. This is where a major part of medicine fails. You see, most doctors believe that secondary prevention is exclusive to the primary care provider. (Note to Emergency docs, in 2014 you are a primary care provider! Your opinion on whether or not you should be is not relevant to the fact.) But many specialty doctors, and surgeons especially, do not even consider, much less practice secondary prevention. But it is still a relevant part of the strategy, just on a smaller level. It is the practical application of anticipating what happens next and taking steps to prevent it. Here is an example. Whether or not you practice vascular or cardiac surgery, you operate on blood vessels. You know the parts of these vessels. You know about the clotting cascades. You know when you expose vWF you are going to have clotting. That is why these patients are heparinized, to prevent their condition from worsening. The same holds true in resuscitation. Your prevent hypothermia in trauma patients because it causes clotting disorder. You do not wait until your trauma patient has a clotting disorder to warm them. You anticipate and stop the disease process from worsening! The final part of the strategy is treatment, attempting to return the patient to as close to normal as possible. All the drugs and surgeries and stuff are tactics to effect these strategies.

If you are practicing in a reactionary way, you are simply making noise before your defeat. All the guidelines and simulation in the world will not help. A million super-specialists doing the same will not help. You will spend a lot of money doing it. Your outcomes will not be better.

You must think and act differently. You must act before you are forced to react. You must anticipate; in order for that you need education on how things work and why. You need to think strategically, not just tactically. Do not forget secondary prevention! Stop the disease from getting worse.

Nobody was ever septic before they had an infection. The next time you hear “it is just a virus” remember that opportunistic infection is secondary to viral infection. If you are worried about antibiotic resistance, don’t. The theory of conservative antibiotic administration is fundamentally flawed at the basic biology level. Plus, I offer you my loyal assurance, as soon as there is a market for newer better antibiotics, a lot of smart people will get a lot of money to make them. All organisms evolve over time, the idea a single treatment will always work forever is just stupidity. Don’t leave that kid to get better or worse on their own. Prevent them from getting worse. That is the secret to better sepsis care.