The brilliance of simplicity

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Anyone who knows me would never claim I am simple (at least not if they wanted to live). When I look at the world, or any given problem, medical or otherwise, I see a myriad of interconnected variables from diverse topics. Consequently, it is hard for me to call up compartmentalized information, but I have become quite skillful at dealing with dynamic situations or complex problems.

One of my former co-workers was not particularly valued by the company because of his incredible ability to explain very complex things in a way that was so simple, it seemed obvious and without any loss of accuracy.

In fact he once famously wrote the summary of a cardiac arrest call we were on simply: “Found patient pulseless apneic, followed Asystole protocols to termination of efforts.” Was the patient assessed? Obviously. IV initiated? Clearly. Intubated? (since efforts could not be terminated in that service without a tube, it must have been.) Proper doses of medications at proper times? For sure (they were spelled out in the protocol which we followed). Detect any reversible causes? Nope. Then we would have treated and documented them.

You simply cannot deny the brilliance.

Today, one of my friends still involved in the fire service posted a meme to Facebook that said “failing to train is training to fail.” I found this to be equally brilliantly simple as the code summary above. I see medicine fail to train every day. In fact, the only things medical providers train on regularly is CPR. Some studies have shown that is because medical providers are not very good at CPR. But it makes me wonder… Do medical providers do every other thing so well that studies show they do not need to train on it? I have my doubts. Even in specialty training, much of the “training” is indirectly supervised. So it is not really training, it is more like reviewing the act of figuring things out on your own, and often after a mistake. If somebody notices.

The failures of this system are readily visible and inevitable. People are doing whatever they thought of until either something goes wrong or somebody sees them do something wrong. What if nobody ever sees? What if the first time something goes wrong somebody dies or is seriously disabled?

Here is a real life example. I happened to be in a gynecology ward. In said ward was a patient who was in early childbearing age. She had complications of a laparoscopic surgery, which was converted to an open surgery, which resulted in what was reported to me as “excessive bleeding” and ultimately a unilateral salpingectomy. This of course prompted me to inquire; “What was the impetus to do exploratory surgery on somebody in her age group?” After all, I was there to learn, and I am not an expert at the field and could think of no epidemiological reason, so I really expected to hear some awesome clinical pearl nobody bothered to tell me or write in a book. I was then told that she had elevated cancer markers. So, being a bit naïve as to how “expert” specialists really are, I just blurted out “isn’t gonorrhea in the differential of elevated cancer markers?” At which point a very uncomfortable silence was observed. I thought I should make every effort to be quiet and disappear from the room and did. I later cornered one of the specialists and asked “I thought you were only supposed to use cancer markers to look for recurrence after surgical cure?” I was then let in on the fact that sometimes older doctors do not know all the latest guidelines in medicine because they are so comfortable with their routine; they will not change it, even if presented with evidence. They even have a standard line as to why new practices aren’t valid. “I have experience, and when you have been doing this as long as I have, you will understand.” This whispered dialog between me and the doctor filling me in continued with the question: “So why has she been in the hospital so long?” The answer? Because she was being carefully watch while undergoing treatment for PID and the attending physician who decided she needed exploratory surgery based on her elevated cancer markers thinks she will likely lose the other fallopian tube as well. My final question: “then why isn’t she on steroids?” After another uncomfortable silence, I decided I should not inquire further.

Now while anyone can make a one off mistake, have a bad day, not have enough coffee, etc, I noticed there was a pattern to this particular doctor. He is fully “trained” and licensed. Nobody ever corrects his practice. He is essentially doing what he taught and reinforced himself to do. He has trained to fail.

While tragic, it is not exactly scary. What is scary is I witness it every day, in every department I go to. I recall witnessing the same behavior when I worked in the US. I recall witnessing the same behavior when I worked in Afghanistan. This is not an isolated incident of an isolated doctor in an isolated country. This is everywhere I have been. I can only conclude in my pattern identification method of thinking, that this must be a problem everywhere.

So let us get all medical and diagnose the problem. Physicians are not training to succeed. They are not training in how to think. They are not training themselves to life-long learning and the desire for it. The ones who do are the exception, not the rule. They are mastering the system. 1. Get into medical school. 2. Get out of medical school. 3. Get into specialty choice. 4. Finish it and go do whatever. More often than not “whatever” is a set of behaviors and thought process akin to low level labor. Just like the old Duncan doughnuts commercial, “time to make the doughnuts.”

It is clear; we must train doctors to succeed. We cannot train them to follow a wrote set of behaviors with any level of effectiveness. We must train people how to think critically. How do we do that? Where do we start? Maybe scientific based entrance exams are not the way? Maybe quantitative analysis of study habits is not the way? I am still thinking on a solution, I have none. But the problem is rather obvious.

Medicine is failing to train, it is training to fail.

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Morals are too expensive for the poor

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When I first got involved with Fire and EMS, it was in a middle class suburb. That morphed into an upper class suburb, went into small towns, and eventually led to poor areas like the inner-city and rural America.

The morning of my first full (and busy) night in the ‘hood, just before shift change, there was what at the FD we call a “still alarm,” aka somebody walked up and rang the doorbell. She announced to us that she had just overdosed on crack cocaine. We led her into the station and sat her on the tailboard of the truck. As we went about assessing her, I found myself with the IV supplies and searching for a vein. I found a sliver of the median cubital vein in her left arm. (The term antecubital refers to the surface anatomy, not the vein) As I began the alcohol prep (we did not yet have chlorhexidine) she looked at me and said “oh honey, don’t use that vein…I save that for when I score some morphine.” Without a pause, one of the most capable and experienced fire/medics I ever met looked at her and said “Do I tell you how to smoke crack? No. Don’t tell him how to do his job!” Judging from his next comment I probably had a very incredulous look on my face. “The mayor will not be right down to this neighborhood to tell me to be nicer to people unlike in those suburbs you came from…” With the structure fire the previous evening, extricating the body out of the trunk of a car that was set on fire to cover up the homicide, learning that I could really say what was on my mind to the patients, I knew I was where I belonged, in the eye of the storm.

For my next job (my first EMS only job) I told the hiring manager I wanted the busiest station in the ‘hood and I would accept no other assignment. He looked at me and after a long pause, in a very low voice, said “Nobody has ever asked for that before. In fact we have trouble even staffing that station, it is one of the busiest in the state.” So after agreeing that assignment was a condition of my employment, he gave me directions to get there so I could go and meet my coworkers before I started.

When I got there, I was not surprised to find a station full of the most capable medics in the US and probably the world. They were certainly not the corporate poster boys and girls. We had good times and more than a few stories that are stranger than any fiction ever written.

Upon returning to my home, I had a brief period of employment with a company that was staffed by a bunch of small town yokels who thought they worked in a ‘hood. I lasted about a month before I was back in the ‘hood where I belonged.

But aside from perhaps being “tainted” and losing most of my diplomatic skills or even desire to have diplomatic skills, I came to really understand what it means to be an inhabitant of this socio-economic environment. They face a reality similar to war. There are never enough resources; people do what they must to survive. Education is more of a luxury than a requirement. Death is an everyday fact of life. Laws are made by people who have no connection to this world, and enforced upon its inhabitants with no regard to their reality at all.

This leads them to not only have an innate distrust of authorities, but it also subjects them to the criminal justice system very frequently which further exacerbates their poverty and crushes their social mobility. It means when women who are prostituting themselves on street corners get picked up by the law, not only do they have to live with selling themselves for money, often taking drugs to cope, but the money they gained from it pays bail and a court fine instead of putting food on the table, cloths for school, or gifts under the Christmas tree; the same for drug trafficking offenses and a host of other “moral” crimes.

Here in Europe I have witnessed a similar pattern in issues revolving around gypsies and more and more other poor and disadvantaged people of more traditional and national populations. It has been made shameful to be poor, but not enough resources are allocated to break the cycle of poverty. All the while the rest of us lounge in Starbucks and eat Sushi delivered to our door, while planning our next vacation abroad.

This all sets the stage for what is bothering me:

Healthcare providers who treat the poor and destitute with contempt.

“You called the ambulance at 3am because your kid has a fever?!” Yes, they did. They are not educated healthcare providers. They are scared because they don’t know what to do and actually care about their kid. So they called for help. But often instead of using this opportunity to teach and explain, they are berated and told they improperly used the EMS and ED. Then when I question healthcare providers why they didn’t educate the patient or family, they claim it is too much of a risk because they will be responsible if the kid gets a fever and the family doesn’t come to the ED because it may not be so simple next time. (If you don’t see the hypocrisy in that read it again.)

The same is done to sex workers who are pregnant, have STIs, or were assaulted/abused. The same happens to the alcoholics and drug abusers who are self-medicating themselves for a host of stressors of their life. Going to the psychologist for some talking sessions doesn’t change their problems or their stressors. Here, like in the US, there is less of a stigma being a drunk than being crazy. Many of these people fall through the gaping holes (not to be confused with cracks) in social support systems. Here, some don’t even have their paperwork filled out for their government provided healthcare. In the US, the situation is much worse for the poor; especially the working poor, who may have no access to healthcare or social support at all. Even if they are eligible, they will be socially ostracized for being “lazy,” etc.

Yet healthcare providers of all types are quick to express to these people how distasteful they are at every opportunity? They are quick to berate and cast judgment upon them for their choices, giving no thought or reflection that they do not have the same choices we do. This animosity is amplified if the person in question is an immigrant or asylum seeker.

So how did people who usually get into health fields to help people become so critical of people who need the most help? How can this be changed? Education? Peer pressure? Mandatory time working with the underserved? Since we cannot change the reality of the poor, we must change our perception of them. We must remember that we want to help people. That implies all people, not just the ones we find desirable. Strangely enough, the most positive impact comes from efforts to help the least capable. They do not live in our world. We cannot hold them accountable to our morals and desires. This problem is endemic in medicine today. It will not be quickly or easily solved.

One thing is for certain, we must move in a different direction than we are going. We must become less of “professionals of high society” and go back to our roots of being non-judgmental and trusted friends and advisors. Strangely enough, this seems to be the exact same problem and solution that is being addressed by the current pope in regards to clergy. While it may be a sickness of society and not just healthcare providers, we must be the leaders for change.

We interrupt our normal program to bring you this message.

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Still a post about conflict, not about medicine, and certainly not for the faint of heart or mind.

Looking ahead, looking behind.

It is Sept 11th 2014, 13 years after the famous terrorist attacks on US soil. Today my Facebook page is already full of memes and posts about remembering “first responders”, American unity, and the defense of liberty.

While I remember what life was like in the US on that day in 2001, I look over the world news and my own life since to reflect and find wisdom in what has happened and what the future holds.

The only logical conclusion I can reach is that the success of Al-Qaida on that day was the beginning of the end for the USA. A decade later, Osama may be dead, but he certainly won.

Shortly after the attacks, the US government passed a series of laws, which in the name of “security” basically destroyed the very values that the world held America in esteem for. Things like due process, protection of privacy, against undue search and seizure, etc. were essentially wiped out. As an additional response, in order to protect against “terrorists” the US began militarizing its domestic police forces and turned its internal criminal investigative agencies into domestic intelligence agencies.

The military response was not to go after the nation the terrorists were from. Attacking Saudi Arabia would have been a rather disastrous policy; instead the US “supported” the side in a civil war opposed to the government harboring the mastermind of the attack. In just a few months, countless lives and treasure would be lost battling for part of the world referred to as “the graveyard of empires” for more than a decade. Like the Empires before, the US suffered (after several times “redefining victory”)a crushing defeat.

During this time period, a fictional link between terrorists and the Iraqi government of Saddam Hussein was fictitiously linked together to start another war the US would ultimately waste lives and money on and destabilize the strategically important Middle East for what now looks like generations to come.

Terrorists groups better funded, further reaching, and even able to recruit Westerners from places like the US and Britain have risen to replace them.

Almost unreported military actions in Somalia, Yemen, and around the globe have taken a toll on not only American lives and money, but also on its morality and world opinion. Just this week an investigation of CIA torture was released detailing that some “suspects” were tortured well beyond American or even human conscience. This double standard is not lost on US adversaries.

In the US, a more ethnocentric culture has arisen. This further erodes US diplomatic clout in the world.

On the home-front, government institutions like the Supreme Court and Congress have passed/upheld a series of laws that consolidate power from the democratic masses to a small minority of oligarchs. Using TV propaganda at a level worthy of Vladimir Putin, has so politically divided the US populous that any power they might have in mass has been for all intents and purposes, neutralized. Not a day goes by that Americans who were once thought of the epitome of tolerance and charity in the world are making villains out of the poor and unfortunate within its own society. Thus in effect creating second class citizens, reminiscent of Palestinians in Israel.

Religious fanatics use both the government regulatory system to code into law their religious beliefs (largely Christian) while at the same time creating the false specter of Muslims wanting to implement Sharia law in the US and denouncing Christians as being persecuted by everyone who is not a Christian.

The income gap between the wealthy and the poor increasingly widens each month, and according to the latest statistics, has not only reduced social mobility in the US (the ability for poor people to climb in social position) it has actually become negative. That means you are more likely to fall in socio-economic status than you are to increase. I would be remiss if I didn’t mention the inescapable student loan debt crisis as effectively creating life-long debt slaves, yet Americans will viciously oppose any tax increases. (despite more than 47% of Americans pay no taxes and get a refund)

As Americans become more desperate, fearing the loss of what little they have, they further oppose change to the point of actually labeling initiatives that would help them as “un-American” and evil. For all intents and purposes, they are demanding oligarchy as a form of government, which of course leads to despotism.

The new US culture of “every man for himself” has left the US militarily and economically unable to respond to threats to its own security, such as a resurgent Russia and more aggressive China. From Middle East peace, to NATO interventions, to fighting terror, the US is unable to effectively respond and looks similar to the decline of the British Empire. All the while telling itself it is still the greatest nation in the world. It has even seen a record number of Americans renounce citizenship over the last 4 years as people leave for better opportunity. Once the intellectual and technical powerhouse of the world, the US education system is utterly ineffective. It’s universities costing more and falling well short of other nations, the primary and secondary education not only well behind the rest of the world, but actually demanding to teach myths like creationism. It is so bad, parents are electing for paid, private institutions, and even “home-schooling” where non-accredited parents believe they can teach better than credentialed educators. Children are even criminalized in the public education system for childhood behaviors. That is when they are not socially ostracized and shooting up the place. There is such an aversion to education and science in America, it has one of the leading anti-vaccination and homebirth movements in the world. Intellectualism has been branded as elitism, and homeopathy, once considered charlatanism, or even witchcraft, is not only legal, it is recognized; all because people simply cannot understand modern science due to lack of effective education.

In response Americans demand more restrictions to their rights and further disengage from neighbors “not like them.” Even when friendly nations, long- time allies, and even intellectuals suggest anything that goes against the current dogma, it is immediately rejected as un-American. Considering America is a nation of immigrants, who at one time attracted diverse people for their contributions, this current trend looks more like Russian or Iranian nationalism than “melting pot.”

One of the reasons, perhaps the main reason Westerners and even Americans are going to fight for ISIS and other terrorists groups is not because of embracing a religion. It is because they embrace the chance at social mobility. It is a classic example of volunteering for a military in order to achieve the social mobility and some level of importance and belonging that they cannot find in their home society.

From where I sit across the pond, the complete failure of America is inevitable. Not because I wish it, but because anything that could possibly stop it has been politically crushed under foot by a few hundred of its most powerful and influential citizens.

Modern “terrorism” seems nothing more than a new version of class warfare. Those with nothing attempting a revolution to redistribute power and wealth, not unlike American colonists a couple of hundred years ago.

The Americans who died on Sept. 11 2001 saw America at its height. It looks very different today. I humbly suggest a moment of silence not for those who died, but for those who lived to see America like this.

The contrast between the attack on Pearl Harbor and Sept. 11 2001 could not be more pronounced. The former led to a superpower. The later destroyed it.

I have a card that says I am an expert!!!

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Late last week I was once again involved in a discussion of card courses. You know them as BLS, ACLS, PALS, NRP, ATLS, etc.

 

For many years I was an instructor for many of these courses. Officially I am still an instructor for some of them, even though I have almost no time to teach them anymore. When I worked as a paramedic, I had more “training cards” than I did credit cards. It was always an activity to copy them all for employers every couple of years (front and back) and keep them on 2 printed pages of paper. I can recite their guidelines as easily as The Lord’s prayer.

 

I think this is a good comparison, because these classes are largely like church. The Instructor says their part of the prayer, and the “students,” as they are erroneously referred to answer with their part. Check- off sheets are completed, cards are issued, and for at least 2 years, sometimes as many as 5, these (re)newly minted providers march off as if they really know what to do.

 

It has been my role many times to delicately explain to various specialist physicians (some who are directors or professors of their profession) that they failed the check-off, and in no reflection of their ability, must remediate on the guidelines and “re-test.”

 

While my education in medicine continues (read goes on forever without respite) every day I am faced with a tragic reality about these “courses.” Despite being mandated by a host of healthcare accrediting agencies across the globe, the courses are really not beneficial or even useful to people who are otherwise expert at the material.

 

For many years I advocated that these courses were beneficial for not experts as an interim measure until an actual expert could be engaged. It seems reasonable right? We ask non-experts to do CPR. We ask non-experts to call for and use a defibrillator early. Then we start talking about “fluid boluses”, “life- saving medications,” and all sorts of other interventions. Some of the courses teach providers skills like umbilical vein catheterization or diagnostic peritoneal lavage, as if equipment for these procedures just lays around waiting to be used. Like the provider who rarely or has never performed a procedure is in time of emergency and great stress going to take up arms and fight the rising tide of inequity in order to save a life! (You see where these courses break down yet?)

 

But perhaps the biggest flaw with all of these card courses is that they confer the illusion of expertise and knowledge. Think of the fancy sounding names, “advanced trauma life support”, “advanced cardiac life support”, etc. sounds a lot more important than “physical exam in an emergency” and “CPR with a couple of hospital toys” don’t they?

 

Since I have friends across the healthcare spectrum, all over the world, not a month goes by where there is not some reference or discussion of these guidelines. Sometimes the most basically trained providers not only recite these guidelines as gospel, they actually call subject matter experts stupid, ignorant, uneducated, a menace, etc., for not placing these guidelines as the one and true, omniscient, omnipotent, deity. That anyone who does not follow their hallowed tenants is somehow, un-expert and lacking the most basic knowledge and skills to provide patient care in these realms.

 

But it has been fairly obvious to me by being involved with various experts and research that most of these “guidelines” and therefore “courses” and “certificates of training” are actually not really worthy of more than saying “I know CPR.” Whether as part of a surgical service or the ICU, past BLS, many of these guidelines work on a small minority of patients. Furthermore, some experts, like the American College of Emergency Physicians, have actually, and rightfully, come out with position statements declaring their knowledge superior to these courses and should not be subject to them.

So why don’t say…Trauma surgeons come out with the same position? Why don’t cardiologists? Intensivists? Pediatricians? Why does everyone who take these classes actually think they are expert? Using the example of trauma, when I went to paramedic school, I had about 20 hours of education on trauma. Another 2 “days” of PHTLS, and eventually audited another 2 “days” of ATLS twice before medical school. Did that make me an expert? Did it make me more of an expert that I could cite the studies these guidelines came from?

 

Some years later I now realize just how feeble that knowledge is. I understand how “consensus” guidelines are formed. I witness how “small changes to maintain credibility” are considered superior to broad and sweeping changes. Especially by actors who make money off of marketing or teaching these courses. (I made more money teaching some of these courses than I ever did as a field medic) I still supplement my residency income by teaching them.

 

But I do not believe them anymore. In fact, I don’t even believe in them. I see how those “initial steps” past CPR and defibrillation make resuscitation and restoring function to the critically ill and injured more difficult in surgery and the ICU. Almost every day when a patient that appears to be a complete train-wreck I am reminded that the practitioners earlier in the “chain of survival” were following the “guidelines”. I have a silent laugh about the irony of Humpty Dumpty and all the King’s horses and men and realize that it would be easier to put him back together again if everyone prior did as less as possible, because their interventions often do make it worse.

 

I really wish people with these card courses would stop pretending to be subject matter experts and calling people with far more knowledge and insight derogatory names for not adhering to them. I wish hospitals actually cared about patients enough to come up with their own in-house curriculums than forcing their staff to repeat these mindless information in a can courses every couple of years. I wish I got paid to actually teach people what I have learned about my subject matter than I do to teach these non-sense guidelines.

Maybe one day…