I am sure you can all imagine my delight when the first thing I saw on Facebook this morning was this:
Reading the comments was sort of like watching some inhumane disaster. Tact would dictate you look away and not stare, but I just couldn’t help myself and decided to peruse the comments. Let me just sum it up for you.
Unless you are an emergency doctor or trauma specialist you do not know shit. But Even if you are, once you step outside of the confines of the hospital, you can’t do shit anyway, so it doesn’t really matter.
In all this nonsense, there was some inaccurate legal guidance about liability, some anecdotes, and some of the most entertaining stupidity about medicine on the internet today.
What I really discovered is: If you are not a paramedic you don’t know anything about saving peoples’ lives, much less have the actual skills to do it.
So I wonder…Do I still have the ability and knowledge to save peoples’ lives? I am not a paramedic anymore. Whether I am in the hospital or outside of it, and even my mail often states I am a doctor. I wonder why that is? After all, without a hospital according to these brilliant minds, I am not really that valuable without it. I even remember being told that once a person is a doctor, they never stop being one. I didn’t really like that idea. I was always of the mind that there was some way to just be a person from time to time. I have had my ignorance thoroughly remedied. In what was in my mind a completely outrageous experience as well as a moment of clarity. My wife called me and told me not to come home right away as I was watching the clock tick down to “go home time.” My wife doesn’t usually make such requests, so I could not resist asking why. “There is somebody here waiting for you,” was her reply. “I don’t know who she is and she is waiting at the gate.” (The place we live is surrounded by a giant security gate, mostly because my crazy landlord thinks at any moment somebody could break in and steal all of our worldly possessions or kill us. Not that a fence would really stop somebody so intent.) Being curious, I asked my wife if she inquired to who our mysterious visitor was. Apparently the lady did not want to divulge this information. But now, with my curiosity at its peak and no reason to stay at work, I rushed right home to find out.
When I got home, there was indeed a lady standing just outside the gate. She appeared not to be in any acute distress and looked like your typical elderly grandmother. I greeted her with a kind “hello” and in broken English, she asked if I was Dr. Smertka. At this point I probably should have said “no” but she didn’t seem like a lawyer or a process server, so I acquiesced. From out of nowhere she produced a medical record about 7 inches thick complete with xrays, ct cans, ultrasounds, and pages and pages of hand written doctors notes. She then declared “I heard from my sister-in-law you are a good doctor, so can you tell me what you think I should do?”
I am not the most diplomatic person in the world, but I did manage to summon up a polite “please come inside and sit down while I look this over.” What I was thinking was “Is there a sign on the door that says “Dr. Smertka’s after hours medical advice? What kind of psychopath hangs outside the gate waiting for somebody to come home?” Anyway, I looked it over, and from the notes I could decipher, everyone knows doctors write like shit, and this writing was not only from a doctor, but not in English. My advice to her was “your doctor has made very good decisions and you should continue to follow his recommendations.” You can always tell if it was written by a man or a woman. It has to do with the bone structure of the hands of the different sexes. (A bit of trivia from my biological anthropology studies)
She thanked me profusely and handed over some candy bars she had bought for the occasion and told me that she didn’t know if she was seeing a good doctor or a bad one and I gave her the information she was looking for. I should explain why this is important. Here in Poland the medical education is as good and likely better than most other places. The Polish do education seriously. Unfortunately, there is a reverse Bell curve distribution of the quality of medical providers. They are either very great or incredibly incompetent, there is no median. This is in contrast to places like the US where there are few great or poor doctors, and most seem to fall within the standard distribution. Patients don’t have the insight to tell one from the other, and in classic form, usually go for the one that is nice to them.
But this experience has had a pretty profound effect on me. Sure when you are a paramedic friends and family call you for medical advice. Usually asking “do I need to go to the emergency room or see a doctor?” But nobody waits outside your house for you to get home from work to get a second opinion and then offers you candy in exchange. In fairness, while it wasn’t the average bill for a private medical visit, it was high quality chocolate and probably the limit of her disposable income.
Her condition did not relate to surgery, intensive care, emergency medicine, or austere medicine, topics I have considerable knowledge about. But I was still expected to know at least enough about the discipline of medicine her ailment is treated by in order to recognize the diagnosis and determine that she should in-fact expect to benefit from the treatment plan that was prescribed to her for it because based on my general medical knowledge, it was within the guidelines and very reasonable for the notes I read.
But back to the point of this post, in order to pass medical school, all doctors have to have some knowledge about emergencies. This knowledge and ability far in exceeds the US EMT curriculum, and depending on the school, may meet or exceed the US paramedic curriculum. The school I graduated from requires 2nd year students to sit through a semester of “first aid,” which is a gross understatement for paramedic class in addition to all of your other coursework. You get to learn how to intubate, perform CPR, ACLS, PALS, PHTLS, and all the other “EMS” treatments in the event of an emergency. There is even a final exam after you demonstrate practical ability.
Now being comfortable or proficient at working outside the environment a person normally works in is an entirely different matter. People handle this stress differently. Some get very authoritarian. Some get very shy. There are actually studies that show in stressful situations, many people must be told what to do or they freeze. But it doesn’t mean they are helpless or worthless. By people who are uneducated to this, and are comfortable with their environment, this can easily be mistaken as incompetence.
That leads me to another important point and anecdote, people who really know what they are doing don’t get upset by people who don’t. When I was in my medical school cardiac surgery rotation, I was a very eager student. As an(still) aspiring surgeon and intensivist, I was permitted to harvest a saphenous vein all by myself, with supervision from a surgeon who was later to become the head of cardiac surgery, who at the time was harvesting the mammillary artery for bypass. Being a rather new and inexperienced student who greatly wanted to be impressive, my performance was not what surgeons would call “elegant.” In fact it probably looked like I only had thumbs and tried to kill a small animal. The scrub nurse was emphatically trying to get the surgeon to tell me to stop. Finally he incredulously said to her “he is doing ok, and besides, what could he possibly mess up I could not fix?” That is the attitude of somebody who is comfortable and confident in their ability. It is not a bunch of mouthing off about how a person new to the environment can’t do anything, just gets in the way, and should be either run off or given something trivial to do. That sort of behavior demonstrates being uncomfortable and attempting to hide their incompetence.
Perhaps one of the other outstanding comments is “doctors can’t do anything outside the hospital a paramedic can’t.” Reasons cited for this was lack of equipment, lack of a sterile environment, and lack of knowledge of pre-hospital procedures.
But if anyone is lacking in this instance, it is the paramedic. Medicine in the hospital is no different than medicine outside of it. There is nothing I cannot do with a scalpel inside the hospital that I cannot do outside of it. In the event of a life threatening injury, such as an uncontrolled hemorrhage, sterility is secondary to stopping the bleeding. I can do something most paramedics are not permitted to do in order to stop a hemorrhage; stick my hands in the wound and even extend the wound for access. That is not to say doctors should go around doing that, as it is not always the best course of action. But it is an option. Most paramedics have strict indications on medications and dosages they are permitted to use. A doctor has no such limitation.
One of the seemingly limits of medical education is that doctors are often told what theoretically needs to be done, without being told exactly how or with what. In order to reconcile this knowledge into action, it often takes a moment to think about how to practically do something. One commenter, who I know, recounted his story about how an on-scene physician performed a tube thoracostomy with an ET tube. It was the first I heard of doing that, but I have to admit, it was a cool idea. I could even tell you how to make a water seal with a bottle of sterile water. I have seen both Foley catheters and IV tubing used to make temporary vascular shunts. I have personally performed minor surgeries, while simultaneously providing anesthesia, in a field environment, and the only piece of equipment not usually found on an ambulance that I had was sutures. It seems paramedics do not know what they do not know and substitute what they do know as all there is to it. I have not even begun to list the things I “could” do, if the situation required.
This should not come as a shock to most, but I don’t actually offer to help very often. Sometimes I just observe from a distance and if everything looks like it is going well, I carry on. Sometimes my decision may be so fast, I do not even stop, even if there is no EMS on scene yet. If an intervention was required, I certainly would help. It is a personal moral of mine. As well, as long as I don’t see a major mistake happening or about to happen, I will never identify myself to providers taking care of somebody. I try to do this as often as possible, particularly on aircraft. First I look at how panicked the cabin crew is, then I wait for some eager person to identify themselves as “a medical person” and if it looks under control, I go back to my movie. I have only had to step forward 1 time in all of my flying, and not because it was serious or people were making mistakes, but because there was nobody else answering after 3 calls.
I don’t usually even identify myself as a provider when I happen to be with friends or relatives unless I disagree or see a mistake. Even in those times, I usually phrase my displeasure in the form of a question or suggestion. I try at all costs to avoid “I am a doctor!” If I actually do have to make that announcement, it is because something is seriously wrong or about to be.
I am not yet a trauma surgeon or intensivist. I will never be an emergency physician. I don’t carry my medical license around with me. (It doesn’t even fit in my wallet) Many tell me that my resume and my experience is considerable. Without undue modesty, I know my opinion is valued by many clinical leaders, both in fields I am interested in and ones I am not. (Even if some think I am crazy, but that is another matter) If I actually stepped forward to offer assistance to an EMS crew, in any country, I expect to talk to another doctor, I expect to accompany the patient to another doctor, I expect at some point to have to produce my credentials, I also expect to sign for what I did or did not do. Considering what it takes me to get to the point of offering help, an EMS provider would probably do well to consider my assistance, especially since I will never give my resume to EMS provider on a scene. I am also more than willing to offer my assistance to investigators after an incident I offer to help at.
I think the first few seconds of this clip really says it best.
I am not famous, but perhaps give some consideration to the idea that other doctors who might be of great value in a given circumstance might offer their assistance in an equally unassuming way. For no other reason than they see you are about to make a mistake and the one they are trying to help is not the patient, but you. I would also add, some of the best doctors I have worked with in Afghanistan and whom I would trust over any EMS provider in an emergency are GPs. A few are OB/Gyns. I also know most EMS treatments are nothing more than boy scout level first aid, and more than a few are utter bullshit. Presented in the article in question was a case of trauma. Many EMS providers I have met, especially in the US, don’t know shit about trauma. A PHTLS course or even an ATLS course doesn’t begin to cover it and the discipline advances as fast as the rest of medicine. This is long enough, so I will save my PHTLS story for another day. But as a teaser, the small town fire chief told me I was a menace to patients.