Yet more stupidity from EMS

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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.

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Ebolageddon

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You knew there was going to be a post on this.

Today I was trying to read the news. I say trying because it was filled with pages of exclusive interviews, stories about ebola victims’ dogs, CDC announcements, and support messages and blame for the victims in Dallas.

So here it is, the cold hard truth.

America is not ready for an ebola outbreak. It will never be ready. The reason is simple; it doesn’t have a functioning healthcare system. Hospitals in the US are not a system, they are private enterprises who all happen to follow the same rules in order to get paid by either government safety net programs or private insurance, and in the worst case, by private payers.

Like all private enterprises the most important part of US hospitals is making money. It should come as no surprise that businesses like to cut costs and take every opportunity to do it. The morality of pay for service healthcare is inconsequential to this post.

When you look at US hospitals, they operate at maximum capacity much of the time. There is no “reserve” or as we like to say in healthcare, “surge” capacity. Employees of all types are given the very minimum to keep the business functioning. Things that do not fit into the minimum requirements to function, like high level personal protective equipment, staff training for rare events like ebola, and all manner of employee safety not mandated are simply not done in order to reduce costs.

So when somebody shows up in an emergency room with flu-like symptoms and the folks there are operating beyond capacity trying to make sure patients who are not critically ill don’t have to wait more than a few minutes to see a doctor because they are in the ED because of the utter failure of the primary care practitioners, all the while dealing with heart attacks, strokes, early antibiotic guidelines, and maybe an actual acute emergency, the chances that anyone actually recognizes an ebola case is pretty close to zero. Not just in Dallas, but everywhere.

So how does the CDC figure in to all of this? Well, for one, they put out a really great website and of course in classic Office Space (yea…did you get a copy of that memo?) form, put out all kinds of instructions on what providers should do. They didn’t have a national response team in place in “Outbreak” like fashion to immediately respond and whisk those infected away to the nearest of the 4 isolation facilities in the continental US with a population of 320 million people and the world’s second largest economy. But today that announced it might be a good idea to do that. I often wonder where they get these quacks. The talking head experts over at the CDC cannot stop a resurgent anti-vaccination movement and months into an international epidemic decided maybe it might be good in the future to have people ready to go. Just in Case…Clearly they didn’t get somebody from the fire service to work there.

So everyone from the hospital to the government has latched on to the effective defense of rape culture and blames the victim. “She” didn’t follow the protocol!

Now for those of you who have never spent any time in the real world of emergency response, you can’t just write up a policy, email a video or a few pictures to people, and expect that people will magically be imparted with the psychomotor skills and experience required to actually follow those protocols. Moreover, you don’t even know if they actually work! In my career I have been involved in mitigating emergencies in natural disasters, mass casualty incidents, internal hospital disasters, and even war. There is an often quoted phrase from the military “no plan ever survives first contact with the enemy.” In every instance I have been a part of or even heard of, when the plan was made up by inexperienced people, often by virtue of their title alone, the plan fell apart within minutes and chaos was the result. Only by the efforts of outstanding individuals was any level of success, and certainly not optimal success achieved.

As I discussed on many a Facebook page and private message this week, you need to train. You need to train until the psychomotor skills are automatic and you don’t have to think about them. I don’t live in Fantasyland, I know all of this takes time and costs money. A lot of money.

Even if both of the healthcare workers die and wrongful death suits are won or settled in the millions of dollars by the families of all 3 US victims, it will still be cheaper than equipping and training for events such as these. Equipment and training for far more common scenarios is not in place. Accrediting agencies don’t make realistic demands that it is. Just a bit of smoke and mirrors and a few check boxes on paper.

In hindsight, some of the Dallas hospital staff claim the patient should have been transferred. Which I was advocating for days before their brilliant minds thought of it. (Because if you haven’t heard I am a less capable foreign doctor by virtue of my medical university not being in the USA which doesn’t play into the ethnocentric US healthcare propaganda campaign.) But let’s just take a minute and look at the forest from the trees?

Do we know of anyplace else where the healthcare system was not prepared for an ebola outbreak but probably talked about it a lot? Do we know of any other place where providers did not receive proper training or top quality equipment to deal with ebola patients? Do we know of any other place where healthcare workers were killed after being infected taking care of infected patients?

Yes we do. In Africa.

That is how awesome the US healthcare system is. It suffers from the exact same problems as the third world. The reason is slightly different. In the third world, they don’t actually have the money. In the US, in order to keep profits and stock values high, hospital administrators don’t want to spend the money.

The result is the same; acceptable losses and an insincere apology. Oh, and somebody might resign or be investigated if blaming the victims doesn’t placate the masses.

But there is another important similarity between West Africa and the USA. In fact, this similarity is what actually inspired me to write this piece; panic mongering and denial. It seems there are no shortage of “doctors” going on various TV networks using their credentials to give credit to sensational conspiracy and doomsday scenarios. Somebody should probably make an ethics complaint against these idiots or local prosecutors should bring them up on charges for inducing panic.

There is no shortage of non-medical idiots all over the news and internet giving their completely uninformed opinions about airborne transmission conspiracy theories and even some homeopathic remedies.

Just like in Africa! Imagine that.

The long and short of it is simple. The Ebola monster is not coming to get anyone in America. Even if it does get a few people, in the grand scheme, they are acceptable losses. Perhaps not to their friends and family, but to policy makers, hospital administrators, and regulatory bodies it is cheaper and easier to beg forgiveness than actually prepare for things like this. You should expect to see it again or a few more times before this particular epidemic is over.

It is convenient though, look at how many rights and morals were sacrificed when “the terrorists” were coming. Now it’s Ebola! Forget all the pressing problems and worry that the end is coming yet again! (I must beg your forgiveness for my apparent lack of concern, but I have survived quite a few world endings and I am sure I will come through this one ok too.)

I would offer some advice I once got when getting a medical examination in my younger days. While filling out the health history form, I mentioned to the nurse I did not know what a lot of the things they were asking were. She smiled at me and said “then you don’t have it.”

In that spirit and wisdom, if you don’t know that much about ebola, if you don’t see people walking around in hazardous material suits with self-contained breathing apparatus telling everyone it is going to be ok, and if you don’t hear reports of the President, Vice President, or important government officials hiding out in an undisclosed location, (which I strongly suspect to be an Argentinian brothel or some such) then you don’t have to worry about ebola. Turn the channel, surf another website.

QUIT POSTING ABOUT IT ON FACEBOOK AND MAKING THE REST OF THE WORLD DEAL WITH YOUR STUPIDITY!

If you can’t do that, at least go to church and SILENTLY pray about it.

For future reference, worry less about doomsday anyway. If/When it comes, you won’t be able to do anything about it anyway. Although if you need financial security please purchase my own personal and exclusive end of the world insurance policy. In the event of the end of the world, my company will compensate you the fair market value of all of your worldly possessions. Premiums are only $100 a month. Discrepancies can be settled by arbitration in any post end of the world established court of law.

Healer, Necromancer, or factory worker?

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I often wonder what exactly a doctor is. I am surrounded by doctors who treat patient care as something of a computer program. If:Then

They perform the exact same treatments on patients, regardless of their condition, complaints, etc. I wrote about this McMedicine before, but it never stops amazing me. In fact I am not even sure they are doctors, I could probably take a homeless person off the street and teach him to do what they do in a few hours. Perhaps my favorite of this doctor species are the ones who claim they are afraid of being sued. Let’s face it, when you ignore patients’ concerns, make them wait hours or days to even see you, keep telling them they are not your problem (aka endlessly refer them to specialists) then charge them money, all the while lamenting how hard you studied and worked for too little money, you essentially did nothing for them. I don’t have any sympathy for these doctors. They deserve to be sued and lose.

It is even worse when “experienced” doctors perform outdated treatments because they do not want to change what they have done for the last 50 years. In Poland, it is particularly bad because the paramilitary style of medicine actually calls for senior doctors to order younger ones around, and gives them absolute authority to do so. I have witnessed many times junior doctors cringe knowing something was wrong, and then, in order to keep their job, went right ahead and did it anyway. It makes me wonder if anyone learned anything from the Nuremberg trials. “I was just following orders” is not an affirmative defense.

Not a day goes by it seems that I am not arguing with some non-medical cretin in the US pushing their homeopathy or anti-vaccination stance. These people claim to be healers. I can see how if you give your “patient” a glass of water with some “natural” remedy and they don’t die you can call that a success. It is even better if they have some illness that will self-resolve even if you did nothing and you can get them to pay you for your treatment. If you die, well, at least you didn’t get sucked up into the conspiracy of modern medicine right?

So what actually is a doctor? Well, if I objectively look at what I do, I would describe it more like necromancy. Humans rarely heal and medicine rarely cures. The physiologic response to injury for the body is regeneration or repair. Those are the technical terms. But in everyday English what it means is the cells will either divide and replace damaged ones or a scar will form. In most cases, it is the later. A scar is like a patch, it doesn’t actually “do” anything. It prolongs the ability of the organism (the medical word for you) to compensate before it ultimately dies. (We all will) When it comes to illness, easily 90% of medicine, and likely more, does the exact same thing. It is a patch. It modifies things just enough to keep you going.

It is however, a Faustian bargain. Whether by surgery, you cut something out or put in extra parts or by “medicine” of swallowing pills and applying poultices, you are altering the body just enough to keep it going, but it comes at a cost. Sure the obvious cost is money and whether you are paying directly or indirectly, that may seem like a lot, but that is only part of the price.

Every medicine or surgery you ever get treated with harms another part of your body. Your heart medications may destroy your kidney or your brain. Your brain surgery may destroy your endocrine system. The list is endless. You are making a deal, save your heart today at the cost of your kidney tomorrow. When tomorrow comes, you will double down on your deal. You will get renal replacement therapy or a transplant which will destroy your immune system and eventually succumb to infection. That is if you don’t have a transplant rejection or so upset your electrolyte balance that your heart gives out again.

Then there is pain. Despite what military instructors say, pain is not a good thing. It tells you when you are sick. It causes you to be sicker. In order to relieve your pain, you may have to trade addiction. Some medical experts and moralists would rather you not make this trade. So you are forced into living with pain or living with addiction. Let’s face it. What it really comes down to is life as you knew it is over, your days are numbered, and the choice is how and how long before you reach your end.

Perhaps that is why I don’t really like homeopaths. They simply steal from people. They do not offer the benefit part of the devil’s bargain. They charge for a placebo, one that must be scientifically proven not to do anything to your body. If it did, they would have to legally fall under the confines of medical practice.

So what is medical practice? Evidence based? Science based? Western medicine? Pills? Surgery? We have lots of ways to describe it.

But what does it all mean?

What I do is study (aka observe) natural phenomenon. I then report my observations in a standard way. Hopefully if they are worth reading, somebody will publish them and others will read them. If all really goes well, other will care. In the best circumstances, others will be able to make my observations work for them. Science is collaborative so I read the observations of others, and together with our education and experience, we try to figure out what works when and how well. That is the “science”

The second part is referred to as “the art of medicine.” This means taking the knowledge gained from science and education and applying it to actual people in order to give them the benefit of the Faustian bargain. (prolonging productive life, reducing suffering, saving life, all the things we recognize as medicine)

That means what works for some will not work for others; sometimes for physiologic reasons; sometime for cultural reasons; sometimes for economic reasons. It is the role of a doctor to take into account all of these things in order to “help” people.

To guide in these decisions, there are ethics, morals, culture, and laws. Like any rules or definitions some people always fall into exceptional circumstances, which make these “rules” conflict with each other. In fact, I have noticed the more absolute a rule or moral, the more often they conflict.

When we consider the factory workers I described earlier doing the same thing no matter what, they are not really acting in the capacity of a doctor. They are not giving people the benefit of our devil’s bargain. They are giving patients a chance to spin the wheel and maybe win it. They justify this as best because it removes their responsibility and culpability as the person offering the bargain. Their behavior is not for the benefit of patients, but for their own benefit. “Pay me for a chance to spin the wheel and get better. If you lose, you are unlucky, but it is not my fault.”

A more modern trick is to employ the ethical principle of “self-determination” The patient chooses what they want after being properly informed. Sounds great right? The doctor is not responsible because the patient chooses. Patient cannot complain because they chose it based on their circumstances. Except offering treatment that way is like selling a used car. A doctor can easily make one treatment seem better or preferable to another. It takes years to educate to the level of a doctor so in seconds, minutes, or weeks, patients without benefit of education, scientific research, etc. will be expected to make a “reasonable” decision their life or health relies on. (or a close family member)

Doctors can even object to various treatments on personal moral grounds. In other words they choose for you while making it impossible for you to choose otherwise. Not exactly an objective, educated, and reasoned opinion.

A doctor is often said to be a medicine man, a person who uses their knowledge and experience to help people. Help them with what? The obvious answer is their health and wellness. As I described above, health and wellness is more than simply a disease process.

So I will close this post with a great quote from the former dean of my medical university.

“There are many who have a medical degree. Few of them will ever be doctors.”