“but the operation was successful.”
This is supposed to be an off-color joke, a tale of caution to medical providers who mistake perfecting a process with perfecting medical treatment.
I am not having much success in my current position. Not because I don’t like the place. Not because I don’t love what I do. But I have stumbled into an enclave where perfection of the system is more important than whether it is indicated or the patient is even responsive to the treatment. It particularly frustrates me when I know in advance what is going to happen. When it does I just shake my head.
It has already been explained to me in no uncertain terms, “It doesn’t matter where you are from or what you think you know, you are not bigger than the people who make the protocols.” “That is not the way we do things here, it doesn’t matter if it is better practice, stop doing it.” And of course my all-time favorite, “I see your point, but I disagree.”
It makes me wonder, does the person who dolls out 400mg of ibuprofen, the same dose on the box, available without a prescription, actually know more about critical care medicine than I do? Does the person who spent more than 7 years perfecting techniques, with total disregard to modern medical science, treat patients better than I do? The jury is still out… But as my colleagues wait for me to “kill somebody” as they say, I don’t really worry about it that much. I already have killed people. Dozens in fact and some even survived despite my efforts!
It is not lost on me I studied biological anthropology before going to medical school. The only other doctor I am aware of that did was named “Josef Mengele.” It hasn’t escaped me that his nickname was “the angel of death” and that is the literal translation of my surname. It also hasn’t escaped me that his “experiments” were designed for the advancement of medical knowledge and practice and so have been mine.
So let’s look at how I killed people, with practiced precision. “Advanced Cardiac Life Support”, “Pediatric Advanced Life Support”, “Advanced Trauma Life Support”, my final solutions.
When I first started in my fire/EMS career, I looked up to the paramedics. They always seemed to know what to do. They had defibrillators, life-saving medications, Endotracheal Tubes, Esophageal Obturator Airways, IV fluids; they were gods. All I could do was CPR, give some oxygen, put people on long spine boards, splint fractures, catch babies that essentially fell out on their own with or without my help, and of course, a few techniques that could stop a hemorrhage.
So after some years of EMT-ing around, I went to paramedic school. I would learn to be one of those gods I looked up to. I would learn how to start IVs, give medications, interpret cardiac rhythms, intubate patients, and maybe, after I had done all of those things to a patient, if I ran out of ideas, maybe I could do a few chest compressions or put direct pressure on a wound.
At one point in my career I was considered a highly capable paramedic because I could respond to a call, sit at the head of the cardiac arrest patient, without moving position I could intubate the patient, start an IV in their external jugular vein, attach the cardiac monitor, interpret what I saw, deliver 3 static shocks (200-300-360 joules) and then begin the process of lethal injection. We made a song out of it. “shock, shock, shock, epi, shock, lido, shock, epi, shock, lido, shock, epi, shock, procainamide, shock, epi, shock, magnesium sulfate, shock, sodium bicarbonate after 10 minutes downtime. If the EMT was doing CPR during all of this, bonus; If not, well, I was busy administering “advanced life support.” I could do it all and terminate efforts in 15 minutes. Doing a professional job, I could even clean up the mess, and leave the body nicely presented for any survivors, in hospital or out.
Some years later, some medical scientists decided that multiple antiarrhythmic medications stacked on top of each other was a sure-fire way to make sure the heart would never beat again. At first this made me even more efficient, without the need to remember all of those drugs, doses, etc., I could push what was left even faster before terminating efforts (including escalating doses of epinephrine, 1,3, or 5mg at my discretion). If hypoxia did not shut down your brain and kidneys, my catecholamine doses would fix that! Then those damn medical scientists came along again and took the escalating epi doses away from me. My ability to kill people efficiently was being seriously curtailed by medical advancement.
But I was not done yet! I still didn’t have to do CPR, and I could claim that every patient with a GCS less than 8 absolutely needed endotracheal intubation. Traumatic brain injury, 30 minutes on scene while they hemorrhaged uncontrollably, none of that mattered. “Advanced Life Support…”
Then the scientists took away the imperative of the ET tubes. The static shocks were gone. Even Oxygen delivery was reduced or eliminated. I was dealt a horrible blow. My “life-saving” medications were scientifically found to be either useless or outright harmful. But as sure as I type this today, some of the patients I did those things to lived! I saw it, proof positive that the lady with 50 minutes of downtime in Plaquemine, Louisiana survived not because of the hands only by-stander CPR that her untrained relative provided out of desperation that he saw on TV! Because I administered the proper dose of sodium bicarbonate, recognizing she had more than 10 minutes of “down-time.”
So I believed…
So I had to believe… After all, scientists were telling me I was killing people! I didn’t sign up to kill people. I signed up to save people. I went to school for it. Spent my evenings and weekends in conferences, reading studies, teaching, and practicing my skills in rudimentary sim labs. I memorized all the medications, all of the algorithms, and had taken more “merit-badge” medical courses than any boy scout.
But the facts and truth were in agreement… My treatments harmed well more than they helped. I followed the guidelines. I believed in them. They were made by people bigger and smarter than I was! I practiced my skills. I memorized my algorithms. I followed all of my clinical scores and biomarkers without exception, hesitation or doubt! I was killing people. As sure as day, and as I said, some of them had the audacity to survive in spite of me.
I told myself I was doing the best we knew at the time. I tried to justify to myself I was not smart enough or educated enough to do anything else. I was not a doctor. They knew it all. If they didn’t know, then nobody did.
Eventually I started working as a paramedic in the hospital. It was during this time I had an epiphany. More than one actually… I had started the 2 large bore IVs in a trauma patient, one of thousands during my time there, and I had hooked up the rapid infuser (a machine that could warm to body temperature and jet fluid or blood into people’s veins in seconds.). Advanced Trauma Life Support, a merit badge course for people who have no understanding of trauma, dictated that 3 liters of crystalloid fluids, usually normal saline, be infused for every unit of blood, at the time. I started the IVs, I hung the fluid, I pressed the button. I watched time and time again as blood running from open wounds on the patient lost both its consistency and its color. It ran like Kool-aid. That’s all it was…Water with trace amounts of some substance that made it look red. In this instance I looked at the doctor, the words unspoken as our gaze met, “this was wrong.” We didn’t know why, we didn’t knew what to do, but we knew what we were doing was obviously harming. We had efficiently, with the help of guidelines and technology, removed any chance this patient had to survive. To this day I am not sure how we could have possibly killed her any faster.
But this was not the end of my Eureka moment that day…I also realized when our eyes met that the doctor didn’t know more than I did. He was operating on the same knowledge I was. We both knew it was flawed. It was wrong. We were responsible, and the patient would have been better off if she never came to our hospital, never been “treated” by us. Medical science, the guidelines, the policies, the very treatments, killed people. We had spent years perfecting our ability to do it!
We recited the algorithms like parishioners praying in church. We used simulators to perfect our psychomotor skills, to rehearse our murder ritual. The ancient civilizations of old would be proud of how we sacrificed those who trusted in us to our modern gods of medicine.
So how do I live with myself? How do I look in the mirror? Tell my daughter “I help people”? How do I reconcile I am not just like Josef Mengele? I resolve to be better; to learn from yesterday’s mistakes, to question and re-question our guidelines and algorithms. To set up experiments that find out what is best, not to justify what we are doing is “right.” I do not mindlessly follow algorithms, like prayers in church. I see every patient as individual. I ask myself before every decision, “how will the patient benefit from what I do? Will it harm them? What is the benefit to harm ratio?”
I endeavor to find out, to always know why I am doing what I am doing. The scores and mnemonics no longer have any meaning to me. I don’t care about the merit badge courses or their recommendations. The patient will get an ET tube because they benefit from it individually, not because their GCS (which is not validated to predict the need for intubation, and studies show it fails both ways by tubing people who don’t need it as well as not tubing people who do) is <8 and other such mindless nonsense.
I dismiss those who follow these guidelines as unknowing drones. They are not doctors. They do not help. They kill people with their mindless approach to medicine… Just as I did… The difference between us is that I do not drink the Kool-Aid anymore. I have renounced their false gods. And as a great paramedic once said to me, “I have seen the light and repented.”
The truly ironic thing about it is, the barbaric witchdoctors that still practice this voodoo see me as the heretic. They accuse me of being unknowledgeable. That I am the dangerous practitioner that one day will inadvertently kill somebody.
I have killed more people than I care to estimate, with purposeful and practiced precision. The difference between us is I know what I have done. I accept responsibility and do my best to make up for my inadequacy. My ignorance.
At my job the Dunning-Kruger effect is in full force. Those unaware of their inability see me as the ignorant. The incapable. They see the need to “rein in” the “untrained cowboy” before I really mess up. In all fairness I am more clever than most, as when I do mess up, it is usually in a more spectacular way than most. But not this time.
I hope one day they will mature as providers as I have. I hope they will see the light and repent. I hope they will realize all of their scores and numbers and guidelines are false gods. I hope they realize that many of their treatments are actually death sentences, which they not only order, but carry out with their own hands. I hope these things not to vindicate myself, but so their future patients are not victims of their murderous cult.
But I am a fool. They believe in what they are doing. As sure as I once did. Their scores and algorithms bring them security. Their protocols tell them they are perfecting their skills.
The operations are successful, the patients will die. I am doing my best to stop it, but I am being marginalized; my wisdom seen as ignorance and madness. I can only look on. Knowing the outcome before it happens.
How do I stop it? I do not feel like Josef Mengele. I feel like August Landmesser.