Classical Medicine and booklists.

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Not a week goes by when either a medical student or some other healthcare provider asks me what books they should read. It is actually easier to come up with a list for medical students, because they actually have the background knowledge they need, even if they don’t know how to use it, than it is for other healthcare providers.

Back in my younger days I was involved a lot with classical arts, band, choir, classical dance, and martial arts. One of the things that I learned and applies to all of them is the idea of “classical training.” The ballet mistress was often fond of saying “a classically trained dancer can do any type of dance, a dancer who is not is a one-trick pony.

This can be demonstrated by notable names like Paul Stanley (of Kiss fame) that play The Phantom of the Opera or the classical piano brothers, Alex and Eddie Van Halen…There are also several online articles critically reviewing the music scores from Rock musicians of the 1970s and 1980s comparing both the technical complexity of the instrumentation as well as the musical theory of the scores, which conveniently support my point that a classically trained musician is both more complex as well as skilled than other artists who essentially learned to play by ear or focused on one type of music.

I see this same parallel in medicine. From EMS to the most advanced of specialist doctors, there is an obvious difference in the capability of the provider based on whether they embraced a more classical style of learning compared to being focused on only passing the test or specializing in a given form of medicine.

To better explain this difference, let us look at what it means to be a “classically trained artist.” Whether it is music, dance, drama, or even a martial artist, training is scientific in nature. Music theory, kinesiology, and other basic mathematical and physiological principles are learned and applied. The early exercises are tedious and outright boring, and often do not outwardly resemble what is seen in the finished product. In fact, when you first learn music or dance, there is no music. There is counting. Explanations of how progressions work, chords, scales, combinations, etc. It requires discipline to not get extraordinarily bored and give up. Eventually, these basics turn into rudimentary performance, the kind your parents smile and hope they don’t have to go to. As you progress in skill, the underlying science and technique is not lost or forgotten. Much of it becomes second nature, reflexive, with detailed focus of it in practice, and no hint of it beneath a virtuoso performance. In fact most virtuosos are described as such from their mastery of the technical foundations and application of their respective arts.

Compare

I experienced this first hand throughout my medical career, starting in EMS and all the way through my MD and PhD. At all stages I had peers that focused on a less traditional way of learning. They had more free time, got better grades, could score the hell out of a standardized test, and can even create research papers that look incredible, but have absolutely no scientific basis to their clinical outcomes or conclusions. They are numbers on a page that demonstrate what they want to be true is. It is sort of like a musician that plays by ear. They are able to do it, but completely lack any level of underlying understanding. Consequently, the discoveries as well as guidelines that come from such style are often disproven or found to be ineffective or harmful over time. The actual practice becomes an exercise in dogma and there are no shortages of fads and ever changing consensuses constantly being updated.

How did it become so? Well having had the chance to be educated in both the US and Europe, I have come to recognize a distinct difference in how education is done. US education is largely rote memorization, discordant facts to be memorized and identified on standardized examination. The technique is simply “when I see X my response is Y”. Y = X and therefore X = Y. By memorizing the material that way, the equation can be made longer, if X = Y then Z. As such Z = both X and Y, which becomes a circular form of logic which gives the illusion of complex understanding. Not because the material is complex, but because there are simply more variables which equate to each other.

That is in contra to the more European style of education, which is largely focused on more basic theory which does not explicitly state the equations but rather covers information which leads to “discovery” of patterns, similarities, and equalities. There is far more of what educators call “scaffolding” where what is learned at one level repeats and carries on into others. US educational facilities attempt to emulate this to some degree, but because classes are both seen and sold (in the form of tuition) as individual entities, much of the continuity is lost. That is to say nothing of the discovery or ability to logically deduce the next step or pattern. The US is not alone in this practice, it can also be seen in the UK and Canada. It is the standardized test that becomes the focus. Memorizing what might be on it to identify. I would point out that none of the countries that have achieved high effectiveness of education use standardized testing. But it is a 4 billion dollar a year industry, and drives everything from the making of the exams themselves to books and “study materials” sold in order to pass such exams. I think you can easily see where this essentially nullifies any type of scaffolding or understanding passed association. If you don’t believe or see it, just go to the doctor when you are sick after you have googled and printed out research on any given disease you may be afflicted with and watch their reaction. Question their insights on it. You will find they can regurgitate a lot of associations, but for the most part lack any in-depth understanding of it and will offer you “routine” treatments as those are associated in classic X = Y therefore Z type of understanding. If you press the inquisition and ask “why” you will not get a lecture worthy of any university professor, what you will get is a circular form of association, as I described above.

This style of learning is carried on even after school, residency is taught the exact same way. In fact, many doctors in residency hear “you can forget the stuff you learned in school, it doesn’t matter” from their preceptors. You hear the same thing in the MD portion of medical school when discussing undergraduate science education. “Forget about it, it doesn’t apply.” If it doesn’t apply? Why do you have to learn it? Wouldn’t it just be quicker, easier, and cheaper to essentially tell any student to become a doctor to forget formal or in-depth education and simply emulate a doctor in the specialty you want to practice for a few years? That is essentially what is happening, the training of role specific behaviors, completely ignoring all previous education. That knowledge isn’t even valued by healthcare providers. We see all the time how “mid-level” providers have an abridged medical education, perform the same behaviors and roles, and even claim “we are just as good as doctors” or even contemptuously “young doctors don’t know anything!”. What this effectively demonstrates is not a learned position, but one more like that of a factory worker, where the person with knowledge, but not practical skill mastery is seen as lesser, or of no value.

So when I am asked, “what books should I read?” I respond to the question with a question. “Do you want to be great or do you want to be able to perform quickly?” If you want to be great, you can forget about Tintinalli’s Emergency Medicine Manual (or any other physician level text), because while it will expertly teach you what to do, you will have absolutely no idea why. That “why” will come into play time and time again, as circumstances change, treatments fail, patients fall between the cracks where multiple specialties each do a little, but nobody takes care of the whole. It will determine what treatments and procedures are stocked, performed, and/or paid for. It will not only determine when to do something, but when not to. At which point it will all become essentially the provider feeling lost, fearful, and prudence will dictate taking no action, which ultimately brings harm to the patient. All conveniently brought to you by “I forgot all of that stuff I learned prior to now, so my world is a big mystery on all sides.”

If you simply want to perform, to have the illusion of knowledge and some practical X=Y therefore Z sort of stuff, then by all means, pick up “So and So’s guide to emergency medicine, anesthesia, internal medicine”, or whatever form of medicine makes you happy. Memorize the treatments as they were 5 years ago or watch your podcast from the “experts” of what is in fashion today. Just like somebody that picks up an instrument and tries to play it by ear or learns their favorite dance at a club, you will be able to put on a good show, maybe even one pays money for…But you will never be great, you will never be a virtuoso, you will never be able to adapt and improvise.

If you want to be at that level one day, you need to start with the basic exercises of medicine…Biology, physics, chemistry, biochemistry, molecular biology and all those things that those who are not masters claim are not important or can be forgotten. At first it will not look or feel like you are learning medicine. It will be like learning music theory or the basic movements of ballet. No music, no flash, counting…repetitively. Until you can integrate it without having to stop and think “what do I know about chemistry.” From there you can move on to your rudimentary performance (you know, the recital your parents hope they don’t have to go to, but smile and clap for you anyway) and start picking up books on “medical science” like anatomy, physiology, immunology, etc. Then as your skill as well as knowledge progresses, you move onto more specialized knowledge, but never forgetting to spend time practicing and perfecting your basics. When you have spent the years becoming competent, then you can take the step to not only being able at your craft, but contributing something new to it, by being able to reflect and analyze every aspect of your art and of each of your performances.

Medicine is not an art and a science. That is cliché, medicine is art. A performance. Just like a classical musician or dancer, it is the mastery of the underlying science that permits that performance; the greater the mastery, the greater the performance. The path of the virtuoso…

It is long, at first thankless, and requires tremendous discipline. But if greatness is your goal, there are no shortcuts. No “easy” ways. It is the difference between playing on the stage and commanding it. The difference between community theatre and the Bolshoi. The difference between being among your peers and standing out from them.

The only thing more difficult than accepting the hard way is becoming skilled at the easy way, hitting your peak, and in order to get better, having to go back and start again from the beginning.

The choice is yours.

In the middle of nowhere…

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Well…today I am reflecting. This may come as an unusual twist to my recent writings consisting of acute stressors in life that usually just piss me off…

So today I am considering life from the victory conditions of one of my favorite video games of all time. Generally I like video games, particularly complicated ones. The one I am thinking about today is easily one of my favorites because it is complicated enough to focus the entirety of my thought processes. This indirectly brings peace to me because when I have to focus the entirety of my mental faculties on not getting my ass kicked by the computer, I don’t have any capability to turn to more destructive thoughts.

This particular game, based on WWII, was largely developed by enthusiasts over a decade. While the functions are relatively easy but numerous, the volume of information which must be learned to effectively play the game takes years. After each battle in the campaign, you are scored as:

Decisive victory: you have achieved all predetermined victory objectives and inflicted at least 10x the destruction on the enemy as it inflicted on you.

Marginal victory: you have completed all or a majority of predetermined victory objectives and inflicted 5x the destruction on the enemy as you suffered.

Draw: you have achieved a minority of victory objectives and or caused casualties equal to <4x those inflicted on you.

Marginal defeat: you achieved some of the victory objectives, but with losses equal or greater to those you inflicted.

Decisive defeat: you either achieved none of the victory objectives, and/or lost >3x the amount of casualties inflicted on the enemy.

My life is a marginal defeat. I have my moments, and those moments are usually really good, but they are few, and the losses suffered while not always catastrophic, seem to outnumber the gains.

So this begs the question, if I am losing, why don’t I change something? As if I don’t constantly try to change something… It doesn’t take me too long to figure out if I am winning or losing at something, even when I am perhaps holding on to a vain effort longer than I should.

But I seem to exist in this strange void or limbo. I am simultaneously part of things but also not a part of them. Here are some examples.

Nationality. So far I am still an American, I know I should probably ditch that citizenship, all objective measures determines the drawbacks exceed the benefits, but I can’t seem to bring myself to it. Perhaps sentiment, but perhaps just so I have some form of group identity. After all, I am a Polish National too. (US law allows a person to have up to 3 citizenships, and I do think it would be cool to get a 3rd just to be one of the rare people who have 3. I have actually met a couple of those people, and that is a trophy not many can claim) But if you ask any Polish person, they will tell you that I am not Polish. Not because of my language skills, but because of the way I think and see the world and life. It is a world of possibilities, of opportunities, of dreams and goals, not some mindless grind of be born, go to school, get a monotonous job, get married, have kids, retire, die. Another characteristic feature that distinguishes me from my Polish counterparts is that like most Americans, I believe I can win. At whatever I am doing. Not just do it to some minimal level of competence and/or getting a trophy for coming in 9th. (They give out trophies for 9th place?) But be number 1. The best. The top. The undisputed heavy-weight champion of the world. Now while there are Polish champions, in the greater Polish society, they are generally outcasts, so, I win the outcast award too, simply for trying to be the best.

Conversely, despite my having to go through the headache of filing my yearly tax returns as Americans are the only people left in the world that get taxed as expats, filing special treasury forms for my bank account and life insurance to make sure I am not some hidden millionaire evading my share of US taxes, which is outright laughable with my income. If you ask many Americans, I am definitively not an American. I can’t really figure out why, the reason I am most often told is because “you do not live in America,” but by that standard it would be fair to say any American not living in America is not really American, and that would strip citizenship from some unsuspecting people, like military service members.

So on paper, I belong to both the USA and Poland, but in the practical sense…I belong to neither. The middle of nowhere.

My career, which went from something really good to an utter disaster after moving to Europe (it is not just Poland, Poland has done a lot for me, and I tried living in the UK, that was a disaster not worth repeating) has convinced me that it is Europe in general that is bad for my career. Especially since most places, my previous titles and skill set doesn’t exist or has no perceived value.

Officially I am a doctor and a scientist. What kind? I like to think a good one, but that is one of those “you don’t fit in” issues too…

When I went to medical school it was with the goal of becoming a critical care surgeon. It never occurred to me that medical specialties and practice were different outside of the US. I mean when you hear that America is always the best, you just assume everyone is trying to be like them…Yea, I was naïve and not well-traveled once too, I must apologize for not being born omniscient. (Don’t tell my daughter, she thinks I know it all right now, so I figure I have 3 or 4 years left before she decides I don’t know anything.) It didn’t occur to me to research that it might be different. So not knowing what I didn’t know I just showed up. Forget culture shock, it was everything I knew to be true in life wasn’t shock. Even buying food at a restaurant was simply unfamiliar. I had never paid for food by the weight before, nor had to order each piece of the meal separately to make it look like the picture on the menu…

But as medical school drew to a close, I discovered that returning to the US was not a realistic option. I was now a “foreign medical grad” and as such no matter what I did would rate somewhere on the resident desirability scale between some guy off the street and everyone else rejected this position. It was potentially destructive for me, my family, and any hope of finding a job above poverty wages. My parents are gone, and with the exception of some really good friends, there is nothing else to go back to. But this section is about career, so I simply figured…well then I will just invent it here…

That is turning out to be nothing short of a disaster. In addition to struggling with languages, I am in a culture where such lofty aspirations are actively fought against by all of society. In addition to being outcast for trying to break the 1000 year old status quo, for the benefit of people here! I find myself beset by problems like people not wanting to help me in my endeavors at all. People who take active measures against my efforts for their political gain, and of course…not belonging to any group but being between two of them…the middle of nowhere…

The quick quick summary is that throughout Europe, there are surgeons and there are anesthesiologists. (The latter is also the domain of both emergency as well as intensive care in all but the UK). So in order to make the critical care surgeon specialty work, the path of least resistance would be to get specialty in both. Probably for the only time in my life, I tried to take the path of least resistance, but it doesn’t seem to be that way to me.

When I am asked why I would do such a thing, I summon up all of my passion for helping people in desperate need and give my very best altruism as an answer. It has never been met with “really that is awesome” or even “cool”. Usually it is derision. “Why bother”, “you’ll never make money doing that”, “it will take forever”, and my all-time favorite…”Who do you think you are?”

So when I go to work in surgery, the surgeons without exception are quick to point out that I think like an anesthesiologist. When I work in anesthesia I am told I am too much like a surgeon. I once again seem to be both, but neither. The middle of nowhere… After the last two years I really self-identify more as a surgeon. I haven’t actually finished specialty training yet, trying to do 2 essentially makes me the world’s longest doctor in training, but from the point of view of mindset, surgeons are all about doing. Identify something needs done and do it. Granted there are limits to this for most surgeons, and that limit revolves specifically around operating on patients and very little before or after that act, but my experience with anesthesia is they like to set up systems requiring minimal intervention and are extraordinarily routine driven. That just doesn’t mesh well with my idea of individualized care; especially in environments like the OR or ICU where doctor to patient ratios are so conducive to it. I also don’t like to call for help for simple skills like chest tubes…

Besides, when I was in the UK, the A&E docs always referred to me as a surgeon, so at least 1 group made me feel like I was part of another instead of saying “well, he is like us, but not.” Yes, I know they were only saying that because I worked in a surgical service and they didn’t want to claim me as their own…but…marginal defeat still means some level of objective was achieved…

So what kind of doctor am I? I am in the middle of nowhere…

Now because not having great employment opportunity as at once being part of different things but not all of one doesn’t pay well, I supplement my income by teaching. I also like to do research to change what I see as substandard practice…

Many of my colleagues think that most PhDs are either good researchers or good teachers…and 5 pages in, let me just sum it up…I like to be good at both, and both groups identify me as “not theirs” and I find myself in the middle of nowhere again…This is a recurrent theme for me…

I recently was told by a friend on Facebook there is a superhero named “Dr. Strange” who did his MD and PhD simultaneously…That made me feel like a superhero, because I did exactly that. Looking back it was hard, and I suffered, but for the only time I can remember, I was learning at a rate that actually required my maximum effort and focus…Now I have a lot of time to waste. I would like nothing more to be involved and learning at that rate again. It was challenging. Exciting. Full of discovery. It also came with many compliments about being smart for the first time in my life.

But I haven’t had anyone call me and ask to be on their superhero team…Sort of makes that a hollow victory and lessens the super-ness of it…If anyone thinks you are a hero for being smart, let me set that right to rest too… I have been ostracized, even tortured my entire life for being smart. Nobody likes smart people and I have no idea why? Fear? Envy? I could theorize all day…I even had a girlfriend dump me once because she said it wouldn’t work out because she likes when everyone tells her how great she is, and it didn’t happen too often when she was standing next to me, so I was taking all of the attention she wanted.

What is it like to be smart? Well…I was once dating a different girl who asked me “do you dream in pictures or words?” I thought this was a silly question…both of course…like everyone else…that is when she told me that was not like everyone else. She then went on this speech about lucid dreaming, and how awesome that would be… I asked her quizzically, “you cannot do that?” All of my dreams are that way, ever since I can remember. It’s better than a movie, stop, rewind, rewrite the script, different camera angel, zoom in, zoom out. That is how it always worked for me. It never occurred to me it wasn’t like that for everyone.

I take sleeping on a problem to another level entirely…Consciously, while I sleep… my mind works constantly. It never stops 24/7/365. Just like many other things on this list, it never once occurred to me everyone was not like this until somebody told me.

Patterns. I can quickly spot patterns in everything. Even when others tell me there are no patterns at all. While not perfect, it makes my ability to predict things very accurate a high percentage of the time. It permits me to anticipate and prepare for problems before they happen, in most cases, or avoid them entirely. My wife hates it when I blurt out the next line in a movie that neither of us have seen before or figure out the ending ½ through the movie. (90s movies are the exception because for some reason they thought it is entertaining to essentially change the whole movie part way through). I am also never invited to escape rooms or murder mystery dinners… This happens passively, no effort required.

Complex thought processes. When I look at a conundrum or problem, I don’t do it with compartmentalized information. There is no such thing as simply “what I know about medicine” or “what I know about human behavior.” When a problem arises I identify every piece of information that I have (information I have is the limiting factor, and I want to be first in line if they ever invent the brain plug like in the matrix to learn things) as being relevant to the problem or discussion at hand, as well as identifying how, and what impact it has. Plus it is fast…This also has the added benefit of allowing me to imagine in real time what somebody is telling me as they say it. It helps a lot in pattern identification and breaking down lies, untruths, and cons.

Form without substance…Dogma and church-like rituals that don’t stand up to even basic scrutiny cause a hard stop in my thought processes, like a computer dividing by zero.  This then has to be reconciled and it usually takes me a minute or two to do it. That is when I am not just looking at people like “what the fuck were you thinking?”

“Ninja like reflexes” is how my reactions are often described. From practicing martial arts, catching dropped surgical tools, or dodging stuff people teasing or hazing me throw at me. So fast is the recognition and process it looks like slow motion to me most of the time. It comes with the added bonus of being able to process the geometry of throwing it back too, and in my mind’s eye, I can even imagine the equation angles.  As it happens. During one part of my fire career i was given the nickname “slide rule” for essentially taking the arc out of throwing a basketball though its hoop. It seemed totally unnecessary to use an arc.

Like a sponge…As I mentioned before, the only time in my life I was pushed to my maximum ability to absorb (and consequently integrate) information was while simultaneously studying for an MD and PhD. Short of that level of intensity, learning is effortless, and if experience is a wise teacher and a fool can learn from no other, I am no fool, because when you tell me your experience I can internalize it to the point I can smell the smells, taste the tastes, hear the noises, and tell you how you felt.

Calm to the point of appearing apathetic. Since most of the time thoughts go through my head faster than most actions, I don’t have to act as quickly as I think. Coupled with anticipation and pattern recognition, I can position for success in moments to come, rather than racing to catch up. Actually when I am racing to catch up is when I make the most mistakes at things. Second is when I am prevented from positioning myself for success and having to wait to react.

If you are thinking just now, “wow” this is like a super power… It’s not, it is a terrible curse that alienates people from you, causes people not to believe or trust you, makes them jealous, fearful, and constantly questioning how it is even possible. Which is a crazy question anyway, because it is as natural as anything you do. I have read everything from psychology to neuroscience, psychiatry, every article on the benefits of being left-handed…I have no idea how it is possible, it’s just natural, the way it has always been and it pisses teachers off to no end too. I try to be humble about it, I try to suggest rather than pontificate. But I admit, I sometimes quickly run out of patience for people who think I am not capable of understanding a single topic I have not been involved in for 20 years. I am also merciless when it comes to insulting my intellect, because I have suffered dearly because of it my entire life. When I am standing there telling somebody an answer to a conundrum while they totally ignore me and go on making mistakes trying to figure it out, it doesn’t make me think too highly of them either,because it seems to me, a preventable mistake. An obvious one at that.

When I was young, my dad, who was super smart (he worked in a factory most of his life, wasn’t even a foreman, and his hobby was subscribing to an astrophysics publication and working out the published data equations by hand while he ate dinner), but not formally educated because of lack of money and social status told me that a smart person only ever has 2 choices in life. They can help people or take advantage of them. I chose to help. It doesn’t make you rich. It doesn’t make you popular. Almost nobody ever wants you around until there is a problem and you can expect to be ditched right after it is solved. But for the disaster that is my life…the victory objective I achieved in my marginal defeat was not purposefully or maliciously taking advantage of anyone. Even when my council has been wrong, I have always believed to my core I was trying to help for the benefit of somebody else.
In closing…It’s better to be lucky than smart, but being stupid is bliss…Stupid people are never alone, there is always a big group of them ready to welcome other stupid people in.

well…7 pages…enough of my mawkishness. I need to go chase down another victory objective to make sure I am only being marginally defeated by life. What else can be done..? As another great mentor once said “if you are not winning then you are..?”

The Fire Surgeon

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That is the coolest title I have ever heard…Not one I have ever been called myself, but I was introduced to it by somebody who was. A firefighter and later Emergency Doctor who worked as both a firefighter and doctor for a fire department.

Talk about a dream job…A firefighter and a doctor, if that doesn’t just bleed altruism, I don’t know what does…

There is a popular saying among firefighters, “it’s not something you do…It’s something you are…”

This was popularly described in the movie Backdraft, where one of the characters said to the protagonist, “the funny thing about firemen…night and day, they are always firemen…”

I started my career in the fire department, and fireman is a title I have had. For some time. But more than just a title or a job, it is a way of thinking, a way of living. Few things are more altruistic than answering somebody’s call for help, showing up and doing your best. Which sometimes works out and sometimes doesn’t.

After responding to a fatality call early in my fire career, I promised I would be better than that day. More knowledgeable, more skillful, I would not be caught incapable again… That led to a pattern of behavior, which eventually became a habit. Studying, reading, learning, practicing, trying. The goal everyday was to be better than yesterday. It became a life-long pursuit, it is never enough for me to know or do the minimum. The unyielding goal is perfection. It is not realistically achievable, and believe me, I have my share of failures, and I take them personally. My self-criticism is far in excess of  anything external.

I have been to the temple of St. John, to the traditional home of the Knights Hospitaler, the very birthplace of the Maltese Cross, and origin of all firemen.

But this attitude and devotion to excellence, to a way of life which focuses on having the greatest position in the world, the person who gets called when things go wrong for other people. I still think that is a great honor, something that has to be earned everyday. However, it often doesn’t endear me to other doctors.

I know, call my friends, and have been mentored by some great doctors on the road to becoming one. Some are emergency physicians (a great many), some are anesthesiologists,  and some are (and were) surgeons. But I have noticed that not all doctors are as great as they are. Many of them do not want to be. This creates a lot of conflict for me. I see them as not living up to the expectation, and it makes me angry. Especially when I constantly hear from them “I don’t want to learn anything new or more” or “what’s in it for me?” Learning new and more things is part of being a doctor, it is expected by everyone from licensing agencies to patients. Not learning more is essentially dereliction of duty for doctors, it is fraudulent. “What’s in it for me” severely conflicts with the altruism intrinsic to firefighters. Negligence, laziness, and greed just don’t sit well with me. It never will. It is what it is.

Many doctors I have met, all over the world, are multi generational doctors. Grandparents, parents, etc. were all doctors, so they naturally became one too. They have an amazing sense of entitlement. But they are not alone. If I had a dollar for every person I have met who thinks they are entitled to all sorts of things simply for graduating medical school, becoming a specialist, or achieving a title, I could feed, cloth, and provide medicine to the whole world. It frustrates me.

Today, I was going through my usual routine of checking out my daily dose of expanding medical knowledge, when I ran across an article, linking to a study that described how US surgeons were improperly prescribing opioid medications, and 2 things in the article caught my attention. The first was they claimed there were no surgery specific guidelines for treating pain. This to me is absolutely a merit-less excuse for not knowing how to do ones job. There are many guidelines that describe the treatment of both acute and chronic pain in patients, and surgeons not being able to do it is negligence. The other thing I was struck by is that they were essentially trying to justify insane behaviors like prescribing opioids for 6 plus months at a time and claiming they don’t have the training to recognize, prevent, or deal with addicts. I know every doctor who ever graduated medical school was given instruction and education on treating pain. It is intrinsic to medical education. Now this may have been poorly done, I will accept that as an excuse, but to claim ignorance is disingenuous.

One of the things I have noticed about all forms of specialty training and specialist physicians, is that it doesn’t expand their skills and knowledge. It limits it. Rather than learn about all medicine as it applies to what they will encounter, specialty training purposefully narrows knowledge and capability, and often ends with “that’s not my job.”

There is merit to recognizing ones limitations. There should be no shame for calling for help. But rather than using this in the way it was intended, most specialists I encounter use it at best as a crouch for inability, and at worst an excuse to not make any effort to better oneself. You can see where this conflicts with the very core of my beliefs…

One of the things about firemen is that they are expected to be capable at all aspects of their job. Preventing fires and accidents, pre-planning  for them, mitigating everything from medical emergencies to major disasters and everything in between (like fighting fire), cleaning up after them (salvage and overhaul are the industry terms), and even investigating the causes and laws when there is a fire. It is a soup to nuts requirement. While very few are great at all of it, and teamwork is essential, everyone is expected to have a minimum capability to do their job. They purposefully train regularly on skills to keep ones they don’t use often fresh. Doctors don’t do that at all. Not in any meaningful way. But to me it seems logical. A doctor should be capable of preventing disease, capable of performing the actual interventions, both surgical, and medical that they use, and caring for the patient after these interventions. Perhaps for the rest of the patient’s life.

Not being able to do all of this and requiring a myriad of other doctors for even the most minor or intrinsic aspects of the job, like providing pain control post surgery, should be embarrassing to everyone who cannot do it. Every time they call for help they need to see it as a failure of their ability. They should resolve and rectify these inadequacies. When things go wrong, while “no-fault” education or remediation is a great thing, there is no such thing as “no-responsibility”. While there may be no fault, there is certainly failure, and certainly responsibility.

Another thing doctors like to do is claim that failures are everyone’s doing but their own. “The lawyers”, “the lawsuits”, “patient satisfaction”, “where I work”, “we’ve always done it that way”, I could list every pathetic excuse they use. That’s exactly what they are too, pathetic excuses. Distraction, deflection, denial of responsibility.

That is why I am against malpractice reform in all countries. The only thing keeping the medical profession from utter laziness and inadequacy is the legal profession. In fact tort laws need to be expanded to make sure doctors are accountable.

When I bring this kind of stuff up, a common thing I hear is “that is unprofessional to say such things.” But it is not unprofessional, it is simply not what doctors want to hear. They want to be told how great they are, how special they are, and how much respect they deserve…Bullshit. What is professional is recognizing ones shortcomings, admitting mistakes, apologizing when necessary, constantly trying to improve both the system and ones-self, taking responsibility, doing what is right even when it doesn’t directly benefit them.

Excellence is not a goal. It is a behavior.

If everyone in healthcare and medicine wants to be told how great they are, they need to start earning it. In order to be great they have to be more than the minimum to not get fired or sued. They need to be capable of everything that is required of them, even if it is new, outside their comfort zone and self imposed limitations. Otherwise, the titles and pleasantries are not respect, they are hollow and worthless. A mockery of respect.

One of my former bosses once asked me, if being a firefighter is so great why did I stop? To which I replied “I didn’t, but supposedly becoming a doctor was a promotion.”

It doesn’t seem like a promotion, and the longer I am in medicine, the less impressed I am. I see a majority of doctors as arrogant without merit. Respected without deserving. Demanding without earning.

On 15 April 2017, I am not convinced doctors should be paid anywhere near what they make, and should not be respected anywhere near what they are. The few good ones tolerate the majority of mediocrity and laziness. So they are included and judged by the company they keep.

Inaction is acceptance. It is making me sick and it is in my face every day.

Choc

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The original French word describing what modern physicians in English call “shock,” was first used by the French surgeon, Henri Francois Le Dran.

It described his observations of what happened to patients who were shot with musket balls. These observations were not limited to blood loss or the delivery of O2, but of the totality of the effects over time.

Shock is my favorite subject in medicine. I read and write a lot about it. I am writing it here because I am getting tired of typing it again and again.

For the last 50 years or so, modern medicine has wrongly simplified and attributed shock to the failure of delivery of O2, by several mechanisms which were given names like “distributive,” “hemorrhagic,” “septic” etc…

Shock is multi-factorial, concurrent processes in the body, most notably triggered by a combination of the failure of delivery of o2, inflammation, and kinin cascades. Shock is not so much a disease as it is a point in time of an underlying disease process.

The chronology of this process is compensation, decompensation, multiple organ dysfunction,  multiple organ failure, and finally death.

What makes shock pathological is that in its decompensated phase, instead of helping to maintain homeostasis, it instead inhibits it.

It is important to understand that shock is a systemic process, it is not restricted to a specific area or system. In fairness, depending on the severity and medical treatment, the obvious clinical effects may not always be significant, however, they still exist, and become more important as both the length of time the patient is in shock as well as the severity of it progresses. It would take me no less than a novel to type out every systemic interaction shock has, but I will give a few examples here. In addition the the obvious ones, like inflammation or bleeding, there are changes in protein composition in brain cells and function, particularly in the limbic area, there are changes in metabolism from an anabolic state to a catabolic state. From sex hormones to all of the blood pressure and fluid retention pathways are altered in some way.

Shock may be acute or chronic.

Acute shock is very easy to see clinically, the signs and symptoms, as well as biochemical findings are well described other places so I will not repeat them here. I don’t know any providers who cannot at least recite many of these. We see it often in every condition from dehydration to massive hemorrhage, chances are if you are reading this, you have experienced being in shock at some point in your life (pretty much unless you live in a bubble in a safe space).

Chronic shock, is seen, but rarely described as such, instead being given the moniker of “early stage” or “compensation” for an underlying disease process. A good example of this is heart failure. Heart failure is a response to stressed myocardial cells. In order to maintain cardiac output, we see compensatory mechanisms like faster heart rate, narrowing of blood pulse pressures, early stage hypertension, late stage hypotension. We see late stage cardio-renal disease, which is just the chronic form of AKI in acute shock, by the same mechanisms. Any person who is suffering from a chronic disease is, for all intents and purposes, at a baseline of compensated shock. As we know, this takes a toll on the body and over time, the victim transitions from well compensated to decompensated, with the entire purpose of medical care and support to slow or reverse this process.

The treatment of shock comes in 2 stages, regardless of whether or not it is acute or chronic. The first stage is organ support. Which is probably more accurately described as “system” or “organism” support. This support is designed to reduce stress on other organs and systems subsequent to the underlying cause. This is best demonstrated in general anesthesia, where shock is induced in the patient, and numerous monitoring and organ support techniques are then applied to maintain the level of shock, preventing both decompensation>MODS>MOF>death, as well as normalization secondary to compensation, aka the patient waking up with full function and awareness.

The second stage of the treatment of shock is the repair or regeneration of the underlying cause which incites it. This may take the form of restoring blood flow and subsequently O2 delivery to an infarcted myocardium. It may be the resolution of an infectious process, surgical reconstruction to maintain homeostasis in some way, such as fixation or amputation. It may be any number of medical treatments, such as mechanical ventilation or antibiotics.

I think the most common mistakes for providers attempting to treat shock patients is the oversimplification of what shock is and the lack of awareness that system support is entirely different from treatment of the underlying cause/cure.

This misperception that shock is a disease process, rather than a point in diseases process drives the over-simplification of both its teaching as well as attempts at treatment. This is seen by patients progressing in decompensation despite various established and long-standing treatments expertly applied as well as numerous conflicting study findings of various treatment modalities when applied to shock patients universally, rather than individually.

Because shock affects every system in the body and the entire purpose of all the body’s systems is to maintain homeostasis, the complexity of this I attempt to describe as a set of scales with multiple parts to balance. Applying any treatment to one part of the scale affects every other one. Contrary to more antiquated thought of “doing as much of nothing as possible”, which in a shock state seems rather negligent, and certainly not expert to me…”Do nothing and if the patient lives take credit, if they die deny responsibility”, I profess that to successfully treat a shock patient, precision of treatment, applied at the proper time is the key to success.

Good examples of this range from treatments such as blood transfusion in hemorrhage to steroids in sepsis, and even catecholamine uses in cardiac arrest. There are no shortages of studies which are inconclusive or conflicting. The 2 things missing from many of these studies however are: 1. the differentiation of patient cohorts, with many being lumped into overly broad categories in order to reach statistical significance and power and 2. The utter lack of account for timing of the studied treatment. If you are treating an illness that changes over time, certainly when you apply that treatment is significant in any observation?

Another aspect of shock treatment that I would say is oversimplified is the focus on fixed time points rather than a continuum. Patients don’t just suddenly go from compensated to decompensated to MODS, MOF, death. There is a steady progression from initial stress response, increased physiologic response, early, middle, and finally late decompensation and then through the MODS>MOF> death pathway.

It is also why I am so opposed to the term “irreversible shock”. When exactly is that? Nobody knows until the post-game wrap up. Irreversible shock is MODS>MOF. A time when organ support and medical treatment can no longer maintain homeostasis. It is at this point in time where biochemical and molecular cascades have progressed passed modern medical intervention.

This leads right in to the importance of early recognition and treatment of shock. Since modern medicine lacks the ability to stop or reverse these biochemical cascades, it becomes more important to recognize and treat patient conditions before they reach that stage. In the modern era, shock is the final stage in a disease process where it is possible to intervene. Hopefully one day that will change, but it will not be in the next few years (probably not the next decade, but I remain hopeful).

If you want to be expert, or even successful at treating shock, you have to really understand it, not just some oversimplified explanation of failure of delivery of DO2. You have to see it as a progression over time, not as fixed points. You must understand and recognize the difference between organ support and curative treatment. Finally, you must be accurate and precise in both the type of treatment as well as the timing of them in order not to unbalance one or more scales attempting to balance 1 or 2 others.

The understanding of shock is a river both a mile deep and a mile wide. I would go as far as to say it could be a medical as well as academic research discipline all to itself. Shock is completely unsuited to protocolized medicine.  Treating it is an art, which requires masterful understanding of basic science, before clinical science can even be applied. Especially because of the different physiology and compensatory responses in different age groups.

I hope this has given you at least an insight as to how complex and underestimated shock really is.

Reliving yesterday’s glory

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Quick correction, this video was shared on the NAEMT website, it was created by DHS. That was my mistake in reading the origin of the original post.

First, a few housekeeping items…

This website keeps track of what countries and IP addresses visit this page. What they read, how often, etc. So I know people from every continent are reading this…

It is ok to comment or even say “hello”, and generally as long as you don’t tell me I have no idea what I am talking about you will likely receive a friendly reply.

If you don’t like what I have to say, in your browser up in the right hand corner, there is an “X” and if you press it, you will not have to be bothered by my writing anymore.

In my mind and learned values, “professionalism” means being honest about short-comings, identifying problems, using peer pressure to change undesirable behaviors, and striving to be better than yesterday, not hiding our mistakes and deficiencies to save face.

If you want to be told how deserving and great you are…ask your mom. (She would probably enjoy a call from you anyway) But I call out bullshit when I see it, in my culture, an honest person is held in higher regard than a liar, even if that lie makes you feel good about yourself.

Now then… Let’s get down to it…

I have done my best to remove myself from EMS on social media, and for the most part I am doing well…I haven’t been embarrassed by being compared to the most inept paramedics in months. I haven’t been told how stupid I am for knowing more about sepsis than lactate measurements and surviving sepsis guidelines. (and if you want to kill a septic patient, “surviving sepsis” is a really good start, and lactate is just a number for administrators to bill for and defend their treatments with.) My blood pressure is lower, and I waste less time “educating” people on social media.

But the fact remains I have many friends still in EMS and the fire service and their posts do show up on my wall…Every now and again, like today, it is usually something so stupid I feel compelled to speak about it. Perhaps it is pride in my history and achievements, perhaps I want to give something back to what has given me so much, perhaps I am just a glutton for punishment, but today something crossed my page that not only embarrasses me, but harms the people and profession that so many work so hard to advance. It is without a doubt the most stupid thing on the internet today, even more so than US presidential politics. Normally I do not grace this kind of stuff with a link, but this was so offensive, I want there to be nothing left to the imagination.

Here it is…

EMS has a problem. A big problem. It destroys the people who work in it. Multiple jobs to make ends meet, unsafe working conditions, high stress, largely not included in programs directed at safety forces like Police and Fire, suffering from an identity crisis for about 5 decades, and to top it all off, seemingly hell bent on making sure its workforce can be totally replaced by 2 men and a truck with a computer.

Let us pick it up from the beginning?

There are 2 main philosophies to EMS around the world. The older one was developed by the Germans. The idea of bringing the most advanced care possible to the patient. This is often done with physician level providers, but not exclusively. The EMS providers down in Australia (who in my mind, and others, have the most advanced non-physician EMS in the world by a long shot) decided they were going to make their medics as capable as any doctor. They have achieved that goal by most measures and if anyone is looking for a system to emulate, consider this my endorsement of them. They are determined, forward thinking, have adopted education and scientific research to guide and improve their treatments as well as provider health and safety. They embody all modern EMS should be. They are not perfect, and I have been personally called upon to help with improvements by a few of their folks, but their hearts and minds are in the right place and they will go forward.

The second philosophy, developed in the 1960’s and credited to the USA is the idea of a few minimally trained providers providing “simple, life saving skills” and driving the patient to the hospital, where “definitive care” (whatever the fuck that means…) can be found.

One of my mentors from the fire department, and easily one of the most skilled and greatest fire/medics I have ever met, once said to me “The fire service (and by extension EMS, because we did both) is the last non-military job a non-educated white man could get he could be proud of.” Now without looking into racism and nepotism et al. in the fire service, at the time I thought he couldn’t be more wrong. But I have come to see not only how right he was, but the wisdom in it. One only has to look at the demographics and the many court cases discriminating against women, minorities, etc. to see the truth to the racial component. When I first started on the FD (As my friend from Mumbai once said the first time he got intoxicated at a party, I am “whiter than Casper the friendly ghost”), and my parents could not have been more proud. I could not have been more proud. But in the US, this is not unique to the Fire Service, it extends to Police, and of course…EMS.

Many US EMS leaders (and there are some notable exceptions) are old people. Their idea of EMS education is simply a set of skills, similar to a trade, that anyone with a high school diploma or GED can learn in between 750-1000 hours of non-university level education. They realize, and I fell into the same category myself, it was the best way to get a chance at working in public safety or medicine if you could not go to college (either because you lack the mental capacity or the financial means). Many of them rightfully claim they are pioneers, type A personalities that almost never fit in, who were(are) totally expendable to society, doing things those with higher education do and being successful. They have earned respect, admiration, and thanks, paid for with their very blood and totally consuming their lives.

But those days are over! They are not coming back, and it is time for them to get a lifetime achievement award, a gold watch, and if they want or need to stay (it is not easy to let go of a lifetime that defines a person) removed from leadership and given a more consigliere position.

All over the world, the US EMS philosophy is being proved inferior in patient care, economically unsustainable, and not meeting the needs of the infirm in today’s society. It has run its course and its days are done.

In the 1960s and up until about 1985, medical knowledge was by today’s standards elementary and in many cases outright wrong. We have seen more advances in medicine in the last 20-30 years than the totality of medical advances in history prior. We know the only acute pathologies are some poisonings and trauma (to include burns and other forms of new onset shock). Everything else is either chronic or acute on chronic disease (that includes flora disturbances and neoplastic diseases).

The idea of showing up with lights and sirens on a blazing steed and saving the damsel, or at least the geriatric in distress with a endotracheal tube an 1000ml of normal saline are over. Backboards and all other manner of “life saving” gadgets and ideas are failing fast. Technology is even accelerating this. Today there are hand-held ultrasounds, portable computer tomography being deployed on ambulances all over the world, and machines that can not only analyze, but defibrillate lethal arrhythmias without human intervention. They are even being placed in public spaces and put on drones.  (If you are one of those folks who spends years obsessing over EKG readings and electrophysiology, bad news, that skill is going to be nothing more than a parlor trick in a few years because the computers are getting better at it).

Technology isn’t going to “help” EMS do what it has done for the last 30 years (as in the video), it is going to revolutionize it. It is not going to look anything like what it did. Just as medicine today doesn’t look like it did 30 years ago. EMS providers as the US currently trains and uses them in large sections of the population are going to be replaced by a handheld computer and 2 dudes who can drive and push the stretcher, and will be paid and respected about the same if they continue the practices of yesterday.

Historically, I always found myself at the change between old and new ways. I was in the fire service during its change, I was in EMS for theirs, I am in medicine for theirs. I was also a child when computers were just starting to be available at home (Got my first TSR 80 MC10, when I was 6, my dad bought it used with a tape recorder to store programs on, and when my mom protested the purchase and I had no idea what to do with it, bluntly stated “this is the future, everyone has to learn how to use this”), and I had an internet account before AOL existed, when there were only 19 different locations on the internet. (Let’s not delve into how that happened, we would have to call it “alt law”). So I understand change.

As proved all over the world, the American EMS system is a dinosaur. Its days are over. The German system of bringing the most advanced care to the patient has proved its superiority hands down. It will no longer be economically or socially valuable to do a few skills and drive to the hospital by 2 people in a modified pickup truck that graduated high school.

The future EMS provider is educated, not only to the 4-5% of conditions that they see and define as “emergencies” by 1970s medicine, but to all forms for chronic and acute exacerbations of chronic disease and how to treat it. They are the “community” healthcare providers, outside of the ivory towers, whose goal is to prevent hospitalization and all of its associated costs. They will be called upon to direct patients to the most appropriate care for both medical and social needs. They will not be high school grads, who got 750 hours of training at “the academy” and OTJ guessing of who needs a hospital and who doesn’t. They will not be these people who 40 years later stumbled through a public safety management course or college credit for life experience. The level of entry will be on par with other civilized countries demanding bacheolor’s and more advanced degrees. They will be expected to not only know what to do and why, but to research, and use technology not as an adjunct, but intrinsic to optimal independent patient care. “This is how it is on the street” and “diesel bolus” where hopefully the nurses and doctors will be able to pick up the slack are likewise over. Particularly when medics are functioning in austere or other remote conditions. A pulse, a cert, and 5 years “experience” will not get the jobs of the future.

That is why I take issue with this video, and why it is so pathetic. Forgetting how EMS might have a self-driving car, but somehow there is a massive accident between other self-driving cars for a second, as safety and technology improves, the role and need for EMS in such incidents will decline. The simplistic triage will be replaced. The need to “transport” patients to the hospital will decrease. If a EMS provider can put on a wireless diagnostic and read a patient’s “vitals” I can equally see them at the hospital in real time and with telemedicine a treatment totally independent of the need for anyone else’s input. I still haven’t figured out why the providers are wearing stethoscopes with such technology, but an ultrasound is nowhere to be seen. In medical school one of my professors once chastised a student “that is not a piece of jewelry around your neck, it has a function and a purpose, learn how to use them!” Will a stethoscope even be needed? I rarely use mine anymore. Don’t even carry it around in the hospital.

High flow O2, a backboard, and driving to the hospital is the medicine of dinosaurs. It is the best idea they could come up with with their limited integration of technology and education. Forget me, imagine what younger generations, people of my daughter’s generation, who had smart phones from the day they were born will do with technology! With Medicine using molecular and genetic manipulation! The education they will need will far in exceed a few hours at “the academy” and their economic stressors will make driving every patient to the ED impossible.

Maybe the NAEMT is just pandering to the lowest common denominator of US EMS provider, for prestige, membership fees, or even just imagining reliving the glory days with a smart phone? Maybe they are just using the political technique of anti-intellectualism in order to appeal to their base of support? But this video shows a gross lack of insight and foresight, and I hope that more capable modern providers and leaders will stop sending money to these people to make their pitiful videos, and spend it on associations that advocate real and substantial education, not 2 day card courses, and a future provider whose value to society exceeds 2 dudes, a truck, and a smart phone.

I haven’t even begun to touch on the integration of EMS fellowships and opportunities for physicians in North America, NPs and PAs in an EMS role, et. al. But I also stand by my position, if the US and other systems using the US skill and transport philosophy do not get their heads out of their asses, in a few years, nursing will completely take it over and they’ll all be “unlicensed techs” at the direction of a nurse on the most critical patients anyway, and their pay and working conditions will reflect their lack of value.

Though there still may be a supervisor on-scene not wearing any safety equipment while the rank and file are doing as they are told and not what they see their leaders do.

In any event, without advancing the education and technology of EMS, it won’t be a job to be proud of much longer. If it even continues to exist independently at all.

Anyway, I am sure I will get every idiot on the internet sending me hate-mail now. They always come out on the EMS posts…

The whole point of Emergency Care is being available when normality fails.

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Here I am writing about this again…Why..? Because people still do not get it and on Facebook today there is yet another article written about why people should go to a primary care provider, in this case a pediatrician, instead of an Emergency Department.

The comment section is full of “Emergency Nurses” carrying on some old line about how many people abuse the emergency department and they are busy and only for sick people, and everyone else is wasting their time…

News flash in simple language so the morons can understand it…

Healthy people do not go to the Emergency Department. What is so hard to understand about that? People go to the emergency department because they have a problem. Hence the term EMERGENCY!

Now like any other emergency service, this problem may not be what you want to deal with or specialize in, but you are still called upon to deal with it. If you don’t like that, I suggest another line of work. In fantasy land, where everyone you see matches your adrenaline junky definition of “emergency.”

If you really want to see sick patients, the ED is not the place. I love to work with the sickest of the sick, and I don’t work in Emergency. You know why? Because after working in Emergency for years, along with rotations in medical school, I discovered something…The really sick patients are in the ICU.

Surgical, Cardiac, Pediatric, whatever flavor you like, if “sick” is what you want, that’s where you find it. Its high stress, high mortality, merciless work, but every patient, and usually family too, are really sick.

The modern Emergency Department is primary care. Why? Because providers are lazy and don’t want to change. They want to practice like they did in the 1880s. 9-5, or in the case of some, 9 O’Clock doctor’s office time, which is anywhere from 40 minutes to 2 hours passed 9 until 1 or 2pm. The only doctors worse at telling time are surgeons. As somebody who does work in surgery, let me give you a brief explanation of Surgery time?

“This will be a fast operation” This will take at least an hour.

“This operation will take an hour” Expect to be finished around 3 hours later.

“This is going to be a long operation” 5 hours at least.

Back on point…

Nobody, in any country, in 2017 wants or needs a primary care provider who cannot see them in a matter of hours. This may interfere with “Lifestyles”, “Quality of work/life balance” etc… Guess what? Nobody cares. If you are not available when people need you, you are worthless. If you do not have the equipment to do your job, you are worthless.

Nobody ever called the Fire Department, reported a fire and received the reply: “ Sorry, we don’t have any hoses at our station, so we will have to refer you to a provider or place that does have a hose who can see you in a week, or 2 weeks, or 2 months…”

Nobody goes to McDonalds tries to order food and hears “Sorry, we don’t see walk-ins, you need an appointment, we’ll be happy to set you up with one in a month…If you can pay up-front.”

Another fact of life…You know which patients keep the doors open and the lights on so you have a job in the ED? The ones who are not “emergent.” These patient’s require less time and resources and since there are vastly more of them, they are the ones paying the bills, padding your census, etc. That doesn’t matter if you are in a single-payer system or a private payer one.

If patients knew and understood medicine, there would be no need for you! The reason you go to school as long as you do, and are recognized by non-experts as the people to ask is because they don’t know, and they know what they don’t know. So they seek help from somebody who does, when they need help.

Responding to their needs in their time of “crisis” is why they put memes on Facebook about how great you are. It is why they thank you for your service, it is why you enjoy not only the pay, but a higher social standing than non-providers and even non-emergent providers.

If you are not an emergency provider, get a clue, your outdated, inconvenient, practice needs to change. You need modern equipment and it is expensive, without it, you are just a useless middleman. You need to be available for patients when they need, not at your convenience. If this means you have to set up a practice with rotating shifts around the clock, or at least 1st and second shift, do it! If not, shut the fuck up…Nobody cares about whatever excuse you have not to.

If you are an emergency provider, nobody cares about your lack of job satisfaction because you are not getting an adrenaline fix with every patient. If you don’t like the reality of what working in the ED or A&E is like, just go. But your incessant public displays of bitching about patients and how they “abuse” the place open 24/7/365 with big red lights on all night, how they don’t know what is an emergency and what is not, and all of your other whiney bullshit, is an embarrassment to all emergency providers.

I have told you where to find sick patients. Your bullshit excuses and arguments about who should be in the ED are now moot. I have told you what you need to do in order for patients to find value in a primary care provider. If you do not do them, your bullshit excuses are moot. If you do not like providing minor primary care, it is you who need to leave the ED, not the patients.

Did I use small enough words for you to understand it this time? Because as long as you keep making posts about “Don’t go to the ED you abuser” I am going to make posts calling you out, and if you are some old ED dinosaur who can’t handle modern Emergency practice as defined by patients, evolve or go extinct, because you are no longer needed.

By the way, I tell everyone, go to the emergency department first. Get only follow-up care from people who can see you in 2 weeks or more after they send you to yet another place for the required diagnostics. Otherwise, you will be better (won’t need their services at all and will have no reason to pay them) or you will be in the ED anyway (because your condition will degrade to an emergency or you’ll be dead).

“You would never sue your friend; you would gladly sue your enemy. Make every patient your Friend”

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Said my internal medicine teacher in medical school. (I can’t spell his last name) but total credit for the phrase to Dr. Robert.

Before I get to the heart of what I want to talk about, I need to add some background in order that my point of view can be better understood.

I grew up in emergency service. When other kids were out experimenting with alcohol, sex, drugs, and finding their identity in the world, I was at the fire department, which in the place I grew up in also provided emergency medical service. My goal was simple. I was going to be the best at what I did. The reasons that led me to this goal, stems from constantly being reminded in my youth that by fault of my birth, I would not live up to the resources I consumed. In retrospect I think it looks a lot like the motivation of young Olympians, so much so, that there is actually a psychological theory on “the Olympic mentality,” and when I read it, I found myself thinking, “that sounds kind of like me’ Later in my life I would go on to meet world champion level athletes in my daily activity and found great kinship being around people whose single-minded devotion was excellence in their craft.

While some young people discover gymnastics, ice skating, swimming, or some other athletic pursuit; I found the fire department. To say I was devoted would be an understatement. It was totally life consuming. Like many young people groomed for a field or profession, I missed out on a lot of things. Things I didn’t even know I was missing out on. What’s more, even if I was told, I would not have chosen differently.

But for the loss, there were many gains. Constantly being around older people, I was learning the skills they were learning in their part of life. How to inspect a house you were going to buy, how to determine the quality of an employer, the lessons of raising their kids. But I also learned skills and experiences that many people in their lives will never understand. The feeling of cartilage cracking when doing CPR on a dead person; the fear and joy witnessed at the beginning of life, the anger and sadness seen at the end, and whether it was building construction, hydraulics, operating rescue equipment, or emergency life support, I was acquiring those skills before I was old enough to drive. But aside from those physical skills, my constant proximity to leaders and officers had given me other skills too. The understanding of labor relations, public relations, media relations, system design and function, preplanning, budgeting, and a host of other organizational skills. I had even developed a sense of humor dark enough to joke with any ED nurse, doctor, or emergency provider. But the thing that I value the most perhaps, are the values I learned. Among them, that the mission is bigger and more important than any one person, than any one organization. That mission is simple. When help is called for, that call is answered.

While I certainly took the road less traveled in my career, and it is ongoing, it follows a constant pattern. To add more knowledge and skills to always be able to answer that call. So despite my different titles, locations, and even life experiences, every day is another chance to passionately do the voodoo that I do best on a bigger stage. From suburban Ohio, to around the world, I am not so much a title, but a way of life. So while I worry more about what I will do tomorrow and look at past accomplishments as yesterday’s news, I like to reflect on this blog. So that I can spend time dwelling on the not so simple parts of my experience.

Now enough of “my trip down amnesia lane,” as the Great Robin Williams once said. Let us get to it?

Yesterday was a hard day for me. I spent all night traveling, to arrive for work at 0745. While I had a great day, at the end of more than 36 hours of being functional, I was tired and hungry. I am not as young as I used to be, and I do require a bit more down time between acts of major physical exertion. So, I got my pizza and proceeded to eat and check my Facebook feed before going to sleep.

The number one post on my feed was from one of my earliest role models and later my friend. It was a post out of UK EMS with a picture of an ambulance with the phrase “you wouldn’t call the coast guard for falling in a puddle”.

What this post essentially said was: “We think we are only for emergencies as defined by what we think we want to do in our work. That we are better than the uneducated rabble we life-saving heroes look down on. So unless we feel you are deserving, don’t call us.” You can only imagine how that runs contra to the belief of every call for help is answered, no matter how insignificant. That may sound idealistic to many, but I can offer my loyal assurance, when you are the one making a call for help out of desperation, that call being answered changes your entire life. It is the very essence of altruism. To scoff at it, is in my mind, the ultimate blasphemy.

So I made my little public relations quip and I was out cold. Not enough hours later my phone rang. As I usually do I gauged how urgent I thought it was, and seeing the number, knowing the caller knew both how tired I was and my previous 48 hours, I answered it. Sure enough, it was a call for help. A person in the UK was experiencing a medical problem and couldn’t find a doctor open who would see him. While it wasn’t a serious problem as far as medical complaints go, it certainly is not something that is easily ignored until morning, simply because the symptoms do not permit rest, sleep, or concentration. So I offered my best advice, go to the store and get an OTC med called X. If it doesn’t work, call me back.

No further calls, mission accomplished. So after a few hours of sleep, I woke up still a bit miffed. A person from a country whose medical providers unsuccessfully tried to fuck me for not sucking up to their narcissistic egos could not be reached in a timely manner so said “patient” had to call me in a foreign country. I am pulling no punches, if anyone considers that great patient care or a great system, they are delusional. So I wondered…why didn’t this person just go to the A&E? Then it occurred to me… Because in A&E they wear flair (buttons) that say unless you are dying don’t come. They print smart ass slogans on their ambulances that say “you are beneath us, don’t call.” They have posters and billboards that essentially say “we are paid by your taxes, but we don’t want to help you.”

Now I was pissed. People who work less, less intensely, and get paid exponentially more than me are so unconcerned with their mission that the call for help had to be answered from a different country. By somebody they decided was not one of their good old boys. Nor do I want to be a good old boy in a club such as theirs.

I wonder if a Japanese doctor would commit ritual suicide over such a failure? I would seriously consider it a major failure if somebody had to call a foreign country because I didn’t measure up to the need. I wouldn’t kill myself, but I would certainly resolve to never have that happen again.

Of course my thoughts on this led to a Facebook argument. So let me lay it out again, not because I think it will change the mind of a capable and honorable antagonist, but because somebody sitting on the fence out there might make a good decision one day. Because a burnt out provider looking for a reason to carry on might read it and be rejuvenated. Because just maybe, somebody new might not make their value their own wants and desires, and realize theirs are actually no more important than that of their patients.

Here is a quote that I think sums up both the fire service and medicine nicely.

“Our department takes 1,120 calls every day. Do you know how many of the calls the public expects perfection on? 1,120. Nobody calls the fire department and says, ‘Send me two dumb-ass firemen in a pickup truck.’ In three minutes they want five brain-surgeon decathlon champions to come and solve all their problems.”

― John Eversole

It has been my experience that most doctors need to really read and understand this quote. While educated enough to understand that no system or person is perfect, many doctors it seems to me use that knowledge as an excuse rather than a metric to be reduced to the lowest possible number through constant improvement. I find it even more entertaining when they default to “acceptable losses” but then despite practicing out-dated paternalistic medicine, they then deny responsibility for them. I don’t remember being told in medical school, but I can attest that in both the fire service and the military, the person making decisions is always responsible for them. It is impossible to claim to be the authority but not responsible. That means every time a doctor decides “what is best” for the patient, they assume total responsibility for any negative outcomes. That would be the opposite of modern medical practice where patients decide on a range of informed options presented by a doctor, even if those options are between possible death and certain death.

Patients, especially those from Europe or very poor people from everywhere I have been, recognize the limits of their knowledge and the superior knowledge of doctors in particular. They do not understand medical systems or specialty roles. If I ask 99% of doctors the difference between a member of an engine company, truck company, or rescue company, many would not even recognize I was talking about roles in the US fire service. The same amount would not know the difference between the engineering, deck, operations, and weapons divisions in the Navies around the world. At least 75% of doctors I have met cannot define what a nurse is or what “nursing” as a profession is based on. Those are people they work with every day and are an absolutely indispensable part of patient care. Most of the time doctors just define nurses as a set of skills they perform, rather than a distinct education and philosophy. Maybe there should be a day in medical school where we talk about “and these are your coworkers”? But instead I suspect we will just continue with superficial lip service like “team mates” or some other bullshit buzzword. (In fairness, nurses are not immune to ignorance of their coworkers, but I am not talking about nursing behavior today). Patients don’t recognize gastroenterologists from nephrologists. Many don’t even recognize the difference between Internists and Surgeons. In their mind, as well as in some medical systems, doctors are doctors. They are expected to know the basics of all parts of medicine, whether they have been practicing for a day or decades, whether they are a cardiac surgeon who subspecializes in valve replacement or a general practitioner.

So why do doctors (and EMS providers) seem to believe patients simply “know” what specialist to self-refer to or precisely where to go get the treatment they need? I will point out the same doctors (right down to the person usually) get pissed off when a patient has self-researched their condition and not only knows more about it than the doctor, but actually knows the current treatment guidelines for it while the physician is 10, 15, or even 20 years out of date. Personally I find it quite ironic. What’s more In the Medical community world-wide, there seems tremendous reluctance, even resistance to modernizing the way medicine is provided as well as its specialties. In fact, doctors are moving more away from patient expectations than towards them. Then doctors fear and get angry when they refuse to change their behavior or mindset and the only recourse is for patients to sue them.

I know I take special aim at general practitioners for this. Mostly because I am the one who has to deal with the fallout, both medically as well as emotionally from the patients. In my view general practice is so out of date and out of touch, that I would rather see all patients go directly to the Emergency Department. Making medical diagnosis and decisions without the most minimum of diagnostics seems like guessing to me more than “skill.” Strangely enough, the last article I saw on Medscape on who and why doctors get sued stated some 40% of all doctors sued we primary care providers (the US doesn’t have “GPs” per se, but I will use the terms interchangeably.) Furthermore, the number 1 reason for being sued was misdiagnosis. Well that’s a no-brainer. No time, no labs, no radiology, and relying on the patient’s story, unless they work at a more modern organization. I have no sympathy either. This is 2017, blowing smoke up peoples asses’ is not acceptable. It is not acceptable to diagnose cancer without a biopsy. It is unacceptable to diagnose ovarian cancer based on tumor markers. Why? Because Gonorrhea elevates them too, and that is the difference between a major life altering surgery and an antibiotic. It is not acceptable to diagnose( or rule out) a myocardial infarction without an EKG and labs, even if your patient is complaining of crushing substernal chest pain radiating to the arm and jaw. Why is that? Because it changes treatment modalities. It could mean the difference between an emergent PCI and a referral to cardiology in the morning. Basic diagnostics such as morphology(with diff) and chemistry, should be the absolute minimum labs in any modern practice. Since it is clinically unreliable for even skilled orthopedists to diagnose a fracture from a strain or sprain without an X-ray, A primary care provider trying to do it should be totally unacceptable.

But I am not alone in my thoughts on this. Patients think so too. That is why the Emergency Department is the provider of first resort all over the civilized and developing world. Absolutely nobody is a better traffic cop directing patients to the proper healthcare pathway. (Disclaimer: while I have lots of emergency experience, I am not, nor do I ever want to be an emergency physician). Better still, since the ED is usually well equipped for “treat and street” or “treat and release” from everything from dental pain to a host of surgical procedures, this one stop shop is ideal from diagnostics to many treatments for patients who do not require further diagnostics or more intensive treatment. This essentially makes GPs a middleman. (Disclaimer again: I count at least 2 friends as GPs/PCPs, as well as a few former,) The value of a GP can be debated on certain metrics; I think both preventing ED visits as well as acting as a healthcare traffic cop are not those metrics, where the ED wins out hands down. I will offer that outpatient follow-up as well as managing chronic diseases which are not in an acute on chronic or decompensatory phase are the primary benefit. But with no exception, I am firmly entrenched in the position that the ED should always be the point of first contact and that no patient should ever be disuaded from using it as such. A GP/PCP should be referred to, where the possibility of acute presentation, urgent intervention, and satisfactory diagnostics have already been performed. In effect, the value of these providers is providing follow-up and long term management to those presenting at the ED in the modern world. The days of playing “survive until you can get an appointment” or “diagnosis roulette” ended in the 1980s, and probably even earlier. Now I recognize that somebody will send me a nasty email that says “what about in war, wilderness, or austere conditions!!?” So let me save you the trouble and say those are desperation environments, not the conditions in most civilized countries, though I make an exception for the USA, who have yet to figure out an equitable, effective, or sustainable healthcare system. There cannot be malpractice reform until there is doctor behavior and system reform, as doctors in all countries seem completely uninterested in any type of self-directed change.

Whether or not doctors and to some degree all healthcare providers accept patients are customers, I suspect there will never be a change in their mentality. Most providers are told that at some point, but then go on to ridicule that idea and assume some posture of moral superiority by simply as existing as a doctor compared to “mere mortals.”

But this is where lessons from the Fire Service come into play again. Every Police Officer and most firefighters have heard a member of the public say (probably directly to them) “I pay your salary!” especially when they are not getting their way. Guess what? Patients are paying your salary! Whether you work in a private pay system or a government pay system (tax based), you are the employee of the patient. Now while it is not medically advisable to give the patient everything they want, and certainly Michael Jackson proved that beyond any doubt, it is necessary to give the patient value.

Anyone who has spent the day working at a small fire department understands this concept. Tax payers are not reserved in pointing out that “The firemen sit around all day, eating the equivalent of a Thanksgiving feast twice a day, and when not doing lots of nothing watching TV, are paid to play basketball and ping pong.” So in order to stop tax payers from totally defunding these departments, the fire service takes on a 2 pronged approach. The first is public relations. The world over, not too many people hate firemen, maybe the oddball who legitimately had a bad experience here or there, but with active public outreach, it is firefighters who control the narrative to their favor. The second thing fire departments do is demonstrate value. This takes all kinds of forms. During my time as an exchange firefighter in Slovakia, during a January blizzard in Bratislava, the capital in the formidable Tatry Mountains, I went with a crew dispatched to use their saws to cut a tree which had fallen across the road. In the US this would be the responsibility of a multitude of non-emergent public service, but at the time, it was explained to me “part of our job is to maintain readiness and emergency response capability, if we are not capable of driving on the road, we are not performing our duty.” In the USA, I have been on all manner of “non-emergent” calls with various fire departments, both municipal, and even industrial. Never once did somebody call 911 and hear “sorry, call us back when there is a fire.” (“I am not a specialist in that!” is a common utterance of doctors) Unless there was another emergency responder and even sometimes despite there being another emergency responder, the fire department shows up, and does what it can. In fact, it is possible to go an entire career in some fire departments around the world and never once fight a fire. But showing up in the moment of need, even if it is just to provide moral support, makes you a hero to somebody for the rest of your life. I will offer, that person is not likely to sue you. That person can be counted on to support you during budget time and even during times when a preventable mistake was your fault. There was a time in my life doctors were treated similarly. In fact, my family’s primary care provider when I was growing up, was a legend of a doctor. We had his private phone number, if we called him in the middle of the night, even for something as simple as a fever and not being able to sleep, “Doc” as he was known, would meet you at his office in 20 minutes. Even then, in the 1970s and 1980s, “Doc” could be relied upon to fix whatever your problem was, including an antibiotic injection or sutures, right in his office. No he didn’t have his own labs or X-ray, but in fairness, at the time, Piccolo didn’t make point of care testing machines either. But we live in the Information age, technology is so advanced we can do more from the phone in our pockets than the entire US Government computer systems could do in the 1970s and 80s. How is it possible to accept or make the argument for “no equipment?” If you can spend $700 for your new Iphone, your practice can afford point of care testing for basic labs. Not only that, volume usually makes things cheaper. Ask anyone who deals in retail or wholesale.

“Sorry, we are closed…” The fire department is never closed… The Police department is never closed… The Emergency Department is never closed…Even “Doc” was never closed. But somehow “later”, “tomorrow”, “in 2 weeks”, “ in 40 days” is an acceptable answer for a doctor? Who not only commands some of the highest wages in whatever society they live in, but also the highest of social position? Wow… I am not even sure how to explain that to the parent that has to go to work in the morning to put food on the table for their sick kid when they are up all night. I am not sure how to explain to the new mother that while she worries whether or not she is properly taking care of her first child, who she loves more than life, that the doctor is too busy to help her, if only with a reassuring word. After all, work is not “his life”.

Some would say after hours, “if you think you have an emergency, go to the emergency department.” Those “some” are the answering services of primary care providers. They are the nurse on call lines. They are the emergency communication centers. So riddle me this Batman…If the answer at 0 dark 30 is “go to the ED” why is that not the same answer at 0900? Convenience of the doctor? I don’t see the fire department scheduling the next emergency call or fire at their convenience.

I suspect that some doctors would say “not every patient or condition is an emergency,” and I would not dispute that. But there is no way for the patient to know that in the moment of need. I was on a trans-Atlantic flight once, over the middle of the North Atlantic Ocean, the nearest runway that could accommodate our plane was Iceland. When you are an emergency provider, these details are readily apparent to you. A person who spoke a language nobody else on the plane spoke became distressed. The flight attendant came on the speaker and she didn’t ask if there was a fireman on the plane. She didn’t ask whether or not they should call the fire department. She asked for a doctor. It was an emergency to every crewmember of a major commercial airliner. I was passed a little white phone where a doctor in Frankfurt, with a German accent that barely made his words understandable to me said, “I have only one question, do we need to divert the plane?” To which my reply was “I have not even begun to evaluate the patient…” He waited on the line…

Permit me to point out the Gravity of this situation? With a 747 filled to capacity, the airline was ready to pay the cost of an emergency unscheduled landing at a major airport. They would be responsible to house, feed, and since it is the EU, compensate every passenger on the flight. They would then be required to rebook and transport every person on the plane to their destination, from essentially a tiny Island in the Atlantic, at the earliest opportunity, regardless of cost.

They were willing to do this on the word of “a doctor” whom they had never met, who had no credentials upon him. They didn’t ask how long I had been a doctor. They didn’t ask where I worked or what kind of medicine I practiced. (Probably a good thing too or they might have diverted the plane, nobody waits for the explanation, I am also a paramedic for more than a decade, including a few years at one of the busiest and best hospitals in the world, and a fireman) They asked only 1 question. “Do we have to divert the plane?” They never called for a fireman. But I am sure, had they diverted, the minute the plane touched down, there would have been a fireman there.

But the story doesn’t end with a heroic life save with a medical kit better outfitted than 99% of all US ambulances. It ends with a patient who was dehydrated, had a headache, and was hoping for some aspirin. Which he got…

So how much is answering the call for help worth? Depends on who you ask. But to the scared, the uneducated, the person, or the family, even hearing nothing is wrong or it will be ok is worth all the money they can pay. If it wasn’t, they would not have called or came.

So just keep in mind, if you don’t want to be sued, don’t start off with a “fuck you, you worthless plebe, don’t call me unless I think you are worthy.” Don’t play “guess the diagnosis roulette with the most minimum equipment possible”. I once heard a religious person say “To whom much is given, much is expected.” I would add, “especially from the people who pay your salary one way or the other.”

We are all consumers, we all want value for our money and time. So even if a patient doesn’t need a medicine or a surgery, demonstrate the value that you provide to your patient. If you are not providing the value they need. The person who needs to change isn’t them or how they use your system; it’s you!
In the US Navy, all members are required to learn the general order of a sentry. 1. To take charge of this post and all government property in view.

  1. To walk my post in a military manner, keeping always on the alert, and observing everything that takes place within sight or hearing.

3.To report all violations of orders I am instructed to enforce.

4.To repeat all calls from posts more distant from the guard house than my own.

5.To quit my post only when properly relieved.

6.To receive, obey, and pass on to the sentry who relieves me all orders from the Commanding Officer, Command Duty Officer, Officer of the Deck, and Officers and Petty Officers of the Watch only.

  1. To talk to no one except in the line of duty.
  2. To give the alarm in case of fire or disorder.

9.To call the Officer of the Deck in any case not covered by instructions.

10.To salute all officers and colors and standards not cased.

11.To be especially watchful at night and during the time for challenging, to challenge all persons on or near my post, and to allow no one to pass without proper authority.

A fair few of these are required of doctors in most countries, especially number 5. So if you plan to leave the office and your patients in order to have “your life”, then the reality is your relief is the ED. It makes me wonder; if a patient needs to go to the ED at 1601…Why does the patient need to see you first between 0800 and 1600 for the exact same complaint/problem? It’s not for the ED or the system. It’s for you. The middleman taking his cut. Doesn’t the patient you are managing post ED know they are ok until their next already scheduled appointment? If they are not ok, what are you going to do for them the ED cannot? Do you really believe you are saving anyone money by making them stop at you first sometimes? If they didn’t have to stop at you first, couldn’t that money be put towards expanding the ED? The centralized, equipped, 24/7/365 facility.

Being a doctor does not change the fact that he who has the gold makes the rules. The people with the gold pay your salary. They want value. You ignore that at your own peril.

They don’t teach this kind of stuff in medical schools. Many doctors learn their attitudes from the colleagues who are just speculating, if they ever learn it at all. But you can bet they teach it and live it at the fire department. You can bet that I do. I never heard a person call a fire department in another country because they could not get timely help from their local one first. None of my patients called a doctor in another country because they couldn’t get timely help.

Another one of those fire department lessons…”It’s better to have help and not need it, than to need help and not have it.”