Homemade Soup

I am conflicted. I am having doubts about some of the benefits of medicine. Let me be more specific. In our state, we are told to advise a patient at least three times to go with us to the hospital before we can accept a refusal of care against medical advice (AMA). (For legal purposes all of our refusals are considered AMA). On the other hand, as a medical professional, we are bound by the fundamental tenet, first do no harm.

Sometimes I feel that my required recommendation of transport is actually against the patient’s best interest. (Examples to follow.) In these cases, I may say, “I am required by law to advise you to go to the hospital three times. My advice by requirement is always to recommend transport to the hospital for evaluation by a doctor.” Other times clearly I ardently believe the patient needs to go to the hospital and I will use every trick in my book to get them to go. “I believe you will die a horrible death if you don’t get to the hospital, so we are going to take you to city hospital, okay?”

So why am I losing faith in medicine and in the benefits of patients going to the hospital? Clearly, I am not in every case, but in others, I do have my doubts. The history of medicine is not a stellar one. Think blood letting and hospital acquired pneumonias. Even in my years as a paramedic, it turns out that many of the things we were doing that we thought were helping patients were harmful to them. MAST trousers, high volume fluids in trauma, lasix. A recent study of spinal immobilization in penetrating trauma showed that for the one out of every 1200 patients we were possibly helping we were likely killing one out of every 68.

1999 Institute of Medicine Report, Too Err is Human, estimated that 44,000 – 98,000 people die in hospitals each year as a result of preventable medical errors. That’s more deaths than motor-vehicle wrecks, breast cancer, and AIDS. I also think this seriously undercounts people who may die from medicine contributing to their morbidity. What about people with unnecessary operations? What about people put on meds that may not have been necessary? The tendency in medicine is always to do something. That is what we get paid for. We don’t get paid for recommending against unnecessary treatment.

Now I understand that I am not a doctor and that I do not have the battery of tests that are available at a hospital not the extensive medical education and experience of a physician. It is just that I see so many people taken to the hospital and getting workups that don’t show anything or that show what any one else could see. A patient has the flu, the patient has a GI bug, the patient is dehydrated, the patient has a muscle strain, the patient is old and has wobbly legs.

I guess what I am getting at is in the larger scale on a risk benefit ratio, I am curious the number of people who benefit from their evaluation versus those who may be harmed by the evaluation.

Here are three cases in point all that happened in one day.

A frail old man has grown weaker over the last day and has fallen twice in the last day. His family wants him evaluated, but more than that, they want our advice. We, of course, tell them the weakness could be a sign of any of number of serious illnesses, and that he should be taken by us to the ED for full evaluation by an emergency room doctor and hospital specialists. But the family really wants our advice. They are worried that if he goes to the hospital he will get the flu from all the sick patients already there (like the two we brought in earlier).

The the truth is I see their point. What if we bring him in and he does get the flu or another infection that further weakens him? What if he gets put on other meds to battle whatever irregularities they find at the hospital and he dims because of them?

If he is my father, what would I want for him? In this case, with these symptoms, I would want him to stay home where I would care for him, feed him, and see that he rests in his own bed. I would be more patient. I would wait before sending him to the emergency department. I suppose I would wait for what I saw was a true acute emergency. I think his wife and his daughter are capable of providing such care. This is what I want to tell them, but instead I am bound to follow my script. I am not upset when they decide that they will keep him home, and only call if things change.

An 88-year-old Vietnamese man passes out at the pharmacy. He lives just a few blocks away. he walked over to get his meds, but had to stand in line for over fifteen minutes. He felt woozy and was helped to a chair. He barely speaks any English. His vital signs are good and his 12-lead is normal. He doesn’t want to go, but due to language it is hard to communicate. When we finally get hold of a family member, who, on our advice, tells him he has to go, he agrees to let us take him. Maybe he has had a cardiac event and will walk out of the hospital on many wonderful meds and perhaps with a pacemaker. But maybe he just has the flu, and would better benefit from being taken care of at home by his family and hand-fed hot soup.

Nearly the same scenario plays out later in the day with a Croatian woman who collapses at the post office while waiting in line. She is old and looks pale, but everything checks out okay. We still end up transporting her for an evaluation after getting hold of an English speaking nephew. Maybe she won’t get sicker in the hospital, maybe she will be better able to rest there than in her own bed, surrounded by her family.

I know this is unrealistic, and we do need to pay for gas, ambulances, equipment, mine and everyone else’s paychecks, as the hospitals also have to pay for their staff and physical structures. Still I wonder about runaway health care costs. I wonder about the scientific evidence and if it would show we are truly making a difference but universally urging transport.

I want what I do-- what we do--to matter, and I know it does in many ways. There are just those times where I think it might be better if we could just transport someone home, set them in their own bed, with their family now gathered around them in a familar setting, and perhaps we would leave with some homemade soup as payment for our kindness. 

Risk Assessment

 This post is inspired by a book I am reading – Antifragile: Things That Gain from Disorder by Nassim Nicholas Taleb. In this fascinating book Taleb discusses risk. Take this example which I am modifying from his book:

Would you get on an airplane if there was only a 5 percent chance that the plane would crash?

While the odds may be in your favor that you will likely not crash, the outcome of those small odds is so catastrophic that you would be a fool to board the plane absent astonishing circumstances requiring your seat on the plane (to save a loved one, to prevent a war from starting, to collect a trillion dollars). The possible benefit of getting on such a risk prone plane—is insignificant when compared to the possible drawback of crashing – losing your life.

Most bets we make, according to Taleb, are asymmetrical. The amount to be gained or lost is not equal. If you are going to bet, you want to bet where the losses are minimal and the payoffs far exceed the downside. Position yourself to avoid catastrophe.

While Taleb talks a lot about economics and other subjects, let’s apply this simplified concept to EMS.

***

“Why wasn’t a 12-lead done?”

“I didn’t think it was cardiac.”

***

So your patient has syncope with a recent history of dehydration. You brought the lady in yesterday after a similar episode, and the ED sent her home after hydrating her. She is 80 and appears ill. You have been a medic for twenty years or perhaps you are a cocky brand new medic. Your gut tells you it is not cardiac. In fact you are 95 percent certain it is not, so you don’t bother with a 12-lead...

Your EMS coordinator or training officer pulls you into the office and says your patient in fact had a STEMI and went into cardiac arrest on the way to the cath lab after sitting in a room for 20 minutes until the ED did a 12-lead and spotted the anterior STEMI. If you had spotted the STEMI, the patient would have likely been cathed before going into arrest, and while resuscitated, she likely will have a significantly diminished ejection fraction as a result of the arrest and delay in treatment.

What was the gain from choosing not to do a 12-lead and going with your gut?

You didn’t have to exert yourself to do a 12-lead.

What was the worst possible outcome of not doing a 12-lead?

The patient would be having an undiagnosed STEMI and due to the delay in diagnosing her, she could die before she could be reperfused in the cath lab.

Thus the decision to withhold the 12-lead is in Taleb's view, a fragile one. If you lose, you (and the patient) can be broken. You want always to avoid the state of fragility. You want to be antifragile. Your gut may tell you it’s not cardiac, but in this situation where the possibility of failure exists, having a redundant system like a 12-lead provides you protection. At a low cost of doing a 12-lead, you prevent a catastrophe – missing a STEMI.

Minor exertion versus a patient’s death. The potential gain and the potential loss from the bet that it is not cardiac are not equal. Low upside if you are right, big downside if you are wrong.

Now for those of us who cast a wide net with our 12-leads, this may seem like much ado about nothing. There is no way despite our guts, this patient is not getting a 12-lead, but let’s apply this same reasoning to another scenario.

***

Why did you spend so much time trying to get an ET tube on that lady instead of just popping in a combi-tube?

“I thought I could get it.”

***

Obese female grabbed at her chest, and went unresponsive five minutes before your arrival. She was fortunate enough to get bystander CPR, but it doesn’t look like they are doing it very well. The seconds on her survivability clock are ticking quickly down to zero, unless you can intervene quickly and with great skill.

You put her on the monitor and see she is in a fine v-fib so you shock her X 1 and resume CPR. You want an advanced airway so you can do continuous compressions (instead of 30:2) as well as secure her airway – get more oxygen in and more CO2 out. You have two choices – an ET tube or a combi-tube.

You choose the ET tube. Why?

Well, it may be a better airway. It is the airway the hospital will use if you get her back and she remains unresponsive (under sedation) whereas if you put in a combi-tube, the hospital will eventually pull it and put in an ET. Also, you like intubating. It is a paramedic skill and one you don’t get to do as often as you’d like so you don’t want to pass up on the opportunity. Plus, when you talk about the call later, everyone will ask if you got the tube. If you are a new medic people want to know these things, and you want to show them you are worthy of the rocker on your shoulder. If you are a 20-year medic people will expect you to get it.

And most important of all – you think you can get it. You think there is perhaps an 85% chance you will get it, or maybe scale that down to 75% as you do notice, she has a thick short neck and protruding teeth. Still, you think the odds are in your favor. You go for it!

So what are the risks and benefits?

If you get the tube quickly you are a stud and the ED won’t have to switch out tubes as long as your crew doesn’t yank it. If you can do it without much interruption in CPR, all the better. Now the studies do show that ET attempts cause many interruptions of CPR, and you know that is true, but not in all cases, and sometimes you do intubate flawlessly and with great skill. No interruptions in CPR – even when checking lungs sounds. You can do it!

Now how about the risks?

If you don’t get the tube flawlessly, there could be problems. You will look bad for trying three times and not getting the tube. But wait a minute, we are not really concerned with you, we are concerned with the patient. That’s who the real risk is too.

If you are a medic working by yourself, it takes longer to get out all your equipment to intubate than it does to rip open and insert a combi-tube. If you can’t sink the ET tube on first look, CPR may be interrupted or the patient may not be ventilated well. CPR may be interrupted while you intubate, and your patient who is already on the brink of death may go to the darkness while you dick around trying to get the tube. It may not happen every time, or most times, but some tubes are, shall we say, challenging.

Reward you get the tube. Risk you cost the patients seconds if not minutes that they may not have. An asymmetrical bet. Small upside, big downside if the bet goes wrong.

Given that this patient is likely already on the razor blade edge between imminent tissue death, imminent anoxia and chance of full neurological recovery, I think we have to do everything to obtain immediate airway (oxygenation/ventilation) relief with no delay in compressions.

When seconds count, seconds should count. The risk of the most difficult airway I think is too great in this particular described patient. It is not a 75% versus 95% proposition. It is a possible loss of 10 to 60 seconds when a patient may not have those seconds left.

Wouldn’t it be great if every patient we showed up to in cardiac arrest had a visible life clock hanging on the wall above them. 0 seconds remaining, we don’t even have to go through the motions. 2 minutes remaining, we can take our time rolling up our sleeves and taking control. Or maybe 20 seconds remaining when we have to act fast and with that great skill. Deliver that jolt. Pound those compressions – they must be excellent. Secure that airway.

It doesn’t matter how well packaged the patient looks when we bring them into the ED doing CPR. ET tube, 2 IVs, run through the entire ACLS algorithm. It matters if we can get them back before that last grain of sand falls in their life clock.

We might save a human being who would otherwise pass. So what if they have to change out the Combi-tube to an ET tube later. Big upside, low downside.

***

Now I may be butchering Nasem’s points, and his book is certainly more complex and well thought out and argued than my meager post. The point is reading the book has made me look at a situation that I have struggled with in a new way. I don’t think I was adequately assessing the risks. When a life is at stake, I should err with whatever is more likely to avoid a catastrophic outcome.

Alternate Airways

Far From the Tree

 The other day was busy but boring – at least until I got the call I am going to tell you about. We were just doing EDPs, transfers and emerge-ifers (911s from nursing homes or medical clinics that go to the ED for evaluation). Then we got another EDP – a patient who had expressed suicidal ideations to a social worker. While my third rider was gathering the information from the social worker, a police officer and I were whispering to each other trying to figure out if the patient was a man or a woman. The social worker was referring to him as a he and he had a man’s name, but his voice was very feminine and he had a very feminine manner and complexion.

It wasn’t until we had begun transport and the patient answered my rider’s question about what medicine he took that I paid attention. The man said he was taking female hormones.

“You’re transgender?” I asked.

“Yes.”

“Have you had the operation or are you planning to have the operation?"

“I having it next month,” he said.

“Really? So how would you like us to refer to you? Male or Female?

“Female. You can call me Jen.”

“Okay, Jen,” I said. “I will change that on our form for you.”

“Thank you. That’s very kind.”

“I just read a fascinating book about transgender people,” I said. “Is it true that you felt you were a girl from a very young age, but you just had a man’s body?

“Yes, it’s true,” she said.

“Fascinating.”

I proceeded to tell her and my rider about the book I had read. And that is why I am writing this post -- to tell you all about this great book called Far From the Tree by Andrew Solomon.

When they say of a child, “the apple did not fall far from the tree,” they mean the child is like the parent. Thus “far from the tree” means the child is nothing like the parent. The book, which is mammoth, is about human diversity and the capacity of people to love. Each chapter consists of interviews with parents as well as descriptions of the science and cultures surrounding various disorders. There are chapters on deaf people, dwarves, Downs, schizophrenics, criminals, autistic children, severely disabled kids, and gifted children. In many of the chapters the parents say that if they were told when they were first pregnant that their offspring would be abnormal, they would likely have aborted them, but now, despite the hardships, most expressed deep abiding love and gratefulness for what the experience and their child taught them about themselves and about life. (Of note, the book includes a facinating interview with the mother of one of the Columbine shooters).

As a reader, I could not put the book down. It gave me great empathy and made me appreciate that we are not all the same tree in the forest, and that as a society we are likely better off for our diversity. It certainly gave me a window into the world of transgenders, schizophrenics, autistics, the deaf, and many of the other types of patients we encounter, as well as their families.

I remember many years ago complimenting a mother for keeping her severely disabled child, who was now in her early twenties, instead of putting her in a facility. “But how could we have sent her away?" she said to me, incredulously. "She is one of us. We love her.”

I didn’t really understand then, but I do now. Part of the reason I understand is I am older and have a family of my own now, but I think reading this book really helped me better understand it as well.

Humans are capable of deep abiding love and acceptance and this book testifies to that. I feel I am a better person for what I have read and come to understand.

Far From the Tree is one of the New York Times 10 Best Books of 2012 list.

I can't recommend it enough.