Ha ha ha. Oh me.
After four weeks in the surgical intensive care unit (SICU) I can honestly say I have learned one thing -- well two if you count the standard post-operative care for a middle aged man after a coronary artery bypass graft. I have learned that I would have made a terrible anesthesiologist. What was I thinking? Mesmerized by the glamor and allure? Hypnotized by a well put together and adequately managed clinical elective? I would have hated my life. I would have been filthy stinking rich, but, dang, anesthesiology is not my cup of tea. In as much as anesthesia is a cup of tea anyway. Fourth year has also made me very confident that I dislike surgery and radiology as well, and in that sense fourth year has served me well, but those are boring topics for another boring post. In summary, I love infectious disease. Hurray for bacteria and their organelle possessing brethren: fungi and parasites. You all delight me.
My deeply felt romantic feelings for such things aside, it turns out there aren't many interesting stories that result from 28 days of recording patient vitals onto sheets of individual sheets of paper every day. Not much that could or should be shared at least. What was interesting, however, had nothing to do with the SICU, but due to the fact that I was working with the anesthesiology team as at the VA the anesthesiology team is also the Code Blue team.
Code Blue for those of you not familiar with the secret world of hospital codes is basically "Code the Patient is Dead or Dying and You Have About Fifteen Minutes to Revive Him Starting from When I Stop Reading this Message." At the VA it seems most Code Blues, or simply "codes" as they're otherwise called, are run by three teams. The anesthesiology team, who arrive whenever they orient themselves and figure out where the patient is exactly, manages the airway with all their scopes and instruments; the internal medicine team, who usually arrive later because they actually have work to be doing in between codes, manages the code itself; and a team of spectators of unknown composition who generally mill around watching the two or three first responders work before the other two teams arrive. I'm not sure if this last team is composed of nurses or techs or just office workers, but considering we never know where anything is when we arrive and amongst our scrambling and calling for things one of them usually steps in from their gawking to to hand it to us a few seconds later I think it's safe to say they are at least from the area. All the teams aside, though, the general steps of a code are:
1) Find the patient.
2) Make sure the patient is in fact not breathing and pulseless
3) Control the airway, provide rescue breaths, and start chest compressions
4) Inject things
5) Shock 'em!
6) Repeat steps 2 - 5 a few times until someone eventually says enough is enough
How this all actually forms a story is when I step in one day -- or happen to be in the way as the case may be -- and shock the patient with the defibrillator pads. Although I needed a quick instruction on how to use them, I at least remembered to make sure everyone was clear from the body before zapping the guy -- unlike another student who almost got some collateral zapping. For those of you whose entire visual library of a code comes from ER or Gray's Anatomy the patients tend not to jump up that much or really much at all. Mostly just jiggle a bit. What they do tend to do, however, is smell like burnt people. The electricity running from the defibrillators into the body jumps the heart but also burns a little but of subcutaneous fat as well. It's interesting to say the least. And, although the patient died in my case in spite of our efforts, when patients do come back from the brink in real life they're usually pretty friggin' miserable if even responsive at all. Definitely no heart felt thanks or dramatic moments. Oh wells, someday I'll have a code like they do in the movies. And then a helicopter will land on me. What the hell.
Sunday, November 25, 2007
Sunday, November 18, 2007
A Compelling Work of Transcending Insight
In life's constant pursuit of more titles and honorifics I can finally add to my tally: Scott Crabtree, prize winning author. And the secret to my success? Entering contests with as few qualified competitors as possible. UTHSCSA's department of Humanities and Ethics and Other Such Things recently held such a competition throughout the entire health science center requesting essays covering medical ethics topics of our choice. In the end there were 13 maybe 14 submissions, and add to that the fact that it seems most health professionals tend not to be the best writers I figured I had a pretty good shot. A few hours and a few pages later and I was $250 richer. I didn't win the $1000 grand prize, but I did earn "honorable mention", and I did show my gratitude by not attending the awards dinner. (In my defense I didn't think I would win nor did I know that I had in fact had won until after the silly dinner took place.) My lack of proper thanks aside; since I so like reveling in my own glory I thought I'd share it for all to see. Enjoy Ro!
How Much for a Life: Triaging Friend and Foe
The act of triage is a straightforward, simple process. Quickly assess a patient’s injuries, obtain a rough prognosis, and decide whether they will be given emergent care, deferred care, or only the care which can be readily given to ease their suffering till they eventually, and likely quickly, pass. Despite its simplicity, however, it is readily obvious even to those who have not experienced such an affair that no step in the process is easy. In the rushed, chaotic environment of mass casualty events determining the extent of someone’s injury accurately and swiftly is not undemanding. Determining whether they can be saved is not simple. And making the decision whether to even try or not is profoundly psychologically and emotionally taxing even if the initial adrenalin rush means the full weight of the experience is not felt till some time later. Despite the gravity of the situation the ethics of the matter are also relatively straightforward. Simply put, with limited resources you must do the best with what you have. Few would disagree that those whose injuries make it so their chances for survival are minimal should receive the devoted attention of an emergency care team when there are two others also slowly dieing but whose chances are significantly better. It may be sad to abandon the one in greatest distress, but few would argue against the necessity of such action. Much of this changes, however, when triage comes to the war zone.
In just about every situation a doctor can find himself in he is surrounded by allies. His care is sought after and he is happy to give it. Even if the patient in question has obtained his injuries by engaging in activities the physician is less than supportive of or is a person the physician would not otherwise wish to associate with, the physician graciously extends his services because by default people are people and people deserve medical care. In armed conflicts this de facto starting position patients have is strained as many times the patients are less ordinary old people and more enemy combatants. Sometimes the physician will find he is saving the life of the same person who was only a minute ago trying to take his own. Sides are drawn and each side has sworn to neutralize if not outright kill the other. In settings where the physician can freely care for patients, whether friend or foe, completely and does not have to divide resources the inherent human worth of the individual carries the day and the physician can, should, and will completely devote his attentions to the injured person. In mass casualty events, however, the physician is once again forced to prioritize. He must decide if the life of a foreign gunman, the life of someone devoted to opposing the mission the physician as a military officer is avowed to, is equal to the life of a comrade, fellow allied soldier. In such situations some would question whether the rules of triage are the same. If, for example, when deployed to a relatively small field hospital a physician finds himself with a wounded enemy combatant rapidly losing blood from a large caliber gunshot wound to the abdomen, a thready pulse, significant pallor and the onset of shock fast approaching and also simultaneously a wounded friendly marine with a crush injury to his upper extremity, shrapnel in multiple locations, and moderate blood loss of his own, who should receive immediate care? Both would be classified as “emergent” under the United States Army’s Emergency War Surgery handbook – the former perhaps further subcategorized as “immediate” and the latter as “urgent” – but should the limited medical care be devoted regardless of who is who? Or, alternatively, in some circumstances is the character of the patient just as important as the gravity of his injuries?
Turning to conventional medical ethics would certainly be an appropriate start, but many of the basic principles such as autonomy and non-maleficence are not applicable in this problem as we will assume both patients are wanting the fullness of medical care and the physician intends to hurt neither. Even the concept of beneficence is of limited usefulness. The foreign combatant is at great risk of losing his life and hence it would be appropriate for the physician to devote most if not all of his immediate attention to saving it. Likewise, although the allied marine is at less risk of death the chances for serious long term injury and loss of limb are significant and it would be just as appropriate for a physician to devote most if not all of his immediate attention to stabilizing and repairing this injured soldier as well. Clearly both stand to be saved and both need the thorough attention of most the available medical staff. Beneficence would only suggest that we strive our best to help both, but in situations where we cannot it provides little further guidance. It would seem then that in order to obtain any clarity we must turn to the concept of justice.
Justice, the key concept behind the idea of triage, may be what will guide us here. Using this concept, from a purely medical perspective the standard rules of triage would apply as previously mentioned earlier. The foreign combatant needs immediate care, the allied soldier needs urgent care. Problem solved. Take it back a level to a more public perspective, however, and the costs of such a decision begin to add. A unit removed of one of its normal soldiers is a weaker unit, less effective unit, and a more dangerous unit for the other soldiers still active. Take it back another level to a more political perspective and the costs climb still more. How profitable is the life of a man who only briefly before was violently resisting the power of your nation in its most assertive form and how much more costly is the loss of a marine from duty to the overall success of the mission and safety of the nation as a whole? And take it into an immensely personal level and the cost is not merely an amputation but a life changed. Combat injuries and amputations are not entirely physical and the psychological wounds are often just as damaging – the effect creeping into the lives of family, friends, and forever altering the way the injured sees himself, the world, and his future. With the scales adjusting, a more nuanced perspective would ascertain that foreign combatants have family and friends too, many of which may be in no way involved with the conflict. Their sense of loss would be just as immense if he were to pass away. Likewise, wars are many times fought for minds as often as they are for neighborhoods and lives. The fair and generous treatment of POWs is key to getting insurgent gunmen to lay down their arms and the people to withdraw their support. With so many angles and so many perspectives to contemplate the consideration of justice has certainly opened up the problem of triage in a combat zone but in doing so it has laid it out in snarled disarray. The ethical equation has become an endless series of variables with largely debatable coefficients. With the issue becoming so gray where do we go from here?
The problem of such utilitarianism is that while it allows for a more discriminating approach it also has a tendency to deprive ethics of the moral strength it seeks to preserve. The fine measure of a thousand points of contention allows for rationalization as much as it allows for an exacting analysis of a complicated situation. The vast majority of medical oaths in existence whether they be the Oath of Asaph and Yohanan established for ancient Hebrew physicians, the Declaration of Geneva constructed after the abuses of World War II, the Seventeen Rules of Enjuin developed in Medieval Japan, or the Hippocratic oath created millennia ago are straightforward and fundamental. Although this is partly if not largely due to a need for concision and foundation, there is also strength and clarity in simplicity. When medicine gets mixed with a legion of other issues the central purpose of medicine, healing, quickly becomes diluted. As physicians become less healers and more business men, military officers, and judges the sanctity of life becomes less a commanding value and instead just another option to consider. At times these secondary roles and their duties may be inescapable, but they most always remain secondary. The first step towards gauging the value of a life is the first step away from the soul of medicine, and deciding how much an individual is worth requires a heavy spiritual cost in return. Tending to a seriously injured friendly marine over a sick and dieing insurgent gunman may well be the initial impulse of many a doctor in such a situation, but in doing so he would sacrifice much of what truly makes him a healer. His technical skills may remain, but his soul suffers. If we wish to continue on as doctors and not simply as learned technicians we must hold true to medicine’s foundational principles. In a world of competing priorities the defense of life must always remain priority one.
As interesting and debatable as all this may be the reality is significantly less than a thousand physicians enter military service any given year. Few will see any mass casualty events, and, as in the case of Iraq most Iraqis are treated in Iraqi hospitals, few will ever see a scenario such as this. Its practicality is not where its usefulness lies however. Often times ethical principles must be pushed to their extremes to appreciate their merit. One does not value autonomy until one is pressured to resist it and one does not appreciate honesty until one is tempted to ignore it. Likewise it is easy to accept the idea that the preservation of health and life is the underpinning of medicine, but until one is seriously enticed to believe otherwise they will likely never seriously consider it in their daily actions. It will be a nice idea quickly agreed to and quickly forgotten. Without thinking about at what point we would second someone’s survival for another purpose we will never think about the smaller ways we are already seconding our patient’s health for private incentives and personal biases. We may not be sacrificing insurgent gunmen for the arms and legs of allied marines but many physicians every day provide a little less care in order to get out of the office a little sooner, a little less consideration to personalities who irritate them, and a little less attention to those they think beneath them. One may question when gross discrimination is acceptable if ever, but until they do they will never see the hidden discriminations occurring every day. Most physicians will never triage in a war zone, but everyone balances a countless number of priorities every day and the more we think about them and the more honest we are concerning them, the more we will make the right priorities first in our lives and first in our practices.
Now what to do with all that money.... perhaps get myself a new grill?
In just about every situation a doctor can find himself in he is surrounded by allies. His care is sought after and he is happy to give it. Even if the patient in question has obtained his injuries by engaging in activities the physician is less than supportive of or is a person the physician would not otherwise wish to associate with, the physician graciously extends his services because by default people are people and people deserve medical care. In armed conflicts this de facto starting position patients have is strained as many times the patients are less ordinary old people and more enemy combatants. Sometimes the physician will find he is saving the life of the same person who was only a minute ago trying to take his own. Sides are drawn and each side has sworn to neutralize if not outright kill the other. In settings where the physician can freely care for patients, whether friend or foe, completely and does not have to divide resources the inherent human worth of the individual carries the day and the physician can, should, and will completely devote his attentions to the injured person. In mass casualty events, however, the physician is once again forced to prioritize. He must decide if the life of a foreign gunman, the life of someone devoted to opposing the mission the physician as a military officer is avowed to, is equal to the life of a comrade, fellow allied soldier. In such situations some would question whether the rules of triage are the same. If, for example, when deployed to a relatively small field hospital a physician finds himself with a wounded enemy combatant rapidly losing blood from a large caliber gunshot wound to the abdomen, a thready pulse, significant pallor and the onset of shock fast approaching and also simultaneously a wounded friendly marine with a crush injury to his upper extremity, shrapnel in multiple locations, and moderate blood loss of his own, who should receive immediate care? Both would be classified as “emergent” under the United States Army’s Emergency War Surgery handbook – the former perhaps further subcategorized as “immediate” and the latter as “urgent” – but should the limited medical care be devoted regardless of who is who? Or, alternatively, in some circumstances is the character of the patient just as important as the gravity of his injuries?
Turning to conventional medical ethics would certainly be an appropriate start, but many of the basic principles such as autonomy and non-maleficence are not applicable in this problem as we will assume both patients are wanting the fullness of medical care and the physician intends to hurt neither. Even the concept of beneficence is of limited usefulness. The foreign combatant is at great risk of losing his life and hence it would be appropriate for the physician to devote most if not all of his immediate attention to saving it. Likewise, although the allied marine is at less risk of death the chances for serious long term injury and loss of limb are significant and it would be just as appropriate for a physician to devote most if not all of his immediate attention to stabilizing and repairing this injured soldier as well. Clearly both stand to be saved and both need the thorough attention of most the available medical staff. Beneficence would only suggest that we strive our best to help both, but in situations where we cannot it provides little further guidance. It would seem then that in order to obtain any clarity we must turn to the concept of justice.
Justice, the key concept behind the idea of triage, may be what will guide us here. Using this concept, from a purely medical perspective the standard rules of triage would apply as previously mentioned earlier. The foreign combatant needs immediate care, the allied soldier needs urgent care. Problem solved. Take it back a level to a more public perspective, however, and the costs of such a decision begin to add. A unit removed of one of its normal soldiers is a weaker unit, less effective unit, and a more dangerous unit for the other soldiers still active. Take it back another level to a more political perspective and the costs climb still more. How profitable is the life of a man who only briefly before was violently resisting the power of your nation in its most assertive form and how much more costly is the loss of a marine from duty to the overall success of the mission and safety of the nation as a whole? And take it into an immensely personal level and the cost is not merely an amputation but a life changed. Combat injuries and amputations are not entirely physical and the psychological wounds are often just as damaging – the effect creeping into the lives of family, friends, and forever altering the way the injured sees himself, the world, and his future. With the scales adjusting, a more nuanced perspective would ascertain that foreign combatants have family and friends too, many of which may be in no way involved with the conflict. Their sense of loss would be just as immense if he were to pass away. Likewise, wars are many times fought for minds as often as they are for neighborhoods and lives. The fair and generous treatment of POWs is key to getting insurgent gunmen to lay down their arms and the people to withdraw their support. With so many angles and so many perspectives to contemplate the consideration of justice has certainly opened up the problem of triage in a combat zone but in doing so it has laid it out in snarled disarray. The ethical equation has become an endless series of variables with largely debatable coefficients. With the issue becoming so gray where do we go from here?
The problem of such utilitarianism is that while it allows for a more discriminating approach it also has a tendency to deprive ethics of the moral strength it seeks to preserve. The fine measure of a thousand points of contention allows for rationalization as much as it allows for an exacting analysis of a complicated situation. The vast majority of medical oaths in existence whether they be the Oath of Asaph and Yohanan established for ancient Hebrew physicians, the Declaration of Geneva constructed after the abuses of World War II, the Seventeen Rules of Enjuin developed in Medieval Japan, or the Hippocratic oath created millennia ago are straightforward and fundamental. Although this is partly if not largely due to a need for concision and foundation, there is also strength and clarity in simplicity. When medicine gets mixed with a legion of other issues the central purpose of medicine, healing, quickly becomes diluted. As physicians become less healers and more business men, military officers, and judges the sanctity of life becomes less a commanding value and instead just another option to consider. At times these secondary roles and their duties may be inescapable, but they most always remain secondary. The first step towards gauging the value of a life is the first step away from the soul of medicine, and deciding how much an individual is worth requires a heavy spiritual cost in return. Tending to a seriously injured friendly marine over a sick and dieing insurgent gunman may well be the initial impulse of many a doctor in such a situation, but in doing so he would sacrifice much of what truly makes him a healer. His technical skills may remain, but his soul suffers. If we wish to continue on as doctors and not simply as learned technicians we must hold true to medicine’s foundational principles. In a world of competing priorities the defense of life must always remain priority one.
As interesting and debatable as all this may be the reality is significantly less than a thousand physicians enter military service any given year. Few will see any mass casualty events, and, as in the case of Iraq most Iraqis are treated in Iraqi hospitals, few will ever see a scenario such as this. Its practicality is not where its usefulness lies however. Often times ethical principles must be pushed to their extremes to appreciate their merit. One does not value autonomy until one is pressured to resist it and one does not appreciate honesty until one is tempted to ignore it. Likewise it is easy to accept the idea that the preservation of health and life is the underpinning of medicine, but until one is seriously enticed to believe otherwise they will likely never seriously consider it in their daily actions. It will be a nice idea quickly agreed to and quickly forgotten. Without thinking about at what point we would second someone’s survival for another purpose we will never think about the smaller ways we are already seconding our patient’s health for private incentives and personal biases. We may not be sacrificing insurgent gunmen for the arms and legs of allied marines but many physicians every day provide a little less care in order to get out of the office a little sooner, a little less consideration to personalities who irritate them, and a little less attention to those they think beneath them. One may question when gross discrimination is acceptable if ever, but until they do they will never see the hidden discriminations occurring every day. Most physicians will never triage in a war zone, but everyone balances a countless number of priorities every day and the more we think about them and the more honest we are concerning them, the more we will make the right priorities first in our lives and first in our practices.
Now what to do with all that money.... perhaps get myself a new grill?
Tuesday, November 13, 2007
Duck!
Or juvenile sharp-shinned falcon perhaps? It seems that in addition to an endless supply of deer, 'coons, and 'possums, Mexitexas also has its share of enormous birds of prey. This one buzzed overhead while I was taking out the trash leaving behind a window shattering sonic boom and distinct contrail over my right shoulder. Its target was not my own undoubtedly tasty giblets but a nearby bush full of small, cheerful finches. The falcon landed a few feet short, hopped over to the edge -- as such falcons are apparently want to do -- and then dove in to find himself a delicious finchy snack. The bush immediately erupted with the sounds of about 20 different little birds completely losing their minds, but after a few minutes of chirping, flapping, and what I guess was the falcon barking the falcon emerged barehanded. I felt bad for him, and then took some pictures.
Tuesday, November 6, 2007
Gorked Gourds
So Halloween passed without a single trick-or-treater and Paul and I were left with 5 lbs of some terrible tasting licorice mix he got from who knows where, but nevertheless this Halloween season was enjoyable and for one reason: Paul the Puking Pumpkin.* Too much substance abuse and perhaps a little developmental disorder have lead to this poor Jack-o-Lantern regularly releasing his insides to the outside world. We made it a few days before at Megan and Annie's place, and, though not the finest carving job of all, mine was certainly the only one barfing. What was best was that everyone credited me with such originality and imagination when in truth I had simply stolen the idea from a jack-o-lantern I'd see many, many years before. In reality I am not creative; I just have a surprisingly tenacious if not random long term memory. Our neighbors were probably not so excited about my contribution to the door step as their own pumpkin was a magnificently carved image of a pirate ship. Ours definitely brought down the beauty and class of the display. Unfortunately by the time Halloween came around their jack-o-lantern had been sitting outside so long that it was kind of shrunken and moldy so I didn't bother taking a picture of it. Just imagine a pirate ship on a pumpkin, though. Yeah... pretty awesome huh?*By naming my pumpkin Paul I am in no way implying my condomate Paul has any substance abuse or development disorders. I just like alliteration is all.**
**Or do I?
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