Military Precision
I just finished an Emergency Room shift where a patient was brought in by EMS. An elderly lady had been found by her friend, slumped over on the couch. EMS was called. They found her in Ventricular Tachycardia (VT), a fatal arrhythmia. They administered defibrillation shocks, and she had gone back and forth between VT and asystole (flat line). She arrived in the ambulance bay intubated with a blood pressure, but lost the pressure except for a faint pulse before she could be wheeled hastily down the ER hall to our trauma/code room in the ER. We had lost the pressure, but were able to bring it back using the Advanced Cardiac Life Support (ACLS) protocols that are revised and drilled into all of us who deal with critical care situations in the health care field. We have to recertify every 2 years and the protocols are revised frequently as we learn more effective means through research and experience.
So now I had an initially unstable patient, on a ventilator, with poor long term prognosis, but whose heart was still beating. I called the attending physician and notified her of the events and current state of her patient. I made the recommendation and told her of my plans to fly her back to her cardiologist, and she agreed. I called the cardiologist and he agreed to accept the patient. By the time I finished the conversation, the patient had become more stable. Weather was questionable for the helicopter, and we weren’t sure it would hold. It was ultimately my call, but I discussed it with the cardiolgist . He felt we could transport her by ground, and with incomplete resolution in my gut, I made the call for ground transportation.
As we continued to further stabilize the patient on the ventilator, and with 4 medication drips running, I began to see concern on the face of the respiratory therapist, the nurses, and then the paramedics when they came to pick the patient up. It was too much. Four drips and a ventilator was a lot to manage for one paramedic for an hour long ride to Nashville. I hadn’t thought about that. In my job, from my perspective, I don’t have to set up the IVACS, adjust the settings, and monitor the lines to make sure they are flowing. These people do this every day. They respect me, and if I insist, they’ll try unless they think it is too dangerous. But I respect them and their experience as well, and I see their concern. Air transport would give us two paramedics to attend to the patient. I changed my mind and we called for helicopter transport. If the weather changes, we will have lost time. I will have to deal with that if it happens.
The patient is now more stable and I focus my attention on the 5 other patients in the ER and am aware of two others waiting in the waiting room. We’re backed up now and my relief comes in an hour and a half, I don’t want her to come in to a pile of chaos and I’ve got to get this ER in tighter control. I sew up a finger laceration, and discharge a patient with chronic pancreatitis and Hepatitis C. His problems are the fruits of a long life of drinking and drugs. He is sober now, but the damage is done. He doesn’t have to be admitted this time and I send him home. A woman in her thirties, embellishing her symptoms of knee pain, shows minimal and inconsistent evidence of real disease. I want to be sympathetic and don’t want to miss it if she has a real issue like early rheumatoid arthritis, but I suspect she is drug seeking. She is crying and carrying on and adding greatly to the noise of the ER. I’ve seen elderly people with crippling deformity of all their joints whine less. I give her 8 Lortab, and instructions to follow up with her primary doc, and eventually to see a Rheumatologist. I wonder if the drugs will be given to her boyfriend, who looks really rough, or if they’ll be sold; or if she’ll go to several other places and do what it takes to get more medicine – all the while racking up huge medical bills on the taxpayer dime. As I give her the name of a rheumatologist, I remember – I gave her that name 2 weeks ago – and she hasn’t followed up yet. She’s just back for more narcotics. I can’t take the time to address this today, because I have to get her out of the ER to make way for waiting patients. If the ER gets too chaotic, the potential for mistakes begins rising exponentially. Better to give in and compromise on this issue in the whole scheme of things, at least this time. I turn on the afterburners and get 2 other people admitted, being careful not to cut any essential corners.
I leave my documentation to do later, thus ensuring that I will have to work past my stop time, and be later seeing my boys. I hope they are home. I miss them, and seeing all the illness and lifestyle dysfunction makes me eager to get home and lay my eyes on them, and perhaps call and connect with my parents before I go to bed. Every patient I see always makes me aware of how fragile the lives and souls of the people I love are, and leaves me with the desire to go home and just lay eyes on them, touch them, tell them I love them. They never fully understand how my heart aches for them, but I think they appreciate that something happens when I work and I just need to see them. So they tolerate it.
The rotor of chopper blades outside lets me know the Life Flight has arrived. When the flight medics arrived, I gave report to them, a male and female dressed in flight suits. I took note of how they were dressed to be mobile, with all of the things they were likely to need somewhere on the many pouches on their body, and immediately ready to use. They made changes because the patient has begun twitching as a side effect of one of the medications.
She had not responded to the Ativan I gave. I asked them about it. He answered that ativan usually did not work. They could have added more Propofol, but instead chose to add norcuron to paralyze her. This would give them two drugs, instead of one, which were keeping her stable and under control for the flight. He explained that if they lost the propofol line and she would come out of her sedation. It would be a dangerous situation for her to become agitated and combative in flight. I watched him work with methodical discipline, checking and double checking his lines, his drugs, his doses, then double checking with his partner. The same way he does hundreds of times a month -- in an ER, at a flight scene, landing at an accident scene or in the wilderness. The term came to mind -- "Military Precision"
As he worked, his sleeves pulled his forearms and I saw they were fully covered in tattoos. I looked at his clean, crew cut hair and wondered about his history. Did he have a hard early life? Had he been in the military? Had he been in the desert of Iraq or mountains of Afghanistan when he began learning these skills? I pictured him in combat medic gear and wondered.
They finished packaging up the patient and as I left the ER with my bags over my shoulder, I ran once again into the family of the patient, with whom I had talked to many times that night giving them updates. This patient was to them their mother, wife, grandmother, neighbor, and sister. I explained how fortunate she was that her friend had found her so soon, that the EMS paramedics had done a fantastic job, enabling me to continue to move her forward to improvement. We did not know if she had had another heart attack, but everything was improving. On the other hand, we still had no idea if there would be permanent brain damage. We would just have to wait and see.
They were a family that covered the whole social strata: Some were well dressed and could speak with an educated vocabulary; others spoke with less educated precision and asked questions which revealed widely inaccurate understanding of many things from their lack of education. Others were less polished, but their bodies and hands revealed a lifetime of regular physical work outdoors and, though they spoke in a more common vocabulary, they were intelligent and wise in a practical way. Some were clean and shaven, others reeked of cigarettes, alcohol, and more than a few days since bathing.
A little three year old girl was hanging on to her aunt, asking about when grandma was coming home, waving goodbye to her. As I was talking with her dad, she reached her arms up at me, her sun-bleached blonde hair and blue eyes looking up at me, innocently trusting me, a stranger in a white coat, to pick her up. I picked her up and heard family commenting at how lucky I was to have her offer to let me hold her, and tell her the “the doctor has to go and has things to do” – which, at that moment was the farthest from the truth. I felt like an angel had been sent highlight this moment for me – to show me what was really important. As I held her, she had her eyes fixed in the direction of the helicopter, its flashing red lights reflecting on her face, her eyes, and her hair. She told me about her grandma, and spoke with assurance about her grandma coming back to see her. It was obvious that they were close. Various family members made comments about how much they did together, but they were not necessary. You could hear in the girl’s voice and see in her eyes how deeply these two loved each other.
I watched the helicopter rev up its engines, the rotors picked up speed, and the medic pulled the door closed as it lifted off. Then the flood of emotions came as it always does when I watch a medical transport helicopter taking a patient to a place that had more resources than I could provide here. My job was done, I had done what I could, recognized our limitations, called for help, and now the handoff was complete. Now I could relax. The emotions came as I released myself of the rigid discipline of medical performance and allowing my heart to be free to feel the implications of what had happened: Pride in the EMS paramedics, grateful for the skills I had, and those who had supported me as I directed the ER team. But there was something about the flight medics and the helicopter that made me swell with pride, emotion, relief, and gratitude.
As I watched them lift off, for a brief instance my imagination transformed the Life Flight helicopter into a green camouflaged military helicopter, touching down to pick up a wounded soldier. I saw the military medics, hostile fire and explosions all around. It reminded me that it is from our military, fighting for the vision of good that this country was founded on, that we have made so many successful gains in civilian medicine: ACLS protocols, trauma protocols, treatment for shock, monitoring technology, the medivac helicopters, and the list goes on and on. Much of the technology that saves lives came from the military and from NASA, which is also largely military based.
Things go so much better with disciplined training, and nothing pushes the creative and developmental capacities of a group of people like the heat of battle. That discipline has given us the power to mobilize 150,000 troops and build several cities and campaigns in several countries. We take young high school age recruits from all strata of life and turn them into not only the best warriors, but the best medics, pilots, engineers, leaders, and administrators in the world
Yet we seem to be losing our respect for the discipline it takes to produce excellence. We keep lowering our standards to be more inclusive and allow more diversity – frequently at the cost of quality and excellence. We deemphasize discipline as being too controlling, legalistic, and judgmental-- that it cramps the creative style and individuality of people in training.
Our medical model, reducing the human body into compartmentalized physiological systems, and reducing the professions of the medical field into narrow minded specialties, frequently overlooks the human element needed to give the best care. I like ER work, and I feel I’m good at it. But 80% of the people there are because of lifestyle disorders that have already destroyed their lives: alcoholism, drugs, obesity, poor relationship judgment, inability to keep commitments. We need to be addressing these issues more fervently, so that we are addressing the cure of disease. We run 5Ks and triathlons, hold telethons and benefit concerts for the cure of cancer, heart disease, diabetes, when many of these diseases are preventable with simple lifestyle changes. Why don’t we have fund raisers to build systems to help people lose weight, quit drugs, quit smoking, and become better stewards of their health? Why don’t we put our creative energies into demanding accountability for self care, with passionate and principled fervor? Why don’t we hold people accountable for irresponsible behavior, instead of continuing to reward people for irresponsibility with disability, food stamps, ADC, and so many other entitlements? Why don’t we demand and create payment systems which produce primary care delivery systems to produce healthy patients?
What if we were to take the same strength and features that built our military system, and apply them to our dysfunctional medical system: the same principled passion, the same limitless expectations, the same relentless research, and the same disciplined training? What if our primary care system could produce healthy patients who own the responsibility of their well being with the same degree of success and reliability that our military does when it takes a young high school grad or college grad and creates and awesome and mighty military force?
My little angel that I held tonight, with all her innocence and faith – she may not get to see her grandma return from the Nashville. But what if her grandma had gone to a medical practice that helped her effectively quit smoking 30 years ago? What if we could reliably get her grandfather to quit smoking and drinking now? As it stands now, the odds are that his little innocent girl will continue the generational cycle of addiction to alcohol, smoking, drugs, and obesity.
The rates of these diseases and lifestyle disorders are unacceptably high. Preventing people from smoking, using drugs, using alcohol, and becoming obese would drastically reduce current rates of cancer, heart disease, smoking, HIV, Hepatitis, and motor vehicle accidents. Tennessee is one of the worst states in the nation with respect to obesity, smoking, diabetes, prescription and non-prescription drug abuse. Those are just the hard numbers. Softer numbers are employee productivity, relationship problems, divorce, domestic violence, uncompleted high school and college graduation rates, and an overall decline in national intellectual and productivity capital.
It is okay to have a system that is built on rigorous, relentless, reliable discipline, as long as it is founded on and pointed toward principles that are true. Our military system is rigid and disciplined, but it has to be, in order to be effective. And while it is not perfect, the majority of people who have been trained in it feel a tremendous sense of belonging to family, of fighting for the right. And I think that is because the military still retains, better than any other institution in this country, the foundation upon which this country was built.
Despite all the naysayers, I still believe that this country was founded on principles of freedom. And in particular, I believe the tracks of history clearly demonstrate that it was the collective will of the majority of the founders of this country to build this nation, in faith, on the principles of a God whose benevolence and wisdom they trusted much more than they trusted themselves.
Today we are afraid to insist on a moral standard, or demand excellence. We don’t want to restrict freedom, cause people to become “disenfranchised”, cramp their style, or impose morality. We are afraid to set a standard of excellence for fear of discouraging some who might not make it.
So, once again, I lay my head down late at night, at the expense of sleep, held awake by the call back to primary care. It makes no sense financially-- I am making more money than I ever did in primary care. It makes no sense with respect to lifestyle – I currently work shift work and could keep doing it. But our system is broken, and I think I have some answers. Or at least I have ideas for some new directions that I have borrowed from others. And if I fail, then perhaps some others can learn from me and achieve more than they would have without my efforts.
And so I have to get back to work building, preparing myself to go back into primary care. This time I pray with more resolve, better training, better confidence in the vision, and better preparedness from the thousands of other health care providers whose love for people keeps them looking for answers to a better health care system.
© Chet Gentry, 2011
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