The Ether Way

Medical Idiocracy

Medical Idiocracy*

 

The following was inspired by the presentation of the ASA president and the SAB plenary session at this year’s AUA meeting. It is reprinted  from the  Summer 2008  AUA newsletter.  http://www.auahq.org/Summer2008.pdf

  

 

What a trip! An hour ago I entered the UPenn hyperbaric chamber but there was a power surge and poof! The lights went out, the barometric pressure undulated up down and all over and I found myself in the chamber after the lights came on but different folks were running the unit. I looked at the clock and it was the year 2050! I stepped out to find the tech frantically turning knobs and spinning wheels and trying to figure out what was going on. He did not seem very able as a problem solver.

(The hyperbaric technical society, founded in 2010 and following the lead of the nurses, successfully lobbied and got a law passed in 2020, giving the techs full autonomy to run hyperbaric chambers. The PhD’s all were released. In a repeat of the scenario that occurred with the 20^th century steelworkers, most enrolled in nursing school as a pathway to a remunerative, satisfying, autonomous career.  Notably, the Journal of Hyperbaric Medicine, receiving an insufficient number of submissions, stopped publishing in 2031.)

Wow! I thought. Its 2050! I couldn’t wait to find out how Anesthesiology had progressed and was eager to check this out. So I ran over to the hospital, now called UPMC-HUP (yes…..UPMC bought the UPenn Health system in 2025) to check things out. I really wanted to observe things in my old neuro rooms.

The neurosurgery advances were just magnificent. The robot worked wonders and all the guess work was gone. The UNIX-versant neurosurgeon put the patient in pins, programmed the computer, and was able to oversee six craniotomies at once.  Very cool. But the anesthesia…..the anesthesia was a different matter.

(The many patient safety efforts of visionary MDA’s that started in the mid 20^th century progressed through the first two decades of the 21^st century. The APSF’s work continued with 50 research grants annually, over 60 patient safety standards in effect, and over 100 instructional patient safety oriented videos in use by 2020. Anesthetic death and morbidity was approaching zero. However, The AANA, after a persistent and brilliant lobbying campaign,  got a law passed in 2015 which allowed them to practice independently while concomitantly increasing the number of CRNA and PhD-level CRNA graduates…all according to their secret strategic plan laid out in 2001 and implemented with little resistance from the highly paid, overworked,  and otherwise complacent MDA’s of the early 21^st century. The law specifically allowed PhD level CRNAs to present to patients as their anesthesiologist and their anesthesia doctor. In addition, over the next five years,  in the context of a catastrophic health care funding crisis with rampant systemic rationing of resources,   the AANA brilliantly and  effectively argued that each SRNA was self-funded and MDA’s were overpaid with no added value, given the spectacular safety record of anesthesia. Moreover, they convinced the legislators that it would be in society’s interest to stop funding all MDA anesthesiology residencies.  The federal health care act of 2020 provided for no funding for MDA training while abolishing anesthesia-related lawsuits.  This contributed to the spectacular growth of SRNA residencies over 2020-30. Third world health care, already dreadful, became a calamity as nurses from those countries flocked to the USA to take the newly vacated, well compensated bedside nursing jobs.)

So, my old anesthesia department, august tradition of Dripps, Eckenhoff, and VanDam notwithstanding, was phased out of the medical school in 2030 and now the CRNA PhD’s were running the anesthesia service line.  I must admit they ran an efficient operation. Everyone got propofol, vec, and desflurane. All got the same airway management and most of the patients that I saw woke up just fine.  I was told there was the occasional stroke and the occasional cardiac arrest and post op MI, and sometimes there was an difficult airway related death. In fact the anesthesia death rate had risen since 2008 and those who did not do well in surgery had a financially mandated withdrawal of support. Things like this were necessary in a world with more beneficiaries than workers; it seemed like these negatives were acceptable cost benefit trade offs in order to keep the federal health service running. Other than that it was just like 2008, but with shorter turnover times.

I found one of these latter day anesthesia doctors so I could have a discussion about what was going on. I was eager to hear about how the nascent issues of 2008 neuroanesthesia had grown. So I asked, what had happened to developments in genomics to tailor anesthesia? What about the new brain protection strategies? Had the new laser IR to support brain ATP been translated? Surely that was in use by neuroanesthesiologists of 2050. What new drugs had been developed? How about blood substitutes? Any new monitors? Any continuous CBF and CMRO2 monitors that were being discussed in 2008?  New simulation technology?  Had anything changed since 2008?

The anesthesia doctor I spoke with looked askance at me and suggested that there were no significant problems, the surgeons had solved all the important problems and all the stuff I was asking about, after review by the Best Practices Board of the AANA, had been dropped as just expensive  fluff stuff. They were doing just fine without it.

So after a week or so in 2050, I headed back to the chamber and hoped the “hey dude” gang could get me back to 2008. 

 

 

Story line adapted from the new cult movie, “Idiocracy” If you’ve never heard of it learn more from http://www.imdb.com/title/tt0387808/ or http://en.wikipedia.org/wiki/Idiocracy or just google it.

 

Evil Humors

Like most practitioners, I find myself attending M&M conferences at least 26 times a year.  In my department, these are simply terrific conferences: well planned, meticulously researched, outstanding presentations.  In most instances, I find that I would do as those presenting did.   That is to say, I cannot see any reasonable way of foreseeing or avoiding the bad outcome being discussed, and am not retiring in making this known.  This frustrates some who hope to actively evolve our practice, especially those who view themselves as leaders in the application of evidence to our clinical practice.

So there I was at M&M, listening to a discussion of a case, when a colleague pronounced ‘I know what happened’.  This happens with astonishing regularity.  I listened attentively.  The commentator was far more certain of what had happened and why than was even remotely possible. Confabulation or rationalization? God only knows. 

Throughout the history of medicine, we have continuously believed we have a complete understanding of the biology that underlies the vast majority of the diseases that we encounter.  Whether it is earth elements, evil humors, histamine, prostaglandins, cytokines, NO, genomics, or small RNA; we have never lacked plausible and attractive explanations for the phenomena we sought to understand.  Never.  History continuously proves us and our paradigms wrong.

Once upon a time, syphilis was widely understood to be the great imitator.  If you wave your hands long enough and hard enough, you can use syphilis to explain anything.

We have now identified many syndromes and diseases based on improved understanding of their biology, improved imaging, and improved diagnostic testing. Anaphylaxis? Prion disease? Catastrophic APLA? Schizophrenia? Carcinoid? Serotonin syndrome? Touret’s? Minamata disease? Sarcoid? Ulcerative colitis? Thyrotoxicosis? Lupus? Systemic sclerosis? Consumption? Hoards of others? All of them have been out there forever in one form or another.  All syphilis.

Once upon a time, esophageal intubation was allegedly common.  What about Suxx – K  burns? MH? Carcinoid? Pheo? Latex allergy? Serotonin syndromes? Anaphlaxis to vehicle? Anaphylaxis to NMB? Anaphylactoid reactions(Red Man  Syndrome)? Bacterial contamination of drugs? Posterior Ischemic Optic Neuropathy?  Who knows what else?  All of them were out there.  My guess is that events associated with these were tied back to ‘esophageal intubation.’  The world was overflowing with people who ‘ knew what happened’.  In most instances, our explanations were complete rubbish – rationalizations framed in the context of what we believed was a robust and complete understanding. It is only in retrospect that we can see with excruciating clarity how profoundly wrong our explications were. In most instances, invoking ‘evil humors’ would have been less wrong than most of the explanations offered.

Even now, the temptation to explain that which we do not understand utilizing frameworks(paradigms) we believe are complete and robust is insuperable.  A colleague, someone whom I have enormous respect for, once told me that he truly believed that cardiac arrest during neuraxial anesthesia arose from inadequate vigilance.  This, in spite of years of event investigations which refute it as even remotely plausible.  Whatever it is that causes these tragedies, this much is certain: it isn’t a lack of vigilance (at least not in most of the cases).

"To see what is in front of one's nose needs a constant struggle." - George Orwell

Our hubris is also a source of tragedy over time.  For example, it is now widely accepted that intrapartum asphyxia is the cause of no more than 10% of the cases of cerebral palsy in our world.  The remainder, that is to say the vast majority, seem to be caused by some combination of intrauterine infection and the demise of an intrauterine twin; both of which precede delivery by weeks to months.  Given this, it is unsurprising that escalating monitoring and aggressiveness in the management of fetal hypoxia had no effect on the overall incidence of cerebral palsy.  In retrospect, the absolute inability to make any forward progress on this problem should have made it obvious: the vast majority of CP is not caused by intrapartum asphyxia.  Once again, an invocation of ‘evil humors’ would have been less wrong than the conventional wisdom.  No matter, like the British at the Somme, more resources were pushed forward to deal with the failure.  More policy.  More protocol.  More regulation.  More nurses. Higher tech monitors.  More aggressive management of fetal distress.  All for nought.  How many times did someone at M&M utter ‘I know what happened.’?  Who are the casualties here? Not just the patients.  How many doctors and nurses were devastated by the idea that they might have caused CP in a child? How many careers were ruined? How many millions of dollars were paid for events that were beyond the power of those held responsible? Who is going to apologize to those practitioners? Who is going to pay them back?  Who is going to make it right?  (The answer to the last three: No one.)

As an educator, one of my greatest responsibilities is this: to convey to my students, residents, and fellows an appropriate degree of circumspection regarding the limits of our knowledge and understanding.

‘I know what happened.’ Bullshit.

One of the wisest men I have ever met says: ‘ I don’t know what it was, but whatever it was, it was the worst case of it I ever saw.’

As for me, I know: it’s syphilis.