Wrong Medicine

Some of the stacks of trip reports were nearing four feet high and they filled the musty closet. Dividing them up, we started sorting through them in earnest. The dates indicated that the calls had been run between 1972 and 1978. Most of the narratives were as brief as the treatment lists.

Hall Ambulance’s station one was an older house in an early residential area of Bakersfield, California. It had been, at one time, the residence of the company’s owner, Harvey Hall. In the early days of the ambulance service, Harvey had both lived in the home and run his fledgling ambulance service out of it. 

One of the crews stationed at the home had gone digging in the dusty storage closets and struck EMS history gold. Stacks and stacks of old trip reports from the Mother, Jugs and Speed days of EMS. That’s where we found it. A call run by our medical director back in his days as a paramedic for the service. A cardiac arrest, no less. The total list of treatments given; CPR, BVM, Epinephrine 1mg, Sodium Bicarbonate 2 amps.

The year was 1991. We found this hilarious. We were still in our ACLS infancy. There was no CPR first or AEDs or Amiodarone. Nobody had heard of capnography and there was nothing therapeutic about hypothermia. Yet we felt very advanced looking at our medical directors run report. The massive Sodium Bicarbonate doses of the seventies had long since gone away. 

More than happy to reminisce about the call, our doc read the report with a bemused sort of faraway look and announced, “I remember this guy.” He told us the story of the overweight, mid-sixties male who had collapsed in the parking lot across from the hospital. And then he made an observation that has stuck with me my whole career.

“You know, looking back on it, we killed this guy.” He observed and then corrected himself. “I mean, we didn’t do anything to cause his death, but we certainly pushed his Ph levels so far out of whack that he had no chance of resuscitation.”

“At the time,  we all felt like we were doing the right thing for this guy.” He continued. “Looking back on it now, we see that we were completely wrong.”

Back in my ambulance with the yellowed, old trip report still in my hand, I got to wondering. What am I doing right now, today that’s completely wrong? What will we look back on years from now and say, “Wow, I can’t believe we were doing that to people. It seemed like such a good idea.” What do I believe right now about appropriate medical care that’s actually completely wrong?

On that sunny spring day in 1991 I couldn’t say. Everything seemed to be fairly appropriate. In retrospect,the list was long. I c-spined just about everybody who fell down. I couldn’t treat a patients pain with my morphine but I could treat their PVCs with my Lidocaine. I spent a ridiculously long time getting cardiac arrests intubated and I only assessed tube placement with my stethoscope and eyes.

None of this was technically incorrect. I was following my protocols and my training and doing what I understood to be right for the patient. Just like my medical director back in 1972. Just like every one of us does each day. You see where I’m going with this right?

It’s worth considering that today, right now, a bunch of stuff you’re doing is just flat out wrong. We don’t understand it to be wrong today. 10, 15, 20 years from now, you’ll look back at your 2009 medicine and say, “At the time, we felt like we were doing the right thing, but looking back, we were completely wrong.”

Medicine is the art of guessing. Educated guessing for sure, but guessing none-the-less. We do stuff, we apply the scientific method, we assess the results and we take a better guess. Appropriate care is only appropriate in the context of time.

Part of being resistant to change is having to admit that something that we were doing before that change was less than ideal. It can be hard to admit that we were wrong. To welcome change is to embrace our own inherent fallibility. It’s recognition that nothing were doing is yet ideal. With that in mind we can be ready to move forward and create a more ideal future.

The first step is making peace with the idea that some of our care … much of our care, is wrong.

Comments

  1. A few things I keep wondering about are the indiscriminate application of oxygen and the usage of CPR in at unwitnessed arrest and/or when A(C)LS is more than 10 minutes away. I recently came across a few articles suggesting that oxygen might actually *promote* tissue death in MI ( http://heart.bmj.com/cgi/content/abstract/95/3/198 ). That said, oxygen can be very comforting to a variety of patients (and anything that makes a patient feel/be better without causing harm is great). Preventing dehydrated patients from sipping water is another one, especially if ride to the hospital is >20 mins. There’s a lot of folklore in the protocols, and it will take a long time to sort out what can be backed up with good evidence.

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