Do No Harm

I will not be ashamed to say, "I know not",
Nor will I fail to call in my colleagues when the
skills of another are needed for a patient's recovery

—Excerpt from The Hippocratic Oath

Two great books I’ve read pertaining to the medical industry have been written by the same guy, a surgeon named Dr. Atul Gawande.  It turns out he’s a keen observer of the world around him and a good writer.  Two necessary things if you are going to be reporting on things, obscure to most of us, from the front lines.  The two books, “Better” and “The Checklist Manifesto” explore a few things Dr. Gawande believes are crucial for the medical industry to improve.  The book, “Better” results in a set of rules that any of us can use to improve ourselves through the active participation in the world around us.  I surmised his rules in a book review I wrote a few years ago that we must,  “Ask an unscripted question, don’t complain, count something, write something, and change.”  To some extent I am doing many of those things as I evaluate what’s happening to me at the hands of the medical industry right now, as I go through this medical winter.  I’m trying to do everything right, and nothing is working.  So, according to Dr. Gawande’s script, I can definitely ask an unscripted question, “What the fuck is happening?”.  I am definitely in the mood to count.  We are already deep into the analysis of subjective and objective patient pain.  And I’m definitely writing, you guys are witness to that fact as this is blog number 20 on this subject.  However, I am going to leave the script, my apologies Dr. Gawande, I’m going to have to complain,  I’m definitely complaining this round.  We will see what brings about change.  I am changing.  I hope many of you are too.

His second book, “The Checklist Manifesto” describes how the medical industry took the great “checklist” mentality from the United States Air Force and took a huge bite out of the problem of removing infection from surgery in the medical business.  The checklist is one tool the USAF has used and perfected, throughout the years, out of necessity.  To become a lethal fighting force, a force necessary to violent and ridiculously unsafe things, like dropping bombs from the air, in a somewhat safe manner, they had to figure out how to do it over and over again.  For example,  loading bombs and refueling jet aircraft while the engines are running might be considered one of those ridiculously unsafe things. Hold my beer.  How about reloading, nuclear weapons, on a nuclear bomber, while refueling, with the engines running?  In my early days I led the USAF group certifying the combat loading of the Common Strategic Rotary Launcher, CSRL, for just such an operation.  I did this for and with the Department of Defense Nuclear Weapons Safety Board.  A checklist is key.  As are other things, such as highly trained maintenance and operations personnel.  An insane amount of crew coordination. Leadership. All the things.  And we got those procedures approved.  Of course that’s a very specific break glass scenario.  If B-52 bombers are returning from a mission having already unloaded their nukes and are coming in to “reconstitute” (reloading) more nukes as quickly as they can, all hell has already broken loose.  A crucial mistake on the flightline that might result in another bad day, probably would not be noticed in the big scheme of things…yet we still want to prevent that bad day, so we put in the time to get the procedures approved.  After the reload, of course, the crew has to take off, fly to their target, and do it all again.  They use a checklist.  Dr. Gawande correctly identifies the checklist as key to the success of such a complex situation.  Adopting them isn’t unique or ubiquitous to everything yet.  It is however essential if the job is dangerous and complex. 

A checklist is always the best way to complete a mission with the best outcome.  The Air Force also does an extremely good job at providing feedback after a mission.  The debrief at the end of a mission is the best way to affect change.  The medical industry should also adopt the debrief after surgery to critique what happened during the medical procedure.  In these settings there is no rank. The surgeon doesn’t get to call the shots.  Everyone gets to walk through what happened and provide feedback without fear of any reprisal.  If a physician's assistant sees something differently then the surgeon they need to be able to change that surgeon's attitude or behavior.  Gawande points out that many times, surgical teams may be working together for the very first time, and have never met each other before.  To me, this is a ridiculous construct and an immediate red flag of danger.  Be that as it may, the medical industry has made that work, for the most part.  Until a serious problem shows up.

When a problem does show up, preferably not in the middle of a mission, they might be something that occurs that the Air Force would describe as “self-critiquing”.   This is when feedback comes immediately.  Do something wrong and you know about it immediately.  Self critiquing behavior could show up during surgery, for instance, if the patient starts  bleeding because the surgeon cut  something he shouldn’t.  In the case of most surgeries, for things that are happening, the  patient is under anesthesia.   The success for failure of the activity is going to come later…partcualrly in the business of neurosurgery when operating on the brain, spinal cord or around the nerves of the patient.  The neurosurgeon is not going to know if something went horribly wrong.  Maybe they inadvertently nicked a nerve.  The issue is not self critiquing.  The problem is not going to show up  until much later.  If you want to read another book specifically about neurosurgery I recommend, “Do No Harm”, by John Marsh.  Neurosurgery is one of those things where the surgeon shouldn’t be a cowboy.  I freely admit that in the case of what’s going on with me, taking a conservative approach is a safer option…for the surgeon.  It’s not necessarily the best option for the patient.  It may be.  However, under more extreme conditions, in cases where for instance, the patient can't walk, the doctor should take a closer look at what’s going on. Nothing seems normal about my condition.  Failure to walk should be suggestive of something more extreme.  I argue, in this case, it should be self-critiquing for the medical team vying to do something better for my outcome in this case.  They failed in that regard, so here we are.

Enough about books today. It’s time to figure out what’s really going on in my lower back, my L34, L45 to be exact.  Yesterday I noted improvement given the epidural I received last week.  The same can be said today, but things are changing fast.   I’m experiencing some ability to stand erect and put more weight onto my left leg.  As of this morning, I was nowhere near free of the wheelchair.  My ability to put weight on my leg allows me to use a cane to hobble into the bathroom and shower…where I will remain seated on a bench to shower and clean “my bottom area” as the PT who came to the house referred to it.   This evening, however, my direct impression is that the steroids have already begun to wear off.  Tomorrow I will go to see an orthopedic spinal surgeon who hopefully will make recommendations to seal my fate. Or at least complete what I am classifying as my full 2nd option.  I will meet with another spinal surgeon on Friday for a full 3rd surgical opinion, completely out of network.  I will also see a chiropractor for the second time and hopefully begin traction.  The chiropractor hopes that the second steroid injection would provide some relief in order for me to begin traction.  We shall see if the steroid holds into tomorrow.  Yet another option is a product called Discseel, which is a direct injection of a biological agent called Fibrin that is supposed to literally seal and cement the disc providing a stronger disc.  All of this out patient consulting and alternative medicine was not available to me while I was an inpatient.  It’s also a full time job trying to coordinate all of my care…and doing so myself, for the most part.  Once again…it troubles me greatly to ask what a patient would do without my level of participation and or faculty to be a part of my own treatment.

With all of these options, what is beginning to take shape is the very essence of what I have done my entire life…shaping a complex decision into a space where an actual competent decision can be made.   There is actually a scientific discipline known as decision analysis.  Sometimes, good engineers might just say that decisions are just good engineering.  In reality, good engineering requires good decision analysis for this statement to be accurate.  System engineers have the tools at their disposal to make good decisions, such as optimization and simulation.  But local optimums discovered on the slope of a mountain that indicate higher ground, for instance, doesn’t always mean you’ve reached the highest ground.   And if the flood waters are higher than that local high ground, you still die from breathing in water.    

I have a decision to make.  We make decisions everyday…we actually make them second by second…humans just become very good at the very close-in decisions we make…almost by instinct we navigate the close ones without much trouble. Crossing the street. Avoiding high water, for the most part, we stay on the sidewalk.  Since we are not dying continuously, when it’s raining outside, we don’t realize we are making these decisions (unless we try and drive our car into a creek that has overflowed the road).  However, it’s my contention that most of us would die in the very early minutes of an actual Zombie Apocalypse, or some other form of all-encompassing natural disaster.

I know this because, yes, we can cross the street without dying.  We can cook our food without dying.  We can warm our homes without dying.  But everyday there are people out there winning the Darwin Award.  Every winter someone is tragically warming their house with a Hibachi grille and killing their entire family.  I mentioned in an earlier blog, my friend from Uganda who literally had to swim across a crocodile infested river everyday to get to elementary school.  No joke, no lying, no exaggeration.  Another one of my friends simply couldn’t comprehend this as a reality someone else faced, would face, or could face.  Second nature for someone growing up in Africa 50 years ago.

But here I am…I believe…in my own personal ZA.  How could not being able to walk be anything but apocalyptic to my way of life? I have to navigate this situation.  But, I am also someone trained in actual decision making.  Can I make the right decision?  Will I actually be able to play soccer again?  Will I be able to go sky diving, rocky mountain climbing?  Will I be able to go 2.7 seconds on a bull named “Fu Man Chu” (I don’t want to do that).  

Thirteen years ago, I had to make the same decision, just hours before fusion surgery on my C56.  I had already completed the pre-op testing.  Surgery was scheduled.  I was ready to go.   I waived off the surgery…and felt guilty telling the surgeon after all the preparation.  Never feel bad about doing so.  As a result, I continued to play soccer for what appears to now look like an additional 13 years.  I actually went sky diving (tandem) a few years later.  And I hiked in Kings Canyon with Meatball.   Arguably, my L34 and L45 are currently in worse shape, and more crucial to soccer, for many reasons.  

What will drive my decision this time?  Before we get there I still need more information.  It’s coming in bits and pieces but soon I will have a river of information to decide--will it be accurate?  But ultimately I will decide.  I have to--I’m sitting in a wheel chair.  My ability to walk again will be taking center stage.  I hope you will stay tuned.