Medical Catastrophe

by Ronald W Dworkin

  airway emergency,” I replied, my left eye twitching from nervousness.

  “You don’t keep it lying around all day? Correct?” the inspector asked

  sternly.

  “Oh, no, of course not,” I replied, although I knew anesthesiologists

  had been doing so for fifty years without problems.

  Next, an open bottle of drug caught the main inspector’s attention. I

  had drawn the drug up for my next patient but had yet to throw the bottle away, thinking I might need more.

  “I assume you will use this bottle for your next patient only?” asked

  the inspector.

  Although doctors have been using multi-dose vials on different pa-

  tients for years, a new rule banned the practice to prevent infection. The rule was reasonable and I meticulously followed it, except once. I had

  needed the drug Pitocin to control hemorrhaging in an obstetrical patient whose uterus failed to contract after delivery. My anesthesia cart jammed and kept me from getting a new bottle. The only Pitocin available was in

  the bottle that I had used on the previous patient (but which was still

  sterile). I wanted to use it, but the rule momentarily hypnotized me. I

  hesitated for several seconds while my patient almost bled to death; then I said to hell with the rule and gave her the Pitocin. The drug saved her life.

  Still, I felt uneasy for having violated the rule.

  “That’s correct,” I replied nervously. “One bottle, one patient.”

  The main inspector saw an unlabeled syringe containing the milky

  white drug Diprivan. I had drawn the drug up a few minutes before to use

  on my next patient.

  “Why isn’t this syringe labeled?” he growled.

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  “I just drew it up, so I know what it is. Besides, it’s the only milky

  white drug we use, you know, so there’s no chance of me confusing it

  with another drug, ” I replied with confidence.

  I could tell by the inspector’s face that he didn’t find my argument

  convincing.

  “The drug could be Milk of Magnesia. That’s milky white,” said the

  main inspector with a straight face.

  “Oh, come on,” I giggled. “We don’t use Milk of Magnesia in the

  operating room.”

  I looked for an ironic smile on the man’s face, to see whether he was

  just pulling my leg. There was none. Instead, he glared at me, as if to say,

  “I represent a certain organization well known to you and I don’t recom-

  mend you insult it. That would only make your position, bad as it is,

  worse.”

  “The rule is to label all drugs,” he replied restrainedly, as if somehow

  offended. “Is that clear?”

  He really was a natural-born predator. A passion lived within him, and

  he seemed to harbor the urge to hound and henpeck anyone weaker than

  he was. He would be happy to get me fired. The other inspector regarded

  me with more sympathy. Still, she expected a kind of respect to which she felt she was entitled as the representative of her agency. All good things came from her agency, meaning rules and guidelines that saved people’s

  lives, and therefore good things should be given to her agency—in other

  words, respect. Although she didn’t want to hurt me, her eyes suggested

  that if I continued to resist, I might become the unfortunate victim of

  cruel administrative necessity.

  I repented and put a label on the syringe.

  Some medical writers believe doctors today are so bombarded by

  information that they risk overlooking things, resulting in catastrophes. 2

  These writers preach rules and protocols that help remind doctors to

  check this and remember that. But in my experience, although there is

  real value in rules and protocols, medical catastrophes stem less from

  doctors being flooded with information than from doctors being flooded

  with rules and protocols. Not necessarily with a checklist or a time-out, not necessarily with the rule to label all syringes, but with the hundreds of rules and protocols that collectively guide doctors in everyday medical

  practice and that should be followed, but only “up to a point.” It is not the rules and protocols per se that cause catastrophe so much as doctors

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  having lost control of those rules and protocols to higher-ups—to admin-

  istrators, to inspectors, to bureaucrats, and to civil servants—who prevent doctors from judiciously applying them. Those higher-ups lurk in hospital corridors, fire orders at subordinates at point-blank range, sort out patient lives with the latest rules and protocols, and then stroll away. Deprived of an opportunity to use their own judgment about when to enforce the rules, doctors become little more than clerks. When the inner voice of judgment

  does whisper inside of them, they find it hard to think, because they are afraid; their minds go around and around in a vicious circle; they see a

  rule on one side and a threat on the other; they make decisions, some-

  times senseless ones, in a state of vertigo. Employed doctors feel the most pressure.

  In one case on the West Coast that I am familiar with, an obstetrician

  admitted a patient with gestational diabetes to an intensive care unit.

  Employed by the hospital, the intensivist insisted on giving the patient a flu shot, since a rule mandated that all patients with diabetes get flu shots.

  “But it’s not diabetes, it’s gestational diabetes,” the obstetrician pleaded.

  “It’s different.” The obstetrician wanted to keep her patient from being

  needlessly exposed to the potentially dangerous complications of flu

  shots. But the intensivist feared being fired if he ignored the rule.

  In a second case, an employed obstetrician rejected an anesthesiolo-

  gist’s suggestion that a patient with mild placenta previa be crossmatched for blood instead of just screened for blood. 3 Only with a crossmatch is blood immediately available for transfusion in case of severe hemorrhage. The obstetrician worried that the more expensive crossmatch

  would raise her financial profile and make her a statistical outlier among other employed obstetricians. The hospital had its protocol for managing

  such cases; a bureaucrat had estimated in advance the reasonable cost. If the obstetrician went outside that protocol and incurred a higher cost per case, she risked her job.

  In a third case, an employed anesthesiologist hesitated to give her

  diabetic patient insulin before surgery, worrying that her patient, who was sensitive to the drug, might suffer a dangerous and undetectable drop in

  blood sugar during the operation. The hospital diabetes protocol, working from a nationwide protocol, had decreed insulin to be given when the

  blood sugar reached a certain number. The anesthesiologist hesitated. She didn’t want to ignore the rule, but she feared losing her job.

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  Why bureaucracies put doctors in such an uncomfortable position

  mystifies physicians. Some doctors see a pernicious ploy to award them

  responsibility without authority. The bureaucracy lays down a rule. If

  doctors follow the rule and get a bad outcome, they get into trouble

  because the rule should have been followed “up to a point,” and they

  should have known that point. If doctors ignore the rule and get a bad

  outcome, they get into trouble for not having followed the rule.

  A more li
kely explanation lies in the nature of bureaucracy itself. An

  analogy is helpful. Imagine sitting in a theater and watching the actions of others. We are interested in the movie; what unfolds before us is familiar; the feelings that the actors express are familiar; and after the movie we talk about what the characters might have done differently. Yet, despite

  all that takes place on screen, no decision is required of us. The drama

  takes place in an imaginary world, and nothing we say or do has any real

  effect on that world. Real patient care is a kind of imaginary world for

  bureaucrats. Bureaucrats think and talk about that world. They feel for

  people in that world. That world is familiar to them. They may even have

  once worked in that world. Yet patient care is still a distant world that fails to touch them directly. The major difference between a bureaucrat’s relationship to his imaginary world and a moviegoer’s relationship to his imaginary world is that, for the bureaucrat, decisions do affect the imaginary world. Sometimes bureaucrats forget this fact. When writing rules

  for patient care, they use words, flimsy symbols, and sometimes forget

  the terrible consequences that may follow. Their words or phrases fail to represent with sufficient exactitude what happens in the patient care

  world and the consequences of following them. The result can be catas-

  trophe.

  Ironically, the medical profession is responsible for this bad situation.

  Under the old model of doctoring that guided my father, physicians did

  not have the same obsession with rules, protocols, and algorithms. True,

  my father worked with rules and protocols, and he often followed them.

  But for him the underlying difference between doctors was less one of

  who knew the rules and more a matter of personal taste. My father be-

  lieved that in delicate and difficult matters of patient care, individual variations of temperament and personality among doctors were really the

  dominant elements in any judgment. This was the “gentlemanly,” almost

  aristocratic side to medical practice.

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  In contrast, many doctors today fear individual variation among them-

  selves as much as they fear not having a ready answer for patients. The

  idea that they should manage illness not through universal rules and

  protocols but through personal experience and a half-conscious sense of

  the vital elements in a situation unnerves some doctors. These doctors

  embrace habit. They want to fall into routine. They want to reduce the

  effect of human variation among doctors. They want science to smooth

  out the fluctuations between them. They want “best practice” guidelines.

  They want a rule to tell them what to do.

  Their hopes and fears have led to an explosion in the number of rules

  and protocols in medicine. Those rules and protocols are now dangerous-

  ly under the control of higher-ups.

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  THE PROBLEM OF GOING PART-TIME

  AND WHEN TO RETIRE

  December. Late at night. Cold and tired. My first year in practice. On the other side of the ether screen the surgeon sliced off the patient’s appen-dix. I tickled the roof of my mouth with my tongue to stay awake, a trick I had learned as an intern. To pass the time, I studied my patient’s face.

  An anesthetic-induced sleep does not convey an image of peace. On

  the contrary, it conveys an image of fear. The cheeks are pale. The veins at the temples stick out repugnantly. The bloodshot eyes fasten their gaze on one spot, unblinkingly, as if aware of some invisible approaching

  horror. The hair is busy, hectic, and dank with sweat. Even the nicest nose is snotty, as if the owner were too harried to wipe it. When watching

  someone in real sleep, one has a sense of life reviving, that sleep is a good thing, that a tired spirit is putting forth fresh shoots. When watching

  someone in an anesthetized sleep, one has a sense of life in despair.

  Horrible thoughts seem to reveal themselves on the patient’s face. The

  damp forehead; the cold, bloodless lips; the tearing eyes; the mouth in the shape of a groan—all suggest that the world is getting worse and worse to live in.

  When the case finished I went back to my call room to lie down.

  Although the day-shift physician had been there only a few hours, the

  room looked and smelled as though someone had been living there, sleep-

  ing and eating his meals there, for over a year. An unmade bed. A Styro-

  foam cup filled with old coffee. From the trashcan came the noxious

  smell of rotting tuna salad. Within a few seconds my nose adjusted to the 1 6 3

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  bad odor; yet I knew I wouldn’t sleep well in this stale, stuffy room. I sat down on the unmade bed, took off my cap, then my shoes, giving my feet

  a chance to feel their freedom. I unwrapped my stethoscope from around

  my neck and put it on the table. I wondered if I should take off my scrubs before commencing my hours-long stare into the darkness. It seemed

  senseless to get undressed for that pleasure—not really to sleep, just to lie down on a dirty bed and stare.

  Lying alone in a call room is a special time for doctors. It is the

  moment when the mind is irresistibly attuned to dreams, the heart to all

  those sensations that in the light of everyday life seem silly, absurd, even juvenile. It is also the moment when the doctor ceases to be active, when boredom lies in wait for him, when he is prey to imaginary worries,

  endless self-examination, regret for the past, and fears for the unknown

  future.

  The memory of my patient’s despairing face set the tone for the eve-

  ning. Simply put, I was unhappy with being a doctor. I wasn’t sure why.

  It certainly wasn’t the money. Both my father and my grandfather had

  loved being doctors, and my father, at least, had earned a good living, but compared to what I was earning (even in my first year of practice) they

  were practically paupers.

  Some of my disappointment stemmed from the monotony of an-

  esthesia practice. Ninety percent of the time I would give a patient all the big syringe (the Pentothal), then all the little syringe (the muscle relaxant), insert a breathing tube, and turn the knob on the gas canister. In my early years of training I had a feeling of excited expectation in learning how to do this. By my last year of residency this cooled considerably.

  During the first six months of private practice it came with an ironic

  smile. In the second six months it was transformed into indifference.

  Overspecialization has caused many doctors today to share in this

  feeling of monotony. Wherever they are, the weather outside will have

  changed, their watches will have moved ahead, but their day is exactly

  the same as the one they had three weeks before. They did all this yesterday and the day before, and they know they will do the very same thing

  tomorrow and after. They grow depressed in spirit; they are overcome at

  the assembly line with a daily state of madness that lasts for ten hours, after which, upon returning home, they rest, eat well, get well, and recu-perate, in order on the next day again to grow mad for a while.

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  Yet both my father and my grandfather often did the same thing every

  day, and they enjoyed being doctors. Indeed, most work is monotonous.

  Perhaps my career expectations had been too high, based on fabrications

  of television shows. Real medica
l practice, like real life, was something different—boring and simpler—and I would simply have to submit to it.

  I lay on my bed and listened. The hospital murmured vaguely. I heard

  the sound of an elevator opening, the sniff of someone next door, and the rumble of a toilet flushing down the hall. Then came a severe silence,

  waiting to be pierced by a beeper’s staccato ring, that harbinger of disaster, alerting a doctor to some patient in distress. At home, dogs bark, kids scream, jackhammers pound away in the street, and yet sleep is easy;

  while at the hospital, silence is almost total, one can practically hear two clouds colliding in the sky, and yet sleep is hard—all because of that little beeper sitting two feet from one’s head, waiting to go off like a time

  bomb and putting a tremendous strain on the nerves. Nothing is more

  irritating than being awakened by that beeper. It is more painful than

  doing the entire case for which one is awakened.

  If the position of “doctor” had been more respected, then my discom-

  fort might have been more endurable. But it had ceased to be. It had been respected during my father and grandfather’s time. It is why the two men

  never said they were “retired” whenever people asked them during their

  final years what they did. Like the general who calls himself a general

  long after having left the army, my father and grandfather said they were doctors long after they had stopped practicing. They clung to the title.

  Being a doctor was a high-status position in those days, and they were

  proud of it, while society’s respect got them through the long hours. In a game called Life that I played as a child, the position of doctor was the highest a player could attain, and came with the highest salary, followed (in order) by lawyer, journalist, and teacher. Even in the early 1980s,

  when I went to medical school, the brightest young people often aspired

  to the professions. But later, an entirely new upper stratum came into

  being, composed of people in finance, computers, the Internet, media,

  entertainment, and high technology. Indeed, in today’s version of Life,