Wednesday, September 28, 2016

Technology and the Old Masters

Boy, do I have feels about this. Feeling number one: it’s complicated.

While it’s great to have all the skills, technology will inevitably cause the loss of some older ways of doing things. I’m sure the first OB/Gyn residents to graduate without knowing their way around a foreceps delivery faced some scorn from their colleagues. A few years after Laennec, there undoubtedly was an old-timer who complained to another old-timer to the effect of “Kids today, they don’t even know how to auscultate a chest without their fancy amplifying wooden tubes.” Somewhere in the mists of history, shortly after the introduction of practical glucose assays, there was somewhere a great teacher who complained bitterly about young physicians who didn’t even know the the taste of diabetic urine.

On the other hand, it’s a good idea not to let go of all the low(er) tech ways of doing things, as you made need them when your high-tech gadgets fail you. And high tech or low, it is alays better to have more than one way to do something.

But even so, we have to remember that time and opportunities to practice are limited. “Learn both” is easy to say but hard to practice. If we’re being intellectually honest, we should accept that we already use the training time allotted to the making of a doctor, and if you want to add something you should be prepared either to increase the hours of training or cut something out. And the natural thing to suffer when you introduce a new way of doing a task is the old way of doing a task: patients will not likely suffer twice as much respiratory failure for your convenience in learning and practicing the Glidescope and manual laryngoscopy both.

Which brings me to feeling number two: it’s too early to say goodbye to landmark-only lines. Some rooms are too small, some patients too critical for ultrasound. Machines number one or two in most EDs; they may all be in use.

What you come out of residency knowing how to do is in large part a reflection on your teachers. This physician, I'd wager, trained somewhere where it was ultrasound-guided IJs, all day every day. Tell someone at that program you wanted to put in a blind fem line to learn how to do it and they'd look at you like you just grew a second head.

This is why once you have trained up your residents a bit it's important to put them out on their own, or close to it, in a place where hairy stuff can go down. Code teams. Night shift in the ICU. EMS months. Moonlighting. In those situations the need for hairy shit like a STAT femoral line arises organically.

But this is contrary to the entire thrust of medical culture as it has developed in the last 30 years. In the name of safety, every learner must be supervised at all times. Consequential decisions are left to the higher ups. Uncontrolled and semi-controlled crises, which arise with sick patients all the time, make administrators' skin crawl and they strive to keep residents as far away from them as possible. When something bad occurs, the refrain goes up, "Only the attending should be entrusted with this" -- an attitude that does little for safety, by and large, but quite effectively stunts learning.

What Samuel Shem wrote in the House of God is still true today: doctors learn "by taking risks in those hard times when you were alone with your patient." If you never leave a doc alone, because safety, well…this is where you end up, with physicians that function fine in routine situations but poorly when Death shows up and decides to eat their lunch.

Final feel: education aside, by five years out you should have a good idea where your holes are and be working to fill them. I can put in blind femorals by pulse or landmark (when there is no pulse) as well as under ultrasound; I can put in a blind subclavian with confidence, and my ultrasound guided IJs are respectable. Am I satisfied? Hell no! I want to learn how to use ultrasound at the subclavian and how to do a blind IJ. I've recently started to use Statlocks to secure the lines instead of sutures (fewer holes in the patient, less line infections.) Constant practice of what you know; constant reaching for new and better techniques and tools. The old ways will slowly pass out of knowledge, but a physician humble in their limited knowledge but restless and impatient for perfection will never go out of style.

For always roaming with a hungry heart
Much have I seen and known; cities of men
And manners, climates, councils, governments,
Myself not least, but honour'd of them all;
And drunk delight of battle with my peers,
Far on the ringing plains of windy Troy.

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