Category: Reflections on Life, Being Human, and Medicine

We walked out to do the preflight on our aircraft. The mission was to fly from Naval Air Station Norfolk VA to Camp Lejeune NC and back. It was 1994.  I was the flight surgeon for Marine Medium Helicopter Squadron 774 (HMM 774). We had just finished a preflight briefing in the ready room. I was to be the copilot for the mission. The pilot walked with me to guide me through the inspection.

Our aircraft for the day was a marine CH-46 Sea Knight helicopter. This aircraft was affectionately known as the “Phrog”. It was an unusual aircraft. It was a tandem rotor helicopter. This meant it had two main rotors rather than the usual main rotor for lift and tail rotor for control. This made it look a little bit like a frog, plus it had a tendency to bounce when you taxied it down the runway. Most of them were put into service in the 1960’s.  This last fall, Margaret took us to the Udvar-Hazy Smithsonian National Air and Space Museum facility. I was pleasantly surprised to see a Phrog on display. Amazingly the aircraft there is from my squadron (HMM-774.)  For all I know, the helicopter on display could have been the exact helicopter that I flew that day.

We got to where our helicopter was positioned on the tarmac. The pilot pulled out his flashlight from his safety vest. We carefully pulled and prodded and looked as we did the preflight inspection. He pointed out areas where the control cables could chafe and potentially wear through. He pointed to key areas on the aircraft that had been known to fail or break. 

“If this breaks, we will lose power to that rotor. We would have no control of the helicopter. We would likely do a loop and then crash and die. I know someone who had that happen.”

“If this cable breaks then we would lose control of this part of the helicopter. It is not clear that we would survive that. I know someone who had that happen.”

“This aircraft may actually be older than you. I don’t say that to scare you. I just want to explain why we have to be so careful. It is old and worn.”

The preflight went on and on with similar dire stories of his colleagues and friends who had suffered catastrophic failures and losses. Some had survived. Some had died. 

We finished the preflight inspection and climbed into the cockpit. By the time I strapped in I wondered about what I was doing. Had I told my wife that morning that I loved her? Should I slip out of the cockpit and run inside for one last phone call? Was I crazy to be flying that day?

I did a rapid calculation in my mind.  

On one side of the equation were the risks: I could crash and die. I would leave my wife a widow. I would leave my infant daughter without a father. The tangible risk of that fortunately was small. I had a very experienced marine aviator as the primary pilot. We had a good and well-trained flight crew. They all knew that particular aircraft in and out. We had scoured over the aircraft looking for any potential point of failure.  It looked good.

On the other side of the equation were the benefits: It was going to be a really fun flight. I would get to be at the controls for part of the flight. I also could better understand the operations of my squadron and the flight crews that I was responsible for.

I finished the calculation silently in my mind. I was staying. I focused again on the flight. 

It was indeed amazing. I got a lot of time in control of the aircraft. The pilot even let me taxi the Phrog around Camp LeJeune and fly it most of the way back to Norfolk. It was one of the most enjoyable flights I ever had in the military. It was really worth it.

Risk vs. Benefit. That is the term that describes what we do all the time in life, often without realizing it. 

That equation is one that has followed me and one I use continually in life. It is a key part of what we do in cardiology. We do risk vs benefit calculations with almost every patient interaction. How likely is it that their symptoms or test findings could cause a serious problem for them? Should we do a cardiac catheterization? Can we manage with medicines alone? Are the patient’s symptoms suggestive of a potential for a fatal event? Or are they going to be ok? Can we just reassure them? There is a cartoon of a doctor flipping a coin. “Heads you get quadruple bypass. Tails you just take a daily aspirin!” These are the extremes in the decisions we make on a regular basis. 

How do we make those decisions?  We carefully calculate the risk vs benefit.

For example, for a procedure:

• High risk: Must be a high benefit.
• Low risk: Not as much of a benefit is needed.
• High benefit: Willing to accept a lot of risk.
• Low benefit: Very little risk is acceptable.

Severe coronary artery disease (blocked arteries) especially in a diabetic patient? The benefit from coronary artery bypass surgery is very strong. It justifies the risk of having the surgery.

Stenting an artery in a stable asymptomatic patient with normal heart function? The risk is low. The benefit however is low. There is good data that they will do just as well with treatment with medicines. 

Yesterday I had this discussion with a patient. Should he have a defibrillator implanted? “Doc, just tell me what to do,” he said.  

I know that feeling. That is the attitude that most of us would like to take. None of us like having to make risk vs. benefit decisions. There are uncertainties. We would like to think that are always absolute and clear answers. If there are not, we generally want to just have others make the decisions for us. But to live responsibly we need to look at the facts and balance out the risks and benefits.

I needed for my patient to go further than that. I talked with him about why we would put a defibrillator in along with the tangible risks of doing it and not doing it. I reviewed the accepted standards of care along with what evidence was available to guide our decisions. In the end we made a decision together. The truth was that there were risks on both sides. Fortunately for this patient those risks were low regardless of which decision we made. Oddly the low risk vs low benefit decisions are often the hardest. But we needed to go through the calculation to make the decision.

That brings us to now. 

People are asking the question about whether certain activities are safe or not. 

That is wrong question. 

Nothing is completely safe. There is always risk to everything we do, now more than ever. 

Should I drive to work? I could be in car accident and die. But I also need to get to work. I choose to drive my car to work. I take precautions so that I can do so as safely as possible. But I do so.  Should we go sailing on Lake Michigan? One of us could fall overboard and drown. I could hit something and have the boat sink. The likelihood of both of those things are low. I think about the tangible risks, how I can control those risks along with the benefits (enjoyment, relaxation, etc…) and decide to go.

Is it safe? Is it 100% safe to open up and have church services? Answer: No.  Is it 100% safe to go back to work? Answer: No.  Is it 100% safe to go for a walk outside? Well – you could trip and fall and break a leg. You could have a freak storm come up and be struck by lightning. You could get attacked by a rabid squirrel.

“Don’t be ridiculous!” you are saying to me.  

That is the point I am making. If you are asking if any activity is “safe”, the answer is that no activity is 100% safe. There is always a risk. But we need to be realistic and understand what the extent of the risk is.  We will be ridiculous if we are trying to avoid all risk. That is not the question. 

Is the risk worth it? That is where you need to start looking at the benefit.  If the benefit is low – then no risk is warranted. If the benefit is high then a lot of risk is warranted.

The flight crews in World War II intentionally flew into cities with antiaircraft guns shooting at them.  There were people on the ground with big guns shooting with the very intention of blasting them out of the air and killing them. The flight crews still flew right into that. That is crazy. But the benefit (bombing munitions factories and thereby shortening the war) was so strong, that the degree of risk was warranted.

The soldier jumps out of the foxhole and charges the enemy line despite people shooting at him. But again, the benefit of winning the battle, rather than sitting and waiting to die in a stalemate, is worth the immense risk of charging the line.

There is a process that you go through to calculate the risk vs benefit.

1. What is the risk? How strong is the risk? This is not an emotional question – this is one that you ask realistically. 
2. What is the benefit? Again – this is a question that you need to ask in a mature and calm manner. What will happen if you do or do not do something?  What are the implications of your decision either way?
3. Are there ways to reduce or mitigate the risks? Do they change the equation enough to change your decision?

How does that apply to today?

Should you go to the grocery store?  Is it safe?  Answer: No, it is not safe.  You could run into someone shedding the SARS-CoV-2 virus and get COVID 19 and then get very ill and die. What is the risk? The tangible risk of going to the grocery store, while observing careful social distancing and washing your hands afterwards is very low. What is the benefit? You need to have food. The benefit is pretty high. Can you reduce the risks? Yes – you could send one person into the store, you can wear a mask, you can wipe down the grocery cart with a disinfectant wipe, you can stay 6+ feet away from everyone else, you can plan your trip to minimize your time and exposure in the store, etc… Should you go? That is a personal decision based on the calculation you make about the risk vs. the benefit.

Should you go to the doctor?  What is the risk? At the current time, with all the precautions we have in place, the risk is very low.  What is the benefit? Presumably there is a reason that you have the appointment. Failure to pay attention and to treat your health condition could cause a much greater risk than going to that doctor’s office visit.  Can you reduce the risks? We have eliminated shared waiting rooms, screen both patients and staff for symptoms, insist on frequent handwashing and everyone wears a mask.  Should you go? We have opened our offices up again because we think under the right circumstances that it is.

Should you go to church if and when they reopen?  What is the risk? This is widely variable depending on how the church structures things and how people behave as they go to the service.  The risk could be enormous. A “normal” pre-COVID 19 church service could easily become a “super-spreader” event. One asymptomatic or pre-symptomatic person shedding the virus in close proximity to hundreds of people and singing for 20 minutes could infect dozens of people. On the other hand, an intentionally socially distanced and cautious church service has a lower risk. The risk is not “zero”. The risk is lower. No one really knows that the true risk is.  What is the benefit? That also is variable depending on the person. Some are able to effectively worship from home over the internet. Others cannot. They need the physical presence of others – even from a distance – to be encouraged and strengthened to live their lives.  What can you do to reduce the risks? There are lots of things similar to what I have already described. Should you go? The math is so dramatically individual that I cannot answer that. It is not an easy decision. It is one that each person and family will need to calculate. The answer also may shift and change as the pandemic spreads or wanes in each community. It might also change as we watch what happens in society.

The list of questions goes on.

In a risk vs. benefit approach it will create different risk tolerance depending on the benefit. You might choose in some circumstances to accept fairly high risks (like a soldier charging into battle). In other situations the benefit is so low that you should just choose to stay home and have zero risk. In other words, opening society doesn’t mean that you engage in the same level of risk acceptance all the time. It is completely dependent on whether it is worth the risk.

Should I have gone on that flight that day in 1994?  Even now some of you who are reading this might say that I should not have gone. I had a wife and a small daughter at home. I had invested years in college and medical school to become a doctor. For the thrill of flying a helicopter maybe I should not have exposed myself to the risk of crashing and dying.

My answer: Yes. Absolutely it was the right thing to do. I have never regretted taking that flight that day. It was an amazing experience. It helped me perform my job better. It was also really fun.  I also took great care to reduce the risks. I flew with an experienced pilot. We all had been through extensive safety training. We briefed before the flight. We inspected the aircraft thoroughly before the flight. We planned our course. One of us closely watched the charts for obstacles on the way. We maintained constant vigilance for other aircraft and for problems with our aircraft with attention to safety. I flew several times with them after that flight. Each time I did it I understood the risks. I also understood that it was worth it to me.

What is the right answer to all of the questions about opening up our society again?  Is it safe? Well, no, nothing is 100% safe. But does the benefit warrant the risk? If the benefit is low, then you shouldn’t accept any risk. But if the risk is low, then some things could be done again as long as there is a benefit.  

Will I go into a hospital room and examine a patient with COVID 19? The risk is high. The answer however is: Yes, I will (and I have) as long as there is a real and tangible benefit from me doing so. If I don’t have to go in the room I do not do so. But if it is needed, if there is a real benefit to the patient, I will do so. I will also take precautions to reduce the risk. 

I don’t have all the answers for everything as politicians and leaders consider opening up parts of our society.  The decisions are not easy. They are not straightforward. If, however, all we are asking is whether it is safe, we are deceiving ourselves. As we reopen people will get COVID 19. Some will get really ill. Some will die. What is the degree of the risk for each activity? What is the benefit? Is the benefit enough to justify the risk? 

Someday we will get beyond this and will no longer have to make as many of these hard decisions. Each week and each month we gain more knowledge. That knowledge hopefully will make these decisions easier. Hopefully we will be able to make better and better decisions as time goes on. But for now, we do the best we can. That means we are obligated to measure both risk and benefit to make the best decisions we can for ourselves and our families.

Ok. Our preflight brief is finished. We have done the inspection. We are strapped in. Let’s go flying.