Man, Medicine, and Mike

That was the time that I saved the world. Well, not really.

But that was the attitude of my youth. I have had to learn and grow from those days.

The year was 1993.  I was 2 years out of my internship and fresh from my flight surgery training in the U.S. Navy. Suddenly I was the department head of the medical department for NAVAIRES Norfolk (Naval Air Reserve Center in Norfolk, VA). I was responsible for ensuring the medical fitness of several thousand reservists with the support of a chief petty officer plus about a dozen other corpsmen. Every other weekend we would use reserve physicians and do hundreds of physical examinations. We would obtain routine labs on everyone who had a physical. What bothered me was that there was no clear mechanism as to what to do with the abnormal lab results. There was a real risk that we would detect something serious and then fail to act. The current process was not as tight as I thought it should be. It also was very labor intensive and manual in nature.

I set about trying to optimize and automate the process. What I eventually came up with was a complex macro in WordPerfect to enter abnormal lab results and then generate letters and track the patient responses. I thought it was ingenious. When I finished it and explained it to my corpsmen however, I began to realize how complex it was to use. My next step was to prepare a guide for how to operationalize it. In the end I had a 3-ring binder with too many pages of instructions complete with backups of the macro on floppy disks.

It did work. But it was pretty dependent on me. I am not sure that it survived as soon as I left that job and someone else took over.

I learned a lot in those years in the Navy. I began to get a bit jaded when I would see someone come into a command and make changes and get an award for their work. Then the next person would come and change things back and also get an award for their work. It seemed like there was very little new “under the sun.” 

During that time the work of Edwards Deming and “Total Quality Leadership” or “TQL” was the newest craze for the Navy. It came from Japanese manufacturing efficiency and involved a lot of meetings with flow charts and was just the beginning of what has come to be a steady stream of process improvement techniques. Our commanding officer was very enthused about the possibilities. At the department head level he had us take on a sample project together. We spent the next 6 months meeting. We went through the steps including drawing up flow charts and process maps. We had lists of problems from the current state leading to potential solutions. We met 1-2x/week for 6 months plus an offsite 3-4 day session. In the end we adopted the process that had been recommended months earlier by the division head.

The new process worked very well, however. It was a success. The CO celebrated all of our work and the success of TQL as the “wave of the future” for how efficient and effective operations will be decided.

We had “saved the world” for all time! Or at least in regard to how reservists’ lodging was booked and planned in Norfolk, VA.

Personally, I am a process person. I can remember one physics homework assignment in college. Each problem involved a bunch of repeated complicated calculations. It seemed like busywork to me. I instead spent my time writing a computer program (in Fortran) to do the calculations for me. Once completed it did all of my homework in just a few minutes and did it flawlessly. I spent about the same or more amount of time writing the program as I would have to just do the math by hand. But I was much happier to fix the process than to just do the work.

Over time however I have started to question some of the assumptions that I would make when I was young about “fixing” processes. My WordPerfect macros were nice. But they were not really sustainable. In my youth I really thought I could permanently “fix the world”. What I have since come to realize is that no matter how perfectly groomed the garden may be, once you look away, weeds begin to grow. 

This world is not perfect. Order tends to disorder. Entropy is real and powerful. And no matter how well intentioned I may be, the issue often is not of one large and permanent fix. Rather it is about finding the people and empowering them to be able to push against the entropy.

I no longer look to permanently fix this world.

I still am a big person for process. We should not do stupid and excessive work. We should not try to continually push through a bad process. We should try to fix things. But we also should not so naively think that it is going to be possible to implement a one-time permanent fix for problems. They ARE going to come back. Weeds are going to grow. Sustainability is often far more important than the initial process improvement.

This has far more deep wisdom in it than I think I have been able to communicate so far. Bear with me as I try to explain more.

What is the most valuable use of our time? And how do we think about this world? Is the world like a computer where we can write perfect code and have it work flawlessly every single time it is used? Or is it a flawed world where every week brings another crisis or problem? 

The truth of the matter is that this is a beautiful but very flawed world. Each week does indeed bring a new crisis. If you think that you are going to fix all of the problems forever and permanently you are going to be sorely disappointed. You will find yourself getting frustrated and angry as each new problem pops up. It is as though you put your finger in a hole to plug a leak only to have two more pop up. 

I don’t mean to “rain on the parade” or decrease the value of the “Naval Commendation Medal” that I got for my time at NAVAIRES Norfolk. Humbly I will say that I did good work. But if I had to go back to my younger self I would have a few lessons for him:

1. Improving process is good but remember it is not everything.
2. Keeping things simpleis very important for sustainability. If you create a complex process it will be short lived and your work will be wasted.
3. People are often as important or even more important than process. Investing your time in growing and developing the skills in people is immensely valuable.That work will pay many dividends through years and years that go far beyond the process or problem that is in front of you.
4. It is ok to be optimistic and think that you can “save the world.” But it is wise to know that it is ok if you just improve things for a season. This is a flawed world. Weeds are going to grow. When you plug one hole in the old bag another will soon form and will need to be fixed. Do not tire of doing good. If you can improve the world for the time and place in which you are put you have done a good thing. You don’t necessarily have the save the entire world. It is enough to do good today, here, and now.

It was about 5 am when the call came in. We were being called to assist a volunteer fire and ambulance team in a neighboring area. There was a serious accident on the interstate, and they were asking for our assistance.

I was young. I was only about 20 years of age. My partner that night was Greg. He was a year younger than me. 

In High School I had gone to the community college at night and gotten my Emergency Medical Technician (EMT) training. I then started shadowing and then became an employee of Van Buren Emergency Medical Services (VBEMS). Through college I worked weekends and summers as an EMT on the ambulance. I learned a lot going through that. It was exciting. The adrenaline rush was a big draw. Early on I had to learn how to be able to focus, remain calm and do my job. I am thankful to those who helped mentor me in that role. John was a big teddy bear and just so kind so that I felt welcomed. Scott corrected me after one call where in my nervousness I kept saying, “ok” over and over and over again. Tom told funny stories from when he was young and inexperienced. I can still picture some of the scenes that he would describe in his stories. I can hear his pretend gravelly voice, “It was bad! Real bad!” When he froze on the scene and another rescuer grabbed him, “Use your skills boy! Use your skills!” “Remember the ABCs!” was the punch line of the story. You have specific training. Do not freak out. Go back to what you were trained to do and just do it.

Greg was my partner that evening. In the days when most ambulances were “basic EMT”, VBEMS was in a transition through “Specialist” (able to start IVs and put in endotracheal tubes) to “Advanced” (paramedic trained and able to give medicines, defibrillate, etc.)  Because we were “Specialist” and had a crash rescue service we were called that morning when the basic volunteer ambulance team thought they were in over their heads. It was the first time they had called us for help since our company had gone specialist.

When we arrived on the scene, we saw a semi-truck and trailer in the median and flipped on its side. It was early morning. It was about 40 degrees outside and there was a cold drizzle coming down. The usual array of flashing lights from the fire truck, the volunteers’ cars and the police were lighting up the scene. 

Greg and I walked up to the truck and the oddest thing happened.  

The volunteer rescue workers looked at us, backed away, and said, “Here you go!” They weren’t just asking for our help. They were abdicating to us. I thought we were going to put in an IV and give them some help. They were quite happy to have us be completely in charge.  We were young! Men twice our age were deferring to us and I didn’t really like it very well. 

Inside the cab of the truck the driver was pinned in. The floor of the truck had oddly folded up around his legs pinning them in place between folds of sheet metal. Something electrical was shorting out and every so often he would scream in pain as he would get shocked by the wires. Greg went to work on starting an IV. That meant I was left with the job of “crash rescue.”

I had been trained on crash rescue. I had participated in several training sessions.  Those were really cool. The instructors would get a bunch of old cars from a junk yard. We would take the “Jaws of Life” and all the other tools and we would cut the cars to pieces as we practiced the rescue techniques. 

• Pop the hood and cut the battery cable to prevent electrical shorts and potential fires.
• Pop off the doors with the Jaws of Life. 
• Remove the windshield.
• Cut the A-posts with the Jaws. 
• Crease the roof at the back of the car with the Jaws.
• Flip the whole roof back.
• Pull the steering column up to pull the dash off of the patient (using a come-along winch).

That was the standard routine in those days. I had practiced it numerous times in classes and had done it many times on accident scenes. But this routine was for a car. There were no practice sessions for a semi-truck with a folded-up floor. Everything was foreign. It was hard to know where to start.

We had a “crash rescue” team. We had put out the call for “East County Rescue” but it was a voluntary team. And none of our partners had responded. 

I was in charge. I was young. I had never dealt with anything like this. I had a dozen people staring at me. I had a patient yelling out in pain. And suddenly I was in charge. 

Suddenly I was “the expert.”

I took on the role. I wasn’t going to do this alone however. I took charge and started talking to the fireman who were there. I told them the first thing they needed to do was to try to find the battery or at least a battery cable. We needed to cut the electrical power to the truck. I told them that was their job. 

Next, I asked them what ideas they had. They had been on scene for quite a while before they called us. What had they tried to get him out of the truck? They had pulled the windshield, so we at least had access to the patient. Did any of them have any ideas for how we could get him free? 

Nope.

Inside the truck there was no room to work. The floor was such a folded-up mess that I could barely get a hand around his custom trucking seat and his legs to get to the floor. I couldn’t get any tools in the limited space to bend the metal away that was pinching and trapping his legs in place.

I looked on the other side of the truck (the side that should have been facing the ground). Up inside I could see the bolts that held his seat in place. They were hard to get to, but I could reach them. I called for an air chisel. I started chiseling away at each of the bolts. It was not easy. 

This next moment has been etched in my memory forever.

It was cold. I was wet. I was tired. It was now about 6 am. My shift ended at 6 am. My arms ached from working with them above my head reaching far inside.  The weight of the responsibility for this rescue was heavy on me. All I really wanted to be was in a warm bed somewhere. I was starting to feel a little bit sorry for myself. Why was I doing this job? How did they expect me to do this when I had never been trained for this situation? I wanted to give up. 

But I didn’t have a choice. The victim needed me to keep working. I knew it. I got over my mini “pity party” and reached further in to cut the next bolt. 

One by one I got all of the bolts off. Once I did so the firemen were able to pull the seat out from underneath him. This opened up visibility to the floor. It was still too small of a space for the jaws. But we could use the hand pumped hydraulic tools (porta power). With these we were able to pry the folds in the sheet metal apart. When we had done this his legs came free. Our patient was free of the truck. 

Greg and I were then able to go back to “standard work”. 

• Secondary survey for other injuries. 
• Spinal precautions: Put on the cervical collar. Restrain him on the back board. 
• Load him into the ambulance. 
• Closely monitor him and bring him to the hospital.

It was around 7:30 or 8 am when we got to the hospital. Our relief team was there. We cleaned the rig and cot and got it ready for the next call. 

Surprisingly, our patient wasn’t badly hurt. He had burns on his legs from shorted wires. He had bruises. But as it turned out, he was treated and released from the Emergency Department about the same time as we finished cleaning up!

It is a fun story. It happened over 30 years ago but I can remember it like it was yesterday. But it is more than a fun story. 

It was my first taste of what it means to be an expert.  

As I went through medical school, I started to gain a different perspective on what I had been doing on the ambulance. A lot of what we did on the ambulance was “algorithmic thinking.” That is – to be taught a certain series of steps and to rigidly apply those over and over again. There is nothing wrong with having algorithms. It is good to use the prior knowledge processed by smart minds to figure out the “best” way to do something. But there was a strange rigidity that isn’t always good. I started to become discontent with some of the “after the call” arguments. Did everyone perfectly follow the steps? There would be petty disagreements about which steps we were supposed to have followed in each circumstance. Was a certain situation “black” or “white”? I was beginning to see that there were very subtle shades of “gray”. A soft very light gray doesn’t fit very well into an algorithm. 

Through the years I have been forced to learn what it means to be an expert. Frankly, none of us really like it. Algorithms are safe and comfortable. It is a lot nicer to have clear data to tell us what to do. But often the data is just not there. In those moments you have to put on the uniform of the “expert.” You have to be willing and able to apply “expert opinion” to figure out what to do.

All of the lessons were there on that cold and wet morning so many years ago:

1. Know all of the basics.Have them nailed down. You can’t be an expert until you firmly know the usual.
2. Know the principles:Don’t just know the basics of what to do. Don’t just know the algorithms. You must know whyyou are supposed to do them. You must understand the principles that drove the development of the algorithms. In naval aviation they taught us this. We had to memorize all the emergency procedures. But we also had to learn all the airplane’s “systems” so that we could troubleshoot anything that didn’t fit in the lines of the emergency procedures.
3. Can an algorithm work? Assess the situation and see if it is truly black or white or what shades of gray are present. Is there an evidence-based strategy you can apply? Or does it not completely apply? Do you need to deviate slightly from or adapt the algorithm?
4. Accept and acknowledge complexity.Acknowledge it when the situation is truly unusual. Then go back to the underlying principles to figure out what options you have. Use your brain. Look at the entire situation. Think of options and risks vs benefits of each of them. The first step is often to declare it an “expert opinion” situation. Then you have to analyze and think.
5. Seek broad input.Being an expert does not mean that you function alone. Get the input from everyone who is there. Someone might have a better idea than you. Someone might have dealt with or seen a similar situation. Don’t be shy about getting as much input as you can. This doesn’t mean that it is a democracy. You are not going to put up the decision making to a vote. But you are also humble enough to take input from anyone and everyone. It might a nurse or a technician. It might even be the patient. Being an expert does not mean that you “go it alone.” 
6. Just do your best.Being an expert means that you often have to function in areas where there is no data to tell you exactly what to do. This can be at times paralyzing. I have frequently relived that one moment where I wanted to walk away from the bottom of that truck. I wanted to go find a warm and dry place to lay down and give up. But I was “the expert” that morning. The patient needed me to not give up. I had to keep pushing even if the answers were not clear. Life is not always easy. Sometimes you just have to do your best.

I don’t ever want to relive that morning under the truck. It was cold and wet and kind of overwhelming. But I did my best. We got our patient free. I am proud that quiet little young me took charge. I didn’t do it alone. I pushed and pulled the firemen to give me ideas and help me. I functioned outside of the box. I continued to push forward and work even when it was hard.  I didn’t give up. I functioned in the uncomfortable space where the situation required us to come up with new solutions. And I learned. I learned a lot.

How about you? Are there times and places when you are or should be the “expert?” It can be an uncomfortable space to be.

• Remember your training and knowledge.
• Recognize when the situation is complex and requires you to be an expert.
• Use your knowledge and skills to work through options and answers.
• Humbly ask for and accept input from others.
• Be bold enough to accept responsibility. ^[Do your best.
• Learn from your experience.
• Years later write a fun blog post about it!

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