Life Without the Boogeyman: Alternate Models of Emergency Spinal Care



Now that our review for Academic Emergency Medicine has been published, I wanted to devote a few words to a discussion that didn’t make it into the article.

We spent a lot of time trying to collate what’s known about one specific phenomenon: the blunt trauma patient with an “unstable” acute injury to his spine who suffers sudden neurological deterioration as a result of ordinary physiological movement. The reason we were interested in this event is because, whether or not we admit it, it’s the basis for our current model of prophylactic spinal immobilization. In other words, the reason we place collars, boards, and other devices on patients until they can be “cleared” is because we want to prevent this phenomenon from occurring.

Anybody who reads our review will probably deduce that we’re a little skeptical about this story. The available data is consistent with a clinical entity that is very rare, and when it does occur may be part of the inevitable natural progression of the disease rather than being a movement-provoked (and hence preventable) event.

This fits well with a rational understanding of the pathophysiology. The only mental model that explains the phenomenon of “sudden collapse” would be something like this: the spinal cord is intact, but is surrounded by a vertebral fracture which is both wholly unstable and contains some kind of knife-like bony structure which is poised to transect the cord given the wrong movement. Or perhaps: the bony integrity of the spine is totally lost at some level, and the cord is holding on purely by a few strands of nerve which (like guitar strings breaking) might pop loose with any movement.

These models might make sense to the naive layperson, but any medical professional who understands bones and nerves will have to admit that they’re a little silly. (A more realistic story of unstable spinal injuries, of course, is that disconnected structures compress the spine, causing real but much less dramatic sequela.) Do they never occur? Well, we can’t say that. They are not physical impossibilities, in the sense that they violate a law of thermodynamics or mathematics or grammar. But they are inconsistent with physiology — and in the absence of outcome data, physiological rationale is the only clay we’re working with.

How much room remains on the table for the sudden, irreversible event described in legend? At this point, it’s fair to say there is very little room. We cannot say there is none. There isn’t enough evidence for that. The knee-jerk EBM reaction is to suggest further study, but as Hauswald pointed out in his commentary, that may not be realistic. To make the distinction between “a very rare thing” and “nothing” would require a study of tremendous size, and even then a critic could still ask for more; proving non-existence is a philosophical impossibility.

But as pragmatists, we can say that “very very very rare” and “nonexistent” are clinically indistinguishable. It’s not impossible that beta blockers can cause anaphylactic reactions, that someone being operated upon could slip off the table, or that the hospital could lose power during a course of mechanical ventilation — yet we don’t feel obliged to inform patients about these risks. At some point, scenarios leave the realm of plausible and foreseeable sequelae and enter the territory of “anything’s possible.”

That being established, the question becomes this: if we banish the specter of the boogeyman, what are we left with? Does the entire concept of spinal immobilization become void? Am I an enemy of the board & collar?

No. Here are some alternate models.


The orthopedic model

This places spinal injury on the same level as other orthopedic diseases.

A patient arrives at the ED with a distal radius fracture. What do we do? We examine it clinically, we manage their pain, we obtain appropriate imaging to help guide our care, and — oh yes — we make some effort to immobilize the injury.

Why? Not because we’re afraid of any boogeyman. We aren’t terrified that if the patient lifts his arm and there is some miniscule movement, a hidden razorblade of bone will cut off his arm and render him immobile. Everyone would look at you like you were wearing a silly hat if you suggested that, because it’s a silly thing to say.

Nevertheless, it is probably wise to to make a good-faith effort at limiting movement around the site of injury. Unnecessary manipulation may promote further trauma to muscles, nerves, and vessels, which could induce unnecessary long-term morbidity, prolong recovery, or at least complicate management and increase acute pain.

And maybe that’s how we should view early spinal care. Nothing dramatic. No boogeymen. Just the same logical, unexciting approach that informs our approach to splints, slings, and casts.

You’ll notice that if we fail to apply those devices for five seconds, nobody freaks out, because it’s not that kind of intervention. You’ll also notice we can study their value in controlled studies without anybody gearing up for a lawsuit.


The “correlation is not causation” models

In our paper’s discussion, we briefly mentioned two possibilities that warrant further attention.

We are all supposedly clever people who understand how easily causation can be assigned to unrelated events, yet when a patient moves their neck or back, and shortly afterwards suffers neurological deterioration, we automatically assume that one caused the other. This is called “temporal association,” and while we can’t help but make the connection, it’s wrong as often as it’s right. (See the unfortunate coincidence of “vaccines caused my child’s autism.”)

Other than the cynical explanations of “this association never occurs” (probably wrong) or “it’s purely coincidence” (possible) there are two more sophisticated models worth considering:

  1. The Unmasked Inevitability: An injury exists that would eventually have progressed to a worse neurological status (hours, days, or weeks later). However, the trauma of a movement event induces that deficit to present earlier. The long-term outcome is the same, but the deterioration is now temporally linked with the movement.
  2. The Hidden Aftereffect: Early, unstabilized movement has no immediate effect, but the added insult to the cord promotes edema and other sequelae in the hours/days/weeks that follow. The end result is a poorer long-term outcome that could have been improved by limiting early spinal movement, yet with no obvious association between the two.

Both of these are extremely plausible pathways that we’ve proven to exist in many other diseases. Neither requires the presence of any boogeyman. And since both are completely unrelated to any naive temporal association, either one could only be detected using controlled, outcome-based studies, not this sort of childish anecdote-mongering.


The “forget it, I’m so done” model

Long spine boards may already be on their way out.

EMS services and hospitals around the country are beginning to get aboard the bandwagon of “ditch the backboard in most cases (but keep the collar).” This is very nice. But it’s interesting to examine why it’s happening.

There is no evidence for the benefit of either collars or boards. Any physiological rationale applies equally to both. (Yes, unstable C-spine injuries are somewhat more common than injuries at lower levels, but not so much as to make a difference here.) So why get rid of one but not the other?

It’s because the harms of boards are considered to be greater. There is more evidence that boards cause pain, stasis ulcers, respiratory compromise, and other negatives. However, none of these are major harms, nor are they terribly well demonstrated (most being shown only in small, unreplicated studies where a handful of volunteers were strapped to boards for a few hours). In other words, not exactly a knock-down argument.

If you believe that either device prevents serious morbidity, then these minor risks would not bother you. The only way that the side effects of backboards can be the deciding factor is this: you don’t really think there’s any benefit at all. Some harm + no benefit = out they go.

But remember that on any analysis, the benefits of boards vs. collars are equal zeroes. So once again… why keep one and ditch the other?

The true explanation of the backboard exodus seems to be that everybody finally threw up their hands and said collectively, “I’ve had it with these stupid things.” There was no landmark study or historical turning point. We just saw the writing on the wall.

Since they’re of a kind, the same thing might eventually happen to collars.

Do I think this would be a great idea? No. Because as we’ve discussed in this post, even if we exorcise the boogeyman from our thinking, that doesn’t mean there can’t be any benefit from these devices. It just means the possible benefit becomes more boring and less dramatic, and can now be studied, quantified, and weighed against other factors, rather than being an unassailable matter of dogma. And rather than burning our boards and collars, it means we’re free to recruit them in flexible and useful ways (such as using boards to move patients when it’s the most convenient method, or using collars to stabilize the necks of intubated patients when it’s helpful), rather than invoking them ritualistically.


So what now?

I hope these remarks shine a little light on some possible ways forward. I think many people feel that, if we drop the current model of early spinal care, we’re left with emptiness and nihilism. But really, the current model is based upon a fairytale: if we use our [talisman], we’ll keep away the [boogeyman]. Fairytale-based thinking prevents better understanding, because you can’t study a fairytale. Once we banish that, the entire disease opens up to the kind of rational approach that can stand alongside the rest of our armamentarium, and becomes amenable to the sort of boring explication offered by clinical research.

This is good. Do not fear it.

Those who Save Lives: Kevin Briggs

The Golden Gate Bridge in San Francisco has numerous claims to fame. Once the longest suspension bridge in the world, and still probably the most iconic, it’s a central feature of the SF Bay Area — my own home.

Less admirable is the fact that it remains among the most popular bridges in the nation for suicidal people to jump from. In fact, it’s one of the most “utilized” suicide spots in the entire world, with over 1,600 jumps made so far, most of them fatal. (Exact numbers are hard to come by for a good reason: bridge administrators and media outlets stopped keeping an official tally when they realized it was incentivizing people to ring in big milestones with their own attempts — lucky number 1,000 and so forth.) Someone still tries to jump about once every two weeks, which sounds insane, but is true.

Sergeant Kevin Briggs was a California Highway Patrol officer who spent a large part of his career patrolling that same bridge, which led to an interesting twist on his job description: suicide prevention. See, often times he was the one to notice a pedestrian who looked like they were considering jumping, or were even in the process of climbing over the rail. Sometimes he’d be called in by others who saw it first. Jumpers tended to stand on the “chord,” a ledge of piping just beyond the safety rail and the last solid ground before open air. Kevin would talk to them there, and try to convince them it was a bad idea.

It wasn’t something he had any training to do, at least not at first, or experience with, although he picked that up quickly. He had suicide in his family — as many of us do, since it’s incredibly common — but otherwise, he fell into the role the way many of us fall into our callings. Eventually, he made it his niche, leading a trained team of interveners.

Over the years, he spoke to hundreds of jumpers. At first, he’d approach benignly — “How are you feeling today?” and “What’s your plan for tomorrow?” For those without plans, he’d help them make some, because people with a plan tended to stick around to fulfill it.

Later, he became more direct, asking up front whether they’d come to hurt themselves. Or the simple question: “Others in similar circumstances have thought about ending their life. Have you had these thoughts?”

Either way, the encounters tended to unfold similarly. And as a rule, they went well. Of the countless desperate people he met, only two ended up jumping once he’d managed to make contact.

The jumpers met the pattern recognized by psychiatry as comprising the depressed and suicidal. They exhibited hopelessness — the outlook that things are terrible and will never get better. Most of us can ride out terrible storms, but if there’s no prospect of the storm ever ending, why bother? (“What do you do,” asked one, “when hope isn’t there?”) Then helplessness — the belief that there’s no remedy, solution, decision, medicine, or lifeline that can make a difference. People withdraw socially and lose interest in things they once enjoyed. They retreat from the world. They show up at the bridge because there’s no reason to be anywhere different.

Inexplicably, we in EMS seem to have developed the belief that most suicidal patients are “crazy” — as in psychotic — or dangerous — as in homicidal. As a rule, neither is true. These people aren’t out to hurt anybody. (One of the “ones who got away” politely shook Briggs’s hand and apologized before jumping.) They just want to escape the pain. With alcohol, with drugs, with sleep, with death.

How did Kevin Briggs have so much success? It’s a question that gets more perplexing the more you consider it. By definition, these are people who have lost all hope, exhausted all options, discarded alternatives until they’re ready to embrace the most permanent solution possible. And yet, a total stranger was able to approach them at their final moments and convince them to see things differently. How?

Through no secret system. He didn’t argue, cajole, or debate them. Nor did he tell anybody he knew how they felt or blame them for their actions. Mostly he listened to understand. Used their name to keep them anchored to reality. Occasionally, he’d share personal stories, things nobody else knew, as if bestowing them upon someone made them responsible for his secrets. In the end, merely being there seemed to make the difference.

Many interventions were successful within 10 minutes. Some lasted many hours. The longer the conversation went on, the better his odds, Briggs would say. The human connection grew stronger and stronger. People ready to jump away from nothing would reconsider, because now they were leaving something behind. It’s impolite to leave a conversation. It’s wrong to fail when someone cares about your success. Kevin had made it clear that he cared if they died, and they didn’t want to let Kevin down.

The most important secret of all is that this medicine wasn’t temporary. Another common truism in EMS is that preventing suicide is a Sisyphean task, because if someone wants to take their life, eventually they’ll succeed no matter how many times we slap the gun from their hand. Surely if they don’t jump here, they’ll just jump from the next bridge instead. But that’s not what the facts show. 94% of the ones who reconsidered jumping never tried again, instead living out long and fruitful lives. And the ones who jumped and survived nearly all described the same thought: the moment they stepped from the bridge, they regretted what they’d done. Despite what they’d thought, they didn’t really want to die. “I instantly realized that everything in my life that I’d thought was unfixable was totally fixable — except for having just jumped,” reported one.

Much like reperfusing the STEMI, stabilizing the CHF exacerbation, or patching up the gunshot wound, this business was one of pulling people back from a preventable brink — people with the real potential to eventually leave it behind them.

As one mother wrote Briggs: “Thanks so much for standing up for those who may be only temporarily too weak to stand for themselves.” That sounds like our job, doesn’t it?

Sgt. Kevin Briggs recently retired from the CHP to continue pursuing suicide activism. And last year, work was finally approved on an anti-jumping safety net to be built beneath the Golden Gate Bridge. Maybe soon his brand of heroism won’t be necessary there. But it’ll be needed somewhere. Others are doing their part. Shouldn’t we do ours?

(By the way, the Code Green Campaign, which is trying to make a dent in the number of suicides among EMS providers, has so far been forced to announce a new one every 3.5 days this year. Fire safety isn’t doing any better. But heck, suicide’s not our problem, right?)

Sources and more reading:

Read about more lifesavers at Those who Save Lives: The Royal Humane Society and Those who Save Lives: Harry Watts

Those who Save Lives: Harry Watts

Harry Watts

Who was Harry Watts?

You probably haven’t heard of him, unless you’re English — like he was — and you lived in the 19th century — like he did.

That’s because he was nobody special. He wasn’t a prince or a pope, he never invented a robot or discovered a mountain. Probably never even kicked a ball on television.

What did he do, then? He was born in Sunderland and lived poor. Poor as hell; no shoes poor, family-all-in-one-room poor. His father was a sailor. He had two sisters, and two brothers, one of whom drowned during a storm while Harry watched.

Starting work when he was young, Harry made his living first as a sailor, then as a rigger in the docks, and finally as a deep-water diver (the guys who wear big brass suits and suck air from a hose to the surface). He married and had two kids.

Oh, right. Also, all on his own, he saved the lives of 36 different people.


What, what?

While apprenticing on his first ship, he watched his fellow apprentice take a fall overboard. Harry’s automatic response was to dive in after him, pluck him up, and pull him to safety upon some floating timber. That was number one.

On his second voyage, he was waiting to receive the captain who was paddling back to the ship in a small canoe. He suddenly capsized, however, and was floundering in the waves. Harry grabbed a rope, swam out to the captain, and towed him back to the ship’s ladder. That was number two.

Number three was on the same voyage, when a boy was thrown into the water during a major storm, and the waters were too rough to lower a boat after him. Harry went in, and somehow, they both came out.

He rescued four and five on his next cruise — at the same time. So at the age of 19, he’d saved the lives of five human beings.

“Did you get any reward for these doings, Harry?” he was asked.

“Rewaard! Wey, sartinlees nut; nivver thowt o’ sich a thing. But we helped the two men wi’ dry claes an’ things.”


He got six more all together when an anchor line broke and dropped the anchor directly into a passing boat. There were six men aboard, and Harry went straight overboard while calling for help, landing directly on the wrecked boat in time to save them all.

Then one day at the dock, he saw a crowd gathering to watch a boy drowning in a rough sea. He leapt in, swam out to him, and brought the boy successfully back to shore on the verge of exhaustion.

At age 36, he made a career change from sailor to diver. At this point, he’d saved 17 people (plus one dog), most through risk to himself — sometimes grave. On one occasion he swallowed so much contaminated water from the Thames river (this during the cholera epidemic which had essentially turned it into a flowing sewer) that he was bed-bound for months and nearly died.

Many of those saved were sailors; many others were young children. And if you’ve never plunged twenty feet into rough water, wearing boots and heavy sailor’s clothing, and pulled out a panicked child (clinging like an octopus and trying hard to drown you)… well, you’re missing out. At this point, by the way, he had never received reward or recognition of any kind. As they say,

… There is a hackneyed platitude to the effect that virtue is its own reward, but it is safe to say that the average man does not find such a result sufficient. It might be so in an ideal world inhabited by ideal people, but in this work-a-day world, in addition to the approval of our conscience, we love to have the approval of our fellows and to know that our  acts are appreciated, and especially is this the case when we are actuated by altruistic motives. This is, of course, a form of vanity, but then vanity is almost a universal failing. [source]

But if Harry wanted applause, he certainly wasn’t clamoring for it. Just chugging along and saving lives as they presented themselves.


People take notice

Not long after that, he swam out to save two boys from drowning — while wearing one of his lead diving boots. (Yep.)

About a year later, he saved a couple more, and finally, there came the very first mention anyone had made of his efforts, a brief story in the newspaper:

Yesterday afternoon, about half-past three o’clock, a lad named Smith, about 16 years of age, son of an engineer employed on one of the Commissioners’ dredgers, narrowly escaped drowning. He was on board a dredger in the new Graving Dock, which was full of water, when he accidentally fell overboard. Mr. Harry Watts, in the employ of the Commissioners, gallantly jumped into the water and rescued him. The lad was very much exhausted, but restoratives were promptly used, and he was soon brought round. This is the twenty-second time that Watts has so nobly exerted himself in saving persons who have been in imminent danger of being drowned.

For a while, eyes turned away again. Then he hit number 25, and another story ran in the news, mentioning the man with “a perfect penchant for rescuing lives.” After that, people finally began to notice, and most of his saves received at least a little local attention.

He had countless saves while diving, such as the man who became tangled in a chain and was whipped overboard by a sinking weight — Harry dove in after and managed to free him underwater before they both drowned. Between rescues, he had plenty of interesting adventures, diving at the time being a trade full of explosives, accidents, and rockslides (he even had one memorable fight with a giant angler, or “devil fish,” which he ended up dispatching with a boat hook).

If that was his job, however, his hobby was volunteering with the Sunderland Lifeboat service; there was hardly a wreck nearby that Harry didn’t attend, they would say, and he was involved in rescuing over 120 sailors in extremis during storms. (Those don’t count on his score, of course, since they were team efforts. Just icing on the cake.)

He was 27, and up to 23 lives, when he received his first parchment award from the Royal Humane Society. A little while later when he ticked off number 25, they gave him their bronze medal as well, and when the local “Diamond Swimming Club and Humane Society” heard about that, they thought it just wasn’t cutting it, so they awarded him a gold medal of their own. The RHS gave him another parchment at number 26, and he continued to accumulate medals for his diving and rescue work — even one from the local temperance society for his good-natured efforts against the evil drink.

In fact, when he reached number 32, the local sailors (“gentlemen,” noted the newspaper, “because what constituted a gentleman was the performance of gentlemanly acts”) personally chipped in to cast him a silver medal in recognition of everything he’d done for them, despite the many years since Harry had personally sailed. Later, by widespread acclaim, his mayor wrote to the Queen to recommend Harry for the Albert Medal. Due to bureaucracy or who knows why, nothing came of the request.

An unfortunate turn came when Harry loaned his medals to the local church for an exhibition, and as night rolled around, the entire set was stolen by an unknown burglar. Harry was crushed, and the town of Sunderland felt it a slur on their name; the burglar was caught before long, but the medals were melted and gone. A popular movement arose, and within weeks they had struck replacements for the lot, and they returned them with dignity at a town ceremony. There, the thief himself expressed remorse, saying he wished he were drowned; Harry replied, “Mister, if ye were droonin’ aw’d pull ye oot bi th’ neck!”, and refused to press charges against the man.

He was 51 when he was approached to dive 150 deep to effect a mechanical repair. He was a little past such stunts for pay, he said, although of course he’d do so to save a fellow man, and he recommended some others who were younger and more willing. Their diver went down, and contact was soon lost; they returned to Harry and asked him to live up to his words, as nobody else was willing to go down to attempt a rescue.

He suited up and dived. The working depth was perhaps 120 feet, but it was upon a tiny platform across a bored-out shaft which continued another 300 feet past that; anybody who slipped was going a long way down until they looked like a recycled soda can. Feeling around, he located the other diver, who was dead (fainted, probably, then asphyxiated). He resurfaced, reported the news, then dived again to retrieve the body.

At the ripe age of 52, Harry was one of the divers who volunteered to recover bodies after the Tay Bridge disaster. He offered his services for no charge; when the diving commission attempted to pay him afterwards anyway (maybe because he was a million years old and a living legend), he politely refused and asked it be passed to a charity of their choice. (The man got around; somehow he was on hand at the Victoria Hall disaster as well, and widely applauded for his assistance in the aftermath.)

But never mind all that. His last life was saved at age 66. He and his wife were walking along the docks toward their home when he heard the cries of a drowning boy. His wife begged him not to, but he went; relenting, she cried, “Be quick, Harry!” and in he dove. Grab hold, haul over to a rope, out they came.

Thirty six lives. Not bad for a poor old seaman.


Harry finally rests

When he was 70, Harry retired at last. And although many people didn’t realize it, his wallet was thin; the diving commission didn’t offer a pension, and he’d quietly turned down others from grateful benefactors. That’s how things were when Andrew Carnegie passed through Sunderland to open a library.

Visiting the local museum, Carnegie saw an exhibit of Harry’s medals and asked after the man, now 84 and still full of vim. Surely he must be a war hero of some kind?

Nope. Just a life saver. When he learned who he was dealing with, and had the pleasure of shaking his hand, Carnegie inducted him into his Hero Fund on the spot.

At long last, Harry Watts no longer had to worry.

In Carnegie’s words,

I have to-day been introduced to a man who has, I think, the most ideal character of any man living on the face of the earth. I have shaken hands with a man who has saved thirty-six lives. Among the distinguished men whose names the Mayor has recited, you should never let the memory of this Sunderland man die. Compared with his acts, military glory sinks into nothing. The hero who kills men is the hero of barbarism; the hero of civilisation saves the lives of his fellows.

At the age of 85, Harry’s town of Sunderland was worried that after his death, such a remarkable, yet humble man might be forgotten in the distance and darkness of history. In response, the mayor and several of the town’s luminaries commissioned a biography to be written about his life. You can read it here, and much of this story came from it.

Not a bad goal. Live your life so that when you’re old, someone will insist on writing a book in your honor.

In their words,

The modest merits of this good citizen may, so far as the public are concerned, be summed up in the simple statement that he has saved upwards of 30 lives from drowning. When we consider what are the awards usually apportioned by mankind to the destroyers of their species, the presentation of a gold watch and chain, accompanied by a framed parchment from the Royal Humane Society, in the precincts of a disused School Room, must appear an inadequate acknowledgment of services so signal. But we are new at the business and shall improve as we go forward.

Somebody Should be Upset

Dog at grave

Anybody who’s spent time in medicine (and it doesn’t take long, because nowadays this is often covered in initial training) has heard two contradictory lessons:

  1. Good caregivers must demonstrate empathy and compassion for the suffering of their patients.
  2. Good caregiver must not become too close or attached to their patients.

The reasoning behind both truisms is simple enough. If you don’t care about your patients, you can’t practice good medicine, because that requires caring about what’s ailing them and wanting to do something to help. On the other hand, if you become entangled in the suffering of everybody who sits down on your stretcher, you will die a thousand times in the course of your career. That’s too much tragedy for anyone to bear.

So, you should care, but not too much. We’ve all known providers who don’t care. They’re bad. Bad at medicine, bad people, they don’t like their jobs and patients don’t like them. We’ve all known providers who cared too much, too. They’re good at their jobs, for about six months, then they flame out and quit. See how long you last when you have an extended family of hundreds, it grows each shift, and they’re all dying.

You can find your own strategy to walking this tightrope. Experienced, durable providers seem to become skilled at connecting with their patients, but compartmentalizing it appropriately, so that when things go badly, it doesn’t hit them too hard. You do your best, they survive or they don’t, and you move on to the next patient. It’s not your emergency.

This is probably the right approach. However, I’ve always found it a little bit distasteful. Click here to watch a clip from House that helps demonstrate why.

“When a good person dies, there should be an impact on the world. Somebody should notice. Somebody should be upset.”

Doesn’t that seem right?

A human being, with a lifetime of living behind them, has disappeared forever. There’s no life that isn’t complex enough and full enough and astonishing enough that we couldn’t put it up on a pedestal and watch it for days and discuss it and applaud it and munch popcorn while savoring all the decisions and revisions that we didn’t make, but which are awfully familiar. Even the mistakes aren’t usually so alien that we don’t recognize a little bit of ourselves in them.

When a person like that — and they’re all like that — drops off the face of the world, it should raise an alarm. People should put down their newspapers and look up. It should be a big goddamned deal. There are billions of human on the planet, and they’re all going to die eventually, many in the hands of medical providers, some of them in yours. But the numbers don’t change the fact that for the person who died, their life was their whole life. There should be grief.

Maybe it’s better when there’s family and friends and others to care. If a passing leaves a room full of loved ones in tears, maybe that makes it easier to walk away, knowing the job of mourning is well in hand. No silent snuffing of a candle here; the loss was recognized. That’s not very rational, but it’s how it feels to me. When somebody dies and nobody seems to know, or care, it seems like your duty to give a crap.

Isn’t it an insult to blow it off? When you were chatting with that patient and building your rapport and connecting as fellow people, would you have told them, “Listen, there’s something you should know. We’re getting along now, and we’re friends, and I want the best for you, and I’d fight for it too. We can laugh together or shake hands or hug. If you walk out of here, maybe we’ll even maintain a relationship. But if you die, I’m going to document it, wash my hands, and walk away like you’re just another number. Hope that’s okay.”

Isn’t that a little two-faced and deceptive — like acting friendly to someone, then badmouthing them as soon as they leave? How can you behave both ways and see both as compatible?

I don’t know, and maybe it’s not our job to be professional mourners. Maybe it’s not our job to mark each person’s passing. But in some sense, if we truly care about our patients, it seems like it is, and that’s quite a burden to add to our responsibilities.

What do you think?

Those who Save Lives: The Royal Humane Society

Royal Human Society

Mostly, people get into healthcare because they want to help people. And there’s no bigger and better way to help than saving lives.

Of course, that’s not really a cool thing to talk about, and we’re nothing if not cool, so most new folks clam up about lifesaving pretty quick. Then before long they’ve transitioned all the way to full-on Nicholas Cage burnout mode and managed to forget about that heroic stuff completely. To quote Dr. Saul Rosenberg: “I think the current generation of young people are terrific…. so much smarter, and so much broader, and so much more altruistic. At least until they come to medical school.”

But the fact is that there’s something very basic and very noble about the simple act of saving a life. To help shine light back on that deed rather than on the more ignoble parts of the job we do, I’d like to talk about some notable lifesavers throughout the years. Maybe we can learn a few things from them. Or maybe, at least, we’ll be reminded about the things we used to admire.

Today, let’s talk about…


The Royal Humane Society

In London in 1774, there were a whole lot of people drowning.

It wasn’t hard to understand. Most folks couldn’t swim, and many lived and worked on or near the water, especially the Thames river that flows through the city. Shipping and other water-based commerce was common, along with recreational activities like ice skating (sometimes on thin ice). To make a long story short, death by drowning was a frequent occurrence.

The science of resuscitation was in its infancy, and little was known about what could be done to bring back near-drowning victims. There were some interesting new ideas, but even if they were effective, there wasn’t much opportunity to use them — victims were usually presumed already dead and therefore beyond help.

(Any of this sound familiar? The problem of bystander intervention remains the toughest part of saving lives even today.)

William Hawes and Thomas Cogan were a couple of English physicians who believed that, with the current techniques and their best efforts, some of the drowned victims might be saved. (Hawes had, in fact, been paying out rewards to anyone who brought him recently-drowned bodies still “fresh” enough to be revived.) They thought that medicine could do better. So with some friends and colleagues, they sat down and founded the elegantly named Society for the Recovery of Persons Apparently Drowned, a sort of club with the goal of saving Britons from drowning.

The Society gave out cash rewards to anyone who attempted a rescue, more if they succeeded, and even awarded money to homeowners and publicans who allowed victims to be treated in their buildings. People being people, this quickly led to two-man scams where a “rescuer” and a “victim” would stage a drowning, then split the reward. So monetary prizes were soon discarded, except in rare cases, in lieu of certificates recognizing the lifesavers.

Gradually, the Society (after a few years switching to the the shorter name) began setting up stations and “receiving houses” near the water, where volunteers stored equipment and launched rescues. They were undoubtedly responsible for popularizing the concept of resuscitating the near-dead, and were among of the first to develop any type of rescue service for civilian medical emergencies. Kinda like the grand-daddy of EMS. In their literature, the Society asked:

Suppose but one in ten restored, what man would think the designs of the society unimportant, were himself, his relation, or his friend — that one?

The Society still exists, and has shifted from solely recognizing water rescues to acknowledging all manner of lifesaving heroism using a range of different medals and certificates. Awardees have included Alexander the First and author Bram Stoker.

Read through some of the most recent winners. They’re all good yarns. Humane Societies (not to be confused with the folks who protect animals) now exist in many countries of British descent, such as Australia and Canada, as well as other regions (including my own state of Massachusetts).

If you are honored by the Royal Humane Society, you’ll receive a medal stamped with their emblem: a fat cherub holding a sputtering torch, blowing at it with puffed cheeks, doing his best to fan a dying flame. Across the top:

lateat scintillula forsans

“A small spark may, perhaps, lie hidden.”

Royal Humane Society medal