Because it’s Cold Out There

We rarely think about it. If we did, we’d probably lose our marbles.

But it’s true.

The universe doesn’t care.

We are born, we live for a little while, and eventually, we die. In the duration, we will have hopes and fears, passions, desires, successes and defeats, joy and pain. The whole gamut is out there. And as a rule, the inexorable pull of the world is downward — into darkness, into chaos. Scientists call it entropy. We just call it life.

But it means that at any given moment, if we want to be happy — comfortable, fulfilled, free from suffering — we have to be waging a constant battle. If we ever stop paddling, we start to sink.

There’s a certain point in your youth (maybe this is the moment that you become an adult) when you realize this battle is nobody’s but your own. When you’re a child, your parents agree to fight in your ranks until you can walk and talk and drive a car. But once you step out onto the world stage, the only one wearing your colors is you. As self-centered people, we find this hard to believe; we feel like we’re important players in the grand scheme. But the truth is that although everybody else feels the same way about themselves, they certainly don’t feel the same way about you.

Nobody cares about your problems like you do. Not even remotely close. They’re busy with their own battles, which are just as burdensome to them as yours to you. So we learn that if we want to solve our problems, change our circumstances, or just keep from backsliding in the constant undertow of life, we’re on our own. The tools we bring to the table are the only ones available, and our to-do list has only our name at the top. There is no oversight, unless we have strong religious views; no referee ensures that the dice land fair; and if the game proves too difficult, we don’t get to quit and try another.

Isn’t this horrible?

Of course it’s horrible. What could be more horrible than to be utterly alone in an uncaring universe?

So we try to build ties. From the little twirling piece of driftwood we’re clinging to, we throw out ropes to the other flotsam and jetsam. We bring them close and tie knots in the hope of building a raft that can stay afloat during the next storm. Maybe this way, we think, if I capsize, someone will pull me back in.

This is hard work, though. Because our own problems are bad enough, and to tie ourself to someone else means we’re taking on some of theirs, too. It means when they get hit, it’s our job to try and keep them afloat. That’s a lot of responsibility, and our plate was already full to begin with. (Everybody’s plate is full, no matter how big it may look from the outside.) So at the best, we only make a few really strong ties.

Oh, we might have a lot of weak ones. Folks we know, and who will occasionally drift by to exchange favors or chat. Maybe a group that we’ll cruise with for a while. But make no mistake: they might be floating alongside us, but they haven’t tied any knots in that rope. If you start to founder, the best you can hope for is a little sympathy as they sail on ahead, and maybe toss you a spare life preserver. It’s not their problem.

The ones who really throw in their lot with you — who say that in thick or thin, in sickness or health, they’ll be at your side, fighting to keep you afloat — they’re few and far between. Maybe a little family, one or two close friends. A significant other. That’s all.


What do you think happens when you get older?

If you have the good fortune to live to a very old age, then a lot of things will change. Life is not going to suddenly become easy; if anything, it will become harder. And where are those ties you’ve built?

Dead. Moved away. No longer capable of anything more than clinging to life.

The luckiest among us will make it to the very last pages of life with our partners-in-crime still at our side. The spouse of fifty years, the close and loving family, the lifelong friend. But for most of us, these lifelines are lost over the years, one by one. And eventually, we may have nobody. Nobody to fight for us, to love us, or even to note our passing.


The next time you transport the 80-year-old man with dementia, who never seems happy and complains about everything —

The next time you’re called to the home of the little old lady with toe pain, whose husband died recently after a lifetime spent together —

The next time you pick up the same homeless man from under the bridge, drunk once again —

Try to imagine what it would be like to be truly alone.

Nobody to lean on. Nobody to throw you a rope when you start to founder. Most of all, nobody who gives a damn you exist. Imagine what it would be like to know that you could walk into the sea tomorrow and nobody would even know you’d died — let alone that you’d lived.

We can’t be everything for these people. But one day, hopefully not soon, you might just find that you’ve become one of them. So do what you can, knowing that nobody else is likely to. Knowing that, even when it has little effect, the difference between having somebody to fire a few shots for you, and having nobody — can be all the difference in the world.

Oldest Trick in the Book


I’ve never been to nursing school. But I like to imagine it goes something like this:

On the first day, you walk into class, surrounded by other bright-eyed, eager young students ready to learn the art and science of nursing. Textbooks weigh down your bag, and your pencils are sharp and ready.

Before you stands your instructor, an impressive-looking MSN whose carriage suggests many, many nights spent awake amidst the cool blue lights and quiet beeps of a MICU. As you watch, she strides to the whiteboard and writes in block letters:

Lesson One: The ID Flip

Lesson two is eye-rolling.

Most hospitals, just like most ambulance services, require that clinical staff wear an ID badge at all time. This identifies them by name and role (nurse, doctor, PA, etc.), and often gives them access to secure areas as well.

Long ago, some canny soul discovered that when patients know your name, they can complain about you. If they decide that they don’t like you, whether justified or not, they can call people — like your boss — and unleash angry, entitled, and very personalized tirades about “Sarah Roberts, that mean witch who told me to shut up and stop smoking heroin.”

“Well,” we figure; “if they don’t know our name, they can’t complain.” So although the powers-that-be did insist that badges be worn, we started hanging them in odd places, like from our belt, or inside a pocket. Or covering them with stickers and other things. But the best of all answer of all was elegantly geometric, made especially easy by free-spinning retractable ID clips: simply twist the card so it faces your chest, and the only thing visible is whatever text happens to be printed on the back. Technically, you’re still wearing the thing, and if the boss notices you can just say “whoops, it got twisted,” but nobody can actually read your name, and, ninja-like, you can move through the ward unseen, a bescrubbed ghost.

The nurses have turned this into an art-form, and in some places it’s like finding a four-leafed clover to see an RN with a visible ID (usually I figure they’re new there). But we’ve become awfully fond of this in EMS as well.

People, I realize that the world’s a rough place, that patients can be impossible to please, and that even the best of us need to take steps to ensure we still have a job tomorrow. I do understand this. But there’s a certain point where you have to stop digging trenches, and realize that if you’re giving great care, following procedure, behaving professionally, and generally toeing the line, then you should be willing to stand behind your work. If you’re employed at the kind of place that’s willing to take any complaint as reason to show you the door, I assure you that no amount of ID-flipping will save you. Your days are numbered. Of course, even a good service will eventually start clearing their throat and looking at you pointedly if your personnel file begins to grow particularly fat, but at that point, maybe you really should consider managing your douche coefficient.

Besides, this should all be moot, because when you meet your patient you’re introducing yourself by name anyway. Because that’s just common courtesy when you greet people. And patients are people. Right?

Strive to do the kind of work that allows you the confidence to stand behind it. When someone points at you with forehead veins a-pulsing and demands to know your name so your supervisor can “hear about it,” tell them and tell them proudly. Sometimes, doing the right thing won’t be a defense against trouble — but you can be sure that playing “who, me?” will run out of rope even sooner than that.

Clip your ID somewhere obvious — mine goes on my shoulder — where patients and staff alike can easily see it, and know what to call you and what role you’ll be playing in this show. When I see somebody with a visible ID, I take this as a good sign about their responsibility and willingness to own their work. And those are qualities we need in EMS.

Live from Prospect St: The Reluctant Tumble (conclusion)

Previously part 1 and part 2

Being reluctant to force Joe into an undesired ambulance ride, the crew contacted their supervisor. He arrived, evaluated the patient, agreed with their conclusions, and called Dr. Scrubs to discuss the matter. He was unable to dissuade the doctor from his decision.

The crew and supervisor approached Joe together and informed him of the circumstances; although all parties agreed that he should rightly be able to refuse transport, they felt they had been overruled by a higher authority, and if he would not come voluntarily they would be forced to compel him. Under this duress, Joe finally agreed to be transported, loudly and vocally protesting.

He was taken to his preferred hospital and care was handed off to staff with a full description of the situation. Less than 30 minutes later, another crew was sent back to the hospital to return Joe home; the attending ED physician had deemed his involuntary hold to be invalid and inappropriate, and refused to hold him against his will. No further evaluation was performed.

The encounter was documented extensively and quality improvement measures involving EMS and the base physician are expected.



This case was not medically complicated, but it involved some difficult issues of consent and risk. Let’s look at the medicine and then at the wrinkles.

Medical Considerations

We were dispatched for a chief complaint of a fall — a very common mechanism of injury. When evaluating the fall, what should our main concerns be?

First, we should examine the mechanism itself. How far was the fall? In this case, as it often is, the fall was from a standing height, and from a standstill (i.e. not propelled while running, stumbling while breakdancing, etc.). This is often seen as the dividing line for significant versus non-significant falls; in many areas, falls from standing height or greater are considered an indication for spinal immobilization. (Other areas say greater than standing height; 3x standing height or more; or other numbers.) The elderly in particular are considered at higher risk for spinal injury, due to weakened bones and tighter ligamentous connections between vertebrae.

Typically, a blow to the head with loss of consciousness is also considered high risk for spinal injury. This is under the assumption that a blow with enough force to cause LOC may also have enough force to damage the spine. These considerations are all valid, but should only be seen as some of the many factors involved in stratifying risk; they must be considered alongside other elements like the physical assessment. In some systems, you may be forced to immobilize based on mechanism without other considerations. In others, you may be allowed to rule out immobilization based on certain findings, most of which Joe has; for instance, he denies neck or back pain or tenderness, denies peripheral parasthesias (numbness or tingling) or weakness, ambulated well, turns his head, and has no confounding factors like a distracting injury or altered mental status. In any case, the post-fall presentation was so benign that risk seemed low, and given the patient’s overall reluctance it is highly unlikely that he would have consented to a collar and board.

The use of warfarin (trade name Coumadin), on the other hand, does significantly increase the risk of intracranial hemorrhage (ICH), especially after blunt trauma to the head. Although again, Joe’s assessment was very reassuring — normal vitals, no complaints, and a baseline neurological status — it is very possible for ICH to have a delayed onset of presentation. The best example of this is the subdural hematoma, where cases of moderate severity sometimes take hours or days to develop, due to the venous rather than arterial source of bleeding. This delay is particularly common in the elderly, where (possibly due to shrinking of the gray matter, which leaves additional room for blood to collect before pressure begins compressing the brain) a classic scenario is the fall with a blow to the head, no complaints for hours afterward, and then sudden deterioration. Some sources state that 60% of geriatric fall patients who experience LOC from a blow to the head will eventually die as a result. Since in this case, we were delayed on scene for quite some time, there would be value in ongoing and repeated assessments of symptoms, neurological status, and vital signs while we waited around.

The patient’s pupils were unusual in appearance, which can be an indicator of brain herniation; however, this syndrome typically presents with one very large and round pupil. An irregularly shaped pupil as we saw here is more indicative of a structural defect, the most common of which is probably cataract surgery, which can leave the pupil off-round.

An incomplete medical history is common in scene calls involving the elderly. However, many do carry med lists, and in most cases you can reconstruct the majority of the patient’s diagnoses based on their medications. In this case, we found digoxin (or digitalis), which is almost always used to control atrial fibrillation; this is consistent with the patient’s irregular pulse, and with the warfarin, which helps prevent A-fib induced clots. Metformin (Glucophage) is an antidiabetic that helps control glucose levels. Citalopram (Celexa) is a common antidepressant of the SSRI type. Advair (fluticasone and salmeterol) is a preventative asthma/COPD inhaler combining a steroid with a long-acting beta agonist; it is used regularly to minimize flare-ups and is not a rescue inhaler. Omeprazole (Prilosec) is used for gastroesophageal reflux disease (GERD), aka heartburn. Ibuprofen is a non-steroidal anti-inflammatory (NSAID) used for pain relief and reduction of inflammation.

As VinceD noted in the comments, one essential question in any fall — and indeed in almost any traumatic event — is what caused it. Here we have a somewhat vague account which suggests a mechanical fall, i.e. tripping or loss of balance; this is not necessarily benign, as a history of repeated mechanical falls suggests deteriorating coordination or strength, but it is usually not indicative of an acute medical problem. However, many elderly patients (and some of the younger ones, too) will attribute any fall to tripping, so this claim should be taken with a grain of salt. It helps to have a witness to the event, as we do here, although witnesses are not always reliable either. In any case, what we want to know is: what happened just before the fall? Was the patient simply walking and tripped on a rug? Did he have seizure-like activity? Was he standing normally when he suddenly lost muscle tone and collapsed? Did he complain of feeling faint or dizzy? Was he exerting himself or straining on the toilet? Things happen for a reason.


Ethical and Legal Considerations

The bigger question is whether it’s okay for Joe to refuse transportation.

This is an odd question, because ordinarily we assume that people are free to go where they want, and calling 911 (or having it called for them) does not surrender this right. However, there is an attitude among those with a duty to act, such as healthcare providers and public safety officers, that individuals who are not cognitively able to understand their situation and make decisions in their best interest need to be protected from their own impaired judgment. This is equivalent to taking your friend’s keys so he won’t drive drunk, under the assumption that he wouldn’t want to drive drunk were he making sensible decisions. The legal term is implied consent, the same principle by which we transport children, drunks, and unconscious people.

How do we know if somebody is unable to make their own decisions? There is not an obvious line. For many providers, their rule of thumb is the old “A&Ox4”: if someone knows who they are, where they are, when it is, and what’s going on, then they are alert and oriented and capable of making decisions. Of course, this is only one piece of the mental puzzle. Social workers, psychiatrists, and other specialists have a full battery of tests that can help further reveal cognitive capacity. Can you perform these in the field? It’s probably more than you’re likely to do, although you might perform something simple like the MMSE. But some basic questions that highlight the patient’s judgment can help supplement your routine assessment — questions like, “Suppose you were at the mall when you started to smell smoke and heard the fire alarm. What would you do?” where any rational response is acceptable.

It’s important for the patient to be able to demonstrate that they understand what’s going on. Even someone with ordinary mental competence — unless they’re a fellow knowledgable healthcare professional — needs to be informed (to the best ability of the provider) of the possible risks and consequences of refusing care. In this case, it would involve giving them some description of the above possibilities (spinal fracture, head bleed, etc.), and ideally having the patient then relate them back to you, demonstrating good comprehension of those facts. The base physician’s view that Joe hadn’t fully demonstrated this understanding was a key part of his decision that he needed to be transported against his will.

Other important points are to ensure that the patient knows that refusal doesn’t preclude future care (“if you change your mind, you can always call back”); and that the ability of the providers to evaluate the patient on scene is at best limited. Any implication that you know what’s really happening to the patient or can definitively rule in or rule out any medical problem is unwise and legally risky. In fact, even suggesting possibilities or probabilities can be problematic if you’re wrong; on the other hand, failing to do so can leave them uninformed, so this can be a Catch 22. Your best bet is to outline some basic possibilities, carefully inform them of the limits of your training and resources, and be smart enough that you generally know what you’re talking about in the first place.

One complication in this case is the presence of someone who claims to be Joe’s health care proxy. A proxy (closely linked to the idea of a durable power of attorney) is a person whom, while of sound mind, you designate to make decisions for you if at a later time you are not of sound mind. Crucially, if you are still capable of decision-making, a proxy does not have the ability to override you; their role is to act on your behalf when you cannot. In other words, the decision of Joe’s proxy is only relevant if we do find (or in some areas, if an authority such as a judge has decided) that he’s incompetent to refuse or consent to treatment; thus, her presence does not necessarily alter the basic dilemma.

In this case, the physician’s attitude was that the problem was primarily medical: does the patient need emergency department evaluation to rule out dangerous processes? Medically, he does. However, the first question actually needs to be: Is the patient capable of evaluating risk and making decisions in his own best interest? If he is, then he is technically “allowed” to decide whatever he wants. Even a clearly dying man can refuse medical care based on religious views, personal preference, or any reason whatsoever (although barring a proxy or advanced directive, once he’s unconscious he can usually be treated under implied consent). This is different from the person who actively tries to take his own life; for philosophical reasons we view this as different from passively allowing oneself to die for lack of medical treatment. We prevent people from committing suicide but allow them to refuse medical care.

Realistically, although this fundamental right does not change, it’s fair to consider the surrounding medical circumstances to help decide how pressing and high-risk the matter is. In this case the doctor clearly felt that the risk was so high that it required going to extraordinary lengths, including overruling the patient’s own decisions and potentially even harming him, to ensure that a dangerous situation wasn’t “missed” — in short, that the ends justified the means. Dr. House is famous for this approach.

Legally, in most areas EMS providers are seen as operating under the bailiwick and legal authority of their medical director, and online medical control is an extension of this authority. In other words, within reason we are bound by the orders of medical control. The details of this relationship vary, and are not always fully explored. For an example, consider this true story from 1997 in New Jersey:

A North Bergen dual-medic crew is dispatched to a pregnant, full term female in cardiac arrest. Downtime is unknown, and they work the code for a number of minutes without response. Determining that the mother is likely unsalvageable, and concerned for the health of the fetus, they contact medical control. After a “joint decision” the base physician verbally talks them through performing an emergency C-section on scene. They deliver and successfully resuscitate the fetus, and both patients are transported. The mother is declared dead soon afterwards, but the infant lives for a number of days before dying in the hospital. In the aftermath, the paramedics are cited for violating their scope of practice, and their licenses to practice are revoked in the state of New Jersey. The physician is forced to undergo remediation training to maintain his medical control privileges.

Is the moral that acting in the patient’s best interest is not always a defense against liability? Maybe. Is the moral that medical control cannot authorize you to perform otherwise illegal acts? Maybe. Is the moral that we should protect ourselves before the patient? I don’t know about that, but it’s something to think about. In this case, the course for Joe that seems most ethical to me — allowing the patient to make his own decisions — also lets us avoid potential liability for battering and kidnapping. However, it does force us to refuse a direct order from medical control. Invoking our supervisor gives us a bigger boat either way, and would be a big help to protect us from trouble coming from our employer, one of the most likely sources. It’s also true that, while we may have believed that Joe was competent, he is at least somewhat diminished, so we’re less than completely confident. Nobody wants to put themselves on the line by taking a stand, only to be proven wrong.

Fortunately in this case we were able to avoid getting violent at all, but it was a near thing. If it did prove necessary, it should have been done with ample manpower and many hands; in some areas chemical sedation by paramedics may also be authorized. And I would certainly not recommend acting without the doctor’s signature on a legal document.

With everything viewed in retrospect, the situation would have been much more easily resolved had the doctor not been involved in the process. At the same time, however, if a simple refusal had been accepted, and CQI later went over the call — especially if Joe experienced a bad outcome — the crew would have been in a difficult place.

No matter what, such a situation is highly unusual, flush with liability, and should be thoroughly documented in all respects.

Live from Prospect St: The Reluctant Tumble (part 2)

You kneel beside Joe and ask, “So, would you like to go to the hospital?”

No!” he vociferously replies — a theme that will be repeated often over the next few minutes.

You explain the risks — that given his anticoagulation (Coumadin), and given that he struck his head and seemingly lost consciousness, there is a non-trivial possibility of bleeding into or around his brain. That although he feels well now, it’s not impossible for such a problem to develop insidiously and not manifest with symptoms until it’s too late. That you can take him to the hospital of his choice, in total comfort, he can receive some quick tests, and if nothing is wrong he’ll be back home before he knows it.

Joe wants to hear none of this. He just came out of the hospital, enjoyed it not at all, and that was just the latest episode in a long series of hospitalizations. “They ruined my hip” on one occasion, he opines, and he’s already been fooled before by “home before he knows it.” No sir; he’s not going anywhere.

You try, your partner tries, the neighbors try, the proxy tries. No way, no how.

Well, okay. But this is not the sort of incident to just brush aside, and you’re well aware of the risk inherent to patients refusing transport, particularly in a risky circumstances like this. So you pick up your phone and hit your hotkey for medical control.

“Needletown Hospital; this is Dr. Scrubs. How can I help you?”

“Hi doc, this is Maverick from Poketown BLS 48. We’re on scene with a high risk refusal.”

You fill him in with the story. He asks a couple questions, then requests to speak with Joe, and finally talks to the proxy for a few minutes. When the phone gets back to you, Dr. Scrubs informs you that he really thinks Joe needs to go.

Well, okay. You dive back in, bolstered with a physician’s opinion, and attempt to get Joe on board the hospital train. He’s not having it. The whole entourage keeps hammering away at him, but he’s simply not budging.

You call back Dr. Scrubs, bringing him up to speed. “We’re making no headway here. He just doesn’t want to go.”

He asks to speak to Joe, and the sounds of his best MD magic come wafting over the speaker, but Joe just has less and less polite things to say, until finally he comes out with, “You’ll have to handcuff me before I’m going anywhere! And just go ahead and try it!” He hangs up on the doctor.

You call back. “I gotta tell you, doc, I don’t see us convincing this guy. If you tell me that we must take him, then I’ll take him, but I think we’d have to do violence to him and start a battle royale here. Is that what you want?”

Dr. Scrubs replies, “Well, I think he needs to be seen, and it sounds like his proxy does too. I’d like to hear your opinion.”

You pause, then carefully say, “I do not think that it would be inappropriate to leave him, although obviously it would be preferable if he came in. I don’t know that I’d make the same decision, but I might, and I don’t see the situation as so high-risk as to justify anything really extreme.”

“Head injury, on Coumadin, loss of consciousness, you don’t think he needs to be seen?”

“We obviously can’t clear him here. But he’s stone normal by our assessment from every angle, and he’s not going to be left alone.”

“Well, I don’t think that’s a great idea. And he wasn’t really able to logically explain to me the risks of his decision. Anyway, his proxy agrees, so I’m not sure if I see the problem.”

“Doc, the problem is that although he does have someone here who says she’s his health care proxy, by our assessment he is at this time totally oriented, competent, and exercising sound judgment. So I’m not really comfortable kidnapping him, unless you want to sign a Section [your state’s involuntary mental health process, for those who are a danger to themselves or others].”

“Sure, I’ll do that. I can fax it to your dispatch and to the receiving hospital.”

“So you want us to tackle him?”

“Do what you have to do.”

You hang up the phone and look around. Police have left the scene, but could be easily recalled. Joe sits before you, a 79-year-old in fair condition, but no Evander Holyfield.

What do you do?

What are the legal considerations?

What are the ethical considerations?

Acceptable Risk

Following up on our previous post where we discussed patient refusals, it behooves us to say a few things about risk.

The culture of “everyone goes to the ED” is not writ in stone, and in some places, efforts are underway to expand it into a more sophisticated system. For instance, some patients might be transported directly to detox programs, homeless shelters, urgent care facilities, or psych treatment. Some, of course, don’t need to be transported at all, and can stay home, perhaps with instructions to follow up with their PCP. A few areas are experimenting with, or at least moving towards, the concept of an “Advanced Practice Paramedic” or “Advanced Paramedic Practitioner” who could sensibly and intelligently perform this assessment and triage, determining whether patients need immediate definitive care, or (in essence) “clearing” them of acute high-risk pathologies. Ideas like this may prove central to solving the many problems of healthcare in general and EMS in particular, such as ED overcrowding and the inefficient use of available resources.

However, just like the issue of patient refusals, to even discuss the possibility of such a system requires a fundamental shift in our thinking. At the moment, the approach is, “Try to recognize and treat Sick People — but if you don’t, that’s okay, because they’ll recognize them at the hospital.” Obviously, this practice is based firmly on the presumption that most or all of our patients do end up being evaluated in a full-fledged emergency department. Even the very notion that a patient can refuse to be transported ends up as a grudging allowance — we reluctantly acknowledge that we can’t actually kidnap people, but we still make them jump through hoops to make it entirely clear that we wanted them to go all along.

What if we started to accept that some of these patients don’t need an emergency room? Realistically, and retrospectively, it’s obvious that many of them don’t. Other destinations are more appropriate, and in some cases, no transport at all is necessary. But in order to make decisions like that, we need to be able to accept the assessment, clinical decision-making, and risk stratification of our field providers.

It goes without saying that instituting such a practice would require additional training, and providers (such as this mythical APP) practicing at a higher level than our current EMTs and medics. But it’s bigger than that. We have to be willing to let go of the safety net of everyone filtering through the ED. We have to be willing to accept the field workup as final — or at least, good enough that no further evaluation is immediately needed.

Closely wedded with the prehospital culture that treats patient refusals as bogeymen is the in-hospital culture that says every patient needs a comprehensive workup to rule out every possible killer. It doesn’t matter if the odds are 1,000,000 to 1 that the problem is benign rather than a massive MI or hidden PE; that 1/1,000,000 chance of missing the Badness is still unacceptable, so the patient gets the works.

We have the mindset that any miss is one miss too many.

This costs a lot of money. It puts patients through a lot of hell. But most of all, if we’re going to imagine a world where not every patient ends up even going to the emergency department, we have to accept a world where the ones who don’t will not receive that exhaustive workup.

Certainly, this triage process be handled sensibly, and conservatively, because we’re here to help people, not let them die at reasonable rates. So where do we draw the line? Is one miss in a thousand acceptable? One in a million? One in a billion?

We can draw the line wherever we want, but no matter where, there’s going to be a qualitative difference between a reasonable risk and “we did everything.” Because eventually, we’re going to miss one. A well-trained and conscientious clinician is going to assess a patient in their home, and appropriately conclude that their complaint is not dangerous, and that patient is going to die.

Because it happens — because flukes are inevitable. If we throw the kitchen sink at them, and we still lose, then at least we can hold ourselves blameless. But if we take a more reasonable approach, then we have to accept in advance that occasionally, the chips will fall against us. And that has to be okay.

The prevailing belief today is that anytime something goes wrong, something was done wrong. Adverse outcomes are an indicator of error, either an individual error or a flaw in policy or protocol. If I follow our procedures to the letter, and a patient slips through the cracks, it means we need to change the procedure.

Can we get to the point where we understand that if a situation is correctly evaluated, and the risks are correctly balanced, and we simply happen to get unlucky, that the decision was still right? Where we can stop spending ever-increasing amounts of time and money in the pursuit of ever-more-infinitesimal risk?

I don’t know. But if we can’t, then we’re never going to be able to solve some of these problems. Because perfection doesn’t exist, and chasing it is a good way to get very tired.