Wednesday, September 19, 2007

Bullets from heaven

When it comes to a loved one, death never makes sense, but there are certain ways of dying that just seem to be more difficult to accept than others. Sudden, unexpected deaths, for example, seem to leave deeper, coarser scars than gradual, anticipated deaths. Painful and violent deaths can jar loved ones as if they themselves were stricken. Most frustrating, perhaps, are preventable deaths, which tease us with the possibility that they might never have happened at all. Medical errors are a common reason for such deaths, but at least these are generally good-faith errors; more infuriating are those preventable deaths that result from carelessness, recklessness, or just sheer stupidity. In the movie Babel, when the little boy shoots his father’s new rifle at the travel bus, it is excruciating to watch. We expect to suffer loss from evil, but idiocy makes a surprising and thereby bewildering foe; a terrorist purposefully shooting at the bus would have seemed less senseless and been easier to stomach.

Death by indirect gunfire, thus, may be even more of an outrage to decency than a shooting in cold blood. I for one would rather go by the latter – at least someone will be held to account. We needn’t look far, though, before we see a systemic problem of unchecked indirect gun violence. One can hardly turn on a television of the Middle East without seeing young men firing rifles joyously into the air in celebration of some event or piece of news. I’m sure that for them it’s elating, but there can't be many ways of dying that are more ironic or pointless than being struck down by a stray celebratory bullet. Following the Iraqi soccer team’s victory in the Asian Cup this summer, four people were killed in such a manner. What an odd but horrible piece of knowledge for Iraqi star player Younis Mahmoud that his championship goal resulted in these deaths. Why does the practice continue, you may ask? Ignorance seems to play a large role; a common misconception appears to be that bullets fired skywards will simply continue outward into space. (Ordog) This, unfortunately, turns out not to be the case:

The escape velocity of a bullet has been calculated at more than 7 miles per second. Thus a bullet would have to be fired at a muzzle velocity of greater than 36,766 fps to escape the gravitational pull of the earth and end up in space. Obviously conventional small-arms weapons that we see in civilian practice cannot achieve this type of velocity, so the possibility of escape from the earth is nonexistent. Thus all spent bullets will return to earth. (Ordog)

Examining the physics a little bit more closely:

When a bullet is fired vertically into the air at >2500 feet per second (fps), the air resistance slows the bullet down about 60 times as fast as does gravity. When the velocity decreases, air resistance decreases and has less effect. Gravity reduces the upward velocity at the rate of 32 fps until the bullet has stopped its upward flight; then gravity starts it toward earth at 32 fps, and then there is a 32 fps increase for every second that the bullet drops, less the amount that air resistance holds it back. When the bullet reaches the top of its flight, it is still spinning, and if it is stable it falls back base first. Occasionally, it falls back either point first or tumbles, thus either decreasing or increasing its flight time. With a very sharply pointed bullet, the resistance on the bullet is less, and on the square base much greater, so that bullets coming down nose first fall faster than those that fall base first, but even so, a 150-grain, .30-caliber bullet tends to balance its weight against the air resistance at a velocity of about 300 fps. (Ordog)

This, the CDC summarizes, is a force “sufficient. . .to penetrate the human skull and cause serious injury or death.” In Puerto Rico, where celebratory gunfire is quite common, the news media has estimated that on New Year’s Eve, approximately two people die each year and 25 more are injured.

In a war zone like Iraq or Afghanistan, the threat of raining bullets is only one of your concerns when firing weapons into the air. More dangerous is the worry that you might give someone the wrong impression. In 2002, 48 Afghanis were killed and 117 wounded when U.S. airmen mistook their celebratory gunfire at a wedding party for hostile fire. The same sad story has played out in Iraq several times since then. What, also, about that other presence in the sky? You would think that the deeply religious, before firing their weapons skywards, might pause in fear that God would misinterpret their intentions. What if He thought you were actually firing at Him? Would you not expect Him to return fire?

After the 2005 earthquake in Kashmir, a close friend of mine with connections there told me that the faithful reacted in three different ways. One group found its faith to be a source of strength to get through the crisis. Another lost its faith entirely. A third, moved to extreme anger, fought back by shooting weapons into the sky. How people could have that kind of courage, to take on their god face-to-face, is beyond me. As much respect as I have for their bravery, though, I was also just relieved to finally discover a group of people who were firing shells into the air and knowing exactly what they were doing.

Celebratory gunfire obviously needs to end, and the sooner the better. Following the Iraqi soccer victory, I was glad to see mosque leaders strongly condemn it, but unfortunately, their efforts didn’t seem to have much immediate effect. The practice may already have taken too strong of a cultural hold for it to be vanquished overnight. Where young men have guns, they will likely fire them. While that remains the case, perhaps both the Kashmiris and the wild type gunmen would do well to replace their steel bullets with rubber ones; neither deicide nor manslaughter is a crime that weighs lightly on the conscience.

Friday, September 07, 2007

Medical instinct

I’m not normally a superstitious guy. I don’t read horoscopes, I don’t believe in ghosts, and I’m suspicious of all things spiritual. It’s true that I never admit to having a good day when I’m on call, but that’s more because I’m afraid of how my team might react than any potential consequences. (Good days are highly jinxable, or so I’m told.) This past year, though, when a patient informed me on a particular night that he was going to die before morning, I’ll admit that I was unnerved.

This was the kind of guy who was frail enough to go at any time, but there was no real reason that I could see why he should pass on that particular night. His blood pressure was fine, his labs were reasonable, and in eyeballing him, he just didn’t appear toxic. Why he thought he was going to die was a mystery to me, but he had a look in his eye like he knew something. To make the situation worse, he waited until just before I was heading home to let me know.

I’ve had many patients die, but this was the first time a patient had ever told me before it was going to happen. Usually it’s the other way around; I’m the bringer of bad news. Perhaps if he’d have given me a warning shot, as we’re taught to do (“Doc, I’m afraid I’ve got some bad news for you. . . “), I’d have handled it better. But he didn’t, and the news stunned me. The problem was, since I couldn’t identify anything immediately life threatening to him, I didn’t know what to do about it. I ended up signing out for the cross cover to check in on him that night, and went home for a restless night of sleep myself.

The first thing the next morning I went to see my patient, who was doing fine, precisely as I had left him. Silly me. Apparently, my medical instincts had proven more reliable than his spiritual ones. It was a victory for medicine and science, and I was cleared from incompetence. Either that or the Grim Reaper simply hit the wrong room. I can’t claim to know exactly what transpired that night, but at least the next time somebody announces his or her impending doom, my reassurances to the contrary will carry the weight of a little bit more experience.

Sunday, September 02, 2007

The cost of learning

They say you haven’t put in enough central subclavian lines until you’ve given someone a pneumothorax (an air leak into the chest). That’s when you find out how deep is too deep to plunge your needle. Likewise, you haven’t performed enough lumbar punctures until you’ve given someone a headache, intubations until you’ve chipped someone’s teeth, paracenteses (abdominal needle taps) until you’ve left someone with an ascites leak, or hysterectomies until you’ve punctured someone’s bladder. You haven’t learned how to administer fluids until you’ve put someone into pulmonary edema, or how to diurese someone until you’ve shut down his kidneys. The point being this: to become a competent doctor, you must hurt people along the way. Just as the evolution of a species occurs through the death of its less fit members, the evolution of a physician from inexperienced intern to practiced attending requires spilt blood. Residency, of course, is the prime time for this bloodletting, and the old piece of inside medical advice holds as true as ever: if you value your health, don’t get sick in July.

It’s a little bit depressing to start residency and think that before you finish, there will be scores of victims left in your wake, people who will entrust their care to you and for that trust have to pay a price. Sometimes the price will be small, such as a missed meal after a procedure when a late-tray was never ordered, and sometimes it will be significant, such as when inappropriate antibiotics were ordered for an infection. Rather than sulk, though, I think as residents we have to be vigilant and fight against the threat that our inexperience poses to our patients. In some areas, we are already probably less likely to make mistakes than our seniors; our awareness of our considerable limitations makes us more likely to pay extra attention to detail and to check our facts. The truly dangerous practitioner, it is often said, isn’t the one who knows that he doesn’t know something, but the one who thinks he knows something that he doesn’t. Residents, especially interns, are less susceptible to this particular pitfall, and so one of the best ways to avoid mistakes in residency is also one of the most natural: to ask for help when it is needed. It’s a terrible thing to harm a patient because you are too proud to seek help.

A second way of avoiding mistakes is by learning from those of others. That means being open and honest about mistakes and willing to share them to help others learn. If residency programs collected and distributed a monthly list of mistakes made by their residents, it could be an amazing teaching tool. Personally knowing the people involved would make the lessons all the more memorable.

My purpose here isn’t to methodically go through the ways of reducing medical errors, but simply to point out that, for residents who care, the mistakes of residency and their impact can be greatly lessened. Also, before I start scaring patients away from teaching hospitals, let me point out that there are many reasons why it’s good to have students, interns, residents, and fellows participating in your care. For one thing, our mere presence keeps the attendings on their toes; teaching concepts requires a higher clarity of thought than simply acting upon them. We like to ask questions, and having an additional bright, eager young mind going through the details of your medical case can’t be a bad thing. Less bound by time constraints, we will listen to your full story, and the substantial knowledge that we do possess, while hopelessly incomplete, at least is current. Some procedures we even perform better than attendings, because we do them more often. Truly, to request that no residents or students be involved in your care is to miss an opportunity for excellent care.

Like everyone else, I’ve had my fair share of blunders during residency. I’ve dropped people’s blood pressures, dried out their kidneys, and stuck them with needles to the point of absurdity. There were days when calling me a walking disaster would have been entirely appropriate. I’ve also saved lives, though, and for most of my patients, I know that their care was better because I was involved. Maybe I’m giving myself too much credit, but I think my patients would also attest that despite its fearful reputation, the cost of learning turns out to be surprisingly manageable.