Like most practitioners, I find myself attending M&M conferences at least 26 times a year. In my department, these are simply terrific conferences: well planned, meticulously researched, outstanding presentations. In most instances, I find that I would do as those presenting did. That is to say, I cannot see any reasonable way of foreseeing or avoiding the bad outcome being discussed, and am not retiring in making this known. This frustrates some who hope to actively evolve our practice, especially those who view themselves as leaders in the application of evidence to our clinical practice.
So there I was at M&M, listening to a discussion of a case, when a colleague pronounced ‘I know what happened’. This happens with astonishing regularity. I listened attentively. The commentator was far more certain of what had happened and why than was even remotely possible. Confabulation or rationalization? God only knows.
Throughout the history of medicine, we have continuously believed we have a complete understanding of the biology that underlies the vast majority of the diseases that we encounter. Whether it is earth elements, evil humors, histamine, prostaglandins, cytokines, NO, genomics, or small RNA; we have never lacked plausible and attractive explanations for the phenomena we sought to understand. Never. History continuously proves us and our paradigms wrong.
Once upon a time, syphilis was widely understood to be the great imitator. If you wave your hands long enough and hard enough, you can use syphilis to explain anything.
We have now identified many syndromes and diseases based on improved understanding of their biology, improved imaging, and improved diagnostic testing. Anaphylaxis? Prion disease? Catastrophic APLA? Schizophrenia? Carcinoid? Serotonin syndrome? Touret’s? Minamata disease? Sarcoid? Ulcerative colitis? Thyrotoxicosis? Lupus? Systemic sclerosis? Consumption? Hoards of others? All of them have been out there forever in one form or another. All syphilis.
Once upon a time, esophageal intubation was allegedly common. What about Suxx – K burns? MH? Carcinoid? Pheo? Latex allergy? Serotonin syndromes? Anaphlaxis to vehicle? Anaphylaxis to NMB? Anaphylactoid reactions(Red Man Syndrome)? Bacterial contamination of drugs? Posterior Ischemic Optic Neuropathy? Who knows what else? All of them were out there. My guess is that events associated with these were tied back to ‘esophageal intubation.’ The world was overflowing with people who ‘ knew what happened’. In most instances, our explanations were complete rubbish – rationalizations framed in the context of what we believed was a robust and complete understanding. It is only in retrospect that we can see with excruciating clarity how profoundly wrong our explications were. In most instances, invoking ‘evil humors’ would have been less wrong than most of the explanations offered.
Even now, the temptation to explain that which we do not understand utilizing frameworks(paradigms) we believe are complete and robust is insuperable. A colleague, someone whom I have enormous respect for, once told me that he truly believed that cardiac arrest during neuraxial anesthesia arose from inadequate vigilance. This, in spite of years of event investigations which refute it as even remotely plausible. Whatever it is that causes these tragedies, this much is certain: it isn’t a lack of vigilance (at least not in most of the cases).
"To see what is in front of one's nose needs a constant struggle." - George Orwell
Our hubris is also a source of tragedy over time. For example, it is now widely accepted that intrapartum asphyxia is the cause of no more than 10% of the cases of cerebral palsy in our world. The remainder, that is to say the vast majority, seem to be caused by some combination of intrauterine infection and the demise of an intrauterine twin; both of which precede delivery by weeks to months. Given this, it is unsurprising that escalating monitoring and aggressiveness in the management of fetal hypoxia had no effect on the overall incidence of cerebral palsy. In retrospect, the absolute inability to make any forward progress on this problem should have made it obvious: the vast majority of CP is not caused by intrapartum asphyxia. Once again, an invocation of ‘evil humors’ would have been less wrong than the conventional wisdom. No matter, like the British at the Somme, more resources were pushed forward to deal with the failure. More policy. More protocol. More regulation. More nurses. Higher tech monitors. More aggressive management of fetal distress. All for nought. How many times did someone at M&M utter ‘I know what happened.’? Who are the casualties here? Not just the patients. How many doctors and nurses were devastated by the idea that they might have caused CP in a child? How many careers were ruined? How many millions of dollars were paid for events that were beyond the power of those held responsible? Who is going to apologize to those practitioners? Who is going to pay them back? Who is going to make it right? (The answer to the last three: No one.)
As an educator, one of my greatest responsibilities is this: to convey to my students, residents, and fellows an appropriate degree of circumspection regarding the limits of our knowledge and understanding.
‘I know what happened.’ Bullshit.
One of the wisest men I have ever met says: ‘ I don’t know what it was, but whatever it was, it was the worst case of it I ever saw.’
As for me, I know: it’s syphilis.