The Perfect Student

B''H

Hannah Rose told me many times that she was the "perfect student": doing everything the teachers asked in an overly thorough way. She felt thinking independently only came to her after a professor in graduate school rightfully, in her view, called her a "silly little girl" (lucky he he did this 30 years ago). This occurred when she was doing a presentation on Bach and the professor pointed out how she had stumbled on a very important question. My perfect student then continued with her pedantic report at which point the professor stopped presentation with the above exclamation and told her not to go on. This was a life-changing episode. I ask you, would this happen today? Are we too afraid to correct?

I recently read an article published in the New England Journal of Medicine roughly three years ago[1] recounting in first person singular an event that happened on an airplane to the author. A passenger coded. The author, a neurologist, and his wife, a hospitalist, began resuscitation assisted by an AED, and an Ambu bag, and other equipment. Three other physicians, passengers, an oncologist, a surgeon,  and an anesthesiologist, rapidly volunteered to help. A dang good code team.

After 25 minutes, despite the efforts of, and in the opinion of, these highly qualified physicians, the man was dead. They turned to his wife and informed her that further efforts would be useless. They called the code. At this point in time, the stewardess informed the physicians present that airline policy insisted that CPR be continued until the plane landed and that she and the other flight attendants would take over from five board-certified physicians.

The surgeon, being a surgeon, commonsensically said "this is ridiculous" and walked away. The anesthesiologist and oncologist, showing less, what we call in Yiddish, saykhel, helped with this foolishness until the fasten-seatbelt light came on. Our neurologist, in the article, goes through some mental gymnastics and casuistry, to come to the conclusion that he must continue CPR even while the plane is landing: thus putting his life, his wife's, and the stewardess's at risk for a dead man. Our hero proudly mentions that he had to coach the flight attendant on proper technique on using an Ambu bag on a dead man! Now, all of this was done in the main aisle of the aircraft with all the passengers watching, including five children and the man's wife.

The author's conclusion to this article is that better policies and procedures should be written. I, however, have a different take on this. If I had been present, at a minimum, I might have copied the surgeon. Another option, would have been to pull the lifeless body to a secluded area of the aircraft and continue  "semi-CPR", thus sparing passengers and family from witnessing this travesty and risking no lives. But I am fairly certain that what I would have done, having many times been in similar circumstances when "the rules" make absolutely no sense, would be to turn to the stewardess and say, very pointedly, "you are now going to get your chief medical officer on the line who is going to speak to me and I will take the responsibility of calling this code on my shoulders, ending this farce".

The problem with trying to invent new rules to cover any or all circumstances, to quote one of my former professors, is that "law is a blunt and crude instrument"[2]. Rules do not replace common sense and cannot cover all circumstances. Our neurologist friend, described above, reminds me of what was once said regarding King James I of England: ”the wisest fool in Christendom"[3].

David Brooks in his columns frequently describes what he calls "the organization kid(s)"[4], who follow all the rules, go to the right schools, go to the correct extracurricular activities, do enough community service, but never take any risks so that they can never fail. Our profession and our country is being filled with these people, kowtowing to authority no matter what. By the way, I am a fan of protocols and evidence-based medicine for these have been shown scientifically to improve patient outcomes. They are, however, not a replacement for judgment, practical wisdom, or prudence.

When I was an intern at Kings County Hospital in New York on the Trauma Service, where 90% of the patients ended up in said service by being drunk, on drugs, doing something criminal or stupid, or combination thereof, one of my colleagues did a remarkable thing. The nurses, upon finding one of our patients unresponsive and barely breathing, called a code. My friend responded and what was his first action: Airway, Breathing, and Circulation? No. He asked for an amp of Narcan. Upon injection, the patient, who had been mainlining into his central line, immediately woke up and said, "What the heck" (that is not really what he said). My friend knew his patient and made a judgment. Today, if this occurred, I am afraid such a very good doctor would be written up for not following "protocol". What is clear is that our pusillanimous friend on the aircraft, who I am sure was a perfect student, could never have made such a decision. Far more frightening, is my fear that the physicians of the future will be so regimented and so brainwashed that none of them could make such a decision.

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[1] NEJM 2010; 363:1988-1989

[2] Allan Bloom, personal communication

[3] Sir Anthony Weldon, The Court and Character of King James I (1650)

[4] The Atlantic, April 2001