Spray Painting Them Pink
The paradigm shift in medicine is to fix the underlying problem, not its manifestation.
When the heart stops, oxygen supply to the tissues is cut so drastically that cells have to try to survive without oxygen, a process known as anaerobic metabolism. One of the consequences of this is an accumulation of hydrogen ions from the hydrolysis of ATP exceeding the rate of ATP production, producing a metabolic acidosis. This can be demonstrated on an arterial blood gas sample as a low pH (i.e., less than 7.40) and a negative base excess, otherwise known as a base deficit. It has been demonstrated that the lower the pH and the more severe the base deficit, the worse the patient will do, with death being the likely consequence for those with the most abnormal values.
We were first able to detect this clinically after the invention and development of blood gas analyzers in the late 1950s by John Severinghaus. Physicians began to note this acidosis in the early 1960s when cardiopulmonary resuscitation (CPR) was introduced. It was also noted that if sodium bicarbonate, a base, was administered, the acidosis could be reversed. For decades, it became standard practice to administer “bicarb” as a routine during CPR. The justification was that acidosis could impair cardiac performance and its response to catecholamines such as epinephrine (adrenaline). Because of this, clinicians were instructed to correct acidosis with sodium bicarbonate before giving epinephrine during CPR.
Of course, this was all theoretical because we weren’t directly measuring cardiac performance or catecholamine responsiveness. That was all below our radar. In fact, there are a number of studies and reviews spanning back several years that attest to the fact that such bicarbonate is, at best, of little use or actually harmful because of the severe acidosis it can produce inside the cells (which is definitely beneath our radar).
The simplistic approach was to fix a number that was actually the result of a problem rather than the problem itself. Correcting acidosis by giving bicarb is as effective as treating a suffocating cyanotic (blue) patient by spray painting them pink.
Quality Improvement and Lawsuits
There is a disturbing dynamic in the interplay between quality improvement and our parasitic medicolegal system.
Medical malpractice plaintiff’s attorneys consistently claim that they seek to get rid of bad doctors or bad hospitals, thereby justifying their frequently unfounded attacks on healthcare practitioners and facilities. If these claims are sincere, it suggests that they are providing a quality management service to healthcare. Unfortunately, the reality is quite the opposite.
Is “getting rid” of poor performers the right approach? Do we seek to “get rid” of anyone convicted of criminal behavior by executing all felons, or do we seek to rehabilitate them? What kind of rehabilitation or reeducation is offered to “bad” practitioners? How do we know the “bad doctors” are consistently poor performers? Does the legal process allow any metrics upon which to base these assessments, or is the determination made simply because a legal case can be built against the presumed incompetent and juries’ proclivity to reward sympathetic plaintiffs? What about those situations where an individual makes an unfortunate decision despite a stellar career of providing excellent care?
Rather than improving the quality of healthcare, the medicolegal system seeks to destroy it. The heavy penalties and resultingly high malpractice insurance means there is less money that can be spent on actual healthcare. Do we do this in any other industry? When a school system is failing to educate its students, do we sue them to get rid of the bad teachers and the bad schools? Or do we actually throw more money at them to help them improve? Did we destroy our national intelligence systems after 9/11, or did we throw more money at the problem and create whole new agencies and operational structures? In fact, it seems that in every other sector of our economy, any failings are treated with financial subsidies, especially with the current administration in Washington. It is only healthcare that is consistently expected to do more and more with less and less. We have been penalized with frivolous and ridiculous lawsuits for decades, fronted by specious claims that quality is being sought. And now, with the advent of Obamacare, the overwhelming expectation is that the healthcare industry will receive a financial penalty of 20%.
The paradigm shift in medicine will be to change the medicolegal system so that it is no longer a parasitic and destructive force.
Medicine out of the Box 