A Training & Education Caveat From An MD

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From over the transom, with thanks:

Dear Pete,

I am delighted to see the assembled, organized medical resources and references that Flighterdoc, et al., have made available to your readers and voice a full-throated endorsement to download, print, and distribute while we can. After reviewing the extremely thorough list of foundational medical texts posted 10/11 (Grid Down Hospital: Part IV – Medical Books For Your Hospital Library), I do feel a professional obligation to voice a few caveats, even at the risk of being a wet blanket on someone’s self-sufficiency fantasy (Not Flighterdoc, by the way. He sounds solid as an anvil.).

A few words on me. I am a practicing physician (> 10 years in practice) and am heavily involved in teaching the theory, principles, and praxis of medicine to a range of students across nine years of formal training (from freshman medical students to resident MDs who graduated five years ago now pursuing specialty training.) At present, I am personally and primarily responsible for a dozen medical students and as many specialty residents, so I know whereof I speak with regards to medical education.

Here’s the crux of the issue. While obtaining, storing, distributing, and studying medical resources may be laudable, there’s a reason that it takes so very long to produce a competent physician. At a minimum, two years of prerequisite science classes as an undergraduate, four years of medical school (two years of basic science and two years of hands-on rotations), and a minimum of three years of post-graduate training. And after that, it’s called medical “practice” as more than a tongue-in-cheek euphemism for learning on the job. Physicians aren’t infallible demigods, but it’s a hell of a lot of information to cram in a 3-pound brain before you see your first patient. And when faced with blood, let alone emotion, all bets are off.

Your readers are no more capable of using this veritable treasure trove of medical resources under pressure, on-the-fly, to save kith and kin than they are of rising to the occasion for other technical fields informed by experience such as engineering or electronics. Imagine all of the folks who own an HF, have half a shelf of ARRL references, but can’t be troubled to raise an antenna and get on the air when nothing’s on the line–now put a scalpel in their hands alongside potentially deadly meds. Rather scary, yes? This is exactly the same situation as the “closet full of guns, lots of ammunition, superabundant bluster, and no training whatsoever” clowns as we know and despise.

Here’s my suggestion. Unless you are in fact capable of assimilating and accessing full-bore medical references, dial it back. Focus on first-responder levels of utility, not on recreating a field hospital. Get some training–actual hands-on training that doesn’t presuppose access to a higher level of care or the availability of additional resources. This is the definition of wilderness medicine, by the way.

While I have nearly all of the books suggested and ample equipment to go with them, I’m the exception, even among physicians. I’ve been involved in wilderness and austere medicine for more than twenty years. This is my thing, I teach it professionally, and I can tell you that an eager amateur simply isn’t going to bootstrap it in six months. (If you want to go all Canticle for Leibowitz and spend years in the basement poring through Guyton, Netter’s, and Harrison’s by candlelight before emerging as the next Sir William Osler after the collapse, be my guest and let me know how it goes.) I do see some value to obtaining these resources and using them to recruit and equip physicians/PAs/NPs in the future. I am disgusted at the level of non-preparedness among medical professionals who should know better. I kid you not, my medical students shirk from buying stethoscopes, otoscopes, and other basic tools of the trade because “they’re expensive, and besides, I’m going into radiology.” You’re already going hundreds of thousands of dollars in debt and you can’t be troubled to spend an extra $500 to equip a black bag so that you can be a general physician first and specialist second? You just demonstrated that you never should have been admitted to med school in the first place.

I could go on in this vein and I won’t use this letter to recruit to the classes and organizations through which I teach. If you want to learn to be useful to yourself, your family, and others, get this book, read through it carefully, then come to me and ask for more:

https://www.amazon.com/Medicine-Outdoors-Essential-Medical-Emergencies/dp/0323321682/ref=sr_1_3?ie=UTF8&qid=1476216157&sr=8-3&keywords=auerbach

Less than $20 on Amazon, you cheap bastard. If you get reams of medical textbooks and equipment without the background and experience to apply it, well, it would probably stop a bullet. Or maybe not.

None of the above should be misinterpreted as a criticism of Flighterdoc’s recommendations–he’s on the same page as I am and I wish I knew him. He’s done a spectacular job of compiling first-rate resources–again, download, print, and distribute. I’m just saying that you aren’t going to be running a field hospital when you need one, unless you can recruit someone capable of doing so.

13 responses to “A Training & Education Caveat From An MD

  1. I’ve got a copy of Field Guide to Wilderness Medicine by the same author.
    I’ll check the suggested book out as well-no one in their right mind should complain about 20 bucks for something that could save their life-or the lives of loved ones.
    Now’s the time to get training-otherwise by the time you need it- it will be too late.

  2. I think this was a great example of criticism without negativity. We need more of this in the movement.

  3. Recruiting an ER nurse or doctor into your group would be a good idea that is easier said than done.

  4. Alfred E. Neuman

    Reblogged this on ETC., ETC., & ETC..

  5. To the author, two pieces:
    * How does the DoD train field medics in such a short period of time? Realizing of course that no medic is going to do a quad bypass, but is expected to prevent shock and stabilize patients for transport.
    * To what level should one consider training a civilian force be adequate enough for the first point?

    There has to be some rational middle ground, yes?

    • An MD responds

      drdog09,

      The reason a teachable 18-year-old of no discernible distinction consistently can be converted into a useful medic in such a short time is that the function of a medic is fundamentally distinct from that of a physician. Whereas the medic is “expected to prevent shock and stabilize patients for training,” a physician is expected to be able to provide definitive care once the patient arrives. The initial triage, assessment, and giving of life-saving interventions (hemorrhage control, airway management, etc.) can be reduced to a relatively small number of sequential steps that can be taught rapidly. This is very useful, both in the field and in more mundane circumstances, but it presupposes access to a higher level of care.

      In a civilian context, EMT training is a good way to become well grounded in the basics (and can be completed in a 14-day intensive course). My main gripe with it is the expectation that the roads will be passable, the electricity will be on, and the drugs will be restocked. That is why I encourage interested parties to seek training within the context of Wilderness Medicine–the expectation that conventional medical resources are unavailable due to inaccessibility or dysfunction. Another way to put it is, what do you do after you’ve dialed 911 and you’re waiting for the ambulance to arrive–and you aren’t certain that it will?

      Some wilderness medicine training is limited to medical professionals while other classes don’t presuppose any previous knowledge. Shop around and seize upon an opportunity when you find it. If nothing else, you will likely meet some folks who can serve as informal consultants as you keep learning. Red Cross classes are fine and better than nothing, but they can’t get past the “You, dial 911!” mentality.

      N.B. Dial 911 or go to the ER when it’s available. These are the good days when medical care is so abundant that even those who can’t afford it and are here illegally get the best with little concern for cost. I’m just suggesting that we all develop a contingency plan.

    • An MD responds

      drdog09,

      The reason a teachable 20-year-old of no discernible distinction consistently can be converted into a useful medic in such a short time is that the function of a medic is fundamentally distinct from that of a physician. Whereas the medic is “expected to prevent shock and stabilize patients for training,” a physician is expected to be able to provide definitive care once the patient arrives. The initial triage, assessment, and giving of life-saving interventions (hemorrhage control, airway management, etc.) can be reduced to a relatively small number of sequential steps that can be taught rapidly. This is very useful, both in the field and in more mundane circumstances, but it presupposes access to a higher level of care.

      In a civilian context, EMT training is a good way to become well grounded in the basics (and can be completed in a 14-day intensive course). My main gripe with it is the expectation that the roads will be passable, the electricity will be on, and the drugs will be restocked. That is why I encourage interested parties to seek training within the context of Wilderness Medicine–the expectation that conventional medical resources are unavailable due to inaccessibility or dysfunction. Another way to put it is, what do you do after you’ve dialed 911 and you’re waiting for the ambulance to arrive–and you aren’t certain that it will?

      Some wilderness medicine training is limited to medical professionals while other classes don’t presuppose any previous knowledge. Shop around and seize upon an opportunity when you find it. If nothing else, you will likely meet some folks who can serve as informal consultants as you keep learning. Red Cross classes are fine and better than nothing, but they can’t get past the “You, dial 911!” mentality.

      N.B. Dial 911 or go to the ER when it’s available. These are the good days when medical care is so abundant that even those who can’t afford it and are here illegally get the best with little concern for cost. I’m just suggesting that we all develop a contingency plan.

  6. Anyone who can seamlessly reference Canticle for Leibowitz has gotta be legit.

  7. Thanks very much to the poster…and please PM me @ flighterdoc@gmail.com

    And yes, you are 100% correct. Too many folks seem to think that getting a commercially packed CLS bag and a copy of Emergency War Surgery (that they may have leafed through, but didn’t begin to comprehend) makes them GTG for treatment post SHTF. You’re not, and a CLS bag is almost certainly the wrong stuff for the VAST majority of what people will be needing.

    Reading all the medical textbooks in the world will not make a person a physician. It takes a basic grounding in the medical sciences, with lots (8000 hours or so) of very focused training and experience, just to get to put MD after your name. Actually learning how to be a doctor after that…well, thats years and years more (20+ for me, I started late, and I’m still learning).

    So, it’s time to learn, and we will be going into that in the coming months. Stay tuned….

    • An MD responds

      Dear FlighterDoc,

      I’m thankful that we are in agreement. After you clearly went to so much effort to assemble a judicious bookshelf of medical resources, I hesitated to say anything, but I’m glad I did. Hopefully, this can become an ongoing dialogue.

      One thing about books and resources, the assembler and current owner is not necessarily he who will make a use of them in the future. From that perspective, I would love to see your information obtained and stored even by those who don’t know the difference between and oral and a rectal thermometer. While it may be difficult to wake up medical professionals now, I suspect that a lot of them would be overjoyed to be given access to printed references and equipment in the future if they need them.

  8. True, but…
    1) While I wouldn’t presume to speak for Flighterdoc, the idea wasn’t to try to have anyone homeschool themselves into becoming a physician. Nor even a witch doctor ersatz version of one. It was to give a list of resources adequate to appreciate the task, as well as assemble – or begin to – the resources so that the knowledge of medicine would not be lost in perpetuity, and to begin to be able to provide a higher level of care than what you’d get from the local VFD or ambulance company EMT at 2 AM at the side of the road. Any improvement on medicine from an aid bag – which is the entry-level ante for the game, not the destination – is progress indeed.
    2) In many cases, first aid alone will become Last Aid, if it’s all there is, and you have no higher level of care to hand off to, nor any way to accomplish that higher care yourself.
    3) A field hospital is exactly what you’ll have, like it or not, and be running, if what anything like what we might expect comes to pass. (If you’ve been in a regional disaster, you’ve already been to a come-as-you-are party or two already.) What you won’t have is the current version of County General as it exists today in any city of >1M souls. Given that reality, and possibility that you may be looking at any number of eventualities, from personal catastrophe to general societal collapse, and everything in between, being more prepared rather than less is the proper orientation for everyone.
    4) I would rather have 5 people – esp. starting from the prepper mindset – out of 500,000 or 5,000,000 who went all in, maybe even deciding to attempt nursing, PA, veterinary, dentistry, pharmacy, or medical education, than to only see 500 out of that number get to the wilderness EMT level. (Obviously, I’d like rather more of both types, while we’re wishing). IMHO, people will rise – or just lay there – according to the general expectations, and the limits of their own knowledge base. In that light, the more you know, and the more you understand what you don’t know, the higher the bar is raised, and the farther away the ceiling is.

    If anyone knows better ways to motivate people to get on the ladder and start climbing, by all means bring it forth.

    And the point of the exercise isn’t to hoard books alone as a substitute Doc In A Box, it’s to combine knowledge, and tools, and sufficient training to utilize same, to gain a better capability, in medical treatment just as in any other field.

    I understood the library suggestions as intended in that light.

    And given the bona fides of the correspondent, there is plenty of room for further contributions from same. The dearth of expert contributors from the field, which he so sagely noted and regularly observes, is not unheard of on these pages, and no one willing to fill sandbags will be turned away from this levee-building party.

  9. outlawpatriot

    Like I said, there are gonna be some things you’re just gonna have to walk away from.🙂