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The Emergency Physician as Fighter Pilot (Sort of)

2003; Lippincott Williams & Wilkins; Volume: 25; Issue: 10 Linguagem: Inglês

10.1097/00132981-200310000-00034

1552-3624

Edwin Leap,

Trauma and Emergency Care Studies

I spent several years as a flight surgeon with the Air National Guard and Air Force Reserve. Although I became inactive due to family and job concerns, those were some fun years. I had the pleasure of serving my country and the added enjoyment of learning a unique body of knowledge when I attended the Aerospace Medicine Primary Course at Brooks Air Force Base in San Antonio, TX. I had the further pleasure of flying several times in the back seat of the F-16 D aircraft, which was part of the 181st Tactical Fighter Group, INANG, Hullman Field, Indiana. I came to appreciate the complexity of flying a fighter aircraft. I had no delusions that I was a pilot. I was not and am not a pilot of any airplane whatsoever. But watching the pilots at work engendered real respect. I learned about the medical and operational issues of fighter aircraft when I was in flight medicine school. I saw it firsthand when I was attached to a fighter unit. A combat pilot is faced with enormous challenges. It is his job to safely pilot a multi-million dollar aircraft in harm's way, accomplish a given mission effectively, avoid causing harm to innocents, and all the while stay alive in an environment that is full of danger from enemies and nature. I could never have done it. Most young men, myself included, have at some point fantasized about being combat pilots. The truth is, though, it would have been far too stressful for me. And my command of physics is rudimentary, while my mastery of engineering and electronics is almost entirely absent. Worse, I can get lost in a circular driveway. Piloting an F-16 would have been a poor career choice for me, even if I had decent vision. On the other hand…. How much different is what I do? I wear a cool blue scrub top instead of a cool flight suit. And instead of flying at Mach 2 over foreign combat zones blowing stuff up, I sit in the same four-cornered department year after year, occasionally intubating and resuscitating someone, but mostly handing out narcotics or trying to avoid handing out narcotics. But in fact, there's a pretty strong analogy here. Bear with me, please. The analogy has to do with a thing called “task saturation.” This was something we talked about quite a lot in my flight medicine course. What it means is this: A combat pilot is faced with an overwhelming amount of physical and intellectual challenges when flying. And at a certain point, he can't add any more. I referred to some of the challenges already. He is faced with an aircraft of shocking complexity, as well as a dizzying number of gauges and dials, among the most important being his altitude and attitude indicators, his airspeed indicator, his fuel gauge, his various weapons systems, his compass, his radar, and the systems that tell him if someone else has targeted a missile in his direction. As he watches all of these indicators, he is simultaneously scanning the sky for enemy aircraft, the horizon for hills or towers, scanning the ground for surface-to-air missiles. He is keeping visual contact with other pilots in his flight. At night he is trying to make sure those are stars overhead, not lights on a hill below; it's easy to get an aircraft upside down in the dark or in bad weather. And he is thinking about his family, wondering if he might die. When he encounters the enemy, he is attempting to fly into a position from which he can kill the enemy, preferably by being behind his target. So he is turning his aircraft in high G-force maneuvers that threaten to leave him unconscious as blood drains from his brain in the turn. His G-suit inflates and squeezes his legs while he bears down, grunting to keep oxygen upstairs, turning on his 100% emergency oxygen flow to help him along. As he does this, he still checks gauges, he still maintains awareness of the entire aircraft and of his entire surroundings. As he strains, he attempts to lock his weapons, missiles, or guns onto the enemy. Hopefully, he gets his prey. Hopefully, he doesn't fly into his friends, or blow up a school on the ground with a miss. Hopefully, he goes home to fly another day. This is task saturation. Now it may sound a bit over-dramatic to compare emergency medicine with this scenario. And it is. Most of what we do isn't nearly this sensational. Of course, most of the flights that pilots take aren't either. They're the aerospace equivalent of treating head colds. But in both emergency care and flying, task saturation is real. For us, it goes like this. In room 11 are four Hispanic children. Neither they nor their parents speak any English. Three have colds. The youngest, 7 weeks, has a high fever. A septic work-up is in order. Where is that translator? Where is that number for ATT's translation service? The secretary would get them, but she's filling out the EMTALA paperwork to transfer the head injury that your partner has been taking care of for the past hour as charts piled up in the rack. How do you demonstrate “lumbar puncture” in the language of hand motions and the few bits of Spanish you know? But you don't have time. The triage nurse just brought Mrs. Sharp back, struggling to breath through the fluid that is filling her lungs for probably the 10th time. Respiratory will be down to help as soon as they finish the code blue in CCU. Mrs. Sharp stops you, and signals that she doesn't want to be intubated. But she's confused. You want to speak to her family doctor, but he isn't on call, and the doctor who is doesn't know her from Adam's housecat. Does she have an advanced directive? Her daughter arrives: “Do everything, I have power of attorney! Don't let mama die!” The nurse reminds you that before Mr. Packard can be discharged, you need to fill out his worker's compensation form, and he needs to leave now. But wait, you also need to talk to him about the alcohol abuse that caused his injury. A teachable moment awaits! It is, after all, department policy that this be documented. But as you walk toward his room, your LPN asks if you want to give the baby in room 19 his OPV and DTP? Her mother thinks she needs them, and since she's here…. Mrs. Sharp just stopped breathing. You intubate her, only to find that there are no critical care beds here or anywhere in the area. She'll be yours all night long. Her admitting physician doesn't want to see her because you're there anyway. Could he just call in some orders, he asks. Your partner is free now, having just transferred his head injury. He is immediately pulled back into a room where a young cocaine addict is having an MI. The police come in the back door with a disheveled, almost naked woman in handcuffs. “She's suicidal, doc. Needs to be committed!” As EPs accumulate more things to do, the fewer they'll be able to do well Of course, there is no psychiatrist available at your hospital. The patient is now lucid, and refuses permission to have her records faxed from the local psychiatric hospital. She insists on leaving. You would call her father, but what with HIPPA, you know. The Hispanic child just began to seize. You run to the bedside. The unit secretary glares at you when you ask her to call a translator again. She's currently ordering 10 tests, three ECGs, and trying to prod the nursing supervisor to find beds for admissions. It's probably a febrile seizure. It stopped, and he's nursing, but he still needs a full evaluation. You're paged overhead. On the phone is the local oncologist. He's in his office and has a chemotherapy patient with fever and leukopoenia. He knows she needs to be admitted, but could you just start her work-up? He can't do it because he has tumor conference, and of course, she's uninsured. EMS calls in. Two car MVC, two multi-traumas, 10 minutes out. The charge nurse asks, as she clears beds for the traumas, “Can we give pneumovax to some of Dr. Johnson's patients? He's on the phone, and they're on their way here.” Then, you are called to a semi-conscious teenager. “Here's the suicide note. He said he was going to take something to make sure he died!” The possibilities are large. Your brain is reaching overload as you examine him and go down the list of things you need to do to save his life. That is also task saturation. Here's the equivalent of what we put up with, translated to the world of the fighter pilot: While flying high g-maneuvers, the pilot is expected to take air samples at altitude for environmental monitoring, as mandated by EPA. Before firing on the enemy, the pilot is expected to hail him on radio and ask him to stand down, so he does not cause undue harm to anyone. The pilot is expected to offer aggression counseling intervention to enemy pilots if he does break off engagement to foster international understanding and good will. If counseling is not accomplished within 30 minutes, enemy will receive movie tickets. If the pilot kills the enemy, he will be expected to send a letter of apology to the family of the enemy pilot, expressing his immense regret that the entire event happened. If the pilot misses and injures someone on the ground, he will be subject to court martial and then to civil liability because he should never have attempted the shot if he might have missed. While at base, the pilot will devote himself to continuing pilot education and error reduction programs, including study of aggression, in an attempt to understand the dysfunction that led his opponent to engage in warfare. The pilot will recognize that he is, essentially, a bad person who is only flying to bilk the government out of money. This will all be done alongside normal operational requirements, like protecting the United States from “all enemies foreign and domestic.” Sounds familiar, doesn't it? See patients, treat patients, counsel patients, immunize patients, provide preventive dental care for patients, discuss violence with patients, apologize for not being faster for patients, stay up-to-date, understand all new medicines, be socially conscious, never judge, never complain about giving free care, give patients whatever they ask, dispense narcotics like candy, fill out forms, forms, forms! Don't be too busy, don't be distracted, don't make mistakes, don't get sued. Don't complain. Save lives, comfort the sick and injured. Do your job well and be proud. Don't be bitter. We have made a career out of being the “go-to guys.” The ones willing to do whatever it took. That's fine in some ways. It makes us the last group of doctors who always have to do the right thing. But every time we accept one more straw on our collective bundle, we get closer to breaking. Every time we say we'll do what someone else thinks we should do but for no good reason, we add just a little to the potential burnout of good physicians. We need to focus on our mission. That mission is to save the lives of the dying, and comfort and heal the sick and injured. That's what we signed on to do, not to be the whipping boys for the rest of medicine or for society at large. But as long as we accumulate more things to do with our precious time, more issues to clutter our well trained minds, then we'll just become that much more saturated with tasks, none of which we will be able to do as well as we should.