Memorial Day was originally established to celebrate Civil War heroes in a single unified day, instead of separate days celebrated by the Union and Confederate states. Around the 19th century, Memorial Day expanded to celebrate all veterans who fought as American forces.
As physicians, we learn from one another and are united in our thirst for knowledge to better serve humanity . War, in all its ugliness and chaos, demands innovation in science and technology. Thus, it is not surprising that modern medicine seems to have strong roots during times of war. The ancient philosophers and scientists created a foundation for physicians during the Civil War to innovate to meet the demands of its wounded soldiers, but also to create standards of care that we practice even today. Here are 5 innovations that were developed during the Civil War:
1. LIFE SAVING AMPUTATION
- The old practice of saving limbs with wound cleaning using rats and maggots was replaced with cutting off infected limbs to prevent the spread of infection. In fact, Union soldiers were known for amputations, had less mortality from their procedures, and took no more than 6 minutes to perform. The technique not to cut through joints and to cut far away from the heart as possible became the standard of care.
2. THE ANESTHESIA INHALER
- Stonewall Jackson's surgeon recommended the removal of his left arm after it was injured during friendly fire. When a chloroform-soaked cloth was placed over his nose, General Jackson muttered, "What an infinite blessing," before going limp. The cloth was inefficient as the liquid evaporated quickly, so Dr. Julian John Chisolm invented a 2.5 inch inhaler. Chloroform was dripped through a perforated circle on the side onto a sponge in the interior - the patient inhaled through tubes and the vapors mixed with air. This new method required less liquid; thus, allowing the physicians to treat more soldiers and using less supplies.
3. CLOSING CHEST WOUNDS
- Benjamin Howard, an assistant surgeon, was told to do busy work while his superiors performed the surgeries. He started to experiment and realized that if he closed the chest with staples and linen, the lungs did not collapse as they did when the chest cavity is opened from negative pressure; thus, there was no suffocation. Survival rates quadrupled with this new technique. This technique became the standard treatment.
4. FASCIAL RECONSTRUCTION
Dr. Gurdon Buck, father of modern plastic surgery, looked onto a young 20 year old private named Carleton Burgan of Maryland. This private had battled pneumonia and now the mercury pills had led to gangrene that was moving from his mouth to his eyes. His right cheekbone had to be removed and the young man was willing to try anything to stop the infection. Dr. Buck was the first to photograph his progress of his repairs and use tiny sutures to minimize scarring.
5. THE AMBULANCE-TO-ER SYSTEM
- The Union went into the First Battle of Bull Run on July 21, 1861 not expecting a true battle. As approximately 1,011 Union soldiers lay wounded, the ambulances remained empty, leading to high numbers of mortality. The civilian drivers at the time were, according to some, described as "cowards" or "drunkards."
Jonathon Letterman, the medical director of the Army of the Potomac, created a model of triage that we all know today. He established caravans of 50 ambulances, each with a driver and 2 stretcher bearers. He hired private wagons to carry medical supplies. The ambulances had spring suspensions and a lock box to prevent soldiers from stealing protein, bedsacks, and morphine that was reserved for the injured.
Every war brings innovation and the medical community must not forget the sacrifices made by soldiers, scientists, physicians, and several other professionals who made modern day medicine what it is today.
In this reflection, we must ask the question, have we been effective in preserving that fundamental drive that our predecessors had to innovate to help a large number of people without regard to creating any complex systems that may interfere in allowing the injured to access the innovation?
Memorial Day should make all of us pause and reflect on the many lessons learned across all professions during our times of war. What is even more fascinating is that those lessons continue to teach us today; regardless of how advanced we think we are as a society.
In loving memory of all fallen soldiers,
Many of you might have read the book Toyota Kata, or heard of lean management. Furthermore, many may have heard about lean health care. As the principles of lean management take over organizations across many industries, we find that the most successful organizations are those who achieve integration and implementation of these principles. But, it is not these principles alone that make an organization successful. It is the organizational culture of commitment, leadership development, empowerment, and employee investment that makes the difference.
Health care has become an industry that is one giant green monster that is zapped from many stakeholders, like the government, private corporations, pharmaceutical companies, and insurance companies, all trying to get this monster under their control. But who is really out there protecting the people?
As I mature as a physician in this circus, also known as United States health care system, I am starting to realize a few things. When I was a medical director at a large health system, I saw how decisions in health care are largely led by thinking of margins before patient care. My department was not a revenue generator compared to others, but a cost savings one. But, as I continued to grow my team and expand our services, I realized that no matter how hard I tried the decisions I would make were always under the scrutiny of corporate leadership. How is this different than the practice of medicine?
The decisions that physicians make "out in the field" - in clinics, hospitals, etc - are largely guided by insurance companies, government insurance, hospital policies, and pharmaceutical companies. We often hear, "that costs too much" or "my insurance does not cover that" or "they are not in my network" or when a hospital finds out a patient is not in network, the move to a different hospital happens at lightening speed!
Kata, in Japanese, means a way of doing something, a pattern, or a standard form of movement. So as leaders, the challenge is to get team members implementing a routine without requiring constant input from administration. The idea is to have a routine that nurtures continuous improvement and adaptation. More importantly, decisions are pushed to those who are closest to the issue. So, when Toyota stops the line when a part is not put in correctly, the lights go off, the line stops, managers come over to help repair the part, others assist as needed, and the line resumes once corrections are made. This process is more efficient, has a team approach, allows everyone to adapt and improve the process immediately by correcting a routine to make it more efficient.
Health care today, uses cost benefit analysis (CBA) to the max! The problem is that the budget is a dependent variable, not independent.
Instead of CBA, health care providers and leaders must think in terms of target conditions to move towards their vision. More importantly, not only do organizational leaders must think this way, but physicians must practice this with their patients; thus, developing their patients as leaders of their health care!
Here is an example of how this works, especially in primary care. If I have a overweight type 2 diabetic, my first visit might be discussing the importance of blood sugar control, diet, and how their current medications will help them prevent further organ damage.
1st step: Understand the current situation. What is their current blood sugar control and where do they want to be in terms of their diabetes control? What does the future look like? What is their overall prognosis today if their current situation does not change?
This visit is truly about goal setting. As Charles Duhigg says in Smarter, Faster, Better, goals should be SMART (Specific, Measurable, Achievable, Realistic, Timeline).
2nd Step: Set SMART goals or target conditions to achieve the vision of - coming off insulin, achieving BMI less than 25, having an A1c< 6.5%, etc. Put a timeline together. Discuss potential barriers with possible solutions the patient can use when they might come across these barriers.
3rd Step: Meet frequently. I recommend every 1-2 weeks the first month. Reflect on barriers, solutions, and give feedback of how to improve to stay on tract to achieve the goal set for that month. This is the value of direct primary care, instead of the insurance model.
4th Step: Provide ongoing support and always keep focus of the patients vision. When the vision is realized, celebrate! Get feedback from the patient and provide them with your feedback so that they can lead others.
In my young career, I have held a few leadership positions and have been mentored by great leaders. My Master's program was fantastic and had created a good foundation to build my experiences. All my experiences and positions in health care form my current vision for my fellow Americans: Patient leaders who then lead others in achieving their quality of life.
Imagine a United States health care system that truly implemented Kata principles and SMART goals. Naturally, in this type of system, primary care becomes the most crucial aspect. It is the place where patient empowerment begins and grows. Patients as leaders of their health care must be the mindset of future health care entrepreneurs.
In my company, this is how we achieve success - develop everyone around us as leaders. Whether it be patients, partners, or staff, our focus is to develop leaders. Empowered health care consumers should not be just a term we throw around. It is time we implement this belief and it is the missing ingredient our health care needs. Otherwise, we remain broken.
To better health for all,
"He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all."