If this seems hastily written, I'm sorry -- I'm sitting on an airplane right now, and while I function just fine at 38,000 feet, I'd like to get this out of the road and enjoy the rest of my flight. (That, and they're serving lunch in about half an hour.)

There isn't a whole lot to write about this week, but I do have a lot to say about the few points that stuck out in my mind. First, let me say I don't know anything about cochlear implants, and so I'm going to stay out of that debate. (I may not know anything about the implants themselves, but I have a pretty good grasp of the arguments for and against; all you really have to do is read alt.tv.er these days and that'll do nicely.)

Up on the chopping block first is Mark and his "adrenaline rush." I'm going to say this very slowly: You -- friggin' -- idiot. Before I scream myself hoarse over this, a bit of background. During the summer on the newsgroup, we had a long debate about the incident in Chicago where a kid died a few dozen feet away from the front door of a community hospital emergency department. There were, as in most debates, two sides to the argument; one side said that the doctors and nurses were responsible for his death because they should have "done something." The other side (and the one I was on) said that there wasn't really much they could do for a variety of reasons, foremost among them that it was an uncontrolled scene.

In plain English, an uncontrolled scene means a place with unknown dangers and hazards to life and limb. A few weeks ago, I commented on Pickman's apparent lack of understanding of one of the cardinal rules of EMS: "If anyone has to die from on-scene dangers, it should be the patient, not you." Uncontrolled scenes suck. There could be toxic chemicals floating around, cars who don't know you're there (or don't care, which is far more likely), and people with guns and knives and a grudge against you for no particular reason. EMS is a dangerous line of work, but you take steps to mitigate that danger -- just as a (properly trained) fire fighter would be reluctant to enter a burning building with turnout gear and a self-contained breathing apparatus, so too should a paramedic or EMT think very hard about entering an uncontrolled scene.

There are two very good reasons to not do this, one selfish and one pragmatic. The selfish reason is that you might get yourself killed, and most people don't want that. The pragmatic reason is that if you get yourself killed, you won't be able to help the people you're supposed to. Your partner(s) have to drop what they're doing to come look after you, and you're absolutely no use to anyone with several holes in your chest, unconscious, or dead.

So you need to be cautious.

For a guy who's supposed to be setting policy, Mark isn't so clueful on the existing ones. Sprinting into an environment where you know there's been gunfire to recover a patient is just damn stupid. There is no excuse. It sounds cold, but what choice do you have? I don't get paid enough to risk my neck for every patientout there -- if I wanted to do that, I'd go become a search and rescue technician for the Armed Forces. (And I could have my helicopter, which is older than me, blow up at irregular intervals, but we won't go there.) Being able to do my job properly means that I'm not going to get my ass kicked by an irate bystander or combatant. Generally speaking, this involves having the police at all violent crime scenes or where there are emotionally disturbed people. They tend to take a very dim view of anyone assaulting paramedics or fire fighters and will go out of their way to make sure that everyone knows not to not mess with their fellow public safety workers. (The "agreement" is reciprocal; I know I've said in the past that you treat in terms of priorty based on injury and illness, but if I've got an injured police officer or a fire fighter on my hands, I'm going to deal with them first.)

The problem, as I see it, is the hero complex. If a guy dives off a bridge to save a drowning child, he's a hero in the eyes of the media whether he succeeds or not (for whatever your definition of "success" might be in this case). To the people who do this sort of thing for a living, he's an idiot; if he lives, he's also a very lucky idiot. EMS is hazardous enough to not depend on luck. There's a saying in standard first aid classes: "Don't make their emergency your emergency." Very true. Don't try to be a hero by doing something stupid.

Mark was not only wrong, he was dead wrong, and he's damn lucky he's not dead, period.

(And for the record, I never, ever, give money or my phone numbers to patients. I'm in the book, and they can probably get the phone number for the hospital without much difficulty. To paraphrase Benton, "We're here to treat the patients, not be their friend." This doesn't mean I'm not nice to my patients, and I don't try to be as friendly as I can, it just means that the relationship stays based in medicine and not in sentiment.)

On Accutane and birth control: I don't think it has anything to do with trustworthiness on the part of the patient, the colour of their skin, or anything else. It comes down to litigation. Doctors and hospitals don't like litigation; one of their primary activities in life is avoiding lawsuits. If a patient taking Accutane gets pregnant, carries the child to term, and then delivers with multiple birth defects, it is not inconceivable that the parents would want to sue the hospital and physician for prescribing a drug that is specifically contraindicated in pregnancy. Knowing the United States, they probably would file. Prescribing birth control pills is something of a legal insurance policy against potential litigation -- it won't prevent a lawsuit, but it will drastically reduce the chances of a finding against the institution. I'm all too aware of the problems with non-compliant patients -- you know, the ones who ask for an antibiotic script and then don't take any of the drugs, or the ones who don't come in for follow-up visits. There's no guarantee that the patient will take their birth control pills, but even if they don't, the simple fact that the script exists and was written demonstrates that the physician took steps to at least attempt prevention of a bad outcome.

Watching that initially, I hadn't figure that it would be such a contentious issue, but apparently, it was for some people. It's legal insurance, plain and simple.