No Black Swan

As we reach an asymptote on the Covid-19 graph it is worthwhile to look back and see what was done well and what went wrong. First, many great doctors and nurses stepped up to the plate and served their patients and communities exactly in the same way that they did prior to the pandemic. They showed up to work every day, put their heads down, worked hard, didn’t complain and as wave after wave and new variants of the virus emerged, they continued to work. The nurses and doctors in our community never backed down, but early on they began to recognize the lack of leadership both within their institutions, and at various levels of government and within government agencies, the lack of transparency, accountability, and honesty that ended in poorly constructed Clinical Standards of Care (CSC) directives that were contrary to the ethics and codes of their professions. I have talked to hundreds of doctors and nurses who became conflicted when they were told families couldn’t be involved at the bedside when discussing end of life issues, advanced directives, or even receiving last rights and dying. Can we even begin to understand the lack of humanity demonstrated by the people who promulgated these emergency rules and orders? What was the moral, ethical, or spiritual predicate for their directives—there was none? Professionals—doctors, nurses, technicians who looked upon their service to patients as a vocation became disillusioned.

Sun Tzu in The Art of War states that wars and battles are won and lost before they are fought. Almost 20 years government leaders in Idaho approached the IHA/IMA all the major hospitals in Idaho about planning for mass casualties and pandemics. Over the years because of petty professional and economic jealousies nothing was done. The project was put back into the hands of government agencies and a governance structure with a Board was developed but not until the onset of the pandemic, had a process for triage and mass casualty care been put forward. Rules for a “trauma matrix” were promulgated but never enacted into law. On December 20^th of 2020, a “Temporary Order” was issued establishing for the implementation of CRISES STANDARDS OF CARE. The legislature has never reviewed this “temporary order” as required by law. The hospitals in Idaho at the same time began to promulgate “Clinical Guidelines” to define the scope of practice during a declared crisis. Many issues surrounding these two directives remain unanswered. What is the definition of a “CRISES”? When does one come out of a “Crises”? Is there any economic advantage for providers or limitation of legal liability when an institution asks the STATE to declare a (CSC)? Are patients’ rights and end of life issues respected under such orders? Are physicians allowed to deviate from protocols defined under such orders? Do administrators and government bureaucrats assume a position of agency, inserting themselves between doctor and patient and who is accountable to patients and families under such circumstances?

The people who have led the State’s response over the past two years have failed the people of Idaho. I believe Dr. Hahn has performed her duties appropriately. Advising decision makers and providing information and options is her job. But the deficiencies in the actions of the Governor’s Board, members of several District Health Boards, The IMA and IHA and hospital administrators who called for the initiation of (CSC) have been more than disappointing. Just ask the people who work for them. It all began without recognizing the critical role of nurses during the past two years. Why was an ER or critical care nurse not on the Governor’s Board?

As opined in an article in Medscape yesterday “As healthcare workers continue to weather COVID-19’s ups and downs, there is a determinant of job satisfaction unrelated to pay, benefits or time off: “Have my leaders shown up in a real, meaningful way?” Their answer—a resounding “No”..

The article further explains—Megan Ranney, MD, a practicing emergency medicine physician and associate dean for strategy and innovation with Brown University School of Public Health in Providence, R.I., told me last month that the health systems she’s seen best weather COVID-19 are those where leaders are in the trenches with the front lines. Systems that have had the toughest time have leaders who don’t understand the real pain point’s people experience.

She pointed in the article to other non-physician leaders in healthcare who have excellent reputations for standing behind — not in front of — their teams, and upholding staff concerns and well-being as critical to providing good patient care. “Versus C-suite folks who really are only focused on the bottom line,” Dr. Ranney distinguished. “They see the complaints from workers as distractions” They cast doubts on contrarian points of views even when given by well credentialed physicians and clinicians and scientists and backed up by credible clinical peer reviewed studies. Such people are not only weak leaders but possess’ inadequate personalities for leadership.

In the book BLACK SWAN written by Nassim Nicholas Taleb a “Black Swan Event” is described as a large-scale event that is impossible to predict. We do not recognize these events because we are looking for them to be manifested within the context of our own experiences. In retrospect we might believe that we saw them coming, but we “missed the snap count”. We are now being told by the very people who missed “the cadence” that Covid-19 was such an event. It absolutely was not. “Alibies destroy character” and weak men make excuses instead of accepting responsibility for their mistakes. Mistakes were bound to be made. At best this was a new situation, not an unpredictable event. Things like this will happen again. We should learn from our mistakes and not hide behind them.

Time to start planning for “new situations” so that we may be ready if we are ever hit with an “unexpected large-scale event”. Let some real-life doctors and nurses be part of the planning. They know what is really going on.