Thursday, December 6, 2012

Anti-fragility in medicine: Wartime trauma

Part I: Introducing wartime trauma medicine as an example of anti-fragility

Nassim Taleb's concept of Anti-Fragility is, fundamentally, about harnessing entropy.

Anti-fragile systems break but rebound through repair to grow and progress; they (need and) gain from disorder, from unexpected fluctuations--they evolve over time, improving nonlinearly.

Human physiology embodies anti-fragility. From our immune systems to our musculoskeletal systems, human beings' bodies (need and) gain from exposure to diverse environmental fluctuations (within limits). When our bodies finally fail--after all, we aren't 'made of steel'--our approaches to healing should embrace (in the spirit of fractals) systems of care that are anti-fragile as well (as much as possible). For instance, Nassim cites the airline industry as an anti-fragile operation: each and every error made in aviation practice receives extensive scientific study to figure out which components of the system led to the critical breakdown in that specific case and how this type of event can be prevented in the future in all cases--unfortunate negatives turn into powerful positives. In contrast, in medicine, we are just beginning to recognize our errors as opportunities to develop improved systems of care.

Notably, wartime trauma medicine integrates anti-fragility:
"Among the big challenges in medicine is taking up new stuff that works and letting go of the things that don't. My sense is that the military kind of has a handle on both," said Carolyn Clancy, director of the Agency for Healthcare Research and Quality, the federal agency assigned to finding ways to better apply existing medical knowledge.
Undoubtedly, wars are unfortunate (arbitrary lines drawn in the sand are dangerous); but, delivering medical care to people involved in them provides opportunities for physicians, surgeons, and other healthcare professionals to thinker in real-time, in the face of nuance and complexity. Sometimes, efforts to implement novel approaches to care do not work; attempts to improvise might not save someone's life. However, when serendipity strikes and clinicians stumble upon things that do work more effectively, they are integrated into medical practice quickly as part of a highly responsive system, as has occurred recently:
The conclusion: Medical treatment has gotten better over the nine-year course of the wars. Almost none of the improvement is the consequence of new drugs or new devices. Most of it, ironically, involves old technology and old practices that fell out of favor in the past 50 to 100 years and have been rediscovered and improved. 
Historically, this type of bottom-up evolution (clinical bricolage) has yielded many valuable breakthroughs in medicine. This type of progress results from, in part, numerous small-scale n=1 clinical trials running in parallel constantly during wars as medical teams try to solve trauma problems under pressure. The net result:
"Perhaps war’s greatest contribution to medicine is the chance to run public health experiments on a grand scale under exigent circumstances."
Ideally, domestic healthcare leaders could learn from these military medical experiences to figure out ways to incorporate anti-fragile systems in civilian hospitals and clinics; a process that possesses quite a precedent in modern medicine:
The effect of the First World War (1914-1918) on the development of British anaesthesia. Metcalfe NH.

Abstract: One of the greatest but also most unfortunate ironies in life is how modern medicine owes some of its existence to the deadly cancer of war. For those whose image of armed conflict is one of disease, death and destruction, this will no doubt be a surprise. However, these very conditions have allowed military surgeons and physicians unparalleled opportunities to experiment and develop using large and dependent populations of potential patients. The catalyzing effect of war has seen the ambulance, the hospital, plastic surgery, preventative medicine and penicillin as just a few products whose history is linked to war. This paper examines whether anaesthesia, and in particular British anaesthesia, can be added to this list when focussing on the First World War (1914-1918). The anaesthesia that was being practiced at the outbreak of the First World War had not drastically altered from that of the mid-nineteenth century. Old anaesthetics given via basic facemasks could be performed by many doctors; specialists were rare. This situation, however, altered during the First World War. This is because the vast number of wounded in the war demanded the introduction of casualty clearing stations to help triage and treat the wounded quickly and efficiently. The workload of these 'mini hospitals' created specialist anaesthetist posts within the military. Once in place, the anaesthetists were able to help develop the relatively new concepts of blood transfusion and resuscitation. These were recognized to be vital against shock, something that had previously not been well researched or understood. While at the casualty clearing stations, Geoffrey Marshall readdressed this by studying the effects of different anaesthetic agents in varying amounts of shock. This work led to the popularity of nitrous oxide, ether and oxygen, which in turn stimulated interest in anaesthesia machines. Finally, the treating of facial wounds in casualties at the Queen's Hospital for facial and jaw injuries at Sidcup, highlighted the possibility of endotracheal intubation, a technique that had a drastic effect on the administration of anaesthetics. Although there were no new wonder anaesthetics, something which would not occur until the neuromuscular blocking drugs of the 1940s, many of these concepts moved into civilian anaesthesia and enabled British anaesthesia to be at the forefront of anaesthesia development for much of the twentieth century. 
Interestingly, these 'mini hospitals' illustrate well Nassim's point that small, adaptive institutions gain greater exposure to the envelope of serendipity because they possess the flexibility necessary to innovate creatively and harness entropy.

I'm just starting to flesh out this connection; where it leads remains to be seen.

Amidst the unseen is where serendipity seeds.

To good health,

Brent

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