Saving lives should not require permission

John Hunter set a better example. He tested ventilation on animals and saw that when breathing stopped, the heart weakened and then stopped too. When ventilation started again, the heart could recover. He did not use bloodletting, emetics, or tobacco smoke. His use of bellows to help people breathe became common, but later it was found that too much pressure could hurt the lungs.

In 1837, the Society stopped recommending bellows ventilation because it could damage the lungs.[1] This process is important: try something new, use it, notice problems, rethink, and change course. The bellows were not kept just because respected people liked them. When harm was clear, the advice changed. That is how medicine should work.

The Societies tried using electricity before anyone really understood how the heart's electrical system worked. Luigi Galvani had shown that electricity could make muscles contract, and in 1788 Charles Kite described using electricity to try to revive people. By 1795, the Humane Society of New York had a method for sending electric current through the heart area of someone who seemed dead, more than a hundred years before doctors fully understood ventricular fibrillation.[1]

In medicine, practice often comes before full understanding. Today, we like to think everything moves neatly from lab discovery to trials, guidelines, and approval. But often, doctors notice that something works before they know why. An observation is not proof, but it is often the start of proof.

The best stories were always about people, not equipment. James Parkinson (yes, the same Parkinson whose name is now linked to a disease) got a silver medal for helping save someone in 1777. Czar Alexander I supposedly helped with resuscitation for three hours after a Polish peasant was pulled from the Vilia River. Mrs. Ann Newby, who ran the City of London Lying-in Hospital, was given a medal in 1802 after saving 500 newborns.[1] Five hundred babies got a chance at life because she had the knowledge, courage, and heart to act. She wasn't looking for fame; the lives she saved were her legacy. This is what the Humane Societies stood for: life-saving knowledge is for everyone, and its true value comes when one person uses it to help another.

A protocol has no conscience

I have spent more than four decades in emergency departments, intensive care units, and hospital wards. I have participated in resuscitations in which protocols were indispensable. When a patient loses a pulse, chaos is the enemy. Chest compressions must begin. The rhythm must be identified. Defibrillation, medication, airway management, and the search for reversible causes must proceed in an organized fashion.

A good protocol helps a team move as one when seconds matter, and no serious physician should dismiss that achievement. Modern resuscitation is one of the clearest examples of standardization saving lives.

But the algorithm has limits. It cannot see the patient's face, know the sequence of events that preceded the arrest, interpret the significance of a sudden change in skin color, or recognize that a familiar pattern does not fit this particular person. It cannot decide whether the cause is a pulmonary embolus, a tension pneumothorax, profound hypovolemia, a toxic exposure, or something no one considered when the code began. It cannot tell a physician when one more cycle is persistence and when it has become the prolongation of dying.

I have followed resuscitation protocols while simultaneously departing from the mental comfort they can create. The protocol organizes the work; it does not assume responsibility for the patient. When the code ends, the algorithm does not face the family. The physician does.

Sepsis offers another example. Early recognition, prompt antibiotics, cultures, hemodynamic assessment, and rapid support are essential. Protocols helped hospitals identify sepsis earlier and made dangerous delays less acceptable. Yet a septic patient is not a standardized container into which a predetermined volume of fluid can be poured without thought. An elderly patient with severe heart failure and renal dysfunction may not tolerate the same resuscitation strategy as a young adult with profound dehydration.

I have stood at the bedside trying to restore perfusion while also watching the lungs, the neck veins, the urine output, the blood pressure trend, the lactate, the bedside ultrasound, and the patient's response to each intervention. The question is never simply whether the bundle was completed. The question is whether the patient is improving.

The history of early goal-directed therapy for septic shock is instructive. A highly specified protocol once became the standard that institutions were urged to reproduce. Later, three large multicenter trials, ProCESS, ARISE, and ProMISe, found no survival advantage for mandated early goal-directed therapy over contemporary usual care.[3-5] This did not prove that early recognition or resuscitation was unimportant. It showed that ordinary care had evolved and that the exact protocol was not a universal law.