Emergency medicine, art, and measuring revenge

Six whole months after my first postings, and I can’t say that I have been deluged with enthusiastic support of my proclamations. Yet I persist!

Perhaps a more practical observation is in order. Not much science in my scienceblog. The practice of emergency medicine (EM) is an art. I hope that our practice is informed by science. Academic emergency physicians in big teaching hospitals have the responsibility to base their teaching practice on best evidence and disseminate the science of EM. Yeah, yeah. But still, statistical probabilities are no more than that. And we just trust that our attendings know best. I am a resident at Johns Hopkins in emergency medicine, but only for 6 more days. I am graduating.

Last night I worked overnight. 7pm Monday to 7am Tuesday. One man was stabbed in the back and robbed. The wound was superficial and he had no pneumothorax on chest xray. The laceration was really asking for good old simple interrupted stitches. My attending (boss) asked me to put absorbable stitches under the skin. I didn’t want to do it. Science would say that type of closure is at greater risk of infection. But he was going to a Caribbean island in a few days, and didn’t want to bother seeing a doctor while he was there. We gave him what he wanted.

When science can provide guidelines based on best knowledge at the time, it can lead the way for improving emergency medicine. When guidelines become edicts enforced by [threat of] malpractice, they go to far. Large group practices must be vigilant to ensure that best practice guidelines do not become malpractice puppet strings. The way of rigid thinking lies a robot doctor.

And to bring this ramble back to the subject at hand: dynamic systems analysis and modeling in the social and medical sciences. My patient was actually a native of the same Caribbean island that he was leaving for the following week. He said it was a planned holiday, but I wondered. Some young mugger had stabbed him outside his little shop in east Baltimore. Perhaps his victimization made him want to get home as soon as possible. Flight, not fight. No doubt it was a wise choice, but does this one man’s behavior resonate with any more fundamental group human behavioral and cultural adaptations? I think it does. Why not be furious and seek violent revenge? What makes the difference? Did my guy have a lot to loose? Had he been victimized before? Those factors should be subject to some measurement and perhaps intervention, shouldn’t they?

How do groups of people react to being victims of violence? Do they even act like individuals? When suffered and insult, does the group retract or advance? What other factors determine whether or not a clan digs in and prepares a defense or goes on the attack with a view to punish? Relative perceived strength surely must account for most of the variance not accounted for relative perceived insult. My patient was actually a huge man but the assailant was reportedly a skinny guy. But, that may be contrary to my point, but you can you design an experiment to test this? You can create a model that describes group aggression as a product of insult to the group and relative strength of the group and the aggressor. Do stronger countries react militarily to smaller acts of violence? Are weaker countries slower to anger? Does the big kid in kindergarten turn into a bully because he can physically punish even small insults with little risk to himself?