Chapter IV: Walking Into Teleology
A story about ventilators, forbidden questions, and the scientific boundary that quietly outlawed “why.”
The Door I Opened Anyway
I have been opening doors I was not supposed to open for most of my career.
In the ICU, I will call those doors policies, protocols, and rules, presented as immovable boundaries around what I was “allowed” to do for a patient. At the time, I did not yet have language for the difference between rules that protect patients and rules that protect institutions. To everyone else, and sometimes even to me, it probably looked like I just didn’t like rules.
That wasn’t it.
What I reacted to, instinctively and viscerally, were rules that violated function.
The most absurd example I ever encountered came on my first day running an ICU at the University of Wisconsin.
I walked into a patient’s room and did what I had done thousands of times before. I checked the ventilator: synchrony, pressures, volumes. The patient was struggling. I made a few adjustments.
When I turned around, the room had gone silent.
Faces were pale. Eyes were wide. Someone finally said it.
“You’re not allowed to touch the ventilator.”
This wasn’t because I was a trainee. I was the ICU director. I had spent a decade teaching mechanical ventilation to pulmonary and critical care specialists. I had read Martin Tobin’s Principles and Practice of Mechanical Ventilation, twice. The thing was the size of two Bibles. Ventilation was my obsession.
None of that mattered.
It turns out that the ICU I had accepted leadership of had a long-standing policy: no physician, fellow or attending, novice or expert, was permitted to adjust a ventilator unless a respiratory therapist was physically present at the bedside.
Not supervising.
Not on call.
Standing there.
The reason became clear almost immediately. Decades earlier, someone, likely undertrained, overtired, and working in a different era, had made a ventilator error. A patient had been harmed. The hospital had been sued. Instead of fixing training or clarifying responsibility, the institution did what institutions often do: it outlawed judgment.
From that moment forward, physicians were prohibited from directly managing the single most important machine in critical care.
The consequences were grotesque.
Fellows trained to become ventilator experts were functionally barred from touching ventilators. Overworked clinicians deferred adjustments because finding an RT took too long. Patients labored, desaturated, turned red, and struggled in plain view while the system waited for permission.
I learned that several attendings had already been written up for violations. I learned that a quiet, deeply Midwestern war had been brewing, polite smiles on the surface, formal complaints behind the scenes. I learned that even rescuing a patient from an obviously mis-set ventilator could earn you a reprimand.
I was written up for exactly that.
Standing at the bedside of a flow-starved patient in distress, I did what physicians are trained to do: I fixed the ventilator. The patient stabilized. Later, the email arrived.
Policy violation.
Palm to forehead. Clown world.
Undoing that policy took months of committee meetings, political trench warfare, and emotional exhaustion. Administrators cried in meetings as if basic physician competence were a sacred object being taken away rather than restored. In the end, I don’t think I won by reason. I suspect someone higher up intervened quietly. Fellows were eventually allowed to manage ventilators. Training improved. Patient care improved.
And that may be the only institutional policy I ever successfully changed. Which is exactly why I stopped trying to change most institutional rules.
Rules That Outlaw Judgment
