Chapter VII: The Questions Science Won’t Ask
A rule can safeguard life or outlaw judgment. From the ICU to modern science, this chapter asks what happens when systems forbid the very questions required to understand life.
Rules That Violate Function
In the ICU, I was constantly running into policies, protocols, and rules that defined what I was supposedly “allowed” to do for a patient. What I did not yet understand was that not all rules serve the same purpose. Some genuinely protect patients. Others protect institutions. It was the latter that got me every time. To everyone else, and sometimes even to me, it probably looked like I simply didn’t like rules.
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 literally the new ICU director they had recruited from New York City, where 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. Ventilators were my obsession.
None of that mattered.
It turned 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 (RT) with six weeks of mechanical ventilator training at a vocational school was physically present at the bedside.
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, in my mind, were grotesque.
Fellows in training 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 care was delayed by rules about who was allowed to touch the machine.
I was written up for breaking that rule. On my first day. Welcome to Wisconsin.
Then, a month later, I entered the room of a severely flow-starved, cyanotic patient in distress and unconsciously did what physicians are trained to do: I changed numerous settings and rescued the patient, only to have the RT walk in afterward. Later, the email arrived.
Policy violation.
Palm to forehead. Clown world.
I was so furious that I immediately set out to change the policy, and the effort consumed months. Undoing it required innumerable committee meetings and sparked institutional trench warfare. In the end, I won, but not by reason.
Someone higher up had finally, and quietly, intervened, I suspect out of fear that I would resign if the policy remained in place (I was certainly thinking about it). At last, fellows were allowed to manage ventilators. Training improved. Patient care improved.
As a result of that experience, I never attempted to change an institutional policy again.
Rules That Outlaw Judgment
Looking back, I now see that episode as the first time I encountered a system that prohibited the very knowledge it required in order to function well. This chapter exists because, during the research for this book, I kept running into a similar kind of dysfunction.
