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Physician Misconduct. Chapter 2. The Massacre of the Innocents.

There may be no other event that so inflames fury and intense sadness as the concept of innocent people, especially children, being injured or slaughtered. I think this reaction is centered in the primordial brain, because the visceral reaction is so intense.

The original Massacre of the Innocents is the Biblical tale of Herod the Great ordering the slaughter of all male children under 2 years of age in the region of Bethlehem around 0 CE. It turns out this is currently considered a Myth by both Herod scholars and Biblical scholars... So this is an early historical use of propaganda, in this case by early Christians, to engender the most core central reaction in humans. Slaughtering children is the essence of pure evil: on a large scale the Nazis did this, more recently on large scale in Ukraine. Most recently on focal scale in Uvalde. Not only is the crime the most evil; but the deliberate effort to not prevent it is inexcusable, in many circumstances involves a combination of cowardice, stupidity, dishonesty, cover-up and sheepleness. These same 5 properties actually explain why most people do not speak up when bad things are happening in health care, and why most administrations initially try to cover up misconduct. It is the same story throughout the world and across time.

In medical terms we usually coat it with the expression unacceptably high mortality rate. Generally this occurs in situations where physicians are engaged in true life or death situations, which generally is surgery or very invasive procedures such as cardiology and interventional radiology. Generally the 3 factors involved are: incompetence, impairment (alcohol/drugs), and deliberate mal-intent.

The last category is the rarest, where the physician is actually a true psychopath and deliberately intends to harm or kill the individual. These are the doctors that are generally labelled Dr Death: and these have been neurosurgeons, cardiologists, and general physician psychopaths., These achieve the greatest recognition in books, movies, tv shows because of the fascination the general public has for true monsters. The text-book example is Dr Michael Swango, written about in a couple of books including Blind Eye, by James B Stewart. The description of the cover-up by the State University involved in some of the killings is worth paying attention to. The playbook of deliberately incompetent investigation and cover-up, that other centers replicate to this day. Many of the well known health care psychopaths have not been medical doctors, but nurses (Germany), respiratory technologists (USA), retirement home nurses.

This fascination with killing, though turns to revulsion when it comes to children. In recent years two major children cardiac centers came under scrutiny (in Florida and North Carolina) because of their unacceptably high mortality rates for cardiac procedures. When dealing with patients who are already principally very ill, such as children with serious cardiac malformations, it is very important to pay critical attention to their pre-existent prognosis for survival. To do this well, requires a remarkable level of knowledge of medicine and an unbiased view. These two properties occurring together are actually very rare, reflecting how modern medicine and modern medicolegal medicine have evolved. This relates to why one of the most important recurring themes I use is the importance of unbiased medical experts. This is at the core of the concept of transparency and accountability. This is why I strongly believe that all medical experts on medicolegal cases should be agents of the court and not of opposing plaintiffs and defendants. Simple change, an enormous impact. Much like all other developed nations have found banning military-style weapons from public use has resulted in dramatic decline in mass murders. These two pediatric cardiac programs though also had unacceptably high death rates for procedures that should not have a high death rate. Without having studied them in detail, incompetence seems to be at the core. Just because a doctor is a surgeon does not make them a good surgeon, it requires among other things remarkable dexterity, and calmness under stress.

The most underappreciated, largely because probably the easiest to cover up, is the role of drug or alcohol impairment as the root cause of medical misconduct.

In recent years a few reliable sources have shown that medical error is the 4th or 5th leading cause of death in the US. This assessment though also has to be treated with care. There is an enormous difference, the most enormous difference, between missing 1 dose of a drug like digoxin in an individual with already a very poor prognosis and limited life span with advanced cardiac failure, and someone who is perfectly healthy, having a simple procedure, then dying. It is critical to not rush to judgment, because on the surface it may look straightforward, but there could be an underlying defect like a hereditary clotting disorder.

Another recurring them I will return to is the stratifying of risks and stratifying of injuries. These require incredible knowledge and a considerable ability to be unbiased.

One of the major problems in our current health care system is that by and large physicians have abrogated their responsibility to determine outcomes and injuries, which then has been readily picked up by attorneys and health care writers for newspapers, magazines and tv. So decisions are often made purely for financial reasons (lawyers) which are most often poor financial decisions, or by news reporters who are not schooled in medicine who do not have a solid knowledge of risks and outcomes. Events are described if the news organizations believe they will appeal to their audience, rather than of the true importance of them.

The other aspect of small children is that up to 100 years ago the mortality rate in children under 2 was very high, depending on the infections epidemic at the time, poverty level, or social turbulence, generally in the 30% range. So death of an infant under 2 years of age, has to factor in the essential fragility of very young children. Very bad diarrhea in a 6 year old may be a problem, in a 1 year old it may be fatal, and no one is to blame. Not the parents, not the nurses, not the doctors.

It seems that many of the psychopaths in health care dealing with children may be those with the most contact with very sick neonatal infants, mostly prematures (premis). These are the very few NICU nurses with a psychotic vision of being an angel or mercy. Looking at these though from a cool unbiased perspective, the prognosis for very sick premis is generally poor, so this is not the killing of a child who otherwise is very well, sitting in school with dreams of becoming someone positive in later life.

Psychopaths are clever and are good at hiding their tracks, but they really are very rare. Competency is a major factor in misconduct, but even for an expert evaluator, competency often is difficult to judge unless it is blatant. The one factor that is relatively poorly addressed by most centers, but relatively easy to address, is impairment. There is an unknown number, but tragically I suspect relatively high number of alcohol or drug-impaired doctors who cause considerable harm to patients. Perhaps the best solution for this problem that I am aware of: In the University of California System there is a rapid response team that is dedicated to coming to the scene if a health care worker believes another health care worker is impaired, and will on the spot test them for alcohol and drugs. As with most things there has to be safe-guards that individuals do not use this service specifically and solely to attack their enemy, so there must be measures of accountability in place that this does not occur. This would have an enormous impact on this most critical of medical misconducts. All major health care systems should have this in place.

There is nothing more heart wrenching and anger invoking than the massacre of the innocents, in all situations in which that occurs. All parties that have somehow contributed to it, must be held fully responsible with aggressive legal weighting.

There is nothing worse than the death of a child, and this includes in the healthcare. system, Health care though is no different than other circumstances where a child is under an authority situation,. Transparency and full accountability is essential. It is critical to have the medical knowledge and unbiased view to see what has transpired in a most accurate fashion, and not rush to judgment. Physicians should not out of cowardice abrogate their roles to speak up when they witness true misconduct. For too long the role of those in an administrative position, turning a blind eye/ covering up, have been held blameless. This has to change now..

Richard Semelka, MD