Every now and then an airliner in otherwise perfect flying condition flies into the side of a mountain or crashes at sea. A review of the flight data recorder invariably shows that the crew neglected to look out the window to see what was obvious but instead became engrossed in the multitude of computer screens and indicators that make up the so-called “glass cockpit,” paying for this distraction with their lives and the lives of their passengers.
Modern Emergency Medicine has the same risks as new distractions to patient care multiply at an alarming rate. It has come to the point that, at my current hospital, three-quarters of my time is spent in front of a computer or the clipboard trying to wrestle the patient into the paperwork and very little of this time has anything to do with actual medical care.
Take, for example, ordering medications. I vividly recall (because it wasn’t that long ago) that we used to write orders on a simple green order sheet that required nothing more than a time and a signature. The patient’s allergies were entered at the top of the sheet and using a little bit of judgement I could enter even the most complicated orders quickly and efficiently. We pulled a flag on the chart to alert the nurse or just flagged her down, she drew the medications, gave them to the patient, and signed off on the order sheet with a time.
Now that we have an Electronic Medical Record ordering medications involves a complicated trip through menus and check boxes. First I open the patient’s chart on the computer and scroll to the orders section at which point begins the lengthy process of selecting medications, drilling down the menu for doses, and jumping to a separate menu to document obvious instructions to the nurses.
Medication selected, I hit the “done” button and then am lead through a byzantine socratic dialogue as the program spits pages of information detailing all of the possible interaction of the medication with every other medication the patient is taking, asking me in the process several times for each medication if I am sure, really sure, really really sure I want to order it. And I’m not talking about allergies to that class of medication; today I must decide instantly if the risk of some very rare side effect that I have never heard of and which to truly understand requires reading through two pages of information is worth the benefit; and for every interaction I decide to ignore I must enter a reason why I am being such a damn fool.
Every medication, by the way, interacts with every other one. There is no end to it.
In practice we just “hammer click” through all of it. And I typically just enter my initials in the “reason why” box. Consider that where previously it took me ten seconds to write an order, each individual order now takes three times as long and this time adds up. I currently spend an hour-and-a-half per shift just wrestling with the computerized order entry system for the 200 hundred orders I enter and this time would easily double if I was as conscientious as the bureaucrats who infest the place require me to be.
Keep in mind that paperwork is an elaborate trap designed to pin the blame on the doctors and nurses if something goes wrong. One day my flippant disregard for the check boxes is going to come back to haunt me but what can I do? To be completely and honestly compliant with all of the paperwork would slow the department to a crawl, consequently most paperwork is entirely fraudulent as it documents things that were not actually done in the strictest sense according to the rules. As I mentioned in an earlier post, the nurses whose paperwork burden is terrifying to contemplate, usually have an end-of-shift documentation klatch where all of the useless forms are filled out in an assembly-line fashion.
Orders done, I start my chart. At my hospital patient’s information is stored on two separate computer systems. One is an ancient “DOS” based dinosaur with a 1990s-style rudimentary interface grafted onto it. To obtain vital signs, allergies, and medications for the patient requires a complicated series of keystrokes after which I am rewarded with page after page of useless information through which I must carefully sift for the essential facts. In the year 2012, not unlike a Babylonian scribe, I must then copy the important information to my paper chart, itself a model of streamlined bureaucratic innovation.
Reviewing the results of lab work and tests requires another complicated foray into another system and images from radiology are on a separate machine as well. The results are dictated however and to acquire them requires a Long March through the radiology phone menu.
Our charts are pre-selected templates with check boxes ostensibly because it is easier and faster but nobody fits into the check boxes nowadays. There is no template for Headache, Cough, and Vaginal Pain, for example, and our patients seldom have the decency to have typical symptoms of common diseases. It’s to the point where, on walking out of the patient’s room, my first thought is not about their care or diagnosis but how I’m going to fit it into a chart.
Patient care, the diagnosis and treatment of medical problems is not generally very difficult. I agonize over the paperwork, however. It crushes my soul, inhabits my dreams, and is giving me an ulcer.
Not to mention that while we remain fixated on the flashing lights the patient may be flying into a mountain.
Can’t Get No Satisfaction
I went to a Patient Satisfaction Committee meeting a few months ago and never went again because it was pathetic. Sad to relate but our largely inner-city Emergency Department has been tooling along with satisfaction scores in the low thirty percents and, as reimbursement is at stake, the hospital has become somewhat hysterical about satisfying the customers. At first they implemented something called “AIDET.”
AIDET, for those of you who don’t know, is a bad joke concocted by a bunch of grifters at the Studer Group and sold to gullible hospital administrators as a formula to make patients happier. It is an expensive acronym that describes what is really nothing more than common sense politeness and it enjoins us to Acknowledge, Introduce, tell the Duration of a the visit, Explain, and Thank the patient.
The hospital spent good money on this system and the clipboardeurs strutted like petty Napoleons conducting the many seminars and classes required before the big “Roll-out,” a day that when it finally arrived was greeted with the fanfare we usually associate with launching a fucking aircraft carrier. Banners and Posters everywhere, naturally, as the party faithful expressed their love for Big Brother and the atmosphere was decidedly oppressive, almost Stalinesque.
The medical staff were exempted from the training. Since dissent is not tolerated at my hospital the administration is very careful about offending the doctors, most of whom have legs, are doing the town a favor by working at the hospital, and can get jobs elsewhere pretty quickly. Nothing worse than carrying your clipboard into a meeting and being laughed at by a bunch of doctors.
They never consulted the Emergency Physicians about the thirty-minute wait-time guarantee for the same reason.
So the big roll-out came and nothing. Nada. The patients don’t care. The hospital is still understaffed, still filthy, still has a primitive laboratory that cannot get the results of simple labs in a timely manner, and still has long wait-times.
Additionally, when two-thirds of your patients are looking for narcotics, work notes, or miracle cures to mild, self-limiting illnesses there is nothing that will satisfy them but capitulation or divine intervention. I could double the satisfaction scores by simply giving everybody a complementary thirty-days of Percocet or a Z-pack for everything but so far the administration had not asked us to do this, at least not overtly.
So I went to the meeting and although I was treated politely I was as welcome as your crazy Uncle Milt who is not allowed to live within 600 yards of elementary schools. The Facilitator listened politely to what I had to say but only because she didn’t have the guts to interrupt a physician when he was making sense. Every other rational suggestion made by people to whom the administration should listen before hiring the Studer Pirates was summarily dismissed as non-feasable. Having shot their wad on crazy corporate psycho-bable apparently there is no money to hire a few extra nurses, buy some portable blood testing equipment like they have at the local Urgent Care, or even get a janitor to make a high-speed reconnaissance pass through the Emergency Department at night.
As to suggestions that perhaps the paperwork burden has become too heavy; so heavy in fact that the nurses literally spend three-quarters of their time documenting the irrelevant minutia of patient care, and that patient care would be enhanced if the focus were really on the patients and not paper…well…this was greeted with the disdain you would expect from a person whose entire job revolves around checkboxes and forms.
But this is typical of medical corporate culture and our sad, ruined society at large. The real problems in our Emergency Department are over-crowding, the horrific paperwork burden, primitive equipment, shoddy ancillary services, and a malignant and vindictive culture. These problems require decisive action and money to solve, two things that are impossible to wrest from the grasp of the kakistocracy so they will go ahead blame the staff for the problems (because the underlying premise of AIDET is that the staff suck) and throw some weak-sauce, ineffectual corporate duckspeak at them.
But that was yesterday. When the satisfaction scores continued to wriggle around in the bottom of the toilet they decided to only survey admitted patients (who are generally very happy about their visit) and mirabile dictu, the scores almost doubled.
The underlying premise of AIDET is to ignore real problems and blame the staff who could solve all of the corporation’s problems if they weren’t so mean to the patients. There may be some potential for incremental improvement by using AIDET in a well-run, otherwise solid hospital but all the propaganda in the world can’t fix a cruddy hospital (or a country, for that matter).
It’s a rare Emergency Department that does not advertise some kind of thirty-minute-or-less guarantee and many even have electronic billboards flashing their current wait times into the night like a bug light to attract the casual seeker of late night medical care. Because we have not yet taken complete leave of our senses the guarantees are loaded with small print disclaimers negating them in the case of, laughable as it seems, an actual emergency. And it’s a “Door to Provider” time, not a guarantee of your actual stay in the department.
My hospital implemented one of these guarantees and I found out about it like everybody else, from the billboard. To date I have never received any official guidance on it which is just as well because it’s not as if I’m slacking off and I pretty much work as fast as I safely can anyway. I arrived the other day to find four ambulances just pulled up so let’s just say that the disclaimers are often operating in full force and I don’t usually worry about my “Door to Doctor Time” because I simply cannot work faster than I already do.
Still, I’ve occasionally dealt with patients who throw the guarantee in my face as an opening move in the chess match that is the modern patient encounter. One even angrily thrust the newspaper advertisement at me when I walked in the door which is not the best way to establish a relationship with a guy who is a little more educated than the cashier at Wal Mart taking your coupon for fifty-cents-off a can of string beans.
So lately I’ve been asking the usual question, some variation on, “Have you been to your own doctor about this seemingly chronic and minor complaint?” and I get the special look reserved for not-so-bright ER doctors. Patients are not stupid. Going to your own doctor involves a phone call, an appointment at some later date, a wait of at least an hour after your appointment time and then even more waiting or worse yet, a trip across town for any studies the doctor might order and then the interminable wait for results.
You’d be foolish to go to your own doctor, especially if someone else is footing the bill as is the case with most of our patients. Even if you’re privately insured the extra co-pay doesn’t seem like that much of a deterrent. In this respect Emergency Departments have now unabashedly set themselves up in direct competition with the local primary care physicians for the paying customers. We might as well start booking appointments.
This is how decadent our society has become: I notice a vaguely familiar face slouching into one of the rooms with a complaint of back pain and I ask the nurse if he’s a frequent flier.
“Oh no,” She says cheerfully,” He’s only been here seven times this year.”
This is what passes for a reasonable use of Emergency Services nowadays. Truth to tell however we have a small cadre of patients who essentially live in Emergency Departments. It’s true that I only see many of them every three or four days but there are several smaller hospitals within easy driving distance of ours and the modus operandi of the typical frequent flier is to “make the rounds,” sometimes hitting multiple Emergency Departments in one night until they get what they want which is usually narcotics.
It’s a living, I suppose. A 10 mg Lortab sells for around 15 dollars on the street so on a good night if you catch a few lucky breaks; credulous Nurse Practitioner or candyman physician, you can make pretty good money with a few prescriptions a week. Apparently the illegal prescription drug trade has its own peculiar economics. I once gave a patient the benefit of the doubt and wrote him for six 5 mg Lortab. He refused the prescription. The fives don’t sell well and it wasn’t even worth his time to have the prescription filled.
One of our most notorious addicts has taken to sending in a scout to see which doctor is working and whether she should bother signing in. I’m happy to say that if it’s me the scout gets back in the car and we watch them drive away on the security monitor.
Drug seeking is not unique to one age group, demographic, or race by the way. My worst drug-seekers are little old Methodist church-going ladies who have been on narcotic pain medications prescribed for some distant medical event and never discontinued. Of course we treat them more respectfully than a twenty-year-old punk with chronic back pain but they are as equally demanding and the only reason they don’t lie, steal, and spend their nights laying intricate plans to score narcotics is because they are entitled and wealthy.
Why should you care? Hard as it is to believe, you can be addicted to drugs and actually receive disability benefits for your addiction including free medical care. Essentially you are paid to be a drug addict. If this does not make the blood boil of the few remaining productive members of society it should.
I’ve had a chance to work with Physician Assistants and Nurse Practitioners and have generally enjoyed the experience in the sense that I like having somebody around to help clear out the medical minor-complaint dead wood that chokes every modern Emergency Department. I’m not expected to see every patient they disposition and I have grown used to incomplete documentation and have even adopted a cavalier attitude towards inappropriate testing and irrational medical decision making. By the time I sign off on the chart it’s too late anyway and one must hope for the best.
I think the biggest problems with Physician Assistants and to a much, much larger extent Nurse Practitioners is a lack of knowledge about medicine. It’s as simple as that. Nurse Practitioners in particular have very little in the way of rigorous medical training but can and do work essentially unsupervised.
Although physicians have a reputation for being arrogant I assure you that despite the confidence I try to project, when it comes to medicine I am extremely humble and have a deep respect for the limits of both my knowledge and experience. I know what I know but I am even more aware of what I don’t know. Consequently I have never lost that gnawing fear of patients that started on the first day of intern year. Certainly, and despite ACEP’s incredibly bogus statistics, most Emergency Department patients present for incredibly minor complaints and things that twenty years ago were routinely shrugged off as part of life. But to lose focus is dangerous. There are tigers in the forest of minor complaints. I very mild rash I saw the other day in a patient with no other symptoms and who would have been sent home by nine mid-levels out of ten (and many physicians) turned out to be Idiopathic Thrombocytopenic Purpura with a platlet count of zero. Serious stuff and the notion of a “minor complaint” in the Emergency Department must always be tempered with the knowledge that our patients are a weird cross-section of society and skew heavily towards actually being sick.
A very high level of knowledge is required to sort out thirty undifferentiated patients a shift but not everybody needs a huge workup and maybe the difference between a physician and a mid-level is knowing who does. Sixty-two-year-old with chest pain? Febrile bed-bound lethargic octogenarian? Right lower quadrant tenderness with anorexia? Yeah, we have to order what we order and do so almost on automatic pilot because heart attacks, sepsis, and appendicitis are must-not-miss diagnoses.
But really there is no need to order a Prostate Specific Antigen on an emergency patient and I’ve asked that the mid-levels consult me before ordering a D-Dimer, perhaps the most over-ordered test in the mid-level panoply. I mean (and this is inside baseball stuff for you non-physicians) of course it’s going to be elevated. Look at the patient.
My opinion on mid-levels doesn’t matter in the slightest. If the hospital could, they would replace us all with mid-levels who are cheaper, more compliant, and because they don’t have the same professional and moral culture as physicians, more apt to do what they are told by the corporations that control most hospitals. Remember that if given the choice between the medical care and the illusion of medical care, the money is on the illusion every time because it’s cheaper. It is only a few laws and some residual dread of reality that keeps this from happening but for how much longer no one can say.
I have and continue to maintain that mid-levels are best-suited to the more highly specialized fields such as cardiology and not in the broad based specialties like family medicine where a certain depth of knowledge is (or ought to be) required.
Left Without Being Fed
Consider a typical fast food restaurant. On any given day they are staffed to quickly and efficiently handle a certain number of customers and to this end do their employees, many working at the first job in their life, toil mightily. It’s hard work. I’ve done it.
Suppose for some reason; rock concert in town, confluence of tour busses, rumors of the Apocalypse…use your imagination, suppose they get a sudden surge of customers and go into overdrive to feed them all. After the deluge at the end of the shift the manager might gather the crew and say, “Folks, good job. We usually only see 250 over the lunch hour but we saw 600 today. You all kicked some ass and took names.”
High fives all around. Guilty pride in a job well done because it’s McDonald’s and you’re supposed to hate working there. Does anybody care that one or two customers, on walking in the door and seeing a long line at the counter backed out and went someplace else? Of course not.
Now consider a typical Emergency Department. On any given day they are staffed to quickly and efficiently handle a certain number of patients and to this end do their employees, all of them highly trained with many years of experience in nursing and medicine, toil mightily.
Suppose for some reason; rock concert in town, intersection of train with tour bus, rumors of the Apocalypse…use your imagination, suppose they get a sudden surge of patients and go into overdrive to treat them all. When the shift is reviewed the administrators note that a couple of people signed in and, after seeing the packed waiting room, decided they didn’t really have a discernible emergency and went home…the dreaded Left Without Treatment (LWOT) or Left Without Being Seen (LWBS).
Oh the rending of garments and the gnashing of teeth! Oh the humanity! The number of LWOTs is a metric and by this do the pasty bureaucrats who run the place measure the quality of the Emergency Department. The shift is now regarded as an utter failure. Heads will roll. The nursing manager is seen to sweat and tremble in fear as she calls in her subordinates to give the bad news. Dark rumors circulate of displeasure at the highest levels. Nursing cutbacks are threatened to fix the problem. Even my bonus trembles in its golden cage.
But you know, we saw 120 patients in a shift that is only staffed for seventy. Sure, some of them were nothing; cough, cold, fever, but quite a few were undifferentiated train wrecks and the ambulances never really stopped rolling in. So what if a few people decided not to wait and left?
I guess the customer-service model breaks down in the lunatic world of the goat rodeo. At no other profitable activity would a crew delivering an unthinkable 58 percent increase in productivity with no additional resources be made to feel like they had failed. In the real word world they give awards for this sort of thing. In American Corporate Medicine ruled as it is by plodding and unimaginative bureaucrats who have no real knowledge of medicine this is viewed as a deep personal failure of every individual involved.
The story has to be got straight: Is medicine a customer service business with “clients” and customers instead of patients or isn’t it?
Wake Me When Our Society Collapses
You’ve no doubt seen those annoying ads featuring smug, entitled Americans demanding in one lump sum the money owed to them for structured legal settlements because it’s theirs and they want it now! Apparently we have become such a nation of legal parasites that it requires an industry devoted to servicing them. I guess this is what is left of American exceptionalism; bunches of fat, lazy, entitled morons sucking money out of what remains of the productive class.
I see this every day and it is distressing, or used to be because like a particularly malignant cancer spread past the point of treatment, there’s nothing to do about it now but laugh. You see enough fit, otherwise healthy drug addicts on disability for drug addiction or entire generations of families who have never had to so much as apply for a job and you realize there is no hope for our nation. The sense of entitlement, the religious conviction people have in their absolute right to suck as much from the public treasury as they can is so stifling now that all we have left is humor and devout prayers for a zombie apocalypse to help focus people on the more meaningful things in life.
The entitlement mentality know no age or class distinction, by the way. I find those smug Hoveround commercials equally degrading. Look, grandma, you didn’t put that much into Medicare and a couple of messy hospitalization blew through that in short order. Would it kill you to pay a little for your motorized wheelchair? We’re not talking a lifesaving drug but only a little extra convenience in the kitchen and it’s sort of selfish to expect your grandchildren to foot the bill.
My inlaws don’t care, by the way, and have said as much to me.
In No Particular Order, Why American Medicine is Doomed
1. Legal depredation
2. Out-of-control, self-perpetuating, self-enriching bureaucracy.
3. The insane paperwork that would make a Babylonian scribe shake his head in disbelief.
4. Lack of Electronic Medical Records…the only thing worse being the current crop of electronic medical records; I’d rather and more quickly lithograph my notes after etching them on brass plates.
5. The heavy and ignorant hand of our politically-motivated Coulrocratic Government; they are all a bunch of clowns.
6. Fraud, sweet fraud…lovely fraud of which Medicaid is the ne plus ultra.
7. Younger and younger patients with more and more diseases of the kind we only used to see in the elderly…we are regressing to the dark ages except where ferocious Norsemen once marauded we now have early onset hypertension, diabetes, and childhood obesity.
8. All-you-can eat Chinese buffets; I stopped going after I saw a woman whose chair groaned in protest as she lowered her vast bulk before a plate that looked like a science fair volcano.
9. The insanity of futile care, the ICUs full of the living dead,
10. Cowardly physicians like me who let it happen; our various colleges and professional societies with even less fortitude.
Where the Money Is
As sports are our nation’s state-sponsored religion, the corruption in it is as inevitable as it is horrific and we have not heard the end of the Penn State pedophilia scandal. Just like the Catholic church with its cadre of rogue priests, no doubt similar revelations are coming about coaches from other schools and other programs.
When asked why he robbed banks, the infamous bank robber Willie Sutton matter-of-factly replied, “Because that’s where the money is.” Pedophiles are drawn to sports similarly because that’s where the little boys are.
Joe Paterno is not a hero. He knew perfectly well that his assistant coach was a pedophile and chose to do nothing. I understand that doing the right thing comes at a price but that’s why it is often so difficult…although the rape of young boys does not seem to be that thorny a moral issue. Yet, when weighed in the balance against lucrative television contracts, prestige, adulation, and a place among our undeserving elites the fate of a couple dozen boys was nothing to him. He is not a fallen hero but a squalid fraud and a warning against placing your faith in the corruptible.
It’s just a fucking game.
We Who Are About to Die
I once worked at a hospital where every infraction of the rules was punished by death. I was somewhat insulated from this because it is a little harder to replace a physician than that guy spooning pseudo-meat into my Chalupa but the nurses lived in a constant sweat of fear and even I had a nagging feeling that I was being watched carefully for the Straw That Would Break the Camel’s Back.
Smoke a cigarette on the hospital property? Immediate termination. Park in the doctor’s parking lot rather than make the long, dark walk from an isolated parking lot a couple of chalk outlines from the ghetto? Immediate termination? Take a verbal order from a doctor? Immediate termination? Cell phone at the nurse’s station? Immediate termination.
In fact, I was once texting while standing at the nursing station and some supervisor of something-or-another told me that cell-phones were not allowed and then looked on in helpless fury as I laughed and took his pictures to text to my friend. This is a good way to make enemies and I’m sure I’m going to be the first one up against the wall when “Papa Doc” Press Gainey is installed as out Great Leader and Ruler for Life but I did not come through the irritating hell of medical school and residency to be scolded by a bureaucrat like some wayward candy striper.
It was a miserable place to work I suppose if you had kids in school, a mortgage, and no easy way to stick it to The Man. The staff were on edge, always looking over their shoulders, and the turnover was high despite the usual Chrysobulls from the corporation promising love, community spirit, and all good things to their dearly loved but benighted employees.
The worst part of this was how the hospital handled complaints. You could be the scariest crack addict in town, threaten the staff, and use language that would make a sailor run home to his momma but if you called or wrote the administration opining that you weren’t satisfied with your care the presumption was that somehow, somewhere, the nurse was at fault and if she had just rounded a little more often on the patient or brought them a pillow to rest their scabies-infested head the patient would have left as happy as a lamb.
That the endless miles of paperwork required of the nurses to document their rounding and pillow-dispensing not to mention start and stop times of simple IV medications were seriously impeding their ability to engage in direct patient care or that they were perpetually a few nurses short in a busy modern Emergency Department was never considered.
Naturally the administration’s solution was to create even more intricate paperwork traps to document compliance with hospital edicts. Every room, for example, had a green rounding sheet outside of it upon which the nurse would sign her name every thirty minutes attesting that she had visited the patient. And just as naturally towards the end of the shift the harried nurses, many of whom had been on their feet for the entire twelve-hour shift, surreptitiously filled out all of their sheets with fictitious times, risking immediate termination for doing it no doubt.
I mention this as a metaphor for American Medicine and American life itself. That’s how it is nowadays whether you’re being yelled at by blue-shirted TSA commissars or trying to practice reasonable medicine and nursing in a hospital run by the Borg-like bureaucrats and lawyers who seem to have assimilated us all.
Like I said, most paperwork is a trap of some sort. An intricate web of checkboxes, signatures, and dates designed to isolate and punish doctors and nurses for errors that are inevitable given the complexity of modern medicine, the titanic sums at stake, and the Jurassic predatory legal environment. Like every other aspect of our insane over-litigated and over-regulated country, it is impossible to comply with every dictat of the bureaucracy so invariably most paperwork is done on automatic pilot and we even have complicated software packages to generate reams of irrelevant boilerplate.
The majority of paperwork is fraudulent. We are all criminals now.
They Can Die
Everybody knows a few patients like this. You know, the kind that despite every medical problem possible continue to live for years and years while otherwise healthy people rapidly succumb to the first major medical event of their lives. A certain mythology has developed about these patients, namely that they are incredibly hardy and will even survive a nuclear war.
I had one of my Iron Men (as they are called) die the other day. He was a sixty-year-old man with fifteen stents in his coronary arteries, one functioning carotid artery, countless strokes that had left him blind and paralyzed on his left side, a dialysis port in his chest because all of the available sites on his arms had played out like exhausted gold mines, congestive hear failure, a feeding tube, a tracheostomy, an ileostomy, one leg, and what his doctors charitably called morbid obesity but had to be lifted by six paramedics to be truly appreciated.
Emergency Departments are not busier on a full moon and Iron Men are not made of iron after all although these are pleasant conceits, like campfire tales, to keep us entertained. My patient had only managed to cheat death because he was being followed by small squad of doctors and in his long and non-productive life had used millions of dollars of increasingly expensive and intricate medical care. I know for a fact he spent three months of his last year alone in the ICU.
It’s the ICU. Intensive care. They can keep a flattened dead raccoon alive in the ICU indefinitely if you got it there quickly enough after running it over. It is no virtue of the patient but the incredible effort and money we spend to squeeze every bit of life out of everybody that makes the difference.
It will break your heart.
Somebody’s smartly-dressed, elegant grandmother is comatose. Hadn’t been to church. Goes every Wednesday and Sunday. Found in her kitchen in a puddle of vomit and stool, barely breathing. Had been healthy all her life. Prognosis very poor. In profound shock and admitted to the intensive care unit where every possible maneuver and diagnostic test is thrown at her. Codes several times during the night and on each occasion is snatched reluctantly from death’s jibbering embrace. Fluids. Fluids. Fluids. Horrific substances to goad the heart. Antibiotics. Chemicals. Ions. Suction. Dark blood in the canister. Pink froth in the breathing tube. Tubes. More tubes. A bamboo grove of tubes and poles. Lights. More lights. Scrolling banners of green lights telling the news. Bells. Doctors. More doctors. Somebody will decide if she is brain dead in the morning. Organ procurement starts to circle expectantly.
Urine drug screen positive for cocaine. I guess that explains the tattoos.
Death of a Paradigm
In days of old when kindly doctors smiled beatifically on appreciative patients and carefully diagnosed them them through a combination of a careful history and skillful physical exam there was what was known as the “Review of Systems.” The Review of Systems was a careful series of questions starting in a very general manner and becoming more specific as the patient thoughtfully answered questions. So important was the Review of Systems that the physicians of those bygone days bragged how patients themselves told you everything you needed to make the diagnosis, no matter how obscure it might be, and expensive labs and imaging were only really necessary to confirm what was ridiculously obvious.
We don’t have the Review of Systems today. Like the physical exam and other quaint medical traditions, it has fallen by the wayside. In fact, in our soft, entitled age where my typical Chief Complaint is “Vaginal Discharge, Headache, and Cough” I hardly know where to begin and I grow fearful of asking questions lest I uncover another problem to fit into the crazy constellation of medical, lifestyle, and psychiatric problems that is my usual patient.
I don’t dare ask about Chest Pain, for example. Everybody has chest pain nowadays. I even have three-year-olds whose mother’s write on the the Triage Sheet, “Diarrhea…and Chest Pain.” Then they look at me like I’m an idiot for not getting an EKG. Headaches? Please. Every headache is now “The Worst of My Life” and a “Twelve” on the regrettably ten-point pain scale. Abdominal Pain? Don’t make me laugh. It’s there, It’s excruciating, and it’s ubiquitous.
Instead of questions, I find myself relying on subtle hints and careful observation to ferret out the real Chief Complaint. If, for example, I walk into the room and the patient is stuffing his face with a cheeseburger their abdominal pain is likely a red-herring and I can probably safely ignore it. By the same reasoning, if I find the patient texting and laughing with her friends my suspicion for meningitis decreases precipitously despite the triage note listing “Fever, Ten-out-of-ten Headache, and Vomiting” as the presenting symptoms.
And you’l laugh at my naiveté but I only recently realized that many of my well-looking, happy, healthy patients with a dire Review of Systems but a shiny, sparkly physical exam are, in fact, looking for a work note and are not sick in any manner whatsoever. I’m a proud cynic but I did not want to believe anyone would purposely waste a half hour of my time just to avoid work. At least ask me for some drugs. Have a little respect.
So we toil along, trying to sort it all out. Occasionally I get a patient who denies almost every problem except those related to his chief complaint and I marvel that I can get the correct diagnosis, like those Giants of Old, almost every time.
But for everyone else I’ve started asking, “On a scale of 9.9999 to ten, how bad is your pain?”
Took a little break from writing. Maybe I got tired of hearing my own voice. Maybe I was fed up. I had the urge to bang out an article many times and just as many times I looked outside at the sun and decided to go mountain biking instead…or take the dog to the pond…or do anything but bay uselessly at the Internet moon.
They say that writing is therapeutic but I find it the opposite. It may have been pleasant initially but writing eventually became a tortuous obsession to which I sacrificed sleep, family time, and maybe even a little perspective. My blog contributed to my divorce and maybe I could have used the sleep, especially because, as you may recall, I was a sleep-deprived resident when my blog was at its peak.
And I must confess that the absurdity of American Medicine has finally overwhelmed me and I have come to accept that it is just a smaller part of the rapidly accelerating absurdity of American life. I work pretty hard and though it is not uncommon to for me to see forty patients in a 12-hour shift (with my record being 52) and although I often walk into the department with everyone in a panic because four ambulances have just rolled in and the department is packed with a full-to-capacity waiting room, three of the ambulances are non-acute patients with a little bit of stomach flu, the fourth is a routine elderly chest pain resolved with one sub-lingual nitroglycerin, and the waiting room is mostly colds and back pain.
I’m not exactly saving the world. Out of forty patients maybe ten have medical problems that really need to be addressed and four have real emergencies. I’m kind of naive as I mentioned above so one day, after examining a well-looking twenty-year old and finding absolutely nothing wrong I realized that he had waited three hours to be seen because it was Sunday night and he wanted a work excuse.
You can do that nowadays. Tie up a nurse and a doctor for twenty minutes without having to pay a dime just to get a work note, or a pregnancy test, or drugs, or any and all kinds of things that do not need this kind of attention. And nobody cares who can do anything about it, locked as we are in the suffocating coils of the bureaucracy and the lawyers. We are a nation now fit for nothing but decline, led by the worthless and directed by the likes of those overweight blue-shirted TSA agents who through some kind of utterly bizarre logic strip-search a mother with her three toddlers, chemically test her formula to make sure that this harried suburbanite from Des Moines has not substituted Semtex for her Enfamil, and completely ignore a big, dangerous-looking, unshaven guy like me.
How’s that Hope and Change working for you? Had enough? Still grimly resisting that urge to scrape off the bumper sticker? It’s all right. Nobody likes to admit they were fooled even though it’s now painfully obvious that, like many of us warned you, The Sun King Ra-Obama is nothing more than an empty suit who if he is in fact filled with anything it’s the shopworn doctrinaire leftism that has been such a disaster for most of the planet and apparently needs to be tried again and again because…well…because the purpose of leftism is not to improve the human condition but to ensure, as Orwell warned, that a boot is stamping on the human face forever; in this case the boot is an over-reaching and out-of-control government intent on bludgeoning you into submission with a big brick of government cheese. President Obama and his cabal of like-minded Barons in the House and Senate don’t want to help you, they want to solidify their own power, putting the boot in your face forever. If they have to lay waste to democracy, free enterprise, initiative, personal responsibility and every other virtue that made America exceptional than so be it.
The sad thing is that you voted for the guy because you are a afraid; afraid to be an American and act like an American and have instead embraced the notion that the Mammary State will nestle you in it’s benevolant bosom if you only give up the liberty that is your birthright and accept the domination of an unelected, multi-tentacled bureaucracy in every part of your life.
What the heck. All you’re going to give up in exchange for never having to pay a dime for even the most routine medical care is the ability to be anything but a serf, a comfortable serf for now but the time is coming when the West, finally become nothing more than a crappy nursing home full of drooling, entitled imbeciles, producing nothing and standing for nothing; a civilization reduced to petulance and craven apologies for the cherished values that in distant times American boys stormed impregnable beaches to defend, will collapse from the overwhelming weight of its own folly and short-sightedness.
Then my friends, the World will burn.
Wonderful, Wonderful Copenhagen
Let me get this straight: The economy teetered on the edge last year when billions of dollars invested in imaginary assets evaporated into thin air. In Copenhagen, the President, the Democratic Congress, and the parasitic global bureaucracy propose to set up vast markets trading in Carbon Dioxide, a naturally occurring gas which forms a vanishingly small percentage of the atmosphere, and that this entire multi-trillion dollar market in which your pension funds and other financial instruments will be inevitably intertwined will be based on some pointy-headed Eurocrat allocating permission to burn fuel…and you think this is a good idea?
What on earth is wrong with all of you? Have you taken leave of your senses? Who thinks up this kind of crap and more importantly, didn’t they get the memo that Global Warming, the Rock upon which the Religion of Global Bureaucracy is built, the Shining Promise to the Ruling Class of Make-Believe Jobs Now and Forever and To the Ages of Ages, is a hoax and nothing more than a shabby and now increasingly transparent attempt to put the unruly American spirit in its place?
If the magnitude of the duplicity involved in the hoax of climate change (now warming, now cooling) is not apparent to you now then you are either blind or willfully intent on destroying as much of our personal freedom as you possibly can.
Jumping the Shark
“My arm was numb after I slept on it funny and my mom says I’m having a stroke,” says my essentially healthy 34-year-old patient to the nodding approval of his indulgent mother sitting by the bed.
“How long did the numbness last?”
“A couple of minutes…it went away after I straightened my arm.”
“So your arm went to sleep and now it’s better?” I ask.
“I guess so.”
“You know that just walking through that door costs you four hundred bucks?”
“It’s okay,” interjects his mother,”He’s on disability and don’t have to pay a dime.”
And there, in a nutshell, is the problem with American medicine and why the looming government solutions are insane. Don’t you all realize that when a healthy young man can walk into an Emergency Department because his arm fell asleep and be seen by a doctor, a doctor who will dutifully diagnose him with transient paresthesias or compression neuropathy or God forbid initiate an expensive and highly unnecessary work up; when a patient can present with nothing and less than nothing and run through your money with as much concern as I have for swatting a fly…don’t you all realize that when this kind of patient can leave without being arrested for fraud that American medicine has jumped the shark and making it even more accessible at even less cost to a growing population of supremely entitled citizens will result in nothing but an exponential increase in the baseline ridiculousness of it all?
The Emergency Department is the center of a thriving drug trade that would make an Afghan Opium Warlord gulp in amazement. A truly staggering amount of narcotics leaves here every day and I am sorry to say that, even though I am trying to prescribe less of them, I have had a major part in this. It’s not that I don’t believe in appropriately treating pain. Cancer? Major trauma? Kidney stones? No problem. But every person with back pain, even if they were legitimate patients and not the drug seekers that many of them are, does not need thirty Lortabs…if they’re not allergic to Lortab that is as most of our narcotic connoisseurs eschew the slow onset of pills for the instant rush of Dilaudid (doctor prescribed heroin).
The problem is two-fold: First, there are some patients who are in pain and have a legitimate need for narcotics. You can’t withhold them because other people abuse the system and consequently it is necessary to give people the benefit of the doubt even if you know you’re being scammed most of the time. Second, there is tremendous pressure bureaucratically to make the customers (formally known as patients) happy lest Press-Gainey scores suffer and some imaginary harm come the bottom line as customers who probably don’t pay for their medical care anyway threaten to take their business to some other, more accommodating drug entrepot.
So I’m sending a lot of people out on Motrin and occasionally Valium as a muscle relaxer and reaping the whirlwind of bad feelings and complaints. If you’re in a minor automobile accident and walk in a day later without any injuries this is completely appropriate and why a little fender-bender in which no one was hurt and EMS were not called should be the prelude to a narcotic holiday is not clear.
That many patients lie to get drugs in an incontrovertible fact. I work at two Emergency Departments in town and I have had the same patient on two different days with two different descriptions of the same wreck. I also occasionally get calls two weeks after the prescription for Lortab was written for a minor motor vehicle accident claiming that the pharmacy lost it and could I please write them another prescription?
I have discovered from several of my more straightforward ex-drug seeking patients who now come in occasionally for minor but legitimate complaints (and refuse anything but tylenol or Motrin) that at one time they were selling their Lortab on the street for ten bucks a pill. Apparently you can make a decent living scamming your Emergency Physician or, as the Pharmacist put it, “Hey Doc, did you know that Mr. Smith just filled a prescription for 150 Percocet two days ago?”
No. No I did not.
It would be unfair to characterize the country as a whole from the self-selected few who have formed a symbiotic relationship with the Emergency Department. But just like every medical problem is not an Emergency, every little pain does not need treatment and there was a time, I assure you, when people just took a couple of aspirin and called their doctor in the morning.
Jumping the Shark II
“You know I’m not a pediatrician,” I say to the mother of a well-looking, very healthy baby brought to the Emergency Department for a little spitting up and an inability to obtain an instant appointment with the child’s pediatrician.
Incredulous look. Thinks I am some kind of on-call pediatrician.
“You know I’m not a dermatologist,” I say to a otherwise well man with a faint rash on his neck that started a few months ago.
Disbelief. Anger at my referral to a dermatologist (who I called after coming up with nothing in my dermatology atlas) who will see him in three weeks but unfortunately will probably ask for money up front.
“I want to see the dermatologist now! That’s why I came in.”
Good luck. Heard muttering on his way out that he wanted his co-pay back because “that fucking doctor didn’t do shit for me.”
“You know I’m not your primary care doctor,” I say to the well-appearing woman with a complaint of “I want to be checked for sarcoidosis.”
Scornful look. “Oh, my doctor isn’t doing anything for me,” although I suspect from a cursory review of her online medical records he is as he has at least ordered all of the appropriate lab work.
Somewhere, sometime…I don’t know when…the public has dropped even the pretense that the Emergency Department is anything other than an all-hours urgent care or some kind of one-stop shopping for all of your real and imagined medical problems. It it this impatience, the medicalization of all aspects of life, represented by patients demanding instant treatment for things that thirty years ago would be shrugged off that ensures our health care system will bankrupt us, especially when it is free.
“This patient,” I said to myself, “is going home.”
I know. She’s 85 with the dreaded complaint of “Altered Mental Status” described by the family as a brief period of “staring.” No generalized seizure activity, you understand, and no syncope (fainting), slurring of speech, facial droop, drooling, weakness, confusion, sweating, fever, nausea, vomiting, or any of the other symptoms or combination of symptoms upon whose fulcrum are levered mighty weights of flesh into the processing mill that is your local hospital. In fact, this very pleasant lady felt fine and even the family admitted that she looked normal.
“And I’m not going to spend $20,000 proving she’s fine either,” I continued to myself as I screwed up the courage to throw out the rule book and guide my clinical judgement by history and physical exam. After four years of medical school and four years of residency training I can do that can’t I? Isn’t that what my professors, comfortably barricaded behind the litigation-proof walls of the State Charity Hospital told me I should be doing…especially as my history and physical exam confirmed the diagnosis that seemed obvious from reading the triage note and talking to the the paramedics on their way in?
But then the fear gripped me. That smouldering dull fire in the gut that can only be quenched by a deluge of unnecessary lab tests and studies.
And I paused.
My computer glowed seductively. It would have been easy to click here, click there, and then call the tired hospitalist to admit the patient. We admit for this kind of thing all the time, slipping the patient in behind a smokescreen of irrelevant data; leveraging confusion, convenience, and sloppy medicine into countless unproductive admissions that discover nothing we didn’t already know, treat nothing that we weren’t already treating and, if we are lucky (because the hospital is a cess-pit of infection and risk) leave our most excellent and trusting patients no worse for the ordeal except for some familial inconvenience.
Reaching deep for my last reserves of courage my hand bypassed the keyboard going to the phone instead to discuss this very gracious and patient lady being treated for Parkinson’s disease with her neurologist and to arrange outpatient follow-up for the next day.
Maybe one day I’ll tell you about the Bell’s palsy patient I sent home with no lab work or imaging of any kind.
I am a thrill-seeker. Too bad I’m going to get sued one day and decide that my financial well-being is more important than being a good and faithful steward of your treasure.
This country has changed, even in my lifetime. It used to be a place where people worked and were proud of it as we were proud of out heritage as a pioneer nation, a place were prospectors, inventors, roustabouts, gamblers, swindlers, preachers, cowboys, investors, soldiers, pioneers, farmers, and every variety of people striving for their livlihoods could succeed or fail by their own skills and on their own merits, allowing always for the confounding hand of fortune that sends the river to wash away even the best-tended plantation. It was a country to which my father came with nothing, expecting nothing except opportunity, and for which he had a great love that he instilled in me.
And now we are to be nothing but Belgium. A lot bigger but Belgium just the same. Nothing but another decrepit European social welfare nursing home whose sole pre-occupation is now to become the incessant struggle for money to support a growing class of people who have been seduced by the Obamatariat into giving up uncomfortable and often treacherous liberty for the long, government-cheese induced nap of the nanny state.
It should bother you.
My New Ride
As some of you know, I am a mountain-biker and I just thought I’d share a picture of my new ride. It is a Specialized FSR XC Expert. My first mountain bike was a 1992 Bridgestone MB-4 and while I recall it was a really nice bike, this one has front and rear suspension, hydraulic disc brakes, and weighs less than many top-of-the-line road bikes did back then. There are no mountains in my state. Nevertheless we have plenty of trails, ranging from smooth beginner level to heart-in-the-mouth-take-your-eyes-off-the-trail-and-you-die technical stuff. I tend to ride a combination of paved roads, dirt roads, and the occasional rough terrain and since I can lock out the suspension for hills and really smooth roads this bike suits me well. Yeah, the guys in spandex pass me all the time but they can’t really go off the road much so I don’t mind.
I used to run but got tired of it. Twenty miles on bike is more fun than five miles on foot.
(More questions from real readers. -PB)
What’s the Emergency Department Really Like?
The American College of Emergency Physicians and their bogus statistics notwithstanding, the majority of cases we see are not emergencies. As I have mentioned before, most of the cases we see probably don’t need to be seen at all by anybody in the medical profession in any capacity. I saw 34 patients last night and half of them were for nothing more than cold symptoms, symptoms that at one time in our nation’s history rational people just accepted without feeling the need to seek medical attention. Today of course where everything is a friggin’ Emergency and medical care is absolutely free for the asking I walk into many patient’s rooms to find a tattooed, well-looking white chick and her less-tattooed mother waiting angrily to be seen by The Fucking Doctor Who Was Just Standing Around Typing On His Computer While They Waited Three Hours who then breathlessly spin a dire tale of a little bit of a sore throat and a little bit of a cough that is really interfering with the daughter’s two-pack-per day habit or whatever it is she does to lead a fulfilling life. Either that or it’s a little bit of gas pain or some faint twinge or spasm in the back that has caused a slight discomfort that must be addressed immediately.
That’s a particular species of patient that knows no geographic boundaries, by the way. Even here in the South where people are an order of magnitude more polite and well-behaved than in Yankeeland we still have the ubiquitous fire-plug of a mother escorting her wan daughter, both of them at various corpulent stages on the road to morbid obesity, who insists that not only is something wrong with the daughter but that every single test and study known to medicine must be ordered to ferret out the problem. After taking a history, doing an appropriate exam, and telling the mother that her daughter has a chest cold and is going to do just fine, like clockwork comes that cold-as-fish look of disgust and the inevitable, “We want to see another doctor.”
Either that or, “My sister had the same thing and the doctor over at the Quickie Clinic gave her a shot.”
“Madame, the doctor at the Quickie Clinic works at the Quickie Clinic because he’s an idiot. You’re in the big leagues here and I don’t just give shots.”
Of course I don’t say that.
One patient opined that he could get served at MacDonald’s in five minutes so he didn’t understand why it took four hours to be seen, evaluated, and discharged. He was an otherwise reasonable guy and really very pleasant but that sort of highlights the problem with Emergency Medicine and most Emergency Departments, namely that they are largely highly expensive, completely understaffed Quickie Clinics in which some real medicine is practiced from time to time; the twenty percent or so of patients who have real emergencies or legitimate complaints and are part of our core function in the community ironically causing so many delays for the other eighty percent who should have stayed home that, in our insane and upside down world, the various quality “metrics” used to rate how good a job we’re doing are entirely dependent on the satisfaction of irate people who didn’t need to be seen and did nothing but waste either their own money or the taxpayer’s.
There is, as you guessed, tremendous bureaucratic pressure to decrease waiting times and subsequently to increase patient satisfaction which is one of the most important contributing factors to the so-called crisis in Emergency Medicine, a crisis which wouldn’t exist except that there is money to be made in the high volume business of trafficking in minor complaints and very little incentive not to. Most of our patients, after all, have some kind of insurance and taking money from the government to do what is essentially a well-child exam on a slightly febrile but otherwise healthy-looking toddler is like stealing candy from a baby which is sort of what we are doing (and why the Children’s Health Insurance Program is such a colossal waste of money and a harbinger of what is yet to come when the Sun-King, Ra-Obama, by one gesture of His Mighty Legislative Hand, turns us all into Medicaideurs).
So you can hardly blame the patients. They come because they are encouraged to come-witness one billboard in town showing a comfortably sleeping baby proudly proclaiming that they are a “Pediatric All-NightER” never mind that it verges on child abuse to drag your healthy looking baby into the Emergency Department at two in the morning to share Cheetos with the crack whores-and they come because there is nothing to discourage them; no obstacle except a little bit of waiting and we have never chased anybody away who had a minor complaint for any reason so mundane as an unwillingness to budget some cigarette money for medical care.
Why is it, by the way, that while I have had many people complain of being unable to afford low-cost antibiotics, inhalers, and blood pressure medications I have never, and I mean never, had anybody cry poverty when presented with a prescription for pain medication? I could write a wino living under a bridge for three months worth of Lortabs and he’d accept the prescription without demur. A prescription for Penicillin for his dental abscess?
“Come on, Doc, I ain’t got the money for that.”
So what’s an Emergency Department like? In reality it’s a little like a miniature hospital onto which has been grafted an STD clinic, an Urgent Care, a psychiatric ward, and a small intensive care unit. At any time and within ten feet of each other you can have a critically ill dialysis patient being kept alive by pumps and ventilators, a genteel dowager having The Big One, a teenage girl with some vague menstrual cramps, a smattering of varying kinds and degrees of abdominal pain, several people in “Just To Get Checked Out,” and lots of kids and adults with nothing, apparently just in for the novelty of watching a different television and having a nurse at their command. The only thing we don’t have is an operating room but can the time be too far off when irate patients will opine, angrily, that it’s been three hours and they still haven’t got their appendectomy?
(Just a few random questions from real readers-PB)
What is your job really like?
As you know, I am an Emergency Physician working in a medium-sized community Emergency Department in a medium-sized hospital in a medium-sized city in a medium-sized state. A “community” Emergency Department is not a major trauma center and generally sees mostly medical complaints as opposed to the big urban Emergency Departments that see mostly medical complaints with a varying amount of stabbings, shootings, and other acute medical problems that are the inevitable sequelae of Standing On the Corner Minding Your Own Business.
My hospital was purpose-built a few years ago to sit astride the major nursing home trade routes and commands this commerce for many miles around. There are twenty or thirty nursing homes of varying quality within a quick ambulance ride of the place and, as you can imagine, a large percentage of our patients are the warehoused elderly who present with a varying quality of complaints ranging from the sublimely ridiculous (Altered Mental Status in a demented, contracted 92-year-old who hasn’t moved in two years except when indifferently rolled and slopped by the surly hired hands) to the legitimately dire (septic shock in an otherwise healthy elderly lady).
We also get the usual general medical complaints, most of them incredibly minor, most of which barely rise to the threshold of needing medical care at all much less both barrels of the Medical Safety Net. We address ‘em all however although in my role of community educator I do counsel people on the appropriate and inappropriate use of Emergency Medical Services. I understand that some patients don’t have doctors but a rather large percentage of my patients have doctors and either didn’t want to wait for an appointment or were too lazy and irresponsible, despite having insurance, to inconvenience themselves in the slightest to schedule one.
Eczema, for example, no matter how itchy, is never a medical emergency and don’t expect me to apologize for making you wait five hours to be seen. And standing at the door to your room glaring at me while I work on your fellow citizens who are actually sicker than you won’t make me see you any quicker although I admire both your stamina and your absolute commitment to not walking across the street and getting some skin lotion from Wal Mart, an enterprise that would have taken you ten minutes and was helpfully suggested by the triage nurse.
And for the one thousandth time, fever in an otherwise healthy toddler is not an Emergency either. It’s 3 AM, for Christ’s sake, and you will pardon my incredulity as I look at your playful, active, rambunctious child stuffing Cheetos in his mouth. Oh, and just because we didn’t order any lab work or imaging doesn’t mean we “didn’t do anything.” From start to finish you had some high-powered talent working on you. Your nurse has a college degree and years of experience and assesed you child perfectly in triage. I have a ridicuous amount of training and education and if between your nurse and me we decide that your kid ain’t that sick he probably ain’t that sick. Did you notice the thoroughness of my physical exam? I’m not just pretending to look in his ears, you know. Surely the history and the exam are “something.”
The major difference between this job and many other typical jobs is the pace. I saw 42 patients in twelve hours last night and never stopped working for the whole time. Emergency Physicians don’t get breaks per se. We are usually scrambling to keep things moving and when things get a little slow we try to catch up on our charting, a task made extremely difficult in my particular hospital by The Worst Emergency Medical Record System In The Entire Universe, a little nightmare called Medhost that apparently got its start as a restaurant order and billing system and has not progressed much from there.
But I digress.
We try to keep people moving in and out, either admitted or discharged, but inevitably something comes up and people start waiting for disposition. Part of this is my fault as I am still learning how things work in a real Emergency Department where the process of evaluating, treating, and dispositioning is substantially different than it is in the academic world. On the other hand a couple of critically ill patients or an inexplicable run of ambulances can back up the department for hours, distracting us from our true mission of treating your child’s ear infection at 2AM because your appointment with his pediatrician in ten hours was just not soon enough.
I enjoy my job even if I am glad to leave when my shift is over. It’s not really too stressful. The most aggravating thing about it are the long stretches where every patient seems to be “Otherwise well child, active, playful, with a low-grade fever.” The critical and otherwise actually sick patients are a relief.
What do You Think About Ted Kennedy?
Don’t get me started. First of all, I will never understand the fawning adulation lavished on our corrupt hereditary ruling class by the press. Mr. Kennedy was a voracious parasite on the nation whose appetite for power was only checked by his inability to keep his head in a crisis and his utter unwillingness to dive into the cold waters of Chappaquiddick to even attempt a rescue one of The Little People, a throwaway citizen who was just a hired mourner in the long dirge of the Kennedy odyssey. Mr. Kennedy never held a real job as far as I can tell, never produced any useful good or service, and lead an entirely privileged life out of which he felt comfortable pontificating to the rest of us about Good Citizenship, Duty, Honor, and what constitutes a good life in our now completely insane nation. He was a senator for as long as I have been alive and the web of corruption and influence peddling he spun is the best argument I can think of for term limits.
But isn’t that the problem with American politics; that it is full of people who have done nothing and know nothing about anything but politics and yet feel confident and, what’s worse, divinely entitled to solve complicated problems that are well out of their scope of experience? That’s why President Obama is such a failure and going down like your prom date: Having been sheltered in academia and government for his entire adult life, he doesn’t know anything about the real world, not even enough to know what he doesn’t know.
So sing your paeans and bow your heads. Wax sanctimonious about the passing of your paper mache great men. I don’t mourn the passing of tyrants.
So I had a drug seeker come in the other day with her usual back pain. Lately I have been very stingy with narcotics and after refusing to give her a shot of anything stronger than Toradol I explained that I only give narcotics for patients with fractures or obvious acute injuries and never to patients with chronic pain (which is not strictly true but I thought it would be impolite to point out in front of her family that my records showed six visits in the last two weeks to our other Emergency Departments around town).
In my discharge instructions I cautioned her to return for numbness, weakness, urinary retention, or urinary incontinence (all things that can be caused by spinal cord injury) and wouldn’t you know the next day she showed up with a normal gait, normal neurological exam, normal deep tendon reflexes but having ostentatiously wet herself, something she mentioned to me as she stumped past on the way to her room.
Apparently the internet is loaded with sites where drug-seekers can learn what to say and how to present themselves to Emergency Physicians to get drugs. I’m less than impressed by a patient who endorses twenty-out-of-ten pain in the right upper quadrant brought about by eating fatty foods who I have to shake vigorously to awaken but some of them are quite good. I’ve been burned a few times, suckered into giving Dilaudid to patients who I later discovered to be frequent fliers. The first warning sign is usually the inability of a normal dose of Dilaudid…essentially legal, high-grade heroin…to “touch the pain.”
The Holy Grail for the seeker is, of course, being admitted for intractable pain and being put on a “pump,” or Patient Controlled Analgesia (PCA) which is like having your narcotics on tap. Still, suckering the doctor into giving you a few hits of Dilaudid before the unamused charge nurse hands him a stack of papers detailing your last twenty visits is a major victory as is scoring a ‘scrip for Lortab.
Oh, and just a tip: If you are young, otherwise healthy, and look stoned (because you are stoned) I’m not going to give you anything but some life advice so don’t bother coming in. Your back may or may not hurt but many people older than you with real skin in the game have survived back pain with nothing more than Motrin.
Just an aside, I write prescriptions for Motrin because it only takes one mouse click on our Electronic Medical Record system but I always hand-write on the printed prescription, “Over the Counter, Not for Prescription.” I’m really busy so a minute saved here and there can add up to real time over the length of a shift. I don’t care if you have Medicaid and they will pay for it. It’s not asking a lot for you to throw down a couple of bucks for your own medical care.
I still get frantic calls from patients saying that my prescription says “600 mg” of Motrin and all they sell are 200 mg tablets. I weep for this generation. Have Americans always been this stupid or is this something recent? It’s probably a recent thing. My older patients may or may not have a college education or advanced degrees but most of them seem to have some basic common sense.
We are definitely getting less intelligent. Apparently being a moron is not only an accepted lifestyle choice but, given the growing allure of the welfare state, it is now also a desirable survival characteristic and one that is being aggressively selected for.
Patient of the Week
“My Doctor told me to come in to be admitted for back pain.”
“I have no doubt your back hurts but as you are clearly without neurological deficits, appear comfortable, have no fever, and a negative urinalysis there is no indication to admit. What kind of doctor is he?
“We have an automatic door in the department so it you move quickly it won’t hit you on the ass on your way out.”
The Crying Game
Remember that movie where, after a couple of hours it is finally revealed that the chick is a dude? That’s kind of like President Obama. All of his breathless supporters thought he was a beautiful, sensitive, caring girl but now 200 days into his presidency he has shown everybody his penis and, although they still want to like him, it’s hard now because the chick’s a dude, man. Sort of changes everything. I mean, she still sounds the same, looks the same, is wearing the same clothes but she’s a guy…and all but his most ardent followers must be squirming in their seats to think they were ever attracted.
Sure, the die-hard zealots, those who have in the dead of night surreptitiously scraped off their ”Dissent is the Highest Form of Patriotism” bumper stickers still think he’s good-looking even if he has a twig and berries but the majority of Americans, those who care I mean, are catching on that the Sun God, Ra-Obama, is something of a petty dictator along the lines of Mussolini. That and he is completely out of his element, not very smart, and well along in completely screwing up the one thing he was mistakenly elected to fix. A silver tongue/teleprompter and charm are not a substitute for basic intelligence and some friggin’ common sense, even in the insanity that passes for American political culture.
As many of you know I recently finished my residency training and am now working as a real live Emergency Medicine Attending Physician, completely autonomous and completely responsible for every decision I make. It has been an easy transition so far because, and you may read this as a defense of the need for residency training, my program trained me well to handle the full range of medical emergencies that we commonly (and uncommonly) encounter. More importantly however, my program trained me to be comfortable with the not-so-emergent patients; the ones with a blurry constellation of mild complaints and extremely vague exam findings. The truth is that there is a lot of general medicine in Emergency Medicine and as one of the most common presenting complaint appears to be, “I couldn’t get a quick appointment with my own doctor so I decided to come here,” I am beginning to understand that my job is not to work up everybody all the time for everything. While I still reflexively admit the usual patients (chest pain, elderly with unexplainable pain) I’m sending a lot of people home with instructions to follow up with their own doctor…even going so far as to call the doctor in question for patients I think are unreliable.
I mention this because I sent a patient home with vague abdominal pain who came back the next day and was diagnosed with appendicitis by one of my colleagues. You might say I missed the diagnosis but I respectfully submit that, as the patient was given clear discharge instructions to return if not better (which he did) we can put that one in the win column. It’s either that or we CT scan every patient with no fever, a normal white count, a benign abdominal exam and absolutely none of the classic findings for appendicitis except a very mild, intermittent pain in the lower abdomen that didn’t even localize to the right lower quadrant.
I’m also beginning to appreciate the utility of the “Likelihood Ratio” and how it applies to Emergency Medicine. Our most excellent Program Director drummed statistics into us and we naturally resisted manfully but it is good to now have some theoretical basis upon which to justify not ordering labs or studies that will not effect treatment or disposition decisions. I still reflexively order Basic Chemistry Panels and Complete Blood Counts but one day I’m going to get the nerve not to do it. I wonder how much money we waste checking these things on people who look healthy?
Just file it under not wanting to know everything about every patient when usually it is enough to address the chief complaint and be done with it. Which brings me to one of my biggest pet peeves, that is, the ordering of imaging studies and lab work in triage. Sure, sometimes this practice speeds up disposition but not every patient, for example, with abdominal pain needs an Acute Abdominal Series; a set of four xrays at my hospital. With a few exceptions, the Acute Abdominal Series should be reserved for, well, patients with an Acute or “Surgical” abdomen which I assure you most of my patients do not have. Vague abdominal pain certainly does not qualify and the Acute Abdominal Series is completely useless in either ruling in or ruling out anything useful in the majority of patients for which it is automatically ordered.
If I suspect something is going on I’ll get a CT scan.
Not only is the routine ordering of unnecessary imaging wasteful but once we get the study we are now on the hook for every finding on it, even those that are incidental. If I miss a small pulmonary nodule on an unnecessary chest film that later turns out to have been lung cancer I own it and the ensuing lawsuit. Better not to know…especially if the guy came in for a sore throat and no other respiratory complaints and with a completely normal lung exam.
The triage clerk is killing me.
Michael Jackson is Dead and I Don’t Care
Michael Jackson is dead and, God forgive me, I don’t care. I wasn’t a fan and I didn’t like his music. Sure, I listened to it; it would have been impossible not to but I never bought an album, stopped turning the dial at the sound of his falsetto voice, or really followed his career except that it was part of the cultural noise of our age. I don’t worship celebrities and entertainers either and am completely indifferent to their lives. Oblivious, actually. I’ve been listening to Pink Floyd for thirty years and I can’t name any band member, differentiate who among them is living or dead, or tell you anything about any of them. Don’t know, Don’t care. It’s not important.
Of course I watched Michael Jackson’s opulent funereal. How could I not? I couldn’t tear myself away from this sad commentary on our silly and insipid age where a mincing creep, a pedophile, and a middle-aged man who spent the treasure of a small nation to satisfy his bizarre urges is buried like a pharaoh while better and braver men who sweat and bleed every day are rewarded with nothing more than a flag-draped coffin and the barely concealed derision of the perpetually chattering classes.
What a freak show it was. A parade of Jacksons you never heard of and flocks of B-list celebrities come to preen and feed on entertainment carrion under a grisly sun. I think it’s weird and freakish how the black community has embraced embarrassments like Al Sharpton who delivered the most embarrassing eulogy of the day. What a low-life, likewise flapped in from lonely media desolation to feast on the dead body that seemed hardly enough to feed a couple of washed up singers let alone the small country’s worth of celebrants descended on Los Angeles. Was it some miracle, feeding the multitudes I mean?
The ongoing news coverage was disgusting. North Korea will be lobbing nukes at us pretty soon, the economy is still in free-fall, and everywhere rough beasts, their hour come, slouch towards Bethlehem so you’d think there would be a lot to discuss on serious news outlets but based on four or five obvious facts that were a revelation to no one and only surprising to those who have been living in caves for the last twenty years we were treated to solid, 24-hour coverage of nothing and less than nothing about a guy whose life was really not that complicated and whose death was mundane by celebrity standards…save for the revelation that Diprovan, an induction agent for anesthesia and medical paralysis, is now a recreational drug.
About the only real interest I have in the whole affair is whether and when Michael Jackson’s doctors are going to jail.
You’ve Got to Know When to Hold ‘em
As many of you know I am done with residency and am back in Louisiana working as an Attending Physician in a small but very busy Emergency Department. We have a lot of casinos in our fair city which got me thinking that Emergency Medicine is a lot like high stakes gambling. We are dealt a hand with every patient and after glancing at it, must figure out what kind of cards the patient is holding; whether the guy with chronic back pain really has an epidural abscess or whether he is bluffing, and make our workup and disposition judgments accordingly. We can’t admit everybody, we can’t run every test on everybody all the time, and as this is still a rational world (but getting more insane every day) eventually the majority of patients will be sent home where a certain percentage of them will have a bad outcome from something that we missed because it never occurred to us or from something that we anticipated as a possibility but about which the patient decided to eschew follow up as directed.
I mention this because I actually send people home with no lab work or imaging studies whatsoever which is something I probably only did a handful of times as a resident. I had, for example, a young boy brought in by his father for intermittent abdominal pain for the previous two days, particularly while playing sports, but who presented with no complaints whatsoever and a normal physical exam complete with a benign abdomen, normal testicular exam, normal digital rectal exam negative for occult blood, normal vitals, normal, normal, nothing, nada, zilch.
Could he have had something? Functional abdominal pain? Gastritis? Intermittant testicular torsion? Sure. But he had excellent follow up, reliable parents, and no complaints whatsoever brought in mostly for parental concern and because it was a Saturday and their pediatrician wouldn’t see them until Monday. I felt it was safe to send the kid home because, and maybe I’m wrong here and I will be bombarded by dire warnings from my colleagues to the effect that I am playing with fire or I will change my practice habits the first time I am sued (but did I mention the kid had no complaints and a stone-cold normal and extremely comprehensive physical exam?), on some level our job has got to involve using a little common sense. In this case understanding that the kid was not sick, was in no danger of dying, had vigilant parents who lived only a mile from our hospital with access to a phone, and really had no business being seen in the Emergency Department except that most Emergency Departments are now mostly after-hours clinics with some really sick patients thrown in three or for times a shift to slow things down and keep the waiting room backed-up.
With that being said, I still admit the usual patients with vague complaints who meet certain criteria for age, comorbidity, or reliability. I’m not stupid. But I’m trying, like I said, to use a little common sense.
We have the usual variety of patients but, while we have much less trauma than at my residency program, many of our patients are actually quite sick. I have run quite few codes, intubated often, and have done a lot more procedures on a daily basis than I did as a resident for the same number of patients. I’ve had, for example, quite a run of febrile infants with Fever of Unknown Origin requiring lumbar punctures and several of them panned out as meningitis.
Procedures are a lot easier as an attending in a non-residency hospital. I tell our most excellent nurses what I am going to do, they get all of the stuff ready (the most time-consuming part of most procedures), and they don’t even let me dispose of my own sharps after I am done because, as the charge nurse told me, “Don’t you have some patients you could be seeing?”
A resident’s time is not worth much, in other words, but they aren’t paying me now to hunt up gloves and syringes. We are incredibly busy most of the time and like residency I work non-stop for my entire shift.
My first patient was a woman with vague abdominal pain and an elevated white count who I did actually send for a CT scan (normal of course) but eventually sent home with instructions to return in twelve hours if not significantly better. My second patient was a young lady on oral contraceptives and a smoker with a month of worsening breathing difficulty, chest pain, and “cellulitis” of her calf a month before. Wouldn’t you know that her EKG showed the classic strain pattern (“S1Q3T3″) that you never are actually supposed to see and I naturally started her on Heparin (an anticoagulant) almost as soon as I got her history, being rewarded shortly with an angiogram that showed exactly what I thought it would: big pulmonary emboli (clots) in the arteries of her lungs.
The family thought I was a genius but this one was obvious, an incredibly easy (but very satisfying) diagnosis that in our age of vague complaints presenting far in advance of any classical signs and symptoms is something of a rarity. It’s the minor complaints that really give me fits.
There are days when I explain to the family of a 98-year-old customer, in terror of the the inevitable end, that today is not that day and while the odds of their mother living another month are close to zero, she’s alert, reasonably comfortable, and they have some time to say what they want to say and do what they want to do. There are also days when I must gently insist to a family that despite what they have heard about the mighty apparatus of American Medicine, it will be as ineffectual as casual prayers and there is only time now to steel their hearts and accept the inevitable end.
And then there are days when a simple customer, sorted in triage as a minor complaint, slowly evolves into a horrifically complicated ICU admission whose fragile life depends on the skill and vigilance of the entire Emergency Department staff…and even then the odds are not good. That one will keep me in the Department long after the end of my shift, the extra hours of which gain me nothing materially.
On every day we risk our health in this dangerous profession where we are exposed to the concentrated sickness of the entire city. We risk our careers, too, and our economic viability making thousands of decisions about customers with more medical problems and more medications than I once believed could burden one human being while held to a standard of care that tolerates no mistakes; the slightest of which (something as simple as not giving an aspirin) not only has the potential for disaster but can start the long, expensive slog through the court system where every victory is Phyrric and defeat, the out-of-court settlement, is always the preferred outcome.
And then nobody really pays us for our work although the usual drunks and serial abusers of Emergency Services, customers all, loudly proclaim at the slightest affront to their august dignity that they are “paying our fucking salary.” There are co-pays for some and none for others and some boldly steal medical care, the thought of paying one thin dime for the services of at least the highly-trained nurse who they regard as their personal servant having never entered into their head; medical care being, after all, just another public utility like water and sewage and nobody pays for those things.
The bureaucrats at my hospital have just gone through their annual mission statement contortion and have, on schedule, given birth to the usual smarmy slogan which is going to change the direction of the hospital and solve every one of its problems by focusing on the customer…putting the customer first…taking the customer seriously…making the customer the center of our efforts…making customer service a priority…ostensibly to increase customer satisfaction but more realistically because it is cheaper than hiring nurses to take care of the customers we’ve already got.
But this isn’t Wal Mart and the patients are not customers. Pretending they are degrades the patients and dehumanizes the practice of medicine by substituting clinical judgment and perception with the polite fiction that we are engaged in nothing more than a business transaction, one in which the customer is always right and which is now to be ruled by Press Ganey and Mammon, the Two-Faced God-Incarnate of the bureaucrat.
Come On Now…
92-year-old patient. Demented. The usual medical problems teased out of the the nursing home medication list and the family who insisted he was healthy except for the pacemaker, the feeding tube in the belly, the coumadin for a “heart problem,” the three strokes, the diabetes, and the emphysema (but he’s 92 so he must be doing well). History of benign polyps in his colon. Presented for abdominal pain after a colonoscopy earlier that day.
Why does a 92-year-old man with less than a fifty-fifty chance of living another year get an expensive colonoscopy? I mean, it had better be a good reason. Rectal bleeding. Something like that.
“It was a screening colonoscopy,” said the consultant, “We removed a polyp.”
You have got to be kidding. Remind me never to send you another patient. Would it have killed you to have politely deferred the colonoscopy for another year just to see how things would shake out?
Of course, I was no better because I ordered the deluxe work-up with all the usual laboratory tests and the premium CT scan although his abdomen was benign and he was too demented to really get a handle on his exact symptoms. In my defense and contrary to popular belief, please note that I don’t get extra money for ordering a lot of tests. But I still squandered your children’s money, money which really belongs to our Chinese and Arab creditors and future masters, at a blistering pace.
My job is mostly ridiculous, on some levels anyway. At least we sent the gentleman home instead of admitting him like the family wanted, “just to be safe.”
“Just to be safe.”
The four most expensive words in all of American Goat Rodeodery.
We Just Get Headaches
I had a pleasant conversation with a recent immigrant from Cuba whose wife came to the Emergency Department with a severe headache that she volunteered was the worst of her life and had started abruptly. Naturally with this kind of history and some reasonably high blood pressure we brought the Great Ship of American Medicine about and raked her hull with a full broadside of medical ordinance. We were looking for a ruptured cerebral aneurysm and it took a CT scan of the brain (negative), a lumbar puncture (a “spinal tap”) which was equivocal, and finally a Magnetic Resonance Angiogram (MRA) of her cerebral vasculature to definitively prove that there was nothing really serious going on and she just had a bad headache.
The cost (to your children) was immense and on the way out the husband, who was extremely gracious and not a little impressed at the our thoroughness, shook his head in amazement and said, “You know, in Cuba we just get headaches.”
“We used to just get them here too,” I replied.
Something About the Culture of Medical Training
One of our junior residents did a particularly fine job of intubating a patient who had, to put it mildly, an extremely difficult airway. You know, 600 pounds, no neck, a beard, and instant hypoxia when laid flat.
“Nice job,” I said after we got everything secured and the the patient moving towards the ICU.
The nurses looked at me in horror. “Good Lord,” they seemed to say with their eyes, “Don’t praise the residents, they might get big-headed. Don’t you know you’re supposed to beat them down at every opportunity?”
Just thought I’d share.