Free at Last, Free at Last

After six years of screwing around, I finally have a job. As many of you know I had to repeat my intern year because of a little something I like to call The Biggest Fucking Mistake of My Life. I won’t mention where I did my first intern year because its very name would serve as chum to attract the fearsome creatures guarding its reputation, not to mention awakening Those Who Guard The Sacred Flame of the specialty from whose clutches I barely escaped.
So I’m done with off-service rotations and as of July first will be a fully functioning second year Emergency Medicine Resident (but a PGY-3, you understand). The best thing about this is that I will be working predictable shifts for the rest of my residency with no call and the ability to sleep every day. I actually finished my off-service rotations a few months ago and have been working in this manner ever since. It’s pretty cool but I want to caution those of you thinking of matching into Emergency Medicine because you don’t want to work hard to think again. While it may be true that at most programs you will get what seems to be a ridiculous amount of free time (we work 14 shifts per 28-day block), at the end of a stretch of four shifts you are going to be wiped out, in a good way mind you, but wiped out none-the-less.

The pace at a typical Emergency Department that can support a residency program is relentless. I don’t deny that other residents work hard. I’ve done enough off-service rotations to know that they do. On the other hand the long days of, say, an internal medicine resident are broken up a little with conferences, the occasional slow clinic day, and frequent lulls in the action where one may take a breather which is not the case in the Emergency Department.

In Emergency Medicine when we are at work we are working, usually flat out, for the whole shift. As most residency programs are in what amount to charity hospitals there is never a shortage of patients and they will keep coming and coming, at all hours, and for a terrific variety of chief complaints. If you are ready for this and don’t mind multi-tasking then you will enjoy it. If not, this is not the specialty for you.

I Try to Be Empathetic But Come On Now….

I actually have a great deal of sympathy for addicts. It’s hard not to as they are some of the most miserable human beings you will ever meet. It can’t be much of a life bouncing around the various Emergency Departments in town looking for your next fix, getting more feral as the delay between presentation and your lucky strike, a new resident who has never seen you before, stretches to minutes and then hours.

Where addicts get the money for their habits in between emergency department visits is sometimes a question you do not want to ask. While it is true that some have money from disability and some have family or friends from whom they steal, many do unspeakable things for their drugs, things that would curdle your blood to think about.
There are two distinct philosophies regarding drug seekers. One school of thought believes that it is easier to give them a little morphine or vicodin with the goal of getting them the hell out quickly before they become a space occupying lesion. The other school believes that giving narcotics to the addicted enables drug-seeking behavior and encourages the waste of resources, sometimes leading to delays in treatment for people who are really sick. I probably lean towards the former school of thought because my first instinct is to give everyone the benefit of the doubt. Laughable as it may seem, even drug seekers may occasionally have a real medical problem so I try to be open minded.

But for God’s sake, “Rectal Bleeding” is not the thing to fake if you want drugs. Not only does it involve a complicated and expensive workup but it is going to require me to stick my finger up your ass, not something I generally like doing. And when I get your stat hemoglobin and hematocrit and it is normal I am going to be both disappointed and angry. It’s not as if your stable vital signs and completely benign appearance didn’t tip me off at the beginning of our visit. Indeed, the fact that you couldn’t prounounce the name of the only pain medication to which you weren’t allergic, something starting with a “D,” made me a little suspicious. And then when I discovered that you had a complete workup for rectal bleeding three days before with no findings whatsoever it was disappointing…and embarrassing for me because I was really gung ho to save yer’ friggin’ life until I got the old chart.
I also want to point out that if you are an addict and present with constipation after going on an oxycontin binge, reaching back and pulling feces out of your ass is not going to make me want to help you. You accused me of not caring but there is no way I am going to get close to you until you put your hand, the one covered in fresh manure with half-inch long nails under which is packed several year’s worth of other unspeakable things, down on the bed and stop trying to grab me. If you tried that on the “skreet” you’d get your ass kicked or arrested. Why is it all right in the Emergency Department? I understand that you’re jonesing but it is too much to expect of nurses and doctors to put up with this. If I made the rules I’d taser you and throw you back out on the street.
Wille Sutton robbed banks because that’s where the money is so I guess it makes sense for you to come to the Emergency Department because that’s where the drugs are. But being your dealer is not really our job and athough this would shock you, neither is taking care of you in the hospital or solving your personal problems.
And don’t kiss my ass either. I am not the best doctor in the world and your telling me I am just reminds me how crappy it is to be a resident at the bottom of a steep learning curve. Thanks for ripping that scab off and rubbing salt in the wound. If you just kept your mouth shut and complained of back pain like every other drug-seeker I would have probably given you something…except for that thing with your ass of course.

Silver Bullet

I am no luddite. While I am not on the cutting edge of technology I generally embrace it willingly when it is mature enough to simplify my work. Lately however I’ve had a change of heart about PDAs. Oh, I was enthralled four years ago when I was first introduced to them. Here at last, it seemed, was the one device that would put the bewildering immensity of medical knowledge at my fingertips and eliminate the need to carry the myriad pocket reference books that never really seemed to contain what I actually needed to know.

That’s all most us want. A simple reference book to carry around. A silver bullet, if you will, the one thing that will do the trick. The PDA is not it. Maybe it’s because the thing is so expensive. I already dropped one and fractured the screen. I got a new one from my program but it’s only a matter of time before it is damaged or stolen leaving me $300 in the hole if I want to replace it. Perhaps I have grown to dislike the complexity of the device, especially downloading software which never seems to work for me and my seven-year-old Toshiba laptop. It probably takes less authentication and verification to launch a nuclear missle then it does to download Epocrates. And the silly thing keeps begging me to update it, to synchronize it, and to hold its hand and comfort it.

Supposedly using the PDA to keep track of your patients is all the rage now but unless you are at a hospital that is totally committed to integrating medical records wirelessly and uses bullet-proof software, it is probably more trouble than it’s worth. An index card with the patient’s sticker at the top is actually a lot quicker, especially if you learn to only recored pertinent information. I also find that I can remember the important things about my patients and I don’t need to write much at all.
So I have ditched the PDA and most of my pocket reference books. In their place I carry a Tarascon Pocket Pharmacopia for a drug reference and the most excellent Tarascon Adult Emergency Medicine Pocketbook. The Emergency Medicine Pocketbook in particular, while as compact as all of Tarascon’s Pocketbooks, is packed with nothing but useful information. It at least tells you how to start the workup for the great majority of presenting complaints. Anything else you probably have time to look up later.

Just something to think about, especially those of you starting intern year in a couple of weeks. The Internal Medicine/Critical Care pocket book is a pretty good reference for most of your rotations.

62 thoughts on “Panda-pouri

  1. Pepid is the killer PDA app for EM. Unfortunately it’s expensive, but it’s very good (and it doesn’t nag like Epocrates).

  2. I do love a shiny object and I upgrade these things (and my digital cameras, laptops, etc…) every few months for fun. I am sick and need help! Even so, I plan on using the reliable and infinitely adaptable creativity of the 4×5 note card for 3rd year and beyond.

    The classic PDA seems to be going off the market in favor of these PDA/phone combo things. In my opinion, they are usually not good at either purpose in general. I have heard good things about the Treo, but does anyone have any real world experience? I will be traveling to a new city and new hospital system every 6 weeks and need some consistency in my communication & reference equipment I think. Can I use it in place of a pager?

  3. Your frequent diatribes against those with addiction are, unfortunately, the mainstream view of how we in the medical profession should treat people with this particular condition. Addiction is a long term, chronic illness that has particularly poor outcomes, including premature avoidable death. Like most other chronic diseases addiction happens due to a combination of genetic, social and environmental factors. Like many other chronic illnesses in medicine there are effective interventions that physicians can make that modify the course of this condition. Like many of the other chronic illnesses presenting for medical care, addiction is very common.

    Unfortunately you, like the majority of doctors, probably have no training in how to deal with addiction beyond identification and subsequent streeting of the patient. In reality neither streeting the patient, nor providing a small amount of drug is a particularly helpful intervention.

    Drug seeking and manipulative behaviour are the way in which people with addiction present to medical care…just like diabetics present with infected feet, and lung cancer patients present with hemoptysis, they don’t usually declare their underlying condition at the triage desk. Treating a diabetic foot is a chance to usefully intervene in the underlying illness, just as drug seeking is a useful moment for intervention.

    As a physician involved in addictions medicine I personally don’t really care if you have some underlying hatred of addicts. What I do care about is the fact that the attitude conveyed through your writing, pervasive in most of medicine, is a barrier to effective evidence based care of those people with addiction.

    I am not arguing that the emerg should be the place of treatment for addiction, but it is the primary place of presentation, and therefore developing effective interventions that start in this environment is important.

    I often here doctors say that patients with addiction should just get it together and take care of their own problem. It is important to identify this as opinion. The evidence says otherwise: That doctors can modify the course of this condition in a meaningful way. In no other disease state (with the possible exception of obesity) is it permissable for MDs to ignore all evidence and treat patients based only on their own whim.

    As for some of your specific comments…
    “If I made the rules I’d taser you and throw you back out on the street.” –> I’m glad you are still a resident and don’t make rules yet.

    “…even drug seekers may occasionally have a real medical problem so I try to be open minded.” –> Addiction is a ‘real medical problem’.

  4. Dr. J,
    you typed six paragraphs without telling us what that effective and evidence-based intervention that alters the course of drug addiction is.

  5. Yeah , dealing with addicts is JUST LIKE dealing with an old guy coming in with hempoptysis. Uh huh.

    Re PDA’s. The Treo SUCKS the big one. I too thought I’d found the Holy Grail when this combo phone/PDA came out. I’m now on my FIFTH device due to failure from a variety of reasons. This thing freeze’s up randomly, just like those crummy old computers that you wanted to throw out the window. I’ve spent hours on the phone getting help from the technogeeks that the company hires to constantly troubleshoot this device. Verizon maintains a line SOLELY for the purpose of dealing with this damn thing.

    If I had it do all over again I would have kept my nice, lightweight, slim phone and yes, carried my separate PDA around. Problem is, the stnad alone PDA market is dead. Plus, our friends at ePocrates keep making their program more and more complicated, which in turn requires more and more memory from your PDA. That’s the only reason I went to the Treo- my old (very reliable) Sony Clie couldn’t handle the piggish demands of the “upgraded” ePocrates. All I ever wanted was the damn drug database, but NOOOOOO. Now you have to have all sorts of extraneous crap, AND you can’t synch the PDA without going through the lengthy synch the ePocrates will institute every singly time you synch your PDA.


    -rant off-

    P.S. Keep up the good work Panda. It’s nice to see that there are a few sane doctors out there still.

  6. I have a Treo 700wx and it works great. I have it loaded with all the Unbound software and a few other medical programs and it hasn’t crashed since I got it a few months ago. In fact, it seems to integrate the phone and PDA functions better than any other combo on the market, and it’s sturdy enough to usually survive being dropped. OTOH, it doesn’t have WiFi, which will be a drawback at hospitals that use a WiFi system, and it can’t really replace a pager.

  7. Thanks Planet X, the implied irony is palpable in your comment. I don’t really want to monopolize Panda’s blog with my own prostelitizing, so I’ll keep this comment as brief as possible. The point of my previous comment was not to give a cook book solution to how to treat addicts, rather to point out that Panda’s views are pervasive, and training in how to treat addicts is nearly non-existent. Addicts are difficult to treat, and require physicians to be effective in managing difficult boundaries, apparent mental illness etc…

    A couple of points…
    1) Treatment for addiction, much of it increasingly evidence based, is complex and will not fit in the comments section of even Panda’s blog. If you are seriously interested I’d recomend borrowing a copy of ASAM’s Principles of addiction medicine, which is an excellent resource (borrow it before you buy it…’s way too expensive).
    2) Even if you don’t care a bit about treating addicts, treating them just as you would any patient with any chronic disease is a sanity saving measure for doctors, who often find these folks the most frustrating of all patients.
    3) In an emergency department setting the most appropriate approach backed up with some evidence of effectiveness is probably a brief intervention type strategy. Usually that goes something like this….”I’m glad you came to the hospital today, because you have a serious problem and it’s life threatening. You have an addiction to X and you and I both know it’s going to kill you. This is a common problem I see a lot here. If you want some help with your addiction today I’ll go to bat for you, I’ll arrange a medical detox for you and from there you’ll have to make some decisions about what treatment is best for you. That’s what I’m offering you today. I know the easy choice is to walk out the door and try to get X somewhere else. What I’m asking you today is if you want to make the decision to change your life before your addiction kills you….think about it for a couple of minutes and I’ll be back to talk about it some more.”
    The usual result is that the patient leaves (~95%) and takes you up on your offer (~5%). (there are lots of other approaches to addiction and lots of research….this is just a simple and time-effecient approach that can be used in emerg.)

    One of the keys to the above approach is that it treats the patient respectfully while empowering them to make their own decision. Even if they don’t take you up on your offer they will remember that you treated them respectfully and may come back to see you when they do want some other option. Plus, it’s way less of a headache and if it’s the same sort of message from most ED docs in your dept. it offers consistency of message. It does require some linkages between emerg. and other services…

    (yes, I work in emerg….yes, I really do the above…yes it sometimes helps)

  8. Congratulations on finishing your second intern year…a great day in your life.

    I second NoAcuteDistress on Treo. Do not waste your time. My Treo 700w has never worked satisfactorily with Epocrates. Syncing is a nightmare. Plus the thing has a mind of its own, calls my contacts more or less at random, makes me swear every time I have to place a call when I’m driving (the voice recognition sometimes works great and sometimes fails miserably). All in all it is just too complicated to use. Instruction book is 3 inches thick with a lousy index. It drops enough calls straight to voice mail that it can’t be used as a pager, unless whoever is calling you is not in a big hurry to get you. Not good for an ob doc! So I have a pager AND the heavy Treo, and still find that my Tarascon pocket drug book is the most useful resource I have.

    (I am still missing your USMC identity on this blog page. Please restore it! Thanks from Marine Mom of CPL Chris, deployed to Iraq.)

  9. I believe that the medical model of addiction is simply a myth spun by practitioners to justify their job. No matter what you do, in the end, the light bulb has to want to change.

  10. Time to buy a new laptop! Seven years old, wow. Does it still run on DOS? does it even come with solitaire? 😀

  11. let’s see the 5 year recidivism rate for addicts ‘treated’ like their problem is a disease and not a choice. please, please refer me to the definitive study and explain to me why the twelve step programs are embraced by the allopathic community.

  12. Mike: I make about 60% of what I would in a private practice to do addictions work…there is no financial incentive.

    911 Doc: 12 step programs are a crucial part of addiction treatment. The medical model contains more than just simply medicating people (and I’m certainly not advocating for medicalization of addiction anyways). Relapse is a part of addiction, and increasing the interval between relapses, and decreasing the duration of lapses and relapses is a good goal. I’ve never claimed that there is some magical, medical cure for addiction….but there is evidence for interventions besides streeting folks and telling them to get themselves well.

    The model I’m advocating mainly involves treating patients with dignity and respect and trying to connect them with the best availible options (evidence based options when possible rather than random options). I am constantly amazed, both on line and in life, that other docs will defend their right to treat these patients poorly or not at all…I am arguing that your (or anyones) personal feelings towards the addicted should not be the main determinate of the sort of care they get.

    Doesn’t really seem like that far out of an idea, but this seems the wrong crowd to try to convince anyways….

  13. Nonsense. When they stop being sleep-deprived they will come around. For no other reason it gets tiresome to feel irritated.

    I concluded long ago that the only way to survive this gig and have something left to take home is to be friendly with everyone, regardless.

    As an intern, an RN gave me a pearl of wisdom. A somatizer well known to the ED was in again, with complaints- but this time, that arm pain and hand numbness turned out to be a real zebra, an upper extremity DVT.

    After I got out of the OR I told Judy what the vascular surgeon had found- the patient had something after all!

    Her comment: “even crocks get sick”.

  14. Panda:

    Since you chose your next posting to be on addiction, a topic which interests me because I am a recovering alcoholic, I have this to say:

    You’re a bully.

    No two ways about it. You’re a mean bully. You seem to hate patients who you “judge” as having ailments “beneath” your so-called “skills”. And you have no interest in helping them.

    Tasering them? What happened to “do no harm”?

    Although I agree that drug addicts/alcoholics come to the ER for drugs and aren’t going to get their solutions there, I still say you’re a bully. You probably enjoy their pain.

    As I said before on another post, woe betide you. Because you are treading on a dangerous path with your bully-ism. That path of the Lord. He is watching you….

    (I thought you had washed your hands of this blog. -PB)

  15. Let’s not forget, good Christians, that blowing off steam is one’s right on one’s own blog.

    And writing it all down has therapeutic value to the writer.

    And yes, we all wish that addictionologists were easy to find and patients were striving to see them.

    My strategy is always the same; big, big, friendly, smiling demeanor..hey, it seems there’s a problem here, I can help you for tonight with a very SMALL prescription for a few tablets, and I don’t write for anything stronger than codeine or darvocet….if you are allergic to both I’m afraid you will need to find a different doctor to get anything stronger. Here’s a resource list for you to
    have in case you think about making some changes and getting some help.

    If I catch them in an outright lie, (frequent occurence) I point out the truth discrepancy
    while gently suggesting that perhaps their personal life is in trouble and that their memory may be suffering, and that narcotics are definately too dangerous to prescribe under those circumstances, overdose risk, etc

    Play a straight game, it’s fair, lets the patient know you don’t despise them and are willing to help in a targetted way.

    BTW, DREs under most circumstances can be deferred to PCP. The stat CBC is enough to CYA. DREs don’t have any real place in detecting/diagnosing bleeding diverticulae, the most common cause of BRBPR.

    Polyps never killed anyone by bleeding out overnight. Refer to GI/PCP and maybe avoid excessive pointless unpleasant exams in ED….

  16. I repeat, any patient who is acting the fool needs to be put down with minimal risk to the Emergency Department staff. If this involves a taser followed by soft restraints so be it. Why should the security guards or nurses have to wrestle with some shit-covered, potentially HIV or Hepatitis C infected drug addict who is playing at being insane?

    I say “playing” because if you have enough grasp of cause and effect to modify your attitude and demeanor depending on to whom you are talking you may be an addict, you may have a mental disorder, but you are not psychotic and you can be expected to pull yourself together and behave for at least an hour.

    Hand to hand combat is not part of my job description. It is also not fair to expect the ED staff to accept assault as part of their job and the fact that Joe Blow wants his drugs and is pitching a fit for them ranks well below my concern for our personal safety in the department.

    Taser or wrestling? No contest.

  17. As for DREs, they are low-yield and another one of those things we do even when doing one is silly. But, as I am a resident I do what my attendings tell me. Some are old school and view the DRE as part of every workup for abominal pain.

  18. Yes, I am a little confused as to why any disease gives someone a right to hurl shit at people. I’m really not convinced that in the hands of someone with the proper diseases, that this doesn’t constitute assault with a deadly weapon. If a drug addict started hurling shit at customers in a bank and he was tasered, would anyone go ballistic about that?

  19. (Yeah, I thought so too, Panda, but it seems that you goaded me again….)

    Anyhoo, it never fails to amuse me why people get so angry at my opinions that they will do things like yell: “Please stop posting BRN!!!”, like Road Kill Ninja did.

    I mean, if my opinion angers you so much, Mr. Road Kill, don’t read it. Or ask Panda to ban me.

    But Geez-oh-Man, it’s only an OPINION for Christ’s sakes. You can’t be BRAINWASHED by me!


  20. Road Kill Ninja, and everyone else, I think BRN brings up an excellent point when she suggests you not read her posts. At first I thought she was just a very critical person who was good at choosing to read what she wanted to see rather than what people actually wrote, but her last post is classic troll behavior.
    “I still say you’re a bully. You probably enjoy their pain.”
    “Because you are treading on a dangerous path with your bully-ism. That path of the Lord. He is watching you…”
    Please do not feed the trolls.

    Oh, and congrats to Panda. Sorry I forgot to say it earlier.

  21. Chris: a troll is someone who speaks simply to cause trouble. I am not that. I am a crusader for patients.)

    Also, a note for all doctors here—get ready….

    If you and your cohorts had ever read any of my posts, you might (in your already-made-up minds) seen that I am NOT a troll—- because the reason I speak out so vehemently is for INJUSTICE and a desire to defend the weak and sick who cannot defend themselves against doctor bullies who make the big bucks (despite their pitiful whinings that they make “little money”, which we all know is a crock.)

    (I make about ten bucks an hour as a resident.  After six years of training with two more to go all I have to show for it is a quarter of a million dollars worth of debt, financial ruin, and a net negative income.  Tell it to somebody who cares. -PB)

    I took my nursing vows VERY SERIOUSLY. I will ALWAYS do that. If not me, who?

    I have certain beliefs about Panda. I admit that I may be wrong about him. He may not really be as much of the bully that I think he is, BUT…. he certainly projects an image on the web that is bully-ish—and very negative in terms of patient advocacy and compassion…..and empathy….and other qualities one HOPES that their doctor may NOT have.

    God, how many times has a lost, forlorn and sick patient (whether physically or mentally) desperately gone to a doc hoping for mercy and help whether, in the doc’s opinion, they “deserved” it or not?

    May you critics of me never be in that position. But I have news for you. You definitely will be someday—in your old age. Know why? Because in your old age, insurance or not, you will be at the mercy of a young and cocky doc who “writes you off” as an old dementia-ridden patient who “doesn’t know what’s good for yourself”—-and they will give your case very little thought—-and will let you die early for lack of empathy and “economics”. Whether or NOT you or your family wanted you to die at that time. I’ve seen it a zillion times…

    (I believe I am on the record as generally being in support of expensive medical care for the elderly and multiply co-morbid.  I merely point out that this kind of thing ain’t cheap and no socialized system is going to make it any cheaper.  On the other hand I’m not blind and I see that we often go to ridiculous lengths to preserve the vital signs of people who are technically dead.-PB)

    Come to me then, and ask me how to get “mercy” and “understanding” from doctors.

    Right now, over at Fat Doctor’s blog, there is a post about “entitled behaviors” from patients who have the unmitigated gall to expect more than a 5 minute consultation from their doctors. They are accused of being selfish types who think the “world revolves around them”; aka, the paying patient who thinks “it’s all about me”.

    Again I say, come again to me— when you YOURSELF, you high-and-mighty doctors, are sitting in a doctor’s office yourself, hurting, confused, in pain, and thinking that “it’s all about me”—but you get a resentful doc who thinks: “Oh shut up, you self-absorbed whiner” and gives you a five minute visit with a prescription to shut you up.

    (Did a doctor take a big greasy crap in your Lucky Charms?  You seem to have declared a vendetta.-PB)

    Because I will then ask you, the doctor, (now a patient) this: “But…I thought it WAS about the doctor’s comfort level, their pay, their working hours, their “systems”, and their MEDICAL SCHOOL BILLS.”

    Anyway, this is how I cope nowadays: I say this to the doctors who find their patients leaving them, suing them, etc: if you can’t stand the heat (the doctor’s lot in life) then GET OUT OF THE KITCHEN.

    I wish doctors would stop their stupid complaining. I think the same of their childish complaining as I think of complainers in the trash collecting profession, the postal profession, the morticians’ profession, etc.

    (Nursing school is nowhere near as difficult or demanding as medical training.  Not even close.  It is easy for you to make kitchen analogies because you have never actually been in that kitchen.  Sorry.  Even the nurses tell me that being a resident must suck like nothing else.  Interestingly enough I had to explain to a nurse what call meant.  “You mean you don’t get to go home?” She said, and she was flabbergasted that human beings would willingly put up with 30-hour work days every fourth day for years and years.-PB)
    WE DEAL WITH HUMANS and their sicknesses, folks.

    God what ARE they teaching medical students these days? That it is all like the TV show doctoring?—-where all is glamour and sleeping together?

    Those of you who complain in the fashion that I have commented on don’t DESERVE to be doctors anyway. I rue the day you received your medical degree. May I run away, screaming, from your types. You are money-hungry, false heroes, narcissistic idiots. And I wouldn’t work for you if you paid me $100/hr in gold.

    (Ditto my remarks on Lucky Charms.-PB)

    We need doctors who CARE about the patients they treat. Not doctors who care only about their precious money and time. (And the “logic” of patients’ thinking.)

  22. Congratulations to you on your job!

    My area is social work and I wish there were more doctors like you. //kiss//

  23. I don’t think medical students are expecting a life of glamour and sleeping together. However, I do think they expect a life that allows them to make the salary they deserve and allows them to sleep from time to time (30 hour work days every four days is ridiculous).

  24. Panda, you’re gonna have to give it up. BRN is just as set in her viewpoint as you are in yours. It is funny that she finds you so vitriolic, when I feel her posts have a tone intended to be far more snide than yours, but perhaps that is just because I see more sense in your worldview. I understand her point of you, I really do. But I also don’t think it is necessary for a doctor to give up their entire life in order to be considered compassionate. I do not have to sacrifice my life on the altar of medicine to be a good doc, to get along with nurses and value what they do (and the same goes for social workers, etc). We all have our roles to play. Don’t worry BRN, there are plenty in my medical school and in others across the country that believe your stance on the issues is the best way to proceed. The ones in AMSA that wear the T-shirts that say “ENVISION UNIVERSAL HEALTHCARE” and such. I respect a lot of them as intelligent people and I think they will be good docs. I don’t think less of nurses because I think your debate skills and composure are somewhat lacking; I don’t even think less of YOUR nursing skills. There are good and bad docs and good and bad nurses alike and no one can tell one from the other based on some comments posted on a blog. Best of luck to you in your crusade BRN. Maybe the soundest rationale and most effective means of delivering healthcare in modern America be the national policy 50 years from now. Unfortunately, I don’t really believe that either you, or I, or Panda will really be happy with what we get.

  25. That would be “point of view” rather than “point of you” as written. My proofreading skills have gone down the sink since I stopped writing for a living.

  26. Regarding the news article above?

    From his own words, Panda would have tasered her and kicked her out on the street, thinking he’d gotten rid of another “bothersome drug addict”. And he would have made a lame joke about it while he was doing it.

    That’s what I’m talking about folks–illness of the human body. But of course, Panda and his fans interpret doctoring as “picking which diagnoses” they want to take seriously and fiddle with.

    A rare few doctors take drug addiction seriously. Others, the heartless and uneducated, don’t know or CARE about the heartache of this condition. When confronted with one, they INSTANTLY rule it out as a “trash” diagnosis and don’t any look further for physical problems beyond the typical—like DT’s or whatever. (And they rarely give a heck about the DT’s, even though it is life-threatening.)

    I don’t have any great solutions to the problem, but I sure as heck don’t treat them badly. I don’t treat ANY patient badly.

    The thought of a janitor cleaning around this poor woman is heartbreaking. If you think the Lord wasn’t looking, you’re wrong. And if a non-addicted doctor KNEW THE TRUTH about drug addiction, he would be amazed to know the amount of pain, heartbreak, self-loathing, and self-hatred go with that diagnosis.

    But then, it would simply give Panda fodder for more jokes. You who “judge” will someday get your just desserts…..

  27. Q4 call? When I was a resident we did Q2 or Q3! The Q2 call went away after work hour regs my second year, but it was 30 hours Q3 x 2-3 months in a row!

  28. Until BRN has gotten accepted to medical school, GONE to medical school, graduated from medical school, accumulated a shit-ton of debt along the way, while ruining her credit because she just can’t pay the credit card bills and rent on the amount she is able to get in loans, fucked up all her personal relationships becuase she just doesn’t have any time to give to other people (because if it comes down to relationship v. med school, if you want to be a doctor you’ll pick med school) – and after this, STILL chooses to continue on to practice medicine as an intern and then resident…and for multiple years in a row and STILL generally enjoys what she does…

    she has no room at all to judge you, PB.

    i’m not a religious person. what i do recall is that there’s a christian dogma thingy that BRN should really go back and do some reading on – it’s goes something like “judge not, lest ye be judged.” last time i checked, it hadn’t changed recently, and BRN in tossing about judgements, really should refamiliarize herself with the literature behind her soliloquy.

  29. If anyone is eating anyone “for lunch”, it’s random MSII chowing down BRN. PAWNED

  30. To MJ:

    Check and check mate.

    First of all, I majored in pre-med and was accepted at both a medical school AND a law school. Wrote my thesis in my third undergraduate year. I chose neither medicine nor law—wasn’t my cup of tea. I went on to work as a paralegal and got bored. Then I went to nursing school and found my calling.

    And hello? I already accused Panda and my critics of the Biblical admonition of “Judge not lest ye be judged” in a previous comment. I am the FIRST one who accused Panda of “judging”–but I guess you didn’t read that far back. You read an “angry nurse” comment and judged too quickly yourself.

    I gripe at Panda because of his OVERALL judging and ridiculing of the poor/uninsured/downtrodden—not simply because of one “rant and rave” posting.

    And I don’t need to go to medical school to have credit problems, money problems, or relationship/familial problems due to my work as a nurse.

    (No, but it sure helps.-PB)

    I lost the love of my life because I wanted to study instead of date my boyfriend during nursing school. In fact, one night in the nursing school dorm, while falling asleep with an Anatomy book in my hand, my buddies woke me up because my “love” was buying a slurpee for a girl who didn’t care about studying and WOULD go out at night. But I made quick work of her in front of the 7/11—I don’t think she got the strawberry color of that slurpee out of her hair for a week.

    (I see the 154 IQ didn’t pay any dividends when it came to studying.-PB)

    And ProtonDense is right–Random MSII does a pretty good job of attempting to make scathing remarks to me. Although, I must admit that I see from her/his comments that he/she has an “anti-nurse” attitude and doesn’t like nurses who “sass”. That instantly makes him/her go waaaaay down on my scale of respect. (Misogynistic thinking, ya know?) (Or the female equivalent, whatever.)

    Oh, and also: about your credit rating/relationship problems/financial troubles: Waaaaaahhhhhhh!. Poor baby! Must be tough. DIDN’T THEY TELL YOU ABOUT THAT BEFORE YOU WENT TO MEDICAL SCHOOL? Or were you not smart enough to research your chosen profession?

    (We’re not exactly complaining, just pointing out that you of all people should know that physicians do not spring fully-formed into the world making good salaries and driving nice cars and to insinuate that somehow our job is easy or comes with little effort is something I’d expect from a drug seeker who thinks of me as nothing more than his dealer.-PB)

    Why don’t you go to nursing school? I bet I make more money than you do and am on call much less. So don’t come crying wimpily to me about it. (Hey, I made up a new word! “Wimpily”. I like it.)

    (You are deranged.  First you opine about the evils of physician’s salaries, then you brag that you make a lot of money….except in another post you cried poverty. -PB)

  31. I think we should all take a moment and think about what it must have been like to survive TWO internships. Hair-shrivelling, plexus-stunning, perhaps incurable aftereffects.

    I offer my sincere congratulations.

    But I would watch your language regarding tasers- for no other reason, they don’t work and cause MIs. Don’t you have some magic IM quieting mix? I mean, the shoe-bomber stuff?
    (the doc had a lot of help there, though. Probably not a good comparison.)

  32. BRN, how do you not know that random MSII is female? She just took issue with you using the genderism card in a recent thread (hint- the same thread where you bragged about your reading comprehension- *seriously*

  33. I’m not even going to respond to any of BRN’s posts because I find it far more useful to skip over what could easily be labeled as “misguided” and “religious extremism”, so I’m just going to point out, even if tasers do cause MIs, I think the point he was trying to make is that people in the ED shouldn’t have to deal with combative patients. Period. The reason cops deal with combative people is because they have the training, and more importantly, the guns to suppress those combative people. To the best of my knowledge, most doctors and nurses have little to no knowledge of hand-to-hand or martial arts, and even if they did, it’s not in their damn job description; and they sure as hell don’t carry guns.

    I don’t see what’s so absurd about turfing drug addicts anyway. EDs are usually always constantly busy to the point where if a drug addict comes in, that drug addict is making someone with a real medical complaint wait longer to be seen, because if the doctor is tending to that drug addict, he/she is obviously not tending to another patient at the exact same time. Perhaps a solution to this would be to report all obvious drug-seekers to the police and have them thrown in jail. Why not? Usually the drug-seekers are pretty damn obvious, and it /should/ be a crime to abuse the system like that. Plus one urine test is all you’d need to prove the case that the drug-seeker is in fact a drug-seeker.

    And if it ends up tasing them and they have an MI, well, at least then they’d have a real medical problem instead of just a BS complaint for pain meds.

    (Tasers do not cause MIs.  An MI is a “Myocardial Infarction” or a sudden blockage of a coronary artery.  I think you folks mean “arrythmias” which Tasers don’t cause either.  In fact, when used against the typical person for whom a  PRN tasering might be indicated (young, healthy, belligerant, drunk frat boy) they are harmless and certainly have fewer side effects than Halodol or Seroquel-PB)

  34. The complaints about Panda’s posts are simply absurd. He doesn’t have to be mawkishly sentimental about addicts to provide appropriate treatment for them or to reject dangerous behavior from them. If Panda’s attackers were truly committed to loving and tolerating the worse behavior from irritating folks, Panda would get a love-bath every time he posted thoughts irritating to those people. Yes?

    An interesting book others here might want to check out is Theodore Dalrymple’s “Romancing Opiates”.

  35. Um, actually one of my best friends is a nurse. There was absolutely no sarcasm in my posts when referring to the importance of nurses, social workers, etc. If you choose to read that into what I write, I can’t help it. I even went so far as to state I DIDN’T think less of nurses or even your nursing skills because of went goes on here: I have no doubts you are a good nurse. The fact that you insist on coloring my comments with what is not there only supports the contention of others that you are somewhat unhinged.

  36. Remember folks, the only FDA approved treatment for trolls is to ignore them. Attention makes it worse.

  37. I don’t think BRN is a troll, per se. In my book, trolls are those that make things up or invent a role for themselves that doesn’t necessarily completely jive with what that person might actually believe. Trolls do that just to stir things up and cause trouble. I think BRN is 100% honest in what she believes and how she feels about those that disagree with her. I don’t think she’s 100% balanced in her ability to express her views and opinions and I think she is intentionally contentious in her presentation of her viewpoint (but then again, so is Panda, IMHO). But a troll, not quite.

  38. Incidentally, we are terribly off-topic. I’m sure Panda would prefer if we did not completely hijack his comments section for a discussion as off-track as this one has gotten.

    (No.  I don’t care.  It’s just the internet.-PB)

  39. Random MS2, you are very charitable, and you may be right. BRN may be genuinely unable to control herself long enough to type a cogent response and thus has to resort to rants, insults, strawmen, and posturing. They appear to be deliberately inflammatory, however, and trying to piss people off is the hallmark of troll behavior.

    “I think she is intentionally contentious in her presentation of her viewpoint”

    I disagree that she actually presents discrete viewpoints. Look at her posts here and you see lots of braggadocio (I’m a genius! I have huge breasts! I was accepted to medical and law school!), insults (I hate physicians for some reason!), and self-righteousness (You’re all going to Hell for not agreeing with me!) but little of substance.

    The selective reading of other peoples’ writing and general obnoxiousness is trollish behavior, even if it’s unintentional.

    (Now I get called a misogynist, anti-nurse, and accused of not being able to handle “sass”, whatever that means.)

  40. I agree ryan, considering how many obsessive posts BRN has posted on this post alone. I think hypocrisy has just reached a new high. 😛

  41. She’s pretty obviously not a troll. It’s clear she’s got some degree of mental illness; hardly an uncommon thing on ye olde internets. Thus far in this thread, she has claimed to be: incredibly beautiful, a defender of the poor and helpless, a super genius (literally) and accepted to both medical and law school (but declined for nursing). Then read her posts and note her highly disordered thought processes and lack of logical reasoning or consistency. Occam’s razor says…

  42. Yeah, I think you all may be right in that BRN is not a classic troll. I don’t think a real troll could pretend to be that crazy that well. But I also don’t think that she’ll ever accept that those who disagree with her aren’t being misogynistic or anti-nurse, but are instead becoming prejudiced against her simply because she’s shown herself to be belligerent, unhinged, and unable to respond to what people actually write, rather than what she wants to see. So I don’t see what the difference is from a practical standpoint. Please don’t feed the BRN.

  43. “I don’t think a real troll could pretend to be that crazy that well. But I also don’t think that she’ll ever accept that those who disagree with her aren’t being misogynistic or anti-nurse, but are instead becoming prejudiced against her simply because she’s shown herself to be belligerent, unhinged, and unable to respond to what people actually write, rather than what she wants to see.”

    I think it’s likely that all of the above are true (unhinged etc.) but that she also tries to be intentionally irritating (trolling.) Heck, she even admits it (e.g. “People can’t handle my sassy attitude etc.”)

  44. The worst part is that I’m tricked into following the link to her blog about once a week, just hoping that it will not suck this time. No dice.

  45. I just followed the link to that blog. Oh my God…(my eyes! the goggles do nothing!)

    I kept hoping it was some kind of joke in the tradition of Jack Handy or Stewart Smalley, the Al Franken character that used to say, “I’m good enough, I’m smart enough, and doggone it! People like me!”

    Never again. My curiousity has been satisfied and I’m still shuddering.

  46. Yeah, I just followed the link to BRN’s blog too. What the fuck is up with the enlarged multi-colored text?

  47. Dr. Bear:

    really luv your prose and think you maybe the only one among the bloggers i follow who can do justice to an essay on the etymology of ‘retrospectoscope’ , ‘retrospectoscopy’ etc. as applied by pretentious nurses, midlevels and other “interested” parties like lawyers, etc.

    thanks and keep your cool about residency.

  48. “…one may take a breather which is not the case in the Emergency Department. In Emergency Medicine when we are at work we are working, usually flat out, for the whole shift…”

    What a load.

    I worked during IM residency in the ER and overnight we often were sitting on our ass doing nothing. That NEVER happened in clinic (maybe once). And this is in New York City!

    (Look, your mileage will vary.  But I have worked in five Emergency Departments and I have never sat on my ass doing nothing.  At both of the departments where I currently rotate the rare lull in the action (an empty waiting room I mean) is viewed with wonderment, like rain in the Gobi.   And I believe I was comparing EM residency with IM residency which is mostly inpatient hospital work. Also, clinic is seldom 12 hours in a row for anybody but usually some variation of eight-to-five with an hour for “lunch.”  That’s how it was when I was an FM resident anyways.-PB)

  49. I am a primary care resident and I agree 110% with the posting of the Panda. How often do I see drugseekers come into my clinic with “headaches”, “migraine”, “abdominal pain” and oh yes… BACKPAIN!!! And most of the time the MA’s know they are drugseekers before I even see them. Then we sit around and play this stupid game for a while, I pretend to do a physical exam and think for while about wehich tests to order or which studies to order. Then I have to present these wreks to my staffers, that surely also know what is going on. At the end I end up with three options:

    1) Tell them flat-out about the 5 ER-visits at 5 different places the last 4 days.

    2) Give them 5 vicodin and refer them to pain doctor or orthopedics.

    3) Find a rare non-narcotic I prescribe them that they haven’t heard about.

    I feel horrible every time I tell them to “go to the ER if the pain becomes worse”, but I do not want my clinic to be flooded with druggies and if I start handing out drugs like cotton-candy to them, the word will spread. Many times I give ER-docs heads up about who was there. Many times ER-docs have saved my call-noght by sending such people out of the door without paging me.

    People that talk about “compassion” and label us as uncaring here are typically out-of-touch-people that have never been on-call, never had SICK people in the hospital that you wpould like to spend more time with, but can’t because miss so and so is in teh ER for her fix. Get a grip on reality!! These are poeople that jack up expenses for all the rest of us. They drain healthcare resources, time and money. They typically never work and expect us all others to cater to their least demand.

    My favourite is to lure drugseekers into a trap by having them tell me they are vomiting and “have been vomiting blood”. I give them NG-Tube, strictly NPO and if I can have them admit they have the worst headache in their life I give them a cat scan, put them NPO and only rectal Tylenol, because medical school taught us not to give opiates in suspected head-injuries…

    If I have a sick patient around, someone in need of help I can walk the extra ten miles at any times. If some family I am taking care of have big troubles, I am willing to assist and help with many things, even counselling. However, I am NOT going to sit silently and let drugseekers steal attention just because some dimwit that have never taken a call or never been in an ER (working) tell me I am not compassionate!!

    ER doctors are doing a heck of a job and they are my best friends. Their job is EXTREMELY demanding and they don’t need these parasites around to make it worse. Also, totally agree with the point about tazering them. Are we supposed to bend over 24/7 today?? No way, get lost!! If you guys are so unhappy with “doctors” then become one and see how easy this is or otherwise shut up!!

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