“I got the Swine”

I’m hoarse from explaining influenza to my patients, the numbers of whom showed a small but significant increase over the last two weeks as Swine Flu hysteria grew, peaked, and then receded.  Everybody wanted a pill for “The Swine” for which, unfortunately, there is none except an essentially useless anti-viral that works but has to be given almost before you even know you are sick to have any effectiveness.  Antibiotics are useless against a virus of course and I spent hours explaining to my patients who, being mostly products of the public school system, had no clear idea of the difference between bacteria and viruses or even what these tricky sounding things were in the first place.  To their credit they had terrific self-esteem and confidence in their ignorance so the schools must be doing something.

Undaunted, I came up with all kinds of simple analogies to explain the difference between bacteria and viruses. I thought I was doing pretty well but invariably they would smile, nod at the crazy doctor, and ask for some antibiotics.

Simply because it is the first instinct of the public to seek safety at the Emergency Department I think if we ever have an epidemic of a dangerous and essentially incurable viral illness we are all screwed .  Going to the Emergency Department during an epidemic is exactly the wrong thing to do if all you have is a sore throat and some sniffles.  Some of your fellow citizens sitting next to you in the packed waiting room may actually have Ebola and when we invariably send you home with Motrin and our best wishes you are going to spread it to everybody in your house.

What we need is a public awareness campaign to keep people away from hospitals during an epidemic.   At least we need to put triage out in the parking lot and not in front of the triage nurse’s counter.  That way we can send the not-that-sick or not-sick-at-all home without exposing them to everybody in town.

I’ve got news for all of you: If things get really bad there’s not much The Man can do to help you anyway and if you are old, multiply co-morbid, or unhealthy you will probably die as there are not enough ICU beds or staff who will show up to work to take care of you.

Super Users Revisited

I know everybody and his brother is outraged at the examples of lone-gunmen patients who make so many Emergency Department visits that the cost of their care runs into the millions but the problem is actually much bigger than that.   While the Super Users are an obvious problem, they are also something of a red herring.  Sure, they cost a lot of money but as there are not that many of them we could conceivably solve the problem with a little creative but humiliating bribery (say a permanent suite at the best hotel in Vegas which would be a bargain compared to the alternative) or a couple hundred bucks to the right seedy character and no questions asked.

The real problem is the patients who don’t rise to the level of Super User but nonetheless spend a significant amount of their time trying to wrangle an admission for chronic medical problems, an admission that, as it involves 24-hour care, hot-and-cold-running-narcotics, room service, and chambermaids and butlers who dress like nurses is viewed as something of a vacation from the daily grind of anticipating the next disability check.

I almost always look at the List of Previous Visits before I go see a patient, just to see what I’m dealing with you understand.  It is, for example, useful to know that the last time your asthma patient came in he had to be intubated and spent a week in the Intensive Care Unit.  This kind of information keeps you on your toes.  Lately I’ve noticed quite a few patients coming in for what turn out to be minor complaints who have twenty or thirty Emergency Department visits in the past couple of years, also for what were presumably minor complaints as they were frequently sent home without admission.  Not enough visits to rise to the level of Super User but how many times do most people go to the doctor, much less the Emergency Department, in a couple of years?

I’ve seen a doctor four or five times in the last thirty years but I have so far enjoyed good health.  On the other hand I have patients who have quite a few medical problems but still manage to get through a year with only four or five doctor visits and trip or two to the Emergency Department.    Would twenty doctor visits a year for chronic but easily controlled medical problems be considered excessive?  How about four or five admissions, most of which were probably incredibly weak and more to ward off the legal vampires than for any sound medical reasons?

Anecdotally, and take it therefore for what it is worth, I would say that if I excluded my incredibly co-morbid patients who would die if not symbiotically grafted to every hospital in town as well as the handful of people with rare and unstable conditions, at least a third of my patients have a rather large number of visits, seemingly out of proportion to their medical history.

Don’t get yer’ shorts in a bunch.  I’m just throwing it out there.  But the wails and gnashing of teeth when medical care is finally overtly rationed as it must be under any system where it is given away for free will rend the very stones…and not just from the patients either.  Money drives medicine and the steady flow of government money cannot possibly continue.  Somebody is going to start saying “No” one of these days.

My Pet Peeve

You came to the emergency Department by ambulance, sirens blaring and tires squealing.  You were in excruciating pain, so much so that the ten-point pain scale was inadequate and you swore it was a “twenty out of ten.”  You clutched your chest (or your abdomen or your head) and I, taking you extremely seriously, initiated the Million-Dollar-Workup to find a heart attack (or an aortic dissection or a intracranial bleed).  I poured pain medication into you and stood ready to resuscitate you when you finally succumbed to whatever horror had you in its deadly grip.

So please, a scant half hour after your arrival and while we are well on our way to proving that all you had was a little bit of gas or maybe some particularly vicious esophageal reflux, please do not stand outside the door to the critical care/trauma bay asking when you can go home and demanding food.

Dude, you were dyin’ twenty-five minutes ago.  Can you wait another half hour for a sandwich?