Life or Something Sorta’ Like It

(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.

15 thoughts on “Life or Something Sorta’ Like It

  1. While I understand your opinion of Ted Kennedy and respectfully disagree with a few parts of it, he did serve in the military. Like the 43rd President, he had a pretty cush posting (wikipedia notes that he climbed the Matterhorn), and is by no means a war hero, but he did serve.

  2. I’m not a fan of your black-and-white view of politics, but I *love* your insights on medicine and your searing yet eloquent wit. Keep up the strong work!

    One thing I’d like to know: now that you’re finally making the “big bucks” and you’re the guy in charge, do you think it was worth it? If the answer is still no, I wonder how your answer might evolve as you pay off your student loans and start to enjoy a relatively comfortable standard of living. (BTW, I know you didn’t do this for the money, or at least *just* for the money…)

  3. Truly, I think this is the best post I have read all weekend…and since I totally screwed off for the last day and a half, I have read a ton. 🙂

  4. On a less annoying note, thanks for the insight into community EM, it’s harder to get an idea on what a career in EM would mean not working at an academic institution.

  5. I don’t usually agree with your political bent and often wish you would stick to the doctor stuff, which is fascinating, and I love your attitude, but this “liberal” completely agrees with your assessment of Mr. Kennedy even if it was incorrect about serving in the military. I thought all the pomp and speaches and luminaries for a week was an insult to every other Senator who ever died, where was their big ceremony and flags at half mast? There may even have been a few of those Senators that actually did try to represent their constituents and maybe did a good thing or two. Even my (even more liberal than I) sisters say “He was a great American,” and I’m thinking, what what what? When did he ever put his money where his mouth was? Can’t they see how hypocritical he was? He literally got away with murder and spent his life in the lap of luxury. Makes me sick!

    (Correction noted. -PB)

  6. Brad said: “If the answer is still no, I wonder how your answer might evolve as you pay off your student loans and start to enjoy a relatively comfortable standard of living.

    Most doctors don’t wait to pay their loans in their entirety to “really start living”. Medical school loans are locked in at such ridiculously low (comparatively) interest rates that you gain nothing from hurrying to pay them off.

    With how big some of the loans can get, the only thing that really makes sense is to pay them as slowly as possible. If new-grad docs could make -less- than the minimum payment a month or defer them for even longer, even with the juice still running, they would. That is how low the rates are.

    Not to say they’re trying to cheat anyone, but the cost (in terms of prime-of-life income soaked up by paying them off) would be ridiculous if they tried paying them in full, immediately after they finished residency.

    And yes, here’s another vote for, if not writing about your politics less -often- , at least dialing back the verbiage used from “cartoonishly overblown” to merely “opinionated”.

  7. To add another description of our job – Its like being a waiter where “customer” choices are “unhappy” or “pissed off” about their three hour vist to do more testing than their PCP has done in three months for evaluation of some non-specifif vague reoccuring abdomnial cramnp that has suddenly cuased anxiety at 10 PM after watching a TV show where someone had something wrong.. People have returned and said “You waited on me last time” what???
    Another short clip – A pt with an obvious rotator cuff tear was unhappy because I wouldn’t XRAY her shoulder (no history of trauma, etc…) She said her friend who was an EMT said she should come for xrays. When I told her I was an EMT then I went to 12 years of school to become an ER doctor it did not satisfy or Trump her friends 2 months medical training recomendations. No xray, low Press-Gainey – Haven’t lost any sleep….

  8. Hey Luis,

    That’s news to me about med school loans having “ridiculously low interest rates”. Maybe 6.8% (stafford) and 8% (grad-plus) are low in comparison to credit card rate, but I don’t wtf you’re talking about.

  9. I work in a VA ER; I have also worked in County Med Centers for Level 3 trauma, 2 bed Comm Hispital EDs, usual low ERs, UCs, Occ Health, private practice (now there was a strange foray into economics) and Kaiser, as well as doing house calls.

    Seeing the VA patients gives me a glimpse into national Medicaid/Medicare. I remember one case that sums up both patient thinking and system structure: saw a guy at 2 AM who drove 60 miles (when gas was $2/gal, in an old Ford truck, because I asked, probably averaging max 12 mpg)for an Rx for his scabies. The VA gives out 5% Permethrin, an OTC med, as standard. He spent $20 on gas, 2 hours of total drive time and one hour of ER and wait for Rx time to get a medication that he could have purchased for $3 at his in-town Walgreens. And I advised him of this in case he needed a reapplication in the future. He said, ‘Well, I guess, now knowing that, this was all pretty dumb.’ I agreed with him.

    And we expect citizens to make good judgement calls on medical care when they know the costs. Yeah, right.

  10. Brian:

    Actually, since 2007, the rate for Stafford loans is being cut incrementally each year. They will stabilize at 3.4% in 2012, and stay that way. -That- is “wtf” I am talking about.

    Additionally, the Perkins loans are 5%. Yes, there are fewer of these to go around, but they’re still out there.

    Also, many folks are able to consolidate their loans, either paying the lowest interest rate out of the bunch or, if they’re really lucky, negotiating something even lower.

    Panda did this himself, I believe. He mentions it in an old post that I can’t find right now. In fact, I think I even cribbed the phrase “ridiculously low rates” from that post. I shoulda given credit.

  11. Kennedys and pageantry, even in death. Remember the somber but constant coverage of the death of the former president’s son, with his wife and sister-in-law. Burials at sea, as if for some fallen hero–which he wasn’t–he was just a minor celebrity with no history of service at all. But Navy ships and submersibles were called to immediate duty in the search for wreckage and later recovery of the bodies, and still later used for the funeral.

  12. A bit late, but needs to be said.


    When someone calls you out on a mistake, do more than a cursory fact check before you come back and repeat the mistake. The Stafford loans rates that are being cut annually until they reach 3.4% that you refer to are for undergraduate Stafford loans. Medical students will are stuck paying 6.8% for Stafford loans and 7.9%/8.5% for Grad Plus loans. And no, you can not consolidate them at “the lowest interest rate of the bunch” or negotiate an even lower rate. Consolidation simply turns multiple student loans into one big loan with the interest rate set as the weighted average.

    The reason Panda and others were able to get low rates is because their student loan interest rates were variable and prevailing interest rates were low, so they consolidated their loans to a fixed rate to lock it in. Student loans now start out at a fixed rate, that means the rate won’t be changing when you consolidate.

  13. Ha! The ER I work in uses Medhost. It does suck sometimes, but the docs around here don’t seem to mind it too bad.

  14. We just got hit with Medhost. It is the biggest impediment to quality patient care that I have ever encountered. Because of it, I’m going to seek other employment after 10 years at my current job.

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