Random Notes


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.

Frequent Fliers

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.

9 thoughts on “Random Notes

  1. Another excellent post PB. Do you see EM physicians competing with mid levels in the future or them hurting our job market sort of like what is happening with Anesthesia and CRNAs?

    (CRNAs and their like can compete with anesthesiologists because their field is highly specialized and the majority of their cases are fairly routine. In the same manner that most modern airliners can essentially take off, fly to the destination, and land on autopilot with the highly trained pilot flying along to make a few critical decisions, anesthesiologists may be viewed as an unnecessary expense considering that most of the cases are on autopilot. I don’t think the public would get on a plane if it was being flown by a computer or a mid-level pilot but the perception of medicine is different…and the illusion of care is all that really counts. A couple of laws changed here or there and CRNAs will be practicing independently. Economics demands it. No one is going to go through eight years of medical school and residency for a CRNA salary.

    Likewise with Emergency Medicine. A few critical pieces of legislation and mutatis mutandis, mid-levels will be ordained as independent practitioners of medicine and will be hired in preference to expensive physicians. The hospitals will love it. No more messy contracts with staffing groups, no more insubordination. Like it or not the Emergency Department is going to become a Triage Department with inadequately trained Nurse-Doctors admitting and discharging by script and reflex. -PB)

  2. Panda,

    Great to see you’re back online!!! A Christmas present indeed!

    Thanks for the words of wisdom and entertainment.

  3. You mention too many things that pinch my nerve in the ED. Drug seekers and abuse of the ED by free loaders and system suckers is why I couldn’t apply for a residency in EM this year.

  4. Bartholomew,
    I once felt that way about EM, but then I realized, there’s no escaping these patients. I went to surgery and found a patient who “needed” her colon removed because of her narcotic addiction- she ended up with an infection that nearly killed her because she couldn’t be bothered to come back to the hospital. I went to internal medicine and watched the intern get hammer paged all night long for narcotics, and also more benzo’s for a detoxing guy down the hall. I went to OB/GYN and found a woman admitting to having her 15th child for the extra welfare money, not to mention her entitled attitude when it came to healthcare. There’s the anesthesiologist who pays exorbitant malpractice so a homeless person can sue him. And apparently, Jesus is a medicaid patient who frequents the psych ward; he may have been the most entitled of them all.

    Point is, parts of every job suck; the trick is figuring out which job sucks the least from your perspective. And even though PA’s and NP’s are encroaching upon emergency and family medicine, or CRNA’s encroaching on anesthesia, at the end of the day physicians make a pretty decent living and I really don’t think that’s likely to change even if politicians attempt to go crazy on healthcare cuts. For quite a while now no one has had enough political power to really change anything, and even if that does change, politicians are themselves patients who don’t want to be treated by non-physicians. And since most of America feels entitled to be treated by physicians as well, I just don’t see things crashing down any time soon.

  5. Dear Pb,

    I just wanted to tell u that I have been reading your writings for at least 5 Years. A couple of weeks ago, I matched into EM because like you said – every other part of medicine sucks ass. I just wanted to thank you for all your writing and advice and everything else as I step into the goat rodeo. Do you happen to have any advice as we start intern year? Thanks for everything dude. Hoorah!

  6. You’re back Panda! Glad to see you’re writing again and hope you continue to do so. The site recently got spammed with product ad posts but looks like they were taken care of. As pre-med about to take the MCAT and apply it seems like the realities of medicine are getting worse and worse. Since taking a break from writing has your time spent working in the ER changed how you feel about medicine as a career?

  7. Good to see you back, Panda. I am a former Army Medic (82nd Abn Div, OIF) and a current PA student. I can only speak for myself, but I am acutely aware of my limits. Every day that I learn more I realize just how little I really know, and I don’t see that changing. I completely agree that if one is complacent or ignorant, it’s easy to miss the tiger lurking in the grasses comprised of GOMERS. Keep on keepin’ on, brother.

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