Category Archives: Emergency Medicine

Emergency Medicine Residency (Part 1)

(The following article is directed primarily at those contemplating matching into Emergency Medicine. Those of you who are not may read it but I make no apologies for targeting a particular group of readers. Emergency Medicine has become a very popular specialty lately so I’m sure there is some interest out there. Most of my patients, by the way, even those who know how physicians are trained, don’t know that Emergency Medicine is a specialty. The more chatty ones often ask me what specialty I am going into. Even many of my relatives, and they should know better because I do talk to them now and then, think that Emergency Medicine is something doctors do when they can’t decide on a specialty or if they aren’t smart enough to do anything else.

I am at a small, community program as opposed to a major urban trauma center so our patient mix leans more towards the medical and not surgical/trauma. Not to say that we don’t see some trauma but it’s usually blunt trauma and not penetrating. In other words, I’m just giving you my own perspective. I shouldn’t have to issue any caveats but invariably I’m going to get a ton of irate emails insisting that they do things differently at their program.-PB)


Emergency Medicine is a specialty of speed. Everything needs to be done not only quickly but with an economy of effort that separates the important things about the patient from those that are interesting but not particularly relevant. Victory is declared when the patient has a quick disposition; either treated and sent home, transfered, or admitted to the hospital. Ultimate victory occurs when the patient actually leaves the department. Take for example the typical suicidal patient who has made a lame, self-centered gesture at self-termination. In medical school you are conditioned to explore this kind patient in incredible detail. Consequently, as a new resident your first instinct is to get a detailed psychiatric history, delving deeply into the mileu of the patient’s life to assess his motivations. In reality however, your meaningful discussion with the patient is useless and is only going to delay his final disposition. You know he is going to be involuntarily committed and the sooner he can get somewhere, anywhere, where he can be evaluated by a skilled psychiatrist the better. It’s the psychiatrist’s job to do this kind of thing and he can run circles around you and your rudimentary knowledge of his field. Not only that but as the patient flaps his gums and you pretend to be interested you are falling way, way behind on the eight or nine patients you are working up.

The relevant questions then become, “Did you try to kill yourself, how many pills and of what type did you take, and what do I have to do and what tests need to be ordered to quickly medically clear you for a transfer to an appropriate mental health facility?” The patient usually wants to spill his guts (and if he doesn’t the parents or the loved ones are happy to oblige) but while it is important to be polite, we don’t have the time to hear how you were mistreated as a child. All I want to know is your acetaminophen level and whether it is rising or falling. Not toxic and decreasing? Nice meeting you. I hope you like mushy food and communal televsion. It’s been real. Buh bye.

The idea is to get a disposition. Since we don’t treat long-term psychiatric problems in our Emergency Departement, there is no point in wasting effort. It’s best just to get them out of the department. On the other hand we do treat a variety of medical complaints and on these you need to use the traditonal physician skills of history, physical exam, assessment, and plan. But relatively quickly. It’s a little more complicated than just differentiating lethal from non-lethal complaints but you need to ellicit a chief complaint and tailor your history and physical exam to expose it. Obviously the history should be the longest component of your encounter but even there you can get carried away. I once found myself sitting at a the computer sifting through a patient’s records trying to determine the dates of his seven heart caths at which point I realized that I was eating up time, I wasn’t a medicine resident, and maybe all I really needed was the date of his last heart cath and an old EKG or two to see if anything had changed.

“History of Coronary artery disease with seven stents, last on 2/5/06” is perfectly servicable for the purposes of emergency medicine. If we need more detail we can always get it. You cannot do a six-page medicine-style History and Physical on every patient, even the really sick ones. The typical EM physician works on around four patients per hour so you see how this would be prohibitively costly in time. It is true that some patients present with relatively minor complaints but there is a certain baseline level of paperwork involved with every patient independent of the acuity level.

So you need to be quick and that is one of the skills our attendings try to develop in us. This does not mean, however, that you cut corners. You just need to learn what corners to avoid. Being able to juggle a lot of things at one time is also an essential skill. Every resident in every specialty has to do this to a certain extent but what other residents consider a hectic day is just another routine shift for us. That’s the beauty and the curse of Emergency Medicine. The hours are good. Fantastic for residents even by regular job standards. Now that I am working full-time in the department I rarely go over fifty hours a week and some weeks I barely go over forty. The tradeoff is that we work very hard when we are working. There is seldom time to sit down and there is also no such thing as a break. As long as there are charts in the rack (new patients to be seen, I mean) you have work to do. There are always charts in the rack. There’s a crisis out there or didn’t you get the memo?

Emergency medicine isn’t the hardest job in America, not by a long shot, but I think we have one of the few jobs in the developed world where you can get to the end of a twelve-hour day and realize that you haven’t sat down, had anything to drink, or urinated since before you came on. I know that surgery and medicine residents put in more hours and I have nothing but respect for them but being at the hospital is not the same thing as actually working. In fact, many of the residents in the time-intensive specialties spend a good deal of their time sitting around bitching about how tough they have it which is something that Emergency Medicine residents never have time to do. We’re too busy. We complain of course, but not about staying at the hospital for no reason after our work is done. There is always a reason for us to be there when we are at work; they call it the waiting room. We come to work expecting to work.

But we do get to go home. At first I didn’t believe it was possible but now I am begining to accept the fact that nobody expects us to hang around after out shift is over. Sure, we have to tie up loose ends and ensure that our more complicated patients have a disposition but nobody ever says, “Hey, why don’t you stick around an extra four or five hours in case we get busy.”

My point? If you believe that you’d like Emergency Medicine because you don’t have to work hard you are going to be disappointed. If you like to work hard but also like to have regular hours and a predictable schedule with some time off to think about other things, you are going to be very happy as an Emergency Medicine resident. But thinking of Emergency Medicine as a “lifesyle” residency as is common among medical students contemplating specialty choices would be a mistake. It’s only a lifestyle specialty if you like that kind of lifestyle.

(Next: A Typical Shift For a Typical Resident)

Ask Yer’ Uncle Panda….

Say Uncle Panda, I notice you haven’t written about chiropractors. What do you think about them and chiropractic in general?
Chiropractors serve a useful role in society, particularly when it comes to taking some of the pressure off of used car salesmen who would otherwise have the market cornered on chicanery. Nobody likes to be the only crook in town you understand, and if chiropractors are good for the self-esteem of used car dealers I’m all for ’em. Other than that there’s not much use for chiropractors except to keep second-rate strip malls in business as they make that long descent from shopping mecca to consignment stores and karate studios.

On one hand you have the straight chiropractors who preach a strange religion where manipulating the spine can take the place of vaccines and cure all manner of diseases from cancer to your Aunt Dottie’s lumbago. On the other are the so-called “reform” chiropractors who confine their practice to musckuloskeletal complaints. Six of one, a half dozen of the other. Despite the occasional studies showing that it has a slight advantage over placebos in the relief of chronic pain and other fuzzy symptoms, chiropractic is a lot of sound and fury signifying little or nothing. For the money people spend and the effort they put into it (chiropractic school is four years, after all) I guess I’d want a little more than a slight improvement over a placebo. Just for my self-respect, you understand.

The basis of chiropractic is the theory that misalligned vertebrate (called “subluxations”) are responsible for disease. The old school chiropractor will shoot a plain film of your spine and use this as a basis for manipulating it back into position despite the overwhelming evidence that not only do otherwise healthy people have asymptomatic misalignments in their spines but there is no way to change the alignment anyway short of orthopaedic surgery.

But do what you want. I don’t care.

Hey Uncle Panda, I’m considering Emergency Medicine but I’m concerned that it’s just glorified primary care. What say you?

That’s ridiculous, at least from my perspective. As many of you know, I did a year of Family Practice and while I disliked it intensely, it at least gave me a taste of primary care. Emergency Medicine is nothing like primary care.

Here’s what I saw on a recent shift: Two acute MIs (one with significant ST elevations), one acute pancreatitis with nausea and projectile vomiting, a baby with meningitis and CSF that looked milky when I did the lumbar puncture, a motor vehicle accident with bilateral tibia fractures, a tylenol overdose, vaginal bleeding that turned out to be an incomplete abortion, a couple of strokes, a severe COPD exacerbation, a third nerve palsy (which I diagnosed without an MRI, thank you very much) and the usual minor stuff which, although minor, was still more “urgent” than the usual primary care fodder.

People go to their family doctor for diabetes management. They go to the Emergency Department for diabetic ketoacidosis or when their foot is rotting off as a consequence of distal peripheral neuropathy. That’s the difference. I think I see more truly sick patients in one week in the Emergency Department than I did in a year of clinic in family medicine where, on the rare occasion when somebody was really sick they got sent to the Emergency Department.
Now, it’s true that a lot of our patients could be better served at an Urgent Care. On the other hand one of our biggest source of customers are the local Urgent Care clinics, many of which are staffed by midlevels who have the good sense to drop back and punt.

I think a lot of folks don’t really understand primary care which is the long-term management of chronic conditions and not something we do in the Emergency Department, even if we wanted to which we don’t. We refer to primary care almost as much as they refer to us.

The truth is that you get so used to really sick patients that it begins to seem like primary care.

I am not busting down on primary care and Family Practice in particular. Primary care is neither easy nor quick. That’s why residency-trained physicians need to do it. The reason mid-levels do it is because nobody else will and because, cobra-like, they have mesmerized the Family Practice physicians who are their natural prey into accepting them as equals.

How long does it take to write an article for your blog and where did you learn to write so well?

Some articles write themselves and some I have to sweat over for days. I do experience periodic writer’s block and can go a long time without a decent idea (like the past couple of weeks). I suppose I could always write about how much residency blows but I don’t want to be a one trick pony. Besides, that would be like playing a crowd for cheap laughs. It’s too easy.

I also write most of my articles late at night when I should be sleeping. I hope that you, oh my critics, appreciate this when I don’t provide footnotes and an exhaustive bibliography. I just don’t have time. And I blog for fun so while I feel a responsibility to my readers to provide interesting articles, I do have a real job and to be honest, I make more moonlighting for half an hour than I do from the advertisments on my blog for a month.

In other words, this blog is a labor of love and not a money-maker so sometimes responsibility trumps fun.

I am flattered that many of you think I am a good writer. Let’s just say I’m working on it. I have pretty good role models who include Herman Melville, Mark Twain, Anthony Burgess, George Orwell, Charles Dickens, and Joseph Conrad to name a few. People ask me what I think about the Da Vinci Code. I didn’t read it. I don’t read crap. Period. I used to, of course, but after I discovered Robert Graves I have never looked back.

Read the first page of “Bleak House” or “1984” and compare it to the typical offering at Barnes and Noble and you will see what I mean. Most writing, like most popular culture, is excruciatingly bad. Almost painful to read. I’m probably not too much better but at least I can see where I need to go. One day I will have time to really write something meaningful but not right now.
Paradoxically, the rest of my tastes are completely plebian.

What ED Crisis? (And Other Random Thoughts)

Shake that Money Maker

They say there is a crisis in the Emergency Rooms and while I certainly see a little of its effects at my own program, the crisis is not universal. Some Emergency Departments compete for patients, at least this is my understanding from the numerous billboards I saw the other day as I drove towards Detroit. Surely you’ve seen those billboards? You know, the ones with the pleasant looking ethnically ambiguous doctor, stethoscope carried jauntily around his neck, beaming down at a cherubic youngster whose boo-boo he has just fixed with the caption underneath promising a “New Vision of Health Care” with a guaranteed thirty-minute-or-less wait.

And no, they are not advertising for Urgent Care even though they are clearly angling for urgent care patients. The caption clearly indicates these clean, ultramodern medical establishments are Emergency Rooms. Naturally every Emergency Medicine resident must roll his eyes and curse at the idea of attracting even more ridiculoulsy trivial complaints to make his day even more hectic. On the other hand not every Emergency Department is over-crowded and packed with the indigent and uninsured. A nicely appointed ED in a good part of town can generate real income if it has a favorable payer mix. Even if emergency services themselves are not a money maker they can serve as a loss leader to bring paying customers into the hospital (and out of the specialty centers).

I am not against making money and I certainly realize that competition is ultimately good for the consumer in terms of better services and lower prices. On the other hand one can’t help notice that we are, with the exception of the small fraction of the uninsured who can’t bring themsleves to stiff the system, ridiculously over-doctored in the sense that large amounts of health care firepower, the physician’s time being one of the most important, are brought to bear on complaints that are either so trivial as to be laughable or so serious that they are impervious to our best ordinance.

Take, as one example, my patient of last night who the triage note said was a febrile, nauseous, anorexic, dehydrated infant. The nurse rolled her eyes when I picked up the chart which usually tells you all you need to know. Febrile was an axillary temperature of 99 measured at home and 98.7 in triage. Anorexic was a disinterest in feeding earlier in the day but breast feeding vigorously when I introduced myself. Dehydrated was an extremely wet diaper. Not exactly as billed on the triage note.

I have four kids. Every now and then a viral illness sweeps through all or most of them leading to a solid week of vomiting, diarrhea, and sleepless nights as one child after another succumbs and recovers. I have never taken my kids to the Emergency Department and we rarely take them to the doctor, especially for self-limiting things like that. They’re kids. They get sick. They usually recover. I understand that occasionally a “stomach flu” is meningitis so we are justifiably cautious with ill or toxic-looking children but come on now. EMTALA aside, what we really need is the ability to send people home from triage, as in, “Are you crazy? This is an Emergency Department and you ain’t sick.”

We don’t of course, and the large minority of patients for whom we can and should do nothing contribute to the excessive waiting time for patients who, while not exactly critically ill, never-the-less should be seen sooner than the what can amount to a ten hour or more wait in some departments.

On the other extreme, I see many incredibly old, incredibly sick, fantastically complicated patients who all present for some variation of being as old as dirt and sick as stink. Perhaps complicated is the wrong word. There’s nothing complicated about impending death. When you’re pushing 100 nothing is really standing between you and the Grim Reaper except he’s finishing his bagel and latte and he’ll get to you when he gets to you, dammit. We do what we can but we’re hard up against biology. The interesting thing about these patients is that they swim through the murky depths of American medicine accompanied by a small school of physicians who, like pilot fish, dart ineffectually around their decrepit shark picking off an occasional parasite. Between the cardiologist, the neurologist, the internist, the oncologist, the nephrologist, and the nice young girl in physical therapy who manipulates the fins every now and then these patients devour an incredible amount of medical resources.

My point? Nothing really except we get the health care system for which we pay. The current system can not help but be ridiculously expensive because of the way it is structured. Nothing wili ever change, no matter how or to whom you shift the costs because:

1.Patients are not encouraged or expected to take personal responsibility for their own health.

2. As every insurance scheme insulates the patient from the true cost of health care, there is no incentive for patients to make good economic decisions.

3. The legal environment makes it impossible for anyone in authority to exercise common sense. When I was younger, for example, drunks went to the drunk tank at the police station. Now they all come through the Emergency Department where they are expensive, space-occupying lesions. I understand that in our risk-averse society this is necessary to prevent the possibility of a habitual drunk aspirating his own vomit and dying without immeidate medical care. At the same time this kind of risk management isn’t cheap. If the public knew the cost they might be willing to live with slight chance of a drunk or two dying in police custody.

4. Futile care, which is in no way discouraged, sucks up a vast amount of medical care, everything from the physicians time to the cleaning lady mopping the floor of the ICU. Maybe by the time a patient is being fed through a tube, urinates through a tube, defecates through a tube, and breathes through a tube it’s time to let them go.

5. Doctors don’t know how to say “no” or admit defeat. The temptation, to which we easily succumb, is to shift responsibility by consulting specialists. I understand the need for specialists but by the time a patient accumulates a small platoon of them its time to examine, in terms of mortality versus cost, what all of the hired guns are really buying us.

The true crime is that the zealots believe a single-payer system or some other scheme of “We Swear It’s Not Socialized Medicine” is going to make health care less expensive. Unfortunately, until the structural problems are addressed, health care will just keep getting more expensive. To address them is, ironically, to preclude the need for anything other than consumer driven changes which are the only kind that will work.

Random Ramblings

That Doctor

It’s official, I have become “That Doctor.”

You know, the guy who told them that their father only had three months to live and here he is, six months later, being wheeled in by his triumphant family. I mean, he looks almost the same as when I saw him the last time, maybe a little more cadaverish, perhaps a little less animated than I remember but still clinging gamely to life as only the terminally ill can. And I’m not disappointed in the slightest because he is a fine fellow and the family could not be more pleasant or good humored, a real pleasure to have in the department.

But to set the record straight, I did not say their father had three months to live. I said that the oncologist believed that their father had less than three months to live. But it doesn’t matter. I am now “That Doctor,” the guy who their father has outsmarted and outlasted and they are not shy to remind me of this, a remonstration that I take in the same good spirit it is given. Because I don’t mind. I have arrived. The family is profoundly grateful to all of us for our efforts on behalf of their father and I am flattered to be regarded as a wise physician who was never-the-less outwitted by their crafty old dad.

Preliminary Hell

You should see my private email. I have a fan club of sorts who think I am the very Devil and are very defensive about the current state of residency training. They take particular umbrage to my often stated opinion that academic hospitals view residents as nothing more than cheap labor and extract much more value out of them than they end up paying in salary and benefits. My critics insist that even with the large sum of money paid to the hospital by the government for each resident (an average of $100,000 per year), if you take into account the overhead, the increased liability, and the inefficiencies that are unavoidable in teaching residents the hospital actually loses money and is doing us a favor by letting us tag along.

For my part, because I can add, subtract, multiply, and even have some facility with multiplication’s tricky cousin, long division, I have a pretty good idea how much we are actually worth to the hospital. My critics usually have no idea of this themselves and even the fact that the hospital receives federal money for residents is often a revelation.

But I can end the debate with two words:

Preliminary Surgery.

Was there ever a bigger scam than this? Here you have a collection of disposable residents to whom is owed even less, if possible, than to categorical residents. They’ll be gone in a year, some to their real training that required a preliminary year and some to programs into which they match after another go at ERAS. Consequently, their education is viewed with profound indifference by their employer whose only goal is to extract as much medical labor out of them as possible.

I complain about residency but I have it easy compared to those sorry individuals. I once met a preliminary surgery intern who along with another preliminary intern was in the middle of three months of Q2 call. This means, for those who don’t know, that he alternated 24-hour shifts with his fellow serf.

“But Panda, that’s not that bad,” you say, “He gets every other day off.”

Maybe in a perfect world, one where call was actually call and not an extension of the work day, this would be true but the two interns in question essentially missed sleep every other night, went home exhausted, and came in the next morning as if nothing had happened. It is not like working as a fireman, for example, where you may be at the station but if nothing is going on you can eat, sleep, or just hang out. It was a day of the usual rounding, admitting, and scut which only intensified when everyone else went home.

The fact that they also had to stay a few hours extra past the nominal changing of the guard is of no concern to most people who, as they work at normal jobs, are somewhat cavalier about an hour or two. But this little chunk of time is precious to an intern. Be that as it may, this abbreviated day counted as their day off and their hospital could no doubt point proudly to their compliance with the ACGME work hour rules.

Think about it. If you work Q2, you will work approxmately 96 hours on one week and 72 on the next which, with some creative lying about hours which all surgical residents are strongly encouraged to do, can almost be called 80 hours per week averaged over four weeks with at least one full day off every week and at least ten hours between duty periods. It’s diabolical. Their program, smarting from the ACGME’s smackdown devised a way to work the crap out of the help while following the letter, if not the spirit, of the law.

Is it Too Popular?

Emergency Medicine, once a sleepy little-respected specialty which was regarded as something somebody did if they couldn’t do anything else, has enjoyed a tremendous increase in popularity among American medical students to the point that it is now as competitive as some of the surgical specialties. I think it is lifestyle, more than anything else, that is driving this.

Medical students rotate through the specialties and begin to realize that most of medicine, far from being the glamourous career of which they dreamed, is a grind, a slow slog, or a medical Bataan death march. Then they do a month in the Emergency Department where, while also not exactly what they expected, they see a world where the pace is faster, the decisions are quicker and, wonderous to behold, the hours are regular and you can forget about work when you go home as there is nothing to follow up.

It also feels more like real medicine because, unlike most other specialties where the patients all have baggage from half a hundred previous admissions and hundreds of pages of advice from the small squad of doctors who follow them, it is possible to see a patient who is completely terra incognito and upon whose body no physician has yet planted a flag.

So Emergency Medicine has a tremendous appeal, especially for people with a low tolerance for bullshit and wasted time. On the other hand, it’s not for everybody. I mention this because my program has lost several residents recently who decided that Emergency Medicine wasn’t really what they wanted. All fine guys, don’t get me wrong, but after a little exposure it was either the pace, the shifts, or the obvious lack of depth (compared to, let’s say, cardiology) which lured them away.

I happen to like the pace and the lack of depth as I am (true to the cliche about Emergency Medicine) easily bored and have a short attention span. And I don’t mind working shifts because (as I have mentioned a time or two) all I really want is the chance to sleep every day. I also like to be at home when other people are at work.

But like I said, it’s not for everybody. Unlike the traditional lifestyle specialties, Emergency Medicine is only a lifestyle specialty if you like that kind of lifestyle. You trade relatively benign hours and high pay for continuous work while you are at work and a schedule that only a vampire could love. It also has a very reasonable lifestyle in residency once you clear all of the hurdles of intern year which is important but should not be the most important factor in your selection of a specialty. (Unless of course you are one of those lazy bastards in PM&R in which case you probably laugh and point at the rest of us idiots.)

I think we may see a backlash because Emergency Medicine’s popularity is insane and doesn’t make any rational sense. It’s a good specialty but 20 percent of my graduating class went into it. It’s not that good.

A Patient’s Guide to the Hospital: Part 1

(The first in a series of public service articles for our many non-medical readers.-PB)

In the Emergency Department Waiting Room

Welcome to our Emergency Department. I hope we can take care of your problem. The fact that you are here at 3AM predisposes us to take you seriously. Nobody who wasn’t really sick would drag themselves out of their comfortable bed to sit on ersatz ergonomic plastic chairs reading six-year-old Newsweek Magazines rubbing elbows with the kind of people who have nothing better to do at 3AM.

That just wouldn’t make sense.

While waiting, keep in mind that unlike other customer-service enterprises, the Emergency Department is not first come, first served. We have a system to rank the severity of your complaint which we call “triage,” a French word meaning, “You ain’t really that sick, Maurice.”

The nurse will take you vitals, listen to your story, and if it sounds serious you will go to the head of the line. If your story is not that compelling, well, you may get bumped down a little. So don’t storm the counter demanding to know why the guy vomiting blood went right in while you’ve been waiting for two hours nursing a wicked post-nasal drip.

With this in mind, we come to our first important concept: If you’re not sick, don’t come. Despite the truly astounding medical advances of the last fifty years, we can’t do much for a cold, a mild case of diarrhea, gas, and any number of annoying but non-serious medical conditions. Over-the-counter remedies for symptomatic relief will work just fine, are available 24-hours a day in most cities, and you can be in and out of Wal Mart in ten minutes. That and some of your grandma’s common sense are all you really need and all we’re going to give you ourselves. Why spend eight hours waiting to be told this when you could be no better or worse in your own bed or on your own couch watching something other than the Fresh Prince of Bel-Air?

So stay home. I know you may not have health insurance but in this case it doesn’t matter. The common cold is the great equalizer afflicting king and peasant alike.

But let’s assume you’re sick. The second important concept is that you did not arrive by ambulance. This means that you may have had time to think about coming in. Did you bring a list of your medications? I most certainly do not expect you to remember them all but we need a little more guidance than, “I take three little white ones in the morning.” Think about either making a list or at least bringing your pill bottles. Most pharmacies will even print you a list and if you get everything filled at one place this is perfect.

It was a good thought bringing your pill organizer and I guess we can always painstakingly match each pill by shape, color, and marking in the PDR. But this takes time, a whole lot of time. We do have other patients and we are not just sitting back there drinking coffee talking to our stock brokers.

No we don’t have your medications on our computers. Amazingly enough, we probably do not have access to your medical records in our Emergency Department. There may come a time when everything is on a universal database but for the time being, at 3AM your regular doctor in Muncie, Indiana might as well be on Neptune for all the contact we can make. With this in mind, maybe a list of your medical conditions would be helpful. (I see that by-pass scar so I’m not buying that you have no heart problems.) Pretend that you want to get the best and most efficient treatment from a doctor who has never met you, knows absolutely nothing about you, and will never see you again.

In other words, make our job easy. I once had a lovely 94-year-old lady as a patient who had a binder with her medication list, a list of her allergies, her living will, and copies of her last four or five discharge summaries. That lady instantly got eight points on the ten-point scale. (Most of you start at a four or five) and more importantly, she got the best care possible because there was no guesswork involved. Hell, she even had the names and phone numbers of all of her doctors.

On the subject of being a walk-in, we make great allowances in our patients. Hell, if you’re sick, you’re sick and maybe you were too embarrassed to call the ambulance even if you should have. It is true that some people will dial 911 for a paper cut and some will drive themselves who are later admitted to the ICU. But if you’re not that sick, would a little attention to personal hygiene set you back on your schedule all that much? You may sit around your house in your underwear eating pork rinds indifferent to the daily routine of showering, brushing, and wiping your ass but seriously, dude, a visit to the doctor, while not requiring your Sunday best, is a special occasion.

A word on Children.

You know, if you’re poor you can get them insured under Medicaid. Really. And you won’t pay a dime for doctor’s visits or prescription drugs. It might take some effort on your part to look in the phone book for the county Office of Social Services but once you get them signed up and find a pediatrician, you will never have to bring them in again.

Look, I know little Quintravion threw up twice this evening but look at him now. He’s asleep. Before that he was running around terrorizing the place. It’s true that our threshold of suspicion is low for children but that boy does not look sick. Maybe a little ginger ale is all he really needed.

If you have Medicaid, shame on you. Your kids need to be in bed, not running around here. Not being able to take time off during the day due to your job is a better excuse than not wanting to pay a buck-fifty for a bottle of Children’s Motrin. Come on. I’ll write you a prescription for it but anybody with a pack of cigarettes sticking out of their purse and a cell phone should be able to scrape together a couple of bucks. Hell, I’d pay ten time that just to not have to sit with sick people.

No, I will not write you a prescription for ginger ale.

Out of curiosity, how many people, exactly, do you know who are up at this hour? You’ve been talking on your cell-phone non-stop since you got here. Give it a rest. I’m a doctor, a pillar of the community, and I like to think I have a few friends but I haven’t spent ten minutes this month talking on my cell phone. Hell, I leave it in the car most days. I just don’t have anything in my life important enough to warrant carrying it around, I guess.

There is no such thing as a volume discount by the way, at least not for us. If your other children aren’t sick don’t say they are just to get them checked because since you’re here, you might as well. In case you didn’t know it, there is a large paperwork burden associated with every patient, even those who are not really sick. A one second lie on your part means fifteen minutes of paperwork for me. Have a heart, lady.

Next: Yes, You Can Have a Sammich’.

Mr. Smith Has an Epiphany

I’ve got Your Back

It’s my wife. The pager displays our super-secret marital code for “Everything is all right. I just want to see how you are doing. Call me at home.”

“Hey baby,” I say when my lovely wife picks up, “How’s everything going?”

“I’ll be home in another hour. Sorry. Things are kind of busy tonight and I have a couple of patients I can’t sign out just yet…OK, I’ll see you when I get home…I love you too…bye.”

Mr. Smith sits in his hall bed and gapes.

“Don’t gape, Mr. Smith. Even doctors have families. Hard to believe, huh? You probably think that we live here which is understandable because we’re never closed and there’s always someone here when you come in with one bullshit complaint or another. It’s not like you’ve ever been turned away when you come looking for narcotics. You might not get them every time but somebody always takes you back, treats you with more respect than you probably deserve, and listens intently to your latest drug-seeking gambit.”

“In fact, I even like to go home at a regular hour if you can believe that. Sometimes I can’t because in this department we try to get a disposition on everybody before we leave, something I had almost accomplished until I made the mistake of picking up your chart. But why should I mind? My children will get to bed tonight just fine without me and I certainly spend too much time watching TV with my wife anyways. The importance of your chest pain, on the other hand, does not diminish just because you’ve been here six times in the last two months with a similar complaint. I’m pretty confident that you’re going to be just fine but I’d feel bad chasing you out if this time, and I’m just talking here, it was a real heart attack. I don’t see how the world could get along without your vibrant soul.”

“Oh no. Don’t get up. Sit. Stay a while. I’m on a hunt for cardiac enzymes and this time your blood is going to score! The normal EKG was disappointing, I’ll admit, but your constant “ten-out-of-ten” chest pain radiating up your neck encourages me. This could be the big one. You’ve just got to believe, Mr. Smith.”

“Are you falling asleep? Brave soul! Your pain is so intense that it is no wonder you seek the oblivion of slumber. It was even untouched by the morphine I reluctantly gave you before I realized who you were. I’d give you something stronger but I’m at a loss for what to give except that we both agree it probably starts with a “D”. How can you expect me to remember its name if you can’t?”

“I understand what you mean when you say that you have no power and the man is sticking it to you. On the other hand, here we are. I have a college degree, two years of graduate school, a medical degree and two years of residency training. My attending has all that plus a few years of a fellowship. You may have not graduated from high school and be the most hard-luck guy in town but you have the power to make us dance like trained monkeys just by uttering three little words:”

“My chest hurts.”

“Now that’s power. Not to mention our highly skilled nurses cleaning up your urine and the fine technicians in our lab feverishly analyzing you blood as if you were the great Tsar of Russia himself.”

“So no, I don’t mind seeing you. The paper work is not too bad. I feel kind of silly writing out your discharge instructions seeing as we’ve done it exactly the same many times before. I know you get a good laugh out of “Return to Emergency Department if pain returns and is not relieved by nitroglycerine.” I think it’s funny too. Especially that part about following up with your primary care physician. That guy is always out of town. How on earth can you follow up with him?”

“Don’t worry, Mr. Smith. I got your back. You’re covered. Sleep, gentle spirit. When you awake I hope to give you the good news that your heart is fine and Motrin, not narcotics, will ease the pain.”

Son of Random Madness

I Hope This Doesn’t Catch On

Vanilla extract tastes just like schnapps and has almost the same alcohol content, at least according to one of our frequent fliers who finally sobered up enough to tell me why he was shop-lifting the stuff. Not only that but because it’s not considered an alcoholic beverage nobody really watches it in the supermarket. I was incredulous, of course. You’d have to drink twenty or thirty of the little bottles to get a buzz and that many bottles might be hard to steal.

“Nah,” he said, “They sell it in half-pint bottles at Sam’s Club. I almost made it out the door with a gallon of it before security tackled me.”

But obviously not before he had imbibed a huge quantity of the stuff. The room smelled like vanilla and I imagine if he took a crap it would smell like grandma baking cookies.

Sometimes he comes in smelling like almonds and oranges, a couple of other popular extracts. It’s quite pleasant, really, especially compared to the usual urine and vomit smell of the less creative drunks.

What Do You Expect From Us?

Empathy training is the latest fad to hit medical school. Large quantities of your time will be wasted on this sort of thing. I didn’t dislike empathy training. In fact, because it is so non-rigorous and intellectually vaccuous it provided a pleasant distraction from the usual boring lectures. What’s not to like about sitting in a circle listening to some idiot drone on about the wonderful things you are going to do for your patients once you learn to relate to them? It was even more entertaining to listen to the small minority of students who take this kind of thing seriously and wax orgasmic about making a difference and touching the lives of patients.

In medical school they make a big deal about empathy, doing things like throwing you into incredibly unrealistic standardized patient exercises where you have a careful conversation that touches all of the patient’s socioeconomic and psychosocial high points. You will never do this in the real world unless you are a psychiatrist. You don’t have time. Even in Family Medicine, the paragon of empathy, you will only have 10 or 15 minutes with your patient, barely enough time to address the chief complaint.

Why is it important that you care, anyways? I spend my day providing high quality medical service that is indistinguishable from the service provided by somebody whose heart bleeds for their patients. You can get into a deep meaningful conversation with your welfare mothers on how hard she has it are but how is that going to change your treatment? Are you going to find her a better job? Are you going to follow her home and protect her from her abusive boyfriend? Will you snatch the cigarettes from her purse and shame her into eschewing the things forever?

Of course not. This is why all the empathy crap (and “community medicine” for that matter) is so useless. You can feel everybody’s pain and give your patients a shoulder on which to cry but at the end of the visit they are still as fat, unemployed, lazy, ignorant, drug-addicted, and hopeless as they ever were. If you’re lucky you will have at least addressed their chief complaint and they will go home with a UTI on the way to being cured.

When you try ot whip some empathy on them by pretending to care, they may decide to take you up on your caring and then you’re stuck. You can either back-peddle and admit that they’re on their own or you can spend half your day trying to get them food stamps, disability, or whatever they feel entitled too including your time.

What you’re going to do is give them their Ciprofloxacin, look sad and wise, and say, “Thanks for coming, if it still burns when you pee come back and see me.” That’s what all of that idiotic empathy and “caring” indoctrination shoved down your throat in medical school comes down to. You simply don’t have the time to be a social worker unless you are willing to work for nothing. I have worked in clinics giving services primarlily to the poor and even the shiny, happy doctors who make this kind of thing their life’s work can’t do much more than a hoary old conservative like me. And they grow to despise many of their patients, something I don’t because I don’t have as much emotionally invested in them.

A good rule of thumb is to never order a test or ask a question if you are not prepared to deal with what you find out. If you inadvertantly ask a patient if he has chest pain and he says he does, you must either work it up or find some legitimate reason to exlude a cardiac etiology even if the guy only came in with a case of the clap. The same should apply to psychosocial issues. If you can’t help the patient find a job or get her boyfriend to pay his child support then it’s none of your business and asking about it sets up a false expectation in your patient. If all you want to do is offer some sympathy then you are being incredibly selfish by trying to win admiration for your caring without actually doing anything to help.

The big myth of Medical School is that you will be some kind of compassion demi-god who will have a significant impact on the lives of your patients.

You know the question we ask a lot in the Emergency Department?

“What do you expect us to do for you today?”

This is usually asked to somebody with a vague, mostly psychosocial complaint. It takes people aback. What they want and expect is for us to cure them of everything that’s wrong with their lives which is impossible to do.

Spectator Medicine


Mrs. Jones looks like a cadaver. Her bony yellow legs stick out of the bottom of the gown. A pack of relatives clutch at each of her claw-like hands and stare confidently at the monitor over the bed.

“She’s doing better, right?” Her blood pressure had been coming up steadily. A great-grandson reads the numbers to the relatives standing in the hall who nod in relief.

“We’re giving her fluid. She was pretty dry when she came in.” I am not nearly as optimistic.

Mrs. Jones came to the Emergency Department from her nursing home. According to EMS a nurse had noticed that she was looking more cadaver-ish than usual and became alarmed when she couldn’t get a blood pressure.

“Her doctor said not to give her fluids.” The daughter is the spokesman for the relatives. “He said it would flood her lungs.”

Mrs. Jones’ medical history reads like a pathology textbook. Her congestive heart failure is the least of her problems at this point as it’s competing with severe hypovolemia, probably from diarrhea over the past several days.

“Her lungs sound pretty clear. We’re waiting for the chest x-ray but I’m pretty sure she can tolerate a lot more fluid than we’ve given her. We can always take some of the fluid off later but her organs need fluid now.”

The daughter holds up her hand.

“We want to speak to a real doctor. Our doctor told us to keep residents away from her.”

“I am a real doctor,” I say pointing to my ID badge. The family looks suspicious.

“The other doctor who was in here said she didn’t need that,” says the daughter pointing to the small bag of levophed dripping into her central line. “He said it will make her lungs fill with fluid.”

That must have been my medical student. Or maybe one of the janitors. They clearly don’t buy my explanation of the role of pressors in shock. The daughter throws me a dark look. I promise to get a real doctor to answer their questions.

Several hours later and Mrs. Jones still looks like a cadaver. According to the monitor Mrs. Jones is doing fine though she clearly has one foot in the next world. Her daughter who has become adept at reading the numbers is annoyed that we have not stopped the pressors and have not removed the endotracheal tube, something she insists we do immediately. I don’t think she’s going to be very receptive to the discussion of code status once her mother gets up to the ICU but the prognosis for her mother is grim, cheerfully normal vitals notwithstanding. Mrs. Jones is fighting myelodyplastic syndrome which has converted to leukemia, something I only discovered when I browsed through her old records.

“Why does she need to go to the ICU?” asks the daughter.

“Because she’s dying. The only things keeping her alive are the fluids and the ventilator. I hate to be blunt but surely you are familiar with her medical history.”

“Her doctor said she still had at least six months. You’re not even a real doctor. What do you know?” Some of the relatives look embarrassed. The alpha-relatives, however, are clearly not impressed with me and mutter darkly about a second opinion.

“Let’s get her up to the ICU and you can talk to her oncologist in the morning.”

Mrs. Smith has fibromyalgia. I have hardly introduced myself before her husband mentions this twice. My attending laughed when I picked up the chart. Mrs. Smith is well known to the department. A quick check of the computer shows fifteen visits in the last year for similar pain. She writhes in agony on the bed.

“How long have you had the pain,” I ask, grimly determined to think the best of her.

“Since last night…I’m paining real bad…All Over.” By this time she has learned not to point to a specific spot as we have a distressing tendency to take people at their word and order all kinds of inconclusive and painful tests and studies.

“She gets like this a lot,” says her husband, clearly distressed, “You guys never do nothing for her.”

Normal physical exam. Mrs. Smith has still not caught on that when I am listening for bowel sounds I am actually palpating her abdomen with my stethoscope. Sometimes you have to distract the patient. Neither is there anything unusual in the review of systems or the history except for pain.

“What do you take for your pain?” Her old charts record a bewildering array of pain medications. “Let me try you on some Motrin.”

“I want to speak to a real Doctor,” she says.

The nurse mentions to me that “pain lady” was sleeping soundly just minutes before I opened the curtain.

Mr. Simon’s mother hold the basin as he heaves and vomits a large quantity of red-colored fluid, spits to clear his mouth, then lays back in the bed and continues to curse at the nurses. I’d ordinarily be alarmed but the paramedics told us that his neighbor thought he was hypoglycemic and force-fed him a bottle of fruit punch. His vitals are stable and he’s not tachycardic. On the other hand alcoholics are susceptible to upper GI bleeds from ulcers, varices, and esophageal tears. We send a sample of his vomit to be tested for blood and I make sure to order a type and screen but I don’t think he is bleeding. His blood counts come back normal a few minutes later and his vomit is negative for blood.

“If you stick me again I’m going to kick your fucking ass,” yells Mr. Simon to the respiratory therapist by way of introduction. Aside from being drunk, diabetic, and high on heroin, Mr. Simon’s immediate medical problem is the inability to maintain his oxygen saturation without supplemental oxygen. When he takes off his mask, his oxygen saturation falls to the high seventies. Mr. Simon is only 29 and a heavy smoker but this is definitely not normal. I want to get an arterial blood gas on him. If he thinks the respiratory therapist is hurting him he’s going to enjoy it even less if I have to stick him.

“Stop cursing at the nurses, Mr. Simon,” I suggest gently, “They’re trying to help you.”

“I’m paying your fucking salary,” screams Mr. Simon. “I don’t need this shit from you.” Mr. Simon is what is optimistically known as “self pay” meaning he wouldn’t pay his medical bills even if he had the money.

According to his mother he went on his current binge after being dropped by his girlfriend. He had stopped taking his insulin a day before and his presenting blood sugar was too high to be read by the glucometer. The complete metabolic panel pegged it at 769 which is pretty high but everything else wasn’t too far out of whack. He also had a normal anion gap which was unexpected as the assumption was that he had diabetic ketoacidosis. His potassium was normal so we started him on a modest insulin drip.

Mr. Simon is a mystery. A rancid, abusive, tattooed enigma. His chest films are normal, his respiratory rate is normal, and his GCS is a solid 15. His ABG confirms both a mixed metabolic and respiratory acidosis and a low oxygen saturation. Pulmonary embolism? His D-dimer is low so he’s not making it easy for us. Aspiration? My senior resident starts him on clindamycin as a precaution but would he really be so hypoxic so quickly? Physical exam pretty normal too except that he feels clammy.

Maybe it’s cardiac but unfortunately is EKG is normal. Maybe the cardiac enzymes will give us a clue. I ask him about chest pain but as Mr. Simon answers some variation of “fuck you” to every question, the review of systems is probably going to be a little sketchy.

“Yeah my chest fucking hurts,” He says.

Surprise, surprise. “What does the pain feel like, Mr. Simon?”

“Have you ever had your heart chewed up and then spit back into your chest? That’s what that bitch did to me.” (He points to a scruffy looking young lady who has crept into the room and now shirks against the wall.)

“Not recently. Listen, is it some kind of metaphorical pain or does your chest really hurt?”

“Fuck you. I need to take a crap.”

He’s stable for now although it’s a struggle to keep his oxygen mask on. He keeps pulling it off and threatening to leave. While this isn’t a prison, he is drunk and high so I could restrain him if necessary. He definitely needs to be admitted and I ask the unit coordinator to break the good news to the medicine intern

Mr. Simon was admitted but bolted a few hours later before the source of his hypoxia could be identified. I imagine he is in some hole shooting up with his insulin money.

Mrs. Jones died in the ICU that day.

Mrs. Smith got six vicodin and left gravely disappointed.

Ask Uncle Panda

1. Say, Uncle Panda, what exactly do you like about Emergency Medicine? I thought the hours were crazy and the burn-out rate was high. What about it?

From the perspective of residency training, Emergency Medicine is far superior to any other specialty. First of all, it’s the most like a regular job of any residency. With the exception of off-service rotations which will fill roughly a third of your three year training (most programs are three years long) you will be working set shifts with a pre-determined start and finish time. (Although you shouldn’t expect to get out exactly when your shift is over as there are usually things to either tie up or sign out.)

To my mind, there is nothing more annoying than coming in early to pre-round on patients only to round on them again with the attending. A tremendous waste of effort. I’m also not exactly sure why we need to come in early on rotations like internal medicine. It’s not like the patients are going anywhere. What invariably happens is a short burst of frenzied activity from 6 AM until ten followed by large patches of dead time until around four…at which point there is usually another burst of frenzied activity. I’m sure this pattern is inevitable but that doesn’t mean I have to like it.

As to burn out, I don’t know. I’m new to the profession and I will have to defer to the opinions of my more senior colleagues. It is my understanding that “burn-out” is greatly exaggerated. Emergency Medicine self-selects for people who like variety, working weird hours, and making quick decisions with incomplete information. While this would quickly burn out someone who likes a more deliberative pace, EM physicians look at this as routine and a good trade for working fewer hours and fewer days.

No questions that the pace is a lot more intense than most other specialties. In a busy emergency department the residents are working all the time. Productivity is critical in the “shop” and second and third year residents are expected to see and “dispo” at least 2.5 patients per hour. On a twelve hour shift this works out to 30 patients which is a lot. It is true that some patients have relatively minor complaints which don’t take that much time but as often as not the next three will be very sick with multiple comorbidities. Not to mention the traumas that roll in periodically. The net result of all this is that a good Emergency Medicine resident has to learn how to juggle multiple patients. If you can’t prioritize, organize, and keep track of multiple plans for many different patients you probably won’t like Emergency Medicine.

As to the hours, they are indeed crazy. While most programs make an effort to accommodate your circadian rhythm, when all is said and done you will be working a lot of nights and leading a vampire-like existence. On the other hand you will be driving opposite rush hour traffic, the banks will be open when you get off work, and academic teaching hospitals are a good deal more laid-back after normal working hours.

Does Family Practice suck?

No, of course not. I didn’t like it but that’s just me. As it emphasizes long-term management of chronic diseases it is not for those with ADD, short attention spans, or who get bored easily. I want to dispel the myth, however, that Family Physicians have some sort of leisurely, non-demanding lifestyle. The fact is that like any other job, productivity is important. In family medicine where the reimbursement for the usual visit is low, patient volume is important. A Family Medicine resident may see as many patients in a day as an Emergency Medicine resident. On the other hand he is unlikely to be working on more than two or three at a time, the presenting complaints are usually less acute, and the chances are good that the resident has seen the patient before and can skip some of the usual history taking.

It is also an unwritten but very real expectation of patients that their family doctor spend some time chatting with them. This is a very important part of the art of medicine but it does add to the time for a patient encounter, especially the family medicine patients that want to talk about everything and who will not shut up. A good family physician masters the art of redirecting the conversation without appearing rude and winnowing down a long list of complaints to the most pressing without appearing callous.

In the Emergency Department it is all right to be a little more brisk as the situation demands.

Just a random thought, maybe if they changed the name of the specialty it might attract more guys. Let’s face it, Family medicine has a decidedly feminine, non-threatening ring to it and calls to mind images of gentle, sensitive men nurturing woman and children. This is not how most guys see themselves. What most of us really want to do is get in touch with our inner Cro-Magnon, not our inner child.