Category Archives: Uncategorized

The Great Lawsuit Rush of 2049

The Future of Medicine, Uncategorized

The Future, or Something Very Similar
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“No, I don’t have a spleen, Jimmy. Hardly anybody from my generation does. Or a second kidney, a gall bladder or any other of those useless organs that nobody knows the purpose of. In fact, the Nurse Practitioner Assistant over at Bowel, Bile, and Beyond said that he probably only sees three or four gallbladders a year. He’s not even sure what the gallbladder is for although he thinks it’s part of the immune system or something. He’s the manager, you understand. They send them to a pretty intensive six-week course so he knows what he’s talking about. ”

“But anyway, most of us had all those things removed. Why? Well, let me backtrack a little. Now don’t roll your eye at me. It’s an interesting story and I know they don’t teach you much about these things in holoschool. Even in my day sensitivity training, sexual awareness, and learning our recycling catechisms took up most of the day so we didn’t learn too much history. Oh sure, we learned about Martin Luther King signing the Declaration of Independence and about how the United States lured the Japanese to their destruction at the Little Big Horn but, you know, learning to put condoms on bananas is serious business and important things like that took up a lot of our time.”
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“So you kids know that your old grandpa was a lawyer, right? I went to law school and everything, oh, must have been nearly forty years ago, right after the Burger Wars. Man, those were the days! Not much business for lawyers nowadays of course but things were booming back then. Most of it was in medical malpractice, suing doctors I mean. It’s hard to believe but at that time vast herds of doctors, the law profession’s natural prey, still roamed the country raising huge clouds of paperwork wherever they passed.”
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“They’re all gone now…the doctors I mean…you remember me telling you about doctors, right? Like I said, I know they don’t teach you much about them now in school but at one time doctors, or ‘Physicians’ as they were also called, were completely responsible for everybody’s medical treatment. That’s right Jimmy, back then there were no Cath-in-the Boxes or Tumor Marts. If you got sick you had to go see some pompous, over-educated doctor who asked you a lot of embarrassing questions and then threw a bunch of big words at you before trying to force you to do things you didn’t want to do. It was pretty insulting. I mean, seriously, if I have a history of rectal bleeding, what business was that of my doctor’s, especially if all I was seeing him for was some tummy pain? But that’s what you get when you give somebody from seven to twelve years of training…they get a little big-headed and think they know better. Arrogant bastards. Believe me, nobody shed any tears when the last one was hunted down. Give me a guy with a few weeks of superficial training any day of the week. At least we can talk on the same level and if he doesn’t know something, he can just shrug his shoulders and say, ‘I dunno’ Man,’ not call in even more doctors to ask even more embarrassing questions.”

“So I was a lawyer and business was good at first. I was doing all the usual things. I got my start as a court-appointed malpractice attorney and, after the fire department decided that we were tailgating the ambulances a little too closely for safety, even spent a few years riding shotgun with the paramedics (It’s a lot easier handing the patients and family your card if you’re the first one on the scene, let me tell you).”

The big money, however, was in the hospitals so after a few years of little stuff; you know, the usual ‘If-we-settle-for-a-couple-of-grand-will-your-patient-let-us-exam-him’ things, I started taking on big cases. You gotta’ understand that it was a no-lose situation for us. After the passage of the 58th amendment which emancipated citizens from personal responsibility, what had previously only been assumed became law and doctors had prima facie responsibility for all bad outcomes, non-compliance, and bad habits of their patients. Heart attack from smoking hover-crack? It was the doctor’s fault for not motivating you to quit. Contract a case of HyperAIDS? Hey, the doctor should have warned you about contaminated gerbils and got you into to a clean gerbil exchange program. Eat too many Big Macs…well yeah, I know they’re illegal now but this was before the war and everybody was eating them (before we knew what those sinister clown-faced Mickies were putting in them)…blame the doctor for your high cholesterol. And win in court…big time. The money just kept rolling in, that is, until the doctors got smart and started fighting back.”

“I mean, nobody said they weren’t intelligent. I know your cousin Billy who runs the Colectomatron down at Spleens n’ Things isn’t the shiniest nickel in the kitty but things were different back then. A GED might be all you need for an exciting career in the medical profession today but back then medical professionals were in the top percentile for intelligence in the country. Now, don’t laugh Ricky, it’s true. Billy might not be able to think his way out of paper bag but at one time medical schools only took the cream of the crop, kind of like the interior design schools do today.”

“Apparently a bunch of doctors got together and decided that, since they were taking a beating on missed diagnosis (that’s where the super-genius doctors fail to spot a diagnosis even though, as it has a one in a million chance of occurring, it is fairly common) the only solution was to start working-up and treating everybody for everything all the time. The logistics of this seemed daunting but as a lot of pioneering work had already been done by a group of doctors in a specialty that they used to call ‘Emergency Medicine’ (yes, Jimmy, kind of like Quickie Med but actually a lot slower), the solution presented itself fairly quickly. To start, the doctors installed big CT scanners at all of the entrances to the hospital, usually hidden behind fake plants or Joint Commission decrees, and scanned everybody who came in the door. They were still missing a lot of things so, initially with modified airport baggage handling equipment, every patient who came to the hospital was sedated, placed on a conveyor belt and routed to the appropriate diagnosis and treatment area depending on the chief complaint. At first there was some differentiation. If you had a cold, for example, all you got was a chest xray and intravenous antibiotics before being deposited at the exit three days later. Eventually, however, as liability increased the lines merged and everybody got the works.”

“It was probably horrifically expensive but nobody could say the doctors weren’t being thorough and they didn’t miss too much. I went in one day with a sprained ankle and, after being sedated and passed through the intubation and foley station, I was routed to the Prophylactic Surgery Unit where I had my spleen and all of those other potentially dangerous organs removed before being placed in a full-body cast at the orthopedic pre-processing section. They had immigrant surgeons from Canada and other Third-World countries working on this part of the line and each one did one little part of the procedures as the patient moved by him. After the PSU and the OPS the belt wound around the Antibiotic Holding Area for a fourteen day intravenous course of one of every major class of antibiotics. The doctors eventually added a chemotherapy station ‘just in case’ and everybody got fourteen days of chemotherapy concurrently as well as a (barely) sub-lethal dose of radiation therapy. Upon completion of my infectious disease and cancer prophylaxis I was moved to the imaging section where in rapid succession I was passed through a CT, an MRI, and a PET scanner to make sure nothing had been missed. Finally, I had all my coronary arteries stented and after a quick pass through the lab station for the 3000 or so required tests was topped off with fluids, had my electrolytes replenished, was given a haircut, a shave, a coupon for a day at the spa, weaned from sedation, extubated, and dropped off at my apartment kind of dazed but absolutely as disease free as possible.”

“Eventually they added comprehensive major joint replacement and that was it for the legal profession…or so it seemed. I mean, they checked for everything and did everything you could possible imagine, effectively throwing a brick wall in the path of almost every once-lucrative case. Oh, we tried of course but all the defense had to show was that, while it was regrettable that yer’ stinkin’ granny died, the doctors did everything they could…which was true. No way to argue otherwise. Eventually we tried to get them on the paperwork, you know on the the basis that if it wasn’t documented it didn’t happen, but that’s where those clever bastards really ate our lunch.”

“You see, by that time every doctor was using electronic medical records and their documentation was air-tight. At every processing station of the hospital conveyor the operator pressed a few keys and produced wonderfully complete documentation. I have sneaking suspicion that it was mostly boilerplate but there was no way to tell as the patients were sedated for their whole stay and couldn’t tell you either way what the doctors had done. Sure, the Review of Systems was usually, “Unable to Obtain, Patient Intubated and Sedated” but those mercenary defense attorneys made it sound as if every patient was heroically saved by a dedicated team of doctors even if it was actually mostly cheap Canadian migrant workers doing most of the work.”

“Times were lean, let me tell you. Nobody in the legal profession could find any work. When you get right down to it a lawyer is not really qualified to do much of anything. Eventually roving bands of unemployed lawyers roamed the countryside, terrorizing small towns with nuisance lawsuits against little league teams or shoddy Girl Scout cookies but none of this paid very well and things were starting to look mighty grim, so grim that most of us were thinking of turning to prostitution or other respectable work, that is until an unemployed lawyer named John Sutter made an amazing discovery.”
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“Like most lawyers at that time, Sutter had turned to day labor to keep his BMW from being repossessed and his kids fed. He had been hired to do some demolition on an old, abandoned hospital in Rochester, Minnesota when, on January 24th, 2049, his hammer broke through a basement wall and there, before his eyes, lay acres upon acres of abandoned patient records. Paper charts, I mean, not electronic. Manilla Gold. The good stuff. Thinking quickly, he realized that every single chart represented a patient who was either dead, old, or sick and that, as they predated the assembly line hospital, not only had everything not been done for them but their charts were cornucopias of shoddy documentation, errors of omission, and poorly explained medical decision making. He dug around for a few days before hitting a rich vein of legal gold, the Motherload, in the Oncology section. All he had to do was pull a chart at random, find out if the patient had died, and then sue the doctor for missing something…anything…it didn’t really matter. It didn’t even matter if the doctor was still alive because he could always sue the widow and children out of the doctor’s estate.”

“Of course Sutter tried to keep news of his find secret but soon his fellow attorneys noticed his new suits and fancy dinners at expensive restaurants and it didn’t take long for the news to leak out. Word of the find spread quickly and the great lawsuit rush of 2049 was on! All over the country unemployed lawyers flooded into places like Boston and San Francisco feverishly racing to stake a claim in musty medical records departments and turning what had once been sleepy, decrepit backwaters into overnight boomtowns. The population of Philadelphia, for example, tripled in three months as twenty-thousand lawyers descended like starved locusts.”

“There was tort in them thar’ hills! Pandemonium! Litigation fever swept the nation and all over the country, clerks and bakers abandoned their professions, spent their life savings for mail-order law degrees, and headed to the great litigation fields. Maybe you have seen the holo-pictures of them, standing stiffly by their claims, briefcases held grimly in their hands, ties loosened, and cellphones pressed firmly to one ear. Most of them didn’t strike it rich of course, because although the charts were free for the taking, most lacked the resources to try cases. They usually sold good charts to the big law firms for pennies on the potential dollar who brought them to trial and made the big money. Some of the ‘Forty-niners worked on commission but you had to have a claim to a rich vein of legal ore, say the records of a plastic surgeon, to make it work. Mostly, the ‘Forty-niners returned to their homes after the medical records were played-out, older and wiser but flat busted. If you really wanted to make money the thing to do was to open up an office supply store or trendy coffee shop for the prospectors. Can you believe that some places were charging up to five dollars for a cup of coffee! Insanity!”

“You should have seen it. Creaky little towns like Baltimore took on a wild-west appearance overnight with gambling, illegal Asian fusion restaurants, and latte grandes flowing like water. Every vice known to man could be found except prostitution of course. Apparently the hookers had a little too much self-respect to be associated with lawyers. The fever only lasted a few years. Like I said, even at that time doctors had been hunted almost to extinction and what once seemed like a vast and endless supply of money slowly petered out. The bottom dropped out of the litigation market in the summer of 2052 and that was that. The rush was over leaving nothing but empty designer water bottles strewn over the now-empty streets of medical ghost towns.”

“So that’s kind of why we don’t have spleens. Can’t say that I miss it.”

Rambling Around the Medical Blogosphere

Complementary and Alternative Medicine, Uncategorized

(A roundup of some of the non-seismic events that have been troubling medical bloggers -PB)

Whaddya’ Mean it Doesn’t Work?

I rise in support of the makers of Airborne, an all-natural cold remedy, who are the unfair victims of a class action lawsuit that alleges, among other things, that the product neither works as advertised nor has any legitimate research behind it to back its claims. Developed by a couple of school teachers in the late nineties, this nostrum was promised to do nothing less than cure the common cold and in the process fulfilling the second part of the impossibility trifecta; the first of which was putting a man on the moon and the third, the remote possibility that Whoopi Goldberg will ever make a funny movie. Having been involved in a couple of business ventures myself, I understand the difficulty of marketing a new product in an economy packed to the gills with hundreds of variations of every product you can think of. The spatula section alone at a typical Target, for example, offers a bewildering array of spatulas (spatulae?) each with some carefully researched but ultimately ineffectual angle to attract the consumer. It’s not easy marketing some crap in bottle as the market is currently saturated with the stuff.

Claiming to cure the common cold was a good start because that takes some chutzpah even if it did require a careful strategy to keep the FDA at bay. The teacher angle was pretty good, too. I mean they’re school teachers fer’ Muhammed’s sake. School teachers! Everybody knows they’re smart and that they can do no wrong. They’re, like, untouchable, man! Accusing them of chicanery would be like bludgeoning the Pope with a baby seal. It should have been enough except that the makers of Airborne forgot one important lesson: In this day and age, lawyers are everywhere and if you’re going to sell useless crap to a gullible public, at the bare minimum you’ve got to have some big academic medical center providing cover. They know this in Durham, North Carolina where Duke Integrative Medicine flogs the usual candy-ass Complementary and Alternative Medicine with complete impunity, secure in the knowledge that every brand of snake oil they peddle, from Reiki to Guided Imagery and every breed of utter stupidity in between, bears the august imprimatur of Duke University.

You’re Doing it Wrong

I also rise in support of the New Scotland International School of Medicine, which, as its home page breathlessly informs us, is the Number One Leader in US Medical education. Not bad for a school that just opened its alleged doors a little more than a year ago. Ostensibly a churlish little enterprise taking advantage of some little-known (and perhaps imaginary) World Health Organization loophole conceived by French bureaucrats to legitimaze medical schools in countries ruled by oleaginous fat guys in military uniforms, Stewart University (as it is also known) promises to provide affordable and easily accessible medical training to people who, by virtue of bad grades, poor test scores, lack of a high school education, and other injustices are incapable of gaining admission to more traditional American medical schools.

Is it a scam? What do you think? At the risk of sounding shallow, one look at the nepotic rogues gallery comprising its administration, including the Provost Emeritus whose photograph lools like the last known picture of a Nazi war criminal before he fled to Argentina and the Chief Operations Officer who is a dead ringer for the Girl in the Back of the Bus who smoked cigarettes and let the boys look at her hooters, should be all anybody needs to know. The provost himself is a 32nd Degree Mason and a Member of the Ancient Arabic Order of the Nobles of the Mystic Shrine so, you know, he’s gotta’ be qualified as is the Facilities Director who couldn’t get a date for the prom and decided to get a job with Stewart instead.

Clinical rotations, you ask? Hah! “Clinical rotations,” the eponymous Chancellor informs us, “Are the least concern of a new applicant to medical school.” So apparently yer’ not going to do any. MCAT? College degree? Not required, allegedly, in Burundi or Southern California. A GED will do. That troublesome extra fourth year? Not necessary. The United Nations has decreed it, we believe it, and nothing more need be said. All you gotta’ do is get one of their cut-rate degrees, pass the USMLE Step tests, and finagle your way into the American residency training system with a generic international medical degree and no clinical experience whatsoever.

Oh the seductive allure to those whose dreams of a medical career are otherwise impossible to attain. This school has it all. No admission requirements to speak of. Easy courses taught by a lackluster faculty. Three-year curriculum. Southern California location. One last chance to redeem frustrated dreams, an in-your-face to those who said that your child pornography conviction would forever keep the prize out of your reach. With this in mind I must ask Graham to stop busting down on this little enterprise, this last best hope for those who could be great physicians if they could only get a handle on that, what do you call it, heart-thingy. The fact that this beacon of mediocrity might have to close its alleged doors (if it already hasn’t) would be a great blow to American health care and could be avoided if the school just tried a different marketing approach.

First of all, if you’re going to make a virtue of a weak curriculum, broken-down faculty, and shoddy instruction, you have to protect yourself from your potential critics. The military angle had got to go. The academic left will forgive a lot and tolerate all sorts of assaults on their academic standards but as every single member of Stewart’s executive body is a uniformed, blood-thirsty, baby-killing, My Lai torching, brainwashed, current or former military officer, they are nothing if not a big old fat target. Might as well put a big sign on the alleged doors begging to be shut down. If they’re going to do it right the Chancellor et al need to grow beards, learn how to tell jokes, and give their medical school some whimsical name like the Gesundheit Institute or the Center for Caring. Can’t shut you down if you’re wearing clown suits, home boy, or don’t you watch movies?

Not to mention the school needs to drop the legitimate medical education angle. Nobody’s buying it and it is too hard to fake. Instead, they need to invent some useless crapola and market it to the leftover hippies. I suggest they go au natural and offer degrees in Naturopathic medicine or similar horseshit. It’s not as if there are any standards. You can pretty much make it up as you go along, gleaning whatever you need from head shop catalogues, Wiccan literature, and whatever you can rustle up in the Alternative lifestyles section of your local Barnes and Nobles. Then they need to move to Seattle where they’re into that sort of thing. Give Bastyr University a run for their money.

From Excessive Knowledge, Good Lord Deliver Us

Mid-Level Madness, Uncategorized

(Writing this blog can be difficult. While I am interested in many subjects, developing coherent ideas and putting them down in a logical and entertaining manner does not always come easy. In other words, most of my articles do not just fall effortlessly from my brain. On the other hand, there are some subjects about which I am so interested and have such well-developed ideas that I almost want to avoid writing about them because it feels too much like “phoning it in.” Some run home to their mommies at the first sign of trouble. When I have trouble coming up with anything new I, too, metaphorically run home to the comforting bosom of my mother, revisiting subjects like futile care and the abuse of residents. Precisely because these things are easy to write about and I take great pleasure in doing it, sometimes I feel like a fraud, one who is just repeating himself with only slight variation, and throwing to you, my loyal readers, easy-to-obtain red meat instead of coming up with something original.

With this in mind, please accept the following article as more red meat. I hadn’t planned on writing it but I received so many private emails about what was really just a throwaway line in my last article that I felt compelled to fire up the old easy-writing machine to shoot ducks in a barrel and pluck the low-hanging fruit. You get my drift. I’m not proud of it but there it is. -PB)

Cry Me a Friggin’ River, Why Dontcha’?

It seems that I can’t mention mid-level providers, even in an offhand way as I did in my previous article where I compared Physician Assistants to brand-new interns, without the usual scolding from assorted mid-levels who are quick to rehash the usual half-truths and agitprop about their profession vis-a-vis physicians. It is not enough, apparently, for me to be generally highly complementary to mid-levels in many of my articles but I must instead roll over and submissively urinate, crying Uncle and admitting that the only difference between a physician and mid-level is some inconsequential and medically irrelevant minutia that we had forced on us in medical school and residency but from whose wasteful tyranny the mid-levels have been spared.

This is not the case however and the credence one gives to the theory that Less is Better depends on how much knowledge, the currency of medicine, one has in their possession. Since it is, barring some warping of space-time, impossible to cram the same amount of teaching into a typical two-year-and-change Physician Assistant or Nurse Practitioner curriculum as is crammed into a four-year medical degree, a graduating medical student on his first day of intern year starts out with an advantage in medical knowledge and it’s not an inconsequential one either despite the usual protestation from mid-levels that their shortened curriculum is just as rigorous as the medical school curriculum (but it’s not ’cause they don’t learn any of the useless stuff…see?). Is this extra knowledge important? Of course it is. I am not exactly medical training’s biggest fan but there is not a single thing I learned in medical school, from the structure of cardiac ion channels to neurolation in the embryo that does not, in some way, make me a better physician strictly by virtue of being a more knowledgeable one. It’s easy to stand on the low ground and insist that all of this knowledge is useless but, and maybe I’m missing something, we have not yet arrived at a time where we admire and seek to emulate those physicians who make an effort to limit their knowledge, judiciously deciding that they can do without this or that, and adopting the attitude of one of my fellow students in a now-distant pre-med anatomy class who, exasperated by the depth of the subject matter, said, “This would be a much better class if their weren’t so many word.”

It also should be noted that upon graduation, a mid-level’s mandatory education is at an end while an intern’s is just beginning. Strictly speaking, medical school is a minimum of seven years for all physicians as residency training, although not legally necessary, is a de facto requirement to practice medicine. I will have had eight years of medical training before I feel barely comfortable to practice on my own which is typical. Residency training lasts anywhere from three to seven years (and even more if we count fellowships) which is something that many mid-levels forget or ignore when they assert the equivalence of their training. Additionally, training is not the same thing as punching the clock. In other words, a mid-level can graduate from his program, secure a position, say as an extender for a busy cardiology group, and after a little on-the-job training get into his groove as a paid professional, keeping up with his continuing education requirements of course, but essentially having arrived at a point in his career where he can decide to sit around watching American Idol after he punches out. This is not the case with residency training. Every rotation is training and every day is an exploration of the dark continent of our ignorance, a vast territory whose boundaries no man can see and in which no sooner is one hill crested than we are presented with the prospect of still more hills in the distance. So it goes for eight years and it is the background acquired in medical school and residency, the useless minutia, that provides the foundation for understanding and the ability to synthesize original thinking on medical problems and not to just regurgitate contextless facts.

Now, as to the assertion that because most of medicine is fairly routine a mid-level can handle 90 percent or some arbitrarily high percentage of a physician’s job, the first thing you have to realize is that for those of us in the generalist specialties, even Emergency Medicine, it should surprise no one that fifty percent of what we see is absolute bullshit (if I may be allowed to create statistics from whole cloth, I mean). Far from requiring the skill of an expensive mid-level, most of these presentations could be easily sorted and sent home by a reasonably competent school nurse who has learned even less of that bothersome and useless knowledge. We don’t even need a well-trained registered nurse either because although their focus is patient care and not diagnosis and treatment, registered nurses particularly Emergency Department and ICU nurses, are extremely sharp cookies and they are probably over-trained to assess and send home many of the patients we see.

In other words, in their zeal to devalue medical knowledge, mid-levels are, perhaps unwittingly, bringing into the question not only the justification for having physicians but also for spending money training so many mid-levels to the extent they are trained today. Far better to just allow reasonably motivated high school graduates to take a year or two of basic coursework at their local junior college, give them a white coat and a stethoscope, and let ’em at all of those routine patients. Why not? My undergraduate degree is in Civil Engineering, for example, and any sharp witted, smooth-talking village idiot could make a good case that this contributes nothing to my ability to diagnose and treat disease. The same fellow could also make the case that eight years of medical school and residency training is not necessary to recognize the flu, treat garden-variety diabetes, or write a couple of prescriptions for blood pressure medications. Hell, as long everything goes smoothly and all we expects is low-level primary care then everything is going to be fine. Unfortunately, as we push the boundaries of medicine and reap a bumper crop of increasingly elderly and multiply comorbid patients, most of whom expect to survive their visit to the doctor, the trend nowadays is towards more complex patients, albeit mixed in with some undetermined proportion of sublimely ridiculous chief complaints or cookie-cutter cases that can be handled by our intrepid Junior college graduate.

Mid-levels are quick to note however that the trend even in their professions is towards more, not less education. Obviously some of that useless minutia is of value.

Let me relate a parable. As many of you know I was once an engineer and after graduating with my engineering degree found myself in an engineering firm where I was in charge of a stable of young design-draftsmen, the “mid-level” providers of the engineering world. Most of these design-draftsmen had Associate degrees in Engineering Technology from reputable junior colleges where their curriculum was heavy on drafting with a smattering of low-level engineering design courses. Good guys, for the most part, and I picked their brains for tips on computer-aided design and drafting as many of them had been using AutoCAD for years and were fairly good at it. (Junior engineers nowadays are expected to do a lot of their own drafting, probably because it is easier to do it yourself than prepare a sketch for a draftsman to translate into a finished drawing). The useful thing about well-trained design-draftstmen is that you can send them, for example, the design drawing for a piece of process equipment (a roll cage, conveyor, etc.) and they have the knowledge to produce detail drawings and parts lists without having to bug you all day about it. Same with detail drawings for structural or foundation work. Very few structural engineers, for example, produce detailed drawings of structural steel connections but instead pass the design drawings to a “mid-level” steel detailer who produces cut lists and all of the drawings need to fabricate and assemble the structure. The details are based on the engineers specifications and if, for example, I were to specify a shear-only connection to resist a certain load the detailer would produce the drawings from which the actual pieces could be fabricated. It’s not rocket science and, as a structural engineer, I am quite capable of designing and drawing my own connections but didn’t, habitually, except for the difficult ones that did not fit the cookie-cutter examples in the two major steel design manuals (that would be the AISC ASD and LRFD manuals for those of you who are interested and still following along).

Naturally, when I finished my five years as an “Engineer in Training” (interestingly enough also called an “intern” in the Civil Engineering world) and passed the licensing exam to become a Registered Professional Engineer I was completely responsible for all aspects of the design, drafting, and detailing of everything that passed through my hands including the detail drawing produced by the detailer, himself usually an independent contractor. Did I check every single connection on a large structure, burning the proverbial midnight oil for weeks at a time with a red pen in hand? Of course not. My detailer had been in the business since before I was born and knew a thing or two about steel fabrication. But that was his thing, you see. My thing was design and management and I don’t recall ever taking a detailer or a design-draftsman aside and asking their help for a particularly thorny foundation design problem. That was my thing.

One day, one of the more crusty design-draftsmen let on to me that he didn’t think it was fair that engineers made more money, especially as he believed he could do ninety percent of what an engineer did.

“Well,” I replied, “seeing as ninety percent of my job involves standing around drinking coffee making sure that you’re doing your job I don’t doubt it.”

But you see, the devil is in that left-over ten percent (or fifteen or twenty or whatever percentage makes you comfortable with your career choice). Most of every career is routine, repetitive, and can be handled on autopilot. The difference between medicine and other careers is that one never knows what patient is suddenly going to become one of the ten percent. Consequently we want to avoid the autopilot as much as possible. Emergency Medicine in particular is all about not just treating the ten percent but accurately determining who is part of this dangerous minority and until such a time as we can determine which of the ninety percent only need the school nurse and which need an attending physician, prudence dictates that we have the physician standing by even if many of his cases turn out to be nothing…keeping in mind of course that your definition of “nothing” depends on your training. Many of what I once thought were incredibly complicated patients are now just another boring case of sepsis or meningitis.

In reality the practice of medicine is a team effort, not unlike a symphony orchestra where everyone has a part and an instrument they are expected to play. If any individual from the conductor to the third flute doesn’t do his job well the entire ensemble is going to sound like a high school marching band. While it is true that a good symphony can produce ethereal musical magic from the great composers, they also spend a lot of their time sawing out The Nutcracker to keep the proles interested.
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On another note, many of the critical emails I receive about the difference between mid-level providers and residents start out with some variation of, “I have been a PA for twenty years,” and then proceed to expound on the uselessness of an intern. Well, God bless you. I’m willing to allow that a new Emergency Medicine intern on his first day in the department can probably have circles run around him by a Physician Assistant who has been practicing for twenty years. But we’re comparing apples to oranges here. There is a steep learning curve for a resident and I would not presume to say I am even near to cresting it. That’s why we call it it “training.” On the other hand, a typical Emergency Medicine attending with twenty years of experience can run circles around a twenty-year mid-level and their little dog too. They didn’t get that way by stopping their ears against useless medical knowledge.

Some Simple Math and other Random Thoughts from a Harmless Asian Bear-Mammal

Futile Care, Residency, Uncategorized

I’m Better, Thanks

Like I said, it’s only in residency training where one could be happy to be sick while on vacation. I am just getting over a bout of what was probably the flu and as there is no practical way to take any time off as a resident, about the only time we can lay in bed or otherwise rest is either on vacation or when our day’s off correspond to our illness. They make a big deal about cautioning us not to work when we are sick for the sake of patient safety, of course. That’s all some of our patients need, to be exposed to their doctor’s gastroenteritis or other noxious infections but realistically, what are we supposed to do? In a pinch we can usually take one or two days off but as this involves screwing over the person assigned to back-up call, there is a tremendous reluctance to do this among residents. In other words, most of us would have to be spitting up blood or passing large chunks of our large intestine in our stool before we’ll call in sick. Still, there is nothing worse than having to work three fourteen-hour shifts in a row while running to the crapper every hour. Far better to be at home on vacation where you can at least relax between bouts and get some rest. Not to mention that my empathy for the typical 3AM vague-abdominal-pain-and-oh-by-the-way-can-I-have-a-sandwich patient, never very strong, is non-existent which is probably unfair to the patient (but if the shoe fits…).

Some residency programs are so small that they really have no backup for their residents at all and calling in sick in that situation will cause a major panic as well as instantly refuting the assertion made by shifty hospital bureaucrats that residents don’t contribute to the running of the hospital and are a burden to the put-upon institution. If this were really the case then the hospital would be delighted if we took a generous helping of sick days as this could only improve their bottom line. As is, however, when a resident unit goes down the service into which it had been installed goes into a major panic mode complete with sobbing and pleas for help. The sad thing is that a lot of residents buy into the notion that they are a liability to their program and act accordingly. Yes, I will grant you that a brand-new intern may appear to be good for nothing but he is actually many times more savvy than, for example, a brand-new PA who is actually paid real money, not to mention that the intern can make medical decisions limited only by his self-awareness of his limitations and his own personal comfort level. And by the time he gets a little experience the intern is a definite asset, many times for all practical purposes running the service at night. Good residents are completely trusted to handle routine admissions as well as routine emergencies and while I have never had an attending physician give me any grief whatsoever for calling him in the middle of the night for advice or to run a difficult patient by him, the expectation is that we should be able to handle most things and maybe the call for a patient admitted at 2AM can wait until 0730.

But most of us, like in any other non-government job, work when we are sick.  What choice do we have?

Some Simple Math To Illustrate Where the Money Goes

“But Panda,” many of my regular readers write, “Surely you are exaggerating the cost of futile care. Is this not a red herring, merely a symptom of your dislike of dealing with living cadavers more than a real problem?”

Let me address this question by making three points. First of all, I am not against providing expensive, high tech medical care to the elderly. How could I be? Not only are the elderly the majority of my patients but most of them are completely lucid, healthy enough to enjoy whatever it is the elderly do for fun in their secret recreational vehicle conclaves, and benefit mightily from the installation of the occasional artificial joint or the correction of a once lethal medical condition or two. While it is true that from a purely economic point of view, it would be better if we all died the day after we retire or from the first major medical problem that blindsides us (whichever came first), we are not pure economic creatures and that two-trillion bucks we’re spending should at least do some good.

Second, while there are gray areas in determining when care is futile, I know real futile care when I see it. The patients I often describe, the ones who are older than dirt, not nearly as responsive, and collections of every major pathology you can imagine but who yet manage to cling to some strict constructionist version of life are distressingly common, so common that I probably see and admit at least one or two of them a week to the ICU. (This is not even considering the patients that are post-arrest or on the losing side of a major cerebral vascular accident accident and who are, in fact, dead except for the polite fiction of ongoing organ perfusion.) Suppose that each of these breathing cadavers is admitted to the ICU and stays for a week before either subverting our best efforts and dying or pulling through and being sent back to their pre-death warehouse until the next time. Suppose also that I work fifty weeks a year and see a hundred of these patients in that time. A week in the ICU probably costs close to twenty thousand dollars, maybe more, maybe less, but probably around that if we add the cost of their passage through the Emergency Department.

Folks, that means that about two million dollars of futile, almost entirely wasted medical spending passes through my humble resident hands every year. There are about 5000 Emergency Medicine residents working at any given time in the United States and through our combined hands, assuming that they all see the same patient mix, must thus pass around 10 billion dollars. And that’s only hospitals with residency programs and not even counting direct admissions to the ICU. Assuming that a year of comprehensive medical insurance (not that I’m into that sort of thing, you understand) costs $12,000-or-so a year for a typical family; that’s about 80,000 families worth of medical insurance. Consider also that only one-fifth of the major hospitals in the United States have residency programs of any kind but most still have the usual ICU facilities and it is not hard to see that the bill for futile, end-of-life care siphons off enough money to pay for all of the medical care for about half a million families (again, not that I think we should do this kind of thing). And that’s just direct hospital costs. We probably spend twice as much in non-critical and non-emergent care in the last long, slow, tango with the reaper.

My third point is that there is no incentive at any level of the medical industry to use a little common sense. At the high end, physicians risk severe legal consequences for not doing exactly what the family wants no matter how unrealistic. So dangerous is the legal terrain in this area of medicine that most hospitals have an ethics committee part of whose purpose is to spread legal responsibility. In many cases, however, there is no financial incentive to withdraw care as Medicare makes no distinction between the living and the living dead. At the patient end, the families have no financial stake in any of the decisions they make. If we but charged the families a small fraction of the cost for futile care or, more diabolically, had payment garnished from the patient’s estate upon their death, the families would be looking for the plug, especially in the cases where the ICU serves as an expensive funeral home where families can meet to see the body. If the family ever says, “We want to keep Uncle Joe on the ventilator until the rest of the family can fly in from Seattle,” they should be responsible for the full cost of the additional stay.

Death at 30,000 Feet and Other Random Notes

Uncategorized

(I’m still sick. I Still can neither think coherently nor marshal my thoughts into orderly battalions but must instead send them out in little raiding parties to do whatever damage they can. -PB)

Let Me Through, I’m an Interventional Cardiologist

Let’s be fair. Interns and residents occasionally have trouble running codes. I know that it took me more than a few times to get the hang of it and I still sometimes have to think hard about what to do next. And I have an entire team of experienced nurses, techs, and respiratory therapists helping out, not to mention some of the finest Emergency Medicine attending physicians riding herd over the whole shooting match. For all that we still sometimes lose the patient. We can usually avoid it if the patients goes down in the department, say from a heart attack that happens right before our eyes, but we have a lot of medical firepower to bring to bear on the target and that’s got to count for something. And you also have to remember that if the patient makes it out of the department alive we put them in the win column even if they die in the ICU several hours or weeks later.

So you see, it’s silly to second guess the American Airlines flight crew who did the flight attendant thing but were still unable to prevent the death, apparently from a heart attack, of one of their passengers. I mean, seriously, what do you want them to do? Wheel the lady into the Coronary ICU that they keep in the back of the plane? Start a heparin drip, find an interventional cardiologist among the passengers, and jury-rig a cardiac catheterization lab from a plastic spoon and a bag of airline peanuts? The know-nothing media of course are reporting that the flight attendant and the hapless doctor and nurses who happened to be aboard let the lady die, first refusing her oxygen, then discovering that none of the oxygen bottles were full, and then not saving her with the Automated External Defibrillator which “appeared to be ineffecive.” Apparently nobody in the media knows that some rhythms detected by an AED are not shockable. For all we know the thing may have been working perfectly and didn’t deliver a shock because the lady was in asystole. We don’t shock that rhythm, even on the ground.

No doubt the family of the lady are going to sue the airline. And they’ll probably win because in our death-averse society, there is no place under Heaven were we expect to be at the mercy of nature, not as long as there is someone around with a uniform and deep pockets. Someone has to pay? Don’t they? John Ritter taught us that. Even a major aortic dissection, a killer so fearsome that even when discovered there is often nothing to be done but hope the sucker doesn’t dissect over something vital before the patient can be rushed into the operating room for a highly dangerous, do-or-die, vascular procedure that is usually too late anyways, even a major act of nature like that has got to be blamed on someone. Can’t sue Mr. Ritter’s vascular endothelium so the Emergency Medicine physician, acting with limited information and required to make a split-second decision, will have to do. They’re hoping for 67 million dollars. That’s a lot of money. Three’s Company wasn’t that good of a show. We try to be compassionate to the families of patients but in this case, they are just an obnoxious pack of post-mortem gold-diggers, trying to make one last killing off of Mr. Ritter.

Coulrophobia

In one of the last scenes of the movie “Patch Adams,” the eponymous hero stands on the edge of a cliff and contemplates jumping to his death. All of his dreams of bringing laughter to medicine have failed. His Girlfriend has been murdered by a psychotic patient who he had befriended. He is in danger of being dismissed from medical school because of his unorthodox methods. His illegal clinic, providing bootleg medical care to the poor inhabitants of Appalachia and staffed entirely by like-minded third-year medical students, is failing and things look exceedingly grim until a butterfly brings him to his senses and he proceeds to work all kinds of medical miracles, noteworthy among them obtaining four of five cubic yards of noodles in which to immerse an elderly anorexic patient who has dreamed of this since she was a little girl. Finally, he graduates to become the kind of doctor that Hollywood thinks we all should be. I like the movie very much. I watch it whenever it comes on and, like a bad automobile accident, I can’t tear my eyes away. And yet, I find myself urging Mr. Adams to jump, to end it all, just to spare us the inevitable orgy of self-righteousness at the end of the picture, foreshadowed in almost every scene, that is, paradoxically one of the reasons I love this movie and would recommend it to anyone interested in medical school.

Folks, it just ain’t like that. Patch Adams, as portrayed in the movie and who is based on the real Hunter “Patch” Adams, is about as self-centered as is possible for one human being to be without being an outright psycopath. It’s Patch’s way or nothing. You’re with him or against him. The one constant thread in this movie is that everything is about Patch. Patch’s feelings trump everything else. Your kid has cancer? Patch has got to clown around to make himself feel better about it. Old lady won’t eat?  Nothing to do about it but procure the aforementioned noodles. Got to do it, man. There’s no other way. Compassion uber alles.

Match Day is Coming Up

Match day is a big day, there’s no denying it. I know the cool thing is to pretend that you aren’t excited but I’m not that cool. Two years ago when I was waiting to see not only where but if I had matched into Emergency Medicine I was a wreck for the whole week. Three years ago when I didn’t match I was devastated and was seriously considering quitting medicine entirely for my old career in Structural Engineering. So good luck to all of you folks nervously waiting for match day. Don’t lose heart and remember, a match into your specialty is a win. Don’t sweat not matching into your first choice. These things happen and it is now officially too late to do anything about it. You’ll probably like or hate wherever you match without regard to how high you ranked them or how much you thought you liked the program. The interview and even an away rotation doesn’t really give you an accurate picture of the program so there is a huge element of luck in how well you’ll like the hospital and program where you match.

Random Notes from a Febrile Mind

Uncategorized

(I am sick, the flu or somethin’ and I lack the energy to sustain any coherent ideas. Fortunately I am also on vacation which is great! Trust me, only the experience of residency training can make you happy to be sick while on vacation. Here are some completely random thoughts, some of them completely non-medical. Indulge me, Okay? -PB)

You Folks Have Got it All Wrong

I have received quite a few comments, both public and to my private email address, stating that my recent stories of asinine patients with trivial complaints have driven the last nail in the coffin of the reader’s once burning desire to go into Emergency Medicine. I’m sorry. That’s not my intention. And you have it all wrong. I can only speak for the non-surgical specialties but in these, there is not one single field into which you may match where you will not spend a good deal of your time wading through a lot of bullshit. Medicine, for most doctors, is mostly little potatoes and not the epicurean baked potato buffet that many of you think it to be. Give me any specialty and I can name for you the top ten or twelve presentations that will fill ninety percent or more of your day. And every specialty has to deal with the patients for whom nothing can be done, who really have no need to see a doctor, and have all kinds of emotional problems but very few medical ones although I suppose the more hyper-specialized you become, if you are a true consultant and not just a physician extender for primary care, a lot of these will be weeded out for you.

And let’s face it kids, despite what is shows on the television, medicine is not sexy. Unless you are a pediatrician, the majority of your patients are going to be elderly and pushing their expiration date. Most don’t have a compelling story nor are they flaming beacons of some social cause or another. For the most part they are plain, ordinary folks with complicated but entirely believable medical problems which will defeat both of you and they are not headed for any other redemption but that of our Father in Heaven.

This doesn’t mean that you aren’t doing important, difficult work, just that most of your patients, even the sick ones, can become routine…unless you take to heart the following advice:

There may be boring diseases but there are no boring patients. I have met, briefly of course, counting family, maybe fifty-thousand people in the last seven years and I still cannot predict how anyone is going to act or how any particular patient is going to behave. The secret to enjoying a career in medicine is to be interested in people. You don’t have to like them, you can hold them in contempt or love ’em like a saint, but if you have no interest in mankind you will grow tired of the routine quickly.

Now, as far as specialties go, you will see the greatest range of people with the greatest variety of medical problems in Emergency Medicine. And we do occasionally directly, no-doubt-in-our-minds, save a life or perform some heroic deed of medical prowess. Family medicine residents, for example, probably save a lot of lives the slow, old-fashioned way but intubating and resuscitating a decompensating crack addict? No way. That’s our job. And if he keeps smoking crack? All the better. More practice for us. A real win-win situation.

Code Pink

A couple of weeks ago I had as a patient an elderly gentleman who, seeing the Marine Corps pin on my white coat, disclosed that he had been a Navy Corpsman in the Pacific during World War Two and had taken part in the landing on Iwo Jima. It was a great honor for me to be his doctor that night because our Corpsman (what the Army calls “medics”) are legendary for their courage and this guy probably saved a few Marine’s lives in his time. Which sort of reminded me of “Code Pink,” the Berkeley City Council, and their completely idiotic exercise in civic irresponsibility exemplified by their attack on the United States Marine Corp’s recruiting efforts in their city.

First of all, almost everybody loves the Marines and you’d have to be some kind of brainless moron to think that your dislike is shared by more than a handful of similar brainless lunatics. Even in Berkeley, the most left-wing city in the United States, a place that makes the North Koreans say, “Dang, them folks are really left-wing,” the response to this outrage has not been nearly the happiness and light expected by the tired old hags protesting the lack of masculinity of their own sons. Sorry ladies, not every mother wants her sons to major in expressive dance or learn peaceful conflict resolution from some dope-smoking hippy. Normal mothers, while justifiably fearful of the risks of war to their sons, would prefer them to carry their shields into battle like men and not throw them down in fright at the first sign of trouble.

That’s kind of the secret of Code Pink. It’s got nothing really to do with this war or any other war in particular. It’s a protest against the kind of men they wish their sons had been masquerading as civic virtue and perpetuated by some of the most close-minded and frankly ignorant people who have ever been taken seriously by anybody.  When asked, for example, if the United States should have stayed out of World War Two after the Japanese bombed Pearl Harbor, one of the Code Pink protesters replied, “Well, what were we doing in Hawaii anyway?” If this doesn’t demonstrate a profound ignorance, a truly criminal lack of both intelligence and historical perspective..well. I don’t know what else can be said. The fact that a city council, ostensibly composed of the best and ablest citizens, would give these ladies an ounce of credibility just shows that they, too, are a bunch of gutless pussies of whom their city should be ashamed. And stupid too, because the Marine Corps is not an exclusive club for conservatives. There are plenty of prominent liberals in private life and government who count their service as Marines, not to mention other branches of the military, as one of the most important aspects of their lives. You can be as anti-war as you want to be (although why being anti-war is the default liberal position is not clear except in the context of the virulent Bush Derangement Syndrome with which many on the left are afflicted) but I’m sure quite a few liberal former Marines take mighty exception to being called “baby-killers” and “brain-washed murderers.”

The Marine Corps just ain’t like that. Not only do we not train to kill babies (that would be the other side) but the Corps has precious little interest in its Marine’s political beliefs, voting habits, or even opinions on this war or any other (except in the context of how best to kill the enemy, of course). What the left calls brainwashing is just self-discipline, and primarily the self-discipline to know when to keep your fucking gob-hole shut and when to suck it up for the good of your fellow Marines. We do not have to be unique fucking snowflakes all the time. Occasionally we can think about others which is what Marines do instinctively but professional protesters against everything do not.

As Al Qaeda desperately try to extricate themselves from their own little quagmire in Iraq, as the war tuns in ours and the Iraqi people’s favor after a difficult counterinsurgency campaign that has been little understood by the know-nothings in the media and academia (who know about as much about military operations as I know about the Lesbian subtext of Elizabethan drama), as various Democrats tentatively construct strategies to declare victory after promising defeat, it would be well for everybody, liberal or not, to get on the right side of this thing. Our nation may not be perfect but we’re not shooting women in the head in soccer stadiums. The idea that an uber feminist group like Code Pink would act in cahoots with a terror movement intent on re-implementing the Islamic dark ages when women were property and could be stoned for looking cross-ways at a man boggles the mind…but is just another normal doublethink moment for the lunatic fringes.

The Well Will Run Dry

To hear the various supporters of universal access, single payer, or whatever is the current euphemism for socialized medicine describe it, proclaiming universal coverage is going to solve not only the cost problems of American medicine but also those of access. It’s as if the Obamas and Clintons of the world believe that there exists vast underground reservoirs of medical care which only have to be tapped to provide Americans with all the medical care they can eat. But, as anybody who has waited in our department or cannot get a timely appointment to see his doctor can tell you, we are operating pretty much at capacity right now and not only is there no reserve to tap but medical care is not a tappable commodity anyway, at least not like that. The only extra capacity will come from eliminating waste and unnecessary uses of medical services, something which will not happen when medical care is free because, unless there is some direct cost to the consumer, there is no incentive not to go to the doctor for every little thing.

In fact, everything about “Single Payer” is going to make medical care an even scarcer commodity. Just an increase in demand, that is, giving the Holy 47-million-uninsured (PBUTHN)Â sudden and equal access with no possibility of increasing the supply of medical care, by itself will lead to a relative scarcity. That’s just simple math. Additionally, after an initial bonanza of insurance money to mollify the various short-sighted medical societies pushing single payer (including, unfortunately, my own) the pressure on reimbursements in the absence of any competition will be down, and down, and further down until at some point there will be so little incentive to see more patients for the government dime that we will stop working so hard and adopt a more European approach to a full waiting room or a long list of patients needing elective surgery. Try getting a doctor in the VA to see patients in the late afternoon for a preview. I mean, if we’re going to be government employees (de facto or otherwise) we may as well get all of the perqs including all the usual holidays, coffee breaks, lunch breaks, and the sure knowledge that we can never be fired. Remember, doctors in the German Federal Republic work around forty hours a week. The baby-boomer armies who will shortly pillage and burn their way down our medical Danube are going to need a lot more hours of our time than that to collect their booty of knees, hips, colonoscopies, and other plunder.

The correct play is to make going to the doctor cost something for everyone (no matter the income level) to discourage frivolous use of services, enact national tort reform to begin to give physicians some cover behind which to start to exercise more common sense, to frankly eliminate most government involvement in primary care letting the market decide how much patients will pay for a doctor, and if we must provide free health care, limit it to the extremely poor and to government backed major medical insurance for which all but, again, the very poorest should contribute something. We might also start asking the elderly who have assets to kick in a little more for their own medical costs. I wouldn’t want to bankrupt anybody but would it kill many of the elderly if Medicare was means tested just a little? The idea is to set the stage for a little more patient and family involvement in real medical decision making, not the pretend decision making we have today where the answer is usually, “Do everything that someone else’s money can buy.”

Integral to this would be to start implementing EMTALA like it was intended, that is, to offer only a free screening exam and if no emergency medical condition is discovered, to allow the hospital the option of sending the patient home to follow up with his own doctor for whom they can pay if they want to. This would remove the “out” that people currently have to avoid taking money out of their tatoo budget to pay their minor, primary care-type medical bills. I’d also get rid of the Childrens Hospital (I)nrichement Program, also know as “CHIP.” Almost a complete waste of money as, again, most children just need a little low-cost primary care. I don’t think it would bankrupt us to pay for major medical expenses of children because, and hold onto your hats, most children, even the children of the Holy Underserved, are fairly healthy. Just pay for their necessary major medical care directly out of tax money and stop trying to comprehensively insure a population that doesn’t really need it.

The idea is to decrease the federal obligation, money that we don’t have and the borrowing of which is going to bankrupt our nation. Better to have a low tax economy where people are free to spend their own money how they like. If they decide to get that bitchin’ nose ring instead of their antibiotics, well, that’s just freedom, baby!

Circus of Chief Complaints (Your Tax Dollars at Work): Part 2

Emergency Medicine, Uncategorized

(In reponse to some nervous emails, yes, every patient mentioned had a complete history, review of systems, and physical exam. I’m just distilling the salient elements of the conversation. Okay? -PB)

Actual Patient Interaction Number Six:

“So Mr. Smith, what brings you to the Emergency Department, a place where we handle medical emergencies, at 3AM.”

“My mom is up in the ICU and I just thought I’d come down to get myself checked out.”

“Anything in particular bothering you or is it just a general malaise?”

“Well, my back has been hurting me a lot lately.”

“Is it your usual back pain?”

“Yeah. I’m supposed to see my doctor about it on Tuesday.”

“Does he write you your prescriptions for pain medication?”

“Yeah, but he was out of town last month.”

“Okay, I’ll give you some Tylenol. You need to call him tomorrow to get a prescription for your regular pain meds.”

“I’m allergic to Tylenol, he usually gives me Vicodin.”

“You know that Vicodin has Tylenol in it, right?”

“I’m having chest pain too.”

Actual Patient Interaction Number Seven:

“You need to stop smoking, Mr. Brown.”

“That’s what my doctor says, but he smokes so I don’t see why I should listen to him.”

“You mean a couple of years from now when you’re sucking on oxygen twenty-four hours a day you’re going to take comfort in the fact that your doctor is a hypocrite?”

“Well, he should practice what he preaches.”

“Look, I know your doctor, he’s a fit guy and he smokes, maybe, a pack a week if that.”

“He’s a hypocrite.”

“Yeah, but he’s not coughing up blood like you are.”

“Well, I can’t afford the nicotine patches.”

“Where do you get the money for your cigarettes?”

“My sister gives it me.”

“Why can’t you use the money to buy nicotine patches.”

“Uh…”

“So you get the patches instead of the cigarettes. In medicine we call this killing two birds with one stone.”

Actual Patient Interaction Number Eight:

“My dog ate my pain medication.”

“What kind of dog is it?”

“Uh…I don’t know, it’s a dog, man.”

“is it a big dog? A little dog?”

“It’s just a dog. A German Shepard…Okay?”

“Did you take it to the vet?”

“Huh?”

“Well, it says here that you’re on 180 milligrams of MS-Contin every day. That dose would kill a normal human being if he wasn’t used to it and your dog ate a whole bottle, 30 day’s worth. That’s enough to drop a herd of elephants. So I’m asking you if you took your dog to the vet in respiratory arrest…or maybe he’s just laying dead under the porch…or something?”

“Oh man, I ain’t got a goddamn dog, okay? My fucking roommate stole them.”

“I hope he’s not laying under the porch…”

Actual Patient Interaction Number Nine:

“I don’t know if you’ve talked to the trauma surgeons yet, Miss Green, but they tell me everything’s fine, no internal organs were injured, and they’ll probably discharge you tomorrow after they observe you for a while. You were very lucky.”

“Where’s my boyfriend?”

“He’s talking to the police.”

“Do you think he’ll go to jail?”

“Probably.”

“Do you think he’s still mad at me?”

“I have no idea. Listen, Miss Green, I have two daughters. In fact, you’re young enough to be one of them so I hope you don’t take this as anything other than a sincere concern for you but have you ever considered that you’d be better off without this guy? I mean, you’re young, bright, and obviously very intelligent. You’ve got your whole life ahead of you, completely wide open, and I’d hate to see you end up saddled with a couple of this guy’s kids, without any support, living in some dump, and struggling through life when you could be a real success.”

“But he loves me.”

“I don’t think so.”

“How can you say that?”

“Well, he did shoot you in the vagina….”

Overdoctored

Socialized Medicine and other Bad Ideas, The Money Pit, Uncategorized

Rocking Your Fragile World-View

Let us again consider Albania, a tiny country tucked into a little corner of Europe which is only now emerging out of the communist Dark Ages in which it had stagnated while the rest of Europe moved on. This very poor country sits on the Northern border of Greece for whom it serves as a sort of Balkan Mexico, sending a steady stream of poor illegal immigrants into Greece looking for a better life and overwhelming the Greek welfare state. The average life expectancy (a statistic that sleek United Nations bureaucrats and the People Who Love Them use as a surrogate indicator for the quality of a nation’s health care system) of an Albanian is close to 78 years. A typical Frenchman, since France is held to be some sort of medical Shangri La by many Americans, can expect to enjoy pointless cinema, runny cheese, and l’ennui francaise for around 79 years. The typical American might live a few months less than a Frenchman or other comparable European but he can reasonably expect to live as long as an Albanian as will the typical Greek. The United States spends the most per capita on medical care followed by the French, the Greeks, and lagging way, way behind, the hardy Albanians who, despite spending less per capita on medical care than many Americans spend on frothy coffee drinks, still manage to hang on for a long life that is only a matter of months shorter than that enjoyed by a Frenchman, a Greek, an American, or just about anybody in the the rest of the developed world.

Indeed, those thrifty Albanians manage to spend less than 400 bucks apiece per year on medical care, have almost none of the advanced treatments available in the United States or the European Union, very sketchy access to doctors, and still manage to live long, healthy lives eating their Tavi Kosi and smoking their harsh Red Star Tractor Brand unfiltered cigarettes. By comparrisson, we spend close to 6000 bucks per head per year, the Greeks spend about 2500, and the effete French spend around four thousand. If you look at the rest of the developed world, there appears to be a similar discordance between health care exenditure and longevity. Past around six hundred bucks, typical of most of the Balkans and other emerging European nations that have reasonable sewage and other public health measures, there doesn’t seem to be much of correlation between spending and longevity. Maybe a two or three year difference between the top and the bottom which shouldn’t be anything to get excited about. I can easily think of a couple of cultural factors that might account for a bit of this slight difference. In the United States, for example, every Tupac harvested early to the Lord in a pointless rap war, besides being a mighty blow to the music world, drives down the average life expectancy.

I have also never seen, in all of my extensive travels in Europe, anything remotely similar to the four or five-hundred pound behemouths that roam the American landscape in vast herds, making the buffet lines tremble from the thunder of their comfortable shoes and darkening the parking lots of all-you-can eat waffle joints across the fruited plains. I mean, I’m treating obese kids with with type II diabetes, most of whom have free health insurance via medicaid and of which their parents avail themselves with the same gusto they otherwise reserve for nacho cheese biscuits. Lack of health care is not the problem here, nor is access.

In earlier articles I have suggested that we waste a lot of money in the medical industry. How much, exactly, I am unsure. There is a large gray area between what I would consider the completely appropriate use of medical resources and what I know to be the equivalent of flushing burning hundred-dollar bills down the toilet. But I think that most of my learned colleagues on the medical internet will agree that wasted money accounts for a horrifically large percentage of our total two-trillion-dollar yearly spending binge.

Oh my loyal and long-suffering readers, you who I delight in entertaining with detailed prose as I attempt to wrap the truth of the world, or at least how I see it, in a little bit of humor, a little bit of sarcasm, and a little bit of shameless pandering to the understandable instinct to despise the French; I confess from the depths of my black, misanthropic heart that I am not much of a writer. I try hard, of course, and I can occasionly tame an idea or two in my brain long enough to lead it to paper but since I am having a hard time thinking of a clever way to illustrate exactly how much money we waste in this country on medical care, I’m just going to say it plainly with no art or interesting literary devices. Just Keep in mind two things. First, I’m going to tie it all in to the Albanians and second, every patient I’m going to describe costs the system money even if they are what is optimistically called self-pay (a cheerful euphemsism for “There is No Way in Hell I Would Pay a Dime for my Medical Care”). The temptation is to say, “Well, since they can’t pay there is no money changing hands and therefore no real cost to the health care system.” This, however, is a stunning example of wrong-headed thinking. Every patient costs money to somebody if only because the infrastructure to deal with them has to be maintained. Of all the individuals and organizations involved in delivering medical care, the only ones who will work for nothing are doctors. Try getting a nurse or a radiology tech, for example, to work a few extra hours or fill in some holes in the hospital’s schedule for free. They’d laugh, as would the janitors, clerks, and even the nice ladies slinging the chili mac down in the cafeteria. Medical care is a huge team effort involving expensive infrastructure and many highly skilled and not-so-skilled people, none of whom would even consider volunteering their time except, as I mentioned, physicians who are not only regularly asked but expected to work for nothing as the need arises (a typical Emergency Physician working on a production basis and not as hospital employee, for example, gives away a hundred thousand bucks of his time every year).

So let me just state that In the United States, we are terrifically over-doctored. Much of what we spend is to overtreat either self-limiting things or to throw marginally effective therapy, at least in regard to decreased mortality, at chronic medical problems, most of which are lifestyle related. Either that or we burn through money like drunken sailors on futile end-of-life care for people who have absolutely no quality of life unless we are now measuring quality by how long you can lay motionless in your own urine before a minimum-wage nursing home caregiver decides to roll you around a little. Let me give you a few examples of typical patients to illustrate the many ways in which your money is squandered.

“There, you see? She blinked! I love you Grandma!”

I see this patient or some variation at least once on most shifts. An incredibly frail, some might say cadaverous, woman, somewhere in the neighborhood of ninety who has been in a nursing home for a decade and was doing all right with her end-stage renal disease, advanced senile dementia, and congestive heart failure until about a year ago when something broke loose during dialysis and she suffered a stroke, turning her from a demented elderly lady who had broken her hip twice to a demented, aphasic, ancient lady; completely immobile except when indifferently turned by the staff of the warehouse in which she is stored. Because she can no longer swallow the surgeons obliged her family with a PEG tube (to pour liquid food directly into her stomach) and to protect her airway she breathes humidified oxygen through a tracheostomy (a hole in her neck, with another tube sticking out of it). On a philosophical level we can debate the nature of quality of life but I’m going to go out on a limb here and suggest that laying in your own feces on eroded bed sores is not much of a quality of life. In other words, we’re not talking about a hale and hearty nonagenarian who will live to be a hundred provided she can avoid being admitted to the hospital. This is a patient who is living on borrowed time, one who will not last another six months despite our best efforts and yet, in those last six months we will spend large sums of money on her, probably more than the total spent in her whole pre-stroke life, in an inexplicable quest to stave off death, spending money at an increasing rate the closer she gets to actual “reaper” death and not the living death to which she is condemned.

It is also both amusing and edifying to peruse a list of her medications which, after a decade or two of failing health, has grown into a two-page manifesto, a declaration or our faith in evidence-based chemistry. For starters she is on three-hundred dollars a month of Namenda, a new drug that is only marginally effective in improving the memory of patients with early Alzheimer’s but, if you think about it, is kind of ridiculous to use in a patient who is so far gone that even before her stroke she couldn’t even remember how to feed herself. Because of her cardiac history, she is on the obligatory statin and beta-blocker although against what looming cardiac event we are protecting her is not clear. Because of her atrial fibrillation, for which she recieved an implanted defibrillator two years ago, she is on coumadin. Now that she has no risk of ever getting up to fall it has been cranked up, giving her the occasional gastrointestinal bleed as her doctor disinterestedly tries to control her wildy fluctuating levels. As a little bit of seasoning she is on the digoxin to keep her heart beating as well as the usual four or five narcotics which are poured carefully into her feeding tube at regular intervals with the rest of her medications.

We pour expensive medical care into her in equal measure. The PEG and tracheostomy are only the latest procedures. If the squad of specialsts following her play their cards right, she’s good for at least a few bronchoscopies, an echocardioram, and maybe even a battery change on her defibrillator before they’re through

And she’s a full code. The family wants “everything done,” no matter what, up to and including artificial ventilation, defibrillation, and even more tubes. You see, “She knows we’re in the room, doc. Can’t you see how she perks up when we speak?” Against this kind of faith there is no argument possible, not in our totally out-of-control health care system where, since somebody else is always paying, money is no object. I have no doubt that the last six months of her life is going to cost a couple of hundred thousand dollars. A day in the intensive care unit by itself costs a cool four grand. She will probably burn through a couple of weeks of these before the final, terminal admission where at last, somebody has the common sense to say “no mas” and, after one final orgy of spending (for old time’s sake), we finally let her go.

Where’s the Fire?

Every now and then our already busy Emergency Department is innundated with a surge of patients. The waiting room is packed and the over-flow are seated in folding chairs in the hallway. The chart rack spills over, five rows deep instead of the usual two and you’d think a plane had crashed or the Four Horsemen were abroad. A quick survey of the new charts, however, shows the usual minor complaints, things that eventually turn out to be colds or vague abdominal pain. The panic begins, tempers get short, and, already working at a dangeorus speed, we are expected to double our efforts and move patients. God forbid we get a critical patient at a time like this because that will gum up the waiting room to an unacceptable degree. Why, and please try to choke down your horror, people with minor complaints might even get tired of waiting and leave the department without being seen. Which is sort of the problem. While it is no doubt true that hidden among the irritated patients spilling into the hallway is a real, honest-to-God heart attack or a smouldering acute appendicitis about to become dangerous, the majority of the deluge are patients with complaints that turn out to be minor, self-limiting things or even no problem at all except the siren call of the only representative of the all-giving and all-powerful Man that is open at 2 AM.

Now, I’m not saying that patients don’t need to be seen. Many have no other access to medical care and some are really quite sick. Although I would hate for the Emergency Department to become a primary care clinic for the indigent (a direction towards which we are lurching as hospital bureaucrats think up even more ways to jack up Press-Ganey scores), there is a need for medical care that somebody has to fill. On the other hand many of the complaints are so minor that they don’t need to be seen at all, even if the patient has premium insurance and is followed by the best internist in town. A request for a pregancy test, for example, should never make it past triage. Likewise what is obviously a cold in an otherwise healthy young adult. It is true that both of these complaints might be more than they seem, the pregancy may be an ectopic and the cold may be a Wegener’s friggin’ Granulomatosis but that doesn’t mean that they need to be worked up, a difficult concept for people to understand.

Or, to put it another way, if we work up every minor complaint under the sun looking for a big, bad, macho, internal-medicine-type thrill kill we won’t miss it when it pops up but we are going to have a horrifically expensive health care system with money being spent where it will do the least good. I’m not implying that every cold gets the million dollar workup. We still have a little common sense left. But these patients are dutifully triaged and seen, leading to crowding in the department, already more than a little constipated with “Emergency Department Admissions” (patients with orders for admission but no available beds or nurses in the hospital). There is no “Triage to Home” which is what we really need (and not just in the Emergency Department but in the whole medical profession), that is, a designation for a patient who has been quickly assessed by a skilled nurse, a PA, or even the Emergency Physician making waiting room rounds to not be sick enough for a full work-up and diagnosis. Because somebody pays, you know. Every chronic back pain, every cold, every vague psychosomatic disorder costs money somewhere. The tab is either picked up by Medicaid (and Medicaid patients are ravenous consumers of free healthcare), Medicare, private insurance, or even on rare blue moons when lightning strikes, by the patient himself…but it is all part of the two-trillion dollars we spend every year. Even if the care is unreimbursed the cost to maintain the needed capacity is very real and paid for by everybody.

The idea that some socialized, quasi-socailized, it-ain’t-socialized-much-cause-it’s-single-payer, or any other scheme to give everyone free medical care is going to alleviate the problem is laughable. While there is currently some restraint in the system against using medical resources for minor complaints, it really only effects those who make co-pays for their medical care. If you pay nothing, there is no incentive not to crowd the doctor’s office or the Emergency Department for your free pregnancy test or your motrin. All you have to spend is your time and while our department sometimes slows to a crawl with ten hours waits, you can usually be seen in three or four hours. A long time but I have waited an hour or two to see my doctor for my annual physical (itself largely a waste of money for an otherwise healthy guy) when he is running behind. What’s another couple of hours if it’s free?

What We Have Here is a Failure to Communicate

How many cardiac workups does one person need in a year? Or how many CT scans? Because I work in the Emergency Departments of two rival hospitals I am in the unique position of getting a patient admitted for vaguely cardiac-sounding chest pain and then, as if nothing happened, seeing him at the other department often only a few days later with the same complaint and, unless he remembers me which he may not, no mention in his past medical history of his completely negative nuclear stress test and exhaustive workup. The story is the same for all manner of patients. Some, like drug seekers, attempt to game the system and make the circuit of local Emergency Rooms, shamelessly spinning a tale of woe four or five times a week. Others just don’t know any better and, despite having various deadly conditions definitively ruled-out on multiple occasions at other hospitals, are perpetually looking for the definitve second opinion, or attention, or someone to take care of them for a few days…who knows. Some people just feel bad all the time and have developed a co-dependent relationship with the hospital. They suck down many, many scarce medical dollars in redundant tests, consultations, and brief hospital stays where, in reading the discharge summary, you can sense the dictating physician trying to express his frustration without out-and-out accusing the patient of malingering. For our part, they are what we call “weak admissions,” embarrassingly weak, the kind that make you cringe to discuss with the admitting service.

Some patients, let’s say someone with a volvulous, are incredibly strong admissions. All you have to say is, “The patient definitely has a surgical abdomen, is distended, tender, guarding, and vomitting,” and the admitting surgeon will say, “Okay, I’ll be right in.” Some admissions are decent, like a 65-year-old smoker with pneumonia. You will rarely get an argument or the telephone equivalent of rolled eyes. Some admissions are weak but so routine that the admitting service will demur with little complaint. Some are so weak, so worthless, and such a waste of money that I cringe to hear the voice on the other end of the line, rippling with sarcasm, saying, “You know we admitted him for that last week and found nothing, don’t you?”

Or worse yet, “Oh, we had to discharge him from our practice for violating his pain contract and trying to get narcotics from almost every hospital in the state.”

And you’re left holding the bag, playing a game of legal chicken. The patients may cry wolf but there is going to be a real wolf someday and, like a game of hot potato, nobody wants to be holding the spud when the music stops. I have a patient like this, a serial abuser of Emergency Services whose hospital tab must run in the millions, who came in one day in her usual excruciating pain but which this time was not relieved by her customary dose of narcotics and who turned out to have a perforated colon.

There are two salient points here. The first is that the medical profession does a poor job of coordinating information. It almost makes one wish for a standard, nation-wide electronic medical record accessible by every physician and made mandatory for everyone. In this manner, every prescription, test, study, and discharge summary could be pulled up and viewed by any doctor. The second point is that what we need isn’t a Good Samaritan clause (protecting physicians who offer free care) but a “Wolf Clause” to set an upper limit on the amount of work-ups and Emergency Department visits allowed for one patient. I have a 22-year-old patient, an otherwise healthy young woman, who has been to our department thirty times in the last year, been hospitalized a few times, been worked-up redundantly at both of our big hospitals, and there is nothing physically wrong with her. But she is a spud, and since I’d rather spend your money than risk my livelyhood, we take her seriously every time we see her. We may joke about it and roll our eyes but we don’t dare put our money where our mouths are.

What’s Albania Got to Do With It?

Nothing, really. Except that the Albanians don’t have anywhere near the access to high-tech health care that our citizens enjoy. Like the Greeks and many other Europeans, even their sickest patients are not typically on a long list of medications. There is nothing like our buzzing Emergency Medical hives in Albania where every Albanian who is not feeling well can get relatively instant access to almost every labratory test, imaging study, and specialist known to the medical profession. In Albania, much of what we consider the standard of care is unheard of and reserved for those who can pay for it up front. You certainly will not have your terminal illness interupted by too many of the heroic measures which are routine in our country, even for the poor. People grow old, get sick, and die almost as they have been doing since my ancestors regularly invaded and enslaved theirs.

Ah, Albania! Tarnished Jewel of the Balkans! Despite no medical care to speak of you live as long as we do and even give the perfidious French a run for their money. What does that say about how we spend money? I am pefectly willing to concede that there are quality of life issues at play. Certainly I’m glad that I may one day get an artificial knee if mine should ever wear out. And I also concede willingly that if I were critically ill, I’d be immensely glad to be in Pocatello, Idaho and not Tirana. But I’d like to humbly put forth the notion that most of the money spent on medical care in the United States and Europe is spent on the margins, which is not to say that people don’t want it and don’t demand it, but only that it is spent in large amounts with very little to show for it. Maybe past a couple of thousand a year we’re just pissing in the wind. And maybe what we need to do is to start doing less for most patients, most of time, reserving our big guns for worthy targets and not for killing gnats.

Circus of Chief Complaints (Your Tax Dollars at Work): Part 1

Emergency Medicine, Uncategorized

Actual Patient Interaction Number One:

“So Mrs. Smith, how’s your pain?”

“Oh doctor, it be paining me real bad. Can I get some Dilaudid.”

“How about we start with some Nubain?”

“What’s that?”

“It’s a synthetic narcotic, kind of like Demerol.”

“Is it any good?”

“Sure, it works great and doesn’t give people the rush they get from other narcotics.”

“Oh, I’m allergic to it.”

Actual Patient Interaction Number 2:

“I felt sick, doc. At work.”

“When did it start?”

“About twelve hours ago. But it’s gone now.”

“Really, how are you feeling?”

“Great. I didn’t feel that sick but I thought I’d better come in.”

“So you don’t feel sick now?”

“Naw, I feel like a million bucks. It only lasted about an hour and it’s gone now.”

“So let me get this straight…you sat in the waiting room for upwards of ten hours to be seen by me, it’s two in the morning, you feel fine, and there’s nothing that I can help you with?”

“Well, I need a note for work.”

“You said you weren’t that sick, why didn’t you just finish the work day and go home? I mean, you could have been asleep at home instead of hanging out here watching late-night television.”

“I don’t like my job that much.”

“You realize that your non-problem is still going to cost close to five hundred bucks, right?”

“Well, I really don’t like my job…”

Actual Patient Interaction Number Three:

“What do you mean there’s nothing wrong with my kid?”

“I didn’t say that. I said he had a cold which will get better on its own and there’s nothing you need to do about it except give him some Tylenol or Motrin for his fever.”

“How do you know he ain’t got pneumonia?”

“He doesn’t. He looks great.”

“I want a cat scan.”

“I’m not going to get a CT on a kid with a cold, ma’am.”

“My sister said he needs a CT.”

“He doesn’t.”

“We waited five hours.”

“I’m sorry. He has a cold. Drive home carefully, they tell me it’s snowing tonight.”

“We came by ambulance…can I get a taxi voucher?”

“No.”

Actual Patient Interaction Number Four:

“So, what brings you in Mr. Jones?”

“I’m constipated.”

“How long has it been going on.”

“Almost three years.”

“Uh…okay…what do you expect us to do about it?”

“I need help getting the shit out.”

“There is a fine selection of fiber and other laxatives at Wal Mart. In the pharmacy section…and just like us, they never close. Have you tried any of those things?”

“No.”

“Uh…Okay, well, there you go. I can give you some Colace right now and by the time you get home things should start moving.”

“My mother said you’d scoop it out for me.”

“Not in this lifetime.”

Actual Patient Interaction Number Five:

“I’m going to sue all y’all.”

“We’re doing everthing we can for your mom.”

“You’re not. Can’t you see she’s suffering?”

“I’m trying to make her comfortable.”

“You just don’t care. She’s in a lot of pain.”

“Well, she’s had a lot of muscle and tissue breakdown from laying on the floor in her room in your house for three days. Tell me, does your mother have any health problems?”

“She’s been falling a lot lately.”

The Non-Crisis in America’s Emergency Departments: The Death of Triage

Emergency Medicine, The Money Pit, Uncategorized

Staying Power

I suppose the only good thing about my patient’s twelve-hour wait in the Emergency Department waiting room before he even made it into a room, and his subsequent two-hour wait before he finally saw me, was that the results of the basic lab work ordered in triage where immediately available and, as his chest xray had been done (also out of triage) ten hours previously, it was a matter of five minutes to diagnose him with a fairly serious case of pneumonia for which he was easily admitted. I spent more than five minutes with him of course. When you wait that long, especially with the degree of patience and good humor exhibited by this most excellent gentleman, you deserve some of your doctor’s time, your moment in the sun, whether you need it or not and even if all you want to do is complain (which he didn’t). His total time in the department was about 21 hours because, although quickly admitted, there is such a backlog of patients in our hospital that he didn’t actually go upstairs until almost the end of my shift.

Most patients don’t have to wait that long to be seen. Some days are busier than others and occasionally we get a big run of traumas or critical patients which slows the flow of less-urgent patients to a crawl but twelve-hour waits are the exception, not the rule. Four, five, or six-hour waits are not unusual however, nor is it uncommon for me to admit a patient and find them still in their room (albeit in a more comfortable hospital bed in place of the Emergency Department folding slab) when I come in for my next shift. And occasionally a patient is admitted, receives his definitive treatment, and is discharged from the emergency department.

It can get busy. It has gotten busier lately because my hospital has just opened its new Emergency Department, a huge, modern facility with all the bells and whistles which, because there is such a severe crisis in Emergency Medicine they advertised the hell out of and are now reaping a bountiful crop of patients. So many in fact that the waiting room can take the appearance of a disaster zone with patients draped over every available piece of furniture, fitfully sleeping under hospital blankets while the late arrivals spill into our brand-new architectural gem of a lobby; regrettably confounding the best computer rendered images of its architects who depicted it with smart, well dressed people sitting in casual conversation and not full of three-hundred pound asthmatics crouching amid the greasy detritus of their extended wait. It was so crowded on a recent shift that our sardonic Charge Nurse asked to set up some kind of MASH-like field hospital to start treating the small minority of patients who really needed to be seen sooner than we were getting to them. Maybe an eighty year-old-man incontinent of urine and leaving puddles on the waiting room chairs need to be seen a little more quicky than we are otherwise able, especially as the majority of patients who we see have minor complaints that probably don’t need to be seen by a doctor at all.

Apparently there are some fairly serious complaints waiting for hours at a time which may or may not turn out to be anything but used to be an almost automatic free pass through triage. I’d like to think that our triage system is working but sometimes it gets so busy that even if your chief complaint is chest pain, the only way you’re getting back quickly is if you have EKG findings. Patients with cardiac and pulmonary complaints get an EKG which is shown to a physician who can then decide whether to jump the line and bring the person back. Unfortunately, the word has leaked out that we take chest pain seriously so many less than scrupulous patients work a little chest pain into their chief complaint, muddying the waters and subverting the triage process. But whatever the complaint, it cannot be denied that our Emergency Department along with many others is being deluged with patients.

Many reasons for this are proposed. The mythical 47-million uninsured Americans are dragged in as handy scapegoats. While there may be 47-million people in the United States without health insurance, the majority of our patients have insurance of one form or another. Almost every child we see in our new Pediatric Emergency Department has at least Medicaid (CHIP), to reap the bonanza of which they built the thing in the first place, as do many of the conveyor-belt mothers who bring them in. The elderly who make up the largest segment of our patient population have Medicare and are not shy about using as much medical care as they possibly can. Additionally, while the auto industry is struggling in our state, almost every other patient not in the first two categories seems to have medical insurance courtesy of your car note, not to mention that many private employers still provide comprehensive medical insurance. Our uninsured population is small, as a total percentage of patients, and is mostly illegal or recent immigrants, the working poor, and most especially the young who are invincible and even if they could afford it, wouldn’t dream of spending a dime of their disposable income for anything as prosaic, as non-trendy, as medical care. (In fact, the battle cry of Generation “Y” or whatever they are called nowadays might as well be, “A Thousand Bucks for my Tatoos but Not One Penny For My Doctor.”)

It is also true that many of our patients wade into the morass of our waiting room because even if they have a primary care doctor, not necessarily a given even if you are insured, the waiting time for an appointment can be weeks or even months and any testing or studies beyond basic lab work will be done in a disjointed manner over the course of several visits and referrals with no definitive resolution in a timely manner. There is an understanding in the community that while you may have to wait with winos and hookers, once you get into the department studies and tests will fly thick and fast, allowing those with worrisome but let’s just say less-than-emergent problems to usurp the traditional deliberative slowness of primary care medicine. In this we are perhaps victims of our own success. Many of our attendings are somewhat old-school and are not shy about discharging patients to follow-up with their own doctor but many are not and we find ourselves working up the damndest things. I mean, I’m as interested in uterine fibroids as the next guy but maybe it’s not going to make much of difference if the patient has to wait an extra week to be given the bad news.

Primary care doctors, for their part, take advantage of this and have been known, by the bye, to send a patient or two to the Emergency Department with the expectation that they will get a rapid work-up. Not to mention that as primary care doctors are extremely busy nowadays and are not generally paid enough to make the prospect of late night house calls appealing, the default advice whenever you call your doctor is, “Go to the Emergency Room.” I ask almost every parent who brings in their child at 2AM with what is nothing more than a cold why they hauled the family out of the house and braved the snowy roads of our wintery state to bring the kid in. The inevitable reply is that they called their pediatrician (or whoever was on call) and were instructed to come in.

As a factor contributing to long wait times in the Emergency Department, neither can it be denied that the relative scarcity of not only hospital beds but hospital beds of the required type leads to admitted patients langushing in the department for hours if not days, occupying space and nursing time that is unavailable for new patients. (Chest pain patients, for example, no matter how stable or how unlikely they are to have coronary artery disease but who are admitted for an exercise stress test which will be, as sure as the Pope wears funny hats, completely negative, need a telemetry bed. ) The bottleneck in the department is not real estate per se, you understand. We can always put patients in hall beds, something we aren’t supposed to be doing but which is often unavoidable, but as there is a finite supply of both nurses and doctors there is an upper limit to the number of patients that can be safely managed at one time. It’s not as if we can forget about the admitted patient either, many of whom are actually quite sick and demand a lot of their nurse’s time. How many patients can a nurse realistically be expected to follow anyway? Five? Six? If you think they can handle more you don’t know the amount of work involved in nursing.

As for doctors, we can follow more than that because we’re not actually doing much of the actual patient care (with the exception of invasive procedures) but even we have an upper limit. My attendings can follow a fair number at one time but even they will tell you that past twenty or so, which they can only do because they have residents working for them, things start to get insane and not a little unsafe. I start getting into trouble at around eight or nine, especially if a few of them are complicated, and past that most of my time is spent spinning my wheels as the inefficiency inherent in breaking my attention into too many little chunks starts to overwhelm my ability to concentrate on new patients.

As cognizant as we are in Emergency Medicine of the need for speed, we cannot just run the patients through like cattle which is what would be required on some nights to meet the hospital’s goal of a thirty minute door-to-doctor time. The paperwork alone on any patient, even a simple one, takes a minimum of ten minutes and that’s rushing it. This is not to say that a simple SOAP note and a couple of orders take that long to write but we also document for billing and liability, both of which greatly magnify the complexity of documention. There are also numerous home-grown paperwork initiatives at our hospital, either thought up de novo by an underworked bureaucrat or an over-reaction to the heavy hand of JCAHO or one of several other hospital accrediting crime families.

At my hospital, because an intern denied washing his hands when asked by a JCAHO consigliere, the residents now have to provide a list of their patients by medical record number for every shift with the initials of the attending or the charge nurse verifying that we did, in fact, wash our hands before we touched the patient. Now, if you think about it, to comply with the spirit of the rule every time we washed our hands we would have to have an attending physician, an individual with a staggering amount of education and impressive medical credentials, stand over us at the sink with a stopwatch timing the lathering. Either that or get the Charge Nurse, a gal with two days worth of work to fit into her 12-hour shift, to do the same. This would take, what? five minutes per patient? Suppose I see 18 patients in a typical shift, that’s an hour and a half of valuable (and billable) patient care time involved in a useless task which is not only humiliating but so stupid that it burns. The ironic thing is that for most of my patients, many of whom have only an indifferent relationship with soap, I cannot wait to wash my hands after I examine them and feel like a leper until I can get to a sink.

What actually happens, as you can guess, is that at the end of the shift we make a hasty list of our patients and the attending or the charge nurse just runs down the list initialling, turning a poorly conceived effort to change behavior into more of joke than it already is and producing in the end just another useless piece of paper to be found by future archaeologists excavating “Stupid Age” ruins. But it is a piece of paper that eats twenty minutes of useful time. It all adds up. I haven’t actually turned one in yet. In a training system that thrives on humiliating residents, this is perhaps the most humiliating thing I have ever been asked to do and I’m not going to do it unless they threaten to fire me in which case I will cave…but I’m going to make my attendings or the charge nurse watch me wash my hands. If we’re going to do it, we’re going to do it right.

I digress a little but this does actually lead me to two points.

First of all, in most of the country there is no real crisis in Emergency Medicine except one that is entirely man-made and entirely correctable if there was a real interest on the part of hospitals and even many in our profession to do so. It is true that there are a lot of patients but the real problem is that as a society, we are terrifically over-doctored and while a fair number of our patients have actual, bona fide medical problems which either need immediate intervention or cannot wait for a leisurely referral and a delayed admission, the majority have relatively minor complaints that are either non-life threatening exacerbations of chronic problems, minor but legitimate medical problems that can wait a bit and would be better and more easily handled by the patient’s primary care doctor, or mostly so trivial and of a self-limiting variety that no medical attention is really needed at all. Consider the first four patients of a recent shift, all with a complaint of “the flu” and all of whom were young, relatively healthy people with what turned out to be minor upper respiratory tract infections. Basically nothing more than colds, maybe bad ones but colds none-the-less. Two of them had been seen the day before for the same complaint but took to heart the boilerplate admonition on their discharge instructions to “Return if not Better” and had dutifully waited four or five hours to be told, once again, that while we can send a man to the moon we have no cure for the common cold. If there was really a crisis in the Emergency Department, these four patients would never have gotten through triage. An experienced nurse would have met them at the door and said, “Are you crazy? Go home. Drink some chicken soup like yer’ granny told you to. We are packed to the gills and there is no way you’re going to occupy a valuable bed and the attention of my nurses for an hour just because you have no common sense and nothing better to do.”

They don’t say this, of course, and the patients are dutifully triaged and eventually may even get a five hundred dollar work up for a cold, something for which most people don’t even go to the doctor or interrupt their day in any manner. I assure you that I have worked with a cold or a severe but self-limiting gastroenteritis many times worse than that of many of my patients but the thought of going to my doctor, let alone the Emergency Department, never crosses my mind. (Residency is like that. You’re overworked, don’t have time to eat right, and are exposed to every virus in town.) It’s just common sense. Or used to be until we decided that absolutely everything was not only a medical problem but an emergency.

The lack of common sense is unfortunately built into the system as a result of the Emergency Medical and Active Labor Treatment Act of 1986 (EMTALA), a law designed to prevent patient dumping but which has also had two major unintended consequences. The first is the inability to refuse treatment to anyone for any reason. Ostensibly the law only requires a screening exam to exclude an emergency medical condition, the absence of which allows a participating hospital (all of them, by default, because they all take Medicare and Medicaid money) to send the patient home without any further treatment. Practically, however, when combined with the dangers of an out-of-control and exceptionally predatory legal system nobody is ever refused treatment for any condition, even the aforementioned minor complaints, which has turned the nation’s Emergency Departments into hyper-expensive Urgent Care Clinics that also dabble in a little Emergency Medicine. Unfortunately, unless you are actively dying, even if you have a legitimate medical complaint you are bound to languish in the department because for every one of you there are five people who really have no business occupying a bed. So sorry. Write your congressman.

The second unintended consequence is to make most Emergency Departments highly lucrative profit centers for their hospitals. To defray the cost of providing the free care quasi-mandated by EMTALA, many departments started to aggresively market their services to paying customers, those with insurance, who would have previously never even dreamed of coming to the Emergency Room, once a fearsome place usually located in the worst part of town with scary parking and close exposure to dangerous-looking people. In this respect our specialty is becoming just another customer service business competing for a piece of the two-trillion dollars we spend every year on medical care. That kind of treasure attracts a lot of desperados and there is now even less of an incentive to exercise a little restraint or to educate the public about the limitations of modern medicine. Unfortunately, the minor complaint is the bread-and-butter of most Emergency Departments. They pay well for the time invested and you can run them in and out quickly.

My second point is that for all the howling about a crisis, very little is done to free up more of the doctor’s and nurse’s time, the real bottleneck in the process. The converse is true as we are, as I have pointed out, continuously subjected to one poorly conceived bureaucratic initiative after another, very few of which have any effect on the patients but serve only to tie up valuable time in non-patient care activities. Most of my time is spent looking at a computer or filling out documentation that, it is hoped, will live up to its promised talismanic powers of legal protection. Not likely, of course. I shudder to think of the treasure trove of hastily written documentation, much if it incomplete and a very poor representation of what actually happened for the patient, waiting like some vast treasure trove to rival Cibola and the other Seven Cities of Gold for the intrepid legal conquistador who first dares land on the shores of this savage and incomprehensible land.

How I Am Learning to Throw Money Away With Both Hands and a Big Shovel

The Money Pit, Uncategorized

Other People’s Money

Medical care is expensive and to a large extent this is unavoidable. Medical knowledge has advanced considerably in even my lifetime and there are hundreds of new medical therapies and technologies of unquestionable value to both individuals and society as a whole. It is therefore impossible to bring back the Good Old Days when doctors were paid in chickens or bushels of produce from their grateful patients, all of whose medical care the kindly country doctor could provide out of his well-used black bag. On the other hand, it cannot escape anyone’s attention who works in the medical industry that we waste prodigious sums of money with very little to show for it. I happen to be at the cutting edge of this profligacy but only because we have easy access in the Emergency Department to most of the expensive toys, not to mention that the nature of our specialty predisposes us to use them even when maybe we could substitute a little clinical judgment for technology.

We don’t, of course, for various reasons most of which are out of our control. It cannot be denied, for example, that the threat of litigation drives a lot of our medical decision making. As our good blog friend the Happy Hospitalist points out, a large percentage of the money we spend in medicine is to rule out conditions that are either rare in and of themselves or, if common, not very likely given the clinical picture of the patient. We spend the money anyway because there is very little incentive for most physicians to control costs. Just one successful lawsuit against a physician for a missed diagnosis can damage his ability to maintain his credentials, cost him the average income of any two or three Americans in increased liability insurance, jeopardize his financial assets, and even end his career. Why risk our own money when we can use somebody else’s to protect us, even if it costs millions?

And I do mean millions. Not meaning to brag but I am a veritable titan of excessive medical spending. A brawny legend of mythical proportions. Where my ancient Greek ancestors proudly arrayed the sacred hecatomb before the shrines of their gods, I call them base amateurs. My pen casually checks tiny boxes on order sheets that every day effortlessly transfer many times the value of their paltry burnt oxen from the public treasury to the altar of my gods, chief among them being Expediency, Haste, and Fear.

I have ordered, for example, expensive CT scans of the brain by the hundreds, the only purpose of which was to rule out that one in fifty-thousand chance that we’ll find something requiring an intervention, on people who had no neurological deficits, no symptoms of intracranial pathology, and not even a decent mechanical reason why they should have something wrong in their head. This is not to say that every CT I order is inappropriate. A patient who has never been to the Emergency Department before and presents with the dreaded “Worst Headache of My Life” needs to get a CT of the head, even if his lumbar puncture is negative. That’s just reasonable suspicion and due diligence. But an otherwise healthy young adult with normal vitals, normal physical exam, who tripped on the ice, bumped his head, and has been sitting in the waiting room for five hours eating stale vending machine nacho chips and watching the Fresh Prince of Bel Air? Does he really need any workup at all?

I am embarrassed to say that, just to be legally safe and in proportion to the number of times any particular attending of ours has been named in a frivolous lawsuit, we often obtain a five-hundred-dollar CT of the brain even in face of a normal neurological exam and a chief complaint (“I bumped my head”) that didn’t even exist forty years ago when we had less technology but maybe more common sense..

(We actually have a CT scanner in our department you know….and, By The Blood of the previously mentioned Triune God, we’re going to utilize the hell out of it. The only reason we didn’t put it at the ambulance entrance and have the paramedics run everybody through it was their fear of a little ionizing radiation.)Â

This kind of thing is not confined to the head, of course, or to the overuse of CT imaging. The CT scanner is just the most obvious example of Medical Testing Gone Wild.

It is hard to say exactly how many of the laboratory tests and imaging studies that we order are unnecessary. The point, however, of good clinical medicine is to only order a test to answer a question. If a patient complains of vague abdominal pain but has a benign abdomen (soft, non-tender, non-distended) and if twenty dollar’s worth of quick, in-house labs show a normal white count and no electrolyte abnormalities, then the correct play would be to suspect, strongly, some intestinal gas and send the patient home with strict instructions to return for fever, vomiting, or increased pain. Hell, throw in a serum lactate if you’re worried about mesenteric ischemia and a two-dollar pregnancy test if you have even a slight suspicion about an ectopic pregnancy and you’ve pretty much ruled out everything immediately deadly to the patient and answered almost every possible clinical question in the negative. There is no need for the inevitable ultrasound or CT scan of the abdomen with oral and intravenous contrast which not only costs a couple of large ones but also ties up a bed in the department for two hours at a minimum (the time to drink the contrast, transport, and have the study read). We only order these tests out of fear of sending a patient home with something like an early intussiception and having them decide not to return even if clearly told to do so. What does it hurt, after all, to send the early abdominal pain home except that if it turns out to be something and the patient doesn’t come back, all the jury will care about is that you sent somebody home, not that you exercised what seemed like good clinical judgment and a laudable regard for the public treasury?

Thus does the expectation of zero-defect medicine make cowards of us all. I have ordered hundreds of expensive imaging studies and in almost all cases, where the clinical suspicion of anything being abnormal was low, the studies have been negative. Even the studies that I order with solid history, physical exam, or lab abnormalities as a justification and where I expect to hit paydirt are usually negative. I understand that sometimes a negative study is as important as a positive one but if the pre-test probability is low, maybe we should save ourselves the car fare and give the zebra a little more time to cook. Give the problem time to declare itself, I mean, if it really exists. It sounds cold-blooded but you can’t expect everyone to get a ten-thousand dollar workup for every complaint and then complain about the high cost of medical care. Everything is not an Emergency.

If, on the other hand, we remove enough clinical judgment from the medical profession by penalizing it so severely on the rare occasions when it is wrong, we may as well load every patient on a conveyor belt where, despite their complaint, they pass through a full-body CT scanner, an ultrasound station, an indiscriminate lab station, an automatic EKG, and then have cut-rate physicians in India email treatment recommendations to minimum wage technicians at the end of the line.

On another note, the health care system itself, independent of the threat of litigation, is set up to encourage waste. While we don’t actually have a Health Care System per se, just a bunch of independent doctors and hospitals, there are two common threads that run through all of our medical endeavors and which serve as perverse unifying principles. The first is the obvious and inevitable fragmentation of care in our hyper-specialized industry . The second is the sure knowledge of everyone involved that nobody is actually spending their own money.

Consider the typical Family Practice physician seeing his typical panel of thirty patients a day. If he just manages to keep to his schedule giving each patient fifteen minutes of his time that’s a full eight-hour day, not even counting the various patient care tasks for which he receives no reimbursement but still impose an inexorable demand on his time. Unlike lawyers who bill for every minute of their time, a physician is reimbursed for the amount of time the government (and the private insurance firms that follow the government lead) think he should spend with the patient and not how much time he needs to or actually does. Because the reimbursement is so low physicians are forced to substitute volume for quality, running increasingly comorbid patients (the inevitable result of advances in medical knowledge) through their practice at a breakneck speed without the possibility of adequately addressing their many medical problems safely or economically. In their haste to see all of their patients, primary care doctors are forced to refer many of them to expensive specialists for things that they could diagnose, treat, and manage themselves if they had more time. In this manner, specialists are used more as physician extenders than learned consultants who are only brought into the case to help solve thorny diagnostic puzzles or to perform interventions outside the primary care doctor’s scope.

This “gatekeeper” model, where the primary care physician’s chief purpose is to be a clearinghouse for referrals to other physicians, has been a disaster, both from a financial and patient care point of view. A patient being followed by a squad of specialists, none of whom have the time to adequately coordinate care, not only costs many times what it would cost to just let the primary care doctor bill for the time he needs but it leads to a dangerous fragmentation of care where one set of doctors literally have no idea what the other set might be doing. I have seen it many times, often in the elderly patient on a long and bewildering list of dangerous and often medically contradictory medications. When specialists refer to other specialists sometimes even the primary care physician doesn’t know what the hell is going on.

Volume is the problem. Medicine is not like ordering fast food and most of it cannot be automated or standardized despite the best efforts of our friends in the electronic medical records industry, most of whose products are designed more to capture billable activities than medical information. The patients are becoming more complex, not less, and to continue to increase the speed with which we process them will only lead to more fragmentation and expense. Or to put it another way, medicine is not like building an automobile where individual pieces are built off-site, brought together on the assembly line, and efficiently assembled into economical automobiles by reaping the advantages of specialization and division of labor. Our current medical practices are more akin to hauling the chassis of the car to various locations around town, putting on one piece here, another there, none for exactly the correct model and none in any rational order, and then several years later when it is done wondering why the ignition won’t crank and the “engine warning” light won’t go off.

We tolerate this state of affairs because, no matter how much we spend and how fragmented the care, somebody else is always paying for it giving the end user of medical services no incentive and more importantly, no leverage to change things even if they wanted to which most don’t. My demented granny may be followed by a squad of specialists, she may have had every imaging study and intervention under Heaven and Earth ordered for her, she may have hundreds of thousands of dollars spent to extend her life by a handful of months but since I ain’t paying a dime, spend away and the Devil take the hindmost.

A Real Question From A Real Reader: Panda, Can I Hack It?

Emergency Medicine, Residency, Uncategorized

(Another real question from a real reader, really sent to my real email address. -PB)

Ian writes: “You’ve described what Emergency Medicine is like but what would you say are the ideal qualities of Emergency Medicine doctors? (I seem to handle stress and emotions very well and can easily remain calm in pressing moments)”

Let me back into this question but not without first stressing that I am a resident, not a board certified Emergency Medicine physician, so you have to look at what I say from that perpective. Gruntdoc or Scalpel, both of whom have excellent blogs, can probably give you a better perspective of what it’s like to be habituated to the trenches of Emergency Medicine. I’ll give you my opinion, for what it’s worth, but I am perfectly willing to defer to superior wisdom and experience on this topic.

With this in mind, let’s consider five random patients of one of my latest shifts. They were, in no particular order, the following:

1. A chronic pain patient on 180 mg of MS-contin per day (enough to render comatose a small Cuban village), admitted to the hospital across town for a surgical consultation, put on a luxurious inpatient analgesic regimen by his admitting physician (3 mg of dilaudid IV every four hours as needed), and pretty much living the drug-seeker’s dream who nevertheless had such a desire for a smoke and a beer that he checked out against medical advice and then, when they wouldn’t take him back, decided to try our establishment. While it is true that we sometimes have trouble coordinating information, I happen to work at that other hospital too so it’s not like I couldn’t call my colleagues over there and ask what in the hell was going on.  His several hour stay in our department under my care was characterized by whining, constant demands for narcotics, and several reassessments on my part where I had to wake him from a deep sleep to ellicit symptoms of 20/10 pain all over.

“Does your back hurt?”

“Yes.”

Do your legs hurt?”

“Yes”

Does your face hurt?”

“Yes.”

‘How about your left eyebrow, does that hurt?”

“Yes.”

I refused to give him anything stronger than Toradol before I could talk to his doctor. He slept, whined, and finally called his sister who, when she showed up, constantly asked the nurses to talk to me, accused them of being lazy and became irate when I said, in no uncertain terms, that her opinion of the nurses was absolutely wrong and that she had no idea how hard they work.  They both eventually left in a fit of anger, muttering dark threats that I would be hearing from their lawyer…and they later showed up at the Emergency Room across town for the same complaint.

2. An 89-year-old severely demented woman in the advanced stages of Alzheimer’s disease and with a past medical history that, if you added a few multiple choice questions to it, could have done decent service as a pathology exam. She was dumped from a nursing home with a chief complaint of (imperceptible) “Altered Mental Status.”  I suspected an accidental overdose of her nightly sedative (not that I had any idea of her baseline mental status, you understand) because on the transfer Medication Administration Record (MAR) from the nursing home, the section listing dosages and time of administration was physically cut out of the copied page, likely done to keep us from discovering that she may have gotten an extra dose or two of this or that.  I can only imagine the emotional turmoil of the nurse at the home. Should she pretend nothing happened and possibly have the lady die on her shift or risk having her shoddy nursing skill exposed by calling the paramedics? Eventually she must have decided to compromise and send the patient but cut out the important parts of her medication history, no doubt assuming that the doctors and nurses in the Emergency Department are a pack of morons.

Veterinary medicine at its finest. Patient alert, calm, but totally incoherent. Vitals normal and stable. Vitals of a seventeen-year-old Lithuanian virgin in fact. Nothing really wrong with her except that, and this may be a shock to many of you, she was 89, demented, and none of her many impressive medical problems went away or were cured as a result of our humble efforts. We sent her back after a relatively cheap four-thousand-dollar work-up no worse for the wear, with nothing to show for it but a few more cross-sectional images of her moth-eaten brain mouldering on a server somewhere in cyberspace.

3. Nine-month-old boy brought by his mother at three-in-the by-God-morning because he usually drinks five ounces of formula before bedtime but tonight, oh the horror, only drank three ounces before falling into the blissful sleep in whose gentle embrace I found him when I opened the door. Completely normal physical exam and negative review of systems.  And I mean completely negative. No fever, no coughing, no diarrhea, no nothing. I spent more time than you might imagine with this patient because I didn’t want to believe that anyone could possibly haul their baby out of bed in the dead of night, sit in a crowded waiting room with drug addicts and hookers, and then wait for three hours to tell a guy with 14 years of higher education that her baby was two ounces short of his usual daily formula intake.

She left angry because I was able to give her the good news that her baby was clean, well-fed, healthy, happy, and perfectly normal in every respect and that the CT scan she requested was definitely not necessary.

4. A 22-year-old-woman, eight weeks pregnant by date of last menstrual period, complaining of pelvic pain but eating fast food in her room and exhorting me to hurry up with the preliminaries and get to the ultrasound. Refused a pelvic exam (and I don’t care what some people say, a pelvic is important to work up pelvic pain), left several times to smoke outside, had a beta-HCG consistent with her estimated gestational age, and no real history or physical exam findings that would suggest she wanted anything other than a nice ultrasound picture of her baby to paste in her scrapbook. Putative father soon thrown out for rifling the IV cart for butterfly needles and syringes. Mother professing ignorance of babydaddy’s hyperkleptoremia and finally leaving without so much as a thank you after a perfectly normal eight-hundred-dollar ultrasound, on the taxpayer’s tab, of a perfectly normal eight week intrauterine pregnancy.

And no, I did not give her a picture to take home. Not unless she coughed up eight hundred bucks. All of our imaging is on a computer anyway. Grief all around. She had waited seven hours and almost had a total stranger stick his hands in her kooter fer’ nothing (which is what I heard her tearfully relate to her mamma on her cell phone).

5. 34-year-old women with a chief complaint of “knee pain.” slipped on the ice two weeks ago. Did not seek medical attention at the time. Gait normal. Exam unremarkable. Clinically no indication whatsoever for any imaging studies or for anything at all except a heartfelt, “Life sucks and you occasionally bang your knee,” which of course you can’t write on discharge instructions. Patient angry. Very angry. Storms out in an attempted elopement. In a demonstration in miniature of everythig that is wrong with the American health care system, I was sent to convince her to stay, eventually mollifying her with a completely normal three-view plain film of her offending knee. Reassurance all around. Motrin. Hasta la Vista. Come back if the pain gets worse or for the love of Mohammed, go see you primary care doctor, would ya’? (Can’t write that on discharge instructions either).

Fifteen minutes later, accosted by customer service representative.

“Can you give her a work excuse?”

“Sure. I guess it would be okay for her to rest today.”

“She want’s it for the last two weeks. She missed work and says her boss will fire her if she doesn’t get a doctor’s note.”

“Absolutely not.”

“Are you sure? Come on. All you have to do is sign it.”

“That’s called fraud where I come from…and I’m not going to get sucked into some worker’s comp scam.”

Consider these five of what I assure you are extremely typical patients. Each one with a totally bogus complaint which in a world ruled by common sense would have garnered nothing but laughter and a hearty, “You want to see the doctor for that? When pigs fly, buddy.”  And yet each one was duly triaged, sent back, given serious consideration, was worked up as if money were no object, and perhaps worst of all from the perspective of a resident or attending, required as much if not more paperwork and documentation than a patient with a legitimate complaint. The patient who had eloped from the hospital across town, for example, did not just leave but drew us into the usual Kabuki drama where we pretend he is a legitimate patient and exhort him to stay while he pretends to be a responsible citizen who is just exploring his health care options. Once again, in a perfect world we would have said, “Look, you stupid motherfucker. You were admitted to a perfectly decent hospital for your bogus complaint and they took you as seriously as if you weren’t just some hopped up dope addict. You took up a scarce bed, one that could have been filled by somebody who was really sick, and by eloping you spit in the face of both the overworked resident who admitted you and the busy attending who in laying hands on you assumed complete responsibility for your welfare in the hospital. You had it made. 47 million uninsured my ass. You and your shrew of a sister have never paid a dime for any of your extensive utilization of our health care system but you are such connoisseurs of our product that you act like you are bankrolling the entire shooting match.”

But you can’t say that. Each of these patients must be met with the same grim determination to diagnose and treat as any other.

Consider also that while these five patients represent obvious misuse of Emergency Services, most of the legitimate patients you will see, those with sincere medical complaints, will end up with a completely negative work-up or an embarrassingly weak admission leading to a work-up by someone else which is either negative or tells you exactly what you already knew and which may have been demonstrated several dozen times in the previous few years. I can’t tell you how many patients, for example, brought in for an exacerbation of their congestive heart failure whose symptoms were completely reversed after a few hours in the department (diuretics, oxygen) who are admitted and discharged a day or two later with a diagnosis of congestive heart failure exacerbation.

If you decide on Emergency Medicine, oh my gentle readers, scholars and adventurers all, you will see plenty of seriously injured and critically ill patients. But they will be intermixed with a huge volume of mundane medical complaints, some perfectly reasonable and some sublimely ridiculous, all of which you must wade through to get at the interesting cases. The stress of the job is not going to come from intubating the difficult airway or deciphering the mystery of an inexplicably decompensating patient whose life hangs from a thread passing through your hands. If you don’t like this kind of thing it would be criminally foolish to match into emergency medicine anyway, not to mention that at most Emergency Rooms these patient do not come in huge volumes but are an occasional treat to keep you interested and sharp.  The stress of the job comes from the sure knowledge that while you are in the trauma bay resuscitating the critical patient your backlog of drug seekers and vague abdominal complaints is inexorably growing and, as these are the financial bread and butter of our profession, they may not be ignored.

Chicken Soup For the Emergency Medicine Resident’s Soul: Inspiring Stories From the Emergency Room

Emergency Medicine, Uncategorized

Field of Dreams

There is a lot of Medicaid money floating around out there, particulary in the pediatric population where a large portion of the patients are covered by the Children’s Health insurance Program (CHIP). To legally acquire as much of this bonanza as possible, my hospital built a dedicated Pediatric Emergency Department which opened two weeks ago. It has been aggressively advertised as a state-of-the-art facility with private rooms and limited wait times. It even has a separate waiting room from the adult Emergency Department and video games for the kids.

There has been both the usual adulation from the press and the self-congratulation from the advocates of everything and anything as long as it’s “for the children.” If we step back from the hyperbole however, in a city the size of ours there are not that many real pediatric emergencies…or at least not enough to justify building a Pediatric Emergency Department. The traumas and critically sick children still come to the adult side (also newly constructed) and as we usually get them up to the PICU extremely quickly, what’s left is mostly urgent care and general after hours pediatrics which is, of course, what the hospital is angling for. It looks to be a stunning success and the new department daily harvests a bumper crop of essentially well children eating up a couple or three hundred bucks apiece of scarce medical resources for mostly minor, self-limiting things that are thankfully mostly relegated to the Physician Assistants.

Build it and they will come and this is exactly what is happening. Why go to some crappy urgent care or the wait at the health department with the hookers and drug addicts if you can sit in a nice room with your children watching MTV on a brand-new flat-panel television while you wait for the doctor? Unfortunately, there are still long waiting times, you just wait in a private room instead of the waiting room, an improvement even if this is not what the hospital has disingenuously lead the patients to expect. Rooms are cheap. Doctors and Physician Assistants are not so real estate has never really been the bottleneck. The most common thing I hear when I am sent to the Third Level of Hell (the Pediatric Emergency Department I mean) to help clear out some of the backlog is the exasperated parent asking the nurse when the doctor will see them.

So the other night after my third twelve-hour shift in a row, I was riding the elevator to the parking deck with a disgruntled-looking tatooed couple and their mullet-bedecked toddler. The mother eyed my hospital identification badge, clearly identifying me as an Emergency Medicine Resident Physician, rolled her eyes and looked disgusted.

“How do you like our new Emergency Department?” I asked, somewhat taken aback by the hostility..

“They made us wait six hours just to tell us our kid has a cold,” snorted the mother, her nose stud gleaming in the soft recessed lighting as she and the putative father of her child stormed out of the elevator.

After the doors closed, another passenger looked at me and said, “Well I guess they shouldn’t bring the little motherfucker in if all he has is a cold.”

On The Other Hand….

I don’t have to tell you how much most doctors dislike patients who are google-based medical experts. Not that we don’t like well-informed patients because we certainly do, it’s just that the internet is so jam-packed with misinformation that without a background in science and critical thinking, two things which are not major selling points of our public schools, it is hard for many people to separate fact from fiction much less interpret their information in the appropriate context. The tendency is for people to view anything they see in a written form as the truth, or, as one of my patients put it about her stack of googled articles about the benefits of large doses of Vitamin C, “If it wasn’t true they wouldn’t write it.”

So it was with no small amount of trepidation that I knocked on the door to a patient’s room whose parents, the nurse warned me, had a whole binder of articles downloaded from the internet. The patient turned out to be a sick-looking, febrile nine-week-old baby who required a full septic workup including a lumbar puncture that was positive for a bacterial infection and who was rapidly admitted for IV antibiotics and supportive care. The mother initially apologized and said that although her parents said the baby didn’t need to come in, she had read some articles on the internet and decided to bring him in anyway.

I looked at her binder and the first article was the exact same one I had skimmed on the internet just before knocking on the door. I guess if you’re going to use the internet you may as well use it right.

During my history, I asked if the baby’s vaccinations were up to date. The mother looked embarrassed and said that her parents were against vaccinations and had told her not to get the baby his shots but that she had decided to do it anyway.

“My in-laws are retarded,” Explained the father.

Hope Springs Eternal

I have never seen a sicker patient who wasn’t actually dead or heading that way shortly (e.g. the typical 92-year-old cardiac arrest who looks like a cadaver but who we try to resuscitate anyways). About my age, emaciated, cachetic, profoundly pallorous, and acutely short of breath with any exertion more strenouos than talking. He had what felt like a large, sold mass in his abdomen that started under his left rib cage and seemed to extend into his pelvis. His teeth were rotted, his hair was dry and sparse, he had creepy-looking fungus-like lesions all over his body, and he was covered with a fine layer of what looked like powdered sugar but was actually uric acid salts, an indicator of end-stage renal disease. His chief complaint was hematuria (blood in his urine) but if there was any urine in his blood I would have been suprised. His serum hemoglobin, a surrogate marker for the amount of blood in the body, was 3.9 or about the blood content of a medium sized yorkshire terrier. And yet for all that he was alert, cheerful, and a fairly pleasant guy.

“Do you have any medical problems” I asked.

“No,” he said.

And he was technically correct because a search of our records and those of the other major hospital in town showed that this gentleman, a lifelong resident of our city, had never so much as visted the Emergency Department. Apparently he had been getting sicker and sicker and, like most guys, initially decided to ignore his symptoms but then got so used to being tired and worn out that he forgot he had ever lived any other way.

“I’ve got a good one for you,” I said to the tired medicine resident who was down in the department admitting his sixth vague abdominal pain of the night.

“Ooh, let me guess, another bogus chest pain,” he said wearily, “I can barely contain my excitement.”

“Naw,” I said, “This guy is the real deal.”

I explained the particulars of the case and the resident perked up a little.

“And get this, he has never seen a doctor. He’s terra incognito, man! Virgin territory. You’ll be the first guy to plant the flag, kind of like Neil Armstrong.”

“What studies have you ordered?” the resident asked.

“Not a whole lot,” I said, “We’re going to transfuse him but other than that…well…knock yourself out.”

“I love you, man.”

What I Do, Part Two

Emergency Medicine, Residency, Uncategorized

(This is an another article directed more to people who are interested in a medical career than to those already involved.  Feel free to read along but I again offer my usual warning that there is nothing profound or exciting to follow and I cannot be held responsible for your boredom. I’m going to try to write this without jargon and I will clearly explain everything which is where the boredom is going to come in for those of you who are in the know. -PB)

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Because I am a second year Emergency Medicine Resident, at my program I carry the trauma pager which alerts us whenever a trauma or a seriously sick patient is on the way.  As part of my training I get “first crack” at all these difficult patients, those for whom a delay of immediate interventions or decisions could result in serious long-term disability or death.  Our attendings supervise us but they generally stand back and only correct us if we are doing something either completely wrong or not the way they want to handle things.  It is the attending’s patient, not mine, even if she just stands in the back with her hands folded across her chest looking bored.  As we gain proficiency our attendings stand around looking bored more but to start out we are supervised fairly closely.

We really don’t get as many of this kind of difficult patient as you might imagine.  We get plenty of really, really sick and injured people but in most cases, they are stable enough where a delay of five minutes or even a half hour might not have too many serious consequences.  Most trauma patients that we receive for example, even Level One traumas for which the entire trauma team is mobilized, are stable enough to be taken to the CT scanner before the decision is made by the trauma surgeons whether to operate.  (On the other hand sometimes the patient is so badly injured, particularly in the case of penetrating abdominal injuries, that they go straight to the operating room with barely a how-do-you-do in the trauma bay).

The trauma pager usually but not always alerts us that a critical patient is on the way and gives us time to prepare.  In this case, the terse message on the pager screen said “57 M SVT Chest Pain” which meant that the paramedics were bringing in a 57-year-old man with chest pain who the paramedics believed to be in Supraventricular Tachycardia.  Supraventricular tachycardia, as the name implies, is a fast heart rate with the pacemaker, a focus of electrically active cells in the heart, located above the ventricles in either the atria (the top chambers of the heart) or the atrioventricular node (the specialized cells between the top and bottom chambers of the heart that allows the transmission of electrical signals). A rapidly firing pacemaker in the atrioventricular node is more correctly called an accelerated junctional escape rythm but it looks somewhat like SVT on an EKG.  The heart has a normal physiological pacemaker in the right atrium called the sinoatrial (SA) node but this is not what is usuall driving the heart in SVT.

The heart itself is an electrically active muscle. Unlike skeletal muscle, and with the exception of the SA node, it is not innervated but instead receives its signals to contract via a wave of electrical current generated by the flow of ions into and out of individual heart muscle cells.  The SA node is not directly innervated (attached to nerves) but is modulated with neurotransmitters like acetylcholine released from nerve endings of the parasympathetic nervous system (of rest and digest fame) located close to the SA node. The wave of electrical current produces a progressive cascade of electrical depolarization and repolarization of individual muscle cells, sequentially opening and closing voltage-gated ion channels on the cell surface, that allows the flow of sodium, potassium, and calcium to power the cellular machinary that causes contraction and relaxation.  Usually, this process is initiated in the sinoatrial node which has a natural automaticity and, absent any external influences from the autonomic nervous system, paces the heart at anywhere from 60 to 100 beats per minute.  Every heart cell can pace on its own but since the SA node paces faster, its signals interrupt the pacing potential of the rest through something called overdrive suppression.

I am simplifying things considerably and once in medical school you will learn about the heart in great detail.  Like many things in nature, the mechanism of cardiac activity is wonderfully elegant and simple to understand but frightfully complex once you get into the details.  The important thing to remember is that measurable electric current flows in the heart. An EKG is a representation of this current as it flows towards an electrode (also called a lead) and is more specifically the magnitude of the vector component of the current (well, actually the electrical potential which is a voltage) coming towards or moving away from the electrode.  The EKG, either on a monitor or printed on paper, is a graph of time and voltage with time represented on the horizontal axis and voltage on the vertical axis.  By convention, a printed EKG uses twelve leads, looking at the heart from twelve different electrical points-of-view.   A cardiac monitor like you see over hospital beds or on a portable defibrillator of the kind carried by paramedics is just an EKG with two or three leads instead of twelve.

A normally functioning heart has a distinctive EKG pattern representing the flow of current in the heart.  Abnormalities of the heart cause their own distinctive pattern on the EKG.  A Q-wave, for example, is an abnormal downward deflection on the EKG caused by the lead “looking” through dead (and therefore electrically silent) heart tissue to the opposite side of the heart and is something that develops after a heart attack in many patients.

The patient finally arrived and was a reasonably fit-looking middle-aged man sitting up in the gurney who was awake, alert, and in no obvious distress except he was dripping with sweat.  His chest pain and sweating had started about fifteen minutes before while working in his home shop sweeping sawdust into a dust pan.   The nurses, who actually do most of the work of patient care, hooked the patient up to our monitor and established another intravenous line to complement the one placed by the paramedics as I listened to the rest of the report and looked at the “rhythm strip” printed from their defibrillator.  It showed a wide-complex, monomorphic tachycardia with a rate of 280 beats-per-minute, also known as Ventricular Tachycardia or “V-tach,” not SVT as originally advertised (an earlier strip showed what could have been SVT however).  A normal heart rate is, as we said, anywhere from 60 to 100 beats per minute with an EKG pattern showing that the beat originates in the SA node.  This was a rhyhtm originating in the ventricle and pacing the heart at a rate three to four times normal.  It was “wide complex” because the QRS complex, the pattern of electrical force from the ventricle as represented on the EKG, was of a longer duration than a normal QRS indicating that the normal conduction pathway of the left ventricle (which provides the power stroke of the cardiac pump that sends blood to the body) was being bypassed.

The patient’s medical history was unremarkable, at least from our point of view although I have no doubt that many of my physician friends in Europe would have considered him marvelously complex and lucky even to be alive as this kind of patient is a rarity over there.  The usual COPD (from emphysema), the usual coronary artery disease with a history of two stents (expanded wire cages in the arteries of his heart to open them up and allow blood flow), and the usual non-insulin dependent diabetes.  He was a very pleasant guy and despite his chest pain cracked a few jokes and expressed a little dismay at all the trouble he was causing.  Not twenty feet away in another room was a patient a third his age with no medical problems whatsoever and  complaining vociferously to everyone and anybody about the slow service in our department which is typical and shows how profound are the generational differences of our patients.   Except for his sweating and fast heart rate, the rest of the physical exam was unremarkable.  He was on the usual medications for a guy with his medical problems and had no allergies.

Ordinarily we shock (or cardiovert) V-tach immediately if it is unstable.  Unstable arrhythmias are those producing symptoms; things like low blood pressure, altered mental status, obtundation (unconsciousness), chest pain, or sweating.  In our patient’s case, as he was somewhat stable (talking and perfectly alert) we decided to get everything we needed set up before attempting cardioversion which would certainly be required.  Nobody can maintain that kind of heart rate for long.  If he became unconscious, for example, maintaining an airway would be important so I set up for a possible endotracheal intubation (insertion of a breating tube through the vocal chords into the trachea) while the nurses drew up a couple of milligrams of Midazolam (Versed) for sedation before we jolted him.  I have had patients report that being cardioverted feels like being hit in the chest with a sledgehammer so sedation is the merciful thing to do for conscious patients.

No sooner had the Midazolam been injected into his intravenous line when he rolled his eyes and became limp and totally unresponsive.  The monitor still showed V-tach so now it was definitely time to shock him.  I set the defibrillator to 100 joules, was reminded by my attending to make sure the machine was set to synchronized cardioversion as shocking at the wrong place in the cardiac cycle can make the problem worse, pressed the charge button, and after checking that nobody was touching the patient, pressed the button with the lightning bolt on it and sent the charge into the pads that had been previously glued to his chest.   very satisfying jump from the patient (just like on TV) as every single cell in his heart depolarized, looked around at its neighbors, said “What the fuck?,” and waited for the regular signal coming from the SA node to resume a normal heart beat.

Which is exactly what happened.  After a brief period of asystole (or no electrical activity) the monitor showed a normal cardiac rhythm.  I made sure that the patient was still breathing and that he had a pulse and not thirty seconds later he opened his eyes and asked how he was doing.  In the meantime the cardiology fellow (an internist who is doing additional training to become a cardiologist) who we had previoulsy called arrived to evaluate the patient.   V-tach has many causes from electrolyte abnormalities to a tension pneumothorax (a collapsed lung with increasing pressure in the chest cavity compressing the heart) but in this case, given the presentation the most likely cause was cardiac ischemia which was confirmed by a post-cardioversion EKG showing unmistakable signs of myocardial infarction (a heart attack).   Ten minutes later and after starting an infusion of an antiarrhythmic agent the patient was on his way to the coronary catheterization lab for an emergent “heart cath.”

Total time in our department?  Ten minutes, fifteen at the most which made him both my quickest and most satisfying patient of the week and an official “Perfect Emergency Medicine Patient.”  By this I mean that he arrived with an unmistakable chief complaint, was able to give a good history, had solid physical exam findings, and responded to our intervention beautifully.  Not only that but he had a quick disposition and was taken off our hands early for definitive treatment.  We don’t get many of this kind of patient either.

My next patient was a 14-month-old with a fever, vomiting, and cough.  This is the worst kind of patient because while the child probably has nothing more serious than a cold or some self-limiting viral syndrome, the differential diagnosis is long and sometimes we keep a patient like this for hours and hours, eventually obtaining a perfectly normal lumbar puncture (where we stick a needle through the back to obtain spinal fluid to check for potentially deadly infections) before sending them home.

Pandarandom: Brief Thoughts

Uncategorized

Four Percent

Okay, I confess. I didn’t study for Step 3, the last United States Medical Licensing Exam (USMLE) required to obtain an unrestricted medical license in the United States. My strategy to pass it (which I did by a comfortable margin)? Every time I felt the urge to study I just told myself that 96 percent of American medical school graduates pass it on the first attempt and, while I may not be the shiniest nickel in the kitty, I know some of the four percent guys and that’s just not me. Considering that Step 3 tests things you should know, the only way not to pass is to either have no clue or, and this is a definite possibility, overthink the test and look for deeper meaning in the questions. Either that or choke which has happened.

Since the actual score is not important, all you have to do is pass Step 3. Steps 1 and 2 can influence your residency options but Step 3? Nobody cares so I don’t want to overhype it. Odds are you will pass if you are a graduate of an American (or Canadian, also 96 percent) medical school. If you’re worried, remember that primary care is big on the test. Imagine what you need to know in Family Practice (and it wouldn’t surprise me if Family Practice residents do the best on it) and study accordingly. Ultra-specialized knowledge? Not required. I think you might have a little trouble taking it right out of medical school but if you have done a few “acting intern” rotations probably not.

If you must study, this is one of the few times I would recommend a “trivia-based” review book like First Aid, especially if you are taking Step 3 late in your training in some non-primary care specialty. By show of hands, how many of you surgery residents know (or care) what to do with an abnormal pap smear? Maybe you might want to brush up on things like this. I know you neither have the free time to study like you did for Step 1 or would use it for that purpose even if you did.

Foreign medical school graduates only have a 66 percent first-time pass rate but whether this is a result of the language barrier or lack of knowledge is impossible to know. There are a lot of shoddy medical schools around the world which are not up to the standards of countries like the United States, India, the United Kingdom and the rest of the Anglosphere but I imagine if your native language is Chinese you can factor that in. There may also be a different emphasis on subjects in other parts of the world. But since the test qualifies you to practice in the United States this is just a personal problem.

Osteopaths have a lower pass rate but I’ll wager I’d have a hard time on the COMLEX (their licensing exams) even if they took out the manipulative medicine.

Not surprisingly, on the score breakdown I did best on Emergency Management and poorest on office-based medicine. Emergency Medicine seemed fairly well represented on the test so an Emergency Medicine month where you get to at least see some typical Emergency Department bread and butter cases would probably be helpful (and sufficient). I can not emphasize enough however that knowing the practice guidelines for the bread and butter primary care stuff (colon cancer screening, pap smears) would also be high yield.

A reader writes: “Dear Dr. Bear, are some medical schools better than others?”

Not really. There are differences but they are slight and the effect on your education is marginal at best. In fact, prestigious medical schools do not have a monopoly on good teaching and you might find the teaching actually worse at a top-ranked medical school. Research funding is often used as a surrogate for quality when medical schools are ranked but anybody who has ever been taught by graduate students or high-powered academics, individuals who are often focused on research and only teach because it is in their contract, knows that the quality of teaching has very little to do with the size of the school’s research grants. Generally speaking, there are no appreciable differences between any American medical school as far as the education you will get. First and second year are largely self-study everywhere and based on a syllabus that is remarkably uniform from school to school. You can also desultorily pick your way through a cadaver as easily at Harvard as you can at UAMS. It looks like chicken everywhere and I’m sure gross anatomy slackers are equally represented at every school.

As for third and fourth year clinical education, this is dependent on so many factors that the prestige of your school probably has very little to do with quality. If you think about it, it might even be better to get your clinical experience in the sticks as you will probably not only see more normal cases of the kind that make up most of medicine but you will have more responsibility and exposure.  The prestigious centers tend to have a surplus of manpower and the medical students are more useless than they are at run-of-the-mill medical schools (if that’s possible). Not to mention that an extremely strong academic culture tends to detract from the more useful aspects of clinical medicine.

I did a cardiology month at Duke as an intern, for example, and hardly learned a thing except I read a lot on my own. During rounds, the teaching tended to be directed towards research esoterica, for example relative risk reductions in one study versus another and how those ignorant bastards doing the competing study couldn’t find their ass with two hands and a flashlight. Useful stuff if you are gunning for a cardiology fellowship but not very practical for most people. I’m sure our medical students didn’t get that much out of the discussion although they had the usual frightfully interested facies concealing their boredom.

On the other hand Medicine at Duke was a uniformly excellent rotation with highly dedicated residents and attendings who were more concerned with teaching than patient processing if you can believe it. But you see my point about quality being highly variable.

If you have to pick a medical school, prestige should be a minor criterion. Location, price, and teaching style (lecture versus Problem Based Learning) are probably more important in the end as is institutional culture. Institutional culture is hard to define but let’s just say that different schools seem to select for different types or, as is the case for state schools, draw students who mirror the state’s dominant culture. The medical students I met at Duke were very intelligent and strident in their support for Social Justice and other pillars of the academic left (I only met one conservative student and he said he was viewed as something of a curiosity by his classmates). Nothing wrong with this of course and you certainly should go where you feel comfortable. My medical school in Louisiana was fairly conservative and I didn’t notice a lot of activity in the Social Justice way. Where the battle cry at Duke seemed to be, “To the Barricades, Comrades!,” ours was “Laissez Les Bon Temps Rouler.”

Not an Apology

We have discussed waiting times and delays in the emergency Department on numerous occasions and where appropriate I have even issued an apology or two to people who have been forced to wait longer due to my inefficiency. I most certainly am not going to apologize to the lady in the hall bed last night who accused me of “fucking around with the computer” instead of taking care of her. First of all, documentation is an important part of patient care irrespective of legal and billing requirements so, since all of our charting is done electronically, I do have to occasionally type a sentence or two just to keep my hand in the game and your complaint distinct from eight others I may be juggling at any time. Second, our department is somewhat long in the tooth (although we are moving into our new department tomorrow) and was built for a time when hospitals weren’t nearly as busy and only legitimate Emergencies came through the doors, not the constant barrage of barely urgent complaints that we see today. It is crowded and there is no place for me to work without being in full sight of all of the hall patients. I suppose my patient saw me drinking my Cherry Diet Coke too and what she thought about that I can only imagine.

But seriously lady, if you had brought a list of your medications as well as a reasonable knowledge of all of your many medical conditions I wouldn’t have had to spend fifteen minutes surfing three different computer systems for which I have three different user names and passwords to try to glean something about your history. If there is one thing on which I would like to educate the public it would be the importance of knowing your medical history and medications when you come to the Emergency Department non-emergently. That and the importance to us of having an accurate history and medication list. There is unfortunately no omniscient computer in our hospital on which is stored easy to access information about you and, if you don’t know or can’t be bothered to remember your medical history, it’s going to take me some time fucking around on the computer to piece it together.

The casualness with which many patients easily dismiss inquiries about their health, referring us to “The Computer” or worse yet, their primary care doctor who may not be answering the phone at 2AM, displays a touching but entirely misguided faith in our ability to coordinate information. If you can’t be bothered to write a list at least ask your doctor for a copy of your latest complete history and physical, discharge summary, or medication list.

Oh, and “The Pharmacy Knows” is not a good answer either. I’m sure they do but how about those mail-order drugs that the three pharmacies in town where you fill prescription don’t know about? We’re up against the clock, Ma’am. Help us help you by making our job easier.

Man Up

I’ll go ahead and say it: Glenn Beck is a wuss.

No doubt some of you have been following the story of CNN talk-show host Glenn Beck and his recent experiences as a surgical patient. Billed as an indictment of the health care system, his somber teaser on Youtube describing the horrors he experienced piqued my interest and I’ll admit I followed the story closely to see if he had anything legitimate to say.  The way he described it I got the idea that he had undergone major surgery, woke up on the table, and was in incredible pain the whole time, even on presenting later to the Emergency Department with post-operative complications. As dribs and drabs of the story came out, we learned that nobody in the Emergency Department cared and despite being in excruciating pain he was ignored for an hour while the callous triage nurses chatted with each other.

As it turns out, he had a relatively minor outpatient procedure, a hemorrhoidectomy, under nothing more than procedural sedation and had post-procedural pain. I am not one to scoff at pain, rectal or otherwise, and one of the first things I try to do with my patients is control both their pain and anxiety. But apparently Mr. Beck’s pain wasn’t touched by large amounts of narcotics in quantities that would sedate an entire Cuban village. He was sent home on terminal cancer-sized doses of pain meds and returned several hours later with urinary retention and worse pain which again required horse-killing doses of narcotics. I don’t know how long he really waited in triage, we have only his word and pain makes the clock slow down considerably but he sounded like an extremely difficult patient, a guy who required so much narcotic analgesia that you start to wonder if he’s going to stop breathing.

Now, here is a rare caveat for me: I don’t know the real story and, since the Emergency Department can’t comment due to privacy concerns, we will never know. I also will again state that my first goal after airway, breathing, and circulation is to control pain. But Emergency Departments are busy places which is not, in of itself, an indictment of the health care system. People need to be seen and we see them.  We triage them according to the severity of the complaint. Pain and urinary retention might be triaged lower than chest pain or possible stroke and you may have to wait a few minutes or ten or thirty. Without meaning to sound callous, we get patients all the time who complain of excruciating pain of several hours or several days duration. Some are seeking drugs and some are on the level but the extra half-hour wait is often unavoidable. Nurses can’t give narcotics without an order and the doctors are often busy. Maybe the patients who are occupying the doctor’s time are minor complaints but, except for life and death emergencies, it is not always obvious to the doctor who needs to be seen next. Even if it were, it wouldn’t be efficient for him to be so fluid in his response to triage that he is continuously breaking away from less acute patients to deal with the more acute.

Mr. Beck needs to man up and stop whining. I’m sorry he had a bad experience but we’re doing the best that we can.