Oct
12
State of Fear
October 12, 2009 | 15 Comments
“This patient,” I said to myself, “is going home.”
I know. She’s 85 with the dreaded complaint of “Altered Mental Status” described by the family as a brief period of “staring.” No generalized seizure activity, you understand, and no syncope (fainting), slurring of speech, facial droop, drooling, weakness, confusion, sweating, fever, nausea, vomiting, or any of the other symptoms or combination of symptoms upon whose fulcrum are levered mighty weights of flesh into the processing mill that is your local hospital. In fact, this very pleasant lady felt fine and even the family admitted that she looked normal.
“And I’m not going to spend $20,000 proving she’s fine either,” I continued to myself as I screwed up the courage to throw out the rule book and guide my clinical judgement by history and physical exam. After four years of medical school and four years of residency training I can do that can’t I? Isn’t that what my professors, comfortably barricaded behind the litigation-proof walls of the State Charity Hospital told me I should be doing…especially as my history and physical exam confirmed the diagnosis that seemed obvious from reading the triage note and talking to the the paramedics on their way in?
But then the fear gripped me. That smouldering dull fire in the gut that can only be quenched by a deluge of unnecessary lab tests and studies.
And I paused.
My computer glowed seductively. It would have been easy to click here, click there, and then call the tired hospitalist to admit the patient. We admit for this kind of thing all the time, slipping the patient in behind a smokescreen of irrelevant data; leveraging confusion, convenience, and sloppy medicine into countless unproductive admissions that discover nothing we didn’t already know, treat nothing that we weren’t already treating and, if we are lucky (because the hospital is a cess-pit of infection and risk) leave our most excellent and trusting patients no worse for the ordeal except for some familial inconvenience.
Reaching deep for my last reserves of courage my hand bypassed the keyboard going to the phone instead to discuss this very gracious and patient lady being treated for Parkinson’s disease with her neurologist and to arrange outpatient follow-up for the next day.
Maybe one day I’ll tell you about the Bell’s palsy patient I sent home with no lab work or imaging of any kind.
I am a thrill-seeker. Too bad I’m going to get sued one day and decide that my financial well-being is more important than being a good and faithful steward of your treasure.
America
This country has changed, even in my lifetime. It used to be a place where people worked and were proud of it as we were proud of out heritage as a pioneer nation, a place were prospectors, inventors, roustabouts, gamblers, swindlers, preachers, cowboys, investors, soldiers, pioneers, farmers, and every variety of people striving for their livlihoods could succeed or fail by their own skills and on their own merits, allowing always for the confounding hand of fortune that sends the river to wash away even the best-tended plantation. It was a country to which my father came with nothing, expecting nothing except opportunity, and for which he had a great love that he instilled in me.
And now we are to be nothing but Belgium. A lot bigger but Belgium just the same. Nothing but another decrepit European social welfare nursing home whose sole pre-occupation is now to become the incessant struggle for money to support a growing class of people who have been seduced by the Obamatariat into giving up uncomfortable and often treacherous liberty for the long, government-cheese induced nap of the nanny state.
It should bother you.
My New Ride
As some of you know, I am a mountain-biker and I just thought I’d share a picture of my new ride. It is a Specialized FSR XC Expert. My first mountain bike was a 1992 Bridgestone MB-4 and while I recall it was a really nice bike, this one has front and rear suspension, hydraulic disc brakes, and weighs less than many top-of-the-line road bikes did back then. There are no mountains in my state. Nevertheless we have plenty of trails, ranging from smooth beginner level to heart-in-the-mouth-take-your-eyes-off-the-trail-and-you-die technical stuff. I tend to ride a combination of paved roads, dirt roads, and the occasional rough terrain and since I can lock out the suspension for hills and really smooth roads this bike suits me well. Yeah, the guys in spandex pass me all the time but they can’t really go off the road much so I don’t mind.
I used to run but got tired of it. Twenty miles on bike is more fun than five miles on foot.
Sep
5
Yer’ Stinking Tax Dollars at Work
September 5, 2009 | 17 Comments
(More questions from real readers. -PB)
What’s the Emergency Department Really Like?
The American College of Emergency Physicians and their bogus statistics notwithstanding, the majority of cases we see are not emergencies. As I have mentioned before, most of the cases we see probably don’t need to be seen at all by anybody in the medical profession in any capacity. I saw 34 patients last night and half of them were for nothing more than cold symptoms, symptoms that at one time in our nation’s history rational people just accepted without feeling the need to seek medical attention. Today of course where everything is a friggin’ Emergency and medical care is absolutely free for the asking I walk into many patient’s rooms to find a tattooed, well-looking white chick and her less-tattooed mother waiting angrily to be seen by The Fucking Doctor Who Was Just Standing Around Typing On His Computer While They Waited Three Hours who then breathlessly spin a dire tale of a little bit of a sore throat and a little bit of a cough that is really interfering with the daughter’s two-pack-per day habit or whatever it is she does to lead a fulfilling life. Either that or it’s a little bit of gas pain or some faint twinge or spasm in the back that has caused a slight discomfort that must be addressed immediately.
That’s a particular species of patient that knows no geographic boundaries, by the way. Even here in the South where people are an order of magnitude more polite and well-behaved than in Yankeeland we still have the ubiquitous fire-plug of a mother escorting her wan daughter, both of them at various corpulent stages on the road to morbid obesity, who insists that not only is something wrong with the daughter but that every single test and study known to medicine must be ordered to ferret out the problem. After taking a history, doing an appropriate exam, and telling the mother that her daughter has a chest cold and is going to do just fine, like clockwork comes that cold-as-fish look of disgust and the inevitable, “We want to see another doctor.”
Either that or, “My sister had the same thing and the doctor over at the Quickie Clinic gave her a shot.”
“Madame, the doctor at the Quickie Clinic works at the Quickie Clinic because he’s an idiot. You’re in the big leagues here and I don’t just give shots.”
Of course I don’t say that.
One patient opined that he could get served at MacDonald’s in five minutes so he didn’t understand why it took four hours to be seen, evaluated, and discharged. He was an otherwise reasonable guy and really very pleasant but that sort of highlights the problem with Emergency Medicine and most Emergency Departments, namely that they are largely highly expensive, completely understaffed Quickie Clinics in which some real medicine is practiced from time to time; the twenty percent or so of patients who have real emergencies or legitimate complaints and are part of our core function in the community ironically causing so many delays for the other eighty percent who should have stayed home that, in our insane and upside down world, the various quality “metrics” used to rate how good a job we’re doing are entirely dependent on the satisfaction of irate people who didn’t need to be seen and did nothing but waste either their own money or the taxpayer’s.
There is, as you guessed, tremendous bureaucratic pressure to decrease waiting times and subsequently to increase patient satisfaction which is one of the most important contributing factors to the so-called crisis in Emergency Medicine, a crisis which wouldn’t exist except that there is money to be made in the high volume business of trafficking in minor complaints and very little incentive not to. Most of our patients, after all, have some kind of insurance and taking money from the government to do what is essentially a well-child exam on a slightly febrile but otherwise healthy-looking toddler is like stealing candy from a baby which is sort of what we are doing (and why the Children’s Health Insurance Program is such a colossal waste of money and a harbinger of what is yet to come when the Sun-King, Ra-Obama, by one gesture of His Mighty Legislative Hand, turns us all into Medicaideurs).
So you can hardly blame the patients. They come because they are encouraged to come-witness one billboard in town showing a comfortably sleeping baby proudly proclaiming that they are a “Pediatric All-NightER” never mind that it verges on child abuse to drag your healthy looking baby into the Emergency Department at two in the morning to share Cheetos with the crack whores-and they come because there is nothing to discourage them; no obstacle except a little bit of waiting and we have never chased anybody away who had a minor complaint for any reason so mundane as an unwillingness to budget some cigarette money for medical care.
Why is it, by the way, that while I have had many people complain of being unable to afford low-cost antibiotics, inhalers, and blood pressure medications I have never, and I mean never, had anybody cry poverty when presented with a prescription for pain medication? I could write a wino living under a bridge for three months worth of Lortabs and he’d accept the prescription without demur. A prescription for Penicillin for his dental abscess?
“Come on, Doc, I ain’t got the money for that.”
So what’s an Emergency Department like? In reality it’s a little like a miniature hospital onto which has been grafted an STD clinic, an Urgent Care, a psychiatric ward, and a small intensive care unit. At any time and within ten feet of each other you can have a critically ill dialysis patient being kept alive by pumps and ventilators, a genteel dowager having The Big One, a teenage girl with some vague menstrual cramps, a smattering of varying kinds and degrees of abdominal pain, several people in “Just To Get Checked Out,” and lots of kids and adults with nothing, apparently just in for the novelty of watching a different television and having a nurse at their command. The only thing we don’t have is an operating room but can the time be too far off when irate patients will opine, angrily, that it’s been three hours and they still haven’t got their appendectomy?
Aug
30
Life or Something Sorta’ Like It
August 30, 2009 | 13 Comments
(Just a few random questions from real readers-PB)
What is your job really like?
As you know, I am an Emergency Physician working in a medium-sized community Emergency Department in a medium-sized hospital in a medium-sized city in a medium-sized state. A “community” Emergency Department is not a major trauma center and generally sees mostly medical complaints as opposed to the big urban Emergency Departments that see mostly medical complaints with a varying amount of stabbings, shootings, and other acute medical problems that are the inevitable sequelae of Standing On the Corner Minding Your Own Business.
My hospital was purpose-built a few years ago to sit astride the major nursing home trade routes and commands this commerce for many miles around. There are twenty or thirty nursing homes of varying quality within a quick ambulance ride of the place and, as you can imagine, a large percentage of our patients are the warehoused elderly who present with a varying quality of complaints ranging from the sublimely ridiculous (Altered Mental Status in a demented, contracted 92-year-old who hasn’t moved in two years except when indifferently rolled and slopped by the surly hired hands) to the legitimately dire (septic shock in an otherwise healthy elderly lady).
We also get the usual general medical complaints, most of them incredibly minor, most of which barely rise to the threshold of needing medical care at all much less both barrels of the Medical Safety Net. We address ‘em all however although in my role of community educator I do counsel people on the appropriate and inappropriate use of Emergency Medical Services. I understand that some patients don’t have doctors but a rather large percentage of my patients have doctors and either didn’t want to wait for an appointment or were too lazy and irresponsible, despite having insurance, to inconvenience themselves in the slightest to schedule one.
Eczema, for example, no matter how itchy, is never a medical emergency and don’t expect me to apologize for making you wait five hours to be seen. And standing at the door to your room glaring at me while I work on your fellow citizens who are actually sicker than you won’t make me see you any quicker although I admire both your stamina and your absolute commitment to not walking across the street and getting some skin lotion from Wal Mart, an enterprise that would have taken you ten minutes and was helpfully suggested by the triage nurse.
And for the one thousandth time, fever in an otherwise healthy toddler is not an Emergency either. It’s 3 AM, for Christ’s sake, and you will pardon my incredulity as I look at your playful, active, rambunctious child stuffing Cheetos in his mouth. Oh, and just because we didn’t order any lab work or imaging doesn’t mean we “didn’t do anything.” From start to finish you had some high-powered talent working on you. Your nurse has a college degree and years of experience and assesed you child perfectly in triage. I have a ridicuous amount of training and education and if between your nurse and me we decide that your kid ain’t that sick he probably ain’t that sick. Did you notice the thoroughness of my physical exam? I’m not just pretending to look in his ears, you know. Surely the history and the exam are “something.”
The major difference between this job and many other typical jobs is the pace. I saw 42 patients in twelve hours last night and never stopped working for the whole time. Emergency Physicians don’t get breaks per se. We are usually scrambling to keep things moving and when things get a little slow we try to catch up on our charting, a task made extremely difficult in my particular hospital by The Worst Emergency Medical Record System In The Entire Universe, a little nightmare called Medhost that apparently got its start as a restaurant order and billing system and has not progressed much from there.
But I digress.
We try to keep people moving in and out, either admitted or discharged, but inevitably something comes up and people start waiting for disposition. Part of this is my fault as I am still learning how things work in a real Emergency Department where the process of evaluating, treating, and dispositioning is substantially different than it is in the academic world. On the other hand a couple of critically ill patients or an inexplicable run of ambulances can back up the department for hours, distracting us from our true mission of treating your child’s ear infection at 2AM because your appointment with his pediatrician in ten hours was just not soon enough.
I enjoy my job even if I am glad to leave when my shift is over. It’s not really too stressful. The most aggravating thing about it are the long stretches where every patient seems to be “Otherwise well child, active, playful, with a low-grade fever.” The critical and otherwise actually sick patients are a relief.
What do You Think About Ted Kennedy?
Don’t get me started. First of all, I will never understand the fawning adulation lavished on our corrupt hereditary ruling class by the press. Mr. Kennedy was a voracious parasite on the nation whose appetite for power was only checked by his inability to keep his head in a crisis and his utter unwillingness to dive into the cold waters of Chappaquiddick to even attempt a rescue one of The Little People, a throwaway citizen who was just a hired mourner in the long dirge of the Kennedy odyssey. Mr. Kennedy never held a real job as far as I can tell, never produced any useful good or service, and lead an entirely privileged life out of which he felt comfortable pontificating to the rest of us about Good Citizenship, Duty, Honor, and what constitutes a good life in our now completely insane nation. He was a senator for as long as I have been alive and the web of corruption and influence peddling he spun is the best argument I can think of for term limits.
But isn’t that the problem with American politics; that it is full of people who have done nothing and know nothing about anything but politics and yet feel confident and, what’s worse, divinely entitled to solve complicated problems that are well out of their scope of experience? That’s why President Obama is such a failure and going down like your prom date: Having been sheltered in academia and government for his entire adult life, he doesn’t know anything about the real world, not even enough to know what he doesn’t know.
So sing your paeans and bow your heads. Wax sanctimonious about the passing of your paper mache great men. I don’t mourn the passing of tyrants.
Aug
15
Pandamorama
August 15, 2009 | 27 Comments
Quick Learner
So I had a drug seeker come in the other day with her usual back pain. Lately I have been very stingy with narcotics and after refusing to give her a shot of anything stronger than Toradol I explained that I only give narcotics for patients with fractures or obvious acute injuries and never to patients with chronic pain (which is not strictly true but I thought it would be impolite to point out in front of her family that my records showed six visits in the last two weeks to our other Emergency Departments around town).
In my discharge instructions I cautioned her to return for numbness, weakness, urinary retention, or urinary incontinence (all things that can be caused by spinal cord injury) and wouldn’t you know the next day she showed up with a normal gait, normal neurological exam, normal deep tendon reflexes but having ostentatiously wet herself, something she mentioned to me as she stumped past on the way to her room.
Nice try.
Apparently the internet is loaded with sites where drug-seekers can learn what to say and how to present themselves to Emergency Physicians to get drugs. I’m less than impressed by a patient who endorses twenty-out-of-ten pain in the right upper quadrant brought about by eating fatty foods who I have to shake vigorously to awaken but some of them are quite good. I’ve been burned a few times, suckered into giving Dilaudid to patients who I later discovered to be frequent fliers. The first warning sign is usually the inability of a normal dose of Dilaudid…essentially legal, high-grade heroin…to “touch the pain.”
The Holy Grail for the seeker is, of course, being admitted for intractable pain and being put on a “pump,” or Patient Controlled Analgesia (PCA) which is like having your narcotics on tap. Still, suckering the doctor into giving you a few hits of Dilaudid before the unamused charge nurse hands him a stack of papers detailing your last twenty visits is a major victory as is scoring a ’scrip for Lortab.
Oh, and just a tip: If you are young, otherwise healthy, and look stoned (because you are stoned) I’m not going to give you anything but some life advice so don’t bother coming in. Your back may or may not hurt but many people older than you with real skin in the game have survived back pain with nothing more than Motrin.
Just an aside, I write prescriptions for Motrin because it only takes one mouse click on our Electronic Medical Record system but I always hand-write on the printed prescription, “Over the Counter, Not for Prescription.” I’m really busy so a minute saved here and there can add up to real time over the length of a shift. I don’t care if you have Medicaid and they will pay for it. It’s not asking a lot for you to throw down a couple of bucks for your own medical care.
I still get frantic calls from patients saying that my prescription says “600 mg” of Motrin and all they sell are 200 mg tablets. I weep for this generation. Have Americans always been this stupid or is this something recent? It’s probably a recent thing. My older patients may or may not have a college education or advanced degrees but most of them seem to have some basic common sense.
We are definitely getting less intelligent. Apparently being a moron is not only an accepted lifestyle choice but, given the growing allure of the welfare state, it is now also a desirable survival characteristic and one that is being aggressively selected for.
Patient of the Week
“My Doctor told me to come in to be admitted for back pain.”
“I have no doubt your back hurts but as you are clearly without neurological deficits, appear comfortable, have no fever, and a negative urinalysis there is no indication to admit. What kind of doctor is he?
“A chiropractor.”
“We have an automatic door in the department so it you move quickly it won’t hit you on the ass on your way out.”
The Crying Game
Remember that movie where, after a couple of hours it is finally revealed that the chick is a dude? That’s kind of like President Obama. All of his breathless supporters thought he was a beautiful, sensitive, caring girl but now 200 days into his presidency he has shown everybody his penis and, although they still want to like him, it’s hard now because the chick’s a dude, man. Sort of changes everything. I mean, she still sounds the same, looks the same, is wearing the same clothes but she’s a guy…and all but his most ardent followers must be squirming in their seats to think they were ever attracted.
Sure, the die-hard zealots, those who have in the dead of night surreptitiously scraped off their ”Dissent is the Highest Form of Patriotism” bumper stickers still think he’s good-looking even if he has a twig and berries but the majority of Americans, those who care I mean, are catching on that the Sun God, Ra-Obama, is something of a petty dictator along the lines of Mussolini. That and he is completely out of his element, not very smart, and well along in completely screwing up the one thing he was mistakenly elected to fix. A silver tongue/teleprompter and charm are not a substitute for basic intelligence and some friggin’ common sense, even in the insanity that passes for American political culture.
I’m Back
As many of you know I recently finished my residency training and am now working as a real live Emergency Medicine Attending Physician, completely autonomous and completely responsible for every decision I make. It has been an easy transition so far because, and you may read this as a defense of the need for residency training, my program trained me well to handle the full range of medical emergencies that we commonly (and uncommonly) encounter. More importantly however, my program trained me to be comfortable with the not-so-emergent patients; the ones with a blurry constellation of mild complaints and extremely vague exam findings. The truth is that there is a lot of general medicine in Emergency Medicine and as one of the most common presenting complaint appears to be, “I couldn’t get a quick appointment with my own doctor so I decided to come here,” I am beginning to understand that my job is not to work up everybody all the time for everything. While I still reflexively admit the usual patients (chest pain, elderly with unexplainable pain) I’m sending a lot of people home with instructions to follow up with their own doctor…even going so far as to call the doctor in question for patients I think are unreliable.
I mention this because I sent a patient home with vague abdominal pain who came back the next day and was diagnosed with appendicitis by one of my colleagues. You might say I missed the diagnosis but I respectfully submit that, as the patient was given clear discharge instructions to return if not better (which he did) we can put that one in the win column. It’s either that or we CT scan every patient with no fever, a normal white count, a benign abdominal exam and absolutely none of the classic findings for appendicitis except a very mild, intermittent pain in the lower abdomen that didn’t even localize to the right lower quadrant.
I’m also beginning to appreciate the utility of the “Likelihood Ratio” and how it applies to Emergency Medicine. Our most excellent Program Director drummed statistics into us and we naturally resisted manfully but it is good to now have some theoretical basis upon which to justify not ordering labs or studies that will not effect treatment or disposition decisions. I still reflexively order Basic Chemistry Panels and Complete Blood Counts but one day I’m going to get the nerve not to do it. I wonder how much money we waste checking these things on people who look healthy?
Just file it under not wanting to know everything about every patient when usually it is enough to address the chief complaint and be done with it. Which brings me to one of my biggest pet peeves, that is, the ordering of imaging studies and lab work in triage. Sure, sometimes this practice speeds up disposition but not every patient, for example, with abdominal pain needs an Acute Abdominal Series; a set of four xrays at my hospital. With a few exceptions, the Acute Abdominal Series should be reserved for, well, patients with an Acute or “Surgical” abdomen which I assure you most of my patients do not have. Vague abdominal pain certainly does not qualify and the Acute Abdominal Series is completely useless in either ruling in or ruling out anything useful in the majority of patients for which it is automatically ordered.
If I suspect something is going on I’ll get a CT scan.
Not only is the routine ordering of unnecessary imaging wasteful but once we get the study we are now on the hook for every finding on it, even those that are incidental. If I miss a small pulmonary nodule on an unnecessary chest film that later turns out to have been lung cancer I own it and the ensuing lawsuit. Better not to know…especially if the guy came in for a sore throat and no other respiratory complaints and with a completely normal lung exam.
The triage clerk is killing me.
Jul
13
Poker and Other Things
July 13, 2009 | 16 Comments
Michael Jackson is Dead and I Don’t Care
Michael Jackson is dead and, God forgive me, I don’t care. I wasn’t a fan and I didn’t like his music. Sure, I listened to it; it would have been impossible not to but I never bought an album, stopped turning the dial at the sound of his falsetto voice, or really followed his career except that it was part of the cultural noise of our age. I don’t worship celebrities and entertainers either and am completely indifferent to their lives. Oblivious, actually. I’ve been listening to Pink Floyd for thirty years and I can’t name any band member, differentiate who among them is living or dead, or tell you anything about any of them. Don’t know, Don’t care. It’s not important.
Of course I watched Michael Jackson’s opulent funereal. How could I not? I couldn’t tear myself away from this sad commentary on our silly and insipid age where a mincing creep, a pedophile, and a middle-aged man who spent the treasure of a small nation to satisfy his bizarre urges is buried like a pharaoh while better and braver men who sweat and bleed every day are rewarded with nothing more than a flag-draped coffin and the barely concealed derision of the perpetually chattering classes.
What a freak show it was. A parade of Jacksons you never heard of and flocks of B-list celebrities come to preen and feed on entertainment carrion under a grisly sun. I think it’s weird and freakish how the black community has embraced embarrassments like Al Sharpton who delivered the most embarrassing eulogy of the day. What a low-life, likewise flapped in from lonely media desolation to feast on the dead body that seemed hardly enough to feed a couple of washed up singers let alone the small country’s worth of celebrants descended on Los Angeles. Was it some miracle, feeding the multitudes I mean?
The ongoing news coverage was disgusting. North Korea will be lobbing nukes at us pretty soon, the economy is still in free-fall, and everywhere rough beasts, their hour come, slouch towards Bethlehem so you’d think there would be a lot to discuss on serious news outlets but based on four or five obvious facts that were a revelation to no one and only surprising to those who have been living in caves for the last twenty years we were treated to solid, 24-hour coverage of nothing and less than nothing about a guy whose life was really not that complicated and whose death was mundane by celebrity standards…save for the revelation that Diprovan, an induction agent for anesthesia and medical paralysis, is now a recreational drug.
About the only real interest I have in the whole affair is whether and when Michael Jackson’s doctors are going to jail.
You’ve Got to Know When to Hold ‘em
As many of you know I am done with residency and am back in Louisiana working as an Attending Physician in a small but very busy Emergency Department. We have a lot of casinos in our fair city which got me thinking that Emergency Medicine is a lot like high stakes gambling. We are dealt a hand with every patient and after glancing at it, must figure out what kind of cards the patient is holding; whether the guy with chronic back pain really has an epidural abscess or whether he is bluffing, and make our workup and disposition judgments accordingly. We can’t admit everybody, we can’t run every test on everybody all the time, and as this is still a rational world (but getting more insane every day) eventually the majority of patients will be sent home where a certain percentage of them will have a bad outcome from something that we missed because it never occurred to us or from something that we anticipated as a possibility but about which the patient decided to eschew follow up as directed.
I mention this because I actually send people home with no lab work or imaging studies whatsoever which is something I probably only did a handful of times as a resident. I had, for example, a young boy brought in by his father for intermittent abdominal pain for the previous two days, particularly while playing sports, but who presented with no complaints whatsoever and a normal physical exam complete with a benign abdomen, normal testicular exam, normal digital rectal exam negative for occult blood, normal vitals, normal, normal, nothing, nada, zilch.
Could he have had something? Functional abdominal pain? Gastritis? Intermittant testicular torsion? Sure. But he had excellent follow up, reliable parents, and no complaints whatsoever brought in mostly for parental concern and because it was a Saturday and their pediatrician wouldn’t see them until Monday. I felt it was safe to send the kid home because, and maybe I’m wrong here and I will be bombarded by dire warnings from my colleagues to the effect that I am playing with fire or I will change my practice habits the first time I am sued (but did I mention the kid had no complaints and a stone-cold normal and extremely comprehensive physical exam?), on some level our job has got to involve using a little common sense. In this case understanding that the kid was not sick, was in no danger of dying, had vigilant parents who lived only a mile from our hospital with access to a phone, and really had no business being seen in the Emergency Department except that most Emergency Departments are now mostly after-hours clinics with some really sick patients thrown in three or for times a shift to slow things down and keep the waiting room backed-up.
With that being said, I still admit the usual patients with vague complaints who meet certain criteria for age, comorbidity, or reliability. I’m not stupid. But I’m trying, like I said, to use a little common sense.
We have the usual variety of patients but, while we have much less trauma than at my residency program, many of our patients are actually quite sick. I have run quite few codes, intubated often, and have done a lot more procedures on a daily basis than I did as a resident for the same number of patients. I’ve had, for example, quite a run of febrile infants with Fever of Unknown Origin requiring lumbar punctures and several of them panned out as meningitis.
Procedures are a lot easier as an attending in a non-residency hospital. I tell our most excellent nurses what I am going to do, they get all of the stuff ready (the most time-consuming part of most procedures), and they don’t even let me dispose of my own sharps after I am done because, as the charge nurse told me, “Don’t you have some patients you could be seeing?”
A resident’s time is not worth much, in other words, but they aren’t paying me now to hunt up gloves and syringes. We are incredibly busy most of the time and like residency I work non-stop for my entire shift.
My first patient was a woman with vague abdominal pain and an elevated white count who I did actually send for a CT scan (normal of course) but eventually sent home with instructions to return in twelve hours if not significantly better. My second patient was a young lady on oral contraceptives and a smoker with a month of worsening breathing difficulty, chest pain, and “cellulitis” of her calf a month before. Wouldn’t you know that her EKG showed the classic strain pattern (”S1Q3T3″) that you never are actually supposed to see and I naturally started her on Heparin (an anticoagulant) almost as soon as I got her history, being rewarded shortly with an angiogram that showed exactly what I thought it would: big pulmonary emboli (clots) in the arteries of her lungs.
The family thought I was a genius but this one was obvious, an incredibly easy (but very satisfying) diagnosis that in our age of vague complaints presenting far in advance of any classical signs and symptoms is something of a rarity. It’s the minor complaints that really give me fits.
Jun
14
Bread and Circuses, Water and Sewage
June 14, 2009 | 22 Comments
Customer Disservice
There are days when I explain to the family of a 98-year-old customer, in terror of the the inevitable end, that today is not that day and while the odds of their mother living another month are close to zero, she’s alert, reasonably comfortable, and they have some time to say what they want to say and do what they want to do. There are also days when I must gently insist to a family that despite what they have heard about the mighty apparatus of American Medicine, it will be as ineffectual as casual prayers and there is only time now to steel their hearts and accept the inevitable end.
And then there are days when a simple customer, sorted in triage as a minor complaint, slowly evolves into a horrifically complicated ICU admission whose fragile life depends on the skill and vigilance of the entire Emergency Department staff…and even then the odds are not good. That one will keep me in the Department long after the end of my shift, the extra hours of which gain me nothing materially.
On every day we risk our health in this dangerous profession where we are exposed to the concentrated sickness of the entire city. We risk our careers, too, and our economic viability making thousands of decisions about customers with more medical problems and more medications than I once believed could burden one human being while held to a standard of care that tolerates no mistakes; the slightest of which (something as simple as not giving an aspirin) not only has the potential for disaster but can start the long, expensive slog through the court system where every victory is Phyrric and defeat, the out-of-court settlement, is always the preferred outcome.
And then nobody really pays us for our work although the usual drunks and serial abusers of Emergency Services, customers all, loudly proclaim at the slightest affront to their august dignity that they are “paying our fucking salary.” There are co-pays for some and none for others and some boldly steal medical care, the thought of paying one thin dime for the services of at least the highly-trained nurse who they regard as their personal servant having never entered into their head; medical care being, after all, just another public utility like water and sewage and nobody pays for those things.
The bureaucrats at my hospital have just gone through their annual mission statement contortion and have, on schedule, given birth to the usual smarmy slogan which is going to change the direction of the hospital and solve every one of its problems by focusing on the customer…putting the customer first…taking the customer seriously…making the customer the center of our efforts…making customer service a priority…ostensibly to increase customer satisfaction but more realistically because it is cheaper than hiring nurses to take care of the customers we’ve already got.
But this isn’t Wal Mart and the patients are not customers. Pretending they are degrades the patients and dehumanizes the practice of medicine by substituting clinical judgment and perception with the polite fiction that we are engaged in nothing more than a business transaction, one in which the customer is always right and which is now to be ruled by Press Ganey and Mammon, the Two-Faced God-Incarnate of the bureaucrat.
Come On Now…
92-year-old patient. Demented. The usual medical problems teased out of the the nursing home medication list and the family who insisted he was healthy except for the pacemaker, the feeding tube in the belly, the coumadin for a “heart problem,” the three strokes, the diabetes, and the emphysema (but he’s 92 so he must be doing well). History of benign polyps in his colon. Presented for abdominal pain after a colonoscopy earlier that day.
Why does a 92-year-old man with less than a fifty-fifty chance of living another year get an expensive colonoscopy? I mean, it had better be a good reason. Rectal bleeding. Something like that.
“It was a screening colonoscopy,” said the consultant, “We removed a polyp.”
You have got to be kidding. Remind me never to send you another patient. Would it have killed you to have politely deferred the colonoscopy for another year just to see how things would shake out?
Of course, I was no better because I ordered the deluxe work-up with all the usual laboratory tests and the premium CT scan although his abdomen was benign and he was too demented to really get a handle on his exact symptoms. In my defense and contrary to popular belief, please note that I don’t get extra money for ordering a lot of tests. But I still squandered your children’s money, money which really belongs to our Chinese and Arab creditors and future masters, at a blistering pace.
My job is mostly ridiculous, on some levels anyway. At least we sent the gentleman home instead of admitting him like the family wanted, “just to be safe.”
“Just to be safe.”
The four most expensive words in all of American Goat Rodeodery.
We Just Get Headaches
I had a pleasant conversation with a recent immigrant from Cuba whose wife came to the Emergency Department with a severe headache that she volunteered was the worst of her life and had started abruptly. Naturally with this kind of history and some reasonably high blood pressure we brought the Great Ship of American Medicine about and raked her hull with a full broadside of medical ordinance. We were looking for a ruptured cerebral aneurysm and it took a CT scan of the brain (negative), a lumbar puncture (a “spinal tap”) which was equivocal, and finally a Magnetic Resonance Angiogram (MRA) of her cerebral vasculature to definitively prove that there was nothing really serious going on and she just had a bad headache.
The cost (to your children) was immense and on the way out the husband, who was extremely gracious and not a little impressed at the our thoroughness, shook his head in amazement and said, “You know, in Cuba we just get headaches.”
“We used to just get them here too,” I replied.
Something About the Culture of Medical Training
One of our junior residents did a particularly fine job of intubating a patient who had, to put it mildly, an extremely difficult airway. You know, 600 pounds, no neck, a beard, and instant hypoxia when laid flat.
“Nice job,” I said after we got everything secured and the the patient moving towards the ICU.
The nurses looked at me in horror. “Good Lord,” they seemed to say with their eyes, “Don’t praise the residents, they might get big-headed. Don’t you know you’re supposed to beat them down at every opportunity?”
Just thought I’d share.
Jun
2
Anabasis
June 2, 2009 | 18 Comments
Marching Up Country
(With Apologies to Xenophon)
The campaign draws to a close and will end like many such expeditions do; in a victory of sorts for I have certainly marched into and through the Empire of Medicine with my fellow mercenaries, outwitting the enemy on many occasions, laying waste to his crops and orchards when necessary, and always keeping one step ahead of his mighty armies that sought to harass and encircle me. And yet the cost has been immense and I arrive at the end of this journey with treasure sorely depleted, footsore, battered, and weary with miles to go until I am truly home. Still, having survived this far seems a monumental achievement although at the time it was just a slow slog through inhospitable lands, a wretched journey punctuated by moments of excitement and terror.
Now crest the last hill and view, stretching to the horizon, the glittering waters of the Black Sea beckoning to us like a welcome friend and a reminding us that that we have now come through the worst part of it although many adventure still lie ahead.
The sea! The Sea!
What I Now Know
Most of the job of any doctor is ridiculous. So ridiculous in fact that to get through the the day it is necessary to engage in a little doublethink as you pleasantly churn your way through the reams of useless paperwork, the incredibly asinine patients who you treat just for placebo’s sake, the waste, the inefficiency, the bureaucracy, and every manner of obstacle between you and what you must occasionally convince yourself is a meaningful job. I know this very well.
Occasionally I give narcotics to an obvious drug-seeker or start an enormous work-up on a patient who is surely a malingerer and the nurses give me that sarcastic, rolling-their-eyes kind of look to imply that I am too trusting of the patients and if they were in my position they’d throw the bum out with a couple of Tylenols and big glass of water. Fair enough. Cynical they may be but they are usually spot-on in their assessment of who is really sick and who is missing some essential gonadal chromosome. Although frequent fliers and malingerers occasionally present with hidden but extremely severe acute medical problems, for the most part they and the constant procession of patients with minor complaints need no more of a workup but a good history, a focused exam, and an admonition to return without fail if their symptoms don’t improve. I suppose that most of them don’t need to be seen at all and surely not in an Emergency Department.
In other words I know full well that most of the money with which we hose down the patients is poorly spent and completely ineffectual. I understand this. I get it. Thanks for ripping off the scab and rubbing salt in the wound. You do whatever it takes to get through your day but for my part, it is often necessary to suspend my disbelief and pretend, for sanity’s sake, that every abdominal pain, vague back pain, nebulous headache, and strange constellation of non-specific symptoms is going to pan out; is going to reveal itself to be that one in twenty cases that justifies all of this education, all of the hours, all of the money dumped into my training, and the devastation of my personal life.
Even the Bumper Stickers Suck
Used to be that the most durable object on the planet was a bumper sticker. So durable that they often outlasted the car. In fact, you can still see the occasional Clinton-Gore offering, slightly faded but robust, grimly adherent to a lovingly maintained Nissan Sentra. I mention this because I still see the occasional Obama bumper sticker proudly displayed by the vestiges of those still in abject thrall of the Serpent King Ra-Obama and although it has been less than a year, the stickers are faded, peeling, and look like something printed hastily in some North Korean re-education camp before the entire shift was taken out and shot.
Which is sort of a metaphor for Obamerica, a country that is rapidly turning into a crappy third-rate nursing home where nothing is made, nobody does anything of value, and the only growth industry besides government are breathless special interest groups working hard at the kind of socially conscious jobs beloved of neighborhood organizers, vying for and spending money we borrowed from the Arabs and Chinese to mold another generation of Americans into beggers, whiners, and shrieking social parasites. The country is kind of peeling at the edges and fading, so to speak. Even the Russians are laughing at us, completely baffled at our headlong rush into Marxism, statism, socialism, and all of the other -isms that once, long ago when we were men, we defeated handily.
And the Sun-God hasn’t a clue.
Like I said, even the bumper stickers suck.
May
22
Edumucation and Other Things
May 22, 2009 | 11 Comments
Perspective
While driving through the downtown of our small but not insignificant Midwestern city (there are corn fields five miles from the city center but we do have the state capital and a handful of miniature skyscrapers) I noticed a fat brown squirrel scampering down a tree and bounding across the street in the halting but graceful manner that can only be executed by a squirrel. From between two buildings a large hawk dove at the squirrel and, opening its wings and rotating its talons forward at the last second, grabbed the squirrel by the head nearly decapitating it from the violence of the attack. It flew back into the skyline with the limp body of the squirrel swinging from its claws.
My friends, the squirrel is us, you me and everybody bouncing along through life in our own halting, occasionally graceful manner.
The hawk is death.
Edumucation
Our good blog-friend Cosmic Connie over at Whirled Musings brings up an interesting point about the proliferation of easily obtainable on-line and mail-order degrees. I think she is just scratching the surface of the problem. While it is easy to identify fly-by-night diploma mills, most of what is considered legitimate higher education in this country is essentially the same thing; a lot more expensive with better ambiance and legions of fawning admirers but diploma mills just the same.
In fact, if there is a bigger scam than higher education or one supported by such a collection of self-interested grifters (who nevertheless bask in public adulation) I have yet to hear about it. In terms of shadiness, only the CHIP program, an offshoot of Medicaid designed to funnel Other People’s Money into lucrative Pediatric Emergency Departments and Children’s Hospitals purpose-built to loot this rich bonanza even comes close. Indeed, just as most of the money spent on the goat-rodeo of American Medicine is mostly wasted, most of the money spent on higher education is also mostly just thrown away producing little benefit to society except the employment of fearsome armies of educational bureaucrats who would otherwise be fit for nothing but agricultural labor.
That and serving as federally subsidized day care for 18-to-24-year-olds who would otherwise be inflating the unemployment statistics, safely warehousing them for another four years as sizable majorities of them pursue Mickey Mouse degrees.
Even prestigious universities are mostly now nothing but diploma mills and federal student aid farms where anybody who qualifies for student loans will be fed into the pipeline to emerge at the other end with as much money squeezed out of them as possible. If you think it is otherwise you are sadly deluded. A modern university is a self-perpetuating bureaucratic octopus, growing bloated as only an organization with unlimited access to public money can, and requiring only one thing: a steady supply of warm students shoveled into the front end to be kept in the mill as long as possible.
And the price of a degree keeps going up, outpacing inflation, not because the quality of the educational product has improved but because there is so much federal loan money available to pay for it. The suckers keep lining up to borrow hundreds of thousands of dollars for easy, meaningless degrees that give them something to put on their resume when they apply for a job at Starbucks. There used to be educational standards but now there is a university for everyone and a Mickey Mouse degree to be had at any level of educational ability and for any level of scholarly ambition. May as well get a mail-order degree and save yourself the tuition.
The relevance to Goat Rodeodery? Only that maybe the string of initials after everybody and his brother’s name may not mean as much as was once believed. Certainly the number of initials, abbreviations, and credentials listed on a hospital identification badge is usually inversely proportional to real education.
You Missed It…
Every week or so I get a comment or an email from someone who was once passionate about the idea of Emergency Medicine but after reading my blog decided to eschew it in favor of some other specialty.
Unfortunately, I may have given the wrong impression about Emergency Medicine. It is true that much of American medicine is either a cruel grind or sublimely ridiculous. Keeping this in mind however, Emergency Medicine is a blast. It has everything: Sick patients who really need your help and are mighty appreciative of it. Absolute medical train wrecks who, tenaciously refusing to shuffle off their mortal coil, are dumped onto you with the expectation that you can and will squeeze just a little more functionally pointless life out of them. Shootings. Stabbings. Every manner of human virtue and vice. Minor complaints. Serious complaints. Ridiculous complaints. Really, really ridiculous complaints. You name it, we’ve got it and to reject the never-ending passion play and freak show of Emergency Medicine is to avow a certain disinterest in mankind, a desire to have nothing but sanitized interactions with your patients who have been scrubbed clean (often literally) and filtered through the Emergency Department. People are generally on their best behavior in a clinic or the wards (or at least their better behavior) but in the Emergency Department we see them in the raw; man primordial, folly and nobility magnified.
But you have to love chaos. I’ll give you that. Not that the department is chaotic all of time but every now and then when the waiting room is packed and the ambulances keep rolling in with more critical patients, when the Friday night drunks are particularly demanding and the drug-seekers exceptionally whiny, when you are short-staffed and the charge nurse is making fists at you to move your many patients either in or out; when the impatient families are growing angrier by the minute and everybody is feeling harassed and overworked…when everything seems to be devolving into mayhem, confusion, and carnage you had best be able to prioritize and multitask like a friggin’ supercomputer or you probably actually won’t like Emergency Medicine.
The hurricane rages and blows. Huge waves slam onto the deck as the rigging comes down around your head and the ship wallows in a following sea. You are either the kind of lunatic who laughs at the gale and spits in the wind or this kind of thing intimidates you and you can only cling to the mast in terror. I exaggerate of course but we have had off-service rotators in tears at various points of their brief exposure to Emergency Medicine.
Another Pet Peeve
“You goddman doctors killed my mother (who is sixty-two years old, on hemodialysis three times a week for kidney failure, has bad congestive heart failure, is blind and has double below-the-knee amputations from the ravages of diabetes, has had so many strokes in the last two years that the neurologists just stand in the door and sigh, is recovering from her fifth heart attack, has been in the intensive care unit six times in the last two years, and had a very challenging case of pneumonia which was probably the result of aspirating the chicken soup her daugter fed her even though her strokes have made it difficult for her to swallow and all of her nutrition is poured into a tube going directly into her stomach).”
May
9
Panda-emic
May 9, 2009 | 8 Comments
“I got the Swine”
I’m hoarse from explaining influenza to my patients, the numbers of whom showed a small but significant increase over the last two weeks as Swine Flu hysteria grew, peaked, and then receded. Everybody wanted a pill for “The Swine” for which, unfortunately, there is none except an essentially useless anti-viral that works but has to be given almost before you even know you are sick to have any effectiveness. Antibiotics are useless against a virus of course and I spent hours explaining to my patients who, being mostly products of the public school system, had no clear idea of the difference between bacteria and viruses or even what these tricky sounding things were in the first place. To their credit they had terrific self-esteem and confidence in their ignorance so the schools must be doing something.
Undaunted, I came up with all kinds of simple analogies to explain the difference between bacteria and viruses. I thought I was doing pretty well but invariably they would smile, nod at the crazy doctor, and ask for some antibiotics.
Simply because it is the first instinct of the public to seek safety at the Emergency Department I think if we ever have an epidemic of a dangerous and essentially incurable viral illness we are all screwed . Going to the Emergency Department during an epidemic is exactly the wrong thing to do if all you have is a sore throat and some sniffles. Some of your fellow citizens sitting next to you in the packed waiting room may actually have Ebola and when we invariably send you home with Motrin and our best wishes you are going to spread it to everybody in your house.
What we need is a public awareness campaign to keep people away from hospitals during an epidemic. At least we need to put triage out in the parking lot and not in front of the triage nurse’s counter. That way we can send the not-that-sick or not-sick-at-all home without exposing them to everybody in town.
I’ve got news for all of you: If things get really bad there’s not much The Man can do to help you anyway and if you are old, multiply co-morbid, or unhealthy you will probably die as there are not enough ICU beds or staff who will show up to work to take care of you.
Super Users Revisited
I know everybody and his brother is outraged at the examples of lone-gunmen patients who make so many Emergency Department visits that the cost of their care runs into the millions but the problem is actually much bigger than that. While the Super Users are an obvious problem, they are also something of a red herring. Sure, they cost a lot of money but as there are not that many of them we could conceivably solve the problem with a little creative but humiliating bribery (say a permanent suite at the best hotel in Vegas which would be a bargain compared to the alternative) or a couple hundred bucks to the right seedy character and no questions asked.
The real problem is the patients who don’t rise to the level of Super User but nonetheless spend a significant amount of their time trying to wrangle an admission for chronic medical problems, an admission that, as it involves 24-hour care, hot-and-cold-running-narcotics, room service, and chambermaids and butlers who dress like nurses is viewed as something of a vacation from the daily grind of anticipating the next disability check.
I almost always look at the List of Previous Visits before I go see a patient, just to see what I’m dealing with you understand. It is, for example, useful to know that the last time your asthma patient came in he had to be intubated and spent a week in the Intensive Care Unit. This kind of information keeps you on your toes. Lately I’ve noticed quite a few patients coming in for what turn out to be minor complaints who have twenty or thirty Emergency Department visits in the past couple of years, also for what were presumably minor complaints as they were frequently sent home without admission. Not enough visits to rise to the level of Super User but how many times do most people go to the doctor, much less the Emergency Department, in a couple of years?
I’ve seen a doctor four or five times in the last thirty years but I have so far enjoyed good health. On the other hand I have patients who have quite a few medical problems but still manage to get through a year with only four or five doctor visits and trip or two to the Emergency Department. Would twenty doctor visits a year for chronic but easily controlled medical problems be considered excessive? How about four or five admissions, most of which were probably incredibly weak and more to ward off the legal vampires than for any sound medical reasons?
Anecdotally, and take it therefore for what it is worth, I would say that if I excluded my incredibly co-morbid patients who would die if not symbiotically grafted to every hospital in town as well as the handful of people with rare and unstable conditions, at least a third of my patients have a rather large number of visits, seemingly out of proportion to their medical history.
Don’t get yer’ shorts in a bunch. I’m just throwing it out there. But the wails and gnashing of teeth when medical care is finally overtly rationed as it must be under any system where it is given away for free will rend the very stones…and not just from the patients either. Money drives medicine and the steady flow of government money cannot possibly continue. Somebody is going to start saying “No” one of these days.
My Pet Peeve
You came to the emergency Department by ambulance, sirens blaring and tires squealing. You were in excruciating pain, so much so that the ten-point pain scale was inadequate and you swore it was a “twenty out of ten.” You clutched your chest (or your abdomen or your head) and I, taking you extremely seriously, initiated the Million-Dollar-Workup to find a heart attack (or an aortic dissection or a intracranial bleed). I poured pain medication into you and stood ready to resuscitate you when you finally succumbed to whatever horror had you in its deadly grip.
So please, a scant half hour after your arrival and while we are well on our way to proving that all you had was a little bit of gas or maybe some particularly vicious esophageal reflux, please do not stand outside the door to the critical care/trauma bay asking when you can go home and demanding food.
Dude, you were dyin’ twenty-five minutes ago. Can you wait another half hour for a sandwich?
Apr
23
Can’t Touch This…
April 23, 2009 | 13 Comments
Actual Patient Conversation:
“Man, that Dilaudid didn’t even touch my pain.”
“Uh, Okay. Your CT was negative so you’re fine to go home. I’ll ask your nurse to come discharge you. Come back if you get light headed or start to vomit but otherwise, just take Motrin for your headache and you should be fine.”
“Can you give me a prescription for Vicodins.”
“No. If the Dilaudid didn’t even touch your pain then this must be the kind of pain that doesn’t respond to narcotics and a couple of Vicodin would be useless…I mean Dilaudid is one of the most powerful narcotics we have and it didn’t do a thing. Stick to the Motrin.
“How about some Demerol.”
“No.”
Another Actual Patient Conversation:
“Vicodin doesn’t even touch my pain.”
“I’m sorry. That’s all I’m going to prescribe.”
“Can you give me a ’scrip for my Methadone?”
“No.”
“Well, how ’bout a shot of somethin’ before I go?”
“No.”
“Aw, man. Fuck you. I want to speak to the manager.”
“Sir, this is not the International House of Pancakes.”
Darn You, Manny Rivers!
More than the usual number of incredibly sick, incredibly old, incredibly senile, incredibly decrepit, and incredibly still alive patients today. There must have been a convention because for the first half of my shift the average age of my patients was around 86 and between the eight of them they had 112 distinct medical problems, 38 doctors, 26 artificial joints, six pacemakers, 18 coronary artery stents, and, as three of them had ileostomies, only five functioning rectums. The presenting complaint for seven was some variation of decreased mental status and one had stroke-like symptoms consisting of a slight facial droop although it was later confirmed that this was an old finding, first observed during the Clinton Administration.
A couple of the families were reasonable and declined any further medical care except hospice but the rest wanted “everything done” and committed us to expensive and extremely futile workups and admissions; three of the patients in particular went to the Intensive Care Unit where they are even now laying insensate and demented in their cocoon of medical equipment, either spending their grandchildren’s money or screwing our Chinese and Arab creditors depending on how likely you think it is that we can ever pay back all of the pretend money we are printing to pay for this insanity.
A day in the ICU costs Medicare approximately $4000 once all the costs are factored in. A week or two and we’re talking serious money, much of it totally wasted in the sense that many of the patients on whom it is spent have almost no chance of ever leaving the ICU and, if they do, will be essentially vegetative until they finally die. ICU charges under Medicare are in the Neighborhood of 40 billion dollars per year and rising. Medicare itself spends around 300 billion per year, almost half of that for hospitalizations of all kinds.
I blame Manny Rivers and his surviving sepsis campaign. Sepsis is an infection that leads to shock and, until very recently, was largely fatal especially in the elderly who regularly succumbed to septic shock from bad urinary tract infections or pneumonia (so much so that pneumonia was once know as the “Old Man’s Friend” as it regularly relieved the suffering of the senile and bed-bound). Dr. River’s great gift to medicine was what now seems like a simple method to aggressively treat sepsis that has significantly decreased mortality, extending the lives of many patients who would have otherwise been almost untreatable. The foundation of his method is a five or six liters of inexpensive Normal Saline and, stripping away all of the fancy equipment and the flashing lights, that’s pretty much it.
While generally a good thing, especially as I have seen many elderly septic patients returned to the full enjoyment of their glorious old age, just because we can do something doesn’t mean we need to do it all the time. I don’t always know when care is futile and I am not so arrogant to think I can judge the worth of anybody’s quality of life but there are some cases that are so obviously futile, that for example of a nonagenarian whose every bodily function comes through and out of a tube and who hasn’t so much as moved purposely in a couple of years, that what we do is not only insanity from an economic point of view but also from a human decency one as well. We do what the families want, however, rational or not. First because we are conditioned to never give up. Second because we have surrendered a great deal of medical decision making to the patients and their families even if they are not qualified to make the decisions and, more importantly, as they are not paying for any of their treatment have no skin in the game. Third because we are afraid of the legal implications of withdrawing care, so much so that hospitals have ethics committees for the rare occasion when enough is enough whose principle purpose is to spread the liability.
And fourth, as there is a lot of money changing hands there is little incentive for hospitals not to aggressively treat everybody who comes in. It’s either that or have ICU beds sitting idle generating no revenue whatsoever.
But the madness needs to stop. What we need is a Futility Scoring System, perhaps a simple sum of points given for co-morbid conditions and age above which only comfort care or home hospice will be reimbursed by Medicare. And it needs to become the standard of care.
Now if we could only find someone to put the bell on that damn cat.
Apr
16
More Random Reader Questions and in Which I Give Some Real Medical Advice Without Fear of Being Sued
April 16, 2009 | 16 Comments
(Actual questions from actual readers. -PB)
I know you don’t like chiropractors but what are we supposed to do for chronic back pain?
For chronic back pain I recommend back strengthening exercises, instruction in correct lifting and posture, weight loss, physical activity, judicious use of NSAIDs, and occasionally just sucking it up. For serious back pain which may be the result of a herniated disk, tumors, or occult fractures, I recommend imaging to assess the possible source of pain and such medical or surgical therapy as an orthopedic surgeon may suggest. I’m certainly not sending somebody with a lumbar fracture or ankylosing spondylitis to a chiropractor which would be like going to the barber to have your transmission serviced. It just makes no sense. Most back pain is usually self-limiting, however, and resolves in a few weeks without intervention of any kind. With this in mind, what’s your chiropractor really doing for you? Nothing. Neither is the doctor who enables your narcotic addiction, especially when he writes you a prescription for vicodin just to get you out of his hair.
I am becoming seriously zero-tolerance for handing out narcotics for chronic back pain. It’s your primary care doctor’s job anyway and I’m not really qualified to do it. Oh, and I don’t buy the bullshit stories about allergies to Motrin and other non-narcotic pain medications. A patient who is allergic to everything but Dilaudid (essentially legal heroin prescribed by a physician) is a drug-seeker, period.
What is the secret to good health?
Don’t smoke, don’t stuff dangerous recreational drugs into your body, if you drink do so in moderation, eat a healthy, varied diet without resorting to fads and supplements, and exercise as regularly and as vigorously as your health will allow. Also, get outdoors into the fresh air whenever you can, have an interesting hobby or two if your job doesn’t fill your need for creativity, and get regular sleep.
The rest is just marketing. You don’t need to eat organic foods or make a fetish out of being “natural.” Additionally, all the fish oil and vitamins in the world probably won’t make a bit of difference to your health and if they do, the effects will be marginal and not worth the effort and expense. Good health is mostly common sense, inexpensive lifestyle choices, and genetics.
Eat a fucking steak every now and then.
What do you think of Emergency Department “Super Users?”
The reader is referring to a recent story detailing how just nine patients made 2700 visits to Central Texas Emergency Departments over the course of six years. That’s roughly one visit per week per patient for six years. First, I assure you that this sort of thing is not confined to Texas. I work at two different Emergency Departments and I see my share of “frequent fliers,” some who I have seen multiple times at both departments and usually for what turns out to be either nothing or a minor exacerbation of a chronic medical problem for which they are also seeing their primary care doctor (although to be fair I have intubated one guy seven times in the last three years).
The next question is why do these people keep sucking down medical resources?
The answer is: “Who cares?” Are many of these Super Users mentally ill? Sure, some are. Do they have real medical problems? Of course they do. But what does it matter, really? If they are so sick and so crazy that they suck down a million apiece in medical care, most of it wasted and money that is not available to people who need it, then they need to be institutionalized for their own good because they obviously can’t handle life in any rational manner…except of course they are rational enough to know that they can never be turned away from an Emergency Department and structure their lives accordingly. I say this because every proposal suggested to correct the problem of Super Users does not address the real underlying problem, namely that personal responsibility and civic virtue are no longer required of any citizen and, despite being a nation of a million little rules and regulations, no effort is made to enforce even the slightest amount of common-sense based decency.
In other words, the solution to the problem of Super Users is not to coddle them even more by coming up with yet more government initiatives to essentially beg and bribe the parasites on our system to pretty please stop wasting more medical resources in a month than most people have used in their whole lives, but instead to cut them off at the knees; something that we could easily do, perhaps placing a limit on Emergency Department visits after which you become an automatic Get The Hell Out, except the legal environment is such that it has now become a right to squander as much of the public treasury as you possibly can. It is one of the biggest ironies of American life that while on one hand the productive sector is now supposed to be collectivized, subordinating their rights as individuals to the benefits of their labor in order to provide a living to the non-productive sector, to suggest on the other hand that citizens engaged in criminal abuse of society by essentially stealing collective money should be punished will bring out the usual braying from the defenders of irresponsibility, now screaming about the rights of individuals and how collectivization of responsibility is unacceptable.
Tea Party Update
I was surprised at the turnout. I live in a small Midwestern city of about 100,000 and there must have been 20,000 people at the Tea Party. It was a very nice, enthusiastic, but well-behaved crowd of mostly what looked to be working class and professional people with the odd scattering of Viet Nam veteran bikers who are obligatory at this kind of thing. Very few freaks and the few I saw were actually very nice college kids who dressed like goth punk rockers but were quick to assure me that they were College Republicans at our local Big State University.
There was no counter protest, at least none that I saw. One had been planned but I think the people who showed up for it saw the size of the crowd and said to hell with it. I did talk to two well-dressed, well-spoken law students who, they said, had been sent by ACORN to “infiltrate” the rally. The people around us laughed good-naturedly at this as not only did nobody care but the place was so packed a mouse couldn’t have infiltrated too far. They tried to debate and then got sort of haughty, brandishing their superior academic credentials as proof that we were all misguided but within ten feet of me were two other doctors, a chemical engineer, and couple of lawyers so that generated more polite laughter.
I saw them drift away looking perturbed. Liberals sometimes live in air-tight bubbles and I think they were a little surprised that the crowd was not composed of toothless hicks clinging to their Bibles and guns while waving the Stars and Bars.
Incidentally, if ACORN is now getting federal money, what were they doing proselytizing at a political event?
Apr
13
Don’t Forget….
April 13, 2009 | 5 Comments
A short post today, my apologies, but I want everybody who can to attend their local “Tea Party” on April 15th. As you may recall from American history, back in 1773 American colonists irate over increasingly oppressive duties and tariffs imposed by the British disguised themselves as indians, boarded British Merchantmen in Boston Harbor, and threw their cargo of tea overboard, protesting among other things taxation without representation.
Taxation with representation ain’t so hot either and, as Washington is now completely in the clutches of our home-grown criminal class, I’d like everybody who gives a crap about liberty, free enterprise, and stopping the conversion of our country into just another European mammary state to gather with your fellow citizens at your city’s tea party.
Keep the following in mind:
1. Although the tea parties are being touted as “Conservative” events and their will be many conservatives there, you don’t have to be completely conservative to go. They are more and expression of Libertarianism but conservatives share some similar values so it’s cool.
2. Keep yer’ pro-life, pro-gun, pro-whatever stuff at home. I’m pro-life and pro-gun but this is not the day for it.
3. Be polite to the handful of counter-protesters. They will be freaky and transgendered looking and they will be advocating as many issues as their are protesters, most having nothing to do with taxation, but that’s just their thing. I have been to many conservative events and without exception conservatives and Libertarians are well-dressed, polite, well-spoken, and behave in a way that makes our events family friendly. I have never seen the police have to use pepper spray, dogs, or any intimidation at all to control conservative crowds (in fact most cops are probably on your side) so let’s make it a pleasant day for everybody including the police.
Apr
11
47 Million Uninsured My Ass
April 11, 2009 | 9 Comments
(With apologies to Deborah Peel -PB)
So I had this uninsured patient with a chronic medical problem that was being addressed at The Big Academic Medical Center Sixty Miles Away who came to the department with worsening symptoms from her chronic medical problem, a problem that was competing, I might add, with several others that were lifestyle related. No problem, of course, because people can’t choose when they are going to get sick and if we have to fill in for The Big Academic Medical Center Sixty Miles Away then so be it.
An expensive workup ensued which confirmed the worsening of her chronic medical problem. Score! A slam-dunk admission. A pleasant phone call to the admitting physician who, even though it was 3 AM would agree, ruefully and without the usual surliness and rolling of the eyes that it is our lot to elicit in every doctor in town at one time or another, that the patient really was sick and really did need admission. Unfortunately, as soon as I mentioned the patient’s name he related to me that at her last admission for a similar exacerbation of her chronic medical problem she had eloped, leaving the hospital and her doctor’s care because she believed she was being treated rudely. On her way out she had sworn to “never let them touch me again.”
A week after her elopement and while visiting her sister at the Big Academic Medical Center Sixty Miles Away (a sister who interestingly enough had the same chronic medical problem), she checked herself into their swank Emergency Department for a similar worsening of her chronic medical problem and was admitted; receiving an expensive workup and, on discharge, a follow-up appointment with one of the Leading Specialists in the Field of Herchronicmedicalproblemology, a lady who has written textbooks and who had followed her at the Big Academic Medical Center Sixty Miles Away.
The admitting physician adamantly refused to admit and suggested, not unreasonably, that I transfer her to The Big Academic Medical Center Sixty Miles Away as they were the last to lay hands on her and were most familiar with her condition. The Big Academic Medical Center Sixty Miles Away agreed, without hesitation, to accept her and I even spoke to the Leading Specialist in the Field of Herchronicmedicalproblemology who happened to be on call. Oh how the heavens sometimes align and, just when you think you are heading for a knock-down, drag out patient transfer brawl you see the triumphal field just ahead and prepare to eat the cheeses and hams of victory!
Unfortunately, despite having no insurance, no ability, and no intention of ever paying a thin dime for the hundreds of thousands of dollars of free medical care that she has received and will receive until that tragic day when the treasure we spend will only bore the Reaper, the patient refused transfer to The Big Academic Medical Center Sixty Miles Away citing a litany of complaints against them from rude nurses to bad food, perhaps most damning being her observation that the Leading Specialist in the Field of Herchronicmedicalproblemology didn’t know what she was doing and, “Didn’t do nothing for me.”
Not to mention that the one hour drive would inconvenience her family, their constant attendance with cell phones at ready being a necessary adjuvant therapy for her chronic medical problem.
Oh my gentle readers, scholars all and deeply interested in this insane goat rodeo known as American Medicine, you would have wept at the sincerity of our efforts to prevent her, unsuccessfully, from eloping and leaving the department to nestle in the bosom of her uninsured family. There may be 47 million uninsured (most of whom are young enough to never require expensive medical care or wealthy enough to afford insurance except they have other priorities) but this particular one of them was so unconcerned for her own health that she spurned our best efforts over a matter of overblown pride and convenience for the many visitors she expected. Is she typical of the uninsured? Maybe not. But we can and do move heaven and earth to care for all of our patients, even those who cannot pay. I have never heard of a patient who needed treatment being turned away which is why a wino living on the streets of our country can receive medical care that European politicians living in The Health Care Paradise Across The Water have to fly to other countries (ours) to get.
Apr
5
(In which I answer several random questions submitted to me by readers. -PB)
Hey, Panda, I’m not sure what specialty I would like to do and am considering going to PA school because Physician Assistants can easily move between specialties. Your thoughts?
I often hear the ease of movement between specialties touted as a benefit of being a Physician Assistant or other mid-level provider. The theory is that if you find yourself bored in, say, primary care you can easily find a job in a different, more interesting, or more lucrative specialty. By contrast, changing specialties as a physician is a long, incredibly arduous undertaking. The only way, for example, an internist can credibly practice as a cardiologist is to complete an additional three year fellowship on top of his first three years of residency. If, as another example, I wanted to practice as a surgeon I would have to apply for and complete an additional four years of residency training assuming any surgery residency program would take me which, because of the way medical training is funded, they probably wouldn’t. A Physician Assistant, on the other hand, can get a job with a cardiology group and a few days later, mutatis mutandis, he is a cardiology PA.
Nothing wrong with this of course. The role of a Physician Assistant in many specialties does not require the depth of knowledge of a physician and I repeat, as many Physician Assistants are hired to do the relatively low-skilled grunt work of a practice this depth of knowledge is not required. But unless we’re going to revisit that magical world where two is bigger than four, five years of residency is no different than a little on-the-job-training, and superior knowledge can be had without learning all of that useless stuff, the ease of moving into different specialties should only indicate that a certain…how can I put it…comprehensiveness is not required of a Physician Assistant.
Which is not exactly a ringing endorsement of the depth of Physician Assistant training although if that’s your thing, go for it.
But Panda, can’t Physicians Assistants do 90 percent of what a doctor does?
No. Although to be fair they can do 90 percent of the paperwork so, since fifty percent of my job consists of useless bureaucratic tasks, ipso facto they can do a large part of my job. The conceptual difficulty many of you have is your lack of understanding about the structure of the goat-rodeo-cum-cluster-fuck known as American medicine in which there are three broad specialties. The first is actual, honest-to-Jehovah Medicine of the kind we all imagined we would be practicing long ago before we actually started wrestling the proverbial pig. You know, things like diagnosing and treating diseases using good clinical judgment and appropriate testing and consults.
The second specialty is Tort Medicine which is something we do continuously in an effort to minimize the perceived risk of being named in a lawsuit for a bad outcome that may or may not have been our fault. As this primarily involves throwing vast quantities of money at our patients in the form of useless, unnecessary, or only marginally helpful studies and procedures in an attempt to uncover every single thing that could possibly be wrong with the patient (no matter how unlikely), I see no reason to doubt that Physician Assistants can handle these tasks admirably, the number of boxes you check on the order sheet being often inversely proportional to your knowledge of real medicine.
The third and largest specialty is Boilerplate Medicine in whose service we devote countless hours charting, documenting, and filling out reams of redundant forms, the main purposes of which are to legitimize billing and keep millions of low-level administrators gainfully employed. It is in this specialty where mid-level providers particularly excel and for which most are hired. What are most History and Physicals for routine admissions and procedures, after all, but loads of useless information, grimly documented for the insurance company, surrounding a kernel of important facts? Unfortunately, since you can’t bill insurance companies or the government with a concise paragraph describing everything important about the patient, we have developed check boxes and forms that codify useless information and organize it for easier parsing by bureaucrats; even though for strictly medical communication all most doctors need and would prefer is a brief paragraph.
Or, to look at it another way, I am now after eight years of medical training capable of writing a brief, elegant, and succinct paragraph describing everything you need to know about the patient as well as my assessment and plan which any other doctor can read and understand completely. If this was all I had to do I could probably see twice as many patients but unfortunately, the government and private insurance companies (not to mention the lawyers as there is considerable overlap between Tort and Boilerplate Medicine) need their medical prose like a sailor needs a happy ending and if I can hire a relatively cheap mid-level to crank it out then so much the better.
The real question should be whether someone needs a two-year Masters degree (in the case of Physician Assistants) or one year of fluffy smugness (in the case of Nurse Practitioners or Doctor Nurses or whatever the hell they want to be called) to essentially fill out a bunch of mostly useless paperwork? Surely if clinical skills are not that important, and that’s exactly what a mid-level is really telling you when he insists that his two years of training is equivalent to your seven or more, then we could probably save a heap o’ wampum by training motivated Community College students for an exciting career that we can call “Physician Assistant Assistant” (or PAA) and eliminate the expensive mid-level middleman.
But what about Primary Care? Surely mid-level providers are suited for primary care?
You only say that because you don’t understand primary care or are confusing it with something else. Primary care physicians should and ought to have the highest level of medical knowledge and clinical instincts because they are not specialists and therefore have to be fluent or at least conversant in all of the medical specialties. To the extent that they aren’t is only a reflection on the nature of American Goat Rodeodery where reimbursement and the predatory legal environment makes referring to specialists a de facto requirement for a primary care physician’s financial survival. With this in mind, most specialists are used not in their intended role as sage consultants for particularly difficult cases but as extenders for over-worked primary care physicians, meaning that they primarily see nothing but fairly routine patients with bread-and-butter conditions that the patient’s family doctor simply did not have the time or the legal gonads to address. In this respect mid-level providers are probably better suited to the specialist trade, and the more specialized the better, because it is easier to acquire a superficial knowledge of a highly specialized field than of a broad, non-specialized one. I know, for example, a Pulmonary Medicine Nurse Practitioner whose entire job is to set patients up for bronchoscopy, the pulmonologist’s signature procedure and biggest money-maker. Realistically, however, I could train a high school student to do most of her job.
Now, it is true that primary care physicians see a lot of minor complaints. Hell, I’m an Emergency Physician and I see plenty of them too, some so trivial that it would drive one crazy if it weren’t for a sense of humor or plentiful, cheap whiskey. In fact, a substantial subset of the patients I see have complaints that are not only minor but only twenty years ago wouldn’t even have been considered the kind of medical problem for which someone would legitimately seek medical attention. Can a mid-level provider handle these? Of course. But are they sure they want to make the motto of their profession, “Mid-Level Providers: Wrangling Patients that Don’t Really Need to Be Seen So You Don’t have To?”
Primary Care, in other words, is not just about minor complaints and it is not urgent care either.
What About Urgent Care?
Urgent Care is mostly a scam, at least in cities that have functioning Emergency Departments and I would advise most of my patients to avoid them as an unnecessary and costly middleman. With a few exceptions, if your complaint is minor enough where it can be addressed in an Urgent Care Clinic you probably didn’t need to be seen at all and whatever treatment was prescribed is just a placebo, something to show that we care or to keep you amused while nature takes it course. If your complaint is legitimate or even the slightest bit threatening the practitioner running the place will default to his legal protection mode and refer you to the Emergency Department, off-site Emergency Department triage actually being the only legitimate medical function of Urgent Care clinics.
Can you get a school sports physical at an Urgent Care or a note from your doctor as an excuse when you miss work? Sure you can. But these things are worth what they are worth. The work note is worth nothing medically and the cursory sports physical as it will never pick up any but the most obvious reasons why you might drop dead while playing basketball, fulfills what is mostly a bureaucratic requirement and not a medical one. This is why, by the way, residents love moonlighting at Urgent Care Clinics. Namely because it pays pretty well, the stakes are low, nobody is really sick, and if they are you can easily punt to a higher level of care.
What about Complementary and Alternative Medicine? Can’t I go to Chiropractic School or something like that if all I want to do is primary care? My Chiropractor advertises himself as “Primary Care” so I was just wondering.
Complementary and Alternative Medicine is mostly modern superstitious drivel marketed to people who are, in their knowledge of science and reason, no better than seventh century peasants except that Dark Age peasants had an excuse to be ignorant as they had marauding Norsemen competing for their attention. On the other hand most people don’t think about medicine that much and have no reason to distrust their chiropractor so allow me clear something up for you: Chiropractors, naturopaths and other Alternative Medicine practitioners do not have the same training and education as medical doctors, not in quality and not in quantity, not by a long shot, and therefore they are not qualified to serve as primary care physicians, a job that requires more than some haphazard study of herb lore or a cursory knowledge of the spine. If they had the same training including residency training they would be qualified…but they don’t so they’re not.
Take your typical chiropractor, for example. He has a four-year degree at an institution that was probably nothing but a federal student loan processing mill in which the odds are he never saw a really sick patient, at least not one that wasn’t immediately taken to the nearest Emergency Department. Unlike your Family Physician who has four years of medical school followed by an intensive three year residency, your chiropractor has never rotated on a pediatric ward, in the Intensive Care Unit, on an internal medicine service, a surgery service, or any other of the medical services in which the core knowledge of every physician is developed. He has done no call, been responsible for exactly nothing during his brief pseudo-medical training and has never had to make a decision that mattered to anybody. More than likely he slithered through chiropractic school making a mental list of the many, many things he would never have to worry about (I mean, assuming he was introspective enough for this) and that he would defer to real doctors. He is, therefore along with his naturopath cousins eminently unsuited to recognize, diagnose, and treat general medical complaints.
The funny thing is that I would never try to pass myself off as a surgeon, an obstetrician, an internist, or a neurologists because I lack the training and knowledge to honestly represent myself to the public as something I am not…and yet naturopaths, chiropractors, and the whole pack of Snake Oil Salesmen with a fraction of the training required for the job lack the humility, the self-awareness that comes with an appreciation of their own limitations, to consider that maybe, just maybe, they don’t know enough to be primary care physicians.
No doubt your Chiropractor can fill out forms with the best of them and correctly bill your insurance company but if you have a medical problem serious enough to warrant treatment you should see a real doctor and eliminate the useless middleman. Likewise if you really care about your long-term health.
Not to mention that the primary treatment modalities of practioners of Complementary and Alternative Medicine are extremely ridiculous on a fifth grade biology level. To believe in them, things like subluxations and Reiki, is to place yourself in the company of drooling cretins.
Apr
1
1001 Ways to Die
April 1, 2009 | 6 Comments
1001 Ways to Die
There has got to be a better way to die and surely the patient at the center of our frantic activity couldn’t have wanted this one. I arrived at his room with a code in progress although, as the patient was still alert, most of the activity involved throwing towels on the floor to soak up the large quantities of ink-colored blood pouring from his mouth, his nose, and the edges of his adult diaper. The patient was obviously in severe respiratory distress and one of our junior residents who was running the code prepared to intubate, securing the patient’s airway and providing ventilatory support being the first most reasonable step to…well…I don’t know what except that the family wanted everything done even though no power on earth could reverse what was ordained by cruel nature and metastatic cancer.
As the patient opened his eyes for the last time, gaping in horror as he drowned in his own blood, I’m sure he saw gibbering death slouch into the room, leer at the nurses, and settle into the shadows with a smirk on his face to enjoy the end of the show.
Then, as suddenly as turning off a switch the patient was gone which naturally didn’t stop us from ineffectively performing half an hour of violent maneuvers on his body and throwing all manners of potent but useless medications into it before the family, huddling in terror just outside the door, were convinced and asked us to stop. We slid a breathing tube into his trachea, rammed a big intravenous line into his femoral artery, crammed him full of fluid, ran electricity through his heart, and bounced him around his stool and blood-soaked bedding; only pausing to look hopefully at the monitor for cardiac activity even though he was glassy-eyed and had that dead look about him. Our junior resident even optimistically ordered some O-negative blood (which is what you give if you don’t know the blood type) from the blood bank but we weren’t exactly holding our breath for it to arrive from the deep basement labyrinth of the hospital.
If you can believe it, the desperate struggle against failing organs now at an end, he looked better dead than alive but then, as I first saw him crouching on a bedside commode moaning in terror, I didn’t exactly catch him at his best.
Eternal God Whose great mercy endures forever. Spare me, Your devout but occasionally wayward servant, from this kind of death and grant that I may die peacefully in my bed.
Why People Love Complementary and Alternative Medicine
I had a patient the other day with some very mild conjunctivitis (”pink eye”) which, in otherwise healthy adults is almost always-and I mean the planets align when it’s not-viral or from some other cause that is untreatable except for symptomatic relief. After checking her visual acuity, verifying that her pupils were normally reactive (to exclude iritis which is a big deal), and even doing a completely unnecessary slit-lamp examination of her cornea I was able to give her the good news that her condition was benign, required nothing but symptomatic relief, and would almost certainly resolve completely in the next one to two weeks without the need for topical antibiotics (which we often prescribe even though the evidence for their effectiveness even in the case of mild bacterial conjunctivitis is less than compelling) but only some mild analgesic eye drops.
The patient balked at the thought of one to two weeks, “Won’t the medications you’re giving me make it heal faster?”
“No,” I explained. The eye drops just offer relief of symptoms but nothing we can do will shorten the duration of your conjunctivitis. It’s very mild, we don’t really know what’s causing it, and you should be fine. If it gets worse you can see an ophthalmologist or even come back here.”
“Can’t you give me something to make it heal faster?”
“No,” I explained. The eye drops will just offer relief of symptoms but nothing we can do will shorten the duration of your conjunctivitis. It’s very mild, we don’t really know what’s causing it, and you should be fine. If it gets worse you can see an ophthalmologist or even come back here.”
And so it went for five minutes after which, not convinced, the patient allowed that she would be paying a visit to a well known local Wellness Center, a shameless emporium of every form of snake oil I have ever heard of, where no doubt the magician on duty will provide some magical potion or Eastern herb that will miraculously cure her conjunctivitis in from one to two weeks.
And yes, Gentle readers, there are people in our sad and rapidly deteriorating country who will come to the Emergency Department at two in the morning for mild, and I mean mild, “pink eye.”
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