How’s that Hope and Change working for you?  Had enough?  Still grimly resisting that urge to scrape off the bumper sticker?  It’s all right.  Nobody likes to admit they were fooled even though it’s now painfully obvious that, like many of us warned you, The Sun King Ra-Obama is nothing more than an empty suit who if he is in fact filled with anything it’s the shopworn doctrinaire leftism that has been such a disaster for most of the planet and apparently needs to be tried again and again because…well…because the purpose of leftism is not to improve the human condition but to ensure, as Orwell warned, that a boot is stamping on the human face forever; in this case the boot is an over-reaching and out-of-control government intent on bludgeoning you into submission with a big brick of government cheese.  President Obama and his cabal of like-minded Barons in the House and Senate don’t want to help you, they want to solidify their own power, putting the boot in your face forever.  If they have to lay waste to democracy, free enterprise, initiative, personal responsibility and every other virtue that made America exceptional than so be it.

The sad thing is that you voted for the guy because you are a afraid; afraid to be an American and act like an American and have instead embraced the notion that the Mammary State will nestle you in it’s benevolant bosom if you only give up the liberty that is your birthright and accept the domination of an unelected, multi-tentacled bureaucracy in every part of your life. 

What the heck.   All you’re going to give up in exchange for never having to pay a dime for even the most routine medical care is the ability to be anything but a serf, a comfortable serf for now but the time is coming when the West, finally become nothing more than a crappy nursing home full of drooling, entitled imbeciles, producing nothing and standing for nothing; a civilization reduced to petulance and craven apologies for the cherished values that in distant times American boys stormed impregnable beaches to defend, will collapse from the overwhelming weight of its own folly and short-sightedness.

Then my friends, the World will burn.

Wonderful, Wonderful Copenhagen

Let me get this straight:  The economy teetered on the edge last year when billions of dollars invested in imaginary assets evaporated into thin air.  In Copenhagen, the President, the Democratic Congress, and the parasitic global bureaucracy propose to set up vast markets trading in Carbon Dioxide, a naturally occurring gas which forms a vanishingly small percentage of the atmosphere, and that this entire multi-trillion dollar market in which your pension funds and other financial instruments will be inevitably intertwined will be based on some pointy-headed Eurocrat allocating permission to burn fuel…and you think this is a good idea?

What on earth is wrong with all of you?  Have you taken leave of your senses?  Who thinks up this kind of crap and more importantly, didn’t they get the memo that Global Warming, the Rock upon which the Religion of Global Bureaucracy is built, the Shining Promise to the Ruling Class of Make-Believe Jobs Now and Forever and To the Ages of Ages, is a hoax and nothing more than a shabby and now increasingly transparent attempt to put the unruly American spirit in its place?

If the magnitude of the duplicity involved in the hoax of climate change (now warming, now cooling) is not apparent to you now then you are either blind or willfully intent on destroying as much of our personal freedom as you possibly can.

“My arm was numb after I slept on it funny and my mom says I’m having a stroke,” says my essentially healthy 34-year-old patient to the nodding approval of his indulgent mother sitting by the bed.

“How long did the numbness last?”

“A couple of minutes…it went away after I straightened my arm.”

“So your arm went to sleep and now it’s better?” I ask.

“I guess so.”

“You know that just walking through that door costs you four hundred bucks?”

“It’s okay,” interjects his mother,”He’s on disability and don’t have to pay a dime.”

And there, in a nutshell, is the problem with American medicine and why the looming government solutions are insane.  Don’t you all realize that when a healthy young man can walk into an Emergency Department because his arm fell asleep and be seen by a doctor, a doctor who will dutifully diagnose him with transient paresthesias or compression neuropathy or God forbid initiate an expensive and highly unnecessary work up; when a patient can present with nothing and less than nothing and run through your money with as much concern as I have for swatting a fly…don’t you all realize that when this kind of patient can leave without being arrested for fraud that American medicine has jumped the shark and making it even more accessible at even less cost to a growing population of supremely entitled citizens will result in nothing but an exponential increase in the baseline ridiculousness of it all?

Pill Pusher

The Emergency Department is the center of a thriving drug trade that would make an Afghan Opium Warlord gulp in amazement.  A truly staggering amount of narcotics leaves here every day and I am sorry to say that, even though I am trying to prescribe less of them, I have had a major part in this.  It’s not that I don’t believe in appropriately treating pain.  Cancer?  Major trauma?  Kidney stones?  No problem.  But every person with back pain, even if they were legitimate patients and not the drug seekers that many of them are, does not need thirty Lortabs…if they’re not allergic to Lortab that is as most of our narcotic connoisseurs eschew the slow onset of pills for the instant rush of Dilaudid (doctor prescribed heroin).

The problem is two-fold:  First, there are some patients who are in pain and have a legitimate need for narcotics.  You can’t withhold them because other people abuse the system and consequently it is necessary to give people the benefit of the doubt even if you know you’re being scammed most of the time.  Second, there is tremendous pressure bureaucratically to make the customers (formally known as patients) happy lest Press-Gainey scores suffer and some imaginary harm come the bottom line as customers who probably don’t pay for their medical care anyway threaten to take their business to some other, more accommodating drug entrepot.

So I’m sending a lot of people out on Motrin and occasionally Valium as a muscle relaxer and reaping the whirlwind of bad feelings and complaints.  If you’re in a minor automobile accident and walk in a day later without any injuries this is completely appropriate and why a little fender-bender in which no one was hurt and EMS were not called should be the prelude to a narcotic holiday is not clear.

That many patients lie to get drugs in an incontrovertible fact. I work at two Emergency Departments in town and I have had the same patient on two different days with two different descriptions of the same wreck.   I also occasionally get calls two weeks after the prescription for Lortab was written  for a minor motor vehicle accident claiming that the pharmacy lost it and could I please write them another prescription?

I have discovered from several of my more straightforward ex-drug seeking patients who now come in occasionally for minor but legitimate complaints (and refuse anything but tylenol or Motrin) that at one time they were selling their Lortab on the street for ten bucks a pill.  Apparently you can make a decent living scamming your Emergency Physician or, as the Pharmacist put it, “Hey Doc, did you know that Mr. Smith just filled a prescription for 150 Percocet two days ago?”

No.  No I did not.

It would be unfair to characterize the country as a whole from the self-selected few who have formed a symbiotic relationship with the Emergency Department.  But just like every medical problem is not an Emergency, every little pain does not need treatment and there was a time, I assure you, when people just took a couple of aspirin and called their doctor in the morning.

Jumping the Shark II

“You know I’m not a pediatrician,” I say to the mother of a well-looking, very healthy baby brought to the Emergency Department for a little spitting up and an inability to obtain an instant appointment with the child’s pediatrician.

Incredulous look.  Thinks I am some kind of on-call pediatrician.

“You know I’m not a dermatologist,” I say to a otherwise well man with a faint rash on his neck that started a few months ago.

Disbelief.  Anger at my referral to a dermatologist (who I called after coming up with nothing in my dermatology atlas) who will see him in three weeks but unfortunately will probably ask for money up front.

“I want to see the dermatologist now!  That’s why I came in.”

Good luck.  Heard muttering on his way out that he wanted his co-pay back because “that fucking doctor didn’t do shit for me.”

“You know I’m not your primary care doctor,” I say to the well-appearing woman with a complaint of “I want to be checked for sarcoidosis.”

Scornful look.  “Oh, my doctor isn’t doing anything for me,” although I suspect from a cursory review of her online medical records he is as he has at least ordered all of the appropriate lab work.

Somewhere, sometime…I don’t know when…the public has dropped even the pretense that the Emergency Department is anything other than an all-hours urgent care or some kind of one-stop shopping for all of your real and imagined medical problems.  It it this impatience, the medicalization of all aspects of life, represented by patients demanding instant treatment for things that thirty years ago would be shrugged off that ensures our health care system will bankrupt us, especially when it is free.

“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.

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?

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.

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.

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.

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.

(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.

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).”