Jumping the Shark

“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.


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