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

Field of Dreams

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

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

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

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

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

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

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

On The Other Hand….

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

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

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

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

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

Hope Springs Eternal

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

“Do you have any medical problems” I asked.

“No,” he said.

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

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

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

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

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

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

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

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

“I love you, man.”

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

What I Do, Part Two

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What I Do, Part Two

Pandarandom: Brief Thoughts

Four Percent

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

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

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

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

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

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

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

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

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

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

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

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

Not an Apology

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

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

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

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

Man Up

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

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

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

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

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

Pandarandom: Brief Thoughts

Freeloader Mothership

(Let us delve, oh my long-suffering and indulgent readers, into the realm of real economics, an area of study much neglected in the utopian groves of academe. It’s almost as if our isolated professariat, protected behind the great bulwark of tenure as they are, have become afraid to get their hands a little dirty discussing economics in any but the emotionally satisfying but ridiculous terms of various strengths and and flavors of marxism. -PB)

Can’t Fight Human Nature

The bottom line is this: We are, most of us, potential freeloaders and it is only fear of the wolves prowling outside the door that keeps us working as hard as we do. For my part, if I could find a job that paid as well as Emergency Medicine but required less work, I’d jump on it like a bum on a quarter. It’s not that I don’t like my job because I do. It’s just that taken as a whole, the fun only outweighs the crappiness of much of it if we put a decent salary in the scales. Two hundred thousand a year? A great job but not perfect. Thirty thousand? I’m not getting paid enough to do this shit. In this the Hamburger flipper and I are kindred spirits. We have to ask ourselves every day and every shift if it’s going to be worth it. The burger flipper however, has less to lose by falling into the bosom of the state and having all of his needs provided for by someone else. That’s why disability is so appealing to many of my patients but not to me. The crappy monthly subsidy they would receive as well as the modest benefits allowed by our welfare Social Justice system are not too much less than many of them could achieve on their own with the effort they are willing to expend. Some are just lazy, some sincerely believe that they are incapable of upward mobility, and some are categorically unable to breath and chew at the same time but for whatever reason, work has no appeal quite like leisure supported by somebody else, especially the modest leisure ambitions of the poor and lower middle class which involve, short of winning the lottery, fishing, hunting, eating, watching television, booze, weed, sports, and the other simple pleasures of life. Three week vacation to Italy? Not even on the radar screen. The key concept here is that every one of us has a price at which he will eschew work, or at least work that we must do to live and not a hobby masquerading as a job.

So you see, cradle-to-grave welfare Social Justice of which free medical care is only the first step wouldn’t work for me at the price the nanny state is offering. But that’s the seductive appeal of the European model for people who are not willing or able to make much more than what the nanny-state promises. The huddled masses yearning for the secure bosom of the mammary-government will give up the freedom to enjoy the fruits of their own labor to eat somebody else’s fruit. The problem is that we’re never as frugal with somebody else’s fruit as we are with our own so the natural progression in the self-fulfilling prophecy that is socialism (a word from which even socialists now run screaming), dictated as it is by immutable human nature, is an easy progression from a sense of gratitude to entitlement and then to demands for even more of somebody elses’s fruit. Eventually the ante is upped enough where even productive citizens would be crazy not to take their share of the fruit. People are lazy, not stupid.

Providing the fruit however only works as long as there are enough suckers to pay taxes. Eventually the tax burden, especially in a progressive tax system, makes the economic incentive to expand your little corner of the economy, creating the goods and services that are the wealth of any nation, next to nothing. If I am taxed at 90 percent for any income I make over a certain amount allowed by Your Sweet Lord, the Gubmint,’ the extra money I make for seeing a few more patients or working an extra shift is minimal and not worth getting out of bed except that I can go fishing instead. Your desire to see a doctor, in fact the heart-rending pleas of the baby-boomer hordes about to descend locust-like on the medical care crops will fall on deaf ears. No economic incentive, no production. The money for free medical care, not to mention for every other new right discovered by the Trailer-Park-Ghetto-Academia Axis, has to come from somewhere and it will come from increased taxation. In due time, this excessive taxation will have a deleterious effect on the ability of the productive sector, the little understood, much maligned engine that produces of all the little things in life you enjoy, to continue to create the wealth necessary to make everything free.

Many years ago I worked for a Wood Products company that was considering buying a plywood mill in the former Soviet Union. They quickly dropped the idea because after seventy years of communism (socialism’s retarded cousin) the mill was like most factories in the Soviet Union; a bloated, inefficient, poorly-run concern employing mobs of redundant, low-payed workers making a shoddy product that you couldn’t give away in the West. This particular mill made a third as much plywood with a thousand employees as a typical American mill can make with only fifty. And it was plywood of incredibly poor quality, stuff that even the most dishonest contractor would reject out of hand, and they wasted prodigious amounts of wood doing it.

A typical American plywood mill has one modern computer-controlled lathe that can peel a log down to about the diameter of a broomstick. Veneer, the strip of wood coming off a spinning log and what makes the layers of plywood, is money. The more veneer you get from a log the more plywood you can make at a lower cost. The ex-Soviet mill had five nineteen-seventies era lathes, most of which were broken at any given time, that could only peel a block (a log) to about eight inches in diameter. This valuable piece of the tree was then chipped and used to fire the boilers. American mills occasionally produce large peeler cores but only if the price of dimension lumber (e.g., two-by-fours) that can be sawn from the cores exceeds the value of the veneer. We certainly don’t burn money as hog fuel.

Theoretically the Russian mill was a progressive factory. No one could be fired and everybody had all the benefits that could be offered by the Motherland in that now forgotten dark freeloader empire. But they made crappy plywood that no one would buy unless they were forced which is the modus operandi in a command economy. Most of the workers stood around doing nothing for most of the day, absenteesim was high (but irrelevant if you see my point) and when the time came to pay the piper, the plant (and the whole country) had no value and could not honor its obligation to ensure a worker’s paradise built on the equitable distribution of goods and services by a central committee. Folks, they were selling the mill. And they were desperate to sell it which is not exactly a ringing endorsement of the progressive principles upon which the factory (or the empire) was run. Without incentive, and surely their was no incentive at this plant to even show up much less do quality work, there is no possibility of progress. A factory, and a society, cannot support a mob of time-servers and malingerers for more than a generation or two, particularly in the face of external pressure from more advanced societies, that is, ones that are maybe less “progressive” but more entrepreneurial.

Now consider another large socialist state, General Motors, which at one time I understand used to manufacture automobiles but now is primarily concerned with supporting a large dependency class and for who the production of automobiles is merely a sideline. The unions to which GM is a prisoner, with the best of intentions but now obvious short-sightedness, have contributed mightily to running the company into the ground. For many years, when times were good and Japanese cars were rinky-dink pieces of junk, the management of GM could afford to cave to union demands offering lavish benefits to its employees. People were still buying and the costs could be distributed into the high volume of increasingly poor-quality automobiles being built by employees who slowly, oh so slowly, began to resemble their more progressive comrades in various worker’s paradises around the globe.

Now, the high quality automobiles are being built in Alabama and South Carolina in mostly non-union shops. The benefits aren’t as good but the jobs are there and sustainable for an industry where competition is fierce and an extra thousand bucks per car for benefits to people who haven’t actually worked for the company in forty years makes all the difference. The ripple effects of this kind of sustainable enterprise spread throughout the South. Birmingham, Alabama is a thriving, growing city. Flint, Michigan, once the center of the American automobile industry, is a crime-ridden ghost town for which the joke among real estate agents is that they will cure AIDS before you can sell a house in that depressed market.

Not to mention that the pressure from wages and benefits has forced both Mercedes-Benz and General Motors to invest heavily in automation, technology who’s purpose is to reduce payrolls and expensive employees.

Is this fair? Not the right question because fair’s got nothing to do with it. Since we were talking about plywood mills, I’ll have you know that one of the last non-automated steps of its production occurs on what is known as the “lay-up” line where, for fifteen bucks an hour (good wages in my rural Lousiana Parish), workers fit irregularly shaped shards of veneer (“core”) between two moving ribbons of continuous veneer (“face”) before the entire assembly moves to the press. (Come on, you guys have looked at a sheet of plywood, right?) The person who invents a practical automated lay-up line can patent it and be set for life because the competitive edge provided to Georgia Pacific of not paying those salaries will let them eat their competitors for lunch…until everybody gets an automated lay-up line and then everybody can coexist in a state of uneasy parity until the next breakthrough.

And yet, despite the drive to shed jobs, the result is not a nation of jobless ex-plywood workers clogging the soup kitchens. Progress may be heartless but the net effect, the increase in the material prosperity of a nation by increasingly efficient production of valuable things (either goods or services) spurs new growth in sectors of the economy that the aparatchik running the Soviet Plywood mill couldn’t even imagine. Even in the Wood Products industry for example, although the low-wage menial jobs are almost gone, there is an ever growing demand for someone, anyone, who knows his way around Programmable Logic Controllers, the computerized nervous system of a high tech factory.

Finally, let us consider the United States, one of the largest economies in the world and whose business should be business, not attempting to directly provide for all of the needs of its citizens. We don’t even need government programs to encourage work or even to discourage freeloading. People will find their own way but only provided that there is an incentive to keep the wolf from the door. An economy that diverts large portions of its scarce resources to not only support but encourage the non-productive is not a viable concern for too long; the length of time the ponzi scheme can continue depending of on the momentum you have going into it as well as the willingness of lenders to extend credit. But you can’t support a growing number of eaters on a finite pie. The pie has to get bigger or everybody gets a progressively smaller piece. One day the shieks of Araby and the Mandarins of China will decide that supporting your demented granny’s right to that free fourth heart cath is not a good credit risk and then we’re all screwed.

So sorry.

Freeloader Mothership

What I Do

(With a hat-tip to the Happy Hospitalist.Nothing new or profound here so my regular readers may, if they desire, ignores this article completely or read on and forgive the basic level of information presented. -PB)

A young reader writes, “Dear Dr. Bear, I am a senior in high school and am thinking about being a doctor. What does your job involve?”

I am a resident physician, meaning that I have graduated medical school and am now doing my specialty training, in my case in a specialty known as “Emergency Medicine.” Some people do not know that Emergency Medicine is a specialty but as you will see, its practice does involve some specialized training as well as an approach to medical care that is somewhat unique. I am a little more than halfway through what will turn out to be a four-year period of post-medical school training. Emergency Medicine training is typically three years but I did an intern year in Family Medicine after which, screaming in fright, I made the switch to Emergency Medicine. (I did not get “credit” for that year in my new residency program.)

No matter what specialty you pursue, you will have to do an intern year which will consist of exposure to all of the major medical specialties. You may perceive this to be of little value if you are, for example, going to do dermatology but since Emergency Medicine is a generalist field, every little thing we learn is useful and can be applied somehow. In other words, I have never been delivering a baby on an obstetrics rotation and said, “Man, this is bogus. I’ll never have to deliver a baby in my real job.”

Medical school itself lasts four years and in all but a few cases needs to be preceded by a four year (or however long it takes you) course of study at an accredited college that leads to a Bachelor’s degree. I have a Bachelor’s of Science in Civil Engineering and, unlike most physicians, did not go directly from college to medical school but instead worked as a Structural Engineer (the cool branch of Civil Engineering) for many years. This made me what is called a non-traditional student but if you’re sure you want to be a doctor there is no need to interrupt your journey and you may as well take your lumps when you are young. The process of applying to medical school and positioning yourself for acceptance is well described on the Student Doctor Network and to them I refer you to find all the information you could ever need. Take advantage of it because even ten years ago, when I was applying, this kind of thing either didn’t exist or was a spare sketch of the resource it has become. I think we now have the first generation of people who take the internet completely for granted.

So I am what is known as a Resident, a physician but one who practices under the supervision of other physicians who have finished residency and are fully-trained in their specialty. These doctors are known as “Attendings” or “Attending Physicians.” We are called residents because once, long ago, if you desired additional training past medical school (which was at one time not common or even felt necessary to practice) you lived in the hospital while you trained. While the hours are long in residency, we no longer live in the hospital but the name has stuck. Residents are also called “House Staff” at many hospitals, again with the implication that they belong to the “house.”

Just for your information, you can be a licensed physician and still be a resident. In other words, I occasionally have patients who insist on seeing a “real doctor,” not a resident. Leaving aside the debate as to whether you are a “real doctor” on the day you graduate medical school (you are), licensing in most states only requires that you complete an intern year and have passed all three steps of the United States Medical Licensing Exam. From a legal point of view, there is a basic level of knowledge and skill that every doctor should possess and this is the minimum for legal independent medical practice doing anything which you feel comfortable doing, can get insured to do unless you want to work without liability insurance, can convince hospitals to give you privileges to do, and can convince patients that you know how to do. Practically, however, you need to specialize and get additional training unless your ambition in life is to work at a low-level Urgent Care. I don’t have to tell you that medicine is very complex with a rapidly expanding body of knowledge that one person wouldn’t be able to assimilate in a hundred lifetimes. Specialization is a de facto necessity.

I generally work 14 twelve-hour shifts in every 28-day block. I either work the 9 AM to 9 PM shift or the 9 PM to 9 AM shift, with seven consecutive days on one or the other. Next year I will work seven to seven instead of nine to nine which allows for some overlap between the third year and the second year residents. The most we ever work is three shifts in a row with at least two days off afterwards. Our schedule is set up so we work Friday, Saturday, and Sunday for two weekends in every block but get the other two off. It sounds like a pretty reasonable schedule and it is. We are allowed to trade shifts so if, for example, you need a bigger block of days off you can swap with another resident provided that you don’t violate the work-hour rules for Emergency Medicine.

During our first year we work mostly off-service (not in the Emergency Department) rotating on other specialties such as Trauma Surgery, Internal Medicine, Critical Care, Pediatrics, and Obstetrics to name a few. During second and third year we spend most of our time in the Department with a few months reserved for electives. Some programs mix it up a little more. The advantage of doing all the off-service training early is that by the start of second year, you are done with call forever. “Call” is the practice of spending the night in the hospital, in addition to your regular daytime duties, to take care of your existing patients, admit new patients, and handle emergencies. I did two intern years, approximately 150 nights of call, and got meaningful sleep on so few call nights that I can count them on the fingers of one hand. Considering that you may have call every fourth night for most of intern year and you cannot just go home in the morning afterwards but usually stay until one in the afternoon, you can imagine that intern year can wear you down.

But shift work isn’t too bad. You have to discipline yourself to sleep during the day or else the temptation to carry on as if nothing has happened can lead to a big sleep deficit which manifests as the subjective feeling of always being tired and falling asleep whenever you sit down. But if you can master the art of sleeping during the day you will always be well-rested for your shift, bright-eyed, bushy-tailed, and ready to go.

We also have conferences to attend during the month. Unlike other residencies that may have an hour of didactic training (lectures) every day, because of the nature of our work we throw them all into a once-a-week, five hour block. If you are just getting off of a shift you still have to go. Likewise if you are on a day off. No excuses. On the other hand conference sometimes runs concurrently with a shift and since conference is mandatory, you are excused. It all evens out. We also have a Trauma Conference once a month which is also mandatory as well as an occasional wild-card thing like Animal Lab where we practice procedures (chest tubes, internal pacers, surgical airways, for example) on live, anesthetized pigs or dogs (all of which are euthanize at the end of the lab). I love dogs (I have five of them) so it can be a grim business. On the other hand we rarely get the chance to do a surgical airway on human patients and if one day, the skills you learned on a poor dog help you save somebody’s toddler…well….it will have been worth it. No question about it.

So I mentioned that I am learning the field of Emergency Medicine which, as medical specialties go and despite what you have seen on television, covers a broad range of medical complaints. A “complaint,” by the way, is medical-speak for the problem that brought the patient to the Emergency Department. In Emergency Medicine, we can see patients with complaints that are so idiotic they transcend idiocy and achieve a sort of moronic nirvana (“My ass is sweating”). We also see patients with some of the most serious injuries and medical problems that you can imagine. Like that biker who you saw get hit by a truck when you were twelve who had big chunks of himself smeared across the road. You can bet that if he wasn’t dead at the scene, some Emergency Physician struggled mightily to keep him from dying long enough for the trauma surgeons to save his life.

So it’s a real mixed bag. Some nights you feel like a school nurse treating things that would have kept normal people home and some nights the trauma and serious medical complaints just keep rolling in and the minor complaints stew for hours complaining about the crappy sandwiches and the limited television stations.

The purpose of Emergency Medicine is two-fold. First, our job is to assess and stabilize injured or severely sick patients until they can receive definitive treatment. “Stabilize” means to keep them from dying by reversing or halting the processes that lead to death. Shock, for example, is a common presentation and as it is just brief rest stop on the road to death, a chance for the Grim Reaper to sip his latte and finish his bagel before he gets to you, we treat it aggressively. Now, as hospitals are somewhat crowded and we can not always get even extremely sick patients admitted quickly (and even if we can the admitted patient can wait in the Emergency Department a long time until a bed is available) we often not only stabilize but make the diagnosis and initiate the definitive treatment. Critical care (also known as intensive care) is a big part of our job and while most of us enjoy it, it sucks up huge amounts of time and detracts from our second job which is to see as many patients as possible in the shortest amount of time.

For a practicing Emergency Physician, this means seeing at least four patients an hour to be considered a guy who pulls his weight. It may not sound difficult but while many complaints are minor, some are not and almost every patient we see is completely new, a Rossetta stone who needs to be deciphered. In fact, it is not unusual to get a “drop off,” a severely demented (senile) patient from a nursing home who hasn’t spoken a word since the Clinton Adminstration and for whom you have only a sketchy medical history (if that) and a chief complaint of “altered mental status.” If you’re lucky you can elucidate a reasonable list of her many, many medical problems from the medication list (if it was sent with the patient) but sometimes you have nothing to go on at all. Sorting it out takes time.

On arriving at the beginning of my shift, I pick up a computer tablet, scan the list of patients waiting to be seen, and select the next one on the list. I do this for the next twelve hours, consulting with my attending to some level depending on the seriousness of the complaint. I am now carrying the trauma pager so when a trauma comes in I drop what I am doing (if it is not an emergency) and run the trauma with trauma surgery and the attending who usually just stands back until his resident scews something up (which happens a lot, it’s training you understand). Occasionally critical patients, those with potentially life-threatening problems, come in and I again drop everything to take care of them. All of this is done in cooperation with the nurses who do most of the actual patient care, the Unit Coordinators who keep the administrative life-blood flowing, and a team of allied health professionals which includes Physician Assistants, Respiratory Therapists, Phlebotomists, Radiology techs, and the like.

One of the biggest parts of our job is coordinating care which involves, among other things, arranging consults, calling on-call physicians to admit patients, talking to the medical examiner after a death, calling patient’s primary care physicians, and a myriad other tasks that keep us on the phone longer than any other specialty.

If you like multi-tasking you will like Emergency Medicine.

What I Do

Freeloader Nirvana

No Cows Were Harmed

Your typical leftist, a person conditioned for shameless abasement to every social issue that can be blamed on his distant ancestor who allegedly once shot an indian, eats his bowl of Ben and Jerry’s ice cream with the same gusto he usually reserves for giving other people’s money away in the name of social justice. Ben and Jerry’s, as anyone who has taken the tour-cum-political-indoctrination-session of their environmentally friendly facility in Vermont knows, makes ice cream with a social conscience (sort of Cirque du Soleil meets Baskin-Robbins) and there is no hint of filthy lucre or consumerism allowed in this happy, shiny place, even the kind that paradoxically allows people who would otherwise deny to the very gender-neutral and non-denominational heavens their involvement with materialism to spend five bucks for a high quality confection that is the very essence of unfettered materialism. It’s like paying four dollars for a coffee at Starbucks while writing poetry about lynching Dick Cheney and other evil capitalistic tools. There’s kind of a disconnect. But you see, Ben and Jerry’s is materialism with an alibi. You can feel good eating it knowing that the cows making the milk not only were given no growth hormones but also had full access to all of their reproductive options.

In a similar manner, Social Justice is just welfare with an alibi and is a concept to which the left has cleaved because “welfare,” itself at one time a noble sounding word, has so many justifiably negative connotations that to but breathe your support of it will lose you an election faster than a fat kid can inhale a cupcake. The very word itself carries with it the image of a great mass of freeloaders, relieved from the responsibility of providing for themselves, deciding to trade the struggle for a possibly higher standard of living for a lower one but one which requires no productive effort on their part. An unfair generalization of the poor, but true enough in many particulars for anyone who understands human nature and the destructive effects of a large dependency class on both the the intangible moral fiber of the nation as well as the on the economic growth required to pay the tab for multiplying entitlements. The number one problem, after all, of all the Western Democracies is paying for the freebies that were rashly promised in the deceptive times before people discovered that being non-productive was a viable option.

Without belaboring the obvious (although maybe not so obvious as economics seems to be little taught nowadays in the propaganda mills that pass for universities) a government has three choices open to it to pay for its obligations; things like Medicare, for example, which is an obligation because it promises, by law, to pay for the medical care of the elderly even if and when expenditures outpace the tax revenue required to meet the obligation. Your elected representatives can either borrow money from the private sector and do nothing (always a popular choice) in the hopes that the system will only crash and burn after they are out of office; they can print or otherwise create funny money to throw at the problem resulting in inflation and a comensurate devaluation of the currency; or they can raise taxes, a strategy with tremendous appeal to the purveyors of class envy but which has disasterous consequences on the production of goods and services, stifling as it does the incentive for individuals to be productive and increase the wealth of the nation. This wealth is the sum total of all the goods and services produced and what is required to to serve as collateral for the mortgage we sign when give every American the right to have as many babies as they want on somebody else’s dime or take no responsibility at all for any aspect of their medical care.

And we’re going to justify this kind of thing by invoking Social Justice, a nebulous phrase that is so ghost-like nobody can really define what it means except that by God, somebody’s giving out free money! To some, social justice means equality although it’s a crazy kind of equality. If everybody is equal and medical care is a right, are people who pay for better medical care violating somebody else’s rights? This would make the entire ruling classes of Canada and Europe, people who can and do avail themselves of medical treatment not available to the proles, the biggest violators of human rights on the planet. They need to be arrested. But why stop at medical care? Housing is more important to most people. You’ll die in an hour or two here in the frozen part of Yankeeland without shelter. Your high blood pressure? Hell, that’ll kill you at a leisurely pace. Does the right to housing guarantee a yurt? A crappy apartment in some crime-infested project? A split-level ranch in the suburbs? A mansion? Why the disparity? It is a right after all. My freedom of speech is not better than anybody else’s, why is the right to housing any different?

Some leftists, driven by self-loathing for their privileged upbringing and their hatred for their nation, define Social Justice as payback, extortion to be paid to the poor because once upon a time, some African tribal king sold a distant ancestor of the underserved to a Muslim slave trader who ended up, after being processed in a Portugese baracoon, in the Virgina colonies. The only equitable thing thing to do then, if you go in for this kind of nonsense, is to give everybody who still feels the psychic pangs of the suffering of their distant ancestors a bunch of freebies, paid for by people whose ancestors may have had nothing to do with the distant crimes and in fact, as is the case of my own Greek ancestors, had their own problems at the time. In the name of equality and Social Justice, we’re going to assign collective guilt to people based on nothing but their ability to pay protection money to their leftist masters, a strange notion of justice more in keeping with some third-world kleptocracy than a country built on the principles of individual freedom and inalienable rights.

Throw then, oh you who long for social justice, a general blanket of oppression over everybody who is poor and insist that it is The Man keeping them down despite the fact that a constant stream of immigrants, arriving from countries were oppression truly exists, have somehow managed to pull themselves out of poverty and run circles around the children of the big, bad oppressors, those rough beasts, their hour gone, shuffling towards the trailer parks. It will have to be a general kind of blanket, a big, wet, suffocating blanket because unless you plan on convening a Council of Wizards to divine the complicated mileu of each life-perhaps deciding that a Greek who only suffered a little at the hands of his ancestral oppressors is only equivalent to three-fifths of a real, oppressed man in good standing-there is no way to equitably distribute anything at all. To even try is to exacerbate what isn’t even a problem except that we gotta’ have our alibi.

Freeloader Nirvana

Freeloader Heaven

Screw Social Justice

If you proposed to me that all of the poor were lazy and desired nothing more than to live lives of sloth and overindulgence; smoking their cigarettes, drinking their cheap booze, shooting their drugs, and having their lllegitimate babies willy-nilly at the taxpayer’s expense I would call you a starry-eyed idealist and and someone without a firm footing in the real world. In no way would I want your naive idealism to guide public policy because your point of view would be so extreme as to be ridiculous. And yet if you were to propose the converse, that the poor were all noble creatures mightily striving but failing to obtain their slice of prosperity because they were held back by racism, inequality,and every barrier that could be put in their path by The Man, you would be feted as a deep thinker, a person with a firm grasp on reality, and your own peculiar brand of idealism, as equally ridiculous, would inform a hundred public policy initiatives.

But that’s the problem with Social Justice, especially as it is used to justify giving everyone free health care. It makes the assumption that everyone is a victim and doesn’t allow for the possibility of the freeloader who not only exists in droves but is aggressively selected for in every nanny-state ever created. People may be lazy but they aren’t stupid and, as most people do not love their jobs, if the conditions are set to obviate the need for work many people will tend to do as little work as they possibly can. This sort of society is not sustainable for more than a generation or two as our cousins in Europe are starting to realize and it is certainly going to bankrupt our nation if we continue down the same path. In fact, the number one problem in all of the Western Democracies boils down to the unsustainable growth of entitlements paid to non-productive citizens by a dwindling pool of productive workers. Many of the recent riots in France, for example, were instigated by their government’s clumsy attempts to slightly reduce entitlements, already at levels that would make our most flagrant abusers of the welfare system blush with shame.

With this in mind, you’d think that our goal as a nation would be to reduce entitlement spending, limiting it as much as possible to those hopeless cases who demonstrate that they would actually starve to death or die from lack of primary care if not given a helping hand, not to work towards the opposite goal of giving everyone free everything whether they need it or not. Not that anything is really free. The money comes from somewhere although governments occasionally take leave of their senses and print money with nothing to support it, a short term strategy that fools nobody and leads to inflation and lack of confidence in the currency.

Unfortunately the mob, once it discovers it can vote itself access to other people’s wallets, is difficult to keep in check and the usual dependency triumvirate of ghetto, trailer park, and academia are perpetually braying for somebody else’s money. The extent to which this money can be secured depends on how many productive citizens can be lured onto the dependency plantation, usually by the propaganda of fear and class envy. The problem with creating a welfare state is that it tends to fulfill the dire prophecies of its creators. The more productive citizens are taxed the more economic activity is stifled leading to stagnant economies where there are, in fact, no jobs for many people who would be employed if growth and economic opportunity were encouraged at the expense of stealing from one set of citizens to give to another.

Social Justice is a euphemism for welfare, a word that has been so thoroughly demonized that the left has to invent a more pleasant sounding phrase.

Make Up Your Minds

The usual suspects crying for social justice are deeply conflicted anyway and their outrage is mighty selective. On one hand they argue that a collectivist approach needs to be taken to distribute medical care, essentially saying that doctors and nurses who provide this care should be forced to provide it at whatever price the the congress, acting entirely from self interest, determines to be fair. And provide it even if it entails the majority, through increased taxation, sacrifice some of their material prosperity the use of which for their own purposes is the ultimate freedom. On the other hand if I insisted that for the collective good, the ability of a citizen to sue his doctor be severely curtailed, the usual suspects will wax sanctimonious about the inability of a free people to allow even the smallest of their rights to be violated at any time, in this case the right win a legal jackpot.

Surely some medical lawsuits have merit but under the theory of social justice, for the collective good of the majority who would benefit from cheaper medical care, the minority deserving of malpractice awards would have to suck it up for the greater good. Likewise, if I insisted that for the collective good we put yer’ elderly granny down when she becomes too much of a burden to the nanny state the cries of outrage would ascend to the very heavens.

As if we don’t have enough trouble administering real justice we now have to gear up to dispense social justice, a highly nebulous concept the implementation of which requires that grievance, race, age, social status, intelligence, and other things that Americans should ignore be worked into an arbitrary and impossible behavioral calculus to give to each according to his need and to take from each according to his ability.

Freeloader Heaven