Death at 30,000 Feet and Other Random Notes

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

Let Me Through, I’m an Interventional Cardiologist

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

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

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

Coulrophobia

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

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

Match Day is Coming Up

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

Death at 30,000 Feet and Other Random Notes

Random Notes from a Febrile Mind

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

You Folks Have Got it All Wrong

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

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

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

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

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

Code Pink

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

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

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

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

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

The Well Will Run Dry

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

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

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

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

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

Random Notes from a Febrile Mind

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

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

Actual Patient Interaction Number Six:

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

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

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

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

“Is it your usual back pain?”

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

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

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

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

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

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

“I’m having chest pain too.”

Actual Patient Interaction Number Seven:

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

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

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

“Well, he should practice what he preaches.”

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

“He’s a hypocrite.”

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

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

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

“My sister gives it me.”

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

“Uh…”

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

Actual Patient Interaction Number Eight:

“My dog ate my pain medication.”

“What kind of dog is it?”

“Uh…I don’t know, it’s a dog, man.”

“is it a big dog? A little dog?”

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

“Did you take it to the vet?”

“Huh?”

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

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

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

Actual Patient Interaction Number Nine:

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

“Where’s my boyfriend?”

“He’s talking to the police.”

“Do you think he’ll go to jail?”

“Probably.”

“Do you think he’s still mad at me?”

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

“But he loves me.”

“I don’t think so.”

“How can you say that?”

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

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

Overdoctored

Rocking Your Fragile World-View

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

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

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

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

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

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

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

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

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

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

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

Where’s the Fire?

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

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

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

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

What We Have Here is a Failure to Communicate

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

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

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

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

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

What’s Albania Got to Do With It?

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

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

Overdoctored

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

Actual Patient Interaction Number One:

“So Mrs. Smith, how’s your pain?”

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

“How about we start with some Nubain?”

“What’s that?”

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

“Is it any good?”

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

“Oh, I’m allergic to it.”

Actual Patient Interaction Number 2:

“I felt sick, doc. At work.”

“When did it start?”

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

“Really, how are you feeling?”

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

“So you don’t feel sick now?”

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

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

“Well, I need a note for work.”

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

“I don’t like my job that much.”

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

“Well, I really don’t like my job…”

Actual Patient Interaction Number Three:

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

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

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

“He doesn’t. He looks great.”

“I want a cat scan.”

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

“My sister said he needs a CT.”

“He doesn’t.”

“We waited five hours.”

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

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

“No.”

Actual Patient Interaction Number Four:

“So, what brings you in Mr. Jones?”

“I’m constipated.”

“How long has it been going on.”

“Almost three years.”

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

“I need help getting the shit out.”

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

“No.”

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

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

“Not in this lifetime.”

Actual Patient Interaction Number Five:

“I’m going to sue all y’all.”

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

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

“I’m trying to make her comfortable.”

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

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

“She’s been falling a lot lately.”

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

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

Staying Power

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Other People’s Money

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Does your back hurt?”

“Yes.”

Do your legs hurt?”

“Yes”

Does your face hurt?”

“Yes.”

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

“Yes.”

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

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

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

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

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

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

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

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

Fifteen minutes later, accosted by customer service representative.

“Can you give her a work excuse?”

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

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

“Absolutely not.”

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

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

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

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

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

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

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