Can’t Touch This…

Actual Patient Conversation:

“Man, that Dilaudid didn’t even touch my pain.”

“Uh, Okay.  Your CT was negative so you’re fine to go home.  I’ll ask your nurse to come discharge you.  Come back if you get light headed or start to vomit but otherwise, just take Motrin for your headache and you should be fine.”

“Can you give me a prescription for Vicodins.”

“No.  If the Dilaudid didn’t even touch your pain then this must be the kind of pain that doesn’t respond to narcotics and a couple of Vicodin would be useless…I mean Dilaudid is one of the most powerful narcotics we have and it didn’t do a thing.  Stick to the Motrin.

“How about some Demerol.”


Another Actual Patient Conversation:

“Vicodin doesn’t even touch  my pain.”

“I’m sorry.  That’s all I’m going to prescribe.”

“Can you give me a ‘scrip for my Methadone?”


“Well, how ’bout a shot of somethin’ before I go?”


“Aw, man.  Fuck you.  I want to speak to the manager.”

“Sir, this is not the International House of Pancakes.”

Darn You, Manny Rivers!

More than the usual number of incredibly sick, incredibly old, incredibly senile, incredibly decrepit, and incredibly still alive patients today.  There must have been a convention because for the first half of my shift the average age of my patients was around 86 and between the eight of them they had 112 distinct medical problems, 38 doctors, 26 artificial joints, six pacemakers, 18 coronary artery stents, and, as three of them had ileostomies, only five functioning rectums.  The presenting complaint for seven was some variation of decreased mental status and one had stroke-like symptoms consisting of a slight facial droop although it was later confirmed that this was an old finding, first observed during the Clinton Administration.

A couple of the families were reasonable and declined any further medical care except hospice but the rest wanted “everything done” and committed us to expensive and extremely futile workups and admissions; three of the patients in particular went to the Intensive Care Unit where they are even now laying insensate and demented in their cocoon of medical equipment, either spending their grandchildren’s money or screwing our Chinese and Arab creditors depending on how likely you think it is that we can ever pay back all of the pretend money we are printing to pay for this insanity.

A day in the ICU costs Medicare approximately $4000 once all the costs are factored in.   A week or two and we’re talking serious money, much of it totally wasted in the sense that many of the patients on whom it is spent have almost no chance of ever leaving the ICU and, if they do, will be essentially vegetative until they finally die.   ICU charges under Medicare are in the Neighborhood of 40 billion dollars per year and rising.  Medicare itself spends around 300 billion per year, almost half of that for hospitalizations of all kinds.

I blame Manny Rivers and his surviving sepsis campaign.  Sepsis is an infection that leads to shock  and, until very recently, was largely fatal especially in the elderly who regularly succumbed to septic shock from bad urinary tract infections or pneumonia (so much so that pneumonia was once know as the “Old Man’s Friend” as it regularly relieved the suffering of the senile and bed-bound).  Dr. River’s great gift to medicine was what now seems like a simple method to aggressively treat sepsis that has significantly decreased mortality, extending the lives of many patients who would have otherwise been almost untreatable.  The foundation of his method is a five or six liters of inexpensive Normal Saline and, stripping away all of the fancy equipment and the flashing lights, that’s pretty much it.

While generally a good thing, especially as I have seen many elderly septic patients returned to the full enjoyment of their glorious old age, just because we can do something doesn’t mean we need to do it all the time.  I don’t always know when care is futile and I am not so arrogant to think I can judge the worth of anybody’s quality of life but there are some cases that are so obviously futile, that for example of a nonagenarian  whose every bodily function comes through and out of a tube and who hasn’t so much as moved purposely in a couple of years, that what we do is not only insanity from an economic point of view but also from a human decency one as well.  We do what the families want, however, rational or not.  First because we are conditioned to never give up.  Second because we have surrendered a great deal of medical decision making to the patients and their families even if they are not qualified to make the decisions and, more importantly, as they are not paying for any of their treatment have no skin in the game.  Third because we are afraid of the legal implications of withdrawing care, so much so that hospitals have ethics committees for the rare occasion when enough is enough whose principle purpose is to spread the liability.

And fourth, as there is a lot of money changing hands there is little incentive for hospitals not to aggressively treat everybody who comes in.  It’s either that or have ICU beds sitting idle generating no revenue whatsoever.

But the madness needs to stop.  What we need is a Futility Scoring System, perhaps a simple sum of points given for co-morbid conditions and age above which only comfort care or home hospice will be reimbursed by Medicare.   And it needs to become the standard of care.

Now if we could only find someone to put the bell on that damn cat.

Can’t Touch This…

More Random Reader Questions and in Which I Give Some Real Medical Advice Without Fear of Being Sued

(Actual questions from actual readers. -PB)

I know you don’t like chiropractors but what are we supposed to do for chronic back pain?

For chronic back pain I recommend back strengthening exercises, instruction in correct lifting and posture, weight loss, physical activity, judicious use of NSAIDs, and occasionally just sucking it up.  For serious back pain which may be the result of a herniated disk, tumors, or occult fractures, I recommend imaging to assess the possible source of pain and such medical or surgical therapy as an orthopedic surgeon may suggest. I’m certainly not sending somebody with a lumbar fracture or ankylosing spondylitis to a chiropractor which would be like going to the barber to have your transmission serviced.  It just makes no sense.  Most back pain is usually self-limiting, however, and resolves in a few weeks without intervention of any kind.  With this in mind, what’s your chiropractor really doing for you?  Nothing.  Neither is the doctor who enables your narcotic addiction, especially when he writes you a prescription for vicodin just to get you out of his hair.

I am becoming seriously zero-tolerance for handing out narcotics for chronic back pain.  It’s your primary care doctor’s job anyway and I’m not really qualified to do it.  Oh, and I don’t buy the bullshit stories about allergies to Motrin and other non-narcotic pain medications.   A patient who is allergic to everything but Dilaudid (essentially legal heroin prescribed by a physician) is a drug-seeker, period.

What is the secret to good health?

Don’t smoke, don’t stuff dangerous recreational drugs into your body, if you drink do so in moderation, eat a healthy, varied diet without resorting to fads and supplements, and exercise as regularly and as vigorously as your health will allow.  Also, get outdoors into the fresh air whenever you can, have an interesting hobby or two if your job doesn’t fill your need for creativity, and get regular sleep.

The rest is just marketing.  You don’t need to eat organic foods or make a fetish out of being “natural.”  Additionally, all the fish oil and vitamins in the world probably won’t make a bit of difference to your health and if they do, the effects will be marginal and not worth the effort and expense.  Good health is mostly common sense, inexpensive lifestyle choices, and genetics.

Eat a fucking steak every now and then.

What do you think of Emergency Department “Super Users?”

The reader is referring to a recent story detailing how just nine patients made 2700 visits to Central Texas Emergency Departments over the course of six years.  That’s roughly one visit per week per patient for six years.  First, I assure you that this sort of thing is not confined to Texas.  I work at two different Emergency Departments and I see my share of “frequent fliers,” some who I have seen multiple times at both departments and usually for what turns out to be either nothing or a minor exacerbation of a chronic medical problem for which they are also seeing their primary care doctor  (although to be fair I have intubated one guy seven times in the last three years).

The next question is why do these people keep sucking down medical resources?

The answer is: “Who cares?”   Are many of these Super Users mentally ill?  Sure, some are.  Do they have real medical problems?  Of course they do.  But what does it matter, really?  If they are so sick and so crazy that they suck down a million apiece in medical care, most of it wasted and money that is not available to people who need it, then they need to be institutionalized for their own good because they obviously can’t handle life in any rational manner…except of course they are rational enough to know that they can never be turned away from an Emergency Department and structure their lives accordingly.  I say this because every proposal suggested to correct the problem of Super Users does not address the real underlying problem, namely that personal responsibility and civic virtue are no longer required of any citizen and, despite being a nation  of a million little rules and regulations, no effort is made to enforce even the slightest amount of common-sense based decency.

In other words, the solution to the problem of Super Users is not to coddle them even more by coming up with yet more government initiatives to essentially beg and bribe the parasites on our system to pretty please stop wasting more medical resources in a month than most people have used in their whole lives, but instead to cut them off at the knees; something that we could easily do, perhaps placing a limit on Emergency Department visits after which you become an automatic Get The Hell Out, except the legal environment is such that it has now become a right to squander as much of the public treasury as you possibly can.   It is one of the biggest ironies of American life that while on one hand the productive sector is now supposed to be collectivized, subordinating their rights as individuals to the benefits of their labor in order to provide a living to the non-productive sector, to suggest on the other hand that citizens engaged in criminal abuse of society by essentially stealing collective money should be punished will bring out the usual braying from the defenders of irresponsibility, now screaming about the rights of individuals and how collectivization of responsibility is unacceptable.

Tea Party Update

I was surprised at the turnout.  I live in a small Midwestern city of about 100,000 and there must have been 20,000 people at the Tea Party.  It was a very nice, enthusiastic, but well-behaved crowd of mostly what looked to be working class and professional people with the odd scattering of Viet Nam veteran bikers who are obligatory at this kind of thing.  Very few freaks and the few I saw were actually very nice college kids who dressed like goth punk rockers but were quick to assure me that they were College Republicans at our local Big State University.

There was no counter protest, at least none that I saw.  One had been planned but I think the people who showed up for it saw the size of the crowd and said to hell with it.  I did talk to two well-dressed, well-spoken law students who, they said, had been sent by ACORN to “infiltrate” the rally.  The people around us laughed good-naturedly at this as not only did nobody care but the place was so packed a mouse couldn’t have infiltrated too far.  They tried to debate and then got sort of haughty, brandishing their superior academic credentials as proof that we were all misguided but within ten feet of me were two other doctors, a chemical engineer, and couple of lawyers so that generated more polite laughter.

I saw them drift away looking perturbed.   Liberals sometimes live in air-tight bubbles and I think they were a little surprised that the crowd was not composed of toothless hicks clinging to their Bibles and guns while waving the Stars and Bars.

Incidentally, if ACORN is now getting federal money, what were they doing proselytizing at a political event?

More Random Reader Questions and in Which I Give Some Real Medical Advice Without Fear of Being Sued

Don’t Forget….

A short post today, my apologies, but I want everybody who can to attend their local “Tea Party” on April 15th.  As you may recall from American history, back in 1773 American colonists irate over increasingly oppressive duties and tariffs imposed by the British disguised themselves as indians, boarded British Merchantmen in Boston Harbor, and threw their cargo of tea overboard, protesting among other things taxation without representation.

Taxation with representation ain’t so hot either and, as Washington is now completely in the clutches of our home-grown criminal class, I’d like everybody who gives a crap about liberty, free enterprise, and stopping the conversion of our country into just another European mammary state to gather with your fellow citizens at your city’s tea party.

Keep the following in mind:

1. Although the tea parties are being touted as “Conservative” events and their will be many conservatives there, you don’t have to be completely conservative to go.  They are more and expression of Libertarianism but conservatives share some similar values so it’s cool.

2. Keep yer’ pro-life, pro-gun, pro-whatever stuff at home. I’m pro-life and pro-gun but this is not the day for it.

3. Be polite to the handful of counter-protesters. They will be freaky and transgendered looking and they will be advocating as many issues as their are protesters, most having nothing to do with taxation, but that’s just their thing.  I have been to many conservative events and without exception conservatives and Libertarians are well-dressed, polite, well-spoken, and behave in a way that makes our events family friendly.   I have never seen the police have to use pepper spray, dogs, or any intimidation at all to control conservative crowds (in fact most cops are probably on your side) so let’s make it a pleasant day for everybody including the police.

Don’t Forget….

47 Million Uninsured My Ass

(With apologies to Deborah Peel -PB)

So I had this uninsured patient with a chronic medical problem that was being addressed at The Big Academic Medical Center Sixty Miles Away who came to the department with worsening symptoms from her chronic medical problem, a problem that was competing, I might add, with several others that were lifestyle related.  No problem, of course, because people can’t choose when they are going to get sick and if we have to fill in for The Big Academic Medical Center Sixty Miles Away then so be it.

An expensive workup ensued which confirmed the worsening of her chronic medical problem.  Score!  A slam-dunk admission.  A pleasant phone call to the admitting physician who, even though it was 3 AM would agree, ruefully and without the usual surliness and rolling of the eyes that it is our lot to elicit in every doctor in town at one time or another, that the patient really was sick and really did need admission.  Unfortunately, as soon as I mentioned the patient’s name he related to me that at her last admission for a similar exacerbation of her chronic medical problem she had eloped, leaving the hospital and her doctor’s care because she believed she was being treated rudely. On her way out she had sworn to “never let them touch me again.”

A week after her elopement and while visiting her sister at the Big Academic Medical Center Sixty Miles Away (a sister who interestingly enough had the same chronic medical problem), she checked herself into their swank Emergency Department for a similar worsening of her chronic medical problem and was admitted; receiving an expensive workup and, on discharge, a follow-up appointment with one of the Leading Specialists in the Field of Herchronicmedicalproblemology, a lady who has written textbooks and who had followed her at the Big Academic Medical Center Sixty Miles Away.

The admitting physician adamantly refused to admit and suggested, not unreasonably, that I transfer her to The Big Academic Medical Center Sixty Miles Away as they were the last to lay hands on her and were most familiar with her condition.   The Big Academic Medical Center Sixty Miles Away agreed, without hesitation, to accept her and I even spoke to the Leading Specialist in the Field of Herchronicmedicalproblemology who happened to be on call.  Oh how the heavens sometimes align and, just when you think you are heading for a knock-down, drag out patient transfer brawl you see the triumphal field just ahead and prepare to eat the cheeses and hams of victory!

Unfortunately, despite having no insurance, no ability, and no intention of ever paying a thin dime for the hundreds of thousands of dollars of free medical care that she has received and will receive until that tragic day when the treasure we spend will only bore the Reaper, the patient refused transfer to The Big Academic Medical Center Sixty Miles Away citing a litany of complaints against them from rude nurses to bad food, perhaps most damning being her observation that the Leading Specialist in the Field of Herchronicmedicalproblemology didn’t know what she was doing and, “Didn’t do nothing for me.”

Not to mention that the one hour drive would inconvenience her family, their constant attendance with cell phones at ready being a necessary adjuvant therapy for her chronic medical problem.

Oh my gentle readers, scholars all and deeply interested in this insane goat rodeo known as American Medicine, you would have wept at the sincerity of our efforts to prevent her, unsuccessfully, from eloping and leaving the department to nestle in the bosom of her uninsured family.  There may be 47 million uninsured (most of whom are young enough to never require expensive medical care or wealthy enough to afford insurance except they have other priorities) but this particular one of them was so unconcerned for her own health that she spurned our best efforts over a matter of overblown pride and convenience for the many visitors she expected.  Is she typical of the uninsured?  Maybe not.  But we can and do move heaven and earth to care for all of our patients, even those who cannot pay. I have never heard of a patient who needed treatment being turned away which is why a wino living on the streets of our country can receive medical care that European politicians living in The Health Care Paradise Across The Water have to fly to other countries (ours) to get.

47 Million Uninsured My Ass

Ask Yer’ Uncle Panda: More on Mid-Level Providers and other Topics

(In which I answer several random questions submitted to me by readers. -PB)

Hey, Panda, I’m not sure what specialty I would like to do and am considering going to PA school because Physician Assistants can easily move between specialties.  Your thoughts?

I often hear the ease of movement between specialties touted as a benefit of being a Physician Assistant or other mid-level provider. The theory is that if you find yourself bored in, say, primary care you can easily find a job in a different, more interesting, or more lucrative specialty.  By contrast, changing specialties as a physician is a long, incredibly arduous undertaking. The only way, for example, an internist can credibly practice as a cardiologist is to complete an additional three year fellowship on top of his first three years of residency.  If, as another example, I wanted to practice as a surgeon I would have to apply for and complete an additional four years of residency training assuming any surgery residency program would take me which, because of the way medical training is funded, they probably wouldn’t.   A Physician Assistant, on the other hand, can get a job with a cardiology group and a few days later, mutatis mutandis, he is a cardiology PA.

Nothing wrong with this of course. The role of a Physician Assistant in many specialties does not require the depth of knowledge of a physician and I repeat, as many Physician Assistants are hired to do the relatively low-skilled grunt work of a practice this depth of knowledge is not required. But unless we’re going to revisit that magical world where two is bigger than four, five years of residency is no different than a little on-the-job-training, and superior knowledge can be had without learning all of that useless stuff, the ease of moving into different specialties should only indicate that a certain…how can I put it…comprehensiveness is not required of a Physician Assistant.

Which is not exactly a ringing endorsement of the depth of Physician Assistant training although if that’s your thing, go for it.

But Panda, can’t Physicians Assistants do 90 percent of what a doctor does?

No.  Although to be fair they can do 90 percent of the paperwork so, since fifty percent of my job consists of useless bureaucratic tasks, ipso facto they can do a large part of my job.  The conceptual difficulty many of you have is your lack of understanding about the structure of the goat-rodeo-cum-cluster-fuck known as American medicine in which there are three broad specialties.  The first is actual, honest-to-Jehovah Medicine of the kind we all imagined we would be practicing long ago before we actually started wrestling the proverbial pig.  You know, things like diagnosing and treating diseases using good clinical judgment and appropriate testing and consults.

The second specialty is Tort Medicine which is something we do continuously in an effort to minimize the perceived risk of being named in a lawsuit for a bad outcome that may or may not have been our fault.  As this primarily involves throwing vast quantities of money at our patients in the form of useless, unnecessary, or only marginally helpful studies and procedures in an attempt to uncover every single thing that could possibly be wrong with the patient (no matter how unlikely), I see no reason to doubt that Physician Assistants can handle these tasks admirably, the number of boxes you check on the order sheet being often inversely proportional to your knowledge of real medicine.

The third and largest specialty is Boilerplate Medicine in whose service we devote countless hours charting, documenting, and filling out reams of redundant forms, the main purposes of which are to legitimize billing and keep millions of low-level administrators gainfully employed.  It is in this specialty where mid-level providers particularly excel and for which most are hired.  What are most History and Physicals for routine admissions and procedures, after all, but loads of useless information, grimly documented for the insurance company, surrounding a kernel of important facts?  Unfortunately, since you can’t bill insurance companies or the government with a concise paragraph describing everything important about the patient, we have developed check boxes and forms that codify useless information and organize it for easier parsing by bureaucrats; even though for strictly medical communication all most doctors need and would prefer is a brief paragraph.

Or, to look at it another way, I am now after eight years of medical training capable of writing a brief, elegant, and succinct paragraph describing everything you need to know about the patient as well as my assessment and plan which any other doctor can read and understand completely.  If this was all I had to do I could probably see twice as many patients but unfortunately, the government and private insurance companies (not to mention the lawyers as there is considerable overlap between Tort and Boilerplate Medicine) need their medical prose like a sailor needs a happy ending and if I can hire a relatively cheap mid-level to crank it out then so much the better.

The real question should be whether someone needs a two-year Masters degree (in the case of Physician Assistants) or one year of fluffy smugness (in the case of Nurse Practitioners or Doctor Nurses or whatever the hell they want to be called) to essentially fill out a bunch of mostly useless paperwork?  Surely if clinical skills are not that important, and that’s exactly what a mid-level is really telling you when he insists that his two years of training is equivalent to your seven or more, then we could probably save a heap o’ wampum by training motivated Community College students for an exciting career that we can call “Physician Assistant Assistant” (or PAA) and eliminate the expensive mid-level middleman.

But what about Primary Care?  Surely mid-level providers are suited for primary care?

You only say that because you don’t understand primary care or are confusing it with something else.  Primary care physicians should and ought to have the highest level of medical knowledge and clinical instincts because they are not specialists and therefore have to be fluent or at least conversant in all of the medical specialties.  To the extent that they aren’t is only a reflection on the nature of American Goat Rodeodery where reimbursement and the predatory legal environment makes referring to specialists a de facto requirement for a primary care physician’s financial survival.   With this in mind, most specialists are used not in their intended role as sage consultants for particularly difficult cases but as extenders for over-worked primary care physicians, meaning that they primarily see nothing but fairly routine patients with bread-and-butter conditions that the patient’s family doctor simply did not have the time or the legal gonads to address.  In this respect mid-level providers are probably better suited to the specialist trade, and the more specialized the better, because it is easier to acquire a superficial knowledge of a highly specialized field than of a broad, non-specialized one.  I know, for example, a Pulmonary Medicine Nurse Practitioner whose entire job is to set patients up for bronchoscopy, the pulmonologist’s signature procedure and biggest money-maker.  Realistically, however, I could train a high school student to do most of her job.

Now, it is true that primary care physicians see a lot of minor complaints.  Hell, I’m an Emergency Physician and I see plenty of them too, some so trivial that it would drive one crazy if it weren’t for a sense of humor or plentiful, cheap whiskey.  In fact, a substantial subset of the patients I see have complaints that are not only minor but only twenty years ago wouldn’t even have been considered the kind of medical problem for which someone would legitimately seek medical attention.  Can a mid-level provider handle these?  Of course.  But are they sure they want to make the motto of their profession, “Mid-Level Providers: Wrangling Patients that Don’t Really Need to Be Seen So You Don’t have To?”

Primary Care, in other words, is not just about minor complaints and it is not urgent care either.

What About Urgent Care?

Urgent Care is mostly a scam, at least in cities that have functioning Emergency Departments and I would advise most of my patients to avoid them as an unnecessary and costly middleman.  With a few exceptions, if your complaint is minor enough where it can be addressed in an Urgent Care Clinic you probably didn’t need to be seen at all and whatever treatment was prescribed is just a placebo, something to show that we care or to keep you amused while nature takes it course.  If your complaint is legitimate or even the slightest bit threatening the practitioner running the place will default to his legal protection mode and refer you to the Emergency Department, off-site Emergency Department triage actually being the only legitimate medical function of Urgent Care clinics.

Can you get a school sports physical at an Urgent Care or a note from your doctor as an excuse when you miss work?  Sure you can.  But these things are worth what they are worth.  The work note is worth nothing medically and the cursory sports physical as it will never pick up any but the most obvious reasons why you might drop dead while playing basketball, fulfills what is mostly a bureaucratic requirement and not a medical one.   This is why, by the way, residents love moonlighting at Urgent Care Clinics.  Namely because it pays pretty well, the stakes are low, nobody is really sick, and if they are you can easily punt to a higher level of care.

What about Complementary and Alternative Medicine?  Can’t I go to Chiropractic School or something like that if all I want to do is primary care?  My Chiropractor advertises himself as “Primary Care” so I was just wondering.

Complementary and Alternative Medicine is mostly modern superstitious drivel marketed to people who are, in their knowledge of science and reason, no better than seventh century peasants except that Dark Age peasants had an excuse to be ignorant as they had marauding Norsemen competing for their attention.   On the other hand most people don’t think about medicine that much and have no reason to distrust their chiropractor so allow me clear something up for you: Chiropractors, naturopaths and other Alternative Medicine practitioners do not have the same training and education as medical doctors, not in quality and not in quantity, not by a long shot, and therefore they are not qualified to serve as primary care physicians, a job that requires more than some haphazard study of herb lore or a cursory knowledge of the spine. If they had the same training including residency training they would be qualified…but they don’t so they’re not.

Take your typical chiropractor, for example.  He has a four-year degree at an institution that was probably nothing but a federal student loan processing mill in which the odds are he never saw a really sick patient, at least not one that wasn’t immediately taken to the nearest Emergency Department.  Unlike your Family Physician who has four years of medical school followed by an intensive three year residency, your chiropractor has never rotated on a pediatric ward, in the Intensive Care Unit, on an internal medicine service, a surgery service, or any other of the medical services in which the core knowledge of every physician is developed.  He has done no call, been responsible for exactly nothing during his brief pseudo-medical training and has never had to make a decision that mattered to anybody.  More than likely he slithered through chiropractic school making a mental list of the many, many things he would never have to worry about (I mean, assuming he was introspective enough for this) and that he would defer to real doctors.  He is, therefore along with his naturopath cousins eminently unsuited to recognize, diagnose, and treat general medical complaints.

The funny thing is that I would never try to pass myself off as a surgeon, an obstetrician, an internist, or a neurologists because I lack the training and knowledge to honestly represent myself to the public as something I am not…and yet naturopaths, chiropractors, and the whole pack of Snake Oil Salesmen with a fraction of the training required for the job lack the humility, the self-awareness that comes with an appreciation of their own limitations, to consider that maybe, just maybe, they don’t know enough to be primary care physicians.

No doubt your Chiropractor can fill out forms with the best of them and correctly bill your insurance company but if you have a medical problem serious enough to warrant treatment you should see a real doctor and eliminate the useless middleman.   Likewise if you really care about your long-term health.

Not to mention that the primary treatment modalities of practioners of Complementary and Alternative Medicine are extremely ridiculous on a fifth grade biology level.  To believe in them, things like subluxations and Reiki, is to place yourself in the company of drooling cretins.

Ask Yer’ Uncle Panda: More on Mid-Level Providers and other Topics

1001 Ways to Die

1001 Ways to Die

There has got to be a better way to die and surely the patient at the center of our frantic activity couldn’t have wanted this one.  I arrived at his room with a code in progress although, as the patient was still alert, most of the activity involved throwing towels on the floor to soak up the large quantities of ink-colored blood pouring from his mouth, his nose, and the edges of his adult diaper.  The patient was obviously in severe respiratory distress and one of our junior residents who was running the code prepared to intubate, securing the patient’s airway and providing ventilatory support being the first most reasonable step to…well…I don’t know what except that the family wanted everything done even though no power on earth could reverse what was ordained by cruel nature and metastatic cancer.

As the patient opened his eyes for the last time, gaping in horror as he drowned in his own blood, I’m sure he saw gibbering death slouch into the room, leer at the nurses, and settle into the shadows with a smirk on his face to enjoy the end of the show.

Then, as suddenly as turning off a switch the patient was gone which naturally didn’t stop us from ineffectively performing half an hour of violent maneuvers on his body and throwing all manners of potent but useless medications into it before the family, huddling in terror just outside the door, were convinced and asked us to stop.  We slid a breathing tube into his trachea, rammed a  big intravenous line into his femoral artery, crammed him full of fluid, ran electricity through his heart, and bounced him around his stool and blood-soaked bedding; only pausing to look hopefully at the monitor for cardiac activity even though he was glassy-eyed and had that dead look about him.  Our junior resident even optimistically ordered some O-negative blood (which is what you give if you don’t know the blood type) from the blood bank but we weren’t exactly holding our breath for it to arrive from the deep basement labyrinth of the hospital.

If you can believe it, the desperate struggle against failing organs now at an end, he looked better dead than alive but then, as I first saw him crouching on a bedside commode moaning in terror,  I didn’t exactly catch him at his best.

Eternal God Whose great mercy endures forever. Spare me, Your devout but occasionally wayward servant, from this kind of death and grant that I may die peacefully in my bed.

Why People Love Complementary and Alternative Medicine

I had a patient the other day with some very mild conjunctivitis (“pink eye”) which, in otherwise healthy adults is almost always-and I mean the planets align when it’s not-viral or from some other cause that is untreatable except for symptomatic relief.  After checking her visual acuity, verifying that her pupils were normally reactive (to exclude iritis which is a big deal), and even doing a completely unnecessary slit-lamp examination of her cornea I was able to give her the good news that her condition was benign, required nothing but symptomatic relief, and would almost certainly resolve completely in the next one to two weeks without the need for topical antibiotics (which we often prescribe even though the evidence for their effectiveness even in the case of mild bacterial conjunctivitis is less than compelling) but only some mild analgesic eye drops.

The patient balked at the thought of one to two weeks, “Won’t the medications you’re giving me make it heal faster?”

“No,” I explained.  The eye drops just offer relief of symptoms but nothing we can do will shorten the duration of your conjunctivitis. It’s very mild, we don’t really know what’s causing it, and you should be fine.  If it gets worse you can see an ophthalmologist or even come back here.”

“Can’t you give me something to make it heal faster?”

“No,” I explained.  The eye drops will just offer relief of symptoms but nothing we can do will shorten the duration of your conjunctivitis. It’s very mild, we don’t really know what’s causing it, and you should be fine.  If it gets worse you can see an ophthalmologist or even come back here.”

And so it went for five minutes after which, not convinced, the patient allowed that she would be paying a visit to a well known local Wellness Center, a shameless emporium of every form of snake oil I have ever heard of, where no doubt the magician on duty will provide some magical potion or Eastern herb that will miraculously cure her conjunctivitis in from one to two weeks.

And yes, Gentle readers, there are people in our sad and rapidly deteriorating country who will come to the Emergency Department at two in the morning for mild, and I mean mild, “pink eye.”

1001 Ways to Die