Bread and Circuses, Water and Sewage

Customer Disservice

There are days when I explain to the family of a 98-year-old customer, in terror of the the inevitable end, that today is not that day and while the odds of their mother living another month are close to zero, she’s alert, reasonably comfortable, and they have some time to say what they want to say and do what they want to do.  There are also days when I must gently insist to a family that despite what they have heard about the mighty apparatus of American Medicine, it will be as ineffectual as casual prayers and there is only time now to steel their hearts and accept the inevitable end.

And then there are days when a simple customer, sorted in triage as a minor complaint, slowly evolves into a horrifically complicated ICU admission whose fragile life depends on the skill and vigilance of the entire Emergency Department staff…and even then the odds are not good.  That one will keep me in the Department long after the end of my shift, the extra hours of which gain me nothing materially.

On every day we risk our health in this dangerous profession where we are exposed to the concentrated sickness of the entire city.  We risk our careers, too, and our economic viability making thousands of decisions about customers with more medical problems and more medications than I once believed could burden one human being while held to a standard of care that tolerates no mistakes; the slightest of which (something as simple as not giving an aspirin) not only has the potential for disaster but can start the long, expensive slog through the court system where every victory is Phyrric and defeat, the out-of-court settlement, is always the preferred outcome.

And then nobody really pays us for our work although the usual drunks and serial abusers of Emergency Services, customers all,  loudly proclaim at the slightest affront to their august dignity that they are “paying our fucking salary.”  There are co-pays for some and none for others and some boldly steal medical care, the thought of paying one thin dime for the services of at least the highly-trained nurse who they regard as their personal servant having never entered into their head; medical care being, after all, just another public utility like water and sewage and nobody pays for those things.

The bureaucrats at my hospital have just gone through their annual mission statement contortion and have, on schedule, given birth to the usual smarmy slogan which is going to change the direction of the hospital and solve every one of its problems by focusing on the customer…putting the customer first…taking the customer seriously…making the customer the center of our efforts…making customer service a priority…ostensibly to increase customer satisfaction but more realistically because it is cheaper than hiring nurses to take care of the customers we’ve already got.

But this isn’t Wal Mart and the patients are not customers. Pretending they are degrades the patients and dehumanizes the practice of medicine by substituting clinical judgment and perception with the polite fiction that we are engaged in nothing more than a business transaction, one in which the customer is always right and which is now to be ruled by Press Ganey and Mammon, the Two-Faced God-Incarnate of the bureaucrat.

Come On Now…

92-year-old patient.  Demented.  The usual medical problems teased out of the the nursing home medication list and the family who insisted he was healthy except for the pacemaker, the feeding tube in the belly, the coumadin for a “heart problem,” the three strokes, the diabetes, and the emphysema (but he’s 92 so he must be doing well).  History of benign polyps in his colon.  Presented for abdominal pain after a colonoscopy earlier that day.

Why does a 92-year-old man with less than a fifty-fifty chance of living another year get an expensive colonoscopy?  I mean, it had better be a good reason.  Rectal bleeding.  Something like that.

“It was a screening colonoscopy,” said the consultant, “We removed a polyp.”

You have got to be kidding.  Remind me never to send you another patient.  Would it have killed you to have politely deferred the colonoscopy for another year just to see how things would shake out?

Of course, I was no better because I ordered the deluxe work-up with all the usual laboratory tests and the premium CT scan although his abdomen was benign and he was too demented to really get a handle on his exact symptoms.  In my defense and contrary to popular belief, please note that I don’t get extra money for ordering a lot of tests.  But I still squandered your children’s money, money which really belongs to our Chinese and Arab creditors and future masters, at a blistering pace.

My job is mostly ridiculous, on some levels anyway.  At least we sent the gentleman home instead of admitting him like the family wanted, “just  to be safe.”

“Just to be safe.”

The four most expensive words in all of American Goat Rodeodery.

We Just Get Headaches

I had a pleasant conversation with a recent immigrant from Cuba whose wife came to the Emergency Department with a severe headache that she volunteered was the worst of her life and had started abruptly.  Naturally with this kind of history and some reasonably high blood pressure we brought the Great Ship of American Medicine about and raked her hull with a full broadside of medical ordinance.  We were looking for a ruptured cerebral aneurysm and it took a CT scan of the brain (negative), a lumbar puncture (a “spinal tap”) which was equivocal, and finally a Magnetic Resonance Angiogram (MRA) of her cerebral vasculature to definitively prove that there was nothing really serious going on and she just had a bad headache.

The cost (to your children) was immense and on the way out the husband, who was extremely gracious and not a little impressed at the our thoroughness, shook his head in amazement and said, “You know, in Cuba we just get headaches.”

“We used to just get them here too,” I replied.

Something About the Culture of Medical Training

One of our junior residents did a particularly fine job of intubating a patient who had, to put it mildly, an extremely difficult airway.  You know, 600 pounds, no neck, a beard, and instant hypoxia when laid flat.

“Nice job,” I said after we got everything secured and the the patient moving towards the ICU.

The nurses looked at me in horror.  “Good Lord,” they seemed to say with their eyes,  “Don’t praise the residents, they might get big-headed.  Don’t you know you’re supposed to beat them down at every opportunity?”

Just thought I’d share.

Bread and Circuses, Water and Sewage

Anabasis

Marching Up Country

(With Apologies to Xenophon)

The campaign draws to a close and will end like many such expeditions do; in a victory of sorts for I have certainly marched into and through the Empire of Medicine with my fellow mercenaries, outwitting the enemy on many occasions, laying waste to his crops and orchards when necessary, and always keeping one step ahead of his mighty armies that sought to harass and encircle me.  And yet the cost has been immense and I arrive at the end of this journey with treasure sorely depleted, footsore, battered, and weary with miles to go until I am truly home.  Still, having survived this far seems a monumental achievement although at the time it was just a slow slog through inhospitable lands, a wretched journey punctuated by moments of excitement and terror.

Now crest the last hill and view, stretching to the horizon, the glittering waters of the Black Sea beckoning to us like a welcome friend and a reminding us that that we have now come through the worst part of it although many adventure still lie ahead.

The sea!  The Sea!

What I Now Know

Most of the job of any doctor is ridiculous. So ridiculous in fact that to get through the the day it is necessary to engage in a little doublethink as you pleasantly churn your way through the reams of useless paperwork, the incredibly asinine patients who you treat just for placebo’s sake, the waste, the inefficiency, the bureaucracy, and every manner of obstacle between you and what you must occasionally convince yourself is a meaningful job.  I know this very well.

Occasionally I give narcotics to an obvious drug-seeker or start an enormous work-up on a patient who is surely a malingerer and the nurses give me that sarcastic, rolling-their-eyes kind of look to imply that I am too trusting of the patients and if they were in my position they’d throw the bum out with a couple of Tylenols and big glass of water.  Fair enough.  Cynical they may be but they are usually spot-on in their assessment of who is really sick and who is missing some essential gonadal chromosome.  Although frequent fliers and malingerers occasionally present with hidden but extremely severe acute medical problems, for the most part they and the constant procession of patients with minor complaints need no more of a workup but a good history, a focused exam, and an admonition to return without fail if their symptoms don’t improve.  I suppose that most of them don’t need to be seen at all and surely not in an Emergency Department.

In other words I know full well that most of the money with which we hose down the patients is poorly spent and completely ineffectual.  I understand this.  I get it. Thanks for ripping off the scab and rubbing salt in the wound.  You do whatever it takes to get through your day but for my part, it is often necessary to suspend my disbelief and pretend, for sanity’s sake, that every abdominal pain, vague back pain, nebulous headache, and strange constellation of non-specific symptoms is going to pan out; is going to reveal itself to be that one in twenty cases that justifies all of this education, all of the hours, all of the money dumped into my training, and the devastation of my personal life.

Even the Bumper Stickers Suck

Used to be that the most durable object on the planet was a bumper sticker.  So durable that they often outlasted the car.  In fact, you can still see the occasional Clinton-Gore offering, slightly faded but robust, grimly adherent to a lovingly maintained Nissan Sentra.  I mention this because I still see the occasional Obama bumper sticker proudly displayed by the vestiges of those still in abject thrall of the Serpent King Ra-Obama and although it has been less than a year, the stickers are faded, peeling, and look like something printed hastily in some North Korean re-education camp before the entire shift was taken out and shot.

Which is sort of a metaphor for Obamerica, a country that is rapidly turning into a crappy third-rate nursing home where nothing is made, nobody does anything of value, and the only growth industry besides government are breathless special interest groups working hard at the kind of socially conscious jobs beloved of neighborhood organizers, vying for and spending money we borrowed from the Arabs and Chinese to mold another generation of Americans into beggers, whiners, and shrieking social parasites.  The country is kind of peeling at the edges and fading, so to speak.  Even the Russians are laughing at us, completely baffled at our headlong rush into Marxism, statism, socialism, and all of the other -isms that  once, long ago when we were men, we defeated handily.

And the Sun-God hasn’t a clue.

Like I said, even the bumper stickers suck.

Anabasis