Life or Something Sorta’ Like It

(Just a few random questions from real readers-PB)

What is your job really like?

As you know, I am an Emergency Physician working in a medium-sized community Emergency Department in a medium-sized hospital in a medium-sized city in a medium-sized state.   A “community” Emergency Department is not a major trauma center and generally sees mostly medical complaints as opposed to the big urban Emergency Departments that see mostly medical complaints with a varying amount of stabbings, shootings, and other acute medical problems that are the inevitable sequelae of Standing On the Corner Minding Your Own Business.

My hospital was purpose-built a few years ago to sit astride the major nursing home trade routes and commands this commerce for many miles around.  There are twenty or thirty nursing homes of varying quality within a quick ambulance ride of the place and, as you can imagine, a large percentage of our patients are the warehoused elderly who present with a varying quality of complaints ranging from the sublimely ridiculous (Altered Mental Status in a demented, contracted 92-year-old who hasn’t moved in two years except when indifferently rolled and slopped by the surly hired hands)  to the legitimately dire (septic shock in an otherwise healthy elderly lady).

We also get the usual general medical complaints, most of them incredibly minor, most of which barely rise to the threshold of needing medical care at all much less both barrels of the Medical Safety Net. We address ‘em all however although in my role of community educator I do counsel people on the appropriate and inappropriate use of Emergency Medical Services.  I understand that some patients don’t have doctors but a rather large percentage of my patients have doctors and either didn’t want to wait for an appointment or were too lazy and irresponsible, despite having insurance, to inconvenience themselves in the slightest to schedule one.

Eczema, for example, no matter how itchy, is never a medical emergency and don’t expect me to apologize for making you wait five hours to be seen.  And standing at the door to your room glaring at me while I work on your fellow citizens who are actually sicker than you won’t make me see you any quicker although I admire both your stamina and your absolute commitment to not walking across the street and getting some skin lotion from Wal Mart, an enterprise that would have taken you ten minutes and was helpfully suggested by the triage nurse.

And for the one thousandth time, fever in an otherwise healthy toddler is not an Emergency either.  It’s 3 AM, for Christ’s sake, and you will pardon my incredulity as I look at your playful, active, rambunctious child stuffing Cheetos in his mouth.   Oh, and just because we didn’t order any lab work or imaging doesn’t mean we “didn’t do anything.”  From start to finish you had some high-powered talent working on you.  Your nurse has a college degree and years of experience and assesed you child perfectly in triage.   I have a ridicuous amount of training and education and if between your nurse and me we decide that your kid ain’t that sick he probably ain’t that sick.  Did you notice the thoroughness of my physical exam?  I’m not just pretending to look in his ears, you know.  Surely the history and the exam are “something.”

The major difference between this job and many other typical jobs is the pace.  I saw 42 patients in twelve hours last night and never stopped working for the whole time. Emergency Physicians don’t get breaks per se.  We are usually scrambling to keep things moving and when things get a little slow we try to catch up on our charting, a task made extremely difficult in my particular hospital by The Worst Emergency Medical Record System In The Entire Universe, a little nightmare called Medhost that apparently got its start as a restaurant order and billing system and has not progressed much from there.

But I digress.

We try to keep people moving in and out, either admitted or discharged, but inevitably something comes up and people start waiting for disposition.  Part of this is my fault as I am still learning how things work in a real Emergency Department where the process of evaluating, treating, and dispositioning is substantially different than it is in the academic world.  On the other hand a couple of critically ill patients or an inexplicable run of ambulances can back up the department for hours, distracting us from our true mission of treating your child’s ear infection at 2AM because your appointment with his pediatrician in ten hours was just not soon enough.

I enjoy my job even if I am glad to leave when my shift is over.  It’s not really too stressful.  The most aggravating thing about it are the long stretches where every patient seems to be “Otherwise well child, active, playful, with a low-grade fever.”  The critical and otherwise actually sick patients are a relief.

What do You Think About Ted Kennedy?

Don’t get me started.  First of all, I will never understand the fawning adulation lavished on our corrupt hereditary ruling class by the press.  Mr. Kennedy was a voracious parasite on the nation whose appetite for power was only checked by his inability to keep his head in a crisis and his utter unwillingness to dive into the cold waters of Chappaquiddick to even attempt a rescue one of The Little People, a throwaway citizen who was just a hired mourner in the long dirge of the Kennedy odyssey.  Mr. Kennedy never held a real job as far as I can tell, never produced any useful good or service, and lead an entirely privileged life out of which he felt comfortable pontificating to the rest of us about Good Citizenship, Duty, Honor, and what constitutes a good life in our now completely insane nation.  He was a senator for as long as I have been alive and the web of corruption and influence peddling he spun is the best argument I can think of for term limits.

But isn’t that the problem with American politics; that it is full of people who have done nothing and know nothing about anything but politics and yet feel confident and, what’s worse, divinely entitled to solve complicated problems that are well out of their scope of experience?  That’s why President Obama is such a failure and going down like your prom date:  Having been sheltered in academia and government for his entire adult life, he doesn’t know anything about the real world, not even enough to know what he doesn’t know.

So sing your paeans and bow your heads.  Wax sanctimonious about the passing of your paper mache great men. I don’t mourn the passing of tyrants.

Life or Something Sorta’ Like It


Quick Learner

So I had a drug seeker come in the other day with her usual back pain.  Lately I have been very stingy with narcotics and after refusing to give her a shot of anything stronger than Toradol I explained that I only give narcotics for patients with fractures or obvious acute injuries and never to patients with chronic pain (which is not strictly true but I thought it would be impolite to point out in front of her family that my records showed six visits in the last two weeks to our other Emergency Departments around town).

In my discharge instructions I cautioned her to return for numbness, weakness, urinary retention, or urinary incontinence (all things that can be caused by spinal cord injury) and wouldn’t you know the next day she showed up with a normal gait, normal neurological exam, normal deep tendon reflexes but having ostentatiously wet herself, something she mentioned to me as she stumped past on the way to her room.

Nice try.

Apparently the internet is loaded with sites where drug-seekers can learn what to say and how to present themselves to Emergency Physicians to get drugs.  I’m less than impressed by a patient who endorses twenty-out-of-ten pain in the right upper quadrant brought about by eating fatty foods who I have to shake vigorously to awaken but some of them are quite good.  I’ve been burned a few times, suckered into giving Dilaudid to patients who I later discovered to be frequent fliers.  The first warning sign is usually the inability of a normal dose of Dilaudid…essentially legal, high-grade heroin…to “touch the pain.”

The Holy Grail for the seeker is, of course, being admitted for intractable pain and being put on a “pump,” or Patient Controlled Analgesia (PCA) which is like having your narcotics on tap.  Still, suckering the doctor into giving you a few hits of Dilaudid before the unamused charge nurse hands him a stack of papers detailing your last twenty visits is a major victory as is scoring a ‘scrip for Lortab.

Oh, and just a tip: If you are young, otherwise healthy, and look stoned (because you are stoned) I’m not going to give you anything but some life advice so don’t bother coming in.  Your back may or may not hurt but many people older than you with real skin in the game have survived back pain with nothing more than Motrin.

Just an aside, I write prescriptions for Motrin because it only takes one mouse click on our Electronic Medical Record system but I always hand-write on the printed prescription, “Over the Counter, Not for Prescription.”  I’m really busy so a minute saved here and there can add up to real time over the length of a shift.   I don’t care if you have Medicaid and they will pay for it.  It’s not asking a lot for you to throw down a couple of bucks for your own medical care.

I still get frantic calls from patients saying that my prescription says “600 mg” of Motrin and all they sell are 200 mg tablets.  I weep for this generation.  Have Americans always been this stupid or is this something recent?  It’s probably a recent thing.  My older patients may or may not have a college education or advanced degrees but most of them seem to have some basic common sense.

We are definitely getting less intelligent.  Apparently being a moron is not only an accepted lifestyle choice but, given the growing allure of the welfare state, it is now also a desirable survival characteristic and one that is being aggressively selected for.

Patient of the Week

“My Doctor told me to come in to be admitted for back pain.”

“I have no doubt your back hurts but as you are clearly without neurological deficits, appear comfortable, have no fever, and a negative urinalysis there is no indication to admit.  What kind of doctor is he?

“A chiropractor.”

“We have an automatic door in the department so it you move quickly it won’t hit you on the ass on your way out.”

The Crying Game

Remember that movie where, after a couple of hours it is finally revealed that the chick is a dude?  That’s kind of like President Obama.  All of his breathless supporters thought he was a beautiful, sensitive, caring girl but now 200 days into his presidency he has shown everybody his penis and, although they still want to like him, it’s hard now because the chick’s a dude, man.  Sort of changes everything.  I mean, she still sounds the same, looks the same, is wearing the same clothes but she’s a guy…and all but his most ardent followers must be squirming in their seats to think they were ever attracted.

Sure, the die-hard zealots, those who have in the dead of night surreptitiously scraped off their “Dissent is the Highest Form of Patriotism” bumper stickers still think he’s good-looking even if he has a twig and berries but the majority of Americans, those who care I mean, are catching on that the Sun God, Ra-Obama, is something of a petty dictator along the lines of Mussolini.   That and he is completely out of his element, not very smart, and well along in completely screwing up the one thing he was mistakenly elected to fix.  A silver tongue/teleprompter and charm are not a substitute for basic intelligence and some friggin’ common sense, even in the insanity that passes for American political culture.

I’m Back

As many of you know I recently finished my residency training and am now working as a real live Emergency Medicine Attending Physician, completely autonomous and completely responsible for every decision I make.  It has been an easy transition so far because, and you may read this as a defense of the need for residency training, my program trained me well to handle the full range of medical emergencies that we commonly (and uncommonly) encounter.   More importantly however, my program trained me to be comfortable with the not-so-emergent patients; the ones with a blurry constellation of mild complaints and extremely vague exam findings.  The truth is that there is a lot of general medicine in Emergency Medicine and as one of the most common presenting complaint appears to be, “I couldn’t get a quick appointment with my own doctor so I decided to come here,”  I am beginning to understand that my job is not to work up everybody all the time for everything.  While I still reflexively admit the usual patients (chest pain, elderly with unexplainable pain) I’m sending a lot of people home with instructions to follow up with their own doctor…even going so far as to call the doctor in question for patients I think are unreliable.

I mention this because I sent a patient home with vague abdominal pain who came back the next day and was diagnosed with appendicitis by one of my colleagues.   You might say I missed the diagnosis but I respectfully submit that, as the patient was given clear discharge instructions to return if not better (which he did) we can put that one in the win column.  It’s either that or we CT scan every patient with no fever, a normal white count, a benign abdominal exam and absolutely none of the classic findings for appendicitis except a very mild, intermittent pain in the lower abdomen that didn’t even localize to the right lower quadrant.

I’m also beginning to appreciate the utility of the “Likelihood Ratio” and how it applies to Emergency Medicine.  Our most excellent Program Director drummed statistics into us and we naturally resisted manfully but it is good to now have some theoretical basis upon which to justify not ordering labs or studies that will not effect treatment or disposition decisions.   I still reflexively order Basic Chemistry Panels and Complete Blood Counts but one day I’m going to get the nerve not to do it.  I wonder how much money we waste checking these things on people who look healthy?

Just file it under not wanting to know everything about every patient when usually it is enough to address the chief complaint and be done with it.  Which brings me to one of my biggest pet peeves, that is, the ordering of imaging studies and lab work in triage.  Sure, sometimes this practice speeds up disposition but not every patient, for example, with abdominal pain needs an Acute Abdominal Series; a set of four xrays at my hospital.  With a few exceptions, the Acute Abdominal Series should be reserved for, well, patients with an Acute or “Surgical” abdomen which I assure you most of my patients do not have.  Vague abdominal pain certainly does not qualify and the Acute Abdominal Series is completely useless in either ruling in or ruling out anything useful in the majority of patients for which it is automatically ordered.

If I suspect something is going on I’ll get a CT scan.

Not only is the routine ordering of unnecessary imaging wasteful but once we get the study we are now on the hook for every finding on it, even those that are incidental.  If I miss a small pulmonary nodule on an unnecessary chest film that later turns out to have been lung cancer I own it and the ensuing lawsuit.  Better not to know…especially if the guy came in for a sore throat and no other respiratory complaints and with a completely normal lung exam.

The triage clerk is killing me.