State of Fear

Struggling for Rationality

“This patient,” I said to myself, “is going home.” 

I know.  She’s 85 with the dreaded complaint of “Altered Mental Status” described by the family as a brief period of “staring.”  No generalized seizure activity, you understand, and no syncope (fainting), slurring of speech, facial droop, drooling, weakness, confusion, sweating, fever, nausea, vomiting, or any of the other symptoms or combination of symptoms upon whose fulcrum are levered mighty weights of flesh into the processing mill that is your local hospital.  In fact, this very pleasant lady felt fine and even the family admitted that she looked normal.

“And I’m not going to spend $20,000 proving she’s fine either,” I continued to myself as I screwed up the courage to throw out the rule book and guide my clinical judgement by history and physical exam.  After four years of medical school and four years of residency training I can do that can’t I?  Isn’t that what my professors, comfortably barricaded behind the litigation-proof walls of the State Charity Hospital told me I should be doing…especially as my history and physical exam confirmed the diagnosis that seemed obvious from reading the triage note and talking to the the paramedics on their way in? 

But then the fear gripped me.  That smouldering dull fire in the gut that can only be quenched by a deluge of unnecessary lab tests and studies. 

And I paused.

My computer glowed seductively.  It would have been easy to click here, click there, and then call the tired hospitalist to admit the patient.   We admit for this kind of thing all the time, slipping the patient in behind a smokescreen of irrelevant data; leveraging confusion, convenience, and sloppy medicine into countless unproductive admissions that discover nothing we didn’t already know, treat nothing that we weren’t already treating and, if we are lucky (because the hospital is a cess-pit of infection and risk) leave our most excellent and trusting patients no worse for the ordeal except for some familial inconvenience.

Reaching deep for my last reserves of courage my hand bypassed the keyboard going to the phone instead to discuss this very gracious and patient lady being treated for Parkinson’s disease with her neurologist and to arrange outpatient follow-up for the next day.  

Maybe one day I’ll tell you about the Bell’s palsy patient I sent home with no lab work or imaging of any kind.

I am a thrill-seeker.  Too bad I’m going to get sued one day and decide that my financial well-being is more important than being a good and faithful steward of your treasure.


This country has changed, even in my lifetime.  It used to be a place where people worked and were proud of it as we were proud of out heritage as a pioneer nation, a place were prospectors, inventors, roustabouts, gamblers, swindlers, preachers, cowboys, investors, soldiers, pioneers, farmers, and every variety of people striving for their livlihoods could succeed or fail by their own skills and on their own merits, allowing always for the confounding hand of fortune that sends the river to wash away even the best-tended plantation.  It was a country to which my father came with nothing, expecting nothing except opportunity, and for which he had a great love that he instilled in me.

And now we are to be nothing but Belgium.  A lot bigger but Belgium just the same.  Nothing but another decrepit European social welfare nursing home whose sole pre-occupation is now to become the incessant struggle for money to support a growing class of people who have been seduced by the Obamatariat into giving up uncomfortable and often treacherous liberty for the long, government-cheese induced nap of the nanny state.

It should bother you.

My New Ride

As some of you know, I am a mountain-biker and I just thought I’d share a picture of my new ride.  It is a Specialized FSR XC Expert.  My first mountain bike was a 1992 Bridgestone MB-4 and while I recall it was a really nice bike, this one has front and rear suspension, hydraulic disc brakes, and weighs less than many top-of-the-line road bikes did back then.  There are no mountains in my state.  Nevertheless we have plenty of trails, ranging from smooth beginner level to heart-in-the-mouth-take-your-eyes-off-the-trail-and-you-die technical stuff.   I tend to ride a combination of paved roads, dirt roads, and the occasional rough terrain and since I can lock out the suspension for hills and really smooth roads this bike suits me well.  Yeah, the guys in spandex pass me all the time but they can’t really go off the road much so I don’t mind.

I used to run but got tired of it.  Twenty miles on bike is more fun than five miles on foot.

State of Fear