Edumucation and Other Things

Perspective

While driving through the downtown of our small but not insignificant Midwestern city (there are corn fields five miles from the city center but we do have the state capital and a handful of miniature skyscrapers) I noticed a fat brown squirrel scampering down a tree and bounding across the street in the halting but graceful manner that can only be executed by a squirrel.   From between two buildings a large hawk dove at the squirrel and, opening its wings and rotating its talons forward at the last second, grabbed the squirrel by the head nearly decapitating it from the violence of the attack.   It flew back into the skyline with the limp body of the squirrel swinging from its claws.

My friends, the squirrel is us, you me and everybody bouncing along through life in our own halting, occasionally graceful manner.

The hawk is death.

Edumucation

Our good blog-friend Cosmic Connie over at Whirled Musings brings up an interesting point about the proliferation of easily obtainable on-line and mail-order degrees.  I think she is just scratching the surface of the problem.  While it is easy to identify fly-by-night diploma mills, most of what is considered legitimate higher education in this country is essentially the same thing; a lot more expensive with better ambiance and legions of fawning admirers but diploma mills just the same.

In fact, if there is a bigger scam than higher education or one supported by such a collection of self-interested grifters (who nevertheless bask in public adulation) I have yet to hear about it.  In terms of shadiness, only the CHIP program, an offshoot of Medicaid designed to funnel Other People’s Money into lucrative Pediatric Emergency Departments and Children’s Hospitals purpose-built to loot this rich bonanza even comes close.  Indeed, just as most of the money spent on the goat-rodeo of American Medicine is mostly wasted, most of the money spent on higher education is also mostly just thrown away producing little benefit to society except the employment of fearsome armies of educational bureaucrats who would otherwise be fit for nothing but agricultural labor.

That and serving as federally subsidized day care for 18-to-24-year-olds who would otherwise be inflating the unemployment statistics, safely warehousing them for another four years as sizable majorities of them pursue Mickey Mouse degrees.

Even prestigious universities are mostly now nothing but diploma mills and federal student aid farms where anybody who qualifies for student loans will be fed into the pipeline to emerge at the other end with as much money squeezed out of them as possible. If you think it is otherwise you are sadly deluded. A modern university is a self-perpetuating bureaucratic octopus, growing bloated as only an organization with unlimited access to public money can, and requiring only one thing: a steady supply of warm students shoveled into the front end to be kept in the mill as long as possible.

And the price of a degree keeps going up, outpacing inflation, not because the quality of the educational product has improved but because there is so much federal loan money available to pay for it.  The suckers keep lining up to borrow hundreds of thousands of dollars for easy, meaningless degrees that give them something to put on their resume when they apply for a job at Starbucks.  There used to be educational standards but now there is a university for everyone and a Mickey Mouse degree to be had at any level of educational ability and for any level of scholarly ambition.  May as well get a mail-order degree and save yourself the tuition.

The relevance to Goat Rodeodery?  Only that maybe the string of initials after everybody and his brother’s name may not mean as much as was once believed.  Certainly the number of initials, abbreviations, and credentials listed on a hospital identification badge is usually inversely proportional to real education.

You Missed It…

Every week or so I get a comment or an email from someone who was once passionate about the idea of Emergency Medicine but after reading my blog decided to eschew it in favor of some other specialty.

Unfortunately, I may have given the wrong impression about Emergency Medicine. It is true that much of American medicine is either a cruel grind or sublimely ridiculous.  Keeping this in mind however, Emergency Medicine is a blast.  It has everything: Sick patients who really need your help and are mighty appreciative of it. Absolute medical train wrecks who, tenaciously refusing to shuffle off their mortal coil, are dumped onto you with the expectation that you can and will squeeze just a little more functionally pointless life out of them.  Shootings.  Stabbings.  Every manner of human virtue and vice.  Minor complaints.  Serious complaints. Ridiculous complaints. Really, really ridiculous complaints.  You name it, we’ve got it and to reject the never-ending passion play and freak show of Emergency Medicine is to avow a certain disinterest in mankind, a desire to have nothing but sanitized interactions with your patients who have been scrubbed clean (often literally) and filtered through the Emergency Department.  People are generally on their best behavior in a clinic or the wards (or at least their better behavior) but in the Emergency Department we see them in the raw; man primordial, folly and nobility magnified.

But you have to love chaos.  I’ll give you that.  Not that the department is chaotic all of time but every now and then when the waiting room is packed and the ambulances keep rolling in with more critical patients, when the Friday night drunks are particularly demanding and the drug-seekers exceptionally whiny, when you are short-staffed and the charge nurse is making fists at you to move your many patients either in or out; when the impatient families are growing angrier by the minute and everybody is feeling harassed and overworked…when everything seems to be devolving into mayhem, confusion, and carnage you had best be able to prioritize and multitask like a friggin’ supercomputer or you probably actually won’t like Emergency Medicine.

The hurricane rages and blows.  Huge waves slam onto the deck as the rigging comes down around your head and the ship wallows in a following sea.  You are either the kind of lunatic who laughs at the gale and spits in the wind or this kind of thing intimidates you and you can only cling to the mast in terror.  I exaggerate of course but we have had off-service rotators in tears at various points of their brief exposure to Emergency Medicine.

Another Pet Peeve

“You goddman doctors killed my mother (who is sixty-two years old, on hemodialysis three times a week for kidney failure, has bad congestive heart failure, is blind and has double below-the-knee amputations from the ravages of diabetes, has had so many strokes in the last two years that the neurologists just stand in the door and sigh, is recovering from her fifth heart attack, has been in the intensive care unit six times in the last two years, and had a very  challenging case of pneumonia which was probably the result of aspirating the chicken soup her daugter fed her even though her strokes have made it difficult for her to swallow and all of her nutrition is poured into a tube going directly into her stomach).”

Edumucation and Other Things

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.”

“No.”

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?”

“No.”

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

“No.”

“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…

Old School and Other Things

Old School

I admire the physicians of yesterday who practiced at a time before medicine became so technical but I don’t necessarily accept the premise that they were better doctors.  Certainly their physical exam skills were better honed than ours are today as this was often all they had to establish a diagnosis.  They also had a much better grasp of eponyms, being able to rattle off this triad or that pentad  and their significance to the patient; often pointing out some obvious but rare eponymous physical exam finding to nail the diagnosis.  On the other hand I have a sneaking suspicion that their patients weren’t on such a hair-trigger to see a doctor and many conditions probably festered a bit until the constellation of presenting symptoms more closely mirrored what you would expect (and still see) in the textbooks.  In other words, it is one thing to confidently identify a patient deep in the throes of acute hemorrhagic pancreatitis by observing Grey Turner’s Sign (bruising on the flanks) but quite another to diagnose the same in a patient who may be early in the disease and has come to the Emergency Department or his doctor’s office with nothing but mild abdominal pain and a vague history.

Which is how it is nowadays.  In the Golden Age of Medicine, an era that is fading even from the memories of our oldest attendings and in a time before life had become medicalized to the degree it has today, since it was accepted that doctors couldn’t do much patients tended to stay home until something was obviously wrong.  A patient came in with nausea, vomiting, fever, and severe pain in the right lower abdomen and Bam! Acute appendicitis or nothin’.  Today the pain is mild, the location is somewhat more generalized, and while we may not be as ready with the eponym, our differential diagnosis has to be a tad more comprehensive and the work up, because of the legal consequences of missing a diagnosis not to mention the availability of sophisticated tests and imaging as well as appropriate interventions, needs to be more exhaustive.  It is the exhaustive nature of American medicine, the now firmly established belief that everything is an emergency, that contributes to the high cost of everything we do and I’m not sure if the money we spend has really bought us that much, at least not in relation to the vast sums of money that we continue to dump into the sucking pit of medical care.

I mention this not because I necessarily believe that preemptive vigilance is a bad thing, just that it is an extremely expensive way to practice medicine and it may be that a little more of a guarded approach, a commitment to watch and wait might save a lot of money with no effect on morbidity and mortality.  Surely, as an example, every woman early in her pregnancy with some spotting and mild pelvic pain does not need a full workup for an ectopic pregnancy although if you come through our department and have any of these symptoms, even if your chief complaint was a sore throat, you will have a full battery of expensive tests to rule it out.

Do I take ectopic pregnancies seriously?  Of course I do.  But I’d say that I probably initiate twenty negative workups for every ectopic I find and the positive ones are often clinically obvious with the studies ordered to confirm the diagnosis.   The question is whether waiting a day or two would effect the outcome and whether the occasional benefit of early detection is worth the money we spend ruling out the majority that turn out to be nothing but a little bit of pain from a stretching uterus and a bit of normal physiological bleeding.  Like I said, you can present to any emergency Department or doctor’s office with symptoms so vague that a doctor sixty years ago wouldn’t know what to do with you but today receive a full work-up, no different than if you had waited a few days and your symptoms were more classical.

Getting A Job

Just a few observations about looking for my first post-residency job and with a hat-tip to the folks over at M.D.O.D.:   First of all, it was a pleasant experience after applying to medical school and residency to interview for a job from a position of strength.  You essentially have to beg to get into medical school because you hold no cards whatsoever and no matter how stellar a student you were or how winning your personality, there are many more qualified applicants than there are spots and it may as well be somebody else who gets picked.  Likewise with landing a decent residency position which is, like medical school admission, something of a poodle show for graduating medical students as we trot ourselves from program to program trying to convince them that we are good dogs.  Not a lot of negotiating going on, your understand, both medical school and residency being exclusively “take it or leave it” propositions….at least I never heard of fourth year medical student with so much clout that he could negotiate a residency contract (which is not really a contract at all but a documentation of indentured servitude) to his liking.

As a board-eligible physician however it is more of a seller’s market.  In my specialty there are many more jobs than there are Emergency Physicians to fill them so once you get out of the subservience mode (and certainly by the end of your residency you should be pissed off enough to not want to be every body’s little bitch all the time) you can get, within reason, any kind of job with any kind of pay that you want…all you have to do is recognize that your prospective employers need you more than you need them and act accordingly.  I am not, mind you, advocating arrogance or unreasonable salary demands, just that it is no longer necessary to beg.  In the end, you can walk away from any offer with complete impunity and no hard feelings as long as you negotiated in good faith.

Negotiating is the key.  In most cases the first number they slide across the desk or put into a draft contract is a tentative offer and most employers will not be offended by a little dickering.  Likewise with signing bonuses and even simple things like moving allowances.  Sometimes your prospective employers will offer these things up front but if not, there is no harm in asking for them or any other legal and reasonable concession.  The worst they can say is “no” and the worst you can do is respectfully decline their final offer.  Again, no hard feeling, nobody is worse for the wear.

Your room to negotiate also depends on where and for whom you want to work.  Many markets for Emergency Medicine are saturated and if, for example, you just have to live San Diego you may have to settle for a lower salary than your colleagues looking for jobs in Klamath Falls. The rules of supply and demand do not, after all, always work in your favor.  The same would apply if you wanted a junior faculty position at a Big Academic Medical Center in which case you would have to sell yourself shamelessly and probably settle for a good deal less than you could make somewhere else.

There are also many kinds of practice.  You can sign on with an established group with the intent of becoming a partner, you can work directly for a hospital system as their employee, you can work as a free-lance killer-for-hire locum tenums, or you can work for a hospital as an independent contractor to name just a few options.

Obama Watch: The Love That Dare Not Speak Its Name

“Man-caused disaster” instead of “Terrorism” is the latest euphemism to come out of President Obama’s administration, in this case from his Secretary of Homeland Security, and shows, as if you needed any other evidence but the last eight weeks, with what a pack of morons we are dealing.   Maybe they’ll reconsider the term when Obama is surveying the glowing ruins of an American city destroyed by Alleged Foreign Perpetrators or whatever the euphemism will be for the terrorist group that manages to smuggle a nuclear device into Chicago.

I mention this because I live in an area where the Cult of Obama is very strong and yet, the other night I observed my neighbor furtively scraping the Obama bumper sticker off of his Subaru.  I think people are catching on, in other words, although there will always be the die-hard cadre of fanatical followers who dress their children in paramilitary garb and have them chant paeans of love to the Dear Leader.  My neighbor is not that fanatical however and is a decent enough guy even though his political and economic knowledge is sketchy and based largely on earnest but meaningless slogans.  He probably only voted for Obama because he didn’t know what else to do.  Surely he couldn’t have voted for that old, mean Republican who had a clue but didn’t whisper such sweet nothings into his ear.  Now, in the post-coital period when he lies vulnerable and afraid while Obama is in his kitchen drinking his beer and checking his black book my neighbor feels used and a little dirty.  He’s given it up for a guy who is just not that into him and will never return the love that was so desperately given.

Which is also the trouble with the press.  Although Obama is barely two months into His presidency and involved in scandals that make anything since the Nixon administration look like patty cakes, the paleomedia, our own professional cheer leading class, are still starry-eyed and hoping that their lover will come back for one more roll in the hay that will lead to consummation and justification (Peggy Noonan comes to mind).    I mean seriously, the Obama administration and their enablers in congress took bribes from AIG to pay their bonuses from the recent pork-laden stimulus bill, directly adding provisions to the reconciled bill, and the outcry from the press?  Tepid at best.  Politics as usual.  Ho hum.  President Obama gets a pass because, shucks, the bill was a thousand pages long and how could the Smartest and Sexiest Man in the World be expected to know what His own government is doing?  I shudder to think what it would take to get meaningful reaction out of them who were once the savage watchdogs of our democracy but have now abrogated that role to talk radio.

The press now lays prostate and sticky with sweat, wondering if it was worth it and hoping that The One will come to his senses and love them as they love Him.

Old School and Other Things

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

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

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?

Chicken Soup For the Emergency Medicine Resident’s Soul: Inspiring Stories From the Emergency Room

Field of Dreams

There is a lot of Medicaid money floating around out there, particulary in the pediatric population where a large portion of the patients are covered by the Children’s Health insurance Program (CHIP). To legally acquire as much of this bonanza as possible, my hospital built a dedicated Pediatric Emergency Department which opened two weeks ago. It has been aggressively advertised as a state-of-the-art facility with private rooms and limited wait times. It even has a separate waiting room from the adult Emergency Department and video games for the kids.

There has been both the usual adulation from the press and the self-congratulation from the advocates of everything and anything as long as it’s “for the children.” If we step back from the hyperbole however, in a city the size of ours there are not that many real pediatric emergencies…or at least not enough to justify building a Pediatric Emergency Department. The traumas and critically sick children still come to the adult side (also newly constructed) and as we usually get them up to the PICU extremely quickly, what’s left is mostly urgent care and general after hours pediatrics which is, of course, what the hospital is angling for. It looks to be a stunning success and the new department daily harvests a bumper crop of essentially well children eating up a couple or three hundred bucks apiece of scarce medical resources for mostly minor, self-limiting things that are thankfully mostly relegated to the Physician Assistants.

Build it and they will come and this is exactly what is happening. Why go to some crappy urgent care or the wait at the health department with the hookers and drug addicts if you can sit in a nice room with your children watching MTV on a brand-new flat-panel television while you wait for the doctor? Unfortunately, there are still long waiting times, you just wait in a private room instead of the waiting room, an improvement even if this is not what the hospital has disingenuously lead the patients to expect. Rooms are cheap. Doctors and Physician Assistants are not so real estate has never really been the bottleneck. The most common thing I hear when I am sent to the Third Level of Hell (the Pediatric Emergency Department I mean) to help clear out some of the backlog is the exasperated parent asking the nurse when the doctor will see them.

So the other night after my third twelve-hour shift in a row, I was riding the elevator to the parking deck with a disgruntled-looking tatooed couple and their mullet-bedecked toddler. The mother eyed my hospital identification badge, clearly identifying me as an Emergency Medicine Resident Physician, rolled her eyes and looked disgusted.

“How do you like our new Emergency Department?” I asked, somewhat taken aback by the hostility..

“They made us wait six hours just to tell us our kid has a cold,” snorted the mother, her nose stud gleaming in the soft recessed lighting as she and the putative father of her child stormed out of the elevator.

After the doors closed, another passenger looked at me and said, “Well I guess they shouldn’t bring the little motherfucker in if all he has is a cold.”

On The Other Hand….

I don’t have to tell you how much most doctors dislike patients who are google-based medical experts. Not that we don’t like well-informed patients because we certainly do, it’s just that the internet is so jam-packed with misinformation that without a background in science and critical thinking, two things which are not major selling points of our public schools, it is hard for many people to separate fact from fiction much less interpret their information in the appropriate context. The tendency is for people to view anything they see in a written form as the truth, or, as one of my patients put it about her stack of googled articles about the benefits of large doses of Vitamin C, “If it wasn’t true they wouldn’t write it.”

So it was with no small amount of trepidation that I knocked on the door to a patient’s room whose parents, the nurse warned me, had a whole binder of articles downloaded from the internet. The patient turned out to be a sick-looking, febrile nine-week-old baby who required a full septic workup including a lumbar puncture that was positive for a bacterial infection and who was rapidly admitted for IV antibiotics and supportive care. The mother initially apologized and said that although her parents said the baby didn’t need to come in, she had read some articles on the internet and decided to bring him in anyway.

I looked at her binder and the first article was the exact same one I had skimmed on the internet just before knocking on the door. I guess if you’re going to use the internet you may as well use it right.

During my history, I asked if the baby’s vaccinations were up to date. The mother looked embarrassed and said that her parents were against vaccinations and had told her not to get the baby his shots but that she had decided to do it anyway.

“My in-laws are retarded,” Explained the father.

Hope Springs Eternal

I have never seen a sicker patient who wasn’t actually dead or heading that way shortly (e.g. the typical 92-year-old cardiac arrest who looks like a cadaver but who we try to resuscitate anyways). About my age, emaciated, cachetic, profoundly pallorous, and acutely short of breath with any exertion more strenouos than talking. He had what felt like a large, sold mass in his abdomen that started under his left rib cage and seemed to extend into his pelvis. His teeth were rotted, his hair was dry and sparse, he had creepy-looking fungus-like lesions all over his body, and he was covered with a fine layer of what looked like powdered sugar but was actually uric acid salts, an indicator of end-stage renal disease. His chief complaint was hematuria (blood in his urine) but if there was any urine in his blood I would have been suprised. His serum hemoglobin, a surrogate marker for the amount of blood in the body, was 3.9 or about the blood content of a medium sized yorkshire terrier. And yet for all that he was alert, cheerful, and a fairly pleasant guy.

“Do you have any medical problems” I asked.

“No,” he said.

And he was technically correct because a search of our records and those of the other major hospital in town showed that this gentleman, a lifelong resident of our city, had never so much as visted the Emergency Department. Apparently he had been getting sicker and sicker and, like most guys, initially decided to ignore his symptoms but then got so used to being tired and worn out that he forgot he had ever lived any other way.

“I’ve got a good one for you,” I said to the tired medicine resident who was down in the department admitting his sixth vague abdominal pain of the night.

“Ooh, let me guess, another bogus chest pain,” he said wearily, “I can barely contain my excitement.”

“Naw,” I said, “This guy is the real deal.”

I explained the particulars of the case and the resident perked up a little.

“And get this, he has never seen a doctor. He’s terra incognito, man! Virgin territory. You’ll be the first guy to plant the flag, kind of like Neil Armstrong.”

“What studies have you ordered?” the resident asked.

“Not a whole lot,” I said, “We’re going to transfuse him but other than that…well…knock yourself out.”

“I love you, man.”

Chicken Soup For the Emergency Medicine Resident’s Soul: Inspiring Stories From the Emergency Room

What I Do, Part Two

(This is an another article directed more to people who are interested in a medical career than to those already involved.  Feel free to read along but I again offer my usual warning that there is nothing profound or exciting to follow and I cannot be held responsible for your boredom. I’m going to try to write this without jargon and I will clearly explain everything which is where the boredom is going to come in for those of you who are in the know. -PB)

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Because I am a second year Emergency Medicine Resident, at my program I carry the trauma pager which alerts us whenever a trauma or a seriously sick patient is on the way.  As part of my training I get “first crack” at all these difficult patients, those for whom a delay of immediate interventions or decisions could result in serious long-term disability or death.  Our attendings supervise us but they generally stand back and only correct us if we are doing something either completely wrong or not the way they want to handle things.  It is the attending’s patient, not mine, even if she just stands in the back with her hands folded across her chest looking bored.  As we gain proficiency our attendings stand around looking bored more but to start out we are supervised fairly closely.

We really don’t get as many of this kind of difficult patient as you might imagine.  We get plenty of really, really sick and injured people but in most cases, they are stable enough where a delay of five minutes or even a half hour might not have too many serious consequences.  Most trauma patients that we receive for example, even Level One traumas for which the entire trauma team is mobilized, are stable enough to be taken to the CT scanner before the decision is made by the trauma surgeons whether to operate.  (On the other hand sometimes the patient is so badly injured, particularly in the case of penetrating abdominal injuries, that they go straight to the operating room with barely a how-do-you-do in the trauma bay).

The trauma pager usually but not always alerts us that a critical patient is on the way and gives us time to prepare.  In this case, the terse message on the pager screen said “57 M SVT Chest Pain” which meant that the paramedics were bringing in a 57-year-old man with chest pain who the paramedics believed to be in Supraventricular Tachycardia.  Supraventricular tachycardia, as the name implies, is a fast heart rate with the pacemaker, a focus of electrically active cells in the heart, located above the ventricles in either the atria (the top chambers of the heart) or the atrioventricular node (the specialized cells between the top and bottom chambers of the heart that allows the transmission of electrical signals). A rapidly firing pacemaker in the atrioventricular node is more correctly called an accelerated junctional escape rythm but it looks somewhat like SVT on an EKG.  The heart has a normal physiological pacemaker in the right atrium called the sinoatrial (SA) node but this is not what is usuall driving the heart in SVT.

The heart itself is an electrically active muscle. Unlike skeletal muscle, and with the exception of the SA node, it is not innervated but instead receives its signals to contract via a wave of electrical current generated by the flow of ions into and out of individual heart muscle cells.  The SA node is not directly innervated (attached to nerves) but is modulated with neurotransmitters like acetylcholine released from nerve endings of the parasympathetic nervous system (of rest and digest fame) located close to the SA node. The wave of electrical current produces a progressive cascade of electrical depolarization and repolarization of individual muscle cells, sequentially opening and closing voltage-gated ion channels on the cell surface, that allows the flow of sodium, potassium, and calcium to power the cellular machinary that causes contraction and relaxation.  Usually, this process is initiated in the sinoatrial node which has a natural automaticity and, absent any external influences from the autonomic nervous system, paces the heart at anywhere from 60 to 100 beats per minute.  Every heart cell can pace on its own but since the SA node paces faster, its signals interrupt the pacing potential of the rest through something called overdrive suppression.

I am simplifying things considerably and once in medical school you will learn about the heart in great detail.  Like many things in nature, the mechanism of cardiac activity is wonderfully elegant and simple to understand but frightfully complex once you get into the details.  The important thing to remember is that measurable electric current flows in the heart. An EKG is a representation of this current as it flows towards an electrode (also called a lead) and is more specifically the magnitude of the vector component of the current (well, actually the electrical potential which is a voltage) coming towards or moving away from the electrode.  The EKG, either on a monitor or printed on paper, is a graph of time and voltage with time represented on the horizontal axis and voltage on the vertical axis.  By convention, a printed EKG uses twelve leads, looking at the heart from twelve different electrical points-of-view.   A cardiac monitor like you see over hospital beds or on a portable defibrillator of the kind carried by paramedics is just an EKG with two or three leads instead of twelve.

A normally functioning heart has a distinctive EKG pattern representing the flow of current in the heart.  Abnormalities of the heart cause their own distinctive pattern on the EKG.  A Q-wave, for example, is an abnormal downward deflection on the EKG caused by the lead “looking” through dead (and therefore electrically silent) heart tissue to the opposite side of the heart and is something that develops after a heart attack in many patients.

The patient finally arrived and was a reasonably fit-looking middle-aged man sitting up in the gurney who was awake, alert, and in no obvious distress except he was dripping with sweat.  His chest pain and sweating had started about fifteen minutes before while working in his home shop sweeping sawdust into a dust pan.   The nurses, who actually do most of the work of patient care, hooked the patient up to our monitor and established another intravenous line to complement the one placed by the paramedics as I listened to the rest of the report and looked at the “rhythm strip” printed from their defibrillator.  It showed a wide-complex, monomorphic tachycardia with a rate of 280 beats-per-minute, also known as Ventricular Tachycardia or “V-tach,” not SVT as originally advertised (an earlier strip showed what could have been SVT however).  A normal heart rate is, as we said, anywhere from 60 to 100 beats per minute with an EKG pattern showing that the beat originates in the SA node.  This was a rhyhtm originating in the ventricle and pacing the heart at a rate three to four times normal.  It was “wide complex” because the QRS complex, the pattern of electrical force from the ventricle as represented on the EKG, was of a longer duration than a normal QRS indicating that the normal conduction pathway of the left ventricle (which provides the power stroke of the cardiac pump that sends blood to the body) was being bypassed.

The patient’s medical history was unremarkable, at least from our point of view although I have no doubt that many of my physician friends in Europe would have considered him marvelously complex and lucky even to be alive as this kind of patient is a rarity over there.  The usual COPD (from emphysema), the usual coronary artery disease with a history of two stents (expanded wire cages in the arteries of his heart to open them up and allow blood flow), and the usual non-insulin dependent diabetes.  He was a very pleasant guy and despite his chest pain cracked a few jokes and expressed a little dismay at all the trouble he was causing.  Not twenty feet away in another room was a patient a third his age with no medical problems whatsoever and  complaining vociferously to everyone and anybody about the slow service in our department which is typical and shows how profound are the generational differences of our patients.   Except for his sweating and fast heart rate, the rest of the physical exam was unremarkable.  He was on the usual medications for a guy with his medical problems and had no allergies.

Ordinarily we shock (or cardiovert) V-tach immediately if it is unstable.  Unstable arrhythmias are those producing symptoms; things like low blood pressure, altered mental status, obtundation (unconsciousness), chest pain, or sweating.  In our patient’s case, as he was somewhat stable (talking and perfectly alert) we decided to get everything we needed set up before attempting cardioversion which would certainly be required.  Nobody can maintain that kind of heart rate for long.  If he became unconscious, for example, maintaining an airway would be important so I set up for a possible endotracheal intubation (insertion of a breating tube through the vocal chords into the trachea) while the nurses drew up a couple of milligrams of Midazolam (Versed) for sedation before we jolted him.  I have had patients report that being cardioverted feels like being hit in the chest with a sledgehammer so sedation is the merciful thing to do for conscious patients.

No sooner had the Midazolam been injected into his intravenous line when he rolled his eyes and became limp and totally unresponsive.  The monitor still showed V-tach so now it was definitely time to shock him.  I set the defibrillator to 100 joules, was reminded by my attending to make sure the machine was set to synchronized cardioversion as shocking at the wrong place in the cardiac cycle can make the problem worse, pressed the charge button, and after checking that nobody was touching the patient, pressed the button with the lightning bolt on it and sent the charge into the pads that had been previously glued to his chest.   very satisfying jump from the patient (just like on TV) as every single cell in his heart depolarized, looked around at its neighbors, said “What the fuck?,” and waited for the regular signal coming from the SA node to resume a normal heart beat.

Which is exactly what happened.  After a brief period of asystole (or no electrical activity) the monitor showed a normal cardiac rhythm.  I made sure that the patient was still breathing and that he had a pulse and not thirty seconds later he opened his eyes and asked how he was doing.  In the meantime the cardiology fellow (an internist who is doing additional training to become a cardiologist) who we had previoulsy called arrived to evaluate the patient.   V-tach has many causes from electrolyte abnormalities to a tension pneumothorax (a collapsed lung with increasing pressure in the chest cavity compressing the heart) but in this case, given the presentation the most likely cause was cardiac ischemia which was confirmed by a post-cardioversion EKG showing unmistakable signs of myocardial infarction (a heart attack).   Ten minutes later and after starting an infusion of an antiarrhythmic agent the patient was on his way to the coronary catheterization lab for an emergent “heart cath.”

Total time in our department?  Ten minutes, fifteen at the most which made him both my quickest and most satisfying patient of the week and an official “Perfect Emergency Medicine Patient.”  By this I mean that he arrived with an unmistakable chief complaint, was able to give a good history, had solid physical exam findings, and responded to our intervention beautifully.  Not only that but he had a quick disposition and was taken off our hands early for definitive treatment.  We don’t get many of this kind of patient either.

My next patient was a 14-month-old with a fever, vomiting, and cough.  This is the worst kind of patient because while the child probably has nothing more serious than a cold or some self-limiting viral syndrome, the differential diagnosis is long and sometimes we keep a patient like this for hours and hours, eventually obtaining a perfectly normal lumbar puncture (where we stick a needle through the back to obtain spinal fluid to check for potentially deadly infections) before sending them home.

What I Do, Part Two