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

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

Some Simple Math and other Random Thoughts from a Harmless Asian Bear-Mammal

I’m Better, Thanks

Like I said, it’s only in residency training where one could be happy to be sick while on vacation. I am just getting over a bout of what was probably the flu and as there is no practical way to take any time off as a resident, about the only time we can lay in bed or otherwise rest is either on vacation or when our day’s off correspond to our illness. They make a big deal about cautioning us not to work when we are sick for the sake of patient safety, of course. That’s all some of our patients need, to be exposed to their doctor’s gastroenteritis or other noxious infections but realistically, what are we supposed to do? In a pinch we can usually take one or two days off but as this involves screwing over the person assigned to back-up call, there is a tremendous reluctance to do this among residents. In other words, most of us would have to be spitting up blood or passing large chunks of our large intestine in our stool before we’ll call in sick. Still, there is nothing worse than having to work three fourteen-hour shifts in a row while running to the crapper every hour. Far better to be at home on vacation where you can at least relax between bouts and get some rest. Not to mention that my empathy for the typical 3AM vague-abdominal-pain-and-oh-by-the-way-can-I-have-a-sandwich patient, never very strong, is non-existent which is probably unfair to the patient (but if the shoe fits…).

Some residency programs are so small that they really have no backup for their residents at all and calling in sick in that situation will cause a major panic as well as instantly refuting the assertion made by shifty hospital bureaucrats that residents don’t contribute to the running of the hospital and are a burden to the put-upon institution. If this were really the case then the hospital would be delighted if we took a generous helping of sick days as this could only improve their bottom line. As is, however, when a resident unit goes down the service into which it had been installed goes into a major panic mode complete with sobbing and pleas for help. The sad thing is that a lot of residents buy into the notion that they are a liability to their program and act accordingly. Yes, I will grant you that a brand-new intern may appear to be good for nothing but he is actually many times more savvy than, for example, a brand-new PA who is actually paid real money, not to mention that the intern can make medical decisions limited only by his self-awareness of his limitations and his own personal comfort level. And by the time he gets a little experience the intern is a definite asset, many times for all practical purposes running the service at night. Good residents are completely trusted to handle routine admissions as well as routine emergencies and while I have never had an attending physician give me any grief whatsoever for calling him in the middle of the night for advice or to run a difficult patient by him, the expectation is that we should be able to handle most things and maybe the call for a patient admitted at 2AM can wait until 0730.

But most of us, like in any other non-government job, work when we are sick.  What choice do we have?

Some Simple Math To Illustrate Where the Money Goes

“But Panda,” many of my regular readers write, “Surely you are exaggerating the cost of futile care. Is this not a red herring, merely a symptom of your dislike of dealing with living cadavers more than a real problem?”

Let me address this question by making three points. First of all, I am not against providing expensive, high tech medical care to the elderly. How could I be? Not only are the elderly the majority of my patients but most of them are completely lucid, healthy enough to enjoy whatever it is the elderly do for fun in their secret recreational vehicle conclaves, and benefit mightily from the installation of the occasional artificial joint or the correction of a once lethal medical condition or two. While it is true that from a purely economic point of view, it would be better if we all died the day after we retire or from the first major medical problem that blindsides us (whichever came first), we are not pure economic creatures and that two-trillion bucks we’re spending should at least do some good.

Second, while there are gray areas in determining when care is futile, I know real futile care when I see it. The patients I often describe, the ones who are older than dirt, not nearly as responsive, and collections of every major pathology you can imagine but who yet manage to cling to some strict constructionist version of life are distressingly common, so common that I probably see and admit at least one or two of them a week to the ICU. (This is not even considering the patients that are post-arrest or on the losing side of a major cerebral vascular accident accident and who are, in fact, dead except for the polite fiction of ongoing organ perfusion.) Suppose that each of these breathing cadavers is admitted to the ICU and stays for a week before either subverting our best efforts and dying or pulling through and being sent back to their pre-death warehouse until the next time. Suppose also that I work fifty weeks a year and see a hundred of these patients in that time. A week in the ICU probably costs close to twenty thousand dollars, maybe more, maybe less, but probably around that if we add the cost of their passage through the Emergency Department.

Folks, that means that about two million dollars of futile, almost entirely wasted medical spending passes through my humble resident hands every year. There are about 5000 Emergency Medicine residents working at any given time in the United States and through our combined hands, assuming that they all see the same patient mix, must thus pass around 10 billion dollars. And that’s only hospitals with residency programs and not even counting direct admissions to the ICU. Assuming that a year of comprehensive medical insurance (not that I’m into that sort of thing, you understand) costs $12,000-or-so a year for a typical family; that’s about 80,000 families worth of medical insurance. Consider also that only one-fifth of the major hospitals in the United States have residency programs of any kind but most still have the usual ICU facilities and it is not hard to see that the bill for futile, end-of-life care siphons off enough money to pay for all of the medical care for about half a million families (again, not that I think we should do this kind of thing). And that’s just direct hospital costs. We probably spend twice as much in non-critical and non-emergent care in the last long, slow, tango with the reaper.

My third point is that there is no incentive at any level of the medical industry to use a little common sense. At the high end, physicians risk severe legal consequences for not doing exactly what the family wants no matter how unrealistic. So dangerous is the legal terrain in this area of medicine that most hospitals have an ethics committee part of whose purpose is to spread legal responsibility. In many cases, however, there is no financial incentive to withdraw care as Medicare makes no distinction between the living and the living dead. At the patient end, the families have no financial stake in any of the decisions they make. If we but charged the families a small fraction of the cost for futile care or, more diabolically, had payment garnished from the patient’s estate upon their death, the families would be looking for the plug, especially in the cases where the ICU serves as an expensive funeral home where families can meet to see the body. If the family ever says, “We want to keep Uncle Joe on the ventilator until the rest of the family can fly in from Seattle,” they should be responsible for the full cost of the additional stay.

Some Simple Math and other Random Thoughts from a Harmless Asian Bear-Mammal

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?

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

What I Do

(With a hat-tip to the Happy Hospitalist.Nothing new or profound here so my regular readers may, if they desire, ignores this article completely or read on and forgive the basic level of information presented. -PB)

A young reader writes, “Dear Dr. Bear, I am a senior in high school and am thinking about being a doctor. What does your job involve?”

I am a resident physician, meaning that I have graduated medical school and am now doing my specialty training, in my case in a specialty known as “Emergency Medicine.” Some people do not know that Emergency Medicine is a specialty but as you will see, its practice does involve some specialized training as well as an approach to medical care that is somewhat unique. I am a little more than halfway through what will turn out to be a four-year period of post-medical school training. Emergency Medicine training is typically three years but I did an intern year in Family Medicine after which, screaming in fright, I made the switch to Emergency Medicine. (I did not get “credit” for that year in my new residency program.)

No matter what specialty you pursue, you will have to do an intern year which will consist of exposure to all of the major medical specialties. You may perceive this to be of little value if you are, for example, going to do dermatology but since Emergency Medicine is a generalist field, every little thing we learn is useful and can be applied somehow. In other words, I have never been delivering a baby on an obstetrics rotation and said, “Man, this is bogus. I’ll never have to deliver a baby in my real job.”

Medical school itself lasts four years and in all but a few cases needs to be preceded by a four year (or however long it takes you) course of study at an accredited college that leads to a Bachelor’s degree. I have a Bachelor’s of Science in Civil Engineering and, unlike most physicians, did not go directly from college to medical school but instead worked as a Structural Engineer (the cool branch of Civil Engineering) for many years. This made me what is called a non-traditional student but if you’re sure you want to be a doctor there is no need to interrupt your journey and you may as well take your lumps when you are young. The process of applying to medical school and positioning yourself for acceptance is well described on the Student Doctor Network and to them I refer you to find all the information you could ever need. Take advantage of it because even ten years ago, when I was applying, this kind of thing either didn’t exist or was a spare sketch of the resource it has become. I think we now have the first generation of people who take the internet completely for granted.

So I am what is known as a Resident, a physician but one who practices under the supervision of other physicians who have finished residency and are fully-trained in their specialty. These doctors are known as “Attendings” or “Attending Physicians.” We are called residents because once, long ago, if you desired additional training past medical school (which was at one time not common or even felt necessary to practice) you lived in the hospital while you trained. While the hours are long in residency, we no longer live in the hospital but the name has stuck. Residents are also called “House Staff” at many hospitals, again with the implication that they belong to the “house.”

Just for your information, you can be a licensed physician and still be a resident. In other words, I occasionally have patients who insist on seeing a “real doctor,” not a resident. Leaving aside the debate as to whether you are a “real doctor” on the day you graduate medical school (you are), licensing in most states only requires that you complete an intern year and have passed all three steps of the United States Medical Licensing Exam. From a legal point of view, there is a basic level of knowledge and skill that every doctor should possess and this is the minimum for legal independent medical practice doing anything which you feel comfortable doing, can get insured to do unless you want to work without liability insurance, can convince hospitals to give you privileges to do, and can convince patients that you know how to do. Practically, however, you need to specialize and get additional training unless your ambition in life is to work at a low-level Urgent Care. I don’t have to tell you that medicine is very complex with a rapidly expanding body of knowledge that one person wouldn’t be able to assimilate in a hundred lifetimes. Specialization is a de facto necessity.

I generally work 14 twelve-hour shifts in every 28-day block. I either work the 9 AM to 9 PM shift or the 9 PM to 9 AM shift, with seven consecutive days on one or the other. Next year I will work seven to seven instead of nine to nine which allows for some overlap between the third year and the second year residents. The most we ever work is three shifts in a row with at least two days off afterwards. Our schedule is set up so we work Friday, Saturday, and Sunday for two weekends in every block but get the other two off. It sounds like a pretty reasonable schedule and it is. We are allowed to trade shifts so if, for example, you need a bigger block of days off you can swap with another resident provided that you don’t violate the work-hour rules for Emergency Medicine.

During our first year we work mostly off-service (not in the Emergency Department) rotating on other specialties such as Trauma Surgery, Internal Medicine, Critical Care, Pediatrics, and Obstetrics to name a few. During second and third year we spend most of our time in the Department with a few months reserved for electives. Some programs mix it up a little more. The advantage of doing all the off-service training early is that by the start of second year, you are done with call forever. “Call” is the practice of spending the night in the hospital, in addition to your regular daytime duties, to take care of your existing patients, admit new patients, and handle emergencies. I did two intern years, approximately 150 nights of call, and got meaningful sleep on so few call nights that I can count them on the fingers of one hand. Considering that you may have call every fourth night for most of intern year and you cannot just go home in the morning afterwards but usually stay until one in the afternoon, you can imagine that intern year can wear you down.

But shift work isn’t too bad. You have to discipline yourself to sleep during the day or else the temptation to carry on as if nothing has happened can lead to a big sleep deficit which manifests as the subjective feeling of always being tired and falling asleep whenever you sit down. But if you can master the art of sleeping during the day you will always be well-rested for your shift, bright-eyed, bushy-tailed, and ready to go.

We also have conferences to attend during the month. Unlike other residencies that may have an hour of didactic training (lectures) every day, because of the nature of our work we throw them all into a once-a-week, five hour block. If you are just getting off of a shift you still have to go. Likewise if you are on a day off. No excuses. On the other hand conference sometimes runs concurrently with a shift and since conference is mandatory, you are excused. It all evens out. We also have a Trauma Conference once a month which is also mandatory as well as an occasional wild-card thing like Animal Lab where we practice procedures (chest tubes, internal pacers, surgical airways, for example) on live, anesthetized pigs or dogs (all of which are euthanize at the end of the lab). I love dogs (I have five of them) so it can be a grim business. On the other hand we rarely get the chance to do a surgical airway on human patients and if one day, the skills you learned on a poor dog help you save somebody’s toddler…well….it will have been worth it. No question about it.

So I mentioned that I am learning the field of Emergency Medicine which, as medical specialties go and despite what you have seen on television, covers a broad range of medical complaints. A “complaint,” by the way, is medical-speak for the problem that brought the patient to the Emergency Department. In Emergency Medicine, we can see patients with complaints that are so idiotic they transcend idiocy and achieve a sort of moronic nirvana (“My ass is sweating”). We also see patients with some of the most serious injuries and medical problems that you can imagine. Like that biker who you saw get hit by a truck when you were twelve who had big chunks of himself smeared across the road. You can bet that if he wasn’t dead at the scene, some Emergency Physician struggled mightily to keep him from dying long enough for the trauma surgeons to save his life.

So it’s a real mixed bag. Some nights you feel like a school nurse treating things that would have kept normal people home and some nights the trauma and serious medical complaints just keep rolling in and the minor complaints stew for hours complaining about the crappy sandwiches and the limited television stations.

The purpose of Emergency Medicine is two-fold. First, our job is to assess and stabilize injured or severely sick patients until they can receive definitive treatment. “Stabilize” means to keep them from dying by reversing or halting the processes that lead to death. Shock, for example, is a common presentation and as it is just brief rest stop on the road to death, a chance for the Grim Reaper to sip his latte and finish his bagel before he gets to you, we treat it aggressively. Now, as hospitals are somewhat crowded and we can not always get even extremely sick patients admitted quickly (and even if we can the admitted patient can wait in the Emergency Department a long time until a bed is available) we often not only stabilize but make the diagnosis and initiate the definitive treatment. Critical care (also known as intensive care) is a big part of our job and while most of us enjoy it, it sucks up huge amounts of time and detracts from our second job which is to see as many patients as possible in the shortest amount of time.

For a practicing Emergency Physician, this means seeing at least four patients an hour to be considered a guy who pulls his weight. It may not sound difficult but while many complaints are minor, some are not and almost every patient we see is completely new, a Rossetta stone who needs to be deciphered. In fact, it is not unusual to get a “drop off,” a severely demented (senile) patient from a nursing home who hasn’t spoken a word since the Clinton Adminstration and for whom you have only a sketchy medical history (if that) and a chief complaint of “altered mental status.” If you’re lucky you can elucidate a reasonable list of her many, many medical problems from the medication list (if it was sent with the patient) but sometimes you have nothing to go on at all. Sorting it out takes time.

On arriving at the beginning of my shift, I pick up a computer tablet, scan the list of patients waiting to be seen, and select the next one on the list. I do this for the next twelve hours, consulting with my attending to some level depending on the seriousness of the complaint. I am now carrying the trauma pager so when a trauma comes in I drop what I am doing (if it is not an emergency) and run the trauma with trauma surgery and the attending who usually just stands back until his resident scews something up (which happens a lot, it’s training you understand). Occasionally critical patients, those with potentially life-threatening problems, come in and I again drop everything to take care of them. All of this is done in cooperation with the nurses who do most of the actual patient care, the Unit Coordinators who keep the administrative life-blood flowing, and a team of allied health professionals which includes Physician Assistants, Respiratory Therapists, Phlebotomists, Radiology techs, and the like.

One of the biggest parts of our job is coordinating care which involves, among other things, arranging consults, calling on-call physicians to admit patients, talking to the medical examiner after a death, calling patient’s primary care physicians, and a myriad other tasks that keep us on the phone longer than any other specialty.

If you like multi-tasking you will like Emergency Medicine.

What I Do

Poodle Circus and Other Things (Real Questions From Real Readers)

You seem a little less bitter about residency.  How are things going?

Fine, thanks for asking.  I haven’t had call in about five months and I am gradually starting to forget all about it.  Sleep deprivation has always been my biggest complaint about residency and now that I am getting regular sleep I am pleased to report that I am feeling much better most of the time.  We do not have call in Emergency Medicine and, what’s better, we have a predictable schedule with shifts and conferences clearly layed out.  Oh, I still get tired. Of course I do.  Conferences always seem to fall on a day off or when I am getting off of long night shift and we do in fact work pretty hard. I don’t think there will ever be a resident who isn’t tired most of the time except maybe one of those lazy bastards in Physical Medicine and Rehabilitation.

Not to mention that I feel a lot better about things now that I am actually training for my job.  This is not to say that off-service rotations are not important.  Of course they are.  It’s just that on many rotations the teaching is at a minimum while the work is at a maximum.  There is something to be said for requiring residents to “figure it out themselves” but, and if I’m going way out on a limb here I apologize, doesn’t that sort of defeat the purpose of education?  In other words, if every time I ask an attending a question she snarls and looks at me contemptuously for having the unmitigated gall to not be an expert in a field that I have been exposed to for one week compared to her having studied it for twenty years, well, what’s the point of the rotation?    Whether I can look it up myself is besides the point and my asking for information is not the same thing as being spoon-fed.  I realize that the crusty old-timers are going to snarl and opine that, after crawling to the hospital though snow and broken glass, they had absolutely no supervision and learned it all on their own so I apologize for not being such a fine specimen of prehistoric medical animal.

Medicine is one of the few professions where superior knowledge breeds hostility.  As a Marine infantryman, for example, we never castigated the new guys fresh out of the Infantry Training School for not knowing how we did things in the fleet.  Rule number one is to never bully your subordinates.  You have them at an unfair disadvantage, in the Marines its the Uniform Code of Military Justice, in residency it’s the reluctance of a resident to do anything other than suck it up for fear of being fired.   Either way it reflects poorly on a leader who doesn’t have the empathy to realize this.

Because of the nature of Emergency Medicine residency training we tend to work fairly closely with our attendings for the whole shift.  My program has exceptional attendings all of whom take the time to teach, taking into account of course that we are always extremely busy.  So now that I am being taught the profession instead of just being used as cheap labor to cover call, I naturally feel much better about things.

I assure you however that I occasionally get demoralized and some might even say depressed.  That also seems to be the nature of residency.  You can have a string of good days where you do everything right and feel like you have a pretty good grasp on things only to have a couple of bad shifts, or even a couple of bad patients, where you so obviously show your ignorance and unsuitability for the medical profession that you dread going in for the next shift.  I have had a few shifts like that this week and I am feeling kind of beat down, if you know what I mean.

This is why I laugh at all of the lay people who email me or post snarky comments accusing doctors of being arrogant or having some kind of God complex.  There may be some physicians who have it all figured out to the extent that they always know what to do and never make a mistake but I assure you this is not me and, from discussions with my friends, I am not the only resident who is often humbled by the limits of his knowledge and abilities.  Residency training breeds caution, not arrogance.  If you think your doctor is arrogant it may be because you are, yourself, something of a jackass and cannot handle the fact that patients are not customers, the doctor is not a clerk, and you are not always right. 

I think I want to go to medical school, how hard is it to apply and get accepted?

First you have to get the basics in order which are getting good grades and scoring well on the MCAT.  I don’t have too much advice for that except if you are not incredibly intelligent this is going to require a lot of hard studying in college.  Medical school is pretty competitive and only about half of the college students who apply are accepted.  This might not seem like bad odds at first but you also have to realize that a large number of college freshmen who declare themselves as pre-med discover that they don’t have the right stuff and end up pursuing other careers.  So your odds are pretty good (and I call fifty percent good odds) only once you get through all of the obstacles which include classes like calculus and organic chemistry, the de facto destroyers of medical school dreams at most universities.

It’s not that these classes are incredibly hard, it’s just that the competitiveness of medical school requires that those who make the final cut, the twenty thousand students who matriculate every year, get exceptionally good grades.  When I was working towards my engineering degree, I worked hard but didn’t flinch at a B or even the occasional C.  These are both passing grades and nobody ever asked me about my Grade Point Average when I was applying for engineering jobs.  And there was certainly no GPA requirment for professional licensing as an engineer.  All that was required to sit for the Professional Engineeing Licensing Exam (a test that makes the MCAT look like a pop quiz) was a degree and five years of engineering experience.

But applying for medical school?  You need to get an A most of the time in most of your classes.  Maybe there’s no substantive difference between a 3.7 and a 4.0 GPA but there is a huge difference from an admissions point of view between a 3.2 and a 3.7.  One is an automatic rejection at many medical schools, meaning that your application is automatically shunted into the trash, or at least a big strike against you unless you have an awfully interesting resume (which is how I managed to get in with my GPA).  You definitely have to get very high grades in the BPCM (Biology, Physics, Chemistry, and Math) pre-requisites to even be considered.

The ironic thing is that all you really need to start medical school is the abiity to read and some basic, and I mean basic, biological and scientific knowledge.  In the first couple of days of medical school, for example, you are probably going to cover the equivalent of college semester’s worth of the subject.  You have to understand that college courses, compared to medical school, proceed at a leisurely pace and you will laugh to think that you ever felt college courses to be overwhelming.   The real purpose of the pre-requisuites is not so much to teach you anything but to demonstrate that you have the ability to handle the barrage of material heading your way.  Intelligence aside, if you can’t muster the discipline to do well in college, while you may be able to switch gears in medical school, the conventional wisdom is that you are not worth the risk, especially not when every medical school can find plenty of people who have shown that they can.

I understand that there was once a time when medical school admission was much easier but many matriculants were weeded out in the first couple of years.  As my old professors used to relate, the standard speech to incoming first-years was, “Look to your left…now look to your right.  This time next year both of those people might not be here.”  Now most of the weeding out is accomplished before matriculation and unless you lose that fire, that interest in the profession that keeps even the most jaded medical student slogging through, your chances of not graduating are vanishingly small.  In my class of 100, when all was said and done, only two people didn’t finish.   Several were dropped back a year but they all eventually graduated.

So you see, the big hurdle is getting in, not finishing.  And there are a lot of other hoops to jump through which have nothing to do with grades and make the whole process seem something like a poodle circus.  For the record the requirement for good grades is not a hoop.  It is silly not to have some kind of objective standard of intelligence for people who want to enter what is a highly important, intellectually demanding, and in many ways (as there is a great potential to harm people) a highly dangerous profession.  The real hoops are the nebuluous extracurricular activities that are unofficially offically required by almost every medical school to prove your dedication and your, I blush to call it, moral fitness for the job.

In other words, it is not enough to get good grades and have an inkling that you want to be a doctor because it is a useful, well-paying, interesting career with good job security but you must also prove to the admission committee that medicine is and has been your passion since the second grade and you view it as an almost divine calling to have the opportunity to help your fellow man blah blah blah.  Now, I don’t confess to kow the importance of extracurricular activities to medical school admission.  At some level the members of the admission committee must know that you only went to Zaire to help in a jungle hospital for resume padding.  Maybe American health care is not as advanced as Cuba’s but surely there are not long lines of American residency-trained physicians fighting for visas to practice medicine on the the Dark Continent, Central America, or anywhere else where a young medical school applicant may sojourn for a couple of weeks to demonstrate his commitment to global health care.

In the Pandaverse, if a young medical school applicant mentioned that he had volunteered in Chad the interviewer’s eyes would glaze over and he would ask, “So what does that have to do with practicing medicine in the United States?”  (Hint: Nothing.)

But whatever your feeling about relevance it is understood among the pre-med community that these kinds of activities are required and as the admission community endorses, either overtly or tacitly, this kind of thing you need to put on your frilled ballerina skirt, your ribbons, your muzzle, and jump…I said jump!…jump, poodle through the hoops and count yourself lucky that they haven’t yet lighted them on fire.  The way things are going, it is only a matter of time before an actual medical degree from a Third World country will be a requirement for admission.  Either that or having been intimately involved in the crafting of health care policy for some Brie-eating United Nations Bureaucrat.

Until that day you can probably get by with passing out clean needles to addicts, holding women’s hands at Planned Parenthood while they abort their babies, fetching water for the patients in the Emergency Department, or half a hundred other things that really make no difference and have nothing to do with the practice of medicine.  For my money, the most valuable things you can do are to either shadow a doctor or a resident (to give you a real idea of what is involved) or to get some kind of minor career in the health care industry where you can see if you have the stomach for it.  If you already have such a career then your’re golden because being a Paramedic or a Physical Therapist (for example) speaks for itself about your dedication. 

Research is probably the one thing you can do that will really set you apart from the pack.  Everybody passes out needles.  Hell, there’s nothing to it.  No commitement at all and the self-righteousness you can experience passing out the implements of self-destruction to people who may as well be alien life-forms to you for all you have in common with them is an added bonus.  You also get to practice your faux empathy and it gives you a chance to hate on President Bush for not making Heroin legal.  But the discipline to work for a cantankerous professor, essentially as his bitch, doing his grunt work to have your name on a paper?  That’s what I’m talking about.  It’s difficult and everybody knows it which is why meaningful research as an undergraduate will give your otherwise decent but not spectacular application a boost.

Short of that it’s going to come down to good grades and bogus extracurricular activities of the High School Musical variety, long on talk, short on action, in which you demonstrated some ethereal and hard-to-explain leadership traits.

Any kinds of patients you don’t like?

Naw, I like ‘em all for one reason or another.  The sicker the better.  And I don’t dislike minor complaints either except that sometimes a minor complaint turns into a life-threatening emergency.  Nothing wrong with that actually except if I pick up the chart at the end of a shift.  But the minor complaints, the non-emergent, non-urgent, and sometimes puzzling patients (why on earth did they haul their kids and themselves out of bed at 2AM for a minor cough?) are a large portion of the bread and butter of our specialty and pay the bills, so to speak, that allow us hang around to take care of the two or three patients a shift who are either heading south fast or have arrived and are setting up camp.

(Public Service Announcement: Don’t skip dialysis over the Thanksgiving holiday so you can visit from out of town and eat highly salted holiday foods with your relatives.  I’m just saying…)

But there are, so far, two kinds of patients that annoy me a little.  The first are the drug seekers and frequent fliers who want to jump to the goodies and then get irate if I insist on a history, a physical exam, an assesment, and a plan.  Generally, I am not buying that on each of the thirty times you have presented for your back pain they just gave you some demerol and you were in and out in twenty minutes. 

Lady, the only people who get in and out of here in twenty minutes are the ones heading to the cath lab or the morgue. 

Not to mention that I don’t like being told how I am going to do my job by an amateur (although admittedly an interested one).  I happen to like trying the basic but effective things to break a migraine and 200 milligrams of Demerol is not on the “first do this” list.  I don’t even mind the lies.  Just don’t tell me what to do.  I have the medical degree.  It’s not much but it’s all I’ve got.  

The other kind of patient who annoy me are the ones who are ridiculously impatient.  Now, I understand that a visit to the Emergency Department, particularly a busy one that trains residents, can involve many hours of just sitting around waiting.   The beds are not comfortable and neither are the chairs for the family.  But can’t they get the sense, just by looking around, that we are sometimes insanely busy?  There are not that many doctors. If a trauma or two or a critical patient comes in that’s it for their minor complaint until things settle down again.  I am glad the minor complaints come in, the hospital and the law certainly encourage this kind of thing, but the Emergency Department only functions as your Urgent Care Clinic if there is nobody ahead of you who is sicker.  It’s not first come first served and I sometimes am embarrassed to have to explain it to people.  I apologize for the delay when I finally get around to them because most of my patients are decent people and very understanding but to the minority who are not, if you don’t want to risk the wait then don’t come in with your bogus complaint.  You said you had a problem.  You came to the Emergency Department at 2AM because it couldn’t wait until morning or for an appointment with your own doctor. Consequently, there is a huge prejudice on my part to give you the benefit of the doubt and do a reasonable amount of diagnostic testing and cognitive interpretation. 

Which takes time.  Time for the labs.  Time for the studies.  Hell, time for me to get around to writing up your discharge.  I generally want to get you out as much as you want to go so I can put you in the “win” column but not at the expense of giving you shoddy care.   Don’t keep bugging your nurse.  I have currently and will have in the future a huge incentive to get a disposition on you as fast as possible but a critical patient takes precedence and needs most of my attention until things settle out. 

Poodle Circus and Other Things (Real Questions From Real Readers)

Stealth Medicine and Other Topics

An Apology

I want to apologize to the distinguished elderly gentleman sitting on the hall bed. It was a little insensitive of me to stand at the coffee machine taking my time making a cup of coffee not five feet away from you and your wife while you waited to be seen by a doctor. When I walked around the corner to check the board, although you didn’t know it, I was still only five feet away and I heard every word of your verbal broadside delivered against lazy doctors making people wait in busy hallways while they took in-your-face coffee breaks. After I heard this I quietly asked the charge nurse how long you had been waiting and I was doubly ashamed. I don’t like to see people waiting in the department and I blush to think that on many occasions this is the result of my inefficiency as a resident.

In my defense however, my shift had ended almost an hour before I had that cup of coffee and I was just hanging around waiting for some lab results so I could get a disposition on a patient. I wouldn’t say I was “off the clock” because we don’t have a clock per se but I was certainly not picking up new charts. Even towards the end of a shift residents get kind of antsy about picking up a new patient because, while we sign out patients who will obviously be in the department for a long time, it is common to stay quite a while after the end of a shift tying up loose ends. We never know for sure if a new patient will turn out to be an easy disposition or a disaster who keeps you in the the department three hours past the end of the shift.

One day, towards the end of my shift and after some surrepetitious cherry-picking I selected a low-priority chart with a chief complaint of “headache” which I thought might be a chronic migraine patient and therefore an easy disposition. The patient turned out to have meningitis and required a lumbar puncture, central lines, intravenous antibiotics, intubation, a critical care admission and the kitchen sink. This is not the kind of patient who you sign out. Don’t get me wrong, it was a great patient and I don’t mind staying late for something as important as that but I do like to get home too. The point is that you definitely do not want to pick up an abdominal pain patient with only a half hour left. To much potential for badness.

But I digress. The real point is that long waits are the future of medicine. Not only are there not enough doctors to go around, especially in primary care, but we have an aging and incredibly sick population already making huge demands on our very finite medical capacity. Compounding the problem are diminishing reimbursements to physicians, madcap and increasingly byzantine bureacracy, a predatory legal environment, and the resulting complete lack of common sense that makes it increasingly impossible for physicians to adequately treat the patients they see now let alone the marauding horde of aging baby boomers about to despoil such capacity as we currently maintain. I don’t see how it is going to get any better and more importantly, I don’t see why you put up with it.

You see, I looked at your chart and your complaint, while not trivial, was not something that couldn’t have been addressed by your own doctor if he were so inclined which he wasn’t. Obviously when he factors all of the variables into whatever mental black box he uses to decide whether to fit you into his schedule, sending you to the Emergency Department was the easier choice. I know perfectly well that he is already swamped with patients, many of them horrifically complex, and I don’t envy him as he tries to fit them into his hectic clinic. There must come a point where the relatively small reimbursement he receives for the one extra patient is not worth the time it takes from his family. And that’s the problem in a nutshell with primary care, namely that the reimbursement for the time it takes to sort you out and customize a medical regimen is not enough to make it either economically or professionally appealing. If your doctor only gets a pittance to see you, he needs to see a lot of patients to make a living leaving less time for each one. He’s not a bad guy but he has the same finacial pressures on him as you once had before you retired and if you knew how little Medicare reimbursed him for his time, you could easily do the math and see that he’s not exactly as filthy rich as you imagine him to be.

So I ask again why you put up with it and the answer is simple. Because you have never considered paying a doctor with anything other than insurance and even your co-pay is given reluctantly. On one hand this is understandable. As a retiree you have paid into the Medicare system for your entire life, not to mention paying either directly or indirectly into a private health insurance scheme since you first started working. On the other hand it is also understandable that your doctor isn’t exactly jumping for joy at his reimbursement from either the government or your insurance company, two entities whose sole purpose seems to be playing a game of chicken with doctors, that is, seeing how little they can actually pay them before they throw up their hands and look for another way to make money. So far it’s the doctors who have swerved off the road but eventually this is going to change. I have talked to many primary care physicians who are getting seriously fed up with the way things are going. Like you, they are locked into the insurance mindset but it will only be a matter of time before medical doctors realize that many American retirees are not poor, need fairly detailed primary care, and might be willing to pay for it if they preceived good value for the money. By this I mean the ability to have timely access to their physician with appointments that are long enough to address their many medical problems. When physicians and patients realize that each can provide value to the other, a good service for fair compensation, both of you will finally break free from the insurance prison that has been built around you.

This sort of practice is called “boutique” or “concierge” medicine by its detractors, especially by those who demonstrate their compassion by giving away other people’s time and money as if it were theirs, and they act as if it some completely alien economic model thought up by a zany college professor when it is instead the economic model that governs almost every other transaction between buyers and sellers.

As a patient, you’re locked into medicare and it may gall you to have to pay for a service that you expect to be free. But there you are sitting in the hallway of an urban Emergency Department rubbing elbows with the usual drunks because your primary care doctor did not have time to see you. If access is worth it you’ll pay, if not stand by for longer waits.

Stealth Medicine

To be a chiropractor in America is to lead a double life, trying to fit in with the world of real medicine while at the same time practicing a form of medical therapy based on a thoroughly discredited treatment modality. Officially, chiropractors have backed away from some of their more outrageous claims instead deciding to settle on the huge chronic musculoskeletal pain market of which chronic low back pain alone would seem to provide the potential for rich provender from now until such a time as the sea shall give up her dead. We’ve reformed, they proclaim. All of that hokey subluxation stuff? That’s so ninteenth century. No more relevant than the real medical profession’s use of bleeding back in the Bad Old Days before we got all scientific. Indeed, you’d be hard pressed to find a chiropractor claiming to be anything other than a hard-workin’, back crackin’, pain relievin’, dutiful member of the health care team doing his bit and making sure to refer to appropriate specialist when he gets in over his head.

Nobody here but us super-powered physical therapists. Move along. Nothing to see.

And yet it cannot have escaped your attention that the latest frontier of chiropractors is pediatrics where they hope to make inroads into a population that is not exactly suffering from a lot of chronic musculoskeletal pain. That most kids are fairly healthy is an axiom of pediatrics and the diseases that they acquire are usually fairly benign and self-limiting. They certainly do not have the kind of vague low back pain that is the bane of the Emergency Physician but the delight of the chiropractor. What, then, are the chiropractors proposing to treat in your children? Certainly not real pediatric diseases as the International Chiropractic Pediatric Association is quick to point out. Whatsamatta’? Don’t you read? “The doctor of chiropractic does not treat conditions or diseases.” Says so right in their mission statement. But then a little further down it ascribes complaints in every system to our old friend the subluxation and promises, by judicious adjustment of the pediatric spine, to allow the body to express a better state of health and well-being.

Apparently chiropracty can resolve asthma, ear infections, colic, allergies, and headaches to name just a few. What then, exactly, are pediatric chiropractors doing if it’s not treating conditions or diseases…or is your poor Uncle Panda, lumbering asian bear-mammal as he is, just lost in the semantics? In their mealy-mouthed way, chiropractors are trying to make an end-run around the ridiculousness of their profession to become your child’s pediatrician, a job for which they are singularly unqualified for many reasons the most important of which is that they have no training in pediatrics (the real kind, I mean).

Look at it this way. For the sake of the argument lets say that all chiropractors decide that subluxation theory is idiotic and henceforth devote their lives to evidence-based physical therapy. That’s kind of the angle the so-called “reform” chiropractors take in opposition to their “straight” brethren who ascribe almost every pathology including infectious diseases to subluxations. Would you take your child to a Physical Therapist for routine health maintenance, well child checks, or even something as serious as asthma? Of course not. And no Physical Therapist would touch your child in this capacity for the same reason I don’t perform abdominal surgery, namely that it is well outside of my training and my legitimate scope of practice.

Pediatrics is not surgery. The risks are generally low which is why chiropracters believe they can move into it safely. It’s hard to screw up on a kid after all, even as a legitimate pediatrician but especially as a pretend one. Adjust a few spines, twist a few bones, and marvel that most of your patients never seem to get any diseases despite not being vaccinated. But you’re playing with fire. Eventually you are going to get the childhood leukemia or the cystic fibrosis patient and you, in the full flower of your ignorance, are going to keep adjusting the spine oblivious to the depth of your folly.

Stealth Medicine and Other Topics

Emergency Medicine Residency (Part 2: Event Horizon)

(Once again, a caveat: I am a resident in a medium-sized Emergency Medicine program in an academic setting. Not as academic as Duke or USC but we have most of the players. I have never worked in private practice in Emergency Medicine so while I welcome the comments of those who have, I am describing my views of residency, not private practice. -PB)

The Spice of Life

The other night I was sitting at our PACS workstation (for viewing imaging studies) discussing a fracture with one of the orthopaedic surgery residents. In front of me were the ultrasound pictures of another patient, a woman who I was working up for a possible ectopic pregnancy. I had three charts on the table; one a lower GI bleed, one a headache (cough…drug seeker…cough), and the other a totally lame alleged intentional overdose of Seroquel. I had just discharged a four-year-old who was perfectly healthy requiring only maternal reassurance and I was keeping an eye on one of our habitual drunks signed out to me by one of my fellow residents, to be discharged when he could walk or obtain a ride home.

In no particular order, my other patients on that shift were a minor laceration to the forehead, a couple of nebulous abdominal pains, a few chest pains only one of which would probably pan out (although all were admitted), a possible meningitis requiring a lumbar puncture, a septic shock requiring the works (intubation, lines), a constipation, and a couple of drunks with whom I am on a first name basis.

That’s how I spent my night and that’s pretty typical. An occasional flat-out, full-throttle emergency, a couple of really sick people who might have become real emergencies if they had waited another few hours, some acute but non-life threatening complaints, and a whole bunch of patients who make you scratch your head and wonder what could possibly induce a reasonable human being to leave the comfort of their bed at 2AM to sit in the hall of our department eating cold turkey sammiches’. I mean, without giving too much away, let me just say that I have had vague abdominal pains at one time or another but I have never even considered calling an ambulance to take me to the Emergency Department.

So you see, while Emergency Medicine is a specialty, most of your time is going to be spent on general medical complaints, not actual emergencies. Still more of your time is going to be spent coordinating care; either referring, consulting, or admitting and a surprising amount of working up and treatment goes on before we get to that point. It is hard to get specialists and consultants to come in or admit so one likes to have a rock-solid case before calling. Not to mention that the Emergency Department has become a miniature hospital-within-the-hospital complete with admitted patients and even critical care. Consequently, the consultants and admitting physicians expect us to do a lot before we actually call, sometimes to the point of doing essentially everything for the work-up of a complicated patient including definitive care. When they start asking me the results of C-ANCA studies maybe it’s time for them to admit the patient.
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A typical shift, like March, starts like a lion but goes out like a lamb. On arriving, I grab the first chart on the rack and start the work-up on my first patient. This is the easy part. There is nothing to starting a patient’s work-up. You either have a pretty good idea what’s wrong or you can temporize by ordering studies, a tactic that will buy you anywhere from twenty minutes to an hour (one of our Emergency Departments, if you can believe it, does not have a “stat” lab and the only fast thing you can get are a few lab values off of the ABG on a critical patient). With the first patient comfortably simmering on the back burner, I pick up the next chart and repeat the process. Eventually I have a bolus of six or seven patients waiting for studies and disposition and then things slow down considerably. At a certain point you start getting close to the resident Event Horizon, that point in the space-time continuum where your efficiency drops to zero; as does your ability to see new patients without falling unacceptably behind on the ones you are following. It is surprisingly difficult to keep track of a large number of patients at various stages of their work-up.

Moving patients is complicated by the structure of residency. Our attendings, who see patients themselves, need to lay eyes on every one of our patients and approve the plan. They are as busy as anyone else so while every patient to be discharged or admitted needs their blessing, coordinating this can be difficult, particularly as our attendings are not only seeing their patients but also supervising a couple of other residents.

So if you look at a graph of my productivity, you’d probably see what looks like a huge effort towards the beginning of the shift tapering off to nothing by the last few hours. In other words, while I’m seeing my required quota of patients, once I get a certain number I lose efficiency rapidly. We typically don’t pick up charts on the last hours of our shift but by that time it’s academic anyways as most of our effort is now spent frantically trying to get rid of the ones we have. Another one of the skills our attendings try to teach us is to keep the patients moving through the pipeline without that kind of bottleneck.

Some bottlenecks, however, are unavoidable. Procedures, things like suturing or doing a lumbar puncture, can eat up a considerable amount of time if you a) are not very good at doing them and b) don’t coordinate with your nurse. Coordination is important. The nurses want to move patients as much as you do and if, for example, they have the patient moved to the OB-Gyn room for a pelvic, you need to plan to be available to do the exam when they are ready. You also need to stay on top of the labs and imaging. The sooner you can make a decision the better.
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The other unavoidable bottlenecks are critical patients and trauma, both of which can suck up large amounts of time. Critical care patients in particular, because they are not likely to be taken off your hands by surgery any time soon, can easily set you back an hour, something that many patients in with minor complaints do not understand. Reason number 1024 not to come to the Emergency Department for a minor complaint. It might seem like a good idea when you breeze through triage on a slow night but invariably there will be delays.

Contrary to the popular belief among critics and sour-grapers of Emergency Medicine, although we see some minor complaints (“I couldn’t urinate for an hour but now I can”) we do not do primary care. Oh sure, patients make attempts to get us to manage their chronic problems but you need to avoid the temptation. You cannot do decent primary care on a patient who you have never seen and will probably never see again and certainly not within the confines of an Emergency Department visit. We do not do drive-by pap smears, in other words.

Imagine how things would slow down if we did.

Emergency Medicine Residency (Part 2: Event Horizon)

Emergency Medicine Residency (Part 1.75 A Parable About Trauma and Perception)

Perspective

Consider two separate rooms in the same Emergency Department. In one lies a young man who has been shot in the chest and arrived in full cardiac arrest with the paramedics frantically giving CPR. Red frothy bubbles come out of the gaping hole over his heart whenever the bag attached to his endotracheal tube is squeezed. A Full court press ensues and the trauma bay fills with interested bystanders watching the action as the patient is prepped for an emergent thoracotomy; a procedure where the chest is cut open to expose the heart and allow the repair of any obvious holes (as well as manual compression of the left ventricle to circulate blood).

In another room sits a sixteen-year-old girl, two weeks out from a tonsillectomy, with an emesis basin by her mouth and over which she has coughed or vomitted enough blood to cover the front of her dress. The room is empty except for the Emergency Physician, the nurse, and the anxious family.

Which case is more important? Surely the gunshot wound in the trauma bay is getting the most attention. It is an exciting case after all. It has everything one could possibly want. Blood, gore, violence, the cops, good guys, bad guys, and a young man whose life is hanging by such a fine thread that the Emergency Physician who is not in any way, shape or form a trained cardiothoracic surgeons is preparing to make a very large hole in a chest to perform rudimentary open-heart surgery. This is the stuff of which legends are made.
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“Say, Bob, remember that chest we cracked last month. Man. What a mess that was!”

The young girl in the other room? It’s just a post-tonsillectomy hemorrhage. Not exactly riveting stuff but I submit that this girl is the more important of the two cases. The guy in the trauma bay, after all, is dead and not likely to improve. He’s been shot through the heart or a great vessel and has been without oxygen to his brain for all but the first minute (the time it takes for his heart to pump most of his blood onto the street) of the last official twenty minutes of his life. There is probably nothing left upstairs to save even if circulation is restored. There is literally nothing to lose so everything possible is done and the trauma bay hums with frenzied activity even though the chances of even restoring spontaneous circulation with an emergent thoracotomy in a patient who arrives without vital signs is less than one percent. And only a small fraction of that less-than-one-percent ever leave the ICU except feet first for that last ride to the basement.

And yet this kind of thing defines Emergency Medicine as a specialty. The sixteen-year-old girl? How many of you contemplating Emergency Medicine as a career have ever though about this kind of patient? She seems pretty mundane and yet a patient like this is in mortal danger unless something is done and done quickly.

Everybody knows what to do in an exciting trauma. Big Things. Big Procedures. Lines, tubes, fluids, ventilators. Futile but extremely gratifying. How many of you have even considered how you’d handle a frightened sixteen-year-old rapidly bleeding to death and periodically vomitting another half-pint or two of blood. And no, it’s not as easy as you think. The girl could die. She’s sixteen. She isn’t supposed to die just yet. It’s just a tonsillectomy for which her otolaryngologist humorously prescribed ice-cream to make her throat feel better. If you let her die how will you explain it to the family?

“We did everything we could…I’m sorry,” doesn’t quite cut it in this case.

The moral? Emergency Medicine is not what you think. For every major trauma you are going to see a hundred garden-variety gastrointestinal bleeds, overdoses, strokes, heart attacks, ectopic pregnacies, sepsis and a large variety of other potentially life-threatening presentations. These will be woven into a day mostly spent dealing with relatively minor stuff like vague abdominal pain, headaches, and whatever complaint can be used to access the bounty of The Man. That’s just the way it is.

Emergency Medicine Residency (Part 1.75 A Parable About Trauma and Perception)