Remember those who care for the wounded. Las Vegas and beyond…

My column in today’s Greenville News.  Remembering those who respond in times of crisis; Greenville, Las Vegas and beyond.

http://www.greenvilleonline.com/story/opinion/2017/10/11/remember-those-who-care-wounded/746213001/

It’s hard to put into words the horror we all feel about the events in Las Vegas last week. So I won’t try. But what I will try to do is point out an often unspoken reality. Which is that those who work in emergency care constantly face terrible things with courage and skill and keep coming back for more. And everyone needs to remember that all those folks society counts on are truly remarkable.
Imagine, if you will, being the police officer who is called to an accident. They’re usually the first ones there. They roll up and survey the scene to make sure it’s safe. There’s twisted metal, spilled gasoline, possibly a fire. And all too often, there are gravely injured people covered in blood, surrounded by others screaming for help or trying their best to give aid. They call for EMT’s, paramedics and firefighters. They may start CPR. Or, if it’s the scene of a violent crime, they may be busy fighting to save their own lives, or the lives of others, from a violent death.
Next, those medics and firefighters arrive. Their job is to assess and stabilize the injured and get them to the hospital as fast as reasonably possible. They have to keep the scene safe, manage airways, put in IV lines, administer medications, dress bleeding wounds, shock dangerous heart rhythms, splint fractures and gather information. All in the chaos of passing cars, flashing lights, blistering heat, pouring rain, driving snow or dangerous winds. Never mind that they see heart-wrenching scenes of tragedy and loss; broken bodies of adults and children, grieving spouses, frantic parents. Never mind that sometimes they’re in as much danger as the patients when they treat the victims of violence.
Once they arrive at the hospital, it’s nurses and nursing assistants hurrying to move patients onto the ER bed from the EMS stretcher. Trying to get more information as patients scream, trying to replace IV’s that fell out, check falling blood pressures, slow rapid pulses, cover open wounds. Hanging blood to replace what has spilled on the floor; the tile slick underneath their shoes.
The nursing staff is busily notifying physicians of second to second changes as the gravely injured improve or deteriorate. Looking into the terrified eyes of patients who ask, ‘nurse, am I dying?’ and trying desperately to be hopeful. ‘Not if I have anything to do with it!’ It’s the nurses who are trying to restrain the frantic, confused patients. And sometimes, all too often, the nurses who are threatened, punched, kicked or stabbed by patients. It’s the nurses dealing with us irritable physicians and our demands. And escorting the families to the bedsides of those who died, or whose injuries and illnesses are unlikely to be survivable.
And there are the physicians, moving between rooms, assessing, deciding, placing lines, ordering X-rays and labs, putting tubes in collapsed lungs, evaluating who needs to go to the OR next; in large disasters, deciding who will have to be ignored, as they will not, cannot, survive. Physicians balancing the seriously sick and injured against the not sick at all who come with a rash, a fresh tick-bite, an ankle sprain; all ‘customers’ in the modern hospital paradigm. Customers who need to be seen as quickly as possible, and who are sometimes unsympathetic to the tragedies unfolding around the next hall.
It’s dramatic and it’s glorious in its own way. But all of those wonderful, dedicated people eventually struggle. The pain gets inside them, and even as they do their best, they wrestle with the memories, the question ‘did I do enough?’ And with the fear that it could happen to them or their loved ones. Some of them will face PTSD and depression. Too many of them will kill themselves because it was just too much. And a great many, especially in law enforcement, fire, EMS and nursing, are paid far less than they’re worth.
My heart goes out to all of those responders in Las Vegas. And Miami, Paris, New York, Kabul, Mosul, Houston, Puerto Rico, London. And in every place where brave folks bring hope and order against the background of blood and last breaths.
It’s remarkably hard to describe. And those who endure it all are either too humble, or to wounded, to tell the whole story. So have pity on them. And advocate for them. The world needs them 24/7.
God bless them and ease their pain as they ease the pain of others.

When the living may be dying

His overdose was a bad one.  For the sake of privacy I will not specify.  His overdose may well prove fatal.  But he was talking.  He was frightened. He was, I think, remorseful.  His aged father stood by, eyes wide, face, drawn, controlling his inner anguish.  His mother, looking down, patting her husband.

The anger and brokenness that led to the event most likely seemed small from the perspective of the day; when things went suddenly from ‘I just wanted to go to sleep’ to ‘sir, I have to be honest and tell you that you may die from this.’

I said a prayer for him, and I will again. I have not heard his condition, have not heard his course; he is far away in a place with many resources.  If any place will give him a chance, it’s the place he is now.

But I still see their faces.  I still see the numbers on the lab reports, still know how bad it was.  And I wonder, what is more surreal?  To treat them and pronounce them dead?  Or to talk with them and predict them dead?

It’s a strange thing to behold.  An honor, a privilege and a sorrow.

But far less for me than for that patient and all those who love him and now live in expectation of the worst.

Edwin

Reflections on food, fitness and ER shifts

So I’ve finished up at one job and moved on to another.  I was a director for a year and it was a learning experience.  (More on that another day.)  Right now I’m nearing the final approach after working a long run.  Last week I had five nights, 12 hours duration each.  I stayed in a hotel near the hospital. Then, after two days off at home, I started a run of five days, of 12 hours duration.  I have two to go.  I’m working out of town. Not locums, as I’m employed and working in the same place; it’s just a couple hours away, so I stay here.

A few observations:  It’s hard to turn around from nights to days in 48 hours.  I find myself reading a novel at 1:00 am when I’m getting up at 4.  I find myself drifting to sleep at the keyboard at 1 pm.  I find that caffeine is nice, but sometimes doesn’t help a lot.

When I’m tired I eat.  I started my long run intending to diet and eat well.  To limit my carbs and drink lots of water.  I was going to do pushups and squats in the room. I was planning to resist temptation!  Vade retro satana!  And it worked.  In my mind. The longer I went, the more I craved food.  Sure, for energy.  Not entirely untrue. I was focusing on vegetables and protein, unsweetened green tea and water, apples and low calorie pre-packaged food.  At first.

Fast Forward…

Today I had a breakfast burrito from Sonic, a reasonably healthy hospital lunch and part of a candy bar.  (Leave me alone, it’s dark chocolate!)  I did have an apple, so take that!  Tonight I had half a Pizza Hut Supreme (what? It was thin crust!)  Too much sweet tea, some fried pork skins and the rest of my chcolate bar.  No need to judge me. I’m judging myself.

I rememer thinking, ‘I’ll do lots of pushups.’  But after my latest day shifts, full of very, very sick people, I come home and lie down on the couch.  And it feels really, really good.  I don’t even care what’s on TV. I just want to sit.

Emergency medicine can be an exhausting gig. I’m not whining. I made my bed and I lie in it. Or, should I say, I made my couch.  But the thing is, this is a very physical thing we do.  And coupled with circadian chaos, it takes the wind out of my sails.

I’m not going to play the ‘I’m 53’ card. I feel young, and I feel fit.  However, at the end of the day, there’s nothing like eating bad food and putting your feet up.  Maybe it helps me decompress from the stressors of the day.

Or maybe I’m just weak. Either way, I’m headed back to the couch.

Keep the faith brothers and sisters!

Edwin, Prime Minister of Emergistan.

Even dogs get pain scales.

Unless you’ve been living under a rock, you’re well aware that the United States is in the grip of a really big epidemic of opioid abuse.  The epicenter of much of this has been my beloved Appalachia.  My home-town, Huntington, WV, might as well be re-named ‘Oxycontin,’ or maybe ‘Heroinville.’  It’s ugly.

Enormous amounts of ink have been spilled on this topic, and I don’t intend to explain the genesis of it in detail.  In short, however, about 20 years ago some doctors thought we weren’t being kind enough in our treatment of pain.  Some articles were published to draw attention to this theory.  We started using the pain scale.  0 = no pain, 10 = the worst pain ever.

Around the same time administrators discovered the customer/patient satisfaction score.  Taken together, physicians and nurses were pressured by 1) academic peers and medical directors as well as 2) administrators, to give more pain medication.

So, to recap mathematically:

Pain scale x Satisfaction score = better reimbursement + death

Recently, smart people have discovered that a lot of what we were told to do in clinical practice was probably (to put it delicately) utterly stupid and ultimately deadly.  Having said that, not all of the drug abuse in the country is because doctors gave out too many pills (although pill-mills are obviously a problem).

Some of it, in particular the heroin and fentanyl nightmare, has to do with bad decisions, experimentation and the high marketability of those drugs.  Enormous amounts of those drugs are manufactured in other countries and shipped here (obviously illegally).  Money talks, as it were.

The problem is, research suggests that patients of doctors with very high satisfaction scores often do poorly.  Think of your kids.  How do they turn out if you give them whatever they ask?  Not usually very well.  Often quite badly.  Ditto for patient care.  Nobody should get a CT scan or antibiotic just because they want it.  Nor should they get narcotics just because they scream ‘it’s a ten!’ Or because they ask to talk to the patient advocate or administrator.

The further problem is that administrators (and government) seem to be lagging behind science.  (Not that doctors don’t also; can’t throw too many stones in the glass house.)  But they get all worried when people complain that their pain wasn’t treated. And indeed, in many insurance payment schemes, pain management is really important. Don’t treat pain?  Don’t get reimbused well.

Ultimately, however, this national obsession with pain relief has landed squarely in the emergency departments of the land.  I work in a mid-volume emergency department in a community hospital.  And I’ll recap a few pain complaints that I have seen which illustrate the problem:

‘I had dental surgery and my oral surgeon said if my pain was worse I should go to the ER.’   My pain?  It’s about a 9/10.’  (Texting and laughing.)

‘I had a car wreck a month ago and broke some ribs.  I missed my follow-up appointment but I need more pain medicine.  My pain is a 10/10.

‘I fell down and hurt my knee yesterday.  (Xrays negative, mild swelling.)  Tylenol and Motrin are like taking candy.  I need something stronger.’

‘I go to the Methadone clinic but I didn’t get there today and I need pain control.’]

‘I’ve had sinus pressure for a few days.  No, I didn’t take anything for it. I came here!’

‘I hurt all over, and I’m hot and cold and sweating, and my wife says I have a fever, but I think I’m dying.’ (Did you take anything, he asked, knowing the answer ahead of time?) ‘I didn’t take anything.  I just came here.’

‘This cough is driving me crazy.  Can’t you give me something stronger for my pain?’  Yep, an inhaler so you won’t cough. And here’s a thought.  Stop smoking!

‘My 7-year-old daughter skinned her knee a few days ago and says that Tylenol and Motrin don’t help at all. Her pain is an 8/10.’  A child with a minor injury understands to rate her pain higher…

‘I just started a job as a brick-mason and my back is sore.  Can I get something stronger for the pain?’

‘I have migraines.  My pain is a 15/10 and Imitrex does not help.  The only thing that helps is Dilaudid.  Morphine is like water…’  (????)

‘Well if my wrist isn’t broken from the fall, Doctor, how come it hurst so much!  I mean, it’s a 10/10!’  (Uh, it’s bruised?)

‘My family doctor doesn’t give narcotics.  His office says I should go to the ER.’

‘My pain specialist is out of the country and his office says I should go to the ER.’

The list is exhaustive.  Ask your nurse and doctor friends; especially those who work in emergency medicine.  Ask them about the pain scale and watch them roll their eyes.

We’ve turned pain into a religion; worse, into a kind of physical victimization in which the victim of the pain is always right.  And is always entitled.  In the process, we have allowed people to forget that pain is important and normal. That it is necessary for our safety. That it probably helps healing; a body that doesn’t know there’s a problem doesn’t heal as well.

And we’ve created far too many people whose entire lives are predicated on a drowsly euphoria spent sitting on the couch or in the bed, while other people provide for them and care for them.

In addition, the constant requests for pain meds can distract us from those in genuine pain, and who really, truly need the ‘good stuff.’  The fractures, cancers, sickle-cell, and other patients who need urgent relief.

This is immoral.  It’s bad, bad, bad for our patients. But it’s also terrible for our hospitals; in particulary my beloved emergency department.  Because it means that around the clock, even as we try to make decisions that will hopefully save lives and prevent permanent harm, we are tasked with responding to every whim of the pain-scale.

All day, and in particular all night, our societal pain obsession has been shifted onto the backs of physicians and nurses in the ER.  There is seldom a break from this. And because federal law prohibits financial screening in the ER, many of our more nefarious and manipulative ‘customers’ know that if the pain clinic expects cash, at least the ER doesn’t. If the surgeon wants money to see you in follow-up, you can hoof it to the nearest ER and get pain meds (if you’re annoying enough) and maybe a sandwich or a ride home. And with all due respect, our Medicaid population knows the same thing. So a 3 AM visit for a minor complaint (with pain thrown in as a side) might get some narcotics; and doesn’t cost anything personally.

This leaves staff members exhausted, bitter and burned out. More so when administrators habitually take the side of the ‘customer’ against the already overwhelmed staff.

The bottom line is we’re hurting people.  Patients and professionals alike.

And it turns out, this is so pervasive that even the dogs have pain scales.  My wife and I cracked up when we saw this in the vet’s office.  I mean, pain relief is fine for dogs (it’s mostly NSAIDs). But a visual analog pain scale for dogs?

‘Lassie! Bark once for each pain scale level! What’s that? 20 barks? What are you a pure-bred Lab? It only goes to ten. You’re a drug seeker and you have a problem…Wait, is that my prescription pad?  Go home, you’re stoned…’

America, not all pain needs to be suppressed and most pain doesn’t require an ER visit.  Many people do need pain relief, and this frantic desire to treat every little ache and discomfort makes it harder for us to threat the ones really hurting.

And sometimes, when it comes to your pain scale, you’re just stupid.

Doctor Outspoken (A poem about doctors and free speech)

Doctor Outspoken

Dedicated to all the docs who pay for their opinions with harassment and sometimes with firing.

Oh doctor dear, we need you here!
We need you day and night!
We need your skills
At treating ills
So sick folks are alright.

Oh doctor wise, we need your eyes!
We need your healing touch!
We need your knowledge
From med school and college,
Your training all matters so much!

But doctor loud, doctor proud
we need not hear your thoughts.
You tend to complain
And you’re always a pain,
Remember that you have been bought!

Doctor mad and doctor sad,
Please silence your dissident views.
You’re here for the money
And trust me there honey,
We’ll find other doctors like you.

Oh doctor broken, doctor outspoken
We know that you have a full cup.
But don’t speak your mind
Just smile and be kind.
And oh, one more thing…just shut up.

Oh doctor mister, doctor miss,
Do keep in mind who is in charge!
You heal patients’ woes
But you’re really the foes
Of the suits and the clip-boards at large.

Doctor tired, you could be fired,
For sharing the things that you see.
You just have been ravaged
By business-folks savage;
Who think speech should never be free.

Doctor wise who tells no lies,
Thank you for fighting the fight!
If we all surrender
Then none will remember
When speaking for truth was still right.

Sleeping Around in Odd Places

I used to practice locums medicine; which for the lay-person means traveling to different jobs, sometimes several states at a time.   During that time I stayed in a lot of hotels.  But, occasionally, I had more unique accomodations.  Obviously, if you travel enough you’ll sleep in an airport here and there. No big deal.  I actually like sleeping in airports occasionally.  When you’re stuck, you’re stuck.  Weather or mechanical issues, it’s fun to watch everyone freak out.  I’ve put my carry-on under my head and passed out cold in the waiting area.  Probably snored like a freight-train.

I have also been put up in apartments owned by the hospital. Not necessarily bad, although one of them felt as if it really weren’t in the safest part of town.  I wouldn’t leave my things there, and I insisted on a hotel.  Such is the power of locums.  I had a nice room the next night.

Once I had to spend my first night in a sleeping room, after hours, in the back of a local mental health clinic.  That was a little creepy. Again, I said, ‘no mas.’  I had no interest in being accidentally committed.

I’ve also slept over in hospital call-rooms, even on days off. That can be good or bad, but generally the beds are wretched.  Which always makes me wonder why patients are so anxious to get into them.  I guess any bed beats an ER gurney.

In one small, critical acces facility, I worked 24 or 36 hour shifts and stayed in a converted patient room.  I felt a little like a very old man, raising and lowering the head of the bed, and listening in the hallway to hear nurses walking up and down, taking care of the elderly who were there for rehab.  I ate off of hospital trays, sometimes reclining on my hospital bed.  I may have gotten a little too ‘into character.’

Today, however, was unique. I’m not doing locums per se, but I’m working a full-time gig out of town; three or four on, seven off. The hospital has an apartment that it keeps for us to use.  However, after I worked overnight last night, I was given a key and an address and sent off to find my sleeping hole.    However, at 6:00 am, the lights were dim, the signs were poor and I had almost no idea where to go.  In the dark, I was driving down abandoned streets, looking at windows and doorways, skulking up stairs in a retirement center, trying to figure out just where to go.  Confident I would eventually be arrested, Tased or shot, I went back to the hospital and a few phone calls later I was told where to go.  Indeed, my apartment was on the premises of a retirement community/nursing home. At 6:30 I was admitted to said nursing home where the lights were bright, the news on, and on old man propelled himself in his wheelchair, whilst holding coffee and looking at me suspiciously. It had that feel of a place where the day is about to start, but the changing days mean nothing.

I had a momentary terror, that I had it all wrong.  Was I really leaving my shift, my 53-year-old self sleeping off the busy night?  Was I still in my vigor?  My children still unmarried and my wife a couple hours away, looking forward to my return?

Or was one of the kids going to come to me and say, ‘Papa remember, you retired.  This is your home now!  We’ll visit you later, now go back to bed.’  Shudder.  Anyway…

A kind nurse took me to my apartment, and out of the off timelessness of the nursing home proper.  I slept a while, and left to go home.  However, due to some schedule issues decided to stay in town.

Rather than return to the apartment, which would be in use by the next doc and would consign me to the couch, I got a hotel room.  ‘Ah, rapture!  Cool sheets, dark shades, television before the bed!’

But as I checked in, I was cautioned, ‘we’ll be testing the alarms, don’t worry!’  I didn’t.  And then, for about two hours the fire-alarm intermittently sounded, all but deafening me.  My ears still ring from the thing.

Finally it stopped, and I slept off some of the night shift and its exhausting chaos.  And I was not shot, stabbed, Tased, arrested, committed or restrained due to dementia.

It was, therefore, another pretty good day.

College kids should know you love them…no matter what.

My column in today’s Greenville News.  Love on your kids when they’re in college!

http://www.greenvilleonline.com/story/opinion/2017/08/30/send-college-students-off-tears-and-joy/607968001/

Two of our sons began university classes last week; one a freshman, one a junior. After spending a wonderful Summer with them, Jan and I always find this a difficult time. It requires that we adjust to walking past empty rooms and accept the fact that they aren’t coming back home at the end of each day to scavenge food and tell us stories. Even their high-school junior sister misses them, although she is under the delusion that the house will be neater with brothers away. (Guess what, papa still lives here!)
Of course, we’re hardly alone. All over the state, nation and world, families send their daughters and sons off to be educated. And what a great thing! Broken parents everywhere have lost children to disease, accident, starvation or war and would love to simply have them alive, much less getting an education. I try to keep that in perspective when I feel sorry for myself.
However, as grand as college is, it’s a time of significant stress for our young people. Many are leaving home for the first time. This means great fun and adventure. But it also means a separation from those who have, for at least 18 years, been their constant supports and care-takers. It means leaving the comfort of the known for new places and new people. It exposes the kids, appropriately, to opinions that challenge their own. It introduces them to other kids from different backgrounds, cultures and lifestyles.
In addition, their sudden unsupervised state opens them up to all sorts of opportunities for bad habits and bad decisions. All of this added together can be very difficult. This is especially true in a time when, for a variety of reasons, some young people seem to be maturing later than in previous generations.
Perhaps this is why colleges are reporting more and more students struggling with depression, anxiety and substance abuse. University mental health clinics are always busy. And many kids end up dropping out or transferring to schools closer to home.
However, there’s one stressor we forget. When we send our kids to college we have high hopes and expectations for them. For years we’ve encouraged them, talked about college and even talked to our friends and family members about our kids’ academics. ‘Oh yeah, Joan here is going to Clemson and then med school; she’s going to be a surgeon! Aren’t you baby?’ (She nods her head nervously…) ‘Rick is planning to be an architect, right dear?’ Or a lawyer or an artist. We think that at 16, 17 (or even in their 20’s) they can plan their entire lives and it will all play out as scripted. That they’ll go to university, get that planned degree, go to professional school or grad school, get that awesome job and then we can tell everyone how great they did.
And yet, what if they don’t? What if they’re frightened? What if they’re tempted? What if they feel outcast? What if they get addicted? What if they get pregnant? Perhaps harder for parents (and kids) to accept, what if they aren’t ready, or just don’t enjoy the academic environment and find that they really just want a job and a family? What if, like all humans, they simply miss home and the places and people they love?
The thing is, we parents (and grands) must never let our children’s identities be completely tied to education or career. Because if is, and if it goes wrong, then the whole structure of their precious lives is shaken. I think this may be one of the biggest stressors of all. That is, their desperate fear of disappointing the ones who worked for them and encouraged them to move forward. It must be absolutely paralyzing.
Our children are valuable because they’re our children. That’s the most important and foundational truth they need to hear. Not because of their grades, scholarships, IQ’s, career goals, awards or anything else. And it needs to be followed by this truth: ‘My precious child, if you are unhappy, if school doesn’t work for you, if you change majors or change life-goals, it’s OK. You are not defined by any of it. I love you no matter what; you can always tell me the truth. And home is always here for you.’
So send them off to school with tears and joy! But always anchor their worth to the love of family, not the success or failure of their educational adventures.

Mid-sized ER Madness; Thoughts?

I know, I know, I spend way too much time ranting about work in the emergency department.  But after some recent shifts, my box of rants is full once more.  And what I want to point out is the enormous struggle of the mid-sized emergency departments in America today.

I know this is a problem; I work in them, and I know and talk with people who work in them.  It’s getting harder all the time.  So what is that ‘mid-sized’ ED?  For purposes of my discussion, I’d say (depending on coverage) somewhere from 16,000 to 40,000 visits per year.  Now that’s not scientific, that’s just for the sake of discussion, and based on personal experience.

I’d love to hear commentary from readers, because I’m trying to figure it all out.  But let me start with a story.  When I was fresh out of residency, I worked at dear old Oconee Memorial Hospital in Seneca, SC.  Our volume as I recall was around 23-25K per year.  We had pretty good coverage at first, with three 12 hour physician shifts a day.  Patients were sick but we moved them through.  And when I worked nights, I remember that it wasn’t unusual for me to lie down about 3 am and sleep till 7 am.

Fast forward.  Even at my current job where I see 19K per year, there’s barely a night when patients don’t come in all night long.  So is volume spread out more?  Maybe.  Are patients sicker?  Possibly.  I think some of this may be that patients have no primary care, and so they don’t even have an option to ‘wait till morning.’  In addition, a large number of patient (in all ED’s) are jobless.  So in their defense, 3 am is as good as 3 pm when you don’t have to go to a job in the morning.  (I’m not disparaging; but I do think this is true.  Think about your teenagers who sit up all night in the summer if they don’t have jobs!)

I also wonder if our patients are sicker.  I mean, medicine is pretty amazing nowadays, and people who would certainly have died when I was in medical school now repeatedly survive significant heart failure, MI, stroke, pulmonary embolism, respiratory failure, various infections and all sorts of problems.  And when they do, they have to come back to the ED frequently.

For those with docs in the community, I’m sure the offices are crazy busy all the time. Even those docs have patients they just can’t squeeze into appointments. They use the ED.  And maybe, just maybe, our patients are much more ‘medicalized’ than before.  So much of what the emergency departments see is really psycho-social.  Anxiety, depression, suicidality, substance abuse.  The numbers of these conditions seem to be exploding, and they can seldom afford primary care, much less mental health care.  The all-night ED is the place they go.

And there is a subset of patients who use the emergency department for entertainment or convenience; rides, snacks, a way to avoid arrest.  ‘Officer, I…have…chest pain!’  These also take time and space.

So what happens is all of this descends on departments with limited resources and staff.  And all day, and all night, one physician or two, maybe a PA or NP, struggle to sift through five or six chest pains alongside two stroke alerts, a suicidal overdose, two septic senior citizens, a dialysis patient who missed two appointments and has a potassium of 10 and a femur fracture.  Add to that the family of five with head colds.   Sure, this is what we do.  We are emergency physicians and nurses and mid-levels.  But into this mix, in the mid-sized department, recall that there is:  no cardiologist, no neurologist, no psychiatrist or counselor, sometimes no available ICU beds, possibly no pediatrician and definitely no dialysis in the hospital.

The day is spent sorting, stabilizing, making phone calls, transferring and waiting for ambulance or helicopter to become available.  All the while?  Sifting through very cumbersome and inefficient computer documentation systems designed for billing not flow.  And being scrutinized for through-put, time stamps, protocols, national standards, Medicare rules, re-admissions and all that mess.

I really don’t want to sound like a complainer. What I’m concerned about is 1) the safety of the patients and 2) the physical and emotional health of the caregivers.  At the end of the day, we’re all exhausted.  And so much is going on that we can barely find the obvious stuff, much less the subtle things that can also kill.

It sometimes seems as if departments are intentionally understaffed to save money.  I understand that it’s expensive to have doctors, nurses, etc.  But administrators get mad at folks ‘standing around,’ without realizing that in the chaos and suffering of the ED, sometimes it’s really important to ‘stand around.’  To breathe, to think, to rest, to gather oneself, to look up a condition or problem, to debrief.  To eat.  To pee.

I think that the world of medicine has decended on the emergency department.  I know that we handle it valiently.  But I don’t think it’s safe; and it’s nowhere as unsafe as in the relatively under-staffed and under-equipped mid-sized community hospitals of the world.

I’m proud of what we do.  But some days, most days, I wonder how we do it.

Any thoughts?

Edwin

Pushing the President off a Virtual Cliff Isn’t an Answer

This is my Greenville News column from August 1. I forgot to post it to the blog until today.

http://www.greenvilleonline.com/story/opinion/2017/08/01/pushing-president-off-virtual-cliff-isnt-answer/514120001/

Have you seen the charming computer game that allows you to push President Trump off of a cliff, into a volcano or to some other unpleasant location? It allows tolerant, caring individuals to vent their spleens against the man who they typically say is ‘not my president.’ Of course, it’s only the faintest tip of the iceberg, beneath which is a large mass of angry, violent, eliminationist rhetoric.

Not to be outdone (and certainly not new), I recently saw a similar game that allows players to do terrible things to a virtual former President Obama. In fact (in a search that I hope won’t draw the attention of the fine folks at the Secret Service) I found an entire page of terrible ‘kill Obama’ games.

Of course, there are always fringes; I hope it’s the fringes. But I fear this is becoming an increasingly mainstream behavior. I would like to say I’m surprised, but I’m not. Politics is the new religion, and every religion has its heretics. And what do we do with heretics? We kill them! Everyone used to know that was a bad thing, when it actually involved belief in the supernatural. And we’re still shocked when we see horrific tales from groups like ISIS and the Taliban, where you can still be physically (not virtually) tortured and killed for believing or saying the wrong things.

Now, even in the good old US of A, there’s an underlying rage and disdain that leads some people to harm those who disagree with them. (See the shooting of Rep. Scalise or assorted violent protests on campuses). At the least, that anger allows Americans to publicly fantasize about harm against people whom they consider, thanks to their political position or ideology, sub-human.

Of course, the venom often starts with a Tweet, Facebook or blog post, online comment or speaking engagement. Someone demonstrates that they don’t agree with the latest political or cultural trend. They are called out for their thought-crime, and instantly attacked, threatened, and shunned by a community that points righteous fingers and shouts ‘Shame! Shame!’

Discussion is further shut-down by describing the ‘enemy,’ the ‘other,’ in casually launched terms like racist, sexist, homophobic, transphobic, hateful, intolerant or any number of pejorative adjectives that help put the cross-hairs in more stark relief. (In the old days it was Catholic, Protestant or Pagan!)

The righteous can then proceed to acceptably wish harm on the heretic, as several have recently done (for example) towards Sen. McCain in light of his position on ACA repeal. ‘Should have died in Vietnam,’ one said. Others hoped his tumor would kill him more quickly.

In a post-Christian, rationalist, and scientific world, where we are told we needn’t rely on some deity to hold us to ridiculous and uniform standards of behavior we have come round again to acceptable, post-modern fantasies about killing people who make us uncomfortable.

Admittedly (and as I alluded) people of faith have often led the charge of violence towards the heretic. But for a while, we seemed to be rising above it. At least until the church of politics became the equivalent of the Church of America. (Separation clause aside!)
What strikes me, though, is that the Jesus of the Bible (not the Jesus of modern politics) said in Matthew’s Gospel, ‘’But I say to you, love your enemies and pray for those who persecute you.’

He also said all sorts of other pesky, kind things about greed, caring for the sick, the poor and the prisoners. He even said, as he was being crucified, ‘Father forgive them for they don’t know what they’re doing!’

Christianity teaches us that we’re all ‘works in progress.’ That God will, if we desire, remake us bit by bit, sin by sin, into something far better than what we are, both in this life and in the next. That however bad we are, and He means that, He will forgive if we admit we need it; admit we need Him.

We need to try and see everyone as potential saints, not contemptible demons. Wishing, or doing ill to our opponents is not rational, scientific, libertarian, constitutional, progressive or modern. It’s pre-Christian and un-American. And it harms the hater most.
So stop pushing people off of virtual cliffs. And start praying for all the heretics, however you define them. Turns out, we’re all heretics to someone. That realization alone should open our eyes and thaw our hearts.