Appalachia Deserves Our Respect (And Already Has My Love)

This is my column in yesterday’s Greenville News.  Happy Birthday West Virginia!  June 20,1863.

http://www.greenvilleonline.com/story/opinion/contributors/2016/06/19/ed-leap-appalachia-deserves-our-respect/85974188/

 

photo

Tomorrow is June 20th, a special day in the hearts of my people; West Virginians. On June 20th, 1863, West Virginia entered the Union in the midst of a bloody struggle for the soul of the young nation. It was, prior to that, the sparsely populated, wilderness-filled backwater of the elegant, beloved Virginia, soul of the South. After June 20th, however, it was…well, a sparsely populated, wilderness-filled backwater all its own. But a free state that rejected slavery!
Those who live in South Carolina are generally well acquainted with my fellow West Virginians. I have a theory that West Virginians share a gene which, at various times of their lives, causes them to have an irresistible urge to drive to South Carolina’s coast. In fact, when the mines close down for two weeks every summer, untold numbers of miners and their families head to Myrtle Beach, which has been affectionately dubbed ‘the coal miner’s Riviera.’ Some of my earliest vacation memories are of the Grand Strand. My wife Jan, a true ‘coal-miner’s daughter’ has similar memories.
If you doubt the connection between SC and WV, I have a vignette: my brother-in-law Dave worked in the WV coal mines as a young man out of high school. His early cell-phone plan included, as local calls, Huntington and Charleston, WV and (you got it!) Myrtle Beach, SC.
I write about this today because West Virginia is in the heart of Appalachia, which stretches from Southern New York all the way to Northern Mississippi (passing through the Upstate of South Carolina). Appalachia is defined as a ‘cultural region,’ and indeed it is.
More to the point, I write this because Appalachia is struggling. Although poverty has improved over the decades, Appalachia as a whole still faces financial woes, much of it made worse by those who are all too anxious to kill coal, but provide no other employment options for those terminated as part of an environmental purge. As if the ‘coal industry’ is only some vast robotic behemoth, and does not represent the hopes and dreams, and often the only financial possibility, for an entire ‘cultural region’ of America.
Appalachia is also struggling with rampant drug addiction and broken by the many funerals, ruined lives and crimes that widespread addiction brings in its wake. From pill-mills dispensing oxycontin to meth labs and imported heroin, the toll in lost lives and lost hope is crushing.
When Jan and I have traveled home over the years, deeper and deeper into Appalachia, up Highway 23 through North Carolina, Tennessee, Virginia and Kentucky and then home, it’s easy to see a place of magnificent beauty, resilient people and serious, inexpressible hopelessness. I never know if the drug abuse is the cause of the loss of hope, or the result of it. Cart, horse. It’s all tragic.
Sadly enough, America frequently just isn’t interested. Appalachian people are still acceptable sources of scorn for much of urban, coastal America. They’re live in ‘flyover country.’ Trailer-trash, hicks, rednecks. People who ‘cling to guns or religion or antipathy toward people who aren’t like them,’ to quote a well-known political figure. When a culture is endlessly mocked and derided, its people get the message loud and clear. Don’t try. It doesn’t matter.
But this June 20th I’d like to speak for my ancestors, and the forebears of so many, who settled in the Mountains of WV and other portions of Appalachia after leaving the press and stagnation of Europe. I’d like to speak for those who still live there, and who find solace and connection in the ghosts of their ancestors, the starkness of the mountains and valleys, in the life, faith, culture and music of the cities and towns. Like me, they stay there because in Appalachia, the past and the present are difficult but inextricable.
And if nostalgia isn’t enough, let us remember Appalachian people keep the lights (and i-Pads, DVR’s and electric cars) on by mining coal. They also provide timber and produce, work in important industries and share their region for the recreation of any and all. All too many have also shed their blood in America’s many wars, and continue to boldly, proudly ‘stand on the wall’ around the world.
America loves to talk about its multiculturalism. And one of its greatest cultures is firmly entrenched, despite its pains and struggles, in the vast region we call Appalachia. It deserves our respect.

Never Stop Discovering Your Spouse

Elysa photos 007

This is my most recent Greenville News column.  Inspired, of course, by my amazing wife Jan.  All my love baby!

http://www.greenvilleonline.com/story/opinion/contributors/2016/06/05/ed-leap-never-stop-discovering-your-spouse/85286660/

June is here, and while it certainly isn’t the only month for weddings, it is a popular one. This month, many young men will have a brand new thing called a wife, and many young women a thing called a husband. Both are perplexing, and both are wonderful. As such, I have some insight to share.
Gentlemen, what you have before you after the vows are said and rings exchanged, is a woman of your very own. She has been thinking about this her whole life. In fact, she has been unconsciously (and consciously) evaluating men as husband material since she first realized that there were boys in the world other than her father and brothers. She chose you. (Don’t question it, just be glad…she knows you’re imperfect, trust me.) And what she wants is your love and devotion. She wants you to stand by her and be faithful. She needs to know you won’t run away when things get tough. She needs to know that you still think she’s amazing when her life is a hot mess and her hair won’t do anything right and she just cries for no reason. She does not expect you to figure it out or fix it, as much as you want to do that.
The great wonder is that she just wants you (you among all other men on earth!) to share life with her, hold her, protect her and get old with her. She could have had people better looking, smarter, stronger or richer and every smart husband realizes this. She wanted you to share her mind, heart and body. She probably wants to have your baby. (It’s a compliment of the highest order.) Something about you drew her in to your orbit. Observe this advice, honor her dreams, speak kindly and treat her gently, love her lavishly and you will never in this life find an ally more true or comfort more wondrous.
This beautiful thing before you is yours; and she should be your favorite hobby, best friend, greatest confidant. She will give all of that back and more. But remember what the Little Prince said: ‘You are responsible forever for what you have tamed.’
Ladies? What you have is a man, also of your very own. As a young man, he didn’t probably didn’t think about weddings or marriage as much as you did. But deep inside, he wanted it. He wanted a woman to care for. Good men like caring for things; we protect, we defend, we provide. It’s our wiring. On some level, even as you wove your spell he ‘hunted and gathered’ you. In a hilarious expression of the whole process, ‘he chased you till you caught him,’ as my wife used to say. He is sometimes slow to understand things natural to you. Like feelings. He is sometimes uncomfortable with lengthy discussions of emotions. He is fascinated by your feminine ways, tears, declarations of love and complicated rituals. He struggles with bra-straps and is confused by make-up, skin products and your many shoes. But in all his simplicity, he is far more complex than your friends (or society) lets you believe. He is in awe of you and if you are kind to him, encourage and respect him, he will do anything you ask just to make you happy.
He needs a little space sometimes. And honest to goodness, there are times when he says ‘I’m not thinking about anything,’ and is telling the absolute truth. We men go to that place sometimes, even though your multi-tasking brains can’t fathom it. Let the man have it now and then. Just a little down-time. He’ll be back.
Your husband, properly treated, will love you and the children with a devotion that comes fairly close to worship. And when he says ‘you’re beautiful,’ don’t tell him no, don’t deny it. He really believes it because you are his, and he’s amazed that you agreed to marry him in the first place.
Husbands and wives, his whole process is an incredible mystery. Two people, two complex creatures, with dreams, hopes, wounds, bad habits and all the rest come together and make, as the Bible says, ‘one flesh.’ Two humans who barely know themselves choose to know another and love them for life.
As you pass through the portal of the wedding into the new life called marriage, may you never stop discovering the unfolding, life-long wonder that is your spouse.

After Graduation, Love the Kids. Just Don’t Worship Them

Sam and Tyler K5 graduationhttp://www.greenvilleonline.com/story/opinion/contributors/2016/05/22/ed-leap-after-graduation-love-your-kids/84556782/

Graduation is upon us once more. All across the area high, schools, trade schools and colleges are releasing their eager, bright eyed students into the the next phase of their lives. My wife and I have graduated several times, and have graduated two sons. It’s an emotional, beautiful time when Pomp and Circumstance turns moms into weeping messes of mascara and tissue, and dads into great, red-eyed lumps who choke back tears and say muffled things like ‘I…I’m fo prd ov you. I lvvv you,’ sniff, sniff.

The kids are emotional but boy, are they ready. They toss those hats into the air (as parents try to grab them as keepsakes) and they head off to jobs, or to parties or sometimes to pre-loaded cars headed off for the beach. Some go to their own weddings and some go to basic training, or their first overseas deployment with the armed forces. Big stuff all around.
But as I thought about the whole process I realized that one of the great dangers of a successful society (and by any measure of the world at large or history ours qualifies), is that we are capable of investing all of our worth as parents into the activities and successes of our offspring who are now springing off on their own.

As such, we forget something very fundamental. Once the kids grow up, they can largely do what they want. Just like most of us did. But what does that mean exactly?

Well, first of all those graduates with all of their dreams, like ’I want to do forensics,’ ‘I want to be a marine biologist,’ ‘I want to be attorney general,’ etc. may or may not do those things. Their dreams are useful guiding stars at first, but most of them will change course for a variety of reasons. Thus, I am not a full-time magazine journalist as I originally intended. Nor an Air Force navigator…probably good given my tendency to get lost.

We love to brag about what our kids will do. I certainly do. They are hints of the future, and sometimes we believe their successes will somehow atone for our own shortcomings, our own failed dreams. But it’s important to step back on occasion and realize that the future may look very different from what they, and I, and all of us, think it will be for them.

Second, they may decide that the educational path we hoped for them to follow isn’t right. These days, many college majors are a poor economic bet compared to heating and air or welding. My professional friends in medicine and law are particularly stricken by this. When one says to another, ‘Tim dropped out of USC. He’s decided he wants to be a contractor,’ there’s an almost palpable tension and a pat on the shoulder. ‘Well, he may go back to school later.’ Or he may be a wildly successful contractor. Or he may just like building things more than thinking about things that don’t interest him. Who knew?

Third, they will love and marry people we didn’t expect. Just like we did. We can have all kinds of plans for betrothal and hopes that they’ll find this girl or that guy. But in the end, as Pascal said, ’the heart has reasons of which reason knows not.’

And now the hardest, dear weeping parents, and many of you know this. They will make their own mistakes. They will lose jobs and ruin relationships. They will set themselves back. They will violate, sometimes, the law of man and often the law of God. This is called being human. For Christians, it’s tough realizing your kid is a sinner too. (In the secular, world, the equivalent might be realizing your liberal family raised a Republican and you have to love them anyway. Cheer up! Prodigals do return!)
Allow me to review: the kids will study what they want, work at what they want, love whomever they want and make big mistakes. The best we can do is show the grace and love throughout all of it.

But to love them well, we have to take them off the altar. Our worth as humans cannot be wrapped up in our children. That’s a terrifying and overwhelming idolatry and it holds them to far too high a standard.

So as they get those certificates and diplomas, remember they’re humans. Hope and fear, success and struggle in dynamic tension.

And love them.

 

Doctors and Nurses ‘Getting in Trouble’ too easily…

Trouble

 

My column in the April edition of Emergency Medicine News

http://journals.lww.com/em-news/Fulltext/2016/04000/Life_in_Emergistan__Doctors_and_Nurses_Getting_in.6.aspx

Are you afraid you’ll ‘get in trouble?’ It’s a common theme in America today, isn’t it? We’re awash in politically charged rhetoric and politically correct speech codes. Our children go to colleges where there are ‘safe spaces,’ to protect their little ears from hurtful words and their lectures or articles contain ‘trigger warnings’ so that they won’t have to read about things that might upset their delicate constitutions. All around that madness are people who are afraid they’ll ‘get in trouble’ if they cross one of those lines. I mean, one accusation of intolerance, sexism, genderism, agism or racism, in industry, government or education, and it’s off to the review panel for an investigation and re-education!
Worse, I see it in hospitals now. I hear so many nurses say ‘I can’t do that, I’ll get in trouble.’ I remember the time I asked a secretary to help me send a photo of a fracture to an orthopedic surgeon (with the patient’s consent, mind you). ‘That’s a HIPAA violation and I’m not losing my job to do it!’ OK…
There have been times I’ve said, ‘please print the patient’s labs so they can take it to their doctor tomorrow.’ ‘No way! That’s against the rules! I’ll get in trouble!’ Seems rational. The patient asks for his own labs and takes them to his doctor. It can only be for nefarious purposes…like health!
Sometimes it’s even sillier. Me: ‘Patient in bed two needs an EKG!’ Nurse: ‘You have to put in the order first, or I’ll get in trouble.’ In fact, this theme emerges again and again when I ask for things like dressings, splints, labs or anything else on a busy shift. I’ve expressed my frustration about physician order entry before, and I know it’s a losing battle. But when there is one of me and three or four of them, and ten patients or more, it’s hard to enter every order contemporaneously. But I know, ‘you’ll get in trouble.’
I remember being told, by a well-meaning (and obviously threatened) nurse, ‘if I put on a dressing without an order it’s like practicing medicine without a license and I can lose my nursing license.’ Well that makes sense!
I overheard a nursing meeting not long ago, and it seemed that the nurse manager (obviously echoing her ‘higher-ups’) was more concerned with making sure the nurses didn’t do wrong things than with anything touching on the actual care of human beings.
I suppose it’s no surprise. ‘When all you have is a hammer,’ the saying goes, ‘all the world’s a nail.’ Now that we have given all of medicine to the control of persons trained in management, finance and corporatism, that’s the thing they have to offer. Rules, regulations and ultimately threats.
Of course, ‘getting in trouble’ applies to physicians as well. It just takes a different form. Didn’t get that door to needle, door to door, door to cath-lab, door to CT time? We’ll take your money. Didn’t get the patient admitted in the committee approved time-window? We’ll take your money.
Never mind that seeing patients in a timely manner is rendered nigh impossible by the overwhelming and growing volumes of patients, coupled with the non-stop documentation of said patients for billing purposes. Keep shooting for those times! Times are easier metrics to measure. Times are easily reported to insurers and the government. Times, charts, rules-followed, rules violated. The vital signs of corporate medicine in America today. (And don’t give me that ‘it would all be better with the government in charge.’ Two letters give that the lie: VA.)
No, we’re an industry constantly ‘in trouble.’ But not really for any good reason. We give good care as much as we are logistically able. We still save lives, comfort the wounded and dying, arrange the follow-up, care for the addicted and the depressed. We still do more with less with every passing year.
But odds are, we won’t stop ‘getting in trouble.’ Because for some people, waving the stick is the only management technique they know. Still, it saddens me. I’m sad for all of the powerless. The nurses and techs and clerks and all the rest who are treated as replaceable commodities by administrators who are themselves (in fact) also replaceable. I hate to see nurses, compassionate, brilliant, competent, walk on egg shells in endless fear, less of medical error than administrative sin. Their jobs are hard enough already without that tyranny, leveled by people who should appreciate rather than harass them.
And it saddens me for young physicians, who don’t remember when being a physician was a thing of power and influence in a hospital. They, endlessly threatened and unable to escape thanks to student loans, are indentured for life, short of a faked death certificate.
Finally, it saddens me for the sick and dying. Because we cannot do our best when our motives are driven by fear more than skill and compassion.
The truth is, however, threats only go so far. And once people have been threatened enough, there’s no telling how they’ll respond.
Just saying…

 

Show some patience in the bathroom debate

d87e8246a18b0a04b40041956e38707fhttp://www.greenvilleonline.com/story/opinion/contributors/2016/05/08/ed-leap-show-patience-bathroom-debate/83918244/

 

I have to admit, I never thought that we’d be arguing about who to allow into which restroom. And yet, men and women who identify as other genders feel oppressed that everyone isn’t flinging open the stall doors to welcome them as bathroom-mates. And those (like me) who view it all with a little suspicion are considered worse than troglodytes for failing to keep up with modern progress and diversity.
Let me say from the outset that I am believe, absolutely, there are people who have issues with gender. There are those who are born with indeterminate genitalia, some with chromosomal issues or abnormalities of the endocrine system, and still others with psychological factors which make gender assignment or identity confusing.
However, that reality doesn’t obviate other concerns. Humans have been cautious about sexual predation for a very long time. In particular, but not exclusively, we’ve been suspicious about the motives of men towards vulnerable women and children. Maybe we have some deep ancestral fear of rape and abduction by invaders or raiders. (A thing well known to our forbears within about 200 years.) Isn’t it possible, therefore, that our heightened concern about this issue is not about hatred or intolerance, but represents a well honed biological instinct? That perhaps it is part of some evolutionary, survival-based instinct to protect those who are more susceptible to predation?
This may be why so many of us don’t like the idea of letting just anyone use just any restroom, changing room or locker room. These are often isolated places that typically have no back door for escape. It seems peculiar to me that while we are endlessly cautioned that college women have a one in five chance of being sexually assaulted while in university, we are mocked for having concern about opposite sex strangers in public restrooms. While it turns out the data on college rape isn’t nearly as bleak, the general concern about sexual assault is very real and reasonable.
Even if most transgender persons out there aren’t a particular threat, couldn’t it be that our concern over men lying about their gender identity, to gain access to vulnerable women or children, might be well-placed? And by the way, women are fully capable of sexual assault as well; a quick search for ‘teacher sexual assault’ will reveal a significant number of instances in which a female teacher sexually abused a student in her charge. Equality of opportunity also means equality of suspicion, you see.
Further, we keep hearing that transgender people aren’t pedophiles. Indeed, most probably aren’t. (I like to assume the best.) But neither are most men or women. And yet, most of us recognize the wisdom that a man alone shouldn’t chaperone a camping trip of adolescent girl-scouts, or be ‘house father’ to a sorority. And ask your female friends and family if they want male chaperones for their pap-smears, or if they prefer a female. And a lone young woman might not make the best choice to guide high school boys on a long field trip involving a hotel stay. These things make sense, if only to avoid the appearance of impropriety.
In addition, it is the height of politically correct folly to assume that because one has ‘transcended’ traditional sexual roles or genetic gender that they are, by default, above reproach and incapable of evil. In fact, it is demeaning to assert this. To be accepted as part of the greater collective of society is to be seen as human, not ‘super human.’ This means one is respected, seen as valuable, but also subject to the same laws and cautions as everyone else. Ultimately, since the fairly recent mainstreaming of transgenderism, I doubt if we have enough experience or data to make definitive statements about whether or not the transgendered have any increased or decreased risk of predatory behavior. I do think we can safely assume that those who would pose as transgendered are clearly dangerous, and for most of us I believe that’s the greater fear.
So why don’t we all show some respect for one another and some patience in the face of both titanic cultural shifts and time-honored mores. Then we might come to a reasonable common ground that respects differences and protects all the vulnerable.
Or to use more a more contemporary idea, maybe both sides of the issue deserve some tolerance.

I don’t think that’s too much to ask.

Do you?

Some new, important screening questions for the EMR

Scrolling through FEEMRS (you know, Fancy Expensive Electronic Medical Records System), I was stricken by just how much data is on the chart.  I mean, it’s pretty dang amazing.  But I was, simultaneously, reminded that most of it doesn’t help me.

It helps someone, mind you.  For instance coders and insurance companies.  The complexity of EMR also helps those who track our car to door, door to chair, chair to chair, chair to bed, bed to bathroom, bed to X-ray, request to blanket, request to sandwich, request to TV remote, request to ice chips, complaint to Dilaudid and discharge to angry times.  (The really important stuff!)

But so often, FEEMRS just gets in my way.  I mean, I struggle to find little things like triage information, medications or last menstrual period. And as for visual acuity?  Faggettaboutit!

However, I do think there are some things that might be useful screening questions.  So, here are a few things I think we should have the nursing staff ask on the way into the ED.  I mean, we always ask about drug abuse, interpersonal violence, immunizations, sexual activity, whether or not the withered 98 year old has lately traveled to any Ebola infested exotic locales.  But is it really enough to know if the newborn has stopped smoking? Or are there other more interesting things with which we could further clutter the hallowed screens of our FEEMRS?

I hereby suggest:

What is your preferred pronunciation of the only pain medicine that ever worked for you?  With what letter does it begin?  (Incidentally a patient recently pronounced their favored drug ‘Laudy-dah.’  Awesome.)

What unfortunate thing has lately happened to your medication?  Eaten by dog, stolen by neighbor, smashed by meteorite?   Hey, it could happen…

Is there some species with which you identify and would prefer to be treated as?  Because if so, we may need to call a vet. Or tree surgeon.  (It’s no joke.  Tree-kin is a real thing…I mean, ‘real’ thing.)

First thing that pops into your mind when I say ‘outstanding warrants.’  Go!

What is your favorite kind of sandwich to eat while waiting on your psychiatric commitment.  Just kidding. We have Turkey.  (It’s empowering to offer a choice even if we really don’t have one.)

This is to be asked immediately on arrival into triage.  Right now, how long do you believe you have waited to be seen? One hour, two hours, three hours.

Do you know the patient advocate’s name and phone number?

For abdominal pain:  Please tell me what kind of cheeseburger, chicken sandwich or friend food you have consumed on the way to the ED, and when you finished….oh, you’re still eating it.

This is very useful and instructive: Why are you on disability? With a few mental health exceptions, if it isn’t evident in triage, it will be a good story.

How many times have you been committed to a state or private psychiatric hospital? If the number of suicidal commitments is greater than ten, patient can probably go to the waiting room.  Especially if eating cheeseburger and suffering from simultaneous abdominal pain.

Is there a particular physician you would like very much to see or not to see? Or want to hurt?

Full disclosure.  What are you here to get, and if you had it, you wouldn’t be here at all?  For instance, work excuse, pain medication, etc.

Who told you you should come to the ER, if anyone:  your physician’s office, your attorney, a police officer, your sister’s best friend who is a CNA at a nursing home, or a 24-hours health line?

Do you find it difficult to stop playing video poker on your phone while talking to a clinician?  

Will you please eat these chips and fill out my satisfaction survey while waiting to come back?

Just scratching the surface.  Send me some of yours!

edwinleap@gmail.com

 

Can you be a Christian in the ER? Grace abounds…

BOT_F

Many young physicians in training have asked me, quietly or by e-mail, ‘is it possible to be a Christian and practice emergency medicine?’  I think that they ask a good question, and likely for good reasons.

In their rotations they have witnessed, first hand, life in the ER.  They are uncertain, perhaps, because they see the frustration that boils over in the words and actions of otherwise compassionate and caring doctors and nurses. They hear the bitterness and sarcasm, the profanity, the unkind words spoken behind the glass window that separates professional from patient.

They also see, hear, touch…and often smell…the humanity that pours through the doors of trauma centers, academic emergency departments, community ER’s and all the rest.  There is suffering and loss, and the long, piercing wail of the bereaved down the hall, receiving the worst news of all.  They experience the addicted, the drug seeker who will tell any lie, contrive any store to get the pill or injection he or she so needs and desires.  They witness the poverty and need, the hungry, empty eyes of neglected children.   The may witness, or experience, the explosive violence and cruelty of the drunk, the criminal, the wounded.  In such a place, between suffering patients and suffering staff, what young, wide-eyed Christian wouldn’t ask, ‘Dr. Leap, is it possible to keep your faith and work in the emergency department?’

So here is my short epistle on the topic:

‘To the believers in the hospitals and emergency rooms, the church medical, across the land, around the world.  From your brother Edwin, who these years has fallen and gotten up over and over and who loves you and wishes to encourage you.

It is my prayer that you have strength to face the sickness and pain into which you plunge yourself every day.  All around you come victims; victims of disease and accident, victims of violence and neglect, cruelty and hatred.  The drunk and addicted, the angry and the sad, the suicidal and lost, the rejected and abused, the healthy and also the dying; and all are among the dying in the end.  Remember that all of them, and all of us, are also victims of sin, for it was in our separation from God in ancient times that all of this pain began, and in which death took hold of those originally destined for life.

Remember that the guilty and the innocent alike suffer from this, and that our Lord came to be an intercessor, high priest and atoning sacrifice for all.   Your struggle is against the infirmities of the flesh, but also against the wounds of the spirit that underly all suffering in this veil, until we reach the kingdom where death has no power…and you will be out of work for all eternity.  Amen.

Look around you each day, and consider that the emergency room, the hospital ward, the clinic, the operating room, these are places where the gospel is shown forth to you in power, a great gift from the Father so that you may understand by the example of others’ troubles what spiritual truths lie beneath it all and undergird it all.

Although we are all poor reflections, destined to one day (as the word says) ‘be like Him, for we shall see Him as He is,’ we are still his dim but ever growing likeness.   And we are His hands, feet, mouth, eyes, mind.  Like Him, we who go day in and day out among the lost, the suffering and those who (despite their willfulness) are hostages to evil.

And although we may have sin in our hearts, although we judge and are angry and frustrated, we do His work.  That is, brothers and sisters, we bring love and touch and healing and comfort to those who frequently have done nothing to deserve it, who exhibit no gratitude or intent to change, but who need our love, need the love and redemption of Jesus.  And like Him, we will show it seventy times seven, through temper tantrums thrown our way, complaints, cruel words, irresponsibility, patient satisfaction, EMR (the devil’s work) and every other difficulty.

Dear ones, in the ER, grace is at work, and a model of grace is there for you to enact and understand.  You give undeserved love and care for everyone all day, every day.  The Spirit gives you strength in hardship so that you may be bold, whether rested or tired, prepared or unprepared.  Also, remember that the spirit works in your sinful heart, to your salvation and holiness.  Those your treat are no worse than you and you no greater than them.  There is a great gift of holy humility in that truth.

One day, on that Great Day, you will see that each act, every stitch, every comforting hand, every EKG, every airway, every psychiatric commitment, each and every weary step into the same room with the same patient and same complaint, every unkind word for another physician restrained, every patient act, these were all acts of grace that molded you.   And the Father, Son and Spirit will welcome you, veteran of ten thousand daily trials.

And it is in this way that one can be a Christian in the ER, in the trauma center, clinic, operating room, delivery suite and all the rest despite the trials, temptations and bitterness that the enemy of our souls inflicts up on us in our work.

May the God of all peace guide you and strengthen you in your difficult work, and fill you with radiant, overwhelming love.

And may you have a quiet shift.

 

Dr. Barkus Yellby…the doctor who yells.

 

Unknown

I’ve never been the doctor who yells.  However, if you work in medicine, you’ve met him or her.  I’ll call this physician ‘Dr. Barkus Yellby.’  (For the younglings, this is homage to famed television doctor Marcus Welby:   http://www.imdb.com/title/tt0063927/.)

Not every physician who yells is Dr. Yellby.  Sometimes, and I’ve seen it, a physician yells out of passion, out of urgency.  ‘We need blood right now!’  I get that.  The same doctor is usually nice after the fog of battle blows away.  But that’s not the Dr. Yellby I have come to know.

The Dr. Yellby is angry.  A lot.  In the old days (and not so old days), he threw instruments in the OR when they weren’t what he wanted.  Or if the charts and labs weren’t ready for rounds, he slammed things on the desk and berated wide-eyed nurses who were holding back sobs.

As an emergency physician, I’ve talked to him any number of times on the phone.  ‘Did you even examine the patient?’  ‘Why are you calling me?’  ‘How is this my problem?’  I was reminded of Dr. Yellby a few months ago when I called a surgeon for an incarcerated umbilical hernia.  Silly me, I’ve been trained over the past few years to ‘finish the workup’ and ‘order the CT,’ so a CT I ordered.  ‘I chose…poorly.’

‘How long has she been there?  Did you even examine her?  Now I have to come back in and we’ve had a delay!’  On and on the berating went.  Heck, I didn’t think surgeons did anything without a CT scan these days.  Lesson learned.

I’ve been insulted, cursed and treated like a perpetual intern, all because I either angered the on-call ‘real doctors’ or because I dared to run my all too Appalachian mouth.  Dr. Barkus Yellby, having fussed at me, was deeply offended that I told him ‘I don’t need your crap.’  Shocked, he was, and threatened to report me to the medical board.  We long since made up.  But I smile looking back.

Some time ago I saw a young man who had a nasty open knee injury while skiing out of state. Rather than have surgery as recommended when he was evaluated near the ski area, he came home and went to the local ER.  He was concerned about costs and insurance.

I called Dr. Yellby.  (Remember, there are more than one…)  ‘So he refused care.’  ‘Well, not really,’ says I.  ‘He was worried about the money.’

‘So he refused care.  I get it.  I’ll see him in the office tomorrow.’  He was unhappy.

Today a physician, angry at his patient, told me ‘that’s the last time I’ll ever see him.   He’s yours now.’  I didn’t do anything to earn him, but that was that.  The patient’s family rolled their eyes in humor.  ‘Oh, he’s like that.  He’ll see him again.’  Dr. Yellby had clearly yelled at this family before.  Maybe they were in the habit of yelling back.

I sometimes wish I could be Dr. Yellby.  I’m more sarcastic, I guess.  Maybe passive aggressive.  Now and then it would seem cathartic to have the confidence, the bravado to simply ‘cry havoc and unleash the dogs of…’ well, not war, but at least medicine.  But as much as I wanted to, I never felt the yelling was beneficial.  Besides which, it has to be unhealthy for the ‘yeller.’  In my experience it only unnerves the team, who need the team-leader, ie me, to be calm in stressful situations.  Calm even in anger.

In the end, I’ve come to realize that Dr.Yellby yells most often because he (or she) is just, plain unhappy. It’s a way to rage against the universe, against trouble, against personal frustration and demons.  Maybe it’s a way for a tough, stoic physician to direct all of that inner turmoil to the nearest receptive target.  Dr. Yellby can be a sad figure, screaming in anger to cover up sorrow and loss, regret or substance abuse.

Then again, for a few, it’s bullying and nothing more.  And that’s the saddest of all.

Poor Dr.  Yellby.  Don’t fear her.

Pity her.  And say a prayer that she, or he, finds some peace.

 

 

Referral Realities in the ER

 

dropdown-location-nazarethI remember seeing so many charts in my career on which the well-meaning emergency room physician wrote the following:  ‘Follow up with your primary care doctor.’  Or, if they didn’t have one, ‘follow up in one week with a primary care doctor.’  I laughed to myself.  Usually, the people we say that to have either no insurance, inadequate insurance or inadequate motivation to even call the persons to whom we may refer them.  Or they find themselves in an area with next to no primary care physicians to begin with.  Call all you want. It won’t happen.

The same thing is now happening as administrators, evaluators, educators, attorneys and law enforcement personnel are scrambling to keep up with changes in narcotic prescribing.  The new mantra is that patients with chronic pain should see their primary care physician; or a ‘pain specialist.’  I put that in quotation marks because as in the case of so many specialties, it can be dang hard to find one of those pain doctors. (The real kind, not the store front drug dealer type.) We see it also in emergency physicians and ED policies that say, for instance, ‘we don’t give narcotics for toothaches.  See a dentist this week.’  Again, without cash in hand, and even with it, that may not happen so easily.  It’s also a little short sighted.  Anyone who has actually had a severe toothache will tell you that sometimes narcotics do, in fact, have a role.

And what about mental health?  Every time we have a mass shooting, a new report of epidemic depression and anxiety, bullying or any other issue that touches on mental health, some wise person says the obvious.  ‘People need to be referred to psychiatrists or counselors.’  Brilliant idea!  Except psychiatrists can be elusive.  Their care may be costly and their availability, depending on geography, very limited.  Ditto for counselors and psychologists.

It’s great to say ‘you should go to this doctor or that doctor.’  But the fact is, for some folks the ER is about as far as they can get…even when they’re especially motivated.  Whether it’s because of money, facilities, professional politics or location, often the referral simply won’t succeed.

I’d like for people to see specialists when they need them; or even primary care physicians!  Largely because we can only do so much in the emergency department.  But I’m realistic enough to know that many, oh so many, of the referrals we suggest never get done.

So let’s apply a little reality to our referrals.  And do our best to help our patients navigate an increasingly laborious and complex health care system.