I’d just like local voters to know that I support the candidacy of James Bartee for Oconee County Sheriff. Nothing against the other candidates; two of whom I know personally! But Mr. Bartee has extensive experience, a passion for the safety of innocents and dedication to enforcing the rule of law professionally!
http://www.barteeforsheriff.com/
Edwin
Some things in medicine are obvious. Despite the endless worship of ‘evidence-based’ medicine, and the constant barrage of studies on every conceivable topic, we do certain things because we know they just seem right. I take as evidence the fact that we daily try to save lives, devoting research time, untold gazillions of dollars and heroic clinical effort to our continued goal of staving off death. Why is this? Do we know that death is inherently worse than life? Well, since we can’t see beyond the grave, and can’t exactly engage in double-blind, placebo controlled studies about the after-life, the answer is ‘no.’ But we assume that life is preferable to death, based on our feelings, our sense of the thing.
The same is true in our personal lives. No one can show me a scientific study that details why he or she married a particular person. No one can offer up a mole of affection for empiric analysis. And yet, we don’t doubt the existence of romance, or the reality of love.
And yet, medicine is filled with situations in which ’self-evident truth’ is systematically ignored, and those who believe in it intentionally and often viciously marginalized.
For example, after years of being told that physicians weren’t giving enough treatment for pain, and after years of clinicians saying, ‘yes we are, and too many people are addicted and abusing the system,’ the data from CDC says that far too many are dying from prescription narcotics, far too many infants being born addicted, and far too many people, young and old, are using analgesics and other drugs not prescribed for them. To which many of us say, ‘duh!’
And then there’s the customer service model, the thing which causes clinicians to lose their jobs as satisfaction scores fall due to disgruntled patients (often upset over not receiving the drug they desired…see above paragraph). This is a darling of administrators. And it clearly has flaws. As a recent article in Archives of Internal Medicine points out, physicians with very good ‘customer satisfaction’ scores tend to have patients with poorer outcomes. Do you think?
Of course, Electronic Medical Records is another. Those of us engaged in the practice of medicine on real people can tell you, EMR has promise, but in practice it consistently does three things. Reduces productivity, takes us away from patients and results in far too much data being recorded and stored. It needs to mature, rather than being forced on everyone from above.
There are others, of course. Board certification is beginning to look very much like a profit-generating machine, despite the paucity of evidence that it matters. (I am board certified, so this isn’t sour grapes.) Federal privacy laws (known as HIPPA) has left us awash in unnecessary passwords and regulations. EMTALA, the law which protects the uninsured has probably resulted in more costs, and more loss of qualified physicians and necessary facilities than any other piece of legislation in history. We know it…but few people are interested in studying it honestly.
All I”m saying is that physicians, and ultimately everyone, will have to mix science with good sense, and learn to embrace their own insights and powers of observation.
Studies have their place. But their goal is the discovery of truth. And sometimes, more often than we realize, the truth is right in front of us.
As we say in the South, ‘If it had been a rattlesnake, it would have bit you!’
Edwin
Happy Mother’s Day all! This is my column in today’s Greenville News!
Our family loves Super-heroes. We always have, from back in the days of action figures and pajamas with Velcro-tab cape, of course. We have watched movies, read comics and studied various books about the back-stories, character traits, character flaws and unique skills of each hero. I admit that we tend toward Marvel, but my wife in particular has a fondness for one DC character, the moody and brooding Bruce Wayne, aka Batman (which explains the aforementioned jammies…for the kids, not me).
Last week we were enjoying Marvel Avengers, a movie which features several of our favorites. I’ve long been a fan of both Thor and Captain America, but must admit to a deep respect for Ironman.
When Jan and I were talking about the movie and laughing, I made a comment that one of our sons reminded me of a particular hero. Jan whispered in my ear, ‘that’s what we’re doing…raising Super-heroes!’ Indeed.
Which brings me round, via rocket-powered suits, mystical hammers and super-science to the unique place of mom. As we celebrate Mother’s Day, it’s good to remember that its mom’s job to do just that. To make us people who are useful and good. Even as we wax emotional about the sweetness of the time mothers spend with their sons and daughters, even as we shed tears over mothers long gone, and recall their touch, their kiss, their kindness, we should bear in mind that their function was this: to keep us safe, keep us healthy and prepare us for the future.
It is a hard thing for mothers, to devote themselves to children who will, if raised properly, abscond with all of the love and attention and preparation lavished upon them, and take it to another family. It’s almost scandalous; if it weren’t so very appropriate.
It was, in no small part, my mother’s encouragement that emboldened me to try to go to medical school. And it was doubtless her gentility to me as a child which contributed to the way I lavish my own children with my time and my resources. I left home, but those early preparations for heroism were shared with her grandchildren down the years. In like manner, my mother-in-law raised a Super daughter, who left home to become a force of nature herself, a hidden garden of safety and love for her own sons and daughter, and anyone else who wanders into her influence.
It is tragic when anyone denigrates, or minimizes, the value and effort of motherhood, which is truly an work of epic, Olympic proportions. Love is its own work, if it is true and sacrificial. And on Mother’s Day we remember that motherhood, and mothers, are truly miraculous.
Having said that, I return to the metaphor at hand. What are the Super Powers of mothers? Many, it seems. Perhaps it would be best to list the tools they carry into the daily work of motherhood. The breath of patience, the armor of endless love, the eyes of understanding, the super shoes of errands, the mystical voice of calm, the twin hands of safety and discipline, the pan of feeding (with the magical ability to create a meal from supplies as minimal as broccoli, cinnamon and a cardboard box). They possess the lap of comfort and the mind of encouragement, the eternal words of hope and the laughter of smiling goddesses.
The mother, thanks to good fashion sense, does not wear a utility belt. She does, however, have everything from wet-wipes to clean socks, from pens and pads to chewing gum in that wonder of wonders, mystery of mysteries, the Super Mom purse. Even Marvel Comics’ Stan Lee would find it wondrous, as it contains whatever we need as children, from socks to snacks, screwdrivers to fruit juice.
Mothers, in all their Super regalia, would leave even the Marvel Avengers in a state of hushed awe. Mothers could make Ironman apologize for his arrogance, Batman smile, Spiderman feel loved, Thor tender and would calm the rage of the Hulk with a whisper and kiss. Magneto, who (according to X-men legend) lost his mother to the Nazis, would probably cease his predations on the world if only his dear mother could hold and comfort him.
Even if we aren’t super, all it takes is a glance at moms to know that Super powers are neither lost nor imaginary. They still reside, as strong as ever, in the loving mothers of the world.
This is my EM News column for May. I hope you enjoy it! I’ll put up a link to EM News as soon as it’s available.
Missionary to Emergistan
I know a fine, caring physician who has a heart for God and a heart for people. He often goes overseas to serve the poor and needy in the third world. I saw him in his lucrative practice, where he recently asked this question. ‘Ed, do you do any mission work?’ ‘No,’ I replied. ‘Well, maybe someday’ he said, and patted my shoulder in encouragement.
It bothered me. It seemed like a kind of pity. It bothered me because, like so many great moments, I hesitated. Later, I knew what I should have said: ‘Yes I do! Every day that I walk into that emergency department!’ But I didn’t say that. I smiled and went on my way.
I thought about it some more. Mission work, mission work, where do I go….and it hit me. Every day I travel to work in Emergistan.
Emergistan is less a place than a state of mind. It is a place that is so unlike the rest of the human experience, many individuals find it hard to believe the stories we bring back. ‘People actually suck on their fentanyl patches…and die?’ ‘Yes, yes they do.’ ‘People come to the ER in ambulances for…for colds?’ ‘Yes, yes they do.’ The customs are difficult to explain.
In Emergistan, there seems almost a different kind of language. Spend enough time there, as we do, and you understand some of it. You understand tingling and buzzing, squeezing and spinning, burning and vomicking, and any of a dozen words for genitalia or a hundred words for drugs…tabs, bars, ruffies, Special K, K-2, bath salt and all the rest. You know that two beers means two dozen, that disability doesn’t always mean disability.
But it isn’t just the words. It’s the content, the meaning that evades so many. Even after years we don’t fully understand leaving, with staples in one’s scalp, to go ‘finish the fight.’ We don’t understand a 15-year-old child whose parents are excited about her second pregnancy, or a 22-year-old man thrilled to be committed, once again, because it will help get his disability. We have difficulty with an old lady ignored in her home while sores develop on her back, or a new-born with a broken skull because its cry interrupted someone’s television show. We weep, out loud or silently, at the young father with a new brain mass.
Emergistan is not only a different mindset, it’s practically a different dimension. A place of bizarre time and space. In it, a woman can have an exam, CT scan, labs and pain medicine in a two hour period, even as her husband stamps the floor and curses because, ‘we been here two hours and ain’t nobody done nothing!’ Two hours is interpreted as four, four hours as eight. What most would call a one, or a five is always a ten on the pain scale. And a work excuse is a civil right in the endlessly shifting constitution of the land.
Perhaps it’s no surprise. While we travel there, and while we see many patients like ourselves who do not desire to be there and who are in great peril and great need, we do not grasp the mindset or philosophy of the native Emergistanis…those whose lives seem to revolve around the triage desk, the patient room, the CT scanner, the coveted prescription. They are unfortunate, in some ways, many having been neglected their entire lives. Never nurtured by parents, never loved by spouses, never taught to cope (as evidenced by their constant anxiety), never taught to learn or to strive. Only taught to need, to dramatize, to expect.
I know, our experience in Emergistan makes us cynical. But it may be because so much bad, so much manipulation, so much need, so much pain ends up there. We see it. We see the refugees from normality, the abused and wretched, all mixed in with the abusing and hateful, the dishonest, the reckless and addicted, the slothful and cruel mixed with the dying and broken. It’s hard not to mix them all up.
It’s also hard because we are expected to do it as if it were mission work. For some it is. For some, whose faith or philosophy call them to give altruistically, it is a genuine mission work. For others who do not hold that view, who are compelled by government to work in Emergistan for free, it is a place of bitterness and anger that grows (understandably) with every passing mandate, every new rule about our travels and travails there, imposed by those who have never, ever truly crossed the border with us, who only know that it saves money when we do so at our own expense and risk.
Emergistan gets inside you. Sometimes you love it. It can be a land of thrills and challenges, rescuing hapless Emergistanis from disease and accident, and sometimes from their own bad decisions. Sometimes you hate it because it is all consuming and overwhelming. Or because the tragedy, like a parasite, has found its way into your heart and mind and made you fearful of every cough, every fever, every car you pass on the highway, every person you pass on the street. Emergistan’s doctors bear emotional scars that may never heal in this life.
Here’s the thing. They can call me bitter or angry, burnt out or hateful. But I love Emergistan. It is a kind of home for me, where I spend days and nights, where I make my living, where I support my family. In some ways, I am a dual citizen. I understand the regular world, the world of normal rules and behaviors, of clean offices and polite conversation, where sobriety is expected and work rewarded. But I understand addicts and drunks, violent criminals and irritable, dying old men, fearful mothers with sick children and frustrated, beat-down physicians and nurses. I see so much. I have seen so much.
I can criticize and observe, I can lay out the truth as I see it because I have been there, I have served there. I am a veteran of the daily battles of my second home in Emergistan. I know the truth as no policy maker ever will. I am, and have always been, committed to that other country that daily seems to suck out my soul and daily calls me back again; that rejuventates me with every save, every successful intubation, every good diagnosis, every smile of gratitude from the sick or fearful.
I am a missionary, I suppose. And so are you. And we can hold our heads high, for we have worked in one of the hardest, darkest places in the world. The psychotic, overwhelming, frantic, tragic Republic of Emergistan.
May her streets be paved with oxycodone.
Dear friends and readers! My Emergency Medicine News column, Second Opinion, has won a Silver Award for Best Regular Column, from the American Society of Healthcare Publications Editors.
I’m very grateful to Ms. Lisa Hoffman, my editor at EMN, for submitting my work to this competition.
SILVER
Emergency Medicine News
Second Opinion
February, April, December 2011
Here’s a link to the complete list:
http://www.ashpe.org/pdf/2012-winners.pdf
Have a great day!
Edwin
Here is my column in today’s Greenville News. Enjoy! And remember what you put in the cart at the store…
Everyone loves a good mystery, don’t they? It’s why we enjoy shows like CSI, and The First 48. The idea that we can take the evidence before us and construct an explanation for events, why that’s good fun! And I wonder, sometimes, if folks aren’t taking notes in anticipation of future misdeeds!
It all makes me wonder. Someday, when I’m long gone to glory and the children are far away, someday when these woods and fields are unexplored and wide open before other occupants, I wonder what they’ll think?
How will they explain the assorted animal bones that litter our yard and woods ? I know that they’re the consequence of keeping a pack of dogs around the yard. Thanks to the dogs, I am never surprised when the law-mower flings half a mandible across the yard, or a small skull crunches beneath my foot as I work around the porch. Not that the dogs take the energy to kill anything, mind you. But they’re great at dragging things out of the forest that have been killed by other, more enterprising carnivores. Of course, the collected skeletons may seem a little odd to future excavators, since this place clearly wasn’t an active farm.
Coupled with the scattered shell-casings, lost arrows, abandoned hatchets and machetes characteristic of boyhood, future excavators might take this for a battlefield, a sacrificial location or an abattoir! Small creatures buried in boxes might also make it seem like a burial ground. My daughter recently interred a tiny tortoise in a wee box She tenderly wrapped it in a leaf and flower, with the kind of gentility only a child can show for a thing that seems so inconsequential to silly adults. Of course, I had to dig the hole, but that’s papa’s work.
When the kids were smaller, I wondered what an investigator would think of my last car. Somewhere, under a back seat, there were probably a couple of forgotten diapers, at least two pounds of potatoes in the form of petrified McDonald’s French Fries, enough straws to make a snorkel, enough loose change to re-fill the gas tank and multiple forgotten crayons. The seats themselves likely had enough DNA from childhood incidents and accidents to reconstruct a very confusing crime-scene involving blood, saliva and urine. I imagined the detective scratching his head next to my body, wondering if I had been killed by a diaper wearing short-order cook with a creepy penchant for coloring books.
However, I never wonder about the ’story’ more than when I’m in line at WalMart or some other store that has a wide variety of items. As I check out, someone must be asking, ‘why would he need 500 rounds of .22 ammunition, 50 pounds of dog-food, a blade for a power-saw and scented hand soap?Can I get a deputy on aisle 20?’
And there’s the dietary issue. Sometimes our kids have friends over to visit. I always enjoy the look in the clerk’s eyes as I check out with 10 pounds of hamburger, 6 boxes of Swiss Cake Roles, 10 bags of assorted chips, batteries for the X-box controllers, 10 liters of Coke products, three boxes of Oreo Cookies and an archery target. ‘You don’t want to know,’ I think to myself. The only thing better would be adding a vial of insulin.
So it is with a smile that I view a big screen TV, a leopard print bra, stiletto heels, four gallons of wine and a packet of steaks. ‘Happy Father’s Day,’ it cries out! It is with a laugh that I watch Star Wars action figures, a box of Vanilla Wafers, a pack of juice boxes and some frozen kids’ meals. Mommy needs a little down time, apparently.
It is with wonder and a little surprise that I see frozen dog cookies, a car battery, a stroller, a chainsaw chain and a set of socket-wrenches. Just what sort of vehicle are we building, eh dad?
And it is with a sense of foreboding that I watch as 100 feet of rope, a set of steak knives, a shovel and a gray tarp roll down the conveyor. Family coming to visit? Big plans? I wonder if someone is going to show up on America’s Most Wanted.
I’m fairly easily entertained. But few things entertain me like constructing stories, whether it be from tiny corpses in my yard to scary purchases at the store.
There are mysteries, and stories, all around. Just you watch!
I was sitting around the ER a few days ago when I came up with an idea. What if, for one day, we asked our patients to summarize their reason for coming to the hospital in five words or less?
In an age of too much data, too many computer fields and far too much confusion, five words would be a nice break for some folks.
‘I have a swollen spot.’
‘I am having trouble breathing.’
‘I am out of Lortab.’
‘Keep me out of jail.’
‘Crushing chest pain right here.’
‘Need material for disability application.’
‘I am really very lonely.’
‘I just want to die.’
‘I just want him to die.’
‘Meth makes me feel bad.’
What an elegant, almost poetic way to take a history! Contributions welcome.
Edwin
As the debate over the Affordable Care Act waits on the Supreme Court’s decision, I think it may be a good time to pause and reflect on the basic question we’re all asking: how do we ensure healthcare for the largest number of people, in the most compassionate and cost-effective manner?
It’s a question both left and right are asking. I believe that both sides genuinely want to ensure that care is available. I’m a conservative physician. Worse in the eyes of many, I’m a Southern Baptist conservative, living in the South. (That means I’m pretty much the very embodiment of many progressive nightmares.) But I want to see people have access to healthcare as well.
I work in the emergency department of a busy hospital. I see every sort of illness and injury, from trauma to heart attack, from pneumonia to overdose and everything in between. I have no desire to see anyone suffer. In fact, most of those in my specialty bear the brunt of this desire. The average unpaid charges for an emergency physician, nationally, are about $160,000 per year. Due to unfunded federal mandates, we see the majority of folks who can’t afford care elsewhere.
The problem is, America is politically polarized when it comes to solutions. And this is because both left and right wear blinders.
Conservatives, because we believe in initiative and accountability, too often default to the ‘well, then get a job’ position. Particularly when we have jobs and benefits (lavish or basic) we assume that with a little effort, most folks can get what they need. Sometimes it’s true. Despite how mean it may sound, sloth is alive and well in America.
But in the current economy, even the motivated, even the educated and gifted may have difficulty finding work; certainly finding work with insurance coverage. That’s probably our conservative blind spot. An assumption that if we can do it, everyone else can do it too. I’ll take that criticism as a conservative. Particularly as a Christian conservative, who believes that Jesus called me to compassion for the poor, the widow, the orphan. I need to make sure that the policies I advance, the philosophies I hold dear, don’t trample on the innocent out of ideological expediency. I don’t want to explain that on judgment day.
On the other hand, I know some liberal progressives (we try to keep them thinned out, but there are still a few down here). And the ones I consider friends are genuinely caring. They want to see economic growth, they want to see people free of welfare, off of drugs, living in good homes and getting jobs and educations that allow their families to prosper. But they have a blind-spot as well. They believe that every person’s downfall is ultimately the fault of some other force. Whereas a Christian conservative like me believes that all humans are fallen beings (citizen and leader alike), accountable for their own mistakes, progressives see people as victims of society at large. Victims of policies, economic or social. Victims of government.
While I am sometimes guilty of judging too harshly, the left is equally guilty. But guilty of letting individuals off the hook, as it were. What I see, in the real world of suffering and social crisis, is not only a group of individuals suffering from circumstance, but another group suffering from choice and moral failures. These are the ones who make any healthcare reform nigh impossible. They choose to commit crimes, they choose drugs, they choose promiscuity and multiple children out of wedlock. They have been taught that they aren’t accountable, and have embraced the lesson fully, and endlessly wait for another program, another check, to solve the problem. They are broken, not just externally but internally.
If asked to use healthcare wisely, they won’t. If asked to stop expensive habits that lead to health problems, they won’t. And as sure as anything, if asked to buy insurance, even at a discount, they won’t. Any more than they’ll pay the fine. For they know there will be no consequence to them if they play the victim well.
Healthcare reform is a beautiful dream. If I thought it would work as proposed, I’d support it. Frankly, if everyone has insurance my income will rise. But it won’t work as proposed. Because people are what they are.
I suppose what I’m saying is that we need some more creativity in the process. And some more cooperation. Left and right both see the problem and want to solve lit. But left and right both sometimes refuse to see reality; to the evaluate the evidence.
Only when that ‘evidence based’ hurdle is overcome can we actually find a solution. Even a Southern Baptist deacon/physician can see that.
Today’s diagnostic clues for the ER:
The knife sticking out of the patient’s chest, crying for help as he calls the nurse a ‘b..ch’ might suggest he is a sociopath. And that he wasn’t entirely an innocent bystander.
The ability to text the message, “I’ve been in a car wreck, bring me something from MacDonalds,” while lying on a backboard, suggests that serious injury is unlikely.
A tattoo on the back that says something lewd like, ‘Saddle up’ could indicate a high likelihood of STD.
A patient who says, casually, ‘I’m on the hospital board of directors you know’ is actually saying, ‘all science aside, you’ll do what I ask you to do.’
The comment, ‘I’ve had that degenerative disc disease since I was 12′ is a strong predictor of a pending disability application.
The patient whose face is covered in gold paint probably doesn’t need a work excuse if he survives to discharge.
When the complaint begins with: ‘Well, he was with his daddy’s house all weekend, till I picked him up and found this…’ is likely to involve an attorney and affidavit.
When the complaint involves 1) more than three body systems, 2) more than two decades 3) more than three specialists, you won’t solve it in the emergency department.
If a patient is over 90, wearing dirty work jeans, has a farmer’s tan and says ‘I don’t feel right,’ you have roughly 30 minutes to save his life.
When the elderly patient’s family asks, before you even examine the patient, ‘are you gonna keep him overnight?’ you might as well plan to keep him overnight.
More than three empty narcotic bottles, and a pain scale of 10/10, suggests an economic transaction has been the issue, rather than a medical problem.
Tuck these away, kids. They’ll come in handy someday! And there are plenty more. Send me a few of your own in the comments!
Edwin
This is my Easter Sunday Greenville News column. (I haven’t had time to post it until now!)
He is Risen! Words have such power; power to heal, power to destroy. Power to give hope or dash it on the rocks. When asked what the worst thing I have ever seen in my medical career, I usually explain that telling someone bad news is the worst. Words are more terrible than any wound I have ever seen.
He is Risen! Those are words I can work with. When Jesus walked the earth, He brought light into this dark world. Certainly, He gave words of wisdom, words of love, instructions for compassion and kindness to the poor and broken. But He gave hope for more than that. He gave hope that in Him and through Him, all would be well. That the lost could be redeemed. That God sent His son as ambassador to the hurting, to reclaim them.
And yet, there came that day that He predicted. And on that day, all the hope was beaten and bloodied and hauled upon the worst instrument of torture the ingenious Romans, our cultural ancestors, could devise. The cross. The very word, crux, means torture, torment, misery even as it means the device upon which it was inflicted. There is where the hope went. Hope bled, was pierced and died.
I imagine the words going forth, down Golgotha, across the beautiful city of Jerusalem (may God give her peace). ‘He’s dead. They killed Him.’ Or to some, ‘He’s dead, we killed Him,’ which would be a more accurate statement for all believers to make, given that His purpose was more than kind aphorisms and gentle miracles. Given that his purpose was to die for us, rise, and leave behind the death and sin He took with Him, in the greatest smuggling operation in history
The bad news traveled through the heart of His mother, across mystified Roman soldiers, to every disciple, into every hidden closet. It traveled to the ones He had given sight, the ones He had helped to walk. To the girl He raised, to the ones who saw Lazarus step from the tomb in Bethany and to the very ones who drank His delicious wine at the wedding in Cana of Galilee. He is dead. He is no more. Hope is dead. Hope is no more. All the beauty and wonder He brought to us is a memory, along with so many bright things. All that remains is painful life, and death, and the few simple joys. Oh yes, and Rome, and laws we cannot keep.
How long those days must have been. They took hope down from the crux, they buried Him in a stone tomb. The one who brought hope and healing was wrapped, and lain on stone, behind stone, guarded by soldiers. As if hope were not lost enough, it was placed under arms, and hidden in the earth. Tears streamed down faces, hearts squeezed, stomach churned. Food had no taste. Tables were silent..
How wonderful then, the words ‘He is Risen.’ The words themselves were lightning in the night, sunrise, too good to be true. How unbelievable it must have been! How unprecedented that neither Rome, nor religious authorities, nor even death could hold Him down. And that if they could not hold him, then maybe He spoke the truth. That death need not be feared. That sin could be forgiven. That life could have meaning beyond hard work, beyond food and brief pleasures! He is Risen!
It’s why we love Easter. It’s why we love Jesus. Of course, even the most cynical will pause with respect at Jesus’ teachings on love, on the poor, on kindness. But the rest of us, who believe He is Risen, love Him because He spoke the truth. Because He came back in the most witnessed and recorded event of antiquity. Like a parent who keeps a promise: ‘I’ll be back in a few hours…everything will be fine.’ All of us children can live in hope again because He is Risen.
Death still stalks the earth. I see too much of it. Sin and evil still lurk, around corners and in hearts. We all know that. But they are transitory, disabled. They are powerless before the greatest words in all of history, the greatest light in all our darkness.
Having given all too much bad news in my life, with my eyes downcast, to people expecting the worst, I here and now give the best news ever given:
He is Risen! He is Risen indeed!
Edwin Leap is a husband, father of four and practicing emergency physician. He is also a widely published, award winning columnist.