On free health care and Michael Moore

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Okay, I can’t claim to have seen Sicko.  So I’m not writing to condemn it, or to slam Mr. Moore.  Whatever I may think of his political bent, he does have a way of rattling cages.  I can’t fault the guy for that.

I have, however, been reading some reviews of the movie.  And one of the things that comes through is the way that reviewers believe what Mr. Moore is saying:  everyone would be happier if health-care were free.  And who could deny that reality?  Free!  Everything that’s free is better!

‘Take money out of the equation.’  ‘Make health-care a thing that doesn’t depend on money,’ etc., etc.

I agree.  My ten-year-old son, Seth, has insulin dependent diabetes.  I appreciate the fact that my job allows me to give him access to excellent care.  He wears an insulin pump, which is an enormous advance over multiple injections each day.  His diabetes is going well, and he has the promise of a long life.  Money makes that possible, and for those without money, the possibilities are fewer.  Free care would be a wonderful thing.  I care for patients every day who can’t afford to pay their bills.  They could use some free care for their illnesses, too. 

It does seem an inequity that people struggle to get health care for purely financial reasons.  America has tried to patch that problem in various (usually ineffective) ways, from Medicaid to Medicare, from EMTALA to Social Security/Disability.

I suspect that we’re on our way to a national health insurance system, if not an entirely socialized system. 

I see advantages and disadvantages if this happens.  I suspect that for me, as an emergency physician, it will not change my income.  I’ll make less per patient, but be paid for everyone I see.  I’ll do OK, at least until someone figures out that I’m doing OK, and the government decreases my payments. 

That’s how I see the future of health-care.  Because it is so important, many people believe that it simply has to be free to be equitable for everyone.  See, necessary things are always free, right?  Like housing and food.  All you do is go to the store and ask for it, and you get food!  It’s a wonderful system we have!  Wait, that’s not right, those things aren’t free at all!

Well that’s all I want to point out. Even health-care in the purest idealized socialist system, in the most European, Marxist based, Castro-modeled, academic leftist dream-scape, won’t be free.  Get this:  health care can’t be free. 

It can be free to the people who receive it, provided they are low enough on the economic scale.  But to anyone with money, health care will cost something.  It will feel good to have those surgeries and prescriptions handed out without a bill. No question.  But it will come at the cost of very high taxes.  The money will come from the government, but governments don’t produce…they consume.  And what they consume is productivity in the form of taxes. 

If care in the US is socialized, look for very high income taxes, in the 50% range for most everyone with a decent income.  Maybe that’s where we have to go.  Maybe that’s the wave of the future.  I know many folks who will benefit enormously from that system.  I know some who won’t, and who will feel no desire to be financially productive when so much of their income is going to a federal program. 

I don’t know the answer.  Some days I’m ready to socialize it all, to make it easier across the board.  So everyone gets their antibiotics and procedures.  Some days I want to return to the days of McCartyism and sound a red scare at anyone who wants to offer free anything to some of the societal drags that abuse the system year after year, and in the process steal from me and from my partners.

But whatever way I swing, one thing remains true.  Free health care will never be free.  It will always cost something, and that thing it costs will be money.  And make no mistake about it. 

So however Michael Moore may present it, and however we all want to remove money from the equation, it will always be there, green and silver, staring back at us and demanding to be included in all our plans.

 

Ed 

Obituary

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I’ll call her Tina.  Tina was once a regular fixture of our emergency department. 

Tina was found dead at home.  She was in her 40′s.  Tina loved drugs.  She would come to us at all hours in hopes of receiving a prescription for a narcotic.  They were, it seems, her life.

Tina injured herself for drugs.  She asked others to obtain them for her.  Her boyfriends stole drugs for her. 

Tina’s children were removed from her, because of drugs.  Tina was, in every sense, addicted to pain medicine. 

What else she used, I don’t recall.  Doubtless, she was a chemical lab on legs.  I suspect she had tried almost everything she could find on the streets, as well as whatever she managed get from friends, family and assorted physicians. 

I remember Tina.  I looked at her face now and then and thought, ‘she could be beautiful!’  I knew someone who went to high school with her, and he confirmed my suspicion.  That beneath smudged, over-used eye-shadow and rough, scarred skin, beneath used up veins and broken bones, was a woman who would have made us stop to look twice, in another time or place, another life.

Somewhere along the line, she became a lost soul. Somewhere, sometime, she gave up hope.  She surrendered what the rest of us dream of; home, joy, prosperity, health, family.  She surrendered it for the feeling that certain molecules elicited in her brain.

She surrendered the children she bore, she surrendered her body, her mind, her life, all for the rush.  Or maybe all for the anesthesia from some pain we never quite understood.

See, if anyone needs to know what the word ‘broken’ means, Tina was its definition.  She was broken incarnate. 

This old world is broken, and so are we.  Tina was just a few degrees further off course than the rest of us…but only a few, so I can’t judge her too harshly. 

May God receive her as a broken child. 

I don’t know what Tina believed.  I know that God is  just and merciful.  Maybe, somewhere beneath the mess of her body and mind, behind the desperate addiction to drugs, her soul cried out to him for help.  Maybe, in the worst cases, that’s all it takes.  The desire of a child; the desire to be rescued.

I hope that I see her, on that day, that great and terrible day, standing at the side of Jesus.  I hope that when I say ‘Hi Tina, it’s me, Doctor Leap!’ That she fixes me with a sweet smile, and turns her head a little to the side, her brows wrinkled over clear, questioning eyes.  I hope that Jesus puts his hands gently over her ears and whispers to me, ‘She can’t remember any of that…I wiped it all away and she’s brand new!’  Maybe I won’t remember any of it either.

Tina is survived by children who never really knew her, by family who lost her too soon, and by a host of people who helped her fall from grace. 

May God have mercy on all of them.

We won’t miss her as she was; but the world is a little less for the loss of what she was meant to be.  The devil will pay for that one when his time comes round.

Edwin

Happy Father’s Day, Dad

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My gift to my Dad is a list.  These days, we focus on the failures of parents all too often.  So I want to write a list, for everyone to read, of a few of the things my father, Rev. Keith Leap, did right.

Now that I’m a father, I am constantly shaken with doubt and anxiety, wondering if I’m doing OK.  I try to see the future and think on the past, and to use every day with my children as well as I can.  Now that I’m a father, I see how time slips through our hands like water.  For fathers who care, it moves almost too fast to comprehend.  And in the process, we look and watch and hope that we’re doing it right.  When they tell us we’re doing well, when it comes from our children, it is an enormous validation and relief.
Dad raised my brother and I well.   Heck, neither of us ever went to jail (that Dad knows about).  Neither of us are angry, frustrated or cruel.  Neither of us are violent or profane.  Neither of us have dysfunctional lives or habits.  Both of us love our children and our women more than life; and if a father can convey that, can have sons who hold those things dear, then he has done something incredible; for we live in a world of checked-out, absent, worthless fathers who are little more than the initiators of a biological process.

So here’s a list of some of Dad’s great accomplishments:

Brought us into the world.

Never struck us, or our mother, in anger.

Never taught us that alcohol was a solace or answer to anything.

Taught us that a man can profess faith in Christ and still be a man.  That Christianity is for real men, not sissies.

Taught us to follow where God calls.  Dad went to seminary when I was a pre-teen and my brother Steve was just being born.

Showed us that a man can come back from war and go on with a normal life.  Patriotism is not deforming but defining.

Taught me to shoot a rifle; a thing that made a young boy feel masculine and properly dangerous.

Took me squirrel hunting, and let me feel dangerous by giving me, at the right time, my own shotgun and rifle.

Took me hiking and fishing and bicycle riding.

Let me have a dog and cats.  Let me have goats and rabbits.

Let me play in the woods to my heart’s content, and catch whatever I could find in the creek.

Allowed me to ride in the back of the old purple F-150 truck, and go with him on errands.

Showed me how to work in a garden, to set a row, to plow and hoe and plant and harvest from the rich bottom-land where we lived.

Kept me occupied by making me straighten corn after rainstorms.  I don’t know if it was really necessary, but it gave me something to do in the summer.

Refused to let me roam the highways at night when I was a teen.  As an emergency physician, I now see how dangerous the world is.  Dad clearly knew this, though at the time I felt the average teen angst at being bored at home.

Told me to do whatever I wanted to do with my life.  When I wanted to be a soldier he said, ‘Son, God needs Christian generals too!’  That was very liberating.

Watched Bugs Bunny and Foghorn Leghorn and Roadrunner and Coyote with me, and laughed out loud with me.  Laughter is something we still have in common.

Read books all the time, so that I saw how important that was.  It has been passed along, and now my children read voraciously.

Took me to Myrtle Beach and Pigeon Forge, surely the two places most like paradise to a young West Virginia kid.

Spoke to me like an adult when I was a child, and let me listen to him speaking to his brothers and other adults, rather than shooing me away.

Let me be a child while I was a child, with no pressure to grow up.  Let me become an adult when it was time.

Continues to be a part of my life.

So Dad, there’s part of it.  A few of the things you did right.  There are many more.

Happy Father’s Day!  See you soon.
Love,

Edwin

Father’s Day

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I overheard two women at work discussing their secret sister Christmas gifts for each other.  ‘Those were beautiful panties!  Thank you so much!’  And I realized, this is why men don’t have ‘secret brothers.’  I mean, men might feel it, but seldom articulate the sentiment; ‘Yeah, Dan, I loved that underwear you gave me.  I can’t wait to put it on!’

Obviously, women do this stuff all the time.  Women aren’t challenged by gift giving.  It doesn’t feel odd to them.  They buy each other candles that smell like vanilla and nutmeg, or banana-mango bath oil and raspberry-chocolate scented perfume for their pillows.  They give undergarments and scrap-booking supplies, touching poems and boxes of candy.  They even do it for us, usurping our own gift choices before office parties:

‘Honey, we have to take a gift’.

‘Right, I have a box of Christmas candles that smell like peppermint, or a floral arrangement with cute little elves…which do you want to take?’

‘Pumpkin, there are, uh, there are men there, you  know?’

‘Yes, and their wives will be there too.  What do you want to take?  A box of shotgun shells?’

YES!  That’s what we want to take!  And that’s where I started thinking, with Father’s Day approaching, ‘what if men did have ‘secret brothers?’  Imagine the workplace enthusiasm, as men went to parties expecting cool stuff!   I mean, not the sort of things you see on the Internet as ‘for men!’  The majority of us really don’t want exfoliating lotions or foot massagers, champagne glasses or Onyx and diamond rings.  We want guy stuff!

‘Bob, man, you knew I always wanted a custom-made turkey call!  This is so awesome!’ ‘Dude!  A switchblade?  I have always wanted one!’  ‘A calendar with every NASCAR race marked on it?  This is the most useful gift I have ever received.  Hold me, Tom, hold me!’  Wives and girlfriends would roll their eyes, and console themselves with Lime-Gardenia meditation oils and excessively fuzzy socks.

Sure, women think it’s funny.  They think we want nothing so much as another pineapple wall hanging that they saw in Southern Living.  But men like gifts too!  We just like them to be a little different.  We don’t want a day at the spa; we want a day of quail hunting.  We don’t need a pedicure; we need to go to the Indy 500 time trials.  We prefer to buy our own underwear, thanks, but a pair of camouflage, Gore-Tex gloves for that winter hunting trip would be really nice.

Maybe we should have ‘Secret Brothers,’ because women sometimes fail to understand what other men do; that a copy of the movie Patton trumps anything with subtitles (unless it’s a Samurai flick), and that most of our books should have some reference to a) sports, b) combat or c) our hobby or hero.  (Furthermore, ladies, don’t tell us how the book made you cry because of the way the heroine just never thought he loved her until right before ‘he died…from… sniff…African Sleeping Sickness!’)

But because not every guy will receive a gift from another, like-minded guy, I have a little guide.  And over the years, I have developed a simple rule of three things that almost every man will accept as a reasonable gift.  They are:  a pen, a watch and a knife.  This will cover the gamut of almost all men in the Western Hemisphere, and most in the rest of the world.  See, a pen reminds us that our ideas and insights are meaningful, and sometimes need to be recorded.  (And is useful for writing checks to buy flowers and silky things on Mother’s Day).  A watch reminds us that our time on earth is short, and we must use it well.  (And that we’re late for work).   And a knife reminds us that we have capacity and usefulness; that we are movers in our world, always armed with something that can serve as tool or weapon as the need arises.  (And that we probably need a tetanus shot).

It’s not hard and fast.  But it’s a simple rule to apply to the majority of husbands and fathers.  So, this Sunday, think like a ‘secret brother’, and get the man something he can brag about.   Not something he has to dissolve in bathwater or that you get last minute in the ‘Father’s Day’ section of your favorite store.  He may not smell as nice as you’d like, or have organized ties; but he’ll appreciate it more than you know.

(Printed this week in The Greenville News)

A little clarification on ‘I’m the doctor!’

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I clearly hit a nerve on this piece.  So yes, doctors can be sanctimonious, self-aggrandizing and incompetent all at the same time.  And yes, medicine is not rocket science.  Some of it is very difficult, some is remarkably simple (other than the volume of material).  Some of us are quite mediocre.  However, many physicians are excellent, well read, well practiced and deserve to be treated with absolute trust and respect.

However, I’m not trying to say that doctors shouldn’t listen to what patients have to say.  But I’m saying that we are held to a standard of expertise, and if we’re held to that standard, we ought to be considered experts.  If we aren’t, then we should simply offer a menu in every hospital and doctor’s office, and let patients choose the therapy, medication or surgery they think is best; with the caveat that they cannot sue us for errors.  If you know best, you get to be accountable.

When someone with an odd or obscure disease comes to me, and has information to tell me about themselves or their child, I listen.  I want to know.  I’d be foolish not to. The same with difficult complaints, or persistent symptoms so-far undiagnosed.  We all should listen.  But when someone suggests to me that their idea, however bizarre, however unlikely, deserves my full consideration,and deserves to be refuted by evidence-based studies every time, then I have to respectfully disagree on the basis that I am a physician, and human illness is what I studied and what I understand.

If an engineer suggested something to me as a client that seemed outlandish and bizarre, I might step back and ask.  But I wouldn’t presume to know engineering the way he or she did.  I think that field of knowledge is far too expansive for me to insinuate myself into it.

Admittedly, we all have a body, whereas not all of us have an engineering project in the works.  We do know our bodies, and should insist on the best for them.

But what one reader glibly ridicules as the ‘BS of a huge pool of invaluable experience’ is really quite important.  Some diagnoses and prescription practices do become rote, because one recognizes them as routine.  But the ability to recognize and treat illness and injury requires a great deal of experience.  In my specialty, expertise is defined as requiring something like 50,000 patients or 7 years in practice.  That’s a lot of people.  And knowing how someone looks when they’re about to have a cardiac arrest, or when a child is suffering from appendicitis, these things don’t come by rote, or by reading double-blinded, placebo controlled studies. They come by touching and talking to people, over and over again.

And if someone would like me to cite studies to everyone before doing anything, rest assured, wait times will really go up and patient happiness will really go down.  And most of the very good, very sick people I see won’t understand what those studies mean anyway.  Furthermore, studies are mutable and subject to error, misinterpretation and the Hawthorne Effect. Studies are also subject to
industrial manipulation and political bias.  If we rely only on ‘studies’ or consensus, and ignore self-evident truth and experience, we won’t practice good medicine.  Both are necessary.

So, I maintain that doctors must be kind, and wise, and listen to their patients’ genuine complaints.  But doctors must also be wary, and remember that they are held to a high standard by people who generally expect them to give them solid answers without too much waffling.  I’m going to have to act like the doctor; confident when I can be, and smart enough to look further when I can’t.

That’s what is expected of me!

Ed

I’m the doctor, that’s why! (This months EMN column)

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This is the age of intellectual democracy.  In a frightening departure from millennia of human tradition, everyone is now an expert in everything.  Turn on the television or surf Internet news services.  We somehow believe that polls of individuals are useful for guiding policy, in everything from international politics to morals and religion.  Legislators and marketing experts trust this information, as if masses of humans had extensive experience in diplomacy and warfare, in economics and federal tax structures, rather than what so many do have expertise in; video games and the accumulated out-takes from American Idol.

It’s especially odious in the world of medicine.  How many times do we argue with patients that they don’t need an antibiotic or x-ray, admission or laboratory test?  A family once skeptically asked me to show them the x-ray I had taken of their child, who swallowed a coin.  Once they saw it, they were satisfied that I hadn’t missed anything.  They weren’t radiologists, but they were experts.  Because any idiot can be a physician, right?

Many things have contributed to this maddening state of affairs.  On some level, it’s good.  Americans should be a people willing to ask questions.  This willingness to stand against authority is what made us, and continues to make us, a great nation.  It’s also what drives other countries crazy…we don’t just settle for platitudes and ‘because I said so,’ on either side of the political spectrum.

But there’s more.  Some of this sense of general expertise also stems from the business and customer service model that perpetuates everything from retail stores to medicine and government.  It teaches people that because they are the customer, they are always right.  They can complain, cajole, refuse to pay and endlessly badger anyone in a business or position of authority.  And because we dread to tell them no, to disagree, to (G-d forbid) not believe them, they get what they want.  Ergo, they become tiny little tyrannical experts in everything from cell-phones to angioplasty.

Furthermore, the Internet has blossomed with information ready for the taking.  Go to any medical information site and you can learn enough to ask endless questions of your physician and leave them miserable, even though what you have is just that…information.  It isn’t the same as experience and it doesn’t compensate for years of practice.  Add to that the explosion of assorted ancillary health fields, and the millions of persons yearning to ‘work as a medical professional’ and we are inundated with patients and their assorted spouses, parents, in-laws and cousins twice removed, all of whom have completed medical assistant’s programs and suddenly know as much or more than we, with our pathetic little DO’s or MD’s.

I have conversations with family members who say ‘well, I know you don’t think anything is wrong, but my sister is in LPN school, and she says I have pneumonia and I need antibiotics!’  Let’s see:  LPN school, one year.  Board certified emergency physician, 11 years, plus 13 years in practice.  Oh, I can see why the LPN is smarter than me!  I don’t have enough education or experience!  Or I don’t wear cute scrubs with bunnies or John Deere tractors on them.  Sometimes patients look at me and say, ‘well, I think I need some more tests done.’  ‘Fine,’ I say, ‘what tests do you want?’  ‘Oh, I don’t know, you’re the doctor!’  Precisely the point.

The plain truth of the matter is this:  we are the experts.  After sacrificing years to be educated, and surrendering much of our health, longevity and sanity to work at all hours and learn the complexities of treating sick and injured humans, we deserve the respect we have earned.  We have surrendered it too easily to insurance industry representatives with business degrees, who can deny care over the phone; to consultants in marketing; to intermediate care providers and assorted health-care administrators. But when it all comes down to brass-tacks, whose name always shows up on the chart?  Who goes to court?  Who is accountable for all of it?  The physician.  The expert.  The final word.

It’s time we took it all back.  We are the ones who know the way a person looks when they’re about to die.  We know how to interpret the x-rays and electrocardiograms.  We know whether to worry about that blood-pressure or not.  We know when to operate, and when to send someone home.  We physicians know, intimately, the way the human heart sounds, and the way the pulse feels in the well and in the afflicted.  We recognize the smile of the sick child and the blank stare of meningitis; the blue cast of blood from a ruptured spleen and the gasp of the pulmonary embolus.

It is our education, coupled with the experience of practice, the experience of touching, smelling and seeing and listening to thousands and thousands of persons in every phase of living and dying, that grants us the right to say no and yes to our patients, to agree or to disagree with their myriad and often unreasonable desires.  It is this that should, if we were wise, put us in the driver’s seat of the future of medicine, rather than letting it be guided by the mass of people, or the tottering inefficiency of government guidelines.

So here is our announcement:  Attention patients and families of patients, regulators, government officials, commentators, angry bloggers and reporters:  I am the physician.  That makes me the expert.  I realize that we live in the age of polls, surveys, empowerment and self-help.  I realize that the opinion of the masses generally matters more than the opinion of the educated.  But as one of the educated, as one of those who considers his opinion more valid than many others, let me say what most physicians are too nice to say.  Medicine is not a democracy.  I appreciate your opinion, and you may accept or refuse anything I offer.  You may even tell me what you think, and what has worked before.  But I get the final vote.  I have earned that vote through years of caring for the sick, and I am accountable for my mistakes, as is evident by my very expensive malpractice insurance.  You may refer me to any one of your resources or family members, but in the end, like it or not, one unassailable fact remains:  I’m the doctor, not you.  Deal with it.

Ed Leap

Death Angel

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The hospital where I practice is medium sized, in a semi-rural community. We see lots of medical illnesses and a fair amount of trauma. We also face our share of tragedy. But two weeks ago, it seemed like the death angel was hovering overhead, with no other place to be. A kind of surprise vacation stop for him (or her).

In the course of two weeks, we had a SIDS death, a drowned 19-month-old, numerous multi-traumas, a young man die from fulminant meningococcal sepsis (two hours from door to death), and two high school students killed in the same MVA that left their two friends (also in the car) critically injured.

Those are tough times. I’m always fascinated by the way physicians, nurses, medics, clerks and all the rest cope in emergency departments. I was thinking about the drowned child. We worked that child, resuscitated him, sent him to the children’s hospital, and waited for the news that inevitably came; his ultimate death. And yet, through all of the pain and suffering and loss, we plugged on.

Do you realize, dear brothers and sisters in arms, that most people in our society would crumple to the ground in heartbreaking sobs if they saw 10% of what we see?  That they would immediately go and 1) get drunk, or 2) lie in a fetal position stricken with terror and survivor guilt or 3) begin intense psychotherapy or illicit drugs and 4) consider it one of the most horrible moments of their lives?

And yet, after popping intraosseous lines through the tender bones of children, after putting a chest tube in a screaming
toddler with a tension pneumothorax (as I did last week aftger a cow stepped on the child…that’s rural EM), after telling a family their dear husband/father/mother/daughter/son is suddenly and quite permanently dead, after all this…we keep on going.

We move to the next patient, and focus on the next complaint (which often seems comically trivial by comparison).  We treat the ridiculous things with dignity and professionalism.  We fill out work excuses and prescriptions as the images of cyanotic, broken bodies find their way to the filing cabinets of our minds.

What I’m saying is, in the mix of death and mayhem, of bad news and bad outcomes, we rise to the occasion like gray-winged, blood tipped, angels; fallen, but not quite all the way.  We drop ourselves into the crushing pain of the lives that come to us, and we keep doing it.  Brothers and sisters, this is amazing, and heroic.

Some of us probably develop PTSD, or at least a little of it, that lasts for our entire careers.  Yet we come back.  Some of us struggle with depression; I struggle with anxiety sometimes, from seeing so many bad things that happen rarely, and still extrapolating them to the daily lives of my wife and children.  Some physicians drink and drug and change partners and do all of the things they think will ease the pain.

The problem is, for all our narcotics and sedatives, our pain scales and our facility at finding the source of suffering, we seldom embrace our own.  But at some point, the best thing we can do is turn to it, turn to all of the memories of all the bad things on bad days, and say how much it hurt to see, how much it hurt to absorb the suffering that smothered every resuscitation room and every family conference room like a thick, toxic fog.

If we accept that it was hard, and that it is hard, we’ll be happier for the honesty.  And we’ll see just how proud we should be of the very difficult job we do, day and day out, night after night, in a sometimes terrible place in which we are always moments away from someone else’s tragedy.

God bless you and keep you,

Edwin

Describing the indescribable

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Edwin Leap, MD

www.edwinleap.com

This piece was originally printed in Emergency Medicine News

The 20 codes for EMS; describing the indescribable

How many times have you heard this on the radio:  “Yeah, base, this is Medic 3, and we’re 15 minutes from your facility with a 38 year old white male with, uh, with, some chest pain, numbness all over, headache and anxiety, as well as some bruises from a fall.  He says his pain radiates from his earlobes to his nipples and well, we’ll just give you more details on arrival, base.  This is Medic 3 clear.”

God love those guys and gals, the truth is, if we doctors were on the truck ourselves, we still wouldn’t know what the diagnosis was.  Frequently, when I discharge people from the emergency department, I still don’t know what the diagnosis is.  Thank heavens for ‘Medical Screening Exam’, because that’s about the best I can do some nights.

But I have come to realize that if the medics can’t figure out what to call it in the field, I may be just as puzzled.  Now, physicians live with a much greater sense of ambiguity than paramedics do.  Paramedics have to work within the confines of more straightforward algorithms, designed to save life in a pinch.  But people are puzzling, and sometimes their emergencies and actions defeat the most obvious treatment plans and education, and leave even the brightest going, ‘I just don’t get it…’.

So, in order to help our EMS colleagues, and facilitate our preparation on the hospital end of things, I’ve compiled a list of signals based on common complaints transported by ambulance, and loosely based on our old friends, the 10 codes.  These are much more specific, and much more likely to be used on a daily basis. (Personally, I think they might be useful CPT codes, as well).  I mean, what’s a medic to say when the patient’s complaint is ‘bitten by ex-wife’s pet squirrel’?  Or ‘Penis stuck in mixer bowl’?

I’ve attempted to answer those questions with the following system of 20 codes.

Feel free to post near your EMS desk!  They just might catch on…

20-100    Chest pain from stupid argument

20-101    Chest pain from anxiety

20-102    Chest pain from trampoline injury

20-103    Chest pain from being punched by wife

20-104    Chest pain from boring/dead-end job

20-105    Chest pain, non-urgent, not otherwise specified

20-200    Laceration from altercation with small child

20-201    Laceration from argument with dog

20-202    Laceration from reaching through broken window for beer

20-203    Laceration from opening beer with mouth

20-204    Laceration from inappropriate use of household implement while naked

20-205    Laceration from stupid activity, not otherwise specified

20-300    Overdose on normal dose of Xanax

20-301   Overdose on normal dose of Ambien (also known as sleep)

20-302   Overdose on ridiculous amount of alcohol, attributed to ‘some pill in drink’

20-303      Overdose on confidence, resulting in sound beating or ugly bed-mate

20-304      Overdose on nicotine after recent coronary stint (also known as Acute MI)

20-305      Overdose on non-lethal substance, not otherwise specified (like flour)

20-400   Back pain from lifting refrigerator alone

20-401   Back pain from lifting uncooperative farm animal

20-402      Back pain from having bizarre sex with obese spouse

20-403      Back pain from assuming normal, standing posture while morbidly obese

20-404   Back pain from threat of imminent employment or loss of benefits

20-405   Back pain, unverifiable, not otherwise specified

20-500    Intoxication with fall onto face

20-501    Intoxication with fall out of bed

20-502    Intoxication with fall from bar-stool

20-503    Intoxication in the face of angry spouse

20-504    Intoxication on mouthwash (‘so she won’t know I’m drunk’)

20-505    Intoxication with ridiculous injury, not otherwise specified

20-600    Multiple wounds from jello-wrestling with raccoons

20-601    Lacerations from letting Pit-Bull eat off of body  (see 20-505)

20-602    Antler wounds from attempting to field dress game animal ‘mostly dead’

20-603    Bites from attempting to dress ferret as ‘Ballerina Barbie’

20-604    Lacerations to eyelids from attempting to bathe cocaine-intoxicated cat

20-605    Animal related wounds, not otherwise specified

20-700    Multiple stings from attempting to add hornet’s nest to collection.  In June.

20-701    Burns from attempting to kill yellow-jackets with gasoline, while smoking

20-702    Envenomation from attempting to cuddle with Pit Viper.

20-703    Small red mark, believed to be ‘spider bite’

20-704    Bite or envenomation with offending creature in possession (no, no, no!)

20-705    Bite or envenomation, non-urgent, not otherwise specified

20-800     Patient wearing demeaning, but hilarious attire  (e.g. ‘Bootylicious’ on shorts)

20-801     Patient in need of immediate arrest

20-802     Patient with wife in ambulance, girlfriend coming by private auto (surprise!)

20-803     Extraordinarily attractive patient  (probably needs decon)

20-804     Patient with non-urgent but completely unintelligible complaint

20-805          Patient, annoying, not otherwise specified

20-900          Shortness of breath from walking to refrigerator

20-901          Shortness of breath from thrilling episode of reality show

20-902          Shortness of breath from argument with prom date

20-903          Shortness of breath from smoking 4 ppd in small room full of cat fur

20-904          Shortness of breath from wrestling with law enforcement

20-905          Shortness of breath, no objective signs, not otherwise specified

As you can see, this system is still in its infancy.  However, if you would like to submit codes of your own, please do so through my website.  We could revolutionize both EMS and billing!  And we could learn to speak in cryptic but hilarious code behind the backs of our more illustrious ‘clients’.

It’s almost summer, season of stupid mistakes

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I hate gasoline.  Not because it’s expensive or dangerous, but it always spills on me, no matter what I do.  It spills on me when I pump gas in my car, or when I fill gas cans for mowers.  It spills when I use a chainsaw, it spills when I put it in weed-whacker.  It humilated me once, when I put it into my friend’s tractor, only to discover it took diesel.
Today I was filling a gas can at the local Exxon.  After I pumped two gallons, I noticed a small but powerful leak in the side of the can.  It was spurting out.  I had to put the can in the car!  But if I did, the back of my Durango would have been filled with gasoline before I got home.

So I tried to apply electricians’ tape, which I bought as the clerk laughed, sympathetically.  It failed.  I realized I’d need to buy a new can, which I did, grudgingly, and then washed the gasoline off of my hands where it (of course) spilled on me.

But for just a moment, a brief, ER moment, made worse by the warm sun, cool wind and clear blue Carolina skies, I thought, ‘you know, all I need to do is melt the plastic a little to stop the leak.’  But from somewhere my guardian angel said ‘Stupid!  It’s gasoline!’  That was all I needed.  Like the time I was a resident emergency physician, flying on an MB 117 helicopter, and almost walked into the tail rotor on a tiring, late night run.  Something stopped me.

Now, I believe in angels.  I’ve seen too much not to believe.  But even for those who don’t, my summer advice is this:  take a minute and think.  Before you do almost anything other than breathe, think.

Here are a few useful questions to ask as you think:

Am I drunk?  Will it bite?  Will it explode?  Can I swim?  Will something fall down?  Do I know how to use this device?  Is it flammable?  Will I choke to death?  Does it sting?  Am I allergic to it?  Are people watching with video cameras?  If I attempt this, will I make the news?  Will I end up in the ‘Darwin Awards’ book?  And last but not least, is it really necessary?

Maybe we should give ER patients a pamphlet with these questions on it.  And while we’re at it, we should ask ourselves the same.

In my case today, it made all the difference.  ‘Will it explode?’  You betcha, you stupid redneck!  And here I am writing, instead of asking for more Fentanyl at the Joseph Sill  Burn Center in Augusta, Georgia.

Be careful out there; summer is out to get you!

Ed

Medicine As Performance Art

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Medicine is performance art. Make no mistake about it. When you walk into a patient’s room, you are on the stage. And you had better know your lines. We delude ourselves that this is all science. Oh, there’s science. But how much of what we do is entirely devoid of anything resembling science? How much do we do because the patient expects it? How much because it just makes us feel better?

In tribute to the performance art aspect of our scientific careers, I have a list of things accumulated through the years to help aspiring actors in their roles. By now, a number of new residency graduates have been in their jobs for a few months, and are wondering, ‘What did I get myself into?’ The answer is, ‘a huge mess.’ But that’s another topic. What I have to offer is a few guidelines for difficult situations. A few acting tips to get you through the tough nights and tough days of a difficult profession.

1) Reading glasses. If you don’t need them, some fake ones with a piece of regular glass or plastic might be useful. If you don’t know what the rash is, if you aren’t sure how deep the cut, if you can’t identify the tendon, pull out the old glasses and have a look. Your patients will be impressed with your attention to detail.

2) A lab coat. Now, I don’t really buy into this one, but some people think that a white lab-coat, freshly starched, is like a suit of armor against blood, pus, doubt and lawsuits. To each his own, I say. I stopped wearing mine in medical school, when all of the books and tools in the pockets began to hurt my shoulders, and made me believe I needed a breast reduction.

3) Have a pager, whether you need one or not. You don’t actually have to use it. But when the conversation turns from the patient’s current injury to his bunionectomy in 1968, which resulted from that insect-bite in Vietnam that followed the agent orange exposure and left him disabled for life, then jump as if surprised by a vibration, pull out the pager, look at its blank screen and murmur, ‘They just won’t leave me alone! Excuse me!’

4) Have a few catch phrases. My personal favorites are, ‘Let’s get you some pain medicine and order a few tests, so we can get to the bottom of this. Excuse me while I get things started.’ I also like ‘My kids all had the same thing, and they were just fine’. Another useful one is ‘I don’t know what’s going on here, but I think we may just need to talk to your doctor about admitting you to the hospital!’ (shows your interest and compassion and puts onus on primary care doctor). Some of these are also just exit strategies, to avoid protracted conversations with extended family. I know someone who always says, ‘We’ll get you bunked in for a day or two!’ and then effectively ends the conversation. It’s down home, it’s to the point and I have always admired it.

5) Look things up and tell people you’re going to. Invoke the Internet, which is, to the average person, much like consulting directly with the Almighty. ‘This could be an odd medication side-effect. Tell you what, let me go check it out on the Internet. I’ll be right back.’ They’ll recognize that you recognize your own limitations. If you don’t think it’s a real problem, look it up briefly and then check your web-mail, or see how your e-bay bid on Wilson, the volleyball from the movie ‘Castaway’, is going. This system will only back-fire in people who believe that books are a sign of weakness. They’ll say, ‘that doctor had to go look my problem up in a book!’ If they go elsewhere to find smart doctors who don’t use information developed after 1955, it’s no loss.

6) Do not show fear! You’re a doctor, so answer boldly, even if you’re uncertain. Here’s an example. ‘Doctor, before I go, I wanted to ask you, is it possible that the throbbing pain I get in my foot before bedtime is due to this mosquito bite?’ If you are new to the profession, this might frighten you. You’ll be thinking of Lyme’s Disease or other tick-born entities. You’ll be tempted to ask about foreign travel, and you’ll wonder about infectious arthritis and Malaria. STOP! The proper answer is as follows: ‘That’s interesting. I’ve never seen it, but I suppose it’s possible. Take some ibuprofen and benadryl, and come back if it isn’t any better.’ Say things like this with absolute confidence, but after a brief pause to look up and tap your temple with your index finger while spinning reading glasses in other hand. This is acting at its finest.

7) Some of my partners believe in the magical properties of the tendon hammer. If you take it out and pound on the tendons (assuming you can locate one beneath years of drive-through cheeseburger fat), you’ll again impress your patients with their own physiology, with your diligence and with your dedication to Marcus Welby medicine. If you carry one of the neurology versions, that look like one tire and axle of a Humvee, you’ll impress, but also be expected to explain complex neurological entities like ‘pseudo-seizures’. I advise you to use only the kind that looks like a little tomahawk. Also makes a handy weapon if assaulted.

8) The stethoscope! Take your time using it. Ask patients to breathe deeply, something most of them rarely do. After about 6 breaths, my patients usually say, ‘I feel funny, you know, dizzy-like!’ ‘That’s oxygen sir. It feels odd at first, but you’ll get used to it’. A revered physician I knew used to occasionally listen to our regular nuts with the stethoscope head, while the ear pieces rested serenely against the sides of his neck. No one ever knew the difference.

9) When families seem to think that you’re waffling, and when you may actually be waffling, meet with them in the room of their ill family member and say these words, ‘You know, these things require a delicate balance’. They’ll understand why you have neither admitted, discharged or transferred their loved one, and whey the nurses keep adding different IV medications when the last ones didn’t work.

10) A friend once suggested a ‘scream machine’ for the ED. When you are very busy, press the scream machine repeatedly, and when you walk into the room where the hangnail waited 3 hours, you can say, ‘I’m sorry it took so long, but I suppose you heard…well I can’t really say, but it’s been quite a night!’

These are just a few tips. In the course of many years, every physician develops a set of his or her own acting guidelines. By the time our careers are over, we’ll all deserve an Oscar.