Back Pain, a Prisoner and a Lenten Reminder of Mercy

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She was large, and heavily tattooed.  She was in a striped uniform with handcuffs, her feet shackled. She sobbed because of her back pain.  Her life a long history of mistakes and bad choices; alcohol, drugs, criminality.  Her family, husband and children, a victim of her lifestyle, her addictions, her misdeeds.

They can’t have narcotics in jail, and in fact, narcotics don’t have much role in back pain, we’re finding.  But in jail, she lay on a thin mattress on a concrete pad.  Getting up and lying down were, she said, agonizing.

Was she lying?  Her drug screen positive for amphetamine, it was possible.  The officer with her said, ‘I’ve known her for 15 years.  This is her. Crying and moaning. But what if she really has pain?  It’s tough doc.’

It’s tough for sure.  Knowing as I did that if she went back to jail, she might really be suffering. Knowing, also, that she had a reported history of heart disease even though she was only  in her 30s.  Knowing that she would surely come back with chest pain or back pain, legitimate or illegitimate, if nothing were done.

Ultimately, after two visits, she seemed worse.  She seemed to have difficulty standing.  Her sobs continued.  Her officer and I sympathetic but worried about being tricked.  She was given pain meds and transferred for an MRI.  Maybe there was something going on in her spinal cord. Maybe a hematoma, maybe an abscess.  Who knew?

Here is the conundrum of compassion, as it were.  The compassionate will be cheated, fooled, and lied to.  This is life in the ER. This is life on earth.  The right thing is often, in the rear-view-mirror, exactly the wrong thing, as those who fool us laugh and drive away.

But we have the last laugh.  Because the right thing is just that.  The right thing.  And it’s a great lesson here in the Lenten season.  To show kindness, to give mercy, to expect to be the butt of the joke, the patsy, these are all the ‘price of doing business,’ when our business is being like Jesus.

I believe she had pain, but even if she lied to me, even if she gamed me, it’s OK.   I’m not offended.  She was vulnerable. She was wounded. She was broken.  She was a prisoner. And here’s what Isaiah, God’s prophet, said about captives and prisoners.  And notice, no mention of guilt, or of punishment deserved or earned.  Isaiah 61: 1-3

The Spirit of the Sovereign Lord is on me,
because the Lord has anointed me
to proclaim good news to the poor.
He has sent me to bind up the brokenhearted,
to proclaim freedom for the captives
and release from darkness for the prisoners,a
2to proclaim the year of the Lord’s favor
and the day of vengeance of our God,
to comfort all who mourn,
3and provide for those who grieve in Zion—
to bestow on them a crown of beauty
instead of ashes,
the oil of joy
instead of mourning,
and a garment of praise
instead of a spirit of despair.
They will be called oaks of righteousness,
a planting of the Lord
for the display of his splendor.

Jesus said the same thing at the beginning of his ministry.  Luke 4: 16-21.

Jesus returned to Galilee in the power of the Spirit, and news about him spread through the whole countryside. 15 He was teaching in their synagogues, and everyone praised him.

16 He went to Nazareth, where he had been brought up, and on the Sabbath day he went into the synagogue, as was his custom. He stood up to read, 17 and the scroll of the prophet Isaiah was handed to him. Unrolling it, he found the place where it is written:

18 “The Spirit of the Lord is on me,
because he has anointed me
to proclaim good news to the poor.
He has sent me to proclaim freedom for the prisoners
and recovery of sight for the blind,
to set the oppressed free,
19 to proclaim the year of the Lord’s favor.”[f]
20 Then he rolled up the scroll, gave it back to the attendant and sat down. The eyes of everyone in the synagogue were fastened on him. 21 He began by saying to them, “Today this scripture is fulfilled in your hearing.”

In this passage is healing and liberty.  And nobody is a ‘jailbird’ or ‘scumbag’ or ‘crook’ or ‘junkie.’  Jesus wants to offer this to all.

This Lenten season, can I do any less?  I, a captive of sin as all of us are, delivered and healed? I with blind eyes, seeing clearly thanks to my redemption?  God knows if I lie to him, if I try to trick him. And loves me anyway.

And if it takes showing mercy to the meth-using prisoner with back pain to honor the mercy I received, well it’s a small price to pay.

Edwin

The Pledge of Allegiance to Emergistan

Dear Emergistanis, you know who you are!  Keep up the amazing work!

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I pledge allegiance to the Republic of Emergistan. And to all of my comrades, in ED’s large and small, saving life and limb, day and night, doing more with less, cursing computers, taking care of the people nobody else can, or will, and saying no to narcotics and antibiotics all day long. Amen. Play Ball.

The Women and Men who Love Emergency Physicians

This is my February 2017 column in Emergency Medicine News. Now, doctor, go hug your  husband or wife.

http://journals.lww.com/em-news/Fulltext/2017/02000/Life_in_Emergistan__The_Women_and_Men_Who_Love_EPs.20.aspx

When I go to work I take a lot of things with me. Everyone has their ritual, right? I take my backpack with my computer inside. I take my phone. I take charging cords, the true modern life-line. I take lunch. I carry a pen, flashlight and pocket-knife.
On a more abstract level, I take the wonderful education I received as a medical student and resident, coupled with my years of experience as a physician. I take my drug-store +2 diopter glasses, not only to read and suture but equally important, to look venerable and wise.
But I take something else. It’s certainly as important as all of the other stuff, if not more so in the long run. I take the love and support, encouragement and care of my wife Jan. Now mind you, this is not some hyper-sentimental claptrap. A spouse, for better or worse, is part and parcel, warp and woof of our lives. And in the best of circumstances (which I enjoy), my dear bride gives me encouragement, laughter, stability, passion and the not-so-rare kick in behind when I’m lazy, whiny or grumpy. (As I am so often wont to be.)
She reminds me of my priorities, reassuring me that I matter to her and the children however I may feel. She reminds me that feelings are often terrible lies. (A lesson we would all do well to remember.) In times past she has guided me through career changes because she could sense my unhappiness and dissatisfaction. This is because she loves me and knows what I need; often better than I do. In short, she is my most dedicated advocate.
While I work in the ED, she works hard to manage the children (rather, the teens who require more diligence than mere children.) She looks after the family finances, a thing which is useful in keeping me out of prison for delinquent taxes and in keeping the banker away from the door so that we keep our home.
And in order to keep me moving forward through busy, difficult runs of shifts, she ensures that I have things to look forward to with family when she does our ‘master schedule.’ Even though two of our children are in college, she tries to arrange family events around my days off so that I don’t feel left out. In addition, so that I can enjoy our life together for a long time to come, she takes me to the gym. She sometimes makes me plank. I hate to plank but I do it.
This might sound, to the modern ear, as if my wife is living out some sort of domestic indentured servitude. It is not. It is teamwork. It is unity. It is covenant. We are one. We have common cause in our marriage and offspring.
The result of her remarkable effort is that when I go to work, I can focus on my job. I can carry the love and care I feel at home into the exam room, into the resuscitation room. I am secure and happy. This makes me a far more effective, calm, satisfied physician than I would otherwise be.
Thus, I make the money that we share equally as partners. Not only in our personal corporation but in our lives. I don’t get paid for me; I get paid for us and for ‘clan Leap’ as a whole.
When I come home from work, I come home to smiles, hugs and a welcome-home kiss. I come home to laughter and dinner, or date-night. To stories of her day, and the many other lives she touches, in our family and beyond it.
Sometimes I come home to strategic family planning sessions. Occasionally I come home to a tired or angry or sad wife and it’s my turn to be the one in the supporting role. My turn to fuss at teenagers or call about car insurance claims. My turn to shoo her to bed early and manage things. My turn, on days off, to send her for sanity breaks.
Those of us who are married, or in long-term committed relationships (which we in the South call a common-law marriage) must admit that without our wives or husbands, this whole gig would be much harder, and much more lonely than it is with our dear ones. Furthermore, that the patients we care for are touched and loved on, vicariously, by those who love us. Their role is not subordinate but intrinsic.
Through me, through our marriage bond, every sick child in my care has my wife’s eyes looking down on it gently. Every struggling nursing home patient has some of her kindness. Every difficult, irritable complainer has her patience and every smart-aleck teenager (or grouchy consultant) has her raised eyebrows and crossed arms gazing firmly on their behavior.
All of us owe so much of our professional lives to the women and men brave and loving enough to stay with us through all of our stupid, arrogant, surly behaviors. And to those men and women, let me just say: you are as much a part of our practices as we are. Thank you for being the other half, the silent partner, standing invisibly by us as we do the hard work of medicine.
We couldn’t do it half so well without you.

A Simple, Cheap, Health Fix.

This is my latet column in the Greenville News.  Healthcare is expensive, so it’s much cheaper not to need it in the first place.

http://www.greenvilleonline.com/story/opinion/contributors/2017/03/02/commentary-simple-health-fix/98636916/

I have never wanted to be the medical advice columnist. ‘Dear Dr. Leap, my feet sweat all the time. I’ve tried everything! What should I do?’ Nope, I’m not your guy. Neither do I want to opine on study after study about statin drugs for cholesterol or discuss whether women should take estrogen. There are physicians who love those questions! And I think they’re fantastic. But I’m an emergency medicine physician. Which means I have an attention span only somewhat longer than a Jack Russell Terrier. So as long as no squirrel runs across the room, I’ll finish my thought.
I think a lot about what brings people to the hospital. And I have come to some conclusions. If people want to live healthier, longer and better, then the solutions are not especially complex. But they involve pretty hard decisions. They don’t, however, involve pills.
Obviously some people have terrible diseases and medical events and simply can’t help the medications they need to take. I’m not talking about them. I’m talking about the vast number of Americans who, with a few lifestyle changes, could take no medications and be just peachy.
So here goes. Stop smoking. No, don’t even start smoking. It does nothing but bad things. It makes your teeth decay, gives you mouth, throat and lung cancer, causes emphysema, worsens asthma and costs way too much money. Money you could spend on important medicine, or no medicine, on your kids, or could save for a trip to someplace cool. Seek out help from a physician or support group and put down the coffin nails.
Next, eat less. Being overweight is bad. I’m not ‘fat shaming,’ I’m trying to save lives. Being overweight is unsafe, since you can’t rescue yourself from danger as easily. Being overweight makes you sluggish, strains your heart and causes your hips and knees to wear out, resulting in joint replacements. It makes it harder to exercise. It contributes to diabetes. Obese patients are harder to care for when they’re ill; they don’t always fit in CT scanners and their surgeries are more difficult and take longer to heal. How do you lose weight, you ask? There are lots of plans and lots of people to help. But it starts with the decision to sometimes look at yummy food and say ‘nope, I’d rather be a little hungry but healthy.’
Now this is radical: stop sitting around. Do things. Be busy. Walk, hike, have an active hobby. Stop binge watching shows for hours (in fact, a study not long ago suggested that binge watching increases your risk of dangerous blood clots in the lung). Step away from the tablet, the television, the gaming system and go outside. You needn’t run marathons or Iron Man races to just keep moving. Humans stayed fit for millions of years before there were gyms or exercise equipment. Of course, they were busy trying not to starve or get eaten, so they had an edge on us. But they died by 30 or 40, so we have it a little better.
Also, don’t take drugs of abuse. And if a doctor offers you a narcotic, unless you have cancer or a badly broken bone, say ‘no thanks.’ You’ll be better off in the end. Drugs are killing people in staggering numbers; so is alcohol. Therefore, while you aren’t doing drugs, don’t abuse alcohol. Don’t drink and drive, drink and boat, drink and hike, drink and shoot, drink and fight; you get it. Alcohol is dangerous. Also, wear your seat belt. Or helmet if you ride a bike or motorcycle. Additionally, don’t text and drive!
For simple illnesses like colds, don’t take antibiotics. Don’t ask for them and decline them unless absolutely necessary. In fact, for simple illnesses and injuries avoid doctors, X-rays, CT scans and all of it.
I could go on. But these things alone, if taken seriously, would change the face of medicine and the financial makeup of the entire healthcare system. And the best part? They don’t involve a prescription, an X-ray or even a visit to a doctor. They’re low-tech, low-cost interventions.
Some of my favorite patients are the 90-year-olds who show up for something simple; a bruise or a cut, fresh from yard work.

‘Sir,’ I ask, ‘what medicines do you take?’
‘None.’
‘Who’s you’re doctor?’ ‘Son, I don’t have one. Can I go home now? I have beans to pick!’
‘Well there you go. That’s why you’re 90.’

Life and Limb: the Rural ER

Welcome, readers, to my new column in the Daily Yonder!  It will concern rural emergency medicine and things I see through that particular lens.  Have a great day and feel free to share liberally!  I’m honored by the Daily Yonder to be included on their team, dedicated to all things rural.

Life & Limb: In Rural E.R., Exams Include the Obvious Questions, Like ‘Did You Get a Turkey?’

Once Upon a Time in Medicine

Gather round kids! Let Grandpa Doctor Leap tell you a few things about the old days of doctoring in the emergency room…

Back in the good old days, medicine was what we liked to call ‘fun.’  Not because it was fun to see people get sick or hurt or die, but because we were supposed to do our best and people didn’t wring their hands all the time about rules and lawyers.  Sometimes, old Grandpa Leap and his friends felt like cowboys, trying new things in the ER whether we had done them before or not.  Yessiree, it was a time.  We didn’t live by a long list of letters and rules; we knew what was important. And we were trusted to use our time well, without being tracked like Caribou through electronic badges.  Those were the salad days…

When I was a young pup of a doctor, we took notes with pen and paper and wrote orders on the same. It wasn’t perfect, and it wasn’t always fast. But it didn’t enslave us to the clip-board.  We didn’t log-into the clip-board or spend twenty minutes trying to figure out how to write discharge instructions and a prescription. We basically learned in grade-school.  EMR has brought great things in information capture and storage, but it isn’t the same, or necessarily as safe, as the way humans conveyed information for hundreds, nay thousands of years.

Back then, kids, the hospital was a family!  Oh yes, and we took care of one another. A nurse would come to a doctor and say, ‘I fell down the other day and my ankle is killing me! Can you check it out?’  And the doctor would call the X-ray tech, and an X-ray would get done and reviewed and the doctor might put a splint on it or something, and no money changed hands.

In those days, a doctor would say to the nurse, ‘I feel terrible, I think I have a stomach bug!’  And she’d say, ‘let me get you something for that,’ and she’d go to a drawer and pull out some medicine (it wasn’t under lock and key) and say ‘why don’t you go lie down?  The patients can take a break for a few minutes.’ And she’d cover you for 30 minutes until you felt better.

We physicians?  There was a great thing called ‘professional courtesy,’ whereby we helped one another out, often for free. Nowadays, of course, everybody would get fired for that sort of thing because the people who run the show didn’t make any money on the transaction.  And when you have a lot of presidents, vice-presidents, chief this and chief thats, it gets expensive!

When medicine was fun, a nurse would go ahead and numb that wound for you at night, policy or not; and put in an order while you were busy without saying, ‘I can’t do anything until you say it’s OK or I’ll lose my license.  Do you mind if I give some Tylenol and put on an ACE?  Can you put the order in first?  And go ahead and order an IV so I won’t be accused of practicing medicine?’ Yep, we were a team.

There was a time, children, when doctors knew their patients and didn’t need $10,000 in lab work to admit them.  ‘Oh, he has chest pain all the time and he’s had a full work-up.  Send him home and I’ll see him tomorrow,’ they might say.  And it was glorious to know that.  Or I might ask, ‘hey friend, I’m really overwhelmed, can you just come and see this guy and take care of him?  He has to be admitted!’  And because they thought medicine was fun too, they came and did it.

In those sweet days of clear air and high hopes, you could look up your own labs on the computer and not be fired for violating your own privacy.  (Yes, it can happen.) You could talk to the ER doc across town about that patient seeking drugs and they would say, ‘yep, he’s here all the time.  I wouldn’t give him anything,’ and it wasn’t a HIPAA violation; it was good sense.

Once upon a time we laughed, and we worked hard. Back then, we put up holiday decorations and they weren’t considered fire hazards.  We kept food and drink at our desks and nobody said it was somehow a violation of some ridiculous joint commission rule.  Because it was often too busy to get a break, we sustained ourselves at the place we worked with snacks and endless caffeine, heedless of the apparent danger that diseases might contaminate our food; we had already been breathing diseases all day long, and wearing them on our clothes.  Thus, well fed and profoundly immune, we pressed on.

In those golden days of medicine, sick people got admitted whether or not they met particular ‘criteria,’ because we had the feeling there was something wrong.  We believed one another.  Treatment decisions didn’t trump our gut instincts.  And ‘social admissions’ were not that unusual. The 95-year-old lady who fell but didn’t have a broken bone and didn’t have family and was hurting too much to go home?  We all knew we had to keep here for a day or two and it was just the lay of the land.

I remember the time when we could see a patient in the ER and, because my partners and I were owners of our group, we could discount their bill, in part or entirely.  We would fill out a little orange slip and write the amount of the discount.  Then, of course, the insurers insisted on the same discount.  And then nobody got a discount because the hospital was in charge and everyone got a huge bill, without consideration of their situation.  The situation we knew, since we lived in their town.

Back when, drug reps left a magical thing called ‘samples.’  Do you remember them, young Jedi?  Maybe not.  Young doctors have been taught that drug companies, drug reps and all the rest are Satan’s minions, and any association with them should be cause for excommunication from the company of good doctors.  But when we had samples, poor people could get free antibiotics, or antihypertensives, or all kinds of things, to get them through in the short run.  And we got nice lunches now and then, too, and could flirt with the nice reps!  Until academia decided that it was fatal to our decision-making to take a sandwich or a pen.  Of course, big corporations and big government agencies can still do this sort of thing with political donations to representatives. But rules are for little people.

When the world was young, there was the drunk tank.  And although mistakes were made, nobody pretended that the 19-year-old who chose a) go to the ER over b) go to jail, really needed to be treated.  We understood the disruptive nature of dangerous intoxicated people. Now we have to scale their pain and pretend to take them seriously as they pretend to listen to our admonitions.  They are, after all, customers.  Right?

These days, we are perhaps more divided than ever.  Sure, back in Grandpa Doctor Leap’s time, we were divided by specialty and by practice location; a bit.  But now there’s a line between inpatient doctors and outpatient doctors, between academics and those who work in the community, between women and men, minorities and majorities (?), urban and rural, foreign and native-born and every other demographic.  As in politics, these divisions hurt medicine and make us into so many tiny tribes at work against one another.

And finally, before Grandpa has to take his evening rest, he remembers when hospitals valued groups of doctors; especially those who had been in the same community, and same hospital, for decades.  They were invested in the community and trusted by their patients and were valuable.  Now?  A better bid on a contract and any doctor is as good as any other. Make more money for the hospital?  In you go and out goes the ‘old guys,’ who were committed to their jobs for ages.

Of course, little children, everything changes.  And often for the good. We’re more careful about mistakes, and we don’t kick people to the curb who can’t pay. We don’t broadcast their information on the Internet carelessly.  We have good tools to help us make good decisions. But progress isn’t all positive.  And I just wanted to leave a little record for you of how it was, and how it could be again if we could pull together and push back against stupid rules and small-minded people.

Now, Grandpa will go to bed.  And if you other oldies out there have some thoughts on this, please send them my way!  I’d love to hear what you think we’ve lost as the times have changed in medicine.

Love,

Grandpa Doctor Leap

 

 

The Nativity in the Emergency Department; my December EM News column

Merry Christmas!  This is my December column in EM News.  The Nativity in the Emergency Department.

http://journals.lww.com/em-news/Fulltext/2012/12000/Second_Opinion__The_Nativity_in_the_Emergency.9.aspx

I once wrote a story for Christmas in which the nativity happened in an old, beat-up hunting trailer behind a man’s store, somewhere in the South on a cold winter night. From everywhere and all around, rough people and businessmen and politicians found their way to it, situated as it was in a cluttered backyard of a poor but compassionate store owner. Mary and Joseph had a car that broke down, you see, and they were stuck. I doubt if it’s that original. I suspect Hallmark or someone has done this story over and over.

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Yet it still resonates; it still bounces around inside my mind. I envision that cold night, and the star, and the people in my neighborhood, camo-wearing hunters and bearded bikers, the guy with the meth lab that blew up (no kidding), the men in the garage across the highway. I suppose it’s because the story fits everywhere.

As you might expect, I have this image of the manger scene set in an ED. I think back over my patients, and it makes perfectly good sense to me. I can’t decide if it’s a busy night or a slow one. But there are Mary and Joseph, maybe homeless. We do see the homeless, don’t we? And certainly the poor. “Doctor, we don’t have any money or anywhere to go. Can we stay here tonight?” We might try social work, but face it, they probably went home already. The poor are always among us.

If it’s a slow night, the nurses are stricken with a kind of magic. They fluff Mary’s pillow, and one of them (who used to do OB) notices the way Mary is breathing and holding her belly. “She’s going to deliver!” (For the purpose of the story, Labor and Delivery is full to capacity.) All of the nurses are hovering, getting ice for Mary and coffee for Joseph, who has not so much as the change to buy one.

If it’s a busy night, everyone is frantic, and when Mary says, “I think the baby is coming!” the staff roll their eyes, as if they needed one more thing between the overdoses and the chest pains, the weaknesses and the demanding daughter in the hallway insisting on endless attention for her aging mother.

But they do the right thing, don’t they? They almost always do. We almost always do. Before you can sing “O Little Town of Bethlehem,” the baby is there. He’s crying because they do that. And Mary nurses him immediately after the nurses clean him off. But the nurses, and the doctor who caught him (fumbling, frightened … he hates delivering babies), all of them are somehow breathless. The hair on their necks and arms rises up, chills run along their spines. It’s not fear; it’s wonder. Inexplicable. Another poor baby. So what? Everyone is crying. Nobody knows why. Mary just takes it all in as Joseph wraps his arms around both of them, still in the same dirty sweater, still disheveled.

Of course, there are no animals. And yet. If it’s slow, the sleeping drunk in the next room wakes and stumbles in to see. Looking down, he cries, too. He understands something so deep he can’t express it. Something he forgot about hope and love and parents and forgiveness. He reaches into his pocket, pushes $100 into Joseph’s hand, and goes to lie down again. He sleeps in lovely dreams.

If it’s busy, things suddenly move slowly. Things happen. The mumbling, confused lady with dementia (whose daughter is so demanding) speaks for a few minutes with utter clarity, and finds her way to the door of the baby’s room. She holds her daughter’s hand and laughs, and recalls the details of her own maternity. The meth addict, tweaking and rocking back and forth, sits on the floor and just watches. He is calm. He does not scratch or scream. He is transfixed by the inexorable wonder he always hoped to find in drugs, and by the possibility that he might be whole again, that he might have his own wife, child, and delight. The man dying of lymphoma, passing the room as he is wheeled up for admission, asks the nurse to stop so he can look, and the child fixes its tiny eyes on him. He still dies, but he does it in peace.

The cardiac patient’s chest pain resolves, and the febrile infant in the hall-bed (the one who looked so sick) begins to laugh, cackling, breathless laughter. His fever is gone. Only the babies can see the angels swooping round, touching, healing, encouraging.

I can imagine all sorts of things. An angry mayor, searching for the child. Or professors and priests and ambassadors looking for him later, giving him gifts.

But all I see now is the dawn. Mary is strong. She has no time to be admitted. Joseph says they have to go. They are loaded with formula and money, with snacks and blankets (and diapers). They are hugged and kissed by strangers, and everyone waves goodbye.

The next shift asks, “What was that all about?”

“Don’t know,” is the answer, “but I’m glad I didn’t miss it.”

And the chaos descends again, tempered by inexpressible hope, washed in love.