Where I discuss medicine in general, the weird glory of the emergency department (hence emergistan), medical education, medical politics, medical humor and anything about medicine on which I wish to hold forth.
We’re all familiar with the dogs used by the blind, and more recently with dogs used to comfort those with PTSD. There are even dogs that identify low blood sugar in diabetics!
What I want is a ‘pain scale dog.’ Physicians who treat pain in the emergency department and elsewhere are often confused and frustrated by the pain scale, by its inherent subjectivity and by the abuse to which it is subject.
That’s why I want the Pain Verification Dog. Let me illustrate.
21 year-old-patient presents to emergency department ambulatory. He is healthy appearing but grimaces, saying ‘I pulled it at work.’
Me: ‘What’s your pain scale, sir, if zero is no pain and ten is the worst pain in the world?’
‘It’s a twelve! No kidding, maybe a 15!’
Me: ‘Nurse, call the Canine Pain Verification Team!’ Dog enters room. ‘I repeat sir, what’s your pain scale?’
‘Now it’s a 20! I have to have some, what is it, it starts with a D and it’s all that ever helps!’
Me: ‘Sir, that’s Axon. He’s highly trained and very sensitive to pain scales and he feels that you may be overestimating!’
‘Dude! Get that dog off me! I’m serious! OK, OK! It’s, it’s a ten!’
Me: ‘Sir, I appreciate your situation; but Neuron disagrees. What do you think? Is it really a ten?’
‘I’m serious, I’m scared of dogs! My back hurts and this is making it spasm! OK, OK, it’s, it’s maybe a three, OK? A three! Can I get a Tylenol or something!’
Me: ‘Sir, the pain scale dog team leader, Decem, says “good boy!” Here’s a list of exercises and an Aleve.’
How do you define yourself? How do you describe yourself? In the past, I have tried to avoid immediately categorizing myself by my profession. I always agreed with The Little Prince:
“Grown-ups love figures…When you tell them you’ve made a new friend they never ask you any questions about essential matters. They never say to you ‘What does his voice sound like? What games does he love best? Does he collect butterflies?’ Instead they demand ‘How old is he? How much does he weigh? How much money does his father make?’ Only from these figures do they think they have learned anything about him.”
-Antoine de Saint-Exupery, The Little Prince.
Taken from https://www.goodreads.com/work/quotes/2180358-le-petit-prince
And yet, we do this constantly. Physicians especially love to divide ourselves into groups. Each group has its own characteristics. Most of those reading this (but not all) are EM docs (ER docs if you’re older), also known sometimes as ‘pit docs.’ There are internists, or fleas. Surgeons, or cutters. Anesthesiologists, or gas passers. Pediatricians, or pediatrons. Radiologists, or shadow doctors. Orthopedists, or carpenters. (I kid!) This is a natural division as our specialties are our big, nerdy fraternities and sororities. They are the places we learn to make our living, establish habits of thought and behavior, create world-views and life-long friendships.
Unfortunately, it goes much further than specialty. We are divided between rural and urban, and there are significant problems in that chasm, as physicians in urban teaching centers sometimes have little knowledge of the stark limitations of the rural setting when we call for help or transfers. ‘You don’t have a surgeon? You don’t have an ICU?’ Likewise, rural physicians often forget that even ‘the big house,’ eventually reaches capacity and can’t take transfers; and the presence of the large center (or a helicopter) is no excuse for sloppy care on the outside.
We are also demarcated by into ‘community vs academic.’ In my medical wanderings over the past few years, I have found that this is a point of contention with many community physicians. Research, treatment pathways, algorithms, check-lists and new imperatives seem to constantly emanate from academic centers and flow to the community hospital and its citizens. Community physicians, many of whom have lived through countless swings of the medical pendulum and associated policy changes, are often reasonably skeptical of the latest study, the latest rule about pain medications or sepsis protocols. They feel cut-off from what they perceive is a connection between academics and policy-makers, and they feel particularly excluded if, later in life, they have an interest in entering academia, which seems like a closed club.
Physicians are also increasingly divided by gender and sexuality, as we see various physician advocacy groups pop-up. That’s fine, I suppose, so long as it doesn’t split us further apart but serves as a source of encouragement and connection for the members of those groups. (It becomes toxic when it is used as an exclusionary tool. I was told once that my opinion in a debate was less relevant because I was a ‘straight white male.’)
However, our divisions seem to be at their worst when it comes to politics. And it’s a pity, really, because we have such potential to be models for the rest of the world. I have seen physicians argue politics in person and online. I have been part of some of those debates, and it can be very, very ugly. I have recently withdrawn from most political dialog because it wastes time, causes anger and accomplishes nothing.
But I will give this ‘opinion’ and stand by it. I’ve worked with physicians who were Christian like me, Muslim, Hindu and atheist. I have worked beside ardent progressives and hard-core conservatives who make me look like a socialist (and that’s tough to do). I have worked with physicians who were gay and straight, rural and urban, academic and purely clinical. I’ve laughed and cried with them, eaten with them, encouraged and been encouraged by them. And I’d do it all over again. Because when it comes to our job, our real job of treating the sick, easing suffering and saving the dying, all of our differences evaporate into vapor.
So identify yourself by whatever category you wish. But never forget that we can serve as a model for unity, a model for the greatness of all free people, when we do our jobs well, and do them together for the good of others.
Now, what’s your favorite food? What’s your hobby? Tell me about your wife, husband and children. Because those categories interest me more than all the rest.
‘Patients who suffer from painful conditions
Should always be treated by caring physicians,
Who never forget to give good medications
For problems from fractures to awful menstruation.’
‘The fifth vital sign is your bright guiding light
The pain scale will lead you to do what is right,
So doctor remember to show some compassion
Since giving narcotics is now quite the fashion!’
Thus we were told for a decade or two
As patients stopped breathing and turned rather blue.
But hospitals loved their new high survey scores
And doctors were turned into pill-writing whores.
Yet things are now changing across the whole nation.
There’s blame all around and new drug regulations.
‘What were you thinking? What were you doing?’
‘How could this happen? Someone will start suing!’
In ER’s and clinics and every location
We docs shake our heads with increasing frustration.
We did what they told us despite all our fears
And Pandora’s Pill Bottle spilled out for years.
The pain scale betrayed us and caused too much trouble
The fifth vital sign is a big popping bubble.
The statistics we’re reading have left us quite nauseous.
So we’re trying new things to save lives and be cautious.
Dear doctors it’s you that must make these decisions!
Push back against administrative derision!
And when those ‘above us’ make policy errors
Stand in for the truth to prevent further terrors.
Here’s a column of mine, published today at Politico.com. Everyone wants to make these issues into right/left battles. I was asked to write this, and it concerns mental health, which is a topic very important to anyone in emergency medicine. I have written for publications of various political orientation and I’ve tried not to let the liberal/conservative division limit me too much.
I have a theory that engaged, wise grandmothers could save families a lot of money by helping avoid hospital visits. Personally, my grandmothers were very important to my well-being as a child. Not only did they feed and dote on me, they kept me healthy and safe. I remember the time I made a spear out of a sharpened stick. (OK, one of the times.) I was running with it, and as I drew back my arm to fling it across the field I must have stumbled. It ended up going through the top of my shoe and between two toes, scraping them on the way to the ground.
I limped to the big white house under the maples where Grandma Leap helped me take off my blood-soaked shoe, cleaned the wound, probably applied Merthiolate (didn’t we all spend our summers painted orange?), and said ‘don’t tell your grandpa, he worries!’ Maybe she knew he’d take my now cool, blood-stained spear away. I was none the worse for the wear.
I have seen injuries like this time and time again in the emergency room. Relatively minor affairs; scrapes, bumps, bruises, stings, nevertheless brought to the hospital by anxious mothers and fathers, new to parenthood or simply far more worried than necessary.
I also remember the smell of Vicks Vaporub, slathered across my coughing, wheezing chest. I remember cool cloths applied during fevers. My grandmothers had those simple skills down pat. Honestly, I don’t ever remember coming to the hospital for a fever as a child. And yet, fever is one of the most common complaints for which parents bring kids to the hospital.
‘He started having a fever an hour ago, so we rushed him to the hospital!’
‘Did you give him anything for the fever?’
‘Nope, we just came straight away. We freaked out and decided it was better safe than sorry!’
I hear that a lot. There was a bruise. ‘I freaked out.’ There was a tick, ‘I freaked out.’ There was a rash. ‘I freaked out.’ The baby’s nose was congested. ‘I freaked out.’ Freaking out never helps anything. And from what I can remember, it was simply something my grandmothers never did. Their job was to draw on centuries of collected cultural and family wisdom, apply personal experience, mix it all with loving attention (and food), and bring calm to all situations. Or bring switches as the situation required.
I’m not suggesting that a family member is all that’s necessary in times of medical need. And admittedly, there are plenty of grandmothers who are as ‘freaked out’ as everyone else. (I’ve met them.) Furthermore, lots of grandmothers and grandfathers are already doing this job as primary caregivers of their children’s children. God bless them.
However, it seems to me that we have an unholy confluence of problems that make people seek healthcare for things our ancestors wouldn’t, or couldn’t have. First of all, families are separated for various reasons from wise older relatives; or don’t have any. Second, people have 24/7 access to online health information that often only increases fear. Third, we have enormous numbers of young individuals and parents who never learned much about their bodies. Add that to the general increase in anxiety that mental health workers report across the land, and families are completely overwhelmed by the sorts of ailments that have afflicted mankind since well before modern medicine existed.
It seems to me that with our long history of self-sufficiency, and our deep-rooted connections to place and family, rural America should be one of those places where grandmothers could make a real difference in an era of limited medical access, coupled with enormous medical anxiety.
Maybe, in the mountains, valleys, bayous and plains that make up rural America we can be health pioneers! What we need to do first is educate young people about how to give simple medical care to themselves and others. First-responder and First-Aid/CPR courses are a great place to start. Second, those of use who are more experienced can reach out to young people and young families; neighbors, church-members, strangers at the food-bank, and offer to be there to teach them how to manage life situations. And how not to ‘freak out.’
Finally, those of us in medicine, whether nurse, physician, medic or other, can spend time educating the people we see so that they know when, and most important when not, to worry. And never to freak out.
A thing that grandmothers, in times past, taught us oh so well.
Here we go again. In London three are dead and many injured thanks to the low-tech use of a car and knife in yet another act of cruelty and cowardice in the name of terrorism. If you’ve been on a retreat, in a coma or hiking the AT, here’s a link:
Brits rise up in unity and solidarity, etc. Great. We should all show unity and solidarity. But we should all be able to DO something since the political class as a whole, around the world, seems to think the whole terrorist thing is like a teenage phase and has nothing to do with any particular belief, ideology or policy. Witness the endless handwringing we usually see as police and officials struggle to figure out the attacker’s motivation. ‘Gee, what could it be?’
Fortunately, the Brits have put more police on the streets. ‘Armed and unarmed.’ It’s a great strategy really. One of the dead was an unarmed police officer who clearly distracted the attacker and absorbed the knife so that others could use, you know, weapons to aid him in his pursuit of martyrdom.
I rant on. But what I want to say is this. We individuals cannot predict terroristic acts, and we certainly can’t stop them before they start. That’s the job of law enforcement and the military. We can only do what we can, when these events happen, if we happen to be present.
So I’ve been thinking about things people should know how to do. First of all, we should know how to PAY ATTENTION! I have recently seen a commercial for a cellular company in which a young man streams movies and TV everywhere he goes, on the street, on the sidewalk, on the bus. The world around being, apparently, just too boring. This is dangerous. We should watch and learn. Is that a suspicous package? What does it mean that smoke is coming from under the hood of that parked car in the crowded area? Is that a real gun the scary man pulled out? Or is it just an oddly shaped, giant cell-phone? Why is that gentleman speeding towards me on the sidewalk? Wait, am I on an episode of Impractical Jokers? Paying attention to danger leads to running or fighting which leads to being the guy interviewed the next day about what happened, instead of the one remembered as ‘a really great guy who will be missed.’
We should also read. Learn, from news, books, websites and classes, how to identify concerning behaviors and situations. What does a firearm sound like? What does a bomb blast look-like? (Clue, TV and movies get it wrong a lot.) It’s easy to hear or see something dangerous and immediately think it’s nothing; we want it to be nothing, after all.
One of the sites I visit is Active Response Training. They have lots of articles about self-defense, as well as reviews of mass terror events, etc. They also have excellent classes; I’ve taken one myself many years ago.
Furthermore we should stop being lazy slugs and get in shape. Sheesh, America, there are lots of great reasons to be fit; being attractive to your mate or potential mate is a good one. So is living long and staying away from ER doctors like me. But another is that when you are fit, you can run and fight. This isn’t some right-wing way of looking at things. It’s called an ‘evolutionary advantage.’ Run, bike, lift weights, hit the punching bag. Do it until you’re exhausted then do it some more. Say it with me: Fitness = Survival. It isn’t hard.
As a child I loved the Chuck Jones cartoon production of Rudyard Kipling’s mongoose story, Rikki-Tikki-Tavi. In the movie, Rikki the Mongoose says: ‘A fat mongoose is a dead mongoose.’ That is, a fat mongoose can’t fight poisonous snakes. I’ve never forgotten that lesson. Thanks Rikki! And thanks Mr. Kipling! (Not sure if it’s in the book, but the cartoon message really impacted this kid…)
So what else can we do in an age of terrorism? Emergency physicians like me understand how to manage serious injuries, but we need to encourage citizens to learn 1) first aid with hemorrhage control and 2) CPR. CPR classes are everywhere and typically include use of Automated External Defibrillators or AED’s. In fact, in trauma situations like those involving terrorism, CPR and AED’s are probably not going to be very useful. But it’s good to know for other sorts of emergencies.
DHS has a website and initiative called ‘Stop the Bleed.’ It’s worth a look as there are training videos. Many companies also sell bleeding control kits that citizens can, and I think should, keep in their vehicles or on their persons. A tourniquet and dressing don’t take up much space.
I would encourage young people to consider taking local First Responder or EMT basic classes. It’s information you’ll never regret having, and it looks great on a resume.
We need a veritable army of first responders out there, ready to help while police and EMS are either tied up, on their way or being attacked themselves. Physicians should be part of the effort to teach this material as well.
Last, but not least. Those so inclined should learn to fight. Obviously, the average person isn’t Rambo or an Army Ranger. Most of us will never be up the the level of an MMA fighter. But it may not take all that. MInd you, self-defense classes can be absolute crap. Especially the stuff they foist on nurses and physicians in order to handle attackers and dangerous patients (since security is usually told not to touch anybody…).
And self-defense skills need repetition like all motor skills. But those people who want to learn can learn. Learning to fight, whether boxing, wrestling, martial arts, etc., is hard, painful work. It isn’t for everyone.
.However, sometimes, it takes just a willingness to do something, or anything. I saw a video this week in which a citizen and CWP holder shot, and killed, a man who was holding down a police officer and beating said officer badly. Now, he was armed with a pistol, but might just as well have used the shovel I keep in my truck to hit the guy on the head. Or might have thrown a rock. Or picked up a stick.
In a building, a fire-extinguisher might be just enough delay and distraction. A can of wasp and hornet spray kept in the office is mighty nasty stuff if sprayed in the face.
If so inclined, as many of us are (and far more physicians, nurses, medics, etc. than you might imagine), carry (legally) a firearm or reasonable knife. If the attacker is bent on killing you anyway, can you do worse than fight? You may slow him (or her…sorry). You might keep them from killing anyone after they kill or maim you. Or, if you’re in good shape and have trained in some sort of class or fighting discipline (or just get really lucky…or have angels fighting with you), you might win! Sure, sure, people will call you a monster. But lives will be saved.
It’s a dangerous world, and always has been. But there are things we can do to make it less so.
Sitting back while the danger grows with our fear, apathy and inability?
Those are just bad options.
So: Put down the phone, pay attention, read and learn, get in shape, learn to help the injured and learn (or at least consider) how to resist. America, heck, civilization, needs this now more than ever.
This is a post by the good folks at Social Orbit, an excellent new social media application. Which, by the way, has been giving away signed copies of my book ‘Life in Emergistan.’ I encourage you to check it out and sign up. There’s a banner add over to the side that will take you directly to their site to learn more.
Medicine is changing. A lot of the comradery and connection with our physician peers has been eroded because physicians are all so busy worrying about CPOE, EMR, TJC, metrics, billing, pop-up alerts, patient satisfaction surveys…the list goes on and on. Orbit was founded to create a community where doctors can connect with each other and reconnect with what they love about medicine. Greg Hadden, MD FACEP (co-founder of Orbit) notes, “There is an overwhelming feeling in medicine that the physician is turning in to just another cog in the medical machine. The providers are the heart of medicine and the center of healthcare delivery. While every other company and organization is focused on trying to make medicine more efficient, they are forgetting the individuals in healthcare that actually make it all work.” Orbit wants to focus there.
Orbit is a unique product unlike anything else out there. By putting together a resource that has things that doctors value and by creating a fun environment of collaboration, Orbit hopes to provide something that doctors want to contribute to and engage in. The ultimate goal is to see all physicians sharing, collaborating, and supporting each other. The app also wants to be a one-stop-shop for doctors. Orbit can keep them up-to-date with breaking medical news, help them plan their CME travel, help explore job opportunities, do HIPAA compliant chat, and learn…all while winning some really awesome prizes that focus on helping them recharge their emotional batteries.
The future of Orbit is bright and the developers have a lot of grand plans for the app! “In order to get there, we need doctors to give us a shot.” More Orbiters means a bigger community, more collaboration, more sponsorship, bigger prizes, more frequent prizes, etc. There is incredible potential with this and the developers have a lot of fun stuff they are constantly working on adding and integrating. In addition, Orbit has big plans for expansion into other specialties in 2017 with the ultimate goal of developing additional platforms for APPs, RNs, EMS, and international healthcare providers. However, it’s important to the developers that the rollout is measured and strategic. Says Hadden; “We need to be confident that when we get to that stage we are still able to serve our members by protecting the integrity and privacy of the group. US-based physicians are the only group that our app currently is able to verify and validate. We want to ensure that we are not letting in attorneys, MBA/MHA hospital administrators, recruiters, etc. Also, I think there are a lot of physicians that want to connect in a physician-only platform. As we build out the app, our users will be able to customize the content they see and with whom they interact. As an example, as we progress to include APPs, if a doctor wanted to participate in a physician/APP community then they would be able to do so. On the flip side, if an APP only wanted to connect with other APPs, then they could customize their account to exclude physicians as well.”
ACEP16 marked Orbit’s emergence out of beta testing and its introduction to a larger audience. The Orbit booth at ACEP16 was packed the majority of the time with most of those people coming up to find out what the tagline, “Seriously Fun Medicine”, was all about. Hadden explains, “In Orbit, medicine is a serious business…but it can also be fun!
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.
Dear Emergistanis, you know who you are! Keep up the amazing work!
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.