‘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.
It’s easy to be excited about facts when they support our own opinions. It’s nice to believe that uncomfortable facts are fake. Likewise, it’s comforting to believe that everyone who disagrees with us is ignorant. When the truth is so obvious, we say, how could anyone but an uneducated bumpkin deny it? And yet, it seems that much of our knowledge is incomplete and that our deeply held beliefs may be more fragile than we imagine.
I was thinking about this recently when I listened to a podcast about evolution. It was a discussion about some events that happened last November at the venerable Royal Society in London. It turns out that some well-respected scientists think that perhaps evolution isn’t just due to ‘random mutation and natural selection over time.’
According to some researchers at the meeting, our DNA is even more amazing than previously believed. It appears that external stressors change the way plant and animal DNA works so that creatures adapt much more rapidly than we thought. This doesn’t necessarily mean evolution is wrong; but certainly our understanding of it is probably incomplete.
This poses a challenge to some beliefs that have been held in exactly the same way by scientists, and the lay public, for a very, very long time. Can we handle the change in paradigm? Could we ‘adapt’ if we suddenly found out that evolution is a bit off? After saying for years that it was a not a theory but a hard fact?
The science of medicine changes all the time. For the past 20 years, physicians in training were taught that they should never hesitate to boldly give narcotic pain medication to patients who asked for them. Because after all, ‘why would anyone mislead their doctor?’ And who were physicians to judge? We were told, ‘you can’t create an addict in the ER.’
Except, according to some pesky researchers, it appears you can. Some people can become addicted after a very short course of pain medication. They’re just wired that way. And now pain pills and heroin are killing people in staggering numbers. Our venerable, white-coat clad instructors were wrong. (What? Physicians and professors wrong? Perish the thought…) And now we have to face the facts and change our behaviors as doctors.
New, intriguing information presents itself all the time in many areas of study. The bacteria in our guts may have to do with obesity and mental health. Litter boxes may contribute to human mental illness due to a parasite cats sometimes carry. Socialism in Venezuela is a disaster. Foreign aid sometimes worsens international crises. Who knows what’s next?
But what if we discovered a slam-dunk gene for religious faith that was so powerful that those who had it couldn’t help but believe? Could their detractors still regard them as simpletons or haters? What if we learned that the absence of that gene made for equally solid atheists? How would we believers treat them? What if some transgender people really have a body dysmorphic problem like anorexia? Or that there is a genetic marker that indeed makes them identify with another gender? What if discussing it isn’t hatred, bigotry or compromise, but compassion? What if we find, someday, that the science of climate change isn’t settled?
Obviously science advances. We love that idea until it bumps into us. What do would do when science, or new historical information, or some other new finding puts our personal beliefs in question? Can we let go of our political correctness? Or religious rigidity? Can we stop calling our opponents rude names? Are we OK with new facts when they contradict ideas dear to us?
It’s hard to let go. But just as we look back on our ancestors and smile about their quaint beliefs, someone will eventually do the same to ours. It will likely be the case that we were wrong about many things in ways we could never have imagined.
As times change and knowledge grows, we should all be a lot kinder in the way we view the opinions of others and cautious in the way we view ours own. Today’s unassailable fact could become tomorrow’s flat earth. A little humility, a little willingness to open our eyes and the courage change our minds, are probably in order all around.
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.
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.
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.
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.
(As we all grow more and more divided and arrogant in our views.)
Given the current political climate, a lot of our citizens are reasonably sure they know exactly what Jesus would do if he were here now. I happen to have a few thoughts on that topic myself.
It seems to me that first and foremost he’d disappoint us all by not debating the way we do. He’d actually love the people he was talking with, and want the best for everyone. Screaming matches and endless point-counterpoint were never his thing, or so it appears in the scriptures.
I think that while everyone was trying to convince everyone else about their opinion (and not changing anybody’s mind), he’d be on some street-corner healing sick people. And he’d be doing it in a way that was so dramatic people would think he was a charlatan. ‘There’s no way that paralyzed kid can walk now! It’s just a trick to convince simple-minded, unscientific people!’ That’s what some would say. And Jesus would keep right on healing cancer, HIV, gunshot wounds, schizophrenia and other awful problems.
And those people who were so full of inner pain that they wanted to die, and kept thinking that they had no worth? He’d heal their pain, and cast out demons from them. That’s what the Bible says he did, anyway. He said he was God and he taught about things like demons. People probably wouldn’t like that much; neither atheist skeptics or solid, staid, educated Christians. But the people he healed would love it.
Of course, he’d talk to people at the marches, the rallies, in the halls of legislatures and in the churches. Unlike our milquetoast, pale-faced images of gentle Jesus from Bible story-books, he would sometimes look (and be) angry. Angry about injustice and cruelty, angry about the neglect of the needy. He would also be angry about false teachers and others who robbed men and women of faith in God and left them nothing to comfort them. As before he would be angry at anyone who led others to sin. Occasionally, he would be sarcastic and insulting. He’d have harsh words for lots of pastors and sanctimonious believers. Read the Bible; it’s how he was.
Our many-flavored hatreds would give him plenty of fuel for parables, in order to guide us to the truth. But he would also be unhappy about the division and ideas heaped on people that leave them feeling worthless. Like the idea that humans are a scourge, a virus on earth. Or the obsession with hungry, sick animals while children face the same. And the way men and women are weighed down with one of two burdens, endless victimhood and its chiral image, the belief that some people’s ‘privilege’ causes all the world’s problems. He came to liberate everyone from beliefs that imprisoned them. He condemned religious leaders in his day for giving people burdens but not helping carry them; he would do the same for modern politicians and educators, ministers and mullahs who create anger, tension and violence in order to control and manipulate others.
Obviously, would talk about ‘sin,’ from greed to sexual immorality to idolatry and all the rest. He talked about those things a lot. He’d preach about the coming Kingdom of God and eternal life and redemption and judgment. He was serious about sin, but kind to all sinners, right, left and moderate. Conquering sin and death was his main mission, after all.
That would be just about enough for lots of folks. Because they didn’t come to be pressured about morals or lectured about their personal lives or told stupid fairy tales; they came for justice! For revolution! And they’d ask him to leave. Or maybe scream at him, because it’s what we do when we’re angry and sure we are right.
Ever the gentleman he would leave if asked. But before Jesus left, he might remind all of the passionate, angry people of what he said before:
“You have heard that it was said, ‘love your neighbor and hate your enemy.’ But I tell you, love your enemies and pray for those who persecute you, that you may be children of your Father in heaven. He causes the sun to rise on the evil and the good, and sends rain on the righteous and the unrighteous.’
It seems to me that in his absence he remains present, and his teachings still condemn our hatred 2000 years down the road. If only we’ll listen.
Once upon a time, a loving couple moved from the cold, bleak land of Indiana to South Carolina and bought a house in the woods. It was a lovely first home, and they enjoyed all their time in the house. While they were there, they learned about the beauty of nature; the birds, the raccoons, the deer; the ice storms that shattered trees, the flash floods, the brush fires, the stray dogs trapped in the creek, the giant hornets nests in the woods. It was beautiful all around. Nature is awesome!
Then, after they had brought four amazing children into the world, they said to one another: ‘What the heck! Let’s move further into the wilderness!’ And they had someone build them a house of logs, high on a hill near the state forest. While it was being built, they discovered rattlesnakes. Which are natures wonderful creatures. And soon after it was built and they moved in, they learned about wild hogs. Just one more amazing thing in the yard.
In time, the family learned all about the veritable Noah’s Ark that their home had become. Having grown up without scorpions (how poor life was!), the family learned to shake out shoes and watch where they stepped. Inside the house as well as outside. Gradually, centipedes stopped in. ‘Hello human family, we’re God’s creatures too! And we sting like everything else! Welcome!’ By now the family was not only amazed but mildly annoyed. They learned the centipedes are much harder to kill than scorpions. They felt sad doing it. The first time.
A charming family of giant rats lived under the porch. Such a cute family! And they set the dogs on them, who went to work with canine glee. The dogs later made peace with most of the forest creatures and started to completely ignore them.
One magnificent, exciting year, the family saw a cute little lady-bug (or what they thought was a lady-bug) in the kitchen. And the next day they woke to find, oh, about ten-bajillion of them hanging out all around the house and in the house and in their food and bathroom and on the windows and drapes. Some in the family, it turns out, were allergic to them and wheezed and developed rashes. But oh they were so cute. The family sprayed a chemical around the doors and windows that, years later, still seems to kill the creatures and probably cause cancer.
The house in summer was all abuzz with wonderful things. Carpenter bees slowly, with great dedication, began to bore holes all over the wooden beams of the big log house. The children made great sport of swatting carpenter bees with badminton rackets. It didn’t really help, but a dead bug is, well, you know. Eventually it is believed that the house, like a great building of brittle Swiss cheese, will collapse and kill everyone. Except the bugs, that is! Isn’t that wonderful? Nature…who knew?
Later, various wasps began to engineer amazing nests on the log house; which then developed into entire wasp civilizations. The wasps loved the house, and the family, so much that sometimes they went to bed with them and took showers with them! Stinging is like hugging to wasps. Except it really isn’t. The people engaged in campaigns to kill all the wasps, and enrich pesticide companies. The wasps are silly and always come back. The wasps live in the attic above the bedrooms too. We’re all a family.
Then stink-bugs came, and what a joy! They sing their happy, buzzing sounds all day and night, inside and out, and land in cooking food and brewing tea and onto the hair of unhappy females in the house. And when smushed, they smell terrible! What fascinating little nightmares. The family was told that stinkbugs prey on ladybugs. Isn’t that just a kick in the pants?
Lately, above the bedrooms, there have been noises. Adorable, furry bats have appeared in the big log house on the hill. Flying around inside the house, dropping onto the table. What incredible creatures! They are, apparently, rooming with flying squirrels. Will either of them eat the stink bugs?
The family still loves nature. Maybe, part of loving God’s critters is being in a constant struggle with them. At least then you learn about them in person, not from some sterile display or chapter in a book.
Maybe, just maybe, an apartment in the city would be nice sometimes. Because the creatures, so far, are winning.