Edwin Leap - Husband, Father, Physician, Writer

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Fri, 9 Oct 2009 17:00:00 GMT

Socialism, Jesus and health--care...be careful what you wish for!

Sat, 3 Oct 2009 17:00:00 GMT

What a fascinating time! We’re debating, on a national level, morality. Granted, it’s the morality of access to health-care, but at its heart this is a debate about things moral, and ultimately about things spiritual.

The great irony is that American popular culture loves to make the claim, when it is convenient, that we cannot ‘legislate morality.’ Of course, that’s a nonsense statement. We legislate morality all the time. We believe it is wrong to drive while intoxicated, because it might cause harm to someone, and that someone has intrinsic worth, and harming them is wrong. Morality legislated.

We legislate morality when we say it is unlawful to marry a minor, who does not have the capacity to understand the situation, or when we say it is illegal to sell illicit drugs because they might cause harm to those who buy and use them. We legislate morality when we limit free speech that might be libelous. We legislate morality when we say it is wrong to steal, or to take another persons wife or husband.

And so, it is no surprise that we have arrived at the moral discussion which may lead us to ‘legislate’ morality in terms of providing health-care as a right. But before we move forward, we ought to consider that morality requires a foundation in something transcendent. I’ll get back to that.

It is widely held that health-care, because everyone needs it, should be available to all at a discounted rate, or for free, so that those who can pay don’t need to pay too much, and those who can’t pay needn’t pay at all.

While it sounds very beautiful to say so, and while the name of Jesus is oft-cited in support, since he cared for the poor and healed the sick, it might be a tad more complex than all that.

The reason being, Jesus concern for the poor and sick was rooted in his role as the Son of God. So, he healed them to reach them; he reached them to save their souls and transform their lives; to dispense with their old way of being and bring in a new one. He was gathering citizens for a distant country, the land beyond death, and changing lives in the process. The imagery of baptism was perfect; to die to the old and rise to the new, both now and in the future.

If we believe Jesus is calling us to love, to charity, to give to all without expectation of reward, that is well. If we all live that way, the world will be better. But we don’t. Or we won’t. What the world wants, what reformers want, is for us to behave like Jesus in our duty to the poor, but without any of that pesky religion to muddy the collective social or economic water.

We are told, by some, that Jesus was a socialist. Though the Gospels do not support the idea that Jesus of Nazareth was a socialist in his politics (which were really the politics of heaven, not earth), I’m fascinated by the popular belief that he was; because those who believe it may be onto something. Perhaps, if we all live like socialists, we’ll have a paradise on earth; but with one caveat. If we will make people socialists because Jesus acted like one, then the only sustainable way for us to reform our economy, our health-care, our world is for all socialists to be like Jesus.

That means, we physicians, and politicians, and insurers and attorneys and all the vast, complex panoply of professions will have to start giving a lot more of what we produce. And we must do it on the assumption that, whether we receive monetary compensation or not, we will receive a heavenly reward for doing his will and loving God’s children so well.

Of course, it also means that the poor need no longer worry about rising in society; rising is irrelevant, except as we rise to heaven. The poor, the meek, they will receive their blessing. But maybe not here, maybe not now. Jesus was quick to point out, ‘the poor you will always have with you.’ No socialist utopia to stop it in this life!

If we will be Jesus modeled ‘socialists,’ we may have to be itinerate. We will spend our energies both on loving man and on studying about and loving God. We will know the scriptures in all their wonder and complexity. We will hope for the return of Jesus, who said he was coming back to fix all of the problems of this life with utter finality (and with judgment…a thing annoying to most socialists, who clearly misunderstand Jesus’ brand of socialism). We will expect, in our love of others, to die horrible deaths; as Jesus and most of his disciples did.

We will go to school and work, then give away our efforts because he called us to do it. Of course, many followers of Jesus do this now. But if we want to live ‘morally,’ in our businesses, our health-care system, or anything else, and if we want to impose a morality on the nation, we must remember where it comes from and that it cannot exist as a secular ideology separate from a divine imperative! Our morality, if it will work for all, must rest on a bedrock of absolute truth; and that truth must be eternal and inviolable, not subject to the changes of fashion or political expediency.

So, if we legislate morality, we must legislate faith in order for it to survive. But since we are good post-moderns, good enlightenment-driven scientists, good Marxist leaning citizens of the world, we cannot accept any transcendent, spiritual, Godly, faith-directed guidance, and we certainly cannot have any of it legislated upon us.

And so, we must accept with a sigh the fact that socialism, or even nationally mandated free health-care, cannot function without the underpinnings of absolute love for God, for truth and for our fellow man.

Collectivism, for all it’s purported morality, can only fail, in economies generally or health-care specifically. Because you may make me be a socialist, but I cannot and will not make you be a Christian. And without that, the entire plan will fall to chaos, new inequities and simply more tyranny of a different type.

And as in the history of the church, there will still be martyrs. Who they will be remains to be determined.

Love is the best tool in the doctor bag!

Fri, 2 Oct 2009 17:00:00 GMT

When this is published, we could be on the way to a new healthcare system. I don’t know what that will entail. Few in the government really want my opinion. That’s the way it is; we have limited power. And yet, we have great power.

Last night, at work, I diagnosed a man near my age with new onset diabetes and osteomyelitis of the toe. He was terrified, and fear radiated from his face. He was afraid about diabetes, about neuropathy, about amputation.

We talked a while as I dealt with his blood glucose, then admitted him to the hospital for a surgeon to evaluate the affected foot and a hospitalist to control his diabetes. He thanked me for smiling and being kind. We shook hands and laughed before he went upstairs into his diabetic future. He felt better. He felt that someone cared, a bit, for his situation.

Reform or not, the one thing we can do as physicians is just that. We can be competent and compassionate. We can smile and touch. We can do the right thing as long as government lets us. (Pay attention to that thought, ‘as long as they let us.’ Store it away, and watch the future unfold).

I have been told, by some, that government-run health-care would be better than industry-driven health-care. I have been told the opposite, as well. Each side makes the argument that they will have greater accountability to the sick. Advocates for government suggest that we, as citizens and employers of the government, can hold them to more rigid standards; can get what we want and need more effectively through the legislative process. Those for the market believe that profit will always do a better job of driving customer satisfaction, efficiency and lower costs. That profit and share-holder interests will make the market a better choice.

I have an idea about that. I know what I think. This isn’t the place for my comment on that. What I do think is this. The only direct accountability any patient can ultimately exercise is between care-giver and patient. You can argue on the phone for weeks, and never speak to the right person at an insurance company. They can delay and evade for months. You can also call your representative or favorite government functionary, each of whom works behind a shield of anonymity and distance, guarded by layers of voice-prompts on telephones, or the labyrinthine nature of mail-rooms and e-mail inboxes. None of them are accountable the way we, the providers, are accountable.

And so, we have power. We can do what I did with my diabetic friend. We can touch and smile. We can care. We can do the right thing as much as possible. We can show compassion, live compassion, feel compassion. We entered medicine because, at least at some point in the past, we genuinely cared about the sick, the dying and the broken. Our best hope for the future of medicine is to continue to do the same; or if lost, to rediscover what was driven from our hearts.

Our proximity to the sick is an advantage no one else possesses; and in truth, that no one else desires. And our love for them is the most powerful weapon we have as we try to reform, or repair, or patch or whatever we call the machinations we are imposing on our system.

I don’t know what the future holds. I hope it holds continued jobs, continued freedom and choice, continued competence in medicine. I hope it involves amazing innovations and improvements in quality of life and the survival of human maladies.

But whatever it holds, good or bad, I do know the way to safeguard our place in the process, as physicians, nurses and others. The solution for care-givers is, ironically, to give care! If we give care, if we give love and concern, if we give of ourselves to those suffering, we will have far more power than any government functionary or insurance-company voice on the phone.

We may have our payments cut, our influence squashed, our opinions silenced. But our compassion will continue to connect us, our love will continue to rebuild the broken and our concern for our patients will speak with a thunder no government or corporation can match.

Maybe, in the end, we can reassume control of healthcare. And why not? We know it better than anyone else, because we know the sick better than anyone. We touch them, treat them, listen to them, and even see them leave this life. Those are powerful qualifications for leadership.

But we’ll never have control, ever again, if we give up the one velvet weapon we have, which is love for those charged to our care. For ‘faith, hope and love abide these three, but the greatest of these is love.’

And it’s never more true than in the cathedral of medicine.

Compassion and technology in healthcare reform

Fri, 2 Oct 2009 17:00:00 GMT

Compassion and technology; a marvelous, expensive combination

Does anyone realize that the chaos of modern American health-care is not a tragedy, but a triumph? We’re so busy trying to fix what isn’t broken and ignoring what is, so busy casting stones and casting doubts that we are blind to what we have.

I have practiced medicine in this labyrinth for 16 years. I am an emergency physician. I practice in what may be considered the ‘epicenter’ of modern medicine. Not for its importance, necessarily, but for its strategic location in the health-care system. That is, almost every specialty, almost every kind of human illness or injury, ultimately finds its way to an emergency department.

Therefore, I have seen the good and bad of American medicine. I have seen fantastic physicians and mediocre ones. I have cared for patients in dire distress, and those who were profane, abusive and manipulative. And I have watched as policy-makers, administrators and surveyors have caused both improvements and inefficiencies. But on the whole, I’ll take it any day of the week. Because American health-care represents, for all its limitations and problems, the best that America has to offer.

Why would I say that, when there are uninsured persons and failures? When people slip through the cracks and the cost of modern health-care is enormous? I say it because modern medicine represents a confluence of two great American traditions: compassion and progress. Both of which conspire to cause the marvelous madness of modern healthcare.

As a recent USA Today feature showed, emergency departments see all patients, regardless of ability to pay. This occurs because of a law passed in 1986 called EMTALA, or the Emergency Medical Treatment and Active Labor Act. Legislators, concerned for the plight of the poor, enacted this very beneficient mandate; of course, they failed to enact any means of compensating hospitals or physicians. And yet, emergency department visits are higher than ever, care remains exceptional despite long waits and overwhelmed facilities, and medical practitioners keep coming back to ‘do the right thing,’ at all hours of the day and night.

This behavior is hardly limited to my specialty. Surgeons care for drug-addicted victims of gun-shot wounds; internists and oncologists provide care for the oldest and sickest, despite the gravity of their situations. Impoverished premature infants are seen in high-tech hospitals that are the envy of the world. Cardiologists and neurologists help us to survive heart diseases and strokes that, not so very long ago, would have left us consulting with morticians instead of physicians.

The government, and the physicians, nurses, nurse practitioners, physicians’ assistants and others who care for the sick are possessed with a constantly renewed surplus of concern and compassion. Unfortunately, the combination of compassion and advanced technology makes American health-care the incredibly complex, expensive thing it is.

And that’s the problem, isn’t it? Compassion is not a problem, but cost is. And the cost is high; research is always changing, new drugs and procedures always being produced. We clinicians stand on the shoulders of researchers and business leaders who provide the means by which we can treat even the most extreme difficulties, and often return the sickest, most gravely-wounded individuals to their regular lives. It isn’t cheap. But few of us want to return to the past, when we could do less, with less. Even though the price-tag was lower.

American medicine lives at the nexus of compassion, science and industry. The goal of treating everyone causes increased cost. Our general desire to give the best to everyone in our typical, democratic way causes increased cost. And the continual supply of new ways to treat suffering, and prolong life, increases cost.

Do you doubt me? I’ve seen the poorest, drug-abusing, cigarette-consuming individual receive the best care imaginable for lung disease, heart disease, renal-failure, cancer or trauma; because we hesitate to judge.

We, as a nation, as a profession, are somehow tied to the Golden Rule, and we have difficulty saying no to anyone; not just for fear of litigation, but because it might be us, or our loved-ones, in need in the future. American government, professionals and tax-payers try to give the best of all, to as many as possible, because we view other humans as having transcendent, unconditional worth.

I don’t know the answer. I know suffering remains. I know improvements can be made. I hope that wise leaders engage in some few, wise reforms. But I think we need a moment of congratulatory pause. Our health-care problems are less the symptoms of a national disease than the side-effects of an enormous historical accomplishment. America, land of expensive care and remarkable compassion, should think carefully and move slowly before we cast off the behaviors that make our system of health-care, indeed our very nation, so great.

I am now a part of the Get Better Health Network

Fri, 2 Oct 2009 17:00:00 GMT

Myths of Emergency Medicine and Health-care Reform

Thu, 1 Oct 2009 17:00:00 GMT

To my readers:
I'm not a big fan of spreading things around that I didn't write. But this one is pretty good. It comes from the American College of Emergency Physicians, and addresses the problems of emergency care. I don't agree with everything the college says or does, but I'm on board with most of this one.

I disagree with Myth 2: I think there are probably more than 12% of our patients who could wait more than 2 to 24 hours for care. A recent USA Today article on drug abuse on Medicaid is more in line with what I see. Lots of folks do need care immediately; lots DO abuse the system. But no one is going to study that phenomenon, because they might look mean.

And I don't think we should mandate 'affordable and meaningful health insurance.' I'd love for everyone to have it, but if someone doesn't want it, or a business can't afford it, then mandates are a bad idea.

Still, the general tone of the letter is good, and I applaud ACEP President Jouriles for getting this out!

Edwin

An Open Letter from America's Emergency Physicians

As the physicians on the front lines of emergency care, we see the tragic problems of a failing health care system. We care for people who are ravaged by untreated disease; help worried mothers on weekends with sick children, unable to access a system that's open 9 to 5, weekdays only; and treat the victims of heart attack, stroke and injuries whose very lives depend on our care.

The role of emergency medicine has been badly misrepresented during the health care reform debate. The American College of Emergency Physicians supports comprehensive reform, including universal coverage. But it is vitally important that reform legislation not be based on erroneous perceptions, but instead address the critical problems harming emergency patients. It is time to debunk the myths, focus on the real problems and outline solutions to ensure that health care reform will protect and enhance everyone's access to quality, timely emergency care.

Myth: Emergency medical care is expensive and inefficient. Reducing emergency care will "bend the cost curve" on our nation's rising health care costs.
Fact: The 120 million annual visits made to emergency departments account for only 3% of all health care spending. In addition, emergency departments are equipped with state-of- the-art diagnostic equipment and highly trained physicians who can draw on many hospital resources quickly, providing coordinated, efficient patient care. The fixed costs of being open 24/7 are high, but the variable costs for seeing patients in the emergency department are the same as anywhere else care is provided.

Myth: Emergency departments are crowded with patients seeking non-urgent care.
Fact: Only 12.1% of emergency patients have non-urgent conditions that could wait 2 to 24 hours for medical care, according to the Centers for Disease Control and Prevention (CDC). While this percentage may be slightly higher in some hospitals, the reality is that crowded conditions and longer wait times are primarily caused by patients being "boarded," or forced to stay in the emergency department - often on gurneys lining the hallways - long after they have been seen and admitted to the hospital.

Myth: Your local emergency department will always be there when you need it.
Fact: Hundreds of emergency departments have closed nationwide because of an overburdened emergency care system. Those remaining must accommodate an average increase of 3 million more patient visits each year. Every 60 seconds emergency care is delayed when an ambulance is diverted to a distant hospital because a nearer one is unable to accept more patients. In addition, 75% of emergency department directors report significant problems getting needed on-call specialists, such as neurosurgeons and orthopedists, to provide vital on-call services to emergency patients.

Myth: The need for emergency care will decrease when health care reform is enacted.
Fact: With a growing and aging population, our role in providing care to the sick and injured any time day or night, and our front line responsibility in responding to natural and man-made disasters, will be in even greater demand in the future. Since enacting its universal health care legislation, Massachusetts has experienced an increase in emergency department patients. Emergency medicine is an essential community service that is vitally important to our nation's health care system.

To help ensure our country has a strong emergency care system, the American College of Emergency Physicians supports comprehensive health care reform that includes:

Every person in America must have meaningful and affordable health insurance coverage provided through a combination of employer and individually mandated insurance. It should be means-tested, allowing those in need to receive coverage or financial support to buy insurance. A combination of private sector and governmental solutions may be needed to achieve universal coverage. America is experiencing a dramatically rising tide of uninsured and underinsured patients. Emergency physicians are the only doctors in the country required by federal law to treat all patients regardless of their ability to pay. It is a responsibility we embrace proudly, but many emergency departments and physician groups are closing under the burden of uncompensated care.
Health care costs must be reduced. Significant medical liability reform is needed to eliminate unnecessary, expensive tests known as "defensive medicine." Liability reform can also help increase the availability of critically needed on-call specialists. Widespread adoption of electronic health records could substantially cut costs and improve patient care if there were complete integration of data between the emergency department and other medical settings. Administrative and overhead costs must be reduced.
Quality and patient safety must be improved by eliminating the practice of "boarding" admitted patients in emergency department hallways until they are transferred to an in-patient hospital bed. This can be achieved by establishing quality standards that define how quickly admitted patients are moved to their appropriate care settings, with such information reported and available to the public.
A national surge capacity plan must be developed and resources provided to prepare our nation's hospital emergency departments for public health crises such as the H1N1 pandemic, a terrorist attack or other catastrophes.

With so much at stake, America can no longer ignore the crisis in its emergency medical care system or make health reform decisions based on myths. Go to www.acep.org/realities for information on protecting your access to quality, timely emergency care.

We must act now.

Nick Jouriles, MD, FACEP
President
American College of Emergency Physicians

Pioneers and Pain Pills; my EMN column for Sept. 2009

Wed, 2 Sep 2009 17:00:00 GMT

If the pioneers loved pain medicine the way we do!

The wagons were still, as the wind blew from the West. Family after family was waiting for a word, a signal, any sign that the journey of their lives was about to begin. Crows circled overhead and flies buzzed. But no signal came. Children played tag in the streets, and weathered trail-hands checked and rechecked the harnesses that held oxen to the Conestoga’s they would pull to Oregon. Women in long dresses fanned themselves, and scouts stumbled out of saloons, kissing pretty girls goodbye till next time, assuming they once again survived the road across the plains and mountains of young America.

‘What’s holding them up, young man?’ asked Parson Shealy. The young man he addressed was a helper to Captain Morgan, head of the entire wagon train.

‘Same as always,’ he said and spit. ‘Trying to lay up a full supply of Lortab.’

‘Praise be! My lumbago is terrible!’ The parson sat back on his throbbing gluteus and whispered a prayer of thanks.

Everyone knew that the narcotic wagon was the most important wagon of all. Second only to the water supply (which was obviously needed to swallow the treasured pain medication), the ‘drug-cart’ as they called it, would never be left behind. It was guarded at all times by sturdy, trustworthy men who were always diligent, though apt to fall asleep in the saddle from time to time, and frequently given to complaints of saddle-soreness requiring pain medication.

The word passed down the line, and everyone agreed it was worth the wait. They all knew the terrible stories, some published as dime-novels in the bustling cities of the East, others told round campfires to frighten small children. Stories of brave explorers who twisted ankles, were shot with arrows, or were attacked by bears…and who had not so much as a Darvocet or Ultram to take for their suffering.

Only last year, a train made it two days out of Independence, Missouri, supplied with vast barrels of hastily purchased anti-inflammatories, only to discover that every adult on the trip was allergic to Aspirin, Motrin, Aleve, Advil and Toradol. They returned to the city to wait another year. Their moaning could be heard for miles, and when they arrived back in town, the pharmacies were scenes of chaos and fist-fights for 16 hours.

It just wasn’t worth the risk, traveling without enough pain relief. It was said that old Panther Dan, greatest of all the early Mountain Men (and called ‘Blue Speck’ by natives who traded with him), had very nearly put his Hawken rifle in his mouth when he realized he was snow-bound in the Rockies, and discovered to his horror that his hidden supply of Fentanyl patches had been deftly lifted by a painted lady back in the Dakotas (who subsequently failed to wake up one morning after a night of debauchery and severe pain). Fortunately, Blue Speck found the body of a US Cavalry Scout who had been killed and scalped, but whose pouch was full of Veteran’s Administration Oxycontin that had been overlooked by the band of Cheyenne who had left their arrows in his body.

So it was with a great ‘hurrah’ that Captain Morgan put his knee on a wagon-wheel and announced, ‘we have enough drugs for the crossing!’ Of course, in hoisting his knee to the wagon-wheel, he immediately strained his back, winced and reached into his pocket, popped two Demerol into his mouth, and took a swig of the fire-water he keep in a flask. ‘To Oregon!’ he cried, and the ladies wept, the men cracked whips over the backs of their beasts, and one of the guards of the drug-cart snored loudly and fell from his Appaloosa, landing in the dust with a thud.

The first few days were happy ones. The enthusiasm of the company was punctuated by laughter, songs and drowsiness. The bouncing wagons left everyone uncomfortable, of course, but the daily ration of narcotic that made the inherent discomfort bearable.

A week out, trouble showed its head for the first time as a band of outlaws road into the camp in the night, their leader holding pretty Mrs. Lecroy at gun point, as he asked for prescription drugs. Captain Morgan suspected it was ‘Thick-tongue bill,’ a long feared, drug addicted highwayman. ‘Giiivvv ustht thome of yooor Lorrtabs.’ ‘What?’ the company asked? ‘Donnn maaakk me thaaay ittt aggin.’ At this, Thick Tongue Bill drifted to sleep and dropped the canteen he had been holding as a pistol, and his band found themselves at gun-point, captured by the travelers. ‘What’s your pain scale?’ they asked his helpers. Each of them, little more than boys, looked to the dirt and said, ‘we didn’t mean no harm. But it’s a ten; maybe even an eleven!’ They kicked the ground, expecting to be hung.

No one had the energy to hang anyone, nor indeed even knew where the rope was. Before long even the outlaws received a box of Dilauded for their trouble. Everyone agreed that if their pain was really a ten or eleven, well, they deserved some help. Robbery was hard work, and apt to produce pain. There had, indeed, been lawsuits in which thieves had sued the wagon-companies for not treating their pain. Captain Morgan knew it wasn’t worth the trouble to resist; and dang it, he could relate. His neck was killing him!

Bill and his band road quietly into the dark, constipated but satisfied by the generosity of these kind, pain-afflicted travelers.

The next few weeks were uneventful. The pioneers endured bumps and bruises, thanks to the ministrations of their assorted opiates. Babies had been born to women who screamed far less than in the old days; babies that were themselves drowsy little angels. Only once or twice did arguments break out; but when they did, no one was worried about gun-play. No one could hit a darn thing with a Navy Revolver while taking a proper pain pill. The noise of gunfights did trigger an epidemic of migraine headaches, for which the party stopped three days to recuperate and sit in blissful silence, as the oxen lowed for forage and the horses dragged sleepy riders who hung from their stirrups.

But in Chimney Rock, Nebraska, the trip came to a grinding halt as a troop of cavalry ambled sleepily off the trail and made their way into camp, bearing a crate full of government forms. ‘We’ve been trying to catch up to you since you left Independence! Didn’t you hear? Most of y’all qualify for disability!’ Well, if there was a whoop and holler over the initial drug supply, this was even louder. Couples kissed, old folks with urinary retention wept and children (drowsy from cold medicine) looked up in confusion.

Major Medical, of the 6th Cavalry, looked down from his fine horse and gave the best news of all: ‘being as you qualify for disability, we’ve got a whole band of hard-working folks in Wyoming who have to take your wagons west for you, while you just take it easy in the back. If you can make it the rest of the way to Fort Laramie, someone else will drive your wagon and work for you! You’ll never need work, or hurt again!’

The families were ecstatic and Capt. Morgan was reflective. Another successful crossing with as little pain and effort as possible. The parson whisper a garbled prayer of thanks, and the band traveled on, sleepy and satisfied.

Your Day Radio

Wed, 2 Sep 2009 17:00:00 GMT

I've recorded some audio for SCETV Radio, which is SC Public Radio. Throughout the coming falll, the SCETV radio show, Your Day, will be broadcasting me, reading some selected columns. I'll put up the link to the schedule, and to the pod-casts, available through i-Tunes.

Swords and manhood

Fri, 6 Mar 2009 17:00:00 GMT

A while back, we bought some foam swords. My wife, and to a lesser extent my daughter, have better sense than to stand around and try to beat or be beaten, however soft the weapon. But my boys and I always come back to the sword fight. It calls up stirring images from the best movies and books. It makes us feel like Zorro or a knight from long ago. It stirs our testosterone washed brains like nothing else, that imaginary clash of steel on steel.

Since we aren't interested in getting large wounds requiring lots of staples, we've usually done it with lesser weapons, like wrapping paper rolls, tree branches and our current foamy sabers. The worst we have done (so far) is to employ actual wooden swords used in martial arts training. (This is fun, but fingers and knuckles always get crushed. And they're usually mine). Why do we do it? For males, swords are an emblem of power, authority and manhood. Every man wants a sword; just ask one.

Consequently, every emergency room in America, ours included, seems to have a story of two young men who were sword-fighting, for fun, when someone was impaled or lacerated with a real piece of edged and pointed steel.

Now, I'm no master swordsman, but I know a bit about things with points and edges. And when young adult men take to the woods to sword fight, they usually do it with weapons that are put together about as well as a two dollar box cutter, and they always do it without any training whatsoever. In other words, they may dodge, parry, thrust, lunge and all the rest, but no one has actually shown them how.

Ironic, that boys and young men across America want to sword fight without knowing the first thing about swords, except that they're long, pointy and shiny. Tragic, that boys and young men across America are growing up with the mistaken belief that they are men, when no one has ever shown them what that means.

In America today, untold numbers of children have fathers that either refuse to acknowledge their duty to them, or are barely more than lost children themselves. And countless women who want their men to act like men. Like the guys in the woods, they're hacking and slashing at manhood. But all that's happening is that women are becoming pregnant and abandoned, crimes are being committed with violent impunity, drugs and alcohol are being consumed like water and lives and minds are being wasted in front of televisions.

The problem is, they never had foam swords. I mean, they never had men teaching them fatherhood or manhood from the time they were small. In America, and all over the world, we've lowered the bar for manhood, and for fatherhood, and our sons respond appropriately. We men don't tell them that drunkenness is a danger to them and everyone around them. We don't tell them to honor and love their women. We whine about our marriages and make lewd comments about women far younger than ourselves and sink into the addiction of pornography. And we leave our children, either in fact or in essence, to pursue dollars and careers. We haven't taken them out in the yard and played at manhood. We haven't taught them the fundamentals.

But worst of all, we haven't taught them the absolute joy that they'll feel if they do it right! That there's no better feeling than loving and caring for one's own family. That only a good man makes a happy wife. That a happy wife is a passionate wife. And that children, loved and treasured, shower a thousand different gifts on the father who cares for them. We haven't taught them the joy (and importance) of the fight for their wives and sons and daughters. Our sons' lives and families are in peril, but not because of they lack skill with a blade.

There are millions of good men and good fathers in the world. But we need more. The battle for the hearts of our women and children is a real one. So we need to recruit and train young men. We need to start their drills and exercises early in life, with foam and wooden swords, so that when the time comes, they'll have the skills necessary for the fight. Otherwise, they'll just keep hacking away, getting hurt and causing generation after generation to suffer for their ignorance.

Medblogs Grand Round

Fri, 2 Jan 2009 17:00:00 GMT

Greetings all! I'm hosting Grand Rounds for January 6. I want to tell you about the theme.

Profit in health-care.

What do I mean? Well, lots of things are driving my thinking here. The Obama administration may create long-lasting changes in the reimbursement of health-care, up to and including a single-payer system. To increase the numbers of primary care physicians, there's talk of paying for the medical education of those students interested in primary care, so that they won't have a burden of debt and feel compelled to enter high-paying specialties. (The tacit assumption reasonably being that their primary-jobs won't be very lucrative.) All over the house of medicine, we find invective against the pharmaceutical industry; for manipulating data and (let's be honest) because they seek to make hefty profits.

And if we, as physicians, want to make plenty of cash, are we hypocritical when we come down on big Pharma? I mean, is everything we do, and recommend, really evidence-based and in the best interest of our patients? I don't know all the answers...I'm just posing the question.

So, as physicians and others in the greater health-care world, what do we really think about profit? We're taking care of people in need, many of whom have limited incomes and no insurance. Humans don't always choose their illnesses (though they often do). Many really need medical care; some just desire it.

As health-care providers, we're often working in dangerous environments, subjecting ourselves to the risks of infection, physical harm, lawsuits, exhaustion, relationship troubles and burn-out.

In light of all that, should we be turning a profit? Should we feel entitled to lots of money? Are we any different from other necessary professions? Should your contractor build houses at minimal profit, since people need shelter? Should auto-makers sell cars without much profit, since people need transportation? It's an interesting question.

Will young people endure medical education and practice without the promise of significant profit? Will the young physicians now in practice continue? Or, if we decided to pay less, would they simply become clock-in, clock-out factor workers?

Does the promise of financial gain make us better providers or worse?

Does profit compromise our morality, our compassion for those in need, or even our faith (to those so disposed)?

OK, hit me! Send links and responses to my e-mail at:

edwinleap@gmail.com

As before, you don't have to follow this theme. But if you do, I'll be interested to see what you have to say. I'll tell you my thoughts on January 6.

If you don't blog, and want to add your thoughts, send me an e-mail. I'll make a place to post your opinion. If you don't want your name attached, just say the word.

Have a great day, and a blessed, Happy New Year!

Edwin

A gift of truth

Sat, 13 Dec 2008 17:00:00 GMT

A stocking full of truth!

Merry Christmas to all!

I was trying to think of what I could give you, as a kind of gift for the season. I love getting gifts and I sure love giving them. But the readership of EMN is pretty large and with four children of my own, it would be a financial stretch for me to send you a stuffed animal, toy soldier, book or pocket-knife; a bracelet, pen or watch or any of the things I enjoy giving. So I was thinking between patients the other day about the things I can give you. And I figured it out. I can give you some truth.

One of the things I have always loved is truth. I love absorbing it in books, in quotes, in lectures and sermons. I love passing it on to my children. I love hearing learning the truth in tiny snippets; the sorts of things I scribble into my notebooks, or write in the margin of a book. I love the way it leaps out at me in interactions with doctors and patients; and the way novelists and poets can ambush me with it while I'm skipping innocently through a book. The truth is a gift that's hard as steel, sharp as a razor and absolutely critical; at this point in history perhaps more than at any other.

I enjoy writing for you because I enjoy writing the truth. I have tried to convey it over the years, and you have all responded wonderfully. We share a passion, you and I, for the unspoken, the obvious but neglected, the ‘great purple elephant' in the room that no one wants to mention for fear it may get its feelings hurt.

So, fifteen years into my practice, and 8 years into my writing career with EMN, I think I have some collected truth and a few ‘rules of thumb.' I hope you enjoy. Don't expect anything under the tree...I'm working Christmas Eve!

1) The key to competence is compassion. If we don't truly care for the well-being of our patients, no double-blinded, placebo-controlled, randomized study will make us better. And no system of time-outs, prompts or algorithms will substitute for our developing genuine love for the people entrusted to our care.

2) Loving our patients doesn't mean liking them. It's an important distinction. Loving them, and I mean in a scriptural sense, means doing the right thing because we believe they are also God's children. However, we need not agree with (or agree to enable) their choices, life-styles, or anything else.

3) Loving our patients may mean confronting them. It may make them, and us, uncomfortable and unhappy. This may result in letters written to administration. But speaking the truth will liberate a few from lives they shouldn't live. And that's worth a letter or two in the bad-boy file. And if it liberates you from a job that wasn't good for you, well that's alright too.

4) Tolerance, in medicine or culture, doesn't mean complicity. It means peaceful co-existence. We're all perfectly free to try to change one another's minds, and perfectly free not to change our own. If I tolerate my patient's beliefs or attitudes, it does not mean I have to agree with them.

5) Doing the right thing should never mean doing what we, as physicians, consider morally wrong. The patient's desire for my services does not trump my personal ethic or faith.

6) If I sometimes make a patient, or physician, feel guilty, it's OK. Guilt exists for a reason and needs to be experienced now and then.

7) Uncompensated care is burden we all should share. No specialist should be able to look like a community hero for being a great doctor, and then send his poor and uninsured to the emergency department to ‘eternally temporize,' until they can afford his kind ministrations. It's not fair and it's certainly unrealistic. I don't want anyone to work for free against their will. But I also don't want emergency physicians to be the work-horses of this dysfunctional system.

8) People who are actively seeking disability for entirely unsubstantiated reasons are among those who should be confronted. People who can drink, fight, wreck motorcycles and hunt wild-hogs don't deserve disability. They need to go to work like everyone else.

9) Doctors who treat other doctors like slaves need to be confronted with the following words: ‘I don't work for you.' Hospitals who allow this behavior are naughty, and their administrators ought to be ashamed of themselves. Both of them need to feel guilty, along with those faking disability.

10) Consultants and specialists have a new rule these days: ‘If the patient is very sick, transfer them. If they aren't, then discharge them. If they're in the middle, consult someone else to admit them...like a hospitalist. I don't want to come in and waste my holiness on common chattel in the ER.' The problem is, we shouldn't be in the middle of this. I'm a physician, not an answering service. So are you. So we need to tell the consultants to come and make their own decisions. Like playing tag; ‘you're it!' And don't give me that ‘I'll do you a favor.' No, you're doing the patient and the hospital a favor. So cut the condescension.

11) Guess what? People abuse our services. We have to start setting some rules. Do our patients realize that if they complain of the same things over and over, year after year, we'll eventually miss the real problem? It's like the little boy who cried wolf, for heaven's sake! Is Lortab and a work-excuse really worth the risk to them?

12) Most physicians have to see patients, and generate bills, to make a living. Anyone who is paid a salary as an administrator or academic, and whose salary is not tied to patients seen and bills paid, has a good gig. But they need to be careful about the way they view uncompensated care. If they're being paid by the hospital, which is supported by foundations and paid procedures, they should never tell the emergency physicians: ‘More volume is always good! Like at Wal-Mart!' Some volume is definitely bad...very, very bad.

13) Did that drug-rep pen, or that box of doughnuts, really make me order the more expensive prescription in the face of bad science? I've been entrusted with human lives. I've been trained to make snap decisions involving life and death. I work all night doing the right thing for some of society's most disenfranchised individuals. I argue and cajole patients for their own good and consultants for the patients' safety. I risk violence and infections every shift. I eat fast-food because there is seldom time for a break. Are you telling me that I'm such a moron, and so morally reprobate, that a pizza and an attractive salesperson will make me throw all my ethics out the window? I'm insulted. We should all be insulted by such accusations.

14) See above. If you're a member of a medical board, if you are a board examiner, a member of a quasi-governmental think-tank, a consultant to a political advocacy group or anything else which uses your medical knowledge or position, do you let them pay for your travel and hotel and buy you meals or drinks? Is it possible that such activities might sway your opinion? If so, how do you feel about pharmaceutical representatives visiting doctors and giving out note-pads? If you have any problem with it, look in the mirror. You just might be a hypocrite.

15) Most of us don't mind seeing individuals for free when they need it. But I wonder, in the current economic and moral climate, do they feel any sense of gratitude? Back in the old days, a doctor might get a pie or a chicken. If we see someone for free, then go to their place of business, will we get the same courtesy in a kind of post-modern barter system? Unlikely. Why? We're rich doctors, we can afford it. But the problem is, we aren't and we can't. We still have to make a living. And it isn't about greed. Our work and pay support a host of other groups and individuals. Like our own families and their insurance and education. And we support licensing boards, malpractice insurers, transcription services, billing companies, nurses, secretaries, etc. Every membership is $1000 for heaven's sake! And every patient costs a fixed amount in malpractice. We aren't rich doctors anymore. We're financial conduits. The government can cut us back, but we'll need a lot of breaks in other areas. And lots of folks, besides us, will lose money and employment if it happens.

16) The best care costs money. A high-end lap-top costs a lot because it's a good machine. A BMW costs a lot because it's an excellent car. A Sig-Sauer pistol costs a lot because its owner can depend on it. And health-care, modern, up-to-date, safer than ever, careful, precise, life-saving and life-prolonging will never be the same on the cheap. Bet on it.

17) If we think we know a lot, we're wrong. In 200 years they'll scoff at our simple science, our needles and our poisons. There is so much yet to learn. And I suspect the great surprise will be the way our minds, bodies and souls are unified entities. We think we're so scientific. We divorce our progressive minds from the ages old wisdom of our ancestors; we believe what we can see, and ignore what we cannot test. We stumble in the dark, I fear. What happens when we learn that prayers were more useful in the end than antibiotics? What will we think when we realize that what we thought was our science was simply the miraculous dressed up in medications? What will we say when we learn that our DNA encodes immortality. Don't laugh. You might be surprised.

Merry Christmas! Have a wonderful holiday season. Stand for the truth and speak it fearlessly!

I'm very proud of you, as always, and proud to write this column.

Sincerely,

Edwin

ER Olympics

Mon, 3 Nov 2008 17:00:00 GMT

This is my November column for Emergency Medicine News! So start training...the ER Olympics are just around the corner...during your next shift!

The summer Olympics are long past. I enjoyed watching what little I saw; Jan and the kids and I watched swimming, volleyball, track and field events and gymnastics. I wanted to catch the shooting sports, but never did.

Still, it was a remarkable time. I mean, the drama of Michael Phelps' breathtaking athletic triumph, the crafty use of elementary school children by the Chinese gymnastics team, the total electronic surveillance of every phone and computer in Beijing and the amazing way the west can ‘Ooh' and ‘Ah' over such a remarkably tyrannical state... it was truly a modern Olympics, in the most terrifying use of the word ‘modern' possible.

But it got me thinking. We need to have an Emergency Medicine Olympics! I mulled it around, and started to imagine the games, the training, the competitors. And I came up with a list of the events we might reasonably consider:

1) The 10-meter ‘vomit catch.' Armed only with speed and dedication, the nurses and physicians in this match have to race 10 meters, find the emesis basin and put it under the face of a patient pre-treated with Ipecac, chili-dogs and strawberry Jello. Points for speed, but also for accuracy in placement. Points lost for vomit on anyone's white scrubs. Disqualification if the patient is restrained on a back-board an experiences aspiration.

2) The ‘cup-of-ice' relay. As everyone knows, the best ice on the planet can be found in the emergency department. Chipped every day from pristine glaciers in Antarctica and Greenland, then shipped air-express to ER's all over America, it is coveted by very patient who walks through the door. ‘Can I have a cup of ice?' The question even precedes the statement, ‘I'm having crushing chest pain.' Well, in this competition, four staff members pass a cup of ice from person to person around the perimeter of a large emergency department, the hallway of which is littered with spilled blood, gurneys and elderly patients with walkers. Disqualification for wiping out grandma; points off for falling. Now this, dear friends, is practice for real life in the ER. (Young residents, you may think your most critical and valued skills are intubation and intravenous line placement; au contraire! Your most coveted, most frequently employed skills will be obtaining ice, filling out work excuses, arranging follow-up by phone and explaining your patients' illnesses to serial family members. Sorry! But it's too late to turn back now, isn't it!)

3) Let's face it, we're part physicians and nurses, part ‘mixed martial artists.' Not so long ago I had to employ a fairly uncomfortable Aikido pin to help control an angry, wiry drunk. (Wiry, by the way, is high praise in the South.). So why not have some form of combative competition? How about this: fat, drunk wrestling. A large man or woman, somewhere over 400 lbs, is properly liquored-up, lathered in baby oil, dressed in tank-top, cut-offs and sandals, and put into a room. The ‘patient' is then instructed to attempt to leave the department. The participating staff members are required to restrain the individual. To make it more realistic, we'll have armed security and police-officers stand idly by, urging the ‘patient' on with assorted comments. ‘You got ‘em bubba, don't give up!' We could have team and individual variations. Points off if any one loses a tooth or dislocates a limb. Extra points toward the gold if the patient can be distracted with food or drink. If anyone thinks this is cruel or ‘over-the-top,' they haven't been doing emergency medicine long enough.

4) Just as the Olympics always have new, obscure, pseudo-athletic events, we should have at least one of our own. How about the ‘Form Competition?' In this timed event, a sheaf of transfer forms is placed before the competitors, and based on several case-histories, they have to fill out the forms to exacting specifications, and also ensure that all of the times are accurate, all of the consultants are spelled correctly, and everything is legible. Points for speed, neatness and accuracy. Disqualification for angrily shredding the papers and screaming obscenities; or anything that would actually result in an EMTALA violation.

5) Now, what about the ‘customer satisfaction' games? A series of individuals play patients, and competitors have to see them within fixed time-windows, give them exact diagnoses, fluff their pillows, pat their hands and leave them feeling as if they were the only patient in the entire game; all with a smile. Extra points for hugs, timely follow-up and brisk hand-shakes. Points off if providers have to play the ‘here's a free movie pass' card. To make things more challenging, the athletes in this event will also have to be simultaneously engaged in ‘fat, drunk wrestling,' in order to challenge their magnanimous spirit.

6) Of course, we've addressed providers. What about a few games for patients? I envision the ‘Work excuse and narcotic rescription game.' Here, three physicians are placed in three separate rooms. ‘Patients' must sequentially visit each room and give both a history and physical presentation that results in the health-care provider dispensing, as the name implies, narcotics and/or work excuses. The more prescriptions for controlled substances obtained, the more days off work, the higher the score. In case of a tie, each ‘patient,' must compete for short or long-term disability before a panel of providers. I've met some champs here, so the competition would be tight!

7) The next patient event I would include is the ‘Dramathon.' Here, ‘patients' have to combine physical symptoms with their native sociopathy in what is, ultimately, a combination of athleticism, theatre and possibly criminality. Competitors will be judged on volume of tears, decibels of screaming, quality of profanity, ability to extricate themselves from backboards, number of friends called or ‘texted' on cell-phones, number of family members and friends packed into small cubicles, symptoms mimicked, charges filed by police and time to jump up, pull off their exam gown and storm out the door. It may be, truly, the flagship event of the entire games!

8) A few skills specifically medical skills need to be highlighted. Speed Foley placement (ouch!), Speed Intubation, Timed Leather Restraint application and Timed Medical Screening Exam, come to mind. And of course, ‘Power ordering,' in which the provider, in conjunction with a unit secretary, has to order as many tests as possible after evaluating a ‘patient,' and must order them within a two-minute period, and all with insurance justification. Points for proper usage, points off for using ‘weakness' as a reason for a test (it's just too easy).

9) ‘Language identification and flexibility' will also be a useful competition. A ‘patient' is lying on a backboard, speaking an unknown language and moaning. The provider's goal is to identify the language family, specific language and find the appropriate translator. Use of a ‘translation service,' is acceptable. But here's the hook: the ‘patient' is intoxicated! When you're drunk enough, Arabic and Spanish sound a lot like Algonquin or Cantonese! ‘Bon chance,' brave athletes! Points off if they use a resource that results in the patient accidentally being called anything that might be construed as offensive, like ‘monkey painter,' ‘dog washer' ‘bottle of worms,' or prostitute.

10) But to cap it all off, we have the big-daddy of all. The crowning competition of the ED Olympics. (The name alone might draw some specific, though misunderstood, sponsorship). In the final event, the Emergithon, competitors have to race across an emergency department holding a cup of ice, while wrestling with slippery, obese, dramatic drunks with cell-phones to their ears, who are speaking exposing themselves, speaking Norwegian and asking for narcotic prescriptions and work excuses. The ‘patients' will be vomiting, and will each require a transfer form, and an accepting physician in another facility. But first, they will have Foley catheters and restraints placed, and will have to use a visual analog scale to rate their ‘customer satisfaction.' All in no more than 30 minutes.

That, brothers and sisters, is life in the ED! Start training today! The games will be here before you know it; probably on your next shift.

A new place to read my column!

Sat, 4 Oct 2008 17:00:00 GMT

This month you can start seeing my column in The Baptist Courier (at www.baptistcourier.com), our SC state Baptist newspaper. I"m thrilled and feel very privileged at this opportunity to share my columns with other believers in that venue. You can find this month's column at: http://www.baptistcourier.com/2801.article.

Have a great day!

Edwin

We don't develop our views in a vacuum

Fri, 3 Oct 2008 17:00:00 GMT

One of the fun things about home-schooling is that we read to our children; a lot. Of course, they're excellent readers, but my wife and I love to sit down and read, discuss and enjoy different books with our three sons and daughter. It's a time of bonding, laughter, questioning and sometimes deep consideration.

Unless it's just for fun, like the time I read the horror story they all begged for, and at the end grabbed my youngest son and said (as the book suggested), ‘I'm here for YOU!' The other kids and I didn't learn a lot that night, except that if you scare an eight-year-old well, he'll jump, then fall over as if dead. Oh, and we learned that if you laugh hard enough, you can't breath.

Still, our reading serves a higher purpose than giving the children the shivers. A great deal of the reading we do with them is designed to form their minds and hearts, and shape their world-view. We read stories of courage to make them bold, mercy to make them kind, adventure to teach fortitude and stories of sacrifice to illustrate the cost of love.

We take them far into our formative and vital cultural heritage by reading the Bible, Greek and Norse mythology, classic stories, fables and poems. We are trying, in the best way we know, to create greatness in our children.

Their treasure-trove of knowledge and perception is growing every day. They're becoming critical thinkers, capable of looking at different sides of a question within the framework of their own beliefs. That's exactly what we want.

Of course, Jan and I don't have lots of free time in the evenings. We don't watch a lot of television or movies, and when we finally sit or lie down we usually fall asleep. But it's worth it, because we know our children better, just as they know us. And we are getting a kind of classical education along with them.

The reality is that everyone's thoughts, opinions, tastes and distastes are formed by outside influences. Left alone in a room for an entire childhood, a child will not suddenly become a free-thinking, progressive individual unsullied by others. That child will be a dysfunctional, frightened human with no concept of organized thoughts, and none of the gifts of creativity or higher ideal; no visions of grandeur or hope, no beauty of language or expression. These are things we develop in conjunction with others humans, who teach us in person, or through the various media to which we are exposed.

Everyone is formed by their families, faith, peers and culture. When we read to our children, we aren't doing anything that doesn't happen to every child. We aren't doing anything different except that we're consciously directing our children's minds and hearts in the way we deem best. That's a thing too many parents have tragically been convinced to avoid. You know the line; ‘I don't want to force my opinion on them. I'll let them decide for themselves when they grow up.' The problem is, all of their beliefs are influenced by others.

We do well to remember that everyone's opinions are complex and influenced by many others. We must accept that our teachers, politicians, scientists, businessmen, pundits and all the rest did not wake one day and have fully formed viewpoints, liberated from outside pressures. There are, it seems, no real ‘free-thinkers,' whatever we might like to believe.

Considering this, I'm always a little surprised when politicians are attacked for having any religious influence in their opinions and policies. Religion is one of the most formative forces in life. Anyone who is raised in a religious home will have their views of life, death, humanity, goodness, evil and everything else shaped by that faith. The same is true in a home where faith is not welcome; that is also formative.

Everyone, it seems, has a religion. That religion may be a traditional one, it may be science (which actually does require a kind of faith), it may be socialism or capitalism, materialism or naturalism, but ‘religion' is ubiquitous.

As so many persons rush to expunge religion from the public arena, I wonder if they consider where the ideas of our leaders will originate. Is it so bad that a politician is shaped by an organized moral system, a belief in the value of all mankind and in the certainty of higher accountability?

I hope not. If it is, I guess I'm educating my children out of a political career.

The different tongues of the emergency room

Fri, 3 Oct 2008 17:00:00 GMT

Medicine would be so much easier if we could understand everyone's language. Our hospital cares for many Hispanics. Typically, they bring a friend, neighbor or brilliant 12-year-old child (who is now bilingual) to translate. Sometimes, we have the blessing of an employee who is fluent in Spanish. Failing that, it's off to the ATT language line where, for a fee, we have access to almost any modern language on the planet. It comes in handy in other situations, as well. For example, we occasionally have Clemson University students who, while exceptional chemists, speak assorted exotic languages. ATT to the rescue again!

In other cities, in other lands, the problems are the same. I once did a disaster exercise in Omaha, where one of the major language groups among immigrants was Sudanese. I mean, I can stumble my way through Spanish without calling someone an egg-crate or prostitute, and I even boast a smidgen of French, but Sudanese? My hat is off to those fearless ER docs.

Of course, not all languages are even, well, languages. I remember the night I called the language line to help with a Hispanic gentleman who had been in an altercation. The problem was two-fold: he was intoxicated on Tequila (that great leveler of all men and women); and he spoke an obscure native dialect mixed in with his drunken Spanish. The translator was frustrated. ‘Doctor, he's drunk.' ‘Really? I hadn't noticed.' ‘Doctor, I don't understand his dialect very well.' ‘That makes two of us. Thanks for trying.'

He sang a lot, I know that. Maybe I should have asked for a translator like this: ‘Hello, I need someone who can translate enthusiastic Mexican-Indian dialects interspersed with grammatically incorrect Spanish, set to music but slightly off-key. Please.' He ended up being fine. We closed a scalp wound, did a CT of his head, let him sober up and he was off. So much for the need to understand someone else's language!

But even as I joke about language, I realized recently that there are languages spoken in our hospitals that are much harder to translate than we realize. In fact, we miss many nuances of our patients' lives because we just don't understand the tongues that they are speaking.

See, we care for patients whose language is self-loathing, depression, crushing anxiety, alcoholism, drug-addiction, loneliness, dementia, abuse, and untold dozens of other dialects of the human heart.

This is why we sometimes are frustrated with them. They come back over and over for anxiety or suicidality; they're brought by family members because they dwell in the maddening isolation of aphasic strokes, Cerebral Palsy or Alzheimer's. They can't tell us with any clarity what they need, and we can't tell them with any certainty what we want to do for them or why it's important.

And it isn't so much that we're uncaring; it's that after a while, humans become separated by wide gulfs of experience. We usually don't know what they feel; they have drifted so far into misery, sadness or confusion that they no longer understand what it is to feel normal, accepted and hopeful. The language of the heart can fail in both directions.

We can't ask for a translator. We can't call up the dementia hotline and have another demented individual speak to our patient and calm them. There are abused women and assaulted men, rape victims and drug addicts who will ultimately speak the same language as our patients if they seek them out. But in the dark of the night or the press of the day, we're usually stuck, stumbling through our patients' stories, trying to offer some halting comfort or hope that too often sounds like gibberish to the suffering; or worse, sounds like we come from another planet altogether.

Maybe it's why they drive us crazy; as they try to convey their pain and we fail to grasp it, as we try to offer healing and they can't hear normality anymore, we all become angry and annoyed.

We can learn a bit of it their language by experience, since we all ultimately suffer. Furthermore, all the years we spend among the suffering sharpen our ability to grasp what they're trying to say to us. Just as one may learn a language best by living where it is spoken, or loving someone who speaks it, when we work in hospitals, and especially emergency departments, we are immersed in all the languages human expression.

Fortunately, there is a parallel language we can speak as early as we desire. It's cliché to say that love is the universal language. But I've seen compassion work wonders. Kindness and smiles, touches and looks of concern, calming words and simple interventions like food or drink, a pillow or blanket, a little bit of (as we Southerners say) ‘petting.' These are words and acts that cross all languages, which are always understood, that have never in all human history required linguistic translation.

If you aren't a Protestant Christian, you may not know how we debate one of the spiritual gifts called ‘speaking in tongues,' mentioned in the Bible. Some people think it means speaking or understanding unknown, spiritual languages. Some think it refers to a gift for an earthly language without ever having studied one.

But as I write this piece, I realize that there may be another meaning. Maybe, those tongues are the tongues of the heart. Maybe it means the gift of seeing into the heart of another who is otherwise powerless to convey their suffering or need, or the cause of it, or the thing they hope most to cure it. If so, that would be a gift indeed.

Still, I have to say I'd also love for God to let me speak and understanding musical, ‘Mexican-Indian-Spanish-Tequila.' It was a happy language that could only enhance our mundane medical lives.

I hope that we all learn to speak and understand the languages we need. Because frankly, all our science and studies are worthless if we can't grasp what our patients (or even our colleagues) are saying; with or without words.