Fighting drug abuse in the ER

Fighting Drug Abuse

My latest column in the Greenville News.

http://www.greenvilleonline.com/story/opinion/contributors/2016/04/09/commentary-fighting-drug-abuse-er/82713082/

I have a lot of ER stories that involve drug addiction and drug seeking behavior. I knew a patient who intentionally dislocated his shoulder three times in one day to receive pain medication. Another had a friend who stole an entire dirty needle box in order to rummage through it for injectable drugs.
I have been told by patients that pain pills were eaten by dogs, stolen by neighbors, lost in car crashes, accidentally flushed down toilets and all the rest. People have pled with me because their normal doctor was out of the country. One individual (call him Bob) came to me and was denied narcotics, then returned two hours later with a woman’s ID and saying he was she (call her Carol). ‘You aren’t Carol, I just saw you.’ ‘Yes I am, I’m Carol and I’m in pain.’ ‘Get out,’ says I. The list goes on and on and every physician has a few of his or her favorites.
In the annals of American medicine, it turns out this was all rather new territory, at least in scope. My career began in the early 90s when there were (for various reasons, corporate and otherwise) powerful initiatives encouraging us to treat pain with more narcotics pain medications like Lortab, Vicodin, Percocet and others. We were regularly scolded for being cruel and insensitive about people’s pain when we, young and innocent as we were, expressed discomfort with this practice. I remember being explicitly told, more than once, ‘you can’t create an addict in the ER.’
We were told that pain was the ‘fifth vital sign’ and were taught to use a ‘pain scale,’ which you’ll hear to this day whenever you interact with the healthcare system. ‘What’s your pain on a scale of zero to ten with zero being no pain and ten the worst pain of your life.’ Most nurses can say this in their sleep. We developed smiley face scales for small children to use.
We learned to give narcotics regularly for various types of pain, when they had been previously reserved for cancer, long bone fractures or significant surgeries. Medical boards were encouraged to discipline doctors who were reported to under-treat pain. And hospital administrators, ever in love with the ‘customer satisfaction’ model, pressured physicians whose patients complained about receiving inadequate pain treatment. (High patient satisfaction scores have been studied and associated with poor outcomes, by the way.)
Although it’s difficult to quantify because physicians feared for their jobs, I’ve spoken to many physicians over the course of my medical and writing career who were told by their employers to give narcotics when requested or risk loss of income or of employment.
This happened even in the face of staff who knew the abusers. We used to keep files so that even new physicians could tell who the problem patients were. Eventually, we were told to stop. It was a kind of profiling and it was unacceptable. Always assume they’re telling the truth, we were told.
Sew the wind, reap the whirlwind. Since 1999 prescription narcotic overdoses soared, quadrupling over the period to 2014 according to the CDC. Over that period there were 165,000 deaths from prescription opioids, most commonly Hydrocodone, Oxycodone and Methadone. In 2014, over 14,000 people died from those drugs.
Now, the move is from condemning our insensitivity to questioning our judgement. Prescription drug abuse is a high priority for state and federal law enforcement, state medical boards, the Drug Enforcement Agency and The Centers for Disease Control (which recently released new, more conservative guidelines for chronic pain treatment).
States are using online prescription monitoring programs and many hospitals are putting policies in place to give as few narcotics as possible in emergency departments. It’s a Catch-22 of course, as some patients with legitimate pain are told to find pain specialists or family doctors, when they either have no money to do so, or have no physicians in the area taking patients. Thus, they circle back to the ER where we try our best to remain both diligent and sympathetic.
Physicians and hospitals are now engaged in a constant battle to combat drug abuse, to save lives and help empower the families of those struggling with addiction, who are desperate to help their sons, daughters, husbands and wives.
I hope we maintain our compassion. But I also hope that it keeps getting harder to walk into an office or ER and get addictive, lethal prescriptions.
Because it’s time for this nightmare to stop.

 

 

Ride or no ride, people sometimes need pain relief

I understand the concerns about narcotic abuse.  I was there, in residency 24 years ago, when the mantra was ‘you don’t do enough for pain.’  We all did more.  Now, all these years later, we’re told ‘you do too much for pain!  What were you thinking?’  It’s all madness.

But what I find a little troubling is a tendency I see now in the various hospitals where I work.  That is, a patient comes in with what seems to be legitimate pain.  I order pain medication.  And I am told, ‘he can’t have it until he has a ride.’  Sometimes the complaint is deception.  Often, the complaint is legitimate.

The official policy most places, however, is ‘no ride, no meds.’  This seems unduly harsh to me.  I understand, dear nurses, that you don’t want to have to babysit for hours. I don’t either.  And I understand liability.  Still, there are times when people are hurting.  Kidney stones, for instance, or fractures.  They genuinely need a medication but they either came by EMS or drove themselves and can’t drive home.

I’m not trying to blame anyone.  But can we all put our heads together and find a better way to do this?  A more compassionate way to do it?

I’m no starry-eyed simpleton.  People abuse drugs and use the ED to get those drugs.

Many, on the other hand, just plain hurt.

Ride or no ride, they need help.

 

 

The New Religion of Narcotics

I just finished reading Neil Gaiman’s fascinating novel, Gods of America.  Here’s a link to it on Amazon.  http://www.amazon.com/American-Gods-Authors-Preferred-Text/dp/0062080237/ref=sr_1_1?ie=UTF8&qid=1362266866&sr=8-1&keywords=American+Gods  I first learned about his work by watching the movie Stardust, then reading the novel.

One of the themes of Gods of America is that the deities of the old world came to America in the hearts of their followers, but over time lose their followers and thus their power.  A war is arranged between the ‘old gods,’ and the new ones that Americans have instituted.  In the story, media, technology, entertainment and others are the new deities for a new age.

I thought about it as I considered my work.  It seems that every day of my life is an endless discussion about narcotics in the emergency department.  Or is it a kind of liturgy to another new god?

‘Can’t I get no Lortabs?’

‘I can’t take Percocet, all I can take is Dilau, Dilaud, what is it called? Dilaudid? I don’t know anything about those drugs, you know!’

‘I’m allergic to the 5mg Vicodin, but I can take the 1omg Vicodin just fine!’

‘Somebody stole my Fentanyl patches and my Morphine pills, and all of my Oxycontin and all I have left is my Methodone, and I only have a few but I don’t see the pain doctor for another month. Now what am I supposed to do, doctor, just suffer?’

‘My nerves are torn up.  I’m out of Xanaxes and my brother’s friends came over and stole all of my Klonopin and Valium!  Sure, I still got some Ativan, but look at how I’m shaking!  Oh, and I’m out of Suboxone.’

‘See, doctor, I have the degenerating disc disease.  I guess I’ve had chronic back pain since I was, oh, 14.  That’s ten years I’ve suffered!  Nobody will do anything for me, so I just take pain pills wherever I can get them.  Can I get some Percocet?’

I could go on.  It’s dialog in a bad novel.  It’s a sonnet to somnolence.  It’s an endless homage to anesthesia.  It’s all but worship.

So it must be a religion.  The people I see are worshippers of pain medication and anxiety medication.  Or maybe, they worship pain and anxiety, and the offer up the drugs to their deities.  Or perhaps they are slipping into amazing dream states, sleeping all the time, and having ephiphanies of wonder and delight.  Scratch that.  They’re dreaming of television and snack food. Of reality shows and disability payments.

And the object, or objects of their worship are taking a terrible toll in lives lost, as epidemic prescription drug abuse sweeps across the land.  (http://oxywatchdog.com/category/surveys-statistics/.)  It’s enabled by a culture that in its own way worships disability and victimization, incapacity and the medicalization of all things.

It makes sense, really.  We cannot possibly suggest that anyone isn’t telling the truth, because a) truth is relative and defined by each person and b) to suggest that would be poor customer service, or discrimination or to be ‘judgmental.’   Furthermore, we reject anything that might suggest an individual take responsibility, or make good moral decisions because morality is relative and faith is irrelevant.

Thus, the internal discord and evil and even legititimate suffering of the human heart must be medical, must be made somatic and mechanistic so that it can be treated mechanistically, and so that no one need concern themselves with uncovering the layers of difficulty and untruth in the human heart, no one need ask hard questions or suggest that one may have guilt or fear for good reasons.  All we want to do is call it a ‘pain’ and offer it a ‘pill.’

Well there you are, America.  We worship at the feet of pain and pills.  We offer our young and our old and our middle aged and vital to the sleepy gods who accomplish so little and cost so much and offer only restless dreams and ultimately breathless deaths.

I will not worship them.  I hate them.  But I acknowledge their power.

Edwin

Sense of entitlement is likely to metastasize (under Obamacare)

This is my July 1 Greenville News column regarding the SCOTUS ruling on the Affordable Care Act, aka Obamacare.  Link followed by text.  Have a great day dear reader!

Sense of entitlement is likely to metastasize

http://www.greenvilleonline.com/article/20120701/OPINION/307010058/Sense-entitlement-likely-metastasize?odyssey=mod|newswell|text|Opinion|s

Obamacare has been ruled constitutional by the Supreme Court, those esteemed individuals we consider sages when they agree with us and tyrants when they don’t. The decision has rendered supporters of the law positively apoplectic, even rapturous. Detractors have been lying in fetal positions taking antacids and trying to figure out how it all happened. Either way, for now it’s a done deal. The politics of the matter remain to be seen.

While not a supporter of the legislation, I am man enough to concede and say that I hope it works. I admit that there are a couple of provisions that are (at least temporarily) merciful in its pages. Among them, coverage for preexisting conditions; a thing that could be very useful for my diabetic teen as he grows older. In addition, there’s the ability to keep children on their parents’ insurance until age 25. With unemployment soaring even among undergraduate and graduate degree holders, mom and dad may have the only insurance available for the kids as they ply their advanced degrees and theses by serving fries and burgers.

The problem I have with the Affordable Care Act (well, one of the problems I have) is that it presumes a certain amount of responsibility among the populace and due vigilance in the government (Not particularly common on either part.)

What I mean is, the Affordable Care Act requires that individuals purchase health insurance or face a fine. The same goes for businesses. Of course, businesses are easy to fine. But individuals? Less so. And really, if the government is unwilling to deport illegal aliens in custody for crimes, or imprison multiple offender drunk drivers with suspended licenses, do we really think they’ll take a person to the mat if they neither purchase insurance nor pay the penalty for failing to do so? Seems unlikely to me. Thus, individuals will not add to the fund from which they’ll draw deeply when they are sick themselves, and finally get insurance (like a death-bed baptism).

The other problem is not about fines or rules, but about lifestyles and attitudes. Hospitals have all too many patients with no sense of accountability, who ‘take’ as a way of life. Not a majority, mind you, but a powerful minority have developed an incredible alacrity for navigating hand-outs, programs, criminal courts, government checks and assorted entitlement programs. This isn’t a screed against the poor, but a shot at the manipulative. All too often they come to hospitals only for pain or anxiety medicine or work excuses. Or for manufactured drama on weekend nights. Frequently, they come to add weight to their somewhat spurious disability applications for things like ‘I can’t keep a job,’ and ‘I get angry a lot.’ (Yes, we actually heard those from healthy young men seeking disability checks.)

These persons, soon to be eligible for insurance, are superb at obtaining food, medicine, money, drugs and influence at the expense of others. They understand how to use state and federal programs with maximal efficiency. And they know that speaking loudly, calling out for ‘patient care representatives’ and filling out negative satisfaction surveys will generally, in most large facilities, get them their snacks, drinks, pain medicine and excuses. The amount of money hospitals spend tracking down frankly false complaints, for pain prescriptions alone, is staggering.

To understand the depth of this problem, just ‘ask a nurse,’ and you’ll get an earful about the awful treatment they endure, the way nurses and other care providers struggle to care for their own kids and make ends meet only to be told by a fully capable adult, ‘I need you to give me my prescription, since I don’t have any money.’ This as their i-Phone and cigarettes spill out of their pockets, and their drug screen lights up for marijuana, cocaine, opioid pain medications and the now ubiquitous Methamphetamine. (All of which they can magically afford).

Here’s my point. If anyone thinks that providing a means to insurance for everyone will make all people better or healthier, they’re wrong. While it will likely benefit many, the patients I’m discussing won’t work on their diets, smoking, drinking, Meth use or their serial paternity. All they’ll understand is that there’s one more way to get things they want without contributing to the solution.

Ironically, in this way the ACA might inadvertently cause entitlement to metastasize even more widely than it already has. I hope I’m wrong. But experience, in the real world, with real human beings, suggests I’m not. I suppose only time will tell.

Homo Sapiens Entitlus: a species emerges

I am here for check...and Sprite!

I am here for check...and Sprite!

Homo Sapiens Entitlus:  a species emerges

There is a staggering degree of entitlement mentality that wanders through America’s emergency departments.  In the 19 years since I finished residency, it has grown in ways I could never have foreseen.  It seems that everyone is entitled to pain medicine (which is causing ever increasing deaths in America) and everyone is entitled to disability at younger and younger ages (‘I got the degenerative disc disease, doc,’ they say at 25 years of age).  Our patients are entitled to work-excuses, and to CT scans, to patient care representatives and in short, entitled to whatever it is they desire.

A recent patient was very angry that we would not give her supplies of both antibiotic ointment and bandages to use for her minor injury over the coming week.  She was adamant that she had no money.  No money, that is, after paying for her cigarettes and smart-phone package.  She was most upset, it seemed, that the nurse failed to bring her a Sprite in a timely manner.

Mind-numbing; truly mind-numbing.

I think over the physicians and nurses, medics and techs, and all the rest who come to work everyday, in places where they are understaffed and often underpaid, and where they will see individuals who will abuse them, and will then say, ‘I don’t know why you’re upset…I pay my bills,’ only to find that those patients have Medicaid.  In fact, the care-givers bringing Sprite and dispensing bandages, working overtime to afford their own children and benefits,  are paying those bills.

But I didn’t write this to moan and complain.  I wrote it to put forth an idea.  My idea is this:  perhaps the ones abusing our systems are the fittest of all!

Consider that evolutionary theory is about survival.  Keep in mind that biologists tend to equate fitness with survival.  It seems, then, that the welfare-queens, the addicts, the chronic criminals, the serial fathers, the Meth-heads who use the system and abuse our good graces may be…the most fit!  They have no compunction about copulation, and thus out-breed the responsible public.  They are sometimes violent and aggressive in positively neolithic ways, and let’s face it, to the modern mind nothing was more true to our natures than that age-old struggle to survive as we envision it in the life of the cave-man!

As the money dries up, and the demands for more sound more loudly, it may be that evolution is happening!   As the workers, the responsible parents, the ones staying up at night helping their kids learn, or caring for sick relatives are asked to do more for less, their opposites find ever more creative ways to receive benefits, avoid work, obtain disability, bring litigation and simply have more time, more things, more children and less responsibility!  And as politicians pander to the loudest and worst among us, the quiet, the best, the producers, the  ones too busy doing right to lobby are simply put upon more and more.  As the morality of the worst becomes ascendent and the ethics of the best are held up to mocking ridicule, it may be that we are simply the victims of natural forces.

Yes, friends, the ones taking and using and abusing may be the fittest of all, in a game where obtaining advantage and survival is all.  And since many believe we have evolved altruism for the collective good, even this tendency (if true) may be aiding the success of those who should not, to all rights, succeed at all as those formerly considered fit are plundered by those now more so.

I’m no Darwinist, though I agree that species change in response to pressures.  And I don’t necessarily agree that survival = fitness (of course, I’m a Christian, so I have a different perspective on that sort of thing).  But from everything I see at work, I have to wonder if I’m not on a fading branch of the evolutionary tree.  And if one day, scientists might not look back upon the time when Homo Sapiens Productive gave way to the rise of Homo Sapiens Entitlus, because the latter had the foresight, and absence of morals, to take what it wanted and continually demand more.  You have to respect their boldness, even if you find their actions horrendous.

In other words, I fear my extinction isn’t so far away.

I think I need a Sprite…of course, I’ll have to get it myself!

(Wait a minute, can I get protection under the Endangered Species Act?   Look at me!  I’m evolving!)

Lost Proverbs of the Emergency Department

Here is my EM News Second Opinion column for June:  ‘Lost Proverbs of the ED.’

Here’s the direct link to EMN.  The text is below.

http://journals.lww.com/em-news/Fulltext/2012/06000/Second_Opinion__Lost_Proverbs_of_the_ED.11.aspx

Lost proverbs of the ED:  found in an old liquor bottle outside an urban emergency department

 

Dear readers:  these proverbs came into my possession recently.  I long suspected there was a hidden body of wisdom, a secret society of people who pass their wisdom along to others.  I was both relieved and shocked to find that I was right.

He who has pain and asks not for medicine is a fool.

He who has no pain and asks not for medicine is a greater fool.

Verily, the number of all pain is 10. This is a great mystery.

Whoever would see long days and joyous life would think carefully,

And never take a knife to a gunfight.

Or a baseball bat to a knife fight.

A big dog is a wonder.

Play rough with it. Make it fight.

Then feed it bacon from your mouth.

Remember that spider? In your basement?

It probably bit you in the night.

Doctors always say abscess for spider bite.

Do you want riches? Do you want prosperity?

Work under the table. Taxes are for suckers.

Get your benefits from saps who work.

Find a woman who will love you.

Find a woman who will have your children.

And also her sister.

Long life is a gift. Gray hair a crown.

But when the aged are a problem,

Ask the doctor to admit them.

Belly pain is a curse and hunger a greater misery.

So never let pain be a reason not to eat.

Burgers solve all problems.

A helmet and a seat-belt make one safe.

But neither makes one cool.

Cool is worth the risk.

Pregnancy is magic.

Remember, you can’t be pregnant.

No way. No how. Unless you are.

Work elevates us. Work pays our bills.

Work drains us and stops fishing trips.

If you have a cold, get an excuse, silly.

Doctors and nurses have money.

Don’t worry about them; they’re rich.

Health care is free … if you insist.

The wise man avoids conflict.

The foolish doctor makes mistakes.

Keep a lawyer’s card in your wallet.

Remember that you are strong. And loud.

Bully everyone you can. But learn to keep your

mouth shut when the cops arrive.

An argument is good

until the police arrive.

Pepper spray is no fun at all.

A thief is the one who gets caught.

Check the hospital cabinets!

Purses can hide lots of bandages.

Life is precious. Who would kill himself?

But saying you’ll do it is great drama,

And everyone feels badly for you.

If your heart is racing, if your skin is drenched,

If you feel afraid and think you might die,

Ask, “Could it be the meth?”

Do not take a chance on fever.

Do not pause to take Tylenol.

Your cousin’s brain caught fire one time, and he ain’t right.

If food and fluid erupt from you like a volcano,

If your stomach aches, be afraid!

No one else in history has ever vomited but you!

There is joy to be had in life. There is beauty.

There is love. How can it all be sweeter?

Oxycontin, that’s how.

Was your doctor good? Was your problem solved?

Did you receive what you deserved?

Do not neglect the satisfaction score.

Family is a blessing. They know all.

Remember, whatever your sister says is true.

She’s a nursing assistant, after all.

When you roll your car, when you hit that tree,

Remember, it was because of the dog.

You only had two beers, right?

Your time is precious. TV shows to watch.

Babies to make. Snack food and sodas.

Ask why your ER visit is taking so long!

What will you do when the ER is empty?

What will you do when the doctors quit?

That won’t ever happen! Funny joke.

Identification is important. For checks, for beer.

ID matters to the parole officer. But don’t take it to the ER.

They’ll only send you a bill, you fool!

Tattoos and piercings make the girl and guy.

They show we’re edgy, bad, sexy.

What’s an infection now and then?

Self-evident truth in medicine

Some things in medicine are obvious.  Despite the endless worship of ‘evidence-based’ medicine, and the constant barrage of studies on every conceivable topic, we do certain things because we know they just seem right.  I take as evidence the fact that we daily try to save lives, devoting research time, untold gazillions of  dollars and heroic clinical effort to our continued goal of staving off death.  Why is this?  Do we know that death is inherently worse than life?  Well, since we can’t see beyond the grave, and can’t exactly engage in double-blind, placebo controlled studies about the after-life, the answer is ‘no.’  But we assume that life is preferable to death, based on our feelings, our sense of the thing.

The same is true in our personal lives.  No one can show me a scientific study that details why he or she married a particular person.  No one can offer up a mole of affection for empiric analysis.  And yet, we don’t doubt the existence of romance, or the reality of love.

And yet, medicine is filled with situations in which ‘self-evident truth’ is systematically ignored, and those who believe in it intentionally and often viciously marginalized.

For example, after years of being told that physicians weren’t giving enough treatment for pain, and after years of clinicians saying, ‘yes we are, and too many people are addicted and abusing the system,’ the data from CDC says that far too many are dying from prescription narcotics, far too many infants being born addicted, and far too many people, young and old, are using analgesics and other drugs not prescribed for them.  To which many of us say, ‘duh!’

And then there’s the customer service model, the thing which causes clinicians to lose their jobs as satisfaction scores fall due to disgruntled patients (often upset over not receiving the drug they desired…see above paragraph).  This is a darling of administrators.  And it clearly has flaws.  As a recent article in Archives of Internal Medicine points out, physicians with very good ‘customer satisfaction’ scores tend to have patients with poorer outcomes.  Do you think?

Of course, Electronic Medical Records is another.  Those of us engaged in the practice of medicine on real people can tell you, EMR has promise, but in practice it consistently does three things.  Reduces productivity, takes us away from patients and results in far too much data being recorded and stored.  It needs to mature, rather than being forced on everyone from above.

There are others, of course. Board certification is beginning to look very much like a profit-generating machine, despite the paucity of evidence that it matters.  (I am board certified, so this isn’t sour grapes.)  Federal privacy laws (known as HIPPA) has left us awash in unnecessary passwords and regulations.  EMTALA, the law which protects the uninsured has probably resulted in more costs, and more loss of qualified physicians and necessary facilities than any other piece of legislation in history.  We know it…but few people are interested in studying it honestly.

All I”m saying is that physicians, and ultimately everyone, will have to mix science with good sense, and learn to embrace their own insights and powers of observation.

Studies have their place.  But their goal is the discovery of truth.  And sometimes, more often than we realize, the truth is right in front of us.

As we say in the South, ‘If it had been a rattlesnake, it would have bit you!’

Edwin

Missionary to Emergistan

This is my EM News column for May.  I hope you enjoy it!  I’ll put up a link to EM News as soon as it’s available.

Missionary to Emergistan

I know a fine, caring physician who has a heart for God and a heart for people. He often goes overseas to serve the poor and needy in the third world. I saw him in his lucrative practice, where he recently asked this question. ‘Ed, do you do any mission work?’ ‘No,’ I replied. ‘Well, maybe someday’ he said, and patted my shoulder in encouragement.

It bothered me. It seemed like a kind of pity. It bothered me because, like so many great moments, I hesitated. Later, I knew what I should have said: ‘Yes I do! Every day that I walk into that emergency department!’ But I didn’t say that. I smiled and went on my way.

I thought about it some more. Mission work, mission work, where do I go….and it hit me. Every day I travel to work in Emergistan.

Emergistan is less a place than a state of mind. It is a place that is so unlike the rest of the human experience, many individuals find it hard to believe the stories we bring back. ‘People actually suck on their fentanyl patches…and die?’ ‘Yes, yes they do.’ ‘People come to the ER in ambulances for…for colds?’ ‘Yes, yes they do.’ The customs are difficult to explain.

In Emergistan, there seems almost a different kind of language. Spend enough time there, as we do, and you understand some of it. You understand tingling and buzzing, squeezing and spinning, burning and vomicking, and any of a dozen words for genitalia or a hundred words for drugs…tabs, bars, ruffies, Special K, K-2, bath salt and all the rest. You know that two beers means two dozen, that disability doesn’t always mean disability.

But it isn’t just the words. It’s the content, the meaning that evades so many. Even after years we don’t fully understand leaving, with staples in one’s scalp, to go ‘finish the fight.’ We don’t understand a 15-year-old child whose parents are excited about her second pregnancy, or a 22-year-old man thrilled to be committed, once again, because it will help get his disability. We have difficulty with an old lady ignored in her home while sores develop on her back, or a new-born with a broken skull because its cry interrupted someone’s television show. We weep, out loud or silently, at the young father with a new brain mass.

Emergistan is not only a different mindset, it’s practically a different dimension. A place of bizarre time and space. In it, a woman can have an exam, CT scan, labs and pain medicine in a two hour period, even as her husband stamps the floor and curses because, ‘we been here two hours and ain’t nobody done nothing!’ Two hours is interpreted as four, four hours as eight. What most would call a one, or a five is always a ten on the pain scale. And a work excuse is a civil right in the endlessly shifting constitution of the land.

Perhaps it’s no surprise. While we travel there, and while we see many patients like ourselves who do not desire to be there and who are in great peril and great need, we do not grasp the mindset or philosophy of the native Emergistanis…those whose lives seem to revolve around the triage desk, the patient room, the CT scanner, the coveted prescription. They are unfortunate, in some ways, many having been neglected their entire lives. Never nurtured by parents, never loved by spouses, never taught to cope (as evidenced by their constant anxiety), never taught to learn or to strive. Only taught to need, to dramatize, to expect.

I know, our experience in Emergistan makes us cynical. But it may be because so much bad, so much manipulation, so much need, so much pain ends up there. We see it. We see the refugees from normality, the abused and wretched, all mixed in with the abusing and hateful, the dishonest, the reckless and addicted, the slothful and cruel mixed with the dying and broken. It’s hard not to mix them all up.

It’s also hard because we are expected to do it as if it were mission work. For some it is. For some, whose faith or philosophy call them to give altruistically, it is a genuine mission work. For others who do not hold that view, who are compelled by government to work in Emergistan for free, it is a place of bitterness and anger that grows (understandably) with every passing mandate, every new rule about our travels and travails there, imposed by those who have never, ever truly crossed the border with us, who only know that it saves money when we do so at our own expense and risk.

Emergistan gets inside you. Sometimes you love it. It can be a land of thrills and challenges, rescuing hapless Emergistanis from disease and accident, and sometimes from their own bad decisions. Sometimes you hate it because it is all consuming and overwhelming. Or because the tragedy, like a parasite, has found its way into your heart and mind and made you fearful of every cough, every fever, every car you pass on the highway, every person you pass on the street. Emergistan’s doctors bear emotional scars that may never heal in this life.

Here’s the thing. They can call me bitter or angry, burnt out or hateful. But I love Emergistan. It is a kind of home for me, where I spend days and nights, where I make my living, where I support my family. In some ways, I am a dual citizen. I understand the regular world, the world of normal rules and behaviors, of clean offices and polite conversation, where sobriety is expected and work rewarded. But I understand addicts and drunks, violent criminals and irritable, dying old men, fearful mothers with sick children and frustrated, beat-down physicians and nurses. I see so much. I have seen so much.

I can criticize and observe, I can lay out the truth as I see it because I have been there, I have served there. I am a veteran of the daily battles of my second home in Emergistan. I know the truth as no policy maker ever will. I am, and have always been, committed to that other country that daily seems to suck out my soul and daily calls me back again; that rejuventates me with every save, every successful intubation, every good diagnosis, every smile of gratitude from the sick or fearful.

I am a missionary, I suppose. And so are you. And we can hold our heads high, for we have worked in one of the hardest, darkest places in the world. The psychotic, overwhelming, frantic, tragic Republic of Emergistan.

May her streets be paved with oxycodone.

Freedom, anyone?

I wonder,do we believe in freedom in America?  I realize how free I am, and I am so thankful for that gift.  I live where I want, in a remote part of the South.  I practice in my own group, not for a larger corporation.  My wife and I chose for her to stay home and for us to have a large family of four children.  We home-school our children, and worship as we see fit; both things which might result in censure or prosecution in some countries.  I own, and carry, firearms within the defined constraints of the law. I can make as much as I want to work for, as long as I pay taxes. And yet, there are those who find that degree of freedom problematic.

Who am I to drive a large truck?  Who am I to presume I can home-school my kids?  Why should I have a large family, what with humans a ‘parasitic infestation’ of the earth?  How dare I have a corporation, when it would be so much more controllable if I worked ‘for’ someone like a good boy?  What makes me think I deserve a significant income?  Why would I even consider practicing, and believing, the tenets of a religion not based on ‘free thinking’ and science?  Wouldn’t it be better if faith were tucked neatly out of the way, in a dark and seldom visited corner of the human  mind?  What sort of monster thinks he should be free to express worship?

We hear a lot about freedom. Freedom to marry whom we will.  Freedom to end pregnancies, to use and view pornography, to use drugs without constraint.  But the truth is, even those who cry for freedom simply want their own form of it, and would love to see it diminished for their political and cultural enemies.

Freedom is in the eyes of the beholder, it seems.  Or in the eye of the one conferring it.

Edwin

Choices: a physician and homeschooler rants

One of the unique things about emergency medicine in America is a law called the Emergency Medical Treatment and Active Labor Act, or EMTALA.  Under this law, any facility that accepts Medicare cannot turn a patient away for financial reasons.  I have said, in many columns, that the idea was reasonable…when first passed under Ronald Reagan.  Very unstable patients were sometimes sent, without arrangements or stabilization, to county/city/charitable hospitals when they should have been initially treated at the for profit facilities where they arrived.

Of course, like every ‘good idea’ from government, bad things arise.  One of these is that people do the math and bring even the simplest of problems for free care.  And another of these, in a struggling economy, is that emergency departments bear the brunt of uncompensated care.  Which means, physician and hospital incomes fall because patients no longer have insurance, or physicians, and come to the emergency room.  When physicians, like myself, suggest that we’d like a tax credit or something for seeing many patients for free, we’re told by government ‘you chose that specialty.  You can choose to do something else.’  Not strictly true, since almost all ER’s fall under EMTALA.  But I guess the bottom line was,  we made a choice.  OK.  I’ll live with it…for now.

Moving on.  I had a conversation with some local educators yesterday.  Two of my sons, who are bright, articulate home-schoolers, would like to take welding at the county public school career center.  They aren’t allowed, despite my paying property taxes like everyone else.  One person, an educator I respect enormously and consider a dear friend, said simply, ‘you chose to home-school.’

Interesting.  My choices, which were made in good faith, to do good things, to serve the public and care for my own family, are somehow things which lock me into a certain trajectory.  A certain tax bracket.  A certain derision, even, as a high earner who should simply carry on doing the right thing as benefits, salaries and respect slip away.

On the other hand:

If I suggest that I should not have to treat an addict because of his or her ‘choices,’ I would be considered the cruelest of cruel.  If I had the option, and elected not to give care to the young man with gonorrhea because ‘it was his choice to fool around,’ or the cocaine induced heart attack, who ‘chose’ to use drugs, I would likely lose my license.

Those who choose to overeat until they can’t walk are rewarded with disability.  Those who choose to have multiple children out of wedlock are given state support.  Those who choose not to go to school, not to work hard at an education or trade, are met with sympathy and programs to get them ‘back on track.’

Choices are essential in a free society.  I just think it’s fascinating how we ‘choose’ to reward or punish them. Especially for those who try to choose the right thing.

Edwin