Emergency Departments of The Rich and Famous

This was my October column in Emergency Medicine News.  All of those cool places to work have a dark side; or at least, a weird side!

http://journals.lww.com/em-news/Fulltext/2015/10000/Life_in_Emergistan__EDs_of_the_Rich_and_the_Famous.15.aspx

The following excerpts will give you an idea of what life can be like while practicing emergency medicine in very beautiful, very coveted areas of the United States. I will not name towns or hospitals, as the situations are highly reproducible from place to place and season to season. We’ll just call it St. Resort hospital. If you doubt me, call up your friends who work in such locales, with the rich, the powerful and the well rested. Or with the sun burnt, drunk and tasteless. Vacation sites cross all demographics, but in different ways.

‘Dr. Leap, I’m having chest pain. I have pretty bad heart disease, and I saw my cardiologist at the University last week. He said I probably need another stent because I’m having chest pain a lot more than normal. But my wife and I decided to drive here for the week. What should I do? My son is a heart surgeon at Mayo Clinic. (Two hours to nearest interventional cardiologist. And of course your son is a heart surgeon!)

‘Dr. Leap, my daughter has a laceration on her face. By the way, I’m a plastic surgeon myself! (Full disclosure, I trained at Harvard and I’m faculty at Duke!) Can you tell me how you’re going to close the wound?’ (Stands close by during closure, asking questions, sniffing and making subtle noises to guide technique.)

From administrator: ‘Dr. Leap, Mr. Whatzit is a very, very important donor to the hospital. It’s critical that he get good care. Do you understand?’ (You mean, unlike the bad care I give everyone else?)

‘Dr. Leap, I live in Big City, USA. This morning, I went for a hike and now I have red bumps on my legs. I’ve been on the Internet and contacted my physician at home. He said I should be very concerned about Brown Recluse Bites and Lyme’s Disease, and that you should give me a prescription for Doxycycline. Oh, and I’m a pharmacist.’ (In the South we call them ‘bug bites’ and go on about our business, remarkably free of antimicrobials. Patient unimpressed with my colloquial knowledge of unspecified ‘bug bites.’)

‘Dr. Leap, I passed out! My wife and I have been married for 50 years and we decided to come to South-Town and ride bikes to lunch. After about six miles, I felt so dizzy I just fell over! Oh, and I’m on Coumadin. And I have a defibrillator. I’m a cardiologist myself, and my electrophysiologist is at Cleveland Clinic and wants you to call.’ (Heat index around 115 degrees, humidity 100%. What were you thinking?)

‘Hey doc, I don’t know how the %#S@% that happened, but I had a few &^%# beers and went out into the surf at night and stepped on that $@^^ stingray. Yeah, I’m drunk. What about it!’ (BP 215/110, which is also his peak and trough alcohol level. Patient hasn’t taken meds, or seen a doctor, since Reagan administration.)

‘Dr. Leap, it’s the funniest thing. I mean, I’m in good shape. I row ten miles a day and run every other. But I came up here for a wedding and I can’t breathe! I have a headache and I’m coughing. My living? Oh I’m a malpractice lawyer. But my sister is head of pulmonary medicine at Washington University. Can you call her? She has a few suggestions for you.’ (Sea level to 10,000 feet in one day; and I’m happy to be told what to do by someone who isn’t here and thinks I’m a hick.)

‘Dr. Leap, I know you say I should be admitted, and you’re right, I can barely walk with that broken ankle. But I have a camp to clean up and an Elk tag to fill. And nobody to drive me back home in my camper. So I hope you aren’t offended when I sign out and go back. Nothing personal. I’ll come back if I have to.’

(This one I get. It’s an Elk tag! Who can blame him?)

‘Dr. Leap, dude, I passed out on the beach and my skin is like, on fire! You have to do something! Oh, and I left all my Oxycontin at home before we brought the RV down. Can you help me out? My doctor is on a mission trip in Asia or some ^$#^.’ (Footnote: (60% BSA covered in sunburns, with scattered blisters. Prednisone, yes. Oxycontin? Nope. )

From Medical Staff office: ‘Dr. Leap: here is the Summer call schedule. Nobody is on call because everybody is on vacation. Good luck.’ (Footnote: technically I’m on call. For everything. At least in some locations.)

Honestly, most all vacation town folks are nice people trying to stay healthy and have fun. The same goes for physicians and administration. But poor planning, unrealistic expectation of local facilities and carelessness take their toll.

So next time you’re tempted by the scenery in that glorious add, just keep this all in mind. Remember to wear your sun screen, acclimate gradually, and remember that 80% of the ‘manageable’ annual volume will probably be compressed into the three months that constitute the lazy, hazy, crazy days of summer at St. Resort Hospital in Vacationville, USA.

Lost and Found

This is my column from the April edition of Emergency Medicine News.

http://journals.lww.com/em-news/Fulltext/2015/04000/Life_in_Emergistan__Lost_and_Found.7.aspx

I recently found something I had lost. Or rather, I found someone I had lost. He was a dear friend from my childhood. We spent days and nights roaming the woods near our homes, catching crawdads and minnows in the creek and turning rocks over to look for banded water snakes. We shot bows and arrows and rode bikes. Standard Appalachian stuff, that.

In the winter, we would sled until we could barely feel our fingers and in the summer, work in gardens and on lawns in the sauna-like Ohio Valley swelter. We took Tae Kwon Do together, working out in a gym free of air conditioning, with a kind and caring teacher. We spent many an hour poring over martial arts magazines in our young zeal to be great fighters (and look cool). In the woods, we would duel with long sticks on logs over creeks, like Robin Hood and Little John. (Or perhaps Porky Pig and Daffy Duck.) And when we once went to Myrtle Beach together, it was unclear whether we were more excited by the ocean or the prospect of buying fireworks (then illegal in West Virginia).

My friend, A, loved animals then (and now). I well recall the day we spent at my grandparent’s house, catching a flock of near-wild Bantam chickens for him to raise. We would follow them up the hill, and they would fly down. We would go down and they would run up. It was exhausting and it was entirely hilarious.

After high school, I lost touch with A. We took very different paths in life. He had adventures and battles of his own. I had the whole college and medical school path, and wife and children. At one point, I wasn’t sure if A was alive or not; I was saddened by that.

However, a while back a mutual friend referred to him. I contacted A and he contacted me and we sat down one day and had a phone conversation that lasted at least an hour; maybe more. We revisited our stories and our joys, and caught up on the blessings and sorrows of our own families. We laughed and basked in the glow of friendship rekindled; of a treasure recovered.

We’ll not lose touch again. We plan to have many more talks. If we lived near one another, we’d probably take long walks again. Odds are, we’d disagree on a few things, like politics, religion and culture. My long lost friend is gay, you see and lives with his long-time partner. And I’m a straight, conservative evangelical. But none of that mattered when we reconnected. We were so happy to talk again that those things were too far down the list to merit discussion. And even if they do emerge, I suspect our talks will be conducted in the framework of mutual concern, respect and shared history; not contention or anger.

I think there’s a lesson for us here. As physicians, we’ll frequently find ourselves at odds with our patients, with our fellow staff or administrators. Sometimes, those differences will be striking. But when we take the time to know people, especially when we have shared history and concerns, we can transcend differences.

Conflicts don’t disappear, of course. To imagine that love means not only tolerance but the total acceptance of every viewpoint is folly, and a kind of intellectual tyranny. However, those differences are put in the right perspective. And the human being before us rises to preeminence.

It’s much like raising children. I have three teenagers now. (One has safely transitioned to the age of 20.) I don’t always understand their music, I don’t always get their jokes and I certainly don’t always share their viewpoints on many issues. Nevertheless, I smile and respect them, I hug them and cook for them, I tease them and play with them. I try to guide them and I would do anything to keep them safe, happy and whole.

People will always clash on issues of faith and culture, lifestyle and religion. These clashes can become bitter and painful. This perhaps more true in medicine than in any other arena, where we daily interact with a vast collection of human beings, some the same and some extremely different from us.

However, if we can remember to see them all as lost friends we haven’t yet met, our practices may be that much easier, and our interactions that much more joyous.

May you find someone you lost and know the same delight.

Sinners’ stories leave the deepest impressions. (And we’re all sinners, by the way.)

My column in Sunday’s Greenville News.

http://www.greenvilleonline.com/story/opinion/contributors/2015/03/27/ed-leap-sinners-stories-leave-deepest-impressions/70569286/

I have met some characters in my career, and their stories are forever archived in the library of my mind. Some of them were physicians, of course. I recall one who, when paged, always called back collect. I could only laugh and shake my head. There was another who made me so angry that if dueling had still been an option, I might have asked, ‘sabers or pistols, sir?’

I recall one of my residents in medical school who disappeared on call nights and in ‘morning report’ (the daily debrief of the night’s joys and terrors) explained how shocked he was that his pager just hadn’t worked all night! Not a good way to earn the love of your co-workers.

Crazy doctor stories are always fun, but in the end they pale in comparison to the stories we hear from our patients. Privacy laws being what they are, I am constrained. Nevertheless, I recall crime confessions made while a knife protruded from one patient’s back. (The prospect of one’s possibly having a luncheon meeting with the Almighty apparently provides a certain moral clarity.) I remember the addict who had perfect, flawless hair and told me the same story, like a church liturgy, every single time I saw him. In short, someone always stole his pain pills.

I’ll never forget the alcoholic (a previously convicted violent criminal), who in his antiquity threatened to kill us every few ER visits. And then, in the harsh, bright, relative sobriety of morning would laugh and shake hands, and amble his way out the door to go home and begin the cycle all over again. My heart breaks at the thought of the young man with mental illness whom we legally couldn’t hold, but whose mother wanted to admit for his own good. I hope she saw him again after he sat down in the taxi, stone-faced, and drove away into the night as she cried.

Thinking over these tales of woe, I realized how few of the things I remember best were good news, or easy situations, or ‘nice’ people (in the traditional sense). I don’t have a great list of happy stories told by polite, productive citizens who were injured while feeding orphans. I remember the difficult ones. I remember the problem children, as it were.

I’m sure any competent evolutionary biologist can devise a reasonable explanation for this. For example, perhaps they were all object lessons. I remember them so that I won’t repeat their mistakes. I once saw a shirt that said, ‘it may be that the entire purpose for your life is merely to serve as a warning to others.’

On the other hand, I remember them in part for the same reason that I read the names in old, overgrown graveyards; so they’ll not be forgotten. Not yet. The same reason I read names on monuments, or the dedications in books. As homage.

But on a different level, I think I remember them because it’s the difficult people, the hard people, the wounded and sad people who need our attention the most. They are the lost children. They the squeaky wheels. Maybe I remember them so that I will know who to look for in the future, and be attentive to their special needs, their deeper wounds, shattered dreams and aching hearts. So I’ll know to look beyond intoxication and anger to the slightly smudged and tarnished image of God before me.

They help me, you know. Here in the Bible belt, it’s always a dangerous temptation to associate worth with being clean and proper and good. One only needs to go back to the scriptures to see that for the lie it is. Some of the best of the cast of Biblical characters were, in some very real ways, some of the worst.

This Palm Sunday we remember Jesus, himself a lover and teller of stories, a man ever drawn to the lives and stories of the broken and suffering, riding into Jerusalem near the end of his time on earth. He was ready to complete his mission to ‘seek and to save that which is lost.’ One of the many accusations against him was that he was a ‘friend of sinners.’ A sinner myself, I’m happy to hear it.

But honestly, it’s no wonder! They recognize their deep need. And they almost always have better stories than ‘nice’ people.

 

A chart should tell a story. (My EM News column for March.)

 A Chart Should Tell a Story. 

My EM News column for March.

 

http://journals.lww.com/em-news/Fulltext/2015/03000/Life_in_Emergistan__Tell_Me_a_Story.6.aspx

 

 

I suppose it is obvious that I am a fan of stories. I like to hear them, read them, watch them, collect them and tell them. I believe I am participating in stories every day of my life. The story of my family is a beautiful epic. The stories I hear at work can break my heart. One of my favorite stories starts like this, as told to me by an adult man in his forties: ‘The thing is, me and my mama live with her boyfriend. And the other night, her boyfriend had a cardiac arrest! And when he had the cardiac arrest, he rolled out of bed, and crushed the Pomeranian.’ I can tell it better in person.

Obviously, story is truly essential to medicine. The history we obtain from patients is a story, a narrative of the development of whatever affliction they are facing. The medical record we generate is a larger version of the story, which includes past conflicts and resolutions, various antagonists and protagonists, symbolism, sub-text, conclusion and all the rest.

The problem is that in medicine, we have murdered the story. But it isn’t a complicated mystery. The murder occurred because the modern medical record is designed to gather demographics, monitor (and modify) our behaviors and generate bills. Therefore, it must be easily interpreted by people, or computer programs, that look for clicks and checks rather than descriptions. After all, it takes time and training to learn to read and appreciate a well-crafted story. But not so long to do a word-search.

I suspect that it is also a generational issue, as younger physicians have grown up with communication shared in short bursts, whether on television, in music, while texting or using various forms of social media. So I suppose that I understand how we have evolved, or perhaps devolved, in our medical communications.

In all fairness one can ‘reassemble’ the story from click boxes and drop-down menus. It just takes effort. It certainly requires more time than it would take to read a story. It’s rather archeological in nature, in fact. One must look at the nurse’s notes and the time-stamps, the triage vital signs and the things ordered, the timing with which they were ordered and interpreted, the consultations, the disposition, the prescriptions, the out-patient tests. All of it, when properly put together, can give an approximation of the who, what, when, why, how and where of the encounter.

But what we often do not have, particularly in times of crisis when the patient suddenly returns, is the luxury to put the pieces together again. Nor do the consultants and primary care doctors and specialists who see our patients later and who very much want to understand what transpired. And yet, as I travel around, and as I look back on various charts to discern what happened on previous visits, I see check boxes, labs, findings, diagnoses (often vague) but no description. The ‘Medical Decision Making,’ or ‘Emergency Department Course,’ are empty fields. In years past, we were told that these were critical parts of the chart that showed the complexity of our thought processes. I suppose EMR has changed that, on some level. But I’m think we’re worse for it. Looking at those particular blank spaces is like listening to crickets in a field. Or staring into an empty room. The absence of words doesn’t help anyone; least of all the patient.

So let me take this moment to encourage everyone to leave a note, even a wee, little note, describing what transpired in that patient encounter. Fine, if it’s strep throat, if it’s an ankle sprain, I get it. I can figure that out. But for anything with the slightest complexity, anything requiring several labs, or studies or consultants, please tell me a story!

It needn’t involve a ‘dark and stormy night.’ But it should have enough information to help the next person reading it. ‘This 14-year-old girl has had two weeks of intermittent cough, fever and shortness of breath. She has a negative chest x-ray but was noted to have scattered wheezes. She was feeling much better after an Albuterol treatment and her parents agree to arrange follow up with her doctor next week.’ It’s not ‘For Whom the Bell Tolls,’ but it’s a nice, simple summary that helps everyone else to have a sense of what happened. And it did so in three, count ’em three (3) sentences!

Chest pain? Summarize it and describe the plan. Trauma? Tell me why they were safe to go home. Headache? Explain, however briefly, why it wasn’t necessary to do more work-up. Heck, make it a game! A kind of ‘micro non-fiction.’ (Micro fiction can be a story as short as six words.) Diligence at this craft makes us more effective, more succinct communicators. And in the press of modern medicine, that can only be a good thing.

When my children were little, bedtime was always accompanied by this question: can you read a story? I’m just asking a similar thing of my colleagues. Before you put the chart to bed, write me a story.

And if it involves a Pomeranian, so much the better.

The High but Worthwhile Price of Freedom. (As a physician, that is.)

http://journals.lww.com/em-news/Fulltext/2015/02000/Life_in_Emergistan__The_High_but_Worthwhile_Price.8.aspx

‘Well I know it wasn’t you who held me down

Heaven knows it wasn’t you who set me free

So often times it happens that we live our lives in chains

And we never even know we have the key.’

Already Gone, by the Eagles

While I was a attending ACEP in Chicago, I had a great talk with a fellow locums doctor. We colluded and laughed about the trials, the hassles and the travel. But we came around to something else. We agreed on this ‘mission statement,’ as it were. It could serve as the motto of every physician who works as an independent contractor, who has his or her own practice, or indeed every independent business-owner across the land. ‘Freedom isn’t free, but it’s worth the price.’

Let me explain, but let me first set the stage. Working in the locums world is a fine way to make a living, but it has its own set of struggles and problems. Travel in itself is a delight; I love seeing different parts of the country. I’ve been in five states so far, from the South Carolina low country to the mountains of Colorado. America is incredible; a place of breath-taking beauty. But leaving my wife and kids behind? That always stings a little. Besides, amazing places are always best shard with those we love best.

The logistics of travel pose their own problems, of course. Flights can be delayed (or missed, full disclosure). Baggage can be lost. Rental cars unpredictable. Hotels can be…scary. And food in some locations can be, well, uninspiring.

Another issue? Credentialing is an enormous pain in the gluteus. Between hospitals and state medical boards, I’ve answered questions, filled out forms, been background checked, finger-printed and otherwise evaluated so many times I’m starting to actually feel like I have something to hide. And honestly, I don’t!

Along with credentialing, there’s the endless request for ATLS, PALS, ACLS, BLS and all the other LS’s. Medical school, residency and board certification aren’t nearly as important as a one day course passed by pretty much every nurse in the country! (That stings a little too.)

And there’s the challenge of changing locations. Each hospital has its own culture, its own power-structure. And each typically has some vestige of old, archaic and labyrinthine rules to follow that mesh unnecessary paperwork, inadequate EMR’s and a generally inflexible medical staff office and nursing office. This can be quite frustrating to navigate. But if one likes an adventure, each hospital is its own continent to explore and conquer.

However, one of the greatest challenges is actually financial. Because the good old US of A isn’t all that keen on independent contractors. The self-employment tax is pretty high, given that I’m paying income tax as well as all of my own Social Security and Medicare costs, along with business taxes, disability and health insurance. Actually, this year our family health insurance was slated for a pretty impressive increase. We were insured through the South Carolina Medical Association, which was trying to clear out everyone in its individual market. As such, my monthly premium of $1600 (with $6000 deductible) would have increased in January to $3000-$4000 per month. (Yes, you read it correctly.) Rest assured, I have already vacated that plan for a more affordable option.

But the point is, both the financial and non-financial ‘costs’ of this sort of life are remarkable. On the other hand, there remains the freedom…

Freedom means that I work when, where and as much or as little as I desire. Freedom means that if I find the rules, regulations and culture of a hospital unpleasant or unfavorable, I don’t go back. I needn’t wait a year, or even two months. Freedom means that I arrange my life in the way that is best for my wife and children, my health, my sanity, my ethics and my financial gain.

I can take a month off, as long as I can afford it. I can travel around the nation or around the world. I am, in fact, my most important customer. I please me, and those most important to me. I am wildly unfettered in my pursuit of the best possible ‘me satisfaction score.’

Those of us who practice locums medicine may keep it up, or may change next year! We may take a new job with a new group and stay put or we may travel around the world. But we don’t have to do any of it. Whatever we do, we know the precious truth. We have valuable skills and flexibility. So we don’t have to stay if we don’t want.

The fact is that once you’ve experienced freedom, a thing too many physicians have never known, it’s tough to go back. Freedom is always out there, calling, offering adventure and opportunity and breaking long-forged, but largely imaginary, chains. It’s all there as long as you believe the benefits outweigh the costs.

For you see, freedom is indeed very expensive. But I believe, in my heart, that it’s worth the price.

Life in Emergistan

Dear readers:  If you would like to order an e-book edition of Life in Emergistan, my latest compilation, please go to this web address:

http://www.nursingcenter.com/lnc/journalarticle?Article_ID=1713150

If you’re kickin’ it old school and would like a print copy, please e-mail Ms. Lisa Hoffman, editor of Emergency Medicine News, with your name, address and phone number, and a copy will be shipped to you:

emn@lww.com

Thanks for your faithful readership!

Edwin

It’s a Tall Order, but Love Your Patients. (My January EMN column.)

 

http://kopell.tripod.com/lb/doctori.jpg

Life in Emergistan: It’s a Tall Order, but Love Your Patients

http://journals.lww.com/em-news/Fulltext/2015/01000/Life_in_Emergistan__It_s_a_Tall_Order,_but_Love.6.aspx

Leap, Edwin MD

Free Access
 I have issues with the customer satisfaction paradigm, but it’s not generally hard to make patients happy. Sometimes, though, it can be nearly impossible. It all depends on our own inner life as physicians and human beings. The key to medicine, to being a beloved physician, is to love our patients.
Figure. No caption a...
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Figure. No caption a...
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This can be a tall order. Human beings are remarkably difficult to love. They are often angry, uncommunicative, cruel, manipulative, and dishonest. (And that’s just the doctors!) Humans resist love almost as fiercely as they desire it. They push one another away with profanity. They anger each other with attitude. They pick until someone lashes out. They remind us of our own human frailty.

So how do we do it? How do we love these people, especially when they come to us in the chaos of our work in the ED? How do we love them when we are weary and they have strange complaints at 2 a.m.? How do we love them when, despite our suggestions on all of their previous visits, they continue to ignore our advice, not take their prescriptions, and not change their lifestyles? Can we love them at all?

It depends. Do you think that loving them means having warm emotions for them? Do you think it means feeling good about them? Or is it having a satisfying relationship with them? If so, loving will be difficult. Because we in the modern West have excised and biopsied, reconstructed and deconstructed the word love until it is nearly unrecognizable.

We want love to be a feeling we have, when in fact, love must be an action we show. When our children are loud and disobedient, when they scream and throw tantrums, it’s often difficult to feel good about them. But we still feed them, bathe them, sing to them, and put them to bed with kisses in hope of a better day or after the terrible twos or threatening threes or whichever phase has passed. (Lately it’s the sarcastic seventeens, but I digress.)

Whatever we feel about the angry drunk, the manipulative attorney, the entitled college student, the addicted gang-banger, when we behave with competence, when we do what is right, and seek their best, we show love for them. A love borne of action, not emotion. A love that is in some ways more steady and true.

I’ve learned that a cycle is born. When I act toward them with competence, I show them love. And when I do that, I learn in time to see them less as numbers (or annoyances) and more as people. A crazy thing then happens; they love me back. And then the magic happens.

I talk to them, and they talk to me. And we come together. I ask about their family, and they ask about mine. I inquire about why they are sad, and they tell me things that shake me to the core and remind me of how I have nothing to complain about when held up to their life story of abuse and addiction, neglect and loss. And because I listen (and sometimes hug them or pray for them), they know I’m human, too. And they come to love me.

In time, you’ll find new, wonderful ways to love. Over the years I’ve learned that everyone wants to hear how beautiful her baby is. I tell her. Because every baby is, if only to her own parents. And they say thank you, and I tell them how blessed they are. And we joke about children. The children then look at me, smile, and reach for me to hold them, and I am the recipient of the blessing.

I’m less and less bothered by little things. I like to get warm blankets, and I like to get cups of water. Yes, I still get annoyed when I’m busy, but I’m a work in progress, you see. If I can order a snack for them, I will. We have a wonderful time when it’s slow and I can sit and hear a life story or tell a joke. And the love grows. By acting in love, love increases.

Love isn’t taught in the classroom, and the boards certainly don’t measure it. It is nigh impossible to apply evidence-based evaluations to love. But once you allow it to start and carry you forward, your heart will thaw like the Winter Warlock and grow like the Grinch.

And your satisfaction scores will probably go up, too.

© 2015 by Lippincott Williams & Wilkins

 

Death takes another Holiday. My December EM News column.

http://2.bp.blogspot.com/-5i4cdnmRWmQ/T9yc-PltQ8I/AAAAAAAAGhQ/0Xe4eoAx3p0/s1600/4.jpg

 

Death takes another Holiday

My December column in Emergency Medicine News

http://journals.lww.com/em-news/Fulltext/2014/12000/Life_in_Emergistan__Death_Takes_Another_Holiday.11.aspx

 

One Christmas morning you wake to head off for your standard Christmas shift. Then the news flashes. “This just in: There is no more sickness or death. Hospital workers are directed to remain home today and enjoy the holiday.”

Figure. No caption a...

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Attribute it to whatever you want. Sudden scientific breakthrough, alien visitation, divine miracle.

You call the ED. “Is everything all right down there?”

You hear celebration in the background, music playing loudly. “It’s crazy,” says the secretary. “Something happened. We have no idea what, but the waiting room is empty. Before midnight we were 30 patients deep. Back pain, chest pain, fever, flu. Remember the woman you left? The one dying of melanoma? Around 2 a.m. there was a flash, and the computers rebooted. We figured she only had hours. We walked into her room, and she was asking for hot apple cider. She got dressed, left, and brought us donuts. Can you believe it?”

You head to work, puzzled. Your neighbor with lung disease is rolling up a snowman with his grandkids, who were in town to see him for what they believed was a last visit. Speeding past a nursing home, you see cars lined up to gather the belongings of the formerly infirm. They are carrying their own bags and crying into the embracing arms of children they had not viewed with clarity for a decade.

Shaking your head, you pull into the parking lot. All of the ambulances sit quietly in spaces. “Busy morning?” you ask the shift manager. “Haven’t gone out since 2 a.m. Strangest night ever. First Christmas Eve without a tragedy.” He tears up and pats your shoulder.

The doors hiss open as you swipe your badge. Inside the rooms are full, as you suspected. But full of revelry. Nowhere in the vast trauma center does anyone gasp, nowhere is a ventilator sustaining the head injured. A man with a head bandaged like a war hero chats with his family in the conference room. All you hear is, “They said they would harvest your organs.” He pulls away the last of the bloody bandages where no blood now flows.

Into the chaos comes the on-call administrator. She is frantic. “This is ridiculous! Someone needs to get these people back into their beds! We are violating privacy and contaminating everyone!”

She hears a voice and looks behind her as her bedridden husband, afflicted with MS for his entire adult life, walks in looking for her. She runs to him. And wonder of wonders, he lifts her.

You are incredulous. And you walk. Up the stairs, down halls, into operating rooms. Nowhere is there any order, as the end of suffering brings joy. Laughter is everywhere, along with weeping powered not by grief but by relief. Sick children skip, ancient patients walk. Curved backs are straight. Nurses and doctors wonder, “What now?”

There are emergency meetings. Angry fists pounded over lost income. Confusion over bonds and debts and staffing. Decisions on how long to remain open. A while, for sure. This might be a fluke.

The hallways are empty except for those awaiting family from far away. No morphine is given. No fluids, no labs. Every pizza place in town has sent food. You realize, from historical photos, that it’s like the liberation of POW camps. The march of men and women who were on the steps of the gallows, now picking flowers and hitching a ride home to people they believed, only hours before, they would never see again.

At the end of a dark and empty hallway, where you pronounced patients dead, you collapse onto your knees in relief and cry a little yourself. You pull into the driveway, and your wife, her eyes misty, kisses you and holds you close, then sits you down to a sumptuous dinner.

You have no idea how you will pay the bills, how you will support the family, what you will do with the knowledge, the skill, the experience. “If everyone is OK, are you still a doctor?” the little one asks.

“I don’t know, my little dove,” you say. “But the thing is, I just don’t care!”

And the best Christmas, since the first, has come at last.

How could an ER miss Ebola? Let me explain…

How did the emergency department staff of a Texas hospital see, and discharge, a patient infected with Ebola? Despite the fact that blame spreads through hospitals faster than hemorrhagic fever viruses, I’m not interested in pinning down a single person, or a single thing, which may have allowed that to happen. I am very interested, however, in offering a few insights into what combination of factors might make it easy to send home a West African with a fever, without establishing the fact that he had a dangerous, contagious disease which finally caused his death.

First of all, America’s emergency departments are straining to keep up with the volume of patients that come through their doors. In 2010, the number of visits in the US was 129.8 million, according to the CDC. This numbers rises every year, despite the belief that the Affordable Care Act would direct people to primary care doctors and away from the ER.

The emergency departments of America bear the brunt of trauma, poisonings and drug abuse, of chronic diseases and social drama. They hold suicidal and psychotic patients for days to weeks when there is no other option available. An Ebola victim, with general, initial symptoms of fever, chills, vomiting, diarrhea, abdominal pain and headache, is a small needle in a big hay-pile of feverish, vomiting, suffering humanity.

Furthermore, many people with insurance (including Medicaid and Medicare) can’t find doctors, and large numbers who had insurance before subsequently lost it in the reshuffling of health benefits that has been going on since the ACA was passed. The emergency department is often all they have.

Second, it’s getting much, much harder to focus on that pesky but ubiquitous feature of the modern hospital, the patient. There is data to enter (which keeps nurses and physicians more focused on screens than adolescent boys playing on their Xbox). The electronic medical records systems are unfortunately complex and rarely intuitive. They require so much information that often, relevant points like ‘fever and came from West Africa,’ can be lost in the midst of endless time stamps, and required fields like ‘feels safe at home,’ ‘denies suicidal thoughts’ and ‘bed rails up, call light at bedside.’

Also, there are rules to follow to avoid censure. There are metrics to measure: time to stroke treatment, time to the cardiac cath lab for heart attacks, time from lobby to room, time from triage to doctor, time to discharge and many more; all of them contributing to the Holy Grail of modern health care, the high patient satisfaction score. (Which is being increasingly tied to job security and reimbursement, despite the bad science involved in the process.) Who has time to focus on a single, sick patient when so much depends on screens, rules and data entry?

Third, the rules for admission are ever more complex, based on what Medicare, Medicaid and private insurers are willing to cover. Patients we admitted without question ten years ago are now sent home and told to ‘come back if you get worse.’ In fact, it’s so hard to admit people that I now send home patients I would never have discharged, simply to avoid the misery of explaining the problem to already over-taxed hospitalists who are themselves constrained hand and foot by impossible rules. In this milieu, an otherwise healthy man with a fever is barely a blip.

I know this because earlier this year I was working in a teaching hospital and called the infectious disease specialist on call. My patient had just returned from a mission trip to the Caribbean and had a high white blood cell count, a fever, chills and rash. I was curious if I should have any particular exotic concerns. The specialist’s annoyed answer was this: ‘Sounds like he has a virus. He needs to see his family doctor this week.’

Now that we have Ebola in the US we are reminded that we in medicine, on the front lines, might miss something important. The medical pundits are wagging fingers and lecturing everyone about how best to manage this crisis. (Lecturing, that is, from the relative calm and safety of television studios, rather than the in the mind-numbing chaos of the ER.)

I agree. We need a plan. But the system, as it stands, functions every day on the very razor’s edge of disaster. We need to address that fact if we’re going to have any hope of dealing with Ebola, or other disasters, in the future.

Keep the faith, fellow Emergistanis. And do more with less.

Here’s my column in this month’s EM News on how we’re expected to do more with less…

http://journals.lww.com/em-news/Fulltext/2014/10000/Second_Opinion__Keep_the_Faith,_Fellow.9.aspx

 

Preface: I love to write about many things. People, pets, children, family, nature. But over and over I come back to a theme: my colleagues in our specialty and the forces arrayed against us. I’m not trying to be the toxic voice, the endless complainer. But if people like me don’t beat the drum, then nothing will ever change for the better.

In this column I will continue to explore issues of physician satisfaction, I am reminded of a lecture I attended during residency. Let me set the stage. During residency I was also a flight surgeon in the Indiana Air National Guard. This was during Operation Desert Storm, although I was not activated for the brief conflict because I was an intern.

Later in the year I attended a conference of the Association of Military Surgeons of the United States, or AMSUS. One of the lectures was given by a young Navy physician, assigned to a unit of Marines who were armor scouts. They were tasked with driving around the desert in smaller vehicles, looking for Iraqi tanks.

Unfortunately, they were not well equipped as they did not have all of the components for the main guns that might have been able to stop those tanks. They went to a supply depot to obtain necessary material, and were denied the material they most needed.

This physician broke down and cried as he told the story. He relayed emotions of immense frustration. He was unable to obtain medical supplies and the members of his unit could not get the essential equipment they required to fight the enemy, had they encountered Iraqi tanks. Fortunately, the Iraqi army didn’t last long, and thus neither did the war.

Stay with me, I have a point. The frustration I saw on the face of that passionate physician is not unlike the frustration I see, and hear, in physicians around the country today. And nowhere is it more evident than in our nation’s emergency departments.

There are striking parallels between warfare and emergency departments today. For instance, violence is almost expected. Some facilities have metal detectors, some have police officers, but all too many have not even so much as a semi-retired security guard with an ancient can of pepper spray. The danger, some nights, is so real it’s palpable as uncontrolled mental health patients, drug seekers, drunks, gang-members and the various problem children of society all find their way to the unguarded and unarmed emergency rooms of America. There is no recourse, and this is frustrating. Sometimes physicians and nurses feel convinced that the administration would prefer to see them injured or dead than to invest in adequate security or risk the harm of a dangerous patient. (Too much paperwork, you know…)

There are false expectations for the mission. I could write an honest mission statement for most ER’s. ‘Here at General Hospital, our staff is expected to abide by the highest standards of professionalism, compassion and medical knowledge. You, the patient, may curse or threaten them as you see fit and rest assured, the patient advocate will take your side. Our staff is expected to see everyone as quickly as possible (don’t forget our ten minute to doctor guarantee). You may report them if your ankle injury is delayed by someone else’s major trauma. It’s no excuse. Our staff will have you in and out in two hours or less, as often as possible, no matter how poor the staffing or how inefficient the electronic medical records. You, the patient, can expect ice, blankets, fluffed pillows, snacks and satisfaction surveys along the way. Poor staffing on our part is no excuse for delays on yours. Please know that we are very serious about reprimanding clinical staff for even the slightest infraction, in order to maintain your patient satisfaction.’

Like large military forces, emergency physicians and nurses also experience ‘mission creep.’ Our job used to be saving life and limb. Now it’s not only those essentials, but also immunizations, palliative care, psychiatric and social placement, data entry and data capture on a massive scale, endless regulatory comliance and every other imaginable activity wisely shunned by the rest of the 9-5 workaday world.

Likewise, we have confusing rules of engagement. ‘If he’s suicidal, don’t let him leave; but don’t touch him because that’s assault. And if you let him leave you’ll be sued, but don’t keep him in a locked room because that violates his civil rights.’

And like the situation with the young Navy physician and his comrades mentioned above, emergency physicians and nurses struggle with inadequate material and resources. We are usually staffed below necessity, so that we work on the razors edge between competence and disaster. (Nurses and doctors, those ridiculous unnecessary accoutrements of medicine, are expensive. So for goodness sake, don’t hire enough of them; what our facilities really need are more vice-presidents!) Our access to specialists is getting harder and harder. We’re informed that they can’t be bothered, so we must transfer anything complicated to a place where on call specialists are daily overwhelmed by their own under-staffing. Our ability to refer to family doctors is all but gone as family doctors stop taking the uninsured (and those on Medicaid) for quite practical economic reasons.

We are further constrained. We once had free samples to give to the poor, but now we take the high road and have nothing free to give our economically challenged patients. (We’ll show those companies!) Further, good, old and cheap drugs are steadily taken away from us by Black Box warnings and profit motives created by those companies. (I’m thinking of getting some leaches.)

We also are expected to do all of this with the most horrific thing to afflict medicine since health insurance; the corporate addiction to EMR. EMR, billed as a step forward in record keeping, medicolegal protection and error reduction has become an incredible financial boondoggle for those at the top with connections. It has crushed productivity and spirits, and mangled the doctor patient relationship, as competent and caring physicians and nurses are chained, body and soul, to the keyboard, from which their eyes rarely drift to appreciate the nuances of humanity. The keyboard which slows them down, earns them the ire of patients, the frustration of those tracking ‘through-put’ and which routinely keeps them one to two hours after work, for no compensation, to satisfy the corporate and government and administrative over-lords of medicine. Rest assured, if you find an EMR you like, someone will take it away. We can’t have an effective weapon in our armory, can we?

So let’s summarize: violence, false expectations, mission creep, inadequate staffing and resources, unmanageable rules of engagement, too few useful drugs and the toxicity of current EMR systems. Are there parallels to fighting a war without proper support and clear direction? I never went to war. But it sure looks that way to me.

I felt bad for that young Navy Lieutenant. I really did. But I feel bad for everyone who is genuinely powerless to make change in an overwhelming situation. For those who know that their opinion doesn’t matter. Not one iota. Is it any wonder physicians and nurses are at their breaking points?

If there are times you want to cry or scream as well, I say ‘no wonder, brother, sister; no wonder.’

Keep the faith, fellow Emergistanis. I’m proud to fight the fight at your side.

Semper a Decem.