Sanitized Human Experience in a Reality Challenged Culture

 

My column in today’s Greenville News.

http://www.greenvilleonline.com/story/opinion/contributors/2017/01/27/commentary-hollywood-sanitizing-human-experience-reality-challenged-culture/97136066/

I love a good action movie. I tend to prefer the Marvel franchise over DC. I think Superman is too perfect and Batman just too moody. I mean, which rich guy would you rather party with? Bruce Wayne or Tony Stark? Exactly.
But I have always been amazed at the amount of destruction wrought by my beloved X-men and Avengers when battling monsters, aliens, gods and other ne’er do wells. Buildings and freeways and bridges destroyed, untold cars exploding, earthquakes and giant holes in the ground. It’s apocalyptic! In fact, if that were really happening, the toll of human dead would be staggering. Tony Stark could probably make a fortune selling coffins, and ER docs like me would be overwhelmed.
Movies like that are obviously meant to be outlandish; and to take your hard-earned vacation money. But I fear that television and movies sanitize too much of our bitter human experience, making misery somehow palatable.
Take regular action films for instance. Whatever the underlying story, it seems that gun-fights are everywhere! Bullets fly in all directions. Then, at the end of it all, bystanders aren’t injured. Nobody lies moaning or screaming for help. We don’t see the pools of blood spreading across the ground, the skin becoming more clammy, more pale as police call for an ambulance, as the paramedics or surgeons try frantically to stop the flow. We don’t see, or hear, the family member of the dead when they’re told what happened. I’ve done that a bunch and it’s something you never, ever forget. Scenes like that don’t make for fun entertainment.
In our movies nobody sees survivors, good and bad, condemned to paralysis, or with colostomies or amputations from those exciting gun-fights. What about characters punched and kicked to a pulp, their faces bloodied until they can’t breathe? They get chronic headaches, brain damage, vision problems, inability to chew or smell. I have seen them die too.
But we’re oblivious to more than real violence. When we watch trials and cheer for justice, when we want this or that person to go to prison for their crime, we sometimes forget that the imprisoned don’t see their families much, and their families miss them for years, or for life. And let’s not forget that prison, real prison, is a place where violence, rape and drug addiction are far too common.
I hate it when someone says, ‘guess he’ll get it good in prison; I hope he enjoys his cell-mate,’ or some other bit of cruelty. It’s never OK to wish for someone to be raped, male or female. Ever. Although prison has a necessary role, maybe we need to revisit the boundary between punishment and torture. We should want better for even the worst; especially if we call ourselves Christian.
There are others disconnects, of course. When characters in movies have multiple sexual partners, it looks like nothing but fun to modern, sexually liberated viewers. But we seldom see the misery of loneliness that comes from all of those connections, made and broken. Films and television do a poor job of showing us the pain and terror of HIV or hepatitis, the anxiety of unplanned pregnancy and the reality of abortion. They fail to reveal the suffering brought by cervical cancer associated with HPV. The don’t show the tears shed over infertility caused by chlamydia or gonorrhea infections; the danger to newborns caused by herpes. It’s also hard to fathom the fact that many who work in pornography are miserable in heart, mind and body, and some around the world are compelled to do it against their will, working as sex slaves.
On screen, getting drunk is just what you do. We have all laughed at intoxicated characters, for as long as actors have played them. But we seldom consider the mortality and disability from car crashes. We rarely think about the way men and women die from head injuries or asphyxiation due to alcohol or drug abuse. We don’t get to witness the abuse and neglect of children, the cruelty to spouses, the lost hope, lost productivity and broken families from both.
We have to remember that what we see in movies and television is seldom the whole story. Sometimes, the truth is better. And sometimes, unfortunately, the reality is a lot worse, and far darker than the screenwriter, producer or director can ever, or would ever, convey to our entertainment soaked, reality challenged culture.

Once Upon a Time in Medicine

Gather round kids! Let Grandpa Doctor Leap tell you a few things about the old days of doctoring in the emergency room…

Back in the good old days, medicine was what we liked to call ‘fun.’  Not because it was fun to see people get sick or hurt or die, but because we were supposed to do our best and people didn’t wring their hands all the time about rules and lawyers.  Sometimes, old Grandpa Leap and his friends felt like cowboys, trying new things in the ER whether we had done them before or not.  Yessiree, it was a time.  We didn’t live by a long list of letters and rules; we knew what was important. And we were trusted to use our time well, without being tracked like Caribou through electronic badges.  Those were the salad days…

When I was a young pup of a doctor, we took notes with pen and paper and wrote orders on the same. It wasn’t perfect, and it wasn’t always fast. But it didn’t enslave us to the clip-board.  We didn’t log-into the clip-board or spend twenty minutes trying to figure out how to write discharge instructions and a prescription. We basically learned in grade-school.  EMR has brought great things in information capture and storage, but it isn’t the same, or necessarily as safe, as the way humans conveyed information for hundreds, nay thousands of years.

Back then, kids, the hospital was a family!  Oh yes, and we took care of one another. A nurse would come to a doctor and say, ‘I fell down the other day and my ankle is killing me! Can you check it out?’  And the doctor would call the X-ray tech, and an X-ray would get done and reviewed and the doctor might put a splint on it or something, and no money changed hands.

In those days, a doctor would say to the nurse, ‘I feel terrible, I think I have a stomach bug!’  And she’d say, ‘let me get you something for that,’ and she’d go to a drawer and pull out some medicine (it wasn’t under lock and key) and say ‘why don’t you go lie down?  The patients can take a break for a few minutes.’ And she’d cover you for 30 minutes until you felt better.

We physicians?  There was a great thing called ‘professional courtesy,’ whereby we helped one another out, often for free. Nowadays, of course, everybody would get fired for that sort of thing because the people who run the show didn’t make any money on the transaction.  And when you have a lot of presidents, vice-presidents, chief this and chief thats, it gets expensive!

When medicine was fun, a nurse would go ahead and numb that wound for you at night, policy or not; and put in an order while you were busy without saying, ‘I can’t do anything until you say it’s OK or I’ll lose my license.  Do you mind if I give some Tylenol and put on an ACE?  Can you put the order in first?  And go ahead and order an IV so I won’t be accused of practicing medicine?’ Yep, we were a team.

There was a time, children, when doctors knew their patients and didn’t need $10,000 in lab work to admit them.  ‘Oh, he has chest pain all the time and he’s had a full work-up.  Send him home and I’ll see him tomorrow,’ they might say.  And it was glorious to know that.  Or I might ask, ‘hey friend, I’m really overwhelmed, can you just come and see this guy and take care of him?  He has to be admitted!’  And because they thought medicine was fun too, they came and did it.

In those sweet days of clear air and high hopes, you could look up your own labs on the computer and not be fired for violating your own privacy.  (Yes, it can happen.) You could talk to the ER doc across town about that patient seeking drugs and they would say, ‘yep, he’s here all the time.  I wouldn’t give him anything,’ and it wasn’t a HIPAA violation; it was good sense.

Once upon a time we laughed, and we worked hard. Back then, we put up holiday decorations and they weren’t considered fire hazards.  We kept food and drink at our desks and nobody said it was somehow a violation of some ridiculous joint commission rule.  Because it was often too busy to get a break, we sustained ourselves at the place we worked with snacks and endless caffeine, heedless of the apparent danger that diseases might contaminate our food; we had already been breathing diseases all day long, and wearing them on our clothes.  Thus, well fed and profoundly immune, we pressed on.

In those golden days of medicine, sick people got admitted whether or not they met particular ‘criteria,’ because we had the feeling there was something wrong.  We believed one another.  Treatment decisions didn’t trump our gut instincts.  And ‘social admissions’ were not that unusual. The 95-year-old lady who fell but didn’t have a broken bone and didn’t have family and was hurting too much to go home?  We all knew we had to keep here for a day or two and it was just the lay of the land.

I remember the time when we could see a patient in the ER and, because my partners and I were owners of our group, we could discount their bill, in part or entirely.  We would fill out a little orange slip and write the amount of the discount.  Then, of course, the insurers insisted on the same discount.  And then nobody got a discount because the hospital was in charge and everyone got a huge bill, without consideration of their situation.  The situation we knew, since we lived in their town.

Back when, drug reps left a magical thing called ‘samples.’  Do you remember them, young Jedi?  Maybe not.  Young doctors have been taught that drug companies, drug reps and all the rest are Satan’s minions, and any association with them should be cause for excommunication from the company of good doctors.  But when we had samples, poor people could get free antibiotics, or antihypertensives, or all kinds of things, to get them through in the short run.  And we got nice lunches now and then, too, and could flirt with the nice reps!  Until academia decided that it was fatal to our decision-making to take a sandwich or a pen.  Of course, big corporations and big government agencies can still do this sort of thing with political donations to representatives. But rules are for little people.

When the world was young, there was the drunk tank.  And although mistakes were made, nobody pretended that the 19-year-old who chose a) go to the ER over b) go to jail, really needed to be treated.  We understood the disruptive nature of dangerous intoxicated people. Now we have to scale their pain and pretend to take them seriously as they pretend to listen to our admonitions.  They are, after all, customers.  Right?

These days, we are perhaps more divided than ever.  Sure, back in Grandpa Doctor Leap’s time, we were divided by specialty and by practice location; a bit.  But now there’s a line between inpatient doctors and outpatient doctors, between academics and those who work in the community, between women and men, minorities and majorities (?), urban and rural, foreign and native-born and every other demographic.  As in politics, these divisions hurt medicine and make us into so many tiny tribes at work against one another.

And finally, before Grandpa has to take his evening rest, he remembers when hospitals valued groups of doctors; especially those who had been in the same community, and same hospital, for decades.  They were invested in the community and trusted by their patients and were valuable.  Now?  A better bid on a contract and any doctor is as good as any other. Make more money for the hospital?  In you go and out goes the ‘old guys,’ who were committed to their jobs for ages.

Of course, little children, everything changes.  And often for the good. We’re more careful about mistakes, and we don’t kick people to the curb who can’t pay. We don’t broadcast their information on the Internet carelessly.  We have good tools to help us make good decisions. But progress isn’t all positive.  And I just wanted to leave a little record for you of how it was, and how it could be again if we could pull together and push back against stupid rules and small-minded people.

Now, Grandpa will go to bed.  And if you other oldies out there have some thoughts on this, please send them my way!  I’d love to hear what you think we’ve lost as the times have changed in medicine.

Love,

Grandpa Doctor Leap

 

 

My column in the Winter 2017 Gray Matters, Newsletter of the Osher Lifelong Learning Institute at Furman University.

 

THE NEWSLETTER OF THE OSHER LIFELONG LEARNING INSTITUTE @ FURMAN

http://www.furman.edu/sites/OLLI/member-resources/Documents/GMJan2017-PDF_reduced.pdf

PAIN MANAGEMENT AND THE TIE TO ADDICTION – PART 2

Sometimes medicine offers us wonderful, almost unimaginable gifts. Heart attacks that were devastating, life-altering events a few short decades ago are now treated with an expediency and skill that our grandparents couldn’t imagine. A couple days pass, and the victim is home with stents in occluded arteries and directions to modify activity and diet. Pneumonia, once the ‘old person’s
friend’ (so called because it took the aged to eternity), is far less terrifying, thanks to both antibiotics and the pneumonia vaccine.

However, some of the things we do give benefits that are less clear. Although it could be an entire column in itself, the ‘stroke center’ movement, with the promise of miracles from ‘clot-busting drugs’, is a thing full of as many questions as answers. And what about depression and anti-depressants? When I looked up the side-effect profile of an anti-depressant a friend was taking, I was reminded that all of them have the potential side effect of increasing suicidal behavior.

But what about pain management? Thanks to improved understanding of the physiology of pain, the persistence of medical providers, and the investment and research of pharmaceutical companies, we have a wide array of pharmaceuticals available for the treatment of pain. Some are over-the-counter, like acetaminophen and ibuprofen. And others, those we refer to as narcotics or opioids (because in previous times they were derived from opium), are useful, potent, and (as is increasingly evident) fraught with danger unless used very cautiously.

Of course, for a very long time, physicians were taught to be judicious in prescribing narcotics. Our venerable teachers warned young doctors in training to be frightened of the side effects. We were especially aware of the very immediate danger that patients would stop breathing and die due to excess sedation. We were also aware that over time, patients on narcotics might develop problems with addiction.

About 20 to 25 years ago, that whole paradigm shifted and physicians were suddenly accused of callous disregard of suffering for prescribing too few narcotics. I remember this because I was in my emergency medicine residency at that time. We were constantly reminded to give more narcotics and be sensitive to pain. We were taught to use the ‘pain scale,’ in which a patient-reported score of zero meant no pain and a score of ten meant ‘the worst pain of your life.’ Never mind that it was entirely subjective and that there was no objective standard, no ‘painometer’ against which to measure it. We were instructed to see pain as the ‘fifth vital sign’ after blood pressure, pulse, respiratory rate and temperature. Of concern to many, these initiatives coincided with the development and aggressive marketing of ever more powerful, addictive medications like Oxycontin tablets and Fentanyl patches and lozenges.

Patient satisfaction surveys included the question ‘was your pain adequately treated?’ Physicians were castigated when those satisfaction survey scores fell. Physicians were instructed, by non-clinician

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administrators, to give more pain medication to make patients more satisfied. (A satisfied customer/ patient is one that may come back!) Physicians who resisted, in the name of science or safety, were too often met with threats of reduced income or job loss if patient satisfaction scores fell. In some instances, physicians were (and still are) reported to state medical boards for alleged inadequate treatment of pain.

I sincerely believe that most of those encouraging us to write more narcotics prescriptions did so out of genuine concern and compassion. People are in pain, so why not treat the pain? In medicine, where science meets suffering humanity, it’s so easy for us to say, ‘Well, it just makes sense, doesn’t it?’ We assume that our compassion will be supported by our science. It happens with infections; sure it’s probably a head cold, but what’s the harm in an antibiotic to keep the patient happy? The child bumped her head pretty hard, so what’s the problem with a CT scan, even though she looks good? The parents are customers, after all, and want a scan!

With tragic consequences, our compassion sometimes causes harm as the Law of Unintended Consequences rears its ugly head. For instance, those antibiotics for colds? They can cause dangerous allergic reactions and life-changing intestinal infections requiring hospitalization or surgery, and resulting in death. Those CT scans everyone wants? Physicians are trying to reduce the number of scans, as many of us are concerned that they may induce malignant tumors later. And those pain medications? The evidence looks pretty damning.

Addiction to prescription narcotics is growing at a terrifying rate in the U.S. Likewise, death rates from narcotic overdoses have soared. The U.S. has seen 165,000 deaths from opioid overdose between 1999 and 2014. http://www.cdc.gov/drugoverdose/data/overdose.html. In fact, opioid-related deaths have now surpassed deaths from firearms in the United States. http://www.cbsnews.com/news/drug- overdose-deaths-heroin-opioid-prescription-painkillers-more-than-guns/ Admittedly, some of those deaths are not due to prescription opioids but rather to injected heroin. However, many heroin addicts began their addiction issues when taking legitimately prescribed pain medication.

Sadly, seniors are not immune. Physicians don’t want to see seniors suffer, so they often give narcotics even for pain that in decades past would not have been treated with those drugs. We give them for back pain, headache, arthritis, or other less serious conditions. And we use them extensively in treatment of chronic, intractable pain. In fact, in 2015, one-third of Medicare recipients received a prescription for an opioid analgesic; some 40 million prescriptions. https://www.statnews.com/ 2016/06/22/many-opioid-prescriptions-seniors/

Furthermore, seniors not only develop addiction, not only die from accidental overdoses, their narcotic analgesics have a host of side-effects, including (but not limited to) the following: excessive sleep, impaired thinking, increased pain sensitivity, nausea, constipation, and cardiac arrhythmia. In addition, opioid drugs contribute to weakness and loss of balance and thus to falls, resulting in head and spine injury, various fractures, and other trauma. Their already impaired reflexes are dampened by their medication so that for those who still drive, it becomes an even more dangerous activity than before.

No one is immune from this devastating epidemic, not rich nor poor, not young nor old. The medical profession, the mental health community, law-enforcement, social services, churches, families, and friends all have to come together and find ways to roll back the rising tide of death and addiction, which came as an unforeseen outcome of attempting to ease suffering with compassion and science.

This problem will be highlighted this spring at an OLLI bonus event, March 31, 2017: Seniors and Opioids: Unexpected Origins of a Greenville Epidemic. I will be speaking in conjunction with James Campell of the Phoenix Center addiction and rehabilitation facility. We really hope you join us to learn more about this pressing public health crisis.

The Nativity in the Emergency Department; my December EM News column

Merry Christmas!  This is my December column in EM News.  The Nativity in the Emergency Department.

http://journals.lww.com/em-news/Fulltext/2012/12000/Second_Opinion__The_Nativity_in_the_Emergency.9.aspx

I once wrote a story for Christmas in which the nativity happened in an old, beat-up hunting trailer behind a man’s store, somewhere in the South on a cold winter night. From everywhere and all around, rough people and businessmen and politicians found their way to it, situated as it was in a cluttered backyard of a poor but compassionate store owner. Mary and Joseph had a car that broke down, you see, and they were stuck. I doubt if it’s that original. I suspect Hallmark or someone has done this story over and over.

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Yet it still resonates; it still bounces around inside my mind. I envision that cold night, and the star, and the people in my neighborhood, camo-wearing hunters and bearded bikers, the guy with the meth lab that blew up (no kidding), the men in the garage across the highway. I suppose it’s because the story fits everywhere.

As you might expect, I have this image of the manger scene set in an ED. I think back over my patients, and it makes perfectly good sense to me. I can’t decide if it’s a busy night or a slow one. But there are Mary and Joseph, maybe homeless. We do see the homeless, don’t we? And certainly the poor. “Doctor, we don’t have any money or anywhere to go. Can we stay here tonight?” We might try social work, but face it, they probably went home already. The poor are always among us.

If it’s a slow night, the nurses are stricken with a kind of magic. They fluff Mary’s pillow, and one of them (who used to do OB) notices the way Mary is breathing and holding her belly. “She’s going to deliver!” (For the purpose of the story, Labor and Delivery is full to capacity.) All of the nurses are hovering, getting ice for Mary and coffee for Joseph, who has not so much as the change to buy one.

If it’s a busy night, everyone is frantic, and when Mary says, “I think the baby is coming!” the staff roll their eyes, as if they needed one more thing between the overdoses and the chest pains, the weaknesses and the demanding daughter in the hallway insisting on endless attention for her aging mother.

But they do the right thing, don’t they? They almost always do. We almost always do. Before you can sing “O Little Town of Bethlehem,” the baby is there. He’s crying because they do that. And Mary nurses him immediately after the nurses clean him off. But the nurses, and the doctor who caught him (fumbling, frightened … he hates delivering babies), all of them are somehow breathless. The hair on their necks and arms rises up, chills run along their spines. It’s not fear; it’s wonder. Inexplicable. Another poor baby. So what? Everyone is crying. Nobody knows why. Mary just takes it all in as Joseph wraps his arms around both of them, still in the same dirty sweater, still disheveled.

Of course, there are no animals. And yet. If it’s slow, the sleeping drunk in the next room wakes and stumbles in to see. Looking down, he cries, too. He understands something so deep he can’t express it. Something he forgot about hope and love and parents and forgiveness. He reaches into his pocket, pushes $100 into Joseph’s hand, and goes to lie down again. He sleeps in lovely dreams.

If it’s busy, things suddenly move slowly. Things happen. The mumbling, confused lady with dementia (whose daughter is so demanding) speaks for a few minutes with utter clarity, and finds her way to the door of the baby’s room. She holds her daughter’s hand and laughs, and recalls the details of her own maternity. The meth addict, tweaking and rocking back and forth, sits on the floor and just watches. He is calm. He does not scratch or scream. He is transfixed by the inexorable wonder he always hoped to find in drugs, and by the possibility that he might be whole again, that he might have his own wife, child, and delight. The man dying of lymphoma, passing the room as he is wheeled up for admission, asks the nurse to stop so he can look, and the child fixes its tiny eyes on him. He still dies, but he does it in peace.

The cardiac patient’s chest pain resolves, and the febrile infant in the hall-bed (the one who looked so sick) begins to laugh, cackling, breathless laughter. His fever is gone. Only the babies can see the angels swooping round, touching, healing, encouraging.

I can imagine all sorts of things. An angry mayor, searching for the child. Or professors and priests and ambassadors looking for him later, giving him gifts.

But all I see now is the dawn. Mary is strong. She has no time to be admitted. Joseph says they have to go. They are loaded with formula and money, with snacks and blankets (and diapers). They are hugged and kissed by strangers, and everyone waves goodbye.

The next shift asks, “What was that all about?”

“Don’t know,” is the answer, “but I’m glad I didn’t miss it.”

And the chaos descends again, tempered by inexpressible hope, washed in love.

The Questions we Cannot Answer

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My column in the December issue of Emergency Medicine News.  Merry Christmas to all and to all a good shift!

http://journals.lww.com/em-news/Fulltext/2016/12000/Life_in_Emergistan__The_Questions_We_Can_t_Answer.13.aspx

I remember the early trials of thrombolytics; not for stroke but for MI. During my residency we were still comparing tPA with Streptokinase. It was pretty incredible stuff. Now we’ve moved beyond that positively ‘medieval’ method of treating heart attacks and have advanced to incredible interventions in coronary and cerebrovascular disease. Furthermore, we are able to rescue more and more people from the brink of death with advanced medications and with techniques, like ECMO, that our medical forebears couldn’t even imagine. These days, people can say things like: ‘I had severe sepsis last year, but I recovered,’ or ‘A few years ago I nearly died of Stage 4 cancer, but here I am!’ Fifty years ago, twenty years ago, their families would have told their stories with sadness.

What we do is amazing. The science behind our saves, coupled with our training and passion, make medicine all but miraculous. I am proud of what I know, proud of what I do. I am so impressed with my colleagues. And I am often awestruck by the scientists and engineers, without whom we would be apes poking bodies with sticks (good-looking apes in scrubs, mind you).
If we could, at the end of our lives, look back at the gifts we gave to the sick and injured, we would see that they far outweigh our errors and mistakes, our losses and failures. And yet, for all our modern innovations, we have limits. We can ask and answer a constellation of questions, and we can fix untold numbers of problems. But there are questions that defy us, and problems that leave us shaking our heads.
In spite of our pride in science, and our common dismissal of all that is ‘unscientific,’ suffering remains, and we can’t answer why. Who knows this better than those of us who have dedicated ourselves to emergency care?
For all of our miraculous saves, men and women, boys and girls, still suffer horrible injuries and have cardiac arrests, fatal pulmonary emboli. They still die at the scene of car crashes. They still develop mental illness and kill themselves. Addiction still separates families and leaves parents weeping for children, lost from life or lost in the jungle of drugs and desperate lives.
Despite the extension of life we offer so many, even the healthiest men and women will, at some point, leave one another and pass away from this life. And, knowing this fact does nothing to ease the pain of the loss. The most ancient husband or wife still shudders and weeps with the loss of a spouse the way a newlywed would; perhaps more bitterly, knowing love more deeply at 85 than ever they did at 25. And yet, for all our scientific wonders, we can’t say what lies beyond this life.
What I’m saying is that for all our medical wonders, there are just questions we can’t answer, and things we can’t fix. And it is likely that our science, however wondrous, never will have that capacity.
We know it. It’s why we cry after failed resuscitations, and why we call our children when they travel, frantic to know they have arrived. It’s why every EMS tone terrifies the parents of teens and every scan of a loved one is terrifying to those of us in medicine. We can’t control the troubles of this life nearly as much as we think.
Mankind has always known this. Ancient physicians, as limited as they were, did their best and wanted more. They saw the dangers of this life, and their own incapacity, with what was likely more immediacy than we. And sick, injured humans have always known the fear of loss, the questions of suffering, the pain of death.
Into this ‘vail of tears’ we proceed every shift. This is why I often tell young physicians that they should read and understand more than medicine. I favor religious faith, natural to mankind as it is. But if they decline religion, they must have a philosophy. Or they should read great novels, stories, poetry; or reach into the depth of music for some kind of solace in this mess of the unknown.
But let me say this, now that December is here: Christmas comes to offer hope to the hopeless and answers to the hardest of questions. There are those of us who believe its message with all our broken hearts. But even those who find it a charming myth can surely see beauty in the story of God (however you perceive God to be) become man. God suffering with men and women and rescuing them. God come to give a hope of forever to humans trapped in mortality. This is especially poignant to those whose lives have been a succession of one devastating loss after another. It is comfort beyond medicine for them to believe in a God, come to forgive their wandering ways, answering them in the midst of their cutting, suicidal, self medicating cries for rescue. No pill is as good as God come to make every loss whole, and heal every pain in eternity. No resuscitation comparable to God come to die and defeat death.
The pain of this life is enormous. We try so hard, but we can do only so much. The manger in Bethlehem is, if nothing else, a beautiful story to remind us that just maybe, there is healing for the wounds that lie beyond our science. Perhaps the very dream that there is meaning, that there is hope, is a suggestion that there is more there, more here, than meets the eye.
And maybe, the manger is even more than a distant dream, more than a quaint bedtime story, glowing as it does in the chaotic night of human suffering that darkens our ER’s and trauma centers.
Merry Christmas!

Malpractice Isn’t a Sin

Dear physicians, PAs, NPs, nurses, medics, assorted therapists, techs and all the rest:

The great thing about our work is that we intervene and help people in their difficult, dire situations.  We ease pain, we save lives. Our work is full of meaning and joy.  However, we sometimes make mistakes.  But remember, in the course of a career you’ll do far more good than any harm you may have caused.

I know this issue lingers in many hearts.  I know it because it lies in mine.  And I’ve seen it in other lives.  I said this once to a group of young residents and one young woman burst into tears. I never knew the whole story, but I imagine there was some burden of pain she was carrying for an error she had made.

But just in case you too have lingering anxiety or guilt about some error you made in patient care, I feel it necessary to say this: neither honest errors nor even malpractice are sins.  They are mistakes, born of confusing situations, fatigue, inadequate experience or knowledge, overwhelming situations, the complexity of disease and the human body, social situations, systems problems, general chaos.  Born of your own humanity and frailty.  Your ‘shocking’ inability to be perfect at all times, and in all situations.  They do not make you evil, bad, stupid or even unqualified.  (PS If you’re not actually a physician but pretending to be one, you’re actually unqualified so stop it.)

As a Christian physician I have contemplated this over and over and have come to the conclusion that God knows my inadequacies and loves, and accepts me, regardless.  He has forgiven my sins.  I embrace that reality every day.  He forgives my pride, anger, sloth, greed, lust, all of them.  But he doesn’t have to forgive my honest errors.  Because they are not sins. Go back and read that again.  Your honest errors are not sins.

Mind you, all of the brokenness of this world is, in my theology, the result of ‘Sin’ with a capital S.  (Not in the sense of minute, exacting moral rules, but in the sense of the cosmic separation of the creation from the Creator.)

So, my mistakes, my failures are born of Sin, but are not ‘sins.’  If my mistakes, if the harm I may cause, come from rage, vindictiveness, cruelty, gross negligence, murder, drunkenness or other impairment on the job, then they could reasonably be due to ‘sin.’  But even so, those sins can be forgiven, and washed away with confession and true repentance.  (Not platitudes or superficial admissions of guilt, mind you, but genuine heart felt ‘metanoia,’ the Greek for repentance, which means ‘to change direction, or change one’s mind.’)

If you are not a believer, join us!  But if you aren’t interested, I love you too and want you to move forward, not burdened by unnecessary guilt.  If you are a believer, and a practitioner, remember that Jesus (The Great Physician) set the bar pretty high and doesn’t expect your perfection, only your honest, loving best.

Mistakes, even mistakes that rise to malpractice, are not sins.  But even if they rise to sin for reasons listed above, they are no worse than any other.  Which means Jesus atoned for them as well.

Move forward in joy.  You were forgiven before you even started worrying about it.

Now go see a patient. The waiting room is full of people who need you!

Merry Christmas!

Edwin

 

 

Learning to be Careful; The Hard Way.

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One of the terrible things about being a physician who has spent his adult life working in emergency rooms is that you have a certain terrible clarity about the dangers of this life. It’s why we’re forever pestering our loved ones with phone calls and texts: ‘are you there yet!’ Or telling the children, ‘be careful! After midnight there are too many drunks on the road!’ Met, of course, with rolled eyes.

We see, we have seen, a shocking variety of ways in which people shrug off this mortal coil. However, it’s always a bit of an eye-opener when you walk through the valley of the shadow in person. I can think of a few times I did. Once, coming home from a residency interview, my dad and I nearly went full bob-sled under a jack-knifed tractor trailer driving downhill on an icy interstate in Maryland. There was the time I was almost stuck in the middle of a 10 foot wall of flames in the woods on our property. I ran out but only later realized how close I came to being barbecue. There was also the time I was bent over a tree that fell in an ice-storm, cutting it with a chain-saw. I stood up to stretch and another tree fell right where I had been bent. My doctor brain ran the possibilities and none were pleasant. I know what happens to the human body.

Now here I am, 23 years into my practice following residency, and I had another brush with my mortality. First, a little back-story. Like many families with multiple kids in high school and college, we are afflicted with vehicles. One of these cars (and I use the term loosely) is assigned to my high-school senior son, Elijah. For a few months the car (an automatic) would simply drop out of gear and lose all power. Thus it was consigned to the local transmission expert for a six week spa treatment, after which the transmission issues seemed fully resolved. But then it wouldn’t start.

So, one day last week Jan (my wife) and I decided to push it into a better location to try and jump the battery and trouble shoot. It was also in the way of the propane delivery truck, so it had to be moved. We were pushing it backwards, she at the front and I behind the open driver’s side door, pushing and steering simultaneously.

It’s a light car, an Infiniti I-10. Moving it was fairly easy. What became immediately clear was that stopping it was more difficulty. We pushed it across our driveway into the yard, which (we sadly forgot) slopes away at about 15 degrees.

The car picked up speed as objects on inclines are wont to do. But I was still behind the door. And it was headed for the many trees and stumps of our own forest. Jan yelled for me to be careful as I ran backwards. Then I tried (like the 52 year old fool I am) to jump into the seat and put on the brake. ‘Au contraire,’ said the involved force vector, which was hurtling the vehicle ever faster into the kingdom of the squirrels. And in my attempt, I fell to the side of the moving metal death-dealer, in front of the open door which my paramedic brother later described as a ‘scoop blade’ or some other horrible thing.

In a not very manly manner, I yelled. A lot. Perhaps to increase my strength as we do when lifting. Or perhaps because I knew it wasn’t going very well and I was very scared. I had visions of the car rolling over me and realized I had to push away. Finally, after being struck on the left shoulder and knee by the car door, I hit the ground hard and rolled away. As did the car, about 75 feet downhill into the woods, in the process nearly tearing off the driver’s side door, knocking down several trees and ending with a dent in the rear bumper and trunk.

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Many a small animal suffered panic attacks that day, and several trees crossed the rainbow bridge, or whatever it is trees cross when they are killed by hurtling bits of steel powered by stupidity.

Jan came to my side and I stood up, my pride injured, my arm black and blue, my knee tender and swollen. Nothing serious at all. The car? Less so. It had to be pulled out of the woods with a winch and hauled off on a flat-bed truck. In truth, I was ready to be shy of that car. I always had fears that it would lose power on the Interstate as Elijah pulled in front of a larger vehicle, or something like that. I’m ready to be done with it. I just didn’t realize we’d dispose of it by crashing it into the woods.

Christian that I am, I see divine providence all around. Maybe this was God’s way of making me sell the car; or scrap it. Certainly, God’s hand was in my escape from the Infinity that might well have launched me (somewhat ironically) to eternity. I am convinced that my guardian angel pulled me clear then threw his hands up and walked away for a snack break, or the weekend off. ‘Lord, I can’t be responsible when someone does something so ridiculous,’ he (or she) might have told the Father.

Even as I am thankful to God, I am also glad that I work-out, and so I have reasonable strength and agility. Among the many health problems associated with obesity and a sedentary life-style, one that is seldom mentioned, is that since life is dangerous, we must be prepared to rescue ourselves from said dangers as much as possible. As Rikki-Tikki-Tavi’s mother said, ‘A fat mongoose is a dead mongoose.’ I’ve always tried to live by that maxim. Except of course for not being a mongoose nor regularly encountering cobras.

I do think the lesson also reminded me to be more wary. I’m a guy who works in an emergency room. Not only do we treat the results of dangerous events, we are around the violent, the ill, needles, chemicals, infections and all sorts of things. I have to be diligent. Furthermore, I drive at all hours of the day and night. I work with power tools, including chain-saws. I handle firearms. I have a (sadly neglected) metal smithy where temperatures reach upwards of 3000 degrees F. I wrestle with my teenage sons. It is possible that God was just saying, ‘look, you’re no Spring chicken. I want you to do a lot more stuff for the Kingdom, so please be careful!’ To which I reply with a heart-felt, ‘You bet Lord, and thanks again!’

I shudder to think of the possible injuries I could have sustained the day the car rolled out of our control. They come to me in flashes of anxiety now and then, as I consider the horrific alignment of physics, anatomy and physiology. Head smashed against tree, hip dislocated, femur snapped like a dry branch, ribs broken, lungs collapsed. But the bottom line is I’m here, I’m fine, and God is good.

And I will try to never accuse any future victim of an accident of being stupid. Because bad things, dangerous and deadly things often start off with the most innocent of motives and accelerate much faster than we can imagine. All too often to terrible conclusions.

So we all need to just pay attention and think before we do, well, almost anything. Life is short. As one of my neurosurgeon friends used to say every time I consulted him, ‘hey, be careful out there, OK?’

Election Related Illness…

Now that the presidential election is past, national emergency departments are seeing an increase in election-related health problems. While anxiety, depression and homicidal rage are what one might expect, it turns out, according to emergency physician Dr. Chuck McShortridge, the bigger issues seem to stem from people sitting at computers all day long and linking to political posts on Facebook, Twitter, Reddit and assorted other online outlets.
“Just last week we had three patients with massive pulmonary emboli. I asked their spouses about surgery, cancer, fractures, trips overseas, and the common thread was this: ‘No, but he (or she) spent the last six months linking to articles about how Hillary is a crook or Donald is a liar, or something like that.’”
Other physicians have noticed the same. Dr. Maggie McFarris reported another issue: “I keep seeing patients who complain of a constellation of symptoms: blurred vision, sleeplessness, carpal tunnel syndrome and in some cases, acute renal failure. I call it Donald-Clinton Syndrome. They never get off the (expletive deleted) couch. All day long it’s ‘that Hillary is a crook who can’t be trusted’ or ‘he hates women’ and links to dozens of articles a day. They don’t eat, they don’t drink, they don’t exercise, they don’t even have sex.”
One spouse we interviewed in the waiting room of a large ER said, “My wife has lost a lot of weight because she won’t eat! Just the other day I made this great vegetarian dish she loves and all she said was ‘I don’t have time, I just found this incredible piece on Trump at Politico and I have to share it!’ I ate dinner alone. Thank God the election is over say she can finally get the Xanax and IV fluids she needs.”
On a related note, some politically active physicians we met in the course of this article are lobbying to have advocacy counted as CME. Dr. Joseph Mooring, known for his bumper-sticker-laden Subaru, political buttons and frequent presence at online forums, stated: “CME? Who has time for that? I’m trying to save America, and in the process American healthcare! I should totally get credit for the hours I’ve logged trying to save the nation!” American Board of Emergency Medicine representatives said the board might be able to work political advocacy into the new Lifelong education modules.
Practitioners are urged to continue to be diligent in looking for election related illness and injury.

Rare Gems in the Rolling Seasons of Life

http://journals.lww.com/em-news/Fulltext/2016/10000/Life_in_Emergistan__Rare_Gems_in_the_Rolling.15.aspx

My column from the October edition of Emergency Medicine News

It’s August. I’m looking out the windows of our log house and across the immense variety of green leaves, on oak and birch, mountain laurel and sycamore, magnolia and honeysuckle. It’s a rain forest here. Indeed, after a long dry spell, we’ve had days and days of soaking rain, with breaks in the clouds so that the sun can raise steam from the earth like water coming up in the garden of Eden.

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But the greens have hints of yellow. And the clouds are not just summer thunderheads but low, fast, and broken. The dogs are lazier than normal, as their crusted red-clay coats begin to flake off to reveal the fur underneath. Even the cats seem less mobile, if that were possible. The evenings, despite the blast furnace of August, cool more than in July.

All in all, the signs are there for those who watch. I grew up watching the weather, watching leaves flipped before storms, listening to the sound of winter winds, smelling storms on the air. I know Autumn is hiding across the Blue Ridge Mountains, a child peeking over and shaping the weather, teasing us, reminding us that summer will soon go on its own vacation and the wind will chill us and drive down the leaves, their red, orange, and yellow as varied as summer green.

But for all my love of Autumn, for all my desire for cool air and the smell of wood smoke, Autumn hurts me. It is the end of summer and the beginning of fall that takes my children from me and forces them back to school and schedules. It’s difficult enough to leave them for work, more so to know that my schedule and theirs conspire to separate something so vital, so elemental, as the time families spend in communion with one another.

Even as I write, my daughter Elysa, a high school sophomore, is finalizing her summer reading. Her brother Elijah, a high school senior, is spending his last days with his girlfriend Tori, who leaves for the University of South Carolina all too soon. My oldest boys, Sam and Seth, will return to Clemson in a few days, closer and closer to independence. The leaves change, the sky is darker, the children are growing up and moving on, with the imperatives and requirements of their own lives, their own passions, their own needs and desires, their own loves.

As difficult as this can be, I recognize that I did the same, as did my wife Jan. And our parents and theirs. This is the cycle, the natural history of the world. We raise and guard our precious children and launch them forth to do the same. And we hope that the chords that tie us remain intact; that the circle remains unbroken.

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Time is Fleeting

What has any of this to do with our work? Our physician lives? The lesson is this: Time is fleeting; life and love are precious. Wives and husbands and children are rare gems in the rolling seasons of life. So waste not, want not, as it were.

The seasons will turn. The clouds race, the school buses arrive, and the graduations loom. In the midst of this, we must never delude ourselves that our money, our directorships, even our retirement accounts will ever be sufficient solace if we look back and feel that we did not use our time wisely with the ones who mattered most of all.

Our work, our patients, our skills all matter to the extent that they help others to live long and well, that they help those parents and children to enjoy the passing years together. Beyond that, they are important but less so than our own people, the ones we are committed to, bound to by vows and rings, by birth and blood, by adoption and choice.

So as the year turns and new opportunities and shifts arise, be honored. But be circumspect. Keep before you the fact that everything changes, but with attention and love, all of our connections can remain intact despite years and geography. If only we value them more than we do our certificates, degrees, incomes and positions.

The clouds will roll and the leaves will fall, my friends, and we might as well watch them pass with joy, not regret.

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