Introducing Social Orbit

This is a post by the good folks at Social Orbit, an excellent new social media application. Which, by the way, has been giving away signed copies of my book ‘Life in Emergistan.’  I encourage you to check it out and sign up. There’s a banner add over to the side that will take you directly to their site to learn more.

Medicine is changing.  A lot of the comradery and connection with our physician peers has been eroded because physicians are all so busy worrying about CPOE, EMR, TJC, metrics, billing, pop-up alerts, patient satisfaction surveys…the list goes on and on.  Orbit was founded to create a community where doctors can connect with each other and reconnect with what they love about medicine.  Greg Hadden, MD FACEP (co-founder of Orbit) notes, “There is an overwhelming feeling in medicine that the physician is turning in to just another cog in the medical machine.  The providers are the heart of medicine and the center of healthcare delivery. While every other company and organization is focused on trying to make medicine more efficient, they are forgetting the individuals in healthcare that actually make it all work.” Orbit wants to focus there.

 Orbit is a unique product unlike anything else out there.  By putting together a resource that has things that doctors value and by creating a fun environment of collaboration, Orbit hopes to provide something that doctors want to contribute to and engage in. The ultimate goal is to see all physicians sharing, collaborating, and supporting each other.  The app also wants to be a one-stop-shop for doctors. Orbit can keep them up-to-date with breaking medical news, help them plan their CME travel, help explore job opportunities, do HIPAA compliant chat, and learn…all while winning some really awesome prizes that focus on helping them recharge their emotional batteries.

 The future of Orbit is bright and the developers have a lot of grand plans for the app!  “In order to get there, we need doctors to give us a shot.”  More Orbiters means a bigger community, more collaboration, more sponsorship, bigger prizes, more frequent prizes, etc.  There is incredible potential with this and the developers have a lot of fun stuff they are constantly working on adding and integrating.  In addition, Orbit has big plans for expansion into other specialties in 2017 with the ultimate goal of developing additional platforms for APPs, RNs, EMS, and international healthcare providers. However, it’s important to the developers that the rollout is measured and strategic.  Says Hadden; “We need to be confident that when we get to that stage we are still able to serve our members by protecting the integrity and privacy of the group. US-based physicians are the only group that our app currently is able to verify and validate.  We want to ensure that we are not letting in attorneys, MBA/MHA hospital administrators, recruiters, etc.  Also, I think there are a lot of physicians that want to connect in a physician-only platform.  As we build out the app, our users will be able to customize the content they see and with whom they interact.  As an example, as we progress to include APPs, if a doctor wanted to participate in a physician/APP community then they would be able to do so.  On the flip side, if an APP only wanted to connect with other APPs, then they could customize their account to exclude physicians as well.”

 ACEP16 marked Orbit’s emergence out of beta testing and its introduction to a larger audience.  The Orbit booth at ACEP16 was packed the majority of the time with most of those people coming up to find out what the tagline, “Seriously Fun Medicine”, was all about.  Hadden explains, “In Orbit, medicine is a serious business…but it can also be fun!

 

www.socialorbit.com

Apple Store link: https://itunes.apple.com/us/app/orbit-medicine/id1120695349?mt=8

Back Pain, a Prisoner and a Lenten Reminder of Mercy

chains-19176_1280

 

She was large, and heavily tattooed.  She was in a striped uniform with handcuffs, her feet shackled. She sobbed because of her back pain.  Her life a long history of mistakes and bad choices; alcohol, drugs, criminality.  Her family, husband and children, a victim of her lifestyle, her addictions, her misdeeds.

They can’t have narcotics in jail, and in fact, narcotics don’t have much role in back pain, we’re finding.  But in jail, she lay on a thin mattress on a concrete pad.  Getting up and lying down were, she said, agonizing.

Was she lying?  Her drug screen positive for amphetamine, it was possible.  The officer with her said, ‘I’ve known her for 15 years.  This is her. Crying and moaning. But what if she really has pain?  It’s tough doc.’

It’s tough for sure.  Knowing as I did that if she went back to jail, she might really be suffering. Knowing, also, that she had a reported history of heart disease even though she was only  in her 30s.  Knowing that she would surely come back with chest pain or back pain, legitimate or illegitimate, if nothing were done.

Ultimately, after two visits, she seemed worse.  She seemed to have difficulty standing.  Her sobs continued.  Her officer and I sympathetic but worried about being tricked.  She was given pain meds and transferred for an MRI.  Maybe there was something going on in her spinal cord. Maybe a hematoma, maybe an abscess.  Who knew?

Here is the conundrum of compassion, as it were.  The compassionate will be cheated, fooled, and lied to.  This is life in the ER. This is life on earth.  The right thing is often, in the rear-view-mirror, exactly the wrong thing, as those who fool us laugh and drive away.

But we have the last laugh.  Because the right thing is just that.  The right thing.  And it’s a great lesson here in the Lenten season.  To show kindness, to give mercy, to expect to be the butt of the joke, the patsy, these are all the ‘price of doing business,’ when our business is being like Jesus.

I believe she had pain, but even if she lied to me, even if she gamed me, it’s OK.   I’m not offended.  She was vulnerable. She was wounded. She was broken.  She was a prisoner. And here’s what Isaiah, God’s prophet, said about captives and prisoners.  And notice, no mention of guilt, or of punishment deserved or earned.  Isaiah 61: 1-3

The Spirit of the Sovereign Lord is on me,
because the Lord has anointed me
to proclaim good news to the poor.
He has sent me to bind up the brokenhearted,
to proclaim freedom for the captives
and release from darkness for the prisoners,a
2to proclaim the year of the Lord’s favor
and the day of vengeance of our God,
to comfort all who mourn,
3and provide for those who grieve in Zion—
to bestow on them a crown of beauty
instead of ashes,
the oil of joy
instead of mourning,
and a garment of praise
instead of a spirit of despair.
They will be called oaks of righteousness,
a planting of the Lord
for the display of his splendor.

Jesus said the same thing at the beginning of his ministry.  Luke 4: 16-21.

Jesus returned to Galilee in the power of the Spirit, and news about him spread through the whole countryside. 15 He was teaching in their synagogues, and everyone praised him.

16 He went to Nazareth, where he had been brought up, and on the Sabbath day he went into the synagogue, as was his custom. He stood up to read, 17 and the scroll of the prophet Isaiah was handed to him. Unrolling it, he found the place where it is written:

18 “The Spirit of the Lord is on me,
because he has anointed me
to proclaim good news to the poor.
He has sent me to proclaim freedom for the prisoners
and recovery of sight for the blind,
to set the oppressed free,
19 to proclaim the year of the Lord’s favor.”[f]
20 Then he rolled up the scroll, gave it back to the attendant and sat down. The eyes of everyone in the synagogue were fastened on him. 21 He began by saying to them, “Today this scripture is fulfilled in your hearing.”

In this passage is healing and liberty.  And nobody is a ‘jailbird’ or ‘scumbag’ or ‘crook’ or ‘junkie.’  Jesus wants to offer this to all.

This Lenten season, can I do any less?  I, a captive of sin as all of us are, delivered and healed? I with blind eyes, seeing clearly thanks to my redemption?  God knows if I lie to him, if I try to trick him. And loves me anyway.

And if it takes showing mercy to the meth-using prisoner with back pain to honor the mercy I received, well it’s a small price to pay.

Edwin

The Women and Men who Love Emergency Physicians

This is my February 2017 column in Emergency Medicine News. Now, doctor, go hug your  husband or wife.

http://journals.lww.com/em-news/Fulltext/2017/02000/Life_in_Emergistan__The_Women_and_Men_Who_Love_EPs.20.aspx

When I go to work I take a lot of things with me. Everyone has their ritual, right? I take my backpack with my computer inside. I take my phone. I take charging cords, the true modern life-line. I take lunch. I carry a pen, flashlight and pocket-knife.
On a more abstract level, I take the wonderful education I received as a medical student and resident, coupled with my years of experience as a physician. I take my drug-store +2 diopter glasses, not only to read and suture but equally important, to look venerable and wise.
But I take something else. It’s certainly as important as all of the other stuff, if not more so in the long run. I take the love and support, encouragement and care of my wife Jan. Now mind you, this is not some hyper-sentimental claptrap. A spouse, for better or worse, is part and parcel, warp and woof of our lives. And in the best of circumstances (which I enjoy), my dear bride gives me encouragement, laughter, stability, passion and the not-so-rare kick in behind when I’m lazy, whiny or grumpy. (As I am so often wont to be.)
She reminds me of my priorities, reassuring me that I matter to her and the children however I may feel. She reminds me that feelings are often terrible lies. (A lesson we would all do well to remember.) In times past she has guided me through career changes because she could sense my unhappiness and dissatisfaction. This is because she loves me and knows what I need; often better than I do. In short, she is my most dedicated advocate.
While I work in the ED, she works hard to manage the children (rather, the teens who require more diligence than mere children.) She looks after the family finances, a thing which is useful in keeping me out of prison for delinquent taxes and in keeping the banker away from the door so that we keep our home.
And in order to keep me moving forward through busy, difficult runs of shifts, she ensures that I have things to look forward to with family when she does our ‘master schedule.’ Even though two of our children are in college, she tries to arrange family events around my days off so that I don’t feel left out. In addition, so that I can enjoy our life together for a long time to come, she takes me to the gym. She sometimes makes me plank. I hate to plank but I do it.
This might sound, to the modern ear, as if my wife is living out some sort of domestic indentured servitude. It is not. It is teamwork. It is unity. It is covenant. We are one. We have common cause in our marriage and offspring.
The result of her remarkable effort is that when I go to work, I can focus on my job. I can carry the love and care I feel at home into the exam room, into the resuscitation room. I am secure and happy. This makes me a far more effective, calm, satisfied physician than I would otherwise be.
Thus, I make the money that we share equally as partners. Not only in our personal corporation but in our lives. I don’t get paid for me; I get paid for us and for ‘clan Leap’ as a whole.
When I come home from work, I come home to smiles, hugs and a welcome-home kiss. I come home to laughter and dinner, or date-night. To stories of her day, and the many other lives she touches, in our family and beyond it.
Sometimes I come home to strategic family planning sessions. Occasionally I come home to a tired or angry or sad wife and it’s my turn to be the one in the supporting role. My turn to fuss at teenagers or call about car insurance claims. My turn to shoo her to bed early and manage things. My turn, on days off, to send her for sanity breaks.
Those of us who are married, or in long-term committed relationships (which we in the South call a common-law marriage) must admit that without our wives or husbands, this whole gig would be much harder, and much more lonely than it is with our dear ones. Furthermore, that the patients we care for are touched and loved on, vicariously, by those who love us. Their role is not subordinate but intrinsic.
Through me, through our marriage bond, every sick child in my care has my wife’s eyes looking down on it gently. Every struggling nursing home patient has some of her kindness. Every difficult, irritable complainer has her patience and every smart-aleck teenager (or grouchy consultant) has her raised eyebrows and crossed arms gazing firmly on their behavior.
All of us owe so much of our professional lives to the women and men brave and loving enough to stay with us through all of our stupid, arrogant, surly behaviors. And to those men and women, let me just say: you are as much a part of our practices as we are. Thank you for being the other half, the silent partner, standing invisibly by us as we do the hard work of medicine.
We couldn’t do it half so well without you.

Life and Limb: the Rural ER

Welcome, readers, to my new column in the Daily Yonder!  It will concern rural emergency medicine and things I see through that particular lens.  Have a great day and feel free to share liberally!  I’m honored by the Daily Yonder to be included on their team, dedicated to all things rural.

Life & Limb: In Rural E.R., Exams Include the Obvious Questions, Like ‘Did You Get a Turkey?’

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

 

 

The Questions we Cannot Answer

img_3316

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

 

 

What do you mean it’s a cold? A poem…

What do you mean it’s a cold?
A poem for viral illness season.

Fever, cough and runny nose,
Muscle aches from head to toes,
Scratchy throat and stuffy ears,
Doctor, please allay my fears!

Can’t I get some Zithromax?
Lortab for my aching back?
Maybe just Amoxicillin,
For my stuffy, whiny children?

You say virus I, but I’m dying;
Surely there ain’t no denying,
What I have is devastating,
And I spent an hour waiting!

Hook me up and make me better,
Else I’ll write your boss a letter;
Don’t you tell me ‘it’s a cold,’
That tired line is getting old.

I know it must be bronchitis,
Strep throat, Zika, meningitis!
I require a strong prescription
For my horrible condition!

Cipro, Doxy, Levaquin
That’s what someone gave my friend,
After two weeks they felt well
So why should I endure this hell?

Please throw in a week off work,
Percocet’s an added perk,
My tolerance for pain is high,
But I am just about to cry!

What, I don’t get any meds?
Drink some fluid, go to bed?
Are you crazy, are you cruel?
I think you’re a quack, a fool!

I’ll go home but I may sue
Everyone, especially you.
I don’t need this here abuse…
Fine, now what about that work excuse?

The Overwhelmed EP in the Single Coverage ER

This was my column in Emergency Medicine News in September, 2016

http://journals.lww.com/em-news/Fulltext/2016/09000/Life_in_Emergistan__The_Overwhelmed_EP_in_a.12.aspx

I was working a 6 PM to 2 AM locums shift a few months ago and was preparing to leave. There were about 15 patients in rooms and 15 waiting to come back. I asked the lone night physician: ‘hey, do you want me to stay a while?’
Her answer, defeated, was this: ‘no, don’t worry. It’s always like this.’ I packed my bag and headed to the hotel, still feeling guilty but also exhausted. And wondering why my colleagues are treated so poorly in emergency departments all over the land.
I see it time and time again. Overwhelming numbers of patients with increasingly complex medical and social problems, versus inadequate physician coverage at all hours of the day, and especially the night. We’ve all done it. Already fatigued, we have five chest pains yet to see, as well as a trauma on the way into the department. Two more patients have fever but don’t speak English and we’re waiting to make the translation line work. And there’s a large facial laceration yet to be repaired. And that’s just the first nine patients. It’s not even three hours into the shift. (And the EMR backup is in process.)
Do we call the cardiologist and internist to take over on the chest pain, ask the surgeon to come and check the trauma and get plastics to close the face? Hardly. Furthermore, that’s just more time arguing on the phone. It’s easier to forge ahead as wait times creep from two to four to eight hours. Furthermore, on days it’s the same; with the added gift of acting as backup for all of the primary care offices.
There was a time when we actually might have asked other staff members to help. Those times are mostly gone. As a specialty, we’ve spent decades saying ‘don’t worry, we’ll take care of it!’ And our fellow physicians have obliged.
But at least, when we’re alone and overwhelmed, we don’t have to worry about lawsuits, patient satisfaction, quality measures, charting, coding, door to needle times, door to CT times, door to doctor times, door to…oh, yeah, we do have to worry about those things. As well as the sound criticism that will follow in the light of day, when all the administrators and other specialties are rested and shocked (shocked I say!) at how things went when we were alone.
The thing is, hospitals get a real bargain out of the understaffed emergency department. The physician does a heroic job of seeing every conceivable complaint and doing it with knowledge, skill, professionalism, urgency and political savvy. If you think of what they bill for that 35 patient, single coverage shift versus what they pay the exhausted physician, it’s a ‘win, win for old admin!’
In fact, emergency department physicians do the work of several people throughout their shifts, from secretary (filling out forms and entering orders), to social worker; from surgeon to psychologist, pediatrician to hospice worker. And we do it while trying our best to keep up with ever more complex charting rules, treatment pathways and admission battles.
We also do it when expectations are ridiculous. For instance, why should we, in a busy urban department, be doing the full stroke assessment when a neurologist could be at the bedside? Why are we arguing about the NSTEMI patient, or managing complex rhythms, when cardiologists (the alleged experts) are available? Why am I doing the neonatal sepsis workup in all the chaos when a pediatrician could come to see the child?
I’ll tell you why. Partly because we’re perpetually trying to prove our worth and fortitude. ‘I can handle it!’ And partly because we simply agreed. Consequently, ’call me when the workup is complete’ is a common mantra in the ED where we are indeed interns for life.
I wonder, are we training our bright eyed residents for this in the trauma center, in the simulation lab? Because when they leave the medical center for the community, this is how it looks. All the exciting, cool stuff. But ‘all by your lonesome.’
I know that lots of jobs are hard. I get that. But from what I’ve seen, all too many emergency departments over the past few years that are miserable, and dangerous, working environments. Does OSHA ever even look at our workplaces? Because when JCAHO does, they just increase the work-load in the alleged interest of patient safety (and their own job security).
We should all be proud of what we do. But we shouldn’t be abused children, or Stockholm Syndrome hostages to inadequate conditions. We should be treated as valued professionals. And if there aren’t enough other doctors to go around, every effort should be made to help and encourage those willing to work in such daunting settings.
And until you’ve come to work a shift alone, with a full waiting room and ten potentially critical patients right up front, you don’t understand what it’s like on the ground. And you have no grounds to criticize anyone facing the same tsunami of expectations and exhaustion in the noble effort to save life and limb, and ease suffering.
In the end, the weary look in the eyes of my colleagues breaks my heart. And something has to be done.
I call foul.

Driving Country Roads to the ER

These days, I work most of my shifts about 45 minutes from my ‘house on the hill.’ At one of those jobs, the day shift starts at 06:30. Which means I’m rising from my bed at 04:30 in order to get on the road in time. I’ve started waking up at four, spontaneously, as if it were the most natural thing in the world.

I lay out my clothes the night before, so as not to awake my darling wife in her sleep. Sometimes I am able slip out without her knowledge. Others she wakes to kiss me goodbye. Then I go downstairs and put together some lunch, get the backpack and make my way out the door. I know that my wife and children are safe upstairs, as I lock the door behind me.

The door creeks a little, or did until my son Elijah oiled it. (One always wonders why a teenage boy oils a front door…) Occasionally I lock it as I realize I left my keys inside, and poor, tired Jan opens the door for me patiently. On the front porch, by the soft yellow of porch-light or the shock of flashlight, I step over dogs freshly awakened from sleep, who look at me with gentle annoyance. The sharp-eyed cats sleep in more secret places, so are seldom seen in the morning. Other dogs (we have five), sleep on the gravel drive in the summer and seem confused as to how to react when my Tundra rolls towards them, slowly, and I roll down the window. ‘Get up, you silly dog!’ Heads and tails down they amble away.

img_2765

Up the long drive and down the road, I am suddenly all but alone on the two lane roads that lead me to Tiny Memorial Hospital. Despite the early hour, I am ‘awake, alert and oriented.’ The sky is dark, and in winter stars shine down when clouds don’t lay low against the earth. I scan the roadside for deer, their eyes reflecting the truck’s headlamps. Opossums sometimes shuffle across, along with squirrels and rabbits. (One day I saw a big, black bear on a hill by the road. He ran away as I stopped for a photo.)
I drive through forests, past sleeping houses and across a dark, still lake where sometimes, the light from a bass-boat shines across the emptiness where someone has fished all night…or started very early. Or a campfire on the shore still burns as their line rests untroubled in the water.

img_2021

It is so early that I drive past gas-stations and convenience stores still dark and locked, the ‘closed’ sign reminding me to keep on moving. The air, even in summer, is cooler and in winter, positively cold. Winter is my favorite, I think, with the heat of the truck turned out, and the chill wind blowing past.

I think as I drive. And I pray. And I listen to the news, a recorded sermon, a pod-cast. Many mornings I turn on an oldies station from the North Carolina mountains; in the loneliness of the drive the music of Sinatra, Johnny Cash and others, make me feel I’ve gone back in time.

I cannot talk on the phone (hands free or otherwise). I pass through places where cell-signals are only a dream, and often even radio reception is poor. Remote areas, mountainous places, lonely and beautiful places defy cell signals and seem to say ‘look around! What else do you need!’ Even at 5 am, I agree.
Eventually I am near, and I find a fast-food joint for the obligatory chicken biscuit and tea, because, well, the South and all. And then I roll into the ER parking lot, lock things up and head to work.
Because this is no urban trauma center, the early morning is sometimes very slow and relaxed. A few patients may be waiting for turnover, but often none. I can sit and think, I can ask about the previous night. I can ease into work. My drive has already prepared me, but it’s nice to have a few minutes peace in the department before the chaos of the day begins. I text Jan. ‘Here safe, love you,’ and she answers. ‘Love you back, have a great day.’
There are those who don’t have to drive long distances. For most of my career it was about 15 minutes to work. And there are those who have long commutes through traffic, and through the waking body of a large city, people and cars just starting to fill its veins and arteries. Sometimes I am jealous. It can be lonely where I am.
But I think I’ll keep it for now. There is a solemnity, a serenity to my mountain and lake commute, with animals heading to bed and people not yet rising, with my own thoughts and prayers to myself.

img_2315
And I suppose that if there were a better way to prepare for the madness, badness and sadness of the ER, I don’t know what it is.