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.

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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.

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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.

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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.

A dark union: EMR meets EMTALA

Ah, EMTALA! The revered ‘Emergency Medical Treatment and Active Labor Act!’ It’s one of those things which is like a nursery rhyme to emergency medicine folks like me. We’ve heard about it from the infancy of our training.  ‘And then the bad doctor sent the poor lady to another hospital because she couldn’t pay!  And the King came and crucified him for doing it!’  The end.

EMTALA, for the uninitiated, is a federal law which ensures that we don’t turn people away from the ER because of finances, and also keeps us from transferring people to other hospitals without that hospital’s agreement.  It also exists to guarantee that we stabilize them as much as possible before they go.

I’ve said before, and always will, it was a good idea.  But like many laws, it was subject to the law of unintended consequences.  For instance, being forced to see lots and lots of people (who may not really be that sick), and do it for free, has huffed, and puffed and blown the hospital and trauma center down on too many occasions.  But that’s not my point here.

My point is that when EMTALA forms meet electronic medical records, chaos can ensue.

Allow me to illustrate:  This is a standard EMTALA form.  Check, check, check, sign.  It takes a busy physician less than a minute, and the nurses a few more since they have to call the other hospital and record times, etc.  This has worked well for a very, very long time.

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Enter EMR.  This is the procedure for doing an EMTALA form at Tiny Memorial Hospital, which has been enchanted by the dark Lord Cerner.  Mind you, I’m sure the ‘powers that be’ feel that this is a perfectly wonderful way to do the form.  Indeed, it captures lots of information and stores it in the system.  But two facts remain:  first, the people who designed the system generally work at Large Urban Hospital, which owns Tiny Memorial.  They don’t transfer things out very often.  They receive things.  Second, most of the patients being transferred are going within the system.  All the data is on the EMR, and it isn’t as if they’re going to some strange facility far, far away.

This, children, is the EMR based procedure (on a cheat sheet developed by a frustrated and confused provider):

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Not long ago my team worked a cardiac arrest at Tiny Memorial, with a successful return of cardiac activity.  Given our size and staffing, it took pretty much all of the staff available and nothing moved for a while.  A helicopter whisked our patient away.

Of all the things we did; drag her out of the car, do CPR, start IV’s, intubate, talk with family, chart, arrange transfer, nothing was as complicated or frustrating as this process to complete the EMTALA form.  In the end, I still got it wrong somehow.

Mind you, I never violated the spirit of the law in any way. She was treated, stabilized (to the extent of our ability) and sent away to a receiving hospital with the capacity to care for her.

I don’t want to impugn the motives of those who developed this.  I’m sure they were trying their best.  But if you don’t use it, you can’t see how hard it is. And you also can’t see how much time it takes in a place with limited resources and staff.

So please, folks, let’s use technology to simplify, not make things more complicated!  And let’s remember that charting isn’t the same as doing the right thing. And sometimes, doing the right thing isn’t perfectly reflected in the chart.

But paper or electrons, it’s still the right thing.  And that’s what EMTALA is about.

 

Thanks,

Ed Leap

Living the Locums Life: A Short Guide in Four Columns

Dear reader and locums travelers, past, present or future.  These are the four columns I have recently written for Emergency Medicine News as a series about locums emergency medicine.  For now, rather than post the entire text of each, or put them in four separate posts, I am lumping them together for your ease.

I hope you find this helpful!

Sincerely,

Edwin Leap

http://journals.lww.com/em-news/Fulltext/2016/05000/Life_in_Emergistan__An_Emergency_Physician_s_Guide.2.aspx

http://journals.lww.com/em-news/Fulltext/2016/06000/LIFE_IN_EMERGISTAN__Locums_Puts_the_World_in_Your.20.aspx

http://journals.lww.com/em-news/Fulltext/2016/07000/Life_in_Emergistan__High_Rates_and_Other_Perks_of.12.aspx

http://journals.lww.com/em-news/Fulltext/2016/08000/Life_in_Emergistan__Rules_for_Locums___Be.17.aspx

 

After Graduation, Love the Kids. Just Don’t Worship Them

Sam and Tyler K5 graduationhttp://www.greenvilleonline.com/story/opinion/contributors/2016/05/22/ed-leap-after-graduation-love-your-kids/84556782/

Graduation is upon us once more. All across the area high, schools, trade schools and colleges are releasing their eager, bright eyed students into the the next phase of their lives. My wife and I have graduated several times, and have graduated two sons. It’s an emotional, beautiful time when Pomp and Circumstance turns moms into weeping messes of mascara and tissue, and dads into great, red-eyed lumps who choke back tears and say muffled things like ‘I…I’m fo prd ov you. I lvvv you,’ sniff, sniff.

The kids are emotional but boy, are they ready. They toss those hats into the air (as parents try to grab them as keepsakes) and they head off to jobs, or to parties or sometimes to pre-loaded cars headed off for the beach. Some go to their own weddings and some go to basic training, or their first overseas deployment with the armed forces. Big stuff all around.
But as I thought about the whole process I realized that one of the great dangers of a successful society (and by any measure of the world at large or history ours qualifies), is that we are capable of investing all of our worth as parents into the activities and successes of our offspring who are now springing off on their own.

As such, we forget something very fundamental. Once the kids grow up, they can largely do what they want. Just like most of us did. But what does that mean exactly?

Well, first of all those graduates with all of their dreams, like ’I want to do forensics,’ ‘I want to be a marine biologist,’ ‘I want to be attorney general,’ etc. may or may not do those things. Their dreams are useful guiding stars at first, but most of them will change course for a variety of reasons. Thus, I am not a full-time magazine journalist as I originally intended. Nor an Air Force navigator…probably good given my tendency to get lost.

We love to brag about what our kids will do. I certainly do. They are hints of the future, and sometimes we believe their successes will somehow atone for our own shortcomings, our own failed dreams. But it’s important to step back on occasion and realize that the future may look very different from what they, and I, and all of us, think it will be for them.

Second, they may decide that the educational path we hoped for them to follow isn’t right. These days, many college majors are a poor economic bet compared to heating and air or welding. My professional friends in medicine and law are particularly stricken by this. When one says to another, ‘Tim dropped out of USC. He’s decided he wants to be a contractor,’ there’s an almost palpable tension and a pat on the shoulder. ‘Well, he may go back to school later.’ Or he may be a wildly successful contractor. Or he may just like building things more than thinking about things that don’t interest him. Who knew?

Third, they will love and marry people we didn’t expect. Just like we did. We can have all kinds of plans for betrothal and hopes that they’ll find this girl or that guy. But in the end, as Pascal said, ’the heart has reasons of which reason knows not.’

And now the hardest, dear weeping parents, and many of you know this. They will make their own mistakes. They will lose jobs and ruin relationships. They will set themselves back. They will violate, sometimes, the law of man and often the law of God. This is called being human. For Christians, it’s tough realizing your kid is a sinner too. (In the secular, world, the equivalent might be realizing your liberal family raised a Republican and you have to love them anyway. Cheer up! Prodigals do return!)
Allow me to review: the kids will study what they want, work at what they want, love whomever they want and make big mistakes. The best we can do is show the grace and love throughout all of it.

But to love them well, we have to take them off the altar. Our worth as humans cannot be wrapped up in our children. That’s a terrifying and overwhelming idolatry and it holds them to far too high a standard.

So as they get those certificates and diplomas, remember they’re humans. Hope and fear, success and struggle in dynamic tension.

And love them.

 

Doctors and Nurses ‘Getting in Trouble’ too easily…

Trouble

 

My column in the April edition of Emergency Medicine News

http://journals.lww.com/em-news/Fulltext/2016/04000/Life_in_Emergistan__Doctors_and_Nurses_Getting_in.6.aspx

Are you afraid you’ll ‘get in trouble?’ It’s a common theme in America today, isn’t it? We’re awash in politically charged rhetoric and politically correct speech codes. Our children go to colleges where there are ‘safe spaces,’ to protect their little ears from hurtful words and their lectures or articles contain ‘trigger warnings’ so that they won’t have to read about things that might upset their delicate constitutions. All around that madness are people who are afraid they’ll ‘get in trouble’ if they cross one of those lines. I mean, one accusation of intolerance, sexism, genderism, agism or racism, in industry, government or education, and it’s off to the review panel for an investigation and re-education!
Worse, I see it in hospitals now. I hear so many nurses say ‘I can’t do that, I’ll get in trouble.’ I remember the time I asked a secretary to help me send a photo of a fracture to an orthopedic surgeon (with the patient’s consent, mind you). ‘That’s a HIPAA violation and I’m not losing my job to do it!’ OK…
There have been times I’ve said, ‘please print the patient’s labs so they can take it to their doctor tomorrow.’ ‘No way! That’s against the rules! I’ll get in trouble!’ Seems rational. The patient asks for his own labs and takes them to his doctor. It can only be for nefarious purposes…like health!
Sometimes it’s even sillier. Me: ‘Patient in bed two needs an EKG!’ Nurse: ‘You have to put in the order first, or I’ll get in trouble.’ In fact, this theme emerges again and again when I ask for things like dressings, splints, labs or anything else on a busy shift. I’ve expressed my frustration about physician order entry before, and I know it’s a losing battle. But when there is one of me and three or four of them, and ten patients or more, it’s hard to enter every order contemporaneously. But I know, ‘you’ll get in trouble.’
I remember being told, by a well-meaning (and obviously threatened) nurse, ‘if I put on a dressing without an order it’s like practicing medicine without a license and I can lose my nursing license.’ Well that makes sense!
I overheard a nursing meeting not long ago, and it seemed that the nurse manager (obviously echoing her ‘higher-ups’) was more concerned with making sure the nurses didn’t do wrong things than with anything touching on the actual care of human beings.
I suppose it’s no surprise. ‘When all you have is a hammer,’ the saying goes, ‘all the world’s a nail.’ Now that we have given all of medicine to the control of persons trained in management, finance and corporatism, that’s the thing they have to offer. Rules, regulations and ultimately threats.
Of course, ‘getting in trouble’ applies to physicians as well. It just takes a different form. Didn’t get that door to needle, door to door, door to cath-lab, door to CT time? We’ll take your money. Didn’t get the patient admitted in the committee approved time-window? We’ll take your money.
Never mind that seeing patients in a timely manner is rendered nigh impossible by the overwhelming and growing volumes of patients, coupled with the non-stop documentation of said patients for billing purposes. Keep shooting for those times! Times are easier metrics to measure. Times are easily reported to insurers and the government. Times, charts, rules-followed, rules violated. The vital signs of corporate medicine in America today. (And don’t give me that ‘it would all be better with the government in charge.’ Two letters give that the lie: VA.)
No, we’re an industry constantly ‘in trouble.’ But not really for any good reason. We give good care as much as we are logistically able. We still save lives, comfort the wounded and dying, arrange the follow-up, care for the addicted and the depressed. We still do more with less with every passing year.
But odds are, we won’t stop ‘getting in trouble.’ Because for some people, waving the stick is the only management technique they know. Still, it saddens me. I’m sad for all of the powerless. The nurses and techs and clerks and all the rest who are treated as replaceable commodities by administrators who are themselves (in fact) also replaceable. I hate to see nurses, compassionate, brilliant, competent, walk on egg shells in endless fear, less of medical error than administrative sin. Their jobs are hard enough already without that tyranny, leveled by people who should appreciate rather than harass them.
And it saddens me for young physicians, who don’t remember when being a physician was a thing of power and influence in a hospital. They, endlessly threatened and unable to escape thanks to student loans, are indentured for life, short of a faked death certificate.
Finally, it saddens me for the sick and dying. Because we cannot do our best when our motives are driven by fear more than skill and compassion.
The truth is, however, threats only go so far. And once people have been threatened enough, there’s no telling how they’ll respond.
Just saying…

 

Some new, important screening questions for the EMR

Scrolling through FEEMRS (you know, Fancy Expensive Electronic Medical Records System), I was stricken by just how much data is on the chart.  I mean, it’s pretty dang amazing.  But I was, simultaneously, reminded that most of it doesn’t help me.

It helps someone, mind you.  For instance coders and insurance companies.  The complexity of EMR also helps those who track our car to door, door to chair, chair to chair, chair to bed, bed to bathroom, bed to X-ray, request to blanket, request to sandwich, request to TV remote, request to ice chips, complaint to Dilaudid and discharge to angry times.  (The really important stuff!)

But so often, FEEMRS just gets in my way.  I mean, I struggle to find little things like triage information, medications or last menstrual period. And as for visual acuity?  Faggettaboutit!

However, I do think there are some things that might be useful screening questions.  So, here are a few things I think we should have the nursing staff ask on the way into the ED.  I mean, we always ask about drug abuse, interpersonal violence, immunizations, sexual activity, whether or not the withered 98 year old has lately traveled to any Ebola infested exotic locales.  But is it really enough to know if the newborn has stopped smoking? Or are there other more interesting things with which we could further clutter the hallowed screens of our FEEMRS?

I hereby suggest:

What is your preferred pronunciation of the only pain medicine that ever worked for you?  With what letter does it begin?  (Incidentally a patient recently pronounced their favored drug ‘Laudy-dah.’  Awesome.)

What unfortunate thing has lately happened to your medication?  Eaten by dog, stolen by neighbor, smashed by meteorite?   Hey, it could happen…

Is there some species with which you identify and would prefer to be treated as?  Because if so, we may need to call a vet. Or tree surgeon.  (It’s no joke.  Tree-kin is a real thing…I mean, ‘real’ thing.)

First thing that pops into your mind when I say ‘outstanding warrants.’  Go!

What is your favorite kind of sandwich to eat while waiting on your psychiatric commitment.  Just kidding. We have Turkey.  (It’s empowering to offer a choice even if we really don’t have one.)

This is to be asked immediately on arrival into triage.  Right now, how long do you believe you have waited to be seen? One hour, two hours, three hours.

Do you know the patient advocate’s name and phone number?

For abdominal pain:  Please tell me what kind of cheeseburger, chicken sandwich or friend food you have consumed on the way to the ED, and when you finished….oh, you’re still eating it.

This is very useful and instructive: Why are you on disability? With a few mental health exceptions, if it isn’t evident in triage, it will be a good story.

How many times have you been committed to a state or private psychiatric hospital? If the number of suicidal commitments is greater than ten, patient can probably go to the waiting room.  Especially if eating cheeseburger and suffering from simultaneous abdominal pain.

Is there a particular physician you would like very much to see or not to see? Or want to hurt?

Full disclosure.  What are you here to get, and if you had it, you wouldn’t be here at all?  For instance, work excuse, pain medication, etc.

Who told you you should come to the ER, if anyone:  your physician’s office, your attorney, a police officer, your sister’s best friend who is a CNA at a nursing home, or a 24-hours health line?

Do you find it difficult to stop playing video poker on your phone while talking to a clinician?  

Will you please eat these chips and fill out my satisfaction survey while waiting to come back?

Just scratching the surface.  Send me some of yours!

edwinleap@gmail.com

 

Can you be a Christian in the ER? Grace abounds…

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Many young physicians in training have asked me, quietly or by e-mail, ‘is it possible to be a Christian and practice emergency medicine?’  I think that they ask a good question, and likely for good reasons.

In their rotations they have witnessed, first hand, life in the ER.  They are uncertain, perhaps, because they see the frustration that boils over in the words and actions of otherwise compassionate and caring doctors and nurses. They hear the bitterness and sarcasm, the profanity, the unkind words spoken behind the glass window that separates professional from patient.

They also see, hear, touch…and often smell…the humanity that pours through the doors of trauma centers, academic emergency departments, community ER’s and all the rest.  There is suffering and loss, and the long, piercing wail of the bereaved down the hall, receiving the worst news of all.  They experience the addicted, the drug seeker who will tell any lie, contrive any store to get the pill or injection he or she so needs and desires.  They witness the poverty and need, the hungry, empty eyes of neglected children.   The may witness, or experience, the explosive violence and cruelty of the drunk, the criminal, the wounded.  In such a place, between suffering patients and suffering staff, what young, wide-eyed Christian wouldn’t ask, ‘Dr. Leap, is it possible to keep your faith and work in the emergency department?’

So here is my short epistle on the topic:

‘To the believers in the hospitals and emergency rooms, the church medical, across the land, around the world.  From your brother Edwin, who these years has fallen and gotten up over and over and who loves you and wishes to encourage you.

It is my prayer that you have strength to face the sickness and pain into which you plunge yourself every day.  All around you come victims; victims of disease and accident, victims of violence and neglect, cruelty and hatred.  The drunk and addicted, the angry and the sad, the suicidal and lost, the rejected and abused, the healthy and also the dying; and all are among the dying in the end.  Remember that all of them, and all of us, are also victims of sin, for it was in our separation from God in ancient times that all of this pain began, and in which death took hold of those originally destined for life.

Remember that the guilty and the innocent alike suffer from this, and that our Lord came to be an intercessor, high priest and atoning sacrifice for all.   Your struggle is against the infirmities of the flesh, but also against the wounds of the spirit that underly all suffering in this veil, until we reach the kingdom where death has no power…and you will be out of work for all eternity.  Amen.

Look around you each day, and consider that the emergency room, the hospital ward, the clinic, the operating room, these are places where the gospel is shown forth to you in power, a great gift from the Father so that you may understand by the example of others’ troubles what spiritual truths lie beneath it all and undergird it all.

Although we are all poor reflections, destined to one day (as the word says) ‘be like Him, for we shall see Him as He is,’ we are still his dim but ever growing likeness.   And we are His hands, feet, mouth, eyes, mind.  Like Him, we who go day in and day out among the lost, the suffering and those who (despite their willfulness) are hostages to evil.

And although we may have sin in our hearts, although we judge and are angry and frustrated, we do His work.  That is, brothers and sisters, we bring love and touch and healing and comfort to those who frequently have done nothing to deserve it, who exhibit no gratitude or intent to change, but who need our love, need the love and redemption of Jesus.  And like Him, we will show it seventy times seven, through temper tantrums thrown our way, complaints, cruel words, irresponsibility, patient satisfaction, EMR (the devil’s work) and every other difficulty.

Dear ones, in the ER, grace is at work, and a model of grace is there for you to enact and understand.  You give undeserved love and care for everyone all day, every day.  The Spirit gives you strength in hardship so that you may be bold, whether rested or tired, prepared or unprepared.  Also, remember that the spirit works in your sinful heart, to your salvation and holiness.  Those your treat are no worse than you and you no greater than them.  There is a great gift of holy humility in that truth.

One day, on that Great Day, you will see that each act, every stitch, every comforting hand, every EKG, every airway, every psychiatric commitment, each and every weary step into the same room with the same patient and same complaint, every unkind word for another physician restrained, every patient act, these were all acts of grace that molded you.   And the Father, Son and Spirit will welcome you, veteran of ten thousand daily trials.

And it is in this way that one can be a Christian in the ER, in the trauma center, clinic, operating room, delivery suite and all the rest despite the trials, temptations and bitterness that the enemy of our souls inflicts up on us in our work.

May the God of all peace guide you and strengthen you in your difficult work, and fill you with radiant, overwhelming love.

And may you have a quiet shift.

 

My Most Important Patient

Medical stethoscope on keyboard as symbol for administration and office

Listening for heartbeat of most important patient

 

This was my column in the March edition of Emergency Medicine News, as linked below.

http://journals.lww.com/em-news/Fulltext/2016/03000/Life_in_Emergistan__The_Most_Important_Patient.13.aspx

My most important patient requires my constant diligence. For this reason, I am seldom far away from him. Only a few minutes inattention and there will be problems. I cannot forget my patient; I am trained to attend to him constantly. I am a professional, and my patient is, ultimately, my customer and the customer’s service is paramount, I am told. I am reminded by policies and procedures as well, and there are those who will contact me, day or night, regarding failure to do what my most important patient requires.
In these 29 years since I started medical school, I have seen many wounded and sick patients of varying degrees of complexity and interest. Legions of fevers and columns of colds, tribes of chest pains and nations of bruises, entire cities of coughs, herds (as it were) of nausea and vomiting and battalions of sprains. Flocks of fractures and entire civilizations of chest pain. But none of them, not one, occupied me like my most important patient.
I was guided by teachers in urgency and priority, I was taught to hurry here, take time there, but always be attentive. I was shepherded by wise physicians before me, but never did any of them put a patient on a pedestal the way my most important patient has been. Neither snakebite nor sepsis, aneurysm nor arterial blockage, pneumonia nor parasite has ever been thrust before me as the most important patient…until now.
What could he have, you ask? What affliction? Who could he be? Of what importance? Celebrity? King? Judge or politician? Child of my own? Parent or priest? Hardly. Not one, not even captains of industry who endow hospitals, have the power of this patient.
This patient, this most important patient of all, stares back at me all day long. I examine and treat him with my hands and sometimes my voice as I stare intently back into his face. I wander off to other ‘patients,’ but all pale in comparison to this one. He violates all privacy and priority and knows absolutely everything. I see a chest pain next-door, or a pelvic pain across the hall; a weeping suicidal woman a few rooms down. I come back and tell my most important patient each secret. The sordid or tragic details of every life I whisper to him, or write upon his screen.
Once my hands loved examining other ‘patients;’ the shape of normal and injured bone, the sound of clear and diseased lungs, the nuance of stroke, the tenderness of the abdomen that took so long to understand. Now I have no time. I must touch my patient, enter the password and let my well- trained fingers run across plastic, not skin or bone. Or speak into his ear with a microphone, far more expedient than time wasted with others. Far more important and billable.
Every time I wander away, my most important patient calls me back; ‘hurry, hurry, tell me about the others! Don’t take too long!’ And others humans, more important than I am, remind me. ‘Don’t neglect your most important patient! Finish everything he needs as soon as you can! He is the key to all of our money! And if you don’t, we will fine you, or punish you in some other way for failing to care for the most important one of all! But make sure the flesh ‘patients’ are happy; give them a little time or they might be upset and not come back, and then what will you tell your most important patient?’
My most important patient is now everyone’s most important patient. He (or perhaps sometime she) is in charge. Sometimes he is shy and recalcitrant and will not wake up, will not look at me with his glowing eye. When that happens, nothing can happen. No orders for labs, xrays or medicine. He is an angry god, and when he is angry no one else can be happy. Sometimes he is confused and plays pranks on me, so that what I thought I said to him is turned on its head or made unintelligible. He is capricious that way; but ultimately far better than ‘people,’ who say and do things that my most important patient isn’t programmed to understand or record. He doesn’t like that, and forces me to do things in a confusing manner because he is angry.
And he is a time miser; he wants all of my time and those who brought him to me (or rather brought me to him, a kind of sacrifice) know that he is greedy and yet expect everything to run as before, when other patients were important.
But I know, and you know, those days are gone like electrons on a wire. Because now, the most important patient of all takes the most time and the most effort and the most diligence because data and billing and tracking and policies are what he does and his handlers love those things the way we used to love humans. And spoiled as my most important patient is, I believe it is unlikely that anything will ever be the same again.
Pity. Humans are interesting. But sick or well, they simply cannot stand in the way of data entry.