Pandora’s Pill Bottle
‘Patients who suffer from painful conditions
Should always be treated by caring physicians,
Who never forget to give good medications
For problems from fractures to awful menstruation.’
‘The fifth vital sign is your bright guiding light
The pain scale will lead you to do what is right,
So doctor remember to show some compassion
Since giving narcotics is now quite the fashion!’
Thus we were told for a decade or two
As patients stopped breathing and turned rather blue.
But hospitals loved their new high survey scores
And doctors were turned into pill-writing whores.
Yet things are now changing across the whole nation.
There’s blame all around and new drug regulations.
‘What were you thinking? What were you doing?’
‘How could this happen? Someone will start suing!’
In ER’s and clinics and every location
We docs shake our heads with increasing frustration.
We did what they told us despite all our fears
And Pandora’s Pill Bottle spilled out for years.
The pain scale betrayed us and caused too much trouble
The fifth vital sign is a big popping bubble.
The statistics we’re reading have left us quite nauseous.
So we’re trying new things to save lives and be cautious.
Dear doctors it’s you that must make these decisions!
Push back against administrative derision!
And when those ‘above us’ make policy errors
Stand in for the truth to prevent further terrors.
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.
Grandpa Doctor Leap
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!
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.
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?’
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.
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):
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.
My column in the April edition of Emergency Medicine News
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.
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!
I was at a locums assignment yesterday using FEEMRS. (You know, ‘Fancy Expensive Electronic Medical Records System?) It was all kinds of busy, with wait times of many hours. And as I slogged along, relearning FEEMRS after a few weeks away, I realized that it takes about one hour of looking at that screen for me to become exhausted.
It’s just too ‘busy.’ Every bit of the screen seems filled with some data, some field, some time-stamp. Oddly, I struggle to find the triage note, the home medications, the history. I struggle to find whatever orders I have entered and to see if they have been completed. I throw my hands up trying to discontinue orders and I nearly weep when it’s time to discharge a patient, a process which takes far too long with various orders, time stamps, discharge instructions, medicine reconciliations, printer selections and all the rest. Honestly, it’s far easier to admit someone to the ICU than to discharge them. At least in terms of computer time.
That’s the thing about FEEMRS. The ‘flow’ is all off. Oh, it’s data rich. But it’s mentally exhausting. Too many clicks, too little useful data, not nearly enough ‘white space.’
Furthermore, there are the orders to sign and the charts to sign. And after you’ve signed them, there’s another place to sign. And if the nurse so much as helps them to the door, and enters that fact with appropriate time-stamp, ‘0300, touched patient on elbow at door,’ well it’s going to need another physician signature to validate the elbow touching event and document that it was necessary, approved and billable.
Docs using FEEMRS across the country are daily beset by hundreds of orders that require signatures the next day; things we didn’t even know were orders. ‘Placed bandaid.’ ‘Paged nursing supervisor for admission.’
A friend of mine was asked to sign nursing orders for psychiatric meds (Psychiatric Meds!!!), placed by nurses for hold patients three days after he went off shift. He wisely refused but was told ‘its OK, everybody does it’
By contrast, this year and last, I worked at TMH (Tiny Memorial Hospital and its several campuses) where I (gasp!) used paper charts or dictated to a human transcriptionist. My patient’s meds were either in front of me or one flip of paper away. My discharge instructions were a check mark away, or three clicks on a different program. And often, for orders, I check a box and handed it to a secretary to enter into the system. In some instances, my prescriptions were written by hand (not perfect) and could be ‘deleted’ or ‘reconciled’ with a simple tear of the paper.
I notice, now, that when I go back to my hotel room after working with FEEMRS, I sleep poorly. No wonder. I’m clicking and looking, scanning screens and logging on and off until 2 am. I tell my kids to stop looking at screens before bed or they won’t sleep well. I keep it up till the wee hours.
FEEMRS is quietly, slowly, electronically killing all of us and making us less concerned with patients than we are with fields, files, clicks and saves.
Something has got to be done…
I just do n’t know what.
Time for a rant! I’ve written a lot lately about caring for our patients, and about caring for our spouses and those things make me very happy. But now and then, things rub me the wrong way.
I was recently working at TMH, or Tiny Memorial Hospital…my vague name for small facilities since I work at several and wish to preserve their anonymity. While there a patient checked into the ED for a fairly unremarkable complaint, for which she was evaluated and treated in a reasonable time.
But before she left, we received a phone call from ‘the Mother Ship.’ TMH is part of a large system of hospitals. The phone call was from the ‘foundation.’ Turns out our patient was a donor well known to said foundation.
Mind you, we never called them, texted them, e-mailed or faxed them. No consultants were contacted, no transfers arranged. We were just doing our simple doctor and nurse thing. But the Mother Ship was inquiring how she was. Which means that someone was notified about her visit to the ED.
Now mind you, it may be that she agreed to this in the process of supporting the institution. Maybe it was a perk. I didn’t ask.
But what bothers me is that if any one of the nurses on staff had so much as looked up their own lab-work, they would have been terminated for a violation of HIPAA, the privacy statute.
This is a common policy, but let me repeat it. According to most hospitals’ interpretation of federal privacy statutes, looking up one’s own results on the hospital computer is a firing offense. Not only so, but spyware is installed so that the staff’s home addresses are cross-linked to those of their neighbors just in case they look up someone else’s information…a friend who asks for information, for instance.
Furthermore, I cannot even hand a patient his or her lab-work to take to his or her physician the next day. Why? It’s a violation of privacy. I don’t understand, but I doubt if I’m supposed to understand. (Almost all things federal dwell in a kind of fog impenetrable by logic and reason.)
But donate enough and someone will know when and where you went to the ER. And that’s just good customer service, right? Right.
Privacy, HIPAA, is for little people.
And yet: Quis custodiet ipsos custodes?
‘Who will guard the guards themselves,’ or as it is commonly rendered, ‘who watches the watchers?’
I don’t know, but I guess we all need to watch ourselves lest we end up fired.
The only other alternative, it seems, is to donate a lot of money.