My column in this month’s SC Baptist Courier. Feel free to share as you like.
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.
This is my February 2017 column in Emergency Medicine News. Now, doctor, go hug your husband or wife.
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.
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?’
My column from the October edition of Emergency Medicine News
It’s August. I’m looking out the windows of our log house and across the immense variety of green leaves, on oak and birch, mountain laurel and sycamore, magnolia and honeysuckle. It’s a rain forest here. Indeed, after a long dry spell, we’ve had days and days of soaking rain, with breaks in the clouds so that the sun can raise steam from the earth like water coming up in the garden of Eden.
But the greens have hints of yellow. And the clouds are not just summer thunderheads but low, fast, and broken. The dogs are lazier than normal, as their crusted red-clay coats begin to flake off to reveal the fur underneath. Even the cats seem less mobile, if that were possible. The evenings, despite the blast furnace of August, cool more than in July.
All in all, the signs are there for those who watch. I grew up watching the weather, watching leaves flipped before storms, listening to the sound of winter winds, smelling storms on the air. I know Autumn is hiding across the Blue Ridge Mountains, a child peeking over and shaping the weather, teasing us, reminding us that summer will soon go on its own vacation and the wind will chill us and drive down the leaves, their red, orange, and yellow as varied as summer green.
But for all my love of Autumn, for all my desire for cool air and the smell of wood smoke, Autumn hurts me. It is the end of summer and the beginning of fall that takes my children from me and forces them back to school and schedules. It’s difficult enough to leave them for work, more so to know that my schedule and theirs conspire to separate something so vital, so elemental, as the time families spend in communion with one another.
Even as I write, my daughter Elysa, a high school sophomore, is finalizing her summer reading. Her brother Elijah, a high school senior, is spending his last days with his girlfriend Tori, who leaves for the University of South Carolina all too soon. My oldest boys, Sam and Seth, will return to Clemson in a few days, closer and closer to independence. The leaves change, the sky is darker, the children are growing up and moving on, with the imperatives and requirements of their own lives, their own passions, their own needs and desires, their own loves.
As difficult as this can be, I recognize that I did the same, as did my wife Jan. And our parents and theirs. This is the cycle, the natural history of the world. We raise and guard our precious children and launch them forth to do the same. And we hope that the chords that tie us remain intact; that the circle remains unbroken.
Time is Fleeting
What has any of this to do with our work? Our physician lives? The lesson is this: Time is fleeting; life and love are precious. Wives and husbands and children are rare gems in the rolling seasons of life. So waste not, want not, as it were.
The seasons will turn. The clouds race, the school buses arrive, and the graduations loom. In the midst of this, we must never delude ourselves that our money, our directorships, even our retirement accounts will ever be sufficient solace if we look back and feel that we did not use our time wisely with the ones who mattered most of all.
Our work, our patients, our skills all matter to the extent that they help others to live long and well, that they help those parents and children to enjoy the passing years together. Beyond that, they are important but less so than our own people, the ones we are committed to, bound to by vows and rings, by birth and blood, by adoption and choice.
So as the year turns and new opportunities and shifts arise, be honored. But be circumspect. Keep before you the fact that everything changes, but with attention and love, all of our connections can remain intact despite years and geography. If only we value them more than we do our certificates, degrees, incomes and positions.
The clouds will roll and the leaves will fall, my friends, and we might as well watch them pass with joy, not regret.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
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?
This was my column in Emergency Medicine News in September, 2016
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.
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.