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

Dear Colleagues: you are not alone! (My column in the SCCEP newsletter, Summer, 2016)

http://www.sccep.org/

You Are Not Alone Guest Column: Dr. Edwin Leap

In this column, SCCEP Member and renowned columnist, Dr. Ed Leap, shares with us some heartfelt compassion and insight about being an emergency physician. Next month, SCCEP will award Dr. Ed Leap the Jack H. Warren Award in appreciation for his many years of leadership supporting the goals and missions of SCCEP and ACEP. Thank you Dr. Leap for your lifelong support of emergency clinicians (docs, nurses, techs) everywhere.

Dear emergency medicine physicians, You aren’t alone. This is very important for you to realize. I mean, I know you aren’t ‘alone.’ You have spouses and children, parents, siblings, neighbors, dogs and cats. That’s all good. You need them.  Also, every shift is chock-full of people and their maladies, which you heroically manage day in, day out. Patients are everywhere. Some are sick and some are injured, and many are addicted and a few are just lonely. They’re inescapable. And nurses. They’re all around also. The ones who carry out your orders, tend to your patients, sometimes ignore what you say and constantly interrupt your train of thought by putting EKGs in your face and shouting ‘Chest pain in room three will you see it!’ Or who constantly ask you ‘is the order in yet?’ You can’t escape them. Even a trip to the restroom will result in a phone call in short order.

Furthermore, there are students and residents to educate, and shape into excellent doctors. (Without killing anyone.) And there are consultants too. The ones who tell you ‘call me when the workup is finished,’ or ‘why didn’t you get the phosphorus level? How can I know what to do without the phosphorus level! Jeez!’ And there are those who refer patients to you. ‘Hey buddy, my patient has pneumonia and needs to be admitted to the hospitalist and has a bed but I need you to check him out first.’ The ones who send you their post-op complication one hour after the surgery.

There are other people all around too. There are administrators and managers, credentialing ladies, people tracking your times and your efficiency and evaluating your patient satisfaction scores. There are medical records people and coders tracking you day in, day out, to keep you on point with the endlessly important charting and billing that are the main purposes of your decades long education. Dear doctor, you aren’t alone. But not because of all of that.

Not because you’re under more scrutiny than at any time in the history of medicine. What I mean is, having traveled this great land of ours doing locums, I assure you that the struggles you face are present everywhere.  Oh, they vary in degrees. Those little oases untouched by the icy hand of EMR can be positively pleasant in their lack of complex charting requirements. And on night shift, in the middle of nowhere, in the mountains, there’s a paucity of people in general. But there will still be complex social situations, still be drug addicts, still be someone who wants to know about your door to needle time. Everywhere you go, there’s ‘that doctor’ who is simply surly and impossible to please when he’s on call.

When I say you aren’t alone, what I mean is that we are a fraternity (or a sorority if you wish). Perhaps better, we are a tribe, a clan, an extended family. Emergency medicine is a small specialty but what we do is so consistent across the country, and around the world, that we can all sit down at conferences or meetings, in airports or over dinner, and share the same stories, the same sorrows, the same laughs over the same archetypes. So when you come home and think that you’re the only one who thinks about quitting, you’re wrong.

We all do it now and then. When you think that maybe you’ve lost your patience with drug seekers, you’re wrong. We all lose it now and then. (I’m not proud…so I won’t go into it.)  If you think that you’re not fit for night shift because you feel terrible after being up, trust me you aren’t alone. Nights make everyone nuts. (As does day shift…and evening shift.) It’s a wonder we don’t all need psychiatric evaluation after long strings of sleeplessness coupled with complex care of the arguably the most demanding people on earth.

Are there days when you just want to go home and cry? Normal. Are there shifts you think you didn’t really know what was going on with anyone? Ditto. (PS, it usually means nothing was going on except drug seeking and the pursuit of work excuses.) Have you wanted to invite your on call specialist to the parking lot for a ‘come to Jesus meeting,’ and you think you have a problem? Nope, I’ve been there. And do you think that you might be the only physician with an EMR ‘inbox’ that’s full to the brim with requests you can barely understand? You aren’t. In fact, I suspect that delinquent charts have exploded in the last few years as charting becomes more and more complex.

Ladies and gentlemen, are there times you think you should have studied harder and tried for that ophthalmology residency? Haven’t we all. You aren’t alone. You aren’t alone in your troubles. But more important, you certainly are not alone in being part of the baddest, toughest, most compassionate and courageous group of physicians in the world.

You’re tough, you’re kind and you’re smart. You endure, no matter how hard or complex the shift, no matter how badly you feel.  You’re weary and irritable and pale. You’re hungry and thirsty and sometimes confused.

But kids, trust me. You’re awesome.

And you aren’t ever alone.

The doctor will show compassion after he’s finished charting

I was working in a hospital recently and saw a note from a CEO on the computer. Notes and memos are ubiquitous these days. Bathroom walls, break-rooms, computer screens. Everywhere there is another reminder to check this, do that, mark those, record metrics, hurry up, don’t make mistakes, sign orders, complete charts, be nice and all the rest.

But this note stood out. In it, the administrator was reminding the medical staff that their job was tolerance, compassion and understanding. I’m not surprised by this. I’m aware that some administrators make ’rounds’ in patient areas and assess how things are going. (Concerns about HIPAA seem irrelevant, as I mentioned in a recent post.)

It seems, in a kind of ironic inversion, that the business side of medicine has tasked itself with telling the medical side how to be nicer doctors, better doctors, caring doctors. I’m not surprised; but I suspect it isn’t due to any collective epiphany about medical professionalism. Ultimately it’s really less about patient satisfaction, that Golden Egg that drives almost everything in medicine now.

But the irony runs deeper. While the CEO can hold forth on lofty, but important themes like understanding and tolerance, while various administrators can stroll through the ICU or various units shaking hands and making nice, physicians are doing something else. Lots of something else.

In the emergency departments where I work, physicians scurry out to see patients then run back to chart. And chart. And chart. And in many instances to sift through the endless possibilities of ICD-10 codes (I recently saw ‘2nd degree burn due to water skis catching on fire.’). Sometimes we are expected to code in more detail. Discharging a patient is, itself, often a complex process filled with orders, searches, clicks, signatures and locating the right printer.

I recently worked at a site with a shiny new nationally known EMR. ‘Please call the hospitalist,’ says I to the secretary. ‘Alright. Will you enter the consult order in the computer so I can document it?’ I’ve been handed faxes to fill out myself and of course, nothing gets done until it’s ‘put in’ the computer. Another rant for another day, as I digress.

The physicians rarely look up from their keyboards to chat, except when running off to see the patients who inconveniently stand between them and their real job of data entry, billing and coding. All done real time. If you don’t do it, by the way, you’ll get e-mails or texts the next day about your unsigned orders. ‘The coding department needs these right away.’

There was a time of collegiality. There was a time when we discussed cases and our feelings and our sorrow and our passion. That was when medicine was about people. Remember them? The upright primates on whom we practice medicine? Now? Now it’s about numbers and billing, metrics and tracking, satisfaction scores and rewards…and punishment.

Little wonder the CEO can round, or hold forth on the intangibles that lured many of us to love medicine in the first place. Physicians aren’t physicians anymore, not since we handed the reigns over to administrators so that we could ‘focus on the practice of medicine.’ And not since billing became so complex in order to justify every pen stroke, every bandaid, every pillow fluff. And not since the growth of administration, which has itself dramatically increased costs just as it has in universities across the country.

I want us to be tolerant and caring, compassionate and kind. But it’s hard to do when your entire job is less about humans and more about business. It’s hard to do when the volume of patients explodes thanks to unforeseen consequences of the ACA, the endless beatdown of EMTALA and the unending medicalization of everyday life. It’s nearly impossible when you’re tracked like a Caribou for every action and every key-stroke. It’s hard to do when there are no rests, no pauses, no coda in the great dance of emergency, or any other, type of care.

I often work in small, slower places. I do it in part because I can sit and talk. I can breath. I can think. Heck, I do it because I can act like a CEO.

Medicine is great. I love my work. But that’s the thing. I love my work. My real work. Meeting the sick and injured, figuring out what’s wrong, sifting through truths and untruths, danger and anxiety, solving problems.

I don’t love the slavery of modern medicine, which will be the same whether it is run by corporations or government. (So don’t kid yourself that nationalized care will solve this problem.) Governments and corporations are virtually interchangeable anyway.

Perhaps worst of all, I don’t like seeing my colleagues, young or old, as the joy escapes from them shift by shift, only to be replaced with exhaustion and bitterness. Or fear of some unknown repercussion from some faceless manager who leaves takes an hour lunch every day and leaves at five.

Maybe CEOs need to be lectured on how to have compassion and understanding towards their physicians and nurses. I think I’ll start rounding in their offices.

And writing my own memos…

The Wonders of Over the Counter Drugs!

Here is my column in the February SC Baptist Courier.  Not everything requires a prescription, you know!

https://baptistcourier.com/2016/02/wholly-healthy-the-wonders-of-over-the-counter-drugs/

I recently had an enormous kidney stone. Well OK, it seemed enormous to me. But in terms of kidney stones, it was reasonably large; 9mm in fact. Large enough that I had to have lithotripsy (the use of sound waves to break up the stone) performed by my friend and most excellent urologist, Dr. Robert McAlpine in Seneca, SC.

As uncomfortable as the whole experience was (and it wasn’t my first rodeo either), I was reminded of something very important, which is that prescription drugs aren’t all they’re cracked up to be. In fact, the best pain relief I had from my kidney stone involved the little blue wonder-pill (for which I would have given a lot of money, let me say), the humble, the magnificent Naproxen, aka Aleve). The reason for this is that the class of drugs to which Aleve belongs (nonsteroidal antiinflammatory agents or NSAIDs) acts to relax the spasms of the ureter, which is the tube from kidney to bladder where the demonic stone takes up residence and tortures its victims. When the spasm relaxes, the pain improves.

This is relevant for many conditions and situations, from kidney stones to cough, because the things found in the average pharmacy or grocery store are magnificent medical manna from heaven. Actually, I remember one of my medical school instructors at WVU, Dr. DiBartolomeo, encouraging us to wander the aisles of the local pharmacy and be awed by the variety of useful things on the shelves.

In an age when tremendous numbers of people take too many prescriptions; in an age when vast numbers are addicted to narcotic pain killers, it’s good for us to remember that there are simpler ways to manage our acute illnesses and simpler tools to employ in the task.

I’m sure I have previously subjected the reader to my rants on treating fever, but in a nutshell, ‘fever is natural, usually good and can be treated with ibuprofen and/or acetaminophen…over the counter.’

Bitten by an insect and itching? Inexpensive antihistamines abound in the local pharmacy, which is a true cornucopia of possible allergy therapies. Sore muscles? Twisted ankle? NSAID’s like Aleve or Advil are sitting in their bottles, bursting with willingness to treat the pain of injury…or kidney stone as related above. Mild poison ivy dermatitis? Calamine lotion and antihistamines are a nice, soothing option for treatment. Ingrown toenail? There are antibiotic ointments, salt-soaks and other wonders. Dirty wound? Pour some peroxide in it and watch the chemical go to work! (Kids love it and it doesn’t hurt.) Head cold driving you crazy? Antibiotics won’t help, but some pseudoephedrine, or saline nasal spray might get you through.

If you take medications or have medical problems already, check with your pharmacist about side effects and interactions. But just remember that there are lots of nice ways to treat your common medical problems that don’t require a doctor visit or an expensive prescription.

The Leap Physician Satisfaction System

This is my column from the November issue of Emergency Medicine News.  Observations on keeping physicians professionally satisfied, healthy and happy.

http://journals.lww.com/em-news/Fulltext/2015/11000/Life_in_Emergistan__The_Leap_Physician.7.aspx

The Leap Physician Satisfaction System

I have never been the director of any professional group. I have, however, been directed. As such, I have a few tips for those who are directors and administrators. I give you my ‘physician satisfaction system.’ It is arranged in no particular order.

In every physician break-room or lounge, there should be a wall for photos of girlfriends, boyfriends, children, spouses, parents, dogs, cats, horses, boats, new shotguns or whatever makes those doctors happy. Emphasis on children and spouses, boyfriends and girlfriends, moms and dads. See below.

Post this where physicians work. ‘If you have a husband or wife, please avoid having a girlfriend or boyfriend. It is unfair to your spouse and children. And it is very, very expensive, as hobbies go. You’re better off with a boat.’

In every physician break room there should be: 1) a recliner 2) a refrigerator with snacks and drinks 3) a television with cable 4) a computer with Internet and without the silly hospital fire-wall. Pay for it yourself if you must.

Know your doctors. The best way to do this is to talk to them. It’s tough to really talk on a shift. The best way to do this is away from work. A quarterly group dinner is a nice touch. Or simply, ‘hey, let’s go to lunch one day and catch up.’ You have to mean it though.

Remember that a married doctor is a unit. When there are important decisions to be made (into which you and your partners are allowed input) invite your doctors’ husbands and wives to give their opinions. You’ll be grateful for the wisdom a loving spouse brings to the table. And remember, nobody is more motivated to make the group money than a spouse with a mortgage to pay and babies to raise.

If you really want to score points, send a card or note to the group spouses now and then. Thank them for their service, their encouragement, their patience. Ask them how their family is doing. Remember that being married to a physician ain’t exactly a pony ride. Everybody needs a kind word.

Attend weddings, celebrate births, have anniversary parties. Visit the sick in your group. Send condolences. Mourn at funerals. Laugh and cry. If you take the time to know them, it won’t be hard. They’ll be family.

Lead…from…the…front. If your docs tell you nights are really hard, work a string of nights. If they tell you that someone on staff is really hard to consult, talk to that person yourself a few times. (Tell those difficult doctors to back off and play nice.) If everyone hates the EMR, do everything you can to make it work for them. Never ask your ‘troops’ to do something you won’t. Never, ever.

Be fiercely partisan towards your guys and gals.

Help your doctors develop long-term plans, including an exit strategy. Don’t talk about it, do it. We can’t all go into urgent care or academics, but we can plan for a slow, steady withdrawal as the years go by. Encourage wise decision making, especially in the young Jedi.

Develop a sabbatical. Encourage your doctors on sabbatical to travel, take a class, enjoy sleeping in their own beds. It may be the longest time they’ve slept all night with their husbands or wives consistently in years. It may be the first full reset of their circadian rhythm since medical school.

Watch your doctors closely. It’s easy to become overwhelmed, depressed, anxious. Help them through mistakes. Let them decompress. Let them be sad. Don’t chastise, teach. Find a local counselor in case they need to talk about that death, that tragedy, their personal demons. Doctors kill themselves sometimes. Try to keep it from happening.

Identify the strengths in your doctors. Some are born leaders; let them move in that direction. Some are brilliant clinicians, use that. Some are great with people. Let them mentor. Some have hobbies or interests that make them better physicians. Celebrate the unique individual gifts that every partner brings to the table. Now and then, use these to remind the hospital what a unique and valuable team you have.

Take pride in your group. A logo and t-shirt would be a nice point of pride. Brag about your doctors. Tell the local newspaper about them. Help them be invested in the community, treasured by the community.

Praise your partners, both to their faces and to others. Write down the good things they do for future letters of reference.

Give your team permission. Permission to succeed, permission to fail. Permission to try new things and sometimes, permission to leave it all behind.

On really busy nights, call in pizza from home. On terrible nights, come in and use your authority to make things happen more smoothly.

There are a lot of schedules, in a lot of ED’s, with holes in the schedule. If you don’t want your entire group to realize this, and leave, and then come back making more as locums than they did before, then be their advocate.

We have a hard job. But with the right leader, it can be wonderful even when it is hard. It’s up to you, directors, to set the tone. Good luck and Godspeed.

We Should Value Life Until The End. (My latest G-News column)

This is my column in today’s Greenville News.  I understand why people ‘want everything done’ when they’re old.

http://www.greenvilleonline.com/story/opinion/contributors/2015/11/15/we-should-value-life-until-end-ed-leap-thanksgiving-health-care-costs/75585450/

It’s a well known reality of health care economics that Americans spend a lot of money in the last year of life. I suppose that almost goes without saying, since serious illnesses and injuries that result in death are costly, at whatever age they occur. Being hit by a car and dying means you were hit by a car… in your last year of life. And that two weeks in ICU before you die is, obviously, expensive. But this truism is usually applied to Medicare dollars in the care of the elderly. This group often has protracted illnesses that require costly treatments, specialty care, hospitalizations and home-health; despite the fact that the improvements in outcome or length of life are often pretty limited.

When I was a young physician (younger…that’s better) I sometimes jumped on the band-wagon and wondered why everyone wanted so much for so little gain. I was always surprised when elderly patients didn’t want ‘Do Not Resuscitate’ orders, or other ‘advanced directives’ to limit care. I would sit with other young physicians and we would ask each other, ‘what does he hope to gain?’ Or of the family members ‘why don’t they just accept the inevitable?’

That was then. I have taken care of the elderly for my entire career. And over the past year, especially, I have worked in some communities with especially high numbers of senior citizens. That, coupled with the fact that I see things differently since I’m, well, less young, has given me new insight. So let’s re-frame the question. ‘Why don’t the elderly want to simply give up and die without a fight?’ To which the answer is, ‘they’ve lived long enough to know that every second is precious.’ Perhaps more importantly, they know that all of the people in their lives are precious.

I have watched elderly couples, 70s, 80s, 90s, and the way that they hold hands. The way they brush the hair from one another’s faces. I have heard them whisper ‘I’m here’ in the emergency room and ‘I love you,’ in the ICU. I recently listened as an older patient called his wife on the phone from the hospital. ‘How are you? Well you sound fantastic! I’m fine’ He encouraged her and comforted her, and wanted to simply hear her voice. They were anchors to one another in a treacherous, frightening world.

My son once reminded me of a saying, which I here paraphrase. ‘We die twice. Once when we breathe our last, and once when someone says our name for the last time.’ The elderly get this. They want to be with the people they love and to be remembered by them. And in particular, those with spouses hold on because that gray, infirm, frail woman or man whose hand they hold is the last repository of an absolute treasure trove of shared memories and stories. No one else knows the same subtle jokes, the same turns of phrase, the same looks that betray fear or joy. Nobody else remembers their trips to the beach or the way their children sounded when they splashed in the pool during vacation. Nobody else knows how to hold their hand just the right way. And no one else understands the importance of touching feet in bed under the sheets, or remembers their favorite restaurant now closed, or grasps the importance of that inexpensive ring worth more than a ten carat diamond.

Friends and children and grandchildren also hold such memories for the aged, or they hope to fill their descendents with those memories before they leave so that, for just a little longer, the stories will survive. They want their love, passion and experiences to remain, and not just in a box in a corner of an attic, that may or may not survive the purge when the house is sold.

The elderly want to fight death the same way we all do. Because life is incredible. And in fact, we should want them around. They have navigated many decades and many challenges. They have wisdom and they have perspective to spare and to share.

This Thanksgiving, if you want to really grasp the holiday, sit down with your older friends, uncles and aunts, grandparents and parents and ask them what they’re thankful for and what they love. (And watch the way they love.) Because odds are, you’ll learn something magnificent and hear some stories that deserve to be treasured.

Then, those ‘end of life’ expenses might suddenly make more sense.

Prayers for a quiet night

Many of you, dear readers, work in busy hospital settings. And often, you do so at night.  I have written a lot about nights down the years.  In fact, my first book was a compilation of columns titled ‘Working Knights,’ in a word play on a column I wrote called ‘The White Knights of Medicine.’

My 2 years of locums haven’t been too bad as nights go. Usually I’ve worked overnight in critical access facilities where nights often meant actual, uninterrupted sleep.  But I’m facing three busy nights, starting tonight.  I’m working in Medium Community Hospital, in a popular tourist location.  I’m not excited, but neither am I filled with dread.  Over the years, I think I have become hardened to nights in a way. While I’m working, I can really pull it together.  Having 22 years under my belt, since residency, makes for confidence.  Working so often alone, in the middle of ‘East Egypt,’ also adds a level of certainty and resilience.  The recovery is the difficult part.  The next day I usually feel fairly awful.  But I get the patients seen, and more importantly (these days) I get the charts done.  I feel like I’m at my peak as a professional.

Some of that also has to do with routine.  I have things I do when I work nights.  First of all, I rarely sleep well the first night.  I accept that fact.  Second, I take enough food and enough drink to stoke the fires all night long (and it’s a pretty big fire when I’m tired).  Third, I wear a jacket or soft shirt because my cortisol drop at night leaves me shivering.  Fourth, I pray.

Yep, that’s right. I have a routine.  It’s no secret that I’m a Christian. I write about it with some regularity.  And thus, I incorporate prayer into my pre-shift routine.  I do it, in fact, for every shift, whether day or night.  Occasionally I forget. God understands.

So what do I pray? Let me give you my routine.

I pray the Doxology, the Gloria Patri, for my family, for my patients and then the Lord’s Prayer ( or Pater Noster if you’re of a Latin inclination).  (If you grew up in some churches you sang the first two and you may know the tune.)  My routine goes like this:

Doxology:

Praise God from whom all blessings flow,

Praise him all creatures here below,

Praise him above ye heavenly hosts.

Praise Father, Son and Holy Ghost.

Amen.

Gloria Patri:

Glory be to the Father, and to the Son and to the Holy  Ghost.

As it was in the beginning, is now and ever shall be.

World without end,

Amen.

Pater Noster:

Father, God, please watch over Jan, Sam, Seth, Elijah and Elysa tonight and keep them in your care.  Bring us all safely home together.  Bless my patients, and let no one be seriously injured, or killed, or die.  And give me insight, wisdom, knowledge and love to do my work.  In Jesus’ name.

Our Father, who art in heaven, hallowed be thy name.  They kingdom come, they will be done, on earth as it is in heaven.  Give us this day our daily bread, and forgive us our trespasses as we forgive those who trespass against us.  And lead us not into temptation, but deliver us from the evil one.  Amen.

I’m not saying everyone should do this. It’s my thing.  It’s my strength in time of trial and fatigue.  And despite it, bad things happen.  God is sovereign over ER’s too.

But I’ll tell you this.  With the right prayer, the right food and drink and a warm jacket, I can endure almost anything night shift throws my way!

God bless you on yours.

 

 

Pass The Salt Please! (My latest in the Baptist Courier.)

Here is my latest column in the Baptist Courier.

https://baptistcourier.com/2015/05/wholly-healthy-pass-the-salt-please/

One of my favorite physician sayings is ‘don’t just do something, stand there!’ Which means that it’s better to do nothing than to do something that doesn’t help. As I move through my career, I find myself agreeing. I am endlessly amazed at the number of things we do for no good reason, and that patients come to expect, also for no good reason. For instance, we believe that every earache and sore throat needs an antibiotic, when it’s clearly not the case. We always give antibiotics for seven to ten days, but without knowing why we picked those durations (other than the fact that they were easy to remember).

We seem to be very gullible when it comes to over the counter cold and cough drugs, even though there’s truly limited evidence that they work. And when the drug companies throw Tamiflu around, we embrace the marketing with joy; despite the fact that it’s a thing of pretty limited benefit (a topic I have covered previously). This isn’t the fault of any one person or group. We want to believe the advice we receive from medical researchers! And as practitioners, we want to have confidence in the things we use to treat the sick and injured.

One of the truly orthodox dogmas of medicine is the low salt diet. If you ask anyone in medicine or nutrition whether to limit salt intake, the answer is a slam-dunk. ‘Of course low salt diets are good for you! Salt is bad!’ For decades we have been taught, and we have preached, the evils of salt. So much so that I remember once when my wife was very ill, and wanted some regular soup (with salt) I was having a terrible time finding anything that wasn’t ‘low sodium.’ However, it appears that like the low fat diet, and the high carbohydrate diet, the low sodium creed may be fading away. (Hopefully the salt-free crackers stocked in hospitals will also be a thing of the past. A Saltine, by definition, should be, you know, salty!)

It turns out that recent reviews of the data on low salt diets suggest that the average American diet just might be well within safe parameters, and that low salt diets only cause small changes in blood pressure (probably only in a subset of patients with high blood pressure). In fact, there is some evidence that diets with normal salt intake may be associated with lower risk of cardiovascular events and death than low salt diets! Who saw that coming?

If you want to read a nice summary of how we developed our ideas on salt, and about the current debate, this is a nice article in the Washington Post.

http://www.washingtonpost.com/blogs/wonkblog/wp/2015/04/06/more-scientists-doubt-salt-is-as-bad-for-you-as-the-government-says/

And for those wanting to delve into the numbers in a large recent study on the topic, here is a link to the PURE study (referenced by the Washington Post), published in the New England Journal of Medicine.

http://www.nejm.org/doi/full/10.1056/NEJMoa1311889

I’m not saying you should start dumping huge amounts of salt on your food. But it may be reasonable to worry a good bit less about salting your food, or finding low-sodium items at the store.

On the other hand, it’s OK for us to keep being the Salt of the Earth. Spiritually the world needs all the salt it can get.

 

The value of religious faith in the practice of medicine

The value of religious faith in the practice of medicine.  Delivered to students at the Virginia College of Oseopathic Medicine, Spartanburg, SC, earlier this year.

Faith in medicine? Why does it matter? I’ll tell you a couple of reasons.

Let me qualify, this is not about evangelism and it is not a crusade. I am a Christian, but you may not be. Nevertheless, you must attend to the three things I am going to mention.

First, it matters because of your humanity and that of your patients. You’re just starting your journey, full of love and goodness and hope. But It matters because humans can be difficult. ‘Check yourself!’ Stabbings, abuse, shootings, overdose, lies. It matters because doctors can be difficult and we need to recognize that. To assess ourselves soberly. ‘You check yourself!’ The rant in the mud and blood. My ‘take it to the parking lot’ attitude.

Next, it matters because however difficult they are, they’re wonderful and beautiful. And however beautiful and wonderful, they’re difficult and sometimes dangerous.  It’s easy to spout platitudes about serving humanity, and it’s even easier when humanity is sweet and gentle and appreciative.  It becomes harder when humans, like doctors, are ugly, angry, uncooperative, resentful, hateful and violent.  Faith teaches us to overcome the problems of humanity in ourselves and in our patients.

Faith also matters because 0f suffering. Biology doesn’t answer suffering. Darwin for all his insight doesn’t answer suffering. This is not to disparage Darwin. It wasn’t his purpose. Neither does chemistry or pharmacology or anatomy or surgery or emergency medicine or oncology. All of those are things to manage or describe suffering. Why suffering? I have some answers, but they lie in theology. You must have some answers. It is part of your job to comfort your patients (as we comfort those we love most, often simply by loving them). But you must answer suffering for yourself. For I believe that much burnout is an excuse to excuse ourselves from the presence of too much suffering. I am not entirely convinced it is wrong to do so.

Finally, faith matters because of hope. What can we offer outside of temporary relief? What can we offer the young mother with life altering cancer? The parent of the dead child? The terminal diagnosis, the lifelong disability, the endless pain? If this world is naturalistic, meaningless, devoid of purpose, then it is doubly hurtful.  It is a horrible thing to experience suffering and then to conclude that perhaps nature is just weeding you out as either less fit or of no further use.

Can you find hope for yourself? Can you give hope if someone asks?

Here are some quotes and insights that have been of value to me.

“There is the great lesson of ‘Beauty and the Beast,’ that a thing must be loved before it is lovable.”
G.K. Chesterton

“What a chimera then is man. What a novelty! What a monster, what a chaos, what a contradiction, what a prodigy. Judge of all things, imbecile worm of the earth; depositary of truth, a sink of uncertainty and error: the pride and refuse of the universe.”
Blaise Pascal

Hope means hoping when things are hopeless, or it is no virtue at all… As long as matters are really hopeful, hope is mere flattery or platitude; it is only when everything is hopeless that hope begins to be a strength.” G.K. Chesterton

Hope is one of the Theological virtues. This means that a continual looking forward to the eternal world is not (as some modern people think) a form of escapism or wishful thinking, but one of the things a Christian is meant to do. It does not mean that we are to leave the present world as it is. If you read history you will find that the Christians who did most for the present world were just those who thought most of the next.”  G.K. Chesterton

“God is love.  That is why he suffers. To love our suffering world is to suffer…The one who does not see God’s suffering does not see his love.  So, suffering is down at the centre of things, deep down where the meaning is.  Suffering is the meaning of our world.  For love is meaning.  And love suffers.  The tears of God are the meaning of history. ”

Philosopher Nicholas Wolterstorff, who lost a son in a climbing accident.

“Contrary to what might be expected, I look back on experiences that at that time seemed especially desolating and painful. I now look back upon them with particular satisfaction. Indeed, I can say with complete truthfulness that everything I have learned in my seventy-five years in this world, everything that has truly enhanced and enlightened my existence has been through affliction and not through happiness whether pursued or attained. In other words, I say this, if it were possible to eliminate affliction from our earthly existence by means of some drug or other medical mumbo-jumbo, the results would not be to make life delectable, but to make it too banal and trivial to be endurable. This, of course, is what the cross signifies and it is the cross, more than anything else, that has called me inexorably to Christ.”  Malcom Muggeridge

It is a serious thing to live in a society of possible gods and goddesses, to remember that the dullest most uninteresting person you talk to may one day be a creature which,if you say it now, you would be strongly tempted to worship, or else a horror and a corruption such as you now meet, if at all, only in a nightmare. All day long we are, in some degree helping each other to one or the other of these destinations. It is in the light of these overwhelming possibilites, it is with the awe and the circumspection proper to them, that we should conduct all of our dealings with one another, all friendships, all loves, all play, all politics. There are no ordinary people. You have never talked to a mere mortal. nations, cultures, arts, civilizations – These are mortal, and their life is to ours as the life of a gnat. But it is immortals whom we joke with, work with, marry, snub, and exploit – immortal horrors or everlasting splendors.”  C.S. Lewis, ‘The Weight of Glory’

I have received no assurance that anything we can do will eradicate suffering. I think the best results are obtained by people who work quietly away at limited objectives, such as the abolition of the slave trade, or prison reform, or factory acts, or tuberculosis, not by those who think they can achieve universal justice, or health, or peace. I think the art of life consists in tackling each immediate evil as well as we can.” C.S. Lewis, ‘The Weight of Glory.’

At present we are on the outside of the world, the wrong side of the door. We discern the freshness and purity of morning, but they do not make us fresh and pure. We cannot mingle with the splendours we see. But all the leaves of the New Testament are rustling with the rumour that it will not always be so. Some day, God willing, we shall get in.” C.S. Lewis, ‘The Weight of Glory.’