Remember those who care for the wounded. Las Vegas and beyond…

My column in today’s Greenville News.  Remembering those who respond in times of crisis; Greenville, Las Vegas and beyond.

http://www.greenvilleonline.com/story/opinion/2017/10/11/remember-those-who-care-wounded/746213001/

It’s hard to put into words the horror we all feel about the events in Las Vegas last week. So I won’t try. But what I will try to do is point out an often unspoken reality. Which is that those who work in emergency care constantly face terrible things with courage and skill and keep coming back for more. And everyone needs to remember that all those folks society counts on are truly remarkable.
Imagine, if you will, being the police officer who is called to an accident. They’re usually the first ones there. They roll up and survey the scene to make sure it’s safe. There’s twisted metal, spilled gasoline, possibly a fire. And all too often, there are gravely injured people covered in blood, surrounded by others screaming for help or trying their best to give aid. They call for EMT’s, paramedics and firefighters. They may start CPR. Or, if it’s the scene of a violent crime, they may be busy fighting to save their own lives, or the lives of others, from a violent death.
Next, those medics and firefighters arrive. Their job is to assess and stabilize the injured and get them to the hospital as fast as reasonably possible. They have to keep the scene safe, manage airways, put in IV lines, administer medications, dress bleeding wounds, shock dangerous heart rhythms, splint fractures and gather information. All in the chaos of passing cars, flashing lights, blistering heat, pouring rain, driving snow or dangerous winds. Never mind that they see heart-wrenching scenes of tragedy and loss; broken bodies of adults and children, grieving spouses, frantic parents. Never mind that sometimes they’re in as much danger as the patients when they treat the victims of violence.
Once they arrive at the hospital, it’s nurses and nursing assistants hurrying to move patients onto the ER bed from the EMS stretcher. Trying to get more information as patients scream, trying to replace IV’s that fell out, check falling blood pressures, slow rapid pulses, cover open wounds. Hanging blood to replace what has spilled on the floor; the tile slick underneath their shoes.
The nursing staff is busily notifying physicians of second to second changes as the gravely injured improve or deteriorate. Looking into the terrified eyes of patients who ask, ‘nurse, am I dying?’ and trying desperately to be hopeful. ‘Not if I have anything to do with it!’ It’s the nurses who are trying to restrain the frantic, confused patients. And sometimes, all too often, the nurses who are threatened, punched, kicked or stabbed by patients. It’s the nurses dealing with us irritable physicians and our demands. And escorting the families to the bedsides of those who died, or whose injuries and illnesses are unlikely to be survivable.
And there are the physicians, moving between rooms, assessing, deciding, placing lines, ordering X-rays and labs, putting tubes in collapsed lungs, evaluating who needs to go to the OR next; in large disasters, deciding who will have to be ignored, as they will not, cannot, survive. Physicians balancing the seriously sick and injured against the not sick at all who come with a rash, a fresh tick-bite, an ankle sprain; all ‘customers’ in the modern hospital paradigm. Customers who need to be seen as quickly as possible, and who are sometimes unsympathetic to the tragedies unfolding around the next hall.
It’s dramatic and it’s glorious in its own way. But all of those wonderful, dedicated people eventually struggle. The pain gets inside them, and even as they do their best, they wrestle with the memories, the question ‘did I do enough?’ And with the fear that it could happen to them or their loved ones. Some of them will face PTSD and depression. Too many of them will kill themselves because it was just too much. And a great many, especially in law enforcement, fire, EMS and nursing, are paid far less than they’re worth.
My heart goes out to all of those responders in Las Vegas. And Miami, Paris, New York, Kabul, Mosul, Houston, Puerto Rico, London. And in every place where brave folks bring hope and order against the background of blood and last breaths.
It’s remarkably hard to describe. And those who endure it all are either too humble, or to wounded, to tell the whole story. So have pity on them. And advocate for them. The world needs them 24/7.
God bless them and ease their pain as they ease the pain of others.

Even dogs get pain scales.

Unless you’ve been living under a rock, you’re well aware that the United States is in the grip of a really big epidemic of opioid abuse.  The epicenter of much of this has been my beloved Appalachia.  My home-town, Huntington, WV, might as well be re-named ‘Oxycontin,’ or maybe ‘Heroinville.’  It’s ugly.

Enormous amounts of ink have been spilled on this topic, and I don’t intend to explain the genesis of it in detail.  In short, however, about 20 years ago some doctors thought we weren’t being kind enough in our treatment of pain.  Some articles were published to draw attention to this theory.  We started using the pain scale.  0 = no pain, 10 = the worst pain ever.

Around the same time administrators discovered the customer/patient satisfaction score.  Taken together, physicians and nurses were pressured by 1) academic peers and medical directors as well as 2) administrators, to give more pain medication.

So, to recap mathematically:

Pain scale x Satisfaction score = better reimbursement + death

Recently, smart people have discovered that a lot of what we were told to do in clinical practice was probably (to put it delicately) utterly stupid and ultimately deadly.  Having said that, not all of the drug abuse in the country is because doctors gave out too many pills (although pill-mills are obviously a problem).

Some of it, in particular the heroin and fentanyl nightmare, has to do with bad decisions, experimentation and the high marketability of those drugs.  Enormous amounts of those drugs are manufactured in other countries and shipped here (obviously illegally).  Money talks, as it were.

The problem is, research suggests that patients of doctors with very high satisfaction scores often do poorly.  Think of your kids.  How do they turn out if you give them whatever they ask?  Not usually very well.  Often quite badly.  Ditto for patient care.  Nobody should get a CT scan or antibiotic just because they want it.  Nor should they get narcotics just because they scream ‘it’s a ten!’ Or because they ask to talk to the patient advocate or administrator.

The further problem is that administrators (and government) seem to be lagging behind science.  (Not that doctors don’t also; can’t throw too many stones in the glass house.)  But they get all worried when people complain that their pain wasn’t treated. And indeed, in many insurance payment schemes, pain management is really important. Don’t treat pain?  Don’t get reimbused well.

Ultimately, however, this national obsession with pain relief has landed squarely in the emergency departments of the land.  I work in a mid-volume emergency department in a community hospital.  And I’ll recap a few pain complaints that I have seen which illustrate the problem:

‘I had dental surgery and my oral surgeon said if my pain was worse I should go to the ER.’   My pain?  It’s about a 9/10.’  (Texting and laughing.)

‘I had a car wreck a month ago and broke some ribs.  I missed my follow-up appointment but I need more pain medicine.  My pain is a 10/10.

‘I fell down and hurt my knee yesterday.  (Xrays negative, mild swelling.)  Tylenol and Motrin are like taking candy.  I need something stronger.’

‘I go to the Methadone clinic but I didn’t get there today and I need pain control.’]

‘I’ve had sinus pressure for a few days.  No, I didn’t take anything for it. I came here!’

‘I hurt all over, and I’m hot and cold and sweating, and my wife says I have a fever, but I think I’m dying.’ (Did you take anything, he asked, knowing the answer ahead of time?) ‘I didn’t take anything.  I just came here.’

‘This cough is driving me crazy.  Can’t you give me something stronger for my pain?’  Yep, an inhaler so you won’t cough. And here’s a thought.  Stop smoking!

‘My 7-year-old daughter skinned her knee a few days ago and says that Tylenol and Motrin don’t help at all. Her pain is an 8/10.’  A child with a minor injury understands to rate her pain higher…

‘I just started a job as a brick-mason and my back is sore.  Can I get something stronger for the pain?’

‘I have migraines.  My pain is a 15/10 and Imitrex does not help.  The only thing that helps is Dilaudid.  Morphine is like water…’  (????)

‘Well if my wrist isn’t broken from the fall, Doctor, how come it hurst so much!  I mean, it’s a 10/10!’  (Uh, it’s bruised?)

‘My family doctor doesn’t give narcotics.  His office says I should go to the ER.’

‘My pain specialist is out of the country and his office says I should go to the ER.’

The list is exhaustive.  Ask your nurse and doctor friends; especially those who work in emergency medicine.  Ask them about the pain scale and watch them roll their eyes.

We’ve turned pain into a religion; worse, into a kind of physical victimization in which the victim of the pain is always right.  And is always entitled.  In the process, we have allowed people to forget that pain is important and normal. That it is necessary for our safety. That it probably helps healing; a body that doesn’t know there’s a problem doesn’t heal as well.

And we’ve created far too many people whose entire lives are predicated on a drowsly euphoria spent sitting on the couch or in the bed, while other people provide for them and care for them.

In addition, the constant requests for pain meds can distract us from those in genuine pain, and who really, truly need the ‘good stuff.’  The fractures, cancers, sickle-cell, and other patients who need urgent relief.

This is immoral.  It’s bad, bad, bad for our patients. But it’s also terrible for our hospitals; in particulary my beloved emergency department.  Because it means that around the clock, even as we try to make decisions that will hopefully save lives and prevent permanent harm, we are tasked with responding to every whim of the pain-scale.

All day, and in particular all night, our societal pain obsession has been shifted onto the backs of physicians and nurses in the ER.  There is seldom a break from this. And because federal law prohibits financial screening in the ER, many of our more nefarious and manipulative ‘customers’ know that if the pain clinic expects cash, at least the ER doesn’t. If the surgeon wants money to see you in follow-up, you can hoof it to the nearest ER and get pain meds (if you’re annoying enough) and maybe a sandwich or a ride home. And with all due respect, our Medicaid population knows the same thing. So a 3 AM visit for a minor complaint (with pain thrown in as a side) might get some narcotics; and doesn’t cost anything personally.

This leaves staff members exhausted, bitter and burned out. More so when administrators habitually take the side of the ‘customer’ against the already overwhelmed staff.

The bottom line is we’re hurting people.  Patients and professionals alike.

And it turns out, this is so pervasive that even the dogs have pain scales.  My wife and I cracked up when we saw this in the vet’s office.  I mean, pain relief is fine for dogs (it’s mostly NSAIDs). But a visual analog pain scale for dogs?

‘Lassie! Bark once for each pain scale level! What’s that? 20 barks? What are you a pure-bred Lab? It only goes to ten. You’re a drug seeker and you have a problem…Wait, is that my prescription pad?  Go home, you’re stoned…’

America, not all pain needs to be suppressed and most pain doesn’t require an ER visit.  Many people do need pain relief, and this frantic desire to treat every little ache and discomfort makes it harder for us to threat the ones really hurting.

And sometimes, when it comes to your pain scale, you’re just stupid.

Doctor Outspoken (A poem about doctors and free speech)

Doctor Outspoken

Dedicated to all the docs who pay for their opinions with harassment and sometimes with firing.

Oh doctor dear, we need you here!
We need you day and night!
We need your skills
At treating ills
So sick folks are alright.

Oh doctor wise, we need your eyes!
We need your healing touch!
We need your knowledge
From med school and college,
Your training all matters so much!

But doctor loud, doctor proud
we need not hear your thoughts.
You tend to complain
And you’re always a pain,
Remember that you have been bought!

Doctor mad and doctor sad,
Please silence your dissident views.
You’re here for the money
And trust me there honey,
We’ll find other doctors like you.

Oh doctor broken, doctor outspoken
We know that you have a full cup.
But don’t speak your mind
Just smile and be kind.
And oh, one more thing…just shut up.

Oh doctor mister, doctor miss,
Do keep in mind who is in charge!
You heal patients’ woes
But you’re really the foes
Of the suits and the clip-boards at large.

Doctor tired, you could be fired,
For sharing the things that you see.
You just have been ravaged
By business-folks savage;
Who think speech should never be free.

Doctor wise who tells no lies,
Thank you for fighting the fight!
If we all surrender
Then none will remember
When speaking for truth was still right.

Mid-sized ER Madness; Thoughts?

I know, I know, I spend way too much time ranting about work in the emergency department.  But after some recent shifts, my box of rants is full once more.  And what I want to point out is the enormous struggle of the mid-sized emergency departments in America today.

I know this is a problem; I work in them, and I know and talk with people who work in them.  It’s getting harder all the time.  So what is that ‘mid-sized’ ED?  For purposes of my discussion, I’d say (depending on coverage) somewhere from 16,000 to 40,000 visits per year.  Now that’s not scientific, that’s just for the sake of discussion, and based on personal experience.

I’d love to hear commentary from readers, because I’m trying to figure it all out.  But let me start with a story.  When I was fresh out of residency, I worked at dear old Oconee Memorial Hospital in Seneca, SC.  Our volume as I recall was around 23-25K per year.  We had pretty good coverage at first, with three 12 hour physician shifts a day.  Patients were sick but we moved them through.  And when I worked nights, I remember that it wasn’t unusual for me to lie down about 3 am and sleep till 7 am.

Fast forward.  Even at my current job where I see 19K per year, there’s barely a night when patients don’t come in all night long.  So is volume spread out more?  Maybe.  Are patients sicker?  Possibly.  I think some of this may be that patients have no primary care, and so they don’t even have an option to ‘wait till morning.’  In addition, a large number of patient (in all ED’s) are jobless.  So in their defense, 3 am is as good as 3 pm when you don’t have to go to a job in the morning.  (I’m not disparaging; but I do think this is true.  Think about your teenagers who sit up all night in the summer if they don’t have jobs!)

I also wonder if our patients are sicker.  I mean, medicine is pretty amazing nowadays, and people who would certainly have died when I was in medical school now repeatedly survive significant heart failure, MI, stroke, pulmonary embolism, respiratory failure, various infections and all sorts of problems.  And when they do, they have to come back to the ED frequently.

For those with docs in the community, I’m sure the offices are crazy busy all the time. Even those docs have patients they just can’t squeeze into appointments. They use the ED.  And maybe, just maybe, our patients are much more ‘medicalized’ than before.  So much of what the emergency departments see is really psycho-social.  Anxiety, depression, suicidality, substance abuse.  The numbers of these conditions seem to be exploding, and they can seldom afford primary care, much less mental health care.  The all-night ED is the place they go.

And there is a subset of patients who use the emergency department for entertainment or convenience; rides, snacks, a way to avoid arrest.  ‘Officer, I…have…chest pain!’  These also take time and space.

So what happens is all of this descends on departments with limited resources and staff.  And all day, and all night, one physician or two, maybe a PA or NP, struggle to sift through five or six chest pains alongside two stroke alerts, a suicidal overdose, two septic senior citizens, a dialysis patient who missed two appointments and has a potassium of 10 and a femur fracture.  Add to that the family of five with head colds.   Sure, this is what we do.  We are emergency physicians and nurses and mid-levels.  But into this mix, in the mid-sized department, recall that there is:  no cardiologist, no neurologist, no psychiatrist or counselor, sometimes no available ICU beds, possibly no pediatrician and definitely no dialysis in the hospital.

The day is spent sorting, stabilizing, making phone calls, transferring and waiting for ambulance or helicopter to become available.  All the while?  Sifting through very cumbersome and inefficient computer documentation systems designed for billing not flow.  And being scrutinized for through-put, time stamps, protocols, national standards, Medicare rules, re-admissions and all that mess.

I really don’t want to sound like a complainer. What I’m concerned about is 1) the safety of the patients and 2) the physical and emotional health of the caregivers.  At the end of the day, we’re all exhausted.  And so much is going on that we can barely find the obvious stuff, much less the subtle things that can also kill.

It sometimes seems as if departments are intentionally understaffed to save money.  I understand that it’s expensive to have doctors, nurses, etc.  But administrators get mad at folks ‘standing around,’ without realizing that in the chaos and suffering of the ED, sometimes it’s really important to ‘stand around.’  To breathe, to think, to rest, to gather oneself, to look up a condition or problem, to debrief.  To eat.  To pee.

I think that the world of medicine has decended on the emergency department.  I know that we handle it valiently.  But I don’t think it’s safe; and it’s nowhere as unsafe as in the relatively under-staffed and under-equipped mid-sized community hospitals of the world.

I’m proud of what we do.  But some days, most days, I wonder how we do it.

Any thoughts?

Edwin

Electronic Devices Shouldn’t be Used as Comforters (for Frightened Children)

The Dangers of Summer

This was my most recent column in the Daily Yonder.  Unfortunately, the Yonder website is down or I’d give you a hot link.

It’s Spring now and all across the land things are bursting with life. Flowers are in bloom, yards are bright with new grass and the sun is high in the sky. My car was, for a while, covered in a thick, green coat of pollen. Carpenter bees are still turning my log-house into Swiss Cheese. It’s pretty out, the sky is blue and the days are warm. Blah, blah, blah. I for one don’t really like this time of year. And it’s mainly because warm weather brings me patients with all kinds of injuries; some of them pretty nasty.

In rural America, there are dangers that seldom occur to people in more populous, metropolitan areas. Ironically, though, rural folks often assume that life in the city is more dangerous. And indeed, murder rates are higher.

However, according to the CDC, deaths from unintentional injuries are 50% higher in rural than urban areas; https://www.cdc.gov/media/releases/2017/p0112-rural-death-risk.html. These differences in death are due to several causes; rural citizens are further from necessary health care and are closer to large lakes and rivers, use dangerous equipment and firearms. Doubtless there are many factors involved in the difference.

Of course, some of the perils of rural life are just the result of living in close proximity to nature and all her deadly charms. In Spring and Summer, we encounter creatures that bite and sting. Just last year, while mowing our lawn, we must have run over yellow-jacket nests at least half a dozen times. By the end of the summer I just let the grass grow. ‘You win!’ I screamed to the little jerks, hiding in their holes. Whether it’s scorpions, hornets, wasps, centipedes, spiders or some other tiny monster, we simply encounter such creatures more in the warm months. And their various stings and bites, while rarely fatal, can cause dangerous allergic reactions. And make your spouse want to leave the area and move to a condo.

Fortunately, deaths from allergic reactions of all sorts are rare, and around 99 deaths per year in the US. https://www.aaaai.org/global/latest-research-summaries/Current-JACI-Research/death-anaphylaxis. Still, If you or your loved-ones are afflicted with such allergies, please talk to your physician about what to keep on hand; hopefully epinephrine injectors will get cheaper. And there are some other brands besides the ‘Epi-Pen’ that should be less costly. They just hurt a lot (the Black Widow) or make ugly wounds (the Brown Recluse).

Poisonous reptiles (Copperhead, Rattlesnake, Cottonmouth and Coral snakes) are also a feature of rural life in many areas. Those who ‘ooh and aww’ in city zoo reptile houses rarely have the singular delight of encountering these wonders in their own yards or whilst walking through the woods. But these creatures, while important to the eco-system, can deliver nasty wounds and in rare cases can be lethal. They’re certainly dangerous to your finances given the cost of anti-venin to treat the bites. So be aware as you go about working and playing in places where snakes are also enjoying the summer sun, or cool evenings.

Remember also that at least in the US, many snake bites occur because people are 1) intoxicated and 2) trying to mess with the snakes. And yes, ladies, this is a peculiar affliction of men that starts with ‘hey, betcha’ I can catch him!’ Actually, I have it on good authority that snakes don’t even like the taste of drunk people and would like to be left alone, thank you very much.

Now, other dangers of rural life have to do with the necessity of power-tools. In my own life, the chain-saw, weed-trimmer and lawn-mower are absolutely essential to keeping nature from simply over-running our house. But as the dear reader knows, these are things to be treated with great respect. Please use appropriate protective gear, like safety glasses, gloves, appropriate clothes and heavy shoes. Of course, those who work on highways or farms use much bigger types of tools and heavy equipment and have to be ever watchful. This is probably more true in Spring and Summer because that’s when farms are busy, roads need to be fixed, bridges repaired, pipes laid, power-lines connected, houses constructed and all the rest. God bless all those folks who make our lives better by doing hard, dangerous work on the hottest of days.

And of course, warm weather brings assorted recreational dangers. Hiking and camping are delights, but someone always manages to fall off of a waterfall or cliff-edge, break an ankle, sustain a laceration or encounter said biting and stinging creatures.
Bicyclists and motorcyclists look forward to warm months so that they can enjoy the open, dry road. But helmets really are important as is appropriate protective clothing, reflective material and good education. I’ve seen patients who left their tanned skin on 50 yards of asphalt. Nobody enjoys that.

Lakes and rivers are warm, and filled with persons who typically want to be dragged at high speed behind a power-boat while skiing, clinging to a large inflatable item for dear life, or kneeling on a wake-board. Likewise, fishermen head to their favorite spots (either in tournaments or alone for peace and quiet) and other aquatic persons kayak, canoe and raft the rivers that draw so many to rural America for vacations. All of which is fantastic! But remember to learn to swim, always wear life-jackets and follow local laws when doing all of the above.

Obviously there’s always the danger of heat exhaustion, heat stroke, dehydration and sunburn. We all have to remember to be careful to stay hydrated and remember that beer and caffeinated sodas don’t help. Also be reasonable about sun exposure and wear sunscreen to hep protect against skin cancers.

And if the gentle reader wishes to avoid painful foreign bodies and sutures, here’s another bit of advice. Wear shoes all; all the time. Simple and to the point.

Spring and Summer are glorious in rural America. But the dangers are many; I’ve only skimmed the surface here. Please remember to be safe, think before doing, follow the laws, don’t drink and boat, drive, ride, ski, pick up snakes, work with power-tools or do just about anything else. If you’re going to drink, find a chair and sit in it. That bit of advice would keep many an ER quiet all night long. Also remember that everything I said you shouldn’t do when drinking is something you shouldn’t do while taking narcotic pain medications.

I hope everyone has a great summer, free of emergencies. And that you can still be around when that first breath of cool air dips down from Canada and a proper season comes back once more.

Just please, please, be careful out there, OK?

(If you’re interested, here’s another link to a nice discussion of the unique injuries common in rural America. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448517/)

Welcome new physicians! Watch where you step…

Today is the day that new resident physicians begin their training all across the United States.  Today, our future family physicians and pediatricians, neurosurgeons and emergency physicians, plastic surgeons and laser tattoo removal specialists (OK, not really a specialty, just a side-line) will begin learning how to be physicians, having completed four years of expensive college and four years of even more expensive medical school.  Anxiety-filled and debt-ridden, they will embark on four to seven (or even more) years of training to make them knowledgeable, technically proficient physicians.

I will occasionally wax poetic and philosophical for their benefit.  But not today.  Today there are practical matters.  Today I want to give them a few pointers, to ease their transition into the maelstrom of post-graduate medical training.

1)  Any flat surface that holds still, is free of gross body fluids and not used as a walk-way or cook-top will serve for a quick nap.  Practice sleeping in odd positions:  sitting upright, reclining at various angles, lying sideways or with your head cradled in your hands.

2)  In my day (always wanted to say that!) we filled our fresh, white lab-coat pockets with review books, algorithms, reference manuals, scissors and calculators.  And candy bars.  You, doubtless, have a smart-phone of some incarnation, which contains all that we had, as well as the Web.  Which means, where we had to play video games in the lounge and find answers in giant, antiquated things called attending physicians and books, you can look up fun facts on hyponatremia and instantly play Angry Birds, whether you’re on rounds, in the cafeteria or hiding in the call-room, pretending you didn’t hear ‘code blue.’

3)  Eventually, you may decide the lab-coat isn’t worth it.  Don’t be surprised.  Your kids will eventually wear it for Halloween.

4)  If you keep the lab coat, what with the extra space in your pockets, carry extra candy bars.  Or protein bars, or whatever it is you crazy kids snack on these days.

5)  Watch where you step.  Trauma patients and cardiac arrests are exciting!    But there’s almost always some body fluid on the floor when the shouting is over.  Try not to get too covered in blood early in your call night.  It’s sticky and gross.

6)  You know so much.  You don’t know anything.  Keep those two ideas in constant tension.  Odds are, your command of modern evidence-based medical research is extremely impressive.  Eighteen years after residency, I can still leave you in the dust when it comes to making decisions and knowing who is sick and who isn’t.

7)  See above.  Learn, as quickly as you can, who is sick and who isn’t.  Hopefully medical school helped; but don’t count on it.  If you know this simple thing, you will know when to go for help, when to panic (or not) and what to tell your upper level residents and attending physicians on rounds.  And you will become that greatest of commodities:  useful.

8)  Look professional, develop your own style.  Be comfortable.  My friend Sherri used to wear pearls on call, with her green scrubs.  They always made her appear elegant, no matter how much pediatric vomit had been hurled her direction.

9)  Patients can be frightening.  But remember what they told you at camp, about bears, raccoons and snakes.   ‘Don’t worry, they’re just as afraid of you.’  This is kind of true.  Except patients really aren’t afraid to ask for pain medicine or call attorneys, whereas you are afraid to do anything since you can’t believe you know anything yet.

10)  You may be more frightened of physicians than patients.  But remember, the people assigned to train you are smart, capable and experienced.  And they put their tentacles in their pants just like everyone else.  Ask them questions, listen and watch.  And remember what I said above:  be useful.  My surgery resident was fond of saying, ‘Help me, don’t hurt me!’

11)  You will soon have a thing called a paycheck.  It will have a stub that shows how much the government is taking from you.  Do not be surprised.  This happens to everyone.  It’s just that you owe a lot more money than most people.   Cheer up!  Everyone expects you to be rich someday, so they can complain about the fact that your rich.  (Whether you will be or not remains to be seen.)  Remember that no matter how little or much you make, never tell a contractor or car-dealer you’re a physician.  Tell them you work in customer satisfaction, or something nebulous like that.

12)  Crazy people, even really crazy people, are sometimes terribly ill.  Pay attention.

13)  Ill people, really ill people, are sometimes very crazy.  Pay attention.

14)  Medicine is inexact.  I promise you will make mistakes. Don’t live in fear, and don’t let error define you.  No one in medicine, or law, is capable of perfection.  Except for being perfectly insufferable, of course.

15)  If you poke things that look like they are filled with blood or pus, they will explode into your face; if you tend to hold your mouth open when you focus, well you know what will happen.

16)  Scalpels really are sharp.  Pneumonia and HIV and TB and Hepatitis really are communicable.  Psychotic patients really will try to choke you.  Medicine is dangerous.  Be careful out there!

17)  Human beings are really frail, vulnerable and hurting.  Be gentle and kind whenever possible.

18)  Have fun!  Don’t think of it as residency, think of it as a chance to spend most of your waking and many of your sleeping hours in a huge, cold-building where people are dying!

19)  Everyone is proud of you.

20)  Pay attention to what the nurses say.  They aren’t always right.  But for quite a while, they’ll be right more than you are.

21)  Only three to seven years to go!  Hang in there.  Remember, it’s no different from Boot Camp.  It just lasts much, much longer.

Pandora’s Pill Bottle. (A poem about the narcotic epidemic)

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.

Grandmothers as an ER Preventative Measure

This is my column in the latest edition of the Daily Yonder.  Enjoy and share as you see fit. Link followed by text.

Life & Limb: Grandmothers — An Ounce of Prevention for a Pound of ‘Freak Out’

 
I have a theory that engaged, wise grandmothers could save families a lot of money by helping avoid hospital visits. Personally, my grandmothers were very important to my well-being as a child. Not only did they feed and dote on me, they kept me healthy and safe. I remember the time I made a spear out of a sharpened stick. (OK, one of the times.) I was running with it, and as I drew back my arm to fling it across the field I must have stumbled. It ended up going through the top of my shoe and between two toes, scraping them on the way to the ground.
I limped to the big white house under the maples where Grandma Leap helped me take off my blood-soaked shoe, cleaned the wound, probably applied Merthiolate (didn’t we all spend our summers painted orange?), and said ‘don’t tell your grandpa, he worries!’ Maybe she knew he’d take my now cool, blood-stained spear away. I was none the worse for the wear.
I have seen injuries like this time and time again in the emergency room. Relatively minor affairs; scrapes, bumps, bruises, stings, nevertheless brought to the hospital by anxious mothers and fathers, new to parenthood or simply far more worried than necessary.
I also remember the smell of Vicks Vaporub, slathered across my coughing, wheezing chest. I remember cool cloths applied during fevers. My grandmothers had those simple skills down pat. Honestly, I don’t ever remember coming to the hospital for a fever as a child. And yet, fever is one of the most common complaints for which parents bring kids to the hospital.

‘He started having a fever an hour ago, so we rushed him to the hospital!’
‘Did you give him anything for the fever?’
‘Nope, we just came straight away. We freaked out and decided it was better safe than sorry!’

I hear that a lot. There was a bruise. ‘I freaked out.’ There was a tick, ‘I freaked out.’ There was a rash. ‘I freaked out.’ The baby’s nose was congested. ‘I freaked out.’ Freaking out never helps anything. And from what I can remember, it was simply something my grandmothers never did. Their job was to draw on centuries of collected cultural and family wisdom, apply personal experience, mix it all with loving attention (and food), and bring calm to all situations. Or bring switches as the situation required.
I’m not suggesting that a family member is all that’s necessary in times of medical need. And admittedly, there are plenty of grandmothers who are as ‘freaked out’ as everyone else. (I’ve met them.) Furthermore, lots of grandmothers and grandfathers are already doing this job as primary caregivers of their children’s children. God bless them.
However, it seems to me that we have an unholy confluence of problems that make people seek healthcare for things our ancestors wouldn’t, or couldn’t have. First of all, families are separated for various reasons from wise older relatives; or don’t have any. Second, people have 24/7 access to online health information that often only increases fear. Third, we have enormous numbers of young individuals and parents who never learned much about their bodies. Add that to the general increase in anxiety that mental health workers report across the land, and families are completely overwhelmed by the sorts of ailments that have afflicted mankind since well before modern medicine existed.
It seems to me that with our long history of self-sufficiency, and our deep-rooted connections to place and family, rural America should be one of those places where grandmothers could make a real difference in an era of limited medical access, coupled with enormous medical anxiety.
Maybe, in the mountains, valleys, bayous and plains that make up rural America we can be health pioneers! What we need to do first is educate young people about how to give simple medical care to themselves and others. First-responder and First-Aid/CPR courses are a great place to start. Second, those of use who are more experienced can reach out to young people and young families; neighbors, church-members, strangers at the food-bank, and offer to be there to teach them how to manage life situations. And how not to ‘freak out.’
Finally, those of us in medicine, whether nurse, physician, medic or other, can spend time educating the people we see so that they know when, and most important when not, to worry. And never to freak out.
A thing that grandmothers, in times past, taught us oh so well.

 

Introducing Social Orbit

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

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

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

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

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

 

www.socialorbit.com

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