Sleeping Around in Odd Places

I used to practice locums medicine; which for the lay-person means traveling to different jobs, sometimes several states at a time.   During that time I stayed in a lot of hotels.  But, occasionally, I had more unique accomodations.  Obviously, if you travel enough you’ll sleep in an airport here and there. No big deal.  I actually like sleeping in airports occasionally.  When you’re stuck, you’re stuck.  Weather or mechanical issues, it’s fun to watch everyone freak out.  I’ve put my carry-on under my head and passed out cold in the waiting area.  Probably snored like a freight-train.

I have also been put up in apartments owned by the hospital. Not necessarily bad, although one of them felt as if it really weren’t in the safest part of town.  I wouldn’t leave my things there, and I insisted on a hotel.  Such is the power of locums.  I had a nice room the next night.

Once I had to spend my first night in a sleeping room, after hours, in the back of a local mental health clinic.  That was a little creepy. Again, I said, ‘no mas.’  I had no interest in being accidentally committed.

I’ve also slept over in hospital call-rooms, even on days off. That can be good or bad, but generally the beds are wretched.  Which always makes me wonder why patients are so anxious to get into them.  I guess any bed beats an ER gurney.

In one small, critical acces facility, I worked 24 or 36 hour shifts and stayed in a converted patient room.  I felt a little like a very old man, raising and lowering the head of the bed, and listening in the hallway to hear nurses walking up and down, taking care of the elderly who were there for rehab.  I ate off of hospital trays, sometimes reclining on my hospital bed.  I may have gotten a little too ‘into character.’

Today, however, was unique. I’m not doing locums per se, but I’m working a full-time gig out of town; three or four on, seven off. The hospital has an apartment that it keeps for us to use.  However, after I worked overnight last night, I was given a key and an address and sent off to find my sleeping hole.    However, at 6:00 am, the lights were dim, the signs were poor and I had almost no idea where to go.  In the dark, I was driving down abandoned streets, looking at windows and doorways, skulking up stairs in a retirement center, trying to figure out just where to go.  Confident I would eventually be arrested, Tased or shot, I went back to the hospital and a few phone calls later I was told where to go.  Indeed, my apartment was on the premises of a retirement community/nursing home. At 6:30 I was admitted to said nursing home where the lights were bright, the news on, and on old man propelled himself in his wheelchair, whilst holding coffee and looking at me suspiciously. It had that feel of a place where the day is about to start, but the changing days mean nothing.

I had a momentary terror, that I had it all wrong.  Was I really leaving my shift, my 53-year-old self sleeping off the busy night?  Was I still in my vigor?  My children still unmarried and my wife a couple hours away, looking forward to my return?

Or was one of the kids going to come to me and say, ‘Papa remember, you retired.  This is your home now!  We’ll visit you later, now go back to bed.’  Shudder.  Anyway…

A kind nurse took me to my apartment, and out of the off timelessness of the nursing home proper.  I slept a while, and left to go home.  However, due to some schedule issues decided to stay in town.

Rather than return to the apartment, which would be in use by the next doc and would consign me to the couch, I got a hotel room.  ‘Ah, rapture!  Cool sheets, dark shades, television before the bed!’

But as I checked in, I was cautioned, ‘we’ll be testing the alarms, don’t worry!’  I didn’t.  And then, for about two hours the fire-alarm intermittently sounded, all but deafening me.  My ears still ring from the thing.

Finally it stopped, and I slept off some of the night shift and its exhausting chaos.  And I was not shot, stabbed, Tased, arrested, committed or restrained due to dementia.

It was, therefore, another pretty good day.

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

Vacations early and vacations late

I write from the large, quiet beach house where 21 family members have been enjoying one another, and the various delights of vacation.  I write from the solitude of the large dining room table which, this morning, was full of adults and children, from six to eighty, basking in the joy of breakfast, the smell of bacon and eggs, the delight of one another, the impending pleasures of a new day’s adventures.

Vacations come in two flavors, I see today. Early vacations in Spring are full of ‘what if,’ and ‘what shall we do,’ as well as ‘how wonderful to be together!’  They are powered by the kids’ freedom from the confines of schedules; they are super-charged by the joy parents have in being liberated from the homework and activities of their young.  Early vacations are made more delightful because not everyone is free yet, the traffic isn’t gridlocked and because (even on Southern coasts), the evenings are breezy and cool and the bed is chilly not from air-conditioning but from nature.

Late vacations are also wonderful.  All time together, laughing, floating in the pool, kickign the soccer ball on the beach, all of it is a sacrament of love.  But this morning, lying in bed, I watched through the window as heavy rain rolled over the side of our rental house; it was a gray dawn, with high dark clouds, and reminded me that Summer is not half over, but sometimes still hints at Autumn.  That Summer is a roller-coaster that runs faster and faster, and its cars are driven ever faster by the return of school, the heat of the season and by the advancing ages of the children we try so hard to keep young and nearby.

This is a late vacation; and an odd one.  Several of two of our children and one of their cousins cannot be here.  One is working, one is looking for an apartment, one is traveling in Ireland.  One will leave for college in a few weeks. They are doing what they should; in the Spring of their lives, in their twenties, life is busy.  But their absence punctuates the reality that all vacations, like every single year, change.  In a sunny homage to Heraclitus, ‘you cannot step onto the same beach twice,’ as it were.  Kids grow up, adults grow old and things move on to jobs and school; as they have and as they should.  The alternatives are for our children to be stunted forever like pets, or to die.  Better they should miss vacation.

The house is quiet, except for the dryer and the occasional young person scrounging for food and saying, ‘good night Papa!’ Or, ‘good night Uncle Ed!’  They make me smile, They inspire me.  And every year, we return to do so many of the same old things, to hold the form and shape of vacation even as the substance (mostly the children) move in and out.  And thus there is miniature golf, and bike rides; pizza night and games; throwing football and Frisbee on the beach.  Even having overpriced ice-cream too late and after too much food.

These are scaffolds that remind us of the past, and on which the young will perhaps build their own future times, or (when the times are right) bring their own loves back into our rickety traditions to enliven them.

This late vacation is drawing to a close, and I will miss it.  But we have a deep trove of memories, all of us, and we have build not only the frame but the solid foundation of love upon which families, this family, can stand for generations to come.

Tomorrow it will be hot and muggy.  But we will run on the beach with reckless, joyous abandon.

Nothing can take that from us as we drain the last drop of joy from this pitcher full of love and tradition.

 

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.

Emergency Medicine: a Model for Unity

This is my April EM News column.  I hope you enjoy it!

http://journals.lww.com/em-news/Fulltext/2017/04000/Life_in_Emergistan__A_Model_for_Unity_and.12.aspx

How do you define yourself? How do you describe yourself? In the past, I have tried to avoid immediately categorizing myself by my profession. I always agreed with The Little Prince:

“Grown-ups love figures…When you tell them you’ve made a new friend they never ask you any questions about essential matters. They never say to you ‘What does his voice sound like? What games does he love best? Does he collect butterflies?’ Instead they demand ‘How old is he? How much does he weigh? How much money does his father make?’ Only from these figures do they think they have learned anything about him.”
-Antoine de Saint-Exupery, The Little Prince.
Taken from https://www.goodreads.com/work/quotes/2180358-le-petit-prince

And yet, we do this constantly. Physicians especially love to divide ourselves into groups. Each group has its own characteristics. Most of those reading this (but not all) are EM docs (ER docs if you’re older), also known sometimes as ‘pit docs.’ There are internists, or fleas. Surgeons, or cutters. Anesthesiologists, or gas passers. Pediatricians, or pediatrons. Radiologists, or shadow doctors. Orthopedists, or carpenters. (I kid!) This is a natural division as our specialties are our big, nerdy fraternities and sororities. They are the places we learn to make our living, establish habits of thought and behavior, create world-views and life-long friendships.
Unfortunately, it goes much further than specialty. We are divided between rural and urban, and there are significant problems in that chasm, as physicians in urban teaching centers sometimes have little knowledge of the stark limitations of the rural setting when we call for help or transfers. ‘You don’t have a surgeon? You don’t have an ICU?’ Likewise, rural physicians often forget that even ‘the big house,’ eventually reaches capacity and can’t take transfers; and the presence of the large center (or a helicopter) is no excuse for sloppy care on the outside.
We are also demarcated by into ‘community vs academic.’ In my medical wanderings over the past few years, I have found that this is a point of contention with many community physicians. Research, treatment pathways, algorithms, check-lists and new imperatives seem to constantly emanate from academic centers and flow to the community hospital and its citizens. Community physicians, many of whom have lived through countless swings of the medical pendulum and associated policy changes, are often reasonably skeptical of the latest study, the latest rule about pain medications or sepsis protocols. They feel cut-off from what they perceive is a connection between academics and policy-makers, and they feel particularly excluded if, later in life, they have an interest in entering academia, which seems like a closed club.
Physicians are also increasingly divided by gender and sexuality, as we see various physician advocacy groups pop-up. That’s fine, I suppose, so long as it doesn’t split us further apart but serves as a source of encouragement and connection for the members of those groups. (It becomes toxic when it is used as an exclusionary tool. I was told once that my opinion in a debate was less relevant because I was a ‘straight white male.’)
However, our divisions seem to be at their worst when it comes to politics. And it’s a pity, really, because we have such potential to be models for the rest of the world. I have seen physicians argue politics in person and online. I have been part of some of those debates, and it can be very, very ugly. I have recently withdrawn from most political dialog because it wastes time, causes anger and accomplishes nothing.
But I will give this ‘opinion’ and stand by it. I’ve worked with physicians who were Christian like me, Muslim, Hindu and atheist. I have worked beside ardent progressives and hard-core conservatives who make me look like a socialist (and that’s tough to do). I have worked with physicians who were gay and straight, rural and urban, academic and purely clinical. I’ve laughed and cried with them, eaten with them, encouraged and been encouraged by them. And I’d do it all over again. Because when it comes to our job, our real job of treating the sick, easing suffering and saving the dying, all of our differences evaporate into vapor.
So identify yourself by whatever category you wish. But never forget that we can serve as a model for unity, a model for the greatness of all free people, when we do our jobs well, and do them together for the good of others.
Now, what’s your favorite food? What’s your hobby? Tell me about your wife, husband and children. Because those categories interest me more than all the rest.

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.

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

Life and Limb: the Rural ER

Welcome, readers, to my new column in the Daily Yonder!  It will concern rural emergency medicine and things I see through that particular lens.  Have a great day and feel free to share liberally!  I’m honored by the Daily Yonder to be included on their team, dedicated to all things rural.

Life & Limb: In Rural E.R., Exams Include the Obvious Questions, Like ‘Did You Get a Turkey?’

Once Upon a Time in Medicine

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.

Love,

Grandpa Doctor Leap

 

 

The Questions we Cannot Answer

img_3316

My column in the December issue of Emergency Medicine News.  Merry Christmas to all and to all a good shift!

http://journals.lww.com/em-news/Fulltext/2016/12000/Life_in_Emergistan__The_Questions_We_Can_t_Answer.13.aspx

I remember the early trials of thrombolytics; not for stroke but for MI. During my residency we were still comparing tPA with Streptokinase. It was pretty incredible stuff. Now we’ve moved beyond that positively ‘medieval’ method of treating heart attacks and have advanced to incredible interventions in coronary and cerebrovascular disease. Furthermore, we are able to rescue more and more people from the brink of death with advanced medications and with techniques, like ECMO, that our medical forebears couldn’t even imagine. These days, people can say things like: ‘I had severe sepsis last year, but I recovered,’ or ‘A few years ago I nearly died of Stage 4 cancer, but here I am!’ Fifty years ago, twenty years ago, their families would have told their stories with sadness.

What we do is amazing. The science behind our saves, coupled with our training and passion, make medicine all but miraculous. I am proud of what I know, proud of what I do. I am so impressed with my colleagues. And I am often awestruck by the scientists and engineers, without whom we would be apes poking bodies with sticks (good-looking apes in scrubs, mind you).
If we could, at the end of our lives, look back at the gifts we gave to the sick and injured, we would see that they far outweigh our errors and mistakes, our losses and failures. And yet, for all our modern innovations, we have limits. We can ask and answer a constellation of questions, and we can fix untold numbers of problems. But there are questions that defy us, and problems that leave us shaking our heads.
In spite of our pride in science, and our common dismissal of all that is ‘unscientific,’ suffering remains, and we can’t answer why. Who knows this better than those of us who have dedicated ourselves to emergency care?
For all of our miraculous saves, men and women, boys and girls, still suffer horrible injuries and have cardiac arrests, fatal pulmonary emboli. They still die at the scene of car crashes. They still develop mental illness and kill themselves. Addiction still separates families and leaves parents weeping for children, lost from life or lost in the jungle of drugs and desperate lives.
Despite the extension of life we offer so many, even the healthiest men and women will, at some point, leave one another and pass away from this life. And, knowing this fact does nothing to ease the pain of the loss. The most ancient husband or wife still shudders and weeps with the loss of a spouse the way a newlywed would; perhaps more bitterly, knowing love more deeply at 85 than ever they did at 25. And yet, for all our scientific wonders, we can’t say what lies beyond this life.
What I’m saying is that for all our medical wonders, there are just questions we can’t answer, and things we can’t fix. And it is likely that our science, however wondrous, never will have that capacity.
We know it. It’s why we cry after failed resuscitations, and why we call our children when they travel, frantic to know they have arrived. It’s why every EMS tone terrifies the parents of teens and every scan of a loved one is terrifying to those of us in medicine. We can’t control the troubles of this life nearly as much as we think.
Mankind has always known this. Ancient physicians, as limited as they were, did their best and wanted more. They saw the dangers of this life, and their own incapacity, with what was likely more immediacy than we. And sick, injured humans have always known the fear of loss, the questions of suffering, the pain of death.
Into this ‘vail of tears’ we proceed every shift. This is why I often tell young physicians that they should read and understand more than medicine. I favor religious faith, natural to mankind as it is. But if they decline religion, they must have a philosophy. Or they should read great novels, stories, poetry; or reach into the depth of music for some kind of solace in this mess of the unknown.
But let me say this, now that December is here: Christmas comes to offer hope to the hopeless and answers to the hardest of questions. There are those of us who believe its message with all our broken hearts. But even those who find it a charming myth can surely see beauty in the story of God (however you perceive God to be) become man. God suffering with men and women and rescuing them. God come to give a hope of forever to humans trapped in mortality. This is especially poignant to those whose lives have been a succession of one devastating loss after another. It is comfort beyond medicine for them to believe in a God, come to forgive their wandering ways, answering them in the midst of their cutting, suicidal, self medicating cries for rescue. No pill is as good as God come to make every loss whole, and heal every pain in eternity. No resuscitation comparable to God come to die and defeat death.
The pain of this life is enormous. We try so hard, but we can do only so much. The manger in Bethlehem is, if nothing else, a beautiful story to remind us that just maybe, there is healing for the wounds that lie beyond our science. Perhaps the very dream that there is meaning, that there is hope, is a suggestion that there is more there, more here, than meets the eye.
And maybe, the manger is even more than a distant dream, more than a quaint bedtime story, glowing as it does in the chaotic night of human suffering that darkens our ER’s and trauma centers.
Merry Christmas!