What Jesus would do, and say, today…

My most recent Greenville News column.

http://www.greenvilleonline.com/story/opinion/contributors/2017/02/10/commentary-some-thoughts-what-jesus-would-do/97743538/

Some thoughts on what Jesus would do today 

(As we all grow more and more divided and arrogant in our views.)
Given the current political climate, a lot of our citizens are reasonably sure they know exactly what Jesus would do if he were here now. I happen to have a few thoughts on that topic myself.
It seems to me that first and foremost he’d disappoint us all by not debating the way we do. He’d actually love the people he was talking with, and want the best for everyone. Screaming matches and endless point-counterpoint were never his thing, or so it appears in the scriptures.
I think that while everyone was trying to convince everyone else about their opinion (and not changing anybody’s mind), he’d be on some street-corner healing sick people. And he’d be doing it in a way that was so dramatic people would think he was a charlatan. ‘There’s no way that paralyzed kid can walk now! It’s just a trick to convince simple-minded, unscientific people!’ That’s what some would say. And Jesus would keep right on healing cancer, HIV, gunshot wounds, schizophrenia and other awful problems.
And those people who were so full of inner pain that they wanted to die, and kept thinking that they had no worth? He’d heal their pain, and cast out demons from them. That’s what the Bible says he did, anyway. He said he was God and he taught about things like demons. People probably wouldn’t like that much; neither atheist skeptics or solid, staid, educated Christians. But the people he healed would love it.
Of course, he’d talk to people at the marches, the rallies, in the halls of legislatures and in the churches. Unlike our milquetoast, pale-faced images of gentle Jesus from Bible story-books, he would sometimes look (and be) angry. Angry about injustice and cruelty, angry about the neglect of the needy. He would also be angry about false teachers and others who robbed men and women of faith in God and left them nothing to comfort them. As before he would be angry at anyone who led others to sin. Occasionally, he would be sarcastic and insulting. He’d have harsh words for lots of pastors and sanctimonious believers. Read the Bible; it’s how he was.
Our many-flavored hatreds would give him plenty of fuel for parables, in order to guide us to the truth. But he would also be unhappy about the division and ideas heaped on people that leave them feeling worthless. Like the idea that humans are a scourge, a virus on earth. Or the obsession with hungry, sick animals while children face the same. And the way men and women are weighed down with one of two burdens, endless victimhood and its chiral image, the belief that some people’s ‘privilege’ causes all the world’s problems. He came to liberate everyone from beliefs that imprisoned them. He condemned religious leaders in his day for giving people burdens but not helping carry them; he would do the same for modern politicians and educators, ministers and mullahs who create anger, tension and violence in order to control and manipulate others.
Obviously, would talk about ‘sin,’ from greed to sexual immorality to idolatry and all the rest. He talked about those things a lot. He’d preach about the coming Kingdom of God and eternal life and redemption and judgment. He was serious about sin, but kind to all sinners, right, left and moderate. Conquering sin and death was his main mission, after all.
That would be just about enough for lots of folks. Because they didn’t come to be pressured about morals or lectured about their personal lives or told stupid fairy tales; they came for justice! For revolution! And they’d ask him to leave. Or maybe scream at him, because it’s what we do when we’re angry and sure we are right.
Ever the gentleman he would leave if asked. But before Jesus left, he might remind all of the passionate, angry people of what he said before:
“You have heard that it was said, ‘love your neighbor and hate your enemy.’ But I tell you, love your enemies and pray for those who persecute you, that you may be children of your Father in heaven. He causes the sun to rise on the evil and the good, and sends rain on the righteous and the unrighteous.’
It seems to me that in his absence he remains present, and his teachings still condemn our hatred 2000 years down the road. If only we’ll listen.

Sanitized Human Experience in a Reality Challenged Culture

 

My column in today’s Greenville News.

http://www.greenvilleonline.com/story/opinion/contributors/2017/01/27/commentary-hollywood-sanitizing-human-experience-reality-challenged-culture/97136066/

I love a good action movie. I tend to prefer the Marvel franchise over DC. I think Superman is too perfect and Batman just too moody. I mean, which rich guy would you rather party with? Bruce Wayne or Tony Stark? Exactly.
But I have always been amazed at the amount of destruction wrought by my beloved X-men and Avengers when battling monsters, aliens, gods and other ne’er do wells. Buildings and freeways and bridges destroyed, untold cars exploding, earthquakes and giant holes in the ground. It’s apocalyptic! In fact, if that were really happening, the toll of human dead would be staggering. Tony Stark could probably make a fortune selling coffins, and ER docs like me would be overwhelmed.
Movies like that are obviously meant to be outlandish; and to take your hard-earned vacation money. But I fear that television and movies sanitize too much of our bitter human experience, making misery somehow palatable.
Take regular action films for instance. Whatever the underlying story, it seems that gun-fights are everywhere! Bullets fly in all directions. Then, at the end of it all, bystanders aren’t injured. Nobody lies moaning or screaming for help. We don’t see the pools of blood spreading across the ground, the skin becoming more clammy, more pale as police call for an ambulance, as the paramedics or surgeons try frantically to stop the flow. We don’t see, or hear, the family member of the dead when they’re told what happened. I’ve done that a bunch and it’s something you never, ever forget. Scenes like that don’t make for fun entertainment.
In our movies nobody sees survivors, good and bad, condemned to paralysis, or with colostomies or amputations from those exciting gun-fights. What about characters punched and kicked to a pulp, their faces bloodied until they can’t breathe? They get chronic headaches, brain damage, vision problems, inability to chew or smell. I have seen them die too.
But we’re oblivious to more than real violence. When we watch trials and cheer for justice, when we want this or that person to go to prison for their crime, we sometimes forget that the imprisoned don’t see their families much, and their families miss them for years, or for life. And let’s not forget that prison, real prison, is a place where violence, rape and drug addiction are far too common.
I hate it when someone says, ‘guess he’ll get it good in prison; I hope he enjoys his cell-mate,’ or some other bit of cruelty. It’s never OK to wish for someone to be raped, male or female. Ever. Although prison has a necessary role, maybe we need to revisit the boundary between punishment and torture. We should want better for even the worst; especially if we call ourselves Christian.
There are others disconnects, of course. When characters in movies have multiple sexual partners, it looks like nothing but fun to modern, sexually liberated viewers. But we seldom see the misery of loneliness that comes from all of those connections, made and broken. Films and television do a poor job of showing us the pain and terror of HIV or hepatitis, the anxiety of unplanned pregnancy and the reality of abortion. They fail to reveal the suffering brought by cervical cancer associated with HPV. The don’t show the tears shed over infertility caused by chlamydia or gonorrhea infections; the danger to newborns caused by herpes. It’s also hard to fathom the fact that many who work in pornography are miserable in heart, mind and body, and some around the world are compelled to do it against their will, working as sex slaves.
On screen, getting drunk is just what you do. We have all laughed at intoxicated characters, for as long as actors have played them. But we seldom consider the mortality and disability from car crashes. We rarely think about the way men and women die from head injuries or asphyxiation due to alcohol or drug abuse. We don’t get to witness the abuse and neglect of children, the cruelty to spouses, the lost hope, lost productivity and broken families from both.
We have to remember that what we see in movies and television is seldom the whole story. Sometimes, the truth is better. And sometimes, unfortunately, the reality is a lot worse, and far darker than the screenwriter, producer or director can ever, or would ever, convey to our entertainment soaked, reality challenged culture.

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

 

 

My column in the Winter 2017 Gray Matters, Newsletter of the Osher Lifelong Learning Institute at Furman University.

 

THE NEWSLETTER OF THE OSHER LIFELONG LEARNING INSTITUTE @ FURMAN

http://www.furman.edu/sites/OLLI/member-resources/Documents/GMJan2017-PDF_reduced.pdf

PAIN MANAGEMENT AND THE TIE TO ADDICTION – PART 2

Sometimes medicine offers us wonderful, almost unimaginable gifts. Heart attacks that were devastating, life-altering events a few short decades ago are now treated with an expediency and skill that our grandparents couldn’t imagine. A couple days pass, and the victim is home with stents in occluded arteries and directions to modify activity and diet. Pneumonia, once the ‘old person’s
friend’ (so called because it took the aged to eternity), is far less terrifying, thanks to both antibiotics and the pneumonia vaccine.

However, some of the things we do give benefits that are less clear. Although it could be an entire column in itself, the ‘stroke center’ movement, with the promise of miracles from ‘clot-busting drugs’, is a thing full of as many questions as answers. And what about depression and anti-depressants? When I looked up the side-effect profile of an anti-depressant a friend was taking, I was reminded that all of them have the potential side effect of increasing suicidal behavior.

But what about pain management? Thanks to improved understanding of the physiology of pain, the persistence of medical providers, and the investment and research of pharmaceutical companies, we have a wide array of pharmaceuticals available for the treatment of pain. Some are over-the-counter, like acetaminophen and ibuprofen. And others, those we refer to as narcotics or opioids (because in previous times they were derived from opium), are useful, potent, and (as is increasingly evident) fraught with danger unless used very cautiously.

Of course, for a very long time, physicians were taught to be judicious in prescribing narcotics. Our venerable teachers warned young doctors in training to be frightened of the side effects. We were especially aware of the very immediate danger that patients would stop breathing and die due to excess sedation. We were also aware that over time, patients on narcotics might develop problems with addiction.

About 20 to 25 years ago, that whole paradigm shifted and physicians were suddenly accused of callous disregard of suffering for prescribing too few narcotics. I remember this because I was in my emergency medicine residency at that time. We were constantly reminded to give more narcotics and be sensitive to pain. We were taught to use the ‘pain scale,’ in which a patient-reported score of zero meant no pain and a score of ten meant ‘the worst pain of your life.’ Never mind that it was entirely subjective and that there was no objective standard, no ‘painometer’ against which to measure it. We were instructed to see pain as the ‘fifth vital sign’ after blood pressure, pulse, respiratory rate and temperature. Of concern to many, these initiatives coincided with the development and aggressive marketing of ever more powerful, addictive medications like Oxycontin tablets and Fentanyl patches and lozenges.

Patient satisfaction surveys included the question ‘was your pain adequately treated?’ Physicians were castigated when those satisfaction survey scores fell. Physicians were instructed, by non-clinician

15

administrators, to give more pain medication to make patients more satisfied. (A satisfied customer/ patient is one that may come back!) Physicians who resisted, in the name of science or safety, were too often met with threats of reduced income or job loss if patient satisfaction scores fell. In some instances, physicians were (and still are) reported to state medical boards for alleged inadequate treatment of pain.

I sincerely believe that most of those encouraging us to write more narcotics prescriptions did so out of genuine concern and compassion. People are in pain, so why not treat the pain? In medicine, where science meets suffering humanity, it’s so easy for us to say, ‘Well, it just makes sense, doesn’t it?’ We assume that our compassion will be supported by our science. It happens with infections; sure it’s probably a head cold, but what’s the harm in an antibiotic to keep the patient happy? The child bumped her head pretty hard, so what’s the problem with a CT scan, even though she looks good? The parents are customers, after all, and want a scan!

With tragic consequences, our compassion sometimes causes harm as the Law of Unintended Consequences rears its ugly head. For instance, those antibiotics for colds? They can cause dangerous allergic reactions and life-changing intestinal infections requiring hospitalization or surgery, and resulting in death. Those CT scans everyone wants? Physicians are trying to reduce the number of scans, as many of us are concerned that they may induce malignant tumors later. And those pain medications? The evidence looks pretty damning.

Addiction to prescription narcotics is growing at a terrifying rate in the U.S. Likewise, death rates from narcotic overdoses have soared. The U.S. has seen 165,000 deaths from opioid overdose between 1999 and 2014. http://www.cdc.gov/drugoverdose/data/overdose.html. In fact, opioid-related deaths have now surpassed deaths from firearms in the United States. http://www.cbsnews.com/news/drug- overdose-deaths-heroin-opioid-prescription-painkillers-more-than-guns/ Admittedly, some of those deaths are not due to prescription opioids but rather to injected heroin. However, many heroin addicts began their addiction issues when taking legitimately prescribed pain medication.

Sadly, seniors are not immune. Physicians don’t want to see seniors suffer, so they often give narcotics even for pain that in decades past would not have been treated with those drugs. We give them for back pain, headache, arthritis, or other less serious conditions. And we use them extensively in treatment of chronic, intractable pain. In fact, in 2015, one-third of Medicare recipients received a prescription for an opioid analgesic; some 40 million prescriptions. https://www.statnews.com/ 2016/06/22/many-opioid-prescriptions-seniors/

Furthermore, seniors not only develop addiction, not only die from accidental overdoses, their narcotic analgesics have a host of side-effects, including (but not limited to) the following: excessive sleep, impaired thinking, increased pain sensitivity, nausea, constipation, and cardiac arrhythmia. In addition, opioid drugs contribute to weakness and loss of balance and thus to falls, resulting in head and spine injury, various fractures, and other trauma. Their already impaired reflexes are dampened by their medication so that for those who still drive, it becomes an even more dangerous activity than before.

No one is immune from this devastating epidemic, not rich nor poor, not young nor old. The medical profession, the mental health community, law-enforcement, social services, churches, families, and friends all have to come together and find ways to roll back the rising tide of death and addiction, which came as an unforeseen outcome of attempting to ease suffering with compassion and science.

This problem will be highlighted this spring at an OLLI bonus event, March 31, 2017: Seniors and Opioids: Unexpected Origins of a Greenville Epidemic. I will be speaking in conjunction with James Campell of the Phoenix Center addiction and rehabilitation facility. We really hope you join us to learn more about this pressing public health crisis.

Malpractice Isn’t a Sin

Dear physicians, PAs, NPs, nurses, medics, assorted therapists, techs and all the rest:

The great thing about our work is that we intervene and help people in their difficult, dire situations.  We ease pain, we save lives. Our work is full of meaning and joy.  However, we sometimes make mistakes.  But remember, in the course of a career you’ll do far more good than any harm you may have caused.

I know this issue lingers in many hearts.  I know it because it lies in mine.  And I’ve seen it in other lives.  I said this once to a group of young residents and one young woman burst into tears. I never knew the whole story, but I imagine there was some burden of pain she was carrying for an error she had made.

But just in case you too have lingering anxiety or guilt about some error you made in patient care, I feel it necessary to say this: neither honest errors nor even malpractice are sins.  They are mistakes, born of confusing situations, fatigue, inadequate experience or knowledge, overwhelming situations, the complexity of disease and the human body, social situations, systems problems, general chaos.  Born of your own humanity and frailty.  Your ‘shocking’ inability to be perfect at all times, and in all situations.  They do not make you evil, bad, stupid or even unqualified.  (PS If you’re not actually a physician but pretending to be one, you’re actually unqualified so stop it.)

As a Christian physician I have contemplated this over and over and have come to the conclusion that God knows my inadequacies and loves, and accepts me, regardless.  He has forgiven my sins.  I embrace that reality every day.  He forgives my pride, anger, sloth, greed, lust, all of them.  But he doesn’t have to forgive my honest errors.  Because they are not sins. Go back and read that again.  Your honest errors are not sins.

Mind you, all of the brokenness of this world is, in my theology, the result of ‘Sin’ with a capital S.  (Not in the sense of minute, exacting moral rules, but in the sense of the cosmic separation of the creation from the Creator.)

So, my mistakes, my failures are born of Sin, but are not ‘sins.’  If my mistakes, if the harm I may cause, come from rage, vindictiveness, cruelty, gross negligence, murder, drunkenness or other impairment on the job, then they could reasonably be due to ‘sin.’  But even so, those sins can be forgiven, and washed away with confession and true repentance.  (Not platitudes or superficial admissions of guilt, mind you, but genuine heart felt ‘metanoia,’ the Greek for repentance, which means ‘to change direction, or change one’s mind.’)

If you are not a believer, join us!  But if you aren’t interested, I love you too and want you to move forward, not burdened by unnecessary guilt.  If you are a believer, and a practitioner, remember that Jesus (The Great Physician) set the bar pretty high and doesn’t expect your perfection, only your honest, loving best.

Mistakes, even mistakes that rise to malpractice, are not sins.  But even if they rise to sin for reasons listed above, they are no worse than any other.  Which means Jesus atoned for them as well.

Move forward in joy.  You were forgiven before you even started worrying about it.

Now go see a patient. The waiting room is full of people who need you!

Merry Christmas!

Edwin

 

 

What do you mean it’s a cold? A poem…

What do you mean it’s a cold?
A poem for viral illness season.

Fever, cough and runny nose,
Muscle aches from head to toes,
Scratchy throat and stuffy ears,
Doctor, please allay my fears!

Can’t I get some Zithromax?
Lortab for my aching back?
Maybe just Amoxicillin,
For my stuffy, whiny children?

You say virus I, but I’m dying;
Surely there ain’t no denying,
What I have is devastating,
And I spent an hour waiting!

Hook me up and make me better,
Else I’ll write your boss a letter;
Don’t you tell me ‘it’s a cold,’
That tired line is getting old.

I know it must be bronchitis,
Strep throat, Zika, meningitis!
I require a strong prescription
For my horrible condition!

Cipro, Doxy, Levaquin
That’s what someone gave my friend,
After two weeks they felt well
So why should I endure this hell?

Please throw in a week off work,
Percocet’s an added perk,
My tolerance for pain is high,
But I am just about to cry!

What, I don’t get any meds?
Drink some fluid, go to bed?
Are you crazy, are you cruel?
I think you’re a quack, a fool!

I’ll go home but I may sue
Everyone, especially you.
I don’t need this here abuse…
Fine, now what about that work excuse?

The Overwhelmed EP in the Single Coverage ER

This was my column in Emergency Medicine News in September, 2016

http://journals.lww.com/em-news/Fulltext/2016/09000/Life_in_Emergistan__The_Overwhelmed_EP_in_a.12.aspx

I was working a 6 PM to 2 AM locums shift a few months ago and was preparing to leave. There were about 15 patients in rooms and 15 waiting to come back. I asked the lone night physician: ‘hey, do you want me to stay a while?’
Her answer, defeated, was this: ‘no, don’t worry. It’s always like this.’ I packed my bag and headed to the hotel, still feeling guilty but also exhausted. And wondering why my colleagues are treated so poorly in emergency departments all over the land.
I see it time and time again. Overwhelming numbers of patients with increasingly complex medical and social problems, versus inadequate physician coverage at all hours of the day, and especially the night. We’ve all done it. Already fatigued, we have five chest pains yet to see, as well as a trauma on the way into the department. Two more patients have fever but don’t speak English and we’re waiting to make the translation line work. And there’s a large facial laceration yet to be repaired. And that’s just the first nine patients. It’s not even three hours into the shift. (And the EMR backup is in process.)
Do we call the cardiologist and internist to take over on the chest pain, ask the surgeon to come and check the trauma and get plastics to close the face? Hardly. Furthermore, that’s just more time arguing on the phone. It’s easier to forge ahead as wait times creep from two to four to eight hours. Furthermore, on days it’s the same; with the added gift of acting as backup for all of the primary care offices.
There was a time when we actually might have asked other staff members to help. Those times are mostly gone. As a specialty, we’ve spent decades saying ‘don’t worry, we’ll take care of it!’ And our fellow physicians have obliged.
But at least, when we’re alone and overwhelmed, we don’t have to worry about lawsuits, patient satisfaction, quality measures, charting, coding, door to needle times, door to CT times, door to doctor times, door to…oh, yeah, we do have to worry about those things. As well as the sound criticism that will follow in the light of day, when all the administrators and other specialties are rested and shocked (shocked I say!) at how things went when we were alone.
The thing is, hospitals get a real bargain out of the understaffed emergency department. The physician does a heroic job of seeing every conceivable complaint and doing it with knowledge, skill, professionalism, urgency and political savvy. If you think of what they bill for that 35 patient, single coverage shift versus what they pay the exhausted physician, it’s a ‘win, win for old admin!’
In fact, emergency department physicians do the work of several people throughout their shifts, from secretary (filling out forms and entering orders), to social worker; from surgeon to psychologist, pediatrician to hospice worker. And we do it while trying our best to keep up with ever more complex charting rules, treatment pathways and admission battles.
We also do it when expectations are ridiculous. For instance, why should we, in a busy urban department, be doing the full stroke assessment when a neurologist could be at the bedside? Why are we arguing about the NSTEMI patient, or managing complex rhythms, when cardiologists (the alleged experts) are available? Why am I doing the neonatal sepsis workup in all the chaos when a pediatrician could come to see the child?
I’ll tell you why. Partly because we’re perpetually trying to prove our worth and fortitude. ‘I can handle it!’ And partly because we simply agreed. Consequently, ’call me when the workup is complete’ is a common mantra in the ED where we are indeed interns for life.
I wonder, are we training our bright eyed residents for this in the trauma center, in the simulation lab? Because when they leave the medical center for the community, this is how it looks. All the exciting, cool stuff. But ‘all by your lonesome.’
I know that lots of jobs are hard. I get that. But from what I’ve seen, all too many emergency departments over the past few years that are miserable, and dangerous, working environments. Does OSHA ever even look at our workplaces? Because when JCAHO does, they just increase the work-load in the alleged interest of patient safety (and their own job security).
We should all be proud of what we do. But we shouldn’t be abused children, or Stockholm Syndrome hostages to inadequate conditions. We should be treated as valued professionals. And if there aren’t enough other doctors to go around, every effort should be made to help and encourage those willing to work in such daunting settings.
And until you’ve come to work a shift alone, with a full waiting room and ten potentially critical patients right up front, you don’t understand what it’s like on the ground. And you have no grounds to criticize anyone facing the same tsunami of expectations and exhaustion in the noble effort to save life and limb, and ease suffering.
In the end, the weary look in the eyes of my colleagues breaks my heart. And something has to be done.
I call foul.

EPIC Go-Live Day! And a prayer for wisdom…

Some dear friends of mine, at Busy Community Hospital, are having a momentous day.  Today is the ‘Go-Live’ for their brand new, shiny EPIC EMR.

For those of you outside the hallowed, creaky halls of medicine, EPIC is one of the most widely used electronic medical records systems in America.  It’s big, it’s expensive, it captures lots of data, integrates ER’s, hospitals, clinics, labs and everything else.  (Probably your cat’s shot records too.)

EPIC is also a company highly connected to the current administration; big donors to the President.  FYI.

The problem isn’t what you get out of it, it’s the cumbersome way you have to put it in.  In my opinion, for what that’s worth, EPIC is not intuitive. It takes a long time to learn to use it well.  I have never used it in a situation where it could be fully customized, but I’m told that makes it easier.  And admittedly, some docs and nurses truly love EPIC and are at peace with it.  I suspect they have implanted brain chips or have undergone some brain-washing.

https://giphy.com/gifs/zoolander-ac38RqTgQXYAM

Typically EPIC instruction occurs over weeks, as it has for my friends.  The first time I used it was in a busy urgent care, which was part of a large medical system.  And I learned it over one hour. On the Go-Live day.  So I’m sympathetic.

Thus, I have a prayer for those in the belly of the beast right now:

A Go-Live Prayer for those with new EMR systems.

Lord, maker of electrons and human brains, help us as we use this computer system, which You, Sovereign over the Universe, clearly saw coming and didn’t stop.

Thank you that suffering draws us to you.

Thank you for jobs, even on bad days.

Forgive us for the unnecessarily profane things we have said, or will say, about this process.

As we go forward, we implore you:

Let our tech support fly to us on wings of eagles and know what to do.

May our passwords and logons be up to date.

Protect us from the dreaded ‘Ticket’ submitted to help us.

May our data be saved, not lost.

Let the things we order be the things we have.

Shield us from power loss, power surge, virus and idiots tinkering with the system.

Give our patients patience to understand why everything takes three hours longer.

And may our prescriptions actually go to the pharmacy.

Keep us from rage and tirades.

Protect the screens from our angry fists.

May everyone go home no more than two or three hours late.

And keep our patients, and sanity, intact.

Great physician, great programmer, heal our computers.

Amen

 

 

 

 

 

 

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.

img_3064

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):

img_3058

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