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

http://www.sccep.org/

You Are Not Alone Guest Column: Dr. Edwin Leap

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

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

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

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

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

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

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

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

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

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

But kids, trust me. You’re awesome.

And you aren’t ever alone.

Doctors and Nurses ‘Getting in Trouble’ too easily…

Trouble

 

My column in the April edition of Emergency Medicine News

http://journals.lww.com/em-news/Fulltext/2016/04000/Life_in_Emergistan__Doctors_and_Nurses_Getting_in.6.aspx

Are you afraid you’ll ‘get in trouble?’ It’s a common theme in America today, isn’t it? We’re awash in politically charged rhetoric and politically correct speech codes. Our children go to colleges where there are ‘safe spaces,’ to protect their little ears from hurtful words and their lectures or articles contain ‘trigger warnings’ so that they won’t have to read about things that might upset their delicate constitutions. All around that madness are people who are afraid they’ll ‘get in trouble’ if they cross one of those lines. I mean, one accusation of intolerance, sexism, genderism, agism or racism, in industry, government or education, and it’s off to the review panel for an investigation and re-education!
Worse, I see it in hospitals now. I hear so many nurses say ‘I can’t do that, I’ll get in trouble.’ I remember the time I asked a secretary to help me send a photo of a fracture to an orthopedic surgeon (with the patient’s consent, mind you). ‘That’s a HIPAA violation and I’m not losing my job to do it!’ OK…
There have been times I’ve said, ‘please print the patient’s labs so they can take it to their doctor tomorrow.’ ‘No way! That’s against the rules! I’ll get in trouble!’ Seems rational. The patient asks for his own labs and takes them to his doctor. It can only be for nefarious purposes…like health!
Sometimes it’s even sillier. Me: ‘Patient in bed two needs an EKG!’ Nurse: ‘You have to put in the order first, or I’ll get in trouble.’ In fact, this theme emerges again and again when I ask for things like dressings, splints, labs or anything else on a busy shift. I’ve expressed my frustration about physician order entry before, and I know it’s a losing battle. But when there is one of me and three or four of them, and ten patients or more, it’s hard to enter every order contemporaneously. But I know, ‘you’ll get in trouble.’
I remember being told, by a well-meaning (and obviously threatened) nurse, ‘if I put on a dressing without an order it’s like practicing medicine without a license and I can lose my nursing license.’ Well that makes sense!
I overheard a nursing meeting not long ago, and it seemed that the nurse manager (obviously echoing her ‘higher-ups’) was more concerned with making sure the nurses didn’t do wrong things than with anything touching on the actual care of human beings.
I suppose it’s no surprise. ‘When all you have is a hammer,’ the saying goes, ‘all the world’s a nail.’ Now that we have given all of medicine to the control of persons trained in management, finance and corporatism, that’s the thing they have to offer. Rules, regulations and ultimately threats.
Of course, ‘getting in trouble’ applies to physicians as well. It just takes a different form. Didn’t get that door to needle, door to door, door to cath-lab, door to CT time? We’ll take your money. Didn’t get the patient admitted in the committee approved time-window? We’ll take your money.
Never mind that seeing patients in a timely manner is rendered nigh impossible by the overwhelming and growing volumes of patients, coupled with the non-stop documentation of said patients for billing purposes. Keep shooting for those times! Times are easier metrics to measure. Times are easily reported to insurers and the government. Times, charts, rules-followed, rules violated. The vital signs of corporate medicine in America today. (And don’t give me that ‘it would all be better with the government in charge.’ Two letters give that the lie: VA.)
No, we’re an industry constantly ‘in trouble.’ But not really for any good reason. We give good care as much as we are logistically able. We still save lives, comfort the wounded and dying, arrange the follow-up, care for the addicted and the depressed. We still do more with less with every passing year.
But odds are, we won’t stop ‘getting in trouble.’ Because for some people, waving the stick is the only management technique they know. Still, it saddens me. I’m sad for all of the powerless. The nurses and techs and clerks and all the rest who are treated as replaceable commodities by administrators who are themselves (in fact) also replaceable. I hate to see nurses, compassionate, brilliant, competent, walk on egg shells in endless fear, less of medical error than administrative sin. Their jobs are hard enough already without that tyranny, leveled by people who should appreciate rather than harass them.
And it saddens me for young physicians, who don’t remember when being a physician was a thing of power and influence in a hospital. They, endlessly threatened and unable to escape thanks to student loans, are indentured for life, short of a faked death certificate.
Finally, it saddens me for the sick and dying. Because we cannot do our best when our motives are driven by fear more than skill and compassion.
The truth is, however, threats only go so far. And once people have been threatened enough, there’s no telling how they’ll respond.
Just saying…

 

Which Veteran’s Are We Celebrating, exactly?

IMG_2009 (1)

I found this advertisement recently.  It was a very kind attempt to honor veterans by giving them free haircuts.  I have intentionally blacked the name and address of the salon.  I mean no ill will.  It’s just an observation.  However, there’s a problem with this flier. It jumped out at me instantly.  Maybe because I played with lots of toy soldiers as a child.  Perhaps because I’ve watched a large number of war movies.

Or it could simply be because I am passionate about history.

What’s the problem?  I mean, someone made a very colorful hand-bill and then found the word soldier, or veteran or something like that and pasted the image as homage.

Many of you have already figured it out.

It appears to be a drawing of Russian Red Army soldier.  Not an American soldier.

Not that Russians or Commies don’t have veterans that they honor.  That’s their business.  But here, an image of an American veteran, past or present, might have been a wee bit more appropriate.

It’s little things like this that remind me that history matters and that all too many Americans don’t really pay attention to it.

Happy Veteran’s Day, ladies and gentlemen!  Thank you for standing for freedom.

 

A chart should tell a story. (My EM News column for March.)

 A Chart Should Tell a Story. 

My EM News column for March.

 

http://journals.lww.com/em-news/Fulltext/2015/03000/Life_in_Emergistan__Tell_Me_a_Story.6.aspx

 

 

I suppose it is obvious that I am a fan of stories. I like to hear them, read them, watch them, collect them and tell them. I believe I am participating in stories every day of my life. The story of my family is a beautiful epic. The stories I hear at work can break my heart. One of my favorite stories starts like this, as told to me by an adult man in his forties: ‘The thing is, me and my mama live with her boyfriend. And the other night, her boyfriend had a cardiac arrest! And when he had the cardiac arrest, he rolled out of bed, and crushed the Pomeranian.’ I can tell it better in person.

Obviously, story is truly essential to medicine. The history we obtain from patients is a story, a narrative of the development of whatever affliction they are facing. The medical record we generate is a larger version of the story, which includes past conflicts and resolutions, various antagonists and protagonists, symbolism, sub-text, conclusion and all the rest.

The problem is that in medicine, we have murdered the story. But it isn’t a complicated mystery. The murder occurred because the modern medical record is designed to gather demographics, monitor (and modify) our behaviors and generate bills. Therefore, it must be easily interpreted by people, or computer programs, that look for clicks and checks rather than descriptions. After all, it takes time and training to learn to read and appreciate a well-crafted story. But not so long to do a word-search.

I suspect that it is also a generational issue, as younger physicians have grown up with communication shared in short bursts, whether on television, in music, while texting or using various forms of social media. So I suppose that I understand how we have evolved, or perhaps devolved, in our medical communications.

In all fairness one can ‘reassemble’ the story from click boxes and drop-down menus. It just takes effort. It certainly requires more time than it would take to read a story. It’s rather archeological in nature, in fact. One must look at the nurse’s notes and the time-stamps, the triage vital signs and the things ordered, the timing with which they were ordered and interpreted, the consultations, the disposition, the prescriptions, the out-patient tests. All of it, when properly put together, can give an approximation of the who, what, when, why, how and where of the encounter.

But what we often do not have, particularly in times of crisis when the patient suddenly returns, is the luxury to put the pieces together again. Nor do the consultants and primary care doctors and specialists who see our patients later and who very much want to understand what transpired. And yet, as I travel around, and as I look back on various charts to discern what happened on previous visits, I see check boxes, labs, findings, diagnoses (often vague) but no description. The ‘Medical Decision Making,’ or ‘Emergency Department Course,’ are empty fields. In years past, we were told that these were critical parts of the chart that showed the complexity of our thought processes. I suppose EMR has changed that, on some level. But I’m think we’re worse for it. Looking at those particular blank spaces is like listening to crickets in a field. Or staring into an empty room. The absence of words doesn’t help anyone; least of all the patient.

So let me take this moment to encourage everyone to leave a note, even a wee, little note, describing what transpired in that patient encounter. Fine, if it’s strep throat, if it’s an ankle sprain, I get it. I can figure that out. But for anything with the slightest complexity, anything requiring several labs, or studies or consultants, please tell me a story!

It needn’t involve a ‘dark and stormy night.’ But it should have enough information to help the next person reading it. ‘This 14-year-old girl has had two weeks of intermittent cough, fever and shortness of breath. She has a negative chest x-ray but was noted to have scattered wheezes. She was feeling much better after an Albuterol treatment and her parents agree to arrange follow up with her doctor next week.’ It’s not ‘For Whom the Bell Tolls,’ but it’s a nice, simple summary that helps everyone else to have a sense of what happened. And it did so in three, count ’em three (3) sentences!

Chest pain? Summarize it and describe the plan. Trauma? Tell me why they were safe to go home. Headache? Explain, however briefly, why it wasn’t necessary to do more work-up. Heck, make it a game! A kind of ‘micro non-fiction.’ (Micro fiction can be a story as short as six words.) Diligence at this craft makes us more effective, more succinct communicators. And in the press of modern medicine, that can only be a good thing.

When my children were little, bedtime was always accompanied by this question: can you read a story? I’m just asking a similar thing of my colleagues. Before you put the chart to bed, write me a story.

And if it involves a Pomeranian, so much the better.

Hospitals should pay for charting time

Pay clinicians for their EMR time!

nurses-charting

 

I have a unique perspective as a physician.  Having traveled to many hospitals in the past two years, working as a locums emergency physician, I can comment on a variety of issues with a reasonable amount of experience.  One of those issues is EMR, or Electronic Medical Records.  I have spent plenty of time writing about this in the past, and I will continue to do so.  Because all across the country the same problems, the same frustrations are evident.  And the institutional lack of concern is well-entrenched and well understood by everyone affected.

Whether working in an academic teaching/trauma center or a small community department, one theme emerges.  EMR is so inefficient, and patient volumes and acuity so high, that charting isn’t done real-time.  Unless it is accomplished with scribes, or by dictation, doctors stay after their shifts, or chart from home, or come in on their days off in order to complete their documentation.  Needless to say, this is unlikely to create the best possible chart. Not only is this true, I have watched as nurses sat for one to two hours after their busy ED shifts, catching up on the ever increasing documentation requirements in their EMR systems.

Weary from a long day or long night, they sift through notes and charts, orders and code-blue records, trying to reassemble some vague estimation of what happened in the chaos of their 8 or 12 hours on shift, when they were expected to function simultaneously as life-savers and data-entry clerks.  Further, the nurses are frequently tasked with entering specific charges for billing as well.  It all constitutes an unholy combination for any clinician.

Dear friends, colleagues, Romans, countrymen; dear politicians and administrators, programmers and thought leaders, this is unacceptable. Entirely unacceptable. If the charting system is so poorly designed, and so counter-intuitive to the work we do that it can’t be used real-time, then it should be replaced with something far better.  And if it isn’t replaced, then everyone needs a scribe to chart for him or her, or we should allow dictation all around.  And if none of that is acceptable, if even those reasonable options are rejected, then every nurse and every physician who stays after shift should be paid their regular hourly rate for time spent charting. The thing is, these systems are generally not the idea of the clinicians who are saddled with them.  They are imposed by corporations and administrators who believe the salesmen and hope to capture more billing and data. They are imposed by the ‘Meaningful Use’ regulations of the Federal Government.  But as a rule, when we clinicians say a system is bad, or won’t work for us, we are patted on the head and dismissed.  ‘It’s fine, it’s an industry standard.  You can learn to use it.  You don’t want to be a problem doctor do you?’

One of my friends is in a group shopping for new systems.  When his partner asked to take the potential EMR for a ‘test drive,’ the salesman said, ‘sure, as soon as you sign the contract.’  Pathetic. I call on everyone involved in implementation of EMR to find the simplest, most physician and nurse friendly systems possible.  And to do it by asking and involving the end user.  By which I mean those who provide patient care, not those who cull through it for billing and documentation. Some people chart more slowly than others.  That can be an individual issue. But when a system consistently causes good, efficient doctors, nurses, NP’s and PA’s to stay long past their shifts, or come in on days off, or chart from their homes (which should be places of recuperation and rest), then we need to give them something back.   Equally toxic, some physicians and nurses can only get out in time by charting in a manner that results in a pages long list of check-boxes, rather than a descriptive, informative story.

America’s emergency departments are overwhelmed with passwords, required fields, clicks and key strokes, at the same time as they are overwhelmed with the sick and dying. They are the last safety net for the uninsured and underinsured. They are the point of rescue for the poor, the brutalized, the traumatized, the addicted, the psychotic.  Day in and day out, nurses and physicians in emergency departments, indeed all over the modern hospital, do their best against sometimes overwhelming odds.  In the midst of this, poor charting systems constitute a crushing blow.

Pay the staff for their time spent charting, or fix the systems.  Or both. But something has to give.

Edwin

 

Rape exams, drug screens and alcohol levels

When I was in residency, sexual assault exams were part of our training.  We spent a lot of time learning how to ask the right questions, how to be gentle and empathetic, how to gather evidence appropriately and thoroughly.

While many hospitals now have SANE programs (Sexual Assault Nurse Examiner), I have never enjoyed the privilege of working with one of them.  I have, for two decades, performed sexual assault exams on my own.

In 21 years of practice, I have been in court (as far as I can recall) no more than three times to testify in a sexual assault case.  That suggests to me that one of two things may have happened in the cases which involved me.  First, the case was never prosecuted for any number of reasons (the alleged victim recanted, law enforcement felt the case was too weak, the story was good but the evidence was inadequate, procedural problems, etc.).  Second, the case was prosecuted and the evidence was so damning that my testimony (separate from the evidence gathered) was irrelevant.  Third, the case indeed went to court but the story and evidence were so poor that no prosecution resulted and it was deemed unnecessary to involve me.  I am not of a particularly legal mind, so excuse me if I have missed other reasons.

I was recently thinking back to a patient I saw some years ago, who alleged that she had been sexually assaulted.  And then I thought back to residency.  And I remembered something that always troubled me.  In residency, I recall being told not to comment, in my chart, on whether or not the alleged victim had been using alcohol or drugs.  I seem to recall (and I may be wrong on this point) being discouraged from obtaining blood alcohol levels or urine drug screens.  (In like manner I was told to note in the chart whether I saw live sperm in samples, but not to remark on their absence.)

Back to the case at hand:  the patient I saw had been drinking copious amounts of alcohol and was clearly very intoxicated.  While I saw her, and law enforcement officers spoke to her, her story changed wildly from assault by multiple men to assault by no men.

Now, I ask you wide and gentle reader, was her alcohol use relevant to the situation?  When asked ‘who assaulted you and describe what happened’ would her recollections be trustworthy?  Would they be sufficiently lucid to possibly put a man, or several men, or a woman for that matter, in prison for years for what could have been consensual sex? And before you accuse me of sexism, remember that in an era of equality, both men and women are capable of sexual adventure as well as being capable of deceit and vindictiveness.

I believe that an alcohol level and drug screen was relevant.  Not in order to punish someone for substance use, not to ‘slut shame,’ but because like sexual assault, arrest and prison are serious, life altering things.  And because one’s ability to recollect what happens clearly can be influenced by drugs.

If I were intoxicated and said that I had seen young man commit a crime, and if my story varied wildly with each telling, it would be evident to all that my impairment was an issue in terms of the validity of my testimony.  I don’t see how it can be any less in sexual assault.

Sexual assault is a problem.  False accusations of sexual assault are also a very real problem. But covering up reality to attain a particular end, however gilded our intentions, is never the right thing to do.

Some things we need to do differently in hospitals.

Walking around the ER in Tiny Community Hospital, I had a few realizations.  In medicine, we hold onto some things very tightly.  We love tradition, we love the known.  We don’t always know why, but we choose ‘the devil we know,’ almost every time, no matter how pointy his horns.

For instance:  ‘No cell phones.’  First of all, has anyone ever seen a cell-phone interrupt anything we do?  No?  Neither have I.  Admittedly, cell phone use can be rude.  If I’m talking to a patient, I don’t want them ignoring me by taking calls or texting to the exclusion of our interaction.  And if I were a patient, I wouldn’t want my physician or nurse to do the same. But honest to goodness, cell phones are ubiquitous.  We communicate with them, schedule with them, navigate with them, learn with them and we entertain ourselves with them!  Even the sign that says ‘no cell phones’ is laughable.  Courtesy?  Please.  But let’s stop deluding ourselves that we can, or should, keep anyone from using their phones while they wait, sometimes hours, to be seen and treated.

How about HIPAA?  Great idea, privacy and all that.  But it has been done to death.  And the unintended consequence is that we have far too many log-on screens and passwords.  Furthermore, our computers time-out so fast we can’t keep up!  And yet, the real threat to privacy isn’t some poor knucklehead looking over our shoulders.  It’s corporations and government, insurers and ‘important’ people who see, and who may share, our most private information.  And none of them are defeated, or indeed affected, by passwords or anything else.

Another bit of silliness:  the idea that a family member or friend isn’t allowed to translate for someone who speaks another language.  Yes, it’s nice to use a service. But the contingencies of time and cost sometimes leave us with little choice other than 1) speak really loud and hope it gets converted into their language or 2) let someone with them do the talking.  In this instance, better is truly the enemy of good.

One close to my heart is the maddening way we treat test and xray results.  Having gone through cancer with my wife, I know the horrors of what we called ‘scanxiety.’  Waiting to know the answer can be heart wrenching. Fortunately, I was connected as a physician, and I was frankly a pain in the neck.  I got the answer as quickly as possible.  But for others, the waiting can be horrible.  Recently my dad had a CT of his lumbar spine due to severe pain.  It took days and days to get results.  Ridiculous.  In 2015, there is no reason for tests results to take two weeks; rarely even two days.  Unless the test is some exotic lab evaluation that has to be sent to East Egypt, we know the results the same day.  Making our patients wait is simply disrespectful, or slothful, or both.  Information travels at the speed of light people; let’s treat it that way.  The days of carrier pigeons and the Pony Express are long gone.

Finally (for today), there’s mental health.  We have woefully inadequate numbers of beds and psychiatrists and counselors for the mentally ill.  And yet, emergency departments have to hold vast numbers waiting on beds that will never materialize, and hiring sitters to do crossword puzzles while the mentally ill (or the pseudo-mentally ill manipulative) sit in bed and take up space in overwhelmed ER’s. We need a better system, sure. But we also need tort reform so that it isn’t so scary to discharge people.  And so we can stop doing a worthless dance that doesn’t make anyone better but merely imprisons them in uncomfortable beds in uncomfortable departments without anyone to actually talk with them.

Anyone else have a few?  What antiquated ideas, what anachronisms do we cling to in medicine?  And why should we jettison them?

Edwin

 

‘They didn’t do nothing in that ER!’

How often do we have this interaction:

‘My wife was here yesterday for belly pain.  That doctor didn’t do nothing! Told me she just needed to get over it. I am not happy and something needs to be done about this!’

(Frequently spoken by spouse.)

Records are reviewed.  Treatment:  Included numerous doses of morphine and phenergan, as well as fluids and Zofran.  Frequent warm blankets were applied.  Labs included:  CBC, Comprehensive Metabolic Panel, Lipase, Urinalysis, Pregnancy Test.  All negative.  Imaging:  CT scan of abdomen and pelvis with contrast, followed by ultrasound of pelvis.  All negative.  Discharge medications:  Hydrocodone, Naprosyn and Phenergan.  Discharge follow-up:  Despite lack of insurance, an appointment has been arranged with general surgery (or gynecology) who will see the patient in one week, whereas it would normally take eight.

When confronted with this fact, patient and family say:  ‘Well yeah, they did all that.  But nobody did anything!’

It’s a peculiarity, I suppose, of our society that even the most aggressive, compassionate and thorough care is considered ‘nothing.’  Perhaps it’s frustration, or perhaps it’s a need for more prescription medication.  Maybe it’s all somatization.  But on some level, I have to believe that we have transcended ‘science.’  People simply don’t believe in the wonders and effectiveness of the very system they count on every single day.  And in a subset of the population, there are two other phenomena.

One, the striking disappointment that seems to emerge with negative CT scans or tests.  As the husband of a cancer survivor, a negative CT scan is enough to bring me to my knees in songs of praise.  To many, it’s simply a failure.  Two?  This is tricky.  But when you don’t feel the cost of any procedure or test, whether because of outstanding private insurance through an employer (typically a public employer), or through Medicaid, the value of the testing, the treatment, the thought processes involved, can all seem as cheap as dirt.

Odd times indeed.  The more we do, the less we are perceived to do.

Inverted homeopathy.

Edwin

 

Distracted driving? How about distracted doctoring?

Here’s my column in June’s EM News.

http://journals.lww.com/em-news/Fulltext/2014/06000/Second_Opinion__Distracted_Doctoring.13.aspx

I have a shiny new Blue Tooth device.  So now, as I zip around town, I can speak without my hands touching my phone. It’s relevant because our county is passing a ban on cell-phone use, unless it is hands-free. This is a national trend, of course, and the catch phrase is ‘distracted driving.’ Everyone knows that ‘distracted driving’ is bad. I’m told, in the media and by friends, that it’s even more dangerous than drunk driving. That it may, in fact, be the root cause of anthropogenic global warming! (I made that one up.)

Mind you, we’ve all done our share of distracted driving. When I was in high school, I attended college classes half-days during my senior year. On the way to dear old Marshall University, I would often stop and buy a bag of ham sandwiches and a large Coke at K-Mart. I was pretty good at juggling drink, food and driving on Route 60 from Barboursville to Huntington, WV. Was I distracted? They were very good sandwiches and the Coke (old school, with sugar) was ice cold; so I’d have to say yes.

Of course, anyone who has ever driven down the highway to the awesome sounds of Radar Love by Golden Earring, or Sweet Child of Mine by G&R, understands fully the intensely distracting value of 80’s rock and roll, often compounded by the bright sunshine and warm air of a summer day. That’s distracting, to be sure.

Although I have to admit, the most distracted I’ve ever been in a vehicle was not when I was driving, but when my girlfriend, now wife, Jan was behind thew heel. We were in college, going somewhere together on a summer day. She was tanned and her black hair was blowing in the breeze. That was when she did that magical trick that gets the lifelong attention of every young man. She took off her bra while driving, and did so through her sleeves. Be still my heart! If I had been driving, I’d have rolled the car for sure.

So I get the distracted thing. It’s tragic for any life to be lost over something as trivial, as silly as the driver looking down at a text or e-mail. On the other hand, it occurs to me that every day, all day, we practice distracted medicine. You heard me. I can’t imagine that we could make medicine much more perilous than we do now. Because the opportunity to actually focus on a patient, complete a thought or finish a task is vanishingly rare.

Think about it. You’re up to your pass-words in EMR, charting some complex interaction involving an angry mother, a drunk father, a sick child and a dog that apparently ate everyone’s narcotics. As you decide how best to describe the situation, a nurse thrusts an EKG in your face. ‘Chest pain in twelve. I need a doctor. Don’t forget to sign and time it.’ You run off to the chest pain, knowing as you do that it isn’t a STEMI. However, there are risk factors. It’s concerning. ‘Nurse, I need you to give three nitro and four baby aspirin and get a chest xray.’

‘Fine. Put it in the computer. Did you put it in yet? I’ll put it in, but will you sign off on it? Doctor, don’t forget to order it.’ The same interaction is repeated every day with lab techs, EKG techs, Xray techs…with almost everyone, because nothing can happen until it is electronically present in a hard-drive. Otherwise, it’s a lie! A deception! A lawsuit waiting to happen! So, you were distracted by the EKG, and then your thinking was interrupted by the insistence that you make sure and document the things you want done, and everyone knows needs to be done.

You’re back at the computer, thinking about something else when Joe Dirt walks up and says, ‘hey, you know how long it’s gonna be? Cause this is ridiculous. And can I get a cup of ice?’ Your badge that says ‘Dr.’ might as well say ‘Dr. Pepper,’ because he has no sense that interrupting you is inappropriate. But then, neither does anyone else.

On the way to another patient the secretary says ‘the urgent care has a transfer, and you’re the only doc here right now.’ Thought process interrupted, as you field a call from across town and accept the patient. What was it you saw in the triage note that concerned you? Oh, never mind.

Next, you need to refer a patient to a specialist. Easy? Hardly. You have another form thrust in front of you, which you are supposed to fill out in order to make things easier on the specialist, by sending insurance information for pre-screening. And almost without fail, large or small hospital, be assured that the transfer forms, ambulance certifications and medication orders for EMS will all be in front of you, either electronically, in print or both. Those are forms for doctors to fill out, not anyone else.

In the midst of this, considering the nuances of abdominal pain becomes problematic. Likewise, trying to use your years of insight to decide if that college student is suicidal, or that roofer is having a TIA, is all but impossible; every thought is interrupted by another request, another need, another demand, another form.

You go back to your computer and you realize it timed out. So you have to re-enter the password, then another password for radiology viewing. You spend as much time entering passwords as you do listening with your stethoscope. It’s hard to think about drug doses when you have to juggle the passwords of your life. But don’t worry about interactions or allergies, because every…single…order is stopped by a pre-programmed warning. ‘Warning! Tylenol may cause liver disease with prolonged use!’ ‘Warning! Without adequate airway management, succinylcholine may be fatal!’ ‘Warning! Phenergan may interact with Lortab to cause sedation!’ After dozens of warnings, one ceases to process them. Or anything else.

It goes on an on. Another call, another form, another field to fill in. More data to enter, more orders to enter and all the while the patient may be very sick, or very complicated, but that matters little in the world of distracted medicine. And then, at the end of the day, when your mind and body should be free, there are more charts to fill out, more data points to enter to complete the record…but you’ve forgotten half of them because you were never allowed to complete a thought.

Of course, this doesn’t count the distracted practice that occurs from patients who have difficulty describing symptoms, or those who outright deceive us with discombobulated stories and misinformation that all lies on our cerebral hard-drives like so much spam, so many cookies, so many viruses or bits of malware.

With every new rule, form or computer field, with every new drop-down menu that requires five minutes to navigate to find ‘fever’ amongst choices like Lassa Fever and Metal Fever, we are distracted. With every electronic prescription that takes five minutes to a 30 second hand-written prescription, we are distracted. And with every demand that we take everyone seriously and treat every ridiculous complaint as a thing of inestimable value, we are distracted.

What we do is important! Shout it from the rooftops! And it’s too important for us to spend our shifts struggling through the brambles of endless, trivial, unnecessary distraction.

We need to push back. This isn’t funny anymore. It’s horrible. It’s devastating. It shortens careers and endangers lives. Just as the driver’s main focus should be driving, our main focus must be the timely and efficient care of patients.

And if our directors and politicians and administrators want us to continue to save life and limb, at all hours of the day and night, they need to realize that distracted practice is at least as dangerous, and maybe more so, than distracted driving.

Shortness of Air; the PC alternative to SOB.

The strange land of Emergistan is full of even stranger ideas.  It seems that the people in charge of medicine (by which I mean everyone but physicians, nurses and mid-levels) are simply losing their ability to focus on reality.  Thus, they focus on anything and everything else.

Case in point.  I work in one facility which no longer uses the term Short of Breath in its charting templates.  The new, updated, customer friendly phrase is ‘Shortness of Air.’  Nobody comes in with SOB; they present with SOA.  Pourquois, you ask?  Good question.

I envision it like this.  Somebody looking over a chart in this small town was shocked (shocked I say) to learn that their dear old grandfather is described as SOB.  (Probably by some damyankee locums doctor from the North.) Of course, we all know it had nothing to do with either the character (or species) of his mother.  It simply meant he is short of breath.

Offended person complains to hospital administration;  thus, a committee is born.  Now, with all due respect, hospitals are generally run by nurses these days.  So I envision a room of former clinical nurses, turned administrators (and dressed quite sharply, by the way) sitting around a conference table and fanning themselves over the vapors they develop when they consider the fact that for years they, too, described old ladies and small children, young men and veterans and all the rest as SOB.  Scandalous!

Granted, it may not be the case. This committee might have been populated with practicing clinicians (but they usually don’t have time for meetings like that), or former lab technicians, xray technicians, security officers, or even current CEO’s, CFO’s, nurse managers, IT employees, etc.  Without the slightest doubt, there was also someone from risk management who realized the enormous legal peril of slander, should anyone else be described with the ages old moniker, SOB.

Other options were likely bounced around over coffee and pastries.  Dyspnea?  Too many letters.   Trouble Breathing?  TB?  (Nobody wants their chart to say TB).  Breathing Problem? (Too much like Blood Pressure).  Ultimately, someone came up with Shortness of Air.

Not to be a stickler, but Short of Air suggest a problem with the atmosphere rather than the body.  The sort of thing that happens when an alien species decides to take the oxygen off of our planet for their own.  Or when an airplane depressurizes.  It suggests a rather collective problem, not the intimate individual trouble of Shortness of Breath.

Long and sort, when I chart at this little garden spot of Emergistan, I have to use Shortness of Air on the template.  Sometimes I use dyspnea, just to show off.  And often, I still free text Shortness of Breath or SOB.  Because that’s the kind of guy I am.

But I have to ask, of all the issues in medicine today, this was the one that had to be addressed?  I guess when it comes down to it, customer satisfaction (or the fear of dissatisfaction) trumps all common sense and nearly all other concerns.

Tragic.  Why, it makes me feel all SOA just thinking about it all!

Edwin Leap

President of Emergistan (self-appointed)