Some new, important screening questions for the EMR

Scrolling through FEEMRS (you know, Fancy Expensive Electronic Medical Records System), I was stricken by just how much data is on the chart.  I mean, it’s pretty dang amazing.  But I was, simultaneously, reminded that most of it doesn’t help me.

It helps someone, mind you.  For instance coders and insurance companies.  The complexity of EMR also helps those who track our car to door, door to chair, chair to chair, chair to bed, bed to bathroom, bed to X-ray, request to blanket, request to sandwich, request to TV remote, request to ice chips, complaint to Dilaudid and discharge to angry times.  (The really important stuff!)

But so often, FEEMRS just gets in my way.  I mean, I struggle to find little things like triage information, medications or last menstrual period. And as for visual acuity?  Faggettaboutit!

However, I do think there are some things that might be useful screening questions.  So, here are a few things I think we should have the nursing staff ask on the way into the ED.  I mean, we always ask about drug abuse, interpersonal violence, immunizations, sexual activity, whether or not the withered 98 year old has lately traveled to any Ebola infested exotic locales.  But is it really enough to know if the newborn has stopped smoking? Or are there other more interesting things with which we could further clutter the hallowed screens of our FEEMRS?

I hereby suggest:

What is your preferred pronunciation of the only pain medicine that ever worked for you?  With what letter does it begin?  (Incidentally a patient recently pronounced their favored drug ‘Laudy-dah.’  Awesome.)

What unfortunate thing has lately happened to your medication?  Eaten by dog, stolen by neighbor, smashed by meteorite?   Hey, it could happen…

Is there some species with which you identify and would prefer to be treated as?  Because if so, we may need to call a vet. Or tree surgeon.  (It’s no joke.  Tree-kin is a real thing…I mean, ‘real’ thing.)

First thing that pops into your mind when I say ‘outstanding warrants.’  Go!

What is your favorite kind of sandwich to eat while waiting on your psychiatric commitment.  Just kidding. We have Turkey.  (It’s empowering to offer a choice even if we really don’t have one.)

This is to be asked immediately on arrival into triage.  Right now, how long do you believe you have waited to be seen? One hour, two hours, three hours.

Do you know the patient advocate’s name and phone number?

For abdominal pain:  Please tell me what kind of cheeseburger, chicken sandwich or friend food you have consumed on the way to the ED, and when you finished….oh, you’re still eating it.

This is very useful and instructive: Why are you on disability? With a few mental health exceptions, if it isn’t evident in triage, it will be a good story.

How many times have you been committed to a state or private psychiatric hospital? If the number of suicidal commitments is greater than ten, patient can probably go to the waiting room.  Especially if eating cheeseburger and suffering from simultaneous abdominal pain.

Is there a particular physician you would like very much to see or not to see? Or want to hurt?

Full disclosure.  What are you here to get, and if you had it, you wouldn’t be here at all?  For instance, work excuse, pain medication, etc.

Who told you you should come to the ER, if anyone:  your physician’s office, your attorney, a police officer, your sister’s best friend who is a CNA at a nursing home, or a 24-hours health line?

Do you find it difficult to stop playing video poker on your phone while talking to a clinician?  

Will you please eat these chips and fill out my satisfaction survey while waiting to come back?

Just scratching the surface.  Send me some of yours!

edwinleap@gmail.com

 

If this is an emergency, hang up and dial 911…

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Currently, in American healthcare, experts are wringing their hands in confusion.  I mean, people have insurance, right?  And yet, healthcare is still expensive and dang it, people just keep going to the ER.  Visits are climbing everywhere and I can speak from personal experience when I say that we’re tasked with more and more complex and multi-varied duties in the emergency departments of the 21st century.

I’m not a medical economist.  I do have some thoughts on the well-intentioned but deeply flawed Affordable Care Act. However, I won’t go there right now.  What I do want to address is the ‘go directly to the ER’ mentality of modern American medicine.

Call your physician.  If it’s after hours, the recording for any physician or practice of any sort in America will have a message:  ‘If this is an emergency, hang up and dial 911.’  It’s a nice idea.  But of course, it presumes that everyone really understands the idea of emergency.  In fact, they don’t.  We understand that, or we try to, but we see lots of things that come in ambulances, or just come to the ER, that really aren’t.

‘I feel fine, but my blood pressure is up.’

‘I was bitten by a spider and I watch nature shows and I know how dangerous they are.’

‘I have a bad cold and I have taken two rounds of antibiotics.  I have an appointment with my doctor tomorrow but I thought I’d just come on in to get checked out.’

The list goes on.  In part, it’s because we do a poor job of educating people about their bodies and their illnesses.  Online searches usually result in someone self-diagnosing Ebola or cancer, so that doesn’t help much.

But in part, it’s because the ER, the ED, has become the default.  Surgical patients are told to have wound rechecks in the emergency department.  Kids with fevers are directed there by pediatricians or family doctors or secretaries.  People who need to be admitted are sent in ‘just to get checked before they go upstairs.’  Or sometimes, so the physician on duty can do the negotiation with the hospitalist, rather than having the primary care physician do so.

Why is the ED the default? In 1986 Reagan championed and Congress passed EMTALA, the Emergency Medical Treatment and Active Labor Act, which says you can’t turn anyone away for reasons of non-payment.  Another well intentioned bit of government meddling, it never provided any funds for it’s expansive act of compassion so many emergency departments and trauma centers simply shut their doors.  You can’t see patients for free all day and still meet your budget.  I think something needed to be done, but it probably went too far.

Fast forward.  Insurance is expensive even when the government mandates it. Whether for fear of litigation or due to over-booked schedules everyone else can always send patients to the ED day or night for any reason.  We still function under EMTALA and that will never, ever change.  Patients have little to no expectation of payment when covered by Medicaid and know it (and thus use the ED for everything, and I mean everything.  We are seeing expanding life-spans for the elderly, but with more complex illnesses being treated and ‘survived.’   We have fewer and fewer primary care providers.

Who actually thought emergency department visits would decrease, and why?  Did they ask anyone who saw patients on a daily basis? Or only lobbyists, administrators and progressive academics with starry-eyed fantasies?

I want to take care of everyone. But the Titanic that is emergency medicine in America is sinking.  We really, honestly can’t bear the burden for all of the chaos of our national healthcare.  And don’t tell me that if we have a single payer system it will change everything, because it won’t.  EMTALA will go on and doctors paid by the feds will not be more productive than they are now, so everything will still flow to the emergency departments and trauma centers of the land.

This isn’t about rejecting the poor, or even criticizing Obamacare.  It isn’t about single payer or Medicare for all. It’s about entrenched behaviors and facing the reality of the system we’ve created which allows one part of the system to attempt to carry the limitations of the rest.

Herb Stein, father of Ben Stein, famously said:  ‘If a thing can’t go on forever, it won’t go on forever.’

And if its’ true anywhere, it’s true in the emergency departments of this great land of ours.

Where the answer to every crisis is: ‘hang up and dial 911.’

Tagged, tracked and monitored. Life as a doctor ‘on the grid.’

 

 

Tagged, tracked and monitored.  Life as a doctor ‘on the grid.’

 

The non-medical reader may wonder what I am complaining about.  Of course, many of you have to be credentialed in your fields as well, whether law or accounting, law enforcement or public service, education, nursing or a trade.  But those of you in medicine know how difficult it can be to become credentialed as a physician, either by a state for purposes of a license, or by a hospital in order to be on staff.  As a locums provider, this is one of the true ‘banes of my existence,’ as every new state, every new facility has to ensure that I am not now, nor have I ever been an axe murderer, drug addict, drug dealer, sexual predator or anything else nefarious.

I’ve grown accustomed to the endless queries of my medical school diploma, my DEA certificates, my file in the National Practitioner Data Bank and all the rest.  I am no longer shocked when asked ‘did you graduate from college?  Did you graduate from medical school?’  I am comfortable with being fingerprinted over and over and I happily check all the boxes ‘no’ pertaining to my theoretical criminal history.

But one question finally got to me.  First some context.  I graduated from medical school in 1990 and started residency the following Autumn.

Question for state license:  ‘What were you doing from May 1990 until August 1990?’  My inherent smart aleck raised it’s angry head and I started to write:  ‘Joined anti-government militia for two months,’ ‘traveled with Taliban,’ or ‘pronounced myself deity and started cult.’  But then I realized the perfect answer.

Question:  ‘What were you doing from May 1990 until August 1990?’

Answer:  ‘My new wife.’

So, as a physician, there were three months where I wasn’t busily serving the medical industrial complex?  Three months when I wasn’t rounding, writing notes,  studying or otherwise kneeling before the great gold Caduceus?  Ghastly! What was I thinking after college and medical school?  Of course, the next question was, ‘what were you doing from June of 1993 to August of 1993.’  I had just finished residency, and was traveling with said wife, moving to a new state and studying for the National Board of Medical Examiners exam, Part III.  Part III I say!  The test those credentialing people expect me to take!

There were two months unaccounted for, when I was not on the vast medical radar!  Can you imagine the horrors that might ensue from an untracked, unmonitored, unproductive physician?  I shudder at the thought.

Credentialing is a pain. But it’s a bigger pain when all of us are treated as if we are criminals on probation rather than professionals trying our best.

Lighten up, people.  It’s a job.  It’s not a life.

Edwin

 

 

 

 

Ride or no ride, people sometimes need pain relief

I understand the concerns about narcotic abuse.  I was there, in residency 24 years ago, when the mantra was ‘you don’t do enough for pain.’  We all did more.  Now, all these years later, we’re told ‘you do too much for pain!  What were you thinking?’  It’s all madness.

But what I find a little troubling is a tendency I see now in the various hospitals where I work.  That is, a patient comes in with what seems to be legitimate pain.  I order pain medication.  And I am told, ‘he can’t have it until he has a ride.’  Sometimes the complaint is deception.  Often, the complaint is legitimate.

The official policy most places, however, is ‘no ride, no meds.’  This seems unduly harsh to me.  I understand, dear nurses, that you don’t want to have to babysit for hours. I don’t either.  And I understand liability.  Still, there are times when people are hurting.  Kidney stones, for instance, or fractures.  They genuinely need a medication but they either came by EMS or drove themselves and can’t drive home.

I’m not trying to blame anyone.  But can we all put our heads together and find a better way to do this?  A more compassionate way to do it?

I’m no starry-eyed simpleton.  People abuse drugs and use the ED to get those drugs.

Many, on the other hand, just plain hurt.

Ride or no ride, they need help.

 

 

No guns allowed…silly sign, silly law.

My column this week in Girls Just Wanna Have Guns.  ‘No guns allowed signs’ are just ridiculous!

http://girlsjustwannahaveguns.com/2014/01/silly-signs-sillier-laws-guns-allowed/

While Christmas shopping with my wife, I was carrying my Smith and Wesson J-frame .38 in my front jeans pocket. It disappeared nicely and was further covered by my barn-coat.

We walked to the front door of the mall, only to find the sign.  You know the sign, the one with a gun in a circle with a slash.  ‘No concealed weapons allowed.’  (As an aside, I always wonder, as a gun afficionado, if they just mean the one drawn in the picture.  No Glocks?  Fine, I have a revolver.  No 1911 style pistols?  No worries, I don’t own one.)

I dutifully took my weapon back to the car and stowed it safely away.  But not without grumbling to my wife. We all know how ridiculous this is.  The sign, meant to keep gang-bangers, thugs and various violent criminals from carrying weapons in public does nothing of the sort.  Nevertheless, I abide by the law.

However, as I considered the lunacy of the law that allows businesses to impose such requirements on the lawful, I had some other thoughts about dangerous things that ought to be kept out of public venues.

Perhaps there should be a sign that says ‘no one with a history of violent mental illness allowed.’  It’s pretty clear that the gun isn’t the main problem if you happen to be crazy and dangerous.  Although obviously a bit difficult to enforce, it sure would send a message, wouldn’t it?  Admittedly, it would result in untold lawsuits about equal access and disability.  But concealed carry is legal as well, and ‘don’t you care about the children?’  Or something like that.  Although designing a symbol might be difficult.  A circle around a nut, with a line through it?

Another one I’d suggest is this. Malls should post signs that say ‘no one allowed who uses ,ethamphetamine, synthetic marijuana, cocaine, crack or any other drug that causes aggressive behavior.’  I’ve met people on those drugs, face-to-face in the emergency department where I work.  Based on my experience, I believe they don’t need to be in the public either.  Sign?  A circle around a wide-eyed guy with rotten teeth, perhaps?

Of course, given that weapons are ‘equalizers,’ we must admit that the world is still full of inequality when it comes to physical combat.  How about, ‘No body builders, weight-lifters, boxers, wrestlers or advanced martial artists allowed.’  I mean, they might be nice but they could still hurt someone couldn’t they? I mean, who wants a side-kick to the head when someone gets upset over a sale item?

We could go on.  No one allowed who has been drinking alcohol within, oh, say, 12 hours.  No one allowed who has recently been arrested or jailed (even non-violent offenders).  After all, if you can’t trust the man with the gun who passed a background check, fingerprints and a class, you certainly can’t trust non-violent criminals, can you?

No one allowed who has been in a fight in the last five years.  No one allowed who is upset over their relationships, angry at the boss; no one who is depressed or has recently started a new psychiatric drug that might lead to impulsive behavior.

The first point is that this would be impossible.  There aren’t enough police officers or Segue-riding mall-cops in the country to kick that many people out.  (And frankly, if you use my entire list, the mall will be pretty darn empty!) Second, we can all find another thing, or group to ban; and we can be reasonably assure that our bans will be completely ineffective at stopping violent crime.

Ultimately, it’s all a function of bad reasoning.  You see, I’m the guy the mall should want to have shopping while armed.  I care passionately about the safety of my loved ones, and of all those around me.  If I ever have to draw that weapon and use it, I will do it with fear and trepidation and caution.  I don’t ever want to need it.

I’m the guy who has handled firearms for as long as I can remember; who has taken classes, practiced and who has thought long and hard about the duties, responsibilities and consequences of carrying a weapon. I’m the guy who views it all with an eye to the historic code of chivalry, to modern law and to the law of God which rules my actions towards others; particularly where life and death are concerned.  Finally, I’m the guy who knows how to treat the injured.  If there is a shooter, you want me, a physician, to be a first responder.  If I’m armed, I might survive (and hang around) to do just that.

We live in a land of silly signs and silly laws, where logic is a fast fading quality.  What a pity we can’t just put a circle and a slash across the signs that say ‘no weapons allowed.’  The crime rate would drop even further.

Silly Scripting Games. Yet another scourge on medicine and nursing.



This is my March EM News column

Silly Scripting Games

 

Our nurses will soon have ‘scripting’ guidelines for their interactions with patients.  This is apparently widespread in many industries.  The idea being, patients will be more satisfied with their care if certain key phrases are repeated to them; phrases which might, possibly, just maybe find their way onto satisfaction surveys.  Wink, wink!

Whether I will have to engage in this tawdry bit of theater remains to be seen.  But bless the nurses and clerical staff!  Here are the early scripts, printed on yet another laminated card to go with the other assorted cards all the staff wear with their ID badges (predicted to weigh at least 5 pounds in total policy reminders before long):

 

“Hello, I’m (name, occupation)”

 

“I’m here to (Meds, Procedures, Clean)”

 

“Is there anything else I can do for your?”

 

Key words:  Safety, Privacy, Care

 

Our nurses and secretaries are wonderful people, and might have had careers in Hollywood if things had gone differently.  But one of the last things they really want to do is act.  Nevertheless,

I know the game.

Someone will read this and think that I’m a Luddite, a curmudgeon, a stick in the mud of progress.  Others will say, as they do about every new customer service initiative, federal ruling, Joint Commission rule or state nursing board policy: ‘It’s only a little thing, so stop being a baby and get with the times.  Sheesh!’

Indeed.  It may be the case.  Only today I was reminded, in a meeting about STEMI, that my group is tragically, woefully lax.  We are failing to use a key phrase that explains why thrombolytics might be given instead of percutaneous intervention.  In order to meet quality indicators (and get paid appropriately), we must write, in the chart, the following magical incantation:  ‘The patient received thrombolytics because his time to cath lab would exceed 90 minutes.’

Silly, lazy doctors, trying valiantly to reach the bedside and touch a patient, make a good decision and save a life when we could be populating data fields!  Bad, bad doctors!  To quote Monty Python and the Holy Grail:  ‘You must spank us!  Yes, spank us all!’  I digress.

Let me bring it round again.  Scripts are about patient satisfaction scores, which remain quite the rage despite some rather damning suggestions that they might not be good for doctors or patients.  Scripts come to us from firms hired, using hospital budgets, to teach us how to increase satisfaction scores in order to put more money in the budget…and on and on it goes.  How much we lose on consultants in order to make enough increased money to pay for consultants is a bit of a mystery to me.

Still, progress marches forward.  So let me suggest how I might find scripts useful:

 

‘Hello, I’m Dr. Leap.  I’m here to take care of you while you’re sick, not do data entry.  Is that OK with you?’  Key words:  care, sick, data.

 

‘Hello, I’m Dr. Leap.  I’m here to preserve your airway and rescue you from your own alcohol toxicity. Is that OK?  Is there anything else I can do for you?  Sorry, I can’t understand when you vomit.’  Key words:  airway, sick, alcohol, toxicity, data, scores…vomit.

 

‘Hello, I’m Dr. Leap.  I’m here to decide if your pain score is really a ten, since you look uninjured. Is there anyone I can go ahead and call to take you home?’  Key words:  ten, uninjured, call, home.

 

‘Hello, I’m Dr. Leap.  The last time you were here you stole an entire drawer of dressings and a dirty needle box.  I’m here to report that.  Is there a parole officer I can call for you?’  Key words:  stole, drawer, needle, parole.

 

‘Hello, I’m Dr. Leap, I’m here to commit you to a psychiatric hospital to help you obtain disability at 30.  Is there anything else I can give you besides my time and my tax dollars to help perpetuate your life of inactivity?’  Key words: commit, psychiatric, disability, 30, tax, inactivity.

 

‘Hello, I’m Dr. Leap.  I’m here to ease your suffering, my dear, stoic little lady.  Whatever you need is fine.  Is there anyone bothering you because I will shut them down!’ Key words:  suffering, dear, stoic.

 

‘Hello, I’m Dr. Leap, I’m here to find out why you’re smoking in the emergency department, and ask you to leave.  Is there any way I can make that happen faster?’  Key words: smoking, leave.

 

‘Hello, I’m Dr. Leap.  I’m here to explain to you that you can’t speak to our nurses that way.  Is there a bar of soap I can shove in your gullet, you nasty man?’  Key words: nurses, speak, soap, gullet, nasty.

 

‘Hello, I’m Dr. Leap.  I’m here to explain to you that you will not be receiving Valium, Ativan, Klonopin or Xanax for your panic attack.  Just like the last four times.  Can I get you a cup of coffee with caffeine?  Key words: Valium, Ativan, Klonopin, Xanax…not.

 

‘Hello, I’m Dr. Leap.  I’m here to protect you from your neglectful parents, little one.  Would you like a coloring book?  Look!  Your parents are too busy texting to hear us talk!  Funny, funny parents in orange jump-suits!’  Key words:  neglect, parents, little one, texting, orange jump-suit.

 

‘HELLO, I’M DOCTOR LEAP!  I DON’T SPEAK YOUR LANGUAGE.  I’LL FIND SOMEONE WHO DOES, OR A TELEPHONE!  IS THAT OK?  IS THERE ANYTHING YOU NEED?  Key words:  LANGUAGE LINE!

 

‘Hello, I’m Dr. Leap.  I’m here to talk to you, not to text you.  Let me know when you put it down.  Is there any other means of communication I can get for you?  Until then, I’ll ignore you.’  Key words:  text, communication, ignore.

 

“Hello, I’m Dr. Leap.  I’m a health-care professional who does great job.  I won’t always follow the script, but then, you won’t always follow the text-book.  I’ll do my best.  If you’re unhappy, tell me and we’ll work it out.  But let’s not play word silly games.  Let’s make you better, shall we?”

Key words:  professional, better, best.

 

Silly game.

 

PS  Send me some samples of your own scripting!  If we have enough, we can write a screen-play!

 

Deciding who needs what…my latest Greenville News column.

Deciding who needs what can be risk business!

http://www.greenvilleonline.com/article/20130203/OPINION/302030022/Ed-Leap-Deciding-who-needs-what-can-risky-business

What do you need?  It’s an interesting question, much discussed in the wake of the current gun debate.  I frequently hear this statement:  ‘no one needs a rifle with a magazine that holds more than ten rounds.’  One caller on a radio show said, ‘nobody needs more than six bullets.’   Others have said, ‘I can’t see why anybody needs more than one gun; it’s ridiculous.  I certainly don’t need one!’

Obviously, there are millions who take the opposing view.  But gun-control aside (as if that were possible in the current political climate), it’s time we start to ask ‘who decides who needs what?’

I can tell you a lot of things I don’t think anyone needs.  Nobody, in my opinion, needs Methamphetamine. Well, not at first, anyway.  In the big picture, it isn’t essential to life.

Of course, having cared for countless intoxicated individuals, young, old, male, female, rich, poor, comic and tragic, I can say that I don’t need alcohol, so perhaps nobody needs alcohol.  Yes, some research suggests a health benefit to certain amounts of alcohol consumption.  But it’s likely that humans were healthy before the first one found a container of fermented fruit juice, drank it inexplicably and woke up with the first hangover.

Cigarettes come to mind.  Who needs them?  Not me.  They cause enormous suffering and death, even though many find them relaxing and pleasurable.  But then, over-eating causes harm as well.  Do we need access to endless calories all day long, as much as our prosperity and ingenuity provide?  Nobody needs cheeseburgers or fried mushrooms.  Of course, I love them just the same.

Americans love their pets.  But are pets necessary?  Who needs a Pit-Bull? Who needs a Burmese Python? I’ll take the former over the latter any day, but I would never feel that I needed either one.  And really, as much as I like cats, who needs a house full of them?

Advocates against over-population often suggest that no family needs more than one or two children. Polygamists might feel that they need more than one wife.  One man feels he needs to leave his wife for another; one woman is confident she needs to hit her husband with a ball bat.  Need is a little subjective, isn’t it?

Is the Church necessary?  I think so, although I wouldn’t impose it on anyone.  I find it necessary for me and for my family.  I’m certain I could find those who would suggest that it is a remarkably destructive force and not only unnecessary but dangerous.  They would say I don’t need it.

Who needs a fast car?  Who needs a large house?  And what about money?  How much money do the rich need? Or the poor, for that matter?  So much of our economic debate hinges on the idea that some people have more than they need, and some have less, and that some transfer based on need has to be effected.  But who can decide such a thing as financial need?  Oh, right, the government.  But is it based on some algorithm?  Some formula?  On dated, failed economic and political philosophy?  Or perhaps on future votes…

Unless by ‘need’ we mean only the most common and basic things like food, water, clothing and shelter,  the rest of our attempts to determine need are often based on ideology and emotion.

You know the perennial argument that ‘ you can’t legislate morality?’  Well, we do it all the time; sometimes wisely and sometimes poorly.  But seldom do we legislate morality more than when we discuss who needs what; whether it’s money, vices, food, weapons, freedom or family.  Because when you tell me what I need, or I tell you, it’s a ultimately a moral judgment about what one of us ‘ought to do.’

We all have different motivations and different reasons to try to shape society and culture in the way that seems best to us.  But whether the issue is taxes, guns, relationships, free speech, school prayer, or any other hot-button topic, we should remember something important.  That is, our claim to know exactly what another free citizen needs only leads to frustration, bitterness and ultimately revenge, once the pendulum of opinion, or power, swings the other way.

Australian gun control

Here’s an interesting link about violent crime in Australia and the UK.

http://voxday.blogspot.com/2012/07/mailvox-aussie-logic.html

The problem with so much in politics is that there is no negative feedback loop.  When politicians institute ideas that are dysfunctional, they don’t retract.  They increase. The logic is, if it works, you need more of it.  (Stimulus, tax, welfare, gun control…insert program or policy).

But if it doesn’t work?  You need more of it as well.  (Stimulus, tax, welfare, gun control…).  Because the government instituted it, it must have been a good idea.  And to withdraw and reassess would suggest weakness or error. And weakness or error don’t get a party, or a politician, re-elected; or a judge re-appointed.

I hope that one day, we can break the cycle.

This link suggests that the governments of Australia and the UK could apply the same lesson.  Let’s hope we can avoid their mistakes.

Edwin