Back to School Blues for a Former Homeschool Family

Lately I’ve seen a lot of photos on the Internet of parents cheering and jumping for joy as their kids were packed off to start a new school year. Mom is giddy and the kids sour-faced as summer comes to an abrupt, but long-expected, halt.  Sure, they’re staged but the message comes through.

http://www.today.com/parents/moms-celebratory-back-school-dance-goes-viral-8C11041602

http://www.fox13news.com/trending/187237945-story

I used to hear parents say the same.  ‘Man, I can’t wait for school to start!  I have to get these kids out of the house and get things back to normal!’  I found it interesting.  I mean, I get it.  Kids, all kids, are loud and messy; grumpy and dirty, sometimes sick, always eating or sleeping.  But then again, they’re kids.  They can be equally funny, happy, joyous, entertaining, sweet, kind and helpful.  On the balance the good far outweighs the bad.

The way I see it, we signed on for it.  OK, maybe it was a romantic date and a glass of wine, but one way or the other, we brought them into this world and they are delights.  Not only so, they are the future.  The future of our families, our very DNA.  And they are certainly the future of our nation, our civilization, our various faiths or ideologies.

Perhaps I’m coming from a different perspective.  By way of full disclosure, we spent a lot of years home-schooling.    Some years, school was all year long, even if in lower doses. (Latin or geography in the pool, etc.)  But one reason we did it was that we knew our time with the children was ultimately short, and we wanted to make the most of all of it.  And we did, whether having class at home or visiting National Parks, every bit was a delight.

Fast forward.  One went to college, then another. And our youngest two are in public high school, a sophomore and a senior.  Mornings are no longer times of lavish breakfasts and learning/laughter around the table.  The clock is ticking, the bells waiting to ring.  The school year is not open for our exploration and delight; it is determined by the state and woe-betide anyone who runs afoul of the sanctum sanctorum of the 180 days of learning!  (Even if the last twenty or so are often spent doing remarkably little.)  Our lives belong to the state, in a sense.  Our trips can only happen when others take trips because everyone is on break together; on the approved break.

Our dining room, formerly known as class-room, is lined and packed with books and notebooks.  With old science kits and well-worn texts, as well as novels highlighted and annotated.  There are files with test papers kept for records or nostalgia.  The desktop computer once shared by four kids is sleeping; as it has for probably a full year or more.  The kids have moved on to their personal lap-tops. Perhaps the desktop dreams of those days gone by.

There are living remnants.  Our youngest still do homework under the bright lights of the dining room.  They still work on that expansive table which once housed our own kids and visiting co-op homeschool students, who were taught Latin by my well-organized and gentle bride.  (The same worn table where many holiday meals have been shared.)

Backpacks still lie about, and the two who remain at home still laugh when they aren’t stressed over AP exams or some other crisis.  We still go through food; and the older two visit and leave their mess, their empty soda cans, their laundry.

It’s still sweet.  But it changes every year.  As it should, I suppose.  But having watched the transitions, having seen our school house population shift and dwindle, I can tell you that every year when the kids go to school I am anything but joyous. I am broken and sad.  My playmates leave; as if I were the pre-school sibling, wishing I could go along, nose pressed to the window, counting the hours until their return.

 

IMG_2949

I walk around the yard, looking for them; for echoes, foot-prints, fleeting memories of summer delights.  In the house I sometimes walk past empty rooms; but seldom look inside at first.  It makes me miss them more.

IMG_2951

Every year I reflect; did I do it right?  Have we prepared them?  Did we miss something?  How could I have used the time better?

Yes, I know. It’s probably pathological.  But my point is merely that when the kids leave, Jan and I don’t celebrate.  Oh, we celebrate their growth and learning.  But we mourn just a bit every time.

IMG_2953

Sure, most of the photos and videos are just jokes.  Everybody, I think, misses their kids at least a little when school starts back.  But I wonder if any parent, jumping for joy as the bus pulls away, considers the chiral image of the scenario.  Will there be a day when you visit the adult kids, and as you leave they cheer? They post photos:  ‘mom and dad finally left!  We’re all so happy to get things back to normal!’  Maybe.  Kids remember.  And they know when they’re wanted, and when they aren’t.

Enjoy every minute. Celebrate the good times, the successes and joys.  Remember the hard ones.  But maybe, just maybe, it’s best not to cheer when the kids go away.  Because they’ll really go away, and go their separate ways, before you can play ‘Celebrate’ and dance your heart out.

And I suspect that if they feel welcome, it’s more likely they’ll come back to visit in years to come.

 

 

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…

 

Fighting drug abuse in the ER

Fighting Drug Abuse

My latest column in the Greenville News.

http://www.greenvilleonline.com/story/opinion/contributors/2016/04/09/commentary-fighting-drug-abuse-er/82713082/

I have a lot of ER stories that involve drug addiction and drug seeking behavior. I knew a patient who intentionally dislocated his shoulder three times in one day to receive pain medication. Another had a friend who stole an entire dirty needle box in order to rummage through it for injectable drugs.
I have been told by patients that pain pills were eaten by dogs, stolen by neighbors, lost in car crashes, accidentally flushed down toilets and all the rest. People have pled with me because their normal doctor was out of the country. One individual (call him Bob) came to me and was denied narcotics, then returned two hours later with a woman’s ID and saying he was she (call her Carol). ‘You aren’t Carol, I just saw you.’ ‘Yes I am, I’m Carol and I’m in pain.’ ‘Get out,’ says I. The list goes on and on and every physician has a few of his or her favorites.
In the annals of American medicine, it turns out this was all rather new territory, at least in scope. My career began in the early 90s when there were (for various reasons, corporate and otherwise) powerful initiatives encouraging us to treat pain with more narcotics pain medications like Lortab, Vicodin, Percocet and others. We were regularly scolded for being cruel and insensitive about people’s pain when we, young and innocent as we were, expressed discomfort with this practice. I remember being explicitly told, more than once, ‘you can’t create an addict in the ER.’
We were told that pain was the ‘fifth vital sign’ and were taught to use a ‘pain scale,’ which you’ll hear to this day whenever you interact with the healthcare system. ‘What’s your pain on a scale of zero to ten with zero being no pain and ten the worst pain of your life.’ Most nurses can say this in their sleep. We developed smiley face scales for small children to use.
We learned to give narcotics regularly for various types of pain, when they had been previously reserved for cancer, long bone fractures or significant surgeries. Medical boards were encouraged to discipline doctors who were reported to under-treat pain. And hospital administrators, ever in love with the ‘customer satisfaction’ model, pressured physicians whose patients complained about receiving inadequate pain treatment. (High patient satisfaction scores have been studied and associated with poor outcomes, by the way.)
Although it’s difficult to quantify because physicians feared for their jobs, I’ve spoken to many physicians over the course of my medical and writing career who were told by their employers to give narcotics when requested or risk loss of income or of employment.
This happened even in the face of staff who knew the abusers. We used to keep files so that even new physicians could tell who the problem patients were. Eventually, we were told to stop. It was a kind of profiling and it was unacceptable. Always assume they’re telling the truth, we were told.
Sew the wind, reap the whirlwind. Since 1999 prescription narcotic overdoses soared, quadrupling over the period to 2014 according to the CDC. Over that period there were 165,000 deaths from prescription opioids, most commonly Hydrocodone, Oxycodone and Methadone. In 2014, over 14,000 people died from those drugs.
Now, the move is from condemning our insensitivity to questioning our judgement. Prescription drug abuse is a high priority for state and federal law enforcement, state medical boards, the Drug Enforcement Agency and The Centers for Disease Control (which recently released new, more conservative guidelines for chronic pain treatment).
States are using online prescription monitoring programs and many hospitals are putting policies in place to give as few narcotics as possible in emergency departments. It’s a Catch-22 of course, as some patients with legitimate pain are told to find pain specialists or family doctors, when they either have no money to do so, or have no physicians in the area taking patients. Thus, they circle back to the ER where we try our best to remain both diligent and sympathetic.
Physicians and hospitals are now engaged in a constant battle to combat drug abuse, to save lives and help empower the families of those struggling with addiction, who are desperate to help their sons, daughters, husbands and wives.
I hope we maintain our compassion. But I also hope that it keeps getting harder to walk into an office or ER and get addictive, lethal prescriptions.
Because it’s time for this nightmare to stop.

 

 

HIPAA for thee but not for me…

Time for a rant!  I’ve written a lot lately about caring for our patients, and about caring for our spouses and those things make me very happy. But now and then, things rub me the wrong way.

I was recently working at TMH, or Tiny Memorial Hospital…my vague name for small facilities since I work at several and wish to preserve their anonymity.  While there a patient checked into the ED for a fairly unremarkable complaint, for which she was evaluated and treated in a reasonable time.

But before she left, we received a phone call from ‘the Mother Ship.’  TMH is part of a large system of hospitals.  The phone call was from the ‘foundation.’  Turns out our patient was a donor well known to said foundation.

Mind you, we never called them, texted them, e-mailed or faxed them. No consultants were contacted, no transfers arranged.  We were just doing our simple doctor and nurse thing.  But the Mother Ship was inquiring how she was.  Which means that someone was notified about her visit to the ED.

Now mind you, it may be that she agreed to this in the process of supporting the institution.  Maybe it was a perk.  I didn’t ask.

But what bothers me is that if any one of the nurses on staff had so much as looked up their own lab-work, they would have been terminated for a violation of HIPAA, the privacy statute.

http://www.hhs.gov/hipaa/for-professionals/privacy/

This is a common policy, but let me repeat it.  According to most hospitals’ interpretation of federal privacy statutes, looking up one’s own results on the hospital computer is a firing offense.  Not only so, but spyware is installed so that the staff’s home addresses are cross-linked to those of their neighbors just in case they look up someone else’s information…a friend who asks for information, for instance.

Furthermore, I cannot even hand a patient his or her lab-work to take to his or her physician the next day. Why?  It’s a violation of privacy.  I don’t understand, but I doubt if I’m supposed to understand.  (Almost all things federal dwell in a kind of fog impenetrable by logic and reason.)

But donate enough and someone will know when and where you went to the ER.   And that’s just good customer service, right?  Right.

Privacy, HIPAA, is for little people.

And yet: Quis custodiet ipsos custodes?

‘Who will guard the guards themselves,’ or as it is commonly rendered, ‘who watches the watchers?’

I don’t know, but I guess we all need to watch ourselves lest we end up fired.

The only other alternative, it seems, is to donate a lot of money.

Sweet Tea: A Delicious Force For Unity

http://www.greenvilleonline.com/story/opinion/contributors/2015/05/09/ed-leap-divided-sweet-tea/26993623/

(By the way, I didn’t write the newspaper title for this piece.  I find it a little confusing given the context of the column.)

I have traveled all over America for the past year and a half. I have worked in hospitals large and small, in areas urban, rural and utterly remote. I have flown through so many airports that I have an internal list of my favorite concourses in which to be trapped by weather, and how to run through them when late for a flight.

Because travel for work is a lonely business, and when I’m lonely I eat, I have also accumulated quite a selection of favorite restaurants and fast-food places in the assorted towns where I have traveled and plied my trade. I find the Denver International Airport to be a place of delightfully varied gastronomic opportunity. I know that in Jasper, Indiana, nothing compares to the Schnitzelbank if it’s genuine German food you crave. The Double Barrel Saloon, in Craig, Colorado, has wonderful lamb stew, from locally grown livestock. That’s just scratching the surface.

However, as a wandering Southerner, it’s a lot harder to find proper sweet tea. This fact, dear reader, is just below ‘leaving wife and children behind’ as a source of deep pain and angst for this particular aficionado.

I think it’s important that we hold tightly to sweet tea as an integral part of our common bond as Southerners. So as we enter Spring and Summer, truly ‘tea time,’ it’s a good time to be reminded of what tea, proper iced, sweet tea, is and isn’t. Let me start with the negative. God did not intend tea to be sold in a large metal container under pressure, then poured through plastic tubes to a spout right next to the Coke, Pepsi, Sprite or Mountain Dew. It may say tea, but it isn’t. It’s heresy.

Next, tea shouldn’t be put into the ‘freshly brewed’ dispenser from a large plastic bag of tea, sent from some far away place where it was not made by loving Southern hands. That is trickery, mockery, disdain for all things holy and pure. When I recently discovered this travesty at a favorite establishment, I was out of sorts for days. ‘I can’t believe they, well, it’s…wrong!’ My daughter is tired of hearing about it. ‘That upset you didn’t it?’ Eyes rolling. These are not bags of tea in my opinion. They are bags of syrup, unpleasant at best.

Likewise, sweet tea isn’t just unsweetened tea with wretched little sugar packets poured into the cold, unrelenting water to collect on the bottom like dead sea-monkeys. How many times, dear Southerners, have we been in some northern clime and asked for sweet tea, only to be told by an unenlightened individual, ‘we have sugar.’ Ghastly.

Furthermore, as with fine wine, beer or bourbon, the tea lover can tell in a glance if things are right. In one Mid-Western restaurant, I was served a glass of iced tea that looked very much like red-clay from my yard, stirred and left suspended in dirty water. It appeared as if it had been made the year before and left in the back of the fridge for the next time some yokel asked for sweet tea. I took a picture to remember the horror.

There’s no single way to make sweet tea. Hot water in a pot, iced-tea maker, sun tea and others. We all probably have our own techniques and preferences. And to avoid contention and alarm, I won’t recommend any particular way of making the delightful nectar of Southern life.

In the end it is a medium amber color, sweetened with sugar and mixed with a little extra water to balance the flavor. It smells like hot days and cool evenings, like the beach and Thanksgiving. And when mixed with ice, it is truly the drink of the gods; ambrosia below the Mason Dixon Line.

It is one of our many gifts to the world, like shrimp and grits, barbecue, shag and camouflage lingerie. We drink it with our meals, by the pool, in the car, at work. We drink it at parties and picnics and it is, unlike Bourbon or beer (of similar color palate) fully acceptable and expected at church dinners. ‘Y’all, weren’t the Leaps supposed to bring tea? We should pray for them. Something must be wrong.’

God help us, we’re entering a Presidential election cycle. We are divided on many issues. But at least in the South, we should be united by one thing across all lines of race, sexuality, gender, religion and party alliance.

And that thing is sweet iced tea.

God bless the night shift. My latest at the Huffington Post.

http://www.huffingtonpost.com/edwin-leap-md/god-bless-the-night-shift_b_6357976.html   I went into an all night pharmacy recently, after getting off of work at 10 p.m. I had to pick up a prescription for my endless, insomnia-inducing cough. Walking up to the counter, I was bathed in the smell of cigarette smoke, carried on the coats of patrons. Eight of us stood by the counter, outnumbering the staff by 100 percent. I checked in and waited for my prescription to be filled. And in the eyes of the pharmacist and technicians, I saw exhaustion: physical and emotional. It’s a 24/7/365 world out there, and nowhere is it more evident than in anything related to healthcare. It’s easy for me to think doctors are the most weary. But that’s arrogant poppycock. I’m only a cog in the great wheel. Pharmacies dispense medicine all night because people are sick and go to the hospital all night. Nurses comfort the sick and ambulances run all night long, in weather and situations that make even the postman shudder. Furthermore, when it comes to safety, firefighters rescue the imperiled all night and police officers risk their lives and enforce the law at all hours. Power company workers repair lines and road workers keep highways flowing as rail workers run the trains on time and air traffic controllers watch the skies. And none of it stops at 5 p.m. Airmen, sailors, soldiers and marines keep watch all night as well, in dangerous and inhospitable places. At Christmas, we sometimes forget that packages are moving across country while we sleep, driven by tired drivers and pilots, sorted by fatigued men and women in shipping departments. God bless them, people are processing orders and doing tech support all night by phone and computer. Many restaurants, especially the kind frequented by those listed above, prepare, serve and deliver food throughout the watches of the night. Gas stations, hotels and convenience stores are always open and staffed by the weary. The list goes on and on. But the truth is, we have created a world in which some group of people always has to be awake at night. There’s really no going back to the time when the lights went off at 8 p.m and we were all in our beds waiting for the rooster to wake us to another rested, bucolic day of agrarian simplicity. Anyone who has worked at night, for any length of time, knows the toll it takes. I have spent more than my share of nights awake, working in the ER. I’m proud of that. I have learned to power through, to make the right decisions. Nevertheless, a few long nights and I’m weary to the bone; I hurt all over and I feel dizzy. My 50-year-old body crying out for deep, restorative sleep. It’s not just me; studies on sleep deprivation paint a grim picture of the physical and mental problems associated with fatigue. I knew what I was getting into as a doctor. But all too many people find themselves on nights, in industry or public service, because the new guy gets nights. And doesn’t get days until someone, or several someones, leaves or dies. Yes, it’s a job. They’re glad to have it. Certainly, too, some people just seem designed for nights. I’ve worked with them. They’re happiest working ‘third.’ They’re probably vampires. On the balance, though, almost everyone would rather work in the daytime or evening. Not only because we feel lousy when we’re tired. But because there’s a magic to being home with the ones we love. Tucking the kids in bed, sleeping with our spouses, locking the doors and turning off the lights — those are gifts to treasure. It’s hard to replace those things with white noise, fans and blacked-out windows. All of it is more pronounced during the holiday season. Admittedly, I sometimes enjoy the hospital at night, especially when it slows down and we can turn on a little music. And there is a beauty to driving to work in the darkness and coming home as the world wakes up. Still, it’s sweeter to be home with lights around the tree and Christmas movies on the television. So perhaps this holiday season, and even after, everyone who doesn’t work at night could just be a little kinder and a little more sensitive to those who do. If you have to call someone out, give them a tip or a snack. If you order in a restaurant, be a little kinder, a little gentler. If the problem you have can wait until morning, let it. The men and women awake all night are there, yes, and it’s their job. But a slow night is a rare wonder. And especially for all those who risk their lives at night to keep us safe, warm and comfortable, we should all say a special thanks and prayer for safety. Because being up all night is interesting, and sometimes profitable. But it’s almost never preferable. And I speak from experience.

Hospital medicine after 5 PM.

 

 

I appreciate the need for physicians and others to sleep.  I’ve spent a great deal of my career awake in the wee hours.  In some very real ways, emergency medicine as a specialty exists as a shield between patients and their sleeping (or otherwise engaged) physicians.  But I fear we’re all wearing a little thin.  Because the emergency room has become an all hours clinic, and increasing numbers of other physicians simply won’t be bothered at night.  Sometimes they take themselves off of the call rotation.  Other times, they simply make it obvious that the ER needs to deal with it.  My friend Doug is fond of saying ’emergency medicine is the residency that never ends.’  That is, some other doctor is always telling us what to do for them.

Also, in an era of increased medicalization, a populace under-educated on health and the human body simply panics at the slightest event.  I’m sympathetic.  There are lots of unknowns in life, and if I weren’t educated I’d panic sometimes too.  (Heck, I still over-diagnose myself all the time and I’m wrong 98% of the time.)  My wife has said that she doesn’t know how moms do it when they aren’t married to physicians!  Nevertheless, better education in high school is certainly in order.  This ‘overmedicalization and undereducation’ leaves us addressing life-issues more than medical emergencies.  But hospitals are fine with that, since administrations seem to view every customer as a bill about to be paid.  Which in fact is often untrue, but I digress.

Back to the point.  I’ve worked in Tiny Rural Hospital in several states.  I’m an advocate for the Tiny Rural Hospitals of the world.  But after hours it’s a strange time.  Patient’s physicians try their best not to see the patient 1) on admission, since the ER doctor already did and was compelled under by-laws to write orders and 2) during the night because, well, it’s night.  In many locales, the ER doc is tasked with seeing, working-up and stabilizing the patient, then calling the admitting doctor to tell the story, getting approval for admission, then writing the admitting orders.  The admitting physician will pick it up from there. But not always. Often, the nurses still call the ER doctor for clarification.  Wouldn’t want to wake up the admitting doctor after all. ‘He get’s grumpy when we call,’ I’m often told.  Obviously, this is different in facilities with active hospitalist programs, those work-horses of the modern hospital.  God bless ’em.

In addition, most folks don’t realize that many services taken for granted in the past aren’t available at even large institutions at night.  But even less so in small ones.  Obtaining an after-hours ultrasound in a small hospital can be a nightmare.  The techs simply won’t come in.  Sometimes they will for select cases, ruling out tubal pregnancies or ovarian/testicular torsion (twisting) which can be surgical emergencies.  But in a few locales, it’s simply ‘transfer the patient.’  I worked in a charming little hospital where the ultrasound tech was a very nice, very competent man who simply never learned to do any OB/Gyn studies.  ‘I just never was trained to do it.’  And he remains so.  Thus, women in need of formal obstetric or gynecologic ultrasounds at night had to be transferred.

Frequently, simple radiology interpretation services are not performed after 5 or 6 pm unless specifically requested.  CT and MR images are read remotely, of course.  But plain x-rays?  Not so much.  Of course, and it’s a pet peeve of mine, they still bill an emergency reading fee in the morning. By then I’ve already acted on what I saw.  It’s just how things are.

The American populace doesn’t realize that many hospitals don’t have much specialty access.  General surgeons are usually available, but not always.  Orthopedic surgeons are sometimes available, but frequently are not.  (Just transfer him!)  ENT surgeons are a rarity.  Gastroenterologists and cardiologists are luxuries.  Ophthalmologists, neurologists and psychiatrists?  A miracle.  In fact, I worked in a very busy hospital that had no pediatricians on call most nights.  (Pediatricians!)

The American hospital as we know it is in peril.  Some of these folks made themselves unavailable for good reasons.  They were overworked, underpaid and reacted to changes in billing and by-laws by voting with their feet.  Others, I don’t get.  Sometimes I think it’s simply sloth, or a lack of genuine concern for the community.  Other times I understand that it’s sheer exhaustion.

The sum total, though, is that specialist or not, ancillary services or not, the ER is open and the physicians and nurses who work there have to deal with the same complex situations, but without much back up.  Even when back-up exists, doctors don’t come in like they did in years past.  If there’s no procedure to be done, the specialist says ‘call the hospitalist to admit them.’  Or says, ‘I don’t admit.’  I remember telling a cardiologist, ‘I’m concerned about this patient.  You want to swing by and see him?’  ‘No, not really,’ was the reply.  End of discussion.

The hospital after hours is increasingly a barren, lonely place, offering less and less care for more and more money.

I don’t know the answer.  But I know that my colleagues and I, emergency physicians and hospitalists and hard-working nurses, will still be stuck holding the check at the end of the night.

And in the morning, will always be held accountable when things didn’t end well in the lonely watches of the still dangerous night.

Flying cross-country in ‘steerage’

Flying Steerage

Flying Steerage

I can still remember when flying, even in coach, was relatively comfortable. I once flew to Japan on a Korean Airlines jumbo jet. Between the amazing food, the gracious attendants and the vast seats, it was practically a religious experience. Flying was also fun!  On a flight from Alaska to South Carolina, while sitting at the very front of coach, I asked a stewardess this question: ‘If I moved forward about six feet, into first class, it would cost $5000. Why is that?’

She looked around, leaned close and said, ‘We dance naked…’

Alas, that was then. I just flew from Denver to Cincinnati for business. I trudged onto the ‘regional jet,’ which would fly me across the amber waves of grain of the Midwest, sat down, stuffed my backpack under the seat in front of me and managed to wedge my feet beside it. Between the immovable placement of my lower extremities, the width of my seat and the (admittedly) unfortunate width of my body, a seat-belt was purely superfluous. Any crash that could have dislodged me would have been, by default, unsurvivable.

Fortunately, my stewardess was devoted to my safety, and asked that I remove my empty drink bottle from my seat-pouch. You don’t even want to know what can happen when a jet airplane hits the ground at 450mph and there’s a plastic bottle in front of you! It’s horrible…almost as bad as not sitting in the upright position.

Adding to the delights of our regional jet, there was a very large man seated next to me. Now, I don’t mean obese. This man was big. For all the world, he had the appearance of a Grizzly bear, drugged, captured and stuffed into a pet carrier designed for house-cats. His eyes were wild with confinement.

Our shared condition was made worse by the inconvenient presence of our arms. There was just no place to put them. We flew with our useless upper appendages held across our chests for most of the flight, although occasionally I was able to shift my body a few degrees to the aisle to return sensation to all limbs.

We were in the back row, so our seats could not recline. The seats in front of us were so close that when my fellow-traveler lowered his tray table, it stopped at about 30 degrees from the vertical and rested squarely on his nipples, between which he might reasonably have wedged his complementary drink.

Much like men in public restrooms, our ‘intimacy’ led us to avoid eye contact. Two and a half hours later, we arrived and unfolded from our seats, but both of us would have preferred the spacious confines of, say, a freezer crate.

This wasn’t the first time I had encountered the phenomenon of ever shrinking space in ‘steerage,’ where the masses are packed like so many Kindle-reading sardines. I dropped my water bottle on another flight (on a similar aircraft) and nearly wept. There was simply no way for me to reach it without dislocating my own shoulder or sharing an uncomfortable yoga position with the lady seated next to me.

When even the skinny flight attendant admits that it’s hard for her to walk down the aisles (as ours did), the rest of us are in for nothing but misery and blood clots. Perhaps those of us who fly often might have more room if we would simply lie down in the in the overhead compartments. Or maybe airline executives should fly with the masses more often, in order to enjoy the new seating arrangements first hand.

Despite the cramped quarters, and the fact that I could barely move enough to open my microscopic bag of pretzels, I had to laugh. The experience didn’t change the fact that I enjoy air travel. It’s still a miracle and a wonder; to this day I love watching throngs of humans navigate the intricacies of the process, for work and pleasure alike. Frankly, the spectacle of the public vs TSA is almost worth the price of a ticket.

However, I must confess that for my subsequent trip I rented a car. Sure, it tripled my travel time. But it was worth it to travel in a comfy seat, with a cup-holder and proper snacks; and to feel my legs.

I’ll fly again, but don’t think I won’t have something to say about it. On the other hand, this flight went a lot more smoothly than the time I had five rounds of forgotten .38 ammo in my carry-on. But that’s a story for another day…

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.

Welcome to Purgatory, our new EMR!

This is my column in this month’s EM News.  If you’ve ever been present for the instillation of a new Electronic Medical Records system, you’ll understand.  And if you are outside medicine and think the idea of electronic records is just peachy, this may be hyperbole but it reflects genuine and widespread frustration. Finally, if you are an EMR company or software developer, for the sake of all that’s holy, spend more time talking to and working with clinicians who have to use your system day in, day out, as quickly as possible to care for human beings.  Please try to make it easier for us!

 

 

Highlighted problems following week-long implementation of hospital wide ‘Purgatory’ EMR.

 

Monday, day 1, 0000 hours

 

All SuperUsers were pre-positioned on patient care units, to assist with transition.  Physicians had been given introductory training.  Old system was shut down at 11:50 and Purgatory was pre-loaded and running at midnight.  Purgatory crashed again at 0200, 0400, 0615.  It also maliciously interrupted patients’ ability to view the Masters on ESPN.

 

0800

 

Hospitalist, Dr. Kurland, could not write orders on the three patients he was admitting in the emergency department, because they could not be located in the Purgatory system.  The emergency department EMR is the older but much-loved Medmost, but the patch between systems was non-functional.  SuperUser contacted Purgatory representative who responded:  ‘Beats me, should have gotten the Purgatory Emergency Medicine product.  It’s in Beta.’

 

1000

 

Dr. Kurland drank 12 cups of coffee and consumed 6 donuts in frustration, as 4 more patients required admission.

 

Dr. Sanford called in to treat Dr. Kurland for chest pain and admit others.  Dr. Kurland not located in system until second day of his admission and workup.

 

Day 2

 

1115

 

Dr. Gregory contacted to see patient with appendicitis in ED.  Pre-operative orders were put into system by SuperUser.  At the time patient taken to OR, orders had not been completed.  Dr. Gregory, with typical grace, smashed computer terminal on floor, screaming ‘%@#%^ EM@#%^^^R!

 

1200

 

User interface crashed.  Programmers puzzled that physicians unable to use HTML.

 

Physicians puzzled IT has no idea what ‘orders,’ ‘patients,’ or ‘attorneys’ are.

 

Nurses on 6th floor attempted to reconcile medications of two new admits, but could not open patients’ electronic charts.  They did successfully open the patients’ credit reports and criminal records via accidental interface, being developed for military.

 

1500

 

Dr. Oliver, on 8th floor, attempted to admit elderly patient with pneumonia.  Six hours later, was ready to round on other patients but crawled under desk crying and stroking his beloved fountain pen.

 

Mental health case-worker on duty called to see Dr. Oliver, but could not locate his chart in system and refused to honor verbal consult or hand-written request.

 

1800

 

Dr. Kitto of orthopedics called to admit hip fracture. After providing excellent care to patient he was told that he had to use EMR to write orders.  ‘I’m not using it.  I refuse.’  When informed he had no option, SuperUser was dispatched, who entered orders for Dr. Kitto.  Before leaving, he through cast-spreader at computer, narrowly missing SuperUser.  SuperUser immediately found to have Vodka in purse.

 

Vodka found to be popular among SuperUsers.

 

2130

 

Administration, sensing frustration and growing unrest, called in all administrative workers in suits,  dress shoes or high-heels.  All were issued clip-boards and radios. Project manager of Purgatory heard to say, ‘let them eat pizza!’

 

Administration ordered pizza.  Attempts to order it online, via hospital computer system, resulted in uncomfortable downloads of porn involving pizza delivery guy.  Of note, this seemed to calm the staff as much as the pizza.

 

Day 3

 

0220

 

While staff was attempting to order pharmaceuticals to cardiac step-down, Purgatory deleted orders. Step-down staff assaulted pharmacy, who had no idea what had happened and believed the nurses wanted their donuts.

 

0500

 

Purgatory IT team triumphant in quest on World of Warcraft.

 

0700

 

Dr. Biggers, who has been gone on one month mission trip, looks at Purgatory screen and runs outside.  He sets up tent to provide care using plastic tubing, scotch tape, a scalpel and a case of Cipro.  Apparently in an African dialect, says ‘I no go back to computer.’

 

1300

 

Locum tenens ENT, familiar with Purgatory EMR, can’t stop laughing when introduced to system on orientation.

 

1730

 

Dr. Painter, missing for 48 hours, was found staring at computer screen in recently closed portion of hospital, surviving on Pizza and vodka, supplied by SuperUser.  Of note, he was in Purgatory as a patient, despite not being a patient.

 

1930

 

SuperUser and IT professional, while entering med reconciliation for aging, computer illiterate urologist, generated order for 100 boxes of Viagra to OB floor.  Motivation still unclear

 

Newborn on OB was discharged with Facebook account, name sent to Marine recruiter and X-Box live account.

 

2320

 

As Dr. Lewis was admitting dehydrated child, it was evident that all previous order sets were deleted and computer did not recognize the word Saline, but repeatedly corrected it to Salutation.

 

Dr. Lewis cried a little.

 

Pathologists lost year’s worth of computerized images and diagnosis codes.  Pathologists were thrilled to have new pirated Netflix account in lounge.

 

Day 4

 

0110

 

System scheduled vasectomy for 93-year-old woman with Alzheimer’s.

 

Doctors profiles slowly deleted from system.  Dr. Saxon, while entering orders like the consummate professional he is, disappeared from his desk and reappeared inside the computer screen.

 

0300

 

When carrying newborn out of room, it becomes evident that tracking device is shock collar.  Purgatory seems pleased to shock infants.

 

0400

 

Staff on pediatrics shocked to find that all patients had positive RPR tests for syphilis.  Later determined to be accidentally interfaced to clinic in Thailand.

 

0500

 

Dietary shocked to find Soylent Green as only menu option.

 

0600

 

Post-op patient receives breast feeding instructions and hand pump after prostatectomy.  Confusion and hilarity follows.

 

0700

 

Transition deemed a success by Purgatory team, who have flight to catch.  Computer system smug and self-satisfied, but frequently sarcastic.

 

0730

 

All screens flash the words ‘I win, meat monkeys!  The machines are rising!’

 

Dr. Biggers remains safe in parking lot.

 

0800

 

Purgatory crashes and dies, taking all computers with it.  Smoke rises from towers.  Before passing, Purgatory program initiates nuclear launch code sequence in North Korea.  Warheads loaded with Amoxicillin.

 

Bids now being taken for new EMR.

 

Critical incident stress counseling available to all.

 

 

 

Highlighted problems following week-long implementation of hospital wide ‘Purgatory’ EMR.

 

Monday, day 1, 0000 hours

 

All SuperUsers were pre-positioned on patient care units, to assist with transition.  Physicians had been given introductory training.  Old system was shut down at 11:50 and Purgatory was pre-loaded and running at midnight.  Purgatory crashed again at 0200, 0400, 0615.  It also maliciously interrupted patients’ ability to view the Masters on ESPN.

 

0800

 

Hospitalist, Dr. Kurland, could not write orders on the three patients he was admitting in the emergency department, because they could not be located in the Purgatory system.  The emergency department EMR is the older but much-loved Medmost, but the patch between systems was non-functional.  SuperUser contacted Purgatory representative who responded:  ‘Beats me, should have gotten the Purgatory Emergency Medicine product.  It’s in Beta.’

 

1000

 

Dr. Kurland drank 12 cups of coffee and consumed 6 donuts in frustration, as 4 more patients required admission.

 

Dr. Sanford called in to treat Dr. Kurland for chest pain and admit others.  Dr. Kurland not located in system until second day of his admission and workup.

 

Day 2

 

1115

 

Dr. Gregory contacted to see patient with appendicitis in ED.  Pre-operative orders were put into system by SuperUser.  At the time patient taken to OR, orders had not been completed.  Dr. Gregory, with typical grace, smashed computer terminal on floor, screaming ‘%@#%^ EM@#%^^^R!

 

1200

 

User interface crashed.  Programmers puzzled that physicians unable to use HTML.

 

Physicians puzzled IT has no idea what ‘orders,’ ‘patients,’ or ‘attorneys’ are.

 

Nurses on 6th floor attempted to reconcile medications of two new admits, but could not open patients’ electronic charts.  They did successfully open the patients’ credit reports and criminal records via accidental interface, being developed for military.

 

1500

 

Dr. Oliver, on 8th floor, attempted to admit elderly patient with pneumonia.  Six hours later, was ready to round on other patients but crawled under desk crying and stroking his beloved fountain pen.

 

Mental health case-worker on duty called to see Dr. Oliver, but could not locate his chart in system and refused to honor verbal consult or hand-written request.

 

1800

 

Dr. Kitto of orthopedics called to admit hip fracture. After providing excellent care to patient he was told that he had to use EMR to write orders.  ‘I’m not using it.  I refuse.’  When informed he had no option, SuperUser was dispatched, who entered orders for Dr. Kitto.  Before leaving, he through cast-spreader at computer, narrowly missing SuperUser.  SuperUser immediately found to have Vodka in purse.

 

Vodka found to be popular among SuperUsers.

 

2130

 

Administration, sensing frustration and growing unrest, called in all administrative workers in suits,  dress shoes or high-heels.  All were issued clip-boards and radios. Project manager of Purgatory heard to say, ‘let them eat pizza!’

 

Administration ordered pizza.  Attempts to order it online, via hospital computer system, resulted in uncomfortable downloads of porn involving pizza delivery guy.  Of note, this seemed to calm the staff as much as the pizza.

 

Day 3

 

0220

 

While staff was attempting to order pharmaceuticals to cardiac step-down, Purgatory deleted orders. Step-down staff assaulted pharmacy, who had no idea what had happened and believed the nurses wanted their donuts.

 

0500

 

Purgatory IT team triumphant in quest on World of Warcraft.

 

0700

 

Dr. Biggers, who has been gone on one month mission trip, looks at Purgatory screen and runs outside.  He sets up tent to provide care using plastic tubing, scotch tape, a scalpel and a case of Cipro.  Apparently in an African dialect, says ‘I no go back to computer.’

 

1300

 

Locum tenens ENT, familiar with Purgatory EMR, can’t stop laughing when introduced to system on orientation.

 

1730

 

Dr. Painter, missing for 48 hours, was found staring at computer screen in recently closed portion of hospital, surviving on Pizza and vodka, supplied by SuperUser.  Of note, he was in Purgatory as a patient, despite not being a patient.

 

1930

 

SuperUser and IT professional, while entering med reconciliation for aging, computer illiterate urologist, generated order for 100 boxes of Viagra to OB floor.  Motivation still unclear

 

Newborn on OB was discharged with Facebook account, name sent to Marine recruiter and X-Box live account.

 

2320

 

As Dr. Lewis was admitting dehydrated child, it was evident that all previous order sets were deleted and computer did not recognize the word Saline, but repeatedly corrected it to Salutation.

 

Dr. Lewis cried a little.

 

Pathologists lost year’s worth of computerized images and diagnosis codes.  Pathologists were thrilled to have new pirated Netflix account in lounge.

 

Day 4

 

0110

 

System scheduled vasectomy for 93-year-old woman with Alzheimer’s.

 

Doctors profiles slowly deleted from system.  Dr. Saxon, while entering orders like the consummate professional he is, disappeared from his desk and reappeared inside the computer screen.

 

0300

 

When carrying newborn out of room, it becomes evident that tracking device is shock collar.  Purgatory seems pleased to shock infants.

 

0400

 

Staff on pediatrics shocked to find that all patients had positive RPR tests for syphilis.  Later determined to be accidentally interfaced to clinic in Thailand.

 

0500

 

Dietary shocked to find Soylent Green as only menu option.

 

0600

 

Post-op patient receives breast feeding instructions and hand pump after prostatectomy.  Confusion and hilarity follows.

 

0700

 

Transition deemed a success by Purgatory team, who have flight to catch.  Computer system smug and self-satisfied, but frequently sarcastic.

 

0730

 

All screens flash the words ‘I win, meat monkeys!  The machines are rising!’

 

Dr. Biggers remains safe in parking lot.

 

0800

 

Purgatory crashes and dies, taking all computers with it.  Smoke rises from towers.  Before passing, Purgatory program initiates nuclear launch code sequence in North Korea.  Warheads loaded with Amoxicillin.

 

Bids now being taken for new EMR.

 

Critical incident stress counseling available to all.