What do You Mean My Child is not Sick?

What is it with parents who get mad at me when I tell them their kids are well? Now "well'' is a relative term and I don't doubt that junior had a runny nose or a temp of 99.8 which of course for him is really high as his normal temperature is 97, and that he even may have vomited once or been in the woods two days ago where the neighbor found a huge swarm of ticks or brown recluse spiders or fungus or spores or molds or some kind of funny smelling goo, but he's not ED sick. I can always tell when this news will be met with incredulity and I always try to ''hang the crepe'' before my diagnosis... "Well Ma'am, GOOD NEWS! Junior appears to be just fine... He probably has a viral illness which should pass in a few days... Be sure to follow up with his doctor should you have any further concerns."

"What? You aren't going to do anything for him?!?"

"Like what?"

"Like give him some antibiotics!"

"Ma'am I don't find anything to treat with antibiotics and they will probably do nothing but give him diarrhea."

Mutter, mumble, snarl.

One of these days I may have to try this...

"Ma'am, you were right, your child is deathly ill with African Sleeping Sickness and the Grippe which he no doubt contracted from wearing wet clothes in a drafty room, or perhaps from a curse... Do you have any enemies who know Voodoo? He will need to be leeched and flagellated until we he can't walk, only then will he be well."

Heavy D

I had a discussion today with one on my nurses about weight. Now, there is nothing wrong with being comfortable in your skin, but when your girth prohibits you from getting all the benefits modern medicine has to offer, you tie the doctors hands in how much we can do to help. I said the magic number was 275 for the average person, especially female. We seem to get a large number of them waddling into the ED complaining of knee and ankle pain, go figure. At that weight, if you lost 100 lbs, you could actually function, but if you are pushing a quarter ton, there is obviously a point of no return.
I only point this out because I had to do a pelvic exam on an extremely obese female today. It reminded me of a patient in residency who weighed 500 lbs. She was pregnant, and doing a pelvic on her required the assistance of 3 people. Later the nurse inquired as to how she got pregnant. Turns out, 2 of her cousins held her thighs back while her husband went to town.
Isn't that a pretty picture.

Mr. Brown

Mr. Brown has been a patient in the ED 48 times this year and that's just about every other day. The E.D. staff all know him and every ED in the country has a Mr. Brown. He is in his sixties and lives alone. He is able to care for himself but just barely. He has real diseases and he has imagined ones. He has physical pain from arthritis and mental pain, we all agree, from loneliness. Out of a hundred or so visits last year he was admitted twice for serious medical problems, and discharged the other times after a pat on the hand and a 30cc hit of maalox.

The other day he told our nurse manager, "You know I got a letter from my insurance company telling me they weren't going to pay for my emergency room visits anymore. "

She expressed concern about this and was about to offer whatever insight she thought appropriate when he continued his thought...

"... I'll bring the letter and show you when I come in tomorrow."

She did manage to stifle her laugh.

Customer or Patient?

One of the silliest things to happen in medicine in my 10 years of practice is the turning to a business model to improve what we do. Now I am a big free market guy and I believe that competition leads to decreased costs and incresed efficiency. So why would I be against learning from business to improve what we do. I wouldn't be if medicine were a business.

With the advent of medicare/medicaid medicine inched away from being a fee-for-service business to a heavily subsidized and endlessly intricate mystery wrapped in an enigma (apoligies to my hero). Used to be a doctor could hire a secretary and a nurse and open an office and do well if he was good and his patients liked him. Okay, that's business. Now I would challenge anyone to show me this Horatio Alger MD. I know there are boutique practices that cater to those with great insurance or great bank accounts but these are more a curiosity than an alternative to the current system.

As I have stated elsewhere, in the Emergency Department we collect about 30% of what we bill. Recent statistics show that each Emergency Physician in the country gives away about $150,000 in free health care a year. This is because of the unfunded federal mandate called EMTALA, and ED physicians are not the only ones affected. If you are a surgeon, for instance, and you want to practice surgery, then you have to have priveleges at a hospital. This is not true for all surgeons, oral-maxilofacial surgeons can skirt this, but let's just speak about your genergal surgeons, vascular surgeons, chest surgeons, trauma surgeons, neurosurgeons, orthopedic surgeons, hand surgeons, urologic surgeons, gynecologic/obstetric surgeons, and pediatric surgeons. These folks have to take call for the hospital at which they are priveleged. When they are on call EMTALA impacts them too, for if any patient comes into the ED with an emergency surgical condition... appendicitis or an open fracture for instance... that patient is now theirs.

Never mind that with many of these patients the surgeon will not see a red cent for their 3am call to the hospital for emergency surgery. Never mind that they are forced to give hours of their valuable time in these patient's care. Now understand also that these surgeons have practices and have scheduled elective procedures for which they will be reimbursed. Now these reimbused procedures are cancelled for the emergency procedure. No wonder they hate the Emergency Department. I'm not saying, nor would they, that the emergency patient should not receive their operation or should not receive care, I'm simply pointing out that this is not a business model.

It grates on me therefore that the business-minded amonst us are still trying to fit a square peg in a round hole. Believe it or not the administration of most hospitals and ED groups care most about postitive customer feedback (see the prior posts on "Press-Gainey Scores"), and less about good outcomes.

So in medicine, which already resembles a huge ponzi scheme run by the government and insurance companies, the physicians themselves are daily bombarded with ways to improve ''customer service''. Never mind that 70% of our ''customers'' are not paying a dime for their care... they still get to fill out surveys about whether their care was timely and caring. A single angry patient, even one in the country illegally, can get a physician called to the carpet because the physician was ''rude'' or ''didn't explain things'' or a host of other complaints having nothing to do with whether they were treated correctly for their complaint.

Here's another wrinkle, if you are a ''customer'' whose sole purpose is to obtain a prescription for narcotics which you can then use or sell on the street at great profit, and you don't get it because you are proved to be a liar and have 30 prescriptions at the local Walgreens for oxycontin written by different physicians at different facilities within the past year, and you receive a randomly distributed ''survey'' you too can get your treating physician in trouble. Physicians have no counter to this, instead we are treated to lectures on improving our "customer service".

For what purpose? In a fee for service environment where we were truly compteting for dollars that would go elsewhere okay! I get it! When half my salary is going into a deep dark hole anyway why the hell should I care about this? When all our beds are full, the waiting room is full, the hall beds are full, and three patients are dying how am I supposed to give warm fuzzies to the mom who brought in her healthy kid for a ''fever'' that we can't document and a ''rash'' that I can't even see?

Most physicians do not organize, picket, or complain outside their professional circle. We are a beaten bunch. My solution is to never look to see whether a patient has a job or insurance... I treat everyone the same. If I'm not slammed I will hold your hand and explain things to you, if not, you may see me for two minutes. Still, it is painfully obvious many times that the arrogant SOB/DOB who is not sick is in the ED simply because we are ''free'' has no intention of ever paying for their care nor any means to (though they can still afford their cigarettes because 'my husband buys them for me'- no shit!). I challenge anyone to point to another profession where its practitioners are forced by federal law to provide their unique skills for free. Sure, lawyers are expected to do some pro bono work, but they are not required to do so unless their firm demands it.

I challenge you to go to a grocery store, gas station, department store, lawyer's office, mortgage company, or utility company and demand their products or services because you ''have to have them to live'' and see if you get them if you do not pay.

Solution? I don't have a viable one, but I do know that, as I have mentioned before, the country as a whole will eventually get what they pay for. If medicine, perhaps the most intellectually, emotionally, and physically demanding profession that exists, ceases to be attractive to our best and brightest then the quality of our healthcare and physicians (currently at least equal to the best in the world) will plummet. It's not rocket science, if you want to increase use and demand for a sevice then just mandate that it be free.

The History of the Swastika

It appears a simple case of ignorance was behind the severe beating administered to a man I took care of the other night. This white gentleman was at a biker bar evidently doing his job as a bounty-hunter when a "whole bunch of ni***** jumped me". Whether or not he had his shirt on at the time is a matter of debate, but he certainly did not have his shirt on when he was brought into the ED. I couldn't help but notice the large swastika tattoos prominently displayed on this gentleman's arms. As I was putting staples in his closely-shaven head (he had sustained multiple lacerations and bruises from an expertly wielded pipe) he educated me on the meaning of his tatoos...

"You know doc, most people think the swastika is a nazi thing. It's not. Now I am a white power guy but I think we should help other races with food drives and stuff... I read some old books and the swastika is a Christian symbol."

Poor guy. Out trying to preach the gospel, his tattoos get misinterpreted or perhaps he just said the wrong thing, and some uneducated troglodytes did a little dance on his head. Turns out he was wrong about the swastika (click 'History of the Swastika' to become enlightened), and wrong about displaying it in such a provocative way. Gentle in the art of persuasion he was not, it did not help that he was also stupid.

Gs Up Hos Down

If you are going to gang-bang and deal drugs and one of the Gs pops a cap into your leg the following will ruin your rep: Being rolled into the ED on a gurney crying like a little girl and grimacing in pain, unable to answer questions like, "What is your name?" and flashing your newly acquired gold teeth to the 25 year old female tech starting your IV who looks right at me as you are crying, and rolls her eyes.

Darwin Was Wrong

Took care of an 18 year old woman yesterday who is a little overwhelmed with her second child. Her complaints were vague and non-specific... "I have a headache that comes and goes... I can't sleep because of the baby... I'm tired." She seemed to me to be exhausted and depressed so I had our psychiatric extender interview her. "Beware," I told her, "I don't think she's very smart."

This assessment was later confirmed by the following exchange:

Psychiatric Extender: "Have you ever been an inpatient in a mental health facility?"
Patient: "Well, I do get really impatient with my husband sometimes."

This just goes to show that Darwin was wrong, at least about humans. In America it is not the case that the most fit individuals are the ones to propogate their genetic material to future generations. Not being judgemental, just stating the obvious. In fact, for those having trouble getting pregnant I recommend the following... drop out of school, drink a lot, lose your job, shoot heroin, and smoke crack. Works every time.

Love is Never Having to Say You're Sorry

Gomer Pyle used to say, "Fool me once, shame on you... Fool me twice, shame on me."

Got a call from one of my EMS crews on the radio warning us that they were coming in with a stabbing victim. They told us the victim was middle aged and had sustained three stab wounds to his chest. This always gets one's attention, but the paramedics told us that the victim was stable and having no respiratory difficulties.

Mr. X had that smell and look about him that gave him a .200 right off the bat on my intuitive alcohol scale (the real number was .221 and the legal limit in most states is .080). I could also tell that he was a professional drinker as he carried himself well for one so loaded.

His story was that he was sleeping when... ''My wife, or whatever you call her, started stabbing at me with a knife." I did not pursue the rest of the story though the police certainly did. His wounds were axillary and had not come close to penetrating the chest wall. I spoke with our surgeon, did and X-ray of the chest, shot him up with some lidocaine, and loosely approximated the wounds as my surgical colleague requested.

As a matter of completeness I checked out this gentleman's prior visits to our hospital. Lo and behold, almost a year ago to the day he had been brought in by ambulance in similar circumstances. His wife ''or whatever you call her'' had smote him in the head with a hatchet fracturing his skull. Seems she had been sent to the pokey for this and had just been released a few days prior.

I was a bit incredulous so I just asked the guy about it. It was, in fact, the same woman both times. I was nonplussed but did manage the following...

"Sir, I don't think she likes you." He replied somberly, "I believe you're right, doc."

You Appear to Understand English...

Me: "Ma'am, how long have you had sinus congestion?"
Patient: "Ever since I got back from Hawaii."
Me: "Assume for a moment that I don't know when that was..."

Me: "Sir, have you ever had an operation on your abdomen?"
Patient: "No, but I did have one on my stomach."
Me: "And what was that sir?"
Patient: "I don't know... don't you have my records?"
Me: "We might sir, but what did the surgeon tell you was the reason for your surgery?"
Patient: "He said I needed something cut out of me."
Me: "And what did he 'cut out of you'?"
Patient: "Something in my stomach."
Me: "And why did you need 'something in your stomach cut out'?"
Patient: "Because the surgeon told me I needed it."

The Punitive Spinal Tap

So if you come in to my department and you simply want narcotics, do what any sensible person would do. Do a little research, make up a story that is believable, and stick to it. Try not to come up with a complaint that I can disprove with a simple test. Especially don't come in with some cockamamie story about how pain is shooting from your big toe to your ear and that you have a headache and your neck hurts. I will do the following... I will express concern about your headache and neck pain and then, after obtaining your consent of course, I will stick a large needle into your lower back and withdraw some spinal fluid to prove that you don't have meningitis. If you make it through this procedure (which really is more scary than painful) then I guess you win... you can have your eight Lortab.

Thing Update

18 hours of meticulous surgery later I believe this gentleman's hand is saved. As to function, time will tell. The hand is incredibley complicated with many musculotendinous connections, multiple vascular structures, and nerves. Most run in their own special compartments within the wrist. I can't begin to describe the complexity of this surgery. The gentleman in question had not even brought his severed hand... we had to get the sherrif to go to his house and bring it in. To see a description of the reattachment surgery click on ''Thing Update" above (a different case obviously but very similar).

On a somewhat humorous note a "google" search for ''severed hand'' produced the following...

Severed Hand Looking for Severed Hand?

Find exactly what you want today.www.eBay.com

Thing

Remeber the Adam's Family tv show and the "character" Thing? The ambulatory hand that lived in a box? I recently saw a patient who had severed his hand cleanly from his arm. He managed to tourniquet the bleeding stump and come to the ED. When we got the hand it looked just like Thing... was held in the "number one" position and had a wedding ring still on. I believe the hand surgeons down the road were able to reattach it and save the man's livelihood.

Dr. Doom Dipshit's email address

Here's Dr. Doom's email address...get him! pianka@mail.utexas.edu

Dr. Doom

So there's this hippie-crunchy prof. at U of Texas who is actively cheering for a worldwide ebola outbreak. Click on the "Dr. Doom" title above to read about him. This guy is a dangerous misanthropic clown. I offer a few insights from the MD side about an ebola pandemic not so much based on hard science as common sense.

First, here are a few choice quotes from Dr. Pianka, who, apparently, has his P.h.D. in biology (these quotes entirely from the story linked above... The Seguin Gazette: UT professor says death is imminent: By Jamie Mobley: The Gazette-Enterprise: Published April 2, 2006)...

• "[Disease] will control the scourge of humanity," Pianka said. "We're looking forward to a huge collapse."
• "The biggest enemy we face is anthropocentrism," he said, describing the belief system in which humans are the central element of the universe. "This is that common attitude that everything on this Earth was put here for [human] use."
• "Although [Ebola Zaire] Kills 9 out of 10 people, outbreaks have so far been unable to become epidemics because they are currently spread only by direct physical contact with infected blood. However, a closely-related virus that kills monkeys, Ebola Reston, is airborne, and it is only a matter of time until Ebola Zaire evolves the capacity to be airborne."
• Does he believe nature will bring about this promised devastation? Or is humanity's own dissemination of a deadly virus the only answer? And more importantly, is this the motive behind his talks?
  Responding to these very questions, Pianka said, "Good terrorists would be taking [Ebola Roaston and Ebola Zaire] so that they had microbes they could let loose on the Earth that would kill 90 percent of people."

What Pianka is basing this on is the concept of ''carrying capacity'', the well known and demonstrable fact that populations of animals are regulated by their environments. Too many animals, not enough food? Death. Epidemic disease in a large, concentrated population of animals? Death. The population numbers shift this way and that and eventually a steady-state is reached again. Now it seems to me that this carrying capacity argument regarding humans has failed many times before... Malthus for one, mainly because of the assumption that humans ARE, in fact, no different than animals.

Pianka makes the same mistake. Not to open a can of worms, but which species other than homo sapiens can alter their health and behaviors to the degree we can? Pianka assumes that what has been a 90% fatality rate with ebola in Africa would be a 90% fatality rate in the west. That is folly. I well remember an epidemiology professor in medical school dramatizing the AIDS "plague" by projecting the image of an iceberg on the screen and telling us in 1993 that the homosexual population represented the tip of the iceberg. In ten years, he said, AIDS would be a heterosexual disease and have claimed tens of millions of lives in America. No one had any faith that science would provide us with an answer, or at least a temporizing medicine, which we soon had in the form of protease inhibitors.

As far as Pianka's claim that antrhropocentrism is the biggest enemy we face I would ask a couple of questions. Given that he thinks extermination of 90% of the human race desirable isn't the biggest enemy we face Dr. Pianka? Secondly, if there are some things on the earth that are for human use and some that aren't what are they? Who will make this determination? Pianka? I have a feeling he would have us all living in caves and eating grass. I say let him lead the way and demonstrate this lifesyle for us then we can choose whether to follow.

As to the last quote I'm sure he is now on the FBI watch list and should be. This guy would have been a great executioner, or a great nazi death camp guard, or a great ''wormtongue'' in the Lord of the Rings. He deserves to be ostracized, but evidently some of his audience are as filled with self-loathing as he is. What in God's name is he doing teaching at a University? Certainly he has free speach rights and we have, in turn, the right to hold him up for ridicule. Too bad for UT but academia is now the refuge of those who have been educated far beyond their intelligence.

Good Day

Once in a while you get a 'thank you' that means a lot. I took care of a teenager three weeks ago who had collapsed in his bedroom after coming home from school. His dad, just returned from Afghanistan, carried him to his car and drove like crazy to the ED. He had a spontaneous intracranial bleed, a real one-in-a-million hit for a kid, and was going to die. I intubated him and sent him quickly to our nearest referral center that had Neurosurgical capability. Today, he walked into my ED with his mom to say 'thanks'. After my recent experiences here it was a real boost to my attitude. Evidently the Neurosurgeons are as puzzled as I am as to why this kid bled, but he should be fine, and, hopefully, live a full and happy life.