Can't Stop Poking it With a Stick

So an anonymous poster commented that my colleague and I were lacking in compassion after reading the prior post. Hmm. I have a few questions for everyone, and particularly for anonymous.

First, at your current job, do you ever speak with your fellow workers about how much it sucks or about old man Smith's dentures or Betty in Human Resources and her poor hygiene? I bet you do. I bet you don't say it to their faces but you know you do it and it relieves stress for you and you get to laugh. Ever see M*A*S*H? Ever hear of "gallows humor"?

Secondly, at whatever job you do, let's say you run a grocery store for the sake of argument, are you mandated by the federal government to give food away to 70% of your customers? After all, without food, people die right? I bet not. In fact, if someone takes food out of your store, even if it's to feed their starving family, don't they get arrested for shoplifting?

Thirdly, is it the case in your job, that the shoplifter can sue you if she slips on the way out of your store and breaks her ankle? Can she, by virtue of the lawsuit, ruin your career as a grocer? Can she get your grocer's license taken away? Your house?

Finally, let's say that you being a compassionate grocer, decide that you will donate some of your valuable produce to unfortunate families, but you find out that you will not be allowed to deduct this loss from your taxable income. Still happy? Still compassionate? I thought not.

Random Numbers

Number of patients I have see in the ED: Approx. 43,000.

Number I will see before retirement: 120,000

Amount of my soul I expect to have left after this: 14.8%

Percentage of real emergencies: 5-7%

Percentage of urgent patients: 20%

Time it takes reflected light to reach the Earth from the Moon: 1.3 seconds.

Percent of patients in ED at 3:00 am either drunk, bored, or stupid: 81%

Amount of time spent hearing about useless social history before my spine buckles and I become a complete circle: 2.6 minutes.

Copies of JFK's book Why England Slept purchased by his father Joseph to ensure it was a best-seller: 40,000

Time it takes me to realize the 18 year old female with headache, abdominal pain, skin pain, fatigue, and a myriad of other complaints just wants a pregnancy test and a work excuse: 0.24 seconds

Number of times the words separation, church, and state appear in the 1st amendment: 0

Value of the look on a drug seekers face when they realize the anaprox and skelaxin won't get them high: Priceless

Okay, That's It!

Here's a list of stressful jobs that most of us can agree on (in no particular order)...

1. Stock or bond trader
2. Bearing Sea crabber
3. College or Pro coach or athlete
4. US Navy SEAL
5. British SAS
6. Green Beret/Special Forces operator
7. Emergency Physician/Trauma Surgeon/Pick any other specialty here
8. Fighter pilot/ Helicopter pilot in Iraq
9. Official food taster for Fidel Castro
10. Britney Spear's child
11. Hillary Clinton's personal assistant or husband

Here's one that's NOT on my list... part-time physical education substitute teacher. Yet, for one poor soul, this job was way too much.

I mean what is it with people? It's a Friday night in the ED. There are three kids screaming from IV sticks and lab draws, one dude dying in bed three from his end-stage liver disease and variceal bleeding, a guy the cops brought in who's under arrest and has just been tazed who is awaiting clearance for jail while uttering, to anyone that will get near him, ''FUCK YOU MAN!", and a family of four from Mongolia (no shit) who barely speak English with an 18 year old daughter who is either declaring herself as schizophrenic OR has meningitis OR encephalitis OR has been badly cursed by a shaman in her native land.

In between it all is the aforementioned part-time PE teacher, in tears, with a headache, allergic to compazine, reglan, DHE, and toradol, who actually looks at me (with sweat and blood on my shirt), and tells ME that her two-day a week job is way too stressful, but that her life will magically turn to fluffy white goodness if she can simply get a shot of stadol and phernegan. KING ME!

"Little Miss Sunshine"

Warning. Off the subject of medicine.

Saw "Little Miss Sunshine" on DVD the other day. Way hyped movie. Big hit at Sundance. I gotta say that I thought it was terrible. I mean we spend most of the movie getting close to a dysfunctional family who are all doing their best to make their 8 year old daughter's dreams of beauty pageant success come true. Her lovable and crotchety grandad, recently kicked out of the nursing home, has been giving her private lessons in between taking hits of heroin and he overdoses and dies. The family presses on through all manner of other terrible obstacles and and the young girl gets her moment in the sun.

Clearly outmatched in looks and talent she gets up on stage to perform her heretofore secret talent number. Turns out it's a striptease. An 8 year old girl does a striptease. Applause? What else was grandpa doing? Where was child protective services? What a piece of shit.

... and Again, and Again.

Got called up to the CCU the other night to run a code. The patient sure looked dead when I got there, blue, mottled, CPR in progress, PEA on the monitor, and we had an arterial line in so we knew the pressure was zero.

Went through the usually worthless PEA/Asystole protocol and brought in the ultrasound machine. The heart really wasn't moving. Tried pacing and what the hell, I threw in some Calcium Chloride just in case she was hyperkalemic. Whammo! Pulse, and pressure return. Wow. Three of her doctors were at the bedside and we all went, ''Wow.'' She was in acute renal failure.

Two hours later, code in the CCU. Same patient, different result. The other doctors had absconded the facility which left me to talk with the family. Lovely.

Dead Again

One of the least favorite parts of the ED job is working a code, having someone die unexpectedly, and then having to tell the family. Imagine having to do it twice on the same patient.

Had one brought in the other day with the wrong ID and told a family their husband and father was dead, only to have them talk to him on the phone a few minutes later.

Then I had to do it all over again with another family(the real one). What a joy that was.

From now on I am going to have DNA evidence and fingerprints to positive ID before I go in the room.

The People Who Don't Care About the First Story but Avidly Read the Second are My Patients.

FIRST STORY: (heard about it but had to google to find it).

Three killed when Benefis Mercy Flight goes down
By PAULA WILMOT Tribune Staff Writer
Grief spread across Great Falls and Montana Wednesday after Tuesday night's crash of a twin-engine Mercy Flight airplane that killed the pilot and a two-person medical team from Benefis Healthcare. Vince Kirol, 58, a Mercy Flight pilot for 12 years; Darcy Dengel, 27, a registered nurse employed by Benefis since 2001, and Paul Erickson, 33, a Benefis paramedic and firefighter for the city of Great Falls were killed. Full story here: MERCY FLIGHT

SECOND STORY: Front page of the DRUDGEREPORT 2/16/07 linked to ABC story.

"Britney's New Look Is Bald". Evidently Britney Spears is on an alcohol and drug fueled descent. Full link here: BRITNEY

Fountain of Pus

Some docs just dig pus. I am one of them. Tonight though, I nearly vomited while doing an I & D (incision and drainage) of a pilonidal cyst. Click the above title to learn about pilonidal cysts.

So a gentleman comes into the ED complaining of terrible pain over his "tailbone", worsening for a few days, and has an abscess just over the coccyx. We see these all the time and most ED docs will drain them and pack them and refer the patient later for definitive surgical treatment. But this one was HUGE I tell you! 4x4 inches, tender, and just begging to be opened and drained.

This guy had a cyst I&D'ed previously so he knew what he was in for and he was a great about the whole thing. I felt sorry for the patient in the next bed as they were privy to our whole conversation and heard me describe the procedure in detail and warn of the fact that when I opened the abscess that the smell would be horrible. I don't think they threw up.

I gave the guy a couple of percocet prior to numbing the area up with lidocaine and then I gloved, gowned, and put on a face shield. I was honestly worried that with the tension this thing was under that I would be covered in pus with the slightest puncture.

There's something so satisfying to me about getting pus out of the body but this was ridiculous. It took a very deep incision to puncture this cyst but when I did the game was ON! I mean pus down the guys butt crack, pus on the drapes, green and black gooey stuff that smelled worse than anything I've smelled ever in my life (except other anaerobic abscesses). Nurses came in from the hall to investigate the source of the smell and peaked in to see the spectacle of me probing this cyst with hemostats and expressing more and more pus.

I packed the thing with a whole canister of iodoform gauze and went through 4 boats of 4x4 gauze. I think I got 12 oz of pus out of this thing honestly. The patient was very thankful and left feeling much better. The smell still lingered four hours later when I left. Now that's some old fashioned down and dirty medicine right there! Medieval barber-like.

The Joust: A Semi-Controlled Rant

I know I am merely a simple car-crash physician. I know I don't have the mental capacity to do something really tough like, say, radiology, but occasionally even a blind squirrel finds a nut.

Emergency Medicine is still a relatively young specialty. In smaller towns that aren't affiliated with a large multi-specialty hospital the ED is still considered the denizen of losers and burn-outs. As more and more board-certified ED physicians take root in the smaller towns however the battle with the consultants often heats up.

In large University hospitals the turf wars of the ED versus the rest of the services were fought and settled at least ten years ago. At my current hospital, however, the battle rages.

We have consultants complaining that we keep patients in the ED too long and the next day the same guys complain we haven't done enough in the ED. We have people complaining about lack of referral patients and people complaining about too many.

The thing that these physicians understand (but forget at three in the morning) is that they aren't really mad at us. We are not the problem. In fact, we are a safety-net and stop-gap because if we didn't exist THEY would have to be in the hospital a lot more. Turns out we physicians are all mad at the following people...

1. The federal government for ever poking it's nose into health care. Medicare, Medicaid, EMTALA, and unfunded mandates. It all adds up to a sense of entitlement- a sense amongst the voting public that health care is a basic human right and they shouldn't have to pay for it. In an ideal world I don't disagree. I MIGHT even agree that some basic level of care SHOULD be a basic right for American citizens. It is most certainly not, however, a right for whoever happens to have made a series of poor choices about how to live their lives, or has just arrived in country after climbing some fence or fording some river or hopping-off some boat. The burden of providing this "right" for the above pitiful flotsam and jetsam of humanity right now is placed directly on physicians, insurance companies, and people responsible enough to have jobs, pay taxes, and insure themselves against illness. It's wrong. It's not American. It is a recipe for disaster.

2. Hospital Administrators. The "business people of medicine", only medicine can hardly be described as a business (see my previous post http://docsontheweb.blogspot.com/2006/04/customer-or-patient.html). So these empty suits control the purse strings of the hospital, have a business degree from Branchwater State Tech, keep a regular schedule, and make savvy behind the scenes business decisions that impact the physicians in every conceivable way (usually by adding another form to fill out to either admit, treat, or discharge the patient). They draw large salaries, belong to rotary, have weekends off, and never have to tell a family that their mommy died or make split-second decisions about life or death. Somehow, I work for these people.

3. Lawyers. I love my attorney but I hate the ambulance chasers (and they are out there and there are a lot of them). I also hate their willing accomplices who will sue and doc any time in hopes of winning the medical lottery.

4. Insurance companies for continually cutting reimbursement to physicians for reasons mostly having to do with number 1 and presenting said changes to us like they are doing us a favor. Hey guys, your cost shifting game is not hard to see through. Piss on you. Grow some balls.

5. Physicians for putting up with it all and not drawing a line in the sand.

6. Patients, especially my 'frequent fliers', for not giving a damn about themselves or anybody else, and expecting me to fix it in an hour