The North American Lookey-Loo

The North American Lookey-Loo is a very common creature in Emergency Departments. They are somewhat shy but can be easily lured out of their holes by any sort of perceived delay in the care of their significant-other. Their method of conflict resolution is passive-aggressivity. When approached they will usually retreat in their holes with their distinctive alarm cry which sounds something like "how much longer?" Commonly, they hover at the door of their significant other's room or near the edge of the curtain and direct their pitiful stares towards the doctor's or nurse's station. They pose a dilemma for proponents of evolutionary theory because their behavior is, in fact, deleterious, in that it inevitably delays disposition of the patient. In fact, their behavior brings out the florid passive-aggressive nature of the powerful nurse-doctor beast. We expect, therefore, that they will select themselves out of the population. Curiously though, they do not seem to be decreasing in number as they may also be seen (in huge numbers) craning their necks out of car windows near motor vehicle accidents or crime scenes. It is therefore possible that their behavior may have an as yet undiscovered reproductive advantage.

Penis on a Slab

There is nothing quite so disturbing to the male pathologist than a penis on the grossing bench (a grossing bench is essentially a large cutting board where we process specimens). So, why was I staring at an amputated penis yesterday? Well, men, sorry to break the news - penile cancer exists, and the treatment of some cases is total excision >:O

Here's an interesting fact: I see about 1-2 of these a year, and without fail they are uncircumcised. Draw you own conclusions, but here is mine: call the Mohel and fire up the Bris!

I have several hippie-dippy, free-love, hug-the-world-type friends. Without fail, they always ask me about circumcision when they are expecting. They also ask about home birth ("It's been done that way for hundreds of years!" Me:"Uh, and the infant and maternal mortality rate used to be ridiculously high too - so let's go with it! Sh#t-head.") After I gag at the patchouli and pot stench permanently embedded in their dread-bag and sandals, I tell them about the penis-on-the- slab. Works every time :)

The "Health Care Walnut"

Click the above title to read a provoative piece on the health care crisis from The American Thinker.

And please see Pana Bear, MD's excellent bit entitled Single Payer Monte and the post prior.

What We Are Up Against

A doc from our hospital recently attended a political event where he met a prominent U.S. senator. He asked the senator what his feelings were about physicians' decreasing reimbursements (often less than 30% of charges - e.g. I get 9$(!) from certain payors for a pap smear, no sh#t.); increasing insurance costs (over $100,000/year after tax for certain specialties); and caps on malpractice damages. The senator replied, smugly: "Well, maybe you can sell one of your houses." Again, no sh#t.

You will be shocked (shocked, I say) to learn 3 things about this senator:
1. He is a Democrat. (no!)
2. He is one of the wealthiest lawmakers in Washington. (you don't say!)
3. A list of his donors reads like a who's who of elite law firms. (I would never have guessed that!)

To sum up: You are a rich doctor, so f*ck you.

The Emmerson Biggins Sign

The Emmerson Biggins sign is clearly demonstrated on this Xray by symmetric soft-tissue densities that project laterally from the mid chest. This poor young woman is burdened by a certain top-heaviness, a certain tendency to fall forward, and a tendency for her condition to draw the stares of construction workers, auto-mechanics, fraternity members, heterosexual men, and jealous women. In extreme cases the patient may suffer from chronic low back pain and need orthopedic consultation for bracing and counter-weighting to correct problems with ambulation and navigating narrow doorways. Research is ongoing but, for some reason, funding is hard to come by. This affliction has gained some notoriety in the press from it's most famous victims, Dolly Parton and Dixie Dynamite, who have managed to parlay it into a career.

I Can See the Future. And it is Bleak.

I am able to make a diagnosis with 100% accuracy without looking at someone's biopsy. Here's how it works:

Me: (to Dr. O, oncologist in hallway) Hi Jim.

Dr. O: Hey, I have a patient for you. She's the sweetest lady, about 60, donates all her time to the church, is a loving wife and parent, has donated both her kidneys to strangers, walks on water, and has found a cure for AIDS. She has a little spot on her lungs I think is nothing. We are going to biopsy...

Me: Stop. Tell her she is going to die miserably. That spot is incurable and aggressive cancer. Tell her she will die weeks before her oldest daughter's wedding.

Dr. O: How did you know her daughter was getting married?

Me: Walk away before I start to weep uncontrollably.

Yes... I am magic.

No Mo Hatin'

Well, there was some gnashing of teeth and busting of ideological bubbles with the last post, so here it goes. I now love all patients. Yes I said it . But with the weekend over I've had time to reflect. I have to look to the future. There is much to be learned from each and every one of them.

From the mother of the healthy child with a runny nose-How to continuously take my nurses' attention away from the MI in bed 8 to ask "How much longer?"

From the drunk in bed 3- How to make the already anxious little girl with a laceration cry by constantly yelling "f**k you mother f**ker".

From the family of the gentleman with psychosomatiform illness- How to berate the doctors and nurses for not being able to do "nuthin" for him, despite his being seen by 5 specialists in the past year.

From the family of the elderly man who has been sick for 3 years- How to look incredulous at the doctor and belittle the hospital staff that they can't solve his medical malady at 3:00 a.m.

Seriously though, I don't hate any patients. Life is too short. And I know that one day as I get old or infirm or sick, I or my family will be able to use these techniques, which, in the past, were inexcusable, have now become accepted and tolerated, and I am sure the way things are going, in the future will be encouraged. So I got that going for me.

"Two Dudes", "Two Beers"

The FBI has issued an all points bulletin for the apprehension of "two dudes", a.k.a. "some dudes", "two huge dudes", "a whole bunch of dudes", "some homies", "those sons of bitches", "some f***ing a**holes", and "these guys". They are responsible for approximately one million assaults in the past two days in every town in America.

Their modus operandi is as follows. They wait for the victim to consume "two beers", "two cocktails", "two glasses of wine", or "two shots of liquor" and then they, for no apparent reason, beat the living crap out of him. Inevitably the victim is assaulted whilst in the midst of "minding his own business".*

They are also under suspicion as accessories to multiple counts of attempted vehicular homicide with the following modus operandi. The "two dudes" mentioned above will buy "two beers" for a hapless female victim and then run her off the road as she drives home.

A large reward is being offered for information leading to the arrest of "two dudes". They are considered armed and dangerous. Multiple descriptions of the perpetrators have been given but the descriptions are so inconsistent that police suspect they are also masters of disguise. Extreme caution is advised if ever approaching "two dudes".

* Thanks to Bard-Parker's comment for this little addition.

Welcome Path Guy

Welcome to you, path guy. I look forward to your scintillating banter and misanthropic diatribes. But you don't have a monopoly on patient hate. Oh, don't get me wrong, I still shed a tear once in a while for the truly tragic case or children who are sick through no fault of their own. But as for the 50 pack year smoker, who believe it or not is having trouble breathing, the chest pain crack head, and the drug seeking tooth ache who is nursing that one last nasty tooth, the hate runs deep.

That is why my new product is going to make me wealthy beyond my dreams. It is a spray that one puts on before having to encounter these patients or their nagging families--Soul Blocker(trademarked). It contains a yet settled on proprietary list of ingredients, including but not limited to yohimbine, squirrel testicle, thyme, tree sap from old growth timber, and whale blubber. It will come in several SPF's (soul protection factors) depending on how vile the creature is you are having to encounter, and leaves you immune to their rants. ER doctors around the world will now be able to leave their shift tired, but not without their soul.

I will let you know when the final product is available. There have been a few setbacks in the initial tests, including erections lasting longer than 4 hours, uncontrollable flatulence, and sticking to everything you touch, but I am sure these can be worked out.

Peace, love, etc...

I am touched by the love I am feeling...

Yes, I am a pathologist - board certified in Anatomic and Clinical Pathology. I'm one of those guys who sits in the sub-basement, next to the morgue, in a windowless office and gets aroused by a case of ulcerating cloacagenic carcinoma (A.K.A. ass cancer). Most medical students are repulsed by pathology - and for good reason: opening a 12 pound necrotic ovarian mass that leaks onto your pants, well, sucks. I speak from experience.

Why do I do this? I hate patients. More accurately, I hate dealing with patients. They are ungrateful and rude; they want your service for free and will sue if their hangnail doesn't heal overnight. Of course, I'm exaggerating - I liked some patients - especially the guys in the VA (Vet speaking to a day 1 medical student: "sure Doc, you can practice a lumbar puncture on me"). I actually left a surgical residency because I hated patients so much and switched to a speciality where I don't have to talk to anyone. I don't know how the clinical docs do it, but I'm glad someone can stand it.

Anyway: hello, peace, love, etc... now I've gotta go open a bowel.

Welcome, Freak.

Dear readers,
You will soon be privy to the musings from the "mind" of a pathologist. He's not a bad sort, just, well, you'll see. Pathologists aren't great at patient care as most of their "patients" are little bits of frozen tissue seen under a microscope or are about to undergo autopsy. What kind of a person goes into pathology? You will see soon. Welcome, freak.

The Cranial Screw-Top

The famous Neurosurgeon Dr. Hfuhruhurr pioneered the Cranial Screw-Top Method of brain transplantation. Unfortunately for us he took his skills to the grave.

Right now I have two patients and three family members in the ED in need of STAT brain-transplantation. It's not just me. My nurse warned me about one of these patients before going into the room. She was discharged from the nearby University hospital yesterday. She has been seen in this ED 8 times in the last month and admitted once. She has a somatiform disorder meaning that every kind of specialist available has studied her from stem to stern and found no reason for her complaints. A psychiatrist also was consulted during her last admission and solved the puzzle. This woman has such severe depression, poor insight, and poor coping skills that her depression is manifested with physical symptoms and complaints.

It does not help that she will not take her prescribed anti-depressant as it is too expensive. It does not help that she smokes pot and crack (evidently not that expensive). She came in here today faking a coma and telling me that she had not been able to keep anything down in two weeks. When asked why she didn't see her primary care provider today she told me it was because she would have to pay for it and that she shouldn't have to pay and that we were free.

This patient would be at the top of the list for the good Dr. Hfuhruhurr. A monkey brain would be better than hers. Again, this was a statement offered by her nurse with which I readily agreed. Her bill today will be in the multi thousands of dollars. Thanks, taxpayers, for footing it. To learn more about Dr. Hfuhruhurr click the title to this post above.

Thanks K.K.

Uncle Sam just called one of our best nurses away. All of us here will miss you girl. You are fantastic. Hope you get a laugh checking in here from time to time. And just remember what I told you, farting and talking about your 'gas' blows the whole image! Mum's the word.

Dr. Edwin Leap is on the Web

Dr. Edwin Leap is an Emergency Physician in South Carolina that writes a monthly opinion piece for Emergency Medicine News. He's great. Please visit his blog clickable at the above title. A good place to start is his "Ask Me" piece which was just published a few weeks ago.

Why Do This to a Child?

Seen in our ED today, a child named "Terabithia". No shit.

Arithmetic and English 101 for My Patients

Arithmetic:

Someone with too much grant money and too much time decided many years ago that simply asking a patient about the amount of pain they were in and sprinkling in a good dose of clinical judgement was not good enough. After years of research various pain scales were born; the "visual analog" or "one to ten" scale being the ones most commonly used in the ED. Most ED docs love these scales and use them at every opportunity (as long as we have picked all the lint out of our belly-buttons).

Wikipedia has a nice little blurb on these scales which can be seen by clicking the above title. One of the things that all these pain scales have in common is a complete lack of objectivity and reproducibility between patients. Here's where the math comes in and stay close 'cuz I'm about to throw some mad knowledge your way.

It is impossible to have "1,000,000 out of 10" pain just as it is impossible to have 12 out of 10 pain etc... It fires every passive-aggressive neuron in my very male brain when I have to wake you up from your substance-induced slumber only to have you tell me that you, at that very moment, are having "12 out of 10 pain". "Yes", you say in response to my question, pain that is every bit as intense as if I were, at that very moment, sawing your leg off with a chainsaw (as seen in Scarface which is the usual example I give someone to illustrate something that might approach "10 out of 10 pain").

When you tell an ER doc or nurse that you have "20 out of 10" pain you are not impressing anyone. If you had "9 out of ten" pain you would be crying, probably vomiting, and barely able to speak. If your demeanor, facial expressions, vital signs, level of alertness, and story do not add up to even two then you will be immediately relegated to the "not sick bullshit pile" and treated with all the urgency demanded by your presentation.

If I'm feeling frisky I might decide to play possum with you where I say "screw my patient statistics, I'm keeping this jerk here until he gets tired of getting a different non-narcotic medicine every hour for his "pain" and signs out AMA."

English 101:

Now we all know what you mean when you do this. What you are engaging in is called "hyperbole". Dictionary.com defines it as follows; "Obvious and intentional exaggeration."

I have seen "9 out of 10 pain". You can't fake it. Hell, you can't fake "7 out of 10", so give me a break, act a little bit, put on a frown, and settle on, say, four. As the best English teacher I ever had used to say, "Demonstrate, do not assert."

Panda Bear, MD on Residency

Lest you think I exaggerate when I speak of the rigors of the medical path please read this post from a current emergency medicine resident.

Butterfly Effect

The previous post got me thinking about a patient I saw recently who had a stinky abscess. He also had a defining tattoo on his neck. I say defining because the moment he decided that a dragon up the side of his neck would be a great idea, he essentially made many decisions. Like not to become a CEO, nanny, salesman, or really any other position in the public eye that would require trust and respect. Who knows, prior to this he may have been destined to become regional manager for UPS or even Vice President. But this decision sent him down another road.

All the patients we see have somehow been affected by the butterfly effect, where a series of unfortunate events or, more likely, decisions, leads them to the ED at that particular moment in time. If a child's grandparents hadn't smoked crack and ignored his mother, who at 14 was knocked up while out all night drinking, and now relies completely on Uncle Sam for food and housing, yet somehow has painted nails and a cell phone nicer than mine, maybe she would have filled the prescription for antibiotics prescribed at the previous ED visit, which was the 10th of the year since mom is usually too high to remember her child's clinic appointment. You see what I am talking about.

So back to compassion, which was the subject of a previous post. If a patient in the ED decided on their own not to study or pay attention in school and decided to be a slacker/thug/etc,. then I believe they can also find a way to pay for their medications and ED visits. I grew up in a relatively poor family of 7 kids, went to public school, and had to pay my entire way through college and med school. Never did I expect or feel that I deserved a handout. But had I not swatted that neck tattoo butterfly away and given into the temptation of dragon neck, I might be cutting the grass of the person who did study and took my place in Med School, thanks to that butterfly.

The FIXX said it best... One Thing Leads to Another

Sex, Tattoos, and Death

When a patient arrives after a 40 minute transport in full asystolic arrest the chances of me making a difference are about zero. It was no different tonight when a 44 year old woman arrived from an outlying area.

She had, in all probability, suffered an acute myocardial infarction and had died instantly from ventricular fibrillation. The paramedics did everything right but the CPR and shocks administered did not abort the rhythm or restore cardiac activity.

During our code in the ED we ran the algorithms per ACLS. I even stuck needles in her chest in case she had a tension pnuemothorax (a collapsed lung forcing the heart to one side of the chest and a reversible cause of sudden death) as I could not see her heart clearly with the ultrasound machine (I saw air). I tried the needles, there was no rush of air, the Xray was normal, her heart was still motionless, and we were done.

During CPR I happened to get a good look at a tattoo over her left breast. It pictured two camels having sex and said underneath it, "Humpin' to Please". My brain did a very quick flip while putting this whole picture together and then it was back to business.

It was in that moment, and before I pronounced her dead, that I was again struck by the strange confluence between sex and death that is sometimes conjured in the heat of a resuscitation (see prior post on the same topic here: One's Mind Wanders).

Conclusions? I have none.

Our Emergency Department as Seen Through a Patient's Eyes

Patch Adams is a Clown

Great post at Nurse Ratched's place, click above title to view.

My Magic Wand

Patients, again, give me too much credit. See exhibit A in the post below and you will see my personal world record for a patient medical history and polypharmacy. This gentleman came in with real disease and fake disease and real complaints and fake complaints and thrust Exhibit A at me. This treatise was hand-written by him and his dear spouse who was at the bedside. Exhibit A did not reproduce well on the scanner so let me complete the picture for you.

Exhibit A, in its original form, came on a yellow sheet of paper. There were four different colors of ink used. The patient and his wife also informed me that it was "not up to date".

At this point I asked my nursing staff to dust off the old magic wand and make sure it was holding a charge. I certainly had precious little from western medicine to offer.

We see two or three "magic wand" patients a day in the ED. Everything from "well they told me I had cancer three years ago but I never went back and now I'm puking and pooping blood" to "my boyfriend doesn't pay attention to me and now I almost want to kill myself but instead I scratched myself on the arm with a fork."

ABRACADABRA!

Exhibit A: Pages One and Two of ED Patient History

Damn Junior!

I just found this old Xray in my files. There is an arrow lodged in this gentleman's left gluteus maximus and the arrowhead is clearly visible in the upper right of the pelvis film. I do not recall the specifics of his story but I do know for a fact that one of the following three things happened.

1. This gentleman was drunk in a deer stand and while trying to get off a quick shot got the arrow all askew and shot himself in the ass.


2. This gentleman was out in the woods in a deer suit and was shot in the ass by a hunter.


3. This gentleman was shot in the ass by his hunting partner who was also drunk. There may still have been a deer suit involved.

My money is on number one as it seems to ring a bell for me. Oh, by the way, indeterminate Throckmorton sign.

Helpful Hints

Just a few helpful hints if you are planning a trip to the ED.

1. Don't say "It's in the computer" when asked about your medications or history. It may be, but if the computers are down, or your medications have changed since the last time you were in the ED, or you have had your spleen, kidney, eye, testicle, and frontal lobe removed, your treatment options may be different now.

2. When asked why you are in the ED, don't say "Momma, you tell him". Second or third person medical histories are notoriously unreliable, and momma can't tell me how much pain you are in, although she will probably come out of the room 20 times and tell me "He's still hurtin, cain't you do somethin?" Also, as stated in a previous post, don't start with the bite from the tse tse fly you received in Burkina Faso in 1982. I only want you know why you are here TODAY.

3. If you are planning on bringing your 3 wk old with a slight amount of spit up or cradle cap that just won't go away, don't. Your child will be exposed to God knows what in the waiting room and will most likely be sick within 1 week of being in the ED. Please consult a baby rearing guide of which there is an entire row at your local Barnes and Noble.

4. If your 90 year old grand mother with a medical history that reads like War and Peace "just ain't gettin' better", please take her back to the same hospital she just got out of after a 35 day stay. If you say "she just wanted to try a new hospital" I will most likely loose control of bowel and bladder as all my body functions will shut down. Even in this computer age, it still takes 3-4 hours, especially at night, to get medical records from another facility, and another couple of hours sorting through them. And I can tell you the new internist is not going to be happy about assuming care or cleaning up a mess.

5. Finally, after triage, if you have a non urgent complaint and it is busy, expect to wait until all the sick patients are cared for. Each time you bitch and moan to the triage nurse, she becomes more passive aggressive, and your wait lengthens. It is especially bad when you ask why they brought the sweaty pulseless guy in ahead of you. That reflects badly on you and all the other hangnail/boil/rash/runny nose crew you run with.

I hope these pointers are helpful as you plan your visit.

My Crystal Ball

My patients give me too much credit. I can answer most of their questions but God bless them, others are just, well, unanswerable without supernatural help. Hence the "crystal ball question"... examples follow.

Q: Will my child catch this?
A: The magic eight-ball says "signs point to yes!"

Q: Can I still go on my trip to Mexico in two weeks?
A: Let me consult the oracle.

Q: How much will this cost me?
A: I have a better idea of where Jimmy Hoffa is buried. Better get out the crystal.

Q: How long will I be in the hospital?
A: Until you get well or you die. Other than that only the crystal knows.

Q: Will they put me in a private room?
A: I don't know, let me ask them... Ball!

Q: If we decide to leave will junior throw-up again?
A: Ball!

I Swear It's Dead but Give me That Stick Anyway (the Unintended Consequences of EMTALA)

Anonymous makes a good point in a comment on my "Can't Stop Poking it With a Stick" post:

EMTALA dates from what, the mid 1980s. Didn't you
know about it when you were choosing your specialty? Knowing about it, why did
you choose a specialty where you're most likely to be hit hardest by
it?

My answer was long and rambling and you may read it if you wish, but the easy answer is that Emergency Medicine interested me and was the best fit for my inquisitiveness and short attention span. Jack of all trades master of none. That's me.

Here I would like to compile a list of the unintended consequences of the unfunded federal mandate called EMTALA. To my nursing and physician colleagues please add to the list as you see fit.

My primary objection is voiced much more eloquently at "Movin' Meat" (click title above to see his EMTALA post) and is, essentially, that EMTALA is nothing more than theft by legislative fiat. Under penalty of law we MUST see all patients with an "emergency condition" or face jail or financial loss. It does not apply to dentists, chiropractors, massage therapists, aromatherapists, shamans etc... Here is my short list of what flows from this communistic scheme...

1. Cost Shifting: Medical treatment has cost. Someone pays. EMTALA has shifted the burden of payment for the uninsured onto the insured, taxpayers, insurance companies, and doctors. As a result, it's harder to get insurance, our taxes go higher, the number of uninsured has skyrocketed, insurance rates have skyrocketed, and doctors make less money. I know, poor rich doctor right? I'm 46 and finished paying off my school loans five years ago. If I keep at this for another 15 years I can retire comfortably (unless I screw up at work and get sued). If you want to get rich and sleep well then stay the hell away from medicine. If you want to work in a tremendously demanding field with high pressure, responsibilities that increase every year, and pay that does not keep pace with inflation then medicine is perfect for you!

2. Insurance Tomfoolery: Since I don't work in the insurance industry I will only say that with my current insurance a medicine that I take daily costs $90 per month cash and $93 per month with my insurance. My taxes, even with the "Bush Tax Cuts" are 33% of my income. I work harder and faster for less money every year, and, when I find an out to a less taxing (in all senses) profession I will take it. I am not alone.

3. Physician Shortages: Speaking of doctors leaving the profession lots of irreplaceable talent in medicine is opting out of the system. Surgeons train for AT LEAST five years, and that's just to do general surgery. Their debt load out of residency can approach $300,000. To do a surgical sub-specialty add $100,000 of debt, a divorce or two, and three more years in the black hole. You can replace an office manager by posting an ad on Monster.com, you can not replace a neurosurgeon or cardiothoracic surgeon if no one is willing to go through residency hell. In other words, these fine humans have to, at least at some point, believe that the sacrifice will be worth it and not just in financial terms.

Now, with EMTALA, specialty surgeons are dropping their hospital privileges like hot potatoes and opening up surgical centers. I don't blame them, if they sign on with a hospital then they have to take ED call and any drunk asshole who falls off a bar stool and breaks his leg at 3am on a Sunday has just blown the whole day for the orthopedist on call. All his paying patients are bumped from his schedule so he can take care of the patient in the ED. I live in a town of 200,000. We have five orthopedic surgeons. Five years ago we had six. Next year we will have four.

We do, in fact, have three plastic surgeons in town. None will maintain privileges at the hospital. So now your complicated ear laceration will be repaired by, well, me. I'm not bad, but I'm no plastic surgeon.

Interventional cardiologists? We have one. We have been trying to recruit another for three years. No one will come here because of the Emergency Department and the burden it would place on them to give away care. How much is it worth to save a patient dying from a heart attack? The answer is a number greater than zero, really, it is.

4. Increased Demand for ED services: The uninsured public has learned over the years that the ED is free (and that you don't have to be a US citizen to take advantage of it). What I mean is that when they are treated in the ED they get a bill which they never pay. Since they have no money and no credit there is no way to collect and no consequences for using the EMERGENCY DEPARTMENT as the "SNIFFLE AND WORK EXCUSE DEPARTMENT". Our collections, a bit below average for Emergency Departments across the country, are about 28 cents on the dollar.

5. Encouragment of Personal Irresponsibility: Because the uninsured public has come to rely on the free care we provide their health maintenance needs are not met. Consequently I often see patients whose untreated hypertension has resulted in a stroke or heart attack. Often there is no one to blame here but the patient and EMTALA. If you had to choose paying a few hundred dollars a year to see your Internist or FP to manage your chronic medical conditions AND you had to pay for your medicine wouldn't it be really easy to fall into thinking that it doesn't matter really because if you get into trouble you can just go to the ED? Believe it or not this truly is the way people think. If you doubt me just look at the number of people who still smoke and don't give me any crap about "evil tobacco companies". People choose and at least in the ED they have usually chosen poorly. Who should pay for this? EMTALA doesn't say and its silence is deafening.

6. ED Overload: Because the ED is the place of first and last resort now for huge numbers of uninsured we physicians are battered by the need to sort through piles of the unsick so that we don't miss anyone who truly has an emergency. In our ED we saw 70,000 patients last year. It was renovated in 1990 to accommodate 25,000 patient per year. Oh, and by the way, you better not miss anything in one of the "unsick" or you will get a letter from an attorney, or, what's often worse, a patient complaint.

7. Nursing Shortages: Because of the now ridiculous demands of the ED, nurses are fleeing. They are not paid on a production basis. They are not supposed to have more than a few patients at one time and they are supposed to focus on the patients they have. The nurses save our asses time and again because they have good clinical judgement AND they spend a lot more time with our patients than we do. It is routine now at my institution to lose a nurse a month and, if they can be replaced, they are replaced by newbies. The only way to make the ED work now is for nurses to cover each other and see each other's patients while they do all manner of extraneous tasks (patient transportation to the floor for instance). I wouldn't work one day in the ED as a nurse. It's unsafe. Congratulations voting public, your government representatives have legislated you into a "guinea pig for newbie nurses" status at many of our EDs. Now before I get a lot of hate mail from nurses let me be the first to say that there are many great newbie nurses out there, but that all of us need to learn to drink from the fire hose that is the ED under supervision.

8. Health Care as a Right: EMTALA, like all the other wonderfully successful government entitlement programs has, WOW, produced a sense of entitlement in the uninsured! As a direct result of EMTALA many people who can least afford to get sick do not think it is their responsibility anymore to either make good choices about their health or pay for the consequences of their bad choices.

9. Bad Math: EMTALA says 2 does not equal 2. You see, because of the need to cost shift, doctors are now payed based on government and insurance company fee schedules. These basically say that a $900 procedure is reimbursed at, say, $250. Now that's new math! I am looking forward to the application of EMTALA to the auto industry so I can finally buy a BMW.

10. Bureaucratic Asexual Reproduction: Lots of full time government jobs created to police EMTALA. Lots of lawyers happy. Lots of politicians elected for giving away other people's stuff. It's easy, after all, to give away other people's stuff, especially those pretentious, rich, selfish doctors. Many of my patients do not deserve the care they get on the back of the taxpayer, but as William Muney (Clint Eastwood) says in Unforgiven, "Deserving's got nothin' to do with it."

The Snidely Whiplash Inverse Proportionality Theorem of "Family Plans"

I wish this blog were not anonymous because I would dearly love to have this medical theorem named after me. I'll do the next best thing therefore and name it for my favorite arch-villain, Snidely Whiplash (click above to learn about him).

I don't know why it irks me so much, but when a nurse comes to tell me that there is a "family plan in room 12" my heart sinks in my chest and I think of stabbing myself through the eye with a pen to lessen the pain I already feel.

A family plan means that there is more than one patient from the same family in the room. The 'reasoning' seems to be something like this, "Junior has the sniffles, we can go the the ER for free and we don't have a regular doctor, let's get the whole clan checked out 'just in case we might be getting sick', plus we can get a work note."

So without further ado, may I present the Snidely Whiplash Inverse Proportionality Theorem of Family Plans (the result of a placebo-controlled double-blind study spanning eight institutions, with approval of their respective institutional review boards, and with and n of over 10000 and p value way less than .05):

The chance of any one patient in a room actually being sick enough to require a prescription is inversely proportional to the number of patients in the room. First corollary, the chance of any patient in the room being sick enough to be admitted to the hospital is proportional to the inverse cube of the number of patients in the room. Second corollary, the chance of me ever seeing a dime for the bill generated from the "family plan" approaches the asymptote of zero if the number of patients in the room is greater than two.