A New Strategy for Asswipes

I sympathize with my consultants for reasons that have been presented here ad nauseum. Still, there are folks on our call list that are master dodgers and defer-ers and general pains in the ass to deal with... Docs who honestly believe that I MEAN to cause them pain by referring sick patients to them. Over the course of months these asswipes sort themselves into a small but real group of bad people. Up to now I have had no way to exact revenge on them but now I do. All fellow travellers take note of this delicious strategy. For the sake of this post let's assume that the asswipe referral doctor is called "Dr. Z".

Of the two or three patients I see per day that want so badly to be sick but just are not, that have 'non organic' symptoms and have been studied out the wazoo, that have, say, "10 out of ten pain, doc, it goes from my pinky toe to my left eyeball and makes my heart stop" I will now do the following.

Me: "Ma'am, I'm afraid that you may have either Fibromyalgia or Chronic Fatigue Syndrome. Just check online and you will see that there are a lot of folks with this problem and I know once you read the symptoms you will know this is what you have. You may want to go ahead and join a support group and print out as much stuff as you can. Now, this is a difficult diagnosis to make in the Emergency Department but take heart! Dr. Z out in town is a national expert in these problems. I recommend giving him a call tomorrow and understand, he's a busy man, but if you just persist a bit he will see you. He may be able to do some specific procedures and tests that will cure you. Good bye and good luck."

Patient: "Oh thank you doctor. I will call Dr. Z in the morning and insist on being seen!"

"I'll Walk it Off"

I covered a local high school football game tonight at the request of one of my orthopedic colleagues. I love football.

I show up at the game and see the same kids that were in my high school 29 years ago or so. There were band geeks who thought they were cool, a kid with a pink Mohawk (very retro dude!), a nearly out of the closet Marilyn Manson clone, and then the teams, and the cheerleaders, and the dance squad, and the fans.

This game is played out with a whole lot of passion and effort and it went down to the last seconds and it was not very good football, but still, I was struck dumb with the following.

In the early fourth quarter I went out onto the field to assess a player from the other team who had an ankle injury. The coaches from both teams were out there and both teams took a knee and took their helmets off and the stands got quiet and everyone was concerned and it was so different from the ED.

So the kid is really hurting but he does NOT have an obvious fracture. I talk to him and do and exam on the 40 yard line and he gets helped to his feet and to the sidelines where he is taped up. Then I start my ED doc's spiel... "You may have a fracture, you probably need an Xray either tonight or..." when the player says, "Doc, I'm good... Don't make me sit... I'll walk it off."

Walk it off? What? Huh? Don't you need an Xray? Don't you want to apply for disability? Don't you want pain medicine? I can write you an excuse if you like?? Huh?

I left the game with renewed faith in about 4% of our population. Thanks kid.

It Begins (Addendum)

From the CDC and ACEP. Ring true guys? I could not readily find the definitions of "immediate", "emergent" etc... but given that about 15% of patients seen in the ED are eventually admitted that makes me think that to get in the "urgent" category can't be that difficult. Your tax dollars at work.

ED Design

We're moving into a new ED at 5AM tomorrow..It's great, blah, blah..Just wondering if anyone knows if there is a design bible/rule that says no ED can have WINDOWS!!
45 new beds and it's in the middle of our hospital and NO WINDOWS!!
Why can't I see outside when I work?!
Does that bother anyone else or just me???

Love Her or Hate Her, Ann Coulter Echos Much of the Medblogosphere...

She's especially attractive when pointing a weapon and is my favorite attorney.

P.S. Came across this piece this evening. Also a good read but light on emotive thinking and heavy on common sense and logic. Yuck.

Tag, M.D.O.D. Contributors! Answers Please...

The rules:

1. Post these rules before you give your facts.
2. List 8 random facts about yourself.
3. At the end of your post, choose (tag) 8 people and list their names, linking to them.
4. Leave a comment on their blog, letting them know they've been tagged.

Eight Random Facts About Me (911doc)

1. When Simon and Garfunkle did their first big reunion I had friends who got me tickets. My parents forced me to go see Liberace instead on the same night. I have never forgiven them.
2. I love football but hate female sideline announcers. It seems that their rigorous qualifications must be simply that they be smokin' hot babes. As I think about it I can not think of one who played football with pads. Steve Spurrier must have seizures having to play nice with them.
3. Cookies and Cream
4. Quirky musical tastes include just about everything... love bluegrass, blues, western-swing, Zeppelin, classical, soft rock... hate techno and hard-core thrash-metal and most rap (but tha doggfather rules!).
5. Tried to avoid medicine because I was warned against it, but it's just in me. What can I say?
6. Mountains not beach.
7. Beer not wine.
8. It was the "War Between the States" not the "War of the Rebellion".

Tagged: ETOTHEIPI, 'Cat, DRX, Oldfart, Gruntdoc, Scalpel, Monkeygirl, Hallway Four, Addicted to Medblogs

Medical Crisis??

Hey folks, just occurred to me to put this thought out for discussion..

What is the "real" crisis in American Medicine?

I think it's that no one will want to be a doctor and there won't just be a shortage of specialty "A", but an absolute shortage of doctors..Medicine has changed so much in my 30 yrs..I really couldn't honestly advise someone to go down this pathway. And it's not just us (EM) it's every specialty..I can't think of a single doc who enjoys what they are doing.

The American public has brought this upon themselves with their attitudes and jurisprudence intervention..When I was interviewing residents/medical students some years ago, I thought they were going into medicine for the "right" reasons..But now, I have since seen those same doctors in practice and they are doing their best to plan a way out of practicing medicine..They'd do anything to get out of this "profession"..

What say you??

It Begins

Well, here goes the start to another weekend. Swing shifts this time, not nights like last weekend. But I'm sure the parade of fools will be similar, just more awake and a little less intoxicated. Here is a sampling of last weekend, in no particular order. Oh, there were a few emergency cases, and a code, but they were nearly drowned out by:

1. The 17 year old by ambulance with pharyngitis.

2. The one year old just not able to sleep with cough and fever, already seen by their pediatrician earlier that day.

3. The 20 year old G7 with belly pain who left AMA after learning her pregnancy test was negative.

4. The dialysis patient who was "too sick" to go to dialysis and presented in acute pulmonary edema.

5. The 40 year old female covered in paint and drywall, obviously working, who presented with severe back pain from an MVA 3 weeks prior.

6. The 73 year old who just can't catch his breath after smoking 2 packs per day for 50 years.

7. And the dozen or so patients who just want a fix (narcs, benzos, it doesn't matter).

So you see, it's easy for me to get fired up for 3 day weekends in the ED. Stamping out disease with clown shoes, one idiot at a time.

CAT

"Gotcha" Medicine

I don't care if you do drugs. I don't care if you smoke marijuana. I don't care how many times you have been seen here in the last month for chest pain, or abdominal pain, or endometriosis. There is almost never a reason to order a urine drug screen. It almost never changes anything I do with the notable exception of cocaine and chest pain so please, nurses, don't come to me and ask me to order this $400 test so we can play detective. Besides the fact that the UDS is notoriously inaccurate and misses a host of intoxicants and many benzodiazepines it is not our job to catch people. In fact, this kind of thinking will burn your ass because while we all remember the story of the boy who cried wolf the point of that particular story is that one day there was a wolf.

I do order them for psychiatric admits but grind my teeth every time because it certainly won't change the fact that someone needs a psychiatric admission and I am left to wonder why I have to do the test here when the test can be ordered at the admitting facility...
but I have quit fighting.

It happened when I was in residency that an internist moonlighting as a detective found on a UDS that someone was using cocaine and this sleuth withheld pain medicines for the patient as a result. The patient signed out against medical advice and died the next day. Legally defensible? Probably. Ethical? No. Smart? No. Waste of money? Yes. Poetic justice? Certainly not for us to determine. Besides, and I don't say 'studies have shown' much, BUT, studies HAVE shown that the most accurate drug screen is the simple expedient of asking the patient if they use drugs.

Another Colleague Leaves the Profession

I recently had the honor of writing a letter of recommendation for a friend of mine who is leaving Emergency Medicine to go back and do an anesthesia residency. This is no small decision. He is going back to four years of low pay, long hours, and the humbling title of 'residenct physician'. I asked him why he was doing this and he wrote me an email that, as I read it, I found myself nodding my head again and again to. So, without further ado, and with his permission, here is his letter to me about why he is leaving Emergency Medicine.


As you remember, this is something I've been thinking about for a while. Basically, over the past couple of years I've become very disillusioned with Emergency Medicine and the direction it is heading. EM has become permeated with too many pseudo-business men who are more concerned with spreadsheets and bottom lines and "customer satisfaction" than they are with promoting the specialty and helping it to evolve. They especially don't seem to care at all about physician satisfaction and well-being.

It is my impression that most ED and hospital directors view their docs as a commodity to be used-up and tossed aside when they get burned out. They also don't seem to care that the ED is being used more and more as a walk-in primary care clinic than as an actual emergency room. I didn't go into this field to take care of a bunch of primary care bullshit that FPs and internists should be taking care of in their clinics.

I'm also disgusted with the growing sense of entitlement and grandiose expectations of the average ER patient. I had hoped this would change when I moved to a different area of the country. And, while it is better here, it's just not enough for me to see this as a long-term career choice. Also, frankly, I'm getting tired of listening to the same bullshit complaints from the vast majority of whiny, emotionally needy patients that stream into the ER at an ever-increasing rate.

Honestly, I'm getting to the point where I hate people in general. I think being in the ER all the time constantly reinforces my impression that people are worthless, and I'm tired of feeling that way. It's just like when my uncle became a cop. He turned into the most miserable misanthrope because he was immersed in the worst side of humanity every day. Therefore, I guess what appeals to me about anesthesia in part is the fact that I don't have to delve too deeply into the social aspects of medicine. My job is to put people to sleep and make sure they don't die during surgery. A lot of the ambiguity and uncertainty that is inherent in EM just isn't there in anesthesia. There's a definite endpoint for each patient encounter. Plus if the patient starts getting on my nerves, relief is just the push of a syringe away.

In the meantime I get to do all the things I like about EM, airway and vent management, vascular access procedures, epidurals and spinals, and critical care among others. Also, they're doing some cool cutting-edge stuff in anesthesia like intra-operative TEEs and EEGs among others, plus I can do a critical care fellowship out of anesthesia and actually get boarded in it so that I can find a job with a critical care group. Plus, a friend from EM residency is already out doing her anesthesia residency, and she's loving it. She and I are very similar, and she thinks it's the best decision she's ever made. Every time I talk to her she tells me how happy she is, while I tell her my latest aggravating stories about the ER.


Good luck old friend.

Before and after Pics of Yankee

I hope these pics get thru to the blog so you folks can see them!
The one on the top is of him about 1 month after his injury!

Darwinism and Medicine

I apologize in advance to any of you who have any of the following diseases.

We had a comment in a recent post about Darwinian selection. I been saying for 30+ yrs that medicine is, by itself anti-darwinian. Think about it. How long would a juvenille onset diabetic live 50 or 60 years ago? Now they live and reproduce until they go on dialysis and even then they still reproduce! Same with sickle cell, hemophilia, 24 wk preemies, putting non-compliant hypertensives on dialysis at 30 yrs old, and we could go on and on..And the genes go on and on. And we get to pay for it all!

And of course, we as doctors, must treat them to the n'th degree. Hell, when I started practice a 24-weeker was called a miscarriage! What kind of quality of life do those babies have? We're just now finding out how those hundreds of thousands of dollars just lead to more hundreds of thousands of $$ keeping them alive in their wheelchairs and feeding tubes, etc...

We are not supposed to make "value or social" judgements. Who better than us to make those decisions? I'm tired of treating that 20 yr old in DKA for the 29'th time who smokes and does drugs(other than his insulin, of course). Sorry if I hurt anyone's feelings, but there are some things the Europeans do better than us!

Etomidate, the "Wonder Drug"

You guys know that I've been practing for a while. I've seen lots of new drugs come and go. But I'm trying to thik if there's been a drug that has had as much impact on my EM practice than Etomidate!

I love this med! It makes ortho, surgical, cardiac procedures so easy! I swear most shoulders just reduce themselves now! Only caveat is use it with a little Versed. Since I started using Versed with it, I have not had any myoclonic reactions. Anybody else out there loving this drug?

AMA??

I know we all wonder WTF when unexpected stuff happens, but thought this was worth passing on. Last Jan we had huge snow storms and our dogs are contained by an underground fence which is great. But the snow was so deep, that my oldest dog(12+) got over the fence on a snow drift and, not knowing where he was, wandered on to the only major road near us and was hit by a car. Luckily the people stopped, got him in a blanket, it was about minus 10, and called the phone # on his collar. He was only a little way from us. Got to him quickly and as I picked him up, I could tell his pelvis was broken. (He never wimpered, so I guess his pain scale was 0/10) We took him to an Emergency Vet clinic(it was about 11PM) and a teenage vet saw him, took xrays,(only saw 1 of his 3 pelvic fx's, which were bilateral acetabular blowouts and iliac wing on the right) gave him pain meds, wanted him to stay in the hopsital and have an ortho-vet see him. Well, I'm an Oldfart remember, so I wasn't about to spend 5 or 6 grand on a dog no matter how much my son and I cried. So we decided to take him home and let nature take it's course. So we had to sign out "AMA".

2 days later, the door bell rang and an officer(Sheriff) was at he door. Says the vet place had reported our leaving AMA and he had come to check on the dog (who was lying on his bed right by the fireplace with all the comforts of home he ever dreamed of). He said they do this on all "AMA's" from vets. Can you believe that?!! WTF!! Does your hospital go check on your AMA pts? I've never been in one that has! WTF our tax $$ at work!

(BTW, the old dog is just fine, just can't hunt anymore although he wants too).

9/11/2007

On 9/11/2001 I walked out of a medical conference at around 9 am and half-overheard a remark in the hallway: something about the Pentagon being evacuated. This, I thought, cannot be good.

Six years later shockingly few people still give a shit.

I remember years back hearing a comment from Bin Laden or some such fuckhead that, in effect: attack, get response, wait six months, guard will be down, attack again. Well, here we go again, except six months is now six years.

When the second plane hit the WTC tower, the world changed. If you haven't absorbed this lesson, you live in a fantasy world.

Sorry, not medical at all, unless you count that I was in the hospital during the attack. Yeah, I know, pretty weak.

Why Emergency Medicine is Not Easy

In the Emergency Department we HAVE to think of the worst possible cause for an illness or injury or we will miss something. This is why we 'shotgun' labs and radiological studies. Other docs think we don't know how to diagnose and treat illnesses in an efficient manner... We are 'cookbook' docs or 'glorified nurses' as I heard recently. Most of the time our workups ARE a huge waste of money but very often we find things that would have gone unnoticed at the local doc-in-the-box, and if we miss something, we end up in court. And one other thing, we have to do all this in an hour or two with, oftentimes, no prior knowledge or records of the patient.

Example. Took care of a 50'ish woman today who hurt her ankle. Simple? She had hurt her ankle two weeks ago in a fall.

The fall was the result of a syncopal episode... she passed out. Why?

She doesn't remember why she passed out but did admit that it had happened before. She said she didn't have any medical problems. She smokes two packs a day and hasn't seen a doctor in a long time.

The ankle was fractured but she has been walking on it for two weeks. It hurts a bit. How is this possible?

Well, she has peripheral neuropathy (decreased sensation in her extremities). Why? She doesn't know. She is not taking her medicines and she doesn't know what they are. So at the bedside I decided to do all basic labs and cardiac markers and get an EKG. The EKG is abnormal and shows evidence of ongoing ischemia which is new from the last EKG. Simple?

Her labs start coming back. Her potassium is high, her thyroid is not working, a chart review reveals that she has had a small heart attack in the past, has been a polysubstance abuser, and has been in myxedema coma in the past (a complication of severe hypothyroidism). She also has a blood glucose of 550. This explains her peripheral neuropathy and her ability to walk on a fractured ankle.

A secondary exam reveals increased pigmentation in the skin and she therefore likely has addison's disease. She gets IV thyroxine and a dose of stress steroids in the ED. She is now admitted for a full cardiac workup and endocrine workup. She will likely get a heart cath and a stent if she needs one, stabilization of her diabetes and other endocrine disorders, and oh by the way we splinted her ankle fracture.

4-Wheelers, ATVs, and Mini-Cycles

I really don't care if you want to ride your motorcycle without a helmet. Go to it. I think you should waive your rights to heroic care if you mash your head-in but don't die, and you should be required to be an organ donor, but that's about it. Feel the wind in your hair. Live life with gusto and go out like a roman candle.

If you think it's cute for junior to ride his ATV at 4 years old, or go for a joyride on the back of your motorcycle, or learn how to ride by himself so he can be a big motocross X-games star then you are a fucking moron. If you let him do this without a helmet then DCS should take your child from you. Sorry. I don't care how upset you are when he gets his head mashed, the child no longer belongs to you because you are a moron and incapable of taking care of a box-turtle, much less a small human.

ATVs, 4-wheelers, trampolines, motorcycles = HELMETS= job security for me. This is not, however, the kind of job security I want.

Well That's Never Happened Before!

The charge nurse came up to me in the middle of a busy shift the other day and said, "Doc, a patient you took care of last month wants to see you."

I ran for the nearest hiding place and she said, "No, it's not like that, she wants to thank you."

"Thank me?" Huh? "Is this a joke?"

"No."

So I went out to meet this woman and she didn't ring a bell. She had a big smile on her face and said to me, "Doctor, I bet that not many people come back to thank you so here I am."

I didn't recognize her because the first time I saw her her face was mashed-in and she was cut in a lot of places and she was quite a pitiful sight. She had been assaulted in her home by an unknown intruder. I CT scanned and Xrayed and numbed and washed and stitched and comforted and three hours later she left looking better but like Fankenstein with big nasty suture lines all over her face.

She looked amazing. She told me that the follow up surgeons had complimented my work and that she was very grateful and thankful for me and best of all, she wasn't scared or crying, she had that air of confidence about her that let me know that if a 'next time' occured that she would end up calling the police to collect the body of the intruder.

Wow. It made my day and I told her so and then went back to work.

I've Got to Say This Sooner or Later

OK, I'm old and tired and maybe burnt, but not burnt out..Never been sued in 30+ years..As I mentioned before, I'm leaving my current position to start up a new EM residency in a Big City..Working in Small City USA today...

Saw a neurotic LOL(little old lady, not laugh out loud)today who was just neurotic about having a pacer put in 4 mos ago and still having chest pain, blah, blah..Took me, oh, 2 minutes to figure out this was no cardiac problem and we go on and have a "non satisfying" encounter. She wants a cardiologist to come see her, etc..I tell her I'm the cardiologist dejur and I'll figure it out,etc..We've all been there..She wants a new doc and luckily we're triple covered so I pass it off to 1 of my colleagues (who just to have been one of my ex-residents!)...

Anyway, she doesn't like this doc, a female by the way for you gals out there, but my bud does her thing and after about 6 hours all is proven benign and she goes home...

There was much wailing and moaning and gnashing of teeth..Many accusations of I'm mean (actually called my friend "evil" because she talked too fast)... God I wanted to stop them as they left and tell them I was right in the first 2 minutes and she was a little old POS.. But I somehow refrained...

Where is it written that we, ER docs, have to take this kind of abuse? That any other doc would tell them to take a hike as soon as they asked for another doc... Why do we put up with this crap? Yes, it's because we don't want another complaint, I know, I know. Why do we let that decide on many of our courses of action?

Further, why would I, as old and experienced as I am, let this bother me so much?? Why did we let the passengers start driving the bus? And would I be such a bad guy if I just started telling all of my pts what they didn't have wrong with them in the first 5 minutes and kicking their ass out the door? Should I cause my group, who I dearly love, that hassle purely for self gratification? Would I be mentally more healthy?(I think so) I don't know the answer, just seeking your intelligent input..

.Thanks, OF

What About a Military Scholarship to Medical School?

I was inspired by Panda Bear's most recent post to start a thread here to answer any questions from aspiring or current medical students who are considering the military's Health Professions Scholarship as a means to finance medical school. I had a great experience in this program and in the service, I would gladly do it again, and will answer any and all questions with complete honesty. The wikipedia blurb on this program is here. Ask away.

Lights Out

This is from my Xray archives and I found it on an old disc. This person put a gun in their mouth and pulled the trigger. The small and large opacities are bullet fragments inside the skull. Also noted is a large skull fracture on the top right of the film which probably extends anteriorly and across the midline (left parietal portion of the skull). The concussion of the bullet entering the skull literally blew skull open. Dead.