An Inconvenient Graph

Ahem. Uh, there was one? Major stream of consciousness to follow.

My name's Howard J. Turkstra. I'm from Kansas City. My hobbies are fast cars and fast women. Because... That's why guys in my car club call me "The Cruiser." I joined the Army because my father and my brother were in the Army. I thought I'd better join before I got drafted.

Son, there ain't no draft no more.

There was one?

or this...

I have to laugh... because I've often asked myself... my foe, my enemy, is an animal. In order to conquer him... l have to think like an animal and whenever possible... to look like one. I've got to get inside this dude's pelt and crawl around for a few days. Who is the gopher's ally? His friend? The harmless squirrel and the friendly rabbit. I'm going to use you guys to do my dirty work for me. All right, show yourself, little varmint! If you've got the guts! Son of a bitch.

USA Today, Years Behind MDOD.

USA Today Headlines . They don't do a bad job with this story, but I disagree that with a few tweaks here and there that this is an easy fix.

Trust me, this won't hurt

A friend encouraged me to share this story.

A few months ago, a very scared and jittery 12 year old boy presented to the ED with a cast problem. He had broken his arm the day before and the orthopod had casted him instead of splinting the fracture. According to those who had seen him the day before, he required very heavy sedation to even approach him for reduction and casting.

His arm had swollen underneath the long arm cast and he had lost the feeling in his fingers which were swollen the size of sausage links.

I grabbed the cast saw and headed into the room. As soon as he saw the device, his eyes popped open wide and he began to retreat. I promised him that the cast saw would only cut cast material and wouldn't cut his skin. He clearly didn't believe me, and the loud rattling noise of the saw didn't help convince him of it's benign intent.

So, to put the young man at ease, I decided to put on a demonstration for him. I once again promised him that it wouldn't hurt him as I placed the blade against the back of my hand.

As I recoiled from the pain, the cast saw bounced across the back of my hand creating 3 large lacerations which instantly began to bleed. I was dumfounded! I had never been cut by a cast saw before.

The kid literally got up and ran to the corner of the room and began screaming.

We finally had to hold the kid down while I spent the better part of the next hour very carefully cutting away the cast.

Now, like Harry Potter after his encounter with Professer Umbridge, the back of my hand displays the scars from my well intentioned truth telling.

The next week, they took the cast saw away for re-calibration.

"Lips" Reversed

A semi corollary to the "lips" of 85's post..

A few years back, about 1980 or so, I remember picking up a chart with the chief complaint of headache. Walked in the room to see a young fellow. Asked him to describe his headache and he says "It ain't that head Doc" I almost pissed myself!

Tx'd him for GC and sent him on his way. Probably the best STD I ever treated!

140 into 280

My favorite patient of the day presented against the following backdrop.....The hospital is full. Our minor care center's 12 beds have all been converted to holding beds for admits awaiting a room. Of our 31 main ER beds, 9 are blocked by more admits, the others full of patients being evaluated. We have 12 stretchers in the hallway (all full) and 21 patients in the waiting room bitching about how slow and uncaring we all are.

Chief Complaint: "My lips are chapped".

I couldn't believe that of all the patients waiting to be seen, this one got a bed.

I went to see her, and began my interview. "What's your emergency today?".

"My lips are chapped", she says.

"When did this start?" I ask.

"When I started dating my new boyfriend".

Rolling my eyes, I said "you'll have to be a little more specific since I don't know when you upgraded your boyfriend".

"'bout a week" was the response.

"does he have a beard?" I wondered.

"yes, he has a goatee" she volunteered.

"well, that's probably causing some irritation of your lips so give them a rest for a few days, use some Vaseline or Chapstick, and you'll be OK", I assured.

She had a very puzzled look on her face, then finally said: "it ain't my mouth lips, it's my pussy lips"!

I should have figured that out myself. Nothing is that easy. Upon further questioning, she then mentioned that she had green vaginal discharge and pelvic discomfort. GREAT! Nothing like a pelvic exam on a 280 pound 'cheezer'.

Sure, 'nuff. She had an STD.

BUT...the story doesn't end here!

3 hours later, she returns to the ED dragging her new 140 pound boyfriend. She wants him checked and treated so they can get back to business...classic.

P.S. Taxpayers....I did both of these exams for free as I am required by law. I also treated both for free. In addition, the time I spent with them kept me away from seeing paying (and certainly more urgent) patients. When we get Obama-care, your tax dollars can pay me to do this! Thanks in advance.

My Rant Against Addiction as a Disease

Just for fun try to find the 5 year success rates, published, from reputable journals, on the success of our current treatment of ''addiction as a disease''. You probably can't and there's a reason. The success rates are no better than going "cold turkey". It's about 5%. This realization has hit me hard as I have seen about 6 or 7 former addicts recently. None of them had gone through the twelve steps or anything like them. They just quit.

Penn and Teller, on their show "Bullshit" do a great piece on this current snake oil and say the same thing. Now I'm not citing Penn and Teller as authorities on medicine, but I have noticed the "recovering" alcoholics, and addicts of whatever substance or behavior they are addicted to, come out of various twelve-step programs helpless and pitiful. They are told that they have no power over their addiction and that they have to surrender to a 'higher power' which may, in fact, be anything they choose, and if I were doing it my higher power would be Brittney Spears.

I don't think it's a jump then, since you have 'no power' over whatever substance or behaviour you are 'addicted to', to simply cave at the first opportunity and to feel terrible about it and go running back to AA or whomever. The fact of the matter is that unless you want to quit that the twelve step programs are not going to work, I maintain they are harmful and destructive. You are getting something from your substance abuse and unless you figure out how to find it without alcohol or drugs then you are going to cycle down to oblivion and waste an incredible amount of time and money on a treatment that doesn't work. I am in the minority of physicians on this one I know and a whole 'science' of addiction medicine has grown and flourished since addiction has won the moniker of disease.

So what is it? It's the easiest choice for the person involved. It's the quick choice, the quick release, the immediate gratification. It's easier than the problem. Simple as that. So, to look inward and honestly or to look outward to others to fix your problem. It's very modern to choose the latter and certainly not based on reproducible data.

Now I'll sit back and wait for the inundation. Think I'll have a cocktail.

Please Do This

I have no ties with this company, in fact, I found it when I clicked the ad on MDOD. There's no reason you can't do this yourself and I didn't read the fine print but this service might be worth it for other reasons. If you bring one of these to your next ER visit the doctors and nurses will think you are a genius.


* THE MANUFACTURER WAS PLEASED WE HAD SENT SOME OF OUR READERS TO THE 'MEDCARD' SITE. THEY ARE OFFERING THE FOLLOWING DISCOUNT FOR OUR READERS...

911doc, to encourage your bloggers to join, I have created a Partner Code: “MDOD”, which, when used during registration, will save $20 on all 3 membership plans. The credit will appear before the order is submitted for payment.
Mike Stephens, CEO
MY MEDCARD, INC.

Study: Shortage of On-Call Specialists Spreads Nationally (American College of Emergency Physicians News, Jan 2008)

It ain't rocket surgery. My crystal ball rocks. This was predicted by yours truly. Why be a doctor?

Could 'cripple' emergency, trauma care.
ACEP News
January 2008

By Kate Johnson
Elsevier Global Medical News

Emergency on-call coverage from specialist physicians is "unraveling" at hospitals across the country, according to a new study--and the crisis may be pushing beleaguered physicians out of emergency medicine and into alternative careers, some observers warned.

The on-call specialist shortage is resulting in delayed treatment, patient transfers, permanent injuries, and even death, cautions a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington.

While the problem is predominantly an issue for hospital emergency departments, it also is becoming a challenge for inpatients who need urgent specialty care, according to the report. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.

The picture is especially grim given the fact that overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, "the proportion of visits by uninsured people is rising at a relatively higher rate," the study's authors wrote.

Citing a 2006 paper from the American College of Emergency Physicians, the study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are orthopedic surgeons, neurosurgeons, plastic surgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, neurologists, and ophthalmologists. While an actual shortage of such physicians may sometimes be to blame, "physician unwillingness to take call appears to be a more pressing issue for many hospitals," the study authors stated.

Although unwillingness to accept on-call duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has traditionally been mandated by hospitals under the Emergency Medical Treatment and Labor Act. However, many specialists are now shifting their practices away from the hospital setting, and are no longer obligated by medical staff privileges, noted the report's authors.

Many physicians also believe payment for on-call care is inadequate, especially when they are caring for uninsured patients. Specialists are also concerned that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, according to the report.

Adverse patient outcomes may be the result of a lack of timely specialty care. One study found that 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability, noted the report. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of patients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk.

"It's not a surprise that we're having this problem - it's a surprise to me that we have any on-call specialists at all," Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry, he said, because the risks of liability were more than he could justify.

Lack of optimal on-call coverage is what will ultimately "cripple" trauma and emergency care, agreed Dr. L. D. Britt, professor of surgery at the Eastern Virginia Medical School in Norfolk. "Some of the specialists are asking for unbelievably exorbitant fees to provide coverage, and hospitals are being held hostage. That's unsustainable for many hospitals - it's a major crisis," he said in an interview.

While Dr. Britt sympathizes with physicians' struggles with payment and liability issues, he believes the true bottom line is simply that obligations are being overlooked.

"It cannot be everyone saying, 'I can't do this.' Something has to give," Dr. Britt said. "Speaking for myself, I consider it my obligation to provide emergency coverage if I am on call. I know that's my responsibility--and I'm a chairman of a department. Some people can find ways out of it, but I'm saying we cannot have all those options out there."

In addition, high fees charged by specialists and paid by hospitals for on-call coverage are not justified based on the premise that on-call coverage increases a physician's liability exposure, he said. "Being on call doesn't give you more litigation than being in general surgery--that's well documented," he said.

Dr. Taylor disagreed.

"The literature is very clear that emergency care is one of the highest liability environments in health care," he said. "You only have to look at what's happened to emergency physician malpractice premiums relative to others not involved in emergency care. Mine almost doubled the last 3 years I worked."

For Dr. Taylor, it is these very liability risks that are at the root of the current on-call crisis. "The liability issue has become the overriding barrier to physicians being willing to put themselves at risk," he said. "Until and unless you solve the liability crisis in emergency care and health care in general, nothing else you do matters."

More troubling than the lack of emergency on-call specialists, Dr. Taylor added, is a shortage of emergency physicians. This newer phenomenon was reported last year in the 2007 Daniel Stern & Associates Emergency Medicine Compensation and Benefits Survey.

"This has applied to on-call specialists for years, but the phenomenon is now spreading to core emergency physicians, who are increasingly seeking alternative careers," Dr. Taylor said, noting that 30% of the study's respondents said they were considering leaving medicine because of the malpractice climate.

Most on-call specialists have a private practice outside of the emergency department - they don't need the ED - so it's not a big surprise they were the first to leave, he explained.

"But now that core emergency physicians, who were trained only to practice emergency medicine, are making the same choices, that should be a wake-up call," Dr. Taylor said. "That's what's different now compared to 2 or 3 years ago."

Happy Valentine's Day!

I've been "saving" this case for a while. I thought that Valentine's Day was the time to present it for your enjoyment.

It will be 2 years this April. I walked in the ER door for my mid-morning shift, not quite awake, and not quite ready for work. As soon as I entered the ER, I heard the nurses talking about a case that they had "saved" for me and laughing as they passed knowing looks between each other.

Anytime I hear this, it instantly pisses me off since it's usually some sort of total cluster-f**k of a case, a crazy patient, a drug seeker, or all of the above.

I picked up the top chart in the rack, and it was an 84 year old lady with at least 15 chief complaints. WONDERFUL.

Down on the list at about #3 or 4 was was that 4 months prior, she thinks she might have fallen on a door knob and it might still be "inside" her.

I sipped my coffee, grabbed a nurse and headed into the room ready to cut the lady off after the first couple of complaints and once again launch into my speech about the purpose and role of the Emergency Department. Surprisingly, when I talked to her, her first couple of complaints related to a vaginal discharge and odor, and the possibility that there might be a door knob up there.

I asked for more details, and she said that in January of that year, she had been stepping over something. She thinks there was a door knob on the floor. Her step across had landed upon newspaper which slid out from under her foot and she came down with her 'devil's den' against the floor. In order to get back up, she had to "ooch around" and thus something might have migrated North for the winter. Since that time, she had been unable to find her priceless antique doorknob, and had noticed a foul personal odor as well as a slight discharge, and an occasional "cold feeling up there".

Now, I thought this lady was off of her rocker. She was all over the place with her idiotic story and had so many other complaints that I thought she was just demented and needed a nursing home for her own safety.

So, I told the RN that we'd just do a speculum exam and thus rule out anything "hiding in the bat cave". As I opened the speculum, I was shocked. There, staring at me was the frickin' hub of a doorknob! The RN saw my face and knew that there really WAS something there!! She did a marvelous job of handing me stuff, keeping her face turned away from the patient, and not looking me straight in the eyes so that she wouldn't completely lose it. She was already vibrating with laughter, and her eyes were tearing with the suppression of her giggles.

I grabbed some ring forceps and got ahold of the hub and then gently broke up the suction and removed the largest door knob I'd ever seen! My God the smell! It was like 'day old meat wrapper meets toilet stall at the men's bathroom of the local high school stadium'. I asked her the story again, but she remained adamant about the slippery newspaper and the "ooching".

I exited the room triumphant with this large antique porcelain doorknob held in my ring forceps!

What I DIDN'T know was that while they were "saving" this case for me, the nurses ordered a pelvic xray! While I was speelunking and looking for the knasty knob (illiteration intended), they were gathered around the xray computer and looking at this image howling with amusement and delight:



Once I got the thing cleaned up, I decided to immortalize it:



The lady was quite appreciative because apparantly, that "cold" sensation was gone, and she was really happy to have her doorknob back! She proceeded to tell me the knob's antique history, and explain why it was so valuable. She wanted to make sure that she could have it back. I saw no reason to send it to Etotheipi's colleagues, so I gave it back to her.

So, I learned a couple of things that morning:
a) little old ladies still sometimes like to twiddle their knob
b) I've still never heard a credible story about how a foreign object gets into your butt or genitals unless it begins with "I stuck xxxxxxx up my xxxxxx....."
c) Porcelain is a very porous stone and will absorb and retain every vile odor known
d) ER Docs can be heros by retrieving and returning little old ladies' favorite antiques
e) Sometmes the term "priceless antique" means "you REALLY don't want to buy this, and don't ask any more questions"
f) Be nicer to the nurses and bring donuts, or they save cases like this one for you!

Have a Happy Valentine's Day!

85

Uniforms

Yesterday, I wandered into our "Lead Unit Secretary's" office for a little good natured kidding. Seems like every time I see her, her job title and responsibilities have changed. I honestly have no idea what she does, or why we need her, but she works hard and puts in lots of hours, so I guess she's somehow important.


Anyway, I began the conversation by saying "so, what is your job title today?" (in reference to the many recent titles and responsibility changes that she's undergone in the last few months).


Immediately, I knew that I had put my foot firmly in my mouth (once again). She was visibly upset as she told me about how they taken away all of her titles, AND gave her even more responsibilities. The title thing was obviously really important to her.


So, I promised that I'd think of a new title for her to use, and one unique to her within the whole institution. She is black, so I knew that I'd have to be racially sensitive...and hell, sensitivity is definitely my strong suit!


She left for lunch, and when she returned there was a job title on her door created with typing paper and a Sharpee. It was the best I could do on short notice.


It said:

Klinical Kare Koordination

Pamela Johnson
Grand Wizard

She seemed initially amused, but when I told her about the new uniform I had devised for her which included a very practical hood that she could pull down to protect her eyes from the glare of her computer screen, she seemed to find my attempt at humor less appealing.



Still, I thought it was better than no title at all!

Gallows Humor

One of our triage nurses today encountered a young suicidal patient. Our waiting times are right now at about 6 hours. Our hospital is full. The ER is full. The surrounding hospitals are full. We are in gridlock. The nurse asked the patient if he had a plan as to how he would off himself (very important in assessing the likelihood of actual suicide), and the patient responded "I'd eat rat poison". The nurse responded, correctly, "Oh, that probably wouldn't do it". He said, "Well, do you have any suggestions?". Guess he's serious.

A Real "Tool"

I need to see something funny. The few posts have been too serious, so...

Some years ago I saw a 20ish year old guy who's CC was "penile problem". When I pulled back the covers this "dickhead" (pun intended) had placed a 10lb cast iron weight upon his erection to, uhh, work it out and build strength. Well, its on the base of his pecker and he had a semi-erect penis that was still too engorged to allow manual removal!

He had to go to the OR for removal of the plate from his tool. It took 4 saws to get thru the plate and he had no permanent damage(unfortunately)..

Oh, and he was uninsured. What a fucking IDIOT!!

National Health Care part II (for Hannah)

This was supposed to be a thread within the National Health Care post....but I guess it was too long and it wouldn't post. So I had to make a separate post.

Hannah: This initially short response turned into a 4 hour tome because of my passion for the issues raised here. I'd appreciate your attention to consider my points and examples. This isn't theory for me. I live it every day. It's doubtful any of the politicians promising "Universal Healthcare" (Democrat or Republican) have spent more than 5 minutes in an ER for anything more than a photo-op.

Thank you for defining yourself as a non-conservative and thus giving me an opportunity to discuss this with you (hopefully in a rational way)!

I (and most if not all of the other bloggers here) want medicine fixed too, we just have different methods in mind to achieve a solution. Read our posts....we're all very unhappy right now (except for Etotheipi who blissfully dissects stuff and avoids the ED)
Most Libertarians and Conservatives aren't mean or nasty. Unlike what you'll hear Hillary or Obama say, we don't want to let people die in the streets....unless maybe it's Hillary, but I digress.

Like 911 has repeatedly said...we believe there must be some level of personal responsibility to health care. If not, it's a waste of time to even treat! Even well insured patients who won't take personal responsibility don't keep their doctor appointments, don't check their blood sugar, etc are a source of ire for docs, and a drain on our system.

We DO see tons of lazy, stupid, entitled, and irresponsible people in the ED. Those folks make up the majority of our problem. But by NO means do I or any of the other bloggers here think EVERY uninsured person is lazy. I'd be willing to bet that you fit NONE of my above adjectives. You read about us bitching about the lazy ones because they drive us so crazy.

Don't feel like we're piling on you here, we're frustrated because people outside of our industry see rising health care costs and insist that the Government fix it. No, No, No...the Government is largely responsible for breaking it! Remove some of the regulations, narrowly define EMTALA, control illegal immigration, give us some tort reform, and the private sector will take care of the problem. Competition drives costs down and improves services. In my town of less than 100K people, we have 9 CT scanners (including 2 of the latest generation models), 5 MRI machines, and a PET scanner...all because of competition between 3 hospitals and several clinics.

Most of the bloggers here work in the health care industry and we see what the tremendous level of Government involvement has done thus far....everything is worse now than it was 15 years ago. "Universal Health Care" doesn't scare me because of the financial perspective (hell, I might even make more....at least at first).

It scares me because we have one of the finest health care systems in the world. Why? Because it's based on free market capitalism. We don't want socialized medicine as providers, and I assure you that you don't want it as a health care consumer.

I could pull out lots of examples, but let's use a common one: Not a day goes by that I don't see a patient with rotten teeth in the ER for a toothache. I have NOTHING against helping the poor....in fact I don't think we help them enough.

We should work harder and spend more to get them back on their feet and back as productive members of society. With a definite END in site to their benefits. NOT the current lifetime of Medicaid as long as they don't work over 25 to 30 hours a week or make above the poverty level. (I'm not talking about folks with mental retardation or other true disabilities...so please don't go there with an attempted rebuttal).

I can give you HUNDREDS of examples for every condition you can think of from "fibromyalgia" (whatever the fuck that is) to chronic pelvic pain, to migrane headaches, to real diseases like congestive heart failure and diabetes.

But back to my toothache example, in almost every single one of these cases (and the other ER docs on here will back me up), the person is wearing very nice clothes, has a late model cell phone, fancy tennis shoes, manicured nails and expensive hair styles - (if female), and he or she usually reeks of tobacco. In other words they have plenty of cash for what they WANT and think is worthy of spending their cash on.

"When did your tooth start hurting?" I ask. The responses are usually weeks to years. "Have you called a dentist to schedule an appointment?" I ask. "No, they're too expensive" or "I didn't have the money to see one" are the usual replies.

It's a matter of priorities and taking responsibility for your own healthcare needs. This is where Libs and Conservative/Libertarian folks part company.

Hannah, I'd be willing to bet that you worry about paying your bills whether to the dentist, PCP, or, ER. Thank you. I'll bet you even AVOID going when you need to because of the cost, and I'll bet you chose the least expensive alternatives available(like a direct care instead of an ED). You're almost certainly NOT the problem or the source of our griping! It's the people who expect all care for free, choose when they're gonna come in (usually at 3am "don't you have a dentist here?", and want it fixed NOW, for free. These people are the problem whether we're talking toothaches, snotty noses, coughs, vomiting for weeks (always with normal lab studies...amazing), severe chronic back pain, exacerbation of "fibromyalgia", twice weekly migrane headaches only relieved with IV Demerol, knee/arm/shoulder/ pain for months etc, etc, etc.

Go sit in you local county ER as a volunteer on a couple of Friday or Saturday nights and see WHO we're talking about. It'll rock your world and change your perspective!

Usually, I'm dealing with a heart attack, a car crash patient, a stroke, and all other kinds of actual emergencies...but these non-emergent freebie people are almost always the most rude, threatening, unappreciative and demanding. ("I'm gonna call my lawyer if you don't hurry up and see me".....funny how once I hear that, their chart always leapfrogs to the bottom of the pile or occasionally gets "lost" behind the desk or into the paper shredder).

Again, the other ER docs will likely back me up on my perception.

As I said in another post when a guy complained that his ER doctor bill was almost $1,000...You've gotta understand that your charges are so expensive because you're paying the bill for all of these other people. Why?...Must be greedy doctors, right? Wrong. It's largely because of a law passed by liberals. (It started here in Texas I'm sad to say by liberals and spread nationwide to become EMTALA). It says they get evaluations regardless of their ability to pay. Of the $1,000 the poor got charged, I'd see about $65 to $70 (out of which I get to spend about $20K a year for malpractice coverage though I've never been sued).
I make no more now than I did 8 years ago and I DEFINITELY work a lot harder. I probably won't make any more 10 years from now. (But my hospital admistrator will, and your political representatives will) .

While in any other business or profession, you'd expect to make more the longer and harder you work, it ain't workin' out that way for most of us in ER Medicine. No other job in the world requires over a decade of training and then expects people to perform a significant part of their work for free. AND risk a lawsuit if the patient is unhappy.

Even the lady I buy donuts from for my nurses spent a single day learning to make the donuts...but she doesn't give them away (and no one expects her to). Health care costs have gone up in the past 10 years, but I make the same....why is that? Your answers are mostly above.

The intent of the EMTALA law wasn't to turn the ER into the cesspool that it has become, but that's what happened. It was a well intentioned attempt to keep hospitals from refusing to treat truly emergent patients. But due to typical liberal "feel-good" legislation...no one ever considered the unintended consensequences of such a law. Now that we see the mess it's created (not to mention the entire culture and mindset it's spawned), it's failures are seen by the Left as a result of the medical establishment and the "Rich Doctors"...BULLSHIT!

You and I don't disagree. I believe every U.S. Citizen should have access to basic healthcare. And I believe non-Citizens can pay for it. But NEWSFLASH...ER Docs aren't trained to be primary care doctors! (I tell patients..."yes, I am a doctor, but I don't specialize in your problem. I take care of EMERGENCIES for a living. It's like taking your broken car to a refigerator mechanic. You'd never do that even though both are mechanics, you know that they're trained for different things. You must see a PCP for your xxxxxx".

I see a number of ways to help the problems without taxing the crap out of everyone or breaking down our current system into a socialist nightmare.Since fewer than 20% of the US population has no health coverage, (based on the latest numbers from 2005) why oh why do we want to screw up health care for the other 80%? I know, it's politically sexy to promise this. It makes the various Presidential candidates seem like they care....NO ONE should be this gullible, yet sadly many Americans are.

First, we definitely need more patient education! Any solution has to be accompanied by an intensive patient education campaign. It's not unusual (saw it just last night) for a parent to bring a baby to the ER because of ONE episode of spitting up!?! Baby was FINE when I saw him. Why you ask would they pack up and come in for ONE episode of spitting up in a 9 month old? BECAUSE IT'S FREE TO THEM.

Here are three quick suggestions:

1) Let docs DEDUCT the bad debt from their taxes encountered by non-paying patients. Then there's some incentive and no less penalty for seeing these folks. This would have to be associated with malpractice or tort reform nationwide (see next issue). But when you get a doc's bill, understand that it's mostly for their knowledge. We spend 11 to 16 years training to be doctors. There are plenty of bright young people (my daughter among them) that are planning to avoid medicine all-together if this socialized crap passes. Unless there's some reasonable financial reward for their many years of study and effort. College, Med School, and Residency are TOUGH! Very few people are gonna do it to be rewarded with socialistic medicine hassles and shitty incomes.

2) TORT REFORM! You'll NEVER get this passed by Democrats who are largely funded by trial lawyers and ambulance chasers. But in Texas, since it's passage in 2002, we've seen frivolous malpractice cases decline and insurance rates decrease. We went from 2 companies willing to write ER Docs policies to 11 companies! This is the result of competition in the marketplace. Despite the spin the left tries to put on the law, a victim of malpractice is still rewarded ACTUAL damages...no matter the costs. The cap was placed at $250K PER OCCURANCE for punative damages only.

3) You can already get student loans forgiven if you go to work in "underserved" areas for a certain number of years. The average med student graduates owing over $125,000 in loans. Set up county run public health care clinics for primary medical issues (the same for dentistry). Work a deal where you pay these docs a reasonable income and forgive their loans if they remain for 3 to 5 years.

Those are easy and fairly immediate solutions to the lack of access problem. The ER just can't continue to absorb these people (plus, I SUCK at primary care...that's not what I do for a living). I'm not managing your "fibromyalgia" since I don't believe in it, and I'm not managing your chronic back pain, either. I'm not an expert in chronic hypertension control or diabetic sugar control.

I'm a "safety net" with some big holes in it.

Thank you for reading.

85


ADDENDUM: OUR FRIENDS AT 'THE HAPPY HOSPITALIST' ECHO, ECHO, ECHO...

ARE YOU LISTENING?? (re National Health Care)

Our colleague from across the pond, Dr. Shroom (pictured at left) writes a blog that can be found here. He's a British ER doc practicing under the umbrella of the National Health Service (please correct me if I am mistaken doctor) which is a lot like what Hillary-care would be. In fact it seems to me that it's eerily similar to our current VA system which is fiendishly beuarocratic rationed-care. I should know, it's where I get my care.

Dr. Shroom was kind enough to comment on erdoc85's "Karma" post where erodc85 opined that, even though the patient whose life he was saving was an evil-to-the-core JCAHO paper-pushing monkey screaming for narcotics (they were almost the last thing he needed to stabilize his inferior myocardial infarction), the result was that in 40 minutes the patient was in the cardiac cath lab having his heart attack stopped in its tracks. The JCAHO standard is 30 minutes so erdoc85 will probably fall out of the 'core measure' goals established by JCAHO and others, and be appropriately punished perhaps (wouldn't it just be great) by the anencephalic ass-monkey whose life he saved. But I digress. Dr Shroom, working in a system that you, the public, seem to think will 'fix' our current crisis says the following...

Nice post. Nothing sums up, for me, the difference between the UK and the US better than the phrase "door to balloon at 3a.m 40 minutes... not excellent". Where [I] work, a large University teaching hospital, a regional centre for interventional cardiology, there is NO balloon out of hours. None. Ever. Go figure.

I, and many like me, will refuse to work in such a system and you, the public, consumers of health care, should rant and scream and picket and protest to stop it. Excellence will no longer be the goal of our care, medicocrity will be the goal and it will be quickly acheived. The idea is that all should suffer equally. The reality is that excellent care will still be available, but it will be for the rich only.

As it stands now excellent care is available to everyone in our country, period, and the money is coming from people with insurance, hospitals, and nurses and doctors in the form of pay cuts and declining reimbursements- and it's not nearly enough. It is killing us, and even criminals and illegals are GIVEN this care by law (see millions of prior posts on EMTALA). Patient's HAVE to own some responsibility for their health care, if they do not, Hillary-care or its clone will make all care here for normal folks just like DMV. I don't want it to happen, I am fighting against it, but until the voting public sees this it is inevitable.

And Dr. Shroom, please understand, I hold you in the highest respect. I am fairly sure from reading your blog that you are an excellent ER physician and probably better at it than any of us car-crash physicians on this blog. I am sorry that you are in a position of learned helplessness dictated to you from above, and, as a side note, if the Archbishop of Canterbury has his way and Sharia law becomes an alternative law of the land in Great Britain then I would run, not walk, over here. We've got a spot for you amigo, even if you are a limey.

ADDENDUM: OUR FRIENDS AT 'THE HAPPY HOSPITALIST' ECHO, ECHO, ECHO...

Karma

With apologies to Etotheipi for the squiggily lines, I have to post this case from my night shift last night. This patient arrived via EMS with "indigestion" at 3 am and was by all accounts a real prick. He was demanding to see to doctor immediately and also demanding morphine, Versed and ice chips. This may seem like a fairly straight forward case.....but you'll love the twist! Read on.


The nurse brought me the EKG which they got immediately per protocol and since he was having an acute inferior wall MI (myocardial infarction) = heart attack, I went straight to his room. There I found a demanding, "I know more than you do" kind of patient who insisted on morphine. His heart rate was in the upper 50's at the time and his systolic blood pressure was about 100. Being astute, I figured that his inferior wall MI also involved his right ventricle so I wanted to be careful about my treatments..especially nitrates, or anything else which might drop his blood pressure. I almost ordered a right sided EKG, but the tech was already gone and I didn't want the hassle of getting her back....plus it wouldn't have changed my management.


I ordered 2 mg of morphine which the patient informed me was an insufficient dose and his pain was 10/10. I explained that he was having a heart attack, and I knew that 2mg wouldn't relieve his pain, but I was trying to "take the edge" off a bit while we got a nitro drip, aspirin, heparin and the other things started. I explained that I didn't want to MASK his pain, but rather to treat the cause, saving his heart muscle being more important to me than his pain. The cardiologist was en route and we should have him in the cath lab in the next 3o minutes or so to get his artery open. I was very patient and explanatory. He on the other hand, demanded some Versed (4mg to be precise) and more morphine ("at least 8 mg"). I knew that we were going to have serious blood pressure problems with this guy, and morphine and Versed weren't gonna help that. I really just wanted to get my low dose IV nitro drip going and see if I could help the pain and improve his overall situation.


Somehow, the nurse misunderstood me and gave the guy a sublingual nitro! The ER docs reading this already know what happened next....his BP dropped to 66/35 and his pain increased, he looked like hell, continued demanding ice chips in addition to his other drug demands He criticised us for "not addressing his pain".


I stayed at his bedside while we pushed the fluids to try and raise his blood pressure. In my nicest and most patient voice possible, I ordered 2 more mg of morphine (even as he protested that the dosage was insufficient). I sat at his bedside and in my best Marcus Welby impersonation, I explained that I'd give him every mg of morphine and Versed we had in the ER if I thought it was the right thing to do....but I didn't. I explained my limitations due to his heart rate and blood pressure. I explained that I really wanted to get nitro started, and unfortunately couldn't use Beta blockers since his heart rate and blood pressure were already so low. I understood his ice chip demands, but I explained that he'd be going to the cath lab very soon, and keeping him NPO was a better strategy at the moment. Like I said, this guy was sick as hell, but he was also a complete prick.


As a way of conversation, I asked what he did for a living (and here's why I'm presenting this case) and he told me that he was a JCAHAO (Joint Commission for the Accreditation of Health Care Organizations) examiner. Turns out he was in one of the little towns nearby doing a survey (torturing the shit out of the staff by nit-picking every little unimportant detail). Well, this was an interesting turn of events!


So, I asked him what he did BEFORE he went to work for JCAHAO (he seemed to "know" a lot about medicine, so I wondered if he was a physician in his previous life). He told me that he had previously been a hospital administrator! I couldn't help myself, nor hold my tongue....I said "so you went from being a hospital administrator to being a JCAHAO examiner"? "That's right" he said. "So, have you ever done anything useful?" was my reply.
I got a real "go to hell" look from this guy, but I figured that I could out run him, and he wasn't going to think fondly of us anyway since I wouldn't drug him up over trying to treat the cause of his pain.


Within 1/2 an hour, his pressure was 99 systolic with the fluid boluses, the cardiologist arrived, and off the guy went to the cath lab where he got two stents and reportedly became pain free as soon as his artery was opened.


So, I took a couple of lessons home from this case. First (no surprise): The JCAHAO folks don't give a tinker's damn about good or reasoned medicine....they just want the stupid pain scale addressed. Second (no surprise), many of the examiners are kooks. Third (ALSO no great surprise) even though my nurse inadvertently tried to kill this guy....as 911 has so eloquently stated....they're harder to kill than cockroaches!


For the sake of completeness.....the patient is now doing well. His door to balloon time at 3am was about 40 minutes....not excellent, but not bad either considering the time of day.
I'd have to say that this was more Karmic (if that's a word) than taking care of my dentist (who had done a root canal on me about 2 months before) when he got epididymitis!


Gearing up for another couple of exciting night shifts. Gotta nap now..........

85

Hey Idiots

This is a public service announcement. You don't have to go to the ED if you have the flu. I just finished 4 of 5 days, and not a single day at any time were there less than 20-30 patients in the waiting room with cold and flu symptoms. Last time I checked, Wal-Mart has two entire rows of medicines that may or may not work as well as meds I may or may not prescribe for your self limited illness. Motrin, fluids and chicken soup go a long way. Yes, you feel bad, but your chances of feeling bad would have been less if you would have taken 10 minutes of your precious free time to get a FREE flu shot ( they were given free at several locations, or at some for $10). You are clogging the ED making me see sick patients in the hall ways with very little privacy. I actually had a 2 pack per day smoker tell me she couldn't afford generic Robitussin, and that she wasn't "in the mood for joking" when I told her she could hold off smoking just one pack and get some meds. POS waste of carbon. And another thing, don't just "hitch a ride" to the ED because your cousin is going. You are also clogging the ED. Wait times this past week and weekend have been many hours, and God forbid a really sick person gets lost in the fray of all this bull shit. Good for 911 getting out. And you jerk offs who come in 2-3 days after an MVA to get "checked out", after consulting an attorney (Johnny "beefcake" Edwards)-you suck cock. You waste my time and suck my soul. I hope you catch the flu from the others in the waiting room while you wait. Take some motrin at home and be glad you didn't really get hurt in your "accident".

I could go on but I'm too tired, so off the the litter box, and good lick cleaning, cough up a furball, and off to bed.

CAT

'Network Docs' Revisited

About a year ago there was a series of posts here bearing on the health care crisis as seen from my perspective. Since our friend Dr. Hinchey from Texas has weighed in on this issue I thought it would be good for those interested to revisit the following posts (the comments are long and especially telling), the larger issue of patient responsibility for their own health care, AND the mess that is billing etc...

Hello Taxpayers

Customer or Patient

Customer or Patient (part deux)

The Joust, a Semi-Controlled Rant

Can't Stop Poking it With a Stick

I Swear it's Dead but Give me That Stick Anyway (the unintended consequences of EMTALA)

The Health Care Walnut

Charity Doc Taking a Breather

Hello Taxpayers (incident 3087)

I have promised in many posts to leave the ER when the opportunity presents. It has presented. In April I will be a part-timer, and if the new opportunity works well I will no longer practice in the ER. I am not alone. America will get what it wants, free health care, and it will be worth what other free stuff is worth. Good luck with all that, citizens and illegals.

Frank Drackman

"Frank Drackman" has made the great transition from Anon to named poster on the blog. He's got some great residency stories posted in the comments section of "Watch Your Language". Be sure to read them. It's an older post, so I wanted to make sure you all make it there to know more about Frank (and his intestinal 'issues').

Welcome Frank from the abyss of the Anonomi and thanks for the laughs!

85

Superbowl Commentary

I BLAME GISELE! BITCHWHORE!

I needed that.

Davey, Davey Crockett (on the public purse)

I am, big surprise, a conservative. I am not a Ron Paul supporter but that's where I found this. I do think this is worth a read. It appears to be genuine though if you read to the bottom of the link there is controversy about how accurate this speach is. Nevertheless, the nail has been hit squarely on the head and the conclusion right in line with my view of the purpose of the public purse.