Monday, July 28, 2008

Reasons I'm Leaving Emergency Medicine (number 6)

Circadian rhythm refers to the body's biochemical sleep cycle. Here's a wikipedia entry that is not bad if you are interested.

All medical students and residents learn the hard way that staying up all night on call and being tied to a beeper is not good for one's general health or mental health. I still can't understand how you can sleep well with a beeper on... I never succeeded in doing anything more than catnap on call, but some people have the gift of quick and restful sleep. I am not one of these people.

The worst thing about Emergency Medicine has to be the nights. Whereas many physicians can kiss the overnight shift goodbye after residency we can not. To be sure, surgeons and some other medical subspecialists still have nights, but they can sleep, if the gods deign, between calls, and they never switch to a night schedule.

Coming up to a string of night shifts still provokes the fight or flight response in me. In the wee hours with ambulances rolling in and kids crying and drunks yelling and phones ringing one is hard-pressed to believe that it will ever end.

Add to this the quick switch back to a day schedule and our 'airline pilot' schedule (working about 15 shifts a month) looks less attractive. For me, it takes me two days to recover from two overnights, and more days to recover from three or four in a row.

It's like this. Start your workweek in Atlanta, for your third day of work catch a flight to London and work regular morning hours there for a couple of days, then fly back to Atlanta for some days off. Repeat.

Admittedly, some ER groups try hard to create some regularity in the docs schedule by staggering the shifts and moving them forward a few hours every few days, but there's just no good way to do this absent having a full time night doc or two.

To the goddess cirdadia... you are a douchebag.

Sunday, July 27, 2008

M.D.O.D. Poll (#2)

Pinky swear in effect. Boarded EM physicians, your kind response is needed on sidebar to right. 

Saturday, July 26, 2008

Hello Taxpayers! (volume 59876)

Warning. Reading this will be a lot like watching a car crash. If you start you will want to stop, but you will not be able to. This is cobbled together from an overnight shift patient who had eloped from the ER, and then called the ambulance to come back in. She did not get the MDOD award for the night, in fact, she came in fourth, but she was the only one on whom I took shorthand. Please excuse the lack of narrative direction, I think you will follow the conversation without it (and oh, by the way, this is not edited to make the patient seem worse... in fact, it is edited with grammatical corrections in place, the 'uh's and 'ummm's deleted, and a partial, but completely true medical history).

Hey I'm 911doc, how can i help you?

I've got jiggers and I'm in a lot of pain all over.

Weren't you seen here earlier today?

Yeah, but I prayed and it went away so I left.

Did you just call the ambulance to come in?

Yeah, the pain came back and I got scared and I didn't think I should drive.

My nurse tells me you've had pain for a year?

Yeah, but it's worse today. About six months ago I was supposed to have some kinda scope or something, but that was when I had insurance... I don't have a doctor, I was supposed to have a scope but I couldn't go.

It says here you were throwing up blood?

Earlier I did, at least I think it was blood, it looked brown, I got really concerned, and I haven't had my stuff done.

What stuff?

That scope thing, I didn't do it.

Why didn't you do it?

'Cuz I had a real bad breakup, I was so depressed I didn't go... I did have insurance then, but I don't now. I don't know why I needed that scope anyway... I don't do the anal stuff, so I didn't get all tore up inside, but sometimes when I sit down it really hurts and I want to know what's going on... it keeps going on.

Seems like you are quite comfortable now...

But the pain is coming back and it's in my legs now.

Have you had any vaginal or anal bleeding or discharge?


Are you pregnant?


Have you ever been pregnant?

Yes, four times, but i don't have any children.

What happened?

I terminated them.

I see. Do you use drugs or alcohol?

No... the pain is so sharp it hurts to go to the bathroom.

You said it hurts all over...

Yes, I have no idea what it is.

Do you have any allergies?


To what?

Some 'antibiotic'.

Do you have any other medical problems?

Yeah, six years ago something happened and I was like The Nutty Professor... they said I had angioedema so I had to wear a mask. I was on all kinds of medication, I was on steroids for a long time, years ago, I was having headaches, the pain got really bad so I couldn't sit then I started throwing up.

Hmm.... unless you had a bad allergy to something wearing a mask doesn't make any sense for angioedema.

I had to wear a mask.

Hmm... the most concerning thing you told me is that you had blood in your vomit. We are going to have to find out what it is... if it's blood then we need to get you admitted.

I took two laxatives they didn't work.

Hurting this much is not constipation, besides that, laxatives don't work right away... I need to order some tests...

My stomach is bubbling and I can't go to the bathroom and feel like I'm going to throw up.

How many times have you vomited?


Who is your doctor?

I don't have one because I was on depo.

You don't have a doctor because you were on depo?

Well I stopped taking it because my blood pressure went up and then he wouldn't see me.

When did you stop taking it?

Its been months since I had one.

Are you sexually active?


Then how do you know you are not pregnant?

I just know.

Okay, let's get started.

Diagnosis after CT scan, failed NGT, normal labs, and $3000 of your money? Formication from cocaine abuse.

Thursday, July 24, 2008

NPR... Clowns!

I do not browse the NPR website because, well, they sound just like TASS or Pravda, but I was alerted to this story by a kind friend. Is there a conservative mole at NPR? If not, they would do well to pull this picture because it makes the story a bit, well, a bit of a farce don't you think? Since they will pull the picture soon I have grabbed it out of the ether to give you the full effect (the 'meat' is in the last paragraph).

пирожные по-прежнему доступным

Wednesday, July 23, 2008

Maxima Culpa

Who is to blame?

This is the current situation as I see it: Many doctors are unhappy; many patients are unhappy; many hospitals are failing financially. So, who is to blame?

I’m not a doom and gloom guy. I actually love my job. When I go to the hospital, I truly feel like I do something good for humanity and myself. My job is interesting, challenging and certainly makes a huge impact on people’s lives. That said, if I had stayed in clinical medicine, there is a good chance I would have one of my annoying patients in my basement pit with a squeeze-bottle of Jergen’s lotion and an industrial sewing machine ready to prep my next suit.

So why am I in the minority? And again, who is to blame?

If you read the New York Times without periodically retching, then you probably live on the upper west side of Manhattan, make 1.8 million dollars a year as a hedge fund manager and will vote Obama because of your infinite care for the less-fortunate (read: guilt). Unfortunately, the NYT is of the very few newspapers that is well-written and has generally good reporting. You just have to hold your nose for the political articles and the opinion pages. One exception is David Brooks. Ya gotta love anyone whose favorite target is baby-boomer self-importance and hypocrisy.

Brooks’ latest article addresses blame. Specifically, in the mortgage crisis, is the predatory lender; the irresponsible borrower; or the culture that considers irresponsibility acceptable the villain in this play?

Translating to medicine: who or what is to blame: the government’s and administrators’ ill-conceived policy decisions; the doctors who have rolled over and allowed these policies to infest medicine; the irresponsible and unreasonable patients who demand perfect care for free; or the culture that says irresponsibility and unreasonableness is acceptable?

Everyone is going to have a different opinion on where the blame lies, and, as we are well aware, opinions are like assholes: everyone has one, they stink, and they are prominently featured in my favorite films including: Juranal Park, Little Anal Annie and Anus the Menace. Since there “is no right answer” to my question, I want to address the issue of culture: physician culture and patient culture.

Physician culture has always been about the patient. Our culture has always emphasized care, compassion, selflessness and helping people in need. Of course there are exceptions to the rule: some docs are selfish assholes and could give a toss if you live or die. However, that doesn’t change the general culture. People generally go into medicine because they want to do something good for humanity.

Patient culture, traditionally, was about respect for physicians, some degree of personal responsibility, and a recognition that docs do the best we can but, regardless, sometimes people stay sick and die. Maybe this is a ‘rose colored glasses’ view of a halcyon past. It is certainly not the reality of patient culture today: physicians are regularly disrespected, personal responsibility is a joke and if things don’t go perfectly, a lawsuit is waiting right around the corner (again, there are obviously exceptions, but it is a cultural trend). This cultural shift is made possible due to something that Brooks points out in his op-ed piece. We see the obnoxious, jerkoff patient being treated quickly, without complaint and for free by the providers and this gives other patients the signal that this behavior is somehow OK. The behavior of our neighbors, previously not tolerated, is accepted, and it becomes a cultural norm.

The irony here is that physician culture, through the focus on ‘compassion’, has actually enabled this shift. Patients, administrators and the government have noticed that docs actually will sacrifice the self in order to ‘do the right thing’ for the patient. Human nature being what it is, leads patients and administrators to become more aggressive and unreasonable. They see our compassion as weakness and take advantage. Docs have rolled over and been asked to eat feces. We have opened our mouths and said “ahhh”.

Or maybe I’m just overanalyzing the whole thing. Wha’eva, I do what I want.

Saturday, July 19, 2008

Reasons I'm Leaving Emergency Medicine (number 7)

It's not M*A*S*H

It's not even close.

I first noticed this in medical school. Don't get me wrong... there were plenty of "Hawkeyes" and "Trappers", but the medical school administration at my rather prestigious school was in the avant of the new guard, and was politically correct from their perfectly trimmed toenails to their Ivy League pedigrees, from their smaller than advertised brains, to their tiny testicles and ovaries, and from their miniscule cache of common sense to their love of 'process' and 'protocol'.

My friends and I did have a few run-ins with these automatons. We had some mandatory touchy feely stuff designed to make us behave contrary to our XX or XY nature and it was widely panned by most folks in my class.

Then we had the proposal put forth by the 'student council' that encouraged us to turn in fellow classmates that we were concerned might have a substance abuse problem. Guess what... about 80 percent of our class had, as is commonly defined, a HUGE alcohol problem. Miraculously, and with some exceptions I'm sure, that 80 percent is now, hell, 8 percent... but the idea that we could rat on each other based on a suspicion ALMOST succeeded in becoming policy.

This was the writing on the wall. Now it's 1984 all over again only the jack-booted thugs carry clipboards. They are the Dr. Frank Burns crowd. Doctors by training... mousy, scared back-stabbers by default. They have won the battle of medicine with attrition by paperwork and incessant inane drivel that is picked up by the MSM and used to scare the population shitless.

Don't eat at McDonalds... don't use your cellphone... don't drive big cars because the planet has a fever... wear your seatbelts... wear your bike helmets... don't smoke... don't tolerate people who smoke... embrace all manner of dangerous sexual practices but check that cigarette at the door mister! Gay? SUPER! Sixteen years old and want an abortion? GREAT! No, we won't tell your parents. Think you may have been raped? You probably were... let's work on your recovered memories.

Trapper is not speaking up to tell folks that, despite their best efforts, there is precious little anyone can do to ward off the scary killers of medicine. The melanomas, the ruptured intracranial bleeds, the genetically determined heart attack, the rectal carcinoma, the leukemia, the lymphoma, the auto-pedestrian facial crunch, the acute traumatic fibromyalgia etc...

Dr. Burns is in charge of most hospitals now. He no longer really practices. He has the political heirarchy wired though, and they are all his clones. Hot-lips is in charge on the nursing side, and, in the military now, God love 'em, they rotate the CO position at all their hospitals between Doctors like Dr. Burns, Nurses like Hot-lips... scratch that... more like Nurse Ratched, and Medical Service Corps types (admin). This makes for a SUPER looking bit of fairness on paper but really, why is anyone BUT a physician in charge of a hospital?

It was true in the medical corps that the good clinicians paid their time back and busted out for the civilian world (there are noteable exceptions to this). The higher you go in the military medical corps the less you practice medicine. I thought this bit of silliness would be absent in civilian land. I was wrong.

The "Pros from Dover" have been tied to a stake, bound, and gagged. Dr. Burns needs to see you in his office now... one of your charts was incorrectly corrected.

Friday, July 18, 2008

Welcome QuiXXote

Dear Readers,

There have been a few comments here and there that MDOD needs a feminine presence. We like our caveman antics just fine thank you! But, when a woman who basically kicks ass in every way asks to join our little fraternity AND she likes football AND has a sense of humor then we dispense with the 'he-man woman-haters club' shit and start sucking in our bellies and doing push-ups.

QuiXXote is a boarded Emergency Physician. She knows most of us here from back when we were just all giddy young wanna-be doctors who actually got excited about getting our first pager. She tilts at mostly the same windmills we do and writes better than any of us. That's her in the picture above (with the boobs where nothing should be- and yes, the rest of us here may rightly be described as 'boobs'). Her lance is sharp, her patience is short, and her skillz are mad.

Welcome QuiXXote.

Thursday, July 17, 2008

Direct Fullfillment (thirty years after Monty Python's Cheese Shop)

"Direct Fulfillment" is a doublespeak phrase... I just learned from the local AT&T store yesterday.

I hereby nominate it to stand alongside the best produced by JCHAO, EMTALA, and HIPAA as award winning, pricey, mindless drivel. It's much funnier when Monty Python does it as above.

Me: Hi, do you have the new I phone?

Sales Rep: We are doing 'direct fulfillment' with the new I phone!

Me: Super! Do you have one here today?

Sales Rep: Well we are doing 'direct fulfillment'.

Me: Well what exactly is that?

Sales Rep: It means you pay us today and we get the phone to you as soon as we can.

Me: How much did Satan get for your soul?

Sales Rep: One million dollars.

Me: He took a loss. SUPER! Bye bye now!


Wednesday, July 16, 2008

Listen Up

After receiving approval to run our impromptu poll on our site from our institutional review board, and after thorough statistical analysis, we have discovered, WOW, that nurses and doctors are terribly unhappy at with their respective professions. I give you the results of the MDOD poll... "Are Providers Quitting?".

Out of 123 respondents 10% are planning to quit when they can afford it, 14% are quitting now, 45% can not afford to quit, 6% are dropping their hospital privileges, and a whopping 30% appear to be in for the long haul. That makes 70% unhappy providers.

So what? So we are not easily replaced. So, unlike flipping burgers, it is really sometimes a life and death thing when you need a physician or skilled nurse. A bad one can kill you, so it's, well, it's kind of important that we actually like what we do. As to the reasons for these results, please read the rest of the blog.

Tuesday, July 15, 2008

Out of Things to Worry About?

People actually get paid for this shit.

Saturday, July 12, 2008

Doesn't it always turn out like this??

Some decades ago, soon after finishing residency, I had what is still my "best save"..We all have one.

Sunday evening in the ED. Call comes in on a hot load, victim of drunk driver on the interstate.

The patient was a 30ish male. Completely FUBAR. Bilateral flails, pnuemo's, EVERY long bone in body broken, pelvic diastasis with urethral disruption, gross blood on DPL(no CT scan back then) I mean every thing in this guy is completely fucked up, except his brain and spine!

If I remember correctly he had about 12 units of blood before going to the OR. But we saved his life and he walked out of the hospital some weeks later. No way this guy should be alive...

But the story changes a bit..Turns out THIS was the DRUNK! He tried to enter the freeway from an exit! And killed a young Mom, Dad and 2 small children..

Fuck me for saving his life...

Doesn't it always turn out like this?

And the Bow Sinks to the Waterline

A friend emailed me this. Let me take a wild flying guess at what happened here. Some poor soul got drunk or had been drinking. He was hurting and was convinced by family to go to the ER. This might have been at the advice of his physician who didn't have an afternoon appointment available for, hmmm, three months. The triage nurse did her job and sent him to a room, but did not believe he was anything other than drunk. Staffing cuts and bottom line thinking from people with suits and clipboards has their ER perpetually short and scrambling. These cuts are happening everywhere because of EMTALA

In the room he sat with a chief complaint of "abdominal pain with ETOH". He was then ignored through nursing shift change, a doctor never saw him because the chart was, thanks to JCHAO, somewhere other than the chart rack. The oncoming nurse did not know the room had a patient. A doctor never knew there was anyone in the room (HIPAA mandates closed doors when able). He was not put on a monitor, and the cleaning lady found him dead 12 hours later after he died from a massive MI or ruptured AAA. Thanks EMTALA, thanks HIPPA, thanks JCHAO. We will now watch as you fry a perfectly good physician and nurse for your bumbling idiotic policies which make every ER a ticking time-bomb. .

Thursday, July 10, 2008

Hey Idiots, Volume 2

Stop clogging my computer with stories about measles outbreaks. This is not news. This is hairy armpit dip shit granola f**kers dragging their snotty-nosed unvaccinated spawn into Whole Foods and interacting with other pseudo-intellectual numb-nuts who thought it would be cool to raise their little Moonbeam "vaccine free" after watching Jenny McCarthy on Oprah. God forbid do a little research. How many of the kids with measles were vaccinated? And what is the Proof of vaccines being connected to childhood diseases or learning (I said proof, not conjecture, or my aunt knows a guy who knows a guy). And just because your child has something, doesn't establish cause and effect. (We have discussed that ad nauseam on this blog) Otherwise there would be over 100 million autistic kids out there, and there just ain't. Alright tree huggers and alarmists, you can post now. I'm sure you are awake at this hour taking care of your poor, innocent child with fever, cough, body aches, sore throat, and rash from a horrible, preventable, disease.

And another thing: turn off that damn cell phone while I am in your room in the ED. Unless you are the Chairman of the Joint Chiefs, I don't give two shits on when Shaquetha is meeting you
at Orange Julius and then heading over to the Gap. I have started central lines, resuscitated family members, drained abscesses, and even done a pelvic exam while people talked on the phone. (Yes, a patient was talking to her girlfriend about her boyfriend while I'm staring at her nasty cervix). Hang the hell up. You are not that important. It can wait until I leave the room, and trust me, usually in the ED I'm trying to get out as fast as I can.


Tuesday, July 08, 2008

Reasons I'm Leaving Emergency Medicine (number 8)

The Business of Medicine:

If there's one thing that flips me out within the first two sentences of a discussion it's talk about our customers. I have beaten this one to death and will simply link to some older posts here and following.

Medicine, particularly Emergency Medicine, IS a business in that it runs on money, but it is in terrible trouble because a whole bunch of folks, mostly politicians, pretend it's a unique business not susceptible to silly things like supply and demand.

As a result of unfunded give-aways and mandates medicine is much more like a mob racket than a business.

Where is our money coming from, and how can we sustain ourselves doing what we do now? The answer is by stealing. All of us in this racket steal from folks with money to pay for those without. When it's done officially this is called taxation, but this kind of stealing is called compassion.

For God's sake at least call it what it is. We started losing this battle with a little teency-tincy program called medicare/medicaid that was only for the most down-and-out and most pitifully poor and debilitated. Now we extend these benefits to illegal aliens, criminals, folks with bogus diseases, and, basically, anyone who shows up at an ER.

In my town it is well known that for misdemeanor offenses and minor felonies that if you develop angina incarcerans that you will only be cited, and the cops will dump you in the ER to be released on your own recognizance after we determine the crack you smoked will not kill you this time (the police can't pay the bill either).

The ER has become very efficient at 'moving the meat'... winnowing through haystacks of primary care, medicine, and psychiatric patients to find the 'needle' patient who has heart disease, a stroke, or new onset schizophrenia.

In the meantime between the 'free' ambulance ride and the 'free' care mandated by EMTALA we lose hundreds of millions, if not billions of dollars doing this, and the there is no disincentive for the abusers. These costs are transferred directly to on-call specialists and the hospital who then transfer the costs to paying patients (and doctors quit or go completely private and otherwise solid citizens despair). Never mind that this "free care" is not tax-deductible, nor is it protected from litigation... not even capped.

If you sell cars it would go like this...

Government (to car dealer):

Ahmed here is new to the country, poor, and needs a car to get to work, give him one for free. Do the maintenance for free, and, if you give him a car with brakes that don't work and he gets in a crash he gets your house. No, you can't claim it as a loss you just need to "figure it out". And oh by the way, his wife needs one too. Pony up dude.

It is unsustainable idiocy and, in the end, hurts the very people it is designed to protect. Don't believe me about doctors quitting? Just within the linked blogs on my site my colleague at "Fingers and Tubes in Every Orifice" quit a year ago. I'm quitting in 8 weeks. Schrodinger's cat is quitting in 8 weeks. Two other friends in ER in another state are quitting (and just two years out of residency). And our impromptu poll is interesting, is it not?

At my hospital within the last four years we have lost three urologists to EMTALA, one general surgeon, and four of our six orthopedists in town are about to go private. We have no neurosurgeon, no pediatric surgeon, no plastic surgeon, no psychiatrist, no endocrinologist, no rheumatologist, we have neurology ten days out of the month, we have ENT fifteen days out of the month, and we have ophthalmology 24 days out of the month. We can not recruit new doctors or nurses. We are a town of 400,000 and we are the only game in town.

Private ERs are opening and insurance only (no medicare) hospitals are opening and doing well. Charity hospitals, our old stop-gap, are gone for the most part. Ten years from now without doing anything we will look just like Canada or England. That may make you happy but it should scare the shit out of you.

So asking me to improve my "customer service" (my Press-Gainey scores), and to get ready for JCHAO is a lot like asking me to put the cover sheet on my TPS reports. Business? Thievery.

Sunday, July 06, 2008

Epiphanies Delayed

Patient 1: 48 year old male with lung cancer and hemoptysis. In ER for 'worsening shortness of breath'. Decided to stop chemotherapy and XRT but not smoking. Smokes 'only a half a pack a day doc'.

Patient 2: 34 year old female with 4 months of pain from her scleroderma and out of all medicines. "They dropped me from my insurance because I missed so many appointments." Here today for worsening pain and because "they" won't see her in clinic anymore. Was able to provide me with list of twenty medicines she needs to have filled. Has no money. Smokes. Chief complaint? Pain from her fibromyalgia. "I have a port and I can help the nurse access it... really all I need is pain medicine". And oh by the way, she has become blind in her right eye over the past few weeks, but this really doesn't bother her as much as the pain.

Friday, July 04, 2008

Independence Day

Thanks to all our brave Soldiers, Marines, Sailors, and Airmen who sacrifice their time and sometimes their lives to keep us free. And, as a true-blue American mutt, happy birthday to us!

What, a post on MDOD absent cynicism? No, silly, here it comes.

Last week I was introduced to a medical provider who is in the reserves. The introduction came by a friend (also a woman and a veteran of the Army Corps of Engineers), and, in retrospect, I think my friend was doing it to get my goat.

This provider has managed, in her now twelve year "military career", to avoid deployment every single time by getting pregnant. She is pregnant now. My friend said to her, "Meet Dr. Peel, she is pregnant for the Xth time, and has managed to time it just right to avoid deployment."

The pregnant gal smirked at me and gave a little thumbs-up and said, and I quote, "You know, I just don't think it's fair to the kids if I deploy."

That's three other providers who would NOT have deployed going in her place every time. That's three other families disrupted. That's wrong. And THAT, is the result of liberal social-engineering in our military. The Marines are the only ones to escape this kind of ridiculous but obvious consequence of the gender neutral service. And, to her credit, my friend who introduced me to this shitbird said later, "You know, that woman really makes me mad... she gives all women in the military a bad name." Yes. Yes.

Wednesday, July 02, 2008

Doctors and Nurses Quitting?

For what it's worth we're doing a poll of nurses and doctors seen at right. Please answer once only... You've got two weeks.

And OBTW, look at the political lines on which congress just voted to cut medicare/medicaid reimbursement. Are you quitting now?

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