Friday, October 09, 2009


I just worked my last shift in the ER, and I had an epiphany.

I have been living and working, for many years now, in a system which is the reverse of capitalism. Suffice it to say that because of federal law we can no longer say 'no' in the ER. Over many years this little nugget has passed into the public mind and those who would be barbarians absent a strong police presence are punishing us with no disincentive.

Unfortunately, our inability to say 'no' is now known by all the other services in the hospital, all of which (with the exception of the Hospitalists) CAN, in fact, say 'no'. Even the good old clinic docs know it and have, just today, bent me over a barrel and had their way with me. Example...

FP or IMed Doc: Hey it's Dr Beeper here... I'm sending you a patient by ambulance who needs to be admitted for something... I think they have ischemia or heart failure or babesiosis... Could you tuck them in to the Hospitalists for me?

Me: Did you call the Hospitalist, sir?

FP or IMed Doc: No.

Me: We will be happy to take care of it for you sir (per script handed down from on high).

And it is with this epiphany that I bid a way-too-late adios to the meat-grinder otherwise known as the ER. I'm done, and I do not suffer under the delusion that my problems are that important to anyone else. They are clearly not. However, when you consider that America is 50,000 boarded EM physicians short TODAY, my problem, in this particular case, will inevitably become yours. Here's how...

The hospital at which I now work is a gem. It is a community hospital with almost every specialty represented. We are a great facility. As a consequence of this, outlying hospitals have decreased their ER capabilities and out-of-county ambulance services now don't bother stopping at the local band-aid station anymore- they just drive to us. Sometimes they call ahead. Here's what's needed to bypass bumfoodle's ER... a patient request.

Now, as I leave this great facility, the ER is perpetually swamped with sick patients and not-sick patients, our hospital is often full and we end up transferring the patients from 50 miles away another 75 miles to whatever facility has beds. The beds are drying up there too.

Why is this? Because a bloated, parasitic host of administrators and paper shufflers are making a good living off our backs... can't run a hospital now and not be letter perfect with the huge governmental regulatory tome which can no longer be bound in a single large metropolitan area phone book and has to be stored on a 160GB hard drive. It is also because ER care for many is, de facto, FREE.

This is the reverse of capitalism, which would, were it allowed to function in health care, make it possible to turn a profit practicing medicine without the smoke and mirrors (and also have the salutary effect of helping people understand about taking care of themselves and get even a rudimentary knowledge of medicine). But profits are evil I'm told.

Grandma is still the best doctor around for normal illnesses, but everyone now thinks that everything is deserving of emergency care up to and including EMS transport across county lines for a toe bruise.

For all of you aspiring physicians, mid-levels, and nurses out there... you DO have job security, but you do not have any chance, by being excellent, of making an excellent wage or building an excellent business. They are coming with the long knives for all of you.

Twenty years ago they used to tell you in school to play sports but to have a backup plan because your odds of making a living playing sports were very slim, but I am here to tell you to lighten-up your academic pursuits... get out on the golf course or the basketball court or the football field. Pick up that electric guitar... move to Hollywood and do movies. Tinker in your basement and invent a better mousetrap. These are the last places in today's America that excellence is rewarded, and, professional sports will always be rewarded because we have become a nation of pantywaists, and pantywaists need their heroes and will not begrudge them their millions.

Adios. I will continue to blog from a place where, when I see a sick patient, I will pick up the phone, make a call (or maybe not), and send them to the ER.


  1. Get the fuck out and don't turn back...

    Best decision you will ever make.

  2. i don't know eto'... i'm already missing the woman who ran into the waiting room yesterday with bloody fists screaming 'i love you all... i hate you all... get the fuck off of me... i love you'. she sure cleared out the waiting room though, quicker than a popcorn fart.

  3. Bit of an Overreaction to that shitty UGA performance last weekend...
    I'm thinkin of goin the "Boutique" route myself...
    NOT "Boutique Medicine", just a regular Boutique with Big Breasted Blondes pitchin overpriced crap to Big Mouthed Yentas...
    Sounds boring, but how many lawsuits do you see for overpriced Manolos???


  4. hey frank,
    i thought georgia played well enough to win except for the losing thing. very interested in the fla-lsu game this weekend. i predict tn over ga. i also predict tebow comes into the stadium walking about six inches off the ground, shitting rainbows, and healing lepers right and left. after the gators win he will ascend into the clouds in blinding rays of light with angels singing and young girls fainting in non-stop orgasms.

  5. 911doc, I thought that was the election last November for the big o.


  6. 911 - I liked your post but a bit confused over this part:

    "We are a great facility. As a consequence of this, outlying hospitals have decreased their ER capabilities and out-of-county ambulance services now don't bother stopping at the local band-aid station anymore- they just drive to us. Sometimes they call ahead. Here's what's needed to bypass bumfoodle's ER... a patient request."

    Here in Mid-town USA, our two hospital ERs advertise how great they are - so it seems as though they WANT business - after all they are advertising for it! It would seem to me that if these two ERs are having the same issues that you're having, they wouldn't be advertising for MORE patients, would they?

    Maybe this is a convoluted clip-board-toting MBA-ish thing that has nothing to do with doctoring.

    Good luck in your next adventure!

    H the IH

  7. 911, Good for you. Give it a while, and you might feel a huge weight lift off your shoulders. Everyone I know who has divorced their first career has said it turned out to be the right thing to do.

  8. happy,

    you have pointed out an important thing... my hospital too, advertises how super they are. while i stand to be educated on this my belief is that it's not the ER where money is made these days, but with inpatient procedures. therefore, if we can cram more and more people through the ER, with an admission rate of 20% or so, we can cover the non-payors with sheer volume... kinda like panning for gold... the more you sift and the more time you spend the more gold you have.

    the losers in this are the ER docs and the hospitalists because we HAVE to see everyone for anything and our patients, in large numbers, are not paying us. when we complain about increased patient loads and increasing demands it is a very easy thing to do, from that nice reclining leather chair in the CEOs office, to fire the ER group or fire the hospitalist group and bring in the next cannon fodder.

    however, it is very difficult to hire another vascular surgeon or neurosurgeon at a community hospital. so, if they choose, the super specialists can tell everyone to fuck off and get away with it, but we on the front lines can not.


  9. I don't get it. Why in the hell would someone want to give an ED doc the job of passing on a patient to a freakin' hospitalist? I am in the "business" and none of our patients have ever been turned over to a hospitalist---some yahoo who knows zip about ANY of our patients. Second, the only time we would ever just send a patient to the ED would be when it is too late to get a CT on a hot belly or a presumed CVA. Maybe I am just clueless. We actually have patients who ask who would provide their care if the need for hospitalization ever arises because they want continuity of care.

  10. anon.
    you are a vanishing breed. my thinking on this is that the clinic docs have to crank through so many patients a day to make ends meet that a sick patient requiring more than ten minutes work goes right to the ER and through to the hospitalist. i think this is particularly bad in the hospital mentioned above because while the hospital itself is great, the catchment area is large and very rural. centralization of good care is terrible for all except those at the center of the circle.

  11. 911Doc, this post recognizes your situation and and also asks the question that should scare us all about socialized medicine. Don't people realize that government control is a system of partial slavery?

    Will Doctors Just Say No?
    7/23/09 - Open Market by Wayne Crews
    What kind of doctors would Obama's system create? Who will go into medicine?

    (Quip: I majored in administration before becoming a doctor.)

    A fictional doctor from "Atlas Shrugged":
    I wonder at the smugness with which people assert their right to enslave me, to control my work, to force my will, and to stifle my mind. What will they expect when they lie on an operating table under my hands?

    Let them discover the doctors that their system will produce. It is not safe to entrust their lives to a man whose life they have throttled. It is not safe if he is a man who resents it, and still less safe if he is the sort who doesn’t.


  12. 911.......

    Know I haven't been around for awhile...but have been reading your excellent as usual posts....just very busy.

    Want to wish you the best of luck and to thank your from the bottom of my heart for every intelligent, insightful, witty, sarcastic word that you have have NO idea how comforting it is to know that others feel the same as I. Not sure if you have had this problem (it would be an interesting topic, I think) but more and more where I work (granted...usually large teaching hospitals), I feel there is a political litmus test for healthcare providers......I have had many elitist attending MDs tell me that I "have no right to be a nurse if I don't believe in a single payer health system, seat belt laws, gun laws, helmet laws, etc" Maybe because I have done this for long...or maybe because I was already a sort of burnt out medic when I started...I have never regarded it as my job to save souls....just to save their body so that they may one day save themselves if they so choose....and if I can't find it in myself at that moment and with that person to be at least be professional. I have never been arrogant enough to think I can change anyone.....but that's liberals for you....the epitome of self-riotous arrogance.

    I am not ready yet to leave the ER.....but am hoping to take care of those worthy of my care (actually...i hope I am worthy) I leave tomorrow to be an ER/ICU float nurse at's as a civilian...but my heart and soul are still in the right place...I am actually excited to start a job again......

    Here's to both of us hopefully falling in love with our jobs all over again....take are the best...and DO NOT STOP BLOGGING PLEASE

  13. I'm a consumer of health care. I own a small company with 7 employees and provide BCBS coverage to employees and their family at no cost to them. All get 20 "personal" days off each year to take care of vacation, sickness and other things that can't get done on the weekend. One employee constantly used the ED as her primary source of care. Why...because she didn't want to use her "personal" days and weekends to go to the Dr. Her behavior changed when I told her to stop or she would have to start paying for her health insurance premiums. When something is free it has no value and is easily abused.

  14. dear anon.,
    I'm surprised you were able to dodge the gender discrimination lawsuit. you speak the truth. thanks.

  15. I do not believe I am one of the vanishing breed because I have only been a NP for about 8 years. Saw a problem with an elderly lady (weird PT/INR numbers, looked like crap, legs the size of elephant's, huffing and puffing, and a cxr that showed a water bottle for a heart. She was admitted, we called the consults: There were no, zip, nada, rein, non, zero EDs or hospitalists involved. We ain't gonna that quality of care if we are salaried, have more government involvement, and more desk jockeys in eye-shades looking our business.

  16. Wish you the best. What do you plan to do now?

  17. Anon 11:59
    FYI, seems you do not know that you cannot dive into employee private health information as you have done without leaving yourself wide open for a lawsuit that could easily put you out of business. If you knew this, I am sure you would not have done it. Your concern was for your rising employee insurance costs, I understand.

  18. Our local urgent care walk-in clinic dumps patients on the ED. Essentially, they keep the easy and profitable fixes, but complicated or unwanted cases are told they'll have to go to the hospital. It's driving the University nuts.

  19. Let's not malign urgent care centers. My partner and I run an excellent urgent care and take care of just about everything (we are both board certified ED docs with 30 years ED experience between us). Now if you are having chest pain and are diaphoretic, have blood pouring out of your anus, or I suspect you have an acute abdomen, I'll send you on down the road. Or if you don't want to pay and have no insurance. I have enourmous overhead, lease, TAXES, payroll, and if you chose crack or a Blackberry over insurance-you be goin' to the University.

  20. too many u's in enourmous, yes I know all to jack-ass spell checkers who look for typing errors over substance

  21. S.C. I don't mean to malign urgent care or people who work there. Just giving an anecdote, not an indictment, sorry if i came across that way.
    I've used the place several times, and they have a good facility. But, they can and do say No, and it gives them a competitive advantage. Enough of one that the university opened a competing urgent clinic across town, to try and keep up.

  22. SCNS, my employer is more than happy to delve into my private stuff as I fell down some steps 4 years ago, hurt my back and I'm still getting phone calls from my employer's "health" services about fall prevention. Ironically my employer is one of the largest for profit hospital chains in the country. Don't believe for one minute your health info is private. Especially when it comes to cost.

  23. My advice was to the small business owner to be careful. Obviously things are not as private as they should be. I've had to protect a few patients when working for private practice when bosses called inquiring. It's a fine line. But once you cross it it's open season. And FYI, it's an easy win.

  24. jennifer,
    heartfelt thanks. in fact, it was specifically to get away from the communist left in academic medicine and the inept left in civilian medicine that i went into ER med. decisive, quick, often wrong, never in doubt. i have no patience for fools or for dithering or for committees. eventually though, the bastards got to me. hopefully i'll laugh all the way to the bank and get to put my foot on their neck eventually. i will press to the ground.

  25. Speaking of ER abuse/overuse, I have a bit of a question, having suffered from the flu for over TEN days now...I have been hearing that ERs and doctors' offices are being crushed with flu sufferers wanting treatment.

    Are these patients expecting you to prescribe them antibiotics? Is there really all that much you can do for a flu patient (who isn't experiencing life threatening symptoms like pneumonia) that they couldn't do for themselves with OTC remedies, if they've had it longer than Tamiflu can help?

    What is going on here? In my own case, I have had a couple of setbacks by not taking time off work until it got really bad and by not getting my vaccination in time. Is there really any reason for MOST people to go to the doctor or ER with this?

  26. dear anon.,
    blame the MSM and the health and human services secretary for making "flu" a scary killer of tens of thousands. it always is (on the extremes of age) but when fear is sown this kind of panic results. to answer your question, these people come in droves to the ER or their doc's office in order to...

    1. pass the virus along to as many as possible
    2. for sympathy
    3. for morbid curiosity
    4. for a work note
    5. for a magic potion
    6. hoping to get narcotics
    7. just to piss me and you off