"Buck" and Modern Medicine

Buck Branaman  is a genius. And the movie "Buck" is worth watching over and over. It's a movie in which you will meet a man like many who chose medicine WANTED to become. Mr. Branaman is one of the worldwide experts in horse-training and he's much more than that, he's probably the best human psychologist I've seen in a long time.

Now the thought struck me while watching one particular part of the film that Mr. Branaman would have quit his profession long ago were it not for the fact that people who seek his services do not compose a huge voting block and, as far as I can tell, pay him for what he does. Some actually save money for years to go to his clinics. Wow.

I can picture the moment when the government decides that all horses have a right to Buck Branaman's time and expertise, pass laws about how he may go about delivering his service,s and how he may be reimbursed. It's going to be the same day that he retires. I mean the way he treats the owner of the renegade Stud-Colt at toward the end of the film is not only a HIPAA violation, it is very POOR customer service, will generate a complaint, and the poor woman's money will have to be refunded.

EXCEPT... EXCEPT!!! The woman herself was grateful for the upbraiding she received and said, after, and through some tears, "He's right.... he's right.... I do have problems I need to fix and the horse is only one of them."

So I'm picturing myself saying something similar in the ER, "No sir, I am not refilling your pain medicines, you have problems which you are covering up by taking them and you are lying to me in order to try to get them from me, now, I can either call the cops on you right now, or I can help you find the help you need, but I am NOT refilling your narcotics."

For me, another job lost. But, thankfully, not for Buck Branaman.... not yet at least. Sometime after EHTALA is passed by congress.

Hiding Out

So far so good with my adieu to the ER, but boy, the things I have learned!

I am currently working in what most folks would call a 'doc in the box'... We are an acute care clinic and do not take appointments. We do some chronic care, a lot of worker's compensation stuff, and once in a while, like today, I am reminded why the ER nearly killed me and destroyed my life. If I can get my head out of my ass long enough, and can find someone that likes my particular flavor of bullshit, you might have the opportunity to read all about it in book form (but I am saying this as much to motivate myself to finish the damn thing as to tease it).

Being in charge of a busy ER is a young man's job ("or woman's" I say with fond memories of Life of Brian and the Judean People's Front). There may be ways of doing it without pegging the adrenaline meter all the time, but I never discovered them. The consequences of my years of adrenaline overdose were obvious to my co-workers, but opaque to me. My nicknames during my ER career (mostly given by my nurses) included, but were not limited to, "Speed Racer", the "rat on crack", and "doc zippy". I'm sure there were others.

It's been almost three months now and I can almost sleep without ambien. And as the learned helplessness of working ER has begun to fade to a bad dream I have been pestered with an occasional thought of maybe working 'just a few' ER shifts to 'keep my hand in the game'. Then today happened.

In my refuge here at the doc in the box I mostly prescribe amoxicillin (way too much), and tell people they did not break their arm, leg, ankle, or toes. Today, an elderly gentleman came in after falling and sustaining a bad scalp laceration... I was back in the ER.

His wife, every bit as intelligent and bull-headed as he was, refused every recommendation I made, and they went like this... "Sir, I need to call an ambulance for you so we can get you to the hospital for a CT Scan of your brain and your C-spine... First of all, you aren't quite sure why you fell which right there makes me concerned about a stroke or TIA, secondly, your laceration goes down to your skull which I can feel with my finger here, and while I do not believe you fractured it I am concerned you could be bleeding inside your brain, and finally, I need to make sure your neck is not broken... you are holding it like it hurts so this is a real concern, and if your neck is broken you could move it the wrong way and be paralyzed for life or dead..."

Patient's Wife: "No, I will put him in my car and drive him [to the Mecca], but he is not going to this [town's] hospital... we made a pact... I don't care if he dies, he is not going to this [town's] hospital."

Of course I made my best arguments, but I could not force this patient to do anything he didn't want to do and I found myself sewing up his huge laceration after we C-collared him. I did manage to persuade them to get an outpatient CT scan of brain and neck, and, of course this man had an unstable high C-spine fracture. He could have, with a sneeze or cough or turn of the head, died. I was tempted at that time to call Dr. Asa Andrew for advice on how to "lifestyle" this guy back to health, but instead I did the right thing...

I spent an hour unfucking the stupidity of this patient-spouse tandem with near panicked phone calls to EMS and the closest neurosurgeon that would bite. Then a guy walked in with a dead nut, and a woman rolled in in a wheelchair telling me a very long story about a fall and an inability to find any doctor that could handle all her complex medical problems which, of course, meant she needed a refill on Lortab.

It was at this time, as soon as I had the first choice dumbass tucked away, that my desire to "pull a few shifts in the ER" vanished like coke off a whore's ass. Amoxicillin. Nice.

The Good Old Days of American Medicine

The 'good old days' for doctors in America were the seventies. But let's talk about the 'good old days' for patients in America. They are right now and they are about to end. 

The good old days for patients have been at the expense of American doctors and nurses and paramedics for thirty years now, and because of EMTALA, Medicare, and gutless politicians and physicians. Group politics, super. See ya later individuality and achievement.

After Obama 'fixes' medicine my life will be easier and I will make more money for less work and with capped liability to boot! I will take some pleasure in pointing this out to all of you muddle headed liberal do-gooders and earth mothers out there, but not too much, because I will pull out a lot more 'pronouncment of death' forms. These patient encounters are easy and there's no risk and I get paid, so cool. You just have to make sure the patient is really dead, and this is only occasionally difficult. Here's a story about what will not happen anymore. 

You will not be an 80 year old smoker who has been struggling to breathe for two days and when you call 911 they will not get there right away. You will not be rushed to the hospital with lights and sirens blaring and you will not be thrust in front of me at 4am with a heart rate of 220, curiously the same as your systolic blood pressure, and I will not, then, do the following...

I will not run into the waiting room to find your family (after shouting out, IV, nitro drip, cardiazem 25 IV, morphine 4 IV, set up RSI, pacer pads!) to find out if you have a living will (you are too far gone to do more than scream and breathe).

Through their tears they will not tell me to 'do everything'.

I will not then run back into your room, pulling a few techs and nurses with me and do the following...

I will not give you 20mg of etomidate followed by 25mg of succinlycholine and slide an 8.0 tube into your trachea and hook you up to a vent.

I will not then push about 50mg of propofol on you before shocking you with 100 Joules of synchronized electricity to get you out of your atrial flutter with aberrancy, and will not rush you to the scanner to make sure you are not dissecting a thoracic aortic aneurysm or pushing against a massive pulmonary embolus.

I will not, after you come back from scan, have a brief moment to look in your eyes (as the propofol has been momentarily stopped), and apologize to you for intubating you (as it seemed like you didn't want me to do it, but I could not trust you (at the brink of death and without documentation) to make a good decision), and have you nod your head to me and try to thank me. 

I will not then send you to the ICU where, in spite of your continued smoking habit and lack of insurance or money, some of the finest critical care physicians I have known will, in all likelihood, succeed in getting you out of the hospital, back home, and comfortably smoking. They will lose money in the endeavor (and sleep and time away from family), but that's what they do now.

Instead, when you call 911, you will get a recording or be put on hold. If you make it past the call screener you will be rushed to the hospice where you will die in a haze of morphine. But, and here's the good part, it WILL be 'free' (and I will be free to take a nice nap on the overnight shift).