Blogging My Surgery - Finis.... (I hope)

Eschars form at surgical sites, burn sites... they are scabs, deep ones, and sometimes when they fall off they start bleeding by pulling away the edge of a vein or an artery to which they are adhered.

The classic case for ER docs is the 'post tonsillectomy bleed'.... usually with kids... its seven days out from surgery and the scab pops off and BOOM, bright red pulsatile bleeding occurs and you better be ready with a good airway team because time is of the essence. It's always a trip to the OR for cautery or whatever the ENT docs are doing these days.

So this happened to me. In all seriousness, I won't be very specific, all my surgeons and docs did a great job, I'm not trying to nail anyone, I just had an infrequent but known post -op complication of massive bleeding after a small eschar popped off a high pressure vessel up in my oro-naso-retro-supra pharyngeal area. I survived and am doing well and there's only the remotest chance it will happen again in the next two weeks so I'm feeling pretty relaxed. PTSD much?

Rather than tell the story bit by bit I thought it would be more interesting to ask what would have happened to me if I were not an ER doctor who knew, the instant this thing popped, just what to do. See, I don't live near any MECCA and my local hospital had no one on call the night this thing went. But I knew all of this and was able to game the system.

Because of EMTALA, the life saving care I needed a few days ago was only available an hour away by helicopter. Our local hospital, now completely incapable of taking care of any surgical emergency after hours (and most surgical emergencies during operating hours) has simply become a way-station, picking the low hanging fruit of sick medical patients with insurance.

The complicated cases must go away because the specialists have gone away and they have gone away because they don't appreciate working for free more than twenty or thirty times a year.

Knowing this and while spewing vast amounts of bright red blood into my sink, I was able to instruct my life-partner (and ex-girlfriend) to say to the 911 operator "My husband is bleeding out.... We need an ambulance now.... the hospital needs to have trauma blood ready to transfuse.... Medic-Flight needs to be called now...." And then she pulled out the doctor card when the high school graduate on the other end of the line started asking things like, "...is the bleeding more or less than a teaspoonfull????"

Then she was able to speak directly with the local ER attending who knew me and knew this was the real deal and ALSO knew immediately that I had to be flown away as soon as possible.

And the local ER was great. They started tanking me with blood and, miraculously, the bleeding had slowed to a trickle, so at this point I was feeling very dizzy, but very good about my chances of making it to where they cold actually fix me. And obtw, JCAHO, your mandatory questions did get asked and were somehow just as important as the real issue at hand, and so for you JCAHO, I answered that I DO NOT feel safe at home, that I was NOT suicidal but, in fact, HOMICIDAL, and that I had lots and lots of guns in the house. Still waiting for the safety benefits of this mandatory JCAHO shit to accrue to me. Waiting..... Hmm, maybe those questions are worthless wastes of time.

Anyhoo. The Medic-flight crew wanted me to sit very still as they got me down to the place that still does complicated stuff. If that miraculous little clot were to dislodge then they were going to turn into a flying blood fountain with the flight medics desperately trying to get an airway in me at 4500 feet with me choking on my own blood. One of the nice things of this excursion was that my hero-clot stood his ground. Way to go Hercules!

Down at the place where they still do medicine and surgery that is hard I was a fairly routine case. The attending surgeon peaked in at one point and the Chief Resident and third year resident fixed me up. Nice work ladies and gentlemen. Really great.

And hey, anesthesia guys, I was just there last week and you fell for the "I'm allergic to succinylcholine" line again! It paralyzes me dudes! Every time! Glad you thought it was funny too. Oh, and nurse in the second ER, sorry about the "you guys don't have a Foley big enough for me" comment, but I was feeling it a bit, you know, realizing, I was probably not going to die.

So here I am. Walking around gingerly, trying not to sneeze or cough. Waiting for the chances of this popping off again to go close enough to zero to go back to my normal routine, and thanking God that I'm typing this, and wondering, just a bit, what would have happened if I did not know exactly what was happening to me when it happened, did not call ahead and get everybody from EMS to local ER to Medic-flight prepped for what was coming, and did not get lucky with a good weather night for helicopter transport AND get lucky with the availability of a bird.

In other words, what if I was Joe Schmoe? Joe would probably be dead, and he would probably be dead due to EMTALA. And we are trying to turn the whole deal into the 'model' built from the worst piece of medical legislation ever passed in this country.

But to end on a positive. Seeing what I used to do full-time through the eyes of a truly emergent patient made me proud to have been a part. You Medics and Nurses and Docs who continue to do this.... you are simply the best. I am proud to have played on your team. RW, you are a saint.

'Pain Scale' Kills Patients

All of us who practice in the hospital setting and probably those of you who practice in clinics are familiar with the 'visual analog pain scale'. I wrote a bit about it on 3/17/07 (can't get a link to work... you can search the blog under 'arithmetic' and get right to it).

I got to thinking the other day, as I wrote out another prescription for Lortab for someone with "ten out of ten" pain, that one of the unintended consequences of the 'visual analog pain scale' has been a huge overprescription of narcotics and the skyrocketing of drug abuse by people who would not otherwise do it. After all, it's from a doctor, no?

I can't pull a .jpg image off the web for you but someone got a few million dollars from the NIH to come up with this 'scale' which is a series of human face caricatures progressing from smile to frown. You then ask THE PATIENT which one represents their pain at that moment. That's it. Science?

At the same time that one of my former employers was taping the pain scale to the back of every chart (at the behest of the 'Joint Commision' or JCHAO, or whatever they call themselves these days), and dinging us for not using it on every patient, the admin-weenies who are, almost to a man, not physicians, started dinging us for 'customer service complaints'. Usually these complaints were about the treating physician's refusal to prescribe narcotic pain medicine. Getting it from both ends, most of us just shrugged and came to some reasonable middle ground. My middle ground is that I will prescribe ten Lortab, no refills, to just about anyone. Sorry... that's just the way it is.

So this little theory of mine was quickly (partially) verified by a google search. Interesting, no? Oh those unintended consequences!

There are those who will still fight this battle... but with every patient that we fight we spend more and more time and field more and more complaints, and it's a wonder some of my colleagues still have the energy.

Medicine is an art and a science, and the assessment of pain can not be reduced to a silly-ass, third-grade, completely subjective cartoon. Docs, why did we surrender to these buffoons? We surely did (in almost all areas of the practice of medicine) ... but why?

Reasons I'm Leaving Emergency Medicine (number 2)

This is a turd.

In medicine today this is what's known as a beautiful turd, a really nice turd, or not a turd at all, but something that only resembles a turd to the untrained eye. What this really is, according to those in charge today, is an opportunity to partner.

See, while I see this as a turd, this observation is not welcome. In fact, it may impact our Press-Gainey scores or our core measures, and this is unhealthy for the group and for the contract. The cynical amongst you might say, at this point, that those seeing this as a golden poo are merely motivated by money but no! They are motivated by a collectivist wisdom which is but a foretaste of humanity's next step up the ladder of evolution.

I admit that my feeble brain is not able to see this, so I am going to go hang out with other non-Mensans and other non-leaders.

To me, medicine today is a turd because we call patients 'customers', try to do better 'customer service' with all comers, most of whom do not meet the traditional definition of 'customer' (ie someone who pays for their services), worship at the feet of a terrible unfunded mandate called EMTALA, and also worship at the feet of a bunch of worthless committee hacks called TOFKAJCAHO (the organization formerly known as JCAHO).

We also shuffle money from the folks who actually gave more than a second's thought to their health to those who have made, and continue to make, poor decisions. In other words, there are tons of doctors and hospital CEOs and legislators who fancy themselves as modern-day Robin Hoods. They are not, they are the Sheriffs of Nottingham, but then again who am I to say, I think the thing at the top of this post is a turd

EMTALA has killed the best medical system in the world, and why? Because some douchebag legislators thought that it would buy them votes (and they were right). I also know how to fix our mess, but, since I major in plain-talk, I will never be elected nor will anyone who says this and here it is.

Everyone in the country should pay for their own medical care even if only for a small portion of it. Buy insurance or not, your choice. Get catastrophic coverage only and establish an HSA. Finance your care. Can't get insurance? There's no one to blame but the authors of EMTALA.

If you walk out of the hospital or out of the ER two hours after calling an ambulance AND you really have no money, no problem, we can arrange for a few hours of community service at the local free clinic. If "the government" wants to mandate that no one be turned away from the ER then let them pay for the care we are legally obligated to give or at least let us deduct it from our gargantuan income taxes.

Emergently ill patients should get our best and that's exactly what they get. They should then pay for what they received in whatever way they can. Insurance rates? Down immediately. ER waits? Gone. Bullshit EMS calls? Gone. Doctor retention and satisfaction? Up (and quickly). My job? Immediately better because I am not constantly presenting the golden turd to my consultants. In other words I'm for the good old American notion of personal responsibility. Hard in the short run, the only sane way to do things in the long run.

Pictured above is a turd. It can not be polished and there's no way to pick it up by the clean end.

21st Century Alchemy... Still a Failure.

The only thing surprising about this article is that it is, evidently, surprising to the author.

* Just found this... Orthopedic surgeons may be leading the charge. Will the government listen to the experts who actually fix people, or will it tie them to the rack?

** And meet my hero.

Georgia O'Keefe

Here's a Georgia O'Keefe painting called "Jack in the Pulpit no. I V." Nice.


On a completely different subject, what is it about physicians that makes us pussies? Somehow the previous generation of physicians rolled over and ate a huge shit-sandwich from the government called EMTALA. Our national organizations, the AMA, ACEP and the like, have acted like a bunch of perpetually-stoned good-time rock and roll maggot-infested hippies and have embraced the fucksticks at JCAHO too.

I know that the premed route is not exactly peppered with economics, logic, or business classes but please, you freaking douchebags, how in the name of all that is holy did you swallow the EMTALA and JCAHO pills? How, exactly, can you provide CABGs for all regardless of their ability to pay? The answer is, you can't, but while trying to accomplish this ass-hattery you will do it by having everybody else pay for it. In other places this is called stealing.

Could you not see, if only from a rudimentary common sense perspective, that EMTALA was going to crush you? Did you not know that when unfunded mandates have been tried previously, or their ugly father called communism, that they have failed miserably and made the situation worse?

Where were you, docs? Out on the golf course? Why were you not on the steps of Capitol Hill marching and carrying signs and threatening to strike? Why? Are you all a bunch of pussies or did you figure that by the time EMTALA ruined medicine that you would be comfortably retired? Damn your eyes for being clueless pussies because not only did you screw the next generation of doctors, you screwed the next generation of patients too.

That IS what happened, OR, in your feel-good liberalism you knew, you knew deep-down, that EMTALA would end fee-for-service and force a "solution" from above because you love government and its power and revere it with religious zeal. Better that all be in a similar state of misery than some have it better than others. OR, you were too busy working, and didn't think your colleagues and national organizations could be that stupid. WRONG!

Well good for you sunshine. Why don't you just move to some socialist heaven with closed borders and frozen social classes and live there. In the meantime you have made being an ER doc, or a doc that gets consults from me, an endless parade of entitled asswipe misery, and you have sucked the soul right from my body. You have wrecked specialty care for everyone outside of a big city. You have also wrecked the best care for the most system which we had and replaced it with mediocre care for all.

Happy now? I thought not, because there are still some in America who have more than others. Still, some rich folks get better care than that guy who ran his stolen car into a bridge abutment, drunk, while running from the police. How will you fix that? Why not go all the way and join the American Communist Party. Fucksticks. Have fun driving your Prius and drinking soy and wheat-grass shakes. Guess what? You are going to die too. Double fuckstick Deborah Peel in your face asswipe douchebags.

*** and thanks to my friend medblogaddict, for this post

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Hate to blow our own horn but we've been saying this stuff for a couple of years now and the Wall Street Journal is late to the party.

Check Here too, and here, and here, and here, and here, and here, and here, and here, and here, and here, and other places, and, finally, here, oh, and here too.

M.D.O.D., we're cynical about medicine and the politicians and entitled teat-suckers that have destroyed it, and you should be too.