The Groveling ED Doc

Dear Hospital Administrator,

I need to blow off some steam. Sorry, in advance. I'm afraid you don't really understand what happens in the so-called "trenches" of my emergency department. Let me tell you just one story today.

A man was transferred from another hospital to our for specialty hand care. According to him he was just "minding his own business" and some dude up and stabbed him in the forearm. It was a through and through wound. The ED at the other hospital took a look and decided the guy had some severed tendons and possibly nerves to his hand. These injuries require, sometimes, a hand surgeon to repair. So he was given some pain medicine, and x-ray, and tetanus and antibiotics, then put in an ambulance for a 50-mile trip to our hospital, because our hospital unlike theirs, has hand surgeons available for emergencies 24 hours a day.

Today was a typical day for the ED. By typical I mean crazy bat-shit busy. The patient was placed in a room and I finally got to him about an hour later. Before entering his room I skimmed his triage note which read, "Dr. Hand Surgeon (name left anonymous) aware of patient coming." Now, it is customary practice for me to evaluate all the patients that come into my emergency department. So that's what I did. I undressed the wound and examined it. The patient was very unhappy with this - I was the second doctor to do so and "nothing yet had been done" to paraphrase the patient. I walked out of the room, ordered some morphine and requested the hand surgery service be called. I told them about the transfer and that Dr. Hand Surgeon was aware of the patient and could you please come see the patient?

I was just going through the motions, as much as this pained me. I knew this patient did not have an condition that required emergency surgery. He needed urgent referral to a hand surgeon, preferably the next day. Nevertheless, our hospital being the level 1 trauma center that it is and with our policy of accepting any and all transfers for whatever reason they may be, I had no choice but to call my hand resident colleague.

The recommendations of the consultant were: loose closure (suture), splint and follow up in the hand clinic. That's it.

Perhaps this doesn't strike you as absurd, so let me spell it out. A patient was transported here for an evaluation of a medical condition that was not an emergency. That's a real expensive ride. And a waste of the patient's time. When he arrived the service he was sent to see did not know of his arrival, so I needed to see the patient first. I had plenty of other patient's to see and my involvement in his care added very little, if anything, to the value of his care. Although it certainly added cost. Then the consulting service gave recommendations that could have been given over the phone.

Believe it not this happens every single day. Unnecessary transfers for non emergent conditions that could be handled with good outpatient follow-up. Or necessary transfers to services who are clueless of the transfer. This takes a considerable amount of my time accepting the patient in my ED and calling he appropriate services, beds, admissions for patient who have known diagnoses.

Let me get back to my story. So, as I am dressing this guy's arm and splinting it, his girl starts yapping away as if I am not there how "we just walk around in our white coast and sit on our asses at the computer the whole day not doing any work," and how the "nurses are lazy checking the email and don't give a shit about their patients." I invited her to look at the email my nurse was not checking but she refused. "I know how you guys work, I know what's really going on." Contrary to what you may think, she was not psychotic. She was, actually, a sort of typical disgruntled, if a bit unfiltered, "customer" who I see every day.

It was hard to restrain myself. "I'm sorry you feel this way, we work very hard here providing you with free care and you should appreciate that. You are rude to assume we are doing anything less than that." But as I say this I know I'm walking a thin line, and have probably crossed it. She is incensed. My candor, as usual, backfires and the patient escalates. I asked security to have her escorted to the lobby.

In medicine we have the maxim: "would you do it if it showed up on the front page of the city newspaper?" I know you think about this all the time. And because you think about it, I think about it. I don't want to embarrass you. But exactly how groveling do we need to be? I'm a highly trained and educated physician. This person was a moron. It is sad that I feel ashamed to stand up for myself and my staff. And I have the very uneasy feeling that if she were to lodge a complaint, the hospital would not back me and instead try to make things all nice to avoid any risk to the hospital's public image.

This is the culture here at our hospital, and to be honest, at many hospitals in this country. It is nauseating. It is a sign that ultimately our patient care is not good, like we have an insecurity complex. Like we know our reputation and the confidence of our "customers" is not that strong. We're afraid people will find our vulnerabilities and exploit them, and that's why we grovel.

The apathetic patient with a bad skin ulcer

A middle aged man is brought in by ambulance to the ED with a report of diarrhea, a wound on his butt and low pulse. As soon as he is brought into his room and the nurse sees him, she comes to find me to say, "he doesn't look as bad as his numbers would make you think." And that would be? His blood pressure is 73/4o something. I take a look at him. The nurse takes a look at me, and like any good nurse, reads my mind and orders her assistants to move the patient immediately to our resuscitation bay.

While the crew is busy getting a second IV and attaching a cardiac monitor, I approach the bed an introduce myself. The patient is pale is a ghost and looks like he has been living in a cave. Turns out he had been. Almost.

"Who called the ambulance for you sir?"

"My VNA."

"Why's that?"

"She said I didn't look too well."

"Where have you been living?"

"In a shed behind my parent's home. It abandoned now that they're dead."

I see dried diarrhea down his legs, although strangely he doesn't smell that bad. Not at all like homeless-drunk bad.

"Where have you been going to the bathroom and what have you been eating?"

"I don't have a toilet no where and I've been eating some food my brother has been bringing me."

He is pleasant, and cordial in his answers. Not at all the combative and confused patient you would typically expect judging from his appearance. He is emaciated, poorly kept, long greasy hair. I don't know why, but a picture of an old hick from the backwoods of 19th century Kentucky diseased with hook worm comes to mind.

But what is even more odd is that he has a list of medicines with him. Many of my patients in far better social circumstances don't even know the name of the medications they've been on for years, or have the sense to carry a list in their wallet. And then he says, "but Coumadin is not on there, I'm taking that too." I can only guess how far off his Coumadin level must be. "And the name of my cardiologist is..." I'm floored. I guy living in a shed wallowing in his own crap actually has a cardiologist and can tell me his name????

Turns out he doesn't have any complaints really. But that blood pressure is still in the toilet, even after 2 liters of fluid. He's mentating perfected well. Really? Nothing's bothering you sir?

So then we go to turn him.

And on his tailbone is a dinner-plate size area of black, rotting flesh with a large gaping hole packed with fetid newspaper. "Got to explore the wound," I hesitantly mumble to myself. I glove up. I want two layers of gloves for this one. No, maybe three. I want a face shield, a gown. No, just give me a hazmat suit. I nervously pull out pieces of the newspaper, unsure of what I will find. It's stuffed in there deep. I mean real deep. Down to the bone, an ulcer large enough to stick in a large grapefruit. And then I see a maggot. I stop and look up at the nurse. She is mortified but maintains composure. The smell is beyond description and I nearly vomit all over the bed. I step away and ask for an instrument kit with some forceps and the overhead surgical light to be turned on. By this time word has got around the department and my colleagues are filing in one by one to gawk with morbid curiosity. I return to the matter at hand and what I see is utterly foul. There is a mass of frantically wriggling maggots trying to escape my detection by burrowing themselves into deep recesses of the ulcer. I pluck a few out and rinse the ulcer with water.

No, strangely, this does not hurt he says. He has no clue what is down there. I tell him there are maggots; he seems indifferent. And that's what I just don't get. I would expect this is an alcoholic or addict. But this level of apathy in a sober person I've never seen before. Before I actually do vomit I ask him to roll back and go to call the surgeon.

The full code reversed

Today the skilled nursing facility, or SNF as we say, sent in a 95 year-old with like a million medical conditions. She was lethargic and had low blood pressure. This indeed was true. As I held the face sheet transfer document with meds, vitals, medical conditions from the SNF, I eagerly scan for the "code status."

FULL CODE. 95 years old. Should have died years ago. And now in my ED where I have all kinds of technology, which are either instruments of life support or instruments of torture depending on the patient.

I don't know what's going on. Probably dehydration, but she's ancient and has problems with every organ, so anything could be wrong. Heart failure? Sure. Kidney failure? Sure. Infection? Absolutely. Thyroid issue? Possible. Simple dehydration? Quite possible. Medication over-use? You bet.

She doesn't perk up with simple IV fluids, but she doesn't swirl around the drain either. She's arousable and talks in disoriented, demented sentences.

I call her health care proxy, the son. "She doesn't want any machines," he tells me. But if her heart stops? "Well then I guess we should make an effort to keep it going." We hear this a lot in medicine. "Try." It seems sane. Seems just. Seems humane. I explain that CPR is brutal and painful. I explain that if a 95 year hold has a cardiac arrest there is virtually no chance of CPR working well and even if so, she ain't going to be walking in a field of daisies. It will be life support and a slow miserable, prolonged death. Well I say that in so many words. But I do my best not to mince words and sugar coat. I've seen too many docs do that because it is easier to say it like that. But honestly, I think patients and their families always appreciate the straight and narrow honesty, even if the truth hurts a lot.

So he agreed that cardiac resuscitation was not reasonable and not what she would want. I've played out these conversations over and over again in my head to get it just right. So much hinges on the way things are phrased, tone, timing.

So what this meant is that the patient was admitted to the regular floor, not to the ICU. This kept a very expensive and valuable ICU bed open for someone who will much, much more likely benefit from life support. And it kept her family - and the rest of us since he bill will be nearly 100% from medicare - from paying thousands of dollars of health care that would much, much more benefit another patient.

This is humane. And it is rationing. And it is rational. Most importantly it is respecting HER wishes, rather than playing into the feeling of guilt that many family members feel when letting go. These situations are never easy, but this one was relatively straight-forward. It gets hard when this same patient is 75, or even younger with a worse disease and worse prognosis.

The man who shit himself

A few nights ago I had my most unpleasant patient ever. EVER. This was not the 25 year old with a wrist abrasion and a minor skateboard accident asking for percocet. This was not another 46 year-old woman with chronic generalized abdominal pain and depression. This was not the irritating and hopeless alcoholic, again drunk with a bump on his head. This was not the 5 week old pregnant girl who called the ambulance because she has some mild cramping. This was not the bipolar 66 year old who comes to the ED every week for a variety of complaints then treats the staff like chopped liver and refuses care. This guy was worse, believe it or not.

A 43 year old man with Crohn's disease. He was discharged the day before from the hospital for "mild Crohn's" exacerbation. He had a several thousand dollar work-up while in the hospital, GI consult, CT scans, the works. Today he got kicked out of his shelter, supposedly for shitting in his bed overnight. Sure loose stool from the Crohn's, but this is not uncontrollable cholera-level diarrhea.

The guy is parked in the hallway right by the workstations and will not let a single staff member walk by without asking for something. He refuses having an IV for fluids, although to be honest it was not really necessary. He openly confesses to me that he has never worked a day in his life because he was "spoon" fed by his mother. He's not used to being in a shelter, "if you know what I mean, man." I don't ask him why he's in a shelter. I can make up the story that is probably pretty close to true. I don't ask him because even asking him the simplest question, like "what did you have for breakfast" turns into a 5-minute nonstop ramble about everything except what I want to know. He wants pain medicine. He wants he diarrhea to stop. He wants some food. He is back because he didn't get the "right treatment." Whatever that is. Can please tell me sir?

Then he shits in his bed. In the hallway. All over, disgusting loose stool. Didn't bother attempting to get to the bathroom. Didn't bother to say "Hey guys, I'm feeling like one's going to come loose, can ya' help to the bathroom?"

The nurse takes him to room and calls me in. I find him sitting in his stool. He starts blathering on and on about his "diarrhea." I can't get him to shut up. I ask him to clean himself up. He makes up more stupid reasons why he can't do this. I mean who the hell does this? I tell the nurse to leave him and say I won't talk to him until he cleans up.

So now he's clean, back in the stretcher. The aides did it by the way. I tell him exactly what I think, well almost minus a lot of expletives, that he's like my 2 year-old son who also shits himself but at least wears a diaper. "I can't wear a diaper man, you know what they say to me at the shelter." No, not really, but it's gotta be a whole lot better than having shit everywhere.

After 7 painful hours in the ED I get him out with some antidiarrheal meds. Admission was not an option. He walked out smiling, like he was happy with his care, what a shit-eating grin that was. Discharged at 10 pm. 15 minutes later the triage nurse calls me and says he's back, complaining again that he didn't get the right treatment. I say tough. He's malingering. He has no place to sleep tonight. To bad for him, but he doesn't have medical condition that needs hospital treatment, a doctor, and a nurse right now. What he needs is some sense of responsibility.

Robotic-Assisted Prostate Surgery: An Allegory of Modern Medicine

I like this story about robotic prostate surgery for what it represents. It is a nice allegory for many things in modern medicine: increasing costs, technology fetish, direct-to-consumer marketing, economic incentives that lead to conflicts of interest. Urologists have a fancy new technology to remove prostate cancer, a robot.

Surgeons trained to use this thing and hospitals that purchase it have a big incentive to do robotic-assisted surgeries: they pay more than conventional techniques and the machines cost a whole lot of money.

Patients don't know any better, but hear about the fancy machine and assume it is better. They read stuff on the internet, or even advertising from the (sole) manufacturer of the robots. They want the robot.

But there is no quality data proving that surgery with the robot is better than conventional surgery. It may be, but who knows? For now everyone is rushing for what looks like snake oil.

Paul Krugman is pissed off at conservatives for ignoring the plain and clear evidence regarding the economic catastrophe that started a year ago. He's not the only one; Michael Specter, writer for The New Yorker, has just published a whole book on the issue of American refutation of reason and evidence.

Is this new? Probably not. Ample social science and psychiatric and neuroscience literature supports a view of the human brain as caught between emotion-driven instinct and the so-called higher cognitive powers. There was very likely an evolutionary advantage for our ancestors to act on instinct rather than reason.

But we're not in the Serengeti anymore. It is not entirely consistent with a highly literate, wealthy, democratic nation that has one of the best education systems in the world.

“It is difficult to get a man to understand something when his salary depends on his not understanding it,” Krugman quotes Upton Sinclair. Indeed, the medical corollary to this is "if you are a hammer then everything looks like a nail." To a cardiologist every patient has a heart problem. All you have to do is look.

As any pithy adage, this says a hell of a lot. Fundamentally everything boils down to incentives. Incentives and nothing more. Those may be moral incentives, but most of the time incentives are simply materialistic, especially in our Faith-embracing but spiritually devoid consumerist culture.

Woman loses baby because of .... H1N1 (swine) flu?

A panic inducing article on the h1n1 flu in the NY Times today. Here is but one case of likely millions of people who have contracted so-called swine flu in the US.

27 year old pregnant woman in hospital for months, ICU, ventilator, coma, and lost fetus.

She scoffs at vaccines. Shame on her (although one was not available, she wouldn't have had one). Says they contain "toxins." Shame on her ignorance.

She presented to the ER with an oxygen saturation in her blood of 70%. One would think a pregnant woman with access to the hospital would be a little more vigilant and seek care sooner.

Her father thought her ICU hallucinations indicated the presence of God in her healing. You're flipping kidding me dude. Amazing how religion blinds people from reality. A rational person would conclude the brutal course of illness was a sign from God that this woman was foolish.

A lot of red flags in this story - things that suggest a certain sociological context, rather than flu pathogenicity itself, that make me think this person was at risk for developing severe flu.

http://www.nytimes.com/2009/10/20/health/20pregnant.html?hpw