Where in the World?

As some of you may know, I’m currently spending some of my time as a “locum tenens” physician. What this means is “Rent-a-Doc.” There are any number of agencies out there that recruit physicians for short-term assignments in ER’s across the country, and as one of a relative handful of residency-trained, board-certified emergency physicians I’m fortunate to be a relatively hot commodity. This is why, after posting my resume online a few months ago, I had forty-three different recruiters from thirty-one different agencies (believe me, I counted) all vying to be my new best friend. Nice for your ego, but still you can only tell the same story so many times.

As far as I can tell, job requirements for a physician recruiter include amiability, persistence, and an ability to guilt the recalcitrant physician into working places he or she would never care to go. (See Palms West Hospital, Loxahatchee, Florida). The other thing that’s interesting about the process is that knowledge of geography is apparently not part of the job description. I had stated in my profile that I was interested in jobs in Northeast Florida, within about an hour driving distance from Daytona Beach. As a result of this detailed geographic preference, I have been told of opportunities in Ft. Lauderdale (241 miles), Tallahassee (258 miles), Pensacola (451 miles), Alabama, Indiana, Missouri, and Ohio. But perhaps I’m being harsh. After telling one of the recruiters that Miami (260 miles) was not really worth a daily commute, he honestly admitted, “We’re based in South Florida. We don’t get around very much.”

(Interesting note: If you do a MapQuest search for directions from Daytona Beach to Miami, step 13 notes “Welcome to the UNITED STATES,” which pretty much confirms everything everyone up here north of I-4 always suspected about Miami. And while we’re on the subject, a real geography story. Jim Cramer, an old high school friend, posted on Facebook that the soccer team from The Netherlands had a particularly hard road to the World Cup finals because they had to play two extra games against Holland and the Dutch. I’ve had to explain to any number of folks that it’s all the same place. I was not, however, able to pull off a follow-up story telling the same folks that people from Albania are known as Albinos, although on occasion I have been able to stress that people from Belgium are known as the Belch.)

So if you’re a frustrated physician who’s had a rough few weeks and needs your ego stroked, by all means put your name out there on the internet. It’s amazing what will turn up...and that on closer examination, there’s often no place like home. At least you can find it on a map.

"Strictly Speaking"

(Edwin Newman, the former NBC newsman best known for his insisitence on the proper use of the English language, recently passed away at the age of 91. His most popular written work, "Strictly Speaking: Will America be the Death of English? reached Number 1 in the New York Times Non-Fiction Best Seller List.)

I have been known to take things far too literally. For example, last week I was told by a paramedic that a patient’s chief complaint was “being unresponsive.” I couldn’t help but wonder how you did that. It’s not like you can be comatose, suddenly regain consciousness, politely note, “Pardon me, but I am unresponsive.” It’s one of those questions I didn’t think you could possibly answer with a “yes,” like “Are you asleep?” But I’m always surprised in this line of work, and I have seen patients who, when roused from their substance-induced slumbers and holding a rudimentary knowledge of medical terminology, have angrily reminded me, “WHAT’S WRONG WITH YOU? DIDN’T YOU HEAR THEM? I’M UNRESPONSIVE!”

Here’s another one. A paramedic called in saying the patient has chest pain “times 0600.” Now, I know, and you know, what he really meant. But that’s not what he said. So I figure if the patient has had chest pain x 0600, it must be 0600 times worse than anybody else’s chest pain. (I’m not sure how to multiply that one out.) It’s like when the paramedic finishes his radio report with “Do you questions or orders?” and you ask them to name the capital of North Dakota. They never said it had to be a medical question, right? And I’m proud to note that during my tenure a decade ago as EMS Medical Director for Volusia County, Florida, the Paramedic State Capital Identification Ratio was the highest ever recorded in the illustrious annals of prehospital care.

Finally, on a somber note, someone recently asked me the “signs of suicide.” I gave the answer that was needed about the risk factors for suicide, but inside I was fighting the urge to say, “The only really definitive sign of suicide is being dead.” And years ago, during my life in public health, I recall being asked to attend “a conference on suicide” and wondering, based on the way the question was asked, if we were for or against it.

(While we’ve been talking syntax, let me share with you the single most annoying grammatical error in American popular culture. In the song “I’ll Be There,” young Michael Jackson wails:

“If you should ever find someone new
I know he’d better be good to you.
Cuz’ if he doesn’t
I’ll be there.”

Five extra credit points, and full permission to burn the Mariah Cary version with a butane torch, if you can spot the problem.)

Praying for Safety

Every now and then you see something that may have escaped your notice for years. I had one of those moments at the Orlando Airport this week. It turns out that the airport has a very nice chapel. It’s located after you go through Security, on the side of the airport that leads to Gates 1-60.

I am aware that many different faiths use intermediaries between man and God. Catholics can pray to the saints to be intercessors for them before The Father, and Hindus worship different manifestations of the divine in order to approach him. But I was not aware that in America, one also needs to get through the Transportation Security Agency to get closer to God. And if you’re departing from Gates 61-150, you may as well just surrender to fate.

Also, I don’t know if you’re run into this yet, but the latest annoyance provided by your Transportation Security Agency ("Needless Obstruction Since 2001") is the full body scanner. I ran into this in Kansas City. You walk in between two, large metal towers and are instructed to literally put up your hands in a position of abject surrender. Surrender to the feds. As if the process already wasn’t as intrusive, politically correct, and totally unscientific or efficient as possible. It’s enough to make me want to start drinking tea.

Light My Fire

Last week I saw a woman who had apparently fallen into a campfire at midnight. Arriving in the ER about two in the afternoon, she said she only came in because once she woke up and loked in the mirror, she realized it was kind of bad. (Another testament to the amazing anesthetic powers of alcohol.)

She didn’t need to see anyone immediately…there was very little to be done other than make sure she got the right kind of follow-up…and so while we were finishing up her paperwork, she walked out of the ED saying she needed to smoke a cigarette. No, she was careful to explain, she wasn’t addicted to nicotine. It was a “hand and mouth kind of thing.” Which is good for her, because I thought she was addicted to the flames.

Bathday Perils

Let’s face it…we’re not all neat freaks. While the United States may represent the most overwashed, overshaved, and nit-free society the earth has ever known, there remain significant variations on the theme. It’s not politically correct to say that some patients stink, so we have our own set of euphemisms to describe their condition. Terms like “earth-centered” and “someone really comfortable with themselves” are examples of these covert comments. Over the years I’ve favored noting that someone was “allergic to soap,” conveying the hygiene message in a way that medicalizes the condition to free the patient from confronting their real problem, like we do with other stuff such as fibromyalgia (meaning “depression”) and metabolic syndrome (meaning “fat”).

Recently, though, I’ve had to reassess my use of this phrase. Witness the allergy list on one particularly aromatic patient I saw in a small hospital in Missouri (transcribed verbatim, including spelling):

Allergy on Medicine

Asprin
Pencillion
Demroal
Dervect
Sulfer
Keyflex

Other allergies

Tomatoes
Strawberries
Purex
Dail
Joy
Palmolive
Irish Spring
Milkweed
Wasp, bees, misquites, tick bites
Pine sole

Avoiding hives is the best excuse ever for not washing. I stand, adrenaline in hand, corrected.

Musings at McDonald's

I’m sitting at McDonald’s waiting for the car’s semi-annual wash and detail. I’m trying to write, but without much success, for as far as I can tell the soundtrack playing above my head seems to intersperse “Do You Wanna MAKE LOVE or Do You Just Wanna FOOL AROUND?” in between other, perfectly reasonable songs. I’ll hear Journey sing “Faithfully,” or the perennially underrated Lou Rawls will croon “Lady Love,” and all will be right in the world, and then I’m suddenly back in college and trying to decide exactly where the fine line is between making love and fooling around, and exactly how many Long Island Iced Teas it will take at Harry Starker’s on the Country Club Plaza in Kansas City to get the date d’jour to consider the same question.

Oh, wait, the music just changed. Now they’re playing a medley of tunes…and I use that term metaphorically at best…by Bread. I wonder if I can poke out my brain with a spork?

(Sorry to interrupt, but the corporate lawyers at McDonald’s just called. They would have me remind you a spork must be handled with care in order to prevent injury, that the points are sharp, and that if you have questions about the use of the spork you should ask your wait staff for help, call our customer service number at 1-800-OK-SPORK (and rest assured that “spork” is pronounced the same in Bengali), or review the instructions found at www.bereallyreallyreallycarefulwithyourspork.com. If you have any concerns that are not addressed, DO NOT USE THE SPORK. They would also have me remind you that McDonald’s properties do not actually distribute the spork, but that this utensil is available to the public at Taco Bell, KFC, and other PepsiCo-owned entities, and that the McDonald’s corporation would be happy to provide support for your spork-induced injury suit against these dastardly PepsiCo corporate pirates who put their profit before your health and safety. After all, if they cared about you they’d spend the extra dime and get you a separate fork and spoon, right? Let’s get ‘em!)

World Cup Farewell

(This was written during my self-imposed hiatus, so it's a bit dated. But it does provide important follow-up information...)

One last World Cup note before we tuck away the soccer ball for another four years. Listening to the “play-by-play” announcers for the past four weeks have convinced me once again that American culture, while eminently democratic in appealing to the masses (including me), lacks a sense of refinement and grace. It’s not just that soccer…okay, football…is referred to as “The Beautiful Game,” and it’s not only that you win but you lose points if you don’t do so with style. It’s the use of phrases such as “He performed nobly for his country” after a particulary good defensive play, and the liberal scattering of words like “rarified” and “tenacity.” By way of contrast, an American commentator described World Cup Final as, “like putting a pig on lipstick.” (And while it may not represent culture, nobody does enthusiasm like Andres Cantor, the Univision commentator who says the word

"¡GOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOLLLLLLLLL!"
followed closely by Al Michaels asking, “Do you believe in miracles?” during the 1980 Winter Olympics, Russ Hodges shouting “The Giants win the pennant! The Giants win the pennant!” way back in 1951, or Jeff Spicoli letting us know that “That was my head! I’m so wasted!”

A number of us have decided that we love the pig, however, so we’re already planning to head out to the 2014 World Cup in Brazil. It just looks like so much fun…and we have our own vuvuzelas… that it would be wrong not to go. So we started talking about other places you could have the World Cup, and that maybe we could resolve world issues through soccer. Maybe Israel could hold the World Cup, teams could be based on religious preference, and they could duke it out over Jerusalem as a way of brigning peace to the Holy Land. Personally, if we do it that way, my bets are on the Catholics. They’ve got a drawing pool of Argentina, Brazil, the Guays (Para and Uru), Italy, Spain, and Portugal going for them. Second place would be the hard-working protestants of Northern Europe…the Germans and the Dutch. (I would put the English in this category, but I don’t think there’s anything that can make those folks play together. Divine might only goes so far.)

This idea is similar to something my father came up with many years ago. He noted that virtually every athlete will, at some point, thank heaven for the most recent victory, despite the fact that God, being the author of life, death, and the universe, probably had other things on his mind than bestowing his grace on an NCAA Division III contest. But since every victorious athlete believes that God is on his side, my Dad thought that the best way to sort this out is to have a football bracket similar to March Madness, with all the teams from religion-based colleges included. (No secular humanist powerhouses, like Alabama, Texas, Florida, or Cal-Berkley need apply). That way you get tussles like Baylor at SMU, Brigham Young against TCU, and Notre Dame against Brandeis. The winner would clearly be the team that God really favors in the end.

(Personally, I’m not so sure that God doesn’t pay attention to football. I like to believe that the Lord is a long-time Saints fan…it fits…and maybe he does intervene in miraculous ways. I mean, Peyton Manning throws a last minute interception in the Super Bowl? Peyton Manning? How can you not see divine hands at work here?)

I this idea a lot, and I know my father’s willing to put good money out there on the Disciples of Touchdown Jesus. And I’m pretty sure he’s right. After all, Peyton did throw that interception…

(Here's the updates. Paul the Octopus, the Clairvoyant Cephalopod who correctly predicted the outcome of every World Cup match involving Germany, had died. Viewing was held at the Olive Garden in Munich.

Larissa Riquelme, the Paraguayan lingerie model who pledged to run naked in the streets of Asuncion if the national team won the World Cup final, has not let a loss in the quarters stand in her way. As her tribute to the bold Guyanos, she was pictured in various patriotic poses in the 7th issue of the newspaper Diario Popular. They're quite stirring, and bound to engender a significant amount of national pride. Yep, that's the euphemism we'll use for that.)

Cost Containment

The first health care provider a most patients see in the ED is the Triage Nurse. It’s a pretty challenging role. The nurse out front becomes the face of the ED, not only responsible for making sure that patient and their families feel welcome and cared for, but also for sorting out the wheat from the chaff, the patients with true emergencies from those who are simply hangers-on.

The other day I saw a patient who had presented to the triage nurse with chest pain. As the story goes, she had gotten a case of the munchies that morning and, finding nothing in the icebox box save a package of questionable “Brown ‘n Serve” sausages, she popped one into the microwave for a bite. Following the obligatory “ding” from the Radar Range (I’m showing my age here), she grabbed the casing and shoved it into her gullet. However, she had neglected to wait the recommended three minutes for the sausage to cool, and developed a severe burning discomfort in her lower chest as the wrapped pork shards flamed down her esophagus and into her stomach.

In many hospitals, triage nurses are also responsible for initiating medical care protocols based on the patient’s chief complaint. Doing so often speeds care, especially when physicians are busy and cannot get to the patient to order labs, x-rays, and certain medical treatments within a reasonable time. They’re really a very good way to increase both efficiency and enhance patient care. However, these protocols are blind to circumstances and to costs. Which is why, by the time I got to the patient, she had been subject to a full cardiac workup, including an EKG; a chest x-ray; and a complete laboratory profile including blood count, coagulation studies, chemistry panels, and enzyme studies to look for evidence of heart damage. I have no idea how much all that cost the taxpayers, because Lord knows this patient is not paying her own bill.

Being the doctor, who works off no set protocol other than the 10% of medicine that is science, the 30% that is common sense, and the 60% that is voodoo, my workup cost the taxpayers less than a dollar. It was called a cold can of Sprite.

Problem solved.