tag:blogger.com,1999:blog-35948813157788519642024-03-13T13:34:12.024-04:00Writing with ScissorsWriting with Scissors is the blog site of Howard Rodenberg, MD MPH, former Kansas State Health Director and columnist for the Journal of Emergency Medical Services (JEMS). He is a father, emergency physician, and slightly-past-fifty curmudgeon with great hair for his age. The "scissors" in question refer to those used by editors to weed out all things opinonated, controversial, or politically inappropriate...translated as "anything funny."Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.comBlogger255125tag:blogger.com,1999:blog-3594881315778851964.post-77505684651442031552021-08-08T20:14:00.002-04:002021-08-08T20:15:32.031-04:00My Eyeball Story<p>This week I
had cataract surgery on my left eye. It’s my second round; the right eye got done
three years ago, and the original plan was that I would get the left one done a
few weeks later. What took three
years? I hate change. It’s the same reason I still drive a beat-up
SAAB that sometimes gets standing water in the footwells and smells like it
needs to get dunked in a vat of fluconazole, and why I truly believe that there
has been no new music created since “Love Shack” in 1989. Plus I was consistently amused by the fact
that I saw two different color spectra between both eyes, such that sometimes I
would sit in the supermarket parking lot looking out from the car, winking one
eye and then another like a railroad crossing just for the effect, until the
puzzled stares of the Cart Cowboys interrupted my reverie. But when the cataract gets so bad that you
miss the end of the suture, you can only blame it on the patient moving so many
times.</p>
<p class="MsoNormal"><span style="line-height: 107%;">I should mention
at this juncture that I’m gun shy about doctors, and ophthalmologists are no
exception.<span style="mso-spacerun: yes;"> </span>It’s because I know at least
one person of any given specialty found on the floor after a medical school
party.<span style="mso-spacerun: yes;"> </span>So when I think of
ophthalmologists, I think of them not as a fine clinicians, but as guys
hoisting themselves up on the rim of the toilet, a scalpel in one hand and a
bottle of vodka in the other.<span style="mso-spacerun: yes;"> </span>I was also
afraid that this particular ophthalmologist, who by all indications is an
excellent citizen, holds grudges.<span style="mso-spacerun: yes;"> </span>Apparently
last time I was sedated, I got kind of mouthy and suggested he had an unnatural
relationship with his mother.<span style="mso-spacerun: yes;"> </span>That’s
probably not a good look.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">(My
reactions under sedation also bode poorly for me if I ever get any frontal lobe
dysfunction.<span style="mso-spacerun: yes;"> </span>I’ve always been of the
opinion that when you lose frontal lobe regulation of your behaviors…be it from
acute encephalopathy, stroke, or dementia…you become more of the person you really
are.<span style="mso-spacerun: yes;"> </span>So those people we think of as
“pleasantly demented” are truly nice people at heart.<span style="mso-spacerun: yes;"> </span>For me, well, it looks like I may as well be
a Haldol drip on the GeriPsych Unit.<span style="mso-spacerun: yes;"> </span>But
on a positive note, the ophthalmologist did note that at age 58, I was
considered part of his “pediatric population.”<span style="mso-spacerun: yes;">
</span>So there’s that.)<o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">I spent the
few days before surgery reminding myself, and especially the Beloved Dental
Empress, that whatever I saw or did, it might be the last time before I
died.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">“Look at me,
I’m holding the puppy. This might be the last time I do this before I die.”<o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">“You’ll be
fine.”<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="mso-spacerun: yes;"> </span>“Look, I’m doing the dishes totally
unpromoted.<span style="mso-spacerun: yes;"> </span>I want you to have a final memory
of me doing my share of the housework before I die.”<o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">“You’ll be
fine.”<span style="mso-spacerun: yes;"> </span>She’s having none of this.<span style="mso-spacerun: yes;"> </span>Her gaze is fixed on the Facebook page for
Mommy Dentists in Business.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">Maybe
something romantic would do the trick.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>“Okay, maybe I won’t die, but this might be
the last time I gaze upon your beauty with both eyes before they rip one out.”<o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">“You’ll be
fine.”<span style="mso-spacerun: yes;"> </span>And then she said I was being
dramatic.<span style="mso-spacerun: yes;"> </span>Imagine that.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">(Did I
mention that I saw one of our closest friends, who happens to be in the same ophthalmology
practice, the day before?<span style="mso-spacerun: yes;"> </span>Told him his
partner was going to rip out my eyeball the following day.<span style="mso-spacerun: yes;"> </span>“Well, good luck with that,” he said
cheerily.<span style="mso-spacerun: yes;"> </span>“You know once we take it out
we don’t put it back.”)<o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">The last
thing I saw the night before surgery was half an episode of the Real Housewives
of Salt Lake City, so I really hoped I wouldn’t die, because a forest of duck
lips would be an awful thing to have burned into your retina for all eternity.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">At 9:15 the
next morning, I marched into the Surgery Center.<span style="mso-spacerun: yes;"> </span>I was wearing scrub pants and a sweatshirt
that said “I Dream Of A Society Where Chickens Can Cross the Road Without
Having It’s Motives Questioned.”<span style="mso-spacerun: yes;"> </span>I
figured if I died, the guys who transport the body may as well get a laugh out
of it.<span style="mso-spacerun: yes;"> </span>That’s me, always thinking of
others.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><o:p>********** </o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">The Surgery
Center itself was pretty slick. It was almost like Disney, where if the Carousel
of Progress stops, it starts up again at the very word they left off no matter
how long the outage.<span style="mso-spacerun: yes;"> </span>The nurses have
their routines memorized to the point where if you interrupt their patter, they
simply push their internal play button and resume talking.<span style="mso-spacerun: yes;"> </span>They put a “safety dot” over the eye that’s
going to be worked on, then get you to lay down the cot, start an IV, have
three rounds of eye drops, and cover you with a blanket up to the neck like
every sci-fi movie you’ve ever seen.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">After a few
moments of either quiet mediation or abject terror…you make the call…another
nurse comes by and takes you to the Laser Room, and now you’re thinking the
Laser Room in Goldfinger, which is why this is when they give you the first zap
of Versed.<span style="mso-spacerun: yes;"> </span>Then the ophthalmogist comes
by and draws something with a pen on your eyeball (probably some version of an
arrow that says “cut here”), and now the Versed kicks in, and you seem to
recall a discussion about someone confessing to a murder under sedation.<span style="mso-spacerun: yes;"> </span>Then I’m looking at a ring of six lights, and
the Star Trek nerd in me wants to shout “THERE ARE FOUR LIGHTS!” I recall
seeing some pink stuff being moved around my eye against a yellow background, and
then I’m being helped off the stretcher and into a chair behind a small wall to
hide the post-op people from the pre-op crowd so the latter don’t run off
scared.<span style="mso-spacerun: yes;"> </span>Then I’m drinking a mini can of
Coke from a paper straw (Save the Planet!) and then I’m in my bed with no idea
how I got there.<o:p></o:p></span></p><p class="MsoNormal"><span style="line-height: 107%;">***********</span></p>
<p class="MsoNormal"><span style="line-height: 107%;">We know that
work tends to be a family, mostly because nobody else knows what you do and
you’ve got to talk to someone.<span style="mso-spacerun: yes;"> </span>So when I
got home, as a courtesy to my friends and colleagues I texted:<o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">“nor dead
cant spell love Versed lors”<o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">(The one
word I got right was Versed.<span style="mso-spacerun: yes;"> </span>That
suggests some kind of pathology, right?)<o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">**********</span></p><p class="MsoNormal"><span style="line-height: 107%;">The rest of
the day was admittedly a blur.<span style="mso-spacerun: yes;"> </span>What I do
know is that I tried to be a good patient.<span style="mso-spacerun: yes;">
</span>I was docile and well-behaved.<span style="mso-spacerun: yes;"> </span>I
took my eye drops at the right times, took my Advil and Tylenol, and stayed in
bed.<span style="mso-spacerun: yes;"> </span>For her part, I recall the Empress
as a benevolent presence.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>This must have been difficult for her.<span style="mso-spacerun: yes;"> </span>Did I mention that she’s a dentist?<span style="mso-spacerun: yes;"> </span>And she and I have discussed the need for her
to attend Consolation 101.<span style="mso-spacerun: yes;"> </span>Until
recently her best gesture of sympathy was a gentle whack on the scalp and an
inquiry as the soothing nature of the blow.<span style="mso-spacerun: yes;">
</span>It’s a work in progress. <o:p></o:p></span></p>
<p class="MsoNormal">Which led to
this morning, post-op day #1. I was
feeling well enough to get up and fix the morning brews.</p>
<p class="MsoNormal"><span style="line-height: 107%;">“No, I’ll do
it,” she offered.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">“It’s really
no problem.”<span style="mso-spacerun: yes;"> </span>I’m perpetually helpful
that way.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">“I WANT TO
BE CARING.”<o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">Part of me
wanted to ask what kind of Shih Tzu of Altruism had seized her brain and shook
until the compassion came loose.<span style="mso-spacerun: yes;"> </span>But
then I realized that my query would probably get me punched in the eyeball or,
as Ron Burgundy says, in the ovary, even though I haven’t got an ovary, because
dentists really don’t know who’s got what anywhere below the mandible.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="line-height: 107%;">So our
lesson today is that when someone wants to be caring, it’s probably best not to
question why. Especially when there’s
firearms in the house, and only she knows where they are. At least she thinks the new reading glasses
from the Dollar Store are cute. Small
victories when you can find them.<span style="font-size: 24pt;"><o:p></o:p></span></span></p>Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com0tag:blogger.com,1999:blog-3594881315778851964.post-323862758512271632018-07-01T05:50:00.003-04:002018-07-01T05:50:19.958-04:00What's the Good Word?
<br />
<div style="margin: 0in 0in 10pt;">
<a href="https://www.blogger.com/null" name="_GoBack"></a><span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;"><em>(Here's another missive from CDI land, in which I get to use The Osmonds, Diane Rheim, Gal Gadot, Ed McMahon, and testicles in the same article.)</em></span></span><div style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><br /></span></div>
<span style="font-family: Calibri;"><span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">We’re all about language in CDI World, which is probably why
I fit in.<span style="mso-spacerun: yes;"> </span>I’ve always been kind of a
Vocabulary Nerd, with an occasional spell of Grammar Guy thrown in for good
measure.<span style="mso-spacerun: yes;"> </span>This is why the song “I’ll Be
There” by the Jackson Five.<span style="mso-spacerun: yes;"> </span>If you know
the song, you’ll recall that twelve-year old Michael Jackson croons in his most
plaintive pre-pubescent voice:</span></span></span><br />
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">“If you
should ever find someone new,</span></span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">I know he’d
better be good to you.</span></span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">“Cuz if he
doesn’t</span></span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">I’ll be
there.”</span></span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">It’s a great
sentiment, right?<span style="mso-spacerun: yes;"> </span>Because if your new
boyfriend is mean to you, you’ll want to fall back on a guy whose closest
companion for years was a chimp named Bubbles (who is, according to Wikipedia,
now living a quiet life at the Center for Great Apes in Wachula, Florida, where
he is said to “enjoy painting and listening to flute music”).<span style="mso-spacerun: yes;"> </span>But it’s horrible grammar.<span style="mso-spacerun: yes;"> </span>There’s no way to doesn’t is a form of the
verb “is” or means “to be.”<span style="mso-spacerun: yes;"> </span>If he isn’t
good to you, that’s one thing.<span style="mso-spacerun: yes;"> </span>But if he
doesn’t?<span style="mso-spacerun: yes;"> </span>You should stay away from
Michael as well, if he can’t figure out why that sentence is so very wrong.</span></span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">(On the
music front, Vocabulary Nerd admits to a certain admiration for The Osmonds,
who managed to fit the word “facsimile” into their ballad “Love Me for a
Reason,” though Grammar Guy notes it was followed by a dangling
participle.<span style="mso-spacerun: yes;"> </span>You learn to take the good
with the bad.<span style="mso-spacerun: yes;"> </span>Plus they’ve got great
teeth.)</span></span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">Here’s a
language thing a little closer to home.<span style="mso-spacerun: yes;">
</span>As all of us in CDI know, specificity is our friend.<span style="mso-spacerun: yes;"> </span>That being said, coding rules recognize that
things in medicine are not always cut and dried, and that there is significant
fuzziness in everything we do.<span style="mso-spacerun: yes;"> </span>We don’t
always know what’s causing a problem, but we can make pretty good guesses.<span style="mso-spacerun: yes;"> </span>So the Rules of the Game allow a clinician to
use words like probably, likely, and possibly to describe what they think
underlies and clinical problem even if they don’t know for sure.</span></span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">There’s a
little bit of hair to be split here, however.<span style="mso-spacerun: yes;">
</span>(Not mine, in which case there’s a lot.)<span style="mso-spacerun: yes;">
</span>My colleague Dr. Douglas Campbell notes that we really should not use
the word “possible.”<span style="mso-spacerun: yes;"> </span>His contention is
that you should have at least a 51% chance of being right before being certain
enough to code a clinical diagnosis as being present.<span style="mso-spacerun: yes;"> </span>So if “probably” and “most likely” suggests
that level of certainty, words like “possible” that suggests less than a 50%
chance of being right shouldn’t be used.<span style="mso-spacerun: yes;">
</span>After all, anything is possible.<span style="mso-spacerun: yes;">
</span>There’s a zero point zero zero zero zero zero zero zero one chance that
both Gal Gadot and Ed MacMahon will appear at my front door tomorrow with a
check from Publisher’s Clearinghouse.<span style="mso-spacerun: yes;">
</span>(Even less so now that Ed’s dead.)<span style="mso-spacerun: yes;">
</span>So how can you code with certainty anything that’s less than halfway
likely?<span style="mso-spacerun: yes;"> </span>Or, as Dr. Campbell put it:</span></span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">“See that
three-day-old taco sitting on your desk? I’d possibly eat it, but I probably
wouldn’t.”</span></span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">The clinical
term that always drove me nuts was “appreciate.”<span style="mso-spacerun: yes;"> </span>In medical school we were told that we
appreciated a heart murmur or some other physical finding.<span style="mso-spacerun: yes;"> </span>But did we really?<span style="mso-spacerun: yes;"> </span>According to definition, if you appreciate
something you “recognize the full worth of” or “are grateful for”
something.<span style="mso-spacerun: yes;"> </span>So who really appreciates a
murmur?<span style="mso-spacerun: yes;"> </span>I have heard a lot of heart
murmurs, but I have never appreciated one.<span style="mso-spacerun: yes;">
</span>I have never been so moved by the whoosh of some blood fighting its’ way
through a narrowed channel, nor by the splash of plasma thudding back into the
chamber from whence it came.<span style="mso-spacerun: yes;"> </span>I have yet
to recognize the full worth of a mid-systolic breeze, to completely and utterly
envelop myself in the moment.<span style="mso-spacerun: yes;"> </span>I have
never called my parents to relate the experience to them, have never pulled a
sweetheart aside and, in a tender moment, told her that while I have absorbed
the full value of the murmur it’s significance is nothing compared to my love
for her.<span style="mso-spacerun: yes;"> </span>Nor have I been uniformly
grateful for the opportunity to listen to a murmur, not for the career in
medicine, not even for the trust of the patient in permitting the intimacy of
the physical exam…no, I’m usually just trying to figure out what it is I’m
hearing because my cochlea have been poisoned by years of monitors with
alarms<span style="mso-spacerun: yes;"> </span>and bells and from listening to
Diane Rheim on NPR, and I’m also trying to figure how just how close I have to
be to hear anything if the patient is hygiene-challenged.<span style="mso-spacerun: yes;"> </span>We should not say we appreciate heart murmurs
unless we really mean it.<span style="mso-spacerun: yes;"> </span>We don’t.<span style="mso-spacerun: yes;"> </span>Just stop. </span></span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">(Two, four,
six, eight, what do we appreciate?<span style="mso-spacerun: yes;">
</span>Aortic Stenosis!” exclaims the Cardiac Cheerleader, pom-poms flying in
the Cath Lab.)<span style="mso-spacerun: yes;"> </span></span></span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">(Speaking of
things that drive me nuts, many of you are probably familiar with
voice-activated dictation programs such as DragonSpeak.<span style="mso-spacerun: yes;"> </span>One of the quirks of these programs is that
every clinician seems to have words they slur or accent or are otherwise
incomprehensible to the program.<span style="mso-spacerun: yes;"> </span>There
are two words of mine that seem to particularly vex the Dragon.<span style="mso-spacerun: yes;"> </span>The first is “hospitalist,” which the Dragon
keeps thinking is “hospice,” and given that a lot of patients admitted to the
hospitalist probably need hospice this may be therapeautic guidance.<span style="mso-spacerun: yes;"> </span>The other is cardiovascular, which every computer-aided
dictation program I’ve ever used seems to think is “testicular.”<span style="mso-spacerun: yes;"> </span>So there’s no telling how many female
patients in my career have had testicular exams which revealed a regular rate
and rhythm without murmur.<span style="mso-spacerun: yes;"> </span>Nuts.)</span></span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">The
glamorous process of CDI chart review has added another term to my List of
Infamy.<span style="mso-spacerun: yes;"> </span>It’s the word “endorse.”<span style="mso-spacerun: yes;"> </span>Have you seen this in your shop?<span style="mso-spacerun: yes;"> </span>Apparently the new trend is to say that “the
patient endorses shortness of breath and a history of CHF” instead of saying
the patient has or said it.<span style="mso-spacerun: yes;"> </span>I have no
idea where this comes from, because when I look up the definition of “endorse”
it goes something like this:<span style="mso-spacerun: yes;"> </span></span></span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">1.<span style="mso-tab-count: 1;"> </span>“To declare one’s public approval or
support”, or</span></span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">2.<span style="mso-tab-count: 1;"> </span>To sign a check or bill of exchange to
make it payable, or to accept responsibility for paying for it.</span></span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">So when the
patient “endorses” a history of shortness of breath and CHF, we might assume
they are showing approval or support.<span style="mso-spacerun: yes;"> </span>“I
LOVE my CHF!<span style="mso-spacerun: yes;"> </span>Best pulmonary edema
ever!<span style="mso-spacerun: yes;"> </span>I’ve got cardiomegaly!<span style="mso-spacerun: yes;"> </span>HUGE cardiomegaly!<span style="mso-spacerun: yes;"> </span>Bigger than China!<span style="mso-spacerun: yes;"> </span>And my love my BNP…five figures!<span style="mso-spacerun: yes;"> </span>My ejection fraction is so bad it’s the best
of the worst!<span style="mso-spacerun: yes;"> </span>Isn’t my LifeVest great!<span style="mso-spacerun: yes;"> </span>Admit me for a little dobutamine and we’ll
Make My Heart Great Again!<span style="mso-spacerun: yes;"> </span>You should
get some CHF too!<span style="mso-spacerun: yes;"> </span>And I‘m paying my own
bill!”</span></span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">Come to
think of it, that sounds familiar.<span style="mso-spacerun: yes;"> </span>Wish
I could place it.<span style="mso-spacerun: yes;"> </span>Must be somewhere in
that chart…</span></span></div>
</div>
Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com0tag:blogger.com,1999:blog-3594881315778851964.post-37818570825833280142018-06-23T05:41:00.000-04:002018-07-01T05:51:20.512-04:00Brief Thoughts<br />
<div style="margin: 0in 0in 8pt;">
<span style="font-family: "calibri";"><span style="font-family: Times, "Times New Roman", serif;">In my middle age I find myself paying an undue amount of attention
to my groin. It's not that it didn't command my admiration and respect in my
younger days. <span style="mso-spacerun: yes;"> </span>Back then, it was more of
a use or lose it kind of thing, the nether id screaming out for activity, to
burst free from the suppressive superego that‘s my Hebraic legacy.<span style="mso-spacerun: yes;"> </span>(This is a polite way of saying I wanted to
be a man whore, as all honest men will confess to be their dream job, at least
until they discover the joy of a committed relationship, the wasteland of
divorce, or the burning sensation of...well, you get the picture.) <span style="mso-spacerun: yes;"> </span>But now it's a more subtle, varied
relationship, made full by the maturity of years and the fact that you buy “Dad
Pants” on purpose because you treasure the space.<span style="mso-spacerun: yes;"> </span></span></span></div>
<span style="font-family: Times, "Times New Roman", serif;"></span><br />
<div style="margin: 0in 0in 8pt;">
<span style="font-family: Times, "Times New Roman", serif;">The latest groin-centered experience (outside of a committed
relationship, of course) occurred when I heard a radio commercial for Tommy
John underwear.<span style="mso-spacerun: yes;"> </span>If that name seems
familiar, it’s probably because you’ve seen it in the sports pages. Tommy John
was a pitcher for the Dodgers who suffered an elbow injury and was treated with
a new kind of surgery that now bears his name.<span style="mso-spacerun: yes;">
</span>Alas, the Tommy John of baseball is not the same Tommy John of
underwear, which deprives the brand of a useful symmetry of things you can do
with your hand and arm:<span style="mso-spacerun: yes;"> </span>Pitch
and…well…pitch.</span></div>
<span style="font-family: Times, "Times New Roman", serif;"></span><br />
<div style="margin: 0in 0in 8pt;">
<span style="font-family: Times, "Times New Roman", serif;">Underwear had never really been much of a force in my
life.<span style="mso-spacerun: yes;"> </span>As a kid, you wore underwear with
fun designs until you switched to boxers as things expanded and (hopefully) needed
more room. <span style="mso-spacerun: yes;"> </span>And that’s pretty much where
it stays.<span style="mso-spacerun: yes;"> </span>It’s not like women’s
lingerie, where the moderately attractive can become alluringly hot through the
art of selective concealment.<span style="mso-spacerun: yes;"> </span>With guys,
there’s no way to conceal anything (and no, a Speedo is nothing more than an
abomination of nature), which is if a guy wants to look hot he has to dress up
so that everything, even the back hair, becomes nothing but a dream.</span></div>
<span style="font-family: Times, "Times New Roman", serif;"></span><br />
<div style="margin: 0in 0in 8pt;">
<span style="font-family: Times, "Times New Roman", serif;">Anyway, according to the ad, Tommy John underwear has a
variety of notable features.<span style="mso-spacerun: yes;"> </span>The one
that piqued my attention was the quick-draw horizontal fly.<span style="mso-spacerun: yes;"> </span>Personally, I’m not quite sure how horizontal
equals quick draw.<span style="mso-spacerun: yes;"> </span>The...ummm...generative
organs are aligned on the vertical (the midline sagittal plane, if you must
know), so it would make sense to align your access on the same plane. You need
access, it’s right there waiting for you.<span style="mso-spacerun: yes;">
</span>The few times I've worn things with a horizontal fly, access usually
becomes something of a fishing expedition because the point of grasp is usually
beneath the opening slit. <span style="mso-spacerun: yes;"> </span>If this occurs
in a public place, it undoubtedly looks to others as if you’re simply having
way too much fun in the excretory endeavor. </span></div>
<span style="font-family: Times, "Times New Roman", serif;"></span><br />
<div style="margin: 0in 0in 8pt;">
<span style="font-family: Times, "Times New Roman", serif;">But I'm also confused by the necessity of the quick-draw fly.<span style="mso-spacerun: yes;"> </span>It would seem to me if you need it that
quick, the moment has already passed. <span style="mso-spacerun: yes;"> </span>To
me, the concept of quick draw implies whipping it out for a quick shot, like your
own personal Wild West single-barrel rifle (or pistol, or derringer, or cap
gun, as the case may be).<span style="mso-spacerun: yes;"> </span>But if you
need to get it out that quickly before the mood goes away, that doesn't say a lot
for the mood to start with; and if you need to get it out that quickly after
hearing the word "draw" before the shots are fired, <span style="mso-spacerun: yes;"> </span>that’s a Little Blue Pill issue that no
underwear can solve.</span></div>
<span style="font-family: Times, "Times New Roman", serif;"></span><br />
<div style="margin: 0in 0in 8pt;">
<span style="font-family: Times, "Times New Roman", serif;">Now back to your regularly scheduled blog.</span></div>
Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com0tag:blogger.com,1999:blog-3594881315778851964.post-64082759321959106902018-06-08T23:43:00.001-04:002018-06-08T23:45:09.220-04:00Scamper and Flit<br />
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<span style="font-size: 12pt; line-height: 107%;"><em><span style="font-family: "times" , "times new roman" , serif;">(Why can't anyone in Coding World get doctors to say what they mean? It has to do with our nuts.)</span></em></span></div>
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<span style="font-size: 12pt; line-height: 107%;"><span style="font-family: "times" , "times new roman" , serif;"><br /></span></span></div>
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<span style="font-family: "times" , "times new roman" , serif;">
<span style="font-size: 12pt; line-height: 107%;">Everyone’s
probably seen the literature rack at the “Welcome Center” between one state and
the next.<span style="mso-spacerun: yes;"> </span>These are those small wooden
fixtures containing stack upon stack of neatly slotted tourist brochures designed
to lure the traveler into making just one more stop to see the pride of (fill
in the name of your small town here).<span style="mso-spacerun: yes;">
</span>Picking up these brochures has long been an addiction of mine, and
there’s a whole tote bag in my bedroom closet full of information about sites I
have yet to see.<span style="mso-spacerun: yes;"> </span>I figure I’ve got about
15 years before someone calls Hoarders and puts me on TV.</span></span></div>
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<span style="font-family: "times" , "times new roman" , serif;">
</span></div>
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<span style="font-size: 12pt; line-height: 107%;"><span style="font-family: "times" , "times new roman" , serif;">So this is
how I knew that I needed to stop one day in Greenville, Illinois, and take a
selfie next to the World’s Largest Golf Tee.<span style="mso-spacerun: yes;">
</span>Why WaKeeney, Kansas, is the Christmas City of the Plains.<span style="mso-spacerun: yes;"> </span>Why Clark’s Fish Camp in Jacksonville houses
the Nation’s Largest Private Taxidermy Collection.<span style="mso-spacerun: yes;"> </span>And why I know about the White Squirrels of
Olney, Illinois.</span></span></div>
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<span style="font-family: "times" , "times new roman" , serif;">
</span></div>
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<span style="font-size: 12pt; line-height: 107%;"><span style="font-family: "times" , "times new roman" , serif;">(For the
record, the Olney brochure was picked up at the Beef House in Covington, Indiana,
where my extended family went this summer after one of the most delightful
funerals I’ve ever attended.<span style="mso-spacerun: yes;"> </span>It’s just outside
of Danville on Interstate 74.<span style="mso-spacerun: yes;"> </span>Ask for
the yeast rolls.)</span></span></div>
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<span style="font-family: "times" , "times new roman" , serif;">
</span></div>
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<span style="font-size: 12pt; line-height: 107%;"><span style="font-family: "times" , "times new roman" , serif;">I bring up
squirrels because I recently had occasion to use the term in the context of CDI.<span style="mso-spacerun: yes;"> </span>I was involved in a discussion about using
CMI data on individual physicians to “call them out” on their performance.<span style="mso-spacerun: yes;"> </span>As a CDI person, I know why this could be
important.<span style="mso-spacerun: yes;"> </span>If you have physicians who
consistently underperform, it may be helpful to confront them individually, either
privately to let them know you’re watching, publicly to utilize peer pressure,
or with their supervisor to use third party influence to achieve CDI
goals.<span style="mso-spacerun: yes;"> </span>All of these are laudable and
perfectly acceptable ways to address individual physician deficiencies.<span style="mso-spacerun: yes;"> </span>(They will all also annoy the very physicians
you’re trying to influence, but the decision to “call out” individual providers
is a philosophical decision each CDI program makes for itself.)</span></span></div>
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<span style="font-family: "times" , "times new roman" , serif;">
</span></div>
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<span style="font-size: 12pt; line-height: 107%;"><span style="font-family: "times" , "times new roman" , serif;">From the
physician side, however, our first reaction is to turn into a squirrel.<span style="mso-spacerun: yes;"> </span>Marlin Perkins and Mutual of Omaha know that
squirrels scamper.<span style="mso-spacerun: yes;"> </span>They avoid, dodge,
evade, and run for cover.<span style="mso-spacerun: yes;"> </span>And when
cornered, they give you a look so gosh-darned cute you simply can’t hit them
with a bat no matter how times they’ve raided your bird feeder.<span style="mso-spacerun: yes;"> </span>And when confronted with adverse information
about themselves, doctors squirrel.</span></span></div>
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<span style="font-family: "times" , "times new roman" , serif;">
</span></div>
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<span style="font-size: 12pt; line-height: 107%;"><span style="font-family: "times" , "times new roman" , serif;">This
behavior, of course, is not unique to doctors.<span style="mso-spacerun: yes;">
</span>Every two-year-old knows how to do this, and is way better at it than
adults because they can really work the cute.<span style="mso-spacerun: yes;">
</span>But doctors are simply better at it, because we’ve been taught to do so
in medical training as a way to avoid confrontation or being caught in the
wrong, we have the intellectual heft to pull it off, and we’ve been doing it
our entire professional life.</span></span></div>
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<span style="font-family: "times" , "times new roman" , serif;">
</span></div>
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<span style="font-size: 12pt; line-height: 107%;"><span style="font-family: "times" , "times new roman" , serif;">Let me give
you an example from my own experience.<span style="mso-spacerun: yes;"> </span>I’m
an ED doc by trade and training, and I’ve sometimes been on the wrong end of
those time studies looking at patient throughput.<span style="mso-spacerun: yes;"> </span>My times were longer than the mean; in fact,
close to the bottom of the group.<span style="mso-spacerun: yes;"> </span>So what
happened?<span style="mso-spacerun: yes;"> </span>Did I take it to heart and
resolve to change my ways?<span style="mso-spacerun: yes;"> </span>Did I take a
serious look at my practice style and gratefully acknowledge the input of my
health care colleagues, especially those who issue the mandates but cannot
actually do my job?</span></span></div>
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<span style="font-family: "times" , "times new roman" , serif;">
</span></div>
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<span style="font-size: 12pt; line-height: 107%;"><span style="font-family: "times" , "times new roman" , serif;">Of course
not.<span style="mso-spacerun: yes;"> </span>I squirreled.<span style="mso-spacerun: yes;"> </span></span></span></div>
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<span style="font-family: "times" , "times new roman" , serif;">
</span></div>
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<span style="font-size: 12pt; line-height: 107%;"><span style="font-family: "times" , "times new roman" , serif;">“Thanks for
the information.<span style="mso-spacerun: yes;"> </span>I’ve taken a look and I
have some thoughts.<span style="mso-spacerun: yes;"> </span>First, I work all
nights.<span style="mso-spacerun: yes;"> </span>As you know, there are no midlevel
providers at night.<span style="mso-spacerun: yes;"> </span>As a result, every
doctor has relatively more patients to see per provider, and it’s well known
that the more patients you’re caring for at any one time the more time it takes
to care for each.<span style="mso-spacerun: yes;"> </span>You’ll notice the data
shows that all of us night shift doctor times are longer than the day shift people.<span style="mso-spacerun: yes;"> </span>You’ll also notice that when I do get to the
patient, I see them faster than anyone else on night sift.<span style="mso-spacerun: yes;"> </span>That’s because instead of signing in for the patient
when they get placed in a room, I don’t do it until I actually see them to
avoid any errors in orders or documentation in the interest of patient
safety.<span style="mso-spacerun: yes;"> </span>(That phrase <i style="mso-bidi-font-style: normal;">always</i> gets you off the hook.)<span style="mso-spacerun: yes;"> </span>And as I’m sure you know (you have to throw
in at least a sentence or two of “collegial language”), patient flow in the ER is
non-linear, so the fact that patients come in as a bolus in late afternoon and
early evening rather then presenting to an empty ER early in the morning may
skew the data as well.<span style="mso-spacerun: yes;"> </span>Thanks again for
the note, and I look forward to continuing our efforts in patient care.”<span style="mso-spacerun: yes;"> </span></span></span></div>
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<span style="font-family: "times" , "times new roman" , serif;">
</span></div>
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<span style="font-size: 12pt; line-height: 107%;"><span style="font-family: "times" , "times new roman" , serif;">I never heard
anything again, and several months later they dropped the measurement altogether.<span style="mso-spacerun: yes;"> </span>I imagine that I wasn’t the only squirrel in
the forest.</span></span></div>
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<span style="font-family: "times" , "times new roman" , serif;">
</span></div>
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<span style="font-size: 12pt; line-height: 107%;"><span style="font-family: "times" , "times new roman" , serif;">So if you’re
going to call out physicians, you have to be prepared for this.<span style="mso-spacerun: yes;"> </span>They will find reasons to prove that you’re
wrong, and you have to realize that sometimes they might actually be
right.<span style="mso-spacerun: yes;"> </span>For example, let’s talk about an
orthopedic surgery group.<span style="mso-spacerun: yes;"> </span>The metrics of
some doctors look great, with high CMI’s; the CMI of others is much lower.<span style="mso-spacerun: yes;"> </span>Call out the slackers, right?<span style="mso-spacerun: yes;"> </span></span></span></div>
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<span style="font-family: "times" , "times new roman" , serif;">
</span></div>
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<span style="font-size: 12pt; line-height: 107%;"><span style="font-family: "times" , "times new roman" , serif;">But not so
fast.<span style="mso-spacerun: yes;"> </span>What kind of procedures do the
lower performers do?<span style="mso-spacerun: yes;"> </span>If the higher CMI guys
do hips and the lower folks do shoulders, they’re not really lower at all; they
just have different patient populations.<span style="mso-spacerun: yes;">
</span>The same can be said of a hospitalist who works nights and mostly does
admits with only the rare discharges.<span style="mso-spacerun: yes;">
</span>How about a cardiologist who does few admits but mostly consults?<span style="mso-spacerun: yes;"> </span>The surgeon who doesn’t do his or her documentation
but has the midlevel provider do it for them?<span style="mso-spacerun: yes;">
</span>What does his or her CMI actually mean?</span></span></div>
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<span style="font-family: "times" , "times new roman" , serif;">
</span></div>
<div style="margin: 0in 0in 8pt;">
<span style="font-size: 12pt; line-height: 107%;"><span style="font-family: "times" , "times new roman" , serif;">So how can
you make sure that your “call-out” is really valid?<span style="mso-spacerun: yes;"> </span>First, you need to make sure the patient populations
are roughly the same.<span style="mso-spacerun: yes;"> </span>You can probably
do some fair comparisons on adult and pediatric hospitalists, as with decent volumes
you would think that the “luck of the draw” would give you roughly equivalent groups.<span style="mso-spacerun: yes;"> </span>But on the surgical side that’s harder to do,
especially if you have only one or two <span style="mso-spacerun: yes;"> </span>physicians who do a certain procedure at your
hospital.<span style="mso-spacerun: yes;"> </span>Having tools that provide some
peer cohort facility measurements can be helpful as well, but be aware that the
squirrels will still find ways to gnaw away at the acorn of data.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span></span></span></div>
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<span style="font-family: "times" , "times new roman" , serif;">
</span></div>
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<span style="font-size: 12pt; line-height: 107%;"><span style="font-family: "times" , "times new roman" , serif;">You’ll also
need to make sure that the documentation is really under the control of the
physician.<span style="mso-spacerun: yes;"> </span>I say this fully cognizant
that from a coding view the physician is clearly the one on the line.<span style="mso-spacerun: yes;"> </span>But in reality, much of inpatient
documentation may be done by midlevel providers, and the physician simply adds
an attestation and signs off on the note.<span style="mso-spacerun: yes;">
</span>In an ideal world the doc would review every notation with a nit comb,
but it simply doesn’t happen.<span style="mso-spacerun: yes;">
</span>(Procedures make money, not post-op notes.)<span style="mso-spacerun: yes;"> </span>So be prepared for the squirrel that says
documentation is the midlevel’s problem, and rather than give a correction
offer to extend your educational efforts accordingly.</span></span></div>
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<span style="font-family: "times" , "times new roman" , serif;">
</span></div>
<div style="margin: 0in 0in 8pt;">
<span style="font-size: 12pt; line-height: 107%;"><span style="font-family: "times" , "times new roman" , serif;">Another trap
to avoid is looking at short-term data.<span style="mso-spacerun: yes;">
</span>There’s a virtual cornucopia of factors that can impact physician
documentation, such as vacation, sick call, seasonal variations in patient
populations, and simple physician fatigue.<span style="mso-spacerun: yes;">
</span>I believe that a full three months of data is the minimum you should use
to evaluate physician performance, but the more data you have, biannually or
even yearly, the more reliable your trends will be.<span style="mso-spacerun: yes;"> </span>More data over longer time frames adds
validity to to your interpretations and tends to defuse some of the firestorms
that result.<span style="mso-spacerun: yes;"> </span>I’m personally very interested
in statistics (Nerd Alert!), and I’ve even tried to apply the concept of
statistical significance to identifying outlying providers based on their CMI
compared with peers.<span style="mso-spacerun: yes;"> </span>I’ve not found any
sharp demarca</span><a href="https://www.blogger.com/null" name="_GoBack"></a><span style="font-family: "times" , "times new roman" , serif;">tions between our providers, but if a clear
outlier is present the use of statistical techniques can help support your
concern.</span></span></div>
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<span style="font-family: "times" , "times new roman" , serif;">
</span></div>
<div style="margin: 0in 0in 8pt;">
<span style="font-size: 12pt; line-height: 107%;"><span style="font-family: "times" , "times new roman" , serif;">The bottom
line is if you’re going to call a squirrel a squirrel, you had better do your
homework first and be prepared for evasion, rationalization, and the like.<span style="mso-spacerun: yes;"> </span>Squirreling is part of human nature, and doctors
are particularly good at it.<span style="mso-spacerun: yes;"> </span>Be prepared.<span style="mso-spacerun: yes;"> </span>Oh, and don’t fall for the cute thing.<span style="mso-spacerun: yes;"> </span>Keep the bat ready.</span></span></div>
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</span></div>
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<span style="font-size: 12pt; line-height: 107%;"><span style="font-family: "times" , "times new roman" , serif;"> </span></span></div>
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</span></div>
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<br /></div>
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Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com0tag:blogger.com,1999:blog-3594881315778851964.post-84169999859701365132018-05-25T23:44:00.000-04:002018-06-08T23:44:59.425-04:00<br />
<div class="MsoNormal">
<i>(Yet another missive from Coding World. It turns out you can't place a diagnostic code into the medical record from a consultant's report. Which means that if a consultant writes something on the charts, you have to ask the patient;s personal hospital physician if they agree before you can code it. Get it? Got it? Good.)</i><br />
<em><br /></em></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Memo from the Full Disclosure Department:<br />
<br /></div>
<div class="MsoNormal">
<o:p></o:p><br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Lying behind my confident attitude, my devil-may-care good
looks, and my abundant modesty lies a nerd.<span style="mso-spacerun: yes;">
</span>I say this knowing full well what that entails, for a nerd is different
than a dork or a geek.<span style="mso-spacerun: yes;"> </span>According to
OKCupid:<br />
<o:p><br /></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
“A Nerd is someone who is passionate about learning/being
smart/academia. A Geek is someone who is passionate about some particular area
or subject, often an obscure or difficult one. A Dork is someone who has
difficulty with common social expectations/interactions.”<br />
<o:p><br /></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Remember that OK Cupid is a dating website, designed to find
people for people who don’t have people (and may be the unluckiest people in
the world).<span style="mso-spacerun: yes;"> </span>So they are morally obliged
to put a positive, quirky spin on the terms.<span style="mso-spacerun: yes;">
</span>Who wouldn’t want to date someone who’s passionate about learning or a
master of a particular domain?<span style="mso-spacerun: yes;"> </span>In truth,
don’t we all have those little social hiccups?<span style="mso-spacerun: yes;">
</span>Aren’t we all unique in our own way?<span style="mso-spacerun: yes;">
</span>Isn’t that cute and endearing and wouldn’t you like to date me?<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
<br /></div>
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(I was actually okay with Nerd, as I thought I had no
obsessions to speak of.<span style="mso-spacerun: yes;"> </span>That is, before
the Dental Empress brought up my thing with buying only hardcover books. And Legos.<span style="mso-spacerun: yes;"> </span>And WKRP in Cincinnati.<span style="mso-spacerun: yes;"> </span>And the fact that I cannot walk inside the
house until I’m sure the interior light in the car is fully off, a trait which
has caused the College Student to call me “Captain Paranoid” rather than the
warmer epithet of “Dad.”)<br />
<o:p><br /></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I bring this up to indicate that after many years of
attempting to be somewhat more normal, I’ve become comfortable with who I am….a
middle aged guy who can admit to liking Barry Manilow and girls in the same
sentence.<span style="mso-spacerun: yes;"> </span>It also means that I can also
freely express my admiration for Star Trek in the most unambiguous terms.<span style="mso-spacerun: yes;"> </span>Which brings us to a small matter of CDI.<o:p></o:p><br />
<br /></div>
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<br /></div>
<div class="MsoNormal">
As we know, one of the rules of the coding system is that we
cannot code off of anything except what’s written in the chart by the attending
physician.<span style="mso-spacerun: yes;"> </span>We can find useful
information in nursing notes, nutritional consults, radiology reports, and
pathology files, but we can’t code it unless it’s been noted by the attending
physician.<span style="mso-spacerun: yes;"> </span>As a result, we wind up
sending queries to physicians asking if they concur with the tissue diagnosis
of a pathology report, or agree with a particular finding on a CT scan or an
MRI that might affect coding, reimbursement, and measure of illness
severity.<span style="mso-spacerun: yes;"> </span>These queries usually take the
form of “Doctor McCoy, the pathologist noted the presence of Pon Farr in the
biopsy sample.<span style="mso-spacerun: yes;"> </span>Do you concur?<span style="mso-spacerun: yes;"> </span>If you agree, please indicate this in your
Progress Notes and Discharge Summary.”<span style="mso-spacerun: yes;">
</span>To which in Klingon we most often hear in angry reply<span style="mso-spacerun: yes;"> </span>“Im qar’a’ pathologist Qel“ or “Dammit Jim,
I’m a doctor ,not a pathologist.”<span style="mso-spacerun: yes;"> </span><o:p></o:p></div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"><br /></span></div>
<div class="MsoNormal">
(Yes, I know you cannot see Pon Farr on a tissue
biopsy.<span style="mso-spacerun: yes;"> </span>But ponder the fact that you
knew this and what it says about you.)<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The simple fact is that doctors understandably don’t want to
pass judgement on their peers, especially if it’s about something out of their
own area of expertise.<span style="mso-spacerun: yes;"> </span>It’s inherent
within physicians to greet such a request with caution.<span style="mso-spacerun: yes;"> </span>So if you ask them to agree or concur with
something out of their ballpark, with medicolegal umpires officiating the game,
they are going to eye that request with suspicion and may well let it go
unanswered or actively reject the query.<span style="mso-spacerun: yes;">
</span>(This is true unless it’s an ER doc, where anyone can level a shot and
it’s considered fair game.<span style="mso-spacerun: yes;"> </span>This is
because most doctors did a month or two of ER during their residency and then
went on to be SPECIALISTS…translated as “person smarter than you”…while the ER
docs were not bright enough to leave.)<span style="mso-spacerun: yes;"> </span><o:p></o:p></div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"><br /></span></div>
<div class="MsoNormal">
I am not immune to this reluctance to confirm or deny that
which I don’t understand.<span style="mso-spacerun: yes;"> </span>This is
especially true given that I made it through my pathology lab course in medical
school not by detecting differences in the cells I was looking at under the
microscope, but because I was able to memorize the shapes and colors on the
stained slices of tissue slides we were issued for class.<span style="mso-spacerun: yes;"> </span>(There was also this story going ‘round about
students crawling through a ceiling in order to get a copy of an exam.<span style="mso-spacerun: yes;"> </span>I’m sure it was just a rumor.)<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Physicians don’t feel that way just about pathology
reports.<span style="mso-spacerun: yes;"> </span>We’re likely to encounter the
same difficulties given any piece of conflicting or incomplete information in
the record, whether it’s a radiology finding or a consultant note.<span style="mso-spacerun: yes;"> </span>I’m not in a position to second-guess the
other guy, goes the thought process, so why are you asking me to do so?<span style="mso-spacerun: yes;"> </span>And yet clinically, we unwittingly do this
all the time, in that we generally guide our clinical efforts dependent upon
the findings and recommendations from our pathology, radiology, and consultant
colleagues.<span style="mso-spacerun: yes;"> </span>That certainly implies
acceptance and concurrence.<span style="mso-spacerun: yes;"> </span>We’re just
loath to say so.<span style="mso-spacerun: yes;"> </span>(Dr. McCoy told Kirk he
was “a doctor, not a bricklayer.”<span style="mso-spacerun: yes;"> </span>But he
still found a way to patch up the Horta, and it still says something about you
if you know what I mean.)<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
So in the end, it’s a matter of semantics, and there’s got
to be a better term to use when we’re trying to get information into the
chart.<span style="mso-spacerun: yes;"> </span>If “agree” and “concur” won’t
work, what can we use?<span style="mso-spacerun: yes;"> </span>We need to look
for words of agreement that don’t imply judgement but do imply active
acceptance and integration into the plan of care.<span style="mso-spacerun: yes;"> </span>Simply saying the results are “noted,” I
think, doesn’t quite do it.<span style="mso-spacerun: yes;"> </span>(I know this
from experience; when nurses in the ER tell me that a patient wants more pain meds to go with
their turkey sandwich and a bag of Cheetos, I usually say “Noted.”)<span style="mso-spacerun: yes;"> </span>So perhaps we can ask, in a yes-or-no query,
if the Attending Physician “acknowledges” the pathology report.<span style="mso-spacerun: yes;"> </span>The common use of the word implies an active
thought process and integration into the plan of care.<span style="mso-spacerun: yes;"> </span>Maybe “accept” fills the bill, as it doesn’t
imply an additional opinion but implicitly says the information is received,
like a gift.<span style="mso-spacerun: yes;"> </span>“Recognize” may not be as
strong, but the word implies integration of the idea with reference to past
events.<br />
<o:p><br /></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In order to improve our responses to these sorts of queries,
we’ve got to quit asking doctors to second-guess their peers.<span style="mso-spacerun: yes;"> </span>The right wording will help.<span style="mso-spacerun: yes;"> </span>Unless it’s an ER doc, of course, in which
case it’s all fair game.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
*************************************************<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Hi!<span style="mso-spacerun: yes;"> </span>Lt. Commander
Grammar Guy here, just beamed in from Deep Space Station K-7 to cause a little
bit of Tribble.<span style="mso-spacerun: yes;"> </span>Today’s agitation is
with anything that calls itself (insert name of city) Memorial Hospital.<span style="mso-spacerun: yes;"> </span>I get that hospitals can be named after
important people who have passed on to the Gamma Quadrant.<span style="mso-spacerun: yes;"> </span>But how do you name a hospital after an
entire city unless that city has been wiped off the face of the earth?<span style="mso-spacerun: yes;"> </span>I had a friend in Starfleet Medical College
who was a graduate of Joplin Memorial High School in Joplin, Missouri.<span style="mso-spacerun: yes;"> </span>We would go to Joplin to visit his parents
and as far as I could tell, Joplin was still there.<span style="mso-spacerun: yes;"> </span>So who was it named for, anyway?<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
(The Vulcan High Command, recognizing that that the Grammar
Guy’s rant is illogical, has in fact discovered that Joplin was named for the
Joplin Creek Valley, which in turn was named for the Reverend Harris G. Joplin,
who settled upon its banks around 1840.<span style="mso-spacerun: yes;"> </span>It’s
my understanding that the Good Reverend has indeed passed on, swept up by the
Great Bird of the Galaxy, so he could in fact qualify as a building’s
namesake.<span style="mso-spacerun: yes;"> </span>The Library-Computer also
tells us that the nickname of Joplin is “JoMo” and that the City Motto is “The
City that Jack Built.”<span style="mso-spacerun: yes;"> </span>Which makes us
want to neck pinch you all into unconsciousness.<span style="mso-spacerun: yes;"> </span>It would be the logical thing to do.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<br />Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com0tag:blogger.com,1999:blog-3594881315778851964.post-40069969185341143862018-05-17T23:17:00.000-04:002018-05-17T23:17:58.878-04:00"I'm Dr. CC. Get Your Medicine From Me."<div class="MsoNormal">
<i>By way of introduction, this post refers to specific terms in Clinical Documentation Improvement (CDI). Hospital payment within Medicare is based on a scheme called MS-DRG's, or Medicare Services Diagnosis-Related Groups. Within each group, the severity of a patient''s illness and needs for care can be further specified by documentation of Comorbid and Complicating Conditions (CC's) and Major Comorbid and Complicating Conditions (MCC's). This post addresses CC's I wish we could use. A couple of them are legitimate clinical issues...and the others? I'll let you decide. Meanwhile, Spotify's playing Clarence Carter...</i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
A few weeks ago, I was giving a presentation to a group of
surgeons. I was talking with them about
CDI, which as you might imagine is as near and dear to the heart of the surgeon
as mindfulness is to Daffy Duck. My
comments engendered a surprising amount of discussion, the upshot of which was
that maybe all patients should just be admitted to the hospitalists with
surgical consults, as the hospitalists write more stuff anyway. (True story.
And an idea not totally without merit.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
One surgeon asked an interesting question when I was
describing what “makes” a CC. “What
about being homeless? These people can’t
keep their wounds clean, can’t get to follow-up care, can’t get their
medicines. And what about
non-compliance? Doesn’t that count for
something?”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The short answer, which you know as a CDI geek, is that it doesn't. These social circumstances, while
subject to coding when documented, count for nothing within the DRG
scheme. The unmistakable message is that
either they’re entirely discounted and negligible, they’re so ubiquitous that
everyone’s care is complicated by it and therefore no one’s is, or they’re
common enough that to give credit for them will costs real money. But as a clinician, I can’t tell you how many
patients have prolonged their own courses through their own non-compliance, or
are difficult to discharge safely because they literally have nowhere to
go. Working with patients, there’s no
question that these circumstances prompt additional evaluations, require more
extensive treatment palms, prolong length of stay, and promote
readmissions. But while codes exist
within ICD-10-CM for these circumstances, they count for nothing within the
MS-DRG scheme.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I also realized I didn’t know how something becomes a CC or
an MCC. I figured somehow it worked through
the Cooperating Parties (AHA, AHIMA, CDC, CMS), but I had no idea how. Is there a nominating committee, and do the
wines each year get revealed at an awards show?
(The nominees for Best CC Related to a Catheter are…can I have the
envelope, please?) Maybe it’s an
illuminati kind of things, with a select few sacrificing a goat while intoning
the definition of a Secondary Diagnosis? <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Because I have no life (at least that week…the Dental
Empress was in Tampa with her high school friends falling out of a sea kayak
while the College Student sat in his room, emerging only to permit The Father
to do Chauffeur Duty), I decided to find out.
An inquiry to Coding Clinic has been submitted and I eagerly await the
reply. But until I do, why not mull over
some of those conditions we see that might be eligible to join these hallowed
ranks. So here’s my list of proposed
CC’s, some real, some…well, real, but less likely to stick.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Non-compliance: There
is absolutely no question that medical non-compliance impacts patient
care. In some cases, non-compliance may
actually be the principal driver of admission, if a condition that was
otherwise well-controlled exacerbates because a patient was non-compliant with
treatment or follow-up plans.
Non-compliance while in the hospital can also lead to the need for
further interventions and care. (An
internship memory is of a 450 pound man who kept going into CHF no matter how
many diuretics we threw at him the day before.
Turns out he was getting salt-loaded in the hospital with midnight
family ruins to Taco Bell, and when he was at home he had no air conditioner so
he kept drinking cold sodas to stay cool.
Discharge plan was no fast food and the hospital chipped in a hundred
for a wall unit. Kept him out all
summer. It was a simpler time.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Granted, there are patients for whom non-compliance is not
of their choosing. People may simply not
be able to afford their medications, have transport issues to and from
appointments, or be able to take time off work for needed follow-up. Perhaps patient education hasn’t been up to
snuff, or educational deficits prevent honest understanding of the Plan of
care. Some prefer the newer term
“non-adherence” to describe the behaviors of this group, because they can’t
adhere to treatment through no fault of their own. That makes some sense to me.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
However, while it is absolutely not politically correct to
say so and flies in the face of most of our extreme liberal concepts, it seems
inescapable that often one chooses their fate.
I got close to fisticuffs in a small group discussion about the social
determinants of heath. These are things like race, income, education,
geography, etc, all of which can absolutely impact upon health and health
care. No argument there. But when I noted that in my ER life, there
were a subset of folks who every Friday, unbidden by cultural concerns or peer
pressure, feel compelled to go to the bar and get their head whacked with a
pool cue, that was considered anathema to the modus of the day. And yet people make the same bad choices over
and over. How many times have I been married again?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Homelessness: If we
spoke before about the social determinants of health, homelessness has to be
near the top of the list. Homelessness
complicates care for all the reasons you might expect…inability to get
medications, inability to attend follow-up…as well as preventing basic hygiene,
all of which can result in increased needs during a hospital stay. Homelessness can also delay discharge while
Case Management seeks out someplace for the patient to go. Clearly CC material.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Patient with Relative in Health Care: If the worst words an ER doc can hear are
“Remember that patient you saw last night,” the third worst are “My aunt is a
nurse.” (I’ll save the second worst for
another time.) Nurses are good people, and they want to be helpful. So when a relative calls they rattle off all
the possible diagnoses, give them a list of all the tests that could possibly
be performed, and then send them to the ER with all this in hand.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Once you see the patient and offer you thoughts based on
years of training and experience, they hand you the cellphone and make you talk
to the relative “who’s a nurse.” (If
you’re lucky, you get to stand in the room for fifteen minutes while they call
another relative to look up the number.)
You have to talk to them before you order labs and xrays, discuss the
results with them, and clear any plan, because the relative in the ER insists
that you do. Meanwhile, the “nurse” has
usually called the patient’s own physician who’s been jolted from his sleep and
demands to know exactly how and why you’re killing the patient. If the case gets to the floor, repeat twice
daily and toss in a few calls to the Respiratory Supervisor and Case Management
to boot. Of course, the patient will
stay just a few days longer because the nurse has to approve of the discharge
plan. One forward-thinking hospital I
know of uses measures of nursing intensity that account for the “difficult
family.” Ahead of the curve.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
(Did I mention that most of the time the relative who’s a
“nurse” is an aunt or cousin who’s actually a CNA in a nursing home?)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Interestingly, patients whose relatives are doctors are
equally insistent on passing the phone to you, but the doctors themselves are
usually much easier to deal with as they still don’t want to wake up at night,
no matter who’s calling. (As my father
says, “Family practice doesn’t mean your family.”) Attorney relatives are even more of a breeze,
because somewhere in their cold little prune hearts they probably realize that
if their second cousin is calling from the ED from 3 AM and already wants to
sue, there’s probably some craziness there.
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Being form New York:
This similar to Nurse as a Relative in workload impact, but seems to be
limited to Snowbirds and Tourists whose primary domicile in within
Manhattan. To put it delicately, New
Yorkers are supremely confident that everyone else is a moron. This includes physicians, which is why
anytime a patient is from New York City I’m supposed to check with their own
doctor, who is on staff at Columbia University or Mt. Sinai Medical Center or
the like, before I do anything. (This is
one time that I thought having a Jewish last name might help, but my accent gives
away that I’m not one of them.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
When this happens, there is a part of me that wants to tell
them that the way you get on staff at an academic medical center is to do a
residency there and be too scared to leave.
That the title “Clinical Associate Professor” means nothing but you’re
in private practice and you let some medical students tag along. That the problem with the Big East Medical
Centers is, in the words of a Johns Hopkins Residency-Trained Specialist, ”They
don’t understand that you can get good neurosurgery in East Pigsty, Rhode Island.” But it’s not worth the time it takes to
orient these Yankees back to reality. So
I dutifully call the doctors as requested, whom I think are trying to be as
nice as a New York doctor can be while dealing with their inferiors. The one redeeming feature of these calls is
that doctors from Brooklyn, Queens, and The Bronx tend to swear a lot, so it’s
fun to put their direct quotes in the medical record and see if there’s a code
for the diagnosis of “low pain threshold wuss.”
(That’s the polite version.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Of course, it’s not all diagnoses. There are some procedures that should be CC’s
as well.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Intubation for airway protection: Patients are not always intubated for
respiratory failure. On many occasions,
they’re intubated for airway protection.
The intoxicated patient or the patient with seizure or stroke may have
an adequate respiratory drive, but altered levels of consciousness, diminished
gag reflexes, or difficulties with swallowing raise the risk of aspiration and
mandate that airway compromise be prevented.
While the patient who is intubated purely for airway protection may be
an inpatient for the same amount of time as one that is not intubated…your
alcohol burns off at a similar rate whether you’re “smoking plastic” or
not…there is no question that the level of nursing care and monitoring required
of an intubated patient exceeds that of a non-intubated peer. This one should be a no-brainer.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Use of an Electronic Medical Record or Patient Satisfaction
Surveys: Find me the doctor, nurse, or other
professional involved in patient care who says the EMR improves their workflow,
speeds their day, enhances patient care, and simply makes their life
better. While you’re at it, send me the
docs who think that Patient Satisfaction Surveys do the same. Begin now.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I’m waiting. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Still waiting.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
What if there were free cookies in it?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
(Crickets.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Enough said. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Administration of Turkey Sandwich and Sprite: This common clinical procedure contributes to
measures of resource intensity through the need for staff to acquire the
sandwich, apply required condiments, put ice in a cup, locate a straw, and cut
off the crusts for those of tender gums.
Multiple applications are often required, and may be accompanied by the
need for puddings and fruit cups.
Paradoxically, provision of such comestibles may actually enhance
measures of Utilization Management, especially when used to drive early
discharge in the Observation Setting.<o:p></o:p></div>
<div class="MsoNormal">
**************************************************<o:p></o:p></div>
<div class="MsoNormal">
Hey, it’s Grammar Guy here.
I can live with the political correctness of “Medical
Non-Adherence.” However, I can’t
reconcile with the term “Psychogenic Non-Epileptogenic Seizure.” This is what we would usually call a
pseudoseizure, but given a new label because psuedoseizure conveys the impression
that patient is faking and maybe the poor dears just can’t help it. It’s kind of like saying that when I was in
my twenties and dating several girls at once I was having “Psychogenic
Non-Intentional Cheating Behavior” instead of being a Hormonal Lying Cheating
Dog. The only saving grace about this
term is after I explained it to a paramedic, he would take great delight in
calling in on the radio about PNES seizures.
And yes, it’s pronounced exactly like you think. <o:p></o:p></div>
<br />
<div class="MsoNormal">
<br /></div>
Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com0tag:blogger.com,1999:blog-3594881315778851964.post-44840766310674377912018-05-17T22:44:00.003-04:002018-05-17T23:15:19.971-04:00I'm Back! (Again.) If you're a regular reader of this blog...and hey, who in the lower 48 states isn't...you'll know that the term "regular reader" is a misnomer, as you can't be a regular reader of an irregular publication. (I suppose you could be irregularly irregular, which signifies atrial fibrillation and a need to listen closely to the list of side effects on the Eliquis commercial; or you could be regularly irregular, in which case Dulcolax may be your product of choice.)<br />
<br />
The blog is irregular because of me. I'll go through these phases where I'm determined to write, and then others where I'm more determined to sit and stare blankly at Facebook. If you look at the dates between my blog postings, Facebook wins. A lot. But I've recently gone through the humbling experience of estate planning for my closer-than-I-would-like-to-think-it-might-be regression to entropy, and I think that even in my dotage (Kim Jong Un is not the only person who can use that word...I'm still working on cofevre) I might have something to say. If nothing else, this blog and the "Keep Our Schools Healthy" Kansas school influenza cartoon are my stakes in eternity, and as Beowulf tells us that's really all you've got in the end:<br />
<br />
"...the kindest to his men, the most courteous man, the best to his people, and most eager for fame."<br />
<br />
(That sounds <i style="text-decoration-line: underline;">exactly</i> like me.)<br />
<br />
As some of you may know, last October I went full-time bureaucrat. I'm the Physician Advisor for Clinical Documentation Improvement at Baptist Health, a five-hospital system in Jacksonville, Florida (I'm in JAX, of course, in my Forever Commune with the Dental Empress). The job is pretty much trying to translate clinical terminology into the administrative language of medicine, and it's really quite fun. One of the best parts is that I've been given the opportunity to write for the blog site of the Association of Clinical Documentation Improvement Specialists (ACDIS). They've been great in allowing me pretty much free rein to write about whatever interests me, and my pieces show up regularly. I have no idea if anyone reads them, but it's fun for me, and I've decided that my goal is to become the "Bad Boy" of Clinical Documentation. I've never been a Bad Boy. I'm very excited.<br />
<br />
I share all this with you because the blog will, from time to time, begin to feature the original versions of pieces I've written for ACDIS. As such, they may have some clinical documentation stuff in them that you may frankly find kind of boring. (It's not an industry built on adrenaline.) But I wanted to post the originals because by the time the ACDIS people get through with the professional edit, they sound like they come from an interesting, informed, and fundamentally sound human being. You know, not me. I also figured that since I had ten or so pieces already saved up, I could get a lot of material out on the blog quickly. At one post a week, that gives me two and a half more months to play on Facebook.<br />
<br />
The first of this genre was posted last May, after I attended my first ACDIS Conference and toured the exhibit hall, goody bag in hand. I'll post the next one tonight as well, with more to follow. Some are incredibly wonkish, some are just fun. More of the real stuff on the way as well. Thanks!<br />
<br />Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com0tag:blogger.com,1999:blog-3594881315778851964.post-35172363120864640372017-06-06T21:56:00.002-04:002017-06-06T22:01:06.779-04:00Salt of the Earth <div class="MsoNormal">
“I think he’s dehydrated,” said the young woman, sitting in
the industrial-strength plastic chair next to her boyfriend.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
It was far too early one weekday morning, and the patient in
question, the potential dehydratee, was sitting up on the cot eating
Cheetos. Fried, not puffy. (Personal note: All Cheetos should be puffy. Both orange and white cheddar are acceptable
flavors.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
“Okay, what’s been going on?” I said.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
“He’s been throwing up all day.”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
“Uh-huh,” agreed the object of her affections. Thin, wiry, he spoke while exposing a thick
tartar of Cheeto residue between his sparse remaining teeth. “I’ve been throwing up all day.</div>
<div class="MsoNormal">
”<o:p></o:p></div>
<div class="MsoNormal">
“How many times have you thrown up today?”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
“A lot.”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Last time I checked, “a lot” was not a number. “How many is a lot?”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
“Twenty. Maybe forty.
“</div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
“You must be feeling better.
You’re eating a Cheeto.”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
“Yeah, but just now.
Besides, I think the Cheetos are what make me throw up.” <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
At a certain point in the conversation, you know you’re not
going to win. All that time you spent
learning about effective techniques for patient education and empowering
individuals to be responsible for their own health become just more hours in
your life you’ll never get back. Kind of
like the first time you saw Avatar or the thirteenth time you saw Team America:
World Police.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
(Okay, I lied about that latter one. Team America:
World Police is funny EVERY time.<o:p></o:p></div>
<div class="MsoNormal">
<br />
Lisa: “If you could
promise me that you would never die, I would make love to you right now.”<o:p></o:p></div>
<div class="MsoNormal">
<br />
Gary: “I WILL NEVER
DIE.” And it’s all puppets.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
So instead of prolonging the conversation, I default into
what is formally called my “Medical Screening Exam.” For those not in the know, when a patient
comes to the door a federal law called EMTALA directs that a ”qualified
provider“ needs to perform a “medical screening exam” to determine the presence
of an “emergency condition” in any patient who presents to the ER. The active ingestion of Cheetos is enough to
convince me, as a skilled and experienced observer, that there is no emergency
medical condition present. However,
unless I acquire additional historical information and perform a physical exam,
there is nothing I can really charge for.
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The Medical Billing Exam completed, I sit down on a rolling
stool and prepare to deliver Canned Speech #12, the one where I say “I’m sorry
you were throwing up at home, but everything looks good now. I could get labs and x-rays, but I don’t
think they’ll be helpful and I hate to stick you full of holes or blast you
full of radiation if we don’t need to.
Whatever it was seems to have gone away, and the fact that you’re able
to eat now is a good sign. Rest, drink
clear liquids…that’s something you can see through, not a Coke…yes, you can see
through vodka but that’s not the same. Anyway, please
follow-up with your own doctor or come back and see us if you need to.” (Sometimes I have to add on to the speech, like
with Addendum 3A: “I’m sorry, I can only
write a work excuse for the time you were in the ER, not for the last three
days you didn’t go to work, Addendum 4c:
“Yes, I know your aunt is a nurse, but…” or Addendum 2B: Yes, I also know the CEO.”)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As I’m accessing the mental file, the young woman speaks up again,
a bit of hesitation and worry in her voice.
“But I know he’s dehydrated.”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
She seems nice, nervous, a little wet behind the ears,
looking for reassurance. I’ll give it another
try. “I understand your concern. But he’s eating fine right now, his
examination’s normal, and I think whatever it was has probably run its course
and he’s gonna be fine.”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
“But it was salty, and when you get dehydrated it gets
salty.”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
A pause. If I could
raise a single eyebrow, I would have been Spock-like. </div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
“What was salty?” <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
There’s a brief moment of doubt, but I forge ahead because I
can feel there’s a story here. I just
don’t know it yet, but I’m willing to incur the wrath of my Charge Nurse by
prolonging my patient throughput times to find out.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
She looked at me, then cast her eyes sheepishly to the
ground. He begins to smile, the Cheeto
ooze tracing across his lips.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
“Well, he wasn’t feeling good…”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
His grin expands to span his orange-dusted face.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
“And I thought maybe, as a special treat…to make him feel
better…and it was almost Wednesday, and we do that once a week…”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The moment of revelation.
“And it was salty.” I nod my head
knowingly.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
“Yes.” She murmurs,
then steels her gaze with a knowing look.
“And everybody says that you have a lot of salt in you when you get
dehydrated.”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
It’s kind of nice to know that in our age, when the internet
arms every man with just enough knowledge to be their own doctor but not enough
experience to know what any of it means, that the spirit of personal inquiry
and those resulting “eureka moments” still prevail. And when someone learns something new, we in
medicine usually honor them accordingly:<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: inherit;">Hail to thee, Discoverer of the Viking Test. You know, the Vikings. From that high school
in Topeka. The one north of the
river. I think it’s called Seaman.<o:p></o:p></span><br />
<br />
****************<br />
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Hypernatremia is a condition where the body’s sodium content is abnormally high.</span><span style="font-family: inherit;"> </span><span style="font-family: inherit;">Sodium is critical to the body in maintaining fluid balance.</span><span style="font-family: inherit;"> </span><span style="font-family: inherit;">When it rises, it’s usually not because someone has been feasting at the salt lick. When someone is severely dehydrated and as water leaves the system, the concentration of sodium in the blood rises.</span><span style="font-family: inherit;"> </span><span style="font-family: inherit;">It’s pretty common in nursing homes, where the ill and infirm often can’t satisfy their own thirst.</span><span style="font-family: inherit;"> </span></div>
<div class="MsoNormal">
<span style="font-family: inherit;"><br /></span>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-family: inherit;">Last month a patient was sent in from the nursing home for hypernatremia with a sodium of over 170 (normal tops out at about 150).<span style="mso-spacerun: yes;"> </span>Looking through his records, we found the usual potpourri of medication lists, Powers of Attorney, and an Out-of-Hospital Do Not Resuscitate Order (DNR) forms.<span style="mso-spacerun: yes;"> </span>This prompted the following conversation at the nursing station:</span><br />
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">“He’s pretty salty.</span><span style="font-family: inherit;"> </span><span style="font-family: inherit;">Like that place where you float.”</span><br />
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">“You mean the Dead Sea?”</span><br />
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">“Yeah, but he’s not dead yet.”</span><br />
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">"Maybe we should just call it the DNR Sea.”</span></div>
<span style="font-family: inherit;">"Whatever floats your boat."</span><br />
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">(Yes, this is a real conversation. Do you doubt? "Vas you dere, Charlie?")</span></div>
<div class="MsoNormal">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "times" , "times new roman" , serif;"><br /></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com0tag:blogger.com,1999:blog-3594881315778851964.post-77576040719814093982017-05-15T21:58:00.000-04:002017-05-15T21:58:16.178-04:00<div class="MsoNormal">
Readers of this sporadic blog may recall a piece I did about
reaping the spoils of the Exhibit Hall at the 2015 Scientific Assembly of the
American College of Emergency Physicians. This week I was at the Annual Meeting
of the Association of Clinical Documentation Improvement Specialists (ACDIS).
For those who don't know, a few months ago I took a career turn to become a
Physician Advisor for Clinical Documentation Improvement. It's been great. I'm
leaning a new set of skills, doing research and data analysis, and helping to
build systems to insure the financial security of a community hospital system.
And as a night shift ER doc of over 20 years, it's also been an introduction to
things like daylight, rush hour traffic, and lunch.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
Allow me to elaborate on the latter, as this is truly a new
and vital concept in my life. When you work in the ER, you eat on the run and
generally in the ER, at your desk or in the break room (the latter when the
JCAHO drops by). But it turns out that if you work in an office during the
daytime at the semi-executive level, you can leave the office and eat. Anyplace
you want, for as long as you want, until you have to attend your next meeting
or you start to feel guilty about being gone. (Which is why all the Jews and
Catholics tend to come back from lunch first. Two fine religious traditions
united by guilt and shame.)<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
(By now you're wondering, "Dr. Rodenberg, Oracle of
Northeast Clay County Florida, just what the heck is Clinical Documentation
Improvement, anyway?" I'm so very glad you asked. Would you like the
Official or the Unofficial Answer?<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
Official Answer: Clinical Documentation Improvement is about
promoting the accurate reporting of clinical diagnoses for the purpose of fully
reflecting the patient's severity of illness, risk of mortality, and needs for
care.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
Unofficial Answer: More words, more buckaroos.)<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
But I digress. I write today to tell you about the exhibit
hall. It's another prime opportunity to scour the vendors to see what I can
acquire in my adult daytime version of Halloween, complete with costumes like
suits and ties that say "Important Professional" or "Clandestine
Russian Operative."<o:p></o:p></div>
<div class="MsoNormal">
<br />
As before, there are rules to the game. You may take only one of each item from any
one exhibitor. As long as you don't have
to talk, you can feign interest in anything.
If you are required to talk, you may not lie. For instance, you cannot say you love a
product, but just don't have the budget authority to buy. You may, however, invoke fixed personal
characteristics as a way to defer further conversation, which comes in handy
when data systems have small type and you've lost your glasses because, by gosh,
you'd love to learn more but you just can't see.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Let’s go shopping! Excelsior!<br />
<br /></div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
*****************<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
One metal water bottle. Turns out that inside the bottle
there was a small piece of paper with usage instructions in both French in
English. I found this out after I had filled the bottle with water and inhaled
the paper during a particularly enthusiastic swig. Once I had assessed myself
for the possibility of aspiration pneumonitis (ICD-10-CM J69.0) and dried out
the paper, I found it to be a most friendly greeting.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
"Great choice!' Here are a few helpful tips to enhance
your enjoyment of your new drink ware."<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
(You know how they tell you you're supposed to start with at
least three positives before you introduce a negative into the conversation?
Apparently that doesn't hold in the Promotional Metallic Beverage Container
Industry. because immediately flowing that chipper introduction ware seven bad
things that could happen to you, culminating in a note that the bottle could be
an "entrapment hazard - don't stuff tongue down bottle neck. Injury can
result. ICD-10-CM S09.93.)<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
Three tote bags, two white and one hot pink. The pink bag
came form a vendor whose second trinket I did not acquire. They had
do-it-yourself charm bracelets in silver, gold, and brass colors. You could
select from any number of baubles to string along the wire, most of which were
either letters or shapes from a box of Lucky Charms. The Dental Empress has
fine taste, and clearly there was no way I could pass this off as David Yurman.
So I deferred.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
Elvis Presley. White suit on Day #1, black suit on Day #2. I
did not get to take Elvis home, but did get my picture taken with him. I posted
it on Facebook. According to the response, apparently I have better hair but he
has better eyebrows. I also took a picture of Elvis with his
"assistant," a pretty little thing who waits for the King down in the
Jungle Room. I did not get to take home the assistant, either. Good hair only
gets you so far.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
Two stress balls, one white and one green. (Insert your own
joke here.)<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
One small ringed binder of sticky notes of various sizes in
Skittles colors. ("Post the rainbow.")<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
Some kind of two-part thing that has a bottom you stick (I
think) to the top ledge of your computer and a top that kind of looks like a
Troll doll with a brush for hair. I was told you take this to brush dust off
your computer. No matter how hard you shake it, it does not sing like Justin
Timberlake.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
A "Las Vegas Trade Show Survival Kit" in a black
knapsack. Inside is a notebook, an expandable button-like thing you stick on
the back of your cellphone so you can grip in between your fingers when you
take a selfie, an Elvis rubber duck holding flowers and a microphone under it's
wings that says "Stress has left the Building," a flashlight, and
deck of cards imprinted with "Deal Me Like They're Hot," five $250
foil-wrapped chocolate poker chips, and two extra strength Tylenol.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
A photo booth montage of four poses of me holding a fake
taco. <o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
A collapsible blue, round, flat, wire-rimmed fan that I
originally thought was a Frisbee. It
flies well.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
A geometric designs coloring book and colored pencils.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
A stone drink coaster bearing a picture of a bridge in Austin,
Texas in a cardboard case whose cover is embossed with the words
"Especially for You."<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
(Do you remember Bob Eubanks and the old Newlywed Game? How
the couple that won got a prize "chosen especially for you?" I always
wondered how that worked. It's not like they could have had that many prizes
just sitting around the back lot, waiting for the final question. No, they must
have interviewed the couples and asked them what they wanted, and then the week
the producers got a dining room set they called the couples who wrote down
"dining room set" on their "What prize can we pick especially
for you?" survey and asked if they could come on own to the studio for
taping. Speaking of which, I've figured out a foolproof system to win the Newlywed
Game but I can't tell you what it is until the Dental Empress and I win the
large Tax-Free Trust Fund selected Especially for Us.)<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
A plastic water bottle. No instructions found inside. I can
learn.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
A daisy-shaped pen in a plastic pot. These were given away
by a Captain America cosplayer. Because if I had an adamantium shield, this is
the first thing I would do.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
A mouse pad.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
A nail file.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
A set of ear buds. (When I was typing, I accidentally wrote
“rear buds.” LOL.)<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
Two stress balls, one white and one green. (Insert your own
joke here. Yep, it was worth mentioning
twice.)<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
A three-inch-tall snowman stress reliever that kind of looks
like a miniature version of the inflatable clown punching bags we used to have
when we were kids. It wobbles when you flick it on the head. The head is also
magnetized so you can dress it up with paper clips.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
Three kinds of phone stand. One cradles your phone so it
stands upright. One holds your phone horizontally. The third, which you paste
the back of your phone, has a kind of folding loop that you bend in place to
keep your phone upright. None of these will work with my Otter Box phone
protector.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
Three decks of cards. It's Vegas, baby!<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
A first aid kid with a single alcohol wipe and six small
bandages just large enough to cover that meth injection site. It's Vegas, baby!<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
(Now that I think about it, maybe the duck is Liberace.)<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
One small, barrel-shaped flashlight on a caribener. You
take it out of the wrapper, push the button to turn it on, and watch it do
nothing. You do this about twelve times before you wonder if there's even a
battery in it. Then you open it up and there's a pieces that says "remove
before use." You realize you've just been a subject in one of those
chimpanzee problem solving, tool-using experiments. You're pretty sure it only
took the chimp eight.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
A portable cellphone power stick.<br />
<br />
<o:p></o:p></div>
<div class="MsoNormal">
Four unflavored chapsticks.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
One bottle of hand sanitizer for keychain use.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
Six coozies. I've got a great idea for a science fair
project. Take cans of soda out the refrigerator. Place the first can in a
single coozie, the second can in two, and so on. Open the cans and measure how
fast the temperature drops in each. Since coozies really don't work, the
temperature will drop at the same rate no matter how many coozies you use. Say
something about a null hypothesis. Take home ribbon. Results are disseminated
on the Internet. American Coozie
Industry fails. Wreak untold economic
damage. Raise tariffs on imported coozies to Bring Back Our Jobs and Make
America Great Again. You're welcome.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
A bottle opener and corkscrew. Finally, someone remembered
we were in Vegas. Keeping that.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
Eighteen pens and one highlighter. Yellow, if you must know.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
Two cylindrical clear, fluid-filled plastic tubes. I thought
they were glue sticks. Turns out was lens cleaner and the other hand sanitizer.
Which explains why I couldn't fix my broken glasses after I sat on them, but
they were certainly clear and germ-free.<o:p></o:p><br />
<br />
I'm probably not invited back next year.<br />
<br /></div>
<div class="MsoNormal">
***************<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
It should also be noted that CDI professionals are mostly
female. I point this out because vendors were not only giving things away, but
raffling them off as well. At ACEP, with a roughly equal mix of genders, the
prizes were specifically neutral. Not so this week. Vendors had drawings for
purses by Michael Kos and Fendi. While I'm not a purse guy, I did register.
Over the years I've learned that it never hurts to have some designer product
hidden in the closet for the next time I do something stupid and the Dental
Empress rolls her eyes at me. Which may be as soon as she reads that Elvis joke
a few paragraphs back. <o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
"What's that? Coming, my dear!"<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
***************<o:p></o:p></div>
<br />
<div class="MsoNormal">
Ahem. Grammar Guy here. Now that the other guy is gone, may
bring up one more item? I realize that one of the glories of language is that
it's alive, not rigid, always in flux, always in change. But it drives me crazy
when everything's a journey. As in
"Begin you CDI Journey with Us!"
Granted, the book definition of journey is simply the act of traveling
form one place to another, but in use the term has some sort of spiritual or
adventurous dimension to it. Long Day's
Journey into Night, Journey to the Center of the Earth, Steve Perry. But this
week it seemed that every project and program was a journey, the end of which
seemed not to be ritual enlightenment or remarkable discovery, but the same old
recognition that change is hard, it's all about the money, and doctors are
curmudgeons. (All of which are true.) So can't we say project, or progress, or
something else? I'll be the first to embrace this change with Open Arms. Who's
Crying Now? <o:p></o:p></div>
Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com1tag:blogger.com,1999:blog-3594881315778851964.post-12504296914625025982017-04-23T09:47:00.000-04:002017-04-23T09:47:33.643-04:00<div class="MsoNormal" style="text-align: left;">
<i>Gentle Reader: Several months ago a fine young physician named Sajid Khan contacted me. It turns out that he actually read my blog (surprise!) and wanted me to contribute a piece to his upcoming book about things newly-hatched ER docs should know about the real world. I was humbled to be asked and I went a little crazy. So crazy, in fact, that after he judiciously cut all the weak material (which, of course. I thought was the funniest but I have issues), he graciously consented to let me use the leftovers for my blog. Some of this might seem familiar, but probably 80% or so is new. And I miss Miss Manners. </i></div>
<div class="MsoNormal" style="text-align: center;">
<b><br /></b></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<b>What I’ve Learned</b></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<b>(with apologies to Esquire magazine)<o:p></o:p></b></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<b>Howard Rodenberg, MD MPH<o:p></o:p></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Getting out of residency is a transition, to be sure. You’ve gone from a pimply-faced pre-med with
a Star Trek poster in your dorm room (Nerd Alert), to a med student with an AMA
bumper sticker on your parent’s old Buick, to an intern (“I’m a doctor, really
I am”), and finally to a resident physician in the specialty of your
choice. And now you’re on the cusp of
becoming an Attending, one of the folks who gets to wear the long white coat at
the more prestigious academic institutions, which is really just a badge of
insecurity that says “I was too frightened to leave.”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Yes, this is what you’ve dreamed of; this is why you
gracefully accepted all the required floggings for the last decade or more of
your life. (Medical Education Motto:
“The Beatings Will Continue Until Morale Improves.”) You’re the one in charge. You’re the one they come to see. You’re the one who stands tall in the saddle,
steaming cup of coffee in hand, while nurses and techs and paramedics and most
of all patients cling to your every word.
Make it so. It’s gonna be
great. Huge. Trumpian.
The Best Thing Ever. Which makes
it all the more perplexing when you get into the real world and find that your
vision of the Attending Physician is a lot like the word inconceivable as
defined in The Princess Bride: It does
not mean what you think it means. In the
community, everyone is an Attending Physician.
(Yep, even that guy.) And
Community Hospital Attending Emergency Physician means Worker. Not Queen, not Drone, not even Larvae to be
feted with royal jelly. Worker.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The simple fact is that being in The Real World is tough,
more so than residency, though in a new and terrifying way. At least in residency you know who your
enemies are because they lie close to you, lurking around every corner and
watching your every move. In The Real
World, you’re being observed from afar, held to standards you don’t know about
by people who don’t know you and can’t do your job. And you can’t see them, for they live in
E-Suites and insurance skyscrapers and government palaces and consultant office
parks many moons of travel from where you pitch your pup tent of a career. How-to guides like this one are full of
invaluable tips to help you navigate this new ocean. You’ll learn about contracts, group
structures, 1099 Forms, how many donuts you can expect to find at a Medical
Staff Meeting, and other useful things that your former Professors, most of
which have NEVER LEFT the warm and cozy confines of the ivy-covered walls, find
inconceivable. (And yes, this time the
word means exactly what you think it means.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But let’s not talk about clinical practice, and let’s not
lose ourselves in visions of what goes on in the Administrative
Playgrounds. Let’s talk about you. Specifically, how you will change over the
next decades, what you will feel, who you might become, and what to do about it
when you do. A career in Emergency
Medicine will change you, and not necessarily for the better. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Here’s what you really need to know, and what I wish someone
had told me.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Emergency Physicians
lie. A lot. You will too.<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
I would certainly agree that, at least in theory, Honesty is
the Best Policy. But there are sometimes
better and worse ways to be honest. As
Emergency Physicians, we develop a skill at obfuscation, which is the first
step down the slippery slope of deceit.
We obfuscate because it generally serves to keep us out of trouble by
telling the truth.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The Lie of Obfuscation occurs when you’re trying to
communicate a message in a way that won’t get you an administrative e-mail
(“Nastygram”). For example, let’s take a
hefty individual complaining of chronic back and knee pain, which you know will
never get better until they drop the poundage.
But instead of saying, “You have this pain because you’re fat and you
need to lose weight,” you say, “You know, you’re kind of a bigger person, and
that might be part of your problem.”
Technically, at 6’1” in a nation where the average male stands 5’9 ½”,
I’m a bigger person. I also weigh 150
pounds fully decked out after a box of Twinkies.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Closely related is the Accessory Lie of Withholding, also
known as Applying the Internal Filter.
Examples including not telling patients they are aesthetically
displeasing oxygen thieves, their babies are ugly, that they really should have
sprung the extra dollars for the good tattoo parlor, that the only good
genitals are unexposed genitals, or that their very existence makes a
convincing argument against Intelligent Design.
This is also the one where you don’t say to the patient on public
assistance who is complaining and threatening to refuse to pay, “You’re not
paying for it anyway. I am.” (The inability to consistently tell the
Accessory Lie of Withholding is probably why I work a lot of night shifts,
avoiding the daylight presence of Administration.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Then there’s the Lie of Feigned Ignorance. Doctors, nurses, and other health care people
know a lot. Most of that which you know
you will tell patients. However, shortly
in your career you’ll begin to notice that you do so in a way that’s
particularly fun for you, especially if it’s juicy stuff. For example, if the patient’s urine tested
positive for methamphetamine after they had told you they don’t do drugs, you
could just walk into the room and say, “Your urine has meth in it.” That’s boring. Or you could sit down and say, “Just remind
me. I think when I asked about drugs,
you said you didn’t do any, right?” When
they confirm that statement, then you get to say, “Well, your urine tested
positive for meth. How do you think that
got in there?” Then you watch them come
up with a story. This is an especially
fun conversation if there are others in the room, for if they are there I
always assume the patient’s okay with them hearing everything I have to say,
else the patient would have shooed them out.
It works especially well with positive pregnancy tests and the diagnosis
of STD.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Most often, though, the things you lie about knowing are
bad. If a patient shows up with three
weeks of painless jaundice, we all know it’s pancreatic cancer and things will
not go well. We will get a CT scan, and
it will show a large mass where the pancreas meets the biliary tree, and more
likely than not the liver will look like
a piece of swiss cheese from metastatic tumor.
But when you discuss the results of the scan, you will find that you
don’t say that the patient has cancer and bad things are about to happen. If I do a thoracentesis (as we old ER docs
used to before radiology figured there were dollars in it), and the fluid that
comes out is bloody, that’s cancer. I
won’t say that, but I know, and you will too.
If there’s an infection raging through the frail body of someone’s
elderly parent, you’ll say that her condition is serious and we’ll do all we
can to help. You won’t say you know
she’s going to die.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
It’s certainly not that ER docs aren’t able to give bad
news. We do it all the time, especially
when death happens suddenly, and are probably so fluent with it that it seems
rehearsed. But when it’s something like cancer, or overwhelming infection, or
an incapacitating stroke, we often don’t have very many answers for what is
likely to be asked, and you’ll hate adding more fear by not being able to
provide knowledge or solace. Definitive
diagnoses are best delivered by someone who is part of the team providing
continuing care. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The worst lie you’ll find yourself telling is The Lie of
False Hope. At the end of life, or in
times of critical illness of injury, all the tools are in the hands of the
physician. The only thing the patient
has left to work with is hope. Hope that
they’ll get well, hope that the medical system won’t fail them, hope that their
deity of choice will see them through, hope that their friends and family will
be there with them as they go into that dark night. The Lie of False Hope is to
give hope where there is none. What
makes this lie worse is that often the patient knows that you’re lying, but accepts
what you say in an effort to postpone contemplating the inevitable. But to give hope where there is none, so
death comes as surprise; to pretend your efforts will mean something when you
know they’re really just for show?
Playing the game of Medical Theater is the worst lie of all. And yet we
do it every day.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
One last note: The
important thing is to lie only at work.
Don’t do so at home. I lost
twenty years with the woman I love because when I was young and a newly-minted
doctor with money, I lied to her about dating someone else. It’s not good. Twenty years apart. Twelve shifts a month for twenty years. That’s 2,880 shifts, and more each month when
I was also paying alimony and child support.
Lying is not a very cost-effective way to live. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Learn to hang crepe<o:p></o:p></b></div>
<div class="MsoNormal">
I used think there’s nothing worse than to walk into a room,
where a family has been nervously awaiting word on a loved one, and have to
tell them their friend or family member is gone. I bothered me when I was new at this game,
but now it’s become a routine. I’ve
found my own way to tell people bad news, just as you will as well. The one thing you can’t do is pussyfoot
around it. <o:p></o:p></div>
<div class="MsoNormal">
But there is something you can do to make the blow easier,
and that’s the hang crepe. In Victorian
times, a household in mourning was identified by a ribbon or bow of black crepe
hung on the doorknob, and the clothes of those in mourning were trimmed with
crepe as well. So when you “hang crepe,”
you’re preparing the family for what, based on your knowledge and experience,
is inevitable, but for them a dreaded fear. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Whenever possible, have someone do this for you. If you’re running a code, ask a nurse to go
tell the family that things are not going well several minutes before you
deliver the news. If you’re at one of
those hospitals that allows families to watch codes, make sure that before they
get into the room have someone tell them about the sights, smells, and sounds
in graphic detail, how long we’ve been working without success, and that the
doctor may ask if it’s okay to stop. All
of these help soften the final blow when you deliver it.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This is also important when the patient is critical but not
yet dead. When you talk to the family,
remember to say that we hope for the best but expect the worst, but we’ll do
everything we can to help. Then be sure
to outline exactly what “the worst” will be.
If the patient survives, you’re a miracle worker. If they die, you’ve told them in
advance. Win-win either way.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>You only remember the
ones who came in talking and left dead<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
You will see thousands of patients in your career. Most you won’t recall whatsoever. Some you might remember when prompted because
it was an interesting story, an unusual diagnosis, or because you managed to
pull a rabbit out of your…umm, right.
The only ones you will remember without promoting are the ones who came
in talking and left dead. You remember
those because no matter how inevitable the death was (as it is in nearly all),
it happened on your watch, and we’ve been taught that this is failure. Success is fleeting. Failure scars.
If you can keep the number in the low double digits, you’re doing okay.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>They have names?<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
Remember that talk in medical school about how patients are
more than their physiology? How each of
them is a unique individual formed by a milieu of culture, beliefs, family
dynamics, and education? Can you recall
learning how illness or injury is really the culmination of a story, and that
story deserves to be heard? And how
asking open ended questions, and allowing time for the patient to respond in
his or her own way, is the best way to build the rapport needed for effective
care?<o:p></o:p></div>
<div class="MsoNormal">
It’s all absolutely correct.
And it’s probably the first thing that goes in the active practice of
emergency medicine. Under constraints of
time and volume, and ever-increasing demands to sacrifice the former for the
latter, you’ll find that the only way you can patients apart is by room number
and chief complaint. Instead of going to
see Mrs. Jones, you’re picking up the clipboard for the Chest Pain in Room
2. And once you’re there, and you ask
when the pain started and she begins what’s probably a delightful tale of
baking cookies for the church supper two nights ago, you’ll find a (polite) way
to cut her off and direct her towards yes or no questions. And with the patient who has multiple
complaints, rather than providing holistic, person-centered care you’ll find
yourself saying, “What is the one reason that brought you to this Level 2
Trauma Center tonight?” Don’t feel bad. It happens.
And it makes those moments s when you can build a rapport with a
genuinely fun and interesting patient all the more valuable. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
(One tip on yes or no questions. If you ask the patient a yes or no question,
and they have to think about it, the answer is always no. No “maybes” in the ED.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>In the ED, kids ARE
little adults<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
This is one of my pet peeves. (Someday I want to get a dog
and name it Peeve.) Most new ER docs are
terrified of taking care of kids. We’ve
been trained that way. We’ve been told
by pediatricians that only pediatricians know how to care for children. They conduct special courses to teach us how
to care for kids, but also to remind us how woeful we are when we do so. Many of us did our pediatric ER rotations
during residency in specialty pediatric hospitals, where the message of the
uniqueness and exclusivity of children, and of pediatric caregivers, is
reinforced. The overall messaging is
constant and consistent. You can’t take
care of kids, because kids are NOT “little adults.”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
There is no question that in the long run, kids have
different needs than adults. But in the
ER, kids are ABSOLUTELY little adults.
Why? Because care still follows
the ABC’s. Perhaps even more so, because
in kids it’s AAABC (AAA means that it’s Almost Always Airway). Drug doses are different and the veins are
smaller, but the same principles still hold. We adapt all the time for the
elderly, the gravid patient, the ones with chronic disease. All we do by reinforcing the myth that kids
are special and unique is to convince physicians, nurses, and paramedics that
their efforts at care are doomed to fail.
In reality, at 2 AM in your ED, kids aren’t really any different. Except that because they haven’t learned sick
behaviors, nor how to lie, they’re more genuine. And quite often more fun than dealing with
their parents. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>People are surprising
hard to kill<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
No essay here, just a notation. I’ve made wrong decisions and judgement calls
during my career. You will, too. But somehow patients survive our best (hopefully
inadvertent) efforts to knock them off.
Take comfort in that.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Dinosaurs know things<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
Twenty-five years out of residency, a physician can claim
dinosaur status. Value your dinosaurs,
because they know stuff. Do you know how
to do a diagnostic peritoneal lavage? A
thoracentesis? A paracentesis? A culdocentesis? Can you read a plain cervical spine film or
an abdominal series? Can you look at an
IVP? Can you convince a surgeon to admit an appendicitis case without a CT? Can
you do a central line without ultrasound guidance? How do you intubate without sedatives or
paralytics? Have you ever done a blind
nasotracheal intubation and dodged flying mucus from lodging within your
flowing locks of large 1980’s hair?
(That includes guys as well.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
These are all things I can do. I don’t say this as bragging, but as a
function of time and circumstance. I
trained in an era where advanced imaging was limited to an 8-bit CT scan of the
head, and you got that only by convincing the attending radiologist to get out
of bed and come to the hospital to read the film. Obstetrics was just starting to use
ultrasound on a frequent basis. It was a
world of clinical diagnosis, where most everything was history and exam. We learned to fly by trial and error. Most times it worked.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
There is no doubt that today’s graduating EM resident knows
more than I did, and probably more than I still do. When I look at a bedside ultrasound, it looks
like someone took a chalk drawing on a sidewalk and poured a bucket of water on
it. I see nothing but a blur of
gray. I’ve gotten pretty good with head
and CT scans, but I’m bad with chest and abdominal studies unless there’s a
pneumothorax, a pleural effusion, a Swiss cheese liver, or a mass the size of a
cantaloupe. We need you to teach us
what’s new, and help us through the maze of bedside technology. But dinosaurs often know ways around things
that you’ve been taught as dogma. Not
because we’re smarter than you, but we had to do the same job without the
toys. And if the particular dinosaur has
been around an institution long enough, he or she knows the political land
mines, and might be willing to tell you before you blow off a limb. Maybe. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
(It should be noted that we really do look better and
smarter than you during computer down time, because that’s our era.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
We’ve also been around long enough to learn that Emergency
Medicine is one of the most static, and the most cyclical, of the medical
specialties. ED care has always been
about triage and the ABC’s. It still
is. While technology has revolutionized
the vast majority of medical care, ER practice is still all about the history,
physician exam, risk assessment, and disposition. (I think that most ER docs can figure out
what needs to happen within the first several minutes of a patient encounter. Labs and x-rays are really for patient
reassurance or another clinician’s use.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Have there been advances in ER care? Of course.
But each advance eventually circles back around to where we were
before. When I first took ACLS over
thirty years ago, the core lesson was all about the need for early CPR and
early electricity to enhance long-term survival. Since then, we’ve gone through mechanical
CPR, IVC-CPR, vest CPR, SCD-CPR, and no ventilation bystander CPR. We’ve moved from a model of direct cardiac compression
to a thoracic pump model. We’ve realized
that rescue breathing is really just a CO2 delivery system. We’ve run through high dose epinephrine,
dropped lidocaine, added amiodarone, dropped bretylium, added vasopressin, and
now we’re cooling patients down if they survive the initial episode. But at every lecture I attend, the message
remains clear; the only thing that really matters in long-term survival from
cardiac arrest is early CPR and electricity.
Ditto with sepsis, where for years it was all about fluids, antibiotics,
and the occasional vasopressor. Then we
had the sepsis bundle with CVP measures, arterial lines, venous oxygen
assessments, steroids, and probably some garlic and wolvesbane thrown in for
good measure. And guess what? Outcome studies still show it’s all about
fluids, antibiotics, and the occasional vasopressor.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Dinosaurs also understand that the tincture of time and
elixir of neglect is often the best care.
You can learn from them when not to do anything. They also know that despite advances in
scientific medicine 70% of what we do is still voodoo, unsupported by
double-blind studies or bench research.
For years, I wore a voodoo bracelet I bought in New Orleans during my
shifts to remind me of this. You should
too.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
(Oh, one other thing.
Dinosaurs think all new grads are snowflakes. Limits on how many patients you can have on a
service? Night floats during internship?
Work hour restrictions? 24/7 attending
supervision? Making more than minimum wage during residency? Signing bonuses
and student loan repayments? Please.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Caring is conditional<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
We all went into medicine because we wanted to help people,
right? It wasn’t all about the
money. (At least that’s what everyone
who makes more than we do says.) We are
physicians because we care.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Here’s the dirty little secret. When it's busy, when people are demanding,
and when nothing seems to be going right...which are more days then you’ll care
to recount in a hectic ER...you won't have time to care. You’ll find yourself in a mode where your
thoughts are more on “moving the meat” and keeping up your end of the workload
rather than being open and compassionate to one and all. You’ll be focused on throughput times,
customer satisfaction, charting, and defensive medicine. I plead guilty to being this way myself. When I walk into a room and say, “What can I
do for you?” to a patient and family, what I often mean is what can you tell me
so I can get you out of my ER, and off my hands, as fast as possible? Or what can you tell me that is going to mean
you stay for a long time and jam up one of my assigned rooms so I don’t have to
see as many patients? I hate being that
way, but it’s my reality, and it will be yours, too. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Does this mean you’ll never care again, that this part of
you is lost forever? Of course not. One of my practice partners likes to say that
after years in the trenches, we have “selective caring.” You take the caring you would have shown to
people who aren’t worthy of it and double, triple, or quadruple up on those who
really need your help. (I use the word
“worthy” on purpose. Make no mistake
about it…your caring and concern, and the emotional energy you invest in the
doctor-patient relationship, is a privilege to be won, not a right or
entitlement for all.) Given that the
vast majority of patients use the ER for primary and chronic care, and that the
ED is the safety net (or wastebasket) for society and certainly the dumping
ground of our health care system, you’ll bottle up that caring and compassion
for most while looking for opportunities to let it out. In the process, you’ll find that your mindset
changes from “What’s your emergency?’ to “Prove to me you’re sick.” It becomes
your own emotional triage tool, helping you to screen for those patients where
your time, caring, and compassion can lead you to those rewards of the heart
that brought you to medicine as a career.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This attitude shift, while inevitable, is nothing to be
proud of. It’s probably a sign of
burnout as well. But it’ll happen, and
it’s not you. It’s the system, and until the way we use emergency services
changes no amount of meditation, yoga, exercise, or anything else we’re advised
to do under the guide of “physician wellness” will make a difference. Really, it’s not you.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>It could always be
worse. You could be a Hospitalist.<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
You know your friendly Hospitalist. That’s the Community Hospital name for the
Internal Medicine residents who didn’t want to do a fellowship, the folks who
do everyone else admits and provide inpatient care. The value of the hospitalist to the health
care system depends on who you ask. If you’re inquiring of health care
theorists, their familiarity with acute inpatient care makes them more likely
to provide efficient, high-quality, low-cost care than physicians who only do
hospital work part-time. If you ask the bean counters, hospitalists provide a
service to the community physicians who will then drive their patients, and
their revenue, to that hospital that provides that service and relieves them of
after-hours duties. If you ask most physicians (off the record, of course),
hospitalists exist so they don’t have to get up at night to see patients nor
make hospital rounds during the day, taking time away from the more
revenue-friendly outpatient practices and procedures. And if you ask an ER doc,
the hospitalist is the one guy thankfully even lower than you on the food
chain, the one for whom even your problems roll downhill.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
To say that is not to disparage the hospitalists in any way.
The vast majority of physicians I know who’ve chosen this kind of practice are
good, smart, caring people, who provide excellent care in often the worst of
cases and social settings. They accept anything and everything that needs
admission. It also means they admit anything we can’t get rid of, even if it
doesn’t really need to stay. As you’ve already gathered even at this early
stage of your career, there are a lot of people who come to the ER and simply
don’t want to go home no matter what. And then there’s the ones who are sent
into the ER by their own doctor because the doctor doesn’t want to deal with
them anymore. So the patient gets sent
them to the ER with a request that they be admitted while the primary care
provider prepares their 30-day notice, copies their records, and places them in
a manila envelope by the receptionist desk.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
(For the record, when that happens and you meet the patient,
you usually understand exactly why the doctor did it. ER Rule 84 J,
Subparagraph 2: “If you say your doctor “fired” you, there’s usually a good
reason for it. Subparagraph 3: “If you say you fired your doctor, see
Subparagraph 2.)<o:p></o:p></div>
<div class="MsoNormal">
So the hospitalist is the final link in the chain. When the
patient genuinely needs to be admitted, or else just refuses to leave, they’re
the ones who get the call. Because they are always there for you, and are going
to bail you out in the end with both that critical patient who needs hours of
one-on-one care as well as that Marvin K Mooney who Won’t Go Now, you want to
be their friend. Still, there are tricks. You figure out which ones want what
tests done before taking an admission, so you speed up the process when you
can. Hospitalists who are nicer to you
when they receive the 3 AM call get the more pleasant patients (preferably
unconscious or intubated, as it makes the History of Present Illness so much
easier when they can’t talk.) If it’s
fifteen minutes before the end of their shift, you learn to stall just a bit
and give the patient to the next one up. But no matter what, you always
apologize profusely for any admission unless it’s so critical a case that you
sound stupid in your haste to atone. And whenever possible, make sure to say
that it wasn’t your idea to admit the patient, but that of the patient’s own
physician and you’re just doing what he said.
It’s good to unite against a common enemy.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Someone told me long ago that ER doctors will never have
other physician friends, because when you call another doctor in the middle of
the night it’s never to ask if they want a beer over breakfast. Yet hospitalists
and ER docs tend to get along more than most. I won’t say we’re all best doctor
friends, but if it’s lonely at the top it’s nice to be chummy at the bottom.
Hospitalists need us to skim off the top. We need them to rake out the bottom.
And nobody else wants to get out of bed a moment too soon.</div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>The “Q Word” is real.
Don’t say it. <o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
<b> </b>Again, no explanation required. Just don’t.
And ostracize those who do. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>There’s no rewards
for courage<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
If something violent goes down in the ER, your job is to get
away. There are people who handle these
kinds of things. They are called
Security and Police. They are not you. Leave.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>If you’re feeling bad
about yourself, call a physician recruiter.
You’ll feel special.<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
<b>The worst possible
phrase in the English language is “Remember that patient you saw last night?”<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
This question is always a disaster-in-situ. There’s a storm of criticism and
second-guessing headed your way. And if
you’re unlucky, it will be followed by a lawsuit. Over the course of your career, you will get
sued, and settlements will be made on your behalf. If your attorneys think you’re wrong, it will
be settled early. If you’re in the
right, it will be settled later, when the cost of defense is more than the cost
of the payout. The process has nothing
to do with the truth, and either way it scars.
You will feel every emotion in the book as you go through the process of
discussions, depositions, and discipline.
It is an experience which provides no positive good and results in a
loss of clinical confidence and a more costly and time-consuming practice of
defensive medicine. Patients are now
potential plaintiffs, and everyone is suspect.
This gets worse over time, as you learn of more physicians who are
abused and victimized by litigation, and as you recognize that other physicians
are driven by dollars to indict their peers.
But as I’ve come to learn, unless you’re losing seven-figure verdicts
it’s simply a cost of doing business. Try
to view it as such. And recognize that
because the accusations hit you in your soul, you can’t. Ever.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Nothing good ever
happens on hospital e-mail<o:p></o:p></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
See above. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Your lifestyle will
expand to meet your income<o:p></o:p></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Remember how you promised to live frugally and pay off your
student loans before doing anything crazy with your hefty post-residency
salary? That was a lie. People will fall all over themselves to give
you “preferred payment plans” and “guaranteed low credit rates” and “special
physician mortgage financing” once you have that MD or DO after your name, and
you won’t be able to resist. Before you
know it, that bathtub of sign-on cash is gone, and you’re looking for extra
shifts at the prison infirmary. Admiral
Akbar was right. It’s a trap. I fell into it. Don’t be me.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Magazines<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
Less obvious things about you will change as well. You’ll find yourself reading different
magazines. No more Muscle and Fitness,
no more Vogue. Now it’s old National
Geographics and Highlights for Children left over in the waiting room. (“Goofus gets angry that he has to wait in
triage and says he knows the CEO; Gallant is grateful to be told the wait time
is four hours.”). Or maybe People or
Cosmopolitan, strewn about the staff lounge which you scan to see which
celebrities have fibromyalgia (Kate Gosselin, I KNEW it!) or to read about the
“Ten Hot Sex Tips You Should Know” and realize that at least six of them will
cause a 3 AM visit to the ER. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Diet<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
Your traditional medical school and residency diet,
affectionately known as the Five C’s (coffee, cola, chocolate, candy, and
chips) will expand to Ten. You will add
cheese, carrots, and celery, all of which are found in diced or cube form on
the platter you’ve brought from the grocery as your contribution to Christmas
Dinner because you’re not giving up one extra moment of sleep to actually cook
something before your shift. You also
bring cheese and veggie platters for Christmas Eve Dinner. And New Year’s eve. And Thanksgiving, Halloween, and when your
best night nurse is transferring to days.
The Ninth C is chicken (fried only), which can be used as a substitute
for turkey when you really want to make a statement of affection for your ER
crew. (The Tenth C is cake, but that’s
usually a nursing duty. Check your job
description.) In terms of actual
cooking, you are allowed to purchase a Crock Pot for the purpose of melting
Velveeta and Ro-Tel or heating Little Smokies in the break room while you’re
working the patient load. But don’t get carried
away and actually make something, or they’ll expect more of the same. Five years of being on matzah ball soup duty
for Christmas Eve and Easter (“The Official Shifts of the American Jew”) taught
me that.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Revel in your white
hat. <o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
Emergency Physicians bask in the joy of righteous
indignation. We are there...the <i>only </i>ones there…for anyone, regardless of
race, creed, color, sexual orientation, socioeconomic status, nature of their
complaint, hygiene allergy, or intrinsic unpleasantness. No other physicians do what we do for so many
so often and so well. We are the Mother
Teresas, the Hard Rock Cafes of Medicine existing to Love All and Serve
All. There’s something very noble about
that, especially if you’re the only one awake keeping the community safe at
night. The feeling doesn’t last once you
recognize you’re expendable, but moral superiority helps you keep going in the
short run.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Use silent
profanity. It makes you feel better.<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
True confession. My
vocabulary has not become more elaborate and refined with the wisdom of
age. I’ve become more vulgar, more
guttural, more “foul than fair” in my choice of words. It’s how I deal with the anger that
inevitably comes with years of unceasing demands to do more for more with less
and less. (That’s the best politically
correct way I have to express everything I dislike about clinical emergency
care.) Every time I pick up a chart of
patient with a chronic complaint, a snot-nosed kid, a headache, a back pain,
anyone who I’m able to see through the patient windows eating Cheetos or
talking on the cellphone, I swear up a hurricane in my head. It helps me deal with my anger and
frustration at not actually being an Emergency Physician, a way to get it out
of my system so it doesn’t show up when I go to the bedside or present a month
later as an upper GI bleed. Profanity
out loud causes problems, but profanity for yourself can be lifesaving. Don’t feel guilty if you do it.<o:p></o:p></div>
<div class="MsoNormal">
Besides, a certain level of comfort with profanity can
actually help your friends. I have a
colleague named Sam who is truly one of God’s good people. Not only will he not swear, but he even has
trouble describing the concrete structures we use for hydroelectric power. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
One night, he’s checking out to me, and he’s trying to
explain how this particular patient was frustrating him. I could tell that he simply couldn’t use the
word that would best express his emotional state. Because I am the Mensch of the Flatlands, I
said, “Sam, I know you want to say (something that rhymes with duck), but I
know you won’t. So I’ll do it for
you. In fact, any time you feel like you
might want to try to say (something that rhymes with duck), call or text me and
I’ll do it for you.” I always keep my
phone on when he’s working in case I’m needed.
Just the kind of guy I am.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Oh, I almost forgot.
There are two times in the ER when you are allowed to use full
language. One is when the patient is
constipated, because telling someone that they’re full of it is not an opinion,
but an objective statement of fact. The
other is when the patient directly insinuates you have an unnatural
relationship with your mother, at which point you are allowed to explain that,
“My name is DOCTOR (rhymes with Brother Tucker) to you.”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Only Mourners and Complainers
know your name.<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
I was recently on a flight from Chicago to Kansas City and
fell asleep before takeoff. When I woke up, I had already missed the beverage
service. I walked up to the front of the plane, where the flight attendant was
eating her lunch, some kind of plastic-encased salad. I asked her pardon for
the interruption, said I was sorry I missed the service, but wondered if there
was still a chance I could get a Coke.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
She glared at me and told me in no uncertain terms that
"I'll think about when I finished" with an expression that indicated
she was not simply making a joke. The message clear, I went back to my seat.
Thirty minutes later, when she came by to pick up the trash, she reminded me
that she had not had time to meet my request with smile that let me know whose
work ethic was running the show, and it wasn't Customer Service.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This is not the only flight I've ever taken. It's not the
only flight attendant I've ever asked for soda after sleeping through the
initial service. But it was one of the few who was genuinely rude. It's
reinforcement that the good and the pleasant becomes routine, and only the bad
stands out in your mind. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Your image of the physician probably started the same as
mine. It's the kindly doctor from the Norman Rockwell Post covers, your own
family doctor who cared for you in a time of need, or genteel portrayals of Dr.
Kildare or Marcus Welby, MD. Maybe your media influence was from a younger
generation, like Dr. Fiscus, Dr. Ross, or Dr. Grey. They have become your models not only because
of their inherent virtue, but also from consistent exposure. You see them at
least once a week, and more often in reruns.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In contrast to that continuous soothing physician presence, Emergency
Medicine is a one-night stand. If you're a player, you only remember the bad
ones. Everything else fades into a joyous blur of hedonistic memory. Similarly,
the vast majority of your patient encounters will be pleasant and routine. You
will not remember them, and the patient will not remember you. On the other hand,
if the encounter has gone badly and the patient has gone sour, or there's been
a confrontation with the patient, friends, or family, they will remember you.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Knowing that you'll never be hailed as a life giving savior
may be hard to handle, especially since we've been indoctrinated to believe
that we'll receive the requisite accolades all through training. It was for me.
I was pretty sure I was going to SAVE A LIFE, walk out of the room into the
Family Circle, and simply absorb voluminous praise. The fact is that in a
crisis, the patient and family will be in such a state they will not remember
who you are. The doctor they will remember is the one who spends time with them
on a daily basis, caring for the patient in the hospital, talking to family and
friends. They'll remember that person as the one who redeemed the patient
because of the constant exposure. Even though what you did was probably the
life-saving moment, you are simply background noise to the acute event.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Is there an advantage to the anonymonity that makes up for
the fact that your glory is dispersed to those less worthy? Well, you can go to
pretty much anywhere you want to and not be recognized, especially if a sweat
shirt is involved. That's not a bad thing, and it's something that like fine wine,
gets better with age.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Normal people are
fascinated and repelled by what you do.<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
After the next bad night shift, offer to take a few of your
staff out to breakfast. Find the most crowded and popular place you know. Start
talking about what went down the night before. Spare no detail. Then look
around you. Have the tables around you cleared, and is your group now sitting
in the middle of a void?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Of course you are. Nobody wants to hear what you do for a
living on their own time. Your conversation disturbs their appetite. But they
want to hear all about it on your time, at a party, at the mall, on the phone. “What’s the weirdest thing you’ve ever seen?”
is a polite way of asking a question you’ll get every time you meet someone new
and at every family gathering. The
easiest way to deal with this is to come up with a standard response. “I could tell you, but I’d have to kill you”
has been used, and making an obscure reference to patient privacy, while valid,
is simply unsatisfying. I;ve taken to
simply saking my head and saying, “I’ve seen…things…” with downcast eyes while
slowly turning away to the bar, where no one will ask you anything except if
you want a lime with that. The fact that
the worst thing you’ve seen is not a mangled trauma victim but the man self-pleasuring
while viewing the Heart Healthy Lifestyle video in Room 14 is beside the
point. The idea is to shoo them away, at
least for the rest of the evening.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Administration never
comes out at night.</b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
Neither does the Joint Commission nor Human Resources. Choose your shifts accordingly.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>It’s a job.<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
It used to be accepted that medicine was a calling, much
like a religious vocation. The training
was hard, the hours were long, the responsibilities were great, but the rewards
were greater. A calling also implies
hardship, self-sacrifice, a giving of your life to the service of others. Medicine is not unique in this regard, to be
sure…people are called in many different ways…but because our calling is the
care of our fellows in their hours of greatest need, medicine has been
exalted. There’s a reason every mother
wants their child to be a doctor.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I still believe that for most of us, medicine started out as
a calling. We go into this because we
want to do good things for good people, and because we think that when you do
so, good things happen to you in return.
It’s an ever-expanding snowball of happiness. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
While I still cling to the idea that medicine is a calling,
I’m not so sure it’s a profession. The
book definition of a profession is an occupation that requires prolonged
training and a formal qualification. But
implicit in the way we sue the term is a degree of autonomy, of allowing the
individual to use their skills and training in unique and innovative ways to determine
their conditions of work and to accomplish a task or goal within the standards
established by his or her professional peers.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
That key criteria, autonomy, is not the case in Emergency
Medicine. We do not work for ourselves,
but for hospitals and contract groups.
Our work conditions are determined not by our peers, but by
administrative bodies outside our scope of practice or influence. Our measures of success are less related to
the quality of our work than to meeting abstract metrics unrelated to patient
care. Our standards of care are determined not by our peers, but by a punitive
system of litigation whose demands exceed our capabilities. The person who works under these conditions
doesn’t sound like a professional. It
sounds like someone who has a job.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
(In fairness, many physicians would tell you they feel the
same. I’ll grant them their feelings, but
all fo their grievances are magnified in the 24/7 pressure cooker of the
ED. There’s also one additional key
difference. Other physicians are still
able to maintain some control over their workday through their ability to schedule,
refer, and defer. We have no such
option, and as such are totally at the mercy of the winds of the day.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The hardest part of life as an emergency physician is
accepting what you do for what it is.
It’s a job, no more or no less.
Recognizing this is at first disheartening. It contradicts everything you’ve ever seen,
felt, learned, or believed about the role of the physician, and everything you
saw yourself becoming when you started the journey to doctorhood all those
years ago. It sometimes takes years to figure
this out. But when you do, it’s an
incredibly liberating moment. Here’s
why.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i>Corollary 1: No commitments<o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
Despite all the rhetoric you’ll hear on the recruiting trail,
emergency physicians are rarely seen as valuable assets to a hospital or health
care system. Let‘s be frank. Hospitals don’t really fret about the quality
of the medical care provided in the ER.
They care about customer service, but that’s not the same thing. They worry about clinical quality only to the
point where it keeps the hospital out of legal or regulatory trouble. Hospitals vest interest and commitment to
physicians who generate referrals and revenue.
We do neither. So while the
hospital is interested in having a body in the ED to dispense smiles and cheer,
it is not interested in nor committed to you.
Ask anyone who’s been through a contract change, or had their
independent group eliminated by a hospital opting to enroll physicians as
employees. It’s true that active
participation in hospital committees and medical staff politics may serve to
stave off the wolves. But your r
allegiance to the hospital, your years of dedication and service, mean nothing
compared with the need for the new CEO to demonstrate he’s an agent of change,
or for the CFO to bring a few more dollars into the C-suite. And if you choose
to stay, you’ll likely have your salary and benefits “low-balled” as a
reward. It’s all about the Golden
Rule: Whoever has (or wants) the Gold
Makes the Rules.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
So why should you feel any long-term commitment to the
hospital? Short-term commitments are
understandable. Someone does you a
favor, you do one in return. But guilt
is a bad foundation for a lifetime relationship, especially when one party feels
a lot less guilty than the other. And
remember that you have no patients who depend upon you, no practice employees
who you support with salaries, and you know that the ER will continue in in
your absence. So why worry about
commitment? Nobody else does.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i>Corollary 2: You can leave<o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
Recognizing that there’s no real covenant between you, a hospital,
a contract group, a patient panel, or a community gives you mobility. If you don’t like your job…and again, it is a
job…you can simply leave and no one will be the worse. You’ll miss some of your colleagues, and
they’ll miss you, but that’s why we have Facebook. So if you’re not happy, leave. Everyone else leaves bad jobs in search of
greener pastures. Why shouldn’t you?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But if you hate your job, but really like where you
live? That leads us to…<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i>Corollary 3: Live where you live. Work where you work.<o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
Emergency Medicine is a Seller’s Market. There are more jobs than physicians willing
to fill them, and that disparity grows when one considers the limited number of
residency-trained, board-certified emergency physicians. As ER volumes grow and the needs for
physicians rise, so do the dollars.
Student loan payoffs and signing bonuses routinely top six figures. It’s a great time to be job searching, right?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The other side of the coin is that many of the best paying
jobs are in places you don’t want to be.
I’m sure that by and large, the people of Connecticut (except Geno
Auriemma) are fine individuals with a quirky yet endearing affection for nutmeg,
but as a native flatlander I have no particular desire to live there. But for the right money, I can work where the
dollars are and still live where I want.
With no connections to a community or commitments to a hospital,
commuting is a way of life for many emergency physicians, doing blocks of
shifts in distant locales, seeing the country on someone else’s money. So if you and your family love the beach, but
the local ER is a cesspool, go ahead and live at the beach. Hop a plane to the hinterlands, do your
shifts, and go home. Don’t juggle your
commitments; dedicate yourself fully to work and rest, then dedicate yourself
fully to family and friends.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This is no just idle chatter. It’s what I do. I live in North Florida and commute for my shifts
at small physician-friendly hospital back in the Midwest that pays well for the
volume of work. I don’t make as much as
I might at the local Trauma Center, but I’m not beat up after every shift, and
there’s still plenty of money out there for a very comfortable life. (The fact is that while we rightfully lament that
we’re not paid what we’re worth, we’re never going to starve. It’s comforting, and freeing, to realize
this.) I’ve got the best of both worlds,
and on someone else’s dime.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i>Corollary 4: Don’t
work a moment more than you need<o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
While it’s exciting to be an ER doctor while you’re young
and single, it’s hard on relationships.
The glamor of being, and of being with, an ED physician wears off fast,
and there’s a lot to be said for having weekends and evenings off where you can
commune with the rest of the world, to have those spontaneous moments with your
partner and your kids that build connections and create memories. Real life doesn’t just happen when you’re off
shift. Don’t live to work. Work to live.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Again, I’m not simply talking to hear my own voice. My career has given me lots of opportunities
to do fun and interesting things. I’ve
flown in helicopters, worked with NASA, served in County and State
government. But working evenings,
nights, weekends, and holidays as a younger man, simply caught up in the Wild
West Cowboy Thrill of it All (Yeee-haw!), has undoubtedly left me with a skewed
sense of priorities in relationships.
The fly-by-the-seat-of-your-pants attitude we have in the ER doesn’t
work in the slow and methodical world of building lasting friendship and love
where presence is everything. You need
to be there when the sun lights up your face on the weekends, and when
relationships begin to fade in the evening shade and die in the dark of night. There’s a reason many Emergency Physicians
talk about their “starter marriages” (plural intentional), and don’t figure it
out until they’re at the point where they can cut back on shifts and work
mostly days. It took me twenty years to
get there. Don’t be me. Make the time.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>ER Math: One night equals two days. Eight > Twelve.<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
Remember how you thought it was cool to work only 12 shifts
per month and have 18 days off? That
math works in your twenties. By the time
you hit 40, you’ll probably still do okay after a single 12 hour shift in a
busy ER, but if you do two or three in a row the following day or two you won’t
want to go anywhere or do anything. And
a single 12-hour night shift in your 40’s puts you out of commission for the
day before (when you’re trying to nap) and the day after (when you’re tryignt o
stay awake). Twelve night shifts over a
month’s time makes you feel like you’re aware of the daylight for about a week,
and that’s only if you have a full block of seven days off. Even at low patient loads, as you age the
nights just get harder to do. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Eight hour shifts have been shown to be more physiologically
sound and, to me, are much easier to do.
You can rest without feeling like you’re on a deadline, and you can
still have a few hours of the day to yourself.
The trade-off is that you need to work more eight-hour shifts to make
the same amount as you would working twelves.
But the trade-off is worth it. In
my most recent ER, the eight hour blocks were called the “Princess Shifts.” I would happily wear glass slippers if all I
had to do was eights.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Don’t kid yourself that you can keep up this work
forever. There’s only so much Provigil
to go around.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Work, don’t teach. <o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
I took an academic job right after residency. I had published a few papers, regularly
taught ACLS, and thought I knew things.
Turns out I didn’t, though that didn’t hamper my promotion and
tenure. Yep, you’ve had that Professor,
too. Those who can’t do, teach.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I have come to believe that you are truly lost in trying to
prepare anyone for the real world of medical practice unless you’ve been in
that same world, in a busy community ER, for at least five to ten years. While I may have bluffed well, and taken
comfort in the fact that patients are surprisingly hard to kill, I’m now
convinced that I was so far off base in some of the academic dogma I spouted
off that while I may have been an excellent academician, I was not a great
emergency physician. And once I got to
the real world, my learning curve was much steeper than it should have been. So if you want to teach, practice first. And then when you go into academics, you’ll
still have some bucks saved up for nice cars and cruise vacations.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Real emergencies are
rare. Realize why.<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
You’ve probably already figured this one out. How many ER patients have you seen without an
actual emergency? About a billion, I’m
sure, but it’s likely that nobody ever explained why. Most doctors in the United States believe
that this is a result of the federal mandate that any patient must be seen in
the ER for a Medical Screening Exam from a qualified health care professional. It’s likely true that the mandate allows some
people to take advantage of ER services when they can’t get help elsewhere, but
that’s not really it. There are economic
drivers at play, one from within the hospital and the other in the mind of the consumer.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
On the hospital side, it’s a matter of costs. Anything with a price can be broken down into
fixed and variable costs. For example,
if you decide to drive to the store, the fixed costs are your car payments,
annual registration, and insurance. You
assume these costs whether or not you choose to drive on that particular
day. A variable cost is the gas that you
use to make that trip, which is an expense you would not otherwise incur. (You may also hear of opportunity costs, which
is the cost of doing one thing instead of another. For example, if you spend an hour at the
store, it costs you an hour of lying on the couch playing Cookie Jam on your
iPad. Or so I’ve heard.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Hospital ED’s have high fixed costs. No matter how many patients show up (or if no
one does), the hospital is still paying for the bricks and mortar, utilities,
nursing and staff wages, technology, office supplies, and the like. These are fixed costs that never go
away. The more patients you see, the
closer the margin between your fixed costs and the concomitant revenue. (Variable costs in the ER…basically consumables…are
a relatively small portion of the total cost).
So even if some of these patients pay little or nothing, the more people
you run through the system the smaller the differential between your fixed
costs and your income stream. It’s often
in the hospitals best interests to keep the doors open for all. (You will often hear in your career that the
ER is not a Revenue Center, meaning it doesn’t make money for the
hospital. Don’t believe it. An ER may lose money when you compare the ER
charges with reimbursement alone. But
ER’s do make money…lots of it…for the hospital when one considers the tests,
admissions, and referrals generated by the ED.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The second has everything to do with consumer choice. This choice is not about the “10 Minute Wait
Time” signs on the highway. This is all
about convenience. Let’s say your child
has the sniffles. You can call the pediatrician’s
office, be given an appointment in two day’s time, try to take work off during
the daytime and hope your employer understands, and fret for two days while
enough snot the fill the Hoover Dam eminates from your child’s nose. If the pediatrician decides that labs or x-rays
are needed, maybe there’s another trip to a lab or outpatient facility, and
then another wait for the results and perhaps for a prescription as well. On the other hand, if I can drop into an ER
after hours, without taking off work, and get everything done…it’s one-stop
shopping, and who wouldn’t take advantage of that? I probably would. In the midst of a busy shift I get angry with
the way people use the ER, but the inflexibilty of our current outpatient
systems to respond to consumer needs has driven them to us. I don’t like it, but I get it.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Know up front that this is a battle you can’t win. As Ray Parker Jr. and Raydio noted, “You
can’t change that.” <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>There’s no glory in
being a wall.<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
For years, residents have been described by their peers as walls
or sieves. Walls block admissions and
find reasons to send people home, while sieves admit anything. Your peers, people with whom you’ve worked
side-by-side during your first few years, want you to be a wall, and you understandably
want to look good in their eyes. So
everyone tries to be a wall.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
That doesn’t work in the real world. Being a wall causes nothing but headaches. You don’t want to be in the situation where
the patient or family pushes for admission and you refuse. You don’t want to be fighting the wishes of
outpatient or specialty family physicians who refer patients to your
hospitals. You don’t want to weigh in on
the borderline case, where 51% of patients do well at home and 49% who will go
sour. It is absolutely reasonable to set
some parameters for what can or cannot be accomplished during an ER visits (no
refill of chronic pain meds, can’t diagnose chronic problems, no elective
MRI’s), but being a wall generates complaints and puts both you and the
hospital at risk. If there are issues
with the appropriateness of an admission, there are people who are paid to sort
that out. Can you make the argument that
being a sieve is inefficient and a poor use of healthcare resources? Of course you can. Does being a wall help you personally or
professionally? Nope. So don’t do it.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>It’s a young person’s
game. Have an escape plan.<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<div class="MsoNormal">
If I was forced to cut this chapter down to two sentences
(ad once an editor gets hold of this, that may be all that’s left), you’ve just
read them. The fact is that you <i>will</i> burn out. The adrenaline rush of acute care wears out
by your early 40’s, beaten into submission by increasing workloads, decreased
physical capabilities, the isolation of your work hours, and the burdens that
your career choice has placed upon your relationships with friends and family. You will hate your job, and you will be angry
you have to go to work, angry at work, and angry when you come home that you
have to go back for your next shift. You will still get excited about some
cases of interest and some patients will remain a real joy to care for. But they will feel like shining stars,
light-years apart in the dark cosmic matter of your work life. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
So my best piece of advice to you, even to the point of
ignoring everything else I’ve said, is to have an Escape Plan. It doesn’t matter what it is. Academics?
A fellowship? Changing
specialites? Getting into
administration, pharacueticals, or medical devices? See the world as a cruise ship doctor? Medical
volunteer work at home or abroad? Or
getting out entirely? I know emergency
physicians who got out to purse a PhD in math, to follow religious callings, to
fly right seat in commuter airliners.
One of my mentors wound up working at a liquor store and loved it. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The most important thing you need to keep in mind is that an
MD or DO is a ticket to anything. You
are not trapped by your degree. A
colleague of mine often says physicians should “leverage their degree.” You’ve survived medical school, residency,
and your clinical years. While you may
need some additional training or experience to meet your goals, nobody can say
you’re not smart enough, not motivated enough, or don’t have the capacity to
learn, grow, and excel. The MD and DO
may not mean anything to those who rely on Dr. Google for their medical care,
but it still means something to those who value drive and ability. Take advantage of this and use your degree to
drive your opportunity.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
My last caveat: Never
quite give up the ER. Like it or not, by
the time you decide to get out it’s already a part of you, and you’ll feel lost
if you never get back in there again.
You’ll miss the sights, the sounds, and even the smells. So every month, do a few shifts. ER doesn’t change that much, the ABC’s will
always be there, and you’ll keep your credibility as a physician with your
friends and colleagues. It’s a pretty
well-paying hobby, and you’ll still have things to talk about at
breakfast. It’ll always be fun to watch
the other tables clear out.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Take care of your ER
family. You need them more than you know
or want to. But don’t love them. Love
your own family more.<o:p></o:p></b></div>
<div class="MsoNormal">
<b><br /></b></div>
<br />
<div class="MsoNormal">
<b>Love and Mercy. Brian Wilson was right.<o:p></o:p></b></div>
Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com1tag:blogger.com,1999:blog-3594881315778851964.post-78060905968198611022017-03-30T06:08:00.001-04:002017-03-30T06:08:02.848-04:00<div class="MsoNormal">
I may have mentioned on these pages that I have an ABBA
fixation. I have no idea why. I wasn’t really into much pop music during
their Nordic heyday, and it’s only within the last decade that I’m become a
true fan. But now I can’t stop. I seek out ABBA eveywhere I can. I even use ABBA as a harbinger of quality. Just last week I walked into a local diner and
noted the soft undertones of “The Winner Takes it All” from the speakers behind
the potted plants. It was like Bjorn personally
telling me it would be a good meal, better perhaps than even lutefisk with
lingonberry jam. It was. Voulez-Vous!
Aha!<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
(The Dental Empress has been most gracious in putting up
with this. However, she draws the line
at liking the musical “Mamma Mia!” In
her mind, it’s the story of a woman who slept around with three guys and has no
idea who’s the Baby Daddy. She thinks a
better title might be “Your Mom’s a Whore.”
She is nothing if not practical.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The ER staff here in this small town has discovered my
Swedish Obession, and now the wee small hours of the morning have turned into
ABBA fest courtesy of a respiratory tech with an excellent 70’s playlist. Thus the background for my tale.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
------------------------------------------------------------------------------------------------------------------</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Several nights ago one of our regulars showed up. He’s known for a number of things, but one of
them was a notable amount of glee with the act of urinary catheterization. It’s not that he jumps for joy…that would defeat
the purpose of catheterization, as it’s hard to hit a moving target, especially
a small one…but he expresses his pleasure is somewhat more demonstrable physical
ways. (After meeting him, one does get the
sense that his options are limited.) So
when he came that evening for another of his umpteenth visits, he not only
requested a catheterization, but requested that a certain nurse perform the
procedure. Fortunately for her, she was
not working that night, and he went away in flaccid disappointment. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
Tonight, however, Catheter Man was back. And to his good fortune, his RN of choice (whom
we will call The Blonde Urinary Queen) was assigned to his room. But she was breathing a sigh of relief, as
his complaint tonight was merely wrist pain. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
When someone has wrist pain, there are a couple of things
you think about. There’s injury, of course,
and arthritis, gout, infection, and the like.
But one of the most common causes of wrist pain is repetitive strain
injury. So I’m planning to ask him what
he does with his wrist that might be causing him pain, and as I’m planning my
strategy I look at his past records and find that he was here last week for
left forearm pain, and I look into the open door to his room and I see him grin
as the The Blonde Urinary Queen passes by.
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Repetitive strain?
Hand and forearm? And he likes to
be catheterized in a most adult way and looks for a particular nurse? Ummm…oh, no.
My head didn’t just go there, right?
Right? <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
No, it couldn’t be. Because
Emergency Medicine is a collaborative effort, I raise my concerns with a
nursing colleague.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
“It might be,” she says.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
(This is my same nursing colleague who has wisely decided
that instead of using negative language, she will use rhymes to convey what she
actually means. She’s recently stopped
using the phrase “Bite Me.”)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
“But why would he do it with his left hand?” By now, I’ve seen the patient and I’m back at
the nurse’s station. Ever-observant, I’ve
noted he appears to be right-handed.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
“Well, maybe he turns pages or uses the remote with his
right.”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
About this time “Super Trouper” comes on the iPhone. I
adore this sog. It’s truly one of favorites. It’s a starring turn for Frida, and in the accompanying
video there’s Agnetha debuting her Saturday Night Fever arm-in-the-air, skyward-finger-point. It’s also the ABBA song which most embarrasses
my son as I put my hand, Agnetha-like, through the sunroof driving down the interstate. Because THAT would never attract attention.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
(For those who want to know…mostly me…Wikipedia tells us:<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
“The song, with lead vocals by Anni-Frid Lyngstad, was the
last to be written and recorded for this album and it replaced the track
"Put On Your White Sombrero". The working title of this song was
"Blinka Lilla Stjärna."<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I’m going to take that to IKEA and see what they can do with
it. It’s probably the name of a DIY credenza
by now.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
So as Frida bemoans her say in Scotland, I rise from my
chair and prepare for the chorus.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
“…a Super Trouper…”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
At this moment, my left hand flies into the air in my best
imitation of the Faltskog Finger. This Travoltian
move causes the tech sitting nearby to say that I should watch out so I don’t
injure my forearm or wrist like Catheter Man.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Responds the nurse,” Don’t worry about it. Doc uses his right.”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Catheter Man calls from his room that he can’t pee. The Blonde Urinary Queen sighs. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Far away from the watchful eyes of Human Resources, this is
why we work nights. <o:p></o:p></div>
<br />
<div class="MsoNormal">
<br /></div>
Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com1tag:blogger.com,1999:blog-3594881315778851964.post-20064005393762579492016-06-03T00:24:00.002-04:002016-06-06T08:48:19.682-04:00Rooms for Rest<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;">The Teen's now the High School Graduate, and in a college
preparatory effort to elevate our conversations from how My Little Pony is
Communist Plot to more lofty topics of intellectual heft, I've found that he is
steadfastly non-committal in many of the great issues of the day. Which
is fine, I suppose, and probably keeps his mind at ease. Unfortunately, I
haven't learned that trick of respite, and I'm well aware that sometimes one
thought will generate a virtual cacophony of mental activity. And my need
to share my opinions...repeatedly and in excruciating detail, especially during
long drives with a captive teenage audience...often results in The Graduate
burying his head deeper into his Nintendo DS.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;">So by now you're intrigued, right? You're sitting
there, asking yourself, "How does Howard Rodenberg, MD MPH, a fine
upstanding member of the Northeast Kansas Medical Community and The Only Guy
Who Verified his Age as 53 on a Children's Storybook App, stand on the critical
issues of that day?" Or at least, "Which bathroom should I use
in the Charlotte Airport?"<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;">I'm delighted that you asked.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;">I happen to be of the belief that anyone can use whatever
bathroom they want. I do not say that because of any inherent beliefs,
one way or the other, about the rights and privileges of the
transgendered. My thoughts on transgendered rights mostly concern just
which pronoun one uses when gender identification doesn't match the anatomy.
I don't want to say "it," or use a made up word like
"shim," but I truly have no clue. Given what I do for a living,
where physiology beats identity every time, that's all I really want to know.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;">I believe that everyone should use the bathroom of choice
because that's what's been happening for thousands of years, perhaps even
millions, since the first band of Homo Erectus (and isn't that a great name for
a species given the current discussion) decided to use a communal waste site
and some were more dainty in their use of leaves than others. It’s never bothered anyone before. It’s not led to a rampant plague of bathroom
oglers nor predators. It’s not eroded
the fundamental values of our nation (that would be urban music and cable
television). It's a non-issue, made into
one by a conservative, rural-dominated
state legislature duking it out with hand-wringing urban activists in a large liberal
city, magnified by a knee-jerk overreach by the federal government when it
should have been left alone, to weasel it's way through the court system for a
dozen years or so before the issue goes away by itself...meaning that everyone
will continue going to the bathroom as they’ve been doing since the prehistoric
scat pile. The whole thing is a chest-beating, cheek-puffing fight for
dominance between two bands of howler monkeys hoping someone will pay attention
while the rest of the zoo patrons are focused on those oh-so-cute river otters
and ring-tailed lemurs. It's the Transportation Security Administration
of Excretory Politics. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;">(As an aside, I've always found it interesting how many
conservative legislatures, while promoting the autonomy of states to defy the
federal government, are perfectly willing to limit home rule if smaller units
of government, such as cities or counties, want to do the same. Government
should be putting down floors to establish a minimal level of service, not
limiting local initiatives by putting up ceilings. I can live quite
happily with conservatism as long as it's based on consistency and common
sense. I'm still waiting.)<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;">If, as mentioned above, physiology beats identify,
function beats form as well. So here is a functional approach to what I
think should happen with bathrooms. Coincidentally, I suspect, it's
what's been happening for the last several thousand years, with no discernible
effect on public morals. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;">If you are a guy, and you think you’re a guy, you go to
the men's bathroom. You may opt to stand near a urinal or enter a stall
and sit. In either case you excrete and leave. This is not a place
for lasting friendships to be made. Socialization in is not permitted
other than to say, "Hey, about those (insert team name here) and grunt in
response. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;">(I say stand near the urinal because there are people who
grasp the urinal during use, which is sad and suggests a real need for human
contact. We do not encourage this behavior, and suggest those individuals
subscribe to match.com immediately.)<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;">If you are a girl, and you think you’re a girl, you go to
the women's restroom. You enter a stall, sit, and excrete. It's my
understanding that they must do something else in there, because they go in
groups and it takes them forever. But as I quite comfortably fit in the
previous category, I'll never know. Nor do I want anyone to tell me.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;">If you are a guy who think he's a girl or a girl who
thinks she's a guy, it is true that you generally have to look the part. But given that constraint, if you're a guy
who thinks he's a girl and you look like a girl, you go to the women's room,
enter a stall, sit, and excrete. You may socialize if you choose. If
you're a girl who thinks she's a guy and you look like a guy, you go into the
men's room, enter a stall, sit, excrete, and hope Senator Larry Craig isn't in
the booth next door because you're not that kind of girl. Or guy. It’s
confusing.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;">If you've had gender reassignment surgery, you can
absolutely use the restroom of your choice. Anyone who has the intestinal
fortitude to get things taken off or added on using scissors and knives
deserves at least that measure of respect. I will use the pronoun of your
choice without hesitation. However, if you were a guy who is now a girl
and has subsequently developed fibromyalgia, I will address you as a female but
will also take that post-operative diagnosis as prima facia evidence that
you're most likely crazy as well. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;">If you're a cross dresser, who just likes to wear
clothing of the opposite gender but are also quite comfortable with your own
gender, use the bathroom at home. Linebackers in heels won't fit in either
gender-based rest areas.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;"><br /></span></div>
<br />
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 115%;">Of course, if at all possible, individuals of any gender
or gender identity should have access to a single-occupancy restroom. This not
only obviates the issues of who else is nearby and their level of comfort, but
makes it a lot easier to read, make cellphone calls or play Avengers Academy on
the iPad at the same time. Except in the Charlotte Airport, where the
restroom attendants will knock on the door of the stall if you take too long
and they hear Black Widow talking to Tony Stark from behind the swinging metal
door. Or so I've heard.<o:p></o:p></span></div>
Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com2tag:blogger.com,1999:blog-3594881315778851964.post-49648718141689268352016-05-23T09:06:00.000-04:002016-06-06T08:54:47.246-04:00The Theory of Everything<div class="MsoNormal" style="color: #454545; font-family: UICTFontTextStyleBody; font-size: 17px; margin: 0in 0in 10pt;">
<span style="background-color: rgba(255, 255, 255, 0); line-height: 16.100000381469727px;"><br /><span style="background-color: rgba(255, 255, 255, 0);">A few weeks back I mentioned nurse practitioners. These are nurses who have gone on to get a Master's Degree so they can work alongside or independently of physicians as higher-level providers of medical care. Nothing wrong with nurses wanting to get more education and advance their career, of course, and more power to them for doing so. What I didn't realize, however, is that much of the class time in spent in nursing research. This strikes me as kind of a fluffy topic (no traditional nursing-based pillow tasks pun intended), because I can't figure out what nursing research is. If we're trying to figure out what clinically works for patients in the real world, we're dealing with the same issues, and the same set of facts, whether the research is done by doctors or nurses. That’s why it’s called clinical research. It’s not doctor research. So I don't quite get what nursing research is if it's not research into clinical care. And if it's not, then that means it's not fact-based, and risks getting lost in rubrics of good feeling and a cornucopia of psychobabble. This is not really a criticism; it's the nature of the beast when you try to quantify that which is inherently subjective. It's a problem when subjectivity becomes confused with fact, and extrapolations are made on unfounded assumptions. You know, like pain scales and patient satisfaction measures.</span><br /><br />(For the record, research that is fact-based does not mean that it's useful or even worthwhile finding out. It's like those studies that appear from time to time as a Waste of Government Dollars, like the one in England a few years back that showed that the girls really do get prettier at closing time. Mickey Gilley knew that years ago, as did his cousins Jerry Lee Lewis and Jimmy Swaggert. As well as anyone who went home at two with a ten and woke up at ten with a two. Not sexist; it works both ways.)<o:p></o:p></span></div>
<div class="MsoNormal" style="color: #454545; font-family: UICTFontTextStyleBody; font-size: 17px; margin: 0in 0in 10pt;">
<span style="background-color: rgba(255, 255, 255, 0); line-height: 16.100000381469727px;">I was talking the other night with one of my nursing friends who's just finishing up her nurse practitioner degree, and she was telling me about their class research project. (This particular nurse is also savvy about why nursing research is so prominent in her curriculum. "The professors have us do a project, write it up, stick their names on it, and submit it to see if they can get published." Yet another way nursing academics are exactly like their physician peers.) She and her classmates have spent the better part of a year trying to figure out why patients with emphysema (more specifically known as Chronic Obstructive Pulmonary Disease, or COPD) don't get the care they need. They've come up with the usual suspects: lack of access to health care, lack of financial resources, lack of health education, and the like. In the end, it seems like in health care, like everything else, it always seems to come down to money...money that drives access to care, to medications, to resources, to education, and even to time to devote to health care and maintenance. But as we discussed her project, we realized that in our rush to blame the system and absolve individuals from accountability...not a specifically medical issue, but a systemic one...we simply ignore all those factors that result from individual free will. There are those who quite actively choose to continue to smoke, to not take advantage of free health care resources, to not use their prescribed medicine as directed, to refuse home oxygen when suggested by the physician. In the shorthand of the ER, we term these behaviors as idiocy.<br /><br /><span style="background-color: rgba(255, 255, 255, 0);">It seemed to me as we talked that we could make this problem a lot easier if we focused on money and idiocy as driving forces for healthy behaviors. And we could do so in a diagram:</span></span></div>
<div class="MsoNormal" style="color: #454545; font-family: UICTFontTextStyleBody; font-size: 17px; margin: 0in 0in 10pt;">
<span class="Apple-tab-span" style="background-color: rgba(255, 255, 255, 0); white-space: pre;"> </span><span style="background-color: rgba(255, 255, 255, 0);">IDIOT?</span></div>
<div class="MsoNormal" style="color: #454545; font-family: UICTFontTextStyleBody; font-size: 17px; margin: 0in 0in 10pt;">
<span class="Apple-tab-span" style="background-color: rgba(255, 255, 255, 0); white-space: pre;"> </span><span style="background-color: rgba(255, 255, 255, 0);">Yes</span><span class="Apple-tab-span" style="background-color: rgba(255, 255, 255, 0); white-space: pre;"> </span><span style="background-color: rgba(255, 255, 255, 0);">No</span></div>
<div class="MsoNormal" style="color: #454545; font-family: UICTFontTextStyleBody; font-size: 17px; margin: 0in 0in 10pt;">
<span style="background-color: rgba(255, 255, 255, 0); line-height: 16.100000381469727px;"><br /></span></div>
<div class="MsoNormal" style="color: #454545; font-family: UICTFontTextStyleBody; font-size: 17px; margin: 0in 0in 10pt;">
<span style="background-color: rgba(255, 255, 255, 0); line-height: 16.100000381469727px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Yes<span class="Apple-tab-span" style="white-space: pre;"> </span>Bad<span class="Apple-tab-span" style="white-space: pre;"> </span>Hooray!</span></div>
<div class="MsoNormal" style="color: #454545; font-family: UICTFontTextStyleBody; font-size: 17px; margin: 0in 0in 10pt;">
<span style="background-color: rgba(255, 255, 255, 0);">MONEY?</span></div>
<div class="MsoNormal" style="color: #454545; font-family: UICTFontTextStyleBody; font-size: 17px; margin: 0in 0in 10pt;">
<span style="background-color: rgba(255, 255, 255, 0);"> </span><span class="Apple-tab-span" style="background-color: rgba(255, 255, 255, 0); white-space: pre;"> </span><span style="background-color: rgba(255, 255, 255, 0);">No</span><span class="Apple-tab-span" style="background-color: rgba(255, 255, 255, 0); white-space: pre;"> </span><span style="background-color: rgba(255, 255, 255, 0);">Bad</span><span class="Apple-tab-span" style="background-color: rgba(255, 255, 255, 0); white-space: pre;"> </span><span style="background-color: rgba(255, 255, 255, 0);">Bad</span></div>
<div class="MsoNormal" style="color: #454545; font-family: UICTFontTextStyleBody; font-size: 17px; margin: 0in 0in 10pt;">
</div>
<div class="MsoNormal" style="color: #454545; font-family: UICTFontTextStyleBody; font-size: 17px; margin: 0in 0in 10pt;">
<span style="background-color: rgba(255, 255, 255, 0); line-height: 16.100000381469727px;">In brief, if you're an idiot, bad things happen. If you're not an idiot, but don;t have money, bad things happen. If you're not an idiot and you have a few bucks, you'll be fine. That's all of health care behavior in a nutshell. And depending on how high up the food chain we consider the idiot, probably explains a lot about the healthcare are system as well.</span></div>
<div class="MsoNormal" style="color: #454545; font-family: UICTFontTextStyleBody; font-size: 17px; margin: 0in 0in 10pt;">
<span style="background-color: rgba(255, 255, 255, 0);">See how easy this can be? </span></div>
<span style="background-color: rgba(255 , 255 , 255 , 0); color: #454545; font-family: "uictfonttextstylebody"; font-size: 17px;"></span><br />
<div class="MsoNormal" style="color: #454545; font-family: UICTFontTextStyleBody; font-size: 17px; margin: 0in 0in 10pt;">
<span style="background-color: rgba(255, 255, 255, 0);">(In reflecting upon this solution, I recognize that I have now personally put any number of nursing, social science, and economics journals out of business, have destroyed tenure for countless academics, and have simplified doctoral theses for any number of graduate students. The only thing left now is to define the extent and the operational mechanisms of idiocy, which in itself remains an expansive topic of study, one that women have been trying to figure out in men since the first Australopithicus said, "Hey, I can walk upright! Guess that lion can't eat me now!" And I have distilled the collected works of Will and Ariel Durant, Jared Diamond, and Yael Noel Harris, all excellent scholars of civilization, into a Cliff Notes version. You're welcome.)</span></div>
<div>
<span style="background-color: rgba(255, 255, 255, 0);"><br /></span></div>
Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com1tag:blogger.com,1999:blog-3594881315778851964.post-60661137631286602952016-05-17T13:45:00.000-04:002016-06-06T08:49:05.657-04:00The New Pet<br />
<div style="margin: 0in 0in 10pt;">
<span style="background: white; color: black; font-family: "arial" , "sans-serif"; font-size: 10pt; line-height: 115%;">Today at the You Can't Make
This Stuff Up Department:</span><span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10pt; line-height: 115%;"><br />
<br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<span style="background: white;"><span style="-webkit-text-stroke-width: 0px; float: none; widows: 1; word-spacing: 0px;">Have you
ever had a chance to fulfill a childhood dream? Has there been something you've
longed for all your life, and now with hard work, effort, and a little bit of
scratch you can finally live out your fantasy? </span></span><br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<span style="background: white;"><span style="-webkit-text-stroke-width: 0px; float: none; widows: 1; word-spacing: 0px;">Meet Bob.
Bob grew up in the Midwest and now lives in sunny California, so when he comes
to Kansas City in April and feels the hint of chill in the early morning air,
he harkens back to the halcyon days of childhood. He thinks about laying in the
grass under a cloudless summer sky, snowball fights on Christmas Day, and
romping through untamed woods and gullies where endless gated communities now
hold court. The only black mark in this nostalgic idyll is knowing that he
never had the pet he always wanted. Sure there were animals in the house, but Nip
the Dog was really his brother's boon companion, and Tab the Cat...well,
belonged to herself, as cats will do. No, he never had a pet that was just his,
something that he could hug and pet and squeeze and pat and rub and caress just
like Hugo the Abominable Snowman and his Pink Bunny.</span><br />
<br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<span style="background: white;"><span style="-webkit-text-stroke-width: 0px; float: none; widows: 1; word-spacing: 0px;">Fast forward
thirty years. Bob's a success. In demand, well respected, flying all over the
country to add to his riches. He's got a wonderful wife, two great kids, two
cars, and a few pets that, just Iike before, seem to love someone else in the
household more than him.</span></span><br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<span style="background: white;"><span style="-webkit-text-stroke-width: 0px; float: none; widows: 1; word-spacing: 0px;">So he
wakes up one morning in the Midlands, having finished his work a day early and
with a full twenty-four hours to himself. He gazes around his hotel suite, the
expensive one with the the soaking tub and the mini-bar that doesn't charge you
every time you jostle a Pepsi, and he thinks, "Today. Now."</span></span><br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<span style="background: white;"><span style="-webkit-text-stroke-width: 0px; float: none; widows: 1; word-spacing: 0px;">He goes
to the specialty pet store. There's something specific he wants, and he's spent
the morning researching where to find it. He buys an airplane carrier for it,
too, because he's going to take it back to California to show his wife and
kids, hear their squeals of delight and their sighs of admiration, and hug it
and pet it and squeeze it and pat it and rub it and caress it.<span style="mso-spacerun: yes;"> </span>Buying this pet is Bob’s ultimate act of
self-actualization.</span></span><br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<span style="background: white;"><span style="-webkit-text-stroke-width: 0px; float: none; widows: 1; word-spacing: 0px;">He buys
it and names it Bosco. He keeps it in the box from the pet store nail the next
morning, when it's time to enter the pet carrier and get on the plane. But
Bosco likes the box, and is young, and afraid, and so Bosco bites. And chews,
and won't let go.</span></span><br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<span style="background: white;"><span style="-webkit-text-stroke-width: 0px; float: none; widows: 1; word-spacing: 0px;">Did I
mention chews? Oh, right. I forgot to tell you. Bosco is a Gila Monster.</span></span><br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<span style="background: white;"><span style="-webkit-text-stroke-width: 0px; float: none; widows: 1; word-spacing: 0px;">Here's
the scoop on the Gila Monster. It's one of the two poisonous lizards native to
the United States , the other being the Mexican Beaded Lizard. They are found
wild throughout the American Southwest. For the record, that's not Kansas. Our
native lizards could be fine domestic companions, which can be surmised by the
fact that nowhere does the word "monster" appear in their names.</span></span></span></span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="background: white; color: black; font-family: "arial" , "sans-serif"; font-size: 10pt; line-height: 115%;">Gila Monsters normally live
underground, are generally shy and retiring, and it seems to take a special
effort to get bit by one.<span style="mso-spacerun: yes;"> </span>This says
something about Bob.<span style="mso-spacerun: yes;"> </span>But you don’t have
to take my word for it:</span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<i style="mso-bidi-font-style: normal;"><span style="background: white; color: black; font-family: "arial" , "sans-serif"; font-size: 10pt; line-height: 115%;">“I have never been called to attend a case of
Gila Monster bite, and I don’t want to be.<span style="mso-spacerun: yes;">
</span>I think a man who is fool enough to get bitten by a Gila Monster ought
to die.<span style="mso-spacerun: yes;"> </span>The creature is so sluggish and
slow of movement that the victim of it’s bite is compelled to help largely in
order to get bitten.”<span style="mso-spacerun: yes;"> </span>-<span style="mso-spacerun: yes;"> </span>Dr. Ward, Arizona Graphic, September 23, 1899</span></i></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="background: white; color: black; font-family: "arial" , "sans-serif"; font-size: 10pt; line-height: 115%;">(While we're speaking of Hispanic
lizards, and especially in this Trumpian moment, I'm reminded of a display at
the Oceanographic Museum of Monaco. There's a tank of small amphibians from
Mexico, really cute little fellows that run about and jump on sticks and eat
bugs and look out at the tourists. The adjoining wall is adorned by a cartoon
version of one member of the company, dressed in a sombrero and holding a pair
of maracas, greeting visitors with a warm, “Hasta la vista, muchachos!”<span style="mso-spacerun: yes;"> </span>It's so cute that not only do you not want to
build a wall to keep them out of the country, but you'll even gladly consider
setting up terrariums along the Rio Grande and provide them with free sticks,
bugs, health care, and college tuition for those eggs that hatch. Of course, it
would never fly in America, but I suppose when your version of undocumented
aliens from south of the border are Syrians you can get away with that.) </span><span style="color: black; font-family: "arial" , "sans-serif"; font-size: 10pt; line-height: 115%;"><br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<span style="background: white;"><span style="-webkit-text-stroke-width: 0px; float: none; widows: 1; word-spacing: 0px;">Bosco is
chewing. He likes this. He has yet to bond emotionally with Bob, and for the
moment thinks of Bob not as his pal for life, but as a probable threat that
just happens to be soft, fleshy, and possibly quite tasty. Bob is macaroni and
cheese, meat loaf, cream gravy; Bob is comfort food. So Bosco keeps chewing,
and won't let go until Bob grabs the carrier with one hand, sticks his other
arm, (Bosco attached) into the box, and whacks his newfound friend against the
rigid plastic walls of the enclosure to make him break his group. Bob thinks
things are going well as he quickly clips the door shut.</span></span><br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<span style="background: white;"><span style="-webkit-text-stroke-width: 0px; float: none; widows: 1; word-spacing: 0px;">Did I
mention that the Gila Monster is poisonous? And that the reason he chews is
because, unlike rattlesnakes who inject their poison through their fangs in
less than an instant, the venom of the Gila Monster slowly flows into the bite
along grooves in the lizard's teeth. So the only way it has to kill it's
struggling prey (or his new best friend) is to chew like there's no tomorrow.
Which, with the life span of a Gila Monster being about a quarter that of a
human being, there may not be.</span></span><br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<span style="background: white;"><span style="-webkit-text-stroke-width: 0px; float: none; widows: 1; word-spacing: 0px;">The swift
blows having done their job, Bosco is back in the carrier and it's time to head
to the airport. Except that as Bob drives, he notices his hand swelling. A lot.
And it's turning colors, reds and blues and purples that he's only seen in
formal photos of the British Royal Family. So Bob does what any normal person
would do in our technological age. He asks Siri to find him the nearest ER.</span></span><br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<span style="background: white;"><span style="-webkit-text-stroke-width: 0px; float: none; widows: 1; word-spacing: 0px;">The
clinical care here is really an afterthought. There are local effects such as
pain and swelling, and more general effects that include weakness and drops in
blood pressure.<span style="mso-spacerun: yes;"> </span>The physician evaluates
the extent of the swelling to determine if there's vascular compromise that
will require emergent surgery (fasciotomy, a particularly nasty procedure) to
release pressure on the blood vessels of the hand. You get some basic lab tests,
start some fluids and give pain medication, and wait. If things seem to be
getting worse, with more swelling, increasing pain, or unstable vital signs,
it's time to find out where the nearest anti venom is. If not, you are often
able to discharge the patient home. Above all, you get everyone you know
(perhaps even flagging down a couple of truckers at a nearby rest stop) to come
see the patient because...let's be honest...Gila Monster bites are cool, and
patients need to be gawked at to be fully engaged in the Teaching Moment of
Animal Safety. As paperwork is always important, it's my understanding that in
cases like this the American Medical Association has concluded it is not a
breach of medical ethics to use the terms "stupid" or
"idiot" in clinical documentation.</span></span><br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<span style="background: white;"><span style="-webkit-text-stroke-width: 0px; float: none; widows: 1; word-spacing: 0px;">What's
more fun is imagining the next day. His right hand freshly bandaged and
splinted, narcotics on board, Bob gets on the flight home. It's an airline
where you can bring a pet onboard as long as it fits in a carrier beneath the
seat. So someone...it could be me...is sitting next to Bob. There's an angry
Gila Monster near my feet, longing to chew through the walls of the carrier and
quite possibly my shoe, sock, and second metatarsal. For me and my fellow
passengers, it's the most nerve-racking three hours in the air since Samuel L.
Jackson had to cope with airborne serpents. </span></span><br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<span style="background: white;"><span style="-webkit-text-stroke-width: 0px; float: none; widows: 1; word-spacing: 0px;">Meanwhile,
Bob is trying to figure out how to explain to his wife that not only did he
purchase a Gila Monster, got bit by a Gila Monster, and almost lost his hand to
that very same Gila Monster, but he is also bringing home that very same Gila
Monster to hug it and pet it and squeeze it and pat it and rub it and caress it
and watch it bite Nip the Dog and Tab the Cat and Delores the wife and Anna the
Daughter and Bob Junior the Son, because there's nothing that brings a family
together like poison-produced pulpy purple puffy painful wounds, even without
the added fun of possible necrosis. And Bob's also reviewing his grade school
knowledge of fractions, so he can figure out exactly how much he's going to
have left in his bank account when Bosco crawls in and Delores walks out.</span></span><br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<span style="background: white;"><span style="-webkit-text-stroke-width: 0px; float: none; widows: 1; word-spacing: 0px;">And as
for me, sitting alongside Bob, my eyes in constant vigil as an evil hiss works
it's way towards my ears from under the seat in front of me? </span></span><br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<br style="-webkit-text-stroke-width: 0px; widows: 1; word-spacing: 0px;" />
<span style="background: white;"><span style="-webkit-text-stroke-width: 0px; float: none; widows: 1; word-spacing: 0px;">I f-----g
hate Gila Monsters on a plane</span></span><br style="-webkit-text-stroke-width: 0px; mso-special-character: line-break; widows: 1; word-spacing: 0px;" />
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Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com1tag:blogger.com,1999:blog-3594881315778851964.post-32834974736381464342016-05-09T10:12:00.001-04:002016-06-06T08:49:16.198-04:00IKEA This! <span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">The Dental Empress and I recently made our second trip to an IKEA store. For those of you who are not familiar with IKEA, it's a Swedish company that...well, I'll let them tell you from their website.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="background-color: white; font-size: 13.33px;">"</span><span style="background-color: white; color: #333333; font-size: 12px; line-height: 18px;">The IKEA Concept starts with the idea of providing a range of home furnishing products that are affordable to the many people, not just the few. It is achieved by combining function, quality, design and value - always with sustainability in mind. The IKEA Concept exists in every part of our company, from design, sourcing, packing and distributing through to our business model. Our aim is to help more people live a better life at home."</span></span></strong></em><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="background-color: white; color: #333333; font-size: 12px; line-height: 18px;"><strong>Ki</strong>tty litter also accomplishes the same goals, but that's not what IKEA does. </span></span></span><span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;"><span style="font-family: "arial" , "helvetica" , sans-serif;">What they really do is design and sell ingenious thematic, space-saving, low cost, build it yourself furniture and related home accessories</span> for urban living. My understanding of urban living might be tempered somewhat by the fact that I've never been a resident of a core urban area, but I think it means residing in extremely tiny and outrageously expensive cubicles in neighborhoods alive at night with the noise of millennial lamenting the capitalism of their parents that got them their college degrees and the lack of safe spaces to whine about it, or in places you probably shouldn't hang out after dark.</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">IKEA is very a cool place. The showroom...and it's huge, not just like a really big Wal-Mart Superstore but Donald Trump HUGE..is laid out in a way that you have to see everything is order to get anything. (This promotes impulse buying of things you never knew you needed, which is why I now have an eight-pack of wooden hangers new kitchen tongs, a battery-powered alarm clock, and two stuffed animals. A fluffy puppy and a Daddy fox with a kit, if you must know.) The products themselves are often quite clever. Designed to maximize function in minimal space, they open, close, expand, contract, twist, and turn, and are able to be mounted on walls, floors, and ceilings in ways you'll never expect short of a zero-G space station. My favorite part of the store is where they've constructed a model apartment with a full kitchen, bathroom, bedroom, living/dining room, and a spare alcove bedroom in less than 600 square feet. It's brilliant stuff.</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">(Just so you know, I didn't buy everything. For example, I put down the fire-engine red heart-shaped pillow with arms that I think are supposed to enfold your child to give them a big hug. Instead, I picked up the pillow and made the arms flail me about the head and face, telling the Empress it was a heart attack. That didn't go over well.) </span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">It's also important to note that everything belongs to some sort of complimentary set, and that each set has a Swedish name. None of these are Swedish words you may have heard of. There is no ABBA four-piece place setting, no Garbo entertainment center, no Vasa sink, no Stockholm Syndrome. Instead, the collections have names like. Oppland, Liatorp, and Stocksund, which according to the Google Translator seem to be made-up words to describe the style, kind of like I'm pretty sure the made-up word "Frito" is a descriptor for the real-life noun "Bandito."</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">So as I was idly looking about while the Dental Empress was taking careful notes to make sure we got the Malm dresser rather than the Hemnes one, I noticed that all the books on the shelves used to fill out the displays are the same. It seems there are about ten individual titles in the entire store, but each one has been used hundreds of times on the shelves. And these are not hollow plastic imitations of scholarship; they complete hardcover books fully printed on each page, umlauts and all. You almost get the sense that IKEA is single-handedly supporting the entire Swedish publishing industry, making works such as "Smultron och Svek" a perennial best-seller. It reminds you of one of those late-night 1980's commercials for Slim Whitman, who reportedly outsold the Beatles in Bulgaria. In a similar vein, you could also say that Annica Wennstrom has sold more than one million books worldwide, without mentioning that 987,000 of them serve as unread fodder in IKEA stores.</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">(Interestingly, where CD's are supposed to be represented, there are only empty jewel boxes. Which means that I have more Swedish music in my home than does IKEA, because I not only have ABBA Gold but also a 1990's CD by Tomas Ledin featuring the song "Du Kan Lita Pa Mej," which I think means "You Can Lita on My Mej." I know this because I also used to watch late-night 1980's commercials for the children's game Husker Du.)</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">The way IKEA works is that as you work your way through the store you pick out what you like, and if there are things that don't fit into your basket you go to the attached warehouse to load up the big items so you can build them yourself at home. And so few hours later, </span><span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">a bit of Sweden has been dragged into the house. ("Look! It's like they're pooping!" exclaimed The Empress as we opened just the end of an eight-foot box, tipped the unopened side skyward, and watched the pieces cascade, one by one, out onto the floor.) Buried within each carton was a set on instructions. The thing the remember is that as an international brand, IKEA has to be able to communicate with anyone regardless of language. So the instructions use pictures only, and the first page begins with a few introductory cartoons. The cartoons show the wrong way to do things on the left, and the correct way to do them on the right. It's kind of like Goofus and Gallant in the old Highlights for Children. ("Goofus leaves as quickly as he can while you're asleep and doesn't leave a phone number. Gallant makes coffee in the morning and says he had a wonderful time.") So one of the cartoons shows a person sobbing because there's a crack in his project from building it on the hard floor; the corresponding picture shows him smiling with the project safely cushioned by a carpet. Another one shows a puzzled man looking at the instruction book; the adjacent drawing shows him calling IKEA for advice. And them there's the picture of one unhappy person looking at a stack of prefab pieces and parts next to two happy ones gazing at the same pile. The message is clear. It takes two.</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">First project is the dresser. The Empress has a tool kit in her house. It contains one ladylike lavender hammer, eight flat head screwdrivers (all the same size) and one narrow Phillips head item, a pair of pliers, a packet of Allen wrenches, and forty plastic cable ties in a rainbow of colors and hues. She also has one cordless drill for which there are no drill bits, but she uses as a power screwdriver. Because I try to obey the admonitions on the right side of the Highlights page (Gallant says "Please use the cordless drill and save your delicate hands;" Goofus says "Go screw yourself"), every minute or so I hear a chirpy, "I'm done! It's because I have a power tool!" Meanwhile, I'm still working on upgrading from moderate to severe carpal tunnel syndrome ratcheting in the second of eight screws, Part #10863. Because I am a supportive boyfriend, I look up and smile at her every time she does this, fighting every urge I have to make some sort of remark about her and power tool (and you can guess where this might have gone, especially in a commuter relationship). </span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">We made it past the drawers in good order, carried the dresser into the closet where it will reside, and put together the storage unit with a minimum of fanfare. The entertainment center, however, was another matter entirely. Multiple boxes, misplaced rods and ratchets, and difficulties fitting pieces together made it a less than joyous coulee experience. The pot came to a boil after I asked her to tip the piece as a whole up so I could attach the top, and as it did I heard the sickening crack of particle board, splitting the wood over both of the bolts that would secure the bottom of a piece backing up the TV to the rest of the structure.</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">"F--k a duck with a f-----g duck f---k.!" I exclaimed. (Even when I curse, I like alliteration)</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">She peered at my with Marlin Perkins interest. "You're mad."</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">"No, I'm not. I'm frustrated. That's different," I lied.</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">"Well, it's not my fault. I helped just like you told me to."</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">I can see where this is going. I'm going to try to bail out the sinking ship, but still make my point. Bad move.</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">"You're right. I should have told you to keep a hand on that piece while it was moving so it wouldn't fall backwards. I thought you would do that and I didn't specifically tell you to. It's my fault."</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">"Yes. Well, it's fine." (Fine is never a good word in a relationship.) "It's on the back and nobody will see it."</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">"No, it's not okay. It's not fully structurally intact. I don't think it's a major problem but it's not okay."</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">I'm not the most self-aware person, but one thing I do know is that after the initial explosion, my voice drops a few scales and I start talking in a slow, measured fashion. I'm now in full James Earl Jones, deep Mississippi mode. She knows this. She thinks it's hysterical that this is the only thing that can shut up my otherwise constant chatter. </span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">"You're seething." There was that a note of glee in her voice.</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">Still looking straight ahead. My teeth are set, my mouth doesn't move. I'm like a bad ventriloquist looking to project my voice somewhere, anywhere at all. </span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">"No, I'm not. I'm frustrated. That's different." </span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">(I've also officially run out of new things to say.)</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">It's now the sound of triumph tinged with just enough righteousness. "No, it's not."</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">It's at this point that I'm looking around the room for some kind of distraction, and my eye falls upon the last page of the instruction book. And it's at that moment that I realized why there was no cartoon of happy people rejoicing over the finished product after the final step. The Swedes may be many things, but they are not liars. For not only have they lured you into buying their products, they are now going to play the ultimate Nordic prank on you, the one that makes up for them all having Seasonal Affective Disorder and being unable to uproot Julian Assange from the Bolivian Embassy. They knew that the after picture should show only the finished project, and not the carnage in blood and relationships that follow.</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">Despite the temporary setback, the Empress and I set things right. We managed to back the entertainment center into a corner so the broken piece is leaning against a wall. And then we went to a local bistro and had two bottles of wine and smoked a hookah flavor called 50 Shades. Afterwards it was 1 AM </span><span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">Steak N Shake for Takhomsak Chili Mac with extra cheese. Gallant says, "May I pour you a nightcap?" And The Empress says, in her best Eva Gabor voice, "Of course, dahling." It's all good.</span><br />
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 13.33px;">(PS: For more information about Sweden, I would refer you to The Suite Life on Deck, "The Swede Life." In a related note, The Teen tells me that the question of London or Bailey is this generation's version of the "who do you choose" quandry. And just so you know, the correct answers to the classic questions are Mary Anne, Julie Newmar, Veronica Lodge, Jennifer Marlowe, and the Green Orion Slave Girl.)</span>Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com0tag:blogger.com,1999:blog-3594881315778851964.post-35109289613824013102016-05-02T09:46:00.000-04:002016-06-06T08:49:27.705-04:00Baby Come Back<span style="font-family: inherit;">Death is final. The end. El fin. It's the existential dread of Homo sapiens, the only species we know of that contemplates it's own mortality. So it's surprising to me how many people come to the ER and say they want to die. Their numbers keep rising, and it's a fair argument to try to figure out why and to assign the requisite blame. (I've even heard the suicide rates of middle-class white men being tied to the rise of Donald Trump.). But while there are truly desperate people out there who need genuine help, it may be surprising to learn that they're usually not the ones who I see in Sinatra's wee small hours.</span><br />
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<span style="font-family: inherit;"><br /></span><span style="font-family: inherit;">That is not to diminish the very real pain of those who are truly hopeless. The ones we're talking about those for whom an attempt at suicide is just an event. People who actually want to commit suicide see it as a resolution. They are they ones who often present in advance, recognizing their suicidal thoughts but not wanting to surrender to them. These are the true "cries for help," and with a bit of experience you can identify them almost immediately. Their despair is palpable, the air between you thick with emptiness, and as you talk you begin to feel that suicidal thoughts are probably not a sign of illness, and that suicide is a conscious, rationale, and even reasonable option. And there are truly suicidal patients who are found by friends or family unconscious and unresponsive, keeping everyone in the dark about their plans, and who are genuinely disappointed that it didn't work and often puzzled by their failure because they've done their research in advance. These are the people in true crisis for whom we should bend every rule and twist every arm to get them the help they need.</span><br />
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<span style="font-family: inherit;">Ah, but then there's the rest, the ones who make up bulk of our "suicidal" clientele. These are the folks who respond to life's stressors by chasing down some vodka and few Tylenol, perhaps guzzling down a handful of their psych medications for good measure, and then call everyone they know (and especially the ex) to let them know they're killing themselves. There is wailing, thrashing, and tears. There is also a lot of texting and cellular calls. This is not a cry for help. This is attention-seeking behavior, or (to use a technical term) a "dramarama." It's the ER equivalent to the Security Theater performance of the Transportation Security Administration. </span><br />
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<span style="font-family: inherit;"><span style="background-color: rgba(255, 255, 255, 0);">While experience gives you a gut feeling abut who's really suicidal and who's not, there are some objective clues to guide the neophyte. First, there's no lethal mechanism involved. This might not have been a clue in the pre-Internet era, but today anyone with a cellphone can figure out how much of what medicine to take to kill themselves. Similarly, if you want to kill yourself by jumping, or with a gun, you don't sit on the railing of a bridge and think about it until someone pays attention, or wave your gun around to make sure it gets noticed. And speaking of cellphones, if you've texted and called people (especially the ex...that wasn't a joke) to let them know what you're doing, you're not in it for real. And they don't put it on a "to do" list, as did one patient whose list, on a thin notepad festooned with flowers and tiny kittens, included things like "buy groceries" and "kill myself." </span><span style="background-color: rgba(255, 255, 255, 0);">(I'm not making this up.) </span><span style="background-color: rgba(255, 255, 255, 0);">People</span><span style="background-color: rgba(255, 255, 255, 0);"> who truly want to commit suicide just get on with it.</span></span><br />
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<span style="font-family: inherit;"><span style="background-color: rgba(255, 255, 255, 0);">A second clue is that the patient, when confronted with the fact that their "attempt" is going to result in consequences, is suddenly no longer suicidal. Patients with psychiatric disorders can certainly have labile moods, but you can't turn depression on and off like a light switch ("It's a clever little Mormon trick."). You don't go from wanting to quit life to laughing and smiling when friends and family (and especially the ex) arrive, ideally to fawn over your poor lost soul. One of the questions I always ask patients is, "If I gave you a clean and painless way to kill yourself right now, would you do it?" It's the ones w</span><span style="background-color: rgba(255, 255, 255, 0);">ho immediately answer "yes" in a firm voice, no tears, looking me straight in the eye that I worry about. If you're investing your energy in weeping and wailing and calling and texting (there's that cellphone again) and wondering where your beloveds (mother, father, boyfriend, girlfriend, or ex) is, you've got no intestinal fortitude for what you claim to have done.</span></span><br />
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<span style="background-color: rgba(255, 255, 255, 0);"><span style="font-family: inherit;">A corollary to this is that patients who are not truly suicidal refuse to cooperate with care when informed that labs may need to be drawn and they may be held in the ER for psychiatric screening, claiming they have "rights' and we can't "make them do anything." We do inform them early n that since they made a suicidal gesture, the law obliges us to hold them for their own safety until they are cleared; and that we hope that they'll cooperate with us in what we need to do. The truly suicidal accept this with resignation. They're beyond caring what happens to them or why. The dramatists rebel, and sometimes it gets ugly. They're also the ones who specify what hospital admissions and discharge plans are acceptable to them, and threaten to call their lawyer. (Standard response: "Go ahead.") But no matter what they ask for a meal tray and a Sprite within 45 minutes of arrival. You can time it.</span></span></div>
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<span style="font-family: inherit;">It also shouldn't be forgotten that there are other kinds of secondary gain from claiming suicidal thoughts or tossing down a few pills. There are a number of "regulars" who are quite skilled at playing the "suicide card." If you have no place to stay, you now get food and lodging for at least a night at a local psychiatric clearinghouse. If you were going to jail, perhaps now you don't. If you're lucky, maybe you even get admitted to the hospital and Case Management invests time in finding you a place to live or getting you signed up for benefits and services. And if nothing else, at least you have time to sober up in a warm, clean place. The psychiatric clearance process often takes time, and at night that usually means you're with us 'til sunup.</span><br />
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<span style="font-family: inherit;">So for many patients who come is with a suicide attempt, especially involving an overdose, they know it's all about attention just as we do. But our medicolegal system, as well as our cultural belief that no one is responsible for their own actions, means that we have to maintain some kind of fiction that something needs to be done rather than just simply calling someone out on their script. That fiction is called the psychiatric screen, and the resultant "Contract for Safety," where the patient agrees in writing to call for help as needed and to follow-up with counseling., because every truly suicidal person is going to be help up by a signature on copy paper. </span><br />
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<span style="font-family: inherit;">But here's the paradox of clinical practice. I really don't mind taking care of these folks. It's fun to watch the show. It's admittedly kind of a power trip to tell people what they can and can't do know that they're on your turf, and watch their faces as they realize they've set events in motion far beyond their control. They're easy patients as well; with very few exceptions, modern overdose management is simply watchful waiting. And from a workload standpoint, it's great. They often need several hours of observation based on the peak blood levels of the drug they took, and then several hours after that to arrange a psychiatric disposition. Which means they clog your rooms up for quite some time, decreasing your patient turnover and ultimately your overall workload. The bean-counters who have never touched a patient but still grade you on throughput time as a measure of "quality" hate it, but from the standpoint of the working doc they prolonged ER stay in entirely justifiable and quite welcome, thank you very much. </span></div>
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<span style="font-family: inherit;">(This is where I take moment to lament the loss of a what we might call "educational" therapy. It is often true in medicine there are both easy and hard ways to achieve the same result. For instance, I can resolve a case of gonnorhea with with a shot in the butt of an antibiotic called Rocephin or with a large oral dose of a different antibiotic. Which one you get depends on how you've treated the ER staff, and if I think you're the victim or the perpetrator. If I think you need a strong disincentive to your continued risky behaviors, or you've been a jerk yo the nurses or to me, you get the shot. It's educational, in that you learn the difference between acceptable and unacceptable behaviors. Twenty years ago, we had a lot of "educational therapy" in overdose management. We'd take these huge half-inch plastic tubes called Ewalds and shove them down the patient's throat into their stomach, under the premise that we were going to wash out their stomach with a tube big enough to get out all the pill fragments. Or maybe we'd just give them a nice big slug of ipecac so they could vomit and puke and upchuck for hours on end. These actions would not only be therapeutic, but serve as disincentives to engage n the same behavior in the future. Alas,science has deprived us of some of it's fun, as it turns out that with rare exception there really re no pill fragments to go after, and by the time the patient gets to the ER there's really nothing left in the stomach to barf up. About all we get to do is make you drink some grainy powdered charcoal...just like in your grill but without the impregnated lighter fluid...if you show up within an hour of your overdose. Maybe if you refuse the urine test we restrain you and pass a catheter into your bladder, but that's about it anymore. Sigh.)</span><br />
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<span style="font-family: inherit;">Most of the one-act plays we see are attempts to curry favor in a relationship. I've never been able to figure that out. It seems to me that if I'm dating (or have just broken up with) someone who takes a bunch of pills in an effort to make me feel bad, the long-term prospects of that relationship are pretty poor. Whenever I think about this, I'm always reminded of the college student I saw while working in Daytona Beach. He was down there for Spring Break, and found his girlfriend walking the beach with another guy. By the time I saw him, he had already taken a few swings at a paramedic, which meant now he was spread eagled on a cot in four-point restraints, and not in a fun, Stevie Nicks, leather-and-lace filled way. </span></div>
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<span style="font-family: inherit;">As I recall, our conversation went something like this:</span></div>
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<span style="font-family: inherit;">Me: "Hey, I'm Dr. Rodenberg. What's going on?"</span></div>
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<span style="font-family: inherit;">Him: "Fuck you, man."</span></div>
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<span style="font-family: inherit;">That's as far as I got in Round 1. The paramedics filled me in on the rest. His girl had gone off with another guy, and he decided to get back at her by taking four...count 'em, four...Tylenol. For the record, I take four Tylenol for a headache. (Yes, I know that's technically an overdose, but I can calculate my weight-based toxic dose so I'm good. The lethal amount can be found online by anyone who's serious about suicide. See above.). He took the Tylenol, then called the girl, who called the police but, in what I can only assume is a flash of insight and maturity, did not return to their hotel room to offer comfort or solace.</span></div>
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<span style="font-family: inherit;">There are other educational interventions besides tubes and purgatives. Reality testing, for one. </span></div>
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<span style="font-family: inherit;">Me: "So I hear you took some pills to piss off your girlfriend. Where is she? is she here now?"</span></div>
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<span style="font-family: inherit;">Him: "She's fucking Bobby."</span></div>
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<span style="font-family: inherit;">Me: "So how's that working out for you?"</span></div>
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<span style="font-family: inherit;">Him: "Fuck you."</span></div>
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<span style="font-family: inherit;">The truth is a harsh mistress. Maybe even worse than an Ewald tube.</span></div>
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<span style="background-color: rgba(255, 255, 255, 0);"><span style="font-family: inherit;">(While this particular entry into the blogosphere addresses those who say they want to die but really don't, let's not forget that there are two related groups in this discussion as well. The first are those people who don't want to die but have done everything in their power to do so. These are the morbidly obese, the ones who can't be bothered taking their medications or seeing the doctor. It's those whose eating habits and lack of exercise are practically invitations to death. It's the smokers, the alcoholics, the drug abusers. You can make a case...weakly, in my opinion, but at least more than for fibromyalgia...that these people have different physiology, that they react differently to stressors and stimuli, and that they are subject to unique and oppressive psychosocial and economic factors resulting in health issues that are not really their "fault." There may perhaps be some truth to that, but there's also truth to the fact that we can choose a healthy lifestyle and that we can take advantage of community resources to help us with our issues. Because we're no longer willing to build personal responsibility into our health care policies, we keep wasting time and effort giving first class medical care to those who don't care enough to do their part. I have no problem caring for someone who's done damage to themselves but is now doing their part...quit smoking or drinking, losing weight, following-up with their own physician. For those who accept no responsibility for their own well-being, at some point our expenditures have to stop. The devil, or course, is in the details. The solution lacks the clarity of what we might call the Jean-Luc Picard Limit. (The line must be drawn here! This far, no further! And I will make them PAY for what they have done!)</span></span></div>
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<span style="background-color: rgba(255, 255, 255, 0);"><span style="font-family: inherit;">Sadly, there's also the other category of people with terrible illness who want to die and you absolutely understand why. There are people with terminal cancer in perpetual pain, those in end-stage heart failure or emphysema where every breath is agony, and patients with degenerative neurologic disease who can't move, eat, or speak. If they say they want to die, it's because it's the last moment of control they have over their own lives when disease has stripped them of everything else. We don't do physician-assisted suicide in the ER. But I will ask these patients and their families if they really want to be fully evaluated and admitted, or can we just do something kinder and gentler, like give you some pain medicine for home and perhaps a bit of steroids to improve your appetite? You'll be surprised how many of these kinds of patients just want to go home and be in peace, and they seem grateful that someone's willing to join them on the plank. And I'll confess that, when I sense that's what going on in a patient who can't speak for themselves, when I see that look of resignation in their eyes, I'll choose a tone of voice for the family that suggests the right answer. Sometimes you need to go gently into that good night.)</span></span></div>
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Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com1tag:blogger.com,1999:blog-3594881315778851964.post-21106743548405766342016-04-21T19:18:00.000-04:002016-06-06T08:49:49.415-04:00FYI<span style="font-family: "arial" , "helvetica" , sans-serif;">I recently saw on Facebook (which is my main source of information concerning cute animals, illustrated recipes, and childhood photos of people I don't recognize and, I think, never did) an advertisement for the Eko Amplified Stethoscope. (Eko, because in America spelling doesn't count, and English majors stay unemployed.). At first glance, this is a great thing. The built-in receiver detects even the faintest heart beat or Korotkoff sounds (yes, I said that just to be pretentious...go look at up, and then recall Dr. Nikolai Korotkoff, who was a Russian surgeon during the Russo-Japanese War. And whom, like Rene Laennec and other folks who came up with some audible medial clues, died of tuberculosis at a young age. I need to get this cough checked out.) The idea, and it's probably true, is that the amplified stethoscope improves the accuracy of your exam in noisy environments like the cacophony of the ER or amidst the siren's blare of the ambulance, which one might think of as the Official Folk Song of the ER. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">(Speaking of which, I just placed an order for a doormat that says, "Ring the Bell and Let Me Sing You the Song of my People." It's signed, "The Dog.")</span></div>
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I don't want an amplified stethoscope. The reason for this is that I'm pretty sure that it will make me hear things I've never heard before, and then I'll have to think about what to do with all those extra splishes and splashes and noises and squeaks. Given that ignorance has long been my bliss, I'm convinced the amplified stethoscope will give me too much information, most of which I ahve no idea what to do with once I know it. While I can think deeply when pressed to do so, I',m porne to be intellectually lazy, and there are lots of things in this world that I jsut don't want to know. It's kind of like thinking of your parents not as the paterfamilias they've become, but as the young and hormYou know you're a product of their coupling, but you have no <span style="font-family: "arial" , "helvetica" , sans-serif;">desire to know any of the whys and wherefores and certainly none of the how. It's simply too much information, and painful to boot.</span></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="font-family: "arial" , "helvetica" , sans-serif;">Too much information seems to be a pervasive theme of modern life. Too many channels. Too much media. Too many pundits. Too many websites (though I do give my highest recommendation to I F---ing Love Science, </span><a dir="ltr" href="http://iflscience.com/" x-apple-data-detectors-result="1" x-apple-data-detectors-type="link" x-apple-data-detectors="true"><span style="font-family: "arial" , "helvetica" , sans-serif;">iflscience.com</span></a><span style="font-family: "arial" , "helvetica" , sans-serif;">). Too many commercials. Too many infomercials. Too many options for loans and insurance and retirement plans and mortgages and credits cards. Ron Burgundy said it best, just before the knife fight: "There's too much news!" (For the record, The Teen and I are hard-core devotees of the Anchorman franchise. When we think about science, of course we think about Madam Curie. We can't see a cat without thinking "Chicken of the Rail Yard." This would seem to unnerve our dear departed Baby the Cat, who seemed to understand English just enough to know that while we loved him today, in the event of of a famine he was the first to go, breaded and fried with a side for Whammy Slaw. He...The Teen, not the cat... has also agreed, if he ever gives a public speech of note, to include the phrase "together we can defeat voodoo" as a tribute to dear ol' Dad.). While the surplus of information is probably nothing to the members of Generation X, Y, Z, or DD (oops...got sidetracked) it's overwhelming to a guy who grew up with four TV channels, the local paper, and the triumvirate of Time, Newsweek, and US News telling me all I needed to know. If I wanted to get shouted at, I didn't read an e-mail or text in all caps; I just turned on The McLaughlin Group. (Moor-TON! Bye bye!) Any thing else you needed was found at the public library in the depths of the Reader's Guide to Periodical Literature and that thirty volume Internet we called the Encyclopedia. You didn't need to research all your consumer options, either. Your pharmacy was local, you grocery perhaps just a bit farther away, it was a big deal to go downtown to a department store, and the local bank that handled all your financial needs and gave you a free toaster with a new account. Was it better, living in a relative degree of ignorance? Maybe, maybe not. Was it easier? Unquestionably. </span></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">(Okay, time for a bit of a rant, because I NEVER do that on my blog. I recall when I was thirteen and got a paper route, I went down to the local bank to open a checking account. It was a pretty proud moment. I put in my initial deposit...probably in the two figures...got my checkbook, and learned how to use the ledger. So when I thought about opening an account for The Teen at our local bank (and I will call out names...CoreFirst in Topeka), I figured it would be the same process. Oh, but it's no so easy anymore. I've recently received a letter form the bank entitled "Exciting Checking Account Changes are Coming!" The changes, of course, are more fees. There's a $7.00 fee if you don't have a total of $5,000 in savings, checking and D's; an active credit card; or 20 or more debit card transactions per month. In addition, if you don't sign up for electronic statements, it's another $3.00 per month. So there's $120 per year in fees to gain access to your own money. It's like someone intentionally sat down to come up with every possible punishment for those of lower income, like young people and the poor, to use banks all the while knowing that they're forced to do so because everyone needs to deposit their paycheck somewhere. It's legal, no doubt, but it's totally heartless. And I'm looking for a bank with what I think are better ethics to move my money, but guess what? They're all the same. Perhaps the theory is to teach kids early on that the banks are out to screw them. That way, there's no surprises when your faith in an institution gets shattered later in life.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">Here's another example of how screwed up banks have become. Remember the crash of 2008, mostly fueled because banks were giving home loans to people who couldn't afford their mortgages or had poor credit? Two months ago I went to finance a home purchase. I felt pretty good about the financing, especially because I had heard about "physician loans" that would allow you to purchase with only 5%, or even 0% down. What a deal, right? But as I called around to banks, it turns out those loans were available only for doctors just out of residency or in the first 10 years of their practice. </span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">So as I now understand, if you just got out of your training program without any track record of holding a long-term job and have several hundred thousand dollars of student debt, we'll give you a loan up to the high six figures with nothing down. But if you've been out a while, have a good credit score and some resources built up, we're going to make you pay 10% up front. The whole thing makes no sense, and with loan polices like these...this a "reputable" lender...and the fact that nobody who helped to engineer the financial crisis has been made to take any kind of personal responsibility for their actions it's just a matter of time of time before the next crash. </span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">I just realized I sound like Senator Sanders. Didn't see that coming. But sometimes you just have to Feel the Bern.)</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">My professional life is not spared this deluge of data. There are a few reasons for clinicians to love Electronic Medical Records (EMR) and a lot of reasons to hate them. TMI (Too Much Information) is one of the latter. Your typical EMR can be thought of as a list, or perhaps a timeline, that captures everything that happened to a patient from prehistory until now. It documents every prescription they're on, any medications they've had before, any encounter with the healthcare system, and any phone call they've ever made. This is great if you want to look up a past hospitalization or an old lab test or X-ray report, or just bill Medicare or Medicaid out the wazoo; it's awful if you want to try to sort out what's going on wth the patient or why they are there to see you today. The EM does not organize, stratify, or prioritize; it does not differentiate current from past problems and therapeutics; and the data presented, in simple shower of output, often bears absolutely no inherent relation to clinical care. While it's true that if you're familiar with the system and you know what you're looking for, you can eventually find it (click click click G-d dammit click click click), if you're wanting a quick and intuitive synopsis of what's going on today it's simply not there. It would take a clinician to tell the EMR folks what we need, and to guide the EMR vendors into building filters that are relevant to clinicians, but as we have all come to know provider input means nothing when billing systems are involved. (And let's make no mistake about it; the root of the EMR is the ability to produce a detailed, supportable bill. Anything else the EMR does, like the real patient safety benefits, the occasional data collection, and the time-consuming and mind-numbing barriers it places between the doctor and the patient, is a side effect.)</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Where I feel this most acutely is not in entering patient data and orders. I'm fortunate that the institution where I work uses voice-activated dictation, because my typing skills are from the pre-digital age. But over the years I've found myself increasingly compulsive in trying to get a quick look through the EMR before I go into a patient's room to see what morass might await. Because I've been working with our system for almost five years and I generally know how it works, I can usually find the latest hospitalization, lab test, or office visit. However, trying to print out the data I need (I'm not good at memorizing a screen and then trying to recall it minutes or hours later) means that I'm forced to print out everything that ever pertained to that visit, including past and current medications, problem lists from the last decade, and all kinds of billing information and timelines. What I need is about a paragraph; what I get cuts down a forest. Too much information.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">I also get too much information from the patients themselves. There's a thing you do in the patient interview process called a Past Medical History, where you ask the patient what other medical problems they might have. There is also the Review of Systems, where you ask about the presence or absence of other medical complaints in order to help fortify to exclude your initial working hypothesis. As long as you get a solid answer, this is helpful. More often, you get someone who says they have to "think about it." I generally subscribe to the idea that if you are otherwise fully within your faculties, and you can't recall if you have a medical problem or not, it's not that important an issue. Similarly, if I ask you if you have a particular symptom and you have to think about your answer, then answer is really no. Priorities matter. (Because patients are lazy thinkers as well, the second most common answer is , "I don't know. You people have that somewhere. Go look at my chart." It's clearly too much to ask people to Keep Track of their Health when they're busy Keeping Up with the Kardashians.) </span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Nurses also unwittingly contribute to information overload. I do understand that at some point in the development of our medical food chain, it was mandated that nurses often have to ask doctors for permission to perform even the simplest of tasks. I'm not in favor of that; for nurses to have to ask permission for everything is demeaning to them as professionals. But somehow this has morphed into the idea that nurses also need to inform the doctor of everything. Patient is in pain. Patient is nauseated. Patient wants something to eat. Patient wants visitors. Patient wants more pain medicine. Patient needs a ride. Patient is now threatening suicide when you've refused their ride and pain medications because they don't want to walk to The Mission. Patient wants to leave because it's taking too long, or they need to be somewhere (usually court). And it's not like the nurses, most of who are extremely capable individuals and know things about patient care and the healthcare are system that are way beyond my pay grade, can't handle these issues themselves, often with better outcomes then with the intervention of a tired, overloaded physician.</span></div>
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<span style="background-color: rgba(255, 255, 255, 0);"><span style="font-family: "arial" , "helvetica" , sans-serif;">(It's tending to the latter that bothers me the most. I've never understood why, if we're up to our tails in gators, we are supposed to drop everything, gather at the patient's side, hold hands and sing Kumbaya, and beg them to stay. Why is the rate of patents who leave Against Medical Advice, who leave without being seen, or who simply elope from the ER, some sort of "quality measure" that doctors, nurses, and institutions are measured on? Isn't "self-triage" a good thing? Don't we want people to take responsibility for their own health, to use their own judgement regarding their need for emergency care? Of course we do...unless those patients are leaving so fast that we can't run up a bill for their visits. I think a great clinical study would be to follow-up on patients who leave the ER on their own accord to see if they actually have any resultant medical issues. But that's above my pay grade.) </span></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">I'm most troubled by the incessant dispensing of nursing information, and the subsequent requests for action, because they come in an environment where nurses are simultaneously demanding more autonomy in medical decision-making and patient care. We see this most prominently in the public policy battles for nurse practitioners to be able to practice outside the supervision of a physician. The push for nurses to function autonomously in the community stands in stark contrast to the abject dependency of nursing practice in the hospital, and seems to expose an inherent contradiction. Either you are an independent professional or you're not. It doesn't seem logical that you can have it both ways.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">(I suppose the nursing ranks could claim that nurse practitioners deserve the right to practice independently because they often have an advanced degree...usually a Master's...as opposed to a Bachelor's or Associate degree for most hospital and office-based nurses. But this seems a spurious argument to me. The training of a nurse practitioner really consists of a year of lecture and a year of supervised preceptorships, which means you sit next to a current nurse practitioner and watch them do things. It's no comparison to the three years of clinical training after four years of medical school that a family physician must have, and it seems incongruous to suggest that an independent nurse practitioner without a similar tenure of supervised work can provide the same level of clinical care.)</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="font-family: "arial";">I</span><span style="font-family: "arial" , "helvetica" , sans-serif;"> am an absolute advocate for collaborative Physician/Nurse Practitioner care. (I feel the same way about working with Physician Assistants). I think these models feature the best of both worlds. Nurses tend to look at psychosocial things doctors don't and can extend the reach of a clinical practice into underserved areas in a cost-effective manner. Physicians represent built-in consultants for management of more complex or problematic patients. Personally, I value the the nurse practitioner as a colleague to discuss problems and ideas from a different point of view. When I'm asked questions by mid-level providers about my diagnostic approach, treatment plans, or simply physiology, it helps keep me focused on the job at hand. (And selfishly, nurse practitioners are able to do those longer procedures, such as suturing, that otherwise take me out of the flow of the ED.) </span></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="font-family: "arial" , "helvetica" , sans-serif;">If nurse practitioner want to be independent practitioners, so be it. But then make them undergo further supervised practice equal to the level of care they wish to provide (three years for family medicine), loosen the apron strings on hospital nurses, and have everyone understand that they will have to accept the responsibility that goes along with an independent practice. To me, that answers the conflict between primary care outpatient and inpatient servile nursing efforts. And responsibility doesn't mean just liability for their actions. I also means giving up automatic physician backup, losing access to a physician referral system, and encountering increasing economic hostility from the medical profession as third-party payers direct their clients to less costly nurse practitioner care. In my own little world, independent nurse practitioners will just add to my workload...another group of folks who will feel entitled to do what most community-based physicians already do with a problem they can't handle, after </span><a dir="ltr" href="x-apple-data-detectors://9/" x-apple-data-detectors-result="9" x-apple-data-detectors-type="calendar-event" x-apple-data-detectors="true"><span style="font-family: "arial" , "helvetica" , sans-serif;">4 PM</span></a><span style="font-family: "arial" , "helvetica" , sans-serif;"> and on weekends, nights, and holidays, or with someone they simply just don't like...send them to the ER. And Lord help us if we get overwhelmed and the patient wants to leave. Better drop everything, grab that turkey sandwich and a Sprite, and get ready to sing.</span></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">(I'm drafting this on a plane descending into Atlanta, and we're passing through a low-lying cloud. A cloud is composed of billions of water molecules suspended in the atmosphere, drawn together by the most minute attractive forces. The molecules themselves are layered to together in such a way that collectively the cloud is totally opaque, but the spaces between the molecules are so vast on an atomic scale that you can fly through them without any resistance or obstruction. You do so in a multi-ton chunk of metal that stays aloft simply and only because air flows faster over a curved surface than a straight one. There's no reason on G-d's Green Earth it should work, but it does. I f---ing love science.)</span></div>
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Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com1tag:blogger.com,1999:blog-3594881315778851964.post-35261093127875376272016-04-16T21:00:00.000-04:002016-06-06T08:48:55.555-04:00EterniCat<div class="p2" style="background: white; margin: 0in;">
<span style="color: #454545; font-family: ".sf ui text"; font-size: 13pt;">I inherited a cat three years ago. Baby was a divorce cat…when we split, the ex
said she couldn’t take care of both the cat and the dogs, and was going to take
Baby to the shelter…so how could I refuse to take him in? He was a pretty good cat for a guy living by
himself…he’d sit on top of the sofa, go out, come in, eat food, steal my food, and
occasionally we would play a game called “Cat Airlines” when I would launch Cat
Flight 328 from the Dining Room table to the Couch, ETA 2.1 seconds from
takeoff. He was also a fine muse, being responsible for my own personal modifications of Player's "Baby Come Back" ("Baby the Cat! Any kind of fool could see...there was something, in your really stinky cat breath") and the King of Pop's "PYT" ("I want to pet you! BTC! Baby the Cat!"). Baby was also the source material for a song co-written with my son called "Baby the Cat Pooped on the Rug in There," which could be adapted to many different musical styles, but usually with the same crappy outcome. Or output, in this case.<o:p></o:p></span></div>
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<span style="color: #454545; font-family: ".sf ui text"; font-size: 13pt;">Anyway, poor Baby went to the Great Litter Box in the Sky a
couple of months ago. I had boarded him
at the vet’s office while I was out of town, so it was decided that Baby would
be cremated and then I could put his ashes in the backyard. What I didn’t realize was that his ashes
would come back to me in a small white box with the name “Baby Rodenberg”
printed on the front.<o:p></o:p></span></div>
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<span style="color: #454545; font-family: ".sf ui text"; font-size: 13pt;">I forgot to take the box out of the car, and it sat in the front
passenger seat for a few more days until the next time I was traveling. I pulled up to the Park-N-Ride near the
airport and turned over my keys to the attendant. As I did, I saw him stiffen up when he saw
the box containing the ashes of Baby Rodenberg waiting to be chauffered to the
lot.<o:p></o:p></span></div>
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<span style="color: #454545; font-family: ".sf ui text"; font-size: 13pt;">I still keep Baby with me in the car. The love of a cat…or at least it’s ashes…is a
gift that keeps on giving.<o:p></o:p></span>Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com1tag:blogger.com,1999:blog-3594881315778851964.post-58295390543318002612016-04-08T15:47:00.002-04:002016-04-08T15:47:57.819-04:00"One, Two, Three Four, Can you Gag a Little More?"While I would by no means consider myself an authority on anthropology, neurobiology, or psychology (if I was, I would have stuck with the right girl the first time and not been divorced twice), I do think that mankind has some kind of deep seated drive to quantify things. If not, we'd be happy knowing only the difference, as apparently the parrots do, between one, two, and more. There would be no notches on a stock, no quipus, no abacus, no computer, and no Starcraft, where the desire to quantify is linked to the need to construct additional pylons. <br />
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We quantify quite a bit in medicine, too, and we do so using scales. For the biostatistically challenged among us (that's <u>all</u> of us), there are three kinds of scales. Nominal scales are used for mutually exclusive, not ordered categories. An animal can be a frog or a giraffe, but not both, and you can't assign any particular value to the difference between them. Ordinal scales involve orders and ranks, but again without a quantifiable difference between them. I like chocolate mint ice cream better then French vanilla, but I can't tell you how much. (Pain scales and patient satisfaction scores fall it this realm). Interval scales are measurements where the difference between the values are meaningful and quantifiable, such as height, weight, temperature, and lab values. There are also musical scales, which really only play a role in clinical medicine when watching the patient in the "Seclusion Room" sing an incomprehensible melody to himself punctuated by pelvic thrusts and shouts of "Bueno!" <br />
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(Speaking of which, the use of satisfaction surveys has gotten totally out of hand, and I'm not even referring to those annoying patient satisfactions surveys, upon which Press Gainey and their ilk have built an empire of flaming straw. I'm thinking of an online survey I filled out about a hotel I stayed at in Phoenix a few weeks back. It was a reasonably nice hotel...the Doubletree Resort in Scottsdale...and I had no issues with my stay. So in the online survey I gave the hotel "8's" across the board. Nothing wrong with it at all, and I'd be happy to stay there again. But moments after the survey was submitted I got a note of apology from the Manager. I actually wrote back and said that everything was fine, I had no complaints, there was no need to apologize. But apparently the Hilton system rates anything less than a 9 as unsatisfactory. So even though I'm perfectly content, this poor man is now having someone thousands of miles away in corporate put a knock on his record. What was the guy supposed to do? Send the actress who plays Clara in Dr. Who up to give me a nubile foot rub? It's mad, it really is. But I digress.)<br />
<br />
Interval scales have long been the "gold standard" in medicine, but in our interest to quantify the unquantifiable and make sure that people who can't do get tenure, we come up with fluffy ordinal things like the 0-10 pain scale (sorry, you can't have a twelve, because ten is unconscious) or the nebulously nominal Prochaska Transtheoretical Model of Stages of Change, ranging from Pre-Contemplation ("I haven't thought of that yet") to Termination ("Been there, done that, got the tee-shirt"). We've explored other examples in this blog as well, most recently "Merrily We Troll Along," January 1, 2015.<br />
<br />
Which leads me to the latest effort in qualifying a patient care parameter. One of the core tenets of emergency medicine is preservation of the patient's airway. In cardiac arrests, for instance,you can do all kinds of nifty tricks with drugs and electricity, but if the patient's airway is compromised...meaning they can't move air in and out of the lungs...the game is up before you even start to play. So making sure a patient, especially an unconscious or lethargic one, is going to be able to keep their airway open is key. The easiest way to to do this is the cheek the gag reflex. If that's intact, the airway is probably okay (at least for the moment), and you can turn your attention to questions of oxygen exchange within the lungs themselves rather than worrying if the oxygen can even get that far. An intact gag reflex also means that if patient vomits up gastric contents (a clinical way of saying Spaghetti-O's and Jello Pudding), this gastrointestinal smorgasbord will not get sucked back into the lungs.<br />
<br />
You check the gag reflex by use of a tongue blade (popsicle stick), gently inserted into the patient's mouth until you touch the back of the throat to elicit the response. The tongue blade is gently inserted unless the patient fights you every step of the way, in which case you may, use as Mr. Scott might say in coaxing another warp out of his dilithium, use "a wee bit more" force. In any event, if they gag on the tongue blade the airway is, at least for the moment secure and you can move on to address other concerns. If they don't, the airway is at high risk and it's probably best to insert a plastic tube through the moth into the lungs to make sure the airway stays open. If they bite the stick in half, they have rabies. Call Animal Control. They will watch the patient for ten days, and if he or she doesn't get better they will cut off the head and check the brain. <br />
<br />
A few weeks ago, one of our regulars showed up. He's very poorly responsive, and is enveloped with a particularly pungent aroma of two carbon fragments about his person (the ethanol molecule...the one in "drinking alcohol" has two carbon atoms, one oxygen atom, and six hydrogen atoms. C2H6O, if you're keeping score). First on the agenda is airway security. <br />
<br />
I suppose it's true that in every profession, certain people are known for specific skills. I'm most known for being able to do procedures in "old school" ways. One of my colleagues has developed a specific test for feigned unconsciousness that involves forceful compression of the testes. (The patient's, not hers.) In this case, the nurse assigned to the patient had a particular expertise in assessing gag reflexes. (For no particular reason, we'll call her "Deaton.") So when assessing the gag reflex produced only a half-heated response, our nurse (whom we'll call again, for no particular reason, "Deaton,") shook her head with a discouraging "I don't like this. It's not very good," we knew we should be concerned. <br />
<br />
Well, not very good is also not very scientific. Science requires way to measure and record data. It also requires that you can name something after someone. So, in that spirit of scientific entrepreneurship, we present to you something called (for no particular reason) the Deaton Gag Scale:<br />
<br />
Deaton Zero. No gag reflex. Patient buys the tube. I bill for at least a half hour of critical care and a procedure. Yippee!<br />
<br />
Deaton One. Not aesthetically pleasing. "I don't like that. Let's try it again. Use a bigger stick. Push harder."<br />
<br />
Deaton Two. Acceptable. "I make that noise when I think of my ex." <br />
<br />
Deaton Three. Dramatic. "Ack ack ack ack ack! No! What the f...k!"<br />
<br />
Deaton Four. Enthusiastic "Oh, yeah. C'mon. Uh huh. Uh huh."<br />
<br />
Interestingly, in field testing this scale others have mentioned that this scheme could also be used in a social setting, and that the "little black books" men are reported to carry might consider adding a Deaton Score to the traditional system of stars. Of course, because I am a Paragon of Puritan Virtue, I have no idea what they mean. And because I adore The Dental Empress, I'm going to keep it that way.<br />
<br />
(Afterthought: As I was reviewing this prior to posting, I was reminded of a patient during my residency, who, when having a urinary catheter placed into the bladder through his...ummm...member, proclaimed "Oh BABY! Oh BABY! Oh BABY!" In a most enthusiastic tone. Which makes me think the Deaton Score can also be applied to the response to urinary catheterization. Though to distinguish it from the first score, it needs a distinct name. How about the Wang Response?)<br />
<br />Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com0tag:blogger.com,1999:blog-3594881315778851964.post-48918668066152186892016-03-30T16:11:00.002-04:002016-03-30T16:12:00.906-04:00ChoicesI don't know anyone in medicine who's particularly happy with their career choice. (Okay, maybe the locums neurosurgeon who gets paid five figures per day to sit in a call room and say things like, "Yeah, that's pretty complex, and since I'm not really familiar with the surgical team here you'll better send that along to a referral center." What a deal.) However, nobody will tell you this. It's true that we may have occasional flashes of genuine delight or emotional reward, but most of physicians just gut it out, showing up for work each day, wading through the teeming masses, deferring work as much as we can (translated as "Go to the ER") and wondering why we're not working at a tire store putting tires on cars, because no one is unhappy when they have new tires; or stacking bottles at Liquor Kingdom, because nobody's unhappy when they leave there, either.<br /><br />It's sad we feel this way because the actual practice of medicine is the easy part. Especially within the vast breadth of issues that come before the ER, there are only so many ways to do things and only so many ways things can go. It's actually very black and white. You're sick or you're not. You're alive or you're dead. You can't be "kind of sick" or "sort of alive." (And you most certainly cannot have fibromyalgia, because it doesn't exist.). Age, race, culture, gender identity, and a host of other characteristics don't change that basic biological equation. There's really not a lot of "gray zone," although that admission puts any number of academics, me in a past life included, out of business. <br /><br />The Internet is rife with stories about why physicians don't like their careers, and I could list the common themes as well as anyone; administrative hassles, government mandates, insurance nightmares, falling reimbursements, crushing student debt, long hours. (The one they won't list...because it goes against the social narrative that everything is someone else's fault...is that physicians and patients themselves are often part of the problem.). While some of the articles I see are understanding of the physician's plight, most are of the "arrogant doctor deserve everything they get, whiney bastards" ilk. So when people ask me about my enjoyment of medicine...or lack thereof...I struggle with the best way to explain it.<br /><br />After years of trying to come up with a politically correct solution, I now think that perhaps I don't actually have to explain it. Maybe what I have to do is turn the question into a riddle and let people figure it out for themselves.<br /><br />In Room 1 is an elderly man with chest pain. In Room 2 is a child with a snotty nose. Room 3 holds a young woman who took an ambulance ride to the ER for a toothache (yes, it happens, and it happens a lot). Who do you see first?<br /><br />It's an obvious decision, right? The person with chest pain might be having a heart attack. The kid with the snotty nose is just that. So you go and see the chest pain patient, ask careful questions and perform a focused yet detailed exam, take a moment to form your differential diagnosis, place judicious orders into the computer based on your assessment, and document your thoughts into the electronic medical record while the encounter is fresh in your mind.<br /><br />Meanwhile, the wait time for the kid goes up, and the parents (if there are two parents) become frustrated because they've taken time off work, or away from sleep, or had to pay a babysitter to bring the child to the ER, or brought the other three kids because they couldn't find a babysitter and are now crawling all over the exam rom. Before you even address the issue at hand you're apologizing for delays, and it takes you extra time to not only calm them down, but also to explain how you care for a kid with a snotty nose, because in medicine, as well as in society, we've indoctrinated new parents into learned helplessness. So what could be a ought to be a five minute encounter becomes twenty, which prolongs your patient throughput times. And if you've tried to provide care without a plethora of labs and x-rays, all of such would prolong patient care times, you've decreased your potential reimbursement.<br /><br />Maybe you can juggle two things at once. Maybe you can have someone quickly show you the EKG from Room 1 to make sure it's not a flaming heart attack, ask one or two questions of the nurse to get the show rolling, and let them start doing things according to a preset protocol whether the protocol is relevant or not. Meanwhile, you duck into Room 2 and get through the kid as fast as you can. It;s an easy case, there's nothing to do for it, and so what if you've not really had a discussion wth the parents? The kid is fine, and time saved. Then you can backtrack to Room 1 and figure out what's really been going on all the time, rolling your eyes at all the lab and x-rays that have been ordered when it turns out the patient's chest pain only happens on Tuesdays. At some point you go back and document both cases in the EMR, noting once again, as you've done before, that it takes exactly the same amount of time to document the care of a kid with a snotty nose or an adult with potentially life-threatening chest pain.<br /><br />Here's a choice: Maybe you go see the toothache first. It's the quickest to be seen, it'll involve a minimum of charting and paperwork, and since there's no dentist in the ER and you personally don't pull, drill, or fill, it's a matter of a couple of prescriptions and an admonition to go see the dentist. Your average patient throughput time will certainly go down. You might even get a good patient satisfaction score. But if you do that, don't you just reward behaviors that abuse the EMS system and the entire rationale for the Emergency Department? And surely someone will call you back to Room 1 if the chest pain patient turns sour.<br /><br />Now take this scenario and recognize that in most busy ER's in this country, your average ER physician is responsible for up to twelve patients at a time. And that the toothache (and maybe even the snotty nose), being a non-emergent condition, has probably been seen by a Physician Assistant or Nurse Practitioner, to be replaced on the doctor's agenda by something like abdominal pain, vomiting, vaginal bleeding, migraine headache, fever, possible injuries from a motor while accident or a fall in a nursing home, overdose, psychiatric crisis, or chronic pain, all scenarios in which it's incumbent upon the physician to do something to make sure there's no actual emergency, but not do too much to take up too much time or generate an excessive bill. All the while navigating family dynamics, patient expectations, social needs, clinical disposition, and appropriate pain management with the inevitable negotiations that accompany them all.<br /><br />(As an aside, our ER has started giving out cards that list the Patient Advocate's phone number as part of our discharge paperwork. Not a bad idea, I suppose; if people have questions about their care, or their bill, they ought to have someone to call. But when you read the card it says to contact the Patient Advocate if you have "concerns" about your care. Nothing there about compliments. Which lets you know exactly where the Patient Advocate, as well as Administration, stands in reference to doctors and nurses. Words matter.)<br /><br />It's an extreme example, of course, but it serves to illustrate the point that emergency medical staff (and, to a lesser degree, all health care providers) are working under a set of inherently contradictory mandates that are plain to everyone involved in patient care but are absolutely invisible to those in the corporate suite: The belief that you can, with no changes in resources and increasing patient loads, have faster greeting times, faster turnaround times, higher billings, and higher patient satisfaction, all at the same time. (Quality of care is an afterthought, and if there's a problem it's time to come down on the physician, for the hospital is not in the practice of medicine and it's simply not right to recognize any pressures or mandates the hospital might put upon the physician as contributing to any errors that might be made.)<br /><br />I've had good bosses and bad bosses, but just like you can pull some valuable lessons out of a bad relationship (which is why I like sushi and know what an eyelash curler is), my worst boss did teach me something that I still think holds true. (Personally, I think he was an idiot, so I assume he got it from somewhere else and was able to read it off an index card.) It's that in health care:<br /><br />(Access) x (Quality ) = Cost<br /><br />Working through this equation, recognizing that access is a "people" number, quality is whatever we happen to define it as at the moment, and that cost is not always counted in dollars but can be counter in time or lost opportunities, it's clear that the paradigm that all things are simultaneously possible is fatally flawed. <br /><br />Let's say that the number of patient being seen ("access") is flat, and improved patient satisfaction is our measure of quality. We know that time spent with the patient is the prime determinant of patient satisfaction. Patients want to move through the system, but they don't want to feel part of an assembly line. So using the equation, increasing patient satisfaction necessarily increases throughput times. We also know that another determinant of patient satisfaction has to do with the amount of care provided in terms of testing and prescriptions. If that's our measure, then costs in dollars rise. <br /><br />If we want to decrease costs, ether as dollars or time, something else has to go. Each provider needs to see less patients (decreasing the access number) or patient satisfaction must fall. This is true even if we use (heaven forbid) true quality of care as defined by clinical metrics as our outcome goal. It's health care stoichiometry. It needs to balance.<br /><br />I don't know the right answer, other than I don't think there is one. I would say that good clinical care is the optimal outcome, but within policy and administrative circles that is clearly no longer the case and that horse has long ago left the barn. There can, in fact, be no right answer when your goals are at odds with one another. What I'm hoping is that someday someone far above my pay grade will actually admit, in a nod to Spandau Ballet, that they know this much is true. But I have no confidence that this will occur before even more physicians and nurses, exhausted and burned out, become mere wage earners trapped in their jobs rather than the caring and compassionate professionals most of us wanted to be.<br /><br />No, there's no right answer, at least not one that I, as an individual physician doing patient care, will ever be privy to. The Administrator du Jour, or the Administration du Four-Year Term, will decide what the right answer is for now, and undoubtedly one component of the answer will be that the providers are just not doing things right. Policies will be written, institutions will undergo "culture change" and "rebranding," metrics will be compiled, and a couple of months later we'll be back where we've started, with administration spending great whopping gobs of cash and rewarding themselves for non-existent accomplishments and providers feeling once again disheartened and disillusioned. No matter how many times you rearrange the deck chairs on the Titanic, the ship still goes down. And while those on the top decks are offered first place in the lifeboats, those in steerage...your doctors and nurses...are locked behind iron grates below decks and left to drown.Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com2tag:blogger.com,1999:blog-3594881315778851964.post-129372013877309212016-03-25T12:36:00.003-04:002016-03-25T12:36:54.647-04:00Bar Mitzvahs and Bomb Shelters
Being a parent is truly the greatest
thing ever. I love my kid like nobody’s business, and I suspect
most parents feel the same way. It’s true that The Teen drives me
nuts in more ways than I can count (and I’m certain he would say
the same about his father), but the real frustration is in seeing
your faults repeating themselves in your child. He and I were
talking about that the other day, one of those pre-dawn chats you
have when you come home early on a night shift and inadvertently wake
up the kid, when he’s not sleepy enough to tune you out but no so
awake that he heads straight for his computer. We talked about the
things he does to get in his own way, and I talked about mine. It
seems like laziness…or at least the ability to be easily distracted
into things that are not productive…is one of my unfortunate
legacies.<br />
<br />
As I get older, I find I’m much more
comfortable with confession and admitting my faults. Maybe this is
the insight and wisdom that comes with age; more likely, it’s
finding excuses for not being all I could have been, shrugging off
lost opportunities based on based on bad habits I can’t break the
same way the patient with end-stage lung disease says they can’t
give up smoking…and since they’re at the end, why bother now?
But I think it’s true that I could have done a lot more in life if
I didn’t get lazy.
<br />
<br />
Here’s an actual example of what I
mean, ripped from the pages of my life just this past week. When I
get home after work, I should be working out so I don’t wheeze
after going up two flights of steps, or so dedicated to the
frustrated writer inside of me that I would be willing to scribe on a
TV tray like Stephen King used to do before Carrie. What I actually
do is eat either two bowls of Apple Jacks or, if I’m feeling
adventurous, make French toast. Then I watch an “on-demand”
episode of The First 48, yelling at the screen the whole time (“Nail
that perp! Nail his a__ to the ____ing wall!), then hit the channel
guide and realize that I can’t stay awake long enough to watch “The
Big Valley” on MyTV. I then retire to bed with my iPad in hand and
find that I’m looking up The Big Valley, then Miss Barabra
Stanwyck, then Richard Long, then Nanny and the Professor, then back
to Barbara Stanwyck again, then off to Double Indemnity, then Fred
MacMurray, then My Three Sons, off to Tina Cole, to the Four King
Cousins (four You Tube videos as well, loads of hairspray
everywhere), then the King Family, next the King Family Specials on
PBS, then Mr. Rogers, and finishing up with searches for Joe Negri.
Robert Trow, Francois Clemons, and Betty Aberlin. Then I’m not
tired anymore so I play an hour of Fishdom. And by now it’s too
late to take a melatonin to get to sleep, because I’ll wake up with
a hangover, and I’ve totally missed the episode of The Big Valley
that I couldn’t stay awake for three hours before.<br />
<br />
<div style="margin-bottom: 0in;">
(Incidentally, if you’ve not seen
“The Bitter Tea of General Yen,” a 1933 film with Barbara
Stanwyck and Nils Asther, it’s well worth a look. Obscure now, but
daring themes for the time. And don’t get the new Fishdom game,
“Dive Deep.” I hate in-app purchases to get to the next level.
Just tell me how much to pay for the game and let me play.)</div>
<br />
<div style="margin-bottom: 0in;">
So as I’m talking to The Teen about
those things in life that get in our way, I mention to him that while
he has unquestionably inherited my wit, charm, good looks, and above
all modesty, he’s also got my tendency to be distracted and lazy.
As I’ve noted before in these pages, he wants to be the next Roger
Ebert, and he unquestionably has the talent to do so. But I’m
trying to explain to him that this means you learn to work on a
deadline, not just when the flash of literary inspiration hits you.
He, of course, rightly points out that I’m just as bad. So he and
I have worked out a deal. We will require each other to blog at
least once a week. If he doesn’t come through, I get to choose a
costume that he must wear throughout the four days of GenCon, the
largest gaming convention in the world. (I’m thinking Fluttershy
of My Little Pony). If I don’t…well, he’s trying to think up
an appropriate penalty because, as he says, “You have no shame.”
No, I don’t, not where embarrassing my kid’s concerned. It’s a
Dad thing.</div>
<br />
<div style="margin-bottom: 0in;">
Brendan’s entry this week is a review
of 10 Cloverfield Lane. (It’s brilliant. Please take a look at
The CriticalFrog.blogspot.com.) But as Brendan is a true movie buff,
able to place films in context with genres and styles, when I see a
movie my mind usually does what it does with my iPad before I go to
sleep, wandering from topic to topic with no particular focus in
mind. So my thoughts on the movie generally center around the fact
that the lead character (played marvelously by John Goodman) is named
Howard, which is my name as well, a point The Teen continually
reinforces with veiled suggestions that perhaps I should build a bomb
shelter in the backyard.
</div>
<br />
<div style="margin-bottom: 0in;">
(For the record, I have no intention of
building a bomb shelter in the backyard. This is not because I have
great faith, as does every pageant contestant since Eve duked it out
with Lilith, in world peace. It is because I’m certain that one of
my fellow doctor friends whom I know has a guest room in his house
will take my in, and that his home has enough tinfoil lining the
walls to stop them from reading our thoughts and enough weaponry to
keep us all alive throughout the Zombie apocalypse and then some.)</div>
<br />
<div style="margin-bottom: 0in;">
Howard’s not a great name. Never has
been, but at least I know how I wound up with it. It wasn’t a
deliberate act on my parent’s part to keep me in comic books and
dateless until my early 20’s (I did that to myself.) It’s a
Fiddler on the Roof kind of thing. In Jewish tradition, you usually
try to hand down part of a name of the most recently deceased
relative, which in English usually translates to using the first
letter of the first name. So when my great-grandfather Harry
Burgheim married a woman named Hennie, and they had a son named
Harold, the die was cast. My Mom was a Harriet, I wound up a Howard,
and my brother is another Harold. And two generations hence, when
we’re gone, another crowd will wind up with “H” names and
wonder why their parents hate them, too.</div>
<br />
<div style="margin-bottom: 0in;">
Just as Christians often get
confirmation names, we also have Jewish names. You usually get this
at a bris or a naming ceremony as an infant, which is why no liberal
Jew has any idea what their Hebrew name really is. These are also
usually passed down from deceased relatives, but not quite as
literally. For example, your name could be Bob (and mine is Bob
every time I got to someplace that asks for my name on an order,
because I’m tired of telling people how to spell “Howard”), and
your late great-grandfather’s name could be Fred, but if his Hebrew
name was Yitzchak yours likely will be too.</div>
<br />
<div style="margin-bottom: 0in;">
As I’ve mentioned, nobody really
knows their Hebrew name unless it’s the same as their actual name
(think the ultra-orthodox in New York, where I understand the name
Pinchas, with a guttural “ch”, really get the ladies going).
This came to be a problem several weeks ago at my nephew Thomas’
bar mitzvah. Before I go any further, I need to say that Thomas did
a magnificent job, even though somehow in his speech he forgot to
thank his best uncle on the planet for his support from afar, which
may or may not manifest itself in an acute deficit of Channukah
presents this year. But I digress.</div>
<br />
<div style="margin-bottom: 0in;">
During the ceremony, different members
of the family are called to the bimah (the stage in front of the
sanctuary) to recite blessings over the Torah before it is read. You
get called up to do the blessings by your Hebrew name, which was a
problem because neither Brendan nor I knew our Hebrew names.
Fortunately, Judiasm is nothing if not a creative religion (we came
up with that whole monotheism thing), so we were assigned Hebrew
names by the enterprising rabbi of the Joliet Jewish Congregation. I
became Avigdor ben Yussel (“ben” means “son of,” and my Dad’s
name, Joseph, does translate into Yussel), and Brendan morphed into
Efron ben Avigdor. It could have been worse. My Uncle Steve got the
alliterative Schmuel Yuel ben Matisyahu, and my nephew Thomas wound
up with Tovia Fivesh Meir ben Shoshana, which sounds like…well, I
don’t know, but probably something that doesn’t go down well on
Tinder.</div>
<br />
<div style="margin-bottom: 0in;">
I didn’t particularly like these
names. So I wrote my sister, who was actually in charge of the
festivities (she’s a Jewish woman; did you really think anyone else
would run the show?), that I wanted a different Jewish name. I
wanted mine to be Moshe Dayan, and I thought Brendan’s might be
Harpo Marx. I was told that changes this year were not an option,
but that I might be able to make a case for next year at my niece
Lauren’s ceremony. I’m still holding out for Moshe Dayan, and I
have an eye patch ready to go. But I think Brendan may opt for
something from Yu-Gi-Oh or Pokemon (Charizard ben Charmander, I
choose you! Gutteral “ch”s all around.)
</div>
<br />
<div style="margin-bottom: 0in;">
(Incidentally, this rabbi was great.
Had a wonderful speaking voice, moved the service along…which
matters when you’re the child of parents who always went to the
early services on Erev Yom Kippur and Rosh Hashonah because they knew
the rabbi had to get up to speed to be able to clear the house for
the late show…and was really a lot of fun. He would ask us to
“kiss the torah” with the edge of our prayer shawls in the voice
of Sebastian the Crab from The Little Mermaid. This made me laugh
out loud, much to the dismay of an old man who shushed me from under
his rainbow-striped tallit that looked like something on the box of
Lucky Charms. This rabbi also plays dodge ball: "I never get to throw things at the kids in the synagogue."</div>
<br />
<div style="margin-bottom: 0in;">
Oh, and in the Sibling Rivalry
Department, I should mention that while my brother screwed up his
blessings, I got mine right. I did so well, in fact, that another
little old guy came up to me at the reception afterwards and wanted
to know if I was a member of a synagogue. When I told him I lived
out of town, he engaged in that well-known game of Jewish Geography,
noting that he had second cousins in Kansas City and did I know them?
He also wanted to make sure that I was going to take The Dental
Empress to Israel. For her part, The Empress was a trooper the whole
weekend, especially when confronted with a bowl of chicken liver…“Try
it first and I’ll then I’ll tell you,” was my Mom’s response
to her inquiry about its’ nature…and she was very understanding
when Dad said she was welcome in any of our pictures, but I’d
better not do something to lose her because he was tired of cutting
the heads of my ex-wives out of family photos. This is the same
father who has given his blessing to this relationship, as opposed to
my priors, because, “this one comes with a house and a job.”)</div>
<br />
<div style="margin-bottom: 0in;">
It also turns out, unbeknownst to the
family in advance, that if you’re over 13 and called to the bimah
to perform the religious duties of an adult Jewish male, it counts as
a bar mitzvah of sorts, a recognition that through your participation
you’re accepting the obligations of an adult Jewish man. So in
addition to the bar mitzvah we thought we were attending, there were
four additional “drive-by” bar mitzvahs that morning between
myself, my brother, my Dad, and The Teen. Which was pretty cool
considering that we didn’t have to go to Hebrew school, we got to
read transliterations of our blessings, and we got to sponge off
someone else’s reception.</div>
<br />
<div style="margin-bottom: 0in;">
But back to 10 Cloverfield Lane.
Bottom line: It’s got a Howard in it. He’s a creepy survivalist
with a bomb shelter and tub of acid in the backward. Howard is a
crappy name. It’s mine, too, which means for the foreseeable
future I’m going to hear an endless stream of 10 Cloverfield Lane
jokes. But at least I used to be Dan Conner, Geln Allen Walken,
Walter Sobchak, and King Ralph, and at least one of them is Jewish.
Could be worse. And as I’ve said, I won’t be building a bomb
shelter in the backyard. I’m just lazy.</div>
Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com0tag:blogger.com,1999:blog-3594881315778851964.post-40143172383048843922015-11-11T23:52:00.002-05:002015-11-11T23:52:53.145-05:00"Bags of Stuff": ACEP 2015<div class="p1" style="background: white; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">You may have heard about changes in the marketing
practices of pharmaceutical companies.
It’s now considered unethical for companies to offer, or for physicians to
accept, gifts from manufacturers of drugs and medical devices. The theory here, of course, is that physicians
who get stuff from these corporations are more prone to use those drugs or
devices regardless of efficacy or cost, driving up health care expenditures
without necessarily benefiting anyone but the purveyors of fine pills and
nostrums.<o:p></o:p></span></span></div>
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<br /></div>
<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">In all faith,
I cannot say that I’ve never been influenced by a drug company. I’ve written before in the pages about how,
on a small scale, I still know the dose of a currently obscure antibiotic
because during my internship a salesman for this drug brought my fellows and I
donuts every single day for a year. And
in the heyday of pharmaceutical marketing, when I had become an attending
physician in the early 1990’s, I went to </span></span><st1:city><st1:place><span class="s1"><span style="color: #454545;">Boston</span></span></st1:place></st1:city><span class="s1"><span style="color: #454545;"> for a weekend on someone else’s to learn
about clotbuster therapy for heart attacks.
(Yes, the other person’s money was the company that made the drug.)<o:p></o:p></span></span></div>
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<br /></div>
<div class="p1" style="background: white; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">Personally, I miss those days. Not because I think I was corrupted by the
process, but because in an era where the practice of medicine and respect for
physicians has been knocked so far off it’s pedestal that we’re like the
shattered bust in the end credits of Peabody and Sherman, it would be nice to
be flattered once again. So yes, I’d
like to be influenced by the drug companies. I would happily take their money to
support research. I would beg to be one
of those players known as a “drug whore,” doctors who get shipped to meetings
both at home and abroad to present lectures on important topics such as Reversing
Anticoagulants and then get to say things like, “There are three agents out
there. I’m going to talk a lot about
one, very little about a second, and none about a third,” and then claim to be
an impartial evaluator of the literature.
Bring it on.<o:p></o:p></span></span></div>
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<br /></div>
<div class="p1" style="background: white; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">However, the simple fact is that emergency
physicians are relatively insulated from that sort of marketing. The reason is basic economics. We don’t do anything particularly profitable. With some rare exceptions, what we do is pretty
basic. We don’t use expensive antibiotics
or symptomatic medications, especially as much of our clientele couldn’t afford
them if we did. Because we have short clinical
attention spans, we don’t prescribe high-cost, long-term maintenance medications. Even most of the IV medications we use have
been around for long time, and while there are some medical devices we use they’re
rarely the innovative, costly, single-use, high-volume supplies used by our
colleagues. It’s not that we can’t use
them; it’s that we don’t need to in order to be the Great Triage Officer of
Life and Death. So there’s very little
money in pushing expensive blood pressure medications or coronary artery stents
to us. We simply just don’t use them.<o:p></o:p></span></span></div>
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<br /></div>
<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">That doesn't
mean we don't get "marketed."</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">There are some pharmaceutical and medical
device companies who bring their wares to display. But it's mostly from
physician recruiters, individual physician groups looking to by pass the
recruiters' fees, and locums agencies trying to find part-time docs to go to
places that nobody can recruit for.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">There are risk management groups, billing
firms, places that outsource documentation, scheduling, and practice management.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">All of them say the same thing and use the
same words, most of which end in "-ize" (optimize, maximize,
incetivize), which is Latin for “make the galley slaves work.” So how do you stand out among the
competition?</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">The answer, of course, is the trinket.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<br /></div>
<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">Here's my
disclaimer.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Trinket acquisition is one of my primary drivers for
attending medical meetings.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">The education tends to be spotty unless you happen to
know a particular speaker is really good.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">I'm not a networker.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Most of the receptions are way too
crowded, and most "open bars" really aren't.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">But I am totally enamored with the
scavenger hunt through the exhibit hall, to see what I can pick up and then
leave in a large tote bag for whatever housecleaner enters my hotel room after
I'm long gone.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<br /></div>
<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">Like any game,
however, you have to know the rules to play:</span></span><span style="color: #454545;"><o:p></o:p></span></div>
<div class="p2" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in; min-height: 20.3px;">
<br /></div>
<ol start="1" style="margin-top: 0in;" type="1">
<li class="MsoNormal" style="background: white; color: #454545; font-stretch: normal; mso-list: l0 level1 lfo1; tab-stops: list .5in;"><span class="s1">You may
take only take one of each item from any one exhibitor.</span><o:p></o:p></li>
<li class="MsoNormal" style="background: white; color: #454545; font-stretch: normal; mso-list: l0 level1 lfo1; tab-stops: list .5in;"><span class="s1">As long as
you don't have to talk, you may feign interest in anything.</span><o:p></o:p></li>
<li class="MsoNormal" style="background: white; color: #454545; font-stretch: normal; mso-list: l0 level1 lfo1; tab-stops: list .5in;"><span class="s1">If you are
required to talk, you may not lie.</span><span class="apple-converted-space"> </span><span class="s1">For
instance, you may not say you don't want to practice in dusty </span><st1:place>East Texas</st1:place><span class="s1"> because you're
afraid the cat's allergies will start to act up.</span><span class="apple-converted-space"> </span><span class="s1">("But
it’s not like that! We have hills and trees! Watch our video!"
exclaims the lovely Miss Longview 2012.) You may, however, invoke fixed
personal characteristics as an excuse, as when dealing with recruiters for
hospitals in the oil-rich sheikdoms of the </span><st1:place>Middle East</st1:place><span class="s1"> ("I'm not
sure my people do so well there.")</span><o:p></o:p></li>
<li class="MsoNormal" style="background: white; color: #454545; font-stretch: normal; mso-list: l0 level1 lfo1; tab-stops: list .5in;"><span class="s1">If you
don't know what something is, you have to ask so you can accurately record
it.</span><o:p></o:p></li>
</ol>
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<br /></div>
<div class="p1" style="background: white; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">Record it, you say?</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">But of course.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Getting the stuff is only half the fun.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Then you get to take it back to the hotel
to sort through it, and catalog in detail what you've obtained.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">(This is best done while eating room
service spaghetti and watching Los Reales in Game 1.)</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Then you compare it to your previous
catalogs to get a sense of how medicine has really changed.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">It's a faster, quicker, and much more
accurate way to look at medical progress than any old textbook or lecture.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span style="color: #454545;"><o:p></o:p></span></div>
<div class="p2" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in; min-height: 20.3px;">
<br /></div>
<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">With this as background, I'm pleased to report to you my gleanings from the 2015 Scientific Assembly of the American College of Emergency Physicians in Boston. Here we go:</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<br /></div>
<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">Eight plastic
boxes of band-aid strips.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Each box contains five band-aids.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">I have never really thought about how many
band-aids I use, so I don't know if this is enough for a week or a lifetime
supply.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">I have resolved to monitor my band-aid use
in the future as part of my own personal Customer-Focused and Culture-Changing
Continuing Quality Improvement project. (I've been looking for an excuse to
work all the hot administrative buzzwords into a sentence.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Bingo.)</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<br /></div>
<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">One golf
towel.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">I think it's a golf towel, because it has
a little grommet in it and some kind of clip. I don't play golf.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">But if I did, I'm not sure what message it
sends that I'm wiping grime onto your product's name.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<br /></div>
<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">One ice
scraper.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">This
is from some very nice recruiters for a hospital system in </span></span><st1:place><span class="s1"><span style="color: #454545;">Southern Illinois</span></span></st1:place><span class="s1"><span style="color: #454545;">. I actually suggested to the Cream Of
Collinsvile that if you're wanting people to move there, reminding folks that
they're going to have to chip snow and ice from their car may not be the best
pitch.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">In retrospect, though, I think maybe they
got it right, because the other selling point would be "We're really close
to </span></span><st1:city><st1:place><span class="s1"><span style="color: #454545;">East
St. Louis</span></span></st1:place></st1:city><span class="s1"><span style="color: #454545;">."</span></span><span style="color: #454545;"><o:p></o:p></span></div>
<div class="p2" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in; min-height: 20.3px;">
<br /></div>
<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">A full-size
selfie stick. Here’s the story. Last month the Dental Empress and I went on a
Mediterranean Cruise. As we wandered the
streets of the </span></span><st1:place><span class="s1"><span style="color: #454545;">Old
World</span></span></st1:place><span class="s1"><span style="color: #454545;">, we
learned that the Official Street Vendor Product of the European Union is the
selfie stick. So at lunch one day
outside the Colleseum we fell into a discussion with a British couple sitting
next to us and a Spansih foursome sitting one table over. The latter group had been drawn into
negotiations with a street vendor (who, I’m fairly certain, was not a native of
the </span></span><st1:place><st1:placename><span class="s1"><span style="color: #454545;">Tiber</span></span></st1:placename><span class="s1"><span style="color: #454545;"> </span></span><st1:placetype><span class="s1"><span style="color: #454545;">River</span></span></st1:placetype><span class="s1"><span style="color: #454545;"> </span></span><st1:placetype><span class="s1"><span style="color: #454545;">Valley</span></span></st1:placetype></st1:place><span class="s1"><span style="color: #454545;">) over the cost of a selfie stick. The initial asking price was ten euros. Then it went down to seven, at which point
the Brits noted that they had bought their selfie stick in Venice for only three
euros, in a fine example of free market economics. The final price was four euros, or a little
over five bucks, accounting for the difference in the cost of living between
the capital and provinces.<o:p></o:p></span></span></div>
<div class="p1" style="background: white; margin-bottom: .0001pt; margin: 0in;">
<br /></div>
<div class="p1" style="background: white; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">(The British couple, while great company
at lunch, were truly a mismatched pair.
He was a young, very quiet IT professional, while she was an older, extroverted
marketer and outdoors enthusiast. They
were describing how their first vacations together were disasters until they
hit on the solution to spend their holidays someplace where neither of them will
be particularly happy. Which is why they’ve
spent two weeks in each of the last three years at a hermetically sealed beach
resort in </span></span><st1:country-region><st1:place><span class="s1"><span style="color: #454545;">Egypt</span></span></st1:place></st1:country-region><span class="s1"><span style="color: #454545;">.
Which plan, as of this writing, probably needs to be rethought.)<o:p></o:p></span></span></div>
<div class="p1" style="background: white; margin-bottom: .0001pt; margin: 0in;">
<br /></div>
<div class="p1" style="background: white; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">Thirteen different sizes and shapes of
tote bags, of which I'm planning on keeping two.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">One is from Long Island Jewish Medical
Center.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">It's really of very high quality, with
zippers and a shoulder strap and quite subtle advertising for a give away item.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">It's also of sturdy fabric, which you
probably need while using the bag as a weapon to fight off the thugs which this
boy from Flyover Country is convinced lurks behind every corner of the New York
Tri-State Metropolitan Area.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">And yes, I cognitively know that at Long Island Jewish
Medical Center I'm more likely to encounter an elderly matron selling raffle
tickets for Hadassah, but they scare me, too.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">The other bag I'm keeping is an insulated
lunch bag forma healthcare management company, because helping</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">me carry my lunch is about the only thing
a healthcare management company will ever do for me.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
<div class="p2" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in; min-height: 20.3px;">
<br /></div>
<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">Two
refrigerator magnets, one of which gives me the warning signs of atrial
fibrillation, which might be helpful on those days my heart skips a beat when I
find those forgotten "science experiments" in the back of my
refrigerator. The other says, "Dammit</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Jim, I'm a Doctor, Not a Data Entry Clerk,
" which is silly because everyone knows the Data Entry Clerk is Yeoman
Rand.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<br /></div>
<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">One round
plastic pizza cutter.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<br /></div>
<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">Six 2 GB flash
drives.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
<div class="p2" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in; min-height: 20.3px;">
<br /></div>
<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">Four of those
things that you plug into your car's cigarette lighter, into which you then put
a USB cable, and then plug into your phone to charge it more slowly then you
burn power listening to Spotify.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">I don't actually know what they're
officially called.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Car charger sounds wrong because you're not actually
charging your car, and you need some other pieces like a USB cord to charge
anything else.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">I do know you can usually find them in plastic buckets
for $3.99 near the check-out of the Quik Trip, which means they're probably
made in </span></span><st1:country-region><st1:place><span class="s1"><span style="color: #454545;">China</span></span></st1:place></st1:country-region><span class="s1"><span style="color: #454545;"> for less then a nickel apiece, which lets me
know just how much those who peddle these promos think of me</span></span><span style="color: #454545;"><o:p></o:p></span></div>
<div class="p2" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in; min-height: 20.3px;">
<br /></div>
<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">Eleven
different sizes and shapes of bottles of hand sanitzer, all of which could pass
by the TSA as they are all less than three ounces in volume.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
<div class="p2" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in; min-height: 20.3px;">
<br /></div>
<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">Four buttons
that say "I love night shifts;" a further button modeling the Flag of
Emergistan (a buzzard on a field of red, green, and blue); and a badge from a
company called Blue Jay Consulting that says "Be Happy" that I picked
up just so I could look at it and say, "Not so much.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Go Royals."</span></span><span style="color: #454545;"><o:p></o:p></span></div>
<div class="p2" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in; min-height: 20.3px;">
<br /></div>
<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">("Emergistan," the Land of Emergency Room, is the creation of Edwin Leap, MD.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">He's an excellent writer, and has the gift for finding positives in the chaotic void.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">From a literary standpoint, he's the good
child you want to live next door, while I'm that distant relative you have to
invite for the holidays, and why you serve Thanksgiving dinner</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;"><a href="about:blank" style="cursor: pointer;" target="_blank"><span class="s2"><span style="color: #e4af0a;">at 10 AM</span></span></a></span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">so you can move him more quickly out of
the house.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Catch up with Dr. Leap at</span></span><span class="apple-converted-space"><span style="color: #454545;"> edwinleap.com</span></span><span class="s1"><span style="color: #454545;">)</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">A plastic
slinky.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">Ten plastic
foam squishy toys, incldung three ambulances, one gold key that won't fit
anything, three balls, a blue and gray fish, a yellow van with the VA logo, a
rhino., and a football.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">Two
toothbrushes, one in a fold-up plastic travel case.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">One box of floss shaped like a tooth.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">A bicuspid, if you must know.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">A rubber duck
with a stethoscope and that head thing that doctors are supposed to wear that
I've never actually seen a doctor wear.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">A faux leather
mini football that seems tough enough for actual play.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">In contrasting this to the squishy
football, the good one is from a company in </span></span><st1:state><st1:place><span class="s1"><span style="color: #454545;">Texas</span></span></st1:place></st1:state><span class="s1"><span style="color: #454545;">.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Which makes snese, because people in the
south take football seriously.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">The promotional football is not a toy.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">It's a lifestyle.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">9 diferent
collapsible coozies, two of which are bottle-shaped.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">There was also one rigid cylinder shaped
coozie which was used to great effect as I put a brown glass bottle of cream
soda (yet another giveaway) inside it, totally covering up the label of the
latter and giving the impression that I was swilling my way through the exhibit
hall...an impression which, truth be told, I did nothing to correct.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">16 different
computer screen wipes.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Most are simply wisps</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">of cloth, but one looks like a soft furry
green sea urhcin, or perhaps an inverted Scrubbing Bubble.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">Seven
containers of chapstick.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Four tubes, three plastic balls.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">Three stuffed
animals. The two bears wearing promotional tee-shirts show great promise as dog
toys.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">The Snoopy dressed in World War I Flying
Ace gear is mine.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">Eight plastic
sleeves that I couldn't figure out until it was explained to me that you're
supposed to stick them to the back of your cellphone so you can put your
driver's license and your credit card in there so you can keep them all
together and eliminate the need for a purse or wallet when you go out.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">it also means that when you lose</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">your phone, you can suffer identity theft
and have your credit ruined as well. I was also told that once you stick it on,
it's nearly impossible to get off. I can't use them myself, because I already
have an "I Was Brave" sticker featuring Thomas the Tank Engine on the
back of my phone from when I got my flu shot last year and didn't pass out.
(I've got a thing about needles.)</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">Seven small
notebooks, including one from a US-Saudi joint venture with Arabic script on
the cover which will go down beautifully with the TSA. Out of this assortemnt,
I'll be keeping a small red one that look like Chairman Mao's.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">I plan to paste fortune cookie papers into
it and quote them frequently in a cryptic yet knowing way.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">One small
travel package of Kleenex.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Why only one, you ask?</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Because there's no crying in ER.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">Three letter
openers with covered blades, because death by an unsheathed letter opener is
just silly.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">Seven
different lanyards with clips for ID badges, so you have seven different ways
to declare your corporate allegiance. (Disclaimer:</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">My ID badge lanyard at work is form
Princess Cruises.)</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">Two large
plastic squeeze bottles, two medium-sized rigid plastic cups with built-in
straws, one travel cup, and one "shaker" from a vendor in Hawaii that
i was told is to be used to mix up protein shakes and the like, but that I will
keep becuase I thnk it would be somehow fitting to make tropical drinks for
sitting poolside in a cup sponsored by the Aloha State.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">Six large
magnetic clips you put on your refrigerator to hang up your children's
drawings.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Only one of them is big enough to use as a chip clip.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">My son is way past the refrigerator art
gallery stage of life.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">So you can guess which one I'm keeping.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">(Shameless
promo:</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">The kid doesn't draw, but he does write.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Check out his blog at</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;"><a href="http://thecriticalfrog.blogspot.com/" style="cursor: pointer;" target="_blank"><span class="s2"><span style="color: #e4af0a;">thecriticalfrog.blogspot.com</span></span></a>.)</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">Lots of candy.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">And lots of little plastic packages of
mints that I might maybe someday use as placebos. But when I do, I'll give them
a fancy name, like Obecalp.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">A sewing kit,
which will prove to be of no use to me as I can sew a screaming kid, but cannot
fathom things like what buttons are or how they got there.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">Eleven small
flashlight, presumably for looking at small things.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<br /></div>
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<span class="s1"><span style="color: #454545;">One tee-shirt
that says, "This is Your Brain on ICD-10."</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">(Okay, you had to be there.)</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">Two yo-yos,
which may also be used as bolos to hunt small game in a survival setting.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">One
collapsible travel cup.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">Three
miniature harmonicas on key chains.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">Two plastic
wishbones.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">One squishy
blue rubber ring and one similarly textured clear rubber ball filled with lots
of smaller pink, green, blue, and yellow balls.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Both of these blink incessantly when
squeezed.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">One
retractable tape measure.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">Two sets of
fake teeth that you can put between your lips.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">When you blow into a small mouthpiece, a
small fan creates a whirring sound.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<br /></div>
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<span class="s1"><span style="color: #454545;">Three gel
packs that I can freeze or heat as needed to provide pain relief when my
Dilaudid runs out.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<span class="s1"><span style="color: #454545;">Badge ribbons.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">If you've been to large meetings lately,
you will have noticed that the recent trend is for attendees to stratify
themselves through the ribbons they attach to their name badge, things that say
"Director" or "Board Member" or "Donor" and the
like.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">(I think these are the convention
equivalents of fifty-five year old men who drive fire-red sports cars, the
rainbow of markings on the amorous mandrill, and male peacock feathers.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">An evolutionary biologist would have a
field day sorting out this competition for status, not to mention the fertile
females.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Or
maybe it's a more innocent behavior, sort of like a certain Labradoodle I know
named Goldie Goldstein who will fling her 70 pounds of dog at your head,
landing with a resounding thud , eyes open, mouth agape, tongue lolling,
drooling everywhere, as her saliva-punctuated way of proclaiming, "Pay
attention to me!").</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">In response to this trend, there were several vendors
giving out additional ribbons with some less important mesages, including
"Troublemaker," "I Run With Scissors," "I Read Your
E-mail," and of course "My Ribbon is Better than Your Ribbon."</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">I got a buch of those last ones.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Two went on my badge so the fertile
females would look at me more than those one-ribbon guys.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<br /></div>
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<span class="s1"><span style="color: #454545;">A small lapel
pin of the Canadian flag.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<br /></div>
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<span class="s1"><span style="color: #454545;">A 3.7 ml
bottle of tabasco sauce, whch I look forward to using in its entirity on one
medium sized tiger shrimp.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
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<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">116 assorted
pens, all fairly nondescript with the exception of one shaped like a femur and
another that has</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">wobbly jack-in-the-box head with strands of blue yarn
hair on the top.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">84 write with black ink, the remainder blue.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
<div class="p2" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in; min-height: 20.3px;">
<br /></div>
<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">A rubber
device that looks like a plastic pocket protector with an attached</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">megaphone.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">What you do is slip this over the end of
your iPhone 5 and apparently an opening on the inside of the pocket is right
over the speaker, which then transmits the sound through the megaphone to the
world at large.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Which is probably a great thing, if you have an iPhone 5
and have a background in cheerleading.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">The Dental Empress is a former cheerleader
(all four years, cheering football and basketball, not wrestling...I understand
that's important in Cheer World) so I know what a "Herky" is, and I'm
currently enamored with the "Cheerleader" by</span></span><span class="apple-converted-space"><span style="color: #454545;"> OMI </span></span><span class="s1"><span style="color: #454545;">but that's as</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">close as I get.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Plus, I went right from an iPhone 4 to a 6
because the same cheerleader told me the 5 was awful, though in retrospect it
probably just needed a megaphone.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">And yes, on this one I had to ask.</span></span><span style="color: #454545;"><o:p></o:p></span></div>
<div class="p2" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in; min-height: 20.3px;">
<br /></div>
<br />
<div class="p1" style="background: white; font-stretch: normal; margin-bottom: .0001pt; margin: 0in;">
<span class="s1"><span style="color: #454545;">That's just
the trinkets.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">I did actually look at some products as well.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">More on that later.</span></span><span class="apple-converted-space"><span style="color: #454545;"> </span></span><span class="s1"><span style="color: #454545;">Now, If only I could find a pen...</span></span><span style="color: #454545;"><o:p></o:p></span></div>
Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com1tag:blogger.com,1999:blog-3594881315778851964.post-788940458298822962015-10-04T20:11:00.000-04:002015-10-04T20:11:02.988-04:00Truth or Consequences<span style="font-family: Times, Times New Roman, serif;">With the Big Ball Drop now nine full months behind us, it seems an
appropriate time to consider some New Year's resolutions. One of mine is
to tell the truth. That may seem like a no-brainer to most people, but
that’s sometimes been hard for me. Frankly, I’ve not been the poster
child for honesty in some of my relationships. I’m on the right road
now, and finding that truth-telling, while sometimes painful and requiring
quite a bit of verbal gymnastics to say what I want without collateral damage
to those I love, is a whole lot easier that digging yourself out of whatever
pit you’ve fallen into. Only took 25 years to figure this out, but at
least I’ve finally got it right.</span><br />
<div style="margin: 0in 0in 10pt;">
<span style="font-family: Times, Times New Roman, serif;"><br />
That being said, this new veneer of veracity also forces me to admit
that I lie like a dog at work. I suspect all ER docs do, even if we don’t
admit it to ourselves. I’ve been thinking about the lies we tell and
trying to discern a pattern…translated as “I’m switching from nights to days
and can’t sleep…and I’ve decided that our lies can be grouped in a manner
similar to Maimonides’s Eight Ascending Levels of Charity. (Maimonides
was the greatest of the medieval Jewish Philosophers, living in Spain and North
Africa during the Twelfth Century. He was also physician to the
Sultan Saladin, which just goes to show that everyone wants a nice Jewish
doctor). So as the most minor Jewish philosopher in Shawnee County,
I’d like to propose the Four Descending Steps of ER Lies.</span><br />
<span style="font-family: Times, Times New Roman, serif;"><br />
</span><br />
<i style="mso-bidi-font-style: normal;"><span style="font-family: Times, Times New Roman, serif;">One Step Down:
The Lie of Obfuscation </span></i><br />
<span style="font-family: Times, Times New Roman, serif;"><i style="mso-bidi-font-style: normal;"><br /></i>
</span><br />
<span style="font-family: Times, Times New Roman, serif;">These are the common, everyday lies; the ones we tell by shading the truth
in a way that keeps us out of trouble. How can a doctor or nurse get in
trouble by telling the truth? Perhaps you missed the memo, but medicine
today is not driven by the provision of great care and the occasional “hard
love” that’s required to change patient behaviors for long-term health.
No, my friend, it’s driven by customer service and customer satisfaction, by
the need to grab and secure your market share, and doing anything that
jeopardizes that…like telling a patient an uncomfortable truth in a way that
puts their continuing patronage at risk…can be a dangerous game for the unwary
physician who suddenly finds himself on the end of a patient complaint. “The
customer is always right” ethos has become so fixed that when the patient is
upset the doctor is presumed guilty, and the only way to prove his or her
actions were appropriate is by documenting the more egregious behaviors of the
patients. Every patient encounter becomes potentially adversarial from
the start, and as most ER docs in this country work for someone else rather
than part of their own group practice and so are considered interchangeable
cannon fodder, every patient interaction is the one that can generate the
complaint to get you fired.</span><br />
<span style="font-family: Times, Times New Roman, serif;"><br /></span>
<span style="font-family: Times, Times New Roman, serif;">You may think this is an over-reaction. But I cannot tell you how
many times in over two decades of doing this that I or my colleagues have been
accused of racism, sexism, homophobia, ageism, Medicaid-ism, socio-economic
classism, and just plain rudeness. And why? Because on occassion we
try to tell people the truth. We explain that they are obese, and they
are responsible for their own diabetes, arthritis, or chronic pain. We
tell people there’s nothing we can do for them unless they stop smoking crack
or drinking alcohol. We remind people that it’s irresponsible to miss
appointments with their primary care doctor or not take their medications,
especially when we’ve built a safety net system specifically to meet their
needs. and while most folks understand and accept what we want to say, there are those who at best have an adverse relationship with the truth.</span><br />
<span style="font-family: Times, Times New Roman, serif;"><br />
</span><br />
<span style="font-family: Times, Times New Roman, serif;">(Speaking of racism, I really enjoyed the guy who came in late one night in
Western Kansas full of himself, as well as a few toxic substances. He was
abusive to all, and as the local gendarmes were assisting his disposition he
called me a racist. “You’re right,” I said, the full glow of my Caucasian
pigment shining upon him. “I hate white people, too.”)</span><br />
<span style="font-family: Times, Times New Roman, serif;"><br />
</span><br />
<span style="font-family: Times, Times New Roman, serif;">So the Lie of Obfuscation occurs when you’re trying to communicate a message
in a way that won’t get you an e-mail the next day. Let’s take the
aforementioned hefty individual complaining of chronic back and knee pain,
which you know will never get better until they drop the poundage. But
instead of saying, “You have this pain because you’re fat and you need to lose
weight,” you say, “You know, you’re kind of a bigger person, and that might be
part of your problem.” Technically, at 6’1” in a nation where the average
male stands 5’9 ½”, I’m a bigger person. I also weigh 150 pounds after a
box of Twinkies.</span><br />
<span style="font-family: Times, Times New Roman, serif;"> </span><br />
<span style="font-family: Times, Times New Roman, serif;">Here are some other examples:</span><br />
<span style="font-family: Times, Times New Roman, serif;"><br />
</span><br />
<span style="font-family: Times, Times New Roman, serif;">Truth: You have asthma and you smoke. What’s that all about?”</span><br />
<span style="font-family: Times, Times New Roman, serif;">Lie: “You know, smoking in the midst of your asthma attack is not such
a good thing. Would you like me to tell you about that?</span><br />
<span style="font-family: Times, Times New Roman, serif;"><br />
</span><br />
<span style="font-family: Times, Times New Roman, serif;">Truth: “This is the fourth time you’ve been here this month for your
(choose one or more) chronic pain, fibromyalgia, alcohol abuse, drug abuse,
mood disorder. At this point, there’s nothing we can do for you and this
is a waste of both our times.”</span><br />
<span style="font-family: Times, Times New Roman, serif;">Lie: “We’re always happy to see you and evaluate you for an emergency
medical condition. Fortunately, there seems to be none present today.”</span><br />
<span style="font-family: Times, Times New Roman, serif;"><br /></span><br />
<span style="font-family: Times, Times New Roman, serif;">Truth: “You tell me you don’t have a doctor, but every time you’ve
been here you said you had an appointment. Then the next time you’re back
you say you missed it. What’s up with that?”</span><br />
<span style="font-family: Times, Times New Roman, serif;">Lie: “It can be difficult getting to see the doctor. We’ll make
another referral for you today.”</span><br />
<span style="font-family: Times, Times New Roman, serif;"><br />
</span><br />
<span style="font-family: Times, Times New Roman, serif;">Truth: “Your doctor (or the Ask-A-Nurse phone line, or Poison Control)
is a moron.”</span><br />
<span style="font-family: Times, Times New Roman, serif;">Lie: “Fortunately, there’s nothing serious going on. And those
lab tests and that MRI and that elective surgery your doctor sent you in for is
just going to take up a lot of time and cost a lot of money, and I don’t think
it’s something we need to do tonight. I think everything’s going to be
just fine. Glad to help.”</span><br />
<span style="font-family: Times, Times New Roman, serif;"><br />
</span><br />
<span style="font-family: Times, Times New Roman, serif;">Truth: “I’m not giving you any pain meds because I’ve looked at your
medical records and the term “drug-seeking behavior” is all over your chart.”</span><br />
<span style="font-family: Times, Times New Roman, serif;">Lie: “I’m sorry, but people have expressed concerns about your use of
narcotic pain medications and I’m afraid I have to honor those concerns.
It’s also not my practice to write prescriptions for chronic pain in the ER.”</span><br />
<span style="font-family: Times, Times New Roman, serif;"><br />
</span><br />
<span style="font-family: Times, Times New Roman, serif;">Truth: “I know you’re going to drink. Could you at least do it
at home where, when you pass out, nobody will call the cops and the ambulance?”</span><br />
<span style="font-family: Times, Times New Roman, serif;">Lie: “I’d like to offer you the chance to go to detox to help with
your drinking.”</span><br />
<span style="font-family: Times, Times New Roman, serif;"><br />
</span><br />
<span style="font-family: Times, Times New Roman, serif;">Truth: “People who really want to commit suicide don’t call their
ex-boyfriend/ex-girlfriend/ex-wife/ex-husband/parent/child to let them know. Here’s
a pamphlet from the Hemlock Society.”</span><br />
<span style="font-family: Times, Times New Roman, serif;">Lie: “I’m glad you called for help.” </span><br />
<span style="font-family: Times, Times New Roman, serif;"><br /></span>
<span style="font-family: Times, Times New Roman, serif;">(Closely related is the Accessory Lie of Withholding, also known as Applying
the Internal Filter. Examples including not telling patients they are
aesthetically displeasing oxygen thieves, their babies are ugly, that they
really should have sprung the extra dollars for the good tattoo parlor, that
the only good genitals are unexposed genitals, or that they are piss-poor
pieces of protoplasm that, through their very presence, make a convincing
argument against Intelligent Design. This is also the one where you don’t
say to the patient on public assistance bitching and threatening to refuse to
pay, “You’re not paying for it anyway. I am.” The inability to
consistently tell the Accessory Lie of Withholding is probably why I work a lot
of night shifts, out of the daytime presence of Administration.)</span><br />
<span style="font-family: Times, Times New Roman, serif;"><br />
<i style="mso-bidi-font-style: normal;">Two Steps Down:
The Lie of Feigned Ignorance</i></span><br />
<span style="font-family: Times, Times New Roman, serif;"><br />
Doctors, nurses, and other health care people know a lot. Most of that
which we know we tell you. We may tell you in a way that’s fun for us,
especially if it’s juicy stuff. For example, if your urine tested
positive for methamphetamine after you had told me you don’t do drugs, I could
just walk into the room and say, “Your urine has meth in it.” That’s
boring. Or I could sit down and say, “Just remind me. I think when
I asked about drugs, you said you didn’t do any, right?” When you confirm
that statement, then I get to say, “Well, your urine tested positive for meth.
How do you think that got in there?” Then I get to watch you come up with
a story. One of the better ones lately involved a woman who was pretty
sure that some guy named Peabody was using her bong last week to smoke meth and
must have left some in there when she was smoking her weed the next day.
(Fair warning: The excuse “I was holding it for someone else in my hand,
and must have gotten in my skin,” doesn’t work. Neither does “secondhand
crack.”) This is an especially fun conversation if there are others in
the room, for if they are there I assume you’re okay with them hearing
everything I have to say, else you would have shooed them out. This works
especially well with positive pregnancy tests and the diagnosis of STD. </span><br />
<span style="font-family: Times, Times New Roman, serif;"><br />
Most often, though, the things we don’t tell you are bad. If you show
up in the ER with three weeks of turning yellow, a twenty pound weight loss,
and no abdominal pain, I can tell you without any further ado that you have
pancreatic cancer and things will not go well. (If you don’t believe me,
look up “painless jaundice” on the Internet School of Doctoring, which is
always right according to patient when I disagree with their research.) If you
show up like this, I will get a CT scan on you, and it will show a large mass
in your pancreas where it meets the bile ducts draining the liver, and more
likely than not your liver will look like a piece of swiss cheese from all the
areas of metastatic tumor in it. But when I tell you the results of the
scan, I will not tell you that you have metastatic cancer and bad things are
going to happen. I will instead tell you that you have a mass in your
pancreas, blocking up your liver, and that while I don’t know what it is we’re
going to need to put you in the hospital to figure it out. Similarly, if
you’ve recently had a biopsy and I can find the results in the computer, I will
probably not tell you what they are if bad. If I’ve done a procedure
known as a thoracentesis, and the fluid that comes out of your chest cavity is
bloody, that’s cancer. I won’t tell you that, but I know. If
there’s an infection raging through the frail body of your elderly parent, I’ll
say that her condition is serious and we’ll do all we can to help. I
won’t say I know she’s going to die. </span><br />
<span style="font-family: Times, Times New Roman, serif;"><br />
It’s not that ER docs aren’t able to give bad news. We do it all the
time, especially when death happens suddenly, and are probably so fluent with
it that it seems rehearsed. (Which, by the time you’ve done this a while, it
kind of is. What changes is not your speech but how the family reacts and
what you do then.) We also don’t mind asking about Living Wills or Do Not
Resuscitate Orders, because they directly influence what we do in the ER.
But when it’s something like cancer, or overwhelming infection, or an
incapacitating stroke, we often don’t have very many answers for what is likely
to be asked. You hate to add more fear by not being able to provide
knowledge or solace. And I truly do think the definitive diagnosis is
best delivered by someone who will follow the patient and be part of their
continuing care. The lie may be explained and possibly even justified,
but a lie nonetheless.</span><br />
<span style="font-family: Times, Times New Roman, serif;"><br /></span>
<i style="mso-bidi-font-style: normal;"><span style="font-family: Times, Times New Roman, serif;">Three Steps
Down: The Lie of Caring </span></i><br />
<span style="font-family: Times, Times New Roman, serif;"><br /></span>
<span style="font-family: Times, Times New Roman, serif;">Unit Clerk: “Good morning! How are you?”</span><br />
<span style="font-family: Times, Times New Roman, serif;">Doctor: “Just happy to be a part of the healthcare system of the
Citizens of Northeast Kansas.”</span><br />
<span style="font-family: Times, Times New Roman, serif;"><br />
</span><br />
<span style="font-family: Times, Times New Roman, serif;">Here’s the dirty little secret. When it's busy, when people
are demanding, and when nothing seems to be going right...which are more days
then we care to recount in a hectic ER...we don't have time to care about you
the way we should. We go into a mode where we care more about what’s been
emphasized to us by administration as the benchmarks of success. Moving
you through the system. Treating you in a way that you won’t make any
fuss. Getting your paperwork right. Eliminating liability.
When I walk into the room and say, “What can I do for you?” during those times,
what I often mean is what can you tell me so I can get you out of my ER, and
off my hands, as fast as possible; or alternately, what can you tell me that is
going to mean you stay for a long time and jam up one of my assigned rooms so I
don’t have to see as many patients? And if I'm able to do that in a way
that allows me to truly care for and about you, that’s just icing on
the cake. </span><br />
<span style="font-family: Times, Times New Roman, serif;"><br /></span>
<span style="font-family: Times, Times New Roman, serif;">Does this mean we never care? Of course not. Here’s a tip:
Show up with a real illness or injury. Look sick. Have something
happen to you that’s beyond your control. Don’t drink and drive, get beat
up, or puke. Have cancer. Have a stroke, a heart attack, or trouble
breathing.<span style="mso-spacerun: yes;"> </span>Be a child. Quit
smoking, lose weight, and take your medications as directed. Don't use me as
your primary care physician for chronic problems, and then get angry when
I can't fulfill your wants. Understand that I'm working as fast as I
can, and accept my apologies for delays in your care. Recognize that when
you’re old, you’re going to feel weak and dizzy and fall and there’s nothing anyone
can do about it unless you break a hip, and then all we can do is fix the hip
but not the weakness and dizziness. (I personally think the back of every
AARP card…including mine, acquired for discount movie purposes at the tender
age of 51…should be stamped with the message, ”If you are over 75, you will
feel, weak, you will be tired, your joints will ache, you will get dizzy, and
sometimes you may fall. You’re old. It happens.”) Deal with
your own angst. If you’re over 30, don’t bring Mommy into the room and
get her to talk on your behalf. Don't lie to me. Respect the
nurses. Stop texting. And be pleasant. Smile.<span style="mso-spacerun: yes;"> </span>If you do, you’ll find that all the caring
we’ve been building up not caring for others will wash upon you like a tsunami
once you have something genuine for us to care about. It doesn't take all that
much.</span><br />
<span style="font-family: Times, Times New Roman, serif;"><br />
<i style="mso-bidi-font-style: normal;">Four Steps Down:
The Lie of False Hope</i></span><br />
<span style="font-family: Times, Times New Roman, serif;"><br />
At the end of life, or in times of critical illness of injury, all the tools
are in the hands of the physician. The only thing the patient has left to
work with is hope. Hope that they’ll get well, hope that the medical
system won’t fail them, hope that their deity of choice will see them through,
hope that their friends and family will be there with them as they go into that
dark night. The Lie of False Hope is to give hope where there is none. It
is the most heinous thing I think I do in the ER. I believe that one
should have time to prepare for death with the mind uncluttered by extraneous
promises or guarantees. What makes this lie worse is that often the
patient knows that you’re lying, but accepts what you say in an effort to
postpone contemplating the inevitable. The English savant Dr. Samuel
Johnson has been quoted as saying, “When a man knows he is to be hanged in
a fortnight, it concentrates his mind wonderfully.” Do we not owe it to
those in the last weeks, days, or moments to allow them to concentrate on the
experience of life at it’s fullest just before the fire dies?</span><br />
<span style="font-family: Times, Times New Roman, serif;"><br />
Why, you may ask, is this worse than not caring? Because as long as
the patient thinks you’re going to do something for them, they can handle the
fact that they are nothing but a task to you. But to give them hope where
there is none, so death comes as surprise; to pretend your efforts will mean
something when you know they will simply result being seen to do something?
Playing the game of Medical Theater is the worst lie of all.</span><br />
<span style="font-family: Times, Times New Roman, serif;"><br />
At long last, that’s the truth.</span><br />
<br />
<div style="margin: 0in 0in 10pt;">
</div>
</div>
<div style="margin: 0in 0in 10pt;">
<br /></div>
Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com0tag:blogger.com,1999:blog-3594881315778851964.post-70475638254110326572015-06-01T10:00:00.000-04:002015-06-01T11:00:22.299-04:00The Doctor's Dilemma<br />
<div style="background: white; line-height: normal; margin: 0in 9pt 0pt 0in; tab-stops: 45.8pt 91.6pt 137.4pt 183.2pt 229.0pt 320.6pt 366.4pt 400.5pt 412.2pt 458.0pt 503.8pt 549.6pt 595.4pt 641.2pt 687.0pt 732.8pt;">
<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">At the start of every
shift I go through my e-mails. I find it a nice way to ease into my workday,
and it's sort of fun to count the minutes you spend reading e-mails, multiply
it by the amount you're getting paid per minute (and make no mistake, every ER
doc knows what that number is), and realize you've just made money by clicking
on announcements of new hires you'll never encounter, seminars you'll never
attend, and the administrative glad-handing that passes for the aura of employee
relations.<span style="mso-spacerun: yes;"> </span>I could tell you that I'm
looking intently for u</span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">pdates on clinical
policies and care pathways that will lead to improved patient outcomes, or
opportunities to fulfill<span style="mso-spacerun: yes;"> </span>my educational
needs, but the truth is I'm looking for Nastygrams.<span style="mso-spacerun: yes;"> </span>Those are the e-mails that start out with some
variation of "Remember that patient?" Any written communication that
starts this way is by definition bad.<span style="mso-spacerun: yes;"> </span>In
the ER world, good news is handed out in person, while bad news is always in
writing (to cover everyone involved </span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">except the proposed
offender).</span></div>
<div style="background: white; line-height: normal; margin: 0in 9pt 0pt 0in; tab-stops: 45.8pt 91.6pt 137.4pt 183.2pt 229.0pt 320.6pt 366.4pt 400.5pt 412.2pt 458.0pt 503.8pt 549.6pt 595.4pt 641.2pt 687.0pt 732.8pt;">
<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";"> </span></div>
<div style="background: white; line-height: normal; margin: 0in 9pt 0pt 0in; tab-stops: 45.8pt 91.6pt 137.4pt 183.2pt 229.0pt 320.6pt 366.4pt 400.5pt 412.2pt 458.0pt 503.8pt 549.6pt 595.4pt 641.2pt 687.0pt 732.8pt;">
<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">(You can also use the “I
know how much I’m making per minute” theory when you’re doing personal tasks
like going to the bathroom.<span style="mso-spacerun: yes;"> </span>I like to think
about it when I’m fetching the patient some water or juice.<span style="mso-spacerun: yes;"> </span>It takes me two minutes to walk across the
ER, open the refrigerator, get the juice, fill a cup from the ice machine, find
a straw and a lid, and take it back to the patient, drag a tray over to the
bedside, open and pour…yep.<span style="mso-spacerun: yes;"> </span>Just bought
lunch.)</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">The Nastygrams come in
several varieties.<span style="mso-spacerun: yes;"> </span>The primary one is
the Patient Complaint.<span style="mso-spacerun: yes;"> </span>The patient disliked
something about what you did or didn’t do, and the Patient Advocate (now
there’s a neutral job title) and other Administrative Poobahs would like you to
review the chart before they confirm your anticipated guilt.<span style="mso-spacerun: yes;"> </span>If that sounds alarmist, it needs to be
understood that one of the current paradigms in health care is that the
customer (patient) is always right, no matter how that plays out against the
backdrop of clinical care.<span style="mso-spacerun: yes;"> </span>It’s all
about the satisfaction scores, about seeing the patient quickly, about making
sure they’re happy during their stay and leaving with a positive impression so
the patient, family, and friends will continue to seek care, and bring their
dollars, to this hospital.<span style="mso-spacerun: yes;"> </span>Which is all
well and good, and something to be pursued, until you recognize that a lot of
medicine doesn’t involve making people happy.<span style="mso-spacerun: yes;">
</span>It’s about doing the right thing and the right time within the limits of
your abilities and resources, and as often as not it means doing what might not
be considered optimal customer service.<span style="mso-spacerun: yes;">
</span>And if the scores come in low, no matter what the reason, it’s the
physician who’s on the hook because otherwise it’s a problem with the system,
and that might implicate the folks in suits.</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Once you review the record,
the complaint is usually not a surprise; and if you've done your documentation
correctly (including direct quotes from the patient of phrases that rhyme with
"brother ducker," "whole mitt," and "brass mole"),
the Cubicle Dwellers have no choice but to reluctantly send a letter to the
patient apologizing for the hard feelings, but regretfully concluding the care
was appropriate. (The line, "It was documented that you acted like an orifice,
and our staff was exactly right to send you on your happy way," is apparently
not part of the template.)</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";"> </span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">(Speaking of which, my
colleagues and I recently got an e-mail from one of our Medical Directors
complimenting our group on the fact that there had been no patient complaints in
the <span style="mso-spacerun: yes;"> </span>prior two weeks.<span style="mso-spacerun: yes;"> </span>I sent back a note and explained that I was
on vacation.)</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">The “customer service”
mantra leads to a strange and costly practice of medicine, where tests are
ordered simply to be doing something or to meet patient <span style="mso-spacerun: yes;"> </span>expectations, drugs are dispensed to make patients
happy or simply because the doctor isn’t up for the fight (I think every ER doc
has experienced their own version of “Give’em What They Want Wednesday,”), and
the time needed to fully understand what’s going on with a patient, to set
realistic expectations for the ER visit, and to provide good explanations of
diagnoses or discharge instructions is truncated by the need to deal with those
complaining more loudly and threatening to leave.<span style="mso-spacerun: yes;"> </span>(I’ve never quite understood why, when
someone wants to leave the ER because they’re not being seen fast enough or
they don’t like the care they’ve received, we need to fall all over ourselves
to get them to stay.<span style="mso-spacerun: yes;"> </span>They are self-triaging
themselves back to the community despite our legally-obligated offer of care.<span style="mso-spacerun: yes;"> </span>Isn’t that what we want people to do…to take
control of their own health care?<span style="mso-spacerun: yes;"> </span>Yes,
unless their departure means less revenue.) </span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">If clinical correlations
mean anything…as they rarely do in the world of customer service…there are
studies that suggest that more “satisfied” patients actually get worse health care
and experience worse outcomes.<span style="mso-spacerun: yes;"> </span>And what’s
more interesting is that those very things you can do to enhance customer satisfaction…like
taking more time with patients to provide teaching and explanations, making
sure family and friends are involved and informed, and going through discharge
instructions carefully and completely…work against the goal of enhanced patient
turnaround times. (More on that later.)</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Which leads us to the
Nastygram by the Numbers.<span style="mso-spacerun: yes;"> </span>I truly do
think it's a welcome development that an increasing amount of medical care is
judged by objective criteria.<span style="mso-spacerun: yes;"> </span>For
example, if we know that patients should get certain medications after a heart
attack, and that old people should get influenza and pneumonia vaccines, it
makes sense to keep count of how many actually get the recommended care.<span style="mso-spacerun: yes;"> </span>These are objective, specific, and measurable
criteria proven to show a benefit to patient care.<span style="mso-spacerun: yes;"> </span>The problem is that many other criteria </span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">we're judged on,
especially in the ER, are totally abstract numerical goals without any clinical
basis or demonstrated outcomes.<span style="mso-spacerun: yes;"> </span>Many of
them are promulgated by what I think of as the "Center" industry,
which are those organizations set up to certify institutions as a Stroke Center, a Chest Pain Center, and others of that
ilk for a healthy fee.<span style="mso-spacerun: yes;"> </span>Which ultimately is not a clinical
designation, but a marketing one.<span style="mso-spacerun: yes;"> </span>(Ever
notice how no hospital markets itself as a "</span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Methamphetamine
Center?"<span style="mso-spacerun: yes;"> </span>It's because the bean
counters don't want those folks...perhaps better termed as "non-revenue
clients"...darkening the door of their ER.<span style="mso-spacerun: yes;">
</span>Strokes and heart attacks mostly involve old people with Medicare, which
means payment. Meth intoxication?<span style="mso-spacerun: yes;"> </span>Not so
much.)</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Despite the fact that
these criteria have no basis in reality, when one of them is not met the
Nastygram follows.<span style="mso-spacerun: yes;"> </span>For example, many
have heard of "clotbuster" treatment for strokes.<span style="mso-spacerun: yes;"> </span>The theory goes that if strokes are caused by
small blood clots that limit blood flow to the brain, these medications get
into the vessels and blast these clots away.<span style="mso-spacerun: yes;">
</span>The catch is that you have to give these medications under four hours or
so from the onset of the symptoms of stroke; b</span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">eyond that time, the
risks of life-threatening bleeding from use of the drug outweigh any benefit
you might see<span style="mso-spacerun: yes;"> </span>The criteria is that once
the patient arrives in the ER, you have an hour from the moment the patient
walks through the door to give the medication.<span style="mso-spacerun: yes;">
</span>If it's given after that first hour, or there's no reason on the chart
why you didn't give the medication (not everyone qualifies and it's not universally
indicated), you "fall out" and your e-mail inbox fills.</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Why one hour?<span style="mso-spacerun: yes;"> </span>Nobody knows.<span style="mso-spacerun: yes;">
</span>It's a totally abstract number.<span style="mso-spacerun: yes;">
</span>Nobody has ever been able to quantify how much brain tissue is lost
between 59 and 61 minutes.<span style="mso-spacerun: yes;"> </span>And while I
would surely agree that quicker treatment times are generally better, sometimes
you need to take the time to discuss with the patient and the family the risks
and benefits of treatment, and the speed of their decision process often does
not match yours. They may want to talk to additional family m</span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">embers, or you may
simply have problems finding anyone to talk to.<span style="mso-spacerun: yes;">
</span>Maybe you need some lab work to make sure the patient actually qualifies
for the drugs, or simply time to get the story<span style="mso-spacerun: yes;"> </span>straight so you know what you're doing.<span style="mso-spacerun: yes;">
</span>And it's worth noting that in a recent study of Certified Stroke
Centers, the majority were unable to meet their own select criteria for
administration of the agent in less than an hour.<span style="mso-spacerun: yes;"> </span>Rather than citing unproven numbers with the </span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">force of law, wouldn't
it make more sense to track your own facility's times, come up with a goal, and
look for roadblocks in the process rather than to come down on individuals for
falling out on criteria that clinically means nothing and can't even be met by
the best of hospitals?</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";"> </span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">(And this is even without
addressing the very real clinical argument that the drugs may not be very
useful overall, and should not even be considered the standard of care.<span style="mso-spacerun: yes;"> </span>Once again the “Center’ industry…no doubt
supported by the pharmaceutical folks who make these drugs…has promulgated a
standard that may not even reflect the best practice in patient care.<span style="mso-spacerun: yes;"> </span>This is similar to what happened with the
standards for cardiac resuscitation over a decade ago, where a perfectly useful
and inexpensive drug called lidocaine used for irregular heartbeats was
magically replaced by a much more expensive and less useful agent called
amiodarone, and nobody could figure out if there was a connection between the
maker’s kind and generous support of the American Heart Association and its’
Clinical Investigators, and the change in standards.<span style="mso-spacerun: yes;"> </span>But I suppose this is all cyclical and really
nothing new.<span style="mso-spacerun: yes;"> </span>At one time I understand it
was popular to be a “Leech Center” as well.)</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">The most recent “quality
benchmark” has been proposed by the Department of Health and Human
Services.<span style="mso-spacerun: yes;"> </span>HHS has set a goal of getting
patients who will be discharged home in and out of the ER in a total time of
two hours.<span style="mso-spacerun: yes;"> </span>They’re even talking about it
being used as a reimbursement factor.<span style="mso-spacerun: yes;"> </span>Let’s
leave aside for the moment that this is a totally abstract number, and that
even the fastest doctor in our ER group did an experiment one month and
couldn’t get her patients out in less than 120 minutes no matter how hard she
worked.<span style="mso-spacerun: yes;"> </span>Given unlimited resources of staffing,
scores of empty patient rooms, and idle x-ray and laboratory machines just
begging for something to do, you could probably meet the goal.<span style="mso-spacerun: yes;"> </span>Nobody has that, and the two hour turnaround for
all discharged patients often becomes a totally unobtainable measure in any busy
ER that can’t be met without tricks of accounting (and there are ways to do
that, some legitimate, some not so much).</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";"> </span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">But the practical issues
beg the question of whether meeting this goal represents a measure of quality,
at least as defined in medicine.<span style="mso-spacerun: yes;"> </span>Fast
turnaround times are possible, as long as the patient has a straightforward
outpatient problem, sufficient ancillary resources are available to permit rapid
lab and x-ray evaluation, and the physicians and nurses are not otherwise
burdened with an excessive number of patients under care or even a single
critical patient which can take them ‘out of the system” for a prolonged period
of time.<span style="mso-spacerun: yes;"> </span>But that’s most often not the
case.<span style="mso-spacerun: yes;"> </span>As an emergency physician, the
nature of the work means I’m not fully dedicated to a single patient at a time,
and I can’t focus on moving that one patient through as quickly as I can.<span style="mso-spacerun: yes;"> </span>I’ve got up to ten or more patients to juggle
at a time, all with different issues, different levels of severity, and
different agendas and expectations that need to be resolved.<span style="mso-spacerun: yes;"> </span>Statistically speaking, the conflict is
really one of modeling ER flow.<span style="mso-spacerun: yes;"> </span>Throughput
goals are based on a linear model of patient arrival, departure, provider
workload, and client movement through the department.<span style="mso-spacerun: yes;"> </span>Patients being the subjective and unpredictable
creatures that they are, those with “boots on the ground” recognize that the ER
actually works on a non-linear model.<span style="mso-spacerun: yes;"> </span>Patient
show up when they choose or need to, have varied complaints, require different levels
of clinical and social interventions.<span style="mso-spacerun: yes;"> </span>Workload
for physicians and nurses follows a non-linear pathway as well.<span style="mso-spacerun: yes;"> </span>So turnaround times mean something, or nothing,
depending on who you ask; and as a result it’s hard to have a coherent dialogue
with between two mutually exclusive perspectives.<span style="mso-spacerun: yes;"> </span>And while shorter turnaround times no doubt
promote customer satisfaction, it’s an open question whether that is equivalent
to quality care, which brings us back to where we started.</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";"> </span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Then there’s the Nursing
Complaint.<span style="mso-spacerun: yes;"> </span>As the power of Nursing Administration
(who represent the majority of "critical" employees) within the hospital
structure grows, the relative power of the physician ebbs.<span style="mso-spacerun: yes;"> </span>It's fine when the paternalistic (at best) or
authoritarian (at worst) physician-nurse relationships of the past become
collaborative in nature.<span style="mso-spacerun: yes;"> </span>But the
pendulum has s</span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">wung so far that the
relationship is often adversarial, with the doctor considered guilty until
proven otherwise.<span style="mso-spacerun: yes;"> </span>Nurses are considered
rare prizes and hard to get, and hospitals commit to specific staffing ratios and
promotional schemes to keep and retain them; physicians are thought of as
interchangeable commodities, especially in this era when most ER docs work not
for themselves, but either as hospital employees or for an outside staffing
group whose bottom line is profit margin and keeping administration happy.<span style="mso-spacerun: yes;"> </span>So who becomes your more valuable asset when
conflict occurs?<span style="mso-spacerun: yes;"> </span>Especially in the ER,
where physicians provide no referrals to the hospital, do not expand the
financial footprint of the facility, and don't generate outside revenue for the
institution?</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">(I'll be the first to
admit I have little to no internal filter at work.<span style="mso-spacerun: yes;"> </span>But I always watch myself when I talk to
nurses, especially if I disagree with their assessment or they've made a
blatant error in care, because I know who's going to win that argument.<span style="mso-spacerun: yes;"> </span>It's not me.)</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Don't misunderstand
me.<span style="mso-spacerun: yes;"> </span>It's not that doctors don't act like
jerks from time to time. They do, myself included, and some of us more often
than others.<span style="mso-spacerun: yes;"> </span>And we've all done things
in a moment of confusion of exhaustion that good nurses have caught and helped
us correct. When these behaviors become routine, we should probably get called
out on it, and in practice we do.<span style="mso-spacerun: yes;"> </span>But
since nurses are "owned" by administration in a way that doctors
aren't, they're routinely protected despite similar behaviors or a frank lack
of knowledge.<span style="mso-spacerun: yes;"> </span></span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";"> </span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">(Want to know something
else that really annoys me? Anonymous complaints.<span style="mso-spacerun: yes;"> </span>We're p</span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">rofessionals.<span style="mso-spacerun: yes;"> </span>I'll sign my name to my concerns if you'll
sign yours as well.<span style="mso-spacerun: yes;"> </span>Otherwise, we both
lose the opportunity to confront each other in search of the truth, and to find
accommodation between our views.<span style="mso-spacerun: yes;"> </span>Or better
yet, just ask what I'm doing and why I’m doing it in real time.<span style="mso-spacerun: yes;"> </span>I really don't mind questions, and an ensuing
discussion if you've got a different point of view. But let's act like adults
here, okay?)</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";"> </span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Finally, we come to the
Billing Questions, the subject of the most recent Nastygram to collect dust on
my electronic desk.<span style="mso-spacerun: yes;"> </span>It concerned a lab
test for hepatitis, and I was asked by the billing office why I ordered the test.<span style="mso-spacerun: yes;"> </span>The way the billing process works is that
anything ordered needs to link up to the discharge diagnosis according to
established criteria (the “criteria” industry is yet another moneymaker.)<span style="mso-spacerun: yes;"> </span>If the test does not relate in a
predetermined way to the discharge diagnosis, no payment for that test is forthcoming.</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";"> </span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">I went back to the chart
to find out what occurred.<span style="mso-spacerun: yes;"> </span>The patient
presented with a probable cellulitis, or skin infection.<span style="mso-spacerun: yes;"> </span>He had also come in with instructions from his
doctor to be tested for HIV, the virus that causes AIDS.<span style="mso-spacerun: yes;"> </span>He wanted this test done, and clinically when
I test for HIV I also test for hepatitis, which is also transmitted through
blood and body fluids (and which you are much more likely to contract from
exposure than HIV).<span style="mso-spacerun: yes;"> </span>They run together in
high-risk individuals, so it always made sense to me think that if you’re at
risk for one, you’re likely at risk for the other. And wouldn’t you like to
know in advance rather than be surprised one day when you wake up looking like
Chiquita Banana? Isn’t that good medical care?</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";"> </span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">But according to the
Billing Lords, with a diagnosis of cellulitis the test not indicted.<span style="mso-spacerun: yes;"> </span>So here’s the dilemma.<span style="mso-spacerun: yes;"> </span>We’re told that medicine is now all about
customer service, and I’m doing what both customers (the referring physician
and the patient) want done.<span style="mso-spacerun: yes;"> </span>I’m probably
helping to secure a referral base by honoring that doctor’s request, and
hopefully the patient will provide a glowing report back to him or her.<span style="mso-spacerun: yes;"> </span>But in the effort to enhance customer service
and provide quality care I've run up a charge that can’t be billed, and in
getting these extra tests I’ve probably increased my throughput times.<span style="mso-spacerun: yes;"> </span>I’m caught either way I turn.<span style="mso-spacerun: yes;"> </span>And none of these issues which come to haunt
me in the Nastygrams involve the actual provision of care for the patient’s skin
infection, which is to prescribe some antibiotics, advise the patient to
elevate and apply warm compresses to the leg, draw a marker line around the
area of redness to make sure it doesn’t get any worse, and wish the patient the
very best of the afternoon.<span style="mso-spacerun: yes;"> </span></span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">In reading back through
what I’ve written, I seem like nothing more than an angry old coot.<span style="mso-spacerun: yes;"> </span>There’s truth in that.<span style="mso-spacerun: yes;"> </span>I am highly frustrated with the current
practice of medicine for any number of reasons, but for the record I don’t
object to being judged in my work.<span style="mso-spacerun: yes;"> </span>I
simply want the standards to be fair and to mean something to clinical practice
and patient care, which should be my bottom line.<span style="mso-spacerun: yes;"> </span>And I want the playing field to be level, to
know that my word means something, and to know that the institution for whom I
work is actually on my side.<span style="mso-spacerun: yes;"> </span>I’ve been
in places where the hospital declared open war on physicians; fortunately,
that’s not the case where I practice now, and I hope the tide doesn’t turn
until I’m ready to hang it up for good.<span style="mso-spacerun: yes;"> </span>But
that spectre is always out there, and all it takes is one new administrator in
just the wrong place to tip the balance…as it inevitably will.</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";"> </span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Thanks for reading.<span style="mso-spacerun: yes;"> </span>I’m sorry it’s taken so long today, but I’ve
been busy writing other paragraphs.<span style="mso-spacerun: yes;"> </span>I
really appreciate your patience and understanding.<span style="mso-spacerun: yes;"> </span>Please be sure to fill out your customer
satisfaction survey.<span style="mso-spacerun: yes;"> </span>Please make sure
you rate me as a “9” or “10,” because anything else is considered a
failure.<span style="mso-spacerun: yes;"> </span>If you like me, the name’s Dr.
Rodenberg.<span style="mso-spacerun: yes;"> </span>If you don’t, it’s Dr. Smith.<span style="mso-spacerun: yes;"> </span>Because we don’t have any of those here in
our ER.</span></div>
Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com0tag:blogger.com,1999:blog-3594881315778851964.post-59121551458243805312015-05-11T12:32:00.000-04:002015-05-11T12:32:52.157-04:00"Fire Phasers, Mr. Grant!"<br />
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">We've all had the
problem of songs getting stuck in our head.<span style="mso-spacerun: yes;">
</span>I've noticed, however, that the problem seems to be more acute as I get
older, and I think this is because as my short-term memory fades, I can no
longer recall any recent tunes that involve anacondas and buns and the like,
leaving large gaps in the mental day needing to be filled with retained
television theme songs from the 1970's, mostly from The Love Boat, which echoes
through my head constantly </span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">anytime I'm on a cruise
ship, much to the total chagrin of The Teen, who, whenever he sees a cute girl
on the ship and his father notices his interest, is likely to have that same
father spontaneously break out in a chorus of "Love!<span style="mso-spacerun: yes;"> </span>Exciting and New! Come Aboard!<span style="mso-spacerun: yes;"> </span>We're Expecting You!" in off-key but
most enthusiastic baritone which will hammer at his adolescent brain until he's
run down the nearest staircase and the sound cannot penetrate the deck plates. </span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Which is why, as The
Teen and I ventured to the frozen North this past week to partake of the
opening weekend of the Minneapolis-St Paul International Film Festival, all
I've heard since I got off the airplane were the musical questions of Who Can
Turn the World On With Her Smile and (you're way ahead of me) if She's Gonna
Make It and, because I am a hormonally addled male nearing the end of my days
of non-chemical enhanced potency, with whom, and how often.</span><br />
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">(For the record,
Minneapolis and cruise ships are not the only places this happens to me.<span style="mso-spacerun: yes;"> </span>My brother lives in Cincinnati, and I cannot
see his phone number pop up on my cell without asking myself if anyone wonders
whatever became of me. <span style="mso-spacerun: yes;"> </span>Similarly, when
Ii was in Seattle a few years back, I spent half the time trying to match up
the gray urban landscape and overcast sky with Bobby Sherman's descriptions.<span style="mso-spacerun: yes;"> </span>I also spent a considerable amount of effort
trying to find the </span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">iCarly building, but
that's a different story.</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">I've not known much
about Minneapolis.<span style="mso-spacerun: yes;"> </span>There's the Mary
Tyler Moore show, of course.<span style="mso-spacerun: yes;"> </span>There's the
Minnesota Vikings, the Minnesota Twins, and the late lamented Most Appropriate </span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Hockey Team Name Ever,
the Minnesota North Stars.<span style="mso-spacerun: yes;"> </span>I know Bronko
Nagurski was a Golden Gopher.<span style="mso-spacerun: yes;"> </span>And
snow.<span style="mso-spacerun: yes;"> </span>Lots of snow.<span style="mso-spacerun: yes;"> </span>So it was admittedly with a somewhat narrowed
point of view that I arrived in the Eng Bunker of the Twin Cities and headed
directly to The Mall of America.</span></div>
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</div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">At first glance, The
Mall is breathtaking in its vastness.<span style="mso-spacerun: yes;">
</span>(It's the only mall I've ever seen that has its own train station and
attached $250/night hotel.)<span style="mso-spacerun: yes;"> </span>I'm sure
most people have heard something of it.<span style="mso-spacerun: yes;">
</span>There is an indoor amusement park complete with roller coasters, a
ferris wheel, and a log flume.<span style="mso-spacerun: yes;"> </span>There are
movie theaters, a bowling alley, a miniature golf course, and more shops and
kiosks than you can count. </span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">But once you get past
that first impression of sheer size and scope, it dawns on you that it's still
a mall.<span style="mso-spacerun: yes;"> </span>Writ large, of course, and all
contained within a nondescript concrete bunker to keep you warm while you do
your destination shopping in the depths of December, but still pretty much just
a mall with stores you can find anywhere else (although it is interesting to
note that because the place is so large, there are sometimes two versions of
the same store located at opposite ends or on different floors).</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Remember Mary's tune that
kept going through my head?<span style="mso-spacerun: yes;"> </span>It didn't
stop at The Mall. So as I'm looking through the Minnesota souvenir stores (of
which, including local crafts, sports, and college memorabilia, I recall at
least nine) and I'm finding myself strangely drawn to Goldy the Gopher, who
seems so much more cute and cuddly and, well, mascoty, in comparison with the
Chickenbird who lives thirty miles east of my house, the Kittycat who lives 45
miles to the west, and the Angry Dancing Wheat two hours to the south, but I am
finding no Mary Tyler Moore show trinkets at all. I would have bought a light
blue WJM blazer and done homemade podcasts </span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">with the news, I really
would have.<span style="mso-spacerun: yes;"> </span>But alas, I'm too old for
consumer culture, and instead the stores are full of natural goods and
healthful candies and homespun clothing and things featuring moose instead of
aerodynamic tam-o-shanters or the Sue Ann Niven cookbook or t-shirts that
proclaim "I HATE SPUNK!<span style="mso-spacerun: yes;"> </span>Guess all I
can do is grow with the times.<span style="mso-spacerun: yes;"> </span>Which is
why I now own a necktie shaped like a walleye.</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">There was one place in
The Mall where the MTM theme was replaced by another, and that was at Star
Trek: The Exhibition. Several years ago I had seen a Star Trek installation in
Las Vegas, and was quite impressed.<span style="mso-spacerun: yes;"> </span>I
arrived at The Mall too late to go into the exhibit that night, but was able to
visit the gift kiosk which, in contrast to the embarrassment of Trek riches I
had seen in Vegas, was comprised of not much more than a few shelves of plastic
phasers and communicators, one each of a Lt. Uhura and and a Lt. Sulu commemorative
plate, and some of the requisite yellow, blue and red tee-shirts. <span style="mso-spacerun: yes;"> </span>I did break down and buy a set of Star Trek
cocktail glasses and a red leather wallet that, when you open it, has the
words, "He's dead, Jim" embossed on the pocket (I'll explain it to
you later.)<span style="mso-spacerun: yes;"> </span>However, I was not willing
to part with nearly seventy dollars for a cheap imitation of a medical
tricorder that purported to say multiple phrases but only spouted (you guessed
it) "He's dead, Jim."<span style="mso-spacerun: yes;"> </span>It might
have been fun to take to work if it said a few other things, but I've found
that people who are not dead generally don't like to be scanned and told they
are, and those who are dead already know it and scanning them is really
redundant.</span><br />
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">As I said, it was a
pretty skimpy gift shop, and I was concerned that the exhibition itself would
follow suit.<span style="mso-spacerun: yes;"> </span>But ever the optimist, I
bought my ticket anyway.<span style="mso-spacerun: yes;"> </span>And not only
was I was surprised at how much fun I had, I was even happier that The Teen,
who knows William Shatner more from a bad rendition of Bohemian Rhapsody than
as James T Kirk (or TJ Hooker, or Denny </span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Crane...but trust me,
he's being educated) had a blast.</span></div>
<br />
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">At this point, I need to
issue a disclaimer and note that if you're not into the World of Star Trek</span><br />
<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">or, even worse, one of
those people who prefers a universe peopled with fictional furballs like Ewoks
and Wookies, and whatever the hell Jar-Jar Binks is, rather than the ABSOLUTELY
REAL Hortas, Talosians, and Gorns, you are going to be bored silly and wonder
if your $16.95 entrance fee could have been better spent on...well, anything.</span><br />
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">But if you are of that
world, it's a 90 minute slice of heaven.<span style="mso-spacerun: yes;">
</span>It starts out with a timeline of space travel, starting with Robert
Goddard and moving through Zefram Cochrane, The Treaty of Khitomer, Voyager,
and Deep Space 9.<span style="mso-spacerun: yes;"> </span>There is an original
Captain's Chair from the Enterprise-D and, more interestingly, one from the
Enterprise-B, captained by Ferris Bueller's friend Cameron (don't make me
explain this).<span style="mso-spacerun: yes;"> </span>There are original
costumes (was Shatner ever really that short and thin?), and an occasional set
dressing where I found myself involuntarily bent over a </span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">recreation of the
Engineering console on the Enterprise-D, trying desperately to bring the warp
drive back online...even though I'd much rather be working alongside my
childhood favorite Montgomery Scott ("Ye canna change the laws of physics!")
rather than the pansy, goody two-shoes Geordi LeForge. (But at least we have
Reading Rainbow.)<span style="mso-spacerun: yes;"> </span>There are models and
props that close-up you can tell are nothing but poorly painted pieces of wood
and styrofoam, but at which you marvel nonetheless.<span style="mso-spacerun: yes;"> </span>And all of this is going on while the theme
songs from the </span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">five Trek series are
being boomed into your head.<span style="mso-spacerun: yes;"> </span>I'm in my
element, and Mary is finally gone, replaced by the knowledge that it's been a
long time getting from there to here.</span><br />
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">For me, the piece de
resistance of the entire exhibit was a recreation of the bridge of THE Enterprise.<span style="mso-spacerun: yes;"> </span>(As Mr. Scott would say in a drunken TNG
rant, "<span style="mso-spacerun: yes;"></span>Show me the
bridge of the Enterprise. NCC-1701.<span style="mso-spacerun: yes;"> </span>No
bloody A, B, C, or D.")<span style="mso-spacerun: yes;"> </span>At heart
I'm an Original Series guy, meaning that I believe that sometimes you can't
talk it out and you just have to blast someone out of the sky.<span style="mso-spacerun: yes;"> </span>So as I walked onto the bridge and stood by
the rail, it like where I needed to be.<span style="mso-spacerun: yes;"> </span>Sure,
there was the Captain's chair, but it didn't feel comfortable.<span style="mso-spacerun: yes;"> </span>You can't command while </span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">seated.<span style="mso-spacerun: yes;"> </span></span><br />
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">There are some who
believe that we all have past lives, and that if you look hard enough you can
find out who you were from who you are.<span style="mso-spacerun: yes;">
</span>Does it mean something that I've always read volumes about naval warfare
and The Great Captains?<span style="mso-spacerun: yes;"> </span>Does it mean
anything that I'm a pretty good leader but a not-so-hot follower?<span style="mso-spacerun: yes;"> </span>Could I be the last verse of the song
"Highwayman?"<span style="mso-spacerun: yes;"> </span>It's been a long
road, indeed.</span><br />
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">But wait, my reverie is
interrupted; here's an exhibit staffer to take my picture.<span style="mso-spacerun: yes;"> </span>And now someone else...some...well, tourist
geek...wants to sit on the chair.<span style="mso-spacerun: yes;"> </span>On MY
bridge.<span style="mso-spacerun: yes;"> </span>And as my reality comes crashing
down, all I can do is take refuge in knowing that there's a candy store three
flights down and to the right that makes caramel apples and an Orange Julius
stand which</span><br />
<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">does, in fact ease the
pain.</span></div>
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">After the Mall we headed
downtown to the film festival.<span style="mso-spacerun: yes;"> </span>(The
Teen, who is currently asleep as I write this pending his forty minute Voyage of Discovery each
morning that we call Taking a Shower, has already posted his first movie review
at thecriticalfrog.blogspot.com. Many more to come.) <span style="mso-spacerun: yes;"> </span>Only been here overlooking the Mississippi for
a few short hours but already like the place.<span style="mso-spacerun: yes;">
</span>Woke up early and walked from the hotel, a brisk trot under gray skies to
the one landmark I know of, which is the bronze statue of Mary Tyler Moore throwing
her hat into the air at the corner of 7th street and Nicollet Mall. Took
selfies.<span style="mso-spacerun: yes;"> </span>Song is back.<span style="mso-spacerun: yes;"> </span>She's gonna make it after all.<span style="mso-spacerun: yes;"> </span>Me?<span style="mso-spacerun: yes;">
</span>Somedays I'm not so sure, but I'll get a beret just in case.<span style="mso-spacerun: yes;"> </span></span><br />
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">First glance means something
to me, and I'm pretty sure I'm going to like Minnesota a lot. Incredibly nice people,
the bird-like sing-song accent (don' 'cha know), delightfully unexpected
multicultural diversity.<span style="mso-spacerun: yes;"> </span>Even in
politics, they either elect people who believe in doing genuine good and
exhibiting common sense like Hubert Humphrey, Paul Wellstone, and Tim Pawlenty,
and when they don't they at least recognize the process for what it is and
elect buffoons (Jesse Ventura) or comedians (Al Franken).<span style="mso-spacerun: yes;"> </span>There are moose, fish, Vikings, Timberwolves,
Ole and </span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Lena, and above all
Goldy.<span style="mso-spacerun: yes;"> </span>It strikes me as a place
relatively free of pretense, where no matter how much money one has you still
need to heat your garage and shovel your way out of the driveway in the dead of
winter, and where politeness reigns because it takes up too much body heat to
be angry.<span style="mso-spacerun: yes;"> </span></span><br />
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">(Did I mention that as I
sit at breakfast writing these notes at the Renaissance Hotel at the Depot in
downtown Minneapolis, a place where the server remembers my choice of tea from
the previous day and that knows how to DO BACON RIGHT, it's April and it's
snowing?<span style="mso-spacerun: yes;"> </span>When it's fifteen degrees
higher and sunny even in my own stark Kansas?<span style="mso-spacerun: yes;">
</span>Which probably answers the question about how this place became such a
large metropolis.<span style="mso-spacerun: yes;"> </span>You clearly have to
huddle together for warmth. You get the sense that here global warming is not
debated, but welcomed.)</span><br />
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<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">I understand there's a
lot more to explore in the Twin Cities, and I certainly intend to come
back.<span style="mso-spacerun: yes;"> </span>But not this time of year.<span style="mso-spacerun: yes;"> </span>Perhaps the third week in July.<span style="mso-spacerun: yes;"> </span>I understand that's when summer has been
scheduled for 2016</span><span style="color: black; font-family: "Courier New"; font-size: 10pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: "Times New Roman";">.</span></div>
Howard Rodenberg MD MPHhttp://www.blogger.com/profile/13885902865817668634noreply@blogger.com0