Tuesday, January 5, 2010

Only 355 Days Left...

One of the skills you learn very early in The Emergent Life is to separate work from home. Some of us do a better job at compartmentalizing than others, and even those of us who think we do well at it have times where our home life invades our workspace and vice versa. But one place where they don’t meet is in holiday gift-giving. For while I got exactly what I wanted for the holidays at home, the Merry Old Elf never even had a chance to drop down the ventilation shaft at the hospital.

So, if you’re starting to look for gifts for me for next year (and you should be), here’s my official ED Holiday Gift List:

I want to be honest with patients. I want to be able to tell them the objective facts of their condition and the consequences they face. I want to tell obese patients that when they have back pain, heart disease, or diabetes, that it will never get better unless they lose the weight. I want to tell smokers that they will never get better unless they quit smoking. I want to be able to tell a drug addict that they will never get better unless they stop using drugs. I want to be able to tell patients that their problem is, in fact, not an emergency, and that this is an inappropriate use of the ED. I want to be able to say to patients, “You smoke cigarettes. You drink alcohol. You have an iPod. Don’t tell me you can’t afford your generic $4.00 medication.” I want to tell them that I will not prescribe pain pills, antidepressants, and other medications to treat the complications of their lifestyles, but will be happy to pass out discount coupons for Weight Watchers, Jenny Craig, and local workout clubs. I will pass out flyers with phone numbers Alcoholics Anonymous, Narcotics Anonymous, Al-Anon, Ala-Teen, domestic violence shelters, the Florida Tobacco Quitline, and every psychiatric and rehab facility within a hundred miles. I want to say these things because if patients hear them, they might act on them, and that will do more to improve health and lower costs than any administrative fix ever could. I do not want to have to apologize to patients, administrators, or attorneys for making people feel bad about themselves when the facts speak for themselves. There should be no repercussions from saying these things, because they are not subjective, but based in fact.

I want a big sign out front of the ED that says: “There is no such thing as a free lunch. Or a Pepsi and a meal tray. Or a bus pass, taxi voucher, or hotel room.”

I want to be able to say to those with lifestyle issues that cause illness or injury that we have enough primary care physicians, educational programs, and residential treatment facilities to help all those in need. I also want to say to those who continually refuse to change their ways, and who are receiving care on the taxpayer dollar, that it is no longer our responsibility to rescue you from your own behavior.

I want another big sign that says “A Lack of Planning on Your Part Does Not Make It an Emergency on Mine.”

I want to know what really goes on inside the mind of the non-verbal child with cerebral palsy or the patient with dementia. I want to feel what it’s like so I can try to reach the person inside, whoever or whatever that may be.

I want to be able to express frustration, sarcasm, and anger when the situation requires it. I’m a physician, supposedly sensitive to the human condition, including my own. Dammit, Jim, I’m a doctor, not a robot.

I want someone to take a leap of faith and put into place ED triage protocols that screens out the majority of non-emergent patients. Nobody does because of fear of liability. But given that ED care is inherently expensive, and the vast majority of minor problems are self-limited anyway, it would undoubtedly help to lower health care costs and be fully consistent with health care reform. It would not be consistent whatsoever with trial lawyers vision of a no-risk society, but it’s what we need to do if we’re serious about change.

I want someone to understand that sometimes, stuff just happens.

I want more days where I can’t find a babysitter and I have to bring my son to work, because there is nothing better than leaving the chaos for a few minutes each hour to check on him in the Doctor’s Lounge, ruffle his hair, and remind myself why I show up for this madness each day. I want this without the guilt that comes from using a television, a laptop computer, and a freezer full of ice cream as child care providers the other 55 minutes of every hour.

I want real plastic bowls and plates to eat from in the Staff Lounge. It’s hard to eat from an unused emesis basin without making inevitable connections between soups, chili, or Chinese food and the more usual contents of these catch-alls.

I want to add excitement to work by not only betting on patient’s alcohol levels, but on the results of drug screens and pregnancy tests, the times needed for any given physician to call us back, the number of profanities used in a 60-second period by a patient with an allergy to Law Enforcement, and the odds that a patient on more than one narcotic is seen by a specific, well-known physician in the area. I want a full-time bookie in the ED (paid on commission, so as not to engender any cost to the hospital) to facilitate this effort and to bolster the local economy.

I want to be able to scream out at the top of lungs “FIBROMYALGIA IS DEPRESSION!”

I want a vending machine in the waiting room. The vending machine would be stocked with Tylenol and Motrin (adult and children’s doses), non-narcotic pain relievers and muscle relaxants, a selection of decongestants and antibiotics, and two-day work excuses. The machine would take cash, credit, and the majority of insurance cards with a magnetic stripe on the back.

I want an invisible disruption field in the ED that automatically neutralizes patient cell phones. Nothing bugs me more in the busiest times that waiting for a cell phone conversation to finish before I can do my job. And if you’re not too sick to be chatting away, you’re not sick enough to be in the ED.

I want there to be health care reform that will actually get patients to primary care and follow-up, not give them the illusion of access. Today only 20% of physicians in America will voluntarily see Medicaid patients. The reasons for this are many…low reimbursement, being the main one…and there is no reason to assume their enthusiasm to do so will rise simply because there are going to be more patients out there who are covered by the program. Getting coverage to people is essentially a fiscal argument, and despite a polarized political environment it’s actually pretty easy to solve once there’s agreement on the need. Actually getting patients in to see a physician seems to me to be the real, and so far ignored, challenge of health care.

I want an internet connection that’s not blocked at work. Otherwise, how are we supposed to look up things of clinical importance that patients use, like “Horny Goat Weed?” Plus it’s a morale booster. Being able to watch YouTube and re-enact the moves of The Pips in plastic rolling chairs at the nursing desk while shouting “WOO WOO” at the appropriate times is priceless.

I want to emulate my younger and more compact friend Dr. Brent Sieger, and be able to spin a 9” by 12” plastic chart like a basketball on my finger. (I always know when I’ve worked a shift immediately after Dr. Sieger, as I have to crank up the patient beds about a foot and a half to do any procedures or exams.)

I want them to re-establish the Drunk Tank back at the County Jail. If you wake up warm, swaddled, and fed in the ED, your hangover mitigated by fluids and vitamins, what kind of moral lesson is that?

I want to be able to publically acknowledge the benefit of instructional punitive therapy.

I want to actually get paid full price for what I do.

I want patients who say they have fevers to actually have them, for patients who have pain to have some reason for it. I want the time to care about patients who need care, to care for people who use the ED because they need to, not because they want to. I want one day a week to be filled to the brim with patients with real emergencies. I want a weekly reminder of why I really went into this business.

(I asked a trusted colleague of many years, Dr. Raul Lopez, who specifically wanted to see his name in print, what he would add to his holiday wish list. He said, “Not to be on.” Amen to that.)


  1. Another great post.

    You're using the wrong emesis basins. The used basins provide a tad bit of flavor to an otherwise dull meal.

  2. Amazing post and spoken like a true conservative! Ha Ha ha! We need to bring back Reagan! Can you bring them back from the dead?

  3. This is really funny but it raises questions to which I'm going to expect some answers!