A Better Trip to the Emergency Department, Part I

(Author’s Note: Several months ago I found this great article about tips to improve your ED experience, and decided it would be fun to comment on it. Problem is, once I got rolling, I kept on commenting…and commenting…and commenting. Every other day there would be a new thought, a new idea to work into the effort. But finally it’s time to stop. So in a first-ever Writing With Scissors exclusive, the next post will be serialized over the next several days. Be there. Aloha.)

Trolling on America Online (yes, I’m the Philistine who keeps them in business; and yes, I know I should change to another browser but I’m simply too stuck in my ways to do so. The tech-savvy Bride also tells me I’ll have to learn to Tweet someday just like John McCain), I ran across an article of interest. Entitled, “Emergency Room Docs Offer Inside Scoop: How to Get Treated Faster, Better” by Eric Wahlgren (http://www.dailyfinance.com, November 29, 2009), the article offered several tips for those who use the Emergency Department (ED) that might expedite their visit.

In general, I have very little use for these kinds of articles, as they rarely reflect the reality of ED care. However, the tips in this piece were actually pretty good, and showed signs of being reviewed by real live doctors working in real live ED’s rather than consultants, “thought leaders,” and other experts who get paid lots of money to cover their ignorance with polysyllabism and sesquipedantism (not bad, huh?), and whose ranks I someday strive to join. However, I’ve felt compelled to offer the following amendments to Mr. Wahlgren’s most commendable effort.

“First, let's debunk a persistent ER "shortcut" myth. If you or a loved one has a life-threatening emergency, by all means call an ambulance, as paramedics can immediately begin care as you're being rushed to a medical facility. But don't expect to get treated any faster for sunburn or a stubbed toe just because you arrive in an ambulance, emergency physicians say. You'll be triaged based on the severity of your condition, just like everyone else. "We have people who've called an ambulance for earwax or prescription refills," says one ER physician…"When they come in by ambulance, they go right into the waiting room."

This is absolutely true. An ambulance ride in and of itself does very little to promote your movement through the system. Paramedics are very good at figuring out quickly who’s sick and who’s not, and when they tell us it’s serious we listen and triage accordingly. But even if your condition is non-emergent, there are other modifiers which impact your ED stay. It does not help your chances of receiving expedited care when you ask the paramedic to avoid certain hospitals or doctors because you have “had problems” with them before, or because they are (choose one or more) racist, sexist, homophobic, incompetent, don’t understand your pain, don’t like the homeless, or hate people without money. Believe it or not, most people whose chose emergency care as a career are pretty proud of the fact that unlike many of our colleagues, we care for anyone who shows up at the door, no questions asked. So don’t even try to to hit us there.

Nor are you seen faster if you phone 911 from the waiting room of the ED because you’re tired of cooling your heels. You will not be seen faster if you call 911 from the treatment area to take you elsewhere because the service is not to your liking; as long as you are capable of making that decision, your desire to go does not mandate my begging you to stay. Possession of a Florida Medicaid Gold Card does not mean the ambulance is your personal taxi. Finally, be aware that “Why did you call an ambulance to bring you to the Level II Trauma Center at 3 AM on a Sunday morning?” is always a legitimate question, as is “Why did you tell the ambulance to bypass three closer hospitals to come here today?” These questions will be asked, and an answer will be expected, even though we both know what the answer really is. (If you’re here for a life-threatening condition, we won’t ask because we’ll already know why and be doing something about it.)

Now, to the tips themselves:

Avoid nights, weekends and holidays: Face it folks, doctors take time off, too, and you'll be seen more quickly if you show up at 10 a.m. on a weekday rather than 10 p.m. on Saturday night -- after there's been a series of car wrecks. "Even if it happens to be less busy on a night or weekend, the staffing is lower," the ER doc in the northeast says. "There may only be five people ahead of you, but it will take a while to get seen." Holidays are also a bad time to go, as is the day right after, as hospital staff may extend their vacations. True emergencies, of course, give little advance warning. But if you have an inkling your bandaged finger, say, may need stitches, best head to the ER as soon as possible, rather than waiting until after work when you'll have plenty of company.”

An ED is generally not somewhere you go on a planned basis. While I would by all means encourage you to go to the ED for an actual emergency, the very nature of a medical emergency precludes preplanning and scheduling. However, should you decide to use the ED for your non-emergency complaint, we would encourage you to contact our maitre d’ and reserve your table for somewhere between three and seven AM. You may indeed be seen faster at that time, but with a somewhat larger dose of skepticism as to the true urgency of your problem. Please also note that our level of concern will decrease with the longer duration of the problem (for good clinical reason…if you’ve lived with it for months, the chances of it being a life-threatening emergency at the moment are very small), and that your pain tolerance is also expected to rise the more time has elapsed since your illness, injury or surgery. And as regards stitches, the advice is exactly right. Wounds left open more than 12 hours (up to 24 on the face) are usually not closed due to an increased risk of infection. So if you think you need stitches, go to the ED now. Do not pass GO. Do not collect $200. (We have staff that will do that for us.)

Some people have also heard that July 1 is a day to avoid. That’s because the new crop of interns and residents (new graduates from medical school and those in specialty training) start their new year. Flushed with shiny new degrees and promotions, many of them actually believe that they know something, which poses a danger to you. (The smart ones learn within about three weeks that they really know nothing. The dumb ones never do.) This myth is simply not true. While the young doctors on call that day might be total screw-ups on that day, the nurses will save your…donkey.

Here’s how this wisdom was beaten into me. I was on call for the internal medicine service during my first month of graduation from medical school, and was called to the ICU to see a patient with a falling BP. I entered the room and promptly did what I thought all good doctors would do. I approached from the right side of the bed as I was taught, and put my stethoscope on the chest. One of the things they never tell you in medical school is that you can’t hear low blood pressure by listening to the heart.

The ICU nurse that night was a guy named Bill, an old Air Force RN who had been doing intensive care since General Pershing’s Punitive Expedition into Mexico. He started laughing. I looked up and him from my auscultatory musings with an annoyed look that can only be generated by an annoyed 24-year-old who doesn’t yet know that he’s in waaaaay over his head.

“What?” I growled.

“You might want to listen to the heart.” He let loose with a hearty guffaw.

What? He was questioning me? OF COURSE I was listening to the heart. At least, I thought I was. Thirty seconds later I realized I actually couldn’t hear any heartbeats, but the “beep-beep-beep of the monitor continued on. This was because I had not fully taken into account the actual dimensions of this very large patient, and I had spent the last two minutes listening to the patient’s right breast. Turns out that breast tissue does not exhibit cardiac activity.

I tried very hard not to let on, though, and repositioned the stethoscope so it looked like I was searching carefully to determine the site of a heart murmur in it’s loudest dimension (a trick which can help to isolate the site of a murmur…honest, it really does.) So I kept listening, and repositioning, and listening, and repositioning, and trying to think if I heard anything and what I would do about it if I did, when the low blood pressure alarm began to wail.

“So, Doc, what do you want to do about this?” The tone had changed. No more laughing, but instead the voice of the career non-com who’s had just about enough of this newbie from OCS.

I mustered up my confident voice, the one I keep in reserve for occasions like scolding the dog (not like it does any good) and instructing patients with STD’s to use protection at all times while having sex (ditto).“Well, I suppose we ought to treat it.”

Sensing that the trap was about to be sprung, Bill raised an eyebrow and the corner of his mouth turned up in a mongrel hybrid of a sneer and a smile. “Well, DOCTOR, what should we use?”

I’m sure you, the rest of the medical world, and even the radio audience at home understands by now that Bill knew exactly what to do and how to do it. He just wasn’t going to share that with me.

“DOC-TAH?” Bill’s voice went up an octave for comic effect. Twitters of giggles were now heard from Vicki, the hot night nurse from Arkansas, who had been in the next room and came to join in on the fun.

It was over. Game, set, and match. Sparkling new stethoscope, pressed lab coat, diploma in hand, and I was nothing more than a good-looking book with a lot of blank pages. I was the walking epitome of the concept that medical school teaches you where to look things up, but residency teaches you what to do. It was time to do justice, love mercy, and walk humbly before your nurse.

Meekly, I whined. “Ummm…what do we usually use?”

“Dopamine is nice,” came the reply. “How much?”

“Ummm…”

“How about we use the protocol, then, doc?” With my abject failure, Bill’s task was done. The intern had been humbled, and the right care given to the patient. “And let me give you a copy of our dosing sheets to stick it in your pocket. Never know when you might need something like this.”

So from that time until now, I put a lot of stake in what the older, experienced nurses want to suggest, and pretty much give them a wide leeway to do what’s best for the patient. When I’m faced with a critical patient and I’m out of ideas, I always ask around if there are any other thoughts; and if nurses I trust say that they want to start some treatment before I can get to the patient, they have carte blanche to do so. I also follow their advice as to what’s best for the nurses. For example, I was told many years ago that disimpaction of stool in the rectum is not an ED nursing procedure. You can give these patients a laxative for home or they can be admitted. Those are the only choices. I have followed this advice religiously, and I’d like to think it has earned me friends on the nursing planet.

One other time to avoid are nights of the full moon, especially when these coincide with a weekend. Despite studies which argue to the contrary, I am firmly convinced that there is something about it…tides, gravitational pull, illumination, reading The Twilight Saga, whatever…that increases the volume of patients seen and the inherent craziness of each. (The Bride has recently earned three billion spouse points for not making me go see it, although I have reconciled myself to the fact that every now and then she’ll cry out the name Edward in the middle of the night.) On the other hand, if you’re not looking for care but an experience, I highly recommend a visit on the Friday or Saturday night of a full moon, especially if it’s Bike Week or Spring Break down here on the Fun Coast.
 

Love and Duty

From my mother's sleep I fell into the State,
And I hunched in its belly till my wet fur froze.
Six miles from earth, loosed from its dream of life,
I woke to black flak and the nightmare fighters.
When I died they washed me out of the turret with a hose.

Randall Jarrell, “Death of the Ball Turret Gunner,” 1945

Mr. and Mrs. Kreslyer came in about 5 AM last night, and I could not have asked to meet two nicer people in the world. She was concerned that her blood pressure was up at home, and that she had a little bit of chest pain. He was concerned because he loved her.

They had been married 62 years, been together since just after World War II. He had been an Army Air Forces pilot, flying left seat and bombardier in B-17’s out of Italy. Small, wiry, full of life, still handsome in a roughish way, he wore a leather jacket updated for the times, but one that let you know who had been and the horsepower he had led.

“It wasn’t at all like they tell you. Things like the Memphis Belle. There was never any crew that stayed together for all their missions. Half of everyone in your crew would be dead by the time you were done. Some of them died from the enemy planes. Most of them died when we got to 30,000 feet and 65 degrees below zero. The planes weren’t pressurized, and the oxygen system froze.

They only added the chin gun to the bombers when the Germans learned the front of the airplane was unarmed. They would go for the front and shoot the bombardier so the plane couldn’t drop it’s bomb load. You could get out the body, but you had to use a hose to wash everything else out of the bubble.

You never flew the same plane. You flew a mixup of all the parts they could scavenge from the planes that were damaged to fix whatever had broken on your ship, and you hoped for the best.

Planes now have satellites from the sky to tell where your direction. We had to memorize sixty constellations to find direction at night. During the day, once we got to know an area, we just followed the roads.

After my 35 missions, the war was over in Europe. They said they’d make me a first lietenant if I signed up again to fly over Japan. I told ‘em they could make me a major general and I still wasn’t gonna do it. So I didn’t.

Young man, I really appreciate your asking me about this. There’s only about 3% of us old vets left, and your generation is losing what we’ve learned.”

Through it all, Ms. Kreslyer, who must have hears the story thousands of times, gazed at him with pure adulation. A smaller woman, but making up in life what she might have lacked in size. Fully made up, enticing smile, bright cheeks, saucy blown brown hair. Not a charactiture of an older woman trying to be young. A geniuine octognerian temptress.

But back to business. I examined her and found that her legs were bent and crippled. It was only then that I noticed a wheelchair in the corner of the room. “What happened?” I asked as gently as I could.

She took my question in stride, her smile never fading. “I got chickenpox 54 years ago. Made me paralyzed from my waist down. But its never gotten in my way. “After all,” she confided with a wink, “we did have some children!”

Good Lord, they were in love. They had met, climbed the peaks of joy, and never fell back down to earth. And this despite trials over half a century that would have induced many people to leave, and that few might argue with, they were still were two kids walking down the aisle in 1948.

“Life is a lot of missions,” he said. “Had that first one in the war, and then,” looking at his wife in what can only be called bliss, ”I got this one. A few others along the way. I’ve been a lucky man.”
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"We are creatures of duty, captain. I have lived my life by it. Just... one more duty... to perform."

Romulan Commander to Captain Kirk, Star Trek, “Balance of Terror,” 1966

I awoke with a start this afternoon with thoughts swirling through my head. Some of my most abstract thinking, and (to be frank) some of the creepiest comes in that moment between sleep and wakefulness, when your subconscious has been cruising the Talladega of REM sleep and your mind still hasn’t filtered the idea that you’re back into consciousness.

Mr. Kreslyer was wrong. Life’s not a series of missions. Not everything you do is directed towards something. Life is instead a duty. It’s full of imperatives. Be born. Grow. Work. Marry. Have joy. Feel sorrow. Go the heaven. Go to blazes. We’re all Romulans.

Life is not pain. We’re built for happiness. But being happy is still a duty. From the moment of conception, there’s a job to do. Develop, live, learn. It seems that only at the exact moment of death is there true freedom. When you die, when the process has begun, in that moment you don’t have to do anything. You just do it, and you die. But what a maddeningly absurd moment that must be, to finally be really free, and know it’s about to be over.

Basic or Advanced Life Support...What's Best?

One of the benefits of having written a column for several years at jems.com is that from time to time I get to recycle and make my life easy. This is one of those times, as I respond to an article in the Daytona Beach News-Journal:

“No Easy Solutions with Lives at Stake.

Medical studies have found no demonstrated benefit to advanced life support care – while there’s no question that it’s more expensicve.

As local government leaders hope for cost-saving suggestions…the question of basic versus advanced life support could emerge as an option worth discussing.”

(Derek Catron, Daytona Beach News-Journal, April 27, 2010)

Fortunately, with all the clairvoyance that I have (I was the one who predicted that the Supreme Court wouldn’t get involved in the recount of the 2000 election), I’ve already addressed the question of BLS vs. ALS in 2002. I’ve made just a few revisions to stay up with the times. But the facts, and conclusions, are unchanged.

In a Perfect World, Is All EMS ALS?

I took a management course last year as part of a master's degree program in public health. One assignment was to watch a video of a man (tanned, healthy and obviously richer than stink) who stood on the deck of a sailboat in San Francisco Bay and proclaimed, "Hi. I'm a futurist." While my first thought was, "How do I get a job like that?" his message, like that of most management "gurus," is that the rules have to be broken to make progress.

I was reminded of this while reading a recent discussion on an EMS listserv regarding the question: "Are there too many paramedics in this world?" The overwhelming response to the poor guy with the temerity to post the question was "No."

We've grown up in a climate where more paramedics are good, more ALS is good, and more everything is good. And even if you reject that culture, job preservation is a pretty good reason to say no.

But this person was right to ask the question, and to try to answer it we need to take a few hints from the futurist and break some of our rules. We need to scientifically address the very difficult and emotional issues from which lesser souls shy away. Do ALS services make a difference? Does everyone in EMS need to be an ALS provider? Are there any dangers in an all-ALS world? For someone born too late for the '60s for anti-war protests, liberal drug use, and the sexual revolution, taking on these issues is the most anti-establishment thing left for me to do.

The place to start is a look at the inherent efficacy of prehospital care. It makes no sense to discuss the format of a system if we don't even know what the system can do, though we seem to have an intuitive sense that ALS care is better than BLS care (and certainly better than no care at all). But if the devil is in the details, the details here are the definitions. Is better defined as more lives saved, or decreased morbidity (the severity of the illness or injury)? Is it characterized by levels of skill or training or by the "toys" available for ALS care? Is it defined by the patient's perception of the amount of care and comfort that can be provided? All of these definitions have different implications for determining the efficacy of an EMS agency.

The core of the contention that we need EMS agencies within our communities is that EMS systems save lives. That may be true—maybe. A close examination of the literature indicates prehospital efforts can be proven to save lives in only two situations: the provision of electrical therapy to patients with pulseless cardiac arrhythmias (ventricular fibrillation, pulseless ventricular tachycardia) and the provision of airway management. (One might make a case for EMS systems preventing trauma deaths, but it seems that prehospital care only prevents death from injury as part of a system with designated trauma-receiving facilities. The advantage to individual patients lies in airway management, as previously noted. In air-transport services, the main advantage is simply the speed to transport to the receiving hospital).

Despite this limited database, we can certainly make a case for the provision of EMS care. But note that neither electrical therapy nor airway management is exclusively the province of ALS services in this new millennium, and certainly the success of electrical therapy is more dependent on response times than anything else. Just like real estate, the mantra for cardiac arrest survival is “location, location, location.”

(Speaking of survival and location, with the new data that’s emerging on the utility of hypothermia to improve survival rates for cardiac arrest, it’s now becoming clear why cities like Seattle and Toronto lead the pack. It’s because it’s wet and cold, and so the body gains the protective benefit of hypothermia in a way that doesn’t happen in Miami. So my advice to all people, especially older ones, is to move north…waaaaay north, like to the Yukon, to insure your best chance of survival. And then maybe I won’t be the youngest person, including checkers and bagboys, at my local supermarket in Daytona Beach Shores. Daytona Beach Shores, which to me is Volusia County’s Elderhostel, has a motto that, “Life is Better Here.” I’ve heard it said that given the average age of its’ residents, “Life is Shorter Here” might be more apropos.”)

I bring up the issue of the millennium because just as the years change, so must our thought patterns about EMS. Ten years ago, the idea that this lifesaving care—electrical therapy and airway management—was the exclusive bailiwick of ALS was probably correct. But changes in technology have made that argument obsolete. BLS providers can now provide defibrillation with semi-automatic or automated external defibrillators, and the advent of the laryngeal mask airway (LMA) and the pharyngotracheal airway (PTL, or Combitube) challenges endotracheal intubation as the "gold standard" for airway management. In addition, evidence is increasing that missed intubation rates are higher than realized and that intubation attempts may do more damage than maintaining airway patency and ensuring oxygenation using nasal or oral airways and good bag-valve-mask technique.

What about those lifesaving episodes that have not been studied? Again, there is probably no doubt that prehospital skills are useful in preventing death and disability due to prolonged seizures, respiratory distress or prolonged cardiac ischemia. But if we look specifically at the differences between BLS and ALS capabilities, my sense is we once again see no clear advantage for ALS providers. Anaphylaxis can kill quickly in the prehospital setting; but if ALS providers can use subcutaneous (SQ) epinephrine and airway management techniques, we find BLS providers are able to use pre-loaded SQ epinephrine and similar airway techniques.

In the case of seizures, airway protection is the highest priority, and short of drug-assisted intubation, both ALS and BLS providers can use nasal airways. IV diazepam does fall within the province of the ALS provider, but rectal diazepam would lie within the tool kit of the EMT. It's also worth recalling that most seizures stop spontaneously.

What about asthma, emphysema and other causes of respiratory distress? An EMT can use noninvasive aerosolized bronchodilators, mechanical ventilation (using continuous positive airway pressure devices or CPAP) and—if all else fails—the LMA/PTL and the old reliable Epi-Pen. For chest pain and angina patients, you can make a case for using noninvasive sublingual (SL) nitroglycerin. We already allow EMTs to use SL dextrose gels. As long as we're not asking for an interpretation, there's no reason to think an EMT can't acquire and transmit a 12-lead ECG.

I could make a strong argument that victims of drug overdoses should not be "awakened" in the field (a topic for another time) and that the supportive care provided by a BLS crew is sufficient during transport. Inhalation analgesia, such as nitrous oxide, and traditional measures of splinting, ice and appropriate spinal padding and packaging can even achieve pain control.

Another point to consider as we evaluate the efficacy of ALS care is that many of the ALS interventions we've relied on for years have been shown to be of no help, if they don't actually cause harm. The continuing debate over the utility of high-flow IV fluids in the prehospital care of trauma patients is a classic example. And we've already mentioned data that casts doubt on the efficacy of endotracheal intubation (in fairness, I must also note that some of our old reliable BLS interventions - MAST suits, for instance - have also fallen by the wayside).

If you're a bit confused because my definitions of ALS and yours differ, it's because I'm talking in terms of absolute extremes. To some extent, this is a result of my "EMS raisin'" in Florida, where only the BLS EMT and the ALS paramedic exist. In other states, there are a basketful of prehospital certifications, including EMT-B (Emergency Medical Technician-Basic), EMT-I (Emergency Medical Technician-Intermediate), EMT-A (EMT-Advanced or EMT-Ambulance) and MICT (Mobile Intensive Care Technician). This fractionation of prehospital personnel adds credence to the argument that ALS and BLS levels of care are increasingly blurred and that the differences between a BLS EMT and an ALS paramedic are really academic.

The key term in my definition of a BLS provider is noninvasive. This phrase holds two meanings for me. The traditional meaning of an invasive procedure is a process characterized by the use of tubes and needles to access body spaces for the administration of drugs and fluids (this conventional meaning is obscured in practice; in Florida, an EMT may start an unmedicated IV in the presence of a certified paramedic). I would continue to subscribe to this idea. But I also consider as noninvasive those procedures performed by EMTs that patients can perform themselves at home and of which any resultant side effects are not likely to require ALS care. These include such procedures as administering SL nitroglycerin, using a nebulized bronchodilator and inserting rectal diazepam (yes, patients do have family members do this for them at home). To the extent that this definition calls for a new class of provider, I plead guilty as charged. However, I believe that if the various state laws governing EMT practice were unified into one national standard, this level of provider would already exist.

So what would I see as the EMS system of the future? It’s a different model than now. It’s composed of a bunch of folks running around on motorcycles for speed and access, with a full advanced BLS kit on the back. There is then an ALS backup transport agency to take the patient to the hospital. Who runs the show…fire, police, third service EMS…is inconsequential as long as there is uniformity in patient care, quality assessment, dispatch, and closest unit response.

Now can I have my sailboat?

Ten years after medical direction, figuring I had been there, done that, and got my t-shirt, I’m back in the debate. Let the games begin.

(If you’re interested in other EMS-related writings, the jems.com folks have been kind enough to archive my work on their site. Simply go to jems.com and put “Rodenberg” into the search box. Enjoy!)

Quick Quotes of the Day

(Actual one-liners from a few shifts in the ED:)

A colleague of mine says he thinks he has alexithymia. He just can't tell you why he feels that way.

(Yep, you'll have to scurry for your dictionaries on that one.)

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Doctor: "Ma'am, I'm going to have to place you under a Baker Act. If you don't know what that is, it's a law in Florida that allows us to hold you here in the hospital until a psychiatrist can see you. I'm worried about your safety, and this is the best way to make sure you stay here and get the care you need."

Patient: "That's communism!"

Patient in adjoining cubicle: "No, it's ObamaCare."

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Patient: "I peed on the floor because I can't hold it in. My (male member) is small."

Doctor (aside to nurse): "Guess that explains why I can hold it in for an entire shift."

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A sad note: A local chiropractor…by all reports an incredibly nice guy, the mayor of a local community…died of cardiac arrest in his office last week.

Noted by a paramedic, channeling the Lord of Dark Humor: “Probably needed an adjustment.”

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A patient drifted off to sleep on the toilet, fell from the throne, and had a laceration ot her head.

Adds a whole new thought to the term restroom.

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Experienced nurse describing bowel care to her student:

"Back in the day, we used to give "Three H Enemas." They were high, hot, and a helluva lot."

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Doctor: "Looks like you've been drinking!"

Patient: "That's just your opinion."

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Nurse: "Okay, why don't you get undressed, slip off your shorts, and put on this gown."

Patient: "Watch out! It's gonna hit the floor!"

(Note: I examined the patient myself. The floor was safe.)

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Nurse: "That seventeen year old girl is just sitting there sucking her thumb."

Unit Clerk: "If she was sucking something else she wouldn't be pregnant."

(That's all, folks! We'll be here all week, so tell your friends! And be sure to tip your nurses and techs...they're out there working hard for you. Good night!)

A Riverdale Mystery

The latest addition to the fictional town of Riverdale is drawing plenty of praise.

This September, long-running Archie Comics will celebrate its 69th birthday by adding a gay character to the gang, one Kevin Keller...

Longtime Archie fan John Wing says he's OK with the new character, but can't help wishing they did it in another way.

"I think getting Betty and Veronica together would be more entertaining," he said.

(David Moye, AOL News, April 25, 2010)

You know what’s always puzzled me about the Archies? I can’t tell you how many times I’ve wondered about who does the different voices in “Sugar Sugar.” If you look at the video (http://www.youtube.com/watch?v=mGL4btEIoTo), there aren’t a lot of clues. Even when Sabrina the Teenage Witch kisses Reggie and he turns into a frog and Archie into a rabbit, all you can tell is that their animal avatars hop back and forth a lot with very little vocal effort, save a somewhat lascivious lick of the lepine lips by the Andrews boy. And you can’t help but notice that Betty and Veronica dance EXACTLY the same way.

I think I can figure out the guys. Archie sings lead, with Reggie kicking in some occasional backgrounds, most notably the “ohohohohOH” that acts as counterpoint just before the chorus. But the girls are a more difficult story. There is a lower girl voice in one verse, and a higher one in the next. The question then becomes, which one is Betty and which one Veronica? Part of me thinks that the high, pure voice is that of Betty, the All-American girl next door, while the lower one must be Veronica; the next day I’ll switch, figuring that anyone who can say the word “Archiekins” has got to be capable of a such a sweet tone that Veronica must be the higher part while the athletic yet feminine Betty occupies the lower register. It’s like the cartoon version of whether you want to be stranded forever with Ginger or Mary Ann. (For the record, while Ginger is clearly hotter and probably better able to resolve an immediate hormonal flurry, the correct long-term answer is Mary Ann. She’s smart, resourceful, and is incredibly low maintenance. Dawn Wells aged a lot better than Tina Louse, and Ms. Wells was busted in 2006 for possesion of marijuana. While the charges were dropped when it was proved that the weed wasn’t hers, if she has friends who leave stuff like that in her car you can only imagine how cool she must be.)

For you purists out there who are busy pointing out that the Archies are fictional characters, YOU’RE JUST WRONG. However, I will admit that they may have been channeled into our reality by Ron Dante, who not only is the voice behind the Archies but also sang lead for The Cuff Links, purveyors of “Tracy,” another of my favorite one hit wonders. Check out the nonsensical video at http://www.youtube.com/watch?v=sjIe_HiBUIU&feature=related .

Oh, and I’d really rather see Ronnie with Cheryl Blossom. But I’ve always had a thing for redheads.

Speechless: Two Quick Tales

Two quick tales from last night's shift that truly left me at a loss for words.

Here’s what I said into the voice recognition software at 4 AM last night:

“The patient calmed considerably after administration of Dilaudid, Ativan, and Zofran. She is subsequently discharged home in stable condition.”

Here’s what it heard:

“The patient came considerably after menstruation of Diludid, Ativan, and Zofran. She is sexually discharged home in stable condition.”

No comment required.

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Our ED is a big place, and its often hard to find someone when you need them. So in order to communicate across time and space, we use a device called a Vocera. Essentially it’s a voice messaging system. At the start of your shift, you log in to the system with your name; in order to contact someone else, you ask the system to find them by name and when the connection is made, you talk to them over the air in real time.

The Vocera device is worn around the neck off a lanyard. Last night our loyal and faithful unit secretary was talking to someone and needed me to participate in the conversation. So she leaned over and dangled the Vocera device towards me. The only way to talk into this thing is to face it head on and shout as loudly as possible. This meant that not only was I staring at her chest, but I was also yelling at it. As a member of the testosterone-fueled branch of the species, I was used to doing the former from time to time over the years, but the latter was an entirely new experience.

After the conversation was over, I felt like I needed to say something to her. (I have to say her because she doesn’t want to be named, even though her name rhymes with both Channukah and Santa Monica.) “Hey, I just got to tell you. That was weird, just talking to your chest like that. I feel like I should get reported to Human Resources or something.”

“Don’t worry about it,” she laughed. “Most men do that all the time. Besides, it’s not like there’s that much to look at anyway.”

Again, I’m speechless.

A Really Bad Day

It was a bad day to start with. That being said, it’s also true that the definition of bad is relative. For most patients, a trip to the ED means it’s automatically a bad day (although for a surprising number of folks, a trip to the ED is a chance to get out of the house and socialize, or get under cover and grab a quick meal). From the view of those of us who work in there, every day starts out as simply “a day” and has nowhere to go but down. This is because of the well-known ED Rule that says using terms like “good” or “slow” to describe your workday provides an instant kiss of death to the rest of your shift, virtually guaranteeing that within the next six minutes a bus carrying the Finnish Methadone Clinic Tour Group will fall off a bridge into the Halifax River. None of them will speak English, and all of them will have pain.

So while most every day is a bad day, there are certainly variations on the theme. There are days that we label as bad for fear of the Gods of Nordic Tour Buses, and then there are the days when things are genuinely nuts, and not in the pleasant, Roger Rabbit sort of way. And that day was one of those days, too many patients with too many complaints who want to give you too much information about each of them, and very little I could do about any of it. They were lined up deep in the waiting room, and the harder you worked to get patients out the door the more you got punished for it, as within moments another one was shoveled into the mix. It was a day when it would have paid to have no work ethic, to keep the patients waiting, and make your own life easier because at least the beds would be full and they couldn’t give you any more. It was, as the phrase goes, not the kind of day I’d signed up for.

In the middle of all this, the radio tells us we’ll be receiving a “Trauma Alert.” Our hospital is a Trauma Center, and injured patients are selectively directed here based on specific criteria. For example, a penetrating injury to the chest or head meets trauma criteria, as do a combination of other lesser factors such as age and mechanism of injury that suggest potentially serious problems. A “Trauma Alert” notification swings the entire ED into action. Specialists are called, nurses are reassigned, x-ray techs descend upon us, respiratory therapy appears from…well, wherever they hide, the lab comes down to run “on-the-spot” testing, a chaplain drops by (actual chaplain joke: “Take two tablets…of commandments…and call me in the morning”), and if you’re lucky during the daytime even a low-level administrator will show up to peek around the corner to say helpful things like, “Oooooh,” and, “That looks bad, “ and, “Yuck,” and, “Why aren’t you moving any faster? Revenues are down and the patient turnaround time is too long.”

(One quick story about a recent Trauma Alert. About a month ago, EMS called to let us know they were bringing us a patient with a self-inflicted gunshot wound to the chest. This is usually not a good thing, so we were quite surprised to hear the patient talking quite animatedly over the paramedic’s radio report. She kept up the conversation on her arrival. “Please!” she cried out to anyone who would listen. “It’s all been a misunderstanding!”

We never did figure out what the misunderstanding was. What we did learn was that she had shot herself at home. This wasn’t known, however, until she drove to a gas station about eight miles down the highway. It was there that the attendant saw a woman pumping gas, quite unconcerned with the large quantity of blood upon her shirt. He rightly called the police, who traced the license plate on the car to the patient’s address. They arrived at her home, found a loaded gun lying across the bed, and were in the process of searching the house for a body when she pulled up in the now topped-off Ford.

In the end, she had an entrance wound over the left breast with an exit over the left flank area; x-ray showed free air in the abdomen, indicating that a gas filled cavity, like the stomach or intestines, have been torn open and air has leaked out. She went to the operating room, had her bowel repaired, and went home a few days later to presumably resume her obession with petrol and firearms. And we all learned a valuable lesson: If you’re going to shoot yourself, make sure the car is filled up first.)

The patient arrived by helicopter, and he turned out to be a middle aged male described by the flight medic as a “well-known transient” in the western part of our county. (I’m not sure gramatically how you can be a “well-known transient,” but there it is). He had been whacked by a car at a high rate of speed while trying to cross the street under the influence of an intoxicating beverage. He was initially unresponsive on the scene, but had now woken up and was complaining mostly of pain in his left chest and hand. On exam, the most notable injuries were in his hand. The bloodied tip of the little finger was hanging on by a thin flap of skin, and there was crepitus (the crunchy sound you feel when the sharp edges of a broken bone move against each other) throughout the rest of his mangled left hand. It was quite a sight, to be sure. But clinically, his most important injury was to his chest, where I found few breath sounds and lots of crepitus from broken ribs. He also had subcutaneous crepitus, which is a separate crunchy feeling, like Rice Krispies or tapioca buried beneath the skin, which results from a communication between the subcutaneous tissue and a gas-filled cavity of the body. The overall picture suggested that the patient had multiple fractured ribs with a punctured lung and free air in the chest cavity, a condition known as a pneumothorax. This is a true emergency, for if the air continues to accumulate within the chest cavity it may eventually build up enough pressure to compress the lungs, preventing oxygenation of the blood, and eventually compress upon the heart so it can’t pump effectively. This condition (a “tension pneumothorax”) is an immediate threat to life, and so once a pneumothorax is suspected the goal is to prevent this lethal complication. There are a couple of ways to deal with this situation, but the best one is to place a tube to draw off blood and air from within the chest, allowing the lung to re-expand and relieving pressure on the other organs if the chest.

I had previously called the trauma surgeon to let him know that the patient was coming. He was stuck in the operating room, but could break away as needed. I called again to tell him what’s going on now that the patient has been seen and assessed. He agreed that we needed a chest tube, and asked if I’d be comfortable doing so.

Comfortable? I’m an EMERGENCY PHYSICIAN, by jingo. Residency-trained, board-certified, battle tested. Able to move from a STD to a heart attack in the blink of an eye. Able to clean up all the messes that happen when the doctor’s office says, “We can’t work you in today. You’d better go to the ER.” Able to get yelled at by lesser physicians at 3 AM and still able to have steak and beer for breakfast. I can keep ANYBODY alive for at least a half hour. Plus, I had seen one done on television a few weeks back and videotaped the episode, so I had a pretty good idea of what to do. (That one was a joke. I don’t do a chest tube every week, but often enough that it’s not an intellectual leap. But with patients who’ve already shown a sense of fun, it’s interesting to tell that to family members before you do a procedure and watch their reaction. It’s also fun when you walk into a room and the patient says, “Are you the doctor?” to reply, “No, but I stayed at Holiday Inn Express last night.” Yet I digress.)

Here’s what you do to put in a chest tube. You have someone grab the patient’s arm and pull it above their head. You do this in the unresponsive patient to get it out of your way. You do this in the awake patient because as soon as you start, they’re going to try to hit you. Chest tubes are not fun for anyone.

You numb up the skin and the tissue underneath as best you can, take a blade, and make an incision down from the middle of the armpit about halfway down the chest. You use a clamp to help spread the wound and scissors to cut through the different tissue layers…subcutaneous fat, fascia, muscle, ore fascia…until you’ve exposed the chest wall. Using a VERY large clamp, you find the top edge of a rib and drive the clamp through the chest wall. It’s tough work…there’s nothing elegant about it…and the chest was designed not to let anything in. It takes force, real force. You know it, the patient feels it, and everyone around you hears it. When the clamp goes in, there’s a loud POP, and out comes a rush of air.

You follow the course of the clamp with your finger and put your digit in the hole to keep it open. With your finger in place, you guide a large plastic tube up to an inch in diameter through the hole. When thumb goes in and hits a pocket of blood, you do a version of the “Fluid Dance.” The Fluid Dance occurs when fluid under pressure…blood in this case…spurts out after the pressure is released. You try to jump out of the way of the bodily cascade while keeping hold of the tube so it doesn’t fall out. Not making the leap is how people lose shoes (and why my work shoes are $12.00 gray Velcro sneakers from Wal-Mart.)

Once in, the tube is connected to a suction drain, and you sew up the wound and secure the tube. This takes longer for me than for others. I’m not a surgeon, and it takes me a while to tie knots, although they’re awfully pretty when they’re done. I remember feeling like my glove got nicked by some scissors while I was sewing him up…whether the assistant cutting suture for me got me or my finger was just in the wrong place, I don’t know…but I didn’t think anything of it until I took off my gloves to wash my hands and found there was blood on my skin under the latex. I was even more surprised to find that, after washing my hands, the blood was still there. Turns out it was my blood coming from a cut on the tip of my left index finger.

I would imagine that a century ago, if a surgeon nicked their finger there might have been some collegial snickering about the “butterfingers” in their midst, but probably not much was thought about it. These days, however, when we know so much more about blood-borne pathogens, and specifically about HIV and hepatitis, a cut on the finger becomes a major league issue. Still there was some hope that the situation might be defused. My finger hurt enough already. I didn’t want it all to get worse.

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The first thing you do after an exposure is ask the patient if they’ve had an HIV test or are positive for hepatitis. There is a formal, quiet, confidential counseling process that’s supposed to go on, but this is not like an HIV test on a concerned citizen. This is the guy I’m saving from himself, the guy who gives nothing to society except some revenue to the liquor store where he buys his drinks. I’m paying for it with my own taxpayer dollars, knowing full well that when he sobers up watching late-night television and finds that his chest tube hurts, he can pick up the phone(“Morgan & Morgan. For the People.” ) and sue me for pain and suffering. I did this for him, put myself, my career, my family at risk for what?

The more I thought about it, the angrier I got. (Still am, to be honest about it.) Patient confidentiality be dammed. So I shouted across the room “Hey, man, you ever get tested for HIV? You know, the virus that causes AIDS?”

After a moment, he yelled back a no. Halfway there.

“How about hepatitis?”

“Yeah, I got Hep C.”

Lovely. Just flippin’ lovely.

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Of course, what happened to me did not bring the ED to a halt. Instead,the patients who were already in the ED were even more upset because the trauma patient had interrupted their care. And since I had worked hard and discharged four patients in the twenty minutes before I was pulled away to care for Transient Tim, the rooms had been filled back up by patients who were upset because they had been PROMISED by the hospital marketing department that it was a “No-Wait ED” and they couldn’t figure out why they were still waiting, let alone that it was the other hospital in town with that advertisement.

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The formal process that we follow is outlined in the “exposure packet,” a ubiquitous manila envelope that will rule you life for the next six months. The process begins with testing of both myself and the source patient for HIV and hepatitis. I also begin a take a “cocktail” of HIV medications until the blood results come back. You have to sign a consent to take the medications. In medicine, you generally sign a consent only when thing have the potential to go wrong. Very wrong.

My blood was drawn for baseline testing. I had my typical panic attack when approached with the needle, but I’m getting better about it…my “down time” afterwards is now only 20 minutes, which is an improvement over the 45 minutes it took last year to stop hyperventilating after I needed an IV. One of our nurses was kind enough to run up the pharmacy to get my meds. Took the first dose then and there, the next in 12 hours, 3 AM. It just kept getting better.

(I have a question for pharmaceutical companies. The doses of this stuff are in milligrams. A tablet of Kaletra has 250mg of total medication, or a quarter of a gram. A gram is a 1/454 of a pound. A tablet of Kaletra, then, has 0.00055 pounds of actual medicine in it. So why are the tablets so big? Is it just some psychological thing so we can say to ourselves, “YES! I TOOK A PILL!” I’m so tired of gagging my way though the medicines, and I’m only a few days done. But I have a much better understanding of non-compliance. Bleeccch.)

The following day I checked in with employee health on the test results. The patient was exactly as advertised. No HIV, no hepatitis B, positive for hepatitis C. I was negative for everything, a fact which I can attribute to clean living, high moral standards, regular intake of fruits and vegetables, and not having anywhere near as many adventures as I probably could have along the way. The next step was to talk with the local HIV consultant who helps the hospital with exposures. Very bright guy, very good at what he does, and I was hoping that he would pat me on the head, reassure me, and send me on my happy way. No such luck. Because the source patient is considered high-risk for HIV, and he might be positive for the virus but within the 6 week window after infection where his test might still be negative. The safest thing for me to do is go ahead and finish out a 28 day course of my HIV cocktail, give it two weeks, and then recheck my HIV titer to make certain there’s no signs of infection. (This also means six weeks of celibacy. This would have been a lot easier to do when I was single, and when there were no opportunities in the pipeline. If there were, you could always defer under the guise of “I don’t want to rush this,” or “We should know each other better,” which usually had the effect of making things even better when the hold was released. Now that I’m married with reasonable access to relations, it’s going to be a lot more difficult to do.) And while the transmission rate of hepatitis C is less than 3% with a blood exposure, it was advised that I get follow-up testing at 6 weeks, 12 weeks, and 6 months just to make sure. (Hepatitis C is fortuitously not transmitted through normal “relations,” for which several parts of me are very glad.)

As I write this, I’m four days into my HIV prophylaxis. I’m not having the most common side effects of these medicines, which are nausea and vomiting. I’m just not hungry, and everything tastes metallic. The only thing I want to eat is plain white rice and nothing else, so that I’ll probably die of pellagra before any virus has a shot at me. I’m also totally wiped out, sleeping 12 or 14 hours a day, which may be the meds or, admittedly, may be psychosomatic. This week I go for my first follow-up appointment with the HIV/hepatitis specialist, and it also turns out my hepatitis B antibodies are undetectable, which means I need to go back for another series of vaccines. I’m already marking my upcoming blood draw panic attacks on the calendar.

And all of this for someone who doesn’t give a damn about anyone or anything, who will continue to abuse the hospitality of a giving society. The thrill of putting in a chest tube, or even of potentially saving a life, doesn’t even come close to making up the anger I feel. And if I’m honest about it, I’m also mad at myself. I could have easily asked the surgeon to do the tube. The guy probably would have done fine until the he could have gotten free of the OR. But it’s what I was trained to do, so I did it. And look what happened.

Today, while I’m eating rice and choking down tablets, if you ask me if a career in medicine is worth it, the answer would be no. I would tell any aspiring physician to use your smarts, run off to Wall Street, rape the system for a decade or so, retire, and then do whatever you really want to do. (Mine involves some combination of travel, fruity drinks, and The Florida Keys.)

In a week when my helping someone else has led to nothing but disaster, I’ve got nothing left for medicine. It happens whenever I’m like this, feeling used or abused by a patient or the health care system and getting nothing in return. The desire get back into the ED will come back in a day or so. It always does. But each time it does, there’s just a little less caring, a little less compassion, and little less sense of making a positive difference in someone’s life. And sadly, that makes me a little bit less of a physician.

An Apology

Cut the tip of my left index finger at work on Wednesday. There will be, in a future entry, much more to come on what exactly that means in today’s world of rampant blood-borne pathogens. But for the moment I’m finding out how hard it is to blog when you have a large bulky dressing on the tip of your index finger. I tend to be a hunt and peck typist and while I’ve gotten fast at it over the years, I’m still not fluent. The big bulky dressing on my finger makes it worse, because the gauze wrapping means I hit four keys at once. So I’m trying to type with the middle finger on my left hand. When I do that, the right hand, sensing some sort of asymmetry, is favoring my use of the middle finger there as well. This leaves me with the feeling that not only is my typing as slow as a basset hound’s learning curve, but that I’m also continuously flipping off the computer, the blog, my readers, and the English language as a whole, including its’ Proto-Germanic ancestors and Indo-European.

To all of you, I’m sorry.

Learning...and Growing

Part of maintaining my board certification in emergency medicine as well as my state licensure is completion of continuing medical education (CME) each year. There are lots of ways to accomplish this…attendance at meetings, online tutorials, and the like. My preferred way to get my time in is through CME publications. Which brought me to the following quotes from the April 2010 issue of “Critical Decisions in Emergency Medicine:”

“Obesity has reached epidemic proportions.”

I was at a meeting once with the CEO of a local hospital that had just started a bariatric surgery program. He was telling me that he expected a large volume of business. That was funny, so I asked if it was a growing and expanding segment of the market. He said it was, and was likely to pose a heavier burden upon society in the years to come. This went on for fifteen minutes. The hospital Public Information Officer looked at us like we were from Mars…specifically, M&M Mars. We had great fun. Lots of fun. Loads of fun. Tons of fun. You get the drift.

“Bariatric surgery is the only effective treatment, and consequently such surgeries are common.”

I guess all that public health stuff I talked about for so many years was wrong. I thought an effective treatment for obesity was diet and exercise. Shows you what I know.

(I really have only one good gastric bypass, or “fatpass,” story to tell. It’s about a colleague of mine who was overweight and wanted to get the surgery. However, he was not big enough to meet the insurance company’s criteria for payment. So in order to get his surgery, he ate everything he could in order to gain poundage so he could have an operation to slim him down.

He got his surgery, and another friend of mine called him the next day to see how he was doing. One of the ways that gastric bypass surgery works is by decreasing the size of the stomach so you can eat less food at a sitting. My other friend was thus understandably stunned to find that the post-operative period was featuring a pan of brownies. “One thing I’ve noticed, though,’ said the erstwhile eater. “After the surgery, I think I have to eat them one at a time.”)

Free Goodies for Docs

One of the perks…a really good perk, to be frank…of being a physician is access to the Doctor’s Lounge. Every hospital has one, although admittedly they vary. At small rural hospitals, there may be nothing more than a couch, a television, and some dated packages of snacks. Bigger hospitals have lounges that look like a British Airways first class frequent flyer club, complete with full-service food lines, big screen televisions, internet access, and a panoply of drinks and other consumables. (The spectrum of snacks will vary…some hospitals, not recognizing that the main drivers of medical practice are science, compassion, caffeine, and sugar, insist on stocking their larders with fruit and juice and granola and Sun Chips and the like. Those hospitals tend to do less well in measures of physician satisfaction. Go figure.)

I recognize it sounds obnoxious, but there is very little that is as satisfying in the middle of getting slammed in the ED than going up to the Doctor’s Lounge and snaring some munchies at will while everyone else has to trudge to the cafeteria or the vending machine for their coffee, stand in line, and drink whatever the machine happens to spit out. Is it fair? No. Is it equitable? No. Does it smack of elitism in our classless society, where people should be measured not by the initials after their name, but by what they contribute to society? Absolutely. (And this is why before going to the Doctor’s Lounge, the socially responsible physician will always ask around to see if anyone else wants some free sodas or ice cream while he’s raiding the pantry.) But would I be willing to trade it? No way. I feel the same way about the Doctor’s Lounge that I feel about physicians getting better parking spaces and nicer treatment from banks and airlines and the way that the police give ED docs an extra five miles an hour over the speed limit and three months after plate expiration because someday we’re going to need each other.

It has occurred to me, however, that the contents of the Doctor’s Lounge can be used as an index of the fiscal health of the institution. The place where I work now is a public hospital with the morally right and valid mission to serve all comers, regardless of financial status. However, the hospital is becoming strapped by increasing demands upon its services from patients who are unfunded or uninsured, and who in this time of recession are really unable to access any other point of care. So there is a continual effort to pare costs to meet budgets in order to continue to provide patient care services.

You’ve probably heard of the canaries that were used in coal mines to detect poisonous gas. I’ve come to the conclusion that the contents of the Doctor’s Lounge are our institution’s own songbirds. For example, in October 2008 when I started work here, the Lounge offered a made-to-order omelet service on Thursday mornings, shrimp cocktail for lunch on Tuesdays, and the food service staff stocked small refrigerators close to physician worksites throughout the institution. Last spring, the omelets went away. (I still see the chef in the halls, who looks genuinely sad when I tell him I miss our weekly visits.) Then the shrimp, which were usually served four to a plastic cup, were reduced to three per serving. And now the peripheral refrigerators are not being stocked, which raises the interesting sight of physicians skulking through the halls holding large plastic emesis basis, going to the main Doctor’s Lounge, and carting off containers full of sodas and snacks to restock their local shelves. Not that I know anything about that.

I’m willing to go along with most of this because I truly believe in the mission of the hospital and I really would miss all the folks I work with. But if they take away the ice cream…specifically the Good Humor Strawberry Shortcake Bars, if anyone’s listening… I’ve got a real career decision to make. And for the record, my loyalty can be bought with Creamsicles.

The Ol' Brush-Off

Photos au naturel are all the rage this month as celebrities strive to exploit their "realness" by refusing to be airbrushed in pics, releasing the untouched versions of photographs that have been digitally altered and, in the case of Jessica Simpson, eschewing makeup all together for a cover shot for Marie Claire magazine.

(Jo Piazza, Popeater.com, April 20, 2010)

Airbrushing? In my ED world we'll take any kind of brushing in some of our clientele. Hairbrush, toothbrush, nailbrush, scrubrush. We find that the lack of brushing...or mere contact with that stuff they call water...is an unfortunately common occurence. I've even told people who have decided that life on the beach is a postive good that Daytona has this thing called the ocean that is full of water, free for the taking.

Clucks for Quacks?

Chickens for Checkups? And finally, the Las Vegas Review-Journal, which becomes the equivalent of a carnival barker during Nevada's bizarre campaign seasons, reports today on the latest between Nevada Democrats and Sue Lowden, one of several Republicans gunning for Sen. Harry Reid's job. After Lowden suggested last week that people consider bartering with their doctors to lower their health care costs, and Jay Leno got in on the fun, a Democratic campaign aide took a goat and four chickens to Lowden's campaign office and asked for details on her barter plan, dubbed "Chickens for Checkups" in the Silver State.

(Patricia Murphy, “Washington in 60 Seconds,” The Capitolist, politicsdaily.com, April 19, 2010)

Years ago, I did part-time ED work in Bolivar, Missouri. Citizen’s Medical Center was a great little hospital, and I fondly remember it for having the best hospital cafeteria ever (families would come there to eat after church of Sundays, it was that good) and a large wall mural featuring a central image of a farmer giving a pig to the physician who just delivered his child. Today, with poor Medicaid rates and the growing ranks of the unfunded and the uninsured, a goat and four chickens are often literally worth more than what I receive for providing care.

So let’s make a deal. You have a non-emergent condition. I have no knack whatsoever for effective housecleaning. Let the barter begin!

How'd That Get There?

In my previous life as a public health official, one of my tasks was to make people aware of the hazards of secondhand smoke. Now that I’m back on the front lines, I feel the need to make the world aware of the latest secondhand scourge. Of course, I’m referring to secondhand crack.

I am certain this is a public health concern because I now have a case series of six patients within the last three weeks who have all tested positive for cocaine in their systems and have no idea how it got there. In one case, it’s thought that it was inadvertently inhaled at a party despite the patient’s best effort to stay out of the room where “that s..t was going down.” A second patient thinks that someone may have intentionally put “crack in my weed.” (The fact that the drug screen showed no evidence of cannabis but positive traces of cocaine seems beside the point.) The third is certain it must have seeped in through his skin while he held the crack for someone else who was actually smoking it. A fourth patient cannot have actually been doing crack because, as noted by her supportive spouse, “Between raising the kids and stripping, she’s too busy to do that.” The patients in cases five and six have never seen crack, do not know what crack is, and only associate crack with overweight plumbers and other home repair professionals. However, we know that in some way they must have been exposed to secondhand crack. It must surely be so, because we know that all patients who come into the ED are inherently honest with their health care provider, especially where the use of illicit substances is concerned.

You may have heard that there is an ongoing discussion regarding the need to report those patients found with drugs of abuse in their systems to law enforcement, and that results of clinically indicated drug tests should be used as a way to ration or limit health care benefits. I used to be in favor of such a plan, but clearly the innocence of these patients demonstrates the fallibility of that approach. We might inadvertently report the innocent for just being in an environment where other, less socially responsible individuals are smoking crack while the patient themselves might have just come over for a “Little House on the Prairie” marathon. And that would be a miscarriage of justice.

I Got Up!

Here’s my Easter story.

The spring of 2006 found The Bride and I on a “couples date” with some of our best friends in Metropolitan Topeka. We had gone out for dinner someplace…I forget where…and then headed to a local dance club to listen to “Disco Dick and the Mirror Balls.”

At some point it occurred to my friend Jeremy and I that as our wives seemed very intent in talking about, well, whatever they were talking about, the only rational thing for us to do was drink. So we did. A lot.

The next day was Easter, and The Bride roused my aching body out of bed to accompany her to 10:00 AM services at a local church. This was one of the “New Wave” churches, with video screens where the choir loft should be and the traditional pipe organ replaced by electric guitars and drums with AMPLIFIERS, and a service featuring LOUD AND BOISTEROUS SINGING, fellowship, LOUD AND BOISTEROUS SINGING, prayer and reflection, and LOUD AND BOISTEROUS SINGING.

One of the songs was called “He Got Up!” It featured LOUD AND BOISTEROUS SINGING with electric guitars, drums, and AMPLIFIERS. And at that moment, with the little microscopic municipal workers engaged in sandblasting every cell of my body with formaldehyde, I finally understood what Jesus must have felt like when he got up, if he was feeling anything like I did. No wonder he didn’t stick around to hang with the apostles too long, but headed home as soon as he could.

I was discussing my spiritual epiphany several days alter with Jeremy, who told me that he had an even more intense religious experience. His wife had made him get up for sunrise mass at 5:30.

The Bride got a billion points for that one.

Learn, Learn, Learn

You’ve probably heard people say that the more they learn, the less they know. If you haven’t heard it, you should. I know it’s true. Every day I live adds to my cornucopia of ignorance, whether it’s having no idea who anyone is anymore in People Magazine, or having no clue of how to use the basic features of my new cell phone. Of course, a life in the ED is a great place for this lesson to be reinforced on a daily basis.

Take drive-through windows at fast-food restaraunts. I always thought the way to use these modern conveniences was to drive up to the menu board, shout your order in the general direction of the speaker, and come around to the window holding out some vain hope that your order will have actually been understood and you will not once again have to explain that you really were serious when you said no mayonnaise.

(Note: It is a well known fact that Jews do not eat mayonnaise. My father once told me that “Any time a person goes into a delicatessen and orders a pastrami sandwich on white bread with mayo, somewhere a Jew dies.” I’m not sure where this taboo came from; it may be because the construction of this creamy concoction usually involves a copious amount of lard. Whatever the reason, it’s clearly a WASP condiment, an ethnic delicacy that I think can be best thought of as…well, actually, its best not thought of at all. My friend Sean, an African-American, tells me that his folks don’t eat mayonnaise, either. Once again the oppressed masses unite. Represent.)

I turns out, though, that there’s another way to get to the drive-in window. What you can do, as demonstrated last week by Mr. Alvin Johnston, is to get drunk and get a craving for Popeye’s Fried Chicken. You then crawl across the hood of the car currently in front of the portal and place your order. When you are encouraged to place your order in a more acceptable manner, preferably away from the property, you retreat to the drugstore across the street and sit quietly awaiting your order on the sidewalk outside. You are then surprised when you are greeted not by a uniformed Popeye’s employee, but by three uniformed police officers who handcuff you to the stretcher despite your protestations of innocence. (When asked why he thinks he got in trouble, he says, “I think they were out of extra crispy.”)

Here’s another thing I’ve recently learned about the fine line between sobriety and otherwise. Mr. O’Malley was brought in by the local gendarmes for public intoxication. Calling our local officers gendarmes makes law enforcement seem more elegant, like calling the big box store Le Target. (I’ve always found it somewhat interesting that while most accidents happen in the home, it’s perfectly okay to be intoxicated within your own residence, but not in the public square where your chances of accidental injury are actually less. From a purely epidemiologic standpoint, the best thing we can do is take every alcoholic, round them up in a grassy supervised pen, and let them sleep it off.)

You’ve probably heard of field sobriety tests. These are those brief exams done by police officers to detect findings that roughly correlate with a blood alcohol level over the generally accepted legal limits. They’re not exact, of course, but failure to pass these tests certainly suggests the possibility of alcohol intoxication. The most common ones are to follow a flashlight or pen with the eyes (high alcohol level produce a particular back-and-forth motion of the eyes called nystagmus), walking a straight in a heel-to-toe fashion (alcohol results in instability of balance), and tests of short-term memory and concentration (both of which are impaired by alcohol use).

The results of these tests, while providing law enforcement with a certain degree of certainty about Mr. O’Malley’s intoxicated status, were considered as inconclusive by the patient himself. It turns out that he had his own field sobriety tests which he was happy to share with me as a way of demonstrating that despite what I might think (and what his blood level would later show), he really wasn’t drunk after all.

The first thing he showed me was that he could bend down the tip of his ring finger on his left hand without bending the middle joint of his finger. For the record, that’s anatomically difficult to do. There are two tendons within each finger that control flexion (bending inwards) of the digit. One runs up from the forearm and wrist to connect to the base of the middle bone in the finger. When this tendon contracts, it bends the first of the two joints of the finger (the proximal interphalangeal joint, or PIP). There is a second tendon that runs up the hand and connects at the base of the last finger bone and bends the second joint (the distal interphalangeal joint, or DIP). The tendons aren’t connected, but are arranged as such so that when you try to bend the tip of your finger, the PIP will automatically flex as well. So this was a real trick, and he emphasized the point by flipping the tip of his finger back and forth like a speed bag at a boxing gym. “You can’t do that if you’re drunk!” he proudly proclaimed. And I did have to admit that it was something I couldn’t do, and it was a pretty impressive feat of digital dexterity. But while clever, it did not really speak to the issue of impaired coordination that is a feature of the intake of two carbon fragments. (We say stuff like that because the alcohol…technically called ethanol…molecule has two carbon atoms. We also say that kind of stuff because it makes us feel smart, and most days in the ED we need all the ego boosting we can get.)

His second feat was to hold his hands parallel to each other, extend his index fingers so they pointed at each other, and rotate his right index finger in a clockwise fashion while moving his left in the opposite direction. Now here was a truly worthy test. This is a clear demonstration of coordination, and he kept going at it with smooth, uninterrupted motion, keeping up a lively conversation while he did so. I, of course, failed miserably to do the same. Which can only mean I must have been intoxicated with something….the love of patient care, perhaps…but clearly I was going to lose this battle.

(I hope that as you read this, you’re trying to do these same things at home, and I fervently hope you’re failing as dramatically as I did. And if you’re like the nurses I work with, the idea of moving one appendage in a clockwise direction and another in a counterclockwise direction stimulated a lively discussion of where else in the body this trick might apply and if tassels help the effect or just get in the way. But for the record I can do one trick, which is to dislocate my thumbs. I’m still trying to find some use for this, but I trust that someday it will either help me to win a bet or defuse a nuclear device.)

So in the end, I gave in to the fact that, as a well trained drinker, he was probably as sober as he was going to get. But the lawyers would still have something to say if he left the hospital and fell in front of a train. So we compromised. Even though we agreed he was just fine, since he looked tired would he be willing to nap here in the ED for, say, twelve hours or so until he got plenty of sleep and a good meal? And coincidentally by that time his alcohol level would be below the legal limit, and he could be released on his own recognizance to seek out more life experiences. We shook hands, and he flicked his finger at me once more to seal the deal. My education continues.

What's the Matter with Kansas?

I’m very proud to be from Kansas. That’s often hard to do, especially during these times when the State is routinely held up as an example of a place of moderate pragmatism gone horribly wrong. But every time we make some progress in rehabilitating the image of our state, the legislature takes us back a step or three.

The latest mechanism for this is a “non-binding” resolution (SCR 1615) which, in the words of the resolution, is “serving notice to the federal government to cease and desist certain mandates” and “providing that certain federal legislation be prohibited or repealed.” The resolution itself is a series of complaints regarding federal conflicts with state’s rights (maybe I’m wrong, but I could have sworn we fought a civil war over this) and a few hyperbolic statements asking the federal government to “cease and desist” from doing things that are unconstitutional (again, I could be wrong, but I thought that was in the job description of the Supreme Court).

So far, the resolution sounds merely like a less erudite version of George Will’s high school civics class. And you still can’t figure out why the resolution was written in the first place. But the next to last paragraph gives it all away. “Be it further resolved: That all compulsory federal legislation which directs states to comply under threat of civil or criminal penalties or sanctions or requires states to pass legislation or lose federal funding be prohibited or repealed.”

That is to say, it’s all about the money.

I can understand the intent behind the resolution. Legislators don’t want to be forced to fund things they disagree with simply because of a federal requirement. For what it’s worth, this is not a Republican or Democrat, liberal or conservative thing…in the “paid professional liberal” world of public health, we hated the “unfunded mandate” as much as anyone. So, for example, when the comprehensive federal funding for the Medicaid expansion within health care reform runs out and the sentiment (or budget) in Kansas favors limiting Medicaid eligibility, the state does not want to be required to spend more dollars against their will. (Either that, or they wish their Senators had cut as good a deal as did Sen. Nelson of Nebraska in the first version of the bill.)

But the resolution goes way beyond the issue of funding. It strikes at the very heart of what it means to be part of a federal system, of a United States. The resolution asks the federal government to respect the 10th amendment of the Bill of Rights regarding the powers reserved to the states, while conveniently ignoring the previous seven articles of the Constitution. The fact is that we live in a representative democracy, where the majority rules. That means that small states such as Kansas have to accept the decisions of the majority, even when we disagree with it. And to be honest, a small state such as Kansas with only four representatives in Congress and two Senators from the minority party is not going to fare well in these times. But that’s the system we have and, to paraphrase Benjamin Franklin, while democracy may not be the best form of government nobody has come up with anything better.

The Law of Unintended Consequences is at play here as well. Supporters will focus on the issue of the unfunded mandate, and it’s clear that efforts to expand health care with state mandates is, in large part, the origin of this bill. But there has been little thought given to what the resolution really means. It apples to all federal legislation without exception. Kansas Democrats (aka “moderate Republicans” on either coast), who often are forced to be shrill just to be heard above the roar, are absolutely right to point out that this puts in jeopardy provisions designed to enforce federal legislation such as the Civil Rights Act of 1964 and the Voting Rights Act of 1965. Surely nobody wants a return to those days, but the resolution specifically requests that such legislation which enforces compliance by individual states be prohibited.

The resolution contains a certain element of hypocrisy as well. The resolution wants all laws that link federal funding to specific requirements repealed. It’s not that Kansas doesn't want the federal money; they just want the cash on its own terms (as, I suspect, so do 49 other states). And yet none of them, Kansas included, are willing to trade absolute sovereignty for being cut off from the federal trough. Nobody is willing to decline all Medicaid funds, all highway dollars, all cash for environmental and health programs. Politically and practically, it’s no viable to kill the golden goose. What apparently does work is to shout at the goose, with a voice that gets harsher as it drifts farther and farther away. After all, when the raft is drifting farther from the ship of state, one has to yell louder to be heard.

Fortunately, a non-binding resolution is simply that. Copies will be waved about, there will be a modicum of grandstanding, and the papers will quietly gather dust in a corner of the State Archives. So I’m not sure why I’m so troubled by it. Perhaps I feel the pain of this resolution because I know many of the people involved in the debate. While there are unquestionably one-issue crazies out there, most of the people in the Kansas Senate are essentially good people who want to do good things. In order to respond to an angry conservative electorate in a Republican primary (where, to be frank, most state legislature races are decided in the Sunflower State), they have to sign onto this kind of bill simply to stay in place and prevent the true ideologues from running the show. Knowing them as I do, I doubt that many of them are happy about it. (I’d like to think that the bill, which was originally intended as an amendment to the state constitution of Kansas, was turned into a non-binding resolution by these moderates of conscience.) The fact that good people of character are forced to support such a concept is perhaps the saddest part of this whole story.

To paraphrase Thomas Frank, that’s what’s the matter with Kansas.