Rich 'Ol Me

I’ve heard that President Obama wants to raise taxes on the wealthy. Much to my surprise, it turns out I’m one of them. It’s not that I didn’t know my income. Every month when the bills are due I do the multiplication, (dollars per hour) x (hours per shift) x (shifts per month). Nonetheless, I had no idea I was wealthy. When I think of the wealthy, I think of folks playing golf and sipping cocktails at the club, living off investments and inheritances. I think of CEO’s and shrewd financiers; I think of Wall Street folks counting their cash, looking down on us from their penthouse views. I think of Robber Barons and Paris Hiltons, of reality stars, Bridezillas, and anyone named Kardashian.

When I think of the wealthy, I don’t think of a guy who’s pushing 50 and still working in an ER, mixing up his days and nights, spending more time in a Hampton Inn and eating instant oatmeal that in his own bed sipping a cup of tea served by a white-gloved valet. (The reality, of course, is that I make my own cup of tea, carry it to the bedroom, and then fight off the cat who just wants to share.) I don’t think of a guy who’s upside down on three mortgages and doesn’t want to default because of some antiquated sense of obligation (thank you, Wall Street…and you enjoy those record profits). I don’t think of someone living paycheck to paycheck with back taxes (from retirement accounts cashed in when the market first crashed…thanks again, Goldman Sachs); with child support and student loans still not paid off over twenty years after med school. I would be perfectly happy to be considered “wealthy” if I actually got paid for everything I do, but given that in some surveys half or more of all ED care is actually “given away” and not reimbursed, I am not so fortunate. And we won’t even get into the questions of liability I face for my actions, problems unknown to attorneys, investment bankers, or policymakers.

As a former professional bureaucrat, I really don’t have a problem paying taxes. What I object to is being labeled as “wealthy” and taxed at a higher rate simply to satisfy someone’s idea of class warfare. There is a clear difference between the “wealthy” who bust their butts to earn their keep, and those for whom the money simply rolls in. For the latter, a higher tax rate is a mere inconvenience; for the former, it’s a form of punishment, a clear message from the government about the value…or lack thereof…of hard work and effort. And the tax code is so convoluted that any sense of fairness is gone…it’s pretty clear that the “wealthy,” at least as I think of them, also have the resources to avoid the biggest tax bites.

But as my father told me some years ago, it’s not enough to have an opinion; you have to know why you think that way and what you would do about it. So here’s the Rodenberg Plan:

First, individuals are taxed at a consistent, graduated rate. The current numbers we have, with a top tax rate of 25%, works for me. Medicare, Social Security, and Medicaid taxes continue as a fixed percentage of income to a maximum rate. There are a minimal number of deductions, such that the tax code can be summarized in an hour-long Power Point presentation. Deductions can apply for dependents, mortgages, taxes paid to states, and student loans. There should be new deductions for those who pay child support and alimony; the recipients of these funds should have to pay taxes upon them as income. Other than that, your tax is your tax. Individual sate income taxes should follow a similar model.

(For the record, I think that if a piece of legislation cannot be fully explained to a lay audience in a sixty minute Power Point presentation…including cartoons and jokes…the legislation is too complex and needs to be thrown out.)

Second, corporate taxes should be based on a graduated but fixed percentage model as well. Tax credits or deductions could be granted for investments in infrastructure, employer support of employee benefits, or the creation of actual, filled jobs. Tax shelters in the form of offshore accounts and domestic loopholes need to be closed.

Finally, entitlement programs need to be means-tested. If I’m fortunate enough to live well in retirement, I’m willing to forego my Social Security payment as the dues I pay to have lived in an affluent society. I have a similar feeling about Medicare benefits; if I can afford my own insurance, I ought to do so rather than taking more money from the public purse. Again, it’s my personal sacrifice for the benefit of having been successful in life. And I believe that within Medicaid, services must be limited on the basis of medical necessity and cost-benefit ratio.

I think this plan has something for everyone. Democrats will like the emphasis or corporate taxation, and making the “wealthy” pay their own way rather than using public funds for a golf-centered dotage. Republicans will appreciate lower individual tax rates and a simplified tax code. Of course, special interest on both the left and the right will find reasons to trash these ideas, just as they will any ideas the real politicians may choose to propose. (This is assuming that the politicians don’t find reasons to trash each other’s idea first.)

Meanwhile, I’ll have to start learning to be wealthy. Maybe next time I drive through Kansas, I’ll rent the Full-Size Car rather than the Compact. And if only I could get the folks at the Hampton Inn to have room service…

To Be or Not To Be

Mr. Rowley was brought to the ER by his son for a drinking problem. Drink was no stranger to Mr. Rowley, nor Mr. Rowley to the bottle. He had been in a detox program in 2003 that had kept him sober for two years, and afterwards had been able to limit his drinking to a glass or so a day. But in the last few weeks he had lost his job, and the drinking returned in force, to the count of a couple pints each day.

I tend to think that alcohol brings out the real person under the everyday veneer, albeit it in an exaggerated form. That’s why every intoxicated person is different. Some are nasty and mean with a few shots in them; some get deep and philosophical, while others are funny and raucous. Some turn out to be just decent people, polite, respectful, who just seem to be drinking to numb the pain of the day. Mr. Rowley was one of those.

Mr. Rowley recognized his drinking was a problem, but he was not interested in detox; he figured he could do that on his own. What he wanted help with was the depression that led to the drinking. Not only had he lost his job, but also his means of support for the three children he loved dearly, as well as the ability to maintain his obligations to his ex-wife and to care for his pets. He felt he had nothing left, that everything meaningful to him as a man as caretaker and provider were being taken from him, and the only way out was suicide. He knew exactly how he was going to do it as well, at home in the backyard with his shotgun. (And being a man who’s been in similar circumstances in the past, I’ve known exactly how he felt.)

When someone states they have thoughts of suicide, and especially when they have a well-thought plan, they inadvertently trigger a set of clinical and legal interventions. Clinically, we make sure there are no medical problems which might be responsible for these dangerous thoughts. Legally, we are obliged to hold the patient in the ER for their own safety until evaluated by a mental health professional. If the psychiatric screener feels the patient represents a clear danger to himself, we are then obliged to continue to hold the patient for formal psychiatric evaluation. While larger communities often have a local set of mental health services, at the rural facility where I work that means transfer to the State Psychiatric Hospital an hour and a half down the road.

Mr. Rowley had made it clear that while he wanted help with his depression, he didn’t want to be admitted to the State Hospital. He wanted to get some therapy, maybe get on some medicine for his depression, then go out tomorrow and look for a job. But he couldn’t have realized that once the process is set in motion, it can’t be stopped. His statements to me meant that he needed psychiatric screening. His statements to the mental health worker mandated further evaluation at the State Hospital. The fact that he was under an involuntary hold meant that he would need secure transport by law enforcement. And knowing that he didn’t want to go meant that we couldn’t tell him what was going to happen, as if he knew he would leave and short of using force there would be no way to stop him.

So we ended up playing this game of buying time with sandwiches and sodas, telling him we wanted to make sure he was sleeping off his alcohol before letting him go, until all the arrangements had been made and the police were here for transport. It’s my job to tell him what’s going to happen, and I did so as softly as I could, for I felt for this man. Polite, reserved, dealt a bad hand in life, and about to be dealt an even worse one by policies and procedures far beyond his control or mine. He tried to negotiate, but there was nothing more to do. The die was cast.

So here’s this proud man, who is a likeable and decent citizen, getting escorted to the State Hospital by police, and not even with the last piece of cake we’d gotten for him out of the hospital kitchen. Short of going in handcuffs, it had to be the most humiliating thing we could have done to him. All of it was legal, and all of it was exactly by the book. And while I really hope we’ve done something good here, and gotten him some care that can help him find a reason to go on, I can’t shake this feeling that all we’ve really done is let him know that the next time he feels this way, asking for help only makes it worse. I wonder if we’ve made suicide a more inviting option, because at least you go out on your own terms. And I wonder if, as noted by Albert Camus, “There is but one truly serious philosophical problem, and that is suicide,” we’ve just helped him answer the question.

Motivators

One of my favorite moments in political history was during the Nixon Administration, when an obscure Federal Judge named Harrold Carswell was nominated to the Supreme Court. In defense against charges that Carswell was "mediocre", Senator Roman Hruska of Nebraska (Republican, Nebraska) stated:

"Even if he were mediocre, there are a lot of mediocre judges and people and lawyers. They are entitled to a little representation, aren't they? We can't have all Brandeises, Frankfurters and Cardozos."

Given how our standards for public life have fallen in the past forty years, I suspect Judge Carswell would have an easier time of it today, at least as long as he believed whatever the current Chair of the Senate Judiciary Committee believed about abortion. But there was a nugget of truth in the good Senator’s statement. Given that a few of us are geniuses, a few are total duds, and most of us lie somewhere in the middle, perhaps we’d all be happier if we strove for the median instead of the top?

We’ve actually discussed this late at night in the ER, and we’ve come up with the following potential morale-building internal slogans:

“Striving for Mediocrity”
“Defining Adequecy.”
“We Aim for the Middle.”
“At Least We’re Better Than Jetmore.”

I think there are lots of advantages to this kind if system. First, as we are a pretty decent hospital, we’re sure to meet our goals. There’s satisfaction in that. In addition, we know that third party payers and government agencies are always looking for outliers, and cast their investigative net accordingly. Being average lets you fly under their view. Finally, it’s the kind of thing that everyone can buy into, because we really are better than Jetmore. We think.

Acuity Axioms

While I won’t claim to understand physics, I do appreciate the way mathematics is used as a constant, objective language to describe the universe. Therefore, you can understand why I’ve always been intrigued by ways in which human behaviors can objectively described by math. Until Hari Seldon comes along to develop the science of psychohistory, the world will simply have to limp along with my brief attempt at such an effort, a few musing which I have modestly termed Rodenberg’s Universal Laws of Inverse Acuity.

1) The severity of the presenting illness or injury is inversely proportional to the number of decibels generated by the patient in registering their discomfort or displeasure. If you’re able to exert that much effort at complaining, there can be very little going on sapping effort from your vigorous noisemaking.

2) The severity of the illness of any one family member is inversely proportional to the number of family members who have accompianied the patient to the emergency room, or to the number of family members to seen by the emergency physician for various medical problems during the same visit.

3) The severity of any one patient complaint is inversely proportional to the number of complaints exhibited by the patient at the triage window. If you are stable enough to think exhaustively about all the things wrong with you, there can be very little really wrong.

Nobel Prize nominations humbly, but gratefully, accepted. Thank you.

Brighter Than You

They say the title does not make the man, and that’s also true in medicine. There are plenty of people out there who are book smart but lack common sense, and some of them carry the title of physician. It's like the old joke about what they call the guy who graduates last in his medical school class. The answer, of course, is “doctor.”

I have an ego as much as the next guy, and I like to think that I’m a reasonably bright citizen. But I also like to think I know my limitations. I know, for instance, that despite reading the CDC guidelines I will not survive the Zombie Apocylaspe, as I’m fairly certain the ability to sporadically blog and complete paperwork for maximum reimbursement pales compared to the ability to kill your own food and build your own fortress. (This is why my son already has reservations to live his post-Apocylatic days with my sister and brother -in-law, who have these qualities in spades.) I also know that I have trouble keeping my shoes tied, like to drive in the left-hand lane, think recording ATM withdrawls in the checkbook is only an option and not a requirement , and am a relatively poor parallel parker.

So I’m fully aware that there are folks in medicine who are a lot brighter than me. That opinion isn’t based on what you might think, like who’s a “specialist” and who’s not. The truth is you get be a “specialist” not because you’re the best at what you do, but because you’re willing to slog away, overworked and underpaid, for umpteen extra years for others who, by dint of seniority and not by quality, have you to do their work for them. And it’s not that hard to become a specialist. If you’re willing to go anywhere, there’s always a training spot somewhere. (A significant reason that I’m an ER doc and not a plastic surgeon is simply that I didn’t want to get beat up for five years of general surgery and two or three more of plastics when I could sail through relatively unabused in three years of ER. A powerful work ethic has never been one of my strong suits.)

My personal view…and one, I suspect, shared by many ER docs…is that most specialists can’t work their way out of a paper bag. They are very, very good at dealing with the handful of things they do routinely (and at high cost). But you’d be stunned at the number of “collegial” phone calls I get from doctors wanting to know what to give their kids for a cold (“Tylenol” is always a good start) or what’s the best thing to do for a sprained ankle. In fact, that was one of the things that first attracted me to Emergency Medicine, as it seemed that ER docs were the only people left who actually knew how to do all those basic things you always thought a doctor…well, at least a doctor on TV…should do. Twenty-five years in, I recognize that was poor basis for a lifelong career choice, and I recognize that the inability of other physicians to take care of the simple things means there are an infinite number of reasons for “real doctors” in their offices with normal hours, the ability to control their workload, and the benefit of actually being reimbursed for the patients you see to use the ER as a convienent whipping boy. But the optimism of youth won out, and now I’m too old with too many mortgages to do something else.

One of the more pleasant discoveries of working ER in a more rural setting is that, in fact, there was a reason you were in the top half of your medical school class. Out here I’ve seen both the best and worst of medicine. There’s the best, because I truly believe that the single most difficult thing to do in medicine is to be a good family physician in a rural area. You’ve got to be able to manage the greatest spectrum of care with the least support, and do it to the same standard as the guy at a teaching hospital with specialty backup for each gonad. There are a lot of these unsung heroes out there, doing the right thing every day in a manner I can’t even approach. But there’s also the worst, as rural communities starving for medical care take whatever they can get, and sometimes it’s that guy at the bottom of his class who’s still called “doctor.”

The problem is trying to figure out how I should respond to the baboon (and, as Groucho Marx notes in “Duck Soup,” that’s an insult to the rest of the baboons) who calls in the middle of the night to transfer you a patient that either don’t want to deal with or they’ve clearly mucked up. Most of the time you grab the phone with righteous indignation, determined to spit out in no uncertain terms exactly what you think of their clinical skills and to suggest that they get a new job selling door-to-door ham, where at least the product is already beyond help. However, after a few seconds reality sets in, and you figure that at least the patient is better off at a hospital that knows what they’re doing (that’s a polite turn of phrase for “get them out of there before someone kills them.”)

Purists…basically those academics, policymakers, and ethicists who exist in a sheltered world…might say that when we come across these scenarios, it’s our duty as physicians to turn in our less capable colleagues to the State Medical Boards. But doing so doesn’t help hospital volumes, and less patients mean less revenues. Making your concerns known in the public record so that the other doctor’s referrals go elsewhere does nothing but get you relieved from your job. Sorry, but that’s the real world. No matter how justified or correct they might be, squeaky wheels in the employ of another get no grease. They get fired.

(Interestingly, while there are always better and worse physicians in a community, I don’t see the same breadth of quality of care in more urban areas. I’m not quite sure why that is. Perhaps it’s because physician practice groups are larger and there are more doctors to “ride herd” on one another, and because hospitals have medical staff and administrative structures to ensure the quality of care. When you’re the only game in town, quality…or lack thereof…is what you say it is, and there’s no one to argue otherwise.)

Needless to say, I’m not about to tell you which physicians I’m thinking of as I write this or what exactly they’ve done. I’m fortunate that at the facility where I work, we have a pretty good record of getting patients out of the hole dug for them by their own doctors. But I can tell you one story that just gives you a sense of some of our referrals.

A middle-aged male was sent to us for evaluation after an intentional overdose of Phenobarbital. Phenobarbital is used mostly as a medicine for seizures, and in large doses it can cause sedation. Management of these overdoes is actually pretty easy. Make sure the patient’s breathing okay, and let them sleep it off. This patient, however, became angry when aroused and started to swing at folks. So rather than simply letting him sleep, the doctor at the other facility decided he needed to be transferred to us. He was apparently loaded into an ambulance with difficulty. He was unloaded with no difficulty at all, because there’s nothing like the steady drone of tires on interstate plus a heapin’ helpin’ or barbiturates to induce a nap.

I checked him out, fully expecting to see what had been advertised…a guy who needed to sleep. What nobody had mentioned…and I’m giving the other doctor of the benefit of the doubt by saying they didn’t know enough to look, because to take the other tack is to call them a liar…is that he also had the snot beat out of him, with multiple abrasions and bruises all over his head and face. That’s a pretty good reason to be agitated, don’t you think?

A few x-rays later (the same x-rays I know they have at the other hospital), we were back to Plan A, and he was admitted to sleep off his mischief. Maybe the other doctor just knew our beds were better for therapeutic non-intervention. But I can’t fault the other doctor entirely for knowing the patient had a better opportunity for competent care at our place. This was proved later that night when he got mad about not being in his hometown ER anymore, and decided to roam about the room flinging chairs and pulling towel dispensers off the wall. The hospitalist on the case decided that the best course of action was to bandage his cracked and blistered feet.

You’re probably asking, as did I, why that was the preferred method of care. Was it out of compassion and understanding, a desire to build trust within the physician-patient relationship? Perhaps it was a show of humility by the physician, a bold statement of service with a Christian precedent?

Turns out she did it because it was smart medical care. With his feet wrapped in gauze, he couldn’t get any traction on the slick, freshly waxed hospital floors. So when he tried to get up, he’d slip back onto the bed. Sure, he could still yell, but hospital property was no longer in the air. It was a flippin’ brilliant move.

See, there’s another doc who’s brighter than me.

Gone Fishin'

Tonight’s notes from the You Can’t Make This Stuff Up Department:

A thirteen year old boy was playing on the banks of a local creek in his bare feet when he stepped upon a dead catfish. As you may know, catfish are so named because they share several qualities with their land-based counterparts, including “whiskers” on the front of their face and an utter indifference to the presence of humans, with the possible exception of when you throw some pellets into the water at a feeding pond. The “whiskers” are actually cartilaginous spines that stay moist and malleable when the catfish is alive and in the water. When the catfish has washed up on the bank of the creek and dried out a bit, the spines become small barbed weapons that tend to get stuck in things. Things like the unshod foot of a thirteen year old boy, who showed up at the front door of the ER with a catfish spine stuck in his foot. Which was, in turn, still attached to the head of the disembodied catfish.

Many people think of medicine as a delicate art. It’s not always. But it was worth the ol’ med school try, so I numbed up his foot and tried to gently remove the catfish head. I made a small incision at the base of the wound hoping to find room to free up the barbs so I wriggle it out with minimal tissue damage. This, of course, didn’t work. Enter the vise-grip pliers, a backward pull, and a lot or torque, which did.

The patient did well and is now home, having negotiated a stop at McDonald’s with his grandmother before leaving the ED.

The catfish head resides in a small specimen cup currently sitting on the desk of the ER Manager.

CITation

The Teen is going to Claymation Movie Camp this year, and since it’s his third summer in a row he tells me he’s going to be a Counselor-in Training, or CIT. Which reminded me that one of the nurses was having her 30th birthday a few weeks back, and she mentioned that she was going to be a puma. “A puma?” I asked, not seeing where this was going. “Yes,” she said, “a puma…a CIT…Cougar-in-Training.”