A Note of Absence

For all of those who have inquired...or at least the one..."Writing With Scissors" has been on vacation over the summer as we spend time with The Teen and study for our Emergency Medicine Recertification Boards. Given that we can spend our spare hours either writing for you or studying for a paycheck, and I have yet to actually sell my book ideas or even interest an agent, I hope you'll understand my decision. Back after the first of October. See you then!

This One's For You

It turns out that one of the benefits of age…although there are too few to mention, at least at my point in life, where you realize that youth was wasted on the young but have yet to assume the role of cranky yet beloved Grandpa…is that you become more comfortable not being cool.

This is why I interrupt the usual gravity of this blog to announce that not only has Barry Manilow just released his first album of all-new material in a decade entitled “15 Minutes,” but also to come out of the honeysuckled arbor and admit that I am an unabashed Barry Manilow fan. Close friends have likely suspected for some time, but only now, when I have reached the age of accepting my own inherent dweebity, do I have the strength to admit it to the world.

There. I said it. And they’re right. It does feel better to be out in the open.

I was a bit too young to be part of the first wave of Manilow Mania, being only 12 when “Mandy” hit the charts. My earliest young musical tastes centered around whatever 45’s Mike Mitchell, a grade school friend who is now an actual real live Professor of Music, played on his hi-fi (that’s how I know about The Cranberries, although of course I had no idea what “Go All The Way” was about), and by whatever Saturday morning cartoon shows were running through my head. The latter explains my continued infatuation with The Archies, The Osmonds, and The Jackson Five, as well as the fact that I still know that:

“The Cattanooga Cats don’t ever purr.
They know how, but not what fer.
The Cattanooga Cats won’t go meow, say meow.
Wouldn’t try, but they know how!
Just doin’ their thing (chu-ba-da, chu-ba-da)”

Later, the music that I knew was based on whatever teen idol’s posters my friends David Brown (grade school) and Doug Reynolds (junior high) and I could tear down from the walls of their respective sister’s bedrooms. This is why I am intimately familiar with the musical catalogue of both The Partridge Family and Bobby Sherman. As a personal note to Karen and Crary, I’m deeply sorry for my part in those episodes. Just for the record, it was ALWAYS your brother’s ideas.

(As some of you may know, Bobby Sherman later became an EMT and served as a CPR trainer with the Los Angeles Police Department, which I think redeems this bit of musical nostalgia within the ER doc’s blog.)

I came to know Barry Manilow in high school, where he was a ubiquitous part of the slow dance scene. Understand that at that age, the best thing a nerd’s hormones can hope for is a slow dance with a girl. Not any girl…there are still standards… but an actual real live double X chromosome girl with breasts that might press up against you as you danced. And Barry came with me through college. Children these days will find it hard to believe, but there was a time when if an evening was going well, three Manilow albums and half a box of wine could seal the deal.

In gratitude for his help, I’ve been a loyal follower through the years. I’m not going to say that everything he does is great. He can’t do rock and he can’t do latin. “I Made it Through the Rain” drives me crazy because I keep thinking he should get a damn umbrella. I’m not too fond of “I Write the Songs,” because I have this vision that if the first caveman who created music by banging their clubs on rocks saw Barry, they’d have turned their clubs on another target. But most of his stuff is pretty good and eminently sing-a-long-able, and some of his pieces are pretty close to perfect. “Even Now” is one of the truest ruminations on past relationships that I know. His best song ever…and one I want played at my funeral, if anybody’s taking notes…is “When October Goes,“ with music by Manilow and lyrics by the legendary Johnny Mercer. It is simply the finest musical meditation ever on aging, love, life, and ultimately the futility of it all. Flippin’ brilliant.

I’ve actually seen Barry twice. The first time was in Jacksonville when he was touring with his last album of new material, “Here at the Mayflower.” It was a good show, most notable for the fact that at one point during the song Weekend in New England…and specifically at the line “When can I touch you?”…someone in the balcony screamed out, “RIGHT NOW BARRY!” Blissfully plugged into their headphones, the band played on, but Barry himself stopped playing and started laughing as if he’d never heard that line before. (The concert also stays in my mind because I lost a bet. I figured that Barry Manilow was so popular there would be at least twenty people of color in the audience of several thousand. Turns out there were eight, auditorium staff not counted. It was like counting minority representation within NASCAR fans. But at least Barry has Oprah.)

The second time was in Las Vegas three years ago, when he was playing the MGM Grand. This was your standard Vegas show, somewhat more intimate than a ten thousand seat arena. Put simply, Barry puts on a great show. He sings what you want him to sing, he involves the audience, he screws up from time to time, he laughs and doesn’t take himself too seriously. He seems genuinely baffled that people still come to see him, and genuinely grateful that they actually still do. Most of the audience that particular night was comprised of “Barry’s Angels,” a fan club dressed in white, some with handcrafted cardboard wings duct-taped to their back. The Bride was clearly the youngest person in the audience, and even at my advanced age I wasn’t that far behind. When two of the fan club ladies asked what brought us to the theater, I reminisced about the past utility of Barry and a bottle to ensure a good night, and they nodded their heads, a faraway longing in their eyes.

The great thing about the Vegas show was that you could see Barry up close. That’s how you can tell he’s had botox. From the corner of the mouth up, he looks perfect. From the corner down, where he can’t have botox because unless Senor Wences is involved the last time I checked singing required actually movement of the mouth, he looks like an old jowly Jewish guy. Which, of course, is what he is.

(Speaking of Senor Wences, remember how he used to draw a couple of eyes on his hand, outline his thumb and index finger with lipstick, stick some hair on the whole thing and then talk to his friend Johnny? My brother got off a good line a few years back when our discussion turned to lonely guys indulging in self-pleasure. He immediately whipped out a pen, drew two dots on his hand for eyes, and made the hand say “It’s horrible! He makes me touch him! Arrrrgggghh!” Okay, maybe it was funnier at the time.)

I knew Barry was probably older than I thought, but didn’t realize until I read in the USA Today article about his new album that he was almost 68 years old. That produced a pause. Sixty-eight is only 7 years younger than my Dad, whose musical talents are limited to a few folks songs on the ukulele (none of them Hawaiian) and an enthusiastic but rousing chant of the family anthem, “The Eggplant That Ate Chicago.” And the article also said that Barry is intent on keeping his private life private, as he should. Yes, I’ve heard the rumor that maybe he’s gay, but it really doesn’t matter. Besides, as a nice Jewish boy, he wouldn’t do that to his mother. No matter where she is today, I know she’s still hoping he’ll settle down with a nice girl, have a child or two, and invite her over once a week for a nice Shabbos dinner. Trust me, it’s what they do.

And while we’re making musical confessions, let me also state for the record that I have a man crush on Tom Jones. I’ve always contended that The Lord speaks in several voices. When he’s imparting knowledge, he sounds like Charlton Heston. When he’s pissed off, he sounds like James Earl Jones. When he wants to express love, he sounds like Barry White. And when he wants to propagate the species, he brings on Tom Jones.

(For the record, I am not sexist about the Voice of G-d. When The Lord expresses either compassion or wants you to feel guilty as sin, the voice is exactly that of your mother.)

I’ve seen Tom twice, each time up close at a relatively small venue, and he is simply masterful. It’s true that women still throw their underwear at him, although some of his fans are now old enough that one wonders if girdles and support hose hold quite the same attraction as lacy bras and panties did before. Nonetheless, both his voice and his sex appeal are fully intact. So I shouldn’t have been surprised to hear a conversation at the table next to us when The Bride and I saw him in Vegas. Shortly after the first song, the wife noted that if Sir Tom beckoned to her, she was going back to his dressing room no matter what. And her husband of many years replied that he would be happy to let her, to know that someday he might also have what Sir Tom had once received. That’s not unusual, is it?

Death of a Dream

Where there is no vision, the people perish. - Proverbs 29:18.

It’s a week before the final launch of the shuttle Atlantis, and I’m watching a PBS show on the Columbia disaster. The thirteen year old boy sitting ten feet away wants to know why I won’t turn it off to look at a funny internet video. I don’t know how to explain to him that retrospectives are all I have left of my childhood dreams of space. And thanks to the Obama Administration’s dismantling of America’s manned spaceflight program, he won’t even have that.

This is such a visceral issue for me that I’m not even sure how to write about it. I was a kid of the Apollo era. While the generation before me remembers the moments when President Kennedy was shot, and the one after benchmarks at 9/11, for my group our touchstones were in space. We remember Apollo 8’s reading of Genesis from space, and the grainy pictures of Apollo 11 on the moon. (Most of us can still recite the first words from the moon.) We remember that these things happened late at night, and most of us saw them with our parents in the living room or in our beds, the whole family living a moment together. We were the ones who stayed awake past bedtimes to follow Apollo 13. We saw the Challenger explode before our eyes, and felt loss a second time with the Columbia. We learned about daring, tragedy, perseverance, and triumph.

Through space, we saw a dream that we all could share. And while many of us, in our childhood ways, wanted to be astronauts, we also knew that just by being an American we were part of that dream. For those of us raised on space, who knew that our future as a nation would take us forward, upward, and outward, manned space flight was not just about boosters and capsules and lunar rocks in a Plexiglass case. For us, the space program was a fundamental part of being an American, about who we could be as individuals, as a people, as a nation. And today, where we’re all adults and our wide-eyed optimism has been tempered by the cynicism induced by moneyed interests and political hacks, watching the Space Shuttle rise from the pad was our last symbol of hope, a final sign that perhaps working together, we could be something larger than what we are.

To be sure, I’m not harboring any illusions about the space program as a whole. For a while I worked in an affiliate support role with NASA at the Kennedy Space Center in Florida, and I have friends who’ve worked in NASA facilities in both Florida and Houston. The space program has not been perfect. There have been problems with design, safety, fiscal care, and mission management. The planned Constellation program undoubtedly had issues to overcome. And while the space program no doubt accelerated technology, I’m certain that we’d still have personal computers, Tang, and Velcro even without Apollo. I also believe wholeheartedly in the unmanned exploration of the solar system and beyond, and would certainly acknowledge that there are a whole host of tasks that robots can do faster, cheaper, and more efficiently than humans.

But to try to elucidate practical reasons for the space program is to completely ignore why we go into space. We go into space because, to paraphrase President Kennedy, not because it is easy but because it is hard. We do it because it gives us something that we may not achieve, but to which we can always aspire. We do it because the infinite reaches of space continually stretch our goals and our imaginations. We do it because only by contemplating the vastness and antiquity of the universe can we address the fundamental questions of the uniqueness of humanity.

We do it because, as Americans, we explore. We expand. We learn. We go farther. And we need men and women to be our vanguard of exploration, because we can’t invest our hearts and souls in a bucket of bolts. We need people to take the risks, to go up and come back and tell us how space feels and looks and tastes and smells, people whose voices we can hear and whose hands we can shake. Space is all about aspiration, inspiration, and destiny. It’s about man.

There’s a practical, and a political, side to this as well. What the administration has done is not just to cut NASA’s budget, but also put thousands of people out of work in the midst of a jobless recovery. It’s hard to fathom that it’s okay to bail out moneyed interests on Wall Street and the auto industry in Detroit, but not consider those workers who support the space program. And if it’s not galling enough that the space program has been wrenched from the imagination of the American people, the President had the nerve to want to come to Florida to see the final launch of the shuttle Endeavor. This is hypocrisy at it’s finest. He’s making sure that he gets to see what he’ll be taking from the rest of us before it’s gone. But hey…it would also be a potential photo op with Rep. Gabrielle Giffords, the wife of Shuttle Commander Mark Kelly. From what I understand about Rep. Giffords, she’s pretty sharp. I’m sure she would have figured the politics, but scorned the posturing. (While I am not a “birther” by any means, perhaps this is one occasion when President Obama’s childhood abroad during the pivotal years of Apollo puts him out of touch with the rest of us.)

The Obama decision to defund the manned space program has utterly destroyed the idea of a national dream at a time when Americans need to unite more than ever. We’re divided politically, with honest disagreement traded for extremism and hate. Class and income gaps are widening, the standard of living is falling, and the American quilt is being torn into a raft of self-focused groups. We’re a people who find fault in other but deny responsibility, and instead of one nation under G-d we’re becoming a nation of ones unto ourselves. What could always unite Americans was a dream. First it was Liberty, Manifest Destiny, the Great American Melting Pot. For my generation, it was the conquest of space. A nation that was built on exploring frontiers, on doing that which no one has done before, now has no outlet for it’s boundless energies and no single goal to unite the country at a time when those forces are increasingly turned inward in destructive ways. Our leaders are taking from us something very real and precious, and replacing it with nothing.

And so my son is likely to be more absorbed in the world within his room more than the heavens above, engaging the universe through electrons and keyboards and not in real time, in a life devoid of real dreams and real heroes. Sadly, despite my best efforts, he’ll likely have no idea what he’s missing. But given the fundamental lack of vision from our leaders, perhaps that’s exactly the point.

Bug Season

I work in an area where there’s lot of hunting and fishing, so I’ve become familiar with the “seasons of the kill.” Right now it’s between seasons in the field, but within the ER Bug Season is in full swing. Bug Season is that time of year when bugs wander into people’s ears and people wander into my domain wanting the bug out. It’s something that’s unique to early summer, and all I can figure is that the bugs, attracted to the porch light on a summer’s evening, suddenly realize they’re gravitating towards the Bug Zapper of Arachnid Doom and think better of it, ducking into the nearest dark spot they can find, knowing full well that if they think twice about it they’ll finish that run to the afterlife. (See Marty Robbins, “El Paso.”)

Those whose ears have been used as insect refuge usually drift in about two in the morning. I’ve never had a bug in my ear (other than the metaphorical one), but it seems to be one of the most excrutiating things imaginable. The skin of the ear canal is paper thing and loaded with nerve endings, so the motion of the bug causes severe pain. In addition, the wafer of skin cells lies directely on top of bone, and bone conducts sound better than air. So every little flicker of the bugs legs or wings is not only felt, but heard as a loud, interminable grating noise. So when you consider that the bug is susally still alive, feet and feelers looking for traction and wings beating against the eardrum…you can get a sense of why getting the bug out constitutes an emergency that even I, with my low tolerance for anything less than an actual acute illness or injury, would recognize as worthy of an ER visit I the wee small hours of the morning.

There are a couple of ways to do this. One is to try to wash the bug out. This usually never works, as most people have already tried it at home and if the bug was dead, it came out. They’re in the ED because the bug, having tenaciously fought the deluge, is still thriving, damper but cleaner. So you have to kill the bug, and the best way is to drown it with some kind of oil of a solution of viscous lidocaine, a thick local anesthetic gel that you squirt into the ear canal and let it sit for ten minutes or so. Then you try to irrigate out the ear again, but this time using an IV catheter and a syringe in order to get a high-pressure blast of water in there. With any luck, the bug pops out. You hope it does, because the expectation from the patient is that you will then dig in the ear for the bug. You try to talk them out of this because a) it’s painful, b) it never works, and c) you’re just going to send them to an ENT guy the next day who actually has micro bug-out-of-orifice stuff in the office. The patient will want the bug out now, so you make a couple of half-hearted blind stabs (we don’t have the kind of ear instrument or scopes that allow you to look in the ear canal as you’re working, nor tools fine enough for the work), which results in more pain and quite likely a little bit of oozing of blood form the ear as you scrape the inside of the canal. You apologize profusely, show the patient whatever you’ve gotten out of the ear (a feeler, a leg, a bit of wing, a strangely shaped piece of wax) to demonstrate some progress, tell them that all bleeding stops eventually, and refer them to the ENT guy on the morning. Which is, of course, what you wanted to do in the first place.

Sometimes bugs beat the odds, and are just slowed enough by the attempted drowning to be flushed out, but still able to make a valiant attempt to get away once they’re back in the light of day. They pop out of the ear canal into a basin of water, often in tatters, their little feet struggling to bring them up for one last breath. It kind of makes you feel for the bug, as you witness their last gasp of buggy life. I was watching this Mutual of Omaha Wild Kingdom struggle for survival and remarked, in what I thought was a fairly deep moment for someone who had eaten nothing but six Hostess Twinkies, three Cokes, and a piece of Hampton Inn Free Breakfast Sausage in the past 36 hours, that the poor creature was “drowning in the waters of his own despair.” So for some reason now all the post-ear bugs in the ED are called “Howard Junior,” and I’m wondering if it’s time to start saying Kaddish for them. But given the way I long to have things named after me, I hope it sticks no matter what the bug’s personal faith tradition might be.

A De-Funding Fallacy

I’ ve always hated the abortion debate. It’s a difficult topic, involving morals, medicine, individual autonomy, and the law, and there is just no way to simplify the issue and have any kind of learned debate. But since learned debate has been expunged from our public discourse, abortion is now framed in labels and sound bites. You’re either pro-life or pro-choice, which I think are terrible labels for both both sides. Abortion is always a bad choice that may, at times, be considered necessary for a variety of reasons, but always a bad choice. And everyone should be also thought of as pro-life, in that we should want the best outcome for all parties involved in this most difficult decision.

With this in mind, I noticed recently that Medicaid officials have ruled that an Indiana law which pulls all state funding from Planned Parenthood to be illegal. As I understand the situation, Medicaid rules prevent service providers to be excluded from participating in the joint State and Federal Medicaid program based the range of services performed by the provider. Planned Parenthood performs abortions, but also provides other services such as family planning, cancer screenings, and care for sexually transmitted diseases. Medicaid can be excluded from paying for specific procedures such as abortions, but the entire agency and all the other services it provides cannot simply be struck from the provider rolls.

What bothers me specifically about the Indiana law, and similar bills passed in many states (one was proposed by Congress as well) is not it’s legal status…that’s up to the courts to decide. What annoys me is that it’s yet another example of how the exercise of partisan politics actually impedes the stated goal of those same Demagogues of Democracy.

Planned Parenthood does perform abortions. They do so out of funds that are privately raised and fees paid by individuals for care. State and federal dollars granted to Planned Parenthood are already prohibited by law for use in support of abortion services. Instead, they are used for family planning programs and screenings for breast and cervical cancer in underserved women.

So if we follow the money, we find that defunding Planned Parenthood as a political statement against abortion won’t affect abortion at all. What does get affected are those activities that help prevent unwanted pregnancy. Decreased availability of family planning services means more unwanted pregnancies, more children in single parent households, more children in poverty, and (paradoxically) likely more abortions as women struggle to cope with the consequences of unexpected pregnancy. And if we are framing the defunding of Planned Parenthood as promoting a “Culture of Life,” doesn’t it make sense that this culture would want poor women to be screened for and get care for breast and cervical cancer in the early stages while these malignancies are still curable, rather than wait until the patient has advanced disease?

I’m not Catholic, but there a lot of things I admire about the Catholic Church. One thing I’ve always found impressive is that their theology is always consistent. Their steadfast interpretation of the Culture of Life sets them against abortions, artificial family planning, and the death penalty. But it also means promoting health, welfare, and social justice for all, as we are all precious creations of God. I suppose that in America, you’re only precious if you can afford your own pap smears and mammograms.

Fitness Fanatic

I have a pretty bad history with physical fitness. In fairness, I need to say at the outset that I’ve been blessed in that my life has had it’s issues, but one of them has not been a battle against weight. I was born a stick person, raised a stick person, and been a stick person my whole life. It’s not my Mom’s falt, either. While she only does two really good meals…Passover and Thanksgiving, both with all the trimmings…and she goes through phases like veal burgers and the ever-popular Sgt. Harriet’s Indiana Baked Chicken…it’s not like there were never brownies or Froot Loops in the house. I suppose it comes naturally, as my Dad was a stick person until he quit smoking in his 30’s. Since then, he’s become gradually more Santa-like, but I think he’s getting more jolly as well. So I’ve always known the weight was coming, but I’ve been fortunate to be able to avoid it until the past year, when thanks to the acute observations of my Cousin Sara the term “muffin top” has entered my vocabulary (and not in the sense that I wish it would have twenty years ago, when a muffin was a college girl and a muffin top was probably the sweater you were trying to talk her out of. Ah, memories).

As a result of my good fortune, I’ve always had a strange relationship diet and exercise. I’ve always been able to eat pretty much anything I want, and I’ll be the first to admit I’ve abused this privilege. It was at it’s worst during my public health years, the best way to get the attention of the STATE HEALTH GUY dedicated to HEALTH and HEALTHY LIFESTYLES was to present an idea with a couple of Hostess Twinkies in your hand. (I’ve since moved on. Now it takes a Suzy-Q, and in deference to the fine people in the dairy industry I chase it down with a glass of milk rather than the preferred Vanilla Coke. I’m just sayin’.) However, one of the great advantages to working in public health is the ability to justify things. So a single Starburst became a serving of fruit, and spearmint lifesavers became vegetables. Twinkies fell into the breads and cereals group, and were a way to show my commitment to the Kansas wheat growers as well as the petrochemical industry (I know the “cream filling” is actually plastic, but I do love it so.)

There is a downside of being a stick person, however. For me, it’s always been a healthy fear of the beach, the swimming pool, and short sleeve shirts. I look like Mac in the Charles Atlas ads on the back of the comic books of my youth, and he’s the one getting the sand kicked in his face. Slow dances made me nervous, because there’s nothing “hunky” for a girl to hold to. And with no upper body musculature, chin-ups and rope climbs in gym class were a nightmare. Most of my life I would have given just about anything to have another twenty pounds on me. So from time to time I would invest in a huge jar of “nutritional supplements”, mix the grainy powder in milk and drink the gummy residue four times a day. After three months I was able to pack on a whopping two pounds, and my Brother-in-Law, whom I actually like because he shoots, kills, and eats things and is my survival plan for the Zombie Apocalypse, laughed at me for trying. So that was the end of that.

I’ve had an even less successful relationship with exercise. From time to time I decide I need to work out. This usually goes well for a few weeks until boredom or pain (whichever comes first) sets in. Then l’m back to my sedentary ways for another year or two. Last year my try at fitness was to buy a Wii. I loved the thing, and for the first couple months of ownership I made sure to a seven game set of tennis every day as well as nine holes of golf. It was great while it lasted, but after six weeks I was still winded going up the steps. Since I live off instant gratification, I decided the Wii wasn’t working, so I shifted to Rock Band. (Note: Taking a top floor apartment with a cathedral ceiling so nobody’s living on top of you seems like a great idea when touring units. When a middle aged guy is dragging groceries up the steps? Not so much.)

The next step was to upgrade to Wii fit. This is a great program. Lots of exercises…cardio, yoga, and balancing work. I especially liked one of the later programs, where you had to sit quietly and unmoving for three minutes until an electronic candle burned itself to the nub. To me, this was the perfect exercise. Don’t move and get fit. And so I still do this exercise, sitting quietly on the floor for three whole minutes at least four times a week whether I need to sit down or not.

This year’s entrant into the fitness sweepstakes is going to be either P90x or the Shake Weight. P90x is the DVD-based workout program featured on late night TV, and it actually seems to work. However, it has started to fall in my estimation because it’s really hard, and my work ethic took the lottery money and is still off on vacation. In addition, a few months ago I saw a guy in the ER who had finished his first round of work and had managed to break down enough muscle tissue that we had to admit him to make sure all the newly-liberated proteins didn’t clog up his kidneys. I was almost as disturbed by the knowledge that his could happen to me as I was by the fact that he came to the ER in 30 degree weather wearing only black boxer shorts with pink and red hearts with a suspiciously open fly, sobbing while holding buckwheat pillow.

(As an aside, it was kind of funny to see how we addressed his issues. We gave him pain meds, of course…good stuff, not skimping…but he continued to whimper. At that point, we shift our internal paradigm for patient care from “poor, poor thing” to “buck up and get some balls.” Interestingly, we never ask female patients to “acquire an ovary.” No doubt a topic for further review.

Pain control is a controversial issue in emergency medicine, and in many states it’s become a political football as well. Most doctors feel they treat pain appropriately, while most patients…at least those who answer surveys… are convinced that they do not. I won’t claim to have any magic answer, or to be the perfect purveyor of pain pills and potions. A lot of it is still a judgment call based on how much pain the patient appears to have (do they look truly uncomfortable or not) and the degree to which the patient’s complaints of pain match the overall appearance. But I do have my own internal list of patients who can have whatever pain medicine they want without argument, no questions asked. You can have whatever you want if:

1) You have just broken a bone
2) You have allowed me to put a clamp, knife, needle, or tube in any orifice, place or space it doesn’t normally belong. (Routine injections, IV's and urinary catheters excluded.)
3) You have cancer.
4) You are in a hospice.
5) You have a toothache. (First visit only.)
6) You ahve a kidney stone.
7) You have a burn.
8) Your care is delayed because the doctor you really need to see, like a surgeon, is either busy in the operating room or is “operating” at home, the local golf course, or the Hotel of Illicit Gratification, hoping that flash in the background was just lightning and not a camera phone.

These criteria stand in contrast to the patient I saw last week, who came in requesting a refill of her narcotic pain medication she had received for a rib fracture six weeks before. I had a chance to look at her records before I saw here, and in addition to her three previous visits for narcotic refills, she had a repeat x-ray that had shown the fracture to be fully healed. I told her that I would be happy to evaluate her, but that I was not going to be comfortable refilling her narcotic prescription for a fracture that was no longer there. At that point I become in turn, “The worst doctor I’ve ever seen, ”the rudest doctor they’ve ever had here,” and the guy who, "doesn’t understand that YOUHAVE TO GIVE ME WHAT I NEED, AND WHAT I NEED IS PERCOCET” Seeing I was not moving from my position, she refused further evaluation and left the ED. The sad part is that it took me longer to document the encounter, dictate addendum notes, and cover my bases from a risk management standpoint than it did to examine, diagnose, treat, and write up a woman who came in just a few minutes later with a life-threatening heart condition. But in this era where medicine is business, the customer is always right, and the ER doctor is nothing more that another disposable vendor of services, dissatisfied people complain and sue. Those who are truly sick are also those who value your care. But the whiners win out in the end, and that’s American medicine.)

So I’m thinking that if a really buff person can kill his kidneys doing P90x. and then cry like a girl about it, the last thing I need is to be dragged into the ED sobbing, my stick physique and my favorite pair of Justice League underwear on full display (although the fly does lie within a picture of Superman…heh,heh,heh). But as I am now the owner of a nascent “muffin top,” I need to try again. Maybe if I downgrade to something like L45q I could pull it off. Or maybe I can use the Shake Weight that they advertise on TV, because it looks like I can do that sitting down. And if I focus on my upper body, it’ll be good to have both forearms the same size again. My right forearm is about an inch larger around than the left, a permanent reminder of several years scooping Baskin-Robbins hard ice cream in high school. Of course, nobody thinks that’s the real reason one forearm is bigger than the other. For the purposes of dispelling that rumor, let’s just say that I dress left. And well.

Another Night, A Few More Stories

There are a lot of annoying sounds in this world. The screech of fingernails on a blackboard. The thump thump thump of the three year old kicking your seatback in time to "It's a Small World" all the way to Florida. And the piercing wail of the EMS radio page an hour after midnight, just at the moment the ED is on the verge of being cleared out and the pillow...or at least a Jerry Springer rerun...beckons to your tousled head.

The call goes out on to an address on Castle Street for a middle-aged female with three months of vaginal bleeding. Several minutes later, we get report from the crew. The patient has only had vaginal bleeding for two months. So it's already 33% better.

Tonight's EMS squad pairs a man and a woman. I ask the distaff paramedic...who is also one of our Unit Clerks...for patient report. Specifically, I say "I've never had a vagina, so hopefully you can tell me why someone who has one that's been bleeding for two months would call an ambulance at 1:00 AM on a Friday night."

The paramedic smiles. "I suspect it has something to do with the alcohol."

Five minutes later, I'm in the room with both the patient and the vapors of her beverage of choice, so I ask. (I have to ask questions in the "why you're here NOW" category pretty often, so there's a set script here. Mine is not the best line. The best I've ever heard comes from my colleague Dr. John Prairie, who's version is, "And what MEDICAL EMERGENCY brings you to this LEVEL II TRAUMA CENTER this VERY NIGHT?")

"I know this is going to sound rude, and I don't mean it to, but what in particular brings you in to see us tonight after two months, instead of when it started or a month ago?"

"I was bleeding so much in the bathroom that they threw me out of the bar."

I finish my history, asking about past history, medications and allergies. "I'm on medications," she says. "For my fibromyalgia."

(I saw that one coming, but for some reason I can't explain just why. I know some people who think they have "Gaydar" or "Jewdar." Perhaps I have "Fibradar.")

Her exam is completely unremarkable...no bleeding to be found...and like many patients, it's going to take longer to do the paperwork then provide the needed care. So as I'm sitting down at the desk, I hear the nurse talking to the local domestic violence shelter.

"She wanted us to let you know she was here. Are her kids okay?"

Yep, she had left her kids at the domestic violence shelter to go out to a bar. And as the story emerges from the fog of war, apparently she's there because she has a stalker. Going to a bar is always a good way to shake them from your trail.

**********
I go into Room 1 to see an older man who's been dizzy. As I start to ask him questions, his wife answers everything. This is another one of those situations where I've developed a standard script over the years. So I say, "Ma'am, I want your input, but I'd really like to hear from him how he's feeling, and then I'll want you to help fill in the gaps."

She blushed, and then the whole family started laughing. "I'm sorry. I always do that."

I asked the patient, "Do you ever get a word in edgewise?"

He shrugged. "Not often."

They seemed like nice people..fun people...so I decided to tell one of my stories. "You know, years ago I saw this little old couple when I was working in Florida. The guy was genuinely sick, but every time I asked him something, his wife would answer for him. And every now and then, when he would actually get out a word of his very own, she would put her hand on his head and say, "Shut up, Mohty. I'm tawkin to do dacotah."

They all laughed, so I figured I was on a roll. "She also wondered if I was Jewish, and if I was single. When she found out from the nurses that I was, she told me all about her granddaughter who was a college student and offerred me her phone number if I wanted to call."

I kept up the show for a good five minutes. Each laugh I got produced another joke or story. I was just on the verge of wrapping up my act by noting that I was there all week, and that you should tip the nurses and techs because they're working hard for you, when the patient finally piped up.

"Hey, doc...do I get to talk now?"

Two points for the patient.

**********
We actually saved a life tonight. A lady came in with chest pain, as we're evalauting her she becomes unresponsive. She has no pulse and is not breathing. This is the kind of stuff we live for. Within moments she's getting ventilated with a mask, receiving CPR, and having sticky-backed pads placed on her chest to give her an electric shock. A few seconds later, voltage converts her heart rhythm from disorganized chaos to a normal rate with a bounding pulse and strong blood pressure. While the nurses prepare to start medication to stabilize her heart rhythm and control her pain, I step out of the room to call the cardiologist to take her to the cath lab. While I'm out of the room the patient's hearbeat again becomes unstable. By the time I run back to the room, the nurses have already given the needed shock and the patient is brought back to life once again. Total elapsed time of hands-on ER doc care: Fourteen minutes.

Another patient came in complaining of headache. She's had neck pain and headaches for years. She's been told the headaches are related to muscle tension, and she's had a compeletley negative workup, but she doesn't believe it. She wants them fixed now. She wants an MRI. I take her history, do her exam, write orders for pain medications, and check her response. I explain to her that in the ER, when the neurologic exam is stable we generally don't do MRI's. I explain it again. I painstakingly document the encounter and the areas of disagreement in the event that she chooses to bring it up the next day with adminsitration. Total hands-on ER doc care, not including observation time to watch for pain relief: Twenty-nine minutes.

I'm sure that says something about what actually constitutes an emergency, why saving lives takes seconds but risk management takes hours, patient expectations versus clinical realities, the problems with consumer-based health care, the silliness of a health care system that promotes equally silly behaviors, and the overall state of medical practice in America. But it's three in the morning, and I've got to see more chronic back pain and kids with runny noses who's crying is keeping up their parents and people who think they might have passed out yesterday but nobody was around to see it while I hope that someone else's grave misfortune will give me a purpose for being here.


I'll let you figure out the moral of the story, because honestly I'm just trying to make it to dawn.