Thursday, June 28, 2012

the health care system is doomed

Is the affordable care act (obamacare) going to solve our healthcare systems problems? Of course not. It may exacerbate them.

I'm glad the supreme court ruled in favor of the individual mandate. I think obamacare is a good thing. At the very least, it recognizes that we have a problem. At worst, it makes the insurance companies richer.

Thirty million people have no health insurance in the country. Will they now get health insurance? I don't know. I don't get how it will work. If they do get the insurance, an already overwhelmed health care system will be more overwhelmed.

As is usual in this country, nobody cares about something like health care until it affects them personally. Most people don't see a doctor that much, don't come into the hospital. They don't realize what bad shape it is in. They don't really care. But here's the thing: It will affect them soon. Their insurance premiums are going to skyrocket. I don't think obamacare will stop that.

What they don't realize is that grandma and grandpa are living longer and longer, many into their 80's and 90's. And of course, grandma and grandpa, as is uusual in the US, have not made any decisions about end of life care. So they will have all the expensive technology thrown at them and they will bankrupt the system eventually. Add these 30 million new entrants into the system and you have a recipe for disaster.

There will be drastic changes in our system in the coming years. Changes, no one is going to like. You won't be able to run to the doctor or the ER for your sniffles. Grandma and grandpa won't get those expensive procedures after a certain age. You will pay more if you are fat, smoke. Its going to create a lot of upheaval and anger. Nonetheless, it is inevitable.

Sunday, June 24, 2012

Dr. Douchebag: A Tale of the Emergency Department

A doctor's perspective on abusive patients in ER. By J.M. Baruch. Originally from the Hastings Center Report. Reprinted from Medscape.

Two gun shot wounds," the emergency medical technician says, breathing fast, the summer night pouring down his face. "One in the right flank, one in the right thigh."

"I don't want to die, doc," pleads the victim, whom I will call Mr. Smith. His vital signs are stable.

"This is the trauma team," I say. "We're going to take good care of you, but we need to ask lots of questions." I press my stethoscope to his chest. "Can you take some deep breaths?" I listen for the airy hollow of a punctured lung but am calmed by the hum of normal respiration, even as his alcoholic breath warms my cheek—or so I believe. He denies drinking, but this is one of those overnight shifts when everyone—motor vehicle crashes, chest pains, depressions, confused grandmas, even rashes—has thrown back one or two.

Once inside, we palpate Mr. Smith's neck, chest, back, abdomen, and muscular extremities. "Does it hurt here, and here, and here?"

He doesn't answer us. Now he acts annoyed and bothered. "Call my cousin," he says.

"Sure," I say, "after we make certain you don't have an injury that needs immediate attention."

"And you are?" he says.

I'd already introduced myself, but I know what he means: Who am I in the hierarchy? "I'm the doctor in charge," I tell him.

"Good," he says. "Go call my cousin."

"First things first," I say.

"Hey, douchebag," he says, his voice hardening. "Call my cousin."

I pretend the comment was what he might, on reflection, consider a regrettable slip of the tongue. But his head arches off the stretcher and his eyes meet mine. "Now, douchebag."

I feel the heat of the trauma team's averted gazes. I say nothing, but inside, I grasp at explanations. He's been popped with two bullets. Maybe he's scared, anxious, emotionally shocked. Or he's a thug, a power-fiend, and now he's vulnerable. He distrusts authority. Perhaps he is drunk, his tongue greased.

He refuses intravenous fluids, blood draws, x-rays. "Let us take care of you," I say, proffering shared control, thinking he'll soften up and participate. "You don't want to die, do you?"

"I'm not afraid of dying," he says, despite his plea on arrival. "Listen up, douchebag. Are you calling my cousin or what?"

I swallow hard. The ache in my stomach will ease somewhat when I find time to eat my tuna sandwich. But the frustration feels bottomless—untouchable and undeniable. "What gives you the right to talk to us this way?" I finally say.

He stares me down. I tear the blood pressure cuff from his right bicep.

"I'm not fighting you. Many patients are waiting to be seen. You're free to go if you want."

He stares at me. "I'm calling my lawyer!"

"Good luck. We'll dress those wounds before you leave."

Afterward, I neither swelled with satisfaction nor sighed with relief. Justice hadn't been exacted. I felt empty, drained of emotion. It was that word: Douchebag. It's important to avoid euphemisms, or a vague term like "expletive." I've been called worse in my career without flinching. It was the way he said it, with his riveting eyes.

The emergency department might be the only sphere of human exchange where one party—patients (and sometimes family)—are permitted to insult, threaten, and even spit at the very people on whom they depend for help, while the offended parties—physicians, nurses, and other health care providers—must not only tolerate the abuse, but treat their tormentors. Although only a minority of patients are difficult, still, you cannot practice emergency medicine without being skilled with, and tolerant of, difficult patients. The challenges they present are shared equally by ED nurses, midlevel providers, and staff. The wide range of people and behaviors populating our practice contributes to a distorted normative standard: uncooperative, vocal, demanding, drug-seeking practitioners of various self-destructive and illegal habits. Yet I found this patient difficult beyond these familiar and forgivable ways.

The specialty of emergency medicine was built on pillars of "egalitarianism, social justice and compassion"[1] and the demand for expert services for the poor and uninsured in society.[2] This ethos was shaped into statute with the Emergency Medical Treatment and Active Labor Act, which codified the principle that any patient who comes to an emergency department must be screened for a medical emergency. EMTALA translates as a patient's right to care—a justified claim on the time, expertise, and, I believe, the empathy of the ED staff.

These moral and legal obligations situate the ED at a boundary where hospital and community blur. The responsibility and challenge of serving marginalized patients who are ignored or discounted by a dysfunctional health care system drew me to emergency medicine. In practice, however, this ideal has been tarnished by those patients who make you feel foolish for caring, who think the right to emergency medical service implies a right to treat the ED staff as their servants. When such patients act out or say nasty things, I'm often at a loss for how to respond. How much tolerance is appropriate? Are certain behaviors so inexcusable that they supersede our responsibility to patients? When the drunk spits at me as I try to examine him? When patients punch staff? When one tosses a bedside urinal, filled to the brim, at a nurse? Or takes the meal just served to her and chucks it on the floor? Are we truly expected to construct empathy out of this?

I've been hearing similar sentiments with greater frequency, usually from physicians—beginners and veterans alike—whom I respect for their skills and compassion. It's strange, but the most empathic, sensitive physicians seem to be the ones to fray at the edges.

Some authors have called for emergency physicians to reaffirm their commitment to their patients and their practice with a virtue-based ethic, "to treat each patient with unconditional positive regard," and respect each one with "common courtesy, sincerity, and willingness to help."[3] These ideals and virtues serve as a moral lighthouse for me when the appropriate action, belief, or emotion feels lost in the fog. But are these duties absolute? Are they too tidy for a health care system that leans on EDs to shoulder the consequences of its shortcomings?

Crowding is a critical problem facing our nation's EDs; Mr. Smith wasn't the only patient there that night. Between 1997 and 2007, patient visits to the ED increased 23 percent nationwide, from 95 million to 117 million.[4] And yet, during the past two decades, approximately a third of hospital-based EDs have closed their doors.[5] Health reform is expected to drive the newly insured to the nation's EDs, since their access to primary care is complicated by both physician shortages and practices that limit Medicaid patients due to the low reimbursement rate. Patients are also sicker on arrival, having delayed medical care until delay is no longer an option.[6] Troublesome individuals disturb fellow patients and undermine the opportunity for efficient, accurate, and sensitive treatment. Moving beyond professional considerations to health policy, the national conversation on spending and resource allocation cannot ignore on-the-ground obstacles to excellent care.

Does the ED's collective duty to greater numbers of patients demand a revised ethos of tough love for extreme cases of misbehavior? Can we ask these patients to leave without legal recourse after extending genuine, compassionate efforts to participate in their care—barring evidence of a medical explanation for their toxic comportment or a mental illness that puts them at risk of harming themselves or others? Consider this sign posted prominently in ED waiting rooms: The emergency department is a community resource. We are honored to do everything within our power to help you. But behavior that interferes with the care of other patients, or that is insulting or threatening to the health care team, will not be tolerated.

How insensitive and unprofessional was I to ask a man with two gunshot wounds to leave? He was uncooperative, obstructing his care and that of others, but those issues did not earn him an exit pass. It was personal. His insults violated some unwritten social contract. Yet any justification feels flat and petty. The burning in my chest is gone; the certainty that gripped me seems silly.

Fortunately for me and Mr. Smith, the account above is not really what happened, merely what I wished I had done at the time. I did care for a man with potentially critical wounds, a nasty attitude, and an affinity for the word "douchebag." He forcibly pushed hands away when we tried to examine him. Efforts by staff to assuage him were met with insults. He denied drinking, but his blood alcohol level was high. Only after he was medicated to make him sleepy could we provide the care he needed. In the end, he escaped major injuries. We never heard "thank you." The last time he called me a douchebag, I was made sick by what I wanted to say back to him. Upholding my professional duties and virtues did not fill me with honor, and my self-restraint was not a source of pride.

But by writing about this—using the imagination as a moral testing ground—I have gained a clearer and more sensitive impression of the event. That said, if empathy is the capacity to imagine oneself as another, or to project one's personality into another's life sufficiently to feel and understand the other person's feelings, then this creative exercise has not fostered empathy for Mr. Smith. But narrative serves as an ideal medium for wrestling with intense incongruity: a patient insults the very people trying to help him, and a physician finds himself on empathy's chilly ledge. Consider the novelist John Gardner's thoughts on the value of fiction: "[It] helps us to know what we believe, reinforces those qualities that are noblest in us, leads us to feel uneasy about our faults and limitations."[7]

Friday, June 22, 2012

bursting your bubble about nursing

Dear John/Jane Q. Public:

I am about to burst your bubble about nursing. You know the profession that is most admired, comes up number one in those polls? Those angels of mercy, Mother Teresa types? The ones that soothe your fevered brow?

Guess what? Nursing is a job. Thats all it is. The difference between your job and my job is that there are sick people at my job. My job is no different than your job. I punch the clock in and out. I do whats necessary to the best of my ability.

Here's the thing: I did not have a "calling" to this job. Mostly I went for this job because of its flexibility, security and variety. I didn't have a deep yearning to help people. Thats just a nice side part.

I do this job to help support my family. If I won the lottery, would I keep doing the job? Hell no. I would be out of there in a heartbeat. I'll let you in on a secret, Mr./Mrs. Public, this is just a job to me. I didn't set out to help humanity. I am not Florence Nightengale. A lot of the time, the job sucks.

I can just hear some people saying: You obviously never should have become a nurse. Blah blah blah. People have this distorted image of nursing as these people who have a need to sacrifice themselves for others. We are these angels of mercy put on earth to serve humanity. Makes me laugh. We do the job, cash the check, go home to the family and try to forget about the job. So don't put your ridiculous expectations on us and then be disappointed that we are just people doing a job.


madness the nurse

Thursday, June 21, 2012

your mother doesn't work here

What makes people think that they have the right to come into the ER and act like complete jerks?

I'm really trying to understand why you come up to the triage desk and act rude and disrespectful - throw your ID on the desk, ask the nurse to go in your purse and get your ID because you have an owie on your finger and can't possibly get it out yourself.

Most people would say, well these people are just jerks in their lives period. Probably so, but there is more to this, people. I have seen people who are living what you would think are normal lives, with nice families turn into a 2 year old in the ER over small stuff.

The whole "they are under stress and people react weird to stress" argument doesn't fly either. It almost feels like when someone decides they need to go to the ER for what they perceive is a problem, they revert to childhood. They cross the threshold of the entrance and become a kid.

You know how when you were a kid and you got a boo boo, you went running to your mother for sympathy, and mom always made it better? You were the center of moms universe for a few moments. That is the kind of mentality that seems to be at work in the ER. People want attention, they want it now or they are going to hold their breath til they turn blue. They throw a tantrum.

Its very bizarre, the behavior that happens in ER. I would bet most people would not even think of acting the way they do in an ER anywhere else. Some days it feels like we have a bunch of pouting 2 year olds in the lobby. Guess what? Your mother doesn't work here.

Tuesday, June 19, 2012

the general idiocy of the human race

I like to keep you up to up to date on the general idiocy of the human race..
Heard of these bizarre things teenagers are doing today?

1) vodka eyeball shots - Apparently you put a bottle of vodka up to your eyeball and pour it in. The eyeball is very vascular so it is absorbed quicky. Is this real? I mean sounds like it would be painful and very damaging to the eye, along with being dumbshit.

2) vodka soaked tampons - Thats right you soak a tampon in vodka and insert it you know where. Again, vascular, quick absorbtion. Seems like this would be messy and you would be dumb as a rock

3) Gummy bear soaked vodka - Nobody will know (aren't you clever...) that those gummy bears you're popping are soaked in booze. and your friends are so co..mpletely void of intellect.

I have yet to see any of this in the ER. Most bizarre thing I have seen: someone smoking embalming fluid soaked marijuana...another rocket scientist.

Sunday, June 17, 2012

there's a human being under there

We do complicated things in the ER sometimes. One of the things we do is called "therapeutic hypothermia", in which we lower the body temperature after a cardiac arrest to preserve brain function.

The patient is intubated, on a vent. We use paralytics, sedatives to keep them out of it during the process. Usually this involves about 3 infusions just for this part. Most of them have had an MI so there are another couple of infusions. So usually you have 5-6 drips going. They need a foley, an OG.

Then there is the hypothermia process itself, that involves wrapping the patient in pads and hooking the pads up to a machine that circulates water throught the pads to cool the body down. A tube is placed in the esophagus and hooked up to the machine to measure body temp.

Lots of stuff to do, in other words. So, the idea is to get them up to ICU as soon as possible. You have a limited amont of time to accomplish all of it. So you are concentrating on getting it all done.

The point of all this? When you have a patient as complex as this, its easy to forget that there is a patient underneath all of those tubes. A human being. Then the family comes and you are reminded that this is someones loved one.

when you become your "disease"

It never ceases to amaze me how some people choose to live their lives. They are miserable people. FOr some reason, they can't express their misery which usually takes the form of depression and a lot of anger. They don't try to get help for themselves. So it comes out sideways. They start to develop vague physical symptoms.

Pretty soon they convince themselves that there is something physically wrong with them. They go to the doctor time after time. All the tests are negative. Then one day a doctor gives them a name for their symptoms. A lot of the time its some weird syndrome or disorder that a lot of medical professionals don't believe really exists.

Its like the the heavens open up and a beam of light shines on them...YES..I now have a name for what is wrong with me. I told everybody that there really was something wrong with me. They take thier "medical diagnosis" on as their identity. Their life revolves around being a sufferer of this "disorder". Their family's life usually revolves around it too.

Woe to anyone who questions or challenges whether they are really "sick". Thats when all of the anger comes out big time. They make threats. They act out. They manipulate.

What a shame that they are limting their, and their families, lives. Whats really weird is that we have become a society in which there are so many dysfunctional people, in order for doctors to deal with them, they are labelled with questionable diseases. Pharmaceutical companies develop pills to treat these same questional diseases and make a lot of money. What a world

Friday, June 15, 2012

be nice to your nurse

You know what the worst part of my job is?

Its not dealing with poop.

Its not dealing with vomit.

Its not dealing with blood.

Its not even watching somebody die.

It is dealing with mean people. There are a fair amount of mean people in the world. You find that out in a job like mine. There are people who will treat you like shit just because you happen to be there. You are the subject of their frustration, bad life, anger problem.

Here's the thing: All of us who work in the ER are human. We have feelings too, believe it or not. We aren't robots. When someone attacks us, it hurts. Yup, even after years of being an ER nurse, I can be made to feel bad. It angers us. We want to attack them right back. We can't.

So we stuff it inside ourselves and move on to the next person. But we don't forget it. We wonder why we were treated like that. We were just trying to do our job. A lot of people would say, let it go, that person was just a jerk. Or they were under stress. Sometimes its not so easy to let it go.

This is the kind of stuff that makes you wonder, why do I do this job? It really is a self abusive job. This kind of stuff happens all the time. Its not rare. Its the kind of stuff that makes nurses quit the profession.

Treat your nurse nice.

Monday, June 11, 2012

Isaac would be proud

I never took a physics class, but I think the basic laws of physics can be applied to the ER...




A nurse sittin' at the desk to take a breather is ectastic until some moron comes to the triage desk, puts on the call light, calls on the phone.

Once the shit hits the fan, it will keep hitting the fan til the end of the shift, unless the world comes to an end.





A nurse tries to call report on a patient. The floor resists saying the nurse is busy, at lunch, just discharged a patient. The nurse must get irate, state the patient is ready to call the administration, call the nursing supervisor to get the report called and the patient upstairs.





When a nurse employs the above tactics to get a patient upstairs, the inpatient nurse calls back to say that, oh yeah, the bed is being cleaned.

Here is a madness rule of the emergency room:


Thursday, June 07, 2012

yer kid is oppositionally defiant and bipolar

We are seeing a lot more adolescents for psych than we have in past years. Its not uncommon for mom or dad to call the police and have them bring teenage son/daughter to ER because they can't handle them. They want us to handle them. Sometimes its even hard to get mom or dad to come down to the ER.

A lot of teens are on heavy duty medication and have already been given a mental health label: depression, anxiety disorder, PTSD, bipolar. My favorite is "oppositional defiance disorder". Isn't it pretty much the job of teenagers to be defiant? Thats what they do.

I really wonder about all of this. Could it be that parents these days haven't got time for their kids and they are acting out, depressed? Maybe its easier to throw a pill at them, then give them attention. I'm not saying that there aren't teens with real problems, but it seems so easy to give them meds. Is it right to l
abel someone so young with a mental health disorder?

A lot of people are starting to wonder about all of this, espescially giving kids psych meds. There is a proposal in my state to have any doctor wanting to give psych meds to a kid having to consult with an agency that would be set up.

In our society we want a quick fix. We don't want to have to put effort into things, even our kids. We just want a medication that will make them act how we want them to act.
Do you ever stop and think about our jobs? The people we deal with? We see everybody from A to Z and some don't fit into A to Z. In the course of my time in the ER I have seen:

- a couple of billionares
- a few big time celebrities you would know
- professional athletes
- politicians
- a former CIA agent

Tuesday, June 05, 2012

resistant clap, coming to your town

Via white coat. This is some scary shit. If this don't make you wear a condom, or insist your sex partner wear a condom, you are crazy. It seems the clap (gonnorhea) is becoming increasingly resistant to antibiotics. There is worry that it will eventually become resistant to all antibiotics.

Complications of untreated gonorrhea:

Women: PID, infertility, tubal pregnancies

Men: epididymitis, infertility

For many years, starting in the 1980's, behavior around unprotected sex changed due to fear of HIV. As HIV has become a chronic treatable disease, it is no longer in the news as much and the fear of it has decreased, leading to less fear of unprotected sex. Young people today didn't go through the era when those with HIV were treated like lepers.

I wish we could give out condoms in the ER. I suppose if we did, some right wing fanantics would say we are encouraging promiscuity. Thats why things like this happen - we can't face reality. You aren't going stop people from having sex, obviously. Condoms should be free and available all over the place.

Monday, June 04, 2012

strange PSA about strokes

Hey I feel sorry for people who have had strokes. Anti smoking PSAs are good. But am I the only one who finds this strange? Your son gives you a sponge bath? Its from the CDC.

How old is too old?

How old is too old?

It seems like at least half of our population in the ER these days is over 80, many into their 90's and even 100. Yup, grandma and grandpa are living a lot longer these days. With age, comes inevitable medical problems. Like heart attacks, strokes.

Its a wondrous medical world these days with sophisticated medication and technology available to extend or save your life. They are expensive too, of course and risky. It forces the question: Should the very elderly be kept alive with technology? Should a 90 year old be intubated? Should a 92 year old get TPA? Should a 89 year old have a AAA repair?

These type of procedures are being done on the very elderly every day. There are times when I am the nurse for a patient who is in their mid 90's and I know that they won't survive, but we go ahead anyway and do all of these interventions. I can't believe what we do sometimes.

Should we be doing it? Is it ethical? Are we willing to pay for expensive interventions for the very elderly as their numbers explode? Get ready for a tax rate of about 50% if it continues as it is now.

We don't deal with death very well in this country. We want to live forever, so as a rule, we don't think about these kinds of situations. We have a hard time even allowing end of life care to be talked about, worrying that their will be "death panels".

We have to decide: Do you or your mom or dad want to be kept alive by machines? Do you or your mom or dad want interventions that are very risky and could lead to worse complications? Those kind of decisions are coming sooner, rather than later.

Saturday, June 02, 2012

the giant red flag

I don't know if this happens in other ERs, but it does in ours. Patients will come in and ask if a specific doctor is there: "Is so and so working today?" "They were just so nice". Hmhmm...okay then.

I had a woman come in who had been there recently and did not get what she wanted. What did she want? I'll give you 3 guesses and the first 2 don't count. She returns because she wanted someone to explain to her why she didn't get it last time. Well, of course nobody was going to come out to the triage desk and have that conversation. She was asked if she wanted to be seen? Yes, but only if she could see a specific doctor...okay that won't be happening either. Turns out that she chose to be seen once again,(I have to admire the optimism here) once again failed in her endeavor.

Moral of the story: If you come into ER and ask for a specific doctor it is a gigantic, humongous, collasal red flag. The end.