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Q:  How did you get so many ER stories?
A:  Good question.  I used to assume that all experienced ER physicians had a repertoire of a few hundred good stories, but I eventually realized that I had far more than my share.  How did I get so "lucky"?  I've spent more than a few sleepless hours wondering about this, and here's what I've come up with:

• Many of the nurses with whom I worked swore that I attracted unusual patients with unusual problems.  I used to believe that such a supposition was statistically unsupportable.  To make a long story short, my faith in statistics is now seriously eroded.
• Most of my time in the ER was spent working the night shift.  Whenever I'd work other shifts, I was struck by how normal the patients were.  If I had to write a book of daytime ER stories, it would be so thin it wouldn't be worth printing.  After midnight, though, I'd often be inundated with one strange case after another.
• Although some people wish to believe otherwise, there are regional differences in behavior.  I have worked in emergency rooms in both rural and urban settings, and the patients in those areas are demonstrably different.  However, it has been my experience that most of the oddball cases come from the suburbs.  Some suburbs are filled with so many wacky people it is a wonder that the government doesn't spike their water with Haldol or some other antipsychotic drug.  As luck would have it, I spent most of my career working in areas that had a high percentage of unusual people who did unusual things, thus giving me a lot to write about.
• I seem to possess a genuine ability to extract latent oddity that other ER docs might gloss over.  For example, a patient with a finger cut casually remarked that he was a cover model for Cosmopolitan magazine.  Most physicians would probably think, "Yeah, right," and just sew up the cut.  But not me.  I pursued the matter and learned he claimed to have a date later on that day with Jackie Onassis, and that Michael Jackson wanted to kill him.  In less than a minute I'd gone from a straightforward ER case to something so odd it could be the top story in the National Enquirer.
• While most of the stories in my book were ones that I experienced, several were contributed by my colleagues—for which I am eternally grateful.

Q: Why have some of the contributors to your book insisted upon anonymity?
A: Probably because they’re afraid of retaliation by their employers, who don’t like to have light shed upon some of the things that occur in hospitals. I think that hospital administrators are primarily afraid of how the public might react if they knew how much of their money is being wasted on cases that are really nothing more than shams. I also think that administrators are attempting to impose an overzealous and lofty standard of professionalism. One need only look at the termination of ER nurse Darva Conger (of Who Wants to Marry a Multimillionaire? fame) to realize that healthcare workers can be whimsically dismissed for engaging in extracurricular activities that are entirely legal but, for one reason or another, rub some administrator the wrong way.

Q:  What do you think of the television show ER?  Is it realistic?
A:  I don't watch it very often.  It's more realistic than medical shows of the past, but it has a long way to go to achieve true realism.  Achieving medical realism on a TV show, I realize, is a challenge.  However, there is much they could do to capture more of the essence of life in a real ER.  Their writers seem to be stuck in a rut, and I'm bored by their minor variations on the same theme.

Q: What about the new* show, City of Angels?
A: From what little I’ve seen of it, I’ve been put off by the fact that it seems to be filled with too much intensity, rage, and stereotyping. In short, it’s a wildly inaccurate depiction of what really goes on in hospitals. (*It was new when I originally posted this, but it was canceled years ago.)

Q: What do you think of Grey's Anatomy?
A: First, I think the name itself is a double-entendre with a simultaneous allusion to Gray's Anatomy (the venerable medical text) and to the anatomy of the show's protagonist, Dr. Meredith Grey, whose attractive body ends up in bed with a surprising number of men, thanks to her perennial angst and penchant for booze. As the series evolved over the first few years, the focus shifted from Dr. Grey to other cast members with more pulchritude, most notably Dr. Isobel "Izzie" Stevens (Katherine Heigl).

From what I've read, the producers of Grey's Anatomy attribute its success to its medical realism. While a few aspects of the show are indeed realistic, it is primarily just a soap opera with a medical theme. I think its writers are running out of good ideas, because lately some of the content has been decidedly less realistic than typical soap operas. In fact, I have repeatedly wondered if the show's medical advisers are being held hostage somewhere because Grey's Anatomy is so incredibly unrealistic that it grates on my sensibilities as a doctor. I am not alone. Dr. Orin Guidry, President of the American Society of Anesthesiologists, sent a letter to Peter Horton, Co-Executive Producer and Director of Grey’s Anatomy, complaining about the number of factual errors in the show. I could literally write a book describing everything about the show that is unrealistic. The producers and writers of Grey's Anatomy obviously believe that this unrealistic material is more intriguing than what happens in the real world. I disagree. If the writers of Grey's Anatomy read my True Emergency Room Stories and Love & Lust in the ER (the latter is a free download), they would find lots of "it really happened" fodder that is more captivating than their fiction (note to the producers of Grey's Anatomy: Don't try taking my story ideas without compensation). As I proved in my books, stories can be real and yet spellbinding. Truth is stranger than fiction any day.

Q: Do you believe that the television shows have overglamorized what it’s like to work in an emergency room?
A: Definitely. 98% of what we do in the ER is fairly dull and repetitious, and 2% is exciting. Naturally, they show the glamorous 2%.

Q:  Is it ethical to write stories about patients?
A:  Apparently so, given that I'm hardly the first doctor to do this.  Clearly, it would be unethical to mention a patient's true name—which I never do.

Q:  Are you worried that any of the patients you mentioned in your book will recognize themselves, get mad, and try to kill you?
A:  I'm not very worried, for the simple reason that most of the patients whom I depicted in an unfavorable (but accurate) light are people who likely do not spend much time reading books.

Q:  What inspired you to become an author?
A:  I like to write.  In the case of the ER stories, I noticed that there aren't many other books available written by ER physicians, and even those books are somewhat constrained in their range of stories.  I decided to inject an ounce of realism into the literary world.

Q:  I want to be an ER doctor—and not just any ER doc, either.  I want my colleagues to think that I'm topnotch and a real star.  Any tips?
A:  Certainly.  First, you must understand that the competency of an ER physician is often viewed as being proportional to the speed with which he can move patient charts into the discharge bin.  You know, treat 'em and street 'em.  However, the primary stumbling block to achieving this goal is that patients often present with more than one problem.  You won't be getting any bonus points or gold stars for attending to these other problems.  In medical school you will be taught that you should listen to your patients.  This is utter nonsense.  If you listen to your patients you might actually discover an important medical problem which needs therapy.  However, dealing with this problem will slow you down, and you will not be a star.  You have to ask yourself what is more important:  being a hotshot ER doc or not sending scores of people to an early grave?  If you answered the latter, you obviously don't have "The Right Stuff."

To achieve your goal of moving on to the next patient as rapidly as possible, you must not make the mistake of performing a complete examination.  Years ago, I knew an ER resident who was viewed as being a star.  How did she achieve this?  By omitting totally superfluous components of the exam.  For example, one patient presented to the ER with a gunshot wound to his leg.  Little Miss Star did not check distal neurovascular function, since she knew that checking pulses, strength, and sensation are trivial matters and would only slow her down, thus tarnishing her stellar reputation.  Instead, Little Miss Star scribbled on the chart that the patient had a "left leg gunshot wound."  This was both the history and the physical exam . . . and the diagnosis.  See how brilliant she is?  Yes, it takes years of training to achieve such acumen.  Mere mortals, like us, would probably spend from now until eternity figuring out that the patient had a gunshot wound in his left leg.  The pen with which she reached such a penetrating observation is now on display in the National Archives.

The bottom line is this:  speed is paramount, and thoroughness is irrelevant.  We live in a culture which glorifies speed and those who achieve it.  Patients are simply obstacles in your path, and the sooner you learn to give them short shrift, the better your reputation will be.  The patients, or your reputation?  It is not a difficult decision.  The history books, Hollywood, and the Nobel Prize Committee are waiting for your answer.  Do not disappoint them.

(A second-year medical student wrote to me asking for advice on how he could impress his ER attendings (supervising physicians) enough to obtain an ER residency position.  In my response to him, I forwarded the above paragraph, then continued.)  Obviously, I was being facetious (although one ER doc literally interpreted my tongue-in-cheek comments . . . leading me to wonder if he's manifesting incipient Alzheimer's disease). However, like most humor, it is based on truth. Little Miss Star really exists, and her amazingly superficial exams truly did impress her attendings. The impetus to "treat 'em and street 'em" is often joked about, but it's SOP (standard operating procedure) for many ER docs. I could give you hundreds of other examples of patients being given short shrift, from an ER doc who failed to detect a severed digital nerve because he thought all was A-OK because the patient could move his fingers, to my brother who was almost paralyzed from a vitamin B-12 deficiency which four docs, two of whom evidently didn't think that physical exams are a worthwhile expenditure of time, misdiagnosed as carpal tunnel disease. That was a nightmare for our family, so I'm a bit touchy about this subject of glaringly superficial exams, and it grinds me that the docs who habitually engage in such practices can be revered instead of reviled. Notwithstanding my personal feelings, the fact remains that speed in emergency medicine is glorified, often even when it is at the expense of accuracy and thoroughness. I don't live in a dream world, and I know that because of time constraints it isn't always feasible to not cut corners in a busy ER. Yet I've seen too many cases in which ER docs are superficial even when time is not an issue. I've heard a couple docs attempt to justify this practice by saying it's the only way for them to keep "in the groove" for speed -- presumably, if they ever did a complete exam, they fear they'd somehow forget how to cut corners. It may be too much to expect a rat navigating a maze to possess a repertoire of behaviors to adapt to changing circumstances, but is it really too much to ask a physician to do this? I don't think so, but a distressingly large number of docs think speed trumps all in the ER. Hence, if you wish to impress your attendings, find out what yardstick they're using. If it's "speed is #1," you have a tough choice:  do you give them what they want (and thereby give patients the short end of the stick), or do you forgo speed for the sake of speed? Do that, and you probably won't become an ER doc -- and thereby won't become someone who might work to change our wacky system in the future. Tough choice? You bet. I'd continue this exegesis, but I haven't had enough coffee today.

Q:  What was one of the most bizarre injuries you've seen?
A:  A 20-year-old woman presented with a perfectly circular cut around one of her nipples.  Initially, she professed to have no knowledge of how the injury occurred, which I felt was a bit less likely than impossible.  Eventually she admitted that she had inserted her nipple into the end of her vacuum cleaner hose so as to make the nipple swell up.  She did this because she was on her way to the beach.  As everyone knows, engorged nipples are one of the requisite accouterments to the augmentation of intersexual appeal.  Without it, a day at the beach just wouldn't be the same.

Q:  Would a vacuum cleaner really make nipples larger?
A:  I've been too busy lately to spend much time enlarging my nipples, so I can't give you a definite answer.  The maximal vacuum produced by different vacuum cleaners varies widely, but I doubt that any standard vacuum cleaner would have enough suction to induce much enlargement.  However, I do know that vacuum pumps can create a vacuum sufficient to produce a substantial enlargement.  In fact, one company makes vacuum chambers specifically for this purpose.  For those who are especially adventurous, they also offer a vacuum chamber for enlarging the entire breast.  First, the good news:  it actually works.  Now the bad news:  the effect is temporary.  You'll probably outlast Cinderella and make it past midnight, but 95% of your gains will have dissipated by the next day.  We live in a cruel world.

UPDATE:  In The Science of Sex, I discuss some techniques that produce permanent breast enlargement without surgery.

Q:  Where did you learn all this stuff?
A:  One of the benefits of being an ER physician is that you get to meet a wide variety of people, some of whom engage in occupations in which the enlargement of certain body parts is critical to their success.  Perhaps not surprisingly, these folks tend to be rather outgoing, and their loquacity has given me information that I could never find in any medical text.

Q:  What was the strangest thing you've ever heard about as an ER doctor?
A:  Given that a significant percentage of ER cases would merit being termed "bizarre" in anyone's vocabulary, asking me which is the strangest case is like asking Bill Clinton who was his favorite extramarital sexual partner—with so many to choose from, how can you tell?  It's a tough choice, but here is one that stands little chance of being published in the Reader's Digest:

Carl returned from a week-long business trip late Friday night.  As he was wont to do, he stopped by a bar on his way home and got totally blitzed.  He staggered home and collapsed next to his wife in bed, quickly falling asleep.  When Carl awoke in the morning he felt extremely nauseated and he ran into his bathroom and vomited a few times.  Initially, he assumed that the nausea was merely the result of his alcoholic binge the prior night.  However, when Carl returned to his bedroom he was overcome by the fetid smell which permeated the air.  He massaged his wife's shoulder to wake her up so he could discuss this with her, but she wouldn't wake up.  She was dead, and had been decaying in bed for a few days.

Q:  How about something less likely to cause nightmares?
A:  OK, I'll give you a heart attack story . . . but not just any heart attack story.  In reading other books of this genre, I've learned that many authors are overly impressed with heart attack cases, believing them to be the sine qua non of a good book of ER stories.  In my opinion, there are only so many interesting ways in which a coronary artery can clot off.  After I've read, "He's in v-fib, Jimbo!  I'll shock him with 200 Joules!  Everybody clear!" in one story, I need an intravenous infusion of caffeine to keep awake through the next one.  Consequently, the only heart attack stories which made it into my book were ones that have some unusual twist to them.  I won't bother repeating the stories in the other parts of this book (which are far more interesting than this one), but I will mention one that should intrigue readers with a medical background.  I had a young police officer as a patient who suffered an MI (myocardial infarction, or heart attack) when he was shot in the chest while wearing  Kevlar body armor.  The bullet didn't penetrate the vest, but the impact hammered the anterior (front) wall of his heart with enough force to severely damage it.  He survived, but he had the heart of an 88-year-old cardiac cripple.  It's like aging 60 years in a split-second.

Q:  Have you ever done anything in the ER that you regret?
A:  Yes.  I had a teenager whose face had been severely mangled in an accident.  Despite the numerous cuts, I could tell that she was stunningly attractive, and I felt it was my duty to do everything I could to restore as much of that beauty as possible.  I regret that I did the surgery myself, instead of calling in a plastic surgeon.  While I think I'm more skilled than an average ER physician in such repairs, I've since been haunted by the knowledge that the plastic surgeon may very well have done a better job.  On the other hand, I had another young lady with a similar injury be so grateful to me for her virtually perfect result that she gave me all sorts of free stuff.  As it turned out, the merchandise didn't belong to her, but that's another story.

Q:  Any other regrets?
A:  Now that you mention it, yes.  A young woman once told me that something happened to her when she had been with a friend of her father.  After she said this, she clammed up.  I had no idea of what the problem may have been until a few years later when I read several news reports about one of the unusual customs of a particular religion:  namely, fathers lending their daughters to their male friends as sexual concubines.  I was shocked that such a practice could continue in this country, but it happens every day.  How could any father—let alone one who professes to be devoutly religious—allow that to happen to his daughter?  I don't know.  In any event, I regret not being worldly enough to consider the possibility that she was being sexually abused.

Q:  Any more regrets?
A:  Yes, not shooting a certain resident under my tutelage.  I used to work as an attending ER physician in a teaching hospital, where one of my responsibilities was teaching residents in the ER.  One day, one of the residents was suturing a patient's laceration without using any sterile field.  Instead, he was just dragging the suture across the stretcher—which is hardly sterile.  When I admonished him for this, he told me that it "didn't matter."  On the contrary, it did matter, and he was the first physician educated since the Germ Theory of Disease was accepted as fact in the 1880s to asseverate that the introduction of germs into wounds was inconsequential.  While he should have learned sterile technique in medical school, I was not upset merely because his position was ludicrously untenable.  What bothered me is that this Texas dude had the gall to tell me that he was just going to keep on doing what he'd been doing.  Thus, he was not merely ignorant, he was stupid.  To save untold thousands of future patients from being victimized by this idiot, I should have pulled out my pistol and erased everything north of his eyebrows.

Q:  Do you have any nominations for the Darwin Awards?
A:  Naturally, but first a brief word of introduction for the uninitiated.  Charles Darwin was the originator of the modern concept of evolution, which holds that individuals with the most adaptive traits are the most likely to survive and pass their genes on to subsequent generations.  In a nutshell, it's survival of the fittest.  Darwin, who dropped out of medical school, apparently gave little thought as to how his theory of evolution may have applied to his personal life.  Darwin married his first cousin and had ten children, three of whom died in infancy.

The Darwin Awards are an extrapolation of Darwin's theory that superior individuals are the most apt to survive, and inferior individuals are the least apt to survive.  As such, the Darwin Awards are essentially Emmys for idiocy.  In other words, people who are too stupid to live usually have abbreviated life spans.  Other than frolicking in the sack with his cousin, Darwin was a politically correct man a century before anyone gave serious thought as to how to euphemize thought control.  Consequently, Darwin did not conceive of the Darwin Awards.  Credit for that must go to the person who realized that natural laws never seem to lose their relevance.

Without further ado, here are a few nominations for the Darwin Awards:

• It's after midnight during a raging blizzard.  Most folks with brains are nestled into a cozy bed, but not Derek.  Attending to one of those pressing tasks which often face unemployed people at 2 a.m., Derek was walking down the middle of a five-lane road while wearing dark clothes.  You can guess what happened to him.
• Josh was sucking on the end of an ink pen while listening to music (and you think your life is boring??).  Ink came out of the pen and coated the inside of his mouth a nice Bic® blue.  As Josh inspected the inside of his mouth by looking into a mirror, he panicked because he had a date later in the evening and he doubted that his Smurf-tinged mouth would harmonize with his macho image.  Ah, such an ill-starred inconcinnity!  He tried rinsing his mouth with water, but Bic® ink is not very soluble in water.  He tried sloshing around a mixture of detergent and water, but even that didn't work.  He knew that gasoline dissolved ink, because he'd previously used it to dissolve ink stains on his clothes.  Gasoline is toxic, and he knew that, but he had no intention of swallowing it.  Nah, he'd just swish it around and spit it out.  Guess what?  It worked!  Josh was so relieved that he sat down to have a cigarette, apparently forgetting that gas vapor is explosive.
• Ed had a number of hobbies, which ranged from gardening to making pipe bombs.  Other than an occasional insect bite, he never got into much trouble with the former hobby.  His affinity for explosives was another matter.  After making a bomb one day, Ed was miffed that the darn thing wouldn't explode.  He didn't want to waste the expensive gunpowder in the bomb, so he decided to salvage it by cutting the pipe open to pour out the powder.  As he was doing this, he discovered that his bomb wasn't a dud after all.
• A man with an affinity for kitchen utensils presented to the ER after he underestimated the depth of his blender in comparison to the length of his penis.  He either had incredibly quick reflexes, or his withdrawal was expedited by the pain of being whacked by a blade tine spinning at 22,000 rpm, because his injuries were surprisingly minor.  He justified this activity by saying that he didn't have a girlfriend—and apparently no Vaseline, either.  Although I was not particularly interested in hearing more, he explained that the sensory delights of the swirling peaches was simply irresistible.

Q:  I'm an ER resident, and I'll soon be graduating and starting to work at a new hospital.  I've noticed that the relationship between ER doctors and the hospital administration is often strained.  Any tips on how I can best harmonize with them?
A:  Of course.  For starters, you might want to avoid writing an exposé such as this.  The hospital brass takes a pretty dim view of anything that might interfere with their cash cow.  For example, one of the patients I mentioned elsewhere in this book was injured when she fell through a glass table at the home of the town's richest man, who was a longtime benefactor of the hospital.  The woman was rather inebriated, as you might imagine.  She was married, too, but her husband wasn't with her.  Does the word "scandal" come to mind?

Within a few seconds of her hitting the door, she was in what could be best described as a catfight with one of the nurses.  I knew that I'd have to be the one to take care of her injury, and I didn't want an angry patient to work on, so I intervened.  I think I was a bit too nice, because the patient was fondling my genitals less than an hour later.  I'll leave the remaining details for you to explore as you read that story or, should you choose to skip it, to your imagination.

When the administration found out that I was going to write about this (even though I didn't include any names), they threw a conniption fit.  Hospital administrators are not ardent supporters of the First Amendment, I've learned.
 

Q:  Why is there sometimes an adversarial relationship between doctors and nurses?
A:  Apart from the potential personality conflicts which can develop in any workplace setting, I think that there are a few primary causes of this tension, such as:

• Some physicians still think they are either God, or God's Right Hand Man, and everyone else is a member of an inferior species.  This delusion is far less common than it once was, but a few physicians find that by clinging to this fantasy they can maintain their self-esteem at an unjustifiable high.  While some doctors do help people, many doctors just pass out pills to people that they would be better off avoiding.
  
• Some nurses have an overblown sense of how much they know.  I have had the pleasure of working with some truly excellent and knowledgeable nurses, but I've also worked with nurses who like to think that they know more than the doctors.  I have yet to meet a nurse who could do something as basic as a complete interpretation of a 12-lead EKG (not just spotting an obvious MI), so I'm not sure what objective basis they have for thinking that they know more than doctors.  In my opinion, the greatest value of a good nurse is his or her clinical judgement and experience, not their ability to match wits with a doctor on a test of medical knowledge.
  
• (Warning:  don't read this section if you are convinced there are no differences in the way men and women think.)  Most doctors are men and most nurses are women. I’m certainly not the first person to think that men and women have very different ways of viewing the world. I used to think I could treat women that I worked with the same way I treated co-workers who were men, but my boss didn’t agree. He took me into his office and, in a very avuncular way, informed me that he had learned through the School of Hard Knocks how to best harmonize with nurses. Basically, he told me to treat them with kid gloves—to baby them, in other words. He said that women are often fueled more by their emotions than they are by logic.

  My first reaction was that this was a very condescending and sexist attitude, but I eventually learned that there is some merit in his message. If you’re already taking umbrage at its apparent offensiveness, you’re just proving the point that your emotions reign over your logic. It’s politically incorrect, but it is true, and it is one of the delicious distinctions that make men and women different. Our brains are different, our emotions are different, and our neurochemistry is different. Frankly, the emotional softness of women is one of the things that men find appealing—and vexing, too. In the workplace, this dichotomy of mindsets creates friction between the sexes. Men can’t understand why women cannot see things with more logic and less emotion, especially in view of the fact that emotion is often a comparatively superfluous ingredient in the success of running a life-and-death business such as an emergency room.

  Let’s briefly consider the case I presented in the book in which one of the nurses I worked with almost had a nervous breakdown after I calmly mentioned to her that she should do her own patient assessments and not rely upon the diagnosis rendered by a security guard. Not surprisingly, the security guard’s diagnosis was dead wrong. What was surprising to me was that this nurse—who was actually a bright person and was otherwise a decidedly above-average nurse—would blindly accept the conclusion of the guard without doing her own assessment. And this was no minor error, either: the patient in question had suffered a cardiac arrest, and every second in which the nurse was behaving as if this was no big deal just brought the patient that much closer to death or permanent brain injury.

  As luck would have it, I happened to be near the hall that connected the ER to the waiting room, where the patient had collapsed.

  Nurse: (seeing me approaching) It’s a seizure.

  Dr. Pezzi: (thinking, yeah, and I’ve got Nikki Cox begging me for a date, too) Does she have a pulse?

  Nurse: I don’t know, I didn’t check. The guard said she had a seizure. He said she twitched.

  Dr. Pezzi: (checking for a pulse and breathing) She’s not breathing, and she doesn’t have a pulse. Let’s start CPR.

  I grabbed the defibrillator, used its "quick look" paddles* to read her cardiac rhythm (ventricular fibrillation), then I shocked her and restored a normal rhythm. She was given some additional treatment in the ER, then transferred to the CCU. Afterward, I mentioned to this nurse (who was a friend of mine) that she should do her own assessments and not rely upon the conclusions of a guard or other nonprofessional. I also mentioned that a patient may jerk if he passed out because his heart stopped beating. This is sometimes misinterpreted as a seizure by some people (and I thought, ahem, lay people).

  * Most defibrillators do more than just deliver shocks. The same paddles that carry the jolt of electricity to the patient can also be used to pick up the electrical activity of the heart (as does an EKG machine) and display it on a monitor built into the defibrillator.

  I thought my interaction with the nurse in this case was rather straightforward. I passed along the above tidbit and asked her to do her own assessments. Big deal, right? The nurse didn’t think so. She went on a crying jag for hours, pouted for the next few weeks, then quit working in the ER.

  Sheesh! If she were a medical student or resident and had made a comparable mistake, one of her supervisors would have ripped her apart. Rather than placidly discussing it as I did, most of them would have peppered their diatribe with incandescent invective. Doctors often become incensed when they think patients have received substandard treatment, and they usually aren’t shy in relaying their opinions. Contrary to what most nurses think, doctors in general are much harder on their colleagues than they are on nurses. The worst upbraiding I’ve ever seen directed at a nurse by a physician was a mere slap on the wrist compared with the lashing that docs sometimes unload upon one another. I know of cases in which physicians, probably overwrought with compunction, thought this was too much to bear so they committed suicide. The most dramatic case was when a resident walked over to a hospital window and jumped out, splattering himself on the sidewalk several stories below. A less tragic but still newsworthy case occurred when Doc A, after a heated discussion with Doc B, chased him for over an hour on the freeway to continue the argument in Doc B’s driveway.

  So why all the acrimony? The answer is obvious: people’s lives are at stake. With so much on the line, it is understandable that tempers will occasionally flare. Physicians are typically very anal, perfectionistic people, and nurses sometimes mistake this perfectionism as arrogance, especially when a doc lets a nurse know that he isn’t satisfied with something the nurse was doing. Yes, there are doctors who are truly arrogant, but this is more common in the old-timers. In all my years in medicine, I’ve seen only a handful of docs who deserved to be called arrogant. However, nurses bandy about the term "arrogant" so often that I think they’re taught a definition of it in nursing school that isn’t in the dictionary. All the whining and moaning by nurses about this subject has done nothing except create an unwarranted stereotype.

  As is the case with most stereotypes, there is some collateral damage that accompanies the rhetoric. Seeking to minimize the risk of their being labeled "arrogant" or abrasive, docs often turn their intensity back a couple of notches. Is that good? Not in my book. How much more laid back can we be without being mute and turning the farm over to the nurses? When I spoke to the nurse mentioned above, I did so as if she were a beloved sister, yet she came unglued. I suppose the only way I could have gotten along with her was to sycophantically tell her she was right even when she was wrong just so that she could maintain her self-image at an unjustifiable high, or I could have just ignored her error altogether. However, if it was your mother who was the patient, I think you’d implicitly expect the doc to not let such a potentially devastating error slide by as if it were less important than a batch of bad fries at McDonald’s.

  Some physicians resent this need to curry favor with nurses by treating them as if their actions were beyond reproach. In my own career, I became so disgusted by this petulant "treat me with kid gloves or I’ll scream" attitude that I eventually gave up and ignored all kinds of errors. I’m not proud of how I abandoned my standard of perfectionism, but I’m certainly not the first person in the world to relinquish my standards just to keep on getting a paycheck.

  Collectively, nurses have done a great job convincing the public that nurses care more about patients than doctors do. That’s just a lot of hogwash, but I see nurses patting themselves on the back all the time as they relish in this self-serving deception. Sure, nurses talk the talk, but do they walk the walk? If they’re so caring, then why are they giving docs such a hard time about delivering the perfect care that patients deserve?

  Fortunately, not all nurses are this way. Some of them are dedicated, bright, caring, and diligent people who do a wonderful job and are a pleasure to work with. I’ve worked in emergency rooms in which the majority of the nurses were topnotch, yet I’ve also worked in places in which most of them were bad apples. In those latter facilities it could be that the bad attitude of a few spread like a cancer to infect the others.

  Some of the battles that I fought with nurses were unimaginable. There was one nurse, for instance, who evidently had no conception of a sterile field. He would routinely touch something in the sterile tray that was holding the instruments I was using to suture a patient’s cut. I reminded him umpteen times that he couldn’t touch anything that was sterile with his unwashed, ungloved hands, and he’d just argue with me—in front of the patient, nonetheless—that what he was doing was OK.

  How can such an idiot be allowed to work in an ER, or even a dog kennel for that matter? The answer is simple: doctors do not run most emergency rooms. Nurses are fond of saying that they run the ER, and the docs just work there. In most hospitals, that’s true. The ER director is usually a nurse who is employed by the hospital, and the ER docs are usually a group of independent contractors who have virtually no say in hiring or firing decisions. I think this is ridiculous. In general, it’s a good idea for those who have the ultimate responsibility to be given the tools and power they need to get the job done right. Physicians are under a lot of pressure—from patients, state medical boards, hospital committees, lawyers, and ultimately from themselves—to ensure that every patient receives optimal treatment. I think physicians resent being subjected to this pressure without having control over some of the variables. For example, one of the nurses I worked with for three years had Alzheimer’s disease. The nurse in charge of the ER, Sally, wouldn’t fire her because she’d been there a long time (no kidding!) and needed the paycheck. So who cares if she is one of the gang and needs money—who doesn’t?

  This is obviously an extreme example that illustrates how the decisions of some women are based more upon emotion than logic. Would most women who are head nurses make a similar mistake? Certainly not. However, after having worked with both sexes, I believe that women are more likely than men to let emotions cloud their thinking. To get back to the original point of this discussion, I think this different way of viewing the world contributes to an adversarial relationship because neither sex can entirely understand what the other is thinking.

  Believe it or not, but I'm not anti-nurse, nor are most doctors.  Physicians are generally appreciative of the work performed by nurses and we give respect when it's due.  Personally, I can think of several nurses that I hold in such high esteem that I think their faces should be chiseled into Mount Rushmore alongside those of Presidents Washington, Jefferson, Roosevelt, and Lincoln.

  Q:  Where in the hospital do you have sex with the nurses?
  A:  It's funny how often I'm asked that question during radio interviews, given that I never mentioned this in my book.  Had I ever done it, I surely would have mentioned it—as they say, sex sells.  The myth of nurses as being hot, young nymphomaniacs is just that:  a myth.

  Oh, but there are exceptions.  In fairness to the woman whose reputation I am about to trash, the following information was provided to me courtesy of a resident who was either a very lucky man, or someone with a real knack for shameless self-aggrandizement.  It's tough to fool an ER doc, but it's possible.

  On to the vicious rumors.  This Internal Medicine resident, who I'll call Pablo, claimed that he and scads of other doctors had intercourse with this CCU nurse, unfettered by any pretext of love.  She was, he claimed, just out to snag a doctor as a husband, and they were just after The Big O.

  I almost gave ol' Pablo a knuckle sandwich when he referred to her as "a whore."  Even if she did have premarital sex, that did not necessarily make her into a prostitute.  Besides, I had a crush on her and, to tell the truth, I still do.  Lisa was without question the most beautiful woman I've ever seen, and from my interactions with her (she'd often moonlight in the ER) she was always a lady.  I had an overwhelming urge to ask her out, but I'm shy.  No, really, I am.

  Anyway, to hear Pablo tell the rest of his sordid tale, Lisa never found a doctor to marry so she gave up trying, married a fellow CCU nurse, Chuck, and moved away.  Broke my heart.

  One of the perks of being an ER attending is that we get to grade residents whenever they do their stint in the ER.  After the thrashing I gave Pablo, I'd bet he's now repairing potholes on a road crew somewhere in Nicaragua.  He should have known that it's not wise to disparage the woman a man loves.

  Q:  Do doctors really know more about sex?
  A:  This is like asking if a plumber really knows more about your water pipes or faucet—of course he knows more.  However, when people ask this question I don't think they're referring to the relatively boring science of reproduction.  Instead, I believe they are asking if doctors know more juicy tips about enhancing sexual performance and pleasure.  In that regard, most physicians are as lost as the next guy.  Eager for vicarious pleasure wherever I can find it, I have devoted years of diligent research to this topic, which is covered in Chapter 11 of my book Fascinating Health Secrets, and in far more detail in The Science of Sex: Enhancing Sexual Pleasure, Performance, Attraction, and Desire.  One of my colleagues, a gynecologist (and you'd think he'd already be an expert in such matters, wouldn't you?), was absolutely mesmerized by that material.

  Q:  Did you ever date a nurse?
  A:  OK, now you get me to fess up!  Hmmm, let me think . . . three nurses, I believe.  'Nuff said.

  Q:  Come on, Doc, can't you give us any juicy details?
  A:  OK, you talked me into it.  So as not to steal the thunder from my chapter on sex, I won't give any of the more licentious stories here, but I will mention one that I couldn't seem to fit in elsewhere.  Years ago, as I was at the home of a nurse whom I was dating, we were talking while sitting on her couch.  She was either incredibly attracted to me, or she found my conversation less than riveting, because she said, totally out of the blue, "Oh, Kevin, shut up and make love to me."  Now there's a comment that only a woman can get away with.

  Q:  But you didn't marry her, did you?
  A:  Pass up a woman with that eloquence?  What, are you kidding?  Tempting as it may have been, I somehow drew upon heretofore untapped reserves of personal fortitude and tore myself away from her.  The problem was not her lack of a silver tongue, as you might imagine.  Instead, it was something that's a bit less easy to overlook.  Early on in our relationship she warned me that once she began to love me she would pull away and turn cold as ice.  Piffle, I thought, no one could be that warped.  Well, I was wrong, and I was forced to renounce my claim to fame as a budding psychoanalytic guru.

  Q:  Did you ever really date a patient?
  A:  Given that I am a summa cum laude graduate of the William Jefferson Clinton School of Speech Obfuscation, you may wish to carefully parse the following answer:  I have never had sex with a patient.  And, to set the record straight, I have never had sex with "that woman, Miss Lewinsky."

  Q:  Did you ever date anyone who read your books?
  A:  How the heck did you find out?  Well, now that the cat is out of the bag, I might as well fill you in on the details.  A woman who read my first book (Fascinating Health Secrets) wrote to me saying how much she liked the book.  After a year or so, we met and . . . well, I knew that she'd really read my book, especially parts of Chapter 11.  I was impressed.

  Q:  So, are you married?
  A:  Nope.  I'm in a hurry to get married, but she was in such a rush to get married that it spooked even me.  Hard to believe, I know, but it's true.

  Several people have asked me why I'm not married.  Here's my answer:  During my years of training, I incorrectly assumed that I would easily find a compatible mate once I entered the real world and began some semblance of a normal life.  Boy, was I wrong!  I knew and dated some perfectly normal and desirable people in high school, college, and medical school.  However, as the years went by there was less and less time to truly interact with people in general and my girlfriends in particular.  Our dates degenerated into sessions in which they would be in the same room as me when I studied.  How exciting!  Eventually, I broke up with them because I felt that our relationships existed only because my partners had an unusually high degree of tolerance for being ignored.  It was not that I didn't want to give them more attention—I simply didn't have the time.  To this day I have no idea why they stuck with me for years.

  After I resumed dating following my training, it did not take me long to realize something that I should have been able to deduce long ago—namely, that there are not many 28-year-old "good catches" remaining single.  You really have to wonder about someone with an expressed intention to commit to someone and eventually marry, if she is still single a decade after high school!  If she has a good reason for this, such as being highly devoted to her work, there is a slightly better chance that she will be normal.  Even then, the chance is slim.  Of all the women I have dated after residency, only two were normal by my definition.  The others possessed a variety of insurmountable character flaws.  Two of them would almost force alcoholic drinks upon me as soon as I would walk in the door, even if I came over in the afternoon.  One of them did it trying to get me in bed.  Isn't this the stereotype of what men are supposed to do?  The other one did it for reasons that I still can't discern; perhaps she was an alcoholic and simply wished to recruit me to her way of life.  Thanks, I'll pass.  A couple of the others wanted to sleep with me, but were reluctant to kiss or hug.  When I asked them about this, they said that kissing and hugging were something special that they would do only if they were very close to someone.  Isn't this putting the cart before the horse?

  Q:  On your web site you answer questions submitted by people.  Is there any question you haven't answered?
  A:  Just one.  A man wrote to me asking what drugs he could give to a woman to knock her out so that he could have sex with her and she'd have no memory of the event.  He claimed that he was an author and was merely doing research for a book he was writing.  Yeah, right.  What really spooked me about this guy was that he was so eager for me to give him very detailed information, such as the exact dose to use and what he could do if he gave too much and the woman had an adverse outcome, such as lapsing into a coma.  This kind of thing is not only sick, but wholly unnecessary.  Since when is it so difficult to find a sexual partner?  My eloquent brother, Ray, once quipped, "Kevin, women want it more than you do."  In any event, I didn't answer his question because I was afraid that the knowledge might be used to victimize some woman.  Even if he were an author, I was afraid of the consequences of disseminating this information.

  I received a somewhat similar question from another person that I decided to answer for no other reason than I happened to be in an unusually voluble mood that day.  He asked me if . . . ah, why paraphrase it?  I'll let him stick his foot in his own mouth.

  Q:  One of my buddies claims that he heard the government is working on an electronic device that can make people do things they wouldn't ordinarily do by suppressing the area of the brain involved in self-restraint.  Have you heard of this and, if so, can you tell me how to make one?  Would it be possible to use this device on women?
  A:  Thank you for restoring my faith in humanity.  When I was a teenager it was de rigueur to procure the sexual favors of a woman by plying her with a chemical that would achieve the same effect, most typically Boone's Farm Strawberry Hill wine.  It is heartening to learn that people are finally taking the moral high ground on this issue and are in search of healthier ways of achieving mind control.  By the way, if you had any idea of how often I've had sex in the past decade you would not be asking me for tips on seduction—it's like asking a homeless person for the latest hot tips about stocks on Wall Street.  But if Dear Abby can dispense advice about romance, I suppose I can spout off on this subject.

  To begin with, the notion of using an electronic device to influence behavior is not as wacky as it may sound.  There are many drugs (both prescription and nonprescription) that can influence thought to varying degrees, and even certain foods and spices can modify cognition and perception.  Nevertheless, these effects are notoriously nonselective, so sending Janine Turner a gift-wrapped container of nutmeg or ginger will not make your lifelong fantasies come true.  In the future, drugs with far more specific actions will be developed.  Until then, you might want to try a dating service.

  Drugs which influence thought achieve their effects by altering neurotransmission, the process of communication between nerve cells.  While it is possible to use electricity to influence thought, this effect is very nonselective—unless you can somehow finagle a way to directly apply electrodes to the surface of her brain without your date noticing it.  But hey, television remote controls were once a pipe dream, and now they're practically an appendage on the right arm of every man.  To the best of my knowledge, though, no one knows how to substantially alter thought using an inductive (non-contact) device.  Otherwise, the authors from electronics hobbyist magazines would be tripping over the cords of their soldering irons in their haste to build such a gizmo.

  Lest you go away with a heavy heart, thinking that scientists have neglected your love life, I can brighten your day by filling you in on some useful tips.  First, a caveat:  you try any of this stuff on my cousins, and I'm coming after you.

  Tip #1:  Buy a bottle of Realm® cologne.  I won't cover this topic in detail here since I tell you more than you ever wanted to know elsewhere on my web site, but I will mention that Realm® contains a pheromone which can have a favorable effect on people around you.  Just hope they attribute this bliss to you, instead of the decor of your surroundings.  If you're studying for a doctoral degree in biochemistry, or if you're desperate for some action this weekend, you may also want to bone up on the pragmatic aspects of how the MHC genes influence your success in dating.  In my web site I discuss some clever ways of how you can exploit this information to outwit Mother Nature.

  Tip #2:  Behavioral scientists, probably bored silly by years of watching rats navigate through mazes, have recently broadened their studies.  Their latest and greatest coup is the discovery that the sexual pump can be primed, so to speak, by scaring the bejesus out of your prospective partner.  To be effective, however, this activity must be socially acceptable, such as a ride on a roller coaster.  Showing her your extensive collection of Soldier of Fortune magazines probably won't work unless you're lucky enough to be dating Carol Howe.

  Q:  Any other strange requests?
  A:  Yes.  I received a call from a woman who read my first ER book and thought she might be interested in me.  Coincidentally, I'd seen her on television.  She was a guest on America's most notoriously trashy talk show (I'd just moved into a new house, and before I installed an antenna this was the only station I could receive).  She said that she had worn a wig on the show to disguise her appearance.  Who could blame her?  Anyone who appears on that show is almost a de facto inductee into the Hall of Fame for Freaks.  She went on to say that she was bisexual, and she wanted to know if that bothered me.  She also explained that her sexual predilections hadn't dissuaded the host of the show who, she claimed, invited her out for drinks in a very transparent effort to seduce her.  So the rumors about him are apparently true.

  Q:  As an emergency nurse, it seems to me that we are seeing more psychiatric patients in the ER than we did many years ago.  Is the prevalence of mental illness increasing?  If so, why?
  A:  I think that mental illness is indeed more prevalent than it was in the past.  While there are many reasons for this increase, I'll mention a few of the factors which seem to have been glossed over:

  • In the United States and other countries, many mentally ill people were once prevented from reproducing by measures that would now be generally considered draconian, such as sterilization and sequestration.  While not all mental illnesses are inheritable, some do have a genetic component.  Consequently, when mentally ill people reproduce they are more likely, on average, to have children with mental illness.
  • Recently, some tantalizing research suggests that certain mental illnesses may be ultimately caused by various prior, or long-standing but smoldering, infections of the brain.  Infections are more likely to be transmitted when people have impaired immunity, when the population density increases, or when there is increasing contact between population groups that were once isolated.  All of these factors are now operative, thus making people more likely to acquire an infection and its possible sequelae, such as mental illness.
  • People are now exposed to considerably more artificial light than they were in the past.  This is especially disruptive to our circadian rhythms when light exposure occurs in the evening and night.  At those times, even low levels of light interferes with the secretion of melatonin, the sleep regulating hormone.  People sleep less than they have in the past, and their sleep is often of a lesser quality.  While this sleep deficit is not the primary cause of mental illness, it may uncover latent oddity in people who have a suitable predisposition.  Also, the suppression of melatonin by light may explain why there seems to be an increase in abnormal behavior around full moon periods.  In case you haven't had your fill of trivia for the day, I'll unfurl another tidbit that may give you something to think about the next time you step on a bathroom scale.  Cutting back on sleep reduces your basal metabolic rate (BMR).  In other words, your metabolism slows down, you burn fewer calories, and you gain more weight.

  Q:  If you were the Surgeon General, what would be your first priority?
  A:  Thank you for asking, George W.  Assuming that I had a cooperative Congress, I'd require tobacco companies to only use heavy smokers as models.  The people they're using nowadays look like people whose worst vice is using sweetened granola.

  In my first opus (Fascinating Health Secrets) I suggested that people might smoke less if they were apprised of risks which really mattered to them, such as becoming an impotent old prune.  The prospect of lung cancer and an early death isn't a sufficient deterrent for most people, but if a guy can't get it up . . . well, where is that nicotine patch, anyway?

  While my suggestions may have appeared to be tongue-in-cheek to some readers, some Canadian officials apparently liked my ideas and proposed similar warnings for cigarettes sold in their country.

  Q:  What advice would you give someone who wanted to be an ER doctor?
  A:  Start taking your Haldol more regularly.

  Q:  What is Haldol?
  A:  A drug used to control psychotic behavior.

  People who are obsessed with becoming an ER physician are never dissuaded by such an apparently flip exhortation.  These folks are usually teenagers or college students whose knowledge of this job was distilled from the glorified depiction of life in the ER issued at weekly intervals by that Grand Dispenser of Truth otherwise known as Hollywood.  I feel morally obliged to dispel their illusions, but young people, I've found, prefer to keep their blinders on and ignore any facts that don't mesh with their idealized notions.  I suppose I can't fault them, since I was probably even more idealistic when I was young.

  Teenagers usually send gushing e-mail messages to me, wiling me with something like, "I want to be just like you.  Can you tell me how?"

  OK, but don't ever say that I didn't warn you.  The recipe for becoming an ER doc is fairly simple:

  1. Get extraordinarily good grades in college and get a high score on the MCAT exam so that you will be accepted into medical school.
  2. Do extremely well in medical school to give you a reasonable chance of being accepted into an ER residency program.  It seems like everybody and his brother wants to be an ER physician these days, so the competition for the limited number of ER residency positions is fierce.
  3. After seven years of working 110 hours per week during medical school and residency, you're now an ER doctor.  If you haven't blown your brains out yet (you'd be surprised how many physicians do just that), take yourself out for an ice cream cone to celebrate.

  Q:  Why are family members usually not allowed to witness a code?
  A:  I think that most physicians are hesitant to have family members witness a code.  In my opinion, the most salient reasons are:

  • It is difficult to know in advance whether or not the observer will interfere with the code. If that person becomes such a distraction that removal from the room is warranted, this requires the attention of the typically limited staff, whose attention would be better focused on the patient.
  • Some observers may be psychologically traumatized by witnessing some aspects of the code.  Again, judging this prospectively is virtually impossible.
  • As an ER doc who used to work at a teaching hospital, I've seen a number of codes run by a variety of people, and I have yet to witness a code that has been executed perfectly. Practitioners usually fulfill most of the major ACLS dictates, yet flub some of the seemingly minor points that can nevertheless have a major impact upon the outcome of the code.  I am not advocating the exclusion of family members to conceal these errors, but it is indisputable that mistakes (even trifling ones) may foster subsequent malpractice litigation.  Moreover, the family members may be eternally haunted by the thought that their loved one may have lived were it not for the mistake.

  Q: Some folklorists claim that some of the ER stories circulating on the Internet are nothing more than urban legends. What’s your opinion on this?
  A: Some of them are probably just urban legends, but I know that some of the cases that have been branded as urban legends are indeed true. I think the impetus for characterizing certain cases as urban legends is attributable to the fact that most folklorists are pointy-headed academics who have very little idea of the types of wacky cases that are actually seen in emergency rooms. With smug condescension and a paucity of facts, folklorists reflexively assume that some cases did not occur because they resemble an urban legend, or something that fits their mold for what they’d like to think is an urban legend. Similarity to a prior event does not necessarily mean that the event in question did not occur. When these stories are disseminated, people often change the story from one iteration to the next. However, that's just human nature (and this tendency has been scientifically documented in a variety of situations). No matter how the story is twisted, warped, colored, and revised as it is retold, this cannot erase the reality of the original event. As an ER doctor who has seen some of these hard-to-believe cases, I can assure you that some very strange events do in fact occur. Some of the things I've seen in the ER have stunned me, and that was one of the reasons I wrote this book.

  Q:  (I'll paraphrase this, since the question came from a reader with whom I've had a long-running dialogue.)  Aside from the murders allegedly committed by Dr. Michael Swango, do you think that there are other physicians who are intentionally killing patients?
  A:  I think it is far more likely that some nurses around the country are deciding who lives and who dies, offing this one or that one at their discretion.  I've heard several nurses talk about giving an injection of HIV-laden blood to patients they hated.  Since nurses are usually the ones who draw blood specimens and give injections/start IV's/etc., they have plenty of opportunity to do this if they are so inclined.  AIDS patients visit hospitals so frequently that nurses are guaranteed an essentially limitless supply of infected blood to inject into patients they detest.  Furthermore, the long latency of HIV infection makes this the perfect crime:  by the time the infection is apparent, linking it to its source is almost impossible.

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  You will have sex about 10,000 times during your life.

  Doesn't it make sense to read a book that can maximize your enjoyment, and the enjoyment you give to your partner?

  Cast away your preconceptions of sex books as being a rehash of things you already know and hence a waste of time.  By reading this book, you will learn many things that Dr. Ruth and other sexologists have never considered.

  The Science of Sex
  Enhancing Sexual Pleasure, Performance, Attraction, and Desire

  by Kevin Pezzi, MD

  Available in printed and Adobe Acrobat e-book versions (will display on any computer)

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  If so, I want to speak with you.  I have several hundred inventions (a few of which are pictured on my web site), but not enough time to market very many of them.  I am looking to partner with marketing professionals who possess the skills required to introduce new products into the marketplace.  In return, I offer you a substantial percentage of the income generated.  Contact me via this page: www.MySpamSponge.com/send.php?handle=erdoc

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