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Many More ER Questions and Answers
Med school: why is it so tough?
Q: Why is medical school so difficult? It doesn't seem very difficult, for example, to memorize that a given muscle has a certain origin and insertion, innervation, and blood supply. So why the fabled difficulty? Steve
A: It is true that the facts learned in medical school are usually simple to understand and memorize. What's difficult about it is that there are an enormous number of facts to master. Some people who ace college miserably fail at mastering medicine, and are booted out of medical school. Besides the sheer volume of the material (in my first year of med school, I accumulated far more class notes than I did throughout college and, paragraph for paragraph, the stuff in med school was often far more information-dense), it is challenging because it can be difficult to keep all the facts straight and not jumbled in your mind. For example, when you begin studying the origins and insertions of the various back muscles, after your first one, you'll likely say to yourself, "Oh, that was easy." However, after your last one, your eyes will likely be crossed. Why? Because many of those facts overlap. Such overlap is conducive to confusion. To understand this, for the next minute or two, pretend that you're a medical student. Here's a short excerpt from my anatomy book:
The trapezius is innervated by the accessory nerve, and C3 and C4. It originates on the spines and supraspinous ligaments of thoracic vertebrae, the ligament nuchae, and the occipital bone; it inserts on the lateral clavicle, the acromion, and the spine of the scapula. The latissimus dorsi is innervated by the thoracodorsal nerve. It originates on the spines of the seventh through twelfth thoracic vertebrae, the thoracolumbar fascia, and the iliac crest; it inserts on the floor of the intertubercular groove. The levator scapulae is innervated by C3 and C4. Its origins are on the posterior tubercles of cervical vertebrae 1 - 4, and it inserts on the medial border of the scapula. The rhomboid major and minor are innervated by the dorsal scapular nerve and C5. The origin of the rhomboid major is on the spines and supraspinous ligaments of thoracic vertebrae 2 - 5, whereas the rhomboid minor originates on the spines of cervical vertebra 7 and thoracic vertebra 1. Both insert on the medial border of the scapula. The posterior superior serratus is innervated by T1 - 4. It originates on the spines of cervical vertebra 7 and thoracic vertebrae 1 and 2. It inserts on ribs 2 - 5. The posterior inferior serratus is innervated by T9 - 11. It originates on the spines of thoracic vertebrae 11 - 12, and lumbar vertebrae 1 - 2. It inserts on ribs 9 - 12. The following are innervated by the dorsal rami of spinal nerves: The erector spinae has multiple segments, and some of these segments are in turn segmented. The portion termed the spinalis thoracis originates on the spines of lumbar vertebrae, and inserts on thoracic vertebrae spines. The longissimus portion of the erector spinae itself has three sections: the thoracis, cervicis, and capitis. The thoracis originates on the accessory processes of lumbar vertebrae and inserts on ribs and thoracic vertebrae. The cervicis originates on the transverse processes of thoracic vertebrae and inserts on cervical vertebrae. The capitis originates on the transverse processes of cervical vertebrae and inserts on the mastoid process. The next division of the erector spinae is the iliocostalis, which also has three subdivisions: the lumborum, the thoracis, and the cervicis. The lumborum originates on the ilium and lumbar vertebrae and inserts on the angle of ribs. The thoracis originates on the thoracic vertebrae and inserts on the ribs. The cervicis originates on the thoracic vertebrae and ribs, and inserts on cervical vertebrae. The splenius is also innervated by the dorsal rami of spinal nerves, and it is also subdivided into the cervicis and capitis. The cervicis originates on the spines of the thoracic vertebrae and inserts on the posterior tubercles of cervical vertebrae. The capitis originates on the nuchal ligament and thoracic vertebrae spines, and inserts on the mastoid process and occipital bone. The transversospinal has two basic divisions: the semispinalis (itself divided into thoracis, cervicis, and capitis), and the multifidus and rotatores. The thoracis originates on the transverse processes of the lower thoracic vertebrae, and inserts on the spines of thoracic and cervical vertebrae. The cervicis originates on the transverse processes of the upper thoracic vertebrae, and inserts on cervical vertebrae spines. The capitis originates on the transverse processes of the upper thoracic vertebrae and lower cervical vertebrae, and inserts on the occipital bone. The multifidus and rotatores originate on the sacrum, lumbar vertebrae, thoracic vertebrae, and cervical vertebrae, and insert on . . . . gee whiz, I forgot. How about asking a personal injury attorney? Those guys are so smart, they're never wrong. While you're at it, ask him about the blood supplies to those muscles, their actions, and their morphology.
Easy stuff, huh? Now imagine keeping this stuff straight a few months or a few years from now on some 1000-question exam (I'm not exaggerating, by the way). Now try memorizing a few hundred thousand times this much information, and keeping all those facts straight after years or even decades when you're suffering from chronic sleep deprivation (working shifts that forever vary from days to afternoons to nights can cause perpetual jet lag). Now imagine that some personal injury attorney wants to sue you for every penny you've made in your life just because you forgot one of those little tidbits you learned umpteen years ago. Now imagine that people bitch about how much money doctors make, even when we're getting $7 checks and spending all of that, and more, on expenses just so we can take care of Medicaid patients (and remember that $50,000 fine if we say no?). Now imagine that the government holds doctors in such contempt that it is forever insulting us. Not content with those $7 checks, they reduced physician reimbursements 5.4% last January, and plan another 4% cut this year. Even if payments stayed the same, we'd still fall behind, thanks to inflation and ever-increasing expenses, some of which (such as malpractice premiums) increase far faster than overall inflation. Not content with that, the government burdens us with labyrinthine regulations and incessant bureaucratic meddling. Now imagine that you worked 110 hours per week for many years to become a doc so you could subject yourself to all this fun, and you see people putting in basements making twice as much per year as you do, and they work half the year and don't need to worry about lawsuits. Now imagine that just about everyone seems to have a gripe about doctors: we're too arrogant. We're cold and uncaring. We give too many pain meds. We give too few pain meds. We make people wait too long in the waiting room. We don't explain things very well. We interrupt our patients. Our handwriting is sloppy . . . blah, blah, blah, blah!
After all that, you'd probably want to scream. I read in a magazine recently about a doctor crying because he was so distraught over how noxious it is to be a physician these days. Can you blame him? Docs endure years of grueling education, clinging to the hope that there will be a reward at the end of the rainbow for all their hard work and sacrifice. However, many physicians find that there is no longer enough reward to justify such an investment of time, money, and energy. Thus, they feel disillusioned, bitter, and let down. Some believe they were suckered by society, which led them on by dangling a carrot in front of their noses, tacitly promising that the sacrifice would be worthwhile. Money. Respect. A good job. Security.
Money? A person can make more money than a doctor by selling real estate, insurance, computers, software, cosmetics, or even Amway. There are countless people who make more than doctors do, even when they work fewer hours in less demanding jobs that require far less education. Plus, as a benefit, people don't bellyache about how much people make if they sell Amway or Mary Kay cosmetics. Nor do they rarely complain because some sports stars make $169,000 per game, causing seat prices to be so expensive that a man might need a loan just to take his family to the ballpark.
Respect? Sometimes. However, it's probably more common to receive scorn, contempt, resentment, and animosity — especially in the ER.
A good job? Read my excerpt on what it is like to be an ER doc for 15 minutes, then ask yourself if this is a good job. If mass murderers or child rapists were subjected to the same treatment, the Supreme Court would outlaw it as being cruel and unusual punishment. It's not a walk in the park. It's not the fantasy stuff on television. Now matter how much you think you want to be an ER doc, it is not the type of life that any sane person could want.
Security? One slip-up could cost you everything. Or you could be sued even if you did not make an error. If you haven't done so already, read about the case I was involved in, then ask yourself how on Earth you could ever feel secure after that. Knowledge cannot insulate you from lawsuits. I know ER docs who are more knowledgeable than me, and they've been sued multiple times. Because emergency departments care for critically ill and injured people, there will inevitably be bad outcomes. We can't patch up every Humpty Dumpty. We can't always save people from a lifetime of abusing their bodies. I recall one time when an extremely corpulent (400+ pounds of quivering blubber) man was reveling in the freedom he felt to eat as much as he wanted of anything he wanted, knowing that if he had a heart attack, we'd just code him and send his blimpish body back for another few decades of terrifying owners of all-you-can-eat restaurants. His wife seemed to believe this wishful thinking, so I thought it'd be wise to educate them on the odds of successful resuscitations: they're low even in the best circumstances, and abysmal when coding beached whales. I couldn't believe their expectations! It didn't take a doc to realize that guy had "heart attack" and "premature death" tattooed on his forehead. And his wife expected me to save him if he coded? And if I didn't? There'd be a chasm between her expectations and the outcome, which might engender a lawsuit. It happens every day.
Being an ER doc is an enormously difficult and stressful job that entails many risks and pays fairly well, but a lot less than many jobs which are incomparably easier. Can you be happy as an ER doctor? Yes, if you're a masochist, or you're fortunate enough to work in one of the few remaining slow-paced emergency departments. Frankly, I'd question whether it was worth it to be an ER doctor even if you could snap your fingers and become one. However, it's obviously not that easy. Or, if you think it is, perhaps you might not mind answering the following question that's similar to the type I faced in medical school:
Question 348: Regarding the musculature of the back (pssst: no fair looking back — this is not an open book test!):
a) The latissimus dorsi is innervated by the thoracodorsal nerve, and it
originates on the spines of the fifth through twelfth thoracic vertebrae, the
thoracolumbar fascia, and the iliac crest; it inserts on the floor of the
1. a and b are true
The correct answer? I'll give it to you in a minute.
In reality, some questions were far more challenging, sometimes presenting options up to "m." Thus, instead of selecting from four options (that's child's play, right?), we'd have possible answers like this:
1. b, f, g, and k are true
By the way, the correct answer was 4. Did you get it?
It's not that I have a poor memory (given that I graduated in the top 1% of my medical school class, how could I?), but I thought that memorization in college was far easier because much of it involved concepts instead of a boatload of facts, some of which seemed in medical school about as similar to one another as one grain of sand is to the next. Hence, keeping all that stuff straight was incredibly difficult.
Sex for drugs? A quid pro quo?
Q: In True Emergency Room Stories, you mentioned a case in which an attractive woman offered you sex in exchange for narcotic prescriptions. Do you think female ER docs ever receive similar propositions from men? Kristen
A: Having no luck with the personal ads, Kristen? No, I doubt that happens. While I think that patient must have been nuts if she thought I'd risk my career for the opportunity to sleep with her, I can understand why she might think the libidos of some men would cloud their judgement. President Clinton comes to mind. However, most women seem more circumspect about their sexual needs. Now that I think of it, the only professional person I know who was not sufficiently prudent was a doc I used to work with in the ER who was famous for boinking a patient in the hospital chapel, of all places — and videotaping it, to boot. Now that's what I'd call brazen sexuality.
Q: In that story, you mentioned that one of your reasons for turning her down was that you have a girlfriend. Assuming you didn't have a girlfriend, do you think you might have succumbed to her offer?
A: Never. I don't currently have a girlfriend, and if I received a similar offer now, I'd be just as resolute in rebuffing it.
Q: I'm not sure I understand your motivations. You've made it very clear that for the most part you hated being an ER doc. So why would you go to great lengths to protect that career?
A: I may not like being an ER doctor, but I love having a medical license, and I can't imagine living without it. However, I can imagine living without the opportunity to have a felonious fling. Let me put it this way. I managed to keep myself from doing anything stupid even when I was 17 years old and had testosterone bubbling out my ears. Now that I'm older, smarter, and less amorous, there is no chance my libido would gain the upper hand.
Q: What about nurses? Do you think they could be more easily tempted? They have less of an investment in their careers, and while they can't prescribe drugs, they usually have more access to narcotics than doctors, according to what I've read.
A: They do, but I've only known one nurse who was fired for stealing drugs.
Q: Did you suspect that she was doing it?
A: She struck me as being a bit daffy, and when she told me that her house burned down, I sensed that may not have been an accident. I think most people would be devastated if their home was barbecued, but not her. She seemed less distraught than I would be if I burned a loaf of homemade bread. In fact, she seemed a bit elated. Hence, I wondered if she started the fire for the insurance money.
Q: Going back to the doc who had sex with a patient in the hospital chapel. Did that really happen? That seems difficult to believe.
A: Yes, it really happened. I learned about it on the day I interviewed for a job at a new hospital. At the time, I didn't give it much thought, because I was so focused on the job and the hospital. The sudden revelation about that doc seemed so bizarre in a "beyond a soap opera" sort of way that it didn't mesh well with reality — at least not my reality. Nevertheless, it happened, and a few years later, it blew up in the press, and the doc lost his medical license. I discussed this case in more detail in another book I'm writing. The last I heard, he was practicing in Saudi Arabia. Given their reputation for being chaste, I thought that was an odd refuge for an unlicensed sex maniac.
Q: What was he like in person? A kook?
A: I never observed any unusual behavior. He just seemed to be a very hard-working guy. He moonlighted in so many emergency departments, I wondered if he ever slept. My boss provided me with the inside scoops on his ongoing depravities.
Q: You mean there's more?
A: Yes. I'll discuss them in my new book.
Q: Can't you give me a hint?
A: OK. Imagine that he's doing a pelvic exam on you, and instead of impressing you with his competence and decorum, he attempted to impress you with the size of his erection.
Q: Did your boss know about that behavior?
A: Yes. He is the one who told me.
Q: So why didn't he turn him in?
A: Good question. I don't know the answer, but in my upcoming book I speculate about one possibility. However, if you think that doc's behavior is wacky, just wait until you hear why I thought that doc was given free rein to continue his rampage. Ah, life in small-town America. It's not as boring as you might think.
Q: I'd like to know what it is like to work different shifts in the ER. Also, how easy is it coping with the night shift which, of course, necessitates sleeping during the day? Kyle
A: The difference between working the day shift and the night shift is . . . well, it's like the difference between night and day. Certain types of cases are far more common at various times of the day. For example, while people can be shot anytime, the incidence of gunshot wounds is less at 9 AM on a weekday than it is at 2 AM on a Saturday (if for no other reason than the fact that criminals often don't get up until noon). I worked in one ER in which 11 PM seemed to be the time that women with pelvic infections would stream into the ER. This puzzled me for years, and I'd think, "Why come in now? Why not call your doctor earlier in the day? Or why not go to the health clinic? Why come in the emergency room at 11 PM?" One night my curiosity got the best of me, and I asked the lovely Lolita, "Why now?" She told me that she woke up after her doctor's office and the health department were closed. I asked a number of others, and often received a similar response.
In general, docs working the night shift see more violent trauma, more heart attacks (given that they often occur early in the morning), and more eccentric patients with odd problems. Day shift docs see fewer oddballs and riffraff, and more decent, normal people. Perhaps this isn't the case in all emergency departments, but it's been that way in all the ER's I've worked in. When I went from working my usual night shift to a day shift, the difference was often so marked that I'd practically want to kiss the decent people and thank them for not being scumbags. Yes, I know that docs should drip with compassion even when dealing with the dregs of humanity, but after a while they tend to wear out their welcome. I grew tired of their lowlife lifestyles: perpetually unemployed, often drunk, overly fond of drugs, sleeping with anyone they could, evidently allergic to soap and water, oblivious to the laws, and characteristically uncouth, rude, demanding, and threatening.
While the day shift is usually busier overall than the night shift, day shift docs are aided by help they get from other physicians. For example, during the night shift, the ER doc reads (interprets) his own x-rays. In most hospitals during the day, a radiologist reads the films. The day shift ER doctor can still look at the x-rays, but it is easier to quickly scan the films already read by a radiologist than it is to laboriously search every square inch of the x-rays — which is something that must be done before deciding on a patient disposition. Someone must carefully check the x-rays. If a radiologist provided me with a reading, I was content to rapidly ascertain that his interpretation was correct. However, sans that interpretation, I was the one responsible for the careful interpretation.
During the day, ER doctors can obtain consultations from a variety of attending physicians (fully licensed physicians, to differentiate them from resident physicians), such as cardiologists. Thus, if an ER doc is puzzling over an EKG, he can often get a cardiologist to read it within minutes. If the ER doc can't intubate a patient, an anesthesiologist can run to the ER during the day. During the night, anesthesiologists are usually sleeping at home.
Furthermore, night shift ER docs face what I call the "cranky resident syndrome." During the day, the on-call residents are already awake, and they're not as tired as they'll be hours later in their shifts during the middle of the night. When an ER doc tells them to see a patient during the day, they usually comply without much resistance. At night, however, they often whimper, complain, stall, and do everything they can to throw up flak so they can try to achieve two main objectives: getting some sleep, and minimizing how many patients are admitted to their service (which they must subsequently care for not only during the admission, but oftentimes afterward in the clinic, too). Frankly, I don't know why some residents try this oppositional strategy; it never worked on me. If I told them to see a patient, I would not back down if they bellyached about it. What did they expect me to say? "Oh, I'm sorry for calling you. You're grumbling about it, so I'll just discharge that patient with refractory asthma so she can die at home instead of inconveniencing you."
Now on to the subject of how night shift workers sleep during the day. Basically, it is a nightmare. Everything about it runs counter to the innate biology of most people, which is to sleep at night. I won't go into the neurophysiology of this, but driving home in the morning sun is not a good way to prepare for sleep. Next challenge: finding a dark, quiet place to sleep. If my neighbor is mowing his lawn, that can interfere with sleep. So can the inevitable sunlight that streams in around the edges of blinds and window shades. It's been proven that even faint light can disrupt sleep. I tried all sorts of things to keep my room dark: covering the window with aluminum foil, sleeping in the basement, or sleeping in a closet. However, even a totally dark room cannot replicate what is best: no light for most of the sleep period, but then gradually increasing light to simulate sunrise. (It is possible to program X-10 controllers to achieve this effect, but most night shift workers are too tired to bother with that!)
Then there is the joy of dating people whose shifts are opposite yours. Back in the days when I had a girlfriend, I'd usually date her in the evening. That was convenient for her, but not for me. No booze, no romping in bed, no chilling out, no watching the end of a movie that came on at 9 PM. Instead, I'd keep glancing at my watch to see how many minutes remained until I had to leave for work.
In short, working during the night always struck me as being very unnatural. I never fully acclimated to it. Some people claim they can, but there is statistical evidence that suggests otherwise. Studies have shown that night shift workers sleep less than others (no surprise there), make more errors (again, no surprise), and live a few years less than people who sleep at night. In my opinion, what is even worse than losing a few years of life is the near-constant feeling of being tired. On those infrequent occasions when I sleep very well, I wake up feeling absolutely fantastic: totally refreshed, bubbling with energy, mentally sharp, happy, confident, enthusiastic, and more patient. That feeling is markedly different from the synthetic alertness I obtain by drinking coffee — the crutch I use to keep me going on days when I don't sleep well.
So why did I usually work the night shift? Two reasons: I thought it was better to try to adapt to one shift than it was to rotate shifts as most ER docs do. Furthermore, my boss paid me an extra $20 per hour to work at night so he wouldn't have to do it. An extra 40 grand per year might sound like enough to make up for the drawbacks of working the night shift, but I don't believe it is.
Now available as a free e-book download
What really goes on in emergency rooms? If you're a fan
of the television show ER, you might think that you know. Not so,
asserts Kevin Pezzi, M.D., an ER doctor and author of True Emergency Room Stories. Pezzi says the show ER only
scratches the surface; the truth is far more interesting — and bizarre.
So bizarre, in fact, that the cases could shock even an experienced ER
physician. "I'm now a firm believer in the saying that truth is stranger
than fiction," he says. "I don't think that anyone could dream up such
Hospitals promising that ER patients will be seen
within 30 minutes
Q: My local hospital guarantees that patients will be seen within 30 minutes of their arrival by a doctor; if not, the patient is given something to compensate them. What's your opinion of this? Is it just a come-on? George
A: If hospitals increased their staffing so you could be quickly seen, that would of course be great. However, I think most hospitals offering this are hyping expeditious treatment to lure patients without increasing physician coverage. Here's how the gimmick works if the ER is busy: the doc pokes his head in the door, introduces himself, briefly finds out what your problem is, then skedaddles out of there to order a lab test, x-ray, or give an order to a nurse, even something as basic as "Put an ice pack on it." When the doc has time later on, he'll return to complete your evaluation. If the ER is not busy, he could complete your evaluation on the initial contact — but of course, he'd do that even if the hospital had no 30-minute guarantee.
While I think that such guarantees are primarily gimmicks unless staffing is increased (or the ER wasn't a busy one to begin with!), they have some merit. Triage nurses — the first nurse you see when you walk in the ER, and the one who determines how serious your problem is and how rapidly you should be seen — usually do a very good job of separating the wheat from the chaff. However, they're not infallible. While working the ER one night in which we had patients packed to the rafters, I glanced out of the ER and saw my girlfriend's brother lying on a stretcher in the hallway. It took me less than a second to realize he had a kidney stone (reputed to be more painful than childbirth), so I took care of him right away. Had I seen him when he first came in a couple hours previously, I could have prevented a lot of misery.
If a hospital truly wanted to speed up patient flow, they wouldn't have a triage nurse, they'd have a triage doctor. I know this is feasible and effective because I've done it at some hospitals whenever I wasn't busy. I'd relieve the triage nurse and tell her to take a break, or she'd work alongside me. Obviously, some people still need to be taken into the "guts" of the ER for a more extensive evaluation and treatment, but some simple cases could be seen and discharged with minutes from the triage area. I'd give those patients the same evaluation and treatment that I would have given them otherwise; the only difference was they wasted no time waiting to be seen.
On the news last night, I saw that Timex developed a watch that allows people to purchase things (at a gas station, for example) without using a credit card. Just wave your watch near a sensor, and presto! Similar technology could be used to register a patient in a split-second, obviating the need for registration clerks to ask for multiple pieces of identification. Or patients could carry a card bearing their medical history in addition to registration information; that would dramatically accelerate patient care.
Physicians can speed up patient care in simple ways, too. Sometimes there are no patients at the triage desk, but the ER itself is full. If I wasn't busy, I'd help the nurses in any way I could: by discharging patients, making beds, cleaning up, and performing other tasks traditionally performed by nurses.
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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
by Kevin Pezzi, MD
Available in printed and Adobe Acrobat e-book versions (will display on any computer)
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Q: Do medical students ever learn on animals? I'm an animal lover, and it bothers me to think that animals might be sacrificed in this way. Nanci
A: Yes, we learn on animals, but we don't snatch Lassie from a loving family. The dogs provided to us were destined to be put to sleep anyway.
Q: Do they feel any pain?
A: No. They're anesthetized, then we do the surgery or experimentation. Afterwards, the dogs are euthanized without ever awakening.
Q: Who actually kills the dogs? The medical students? I'd like to attend medical school some day, but I could never kill an animal.
A: Most medical schools have technicians who take care of the anesthesia and later euthanasia. To some extent, I can sympathize with your position, because I love animals, too. However, the reality is that no one is born with surgical ability. To develop it, you must practice on some animal or person. If we spare the animals, whom do we practice on? Some practice inevitably must be on humans, because of anatomical differences. However, whenever possible, it's usually preferable to practice on animals.
Q: What do you mean "it's usually preferable"?
Q: You really hate them, don't you?
A: Yes. I view them as robbers with a license. I have more respect for other criminals, because at least they don't operate under the pretense of being good guys. I value honesty, and I despise chicanery. I also value people with real jobs. Lawyers don't do any real work. Do they take care of you when you're sick, fix your furnace, build your car, or grow your food? No, they just create paperwork for other attorneys, and confiscate a third or more of the loot. Lest you think that my position on this matter is hopelessly intransigent, I should mention that I don't hate all lawyers, although it may seem that way from my broad-brush indictment. I'm realistic enough to know that some of them do more good than harm. Unfortunately, I think they're in the minority. Overall, I believe that lawyers take far more from society than they return. To appreciate this, don't think of a dollar as an abstraction; think of it as a certificate that verifies you've done a given amount of work. It's more convenient to exchange money for goods or services than it is to barter. So, when I buy food that came from a farmer, I don't go to his farm and work for him, I give him some money. Very basic, right? The problem is that it is so basic that we rarely give it any thought, and consider if someone truly deserves all that money. Malpractice attorneys have made more on one case than an ER doctor could make by saving 100,000 lives. Don't believe me? Let's do the math. I know of malpractice cases in which attorneys made over 6 million dollars, although there are likely cases in which they've made far more. Let's assume that an ER doc makes $120 per hour, and it takes him 30 minutes to save a life. In reality, that's more money than I was ever paid, and ER docs usually see more than 2 people per hour, but let's use these figures just to make it as fair as possible for the attorneys. Thus, an ER doc is paid $60 to save a life. Divide $6,000,000 by $60, and you get 100,000. Now how on Earth is what that attorney did for one person as valuable as an ER doc saving 100,000 lives? It's insane, isn't it? Furthermore, this disparity in value is more extreme than it may seem, because we've yet to consider whether or not an attorney did any good at all. The value of an ER doc saving 100,000 lives is both enormous and unquestionable. Now let's consider what good an attorney might do, if anything. To make this less hypothetical, let's consider an actual case. Over a decade ago, a hospital was ordered to pay $16,900,000 to a mother whose child, born four months prematurely, wasn't perfect. Frankly, it's a miracle that we can keep babies alive when they're that premature. Judging by what I heard about this case, neither the doctors or the hospital did anything wrong, but juries often award sympathetic verdicts. Hence, instead of praising the docs for having the skill to keep the child alive, they were penalized because the kid wasn't perfect. Well, no wonder! But it wasn't the fault of the doctors or hospital that the mother delivered four months early. These docs weren't buffoon or quacks who didn't know what they were doing; they worked at arguably the best obstetric hospital in the state and perhaps the country — a hospital affiliated with a medical school, and the hospital to which other hospitals referred their most complicated obstetric cases. Why? Because the docs there were topnotch. However, as I've pointed out before, there is a limit as to what doctors can do. We can't save every Humpty Dumpty. We can't undo everything done by Mother Nature, or God, or fate.
However, it takes just one histrionic attorney to pump up a jury's emotions, and make them believe that everything was the fault of the hospital and doctors. For his consummate acting job, that attorney received $6,000,000. If a doctor truly did something so heinous as to deserve a $16,900,000 verdict, instead of paying that much, it would make more sense to revoke his license, then shoot him. But what good did that attorney really do? He didn't protect the rest of society from those doctors, because they're still practicing, and in the years since that case they've saved countless lives that could not have been saved by less experienced, less knowledgeable doctors working in less capable hospitals. He didn't protect us from some bad hospital. In the years that hospital has existed, it's cared for hundreds of thousands of patients, many of whom could not afford to pay for their care in that urban area. By delivering that free care, that hospital served as an important safety net for people in that vicinity. After that verdict, the hospital was so financially devastated that they teetered on the brink of bankruptcy. Had the hospital closed, countless future patients would have been victimized. Even if the hospital survives, their cutbacks will inconvenience and imperil thousands and thousands of patients for years into the future. It takes a lot of belt-tightening to make up $16,900,000. For inflicting this burden in such a dubious case, this attorney made as much as an average person makes in six lifetimes. Was what that attorney did truly worth six lifetimes of work? Of course not. In fact, a good case could be made for proving that he did nothing of value.
These enormous verdicts are draining a lot of money from our healthcare system. If attorneys truly cared about the quality of healthcare, they wouldn't accept those multi-million-dollar fees; they'd use that money to hire more doctors and nurses so patients in emergency rooms, for example, could receive better care and doctors wouldn't have to cut corners as they race from patient to patient. Instead, attorneys use such fortunes to buy mansion and jets, and to play sugar daddy to beautiful women young enough to be their daughters or granddaughters.
Yes, I hate attorneys.
Q: Now I can see why. I never thought about malpractice in this way before. I assumed it was only bad doctors who were sued.
A: Nor do most people think about how they're affected by this out-of-control malpractice problem. When people go into an ER for treatment and they wait, and wait, and wait, I doubt it ever occurs to them that there could be more nurses and doctors working if so many billions of dollars weren't confiscated by lawyers. Through their taxes, insurance premiums, and via direct payments, people spend an enormous amount of money for healthcare. If they knew how much of that money went for legal care, not medical care, they'd be incensed. The direct payments to lawyers and their clients is just the tip of the iceberg. To help counter the vicious aggressiveness of attorneys, doctors "cover their ass" by ordering more tests and referrals to prove they were correct so as to minimize the chance of being successfully sued. Apart from more tests and referrals, many other aspects of medical practice are influenced by the perpetual fear of malpractice shakedowns. One of the reasons antibiotics are overused is because docs often fear a lawsuit if they don't use them. However, many people given antibiotics have either a viral infection or a mild bacterial infection for which antibiotics are not required. Inappropriate use of antibiotics contributes to bacterial resistance in both the recipient and in the population as a whole, so this is not a trivial concern. However, physicians know they're more likely to be sued for not prescribing them than they are for prescribing them. So what do they do? They prescribe them more often, even in cases in which their need is questionable. Physicians should share some of the blame for knuckling under in this manner, but it's human nature to cover your ass (CYA). People in other professions do it too, even when they face considerably less risk than doctors.
Q: But aren't lawsuits against ER docs infrequent enough so this would not be a day-to-day concern?
A: No. One of my former bosses, who knew far more than I about legal matters, told me than ER physicians average a lawsuit every two years. I'm sure that varies from state to state, and county to county, since some areas are far more litigious than others. Since lawsuits stretch out for years in many cases, even if a doc is sued only every two years, he could be constantly involved in one or more cases for the rest of his career. This pervasive stress is very debilitating, and it can suck the joy out of life — your life, if you become an ER doctor.
Q: Thanks, I'll pass. If I become a doctor, I'll choose some easier specialty, like dermatology. Even if an ER doc is fortunate enough to avoid being sued, it doesn't sound as if that specialty is very tolerable, considering its crazy hours and breakneck pace. But, out of curiosity, was every day in the ER a bad day?
A: Not at all. About once per week, on average, I'd have a fantastic day that left me feeling exuberant.
Q: Well, now I'm curious. What was different about those days that made them so much better?
A: Several things. Here are a few that come to mind:
Now I'll tell you about a tragic case that I wish I'd seen. An ER doc in my group saw a young child with what he thought was a scratched cornea. He prescribed eye drops, applied an eye patch, and told them to return the next day for a recheck, since this was a weekend. On the return visit, the eye was filled with pus. It wasn't merely pus on the outside of the eye (such as what happens in conjunctivitis or "pink eye"), it was pus inside the eye. What happened? The child did not have a scratched cornea, as that doc thought, he had a perforated cornea: a cut or laceration through the cornea that introduced germs inside the eye. This caused a horrendous infection that necessitated removal of the eye.
So why do I wish I'd seen that child? Because I'm confident I could have detected the perforation and airlifted the child for immediate ophthalmologic treatment that could have prevented this disaster. I know how difficult it can be to examine the eyes of children that age, but unlike some docs (such as the doc in this case), I never give up until I'm darn sure I'm correct. That sounds easy, right? It's not. The child is often crying, screaming, thrashing wildly, and rolling his eyes or holding them shut. The parents are often upset. The nurses are often impatient to get the child out of there so we can get to work on other patients in the often-backlogged ER. Furthermore, you can't get just one good look at the eye from one angle; to assuredly detect a corneal perforation, you must examine the eye from a number of different angles. Why? Think of a crack in glass. If you view the crack straight-on, the crack might be almost invisible. However, if you view it from an angle, it's clearly visible. That's because the discontinuity in the glass alters the optical refractivity of the glass. That's just basic physics. When a cornea is perforated, the defect through it is obvious — at least it is to me. If I had to, I'd sedate a child to get a good look. The risk of sedation is utterly trivial compared with the risk of failing to detect and treat a serious problem.
You might wonder why the doc didn't detect the laceration. There are two possibilities:
1. He might not have known what a corneal perforation looks like. Perhaps I missed this somewhere in my training, but I never recall reading about the "Pezzi technique" of oblique inspection to detect corneal lacerations. To check my memory, I pulled out the main textbook I used during residency, Rosen's 2303-page Emergency Medicine. This text is the preeminent one used by most ER docs. On pages 1043 to 1044 of the second edition, there is a discussion of corneal lacerations. In terms of detecting them, they discuss all sorts of clues: iris prolapse, a shallow anterior chamber, pupillary alteration, slit lamp examinations, and fluorescein staining. Interestingly, and alarmingly, nowhere do they mention the simple expedient of oblique inspection for a refractive defect. Perhaps they figure that everyone knows this; even children can differentiate broken versus unbroken glass without knowing anything about optical refraction. When I became a doctor and first saw a lacerated cornea, I instantly realized that its appearance was reminiscent of broken glass. I recalled my college physics, thought "Yup, that makes sense," called in an ophthalmologist, and helped save that patient's eye. Every case I've seen was glaringly obvious, but only because I'd inspect from multiple angles. I can do that in a few seconds in an adult. In a child who is going berserk, that can be difficult and conceivably necessitate sedation to perform a through exam.
2. He might have been reluctant to sedate the child. Sedation takes time — time that's well spent, in my book. However, our boss (a man who somehow obtained his position without residency training in emergency medicine) did not agree. He objected to my using sedation on a child who had a foreign body impacted deep within his ear canal which caused a painful infection. His mother took him to his doctor, who prescribed narcotics and ear drops but did not remove the foreign body, thus violating one of the most basic principles of medicine, namely: if a foreign body is present and causing an infection, it must be removed. It is futile to attempt eradication with antibiotics, especially when the foreign body is blocking ingress of the antibiotic — as was happening in this case, in which the foreign body obstructed the ear canal, preventing the antibiotic drops from getting into the pus-filled space between the foreign body and the ear drum. I knew the foreign body must be removed. My boss thought I should have just referred him to see an ENT doc. Since I saw him on a Saturday, I knew it'd be at least two days until he could get an appointment (if he were lucky). If it was your child, you wouldn't want him to suffer a few more days until he could be seen; you'd want the problem taken care of now. The child was already on narcotics and still miserable, so I thought it would be cruel and incompetent to do what my boss recommended. Furthermore, it isn't a good idea to let an infection (especially one in that area!) go unchecked, because it could turn into a much more serious infection. Consequently, it would have been risky, cruel, and incompetent to delay this child's care. I tried to remove the foreign body without sedation, and in almost all cases, I'm able to do that. However, this was a difficult case. The child was 3½ years old, making him too young to be cooperative, but old enough to have enough strength so that holding him still was difficult. The foreign body was deep within the ear canal, and hence adjacent to the ear drum — a structure I did not want to inadvertently puncture if the child jerked at the wrong time. Since the foreign body filled the ear canal, I could not easily get something behind it and pull it out. I removed countless ear foreign bodies, and only twice needed sedation on kids so they'd be more cooperative with delicate ear procedures. In this case, I sedated the child, removed the foreign body, and the child was fine thereafter. I was happy, the child was happy, the mother was happy . . . but not my boss. He evidently feared my use of Versed®, which he termed "a powerful drug." Sure it is; that's why I used it, Dr. Dingbat! That is why Versed® is made: for sedation. Furthermore, I was using it with careful monitoring in an emergency department of a hospital, not a mud hut in Zambia! ER docs sedate people all the time; it's one of the things we do to be more humane, and to help facilitate better outcomes. I didn't go around willy-nilly sedating kids for no reason.
In any case, it is possible that the doc in the botched eye case knew our boss did his best to discourage use of Versed®, at least in kids. If that is the case, Dr. Dingbat can congratulate himself on contributing to a catastrophic outcome that will haunt that child the rest of his life. If you think there is a bit of animosity between me and Dr. Dingbat, you're correct. In my next book, I'll present the longest, most intense case I've ever discussed. That case convinced me that Dingbat was a man who was less concerned with doing the right thing than he was with looking good. It's a bizarre case that involved reprehensible conduct on the part of the ER staff toward the patient, yet it was the patient who ended up in jail afterwards.
To return to the topic we were discussing before this long tangent, it is rewarding for me to do a better job for a patient than what another ER doctor could do. In the case of the child with the perforated cornea, it's very likely I would have detected it, so that child wouldn't now have a glass eye. In the case of the child with the ear foreign body, I know I did a better job than my boss, who would have referred the child to an ENT doc and hence inappropriately delayed his care. It was also rewarding for me to take that man with the arm sliced open by rebar, and give him back a "like-new" arm. In these and many other cases, I've done an above-average job, and that's very rewarding. I don't claim to be perfect, because that's a virtual impossibility in an ER in which a doc sees several thousand patients per year, many of them at times when he's rushed and must choose between cutting corners, or further delaying the care of subsequent patients. Darned if you do, darned if you don't. That's the very nature of ER: being caught between a rock and a hard place.
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Many More ER Questions and Answers Part 1
Many More ER Questions and Answers Part 3
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