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More ER Questions and Answers

MISCELLANEOUS QUESTIONS

Is being an ER doc really that bad?

Q: Is being an ER physician really as stressful as I heard?  I've heard it's possibly the worst job in the world, next to being Monica Lewinsky . . . is it really that bad?

A: Yes.

One of my friends, Tracey, has dozens of physicians as friends and family members, but none of them are ER doctors.  When we initially began corresponding by e-mail, Tracey found it difficult to understand why I possess such a jaundiced view of emergency medicine as a career.  Recently, however, Tracey went to the ER (for the first time in her life) and the next day she called me to say, "Oh my God!  Kevin, how could you put up with working in the ER for 11 years?"  It's interesting to note that her opinion changed so remarkably just after witnessing some of the wacky things that go on in the waiting room.

Inquiring minds want to know!

Q:  Have you ever treated any celebrities?  If so, who?  And what did you treat them for?  Ashley

A:  Yes, I've treated several celebrities before, but I'm certainly not going to name them.  I think the only celebrity case I mentioned in my book (without naming him, of course) is a towering NBA star who was beaten up.

Would an ER doc think a patient with frequent migraines is a drug seeker?

Q:  Dear Dr. Pezzi: I get frequent migraines since June 2002 and I’ve been to the ER about 3 times per month up until the end of November.  This is largely due to the dramatic decrease of stress and the propranolol I’ve been taking.  Now it’s only necessary to go once a month around my period.  I get Demerol, Maxeran and Toradol.  In your eyes, would you be suspicious of someone going to the ER only once a month as a “drug seeker”?

Frustrated in Ottawa, Canada.

PS:  Why don’t we have cute docs like you up here?

A:  Gee whiz, if you keep that up, I'll move up there!  :-)  I'm tired of falling asleep with a book in my arms . . . .

Now on to your question:  ER doctors usually attempt to ascertain whether patients have legitimate problems whenever there is a possibility of secondary gain (drugs, money, time off work, etc.).  In the case of patients who requested narcotics for various problems, I had to judge whether or not I thought the need was genuine.  Believe me, this is subjective, and very much open to different interpretations by different practitioners.  We're all fallible, and we all reach incorrect assessments at times.  I know I've been hoodwinked and given drugs to folks who were great actors, and I wouldn't be surprised if I went overboard in withholding narcotics from one patient that I distinctly recall.  I had another patient years ago that everyone on the staff thought was a drug seeker, but I was absolutely convinced that she was not.

Personally, I think that frequency of presentation to the ER is not a good criterion for judging whether or not the patient is legit.  Obviously, some people do have frequent migraines, and they should not be penalized for that.  Better criteria are:  Does the patient seem to be in distress? Does their countenance change when they think I'm not looking at them?  Does the patient follow up with his or her doctor?  Is the patient receptive to my tips on adjunctive ways to minimize migraines?  Does the patient obtain transient relief when I perform certain diagnostic maneuvers that should lessen migraine pain?  Does the patient claim to be allergic to every NSAID (non-steroidal anti-inflammatory drug) under the sun?  Does this patient make the rounds at other local hospitals?  Does the patient seem histrionic?  Is the patient a stable member of the community, or someone who screams FRAUD:  no driver's license, no Social Security card, no phone, no address, no job, and no person to contact in case of emergency?  Does the patient come to the ER with people who seem on the up and up, or who seem shady?  Does the patient seem nervous when they think police are headed to the ER?  (I have a wild story in True Emergency Room Stories that illustrates this very well.)  Has the patient recently obtained narcotic prescriptions from a slew of doctors?  (Pharmacists sometimes call to inform us of this.)  Does the patient seem too impatient to get the narcotic?  I've had a few migraines in my life, and I know how horrendously agonizing they can be.  I never sought treatment for the first one, and I let the second one go for a day before I obtained Cafergot.  The last major one occurred when I was working in the ER, and an Imitrex injection relieved 95% of its pain.  While migraine pain can be incapacitating, it isn't unreasonable to delay treatment a few minutes so the doctor can take a history and perform a physical exam.

In my opinion, one of the least appreciated factors that contribute to headaches is intake of essential fatty acids.  I discussed this on the Medical Q & A page of my web site.

Who conceived of the ER concept?

Q: I'm doing a report about the most influential person or event in the 20th century and I was wondering who came up with the idea of an emergency room? Thank you. Megan

A: The idea of an emergency room germinated in the collective minds of many people—there was not one person who conceived of this concept.  It grew out of the "necessity is the mother of invention" stimulus when individuals realized that victims of trauma (and people with critical medical problems) had special needs that were not being met by the old way of doing things.

Comparing the television show ER with reality

Q: Hi! I am a freshman college student, and I am doing a paper on the differences between the TV show ER and real life in the ER.  I was wondering if you could give me a few examples of these differences.  It will be greatly appreciated. Thank you.

A: Compared to a real ER, the show ER:
-- is too superficial.
-- is loaded with grossly inaccurate depictions of what we actually do in the ER (as opposed to what's done on an inpatient basis).
-- fails to come anywhere near reality in terms of showing the types of bizarre cases that are seen in real ERs (too bad for the show, since they're missing out on a lot of great fodder for stories). However, the thought police—um, excuse me, Hollywood executives—will only show whatever they deem to be politically correct.
-- is too intense (yeah, we get that way at times, but we're usually far more placid . . . it's the rookies who are incandescent).

PS: It sounds as if you attend a fun college!

Can a woman be defibrillated with her bra on?

Q:  I've watched many medical shows.  In these shows they often use the process of defibrillation.  In the show ER, they showed a woman in cardiac arrest.  The doctor cut off her shirt but left her bra on and defibrillated her.  Is it true that if you are defibrillating a woman you must always remove the bra?  Did the show ER make a mistake?

A:  If the bra did not contain metal it wouldn't make any difference unless the bra somehow interfered with proper placement of the paddles.  If the bra did contain metal I'd be concerned that it would either interfere with the distribution of the electrical current, or could concentrate it and thereby produce a burn.  In my experience I've never seen a woman defibrillated with her bra on; it only takes a second to cut it off.

Do doctors always defibrillate correctly?

Q:  Have you ever seen doctors make errors in defibrillation?  On television they make errors all the time during CPR, but do doctors make mistakes, too?

A:  Yes.  Here's the worst example I witnessed.  Years ago I was an attending ER physician in a teaching hospital, and one of the residents was shocking (defibrillating) one patient so much that the room smelled like burning flesh!  I told the resident to give the medications a chance to work, and to shock the patient less frequently.

Inadequate portrayal of reality on TV shows

Q:  Since you're a doctor, you probably notice when television shows don't do a good job of portraying reality in regard to medical events.  Do the shows ever make major mistakes?

A:  All the time.  One that I've seen countless times is when an actor is portraying someone who is shot (for example), and as soon as he loses consciousness, someone immediately announces, "He's dead."  In reality, most real gunshot victims are still alive after losing consciousness — they've just lost so much blood that their cerebral perfusion is inadequate to maintain consciousness.  However, if such people are given prompt medical/surgical care (e.g., administration of intravenous fluids and blood, controlling the hemorrhage, etc.), their lives can often be saved.

She's got the wrong guy

Q: HELLO NOAH WYLE!  I just want you to know that I think you are absolutely beautiful.  I wish nothing but happiness and success to you.  I saw you on Rosie O'Donnell the other morning, and I think you are very eloquent.  You are my favorite (you are way better than George Clooney). 

A: Sorry to burst your bubble, but I'm not Noah Wyle.

Q: Well anyway, stay real and I hope to meet you one day.

A: OK, I'll stay real.

Strike three

Q: Hi! I've sent out two e-mails so far to other ER sites requesting this info, and haven't received anything. I hope you can help. I have a bet with my sister that Mark Greene's father is in fact the same actor that played the role of Edward Rutledge, delegate from South Carolina in the movie/musical 1776. The actor's name is John Cullum. Can you tell me the name of the actor who plays Mark Greene's father? This actor was also in the show Northern Exposure. Hope you can help! Virginia

A: Sorry, but I can't help.  I'm an ER doc (a real one, not a TV one) and my book of ER stories is all based on fact, and everything on my site (e.g., reviews of other books) is also centered around real ER material.  To be honest, I'm not a fan of the fake ER stuff on television, and I know very little about the actors.  I'd tell you if I knew, but I'm just not knowledgeable in that area.

Should ER "frequent flyers" pay for frivolous visits?
Is there a positive aspect to these frivolous visits?

Q: Hello! First, I loved your web page and found it very interesting. Do you think people who repeatedly use the emergency department should pay a user fee if they don't have an emergency?

A: Yes. Food, housing, transportation, and other basic living expenses aren't free, and I see no reason why medical care should be free (actually, it's never free—it's just subsidized by people who pay), especially when people visit the ER for ridiculous reasons.  As just one example, I had a patient arrive in the ER by ambulance because she wondered if her vagina was too loose!  Unfortunately, such patients are not a rarity in the ER; during one night, every patient I saw came in for a looney reason.  Curiously, politicians and the press constantly moan about healthcare costs, but they ignore some of the factors that contribute to the problem, such as utterly frivolous visits.  The cost to the taxpayers (she was on welfare) for me to explain that she should discuss her vaginal tightness with a gynecologist (not an emergency doctor, for heaven's sake!) was about $800, most of which was due to the ambulance charge.  Aren't you glad that your tax dollars are going to such a good use?  For a small fraction of that fee, she could have purchased a device that would effectively tighten her vagina.  I discussed this in The Science of Sex.

Q: What type of people do you see frequenting the ER:  uneducated mothers, hypochondriacs, lonely seniors? Thank You!!! Kimberley

A: All of the above, and more.

Q:  Isn't there a positive aspect to these frivolous visits?  If nothing else, I think they'd give you a welcome break from treating one serious case after another.

A:  I don't agree.  There are better ways to give an ER doc a break, such as giving him 15 minutes to sit down and eat lunch.  In a busy ER, there is little or no spare time.  If a patient presents for a frivolous reason, that person doesn't give the ER doc a break; he or she just gives the ER doc more work to do, so he must rush even more with his legitimate patients.  Some break!

I don't know any ER physician who welcomes frivolous patients.  We already have plenty of patients with real but not critical problems (e.g., ankle sprains, ear pain, cuts, etc.) to give us a break from handling the life-and-death cases.  Furthermore, and this may surprise you, I thought it was less stressful dealing with bona fide emergencies than it was dealing with the looney cases.  Why?  Because the treatment for emergencies is generally well-defined.  In contrast, I've encountered hundreds of odd cases for which there is no textbook answer on how they should be managed.  I didn't see any oddball cases during medical school or residency, perhaps because patients in that area (Detroit) were too preoccupied with other matters to have the time or inclination to go to an ER for a "you've got to be kidding" reason, or perhaps because the triage nurses couldn't stop laughing when confronted with such cases.  As a result, when I became an attending ER physician in the suburbs and rural areas and saw patients with bizarre reasons for visiting the ER, I was totally unprepared and had to wing it.  Sometimes such improvisation wasn't difficult, but other times I'd scratch my head and was so stumped I couldn't even think of a diagnosis.  Every patient who visits an ER must have a diagnosis, but some people come in for non-medical reasons, such as a guy who wanted me to help him find a date.  How can I append a medical diagnosis to something like that?  He wasn't depressed, suicidal, manic, psychotic, drunk, or on drugs.  Basically, he was just horny and, like an increasing number of people, thought that the ER was the place to go when you have an insolvable problem.  Considering the fact that I can't find a girlfriend, I'm not the person to ask for dating advice.

Here is another reason why frequent flyers are a danger to themselves and society.  A friend recently told me about a patient who came to the ER 61 times in eight months.  She said there is nothing wrong with the patient, so they just put her in a room for a few hours until she decides to leave.  Time out.  Everyone dies sooner or later, and most of us experience a potentially serious medical problem long before we're ready to die of old age.  Therefore, not examining the frequent flyer is risky.  If something happens to her — and sooner or later it will — the ER doctor and hospital face the possibility of a massive lawsuit.  To make enough money to be set for life, all an attorney must do is get wind of the fact that this patient was entered into the ER log, request copies of her nonexistent medical records for that day, and then smile broadly as insurance companies write checks with a lot of zeros in them.  The fact that the patient was a frequent flyer and cried wolf too often is not a viable defense.  It should be to some extent, because it is human nature to discount people who repeatedly raise false alarms.  In a Court of Common Sense, her heirs might not have the chance to become instant multi-millionaires because the judge might say, "Sorry, tough luck.  Your mother abused the emergency care system.  She should have gone to the ER only when necessary.  ER personnel are already stretched thin, and it is understandable why they would ignore someone who habitually cried wolf.  The award is zero.  Let this be a lesson to the rest of you frequent flyers out there.  This is an imperfect world with an imperfect and overtaxed emergency care system.  Anyone who abuses the system does so at their own peril.  Court is now dismissed."

Should the ER be a "safety net"?
Will ERs of the future be "Access Centers"?
Goofy reasons for going to the ER

Q:  Don't you think that emergency rooms should be a safety net?  That is, a place for someone to go if they've fallen through the cracks of our healthcare system?  Loni

A:  Yes and no.  Yes if that person truly has a significant healthcare need that that can't be otherwise met, but no if that "safety net" is just a euphemism for an all-encompassing Welcome Sign to say it's OK for anyone to come to an ER for any reason.  As I pointed out in my book, more than a few people come to emergency rooms for reasons that are so goofy I had to bite my lip to keep from laughing.  Instead of being legitimate patients with legitimate problems, I had to strain my brain just to think of some semi-plausible diagnosis to put on the chart.  With rare exceptions, those people are the type who don't pay their bills, which means that you and I pay for their "emergency care."  Furthermore, those people harm legitimate patients in the ER because they often increase the waiting time for other patients.  Therefore, if you view those sham visits as a crime, they're not a victimless crime.

Many proponents of the safety net concept fail to understand that there are other healthcare resources, such as urgent care centers, that can meet the needs of a legitimate patient just as well as emergency rooms as long as that patient doesn't have some bona fide emergency.  Here is what I wrote in a discussion of this topic on an emergency medicine newsgroup:

Perhaps our first statement to patients presenting to the ER should be, "Welcome to the Emergency Department. What's your emergency?" Eventually, the message might get through to some people that we're there for emergencies. No doubt, some members of this list who think that we should gladly treat anyone who walks in the door will think that instead of asking patients what their emergency is, we should begin singing the old Burger King ad jingle, "Have it your way, have it your way . . ." :-)  For those folks, I have a question: wouldn't it make more sense for patients without emergencies to go to an urgent care center, or a walk-in clinic? The cost is less, the wait is usually much less, and the environment is considerably more pleasant. Speaking of the latter, I've worked at some ERs in which many patients in the waiting room and ER itself could see every trauma patient wheeled in by the paramedics. Perhaps the worst case was when a young child was taken to the ER because he sneezed once (no exaggeration, unfortunately), and that kid was treated to the sight of a man missing half his skull and brains trailing an unbelievably long streak of blood from the entryway to the Trauma Room — which was poorly placed at the back of the ER. I can think of about 1001 slightly less gory things that traumatized waiting patients — not to mention the frequent blood-curdling screams and profanity that often emanate from ERs. Perhaps we're acclimated to such noxiousness, but many of our patients are not. I've even seen adult patients with legitimate problems walk out of the ER because they were too traumatized by what they heard.

Rather than trying to discourage sham patients from going to ERs, some ER docs have thrown in the towel and embrace the concept of "access centers."  If this concept is fully implemented, it will further divert attention of emergency rooms away from their primary responsibility, which is to care for people with emergencies.

Unfortunately, this Access Center movement is gaining acceptance.  Thus, your grandchildren won't be watching ER on television, they'll be watching AC, or Access Center.  Let's take a sneak peek at a future episode of this show, based upon some of the "access-type" patients I've seen in the ER:

Nurse:  Good morning, doctor.  Here's your first patient.  She's really upset.
AC Doc:  Why?  What's wrong?
Nurse:  She's ticked about the fact that her hairdresser gave her a bad perm.
AC Doc:  But I don't know the first thing about perms, or perms-gone-bad!
Nurse:  But you're the AC doc, and she's in the AC!
AC Doc:  Oh, yeah, right.  OK, what else do I have?
Nurse:  In room #2, you a patient . . .
AC Doc:  (excitedly interrupting) . . . with a heart attack?  Major bleeding?  Something that makes me think what I'm doing is actually worthwhile?
Nurse:  Uh, no, sorry to disappoint you.  It's a 25-year-old man who wants you to help him find a date.

You're probably thinking that I made up these stories to dramatize my point.  Wrong.  Both of these goofballs — um, excuse me, patients — actually came to the ER and I saw them.  I've seen many more equally ridiculous "patients," and this trend of anyone going to an ER for any reason seems to be getting worse all the time.

As I've said before, I've never begrudged treating any legitimate patient even if that patient didn't have insurance and couldn't pay.  However, after years of attending to people who came to the ER for odd reasons, I've grown weary of all the sham visits.  I think most laypeople think that what burns us ER docs out is the intense cases like heart attacks and gunshot wounds.  Nope.  Those cases are easy to manage because I could treat those patients by doing what the textbooks say.  The tough cases, and the ones that are so draining, are the ones for which there is no pat medical treatment.  Imagine that you own a restaurant, and the government legally obligates you to take care of anyone who walks in your door.  If they're hungry and want a meal, you're all set.  But what if their car broke down, and they expect you to go fix the engine?  Not exactly your line of work?  Tough luck.  The government says you must help, so get going.

In retrospect, I wonder if that 25-year-old who wanted a date came to the ER because he thought I'd set him up with a single nurse.  As we all know from watching TV, nurses are usually nymphomaniacs, right?  Of course, I'm being facetious about the last part, but now that I think of it, it wouldn't surprise me that what he had in mind was a nurse twixt his sheets.

Are American medical schools the best?

Q: Are foreign med schools really of lesser quality than US schools, or is that just another US stereotype?  Rachel

A: There are some excellent foreign medical schools, but in general an average foreign medical school isn't as good as an average American medical school. That asseveration will undoubtedly anger some foreign medical students, so I'll substantiate my opinion by mentioning a few facts:

1. Many foreign medical schools accept students directly out of high school. American medical schools traditionally require applicants to possess at least a 4-year college degree, and that isn't a superfluous requirement. If American medical schools accepted 18-year-old high school grads, almost all students would be overwhelmed by the intensity.

2. Many foreign medical schools have lax admission standards, often no more than: Do you have a pulse? Can you pay our tuition? In contrast, American medical schools are so selective that even bright, hard-working students can get ulcers worrying about whether or not they'll be selected.

3. Judging from my personal experience as an attending ER physician teaching graduates of both American and foreign medical schools, I was surprised — actually, stunned would be a better word — by some amazing gaps in knowledge and procedural skills by foreign grads. I described elsewhere in my web site the one American grad who didn't suture correctly (actually, he could place the sutures just fine, but the numbskull refused to use sterile technique). The suturing skills of foreign grads were often so poor that I'd sometimes need to remove all of their sutures and do the procedure myself (the hard part was explaining to the patients why I needed to remove the sutures that Dr. Pablo just placed, and do the entire procedure all over again).

My dismay over their suturing skills paled in comparison to the horror that engulfed me when I'd see a typical FMG (foreign medical grad) try to place a central IV line. Or I could point to their sometimes glaring lack of common sense. A case in point. During a long code, I had to leave the patient in the hands of the FMG medical resident so I could attend to other patients in the ER. When I popped back in the room, it had a pronounced odor of burnt flesh due to the fact that the FMG would order some drug and immediately shock the patient after it was administered — even before the drug entered the patient from the IV line. I explained to the resident that he'd have much better luck defibrillating (shocking) the patient if he let the drug circulate for a bit. The end result was that the patient was shocked so often that he began to cook, just like a huge turkey. Miraculously, the patient survived.

How do I find the time to write and invent?

Q: I looked at some of your inventions on your web site.  How do you find the time to do all the interesting things that you do in addition to writing? I though ER docs had no life?

A: I've been asked that question many times!  In a nutshell, here's my answer:

-- I was able to do a lot of writing while working at one of my prior jobs since that ER was fairly slow during the night shift.
-- Even though my career average is about 40 hours of work per week, that's usually done in three days, thus leaving me with a 4-day "weekend" every week.
-- I don't do many typical "guy" things, like watch sports on television.
-- I'm not yet married, and I have no children.  However, at my last house I became very close with one of my neighbors and their kids, and we'd do a lot of things together such as snowmobiling, boating, bike riding, baking cookies, playing baseball, and eating pizza—sort of blows my image of being a health expert, huh?
-- I've been told that I'm incredibly energetic.  Sometimes I just feel like vegging out, but I usually keep fairly busy.

Is there a need to expand access to ERs?

Q: What do you think of the talk by politicians to expand access to the ER?  During his term as President, Mr. Clinton has said that he'd like to make it easier for people to make use of ERs.  Now that Bush and Gore are vying for the Presidency we're hearing more of this talk.

A: I think it's a bunch of malarkey.  Anyone can walk into an ER for any reason, and that's true if the person is rich or poor, a citizen or a non-citizen, and regardless of whether or not he has an emergency or even anything that could be construed to be a medical problem.  For example, I've seen people come to the ER because they were horny, or because they wanted a date, or for dozens of equally ridiculous reasons.  In short, there is no barrier that keeps people out of emergency rooms.  So Clinton wants to lower the threshold for emergency care?  How much lower can it go?

Saving money on ER & hospital bills

Q: I have a job that does not provide medical insurance.  Do you have any tips for saving money on emergency room or hospital bills?

A: You bet I do!  Let's begin by seeing how you can reduce an existing charge, then we will look at other ways of saving money on healthcare.

If you pay your own hospital bills, here's a tip that can save you a lot of money.  Hospitals tailor their inflated charges to insurance companies who, in turn, habitually pay less than 100% of the bill.  Although they will never admit it, hospitals are tickled to death when they receive 70% of their charges.  Hospitals may act as if they expect people not covered by insurance to pay their entire bill, but is this fair?  Of course not.  They would then be paying even more than the insurance companies. Let's take a look at a real-life example of this.

I took my brother, who required a minor surgical procedure, to the ER.  Except for the registration, I did everything:  the surgery, the medical and nursing notes (doctors can do them, too), and the discharge instructions and paperwork.  I even cleaned up after myself!  The hospital contributed a suture kit that cost them $15, and a few miscellaneous items.  Cost to them?  Less than $25.  Cost to my brother?  $750.  (That was just the hospital bill. Someone who did not have a doctor as a friend or relative would be stuck with physician charges as well, but I did the procedure free, of course.)

$750?  That's unconscionable!  I told my brother to offer the hospital two-thirds of their bill as payment-in-full, in a note explaining that they would be lucky to collect that much from an insurance company.  Did they pester him for the remaining $250?  Nope!

Another way to reduce—or eliminate—an existing charge is to write a letter complaining about some aspect of the service.  To mollify you, some hospitals routinely reduce or eliminate your bill if you have an apparently legitimate or at least semi-plausible gripe.

Now let's look at a few ways of avoiding charges by avoiding the need for treatment in an ER or hospital:

Educate yourself:  While watching quiz shows on television or listening to people recite sports statistics from eons ago, I am amazed by the amount of trivia that people know.  I am also amazed by how little the average person knows about medical care.  The number of misconceptions is rather amazing, too.

It doesn't take a rocket scientist to learn basic healthcare.  Since you won't be writing your own prescriptions or performing your own major surgery (although some people try this!), you won't need to spend a decade or more learning medicine, as doctors do.  You can learn all you need to know by reading a book of tips on ways to stay healthy, such as my book Fascinating Health Secrets.  (Please pardon the shameless plug, but I have yet to find another book that is packed with more useful information.)  Actually, after reading that book you will know more than a doctor about ways of maintaining and improving your health; most of the information learned by physicians is directed toward the diagnosis and treatment of disease, not its prevention.

Treat yourself better than your car, boat, or favorite inanimate object:  Here's another thing that amazes me:  the number of people who obsess over every little detail of their car, house, yard, or you-name-it, yet treat their body as if it were a disposable item.  While waiting in line at the supermarket I often look at what other people purchase.  After doing that for years, I know that most people fill themselves with processed junk and nutritionally vacuous foods.  For example, very few parents know what fruit juices are good for their kids, and which are not.  Considering how much juice kids drink these days, it seems to me that it would be a worthwhile investment for a parent to take 30 seconds to read about this topic.  Another example:  people eat too many foods made with white flour and very few foods made with whole wheat or other whole grains, such as oats. 

By the way, don't think that a bread is whole wheat just because it's brown.  Food manufacturers often trick customers by adding dye to make a bread look like it is whole wheat.  Another trick they use to thwart customers who read ingredient labels is to call flour "wheat flour."  Well, how much flour isn't made from wheat?  Not much.  By calling it "wheat flour" they're doing their best to approximate it to the term "whole wheat flour."

Research has shown that people who eat more whole grains are less likely to develop diabetes or die of a heart attack than people who think that "enriched" white flour is good enough.  It isn't.  Imagine that I steal $100 from you, and return $20.  Am I enriching you?  Hardly!  The same is true of "enriched" white flour.  It is processed until its nutritional content is only slightly better than that of Styrofoam, then a few vitamins and minerals are tossed in—that's the so-called "enrichment."  What they fail to add are a number of equally important vitamins, minerals, and other essential nutrients that were found in the original grains.

Yet another example:  people consume FAR too many trans-fatty acids.  Your intake of these should be zero or next to zero since they are as foreign to your body as water is to your car's gas tank.  Besides raising your cholesterol level, trans fats are incorporated into cell membranes.  If you'd had biology, you know that cell membranes influence directly or indirectly just about everything that goes on in the body—everything from influencing your sex life and mood to your SAT score and the beating of your heart.

Besides eating the right foods, it is important to avoid obesity.  Unfortunately, the incidence of obesity is at an all-time high, and it's getting worse every year.  Obesity predisposes people to a number of diseases such as diabetes, high blood pressure, heart attacks, arthritis, and cancer.  Because it takes so much money to fight those diseases, the current epidemic of obesity is one of the reasons why our healthcare costs are soaring.

Parenthetical comment:  Now that we're in a Presidential election year, pharmaceutical companies are being whacked around like a piñata as if they're the primary factor responsible for the upward spiral in healthcare expenditures.  Sure, the latest and supposedly greatest drugs are overpriced, but some older and still effective drugs are true bargains.  For example, one of my brothers needs to take a life-saving drug that costs a whopping $4 (yes, four dollars!) per year.  OK, that drug needs to be injected, so let's factor in the cost of the syringes, alcohol prep pads, and Band-Aids.  Even after all that, the yearly cost is still less than $10.

By the way, you are not necessarily better off by taking the latest drugs.  Some of their supposed advantages are nothing more than hype drummed up by overly imaginative marketing gurus, who—by using an endless parade of trinkets and stunningly beautiful women as drug reps to hawk their high-priced products—dupe doctors into believing their propaganda.  Furthermore, a distressing number of new drugs prove to be more toxic than their tried-and-true alternatives.  In their eagerness to make money, pharmaceutical manufacturers sometimes turn a blind eye to these problems and hope that the profits generated by drugs sales will more than compensate for money lost through various lawsuits.  By taking new drugs, you are in effect an unpaid guinea pig.  If you value your health you are better off by sticking with a drug that has withstood the test of time unless there is a very compelling reason to choose the new drug.

Recently, one of the major weekly newsmagazines had yet another "drug costs are out of control and we've got to do something about it" article.  A portly couple were pictured above a tally of the drugs they took and their cost.  They were taking a number of drugs to combat diabetes, high blood pressure, and arthritis—not coincidentally, all of those are diseases in which obesity plays a major role.  Why doesn't someone suggest the obvious thing:  lose weight?  If they weren't overweight, their drug bill would be zero or very close to it.  However, it's not politically correct to assign personal blame to patients for contributing to their illnesses.  Instead, a politician must point the finger at an external target—in this case, a drug company.

By eating right, avoiding obesity, exercising, not smoking or using drugs, limiting alcohol consumption and risky behavior, our collective health would be so great that doctors would be standing in unemployment lines.  Let's not forget that fact:  while doctors give lip service to health promotion, they'd be as glad to see all of their patients healthy as a prostitute would be to see all of her customers suddenly become devoutly religious and moralistic.

Full-moon madness?

Q:  Enjoyed your site.  My query is, is there any empirical evidence to support such things as a higher incidence of ER trauma at the full moon, or after major sporting events?  (Going back to the idea that men would get drunk and abuse their family after the Super Bowl?)
Thanks!  Irene

A:  There is certainly lots of anecdotal evidence which links full moons with an increase in the ER activity—not to mention that the cases tend to get stranger around those times, too.  As you may have noticed I discussed this on my web site (on the main Q&A page).  There are also numerous examples throughout history in which violence immediately follows some emotionally-charged sporting event.  Some authors have attributed this to the well-documented testosterone surge that occurs in males who either participate in a sporting event and win, or who are fans of the winning team.  Personally, when I have a testosterone surge I have something on my mind other than joining a mob of crazed sports fans and participating in a riot.

I don't think that fluctuation in testosterone levels explains the rowdy behavior because those who lose (either as a participant in a sporting event, or vicariously as a spectator) experience a drop in testosterone levels, yet those people are no less inclined to engage in disorderly or destructive behavior than are the winners.

She wants immediate treatment?  OK, let's take some money from Britney Spears or Bill Gates and give it to doctors and nurses . . . then she won't have to wait

Q:  During a 24 hour shift in the Emergency room, how many doctors are on-call?  Since so many people go to Emergency rooms for a simple cold or fever what do you call an emergency?  Personally I think a hospital does not have enough doctors in the ER to separate the patients between severe and mild cases and let the ER run smoother, why is that?  Do we just don't have enough doctors today or do they want to get paid more to work night time?

I have so many questions that I couldn't find in your Q&A.  I'm a soldier and I have a persuasive speech do soon and my topic is that there are not enough doctors in the ER and it takes too long to get treated.  If you could answer some of my questions and tell me more.  Sincerely, Aleksandra

A:  Hi Aleksandra,

> During a 24 hour shift in the Emergency room, how many doctors are on-call?

In most ER's there are technically no ER doctors on-call.  Whomever is working in the ER at that time is THE emergency room doctor.  Every hospital maintains an on-call roster of specialists, ranging from Internal Medicine and Pediatrics to Neurosurgery, but those physicians participate in patient care only after the referred patient has been treated by the ER doctor.

> Since so many people go to Emergency rooms for a simple cold or fever
> what do you call an emergency?

I term an emergency anything that is life-threatening or may result in permanent disability if not promptly treated.  Also, it is appropriate to say that certain painful but not life-threatening conditions (such as kidney stones) are emergencies.  Judging from what I see patients coming to the ER for, there is absolutely nothing that people do not term an emergency.  I've seen people come to the ER because of a single uncomplicated mosquito bite or because a person sneezed once.  You think that's silly?  I've even seen patients in the ER because they wanted me to help them get a date!  If you've read my book, you'll know that I'm just scratching the surface with this list.

> Personally I think a hospital does not have enough doctors in the ER to
> separate the patients between severe and mild cases and let the ER run
> smoother, why is that?

Several hospitals do in fact have such appurtenances as you describe, and they're generally termed a "fast track" or an urgent care center that is sometimes, but not always, adjacent to the true ER.

> Do we just don't have enough doctors today or do they want to get paid
> more to work night time?

In general, anyone who works a night shift should be handsomely compensated for their sacrifice.  People who work night shifts typically live a few years less than people who work day or afternoon shifts.  Furthermore, night shift workers often have their entire personal lives permanently disrupted as a result of their work.

Do we have enough doctors?  It's easy to debate both sides of that equation.  Rather than increasing the supply of doctors, I think it would be better if people took better care of themselves so that fewer doctors were needed.

> I have so many questions that I couldn't find in your Q&A.  I have a
> persuasive speech do soon and my topic is that there are not enough
> doctors in the ER and it takes too long to get treated.

Yes, it sometimes does take too long to be treated in an ER, and that's primarily because ER directors have no way of knowing in advance how busy a shift will be.  The ER may be empty at 11 P.M. and have 100 patients in it by midnight.  How can you schedule for such variation?  It would be nice if there were four times as many ER doctors always working so that no patient would ever have to wait to be treated, but unless society is willing to pay us more (and they aren't), we'd have to work for 4 times less money per hour.  Ask anyone if they'd still work at their job if their pay was cut by 75%, and I think you'll find that almost no one would continue that job.  As it is, ER doctors have one of the toughest and most stressful jobs in the world, and to cut their pay would be an insult.  I'm sure some ER docs would be willing to work more if they were paid for it, but who would pay them?  The government?  Insurance companies?  Your parents?

If someone is willing to pay, he won't have any problem finding a doctor who is willing to immediately treat him or his loved ones.  Anyone who doesn't want to wait for treatment in the ER is free to contact the ER doctors that staff that hospital and arrange to privately call them whenever they're needed.  Interestingly, this topic was recently debated on one of the Internet Emergency Medicine newsgroups to which I belong, and some of the docs said that for $500 they'd be happy to rush to the ER to take care of any patient who didn't want to "wait in line" (so to speak).

Now before anyone accuses those doctors of being greedy, take a look at what other people are charging.  Bill Gates has taken billions of dollars from people and in return given them buggy, quirky software that is oftentimes so frustrating to use that it recently provoked one computer magazine columnist to say that he'd like to lob some grenades toward Redmond, Washington (home of Microsoft).  And take a look at sports stars.  Why do tickets cost so much?  Why do the tennis shoes and other stuff they endorse cost so much?  Because sports stars insist upon being paid more than kings—and, by the way, far more than doctors.  Some businessmen make more in a day than doctors do in a year.  And guess who pays those businessmen?  You and I do whenever we buy something.  My point is this:  society attaches a certain value to the goods or services produced by an individual, whether they're a doctor or a guy who is paid hundreds of millions of dollars for knocking a ball in a cup.  In my opinion, society's values are skewed, and people who arguably do very little (and certainly NOTHING important, such as a sports star) are paid far more than doctors.  Hence, if people don't want to wait for treatment in an ER, the solution is simple:  take the money that's now being paid to people who do nothing of true value and give it to the medical and nursing professions.  They'll increase their supply, and everyone will receive immediate, topnotch treatment.  However, society has already spoken, and they've told doctors and nurses that they are considerably less important than sport stars and scantily-clad teenage singers who can barely sing.  Those are not my values, and judging from your message I don't think those are your values, either, but that's the way it is.

Q:  Aleksandra responds:  Thank you very much for replying to my questions, if I had met you in person I'd try to debate with you on ER doctors.  I still don't understand why you'd want to be paid overtime.

A:  Well, comrade, who doesn't want to be paid overtime?  In the United States there's a law which stipulates that people be paid at least time-and-a-half for working overtime, but there are exceptions.  For example, there appears to be a loophole so that doctors are paid only their usual rate, not 150% of their rate as everyone else receives.  Yet that's apparently not good enough for you, and you'd like doctors to work overtime for free.  Is that a realistic expectation?  If you think it is, please come by my house this summer because I have a LOT of work to do outside and I'm so happy that I've met someone who believes that people should work for free!

All silliness aside, let's examine the long-term consequences of what you seem to be proposing, which is that doctors should work for little or nothing.  If that were the case, do you think that smart people would still apply to medical school and sacrifice the best years of their lives while working 110 hours per week during medical school and residency?  No way!  As I've said before, do you really want a neurosurgeon with an average IQ poking around inside your skull?  Of course not!  When you need medical treatment you want the brightest possible person to take care of you.  However, if we were to follow your wishes, which strike me as socialist dogma from one of the world's great utopias such as Russia, anyone with an IQ of 140 who could be a neurosurgeon would very likely choose another career in which he'd be fairly compensated.

Here's another point you should consider:  if you make something free, the demand for that product or service becomes essentially infinite.  If doctors worked overtime for free, there would be such an increase in demand for medical services that doctors would never sleep.  Inspired by your statement, I asked 5 people to make a list of what they'd want done if doctors would treat them for free.  Those 5 people collectively came up with 117 things they'd like done, ranging from breast reduction to removing a facial mole to investigating "why I've been so gassy lately."  If McDonald's gave away Big Macs and other sandwiches, it wouldn't have taken them decades to sell 100 billion—they could have given away 100 billion in less than a year!  Why don't you send an e-mail to the Chairman of McDonald's and suggest that he give away free food?  I'm sure he'll be happy to hear from you!

As it is, doctors DO give away a lot of free medical care.  The last time I kept track, I gave away over $70,000 of care in a year.  Compared to my income, that's a huge proportion!  Can you name one other profession that gives so much for free?

ER 101

Q:  When were emergency rooms originated and what are some duties of hospital emergency rooms?

A:  Modern emergency rooms have existed for only a few decades.  By "modern" I mean an ER continually staffed by physicians trained in emergency medicine.  Prior to this, emergency rooms were generally staffed by interns and residents.  I used to work as an attending physician in a teaching hospital, and I know that while a few residents are reasonably competent in treating emergencies, most residents are not.  I suppose that people living in those bygone times must have had an incredible tolerance for emergency-related mortality.

What are the duties of hospital emergency rooms?  Primarily to treat any patient with a medical, surgical, or psychiatric emergency.  However, most ER patients do not have emergency conditions.  Some have urgent conditions (e.g., a cut), some have understandable reasons for wanting immediate treatment (e.g., a sore throat), but many patients visit the ER for unfathomable reasons (e.g., patients who want help in finding a sexual partner).  Gee, with so many dating sites on the Internet, who needs an ER doctor to find a date?

Was it really me?

Q:  Were you personally involved in all of the cases in your book?

A:  Of course not.  Many contributors wished to remain anonymous, and rather than saying "Here's another story from an anonymous contributor" and "Here's yet another story from an anonymous contributor" I thought it would be better to inject a uniform identity (me!) into those stories.  Admittedly, my disclaimer is a bit nebulous:

Names in this book were changed to protect the confidentiality of patients and contributors who requested anonymity. The first person linguistic presentation used herein is a means of effecting literary cohesion and avoiding exhaustive repetition of attributing stories from anonymous contributors, and hence should not be construed as being applicable in all cases in a literal sense.  Translated from the legal mumbo-jumbo:  I, me, myself, or Dr. Pezzi might not necessarily refer to me but instead to an anonymous contributor.  I've had an interesting life, but it's not been that interesting!

In retrospect, it probably wasn't a great idea to use that first person linguistic presentation since it led people into making some mistaken assumptions about me, but that's something I can change in subsequent books.  Live and learn, right?

Does medical knowledge diminish belief in a Creator?

Q:  Kevin,
Thank you so much for the response on my other question.  I really appreciate it.  I'd be fascinated to know what ideas you have about religion/God, and perhaps Christianity itself.  Does knowing all the intricate details about the human body somehow diminish any sort of spirituality, or perhaps encourage it?  I'm intrigued.  Thank you again.  Cindy

A:  In my experience, knowing the intricate details of the human body did not diminish spirituality whatsoever.  In fact, it had the opposite effect.  Before medical school, I didn't believe in God.  I assumed the scientific theories of evolution were the sole explanation for how mankind developed, and that the ultimate genesis of all living organisms was a chance event which occurred in some primordial "soup" that scientists are still speculating about.

However, as I learned in medical school how incredibly intricate the human body is, I realized the improbability of all this developing by chance.  Frankly, I didn't understand how it was possible.  I can understand how genetic mutations can occasionally produce beneficial changes that are favored by the process of natural selection; this phenomenon is operative today and it is inescapable.  However, I think that this mutation/natural selection process of genetic advancement fails to explain major improvements as opposed to progressive incremental improvements.  For example, the first blob of life, as scientists understand it, was a very primitive one-celled organism that did not have DNA, RNA, or other highly complex and advanced components that are in our cells.  I asked myself, "So how did DNA arise?  Was it just a mutation?"  If so, that still does not explain how DNA became the operative repository for the structural and functional aspects of life, since DNA by itself is worthless.  For the DNA "message" to be translated into proteins, DNA needs messenger RNA, ribosomes, and countless other "ingredients" to make sense of the DNA code and then transform that into useful proteins.  If just one element is lacking, the rest of the parts are worthless.  It's like removing one chip from your computer:  even though it is almost intact, it won't work.

I suppose scientists may attempt to explain this quandary by postulating that the various elements sort of "waited around" for all of the parts to be formed.  I don't agree with this.  To begin with, every living thing that I know of seems to be programmed to get rid of useless baggage, so to speak.  Evolutionists must agree to the veracity of that statement, since evolution produced countless structural and functional variants that proved worthless and hence were "pruned off" or discarded.  If we maintained the remnants of these failed "experiments," life would have long ago morphed into strange, highly dysfunctional and bizarre organisms that wasted most of their energy maintaining these useless vestigial parts.  Yes, we do have some vestigial parts (e.g., the appendix), but those are the exceptions, not the rule.  Even body odor (and its attendant pheromones) plays an important role.  Have you heard the historical tidbit about Napoleon beseeching his wife Josephine not to bathe before he returned from battle?  In addition to his political notoriety, Napoleon seems to have been one of the first people to key in on the fact that the chemicals in body odor play a role in sexual attraction, libido, and sexual pleasure.

Consequently, I think the only plausible explanation that evolutionists can suggest is that major subsystems of life (such as information encoding/decoding as expressed by DNA/RNA and its complementary components) arose essentially intact.  But what is the chance of that?  That's about as likely as randomly throwing a bunch of chips together and having them form a computer that somehow understood the code for running Microsoft Windows.

In sum, I think there are significant reasons why the subsystems of life could not pop into existence fully formed and functional, and I also think there are significant reasons why life would never tolerate the perpetuation of parts of these subsystems, waiting for the day eons in the future when the last piece of the puzzle would be formed and that subsystem will at last be functional.  Until that last piece is present, all of those other parts were just useless baggage.  Hence, natural selection would select against them, not for them.

This is but one reason why I think life as we know it did not arise by chance.  If I had the time, I could fill a book with other reasons.

Are ER doctors social misfits?

Q:  My aunt, who works at a hospital in NC, says that most ER docs have no social skills and the majority have personality disorders.  Did you find this to be true?  Thanks again for your time.  Cindy

A: Yikes, what an extreme statement!  No social skills?  Personality disorders?  Does your aunt have an axe to grind?  Did an ER doc dump her or something?  I can't imagine why someone would make such a broadly-directed negative statement.

No, I do not think that most ER docs have personality disorders and no social skills.  I think that most ER docs are often rushed and, given the nature of their work, when they're sufficiently rushed they cut back on social  pleasantries.  Let's say that your aunt is the next patient to be seen, and she's having crushing substernal chest pain—maybe the "big one"—a massive MI or "heart attack."  Would she prefer that the ER doc, now seeing another patient with chest pain, warmly introduce himself to that patient, shake his hand, and exchange introductory greetings with that patient's wife and family members who are by his side?  Does your aunt want that ER doc to patiently wait—never interrupting, of course, because that's rude—while the patient, his wife, and other family members ask questions about the diagnosis, treatment, and prognosis?  Heck no!  Your aunt wants that doc to skedaddle out of there in a heartbeat—no pun intended—and see her!

Do you see what I'm getting at?  Given the choice between saving more lives or being a laid-back nice guy, most ER docs would choose option #1.  They're more than willing to be nice if permitted by time and circumstances, but these days ER docs are often rushed from the minute their shift begins until three hours after it ends.  The pragmatic need to curtail social pleasantries while rushed may lead some people to the mistaken conclusion that ER docs aren't nice guys.

Let's take a look at some of my behaviors on each end of the "nice continuum."  On one extreme of this continuum, I can be very nice.  I've made patients get-well cards.  I'd play with their kids and give them scratch 'n' sniff stickers I bought.  I'd sing songs for children.  I'd show them gizmos I've made.  I'd give them pizza if I'd ordered some for myself and the ER nurses.  I made baked goods for them.  I'd give them free drugs from my personal stockpile.  I'd make housecalls for free to check up on how they were doing.  If they were admitted, I'd sometimes visit them.  I'd give them free books (and not just ones I've written, either).  I'd make them assorted presents.  I'd give them my home phone number so they could call me at any time if they had questions.  And yes, I'd even shake their hand, smile, and introduce myself.  Now tell me that your aunt is any nicer than this.

On the other extreme of this continuum, I could—if circumstances warranted it—be very abrupt.  "Just the facts, ma'am—no need to tell me a long story about what your waiter told you on your last trip to Jamaica."  Some patients have no idea that other patients are waiting, and if I gave them all the time they wanted I could listen to some of them for hours and still not have a complete medical history.  So if I'm abrupt does that mean I'm not a nice guy, or does that mean that I care more about results?

Comment from a reader who read the above question & answer:  "Great answer to a very bizarre question.  I don't know if you'd be able to change the aunt's perspective; however, the niece (naive and gullible as she may be) has no reason to perpetuate the aunt's philosophy on ER docs.  I'm still trying to figure out where she came up with the personality disorder diagnosis, though.  I can understand her misinterpretation of brusqueness as a lack of social skills ... but personality disorders?  I could understand thinking that about a mortician ... or a porn store manager ... or perhaps even a proctologist ... but an ER doc?  Go figure."

Misuse of emergency rooms

Q:  Do you have any input on the problems with people using the ER for medical problems that are not warranted as "emergency" or should be seen in a PCP (primary care physician) office?  Lauren

A:  Yes.  There is no question that most ER patients do not have an emergency, or anything that could be reasonably construed to be an emergency.  I understand why someone would go to the ER with a painful sore throat, for example, if that person couldn't get an appointment with their doctor the next day, but I've seen many ridiculous ER visits.  Here are just a few:

-- A woman complained of itching, which she'd had for about three years.
-- A man wanted me to help him get a date.
-- Another man brought his ex-fiancée with him to the ER (she'd just dumped him) so that I could convince her that she should marry him.  (Incidentally, I didn't even try!)
-- A woman complained of a bad hair perm.
-- Another woman called 911 and came to the ER via ambulance with her husband because she wasn't sexually gratified while having sex with her boyfriend, a crack dealer.  She wanted to know if the reason why he could not satisfy her was because he was on crack and therefore couldn't last long enough, or because her vagina was too loose.
-- A woman complained of feeling full after eating a very large meal.
-- A person complained of itching around the site of a single mosquito bite.
-- A man came to the ER complaining of chills he'd experienced during a cold shower that resolved after the shower.
-- Another man complained of passing gas.
-- People who want me to refill prescriptions they obtained from their personal physician.
-- A woman wanted me to diagnose her problem in spite of the fact that the super-specialists at the Mayo Clinic could not figure out what was wrong with her.

During one night shift I saw about 22 patients, all of whom presented with wacky reasons.  Unless such ER visits were reasonably prevalent, such an agglomeration of wacky ER patients would virtually never occur.  For example, if 5% of patients came to the ER for wacky reasons, the chance of seeing 22 in a row is 0.0000000000000000000000000000238.  With odds like that, it makes winning the lottery seem like a sure bet.  My point in mentioning these statistics is to show that the only reasonable explanation for seeing 22 wacky patients in a row is that their prevalence is far higher than 5%.  In fact, that's borne out by my experience, and the experience of other ER doctors.

Different people react in different ways to this problem.  Some are outraged by the monetary waste, while others simply are amused by some of the wacky visits.  One of the most serious consequences that is rarely appreciated is that such wacky ER visits, in addition to visits that are prompted by more legitimate but still not urgent problems, clog up emergency rooms and divert attention away from legitimate ER patients.

Impact of ER staff shortages

Q:  Hello my name is Tracy, and I have an essay due soon.  I am writing about the current staff shortages in the emergency room and the toll it takes on the doctors and nurses, physically as well as mentally.  My question to you:  do you feel that there is enough medical staff to cover all the patients in ER?  And how do you feel about the staff shortages and the dangers that could come to patients due to the current shortage of medical staff?

A:  > Do you feel that there is enough medical staff to cover all the patients in ER?

At times there are, but there are many times in which we're dangerously understaffed.  For example, I've had times in which I've run three codes at once!  Running any one code is stressful enough, but running three at a time is a nightmare for both myself and the patients involved.  Why?  Running a code involves more than just ordering medications and doing procedures such as intubation or central venous line placement.  To run a proper code, it's critical to monitor the patient's response to the meds and other interventions.  Besides almost constantly watching the cardiac monitor that displays the heart's electrical activity, I check for pulses and monitor the efficacy of the cardiac compressions and ventilation performed by other members of the resuscitation team.  In short, running one code is sufficient to keep me totally occupied.  Now try running three codes at once . . . what happens?  Inevitably, I have to cut corners on each patient and "dilute" myself by spreading myself between those three patients.  It's either that, or arbitrarily decide that I won't work on one or two patient(s); therefore that patient/those patients will die.  I don't like to play God in such a manner, so I spread myself between the three patients.

> And how do you feel about the staff shortages and the dangers that could
> come to patients due to the current shortage of medical staff?

I think it's bad for the doctors and nurses, since it tends to burn us out sooner.  It's obviously bad for the patients, too.

Incidentally, in the near future I'll be posting an interview on my web site that addresses this topic in more detail.

More patients but less staff.  Is this the recipe for quality care?

Q:  Greetings!  I came across your website while researching the topic of ER's for a freelance article I am writing for a newspaper.  The problem in this area seems to reflect a national trend of ER usage increasing while beds & staffing decreases.  What, in your opinion, is the future of trauma care & emergency rooms in the United States?  Shelley

A:  Hi Shelley,

We have the same problem in Michigan.  Typically, in this area ER utilization increases by about 15% per year, which is substantially greater than the rate of population expansion.  Obviously, 15% more emergencies are not occurring every year; the explanation for the startling increase in ER volume is that in the minds of ER consumers the threshold for what constitutes a legitimate reason to visit the ER is progressively lowered every year.  Considering some of the inane reasons that cause some people to go to an ER (see above), I wonder how much lower that threshold can go.

> What, in your opinion, is the future of trauma care & emergency rooms in the United States?

Unless hospital administrators relent and increase staffing, I don't see any way that ER personnel can stretch themselves to care for an ever-expanding number of patients.  I've worked in ERs in which I often had to do everything as fast as I could:  write, talk, dictate, read x-rays and EKGs, do procedures, and run (literally) to see the next patient.  Somehow I survived in that pressure cooker for 5½ years, but it was an extremely noxious place to work.  We tried to recruit new physicians, but several board-certified ER doctors worked with us for anywhere from a day to a week before deciding that they wanted an easier job.  Who could blame them?  We were very well paid at that hospital, but money cannot compensate for a hellacious existence.  Furthermore, patients deserve first-rate care, but the only way to survive as an ER doctor when you're stretched beyond your limits is to cut corners.  Unfortunately, cutting corners as a coping mechanism has been so institutionalized in many ER doctors that they habitually cut corners even when the ER is not particularly busy.  In fact, during one lecture a noted ER doctor advocated to his colleagues in the audience that they should cut corners all the time so that they wouldn't upset their routines.  I think that it is reasonable to limit behavioral repertoires to simplify learning for animals, but anyone intelligent enough to be an ER doctor presumably possesses the mental wherewithal to have a more adaptive and expansive range of behaviors.  Therefore, I think that ER doctors should cut corners only when there is no alternative, but to routinely do that is lazy and reprehensible.

Reply from Shelley:  Thank you so much for the information.  I do see the future of ER's as more than just a financial issue, it is scary to read about these matters in-depth.  Also as for the misuse of ER's, I would hate to be intimately involved with that.  I can see where the ER physicians would become jaded!

Do I ever sleep?

Q:  I came across the web site for your book and then went to your personal site.  I just want to know when you have time to sleep?  Do you do something special to give you energy or is it just natural?  I know exercising helps.  But man, with all your hobbies, book writing, working, and inventions, it seems like sleep just doesn't play a part.  I'm totally not being facetious, I'm really interested in knowing.  Thanks, Trish.

A:  Hi Trish,

No, I don't take anything to give me energy.  I just try to make productive use of my time until I meet someone that I want to marry . . . then I'm sure I'll find more enjoyable ways to spend my free time!

Choosing a specialty / Med school tips

Q:  Dr. Pezzi,

I feel compelled to drop you a line and say that I *thoroughly* enjoyed reading your website tonight.  I love how you call things as you see it; you certainly don't airbrush the blemishes of being an ER doctor.  I've already placed an order on Amazon.com for your ER book.  I found your site by chance while looking for information about life as an ER doctor.  I'm going to be a M1 at Northwestern Medical School this Sept.  I know it's early to be contemplating what specialty I should pick, but I've always had a strong desire to be an ER doctor.  However, after reading your site,  I'm going to think long and hard about my decision.  Thanks for your frank observations.  Other sites don't give the real deal like you do.

I'm curious about what you think of other specialties.  I know you said if you could pick your specialty again, you would have chosen plastic surgery.  But what about other fields, such as radiology?   I'm curious as to your opinions of radiology since I hear many good things about it.

Regards,
George

A:  Hi George,

Thank you for your comments.

Radiology is a good choice, too.  I also think that dermatology would be a very tolerable specialty, but it was too sedate for me at the time I was in medical school.  However, many dermatologists are now performing liposuction, hair transplants, and laser skin resurfacing, so that specialty is more interesting than it once was.

I think the basic problem with emergency medicine is that ER docs get "beat up" (figuratively speaking).  When you're young, it's fairly easy to muster enough adrenaline to keep up with the demands of working in a busy ER, but after several years the incessant need to work in overdrive becomes increasingly noxious.  Hence the staggering dropout rate for emergency medicine.

If you do decide to go into ER, let me know and I'll pass along some of the lessons I've learned (the hard way) that will hopefully make your life somewhat easier.

Dr. Pezzi,

Thanks for sharing your thoughts.  I've always been attracted to the idea of being an ER doctor for several reasons.  I like the power that ER doctors have -- they're sort of like generals manning the station and leading the troops.  I also like the element of surprise -- ER doctors can never be quite sure who will be sent their way.  But most importantly, ER doctors sort of act like God.  They can, through superior technique, snatch a patient that seemed destined for the claws of death.

But then again, the above is really just a figment of my imagination and daydreaming.  Reality doesn't often coincide with the movies that we visualize in our heads.  Thanks again for your honest portrayal of life as an ER doctor.  I don't know what I'll end up picking as a specialty in four years, but if I choose ER, I will definitely ask you for pointers.  :-)

By the way, I noticed on your website that you graduated second in your medical class and attained AOA acceptance after your sophomore year in medical school.  That is quite impressive.  Any advice on how to ace medical school?  I know in your Q&A you listed some tactics for college, but I was curious if you had any advice for medical school?  You recommend Lorayne's memory book.  I've read that book, but I've never been diligent enough in actually trying to use the various systems he has.  You also mentioned reading ahead for class.  Would that same advice hold true for medical school?

Thanks a lot for your time.

> Any advice on how to ace medical school?

I think the most important thing is to use the techniques in that memory book.  They may seem to be a pain to use at times, but they'll help solidify your memories and keep closely-related but distinct facts (of which there are zillions in medicine!) from interfering with one another.

> You also mentioned reading ahead for class.  Would that same advice hold true for medical school?

I think that's a very good idea.  During the year I attended classes (the first year; I skipped almost every second-year class and read on my own, just showing up for labs & exams), I found it was very helpful to read the old scribes in the morning for the lectures scheduled for that day.  Many profs just repeat the same lecture, year after year.

Dr. Pezzi,

Thanks for the help.  It's great to get advice from those that have trekked the path before.

Many thanks, George.

What is my pet peeve about working in the ER?

Q:  What is your pet peeve about working in the ER?  Thanks, Rob.

A:  I suppose my pet peeve concerns the expectations society places upon ER doctors and other physicians.  Essentially, society expects ER doctors to be perfect even though most of what we deal with is nebulous and subjective yet we work under incredible time pressures in which major decisions need to be made within seconds without having all the information needed to make those decisions.  Even when the decision can be made within minutes instead of seconds, an ER doctor's job can be nightmarishly difficult.  For example, consider a rather common presentation in the ER:  an elderly person complaining of being "weak and dizzy" or just not feeling well.  This person could be suffering from the general effects of aging or have a stroke, a heart attack, a cardiac arrhythmia, poor circulation, internal bleeding, anemia, an electrolyte imbalance, any one of a zillion hormonal disorders, depression, anxiety, a poor diet, pneumonia or other infections, diabetes, a medication side effect, carbon monoxide or other toxic exposure, and I could go on and on and fill a book with possibilities.  Now put yourself in the ER doc's shoes.  Most likely, he's never before seen this patient, but in the 15 minutes of his shift that is devoted to this patient he needs to arrive at the correct diagnosis without running too many tests lest some hospital administrator or bureaucrat complain about excessive utilization of services.  Incidentally, that is 15 minutes to do everything:  interview and thoroughly examine the patient, look at her old medical records, interpret her EKG, x-rays, and lab tests, speak to her doctor, jot down notes, dictate her complete chart (my charts for such patients would usually be at least two pages of single-spaced text), and often call the on-call resident and repeat the case all over again.

Now imagine that you see a thousand such patients per year (in addition to thousands more with other problems) and society expects you to never be wrong — but remember, you can't run all the tests you'd like, because society is trying to curtail medical expenses.  Furthermore, you can't leisurely make your diagnosis while sitting in a quiet office without distractions; you need to make your decision as you're enmeshed in the chaos of the ER.  (Want an example of this?)  Do you want this job?  Well, good luck.  People are human and humans make mistakes even when the task isn't difficult.  For example, you can add and subtract numbers just fine, but can you do it 5000 times without making a mistake?  (Psychologists and others who've studied this issue know the answer is "no.")  Simple math is inestimably easier than being an ER doc, yet if you got 90% of the math questions correct you'd be awarded an "A" but an ER doc who botched 10% (or even 1%) of his cases would be quickly fired.

Against this backdrop of societal expectations for physicians to be perfect despite the fact that their work is considerably more challenging and iffy (given our imperfect scientific knowledge) than simple math problems that virtually no one can answer flawlessly, I must conclude that society places unrealistic expectations upon physicians.  That would be more tolerable to me if society were equally hard upon people in other professions, but it isn't.  For example, if an airline pilot made an error that killed half the people in his plane, attorneys would sue the airline company (as if it were their fault), not the pilot — even though pilots often make more money than doctors.  Or if a judge incorrectly decided that a person isn't a danger to society and released him a day before he slaughtered a dozen people, would that judge ever be sued for making an error?  Ha!  Judges are immune to the consequences of their errors.  Or if a scheming President bombed a foreign aspirin factory in an abominable attempt to divert attention from his personal scandals, will that President ever be personally punished?  Obviously not.  (Incidentally, the only ones who will ever suffer retaliation from that mistake are innocent Americans killed by terrorists seeking revenge for the bombing.)  Update:  I wrote the preceding sentence long before September 11th . . . eerily true, wasn't it?

On January 31, 2003, NBC's Dateline reported a recent case in New York in which four boys aged 16 to 17 set out in a boat on a bitterly cold night.  The boat began taking on water, and one of the boys called 911 on his cell phone.  Dateline reported that "the operator who took the call and her supervisor didn't alert rescuers."  As a result, no rescue craft were dispatched, and all four boys died.  Imagine what would happen if those four boys were in some comparable peril in an ER, and the ER doctor sat on his hands and did nothing.  You don't need a crystal ball to predict the outcome:  he would be sued for many millions of dollars, and the outraged jury would award several million more in punitive damages.  It would be a huge scandal, and the state medical board would revoke the doctor's license.  The state prosecuting attorney might even file criminal charges against the doc.  From what I heard, that 911 operator and her supervisor didn't even receive a slap on the wrist.  Dismissal?  Massive personal lawsuits?  Jail time?  Ha!  Those people don't have MD after their names, so if they doom someone to death by an incompetent performance, they get off scot-free.  Why?  Why does society blast errant docs with both barrels, yet gives a pass to other people who make heinous mistakes?

Whether it's an idiotic 911 operator, a waitress botching your order, a mechanic who doesn't correctly fix your car, a real estate agent who gives incorrect answers to your questions, or a paper-pushing automaton who can't even fill in the blanks correctly (as I know all too well after seeing three people make a laughable number of errors while processing a routine mortgage application), it is clear to me that we're enmeshed in a world of mistakes yet people are so inured to those mistakes that they often fail to even register, let alone spike the threshold of retaliation.  In contrast, the retaliation faced by physicians is draconian.  It's not "I'll give her a 10% tip instead of a 15% tip," it's "I'll call 1-800-SUE-ADOC and have a lawyer sue the doctor for millions!"

As if that isn't bad enough, doctors are often sued just because they're doctors, not because they did anything wrong.  I've been involved in such a case, and you're welcome to read about it.  After all this, don't you think that physicians would be a bit touchy about how they're whacked for their errors yet others who make errors get off scot-free?

Another pet peeve I have is how some patients think that diagnosis is a one-way street.  It's not.  It's a two-way street in which the ability of the doc to arrive at the correct diagnosis is dependent upon the ability of the patient to give a good history.  After all, we're doctors, not veterinarians.  Based upon my experience, more than a few people thought I could tell them what their problem was the second I walked into their room.  Here's an excerpt from one of my books:

"Hi, Doc, I’ve got a cough. What’s wrong with me?"

I’d just stepped into the patient’s room. I felt like saying, "Mr. Smith, you have a bronchogenic carcinoma in your right lung that’s complicated by a secondary pneumonia. However, I’m concerned that you’re not mounting an adequate immune response, so we’ll have to admit you for intravenous antibiotics. Furthermore, my Star Trek scanner has informed me that your hepatic and renal functions are compromised, so I’ll need to adjust the antibiotic dosing schedule."

But I’m not that much of a smart-aleck, so I kept silent. Nevertheless, whenever such a situation arose, I’d think, "Hmm . . . you could have pneumonia, a collapsed lung, cancer, a cold, asthma, an allergic reaction, gastroesophageal reflux, tuberculosis, a lung abscess, a tracheoesophageal fistula, bronchitis, a pulmonary embolism—or perhaps you inhaled a speck of dust."

I used to think that such patients couldn’t possibly be serious, but they were. As if they were given a script, the conversation would continue:

Dr. Pezzi: Well, Mr. Smith, I don’t know yet.

Patient: You don’t know?

Dr. Pezzi: Not yet. I just stepped in your room.

Patient: You don’t know? Aren’t you a doctor?

Dr. Pezzi: Yes, I am, but I’ll need to ask you some more questions, do a physical examination, and possibly run some lab tests or x-rays before I can give you a diagnosis.

Patient: I told you what’s wrong—I’ve got a cough! Now why can’t you tell me what’s causing it?

Dr. Pezzi: Because there are many things which can cause a cough, and I need more information to make a diagnosis.

Patient: I thought you were a doctor!

I’m a doctor, not a magician. Doctors make decisions based upon information, and one isolated bit of nonspecific information is insufficient to arrive at a definitive diagnosis. I used to assume that everyone knew that, but I learned that many folks harbor the misconception that doctors possess some sort of magical ability.

Having been in such situations numerous times, it seems to me that the patients involved fall into one of two different categories: a fifty-ish male who is genuinely peeved that I cannot offer an instantaneous diagnosis, and people in their late teens. With the latter, I would often sense that they wouldn’t mind me injecting some humor into the situation, so I’d whip out some high-tech gizmo out of a pocket, make some beeping sounds, and announce, "Aha! The Star Trek scanner indicates that you have a cold with secondary bronchospasm." Invariably, we’d share a big laugh. However, if I’d tried that with Mr. Smith, he probably would have grabbed the shotgun off the window rack in his Ford pickup truck and filled me full of buckshot.

Will being more careful eliminate malpractice?  An explanation for why the answer is a resounding NO!
How attorneys exploit medical ambiguities, and my antipathy toward Monday-morning quarterbacks

Q:  If doctors were more careful or conscientious, wouldn't that eliminate malpractice?  Mike

A:  No.  One of the problems is that not even the smartest, best educated, and most experienced doctors in the world can ever be certain of everything they do because there are too many ambiguities and unknowns in medicine.  Patients present to us with diseases that we haven't yet recognized, let alone named or understood.  People often greatly overestimate our current extent of medical knowledge.  To uninformed people, it often seems truly impressive and virtually complete.  In reality, there are many things that we don't know, and won't know for years, decades, or centuries.  In the interim, doctors must make do with imperfect and incomplete knowledge.  At any stage of the game, is being more careful or conscientious a satisfactory substitute for gaps in knowledge?  Of course not.  This is akin to asking someone to drive blindfolded down a road full of potholes, expecting the driver to avoid the potholes by being more careful.

Ironically, doctors who strive to be more careful and never miss anything sometimes do more harm than good.  Imagine that you're an ER doctor treating someone with a bad headache.  Should you just give the patient something to relieve the pain, or should you also do tests such as a CAT scan and lumbar puncture (spinal tap) to exclude some serious cause for the headache, such as a subarachnoid hemorrhage?  The history and physical exam will help the doctor decide if those tests are needed, but that information isn't 100% reliable and any physician who treats it as such is going to miss some serious cases.  So should doctors do CAT scans and spinal taps on everyone to "be careful" and ascertain that nothing is overlooked?  Even if you ignore the expense of those tests, the time it takes to do them, potential complications, and the pain and inconvenience to the patient, you may not be doing the patient any favor by "being careful" because the results you obtain from those tests might falsely lead you to believe that still other tests are required, such as angiography, that are even more costly and risky.  Therefore, once you start down the "being careful" path, you may be compelled to do more tests that may put your patient in peril.  Medical testing is not without risk, and until it is, such testing cannot be simply viewed as something that good, careful, conscientious doctors do whenever there is doubt — because there virtually always is some uncertainty.

There are no pat answers for precisely determining a threshold of when diagnostic testing should be instituted in ER patients with headache.  Even the best ER doctors debate about when headache patients should be put through the mill for testing.  If a doc thought he was 99.9% certain that the patient didn't need any testing, is that good enough?  Remember, he might miss one case in a thousand.  One case in a thousand may not seem like much, but I've treated 7000 patients in a year.  Is seven missed cases too much?  If it is, should I do more tests?  Before you answer, remember that if I lower my threshold for testing I may miss fewer cases but subject far more patients to potential harm.  So where do I go for guidance?  The Psychic Friends Network?  A crystal ball?  A Ouija board?  Perhaps I should ask an attorney, because they think they always know what's best.  Of course, attorneys have the luxury of being Monday-morning quarterbacks, and with this benefit of hindsight, they're never wrong.  But even an imbecile has 20/20 vision in hindsight.

To further complicate this problem — as if it were not already complicated enough — doctors can never know if their estimation of their certainty is accurate or not.  If a doc thinks he's 99.9% certain, how can he possibly know that?  He can't!  His estimation of his certainty is just a guess, based in part by some science and experience, and a whole lot of intuition, guessing, and blind faith.

Attorneys love this uncertainty.  It's one of their primary tools for finding fault with doctors.  But is this uncertainty the fault of the doctors, or just the fault of our current imperfect understanding of science?  Even though the latter is the correct explanation, it's doctors who bear the brunt of our scientific shortcomings.

What's different about my book?

Q:  Judging from your page of ER book reviews, you've read just about every such book.  How does your ER book differ from the others?

A:  In my opinion, some of those authors failed to give readers an accurate depiction of reality by treating some topics as if they're off-limits.  While we don't have overt censorship in this country, there are nevertheless strong pressures placed upon authors to either not cover certain subjects or to present them only if they're portrayed in a sugar-coated politically correct way.  Consequently, many ER books are homogenized and made disappointingly bland by being stripped of some interesting but taboo subjects.  I give the thought police heartburn because I think that anyone who shells out money for a book should be treated to a no-holds-barred accounting of what really goes on in emergency rooms.  Most readers like my candor, and for those who don't there's always The Disney Channel.

Can a patient choose who treats her in the ER?

Q:  I want to know if I went to the emergency room and there was a certain doctor on-call and I refused to let him check me, could I request to see another doctor?  Teresa

A:  Do you mean the ER doctor currently working in the ER, or a specialist he may call in to treat a specific condition?  Not knowing what you're referring to (since many people think ER docs are "on-call"), I will answer both possibilities.

You don't like the ER doc:  This isn't a problem if there is more than one doctor working during that shift.  I've seen it happen, such as when a patient requested that I see him because the doc working with me, my boss, was a "foreigner."  He spoke perfect English (better than most Americans), but rather than trying to change the patient's mind, it was easier for me to see that patient.  On the other hand, if there is just one ER doc working, you don't have a choice (unless you don't mind leaving the ER and traveling to another one).  You won't convince the ER doc to call in one of his ER colleagues, on the chance that you might like that person more.  Frankly, if you have a genuine emergency, you won't be too picky about who treats you. If they save your life, you'll gain a sudden fondness for them, trust me.

If you don't have an emergency, you can request that your personal physician be summoned to the ER.  Some private docs will oblige the request, but most will just say "Have the patient call tomorrow for an appointment."  One warning about this, though.  You may adore your private doc.  You may think he's a real sage.  But most likely, he doesn't know as much as the ER doc does about treating emergencies (or even urgent conditions).  I don't care if your doc is an old-timer who was treating patients before I was born; he usually isn't the one who is most adept at managing acute conditions.  Here is an excerpt from one of my books:

As I examined a multimillionaire with a head injury in the ER, his family asked that I call his doctor.  They didn’t express any mistrust, but they looked a bit uneasy having the patriarch of their family examined by someone who looked like the "before" model for a Clearasil^® ad.  I may have zits, but at least I know how to take care of someone with a head injury.  This doc didn’t know much about head injuries, but he looked the way a doctor should look—and that’s the important thing, right?  As I watched him perform his exam it was obvious that he didn’t have any idea of what he was doing, but he did enough doctor-type stuff, like checking reflexes, to make the family believe that God’s right-hand man was there to save him.  I found his performance rather comical and I was so close to bursting out with laughter that I had to leave the room.  I haven’t been very fond of that doctor ever since he misdiagnosed a friend of mine who saw him for abdominal pain.  He said it was all in her head.  It wasn’t.  It was cancer, and it wasn’t discovered until it was too late to save her.  She’s dead now, but the important thing is that the doc still looks spiffy.

You don't like the specialist the ER doc calls in:  Generally, you're out of luck if you don't like the on-call specialist.  Every hospital I've worked in has one specialist on-call for cardiology, one for general surgery, one for neurosurgery, one for pediatrics, etc.  Almost invariably, a doctor would refuse to come to the ER on request if he was not on-call (barring mass disasters).  His first question would be, "Why doesn't the on-call doc handle the case?"  If told that the patient did not like the on-call doc for some reason, the other doc would likely avoid you like the plague.  With odds of better than 10,000 to 1, he knows his colleague is perfectly qualified to manage your case.  Hence, he'd think, "So why isn't that good enough?"

Q:  Is this not the law?  If not, I believe it should be.  I should be able to request another doctor if I do not want the doctor that's on-call to check me!

A:  No one can treat you unless you want them to, unless you're unconscious or incompetent (e.g., drunk), in which case we have implied consent to treat whatever serious problem(s) you have.  However, if your condition is not severe enough to preclude you from shopping around, you're free to try to find a physician you like better.  You'll have to do that on your own, though.  Emergency departments rarely have the time to help you shop around for a doc you like more.

Q:  Thank you for clearing this up for me.  I asked because my mother went to the ER on a night when Dr. Page was working.  My mother had heart problems and was predisposed to pneumonia.  Her regular doctor knew this, but he was not on-call.  Dr. Page just gave her cough medicine and a shot and sent her home.  She died March 10.  We believe that if he would have admitted her then she might have had a chance.  Thank you again for your time.

A:  I now have a better idea of what happened and why you posed your questions.  With this additional information, I can give you a response that is more specific.

ER doctors routinely inquire about past medical problems.  Thus, Dr. Page should have been aware of your mother's problems.  ER physicians can also obtain information by reviewing past medical records, analyzing the patient's medications, and speaking to the patient's private doctor.  However, the ER is sometimes too busy to make old chart reviews practical, and it isn't always possible to reach the private doc.  He may be in an area in which there is no cell phone reception, or one of his partners may be on-call for him (and that doctor likely doesn't know his patients).

Without knowing exactly why your mother died (was it pneumonia or heart failure?), and more details of the case (e.g., her EKG, chest x-ray, arterial blood gases, various blood tests, etc.) it isn't possible for me to say whether Dr. Page failed to exercise proper caution in treating your mother.  However, I can tell you this:  many patients with pneumonia are actually better off when they are sent home, rather than admitted to the hospital.  Hospitals are notorious for being havens for antibiotic-resistant bacteria.  The last thing a pneumonia patient needs is to pick up a super germ.

However, if your mother had hypoxemia (low arterial oxygen level) or a heart problem triggered by the extra work induced by the infection (metabolic rate, and thus cardiac workload, increases during some infections), she should have been hospitalized.

Links to other pages in the More Q&A section:

Medical questions

Questions about becoming an ER doctor

Questions about other ER personnel

Very miscellaneous questions

Questions about love and sexual attraction, libido, pleasure, and performance

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