EMED-L is an online discussion group for people interested in emergency
medicine. Most of the participants are ER practitioners — either ER docs
or nurses, but we do have a smattering of EMTs, paramedics, medical students,
journalists, and even an occasional lawyer . . . hey, this is America, the land
of litigation. We even have an ex-con who, after being hounded by the FBI,
nurtures an incandescent hatred of the United States. If you spend much
time perusing EMED-L, you'll soon key in on the most prolific stars of that forum: Dr.
Bob Solomon, Dr. John Meade, Dr. Joe Lex, Dr. Jeanne Lenzer, Dr. Jeffrey Mann, and my alter ego, Dr. Willie
Franklin, a man with a real knack for phrasing things in an entertaining and
incisive manner (tip: if he ever writes a book, buy it!).
I included these postings (a few of which are from a related list) so that
people thinking of going into emergency medicine can get an idea of some of the
everyday — and once in a lifetime — issues ER doctors face.
A list member solicited comments
about what underlies clinical hunches. Here is my response:
I've had similar experiences, but these usually pertain to cases in the
psychiatric/social realm. For example, I had a patient with a cut on his hand
who struck me as being an oddball. Perhaps it was his claim that he was on the
cover of Cosmopolitan last month (yeah, right . . . a Cosmo cover
of an obese, unattractive male?), or his concern that repairing his laceration
would delay his imminent flight on a jet to dine with Jackie Onassis in Europe.
This piqued my curiosity, so I dug deeper and learned that this jet-setter
wannabe harbored an elaborate fantasy about how Michael Jackson wanted to have
him killed. (Wouldn't this guy make a great guest for the Jerry Springer Show?)
His paranoia was enough to make me think he might try to preempt that attack by
assassinating Jackson, so after he gave me his autograph, I had him committed .
. . and thus ensured the safety of an even stranger person, Jackson himself.
Another patient with a hand cut told me he'd cut himself on a knife, after which
he assumed I'd just whip out the laceration tray and go to work on him. Whoa,
not so fast — I want more details than that! I continued my
history/interrogation, and learned he'd cut himself while stabbing his
girlfriend. Time to dial 911 . . . .
In another case, the fact that an out-of-state patient failed to produce a
driver's license during registration was enough to make me grill him. An hour
later, after a high-speed police chase, the officer I'd summoned told me that
guy was on a multi-state crime spree. ("Was" is the operative word . . . he's
now in prison.)
I also ended the career of a 17-year-old kid who was on the lam after shooting a
police officer a month previously, and enough other criminals to make me think I
might be a good detective. Some of these cases were obvious, and some had only
very subtle clues. Nurses often claim that I possess a talent for drawing odd
patients to the ER. Scientifically, that is implausible. What is plausible is
that I have a knack for detecting latent oddity, criminal activity, or
duplicitous behavior . . . which, parenthetically, reminds me of the first time
I saw Clinton on television in the early days of his first Presidential
campaign. In a split-second, even before he spoke, I knew from his countenance
that he was a liar. I didn't just think he was a liar, or guess he
was a liar, or opine that he was a liar, I absolutely KNEW it. I am not
mentioning this story to bash Clinton, and if you are a Clinton defender, please
don't rush to his defense — I want to keep this discussion on a clinical level.
The human countenance can be analyzed both statically and dynamically. I think
more emphasis is given to the static features, and much of the gamut of emotion
and behavior can be seen in photographs that, of course, capture only static
features. However, I think the dynamic features — that is, how the face moves —
provide a wealth of clues, too. Given the myriad number of facial muscles,
contraction speeds, degree of contraction, and possible combinations, there is
an infinite number of dynamic facial features which can telegraph a wide range
of otherwise latent signals about the personality and emotional state of that
person. Wouldn't I make a great airport screener? :-)
Furthermore, I think that if you carefully listen to the totality of what
patients say, the "total" can be greater than "the sum of the parts." Here's an
example. I had an anxious patient with a seemingly endless list of complaints,
none of which fit any clinical pattern. It wasn't WHAT she said, it was HOW she
said it, and in an instant this hodgepodge of complaints coalesced in my mind,
and I KNEW why she'd come to the ER. I said, "Ma'am, you think you have AIDS,
don't you?" She burst out crying. "Yes! I was afraid to say it. I've been
waiting a long time to come in, because I didn't have the courage." She revealed
that she'd had unprotected intercourse. I assured her that the risk of
contracting an HIV infection via vaginal intercourse from someone who is
exclusively heterosexual and doesn't use drugs is vanishingly small, and sure
enough her HIV test was negative. OK, so much for the happy ending. From her
laundry list of complaints, she could have been anxious about anything from
losing her job to fretting about an asteroid strike in North America, but I
zeroed in on one specific fear, and sure enough that was the one that prompted
her ER visit. I can't definitively explain how I knew it was this one, and not
any of the zillion other possibilities. My guess is that whenever someone speaks
to me, I automatically read between the lines. When enough of these "reading
between the lines" clues point in the same direction, bingo! I know what they're
getting at, even if they are beating around the bush, or doing their darnedest
to keep their true feelings a secret . . . à la Clinton.
In a discussion
titled "Nurses are out of control," one list member wondered if we
should discuss such a potentially inflammatory subject. My response
While Dr. Mann is probably correct in his assumption that this discussion
may be inflammatory, I don't think we should bow to pressure to not broach
politically incorrect topics that have merit. Unless I'm mistaken, the
primary raison d'être of this EMED-L discussion group is to discuss topics that
improve patient care, and this "inflammatory" discussion does have the
potential to improve patient care. How? I'll give one example.
I'm an inveterate perfectionist, and this has created a lot of friction between
myself and nurses whose standards are somewhat less meticulous. While
there are some excellent and equally perfectionistic nurses, after working with
hundreds of nurses it is my opinion (that I can substantiate with an endless
list of stories) that the average nurse is less of a perfectionist than I am.
Furthermore, some of those nurses have pulled all sorts of shenanigans in an
attempt to get me to relax my standards. I'm certain that I'm not the only
physician who was subjected to this pressure. Sometimes this pressure has
been egregiously direct (such as when one male nurse — who happened to be
drunk at work — challenged me to a fistfight in the ER parking lot), and other
times this pressure was passive yet impossible to ignore. Here's an
example of the latter (excerpted from my web site):
Let’s briefly consider the case I presented in the book in
which one of the nurses I worked with almost had a nervous breakdown after I
calmly mentioned to her that she should do her own patient assessments and not
rely upon the diagnosis rendered by a security guard. Not surprisingly, the
security guard’s diagnosis was dead wrong. What was surprising to me was that
this nurse — who was actually a bright person and was otherwise a decidedly
above-average nurse — would blindly accept the conclusion of the guard without
doing her own assessment. And this was no minor error, either: the patient in
question had suffered a cardiac arrest, and every second in which the nurse was
behaving as if this was no big deal just brought the patient that much closer to
death or permanent brain injury.
As luck would have it, I happened to be near the hall that
connected the ER to the waiting room, where the patient had collapsed.
Nurse: (seeing me approaching) It’s a seizure.
Dr. Pezzi: (thinking, yeah, and I’ve got Nikki
Cox begging me for a date, too) Does she have a pulse?
Nurse: I don’t know, I didn’t check. The guard said
she had a seizure. He said she twitched.
Dr. Pezzi: (checking for a pulse and breathing) She’s
not breathing, and she doesn’t have a pulse. Let’s start CPR.
I grabbed the defibrillator, used its "quick look"
paddles* to read her cardiac rhythm (ventricular
fibrillation), then I shocked her and restored a normal rhythm. She was given
some additional treatment in the ER, then transferred to the CCU. Afterward, I
mentioned to this nurse (who was a friend of mine) that she should do her own
assessments and not rely upon the conclusions of a guard or other
nonprofessional. I also mentioned that a patient may jerk if he passed out
because his heart stopped beating. This is sometimes misinterpreted as a seizure
by some people (and I thought, ahem, lay people).
* Most defibrillators do more
than just deliver shocks. The same paddles that carry the jolt of electricity to
the patient can also be used to pick up the electrical activity of the heart (as
does an EKG machine) and display it on a monitor built into the defibrillator.
I thought my interaction with the nurse in this case was
rather straightforward. I passed along the above tidbit and asked her to do her
own assessments. Big deal, right? The nurse didn’t think so. She went on a
crying jag for hours, pouted for the next few weeks, then quit working in the
Sheesh! If she were a medical student or resident and had
made a comparable mistake, one of her supervisors would have ripped her apart.
Rather than placidly discussing it as I did, most of them would have peppered
their diatribe with incandescent invective. Doctors often become incensed when
they think patients have received substandard treatment, and they usually
aren’t shy in relaying their opinions. Contrary to what most nurses think,
doctors in general are much harder on their colleagues than they are on nurses.
The worst upbraiding I’ve ever seen directed at a nurse by a physician was a
mere slap on the wrist compared with the lashing that docs sometimes unload upon
one another. I know of cases in which physicians, probably overwrought with
compunction, thought this was too much to bear so they committed suicide. The
most dramatic case was when a resident walked over to a hospital window and
jumped out, splattering himself on the sidewalk several stories below. A less
tragic but still newsworthy case occurred when Doc A, after a heated discussion
with Doc B, chased him for over an hour on the freeway to continue the argument
in Doc B’s driveway.
So why all the acrimony? The answer is obvious: people’s
lives are at stake. With so much on the line, it is understandable that tempers
will occasionally flare. Physicians are typically very anal, perfectionistic
people, and nurses sometimes mistake this perfectionism as arrogance, especially
when a doc lets a nurse know that he isn’t satisfied with something the nurse
was doing. Yes, there are doctors who are truly arrogant, but this is more
common in the old-timers. In all my years in medicine, I’ve seen only a
handful of docs who deserved to be called arrogant. However, nurses bandy about
the term "arrogant" so often that I think they’re taught a
definition of it in nursing school that isn’t in the dictionary. All the
whining and moaning by nurses about this subject has done nothing except create
an unwarranted stereotype.
As is the case with most stereotypes, there is some
collateral damage that accompanies the rhetoric. Seeking to minimize the risk of
their being labeled "arrogant" or abrasive, docs often turn their
intensity back a couple of notches. Is that good? Not in my book. How much more
laid back can we be without being mute and turning the farm over to the nurses?
When I spoke to the nurse mentioned above, I did so as if she were a beloved
sister, yet she came unglued. I suppose the only way I could have gotten along
with her was to sycophantically tell her she was right even when she was wrong
just so that she could maintain her self-image at an unjustifiable high, or I
could have just ignored her error altogether. However, if it was your
mother who was the patient, I think you’d implicitly expect the doc to not let
such a potentially devastating error slide by as if it were less important than
a batch of bad fries at McDonald’s.
Some physicians resent this need to curry favor with nurses
by treating them as if their actions were beyond reproach. In my own career, I
became so disgusted by this petulant "treat me with kid gloves or I’ll
scream" attitude that I eventually gave up and ignored all kinds of errors.
I’m not proud of how I abandoned my standard of perfectionism, but I’m
certainly not the first person in the world to relinquish my standards just to
keep on getting a paycheck.
Collectively, nurses have done a great job convincing the
public that nurses care more about patients than doctors do. That’s just a lot
of hogwash, but I see nurses patting themselves on the back all the time as they
relish in this self-serving deception. Sure, nurses talk the talk, but do they
walk the walk? If they’re so caring, then why are they giving docs such a hard
time about delivering the perfect care that patients deserve?
Fortunately, not all nurses are this way. Some of them are
dedicated, bright, caring, and diligent people who do a wonderful job and are a
pleasure to work with. I’ve worked in emergency rooms in which the majority of
the nurses were topnotch, yet I’ve also worked in places in which most of them
were bad apples. In those latter facilities it could be that the bad attitude of
a few spread like a cancer to infect the others.
Some of the battles that I fought with nurses were
unimaginable. There was one nurse, for instance, who evidently had no conception
of a sterile field. He would routinely touch something in the sterile tray that
was holding the instruments I was using to suture a patient’s cut. I reminded
him umpteen times that he couldn’t touch anything that was sterile with his
unwashed, ungloved hands, and he’d just argue with me—in front of the
patient, nonetheless — that what he was doing was OK.
How can such an idiot be allowed to work in an ER, or even a
dog kennel for that matter? The answer is simple: doctors do not run most
emergency rooms. Nurses are fond of saying that they run the ER, and the docs
just work there. In most hospitals, that’s true. The ER director is usually a
nurse who is employed by the hospital, and the ER docs are usually a group of
independent contractors who have virtually no say in hiring or firing decisions.
I think this is ridiculous. In general, it’s a good idea for those who have
the ultimate responsibility to be given the tools and power they need to get the
job done right. Physicians are under a lot of pressure — from patients, state
medical boards, hospital committees, lawyers, and ultimately from themselves —
to ensure that every patient receives optimal treatment. I think physicians
resent being subjected to this pressure without having control over some of the
variables. For example, one of the nurses I worked with for three years had
Alzheimer’s disease. The nurse in charge of the ER, Sally, wouldn’t fire her
because she’d been there a long time (no kidding!) and needed the paycheck. So
who cares if she is one of the gang and needs money — who doesn’t?
above posting caused a list member (who is a nurse) to jump to the defense of
nurses. I've never understood this mentality. Can't nurses
understand that there are good nurses and bad nurses, and that a criticism of
poor performance should not incite them to reflexively assail anyone who has the
temerity to criticize a nurse — people who are evidently sacrosanct, judging
by the fact that reprehending any nurse or nurse error, no matter how
indefensible, often triggers a vehement denunciation of the person broaching
I think that Jeannine Dakshaw, RN misconstrued some of my statements. To
begin with, a cogent explanation of why I was troubled by some egregious conduct
by nurses is not, as she said, downplaying what nurses do. By analogy,
when a prosecutor or judge lambastes the criminal element in our society he is
not criticizing law-abiding citizens. This is not a trivial point.
In my opinion, this "us versus them" mentality induces some nurses to
reflexively jump to the defense of their brethren even when the criticism that
aroused their ire was specifically targeted toward clearly indefensible actions
and was not an overreaching global condemnation. When a nurse objects to a
discussion of blatant nursing errors, it makes me wonder if she thinks that
nurses are sacrosanct and immune from censure.
Next point. Nurse Dakshaw, who was evidently paraphrasing me, then went on
to insinuate that docs have a need to be superior.
What? Where did THAT come from? Mars? Did I say anything about
being superior? Of course not! What I said was "Physicians are
under a lot of pressure — from patients, state medical boards, hospital
committees, lawyers, and ultimately from themselves — to ensure that every
patient receives optimal treatment."
It's incomprehensible to me how this statement could be twisted so radically.
How on Earth could "striving for optimal treatment for patients" be
interpreted as striving for superiority? Are there any psychiatrists on
the list who'd like to hazard a guess on that one? I'm tempted to dive
into an exegesis of it, but I'm doing my best to keep my gloves on, so to speak.
I also disagree with Nurse Dakshaw's attempt to divert attention from a valid
issue by saying that we should stop criticizing people (evidently even those who
make mistakes) and begin caring for patients.
Since when is it in the best interests of patients to NOT cast a light upon
nursing errors that endanger patients' lives? And why would anyone think
that finger-pointing (valid or otherwise) and caring for patients are mutually
exclusive things? They're not. Furthermore, I cannot recall any
free-floating finger-pointing on this list. When list members point a
finger, they usually have ample justification for putting something in their
I do agree with Nurse Dakshaw's assessment that nurses are underpaid and
overworked. I think I can speak for all physicians on this list when I say
that physicians are generally appreciative of the work performed by nurses and
we give respect when it's due. Personally, I can think of several nurses
that I hold in such high esteem that I think their faces should be chipped into
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Consequences of ER misutilization
John Schoffstall, MD wrote that the only drawback to ER
misutilization was economic.
I disagree. That would be true if ERs had an unlimited staff of docs,
nurses, and techs, but that is never the case. The reality is that our
most precious resource — our time — is very limited, especially in busy emergency
rooms. If our time is frittered away dealing with patients who don't
belong in an ER, we have less time to attend to the legitimate patients who
could benefit from more time and attention. Here's an excerpt from my web
"Even if all the medical needs of a patient are
met, patients often have emotional needs that should be addressed, too. What
about a man with a myocardial infarction who is scared out of his wits about
dying? We're not going to automatically assuage his fears just by pumping him
full of clot-busting TPA, and his anxiety can in fact contribute to his medical
problem and, for example, promote arrhythmias. Thus we should allay his fears,
but if time is short--as it so often is these days--the emotional support is the
first thing to go."
Hence, I don't think that patients who dilute our time are just a benign
annoyance. They detract from the TLC we could give to patients who need
it. They also detract from the time we could spend better explaining
things to patients.
In another discussion of ER
misutilization, another list member (Bob) opined that this problem is not
frequent. From that, I inferred he'd never worked in some of the areas I
have. Here's my response:
Where do you work, Bob? I've worked in several ERs in Michigan, and
judging from my experience I think more than a small minority of patients take
advantage of us. I'll substantiate that opinion. 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 addition to the patients presenting with clearly wacky reasons, there are
patients with legitimate (or possibly legitimate) problems who abuse the ER.
An example: a lady with an 18-year history of chest pain whose
etiology had yet to be nailed down by the gurus at the Mayo Clinic, the
University of Michigan, or by our local cardiologist extraordinaire. A
reasonable patient might conclude that since she had chest pain for 18 years and
no tests pointed to any dangerous condition (or ANY definable condition, for
that matter) that she wouldn't need to worry about dropping dead in the next
five minutes. I saw this patient in the ER hours after her most recent
discharge from our hospital; she went home and since the chest pain was still
present, decided that she needed to be in the hospital again. I've never
seen a cardiologist so exasperated and so livid.
I've seen thousands of patients for whom I've yearned to put "You must be
kidding!" as the primary or secondary diagnosis. Judging from the
contact I've had with ER physicians around the world, I think that these
frequent BS emergency room visits are a plague that afflicts only the United
States — for reasons that are obvious to anyone whose eyes are open. No
need to elaborate on THAT etiology!
I think that some of my colleagues view these BS ER visits as a benign problem.
I don't think they're so benign. To begin with, they siphon billions of
dollars away from legitimate uses. Secondly, they dilute the attention of
the ER staff toward legitimate patients. Thirdly, they increase waiting
times for all patients. Fourthly, such egregious behavior sometimes puts
real patients in peril. As an example of the latter, I saw a woman in the
ER who'd called 911 and presented via ambulance because she wondered if her
vagina was too loose. Since we had a limited number of ambulances in that
county (and don't all counties have the same limitation?), I explained to her
that her whimsical and out-of-the blue curiosity about the tightness of her
vagina might result in the fact that some elderly person with a heart attack
might die because the ambulance that WOULD HAVE promptly taken that person to
the ER was instead busy taking this goofball to the ER.
Shall I go on? Then there's an unscrupulous man who cloaked his total
absence of any medical problem as chest pain just so he could get a free ride to
the hospital in an ambulance. After I did the usual expensive chest pain
workup, he confessed that he never had chest pain — it was just a ruse so he
could get to the hospital to visit his girlfriend, an inpatient at the time.
I could fill a couple of books with such shenanigans. So are they a rare
event? Not in my experience.
In a subsequent posting, I continued on:
On one hand, I think it's fortunate that Bob Solomon and others aren't
rattled by the inordinate number of people who abuse the ER for obvious
non-emergencies (or even non-medical problems) because such a state of
equanimity is good insulation from burnout, as Bob suggested. On the other
hand, if all of us who are cognizant of the problem turned a blind eye toward
it, I think we'd be abandoning our responsibility toward society. After
all, if we're using their money, I think we're morally, ethically, and
legally compelled to minimize the extent to which it is frittered away.
I think I've done my part to illuminate this problem. I've written about
it in my book, and millions of people have heard me discussing it in radio
interviews. However, our "leaders" in government seem too
weak-kneed to address the matter — they dare not alienate a potential
voter! If I had my wish, people who came to the ER for silly reasons would
pay for those visits themselves. I think that's just common sense, but
some people would label it as being too draconian. So why not start with
four years of health education in high school? Increased knowledge on the
part of patients would obviate some ridiculous ER visits.
I thought it was imperative to address this issue before September 11th, and
since then I'm more convinced than ever that it is critical that we don't
squander money catering to the collective quirks in society. If nothing
else, this money is better spent fighting the war on terrorism — NOT
reassuring ladies with loose vaginas, not repeating chest pain workups for the
1000th time, and not providing $3000 "taxi rides to the hospital so a man
can visit his girlfriend" (if you're wondering about any of these, just
read my preceding post).
Bob, who admitted that he was decidedly left-wing on
issues of healthcare, speculated that I thought people who abused ERs were
undeserving poor people. I responded:
No, Bob, your assumption isn't correct. I used to be dirt poor and I
possess no antipathy toward poor people. What bothers me is fiscal
insouciance, and that's manifested not just by poor people but also by people
such as the obese middle-aged woman who came to the ER with a multi-year history
of knee pain who requested a refill for ibuprofen. She didn't want to buy
it OTC because then she'd have to shell out the whopping $7. Add up the ER
charge and the higher cost of prescription ibuprofen, and her reluctance to
spend $7 cost her insurance company (and the people who pay its premiums)
hundreds of dollars. Want another example? I can give you thousands
of them. You might counter that such a problem could be averted if
insurance companies paid for every imaginable OTC drug. Certainly they
could, but that would just increase premiums. Since you're smart enough to
look at the down-range consequences of this, I need not mention that increased
premiums would force more people to do without insurance. Basically,
people with insurance are inured to co-payments and deductibles, and this need
to purchase OTC drugs is, in effect, just another reflection of the fact that
most insurance policies are there to shield us from major bills — not to pay
every last penny of healthcare costs.
On another matter, in EMED-L and other venues I've heard people discussing
Medicaid recipients with the tacit assumption that they're poor. That
assumption isn't always valid. I've seen Medicaid recipients with new
Corvettes, Jeep Grand Cherokees, snowmobiles, motor homes, $400
"designer" purses, expensive jewelry and clothes, etc. Shall I
also mention the out-of-state shopping trips to the Mall of America? Oh,
and let's not forget that more than a few Medicaid recipients are so poor that
they qualify for government assistance yet they can afford hundreds of dollars
per day to spend on drugs, booze, cigarettes, lottery tickets, and
prostitutes. Even apart from such flagrant (but unfortunately not rare)
abuse, the average Medicaid recipient has cable television, designer tennis
shoes for their kids, a microwave oven, a VCR, a stereo system, the latest
computers (I know some Medicaid folks who have much better computers than my
2-year-old system), air conditioning, a decent if not luxurious car, a bike and
other sporting goods, and enough food to eat to result in obesity. One
might reasonably ask if such people are truly poor. Compared to many
people in other countries, such people aren't poor, they're unimaginably
rich. In this country, poverty isn't defined by any rational standard;
instead, it is defined by stated income below a certain threshold that is
conveniently raised frequently by left-wingers who perceive the need to justify
their continued "war on poverty."
Here's yet another left-wing disaster that we're all paying for. When I
was an undergraduate I worked for the University tutoring minorities and
athletes. As a tutor, I was privy to some inside information. At
that university, minorities could sign up for certain class sections that were
reserved for minorities. "Students" in those sections were
guaranteed a passing grade if they showed up for the exam and signed their name
on the test. If they tried to answer any question, they received a
"B," and if they got any question correct (even by random chance),
they were given an "A." That policy was obviously intended as a
crutch to give a degree to people who could never obtain one legitimately.
I thought, "Why not dispense with this pretense of education and just give
those folks their sheepskin the second they matriculate? After all, it'd
save the taxpayers 4 years of tuition, room, and board."
Unfortunately, the long-range consequences of these well-intended left-wing
crutches are disastrous. People with those sham degrees are foisted upon
the real world, where they give the rest of us heartburn.
By the way, most of my students never bothered to attend my tutoring
sessions. Many of them evidently figured out that they were given a free
ride through life, so why should they lift a finger and try?
Now this topic began to heat up (you'll see!):
Judging from some of the vitriolic rhetoric this topic stirred up, I think
some list members forgot that the thread of this discussion is ER ABUSE, not
legitimate use of the ER. While I believe, as a matter of principle, that
people should pay their own way through life unless they're somehow disabled,
over the years I've cared for countless no-pay or "low-pay" (e.g.,
Medicaid) patients and I never begrudged giving them care as long as they had a
legitimate or even semi-legitimate reason for being in the ER. However,
when people (regardless of their insurance/financial status) came in for a
clearly goofy reason ("Hey, doc, I missed work last Tuesday and I need you
to give me a work excuse for that day . . . and, by the way, I'm planning to
miss tomorrow, too, so can you also give me that day off?") I'm less than
thrilled about such sham visits. I think that the fraudulent nature of
such ER ABUSE would trouble anyone who is ethical.
Lori Spies insinuated that I may possess some antipathy for poor people.
Anyone who knows me — as opposed to misconstruing what I say in the EMED-L
forum — would know that that insinuation is ridiculous. I used to be
poor, and I'll never forget the privation of being poor. I'll never forget
the time I had to stretch half a jar of peanut butter to last two weeks, because
I had no money for food and it never occurred to me to ask for assistance from
the government. After being poor, I can truly empathize with people who
are poor, so you can rest assured, Lori, that I don't possess a shred of
antipathy for the poor. To reiterate, what bothers me about this current
EMED-L discussion thread isn't that some poor people abuse the ER system, it's
that ANYONE abuses the system. In fact, I gave examples of people abusing
the system who were not poor — perhaps you missed those discussions. If
nothing else, my concern about these fraudulent ER visits is that they divert
money from more pressing needs. There is a limited amount of money to be
spent, and any dollar spent on such foolishness is a dollar that can't be spent
on something vital. Therefore, anyone who turns a blind eye to this
problem is, in my opinion, constitutionally corrupt.
I think that liberals sometimes fancy themselves as people who are more caring
than conservatives, who they like to paint as being cold-hearted. After a
blizzard I drove by the home of a man who lived a mile or so from my house.
I'd seen him in the summer and while I'd never spoken to him, I knew that he was
around the age of 70, missing a leg, and obviously poor judging from the shack
he lived in. In the area in which I lived, hundreds of well-to-do liberals
passed by his house and did nothing, even though this elderly one-legged man was
known to everyone in the area. So what did I do? I went home, loaded
my snowblower and snow shovel onto a sleigh, and towed that with my snowmobile
to his house, where I spent hours removing 4 feet of snow from his driveway,
sidewalk, and porch. Or there were the times when I made free housecalls
to check on sick or injured children. I've done so many things for poor
people that I couldn't begin to remember even 1% of the cases, and I wonder if
liberals have done more. Perhaps some have, but I'd wager that the
majority of them just like to sit on their butts and tell themselves that
they're wonderful people because they care. Well, words are cheap — what
matters is action. I've spent countless hours helping people (for free)
with my snowblower, or medical knowledge, or in countless other ways. The
minute I see a liberal do more is the minute I'll acquire a new respect for a
person who puts his principles into action. The only tangible thing I've
seen liberals do for poor people is to vote for higher taxes so they could
collectively force people in the higher tax brackets to pay more money.
I've known thousands of liberals, and not one of them ever did anything else to
help poor people. Would they lift a finger and do what I did to help?
Obviously not. In fact, judging from some of the amused comments I
received from liberals I knew, some of them truly couldn't understand why I did
what I did. Furthermore, their comments revealed a thinly-disguised
contempt for poor people. "Eewww, Kevin, you helped that old
one-legged man in the shack???" So, in my experience liberals are
people who possess an unfathomable amount of self-deception and are people who
like to hold at arm's length people who they claim to champion: the poor.
So I offer this friendly challenge to liberals: if you want people to
believe that you're so wonderfully caring, stop spending so much time basking in
the certainty that you're such admirable people. Don't just imagine that
you're caring, show me. Better yet, show that poor person who lives a mile
away from you.
A list member sent me the following private e-mail
in response (quoted with permission):
Hello. I really appreciated your posting re: not apathy for the
poor. I too have been criticized or at least looked at with amusement for
my charity work more than once ("Why do you want to go down THERE and
volunteer? You could do_______ instead).
I think like you bro!
Take care, Omi the Nurse
Then she added:
It is not often that you find somebody with such views. I have
appreciated your responses in this thread of conversation over the last few
days. There is a difference in having compassion and dealing with well,
with either ignorance or sheer stupidity, I am not sure what.
Take care, Omi
In an e-mail to her, I said:
You have a very good point. There are people masquerading as patients
who take time and money away from real patients. I want to devote my
energy and TLC to patients with real problems, not the people who are abusing
How to dissuade misutilization of
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.
Patients with TPROS (totally
positive review of systems)
When confronted with a 15-year-old patient with a TPROS (totally positive review
of systems), I squeezed a flock of her hair, being careful to not put ANY
tension on the hair that might pull on the hair roots. As I squeezed her
hair, I asked her, "Does this hurt?" She responded, "Oh my
God, that really hurts!" I then explained to her Mom that hair
has no pain receptors (if it did, we'd scream during haircuts). The Mom
understood the point of my demonstration: that her daughter's TPROS was
Is there any relaxation of the
standard of care when such standards are just pie in the sky?
Henry J. Siegelson, MD wrote that there is, or should be,
some medico-legal immunity when ER personnel care for mass casualties.
I agree there SHOULD BE relative immunity in such a circumstance, but is this
codified anywhere? For example, while working in a small ER staffed just
by myself and one nurse, I once coded three patients at the same time (an aside:
this occurred a day after I asked the nurse if they ever get any codes in that
hospital, since I'd worked there over a year with nary a code). Yes, we
had the ER clerk call for reinforcements, but by the time they arrived the codes
were over. End result? One successful code, and two deaths. I
was not sued for the two deaths, but I wondered "what if?" Could
I plead that, given the circumstances, it was impossible to optimally code three
patients at once with two personnel?
On a more mundane level, is there ever any consideration of how busy the ER is
if there is alleged malpractice? I worked in an urban ER with
single-coverage night shifts in which I'd frequently have dozens of seriously
(even critically) ill or injured patients at the same time. Should I see
the comatose diabetic or the lady in septic shock? Or the kid with
possible meningitis? Or the guy writhing in pain with a kidney stone?
Or the guy with an MI? Or the teenager with a gunshot wound? Or the
kid hit by a car? Or the suicidal patient who finessed her way out of
restraints and is skedaddling out of the ER? Or the asthmatic gasping for
breath? That ER was such a hellacious place to work that when we tried to
recruit board-certified ER docs with experience in reasonably high-acuity (we
thought) ERs, those docs would quit after anywhere from one day to one week (in
spite of our high pay),
citing "this is too much" or words to that effect. If I were
smarter, I'd probably arrived at the same conclusion. Yet SOMEONE needed
to staff that ER, and the ER director refused to institute double coverage.
The "standard of care" is fine in an idealistic sense, but is it
pragmatic enough to account for real-life circumstances that preclude the
delivery of optimal care to everyone?
After some rumblings about a
possible nationwide strike by fed-up ER doctors
One of the reasons I wrote my book of ER stories (True
Emergency Room Stories) was to make more people aware of how the malpractice
situation is spiraling out of control. The ultimate victims are the
patients, because they're harmed by increased healthcare costs catalyzed by
skyrocketing insurance premiums, and they're sometimes harmed by defensive
medical practices. As Bob Solomon pointed out so clearly, patients are
also harmed when their access to physicians is restricted because doctors close
up shop and move elsewhere. Of course, this ancillary damage is never
considered by attorneys who purport to be the champions of "the little
guy;" they act as if their rapacious tactics are purely beneficial.
The increased cost of healthcare ultimately filters to the patients, forcing
some of them to forgo medical insurance.
It's no secret that medicine is an increasingly noxious profession.
Physician income can be whimsically slashed by insurance companies and the
government, while malpractice premiums and other expenses snowball. Add to
this the perpetual hassles of interfacing with the managed care bureaucracy, and
it's no wonder that some people who would have chosen medicine as a career, now
cognizant of the painful realities of what it's like to be a doctor, are
choosing another profession. Very intelligent people don't need a medical
career; they have their pick of alternate professions. Make a field less
rewarding, and the end result is that the aptitude of applicants drops. In
my opinion, one of the most onerous consequences of the current climate of
medical practice is that it's repelling some of the best and brightest people.
Some medical schools are so desperate for truly qualified applicants that
they're now accepting people who would not have stood a snowball's chance in
hell of being accepted into medical school a generation or two ago. Those
people who say "no thanks!" to a medical career aren't harmed; they
will be amply rewarded in whatever profession they choose. Who suffers
from this diversion of brainpower are future patients who will be treated by
doctors with IQ's of 110, instead of docs with IQ's of 130, 140, or higher.
Granted, there will probably always be a small pool of gifted people with
admirable altruism who will still choose medicine as a career no matter how much
the rewards are decimated, but most people want to be adequately compensated for
their talents, education, and expenses incurred in the pursuit of that
education. Hence, the pool of applicants will dry up. Medical school
applications have fallen for four years in a row — incontrovertible evidence
that potential physicians no longer believe the rewards of medicine are adequate
compensation for the demands of medicine.
Besides the worrisome efflux of applicants, in recent years we've witnessed a
phenomenon once unthinkable: doctors chucking their careers for outwardly
less rewarding jobs in real estate, financial planning, law enforcement, and
even tending bar (I know one surgeon who's now a bartender). Obviously,
this doesn't bode well for the future.
I've done my best to popularize this crisis by mentioning it in my book and
radio interviews, but at times I think I'm a lone voice in the wilderness trying
to inculcate the notion that society should stop whacking docs around like a piñata
if it wishes to attract the most gifted people into medical careers. I'd
love to hear from anyone who has an idea on what we can do to make the general
populace understand that they have a vested interest in drawing the smartest
people into medicine.
The scenario: malpractice
insurance premiums for ER docs are skyrocketing, inciting ER physicians to
consider dropping their malpractice coverage. One group member asked if
such a move would be in the best interests of hospitals. My response
Obviously not, so they'd try to block our exodus from the ranks
of the insured. However, if ER docs exercised their collective power and
mutually agreed to drop their coverage after a set date, hospitals would have no
choice but to allow uninsured ER docs to work. Perhaps this would be an
equitable means of forcing this medical liability crisis to a head without
compromising patient care — we wouldn't need to abandon our responsibility to
care for patients, or even threaten to do so (which may further erode our
already questionable support from society).
Attorneys determined to sue, even
when their experts say there's no case
It's too bad that other attorneys are not as principled as Abigail Williams.
A few months ago I stumbled across an interesting site on the Internet in which
lawyers sought advice from their compatriots. Were these learned and
distinguished officers of the court seeking ways of arriving at truth and
justice? It strained credulity.
The first message caught my eye. A personal injury attorney was bemoaning
the fact that the doctor he'd paid to review a potential malpractice case
concluded that there had been no malpractice. He asked his fellow
extortionists, um, colleagues, how he could get a doctor to tell him — and the
court — what he wanted to hear. Two points: (1) When a lawyer is
paying a doctor $400 per hour to find dirt, the doctor usually finds dirt.
(2) When your hired hand says there ain't no case, there ain't no case.
Nevertheless, the attorney kept searching for a doctor who is greedy enough to
say anything, and he'll find one sooner or later.
Should all patient
encounters be chaperoned?
A list member (Danny McGeehan) made two statements,
the first of which is that a doctor or nurse should never be alone with a
patient, and the second of which was that the extra time and burden associated
with chaperoning may increase turnaround times, but such a delay was not as
important as fending off allegations of sexual impropriety that may result if
all patient encounters with the opposite sex are not chaperoned. Keep in
mind that all intimate exams (e.g., pelvic or breast) are routinely
chaperoned. My response follows:
In regard to the first point, I think it's going overboard to have a chaperone
tag along with every nurse, physician, or other healthcare provider. I
believe that it is incumbent on us to do what is in the best interests of
the majority of our patients, and I am certain that most of them would truly
resent having a chaperone (who, because of economic considerations, would
almost certainly be a nonprofessional) being made privy to their secrets.
On rare occasions, though, I have asked a nurse to accompany me when a female
patient made prefatory comments which led me to believe that she had more on
her mind than just an exam in the ER.
I must also disagree with the second point raised by Dr. McGeehan.
Turnaround times can sometimes have a critical impact on patient care.
Triage nurses usually do a good job of separating the wheat from the chaff,
but they don't always identify 100% of the patients who need to be seen
immediately. If waiting times for these mistriaged patients increase,
some tragedies are bound to occur. And let's not forget that many less
critical patients are in pain or are otherwise suffering. Shall we
subject them to a longer wait just so that we can rebuff allegations made by
the occasional patient who is either avaricious or a fruitcake?
If chaperoning is such a good idea, why limit it to the ER? Shouldn't
psychologists and psychiatrists be chaperoned? How about police
officers? Or massage therapists? Or babysitters? Or
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ER docs with their blinders on
Mr. Westerfield's story reminds me of a somewhat similar story. One of
my colleagues, a board-certified ER doc, once insisted to me that a patient
couldn't be experiencing an asthma attack because she wasn't wheezing. I
countered that she wasn't wheezing because she was moving too little air; I
thought that lesson was part of Asthma 101. Still, the other doc
maintained that no wheezing = no asthma. Inexplicably, after he
failed to detect wheezing he concluded she was fine and could be discharged
despite the fact that she was clearly dyspneic and, from my standpoint, looked
like she'd die if not treated. I treated her and with her increased airflow
she began wheezing — an apparent paradox for docs who flunked Asthma 101.
Consequently, my partner was baffled. Eventually, she cleared up
A few years later around shift-change time that same doc presented a case to
me that, based on his description, sounded like a textbook case of central
cord syndrome (CCS). I told him of my suspicion, but he said the patient
was just "fat and lazy" and a few more pejorative terms. I
examined the patient, verified my preliminary diagnosis, and told my partner
that this patient clearly had a CCS. Characteristically for him, he kept
his blinders on and went home, refusing to even reexamine the patient. I
admitted the patient and the neurosurgeon verified that it was indeed a CCS.
Another day, another patient, and another refutation of the fact, taught by
some risk-management "experts," that turning over patients at
shift-change time is bad for the patient and increases risk. This time
the doc was another board-certified ER doc, but her judgment was usually
sound. However, on that day she concluded that a certain drunk had a
benign cause of abdominal pain and she told me I could discharge him after
checking his labs. "Don't even bother to exam him — he's just a
drunk," she said. I ignored her advice, examined the guy, and less
than a second after my hand felt his belly I knew he was a keeper (ER lingo
for a patient with a real problem who is certain to be admitted). I got
an upright chest x-ray which showed free air under the diaphragm, and I
cheated some malpractice attorney out of his condo in Aspen.
I'm not claiming that I'm a great diagnostician because I picked up on these
cases that failed to even register on the radar screen of my partners — for
heaven's sake, they were utterly obvious. The moral of the story is that
docs can sometimes be too hard-headed for their own good, and they sometimes
tenaciously adhere to the first diagnosis that occurs to them even when other
facts clearly indicate that the first diagnosis is wrong.
After one list member complained
that then-candidate George Bush doesn't care about healthcare, I responded, then
segued into a cogent (I think) proposition that ER doctors are forced to work
for free . . . isn't this slavery?
That is not true, Jason. Bush may be espousing less generous plans than
Gore, but it is not accurate to say that he has not advanced any healthcare
initiatives. Furthermore, it is important to remember that the government
NEVER truly gives anything to anyone; it merely enacts laws which compel Citizen
A to give money to Citizen B. Just because the money is funneled through
the government, rather than being directly handed over, just not change the
reality of this fact which is, quite frankly, tantamount to slavery. Since
people must work to make money, the government is compelling Citizen A to work
for Citizen B without Citizen B having to do ANYTHING for Citizen A.
Furthermore, shortsighted politicians who are eager to throw money at today's
senior citizens and other special interest groups are ignoring the fact that the
real crisis is how to return to the Baby Boomers when they retire a fraction of
what they've paid into the system for Social Security and Medicare. When
we retire, we will get far less than today's senior citizens. Does Gore
care about that? Evidently not. He wants to give today's seniors
more, which will result in tomorrow's seniors getting less. There is only
so much money to distribute, and if you give it to one person, you cannot give
it to another.
A list member (Anne) then suggested that all citizens
have been both "Citizen A" and "Citizen B" at various
times. My response follows:
I agree. However, just because we've benefitted from public education (as
Anne suggested), does this obligate us — AND the multitudes who have not
received taxpayer-supported educations — to keep on giving money to others
indefinitely, especially when this giving has no logical nexus to education?
Yes, I attended a publicly funded medical school, but I've paid enough in taxes
to pay for my education many times over. Let's also not forget that most
healthcare providers reimburse society in another way: by providing care
to patients who either cannot pay, or those who have "cents on the
dollar" insurance like Medicaid. Apparently Anne does not feel as if
that is enough, and she wants to burden taxpayers with the need to pay for yet
another politician-inspired "crisis." I've already given away
more than $1,000,000 of care to people who could not afford to pay for their
healthcare. Is this not enough, Anne? Have I not done my "fair
share"? Evidently not, because Anne would like to elect a politician
who could compel me to give even more. I'm curious, Anne: what
percentage of income do you feel is reasonable for the government to
Addendum: the government obligates ER doctors to provide free
care to anyone who walks in the door. First, let me preface what I'm about
to say by indicating that I don't mind giving free healthcare to people who
truly need it and cannot afford it. However, the government doesn't
just force me to provide free care to poor people with emergencies, it forces me
to provide free care to anyone who can't pay who comes into the ER even if they
come in for a ludicrous reason that has nothing to do with medicine, let alone
an emergency. Now that riles me! Imagine this: what if
you owned a restaurant, and the government compelled you to feed any poor person
who walked in your establishment? Or what if you owned a store, and the
government allowed poor people to take your merchandise without paying? Or
what if you clean houses, and the government forced you to do free housework for
poor people? Or what if you work in an automobile factory, and you were
forced to build cars without pay a few days per week? You'd be justifiably
outraged, wouldn't you? (If you say "no," write to me, tell me
what you do for a living, and then tell me that you would not mind if the
government required you to give away your products or services without any
compensation, limit, or even without a "thank you." Then tell me
that wouldn't bother you.) Considering the amount of free care we provide,
ER doctors have been remarkably tolerant of this forced confiscation of our
services — which is how we put food on our tables, take care of our loved
ones, and pay our bills and taxes. Instead of thanking us, the government
is forever reducing our incomes by decreasing Medicare and Medicaid
reimbursements (which were insultingly low to begin with) and enacting laws and
regulations that make the practice of medicine a nightmarishly risky occupation
(e.g., something as simple as transferring a patient to another hospital can
result in a $50,000 fine unless the correct papers and procedures are
followed). Well, the good old days of ER doctor complacency are
over. ER docs have been shafted so many times that they've finally said
"enough is enough" and are considering going on strike.
Interestingly, other doctors aren't subject to the same confiscation. No
matter how poor you are or how much you need them, you can't walk into the
office of an eye doctor and demand free glasses or contacts. You can't see
a plastic surgeon and demand free surgery, even when that surgery is not
frivolous, such as cancer reconstructive surgery. You can't force a
dentist to take care of a bad tooth for free, even if you have the worst
toothache in history and a dental infection severe enough to threaten your life —
who'd take care of you then? An ER doc, of course. You can't force a
dermatologist to treat your acne for free, even if that acne is severe enough to
result in permanent scarring. Yet ER docs cannot refuse to give care to
anyone, for any reason, even if it's someone with belly button lint, a bad hair
perm, difficulty getting a date, or a questionably loose vagina — all cases
I've seen in the "emergency room.". If the government forces us
to provide care to anyone, it should pay us for the uncompensated care.
Yet it doesn't. Does such forced confiscation exist anywhere else within
our supposedly just government? Being forced to work without pay isn't
just tantamount to slavery, it IS slavery. Just because ER docs aren't
slaves 100% of the time does not make it right. Anyone who wishes to give
away their goods or services is free to do so. That's called
"charity" or "volunteering." However, no one should be
forced to work for free — that's slavery, no matter how you try to sugarcoat
it. Slavery isn't just an abomination for everyone except ER doctors, it
is an abomination for all.
Currently, there is a move in the United States for black people to obtain
reparations for the slavery of their ancestors, even though the prospective
recipients of such reparative payments were themselves not slaves. If such
reparations are just, it'd be even more just for modern-day slaves — ER
doctors — to be paid for the forced work they gave. Hence, I think it is
time we, as ER doctors, banded together and demanded reparations.
Pros and cons of ER?
A nurse (Brandy) considering ER work asked for its pros
As with anything in life, there are pros and cons associated with working in the
ER. The primary advantage for nurses is that it isn't boring, unlike some
of the other nursing specialties in which you treat a much narrower variety of
conditions. If you're sharp, you also have the chance to do some real good
since ER nursing is one of the few branches of nursing in which you often see
the patient before the doctor does.
As far as the cons go . . . well, where do I begin? Working nights,
weekends, and holidays is a real drawback, but you will face that with most
other branches of nursing. The unpredictable pace of the ER is another
drawback, since that will invariably lead to many missed meals and breaks.
Some nurses regret the lack of continuity in patient care, which brings me to
another point. The patients whom you'll see again and again and again
in the ER are usually the ones you don't want to see again, and the ones
you do will be seen for follow-up by their docs, not in the ER.
My ER residency director was fond of saying that "ER medicine is scumbag
medicine." I had no idea what she was talking about at the time,
since I assumed that people are all pretty much the same. I wish that were
true, but I've learned that it isn't. When you work in the ER you'll
encounter a much higher proportion of people who abuse alcohol and/or drugs, and
people who are abusive, mean, cruel, self-centered jerks. Dealing with
these people is one of the factors that is responsible for the high rate of
burnout amongst ER personnel.
Good luck in your career, Brandy.
What causes pain with Dermabond
("super glue for skin") application?
While the exothermic liberation of heat may be the primary factor
responsible for pain with application, another possibility is chemical
irritation. Dermabond (octyl cyanoacrylate) is chemically very similar to
the cyanoacrylate "super glues" (of which there are a few different
formulations). I learned — the hard way — that such glues emit a
highly reactive gas. I used super glue to bond a clear label onto a
snowmobile I'd made. Since the glue was crystal clear, I thought it would
be ideal. Wrong. The glue emitted an invisible gas that turned the
plastic label into a milky white color (this was obvious from the pattern, and I
later read a technical paper that substantiated my hypothesis). If this
same gas is liberated from Dermabond, its vapor pressure could force it into the
List member seeking advice on how to
reduce post herpes zoster (shingles) itch
Have you tried desensitization with topical capsaicin? That works by
progressively depleting substance P, a neurotransmitter which mediates itch, in
addition to other sensations. It may initially exacerbate itch before
substance P is depleted, but once that is accomplished it can produce a
long-term amelioration of itch with continued application.
Who removes sutures in your ER?
Nurses performed suture removal in all of the ERs in which I've worked unless
the removal was complicated and/or unusually delicate (e.g., eyelid).
However, I think that it is important to stress to patients that the wound is
susceptible to partial or complete dehiscence for several more weeks, and that
timing of suture removal does not mark the end of the healing period but instead
is dictated by the need to limit scarring and the risk of infection. I
also stress to patients that optimal healing is contingent on adequate nutrition
(e.g., protein, copper, vitamins B6 and C, etc.). Finally, I think that
Steri-Strips should be applied after suture removal whenever possible since they
reinforce the wound. While most wounds do not completely dehisce, small
areas of partial dehiscence are fairly common which can lead to increased
scarring and infection as well as a prolonged healing time.
member inquired about lung sounds
I have two such packages on lung sounds that consist of an audio cassette with
an accompanying short (~100 page) book. One is entitled Normal &
Abnormal Breath Sounds by Blackwell and Czlonka (published in 1990 by
Springhouse Corp.) and the other is Lung Sounds: A Practical Guide
by Wilkins and Hodgkin (published in 1988 by Mosby).
It's relatively easy to make your own recordings, too. I've made several
stethoscopes and portable phonocardiograms, the audio output of which can be
fed into a tape recorder or computer.
Dr. Jeffrey Mann asked for input on
impedance cardiography. I responded:
I'm not convinced that measuring impedance will accurately reflect cardiac
output and related parameters in all patients. I made a noninvasive
cardiac output monitor about 11 years ago, and when I did the engineering for it
I considered using impedance because it's seductively easy. However, the
problem (as I see it) is that there are many pathways of different impedance
between the electrodes. The manufacturer claims that the current
"seeks the path of least resistance: the blood-filled aorta."
Really? Gee, that wasn't what I learned in college. I was taught
that when multiple pathways exist between electrodes, electrons fan out, so to
speak, in such a way that the current density is inversely proportional to the
impedance of any given pathway. Thus, the "blood-filled aorta"
may be the path of least impedance, but it certainly is NOT the only pathway
electrons can take. Countless other pathways exist, and they too vary in
impedance. Because of the capacitive effect (I'm using
"capacitive" in its physical sense, not in its electrical sense of
being a capacitor) of the lungs, there is less cyclic variation in impedance
through these secondary channels than though the primary channel of the aorta.
Nevertheless, how can the machine differentiate amongst these primary and
secondary cyclic variations? I know how I'd approach this, but the problem
is that it requires a number of assumptions that may or may not accurately
reflect the anatomical and physiological variations in different people.
A list member asked if an anemic
patient can be cyanotic
Yes. The presence of anemia does not preclude cyanosis. However,
with increasingly severe anemias the visual perception of cyanosis can be
masked. I've heard various figures quoted as to the threshold of
hemoglobin below which visual detection of cyanosis is obscured, but I think
that number is contingent on several factors, such as ambient lighting (since
different light sources vary in intensity and spectrum), the patient's skin
coloration, and whether you're talking about central or peripheral cyanosis.
A list member asked why we forget
I don't know of any specific neuronal pathway that quickly erases dream
memories, but I've thought about this matter from both a teleological and
Darwinian perspective. My conclusion is that it would be incredibly
NON-adaptive if we did not quickly forget dreams. Of all the billions of
memories in your head, imagine how difficult life would be if you had to sort
out which were valid memories, and which were dream memories.
However, if you wish to retain memory of a specific dream, just make a
conscious effort to memorize it as soon as you wake up (or jot it down, or
dictate a synopsis into a bedside tape recorder). Just by trying to
memorize dreams upon awakening, I can vividly recall dreams I had as a
teenager. Of course, I've automatically labeled those memories as
"dream memories." Without that conscious effort to memorize a
dream, I think it would be too easy to confuse dreams with reality.
A discussion about eye magnets
Thanks to Joe Lex for a wonderfully informative posting on the topic of eye
magnets. The only things I have to add are:
-- Every permanent magnet eye magnet I've seen uses magnets that aren't
particularly strong. Using state-of-the-art permanent magnets, it's easily
possible to make your own eye magnet that is much stronger than those
-- Permanent magnet eye magnets are useful only for the extraction of ferrous
foreign bodies. A conventionally-wound electromagnet has the same
limitation. Interestingly, it's possible for a specially-wound
electromagnet to also attract nonferrous substances such as aluminum, brass,
lead*, and copper*.
To my knowledge, no such device is currently sold, probably because there isn't
enough market demand for it — or am I wrong in assuming that? (*
Thus, it is possible to literally suck a bullet out of a patient without
surgery. Some bullets are left in place because the damage inflicted by
the surgery is, in the opinions of surgeons, too great to warrant removal of the
bullet or, in the case of shotguns, pellets. If I were a patient carrying
lead, I'd prefer to get it out of my body.)
-- I made an electronic device that locates either ferrous or nonferrous foreign
bodies near the surface of the body or even in deep puncture wounds anywhere in
the body. There is a picture on
my web site of the first two such devices I made, and later models extract
the foreign bodies in addition to localizing them. I developed these
gizmos because our conventional ways of extracting foreign bodies often cause
significant tissue trauma, and because foreign body extraction using
conventional techniques is often a lot easier in theory than it is in practice.
By the way, if anyone has a hankering for a medical device that doesn't
currently exist, tell me what's on your "wish list." If I make
the device, I'll give the first one to you (free!). I'll even include the
batteries and completely assemble the device . . . I thought I should mention
that in case any of you are parents still reeling from the frustration of
unwrapping presents on Christmas day to find two dreaded phrases:
"Batteries not included" and "Some assembly required."
ER docs lamenting the need to take
the ACLS (Advanced Cardiac Life Support) course
Can anyone enlighten me as to how ACLS became a course that is separate from
medical school and residency? I've heard many ER docs denigrate the need
to certify in ACLS as "badge medicine." Yes, the ACLS
information is important, but isn't that what medical school and residency are
for? It's also critical that we correctly diagnose and treat abdominal
pain, so why haven't the gastroenterologists banded together and made us
certify in belly pain management? Certainly, those diseases can be life
threatening, too. Or why haven't obstetricians stipulated a similar
requirement for the management of complicated L&D? Or why haven't
infectious disease specialists instituted a course relating to their purview?
And on and on . . . .
Considering the steep fees charged by the AHA*,
I've wondered if this wasn't a politically motivated move designed to keep
cash flowing into their coffers.
* AHA = American Heart Association, the organization
behind ACLS. In my opinion, if the AHA truly cared about people (as
opposed to profits, political clout, and just plain focusing on their own aggrandizement),
they would encourage people to reduce their intake of trans fatty acids and
implement other changes that reduce cardiovascular risk. Their
educational efforts are mickey-mouse at best.
A discussion of the propriety of
cameras in the ER
Two years ago a television producer who'd read my book of ER stories contacted
me with an idea for a new TV show. He wanted me to carry a hidden camera
as I worked in the ER, and by doing that he assumed we could obtain a number
of unusual cases similar to the ones in my book. I explained to him that
was both unfeasible (since it took over a decade for me to acquire my
collection of stories) and unethical, and I refused to participate. I
suggested we reenact the cases using actors so that the patients' identities
were camouflaged, but he didn't believe that viewers would be interested in
watching such depictions of real events. That's odd, since viewers seem
to have a boundless appetite for medical shows which portray imagined
events that have been concocted by TV writers who apparently have little
conception of what really goes on in emergency rooms.
Another thought: I don't know if this dearth of realism is the fault of
the television producers, writers, directors, or actors, but I've yet to see any
medical show that accurately depicts some of the most bizarre, wacky, and
intense moments that occur in real ERs. Even the "real ER" shows
miss the mark, because the cameras aren't around enough to capture some of the
most memorable occurrences. Another factor is that people behave
differently in the presence of cameras.
After doctors on an airliner
administered an injection to control an unruly passenger, a list member asked
about the doctors' authority to do this. Here's my answer:
In my opinion, what they did was tantamount to what we sometimes do in the ER
when we administer "chemical restraints" to unruly patients to protect
them, us, or both. The fact that the venue was an aircraft rather than an
ER makes it seem more dramatic, but I don't see any substantive difference
between the two circumstances.
The etiquette of when to use
I agree with Dr. Butler that titles are contextual. That got me thinking
about how Dr. Laura Schlessinger habitually uses her "doctor" title on
her talk radio show even though her Ph.D. is in physiology, which has nothing to
do with the advice and "moral guidance" she delivers. I don't
want to turn this into a cat fight about her (since she can be so polarizing and
she obviously rubs some people the wrong way), but I'm curious about what other
list members think about the propriety of her use of the title
"doctor." On one hand, I suppose she is legally entitled to use
it, but on the other hand it smacks of an ethical deception. I've twice
heard her mention that her Ph.D. is in physiology, but I culled those two
mentions out of years of listening to her shows — ergo, she's not issuing the
"my Ph.D. is NOT in psychology" disclaimer very often. How does
her use of the "Dr. Laura" title strike you? Justified?
Thank you in advance for weighing in on this matter.
Medicine and politics are
inseparable, so we discuss it
A list member complained about several things during the 2000 Presidential
election, including the fact that Bush professed to be pro-life yet was Governor
of Texas at a time when Texas ranked first in the nation for executions of
convicted criminals. She then criticized Bush for immigration problems
along the Texas-Mexico border, and then berated Bush for not rolling out the red
carpet for those illegal aliens. (With voters like her around, I am glad
I'm not a politician.) Here's my response:
Have you forgotten that those people were executed for committing heinous
crimes, most often murder? It is quite a stretch for you to equate capital
punishment of a convicted felon with a pro-life stance in regard to innocent
unborn babies; surely you can appreciate that there is no moral equivalence
between these entirely disparate situations.
In regard to the other points you raised, they are utterly pointless unless you
consider them in the context of two things: 1) How did they CHANGE during
Bush's tenure as governor? 2) How did this relative change compare with
states that faced comparable problems, such as illegal immigration? Many
of the problems you mentioned are directly traceable to the influx of illegal
immigrants that has occurred during Clinton's presidency. The federal
agency (INS) that is responsible for this problem is under the control of the
President, not Governor Bush. If the President allowed scads of illegal
immigrants to overrun your home town, would you blame the President or would you
blame your mayor? Unless I'm reading you incorrectly, you think it would
be more plausible to blame the mayor.
In response to your third point about how HMO's did not renew their contracts
with Medicare last year because the federal reimbursements were lower than their
costs: this is a simple consequence of the fact that the federal
government has been duped by managed care organizations. Collectively,
they got their foot in the door by promising to lower health care costs, but
this proved to be an illusion. They have no secrets or magic for lowering
costs; their way of reducing costs is to dump the ones who need them the most,
and keep the ones who need them the least. And we're rewarding them with a
piece of the pie by continuing to do business with these sharks? In our
economy, people or corporations are given money that is generally commensurate
with the value of the goods or services they produce*.
So what is the value to society of managed care organizations that seek to
profit by economizing in such an execrable way?
* Yes, I know there are exceptions, such as
Enron, or Microsoft, which makes first-rate profits, but gives us bug-filled
and poorly conceived second-rate software.
The real problem is not the avarice of the CEOs or stockholders of the managed
care organizations (MCOs), because it is reasonable to expect that ANY
for-profit corporation will seek to maximize its profits. Instead, the
problem is that our national "leaders" have been asleep at the
wheel. In my opinion, these for-profit bloodsucking MCOs never should
have been allowed to get their tentacles into our healthcare system. And
who let them? Our shamelessly stupid politicians who devote most of
their energy into partisan bickering and grandstanding. Bush has made it
clear that it's time to put this divisiveness behind us, but Gore embraces
this discord as his only hope for winning the election.
Shortly after the terrorist attacks
on 9-11, before we knew who was behind this
Jeanne Lenzer urged us not to pre-judge who may be behind this. I don't
think that President Bush is going to pre-judge, nor have I seen any
administration official specifically mention any person or group as being
responsible for today's attacks. However, recent history strongly suggests
who is likely to be behind this abomination. Once we obtain credible
evidence, I think it is time to view pacifism as an anachronism as outmoded and
useless as the attempted pacifism of Hitler by Chamberlain prior to World War 2,
and to declare war on the enemies of the United States. They're out to
destroy us, Jeanne, and if we don't clip their wings now, they'll just get
stronger in the future. Imagine if they possessed an extensive nuclear
capability, as they inevitably will at some point in the future. They'd
obliterate all of our major cities and destroy a substantial portion of our
infrastructure. Imagine if we couldn't treat patients correctly because
the plants were destroyed that manufacture our pharmaceuticals, instruments, and
other supplies. Now imagine if the terrorists implemented a second wave of
chemical or biologic attack — with an enfeebled infrastructure, they could
virtually destroy the United States (which is, of course, their goal).
Let's not forget that we're dealing with people who are fundamentally different
than us: witness their gleeful celebration when they heard of the attacks.
Coincidentally, a couple of days ago I answered a reader's question on my web
site, and while discussing the general issue of culpability I said "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. The only ones who will ever
suffer retaliation from that mistake are innocent Americans killed by terrorists
seeking revenge for the bombing."
No, I don't have a crystal ball, but anyone with common sense can see that the
writing is on the wall. Enemies of the US declared war on us, and failing
to retaliate will not dissuade them. Nor will being nice and inviting them
to pleasant chats at Camp David. Nor should we continue giving them
"humanitarian aid." If your neighbor was lobbing grenades into
your house, would you give a hoot if that neighbor's children were malnourished?
My posting caused a vacuous list member to
misconstrue what I said, so I clarified this:
When I said in my last posting "If your neighbor was lobbing grenades
into your house, would you give a hoot if that neighbor's children were
malnourished?" I, of course, did not intend that to be a LITERAL rhetorical
query, although one list member interpreted it as such. Since it was just
announced that some of the pilots involved in yesterday's attacks were trained
in the United States, I think it is suicidal (and THAT you can interpret
literally) for the United States to train foreign pilots and to educate them in
our universities so they can use that information against us. During World
War 2, any American suggesting that we continue to train German and Japanese
pilots and scientists would have been viewed as having rocks in his or her head.
We're at war, and it's time we stopped aiding and abetting our enemies.
And yet another list member did not like what I
said, evidently because he identified with the group I criticized. Here's
I provoked the ire of Dr. Nadeem Al-Duaij by stating, ""Let's not
forget that we're dealing with people who are fundamentally different than us:
witness their gleeful celebration when they heard of the attacks."
Rather than back down, as he would undoubtedly like me to do, I'll provide
further substantiation of my asseveration. First, let's consider how the
United States responds to any foreign enemy: it makes every effort to
select a SPECIFIC target and to implement a plan designed to destroy that target
while limiting collateral damage. In contrast, terrorists typically adopt
an antithetical approach: they usually target innocent civilians,
including women and children. So, Dr. Al-Duaij, I still maintain that
"they" are fundamentally different than us. By the way, I
intentionally refrained from specifying if the "fundamentally different
than us" phrase meant that they were better than us, or worse than us.
Your obvious anger strongly suggests that you reflexively assumed that I
intended to slam a group of people. Why bother? I left that
conclusion to your own sense of propriety.
Another reason why I maintain that "they" are fundamentally different
than us is this: over many years, I've watched their spokespersons
staunchly defend their heinous and unrelenting attacks of terrorism as being a
justifiable response to the supposed Israeli usurpation of their land.
While I am not sufficiently knowledgeable on this issue to pass judgement on
whether their claim is justified or not, I DO know that their response (the
indiscriminate and seemingly perpetual murder of innocent people) is an absolute
abomination. Just because Arabs are frustrated in their efforts to get
Israeli to give up land (or heaven knows what would truly appease them) DOES NOT
GIVE THEM THE RIGHT TO KILL INNOCENT PEOPLE. Dr. Al-Duaij seemingly
suggested that I should excuse the ebullient response of the Palestinians as
being a knee-jerk response to their years of oppression. OK, I'll excuse
their reactions as being fueled by emotion, not intellect. What I WON'T
excuse is how Palestinian leaders and spokespeople (who are for the most part
educated people who SHOULD know better) typically condone their acts of violence
as being righteous. Again, if they think that is righteous, their cerebral
wiring is substantially different than mine. Yes, I know that Arafat
condemned this most recent attack, but his past intransigence has directly and
indirectly supported the continuance of terrorism.
Yet another reason why I think "they" are different than us is this:
some Middle Eastern and other nations (no need to name them) are known to
bankroll terrorism. They may not be the ones directly attacking the United
States and its citizens, but by providing money and a safe refuge, they are, in
legal terms, accessories to murder. If they wish to avoid the wrath of the
United States, they should "police their own," so to speak.
Consider this as a thought experiment: if a band of radicals in the United
States were using the US as a base from which they launched terrorist attacks
against civilians in other nations, would the United States government tolerate
this activity? Of course not! The BATF (Bureau of Alcohol, Tobacco,
and Firearms) and the FBI would raid them and they'd be prosecuted in federal
court. In contrast, do Middle Eastern countries prosecute known
terrorists? No, they typically receive adulation, not a jail sentence.
In closing, I'd like to reassure Dr. Al-Duaij by saying that I do NOT believe
all Arabs are terrorists. Of course not. In fact, during my freshman
year of college I lived in a duplex, and the other tenant in this duplex was an
Arabic professor who wasn't very mechanically inclined. As a consequence,
his wife asked me if I'd assemble a pool she'd purchased for her children.
She was so grateful to me for assembling the pool that she made me all kinds of
food — very delicious, by the way! :-) I know that
Arabs, just like other people, can be very sweet and loving people, so I
certainly don't mean to suggest that they're all radical terrorists.
However, the one complaint I have against them in a general sense is that they
don't do a good job of assisting in the extermination of terrorism or
"policing their own," as I mentioned above. In fact, some Arab
nations are veritable cheerleaders for terrorism. Is that how to get into
the good graces of the world? No, that's how to become a pariah.
In response to some of the "don't you know that the United States isn't
perfect?" e-mails I've received. First, let me say the obvious:
Duh, no kidding! Please excuse us for this, but if you look at the 2000
Presidential election (in which it was clear that many people are too stupid to
follow directions and punch the correct chad), it's no wonder why Americans can
be so easily duped into voting for politicians who make so many pathetically
stupid decisions (on both foreign and domestic issues) that they regularly
provoke the wrath of people here and abroad. Consequently, I won't defend
those jerks by claiming they're perfect, or even close to it . . . but look at
the alternative. If you're a student of history, you know there is some
evidence that President Roosevelt could have averted the attack on Pearl Harbor,
but he chose not to do that so he could justify our joining the combatants in
World War II and rally the American people behind the war effort.
Considering our enormous sacrifice of men and money (which American taxpayers
are still paying for), one might think that such an act would elicit some
gratitude around the world, especially from the 90% of you who would now be
German or Japanese slaves had we not defeated them so you could be free to live
your own lives. Instead of gratitude or neutral indifference, we
frequently hear "Death to Americans!" and other such incandescent
rhetoric. If you believe that, ask yourself this question: what
other country (besides the United States) is as kind to its vanquished
foes? Germany and Japan did everything they could to defeat us, and Japan
(in particular) was viciously and mercilessly cruel to American prisoners.
After we won the war, we could have taken over their countries and harshly
subjugated them, but did we? No, we poured billions of dollars into
rebuilding them, and we bent over backwards to be friends. As a result, we
now have amicable relations with them, and their citizens are free. By the
way, if we were the mean pricks that we're often alleged to be, we could have
demanded war reparations — which means that taxpayers in Germany and Japan
would have paid for World War II, instead of that war being paid for primarily
by US taxpayers. We could have gone further and literally enslaved you, as
Germany and Japan did to so many during World War II. Heck, right now I
could have a cute little Fräulein making lunch for me. But no, American
politicians, who had the power to literally rule the entire world with an iron
fist after World War II, instead used that power to benefit people who just
weeks before were doing everything they could to kill us. Tell me that
you'd be so charitable in such a circumstance!
This discussion thread continued after a list member
seemingly excused the terrorism by presenting a long list of examples of what he
viewed as past examples of American impropriety. He then asked what
conclusions we'd draw after reading his list.
My conclusion? It seems to me (but correct me if I'm wrong) that you're
attempting to justify CURRENT terrorist attacks against innocent civilians by
pointing an accusatory finger toward PAST (in some cases, centuries old)
American actions against specific targets. Just as present Americans are
not responsible for slavery (not to mention the fact that half of the US fought
to free the slaves), present Americans are not at all responsible for past
wrongful acts. That said, I think it is obvious that your list is
overreaching if it purports to insinuate that all of the acts were wrong.
For example, the Vietnam War was an attempt (albeit a half-hearted one) to give
freedom and democracy to oppressed people. Does that offend your
I fail to understand why any just person would not be outraged by either
terrorism or its apologists. That said, I totally agree with Dr. Ragland's
seeming viewpoint on the propriety (or, more appropriately, the LACK of
propriety) on the strikes ordered by then-President Clinton against the Sudan
pharmaceutical plant. I was outraged by this at the time, and I remain
outraged by this egregious abuse of American power. If Sudan wishes to
punish CLINTON for his moral turpitude, I'll applaud their actions.
However, I think it's clearly wrong for any person, group, or nation to
specifically target Americans who bear not the slightest shred of culpability
for wrongful acts.
Another list member (Ron Pristera) raised an
excellent point by challenging people to think of a country that is more
benevolent than the United States. I wholeheartedly agreed with him, then
For those of you who've tried to serve up feeble excuses for the slaughter of
innocent Americans, please address this question: what nation does so much
and gives so much to nations around the world? We give humanitarian aid to
people in the Middle East, and they demonstrate their gratitude by cheering the
death of Americans whose only crime was to be born in the United States.
In recent years, numerous American missionaries were murdered . . . but does
that dissuade us? No, many Americans with admirable devotion and idealism
give up cushy lives in the United States in an attempt to help underprivileged
people in foreign countries. Yet if you listen to the vitriolic rhetoric
emanating from the Middle East, we're "the Great Satan." No,
we're not the Great Satan. We're the most selfless and avuncular nation in
the history of the world, even when our good deeds put us in peril. When
our predecessors committed aggressive acts (some justified, some not), are
current Americans taking advantage of people we've supposedly oppressed?
Let's consider the much-maligned oppression of American Indians. We
haven't just given them the rights afforded to any citizen, we've given them
rights and privileges not enjoyed by other Americans. Apart from their
ability to disregard fish and game laws, they also have the right to operate
casinos. I've read that some tribes are so rich every member receives a
$100,000 check every year just for being a member of that tribe. Yes,
we're really oppressing those people. Clearly, while the United States may
not be a perfect country, no other nation is as kind to its past and present
enemies. For example, in World War 2 Germany and Japan were hell-bent on
seeking our destruction, but what did we do immediately after vanquishing
them? We helped rebuild their nations and even protected them. This
benevolence is unprecedented in the history of the world, but in spite of our
commendable acts we're lambasted as "the Great Satan." OK, you
apologists for terrorism: try apologizing for that.
After still more list members applauded or excused
the terrorism (proving that sanity is not a prerequisite for membership in this
group), I unloaded another salvo:
I have a question for the members of this list who attempted to excuse the
terrorist attacks by saying that the United States isn't perfect: imagine
that YOU were one of the people trapped on the top floor of the World Trade
Center, and you had to choose between being barbecued by 1500° flames, or
jumping to your death. As you were roasting or falling (your choice as a
free American), would you think that the people who did this to you were
Or how about a different scenario: imagine that it was your wife or child
who died in the WTC by burning, jumping, or being crushed. Would you still
lob feeble excuses for the terrorist attacks?
These questions are not merely academic rhetorical questions. The ability
to empathize is important for healthcare personnel, and if you attempted to
excuse the attacks I think you lack the ability to put yourself in another's
Temporarily, I wimped out and wrote the following:
Over the past few days I've pondered the advice given by Jeanne Lenzer and
others for the United States to restrain the inevitable retaliation. At
first, I thought that Jeanne was an inveterate pacifist who possessed an
impossibly high threshold for recognizing when an opponent threw down a gauntlet
that could not be ignored. Upon reflection, however, I think there is a
lot of merit in what she advised.
From a practical standpoint, we cannot eliminate terrorism by killing bin Laden
and every other terrorist in the world today. If any of you watched
"60 Minutes II" tonight, you probably realized that the anti-American
sentiment is so prevalent and so ingrained in Muslims in Afghanistan (and other
countries, no doubt) that it can't be eliminated by killing only the
intransigent members of their culture.
I suppose it is human nature to denigrate people with whom we're unfamiliar.
Back in the days when the USSR was THE enemy, I thought that Russians were evil
people bent on our destruction. However, after I got to know some
Russians, I realized that they were in many respects more likeable and admirable
than many Americans I know.
Considering the extreme provocation of September 11th, I think that President
Bush has no choice but to respond with force. However, I think the
retaliation should be extremely selective — so much so that it precludes any
chance of collateral damage. The real solution to the ongoing terrorist
problem is to dramatically increase their contact with us so they can see us as
fellow human beings rather than as a country that either ignores them or
sporadically lobs cruise missiles into their backyard. Although our
initial reception would probably be lukewarm at best, if we went in with good
intentions (and several boatloads of food, medicine, books, toys, and whatnot),
their feelings might placate somewhat over time. I realize this sets a bad
precedent by showing that the way to get a warm fuzzy from America is to kill a
few thousand of its citizens, but in this case I think that we should, for our
own self-interest if nothing else, TRY to reach a friendly accord with them.
Perhaps this is too much of a Pollyanna approach. Perhaps it is us and our
culture that they despise, and any additional exposure will only strengthen
their resolve to annihilate us. If that's the case and they cannot be
placated no matter what, then we can forget about cruise missiles and dust off
the ol' neutron bomb. If we cannot appease their anger and turn them into
tolerant neighbors if not friends, then they will continue their attacks and
will no doubt be much more successful in the future. While the United
States is the world's most powerful country, I think our openness makes us
extremely susceptible to a virtually limitless number and variety of terrorist
attacks. Imagine what a few thousand terrorists could do in the US if they
unleashed wave after wave of attack — they could kill untold millions of
Americans and destroy the fabric of our society. Thus, if placation is a
pipe dream, we'll need to snuff out not just the cancerous cells but also the
pre-cancerous cells. That should, of course, be a last resort, since
history has shown that even arch enemies can become good friends. I'd much
rather be friends. The question is: do they?
Yes, that was too much of a Pollyanna approach!
I prove that lawyers are far more of a threat to the public than are
A list member discussed how patients sometimes stop by the
triage desk for a blood pressure check, but she was advised by administration
not to do that unless the person registered as a patient. She then asked
if other list members provide free BP checks. I was annoyed that lawyers
are evidently succeeding in taking away yet another public service, so I
We've done that at every hospital I've worked in. It's a useful public service, and it passes the "would I do it for my brother?" test, so I think it is clearly beneficial. However, the administrators at your hospital are no doubt cowered because they are wary of the possible legal consequences. Given that American lawyers are not just litigious but rabidly litigious, they sometimes sue even when the care has been flawless. If anyone doubts that such an abomination could occur, I'd be happy to provide a case that illustrates how out of control lawyers are.
If I may generalize this topic, I think that lawyers are far more of a threat to the public than are terrorists. If that seems like an overly contentious and flip allegation, just wait. Lawyers love to pontificate about how their actions helps the public by financially sanctioning healthcare practitioners who make mistakes. In theory, this should decrease the chance of future errors by providing a strong disincentive to err. In reality, there are a couple of problems with that opinion. First, lawyers will sue even if there has been no malpractice. What useful lesson can healthcare practitioners glean from this? Second, in cases in which there has been a medical error, the financial penalty INCREASES the chance of future errors. That's good for attorneys, but bad for everyone else. Attorneys siphon billions of dollars every year from the healthcare system. The exact amount is difficult to pinpoint because the costs are both direct (e.g., malpractice awards and settlements) and indirect (e.g., defensive medicine). In any case, the amount ranges from tens of billions of dollars to over a hundred billion dollars. That money could be better spent on reducing the chance of future errors. Here is one example: it is no secret that there is a nursing shortage. Why? Because many people who are smart enough to be nurses know that they'll obtain more rewards and less hassles in other occupations. With a nursing deficit, it is indisputable that nurses are sometimes spread too thin and overworked. This heightens the chance of an error, thus putting the public at risk. If some of the money now being diverted to attorneys were instead given to attract, train, and retain more nurses, this would unquestionably improve the delivery of healthcare. If lawyers genuinely cared about people, they'd support this initiative.
Yet another way in which lawyers are harming patients and increasing the chance of future errors is by making medicine such a noxious profession that an increasing number of our best and
brightest students opt for non-medical careers. I've discussed this asseveration at length before so I won't elaborate on it now, but suffice it to say that today's medical students are, on average, not as bright as they were a generation or two ago. The equation is simple:
Dumber doctors = more chance of medical mistakes = happier lawyers
Healthcare practitioners and patients have parallel interests, while patients and attorneys have conflicting interests. In spite of this, lawyers are crafty enough to spin their shenanigans in such a way that many people are duped into thinking that lawyers help people. Perhaps they do in some cases, but they do more harm than good, and thus are a public menace.
Supposedly, medical malpractice is responsible for up to 98,000 deaths per year in the United States. If we could prevent even a fraction of those deaths by training more and better-qualified nurses and doctors, we could prevent more deaths in one year than were lost in the entire history of this country as a result of terrorism. Thus, it is time to stop looking at lawyers as a benign annoyance, and realize just how apt the "bloodsucker" epithet truly is.
My posting prompted a reply from a list member
who is a medical student. He began by implying that patients don't care
how smart doctors are. I replied:
Oh yes they do. If you become an ER doc, Jeff, you'll see many patients whose care has been botched for one reason or another by other doctors. Sometimes the patients are not cognizant of these errors, but when you detect something the patient's doctor overlooked and the patient knows about this, I assure you that patients are quite appreciative. I've received some glowing letters of praise that were more complimentary than anything my mother could dream up. :-)
Jeff then went on to say that patients are more
concerned with performance than IQ. That may be indisputable, but I
objected to his attempted trivialization of IQ, so I responded:
There is a correlation between IQ and performance. A person with an IQ of 100 cannot be a good doctor, no matter how kind, caring, and well-intentioned he is. A doctor with an IQ of 120 is far less likely to be a superb doctor than a physician with an IQ of 150. Bottom line? IQ is predictive, and in a very tangible, palpable way. What doctors do has an immediate, discernible impact on the lives of patients. This is not some abstract measure. Docs with more brainpower are better equipped to perform the more challenging cognitive aspects within the purview of medicine.
Jeff concluded by saying that patients expect
performance. I won't quibble with that, but he said it in such a way that
he was seemingly implying that there is a disconnect between performance and IQ,
so I said:
Yes, and smarter people are more likely to do an excellent job. Hence, patients have a vested interest in how smart their doctors are.
Since Jeff is currently a medical student, I
think he may have been a tad defensive when I mentioned that the average medical
student is not as bright as his predecessors. No doubt, some highly
intelligent people still go into medicine. However, medical schools are
faced with declining numbers of applicants (four years in a row, at this point),
so they must be less choosy.
My second posting in this thread inspired another
person to write. She began by implying that IQ is not an accurate
assessment of intelligence. I responded:
Just because there is no perfect test to assess intelligence, does this mean we should never attempt to quantify it? If the absence of perfection were a useful yardstick by which we'd judge which tests are worthwhile and which are not, we would not do many tests because few tests are perfect, including those in psychometrics and medicine.
She then claimed that tests do not accurately
reflect future potential. I said:
Again, no test is perfect, but there is a reasonably strong correlation between IQ and success in life, proving that IQ is not some abstract measure without relevance in the real world. People with IQs of 75 rarely become smashing successes in life (unless they're an athlete, an entertainer, or pulchritudinous), but people with IQs of 150 often do. Other qualities, such as perseverance, also play an important role and are not tested by intelligence tests. However, intelligence tests are designed to gauge the intelligence quotient, not the success quotient. In spite of this, intelligence is fairly predictive of success.
She then wondered why premedical students take
the MCAT exam rather than an IQ test. In other words, if IQ tests are so
good at predicting success, why not just administer IQ tests rather than the
The MCAT is designed to assess aptitude for medicine. As such, it is an amalgam of general intelligence assessment along with multifaceted ways of testing various skills and knowledge. It does more than measure intelligence, but make no mistake about it:
intelligence IS measured by the MCAT. People with lackluster IQs do not ace the MCAT, even if they have somehow obtained some skills and knowledge that would otherwise favorably affect their MCAT scores.
She then claimed that (1) when it comes to being
a good doctor, things other than intelligence are most important, and (2) just
about anyone can be a good physician if he works hard enough. I disagreed
with both opinions:
One might also argue that strength is not the most important thing when it comes to being a professional football player. If it were, coaches would determine who makes the team every year by having prospective players participate in a weightlifting contest. While strength may not be the
most important thing in gauging success in football, it is critically important to success in that endeavor. There are no 98-pound weaklings in the NFL. Similarly, while you may argue that intelligence is not the
most important thing, it is indisputable that intelligence IS critically important to physician performance. In fact, it is obvious to me that intelligence is indeed the foremost criterion. If it isn't, what else is paramount?
Caring? I know scads of caring people who couldn't hack medical school. Ergo, that attribute does not predict who will be a good physician. Intelligence is far more predictive than
"caring" — which, by the way, is such a nebulous and subjective thing that it would be virtually impossible to quantitate.
In my opinion, compassion and bedside manner have been oversold in
determining who is a good doctor. I am not trying to trivialize their
merit, because doctors deal with humans, who have a genuine need for
compassionate care. However, a doc's bedside manner does more to determine
who SEEMS like a good doctor than who really IS a good doctor. I know
doctors who graduated at the bottom of their medical school class who I wouldn't
trust to put on a Band-Aid correctly, yet some of those docs do a superb job in acting
like a knowledgeable and caring doctor. In fact, one doctor knew he
was behind the curve in terms of knowledge, yet prided himself in how he could
portray himself as being an all-knowing sage.
A list member asked for advice about
equipment or protocols to deal with moving morbidly obese patients
Good question. The "use more staff" approach doesn't always work, because in
some small hospitals, there isn't sufficient staff to lift some of these
patients. The heaviest one I saw was too large to fit through the door of her
home, so when EMS went to get her, they summoned a local fire crew that widened
her door frame using a chainsaw. That patient never got out of bed; her
neighbors brought her food (evidently, lots of it) . . . and what they did with
her waste, I was afraid to ask. She weighed too much to use the distributed
scale technique, in which body weight is distributed between two scales, one for
each foot. Therefore, we used the hospital's truck scale to weigh her (but why
that hospital had a truck scale is beyond me, since morbidly obese people that
large don't present frequently enough to warrant such a purchase). In any
event, after trying to lift that patient, several nurses were soon off work,
nursing their sore backs.
A list member mentioned a web site
offering pearls of wisdom for ER docs
Thanks to Dr. Sofsky for mentioning this. Properly utilized, the
information in this site could dovetail with our efforts to provide more timely
and cost-effective care. For example, I was intrigued by the tidbit about "Tap
water is an adequate cleansant for minor wounds." Of course it is. Given my
affinity for using chainsaws and other power equipment, I've had plenty of dirty
wounds that I flushed with tap water. They all healed promptly, and in an
exemplary manner. Theoretically, according to the textbooks, tap water is far
from an ideal medium: it isn't sterile, and it's hypotonic. That's why I always
used sterile bottled saline for wound irrigation in the ER. But at home? I knew
that expense was superfluous.
A premedical student on our list
asked for advice on getting into medical school. I didn't give him the
usual trite advice
On my web site I have numerous tips for enhancing memory and brainpower to
augment academic success. I also discuss a fairly novel way for a medical school
applicant to set himself apart from the crowd: to invent and make an
innovative medical device. That's bound to make an applicant stand out. First,
let me dispel a few myths: making electronic devices isn't rocket science.
I've made dozens of medical devices, ranging from pocket phonocardiograms and
echophonocardiograms to noninvasive cardiac output monitors, intubation
detectors, foreign body detectors, etc. A few of my devices
are posted on this page.
On to the next myth: people often assume that most of the good ideas have
already been thought of, and they don't stand a chance of developing anything
new. Not true. You're probably far more creative than you imagine. Also, we're
not nearly as advanced as we sometimes think. At any given time, people tend to
be overly impressed with the current state of the art in medicine. To gain some
perspective on this, you might want to read some actual newspaper and magazine
articles from a century or more ago. I did that as an undergrad, and it helped
me understand this tendency. I think people have an innate need to glorify the
current medical technology and knowledge base, because that helps mitigate their
fear of disease and death. In any case, we're not in the Stone Ages, but we have
a long way to go before we know everything. And won't that day be a sad day for
the malpractice attorneys! :-)
Next myth: it takes a fortune to develop electronic circuits. Not true.
Most integrated circuits, transistors, diodes, capacitors, resistors, and
whatnot are dirt cheap. You can spend more money on a meal at McDonald's than
you can on some circuits. I think the most expensive circuit I made was the one
for the echophonocardiogram, which combined a pocket electronic stethoscope with
a digital filter along with a phonocardiogram and an echocardiogram. The cost
for this was about $110, but most of this was in the case, lithium batteries,
and precision Swiss gear motor used for driving the paper. In any case, $110 is
a drop in the bucket compared to the total spent by medical school applicants.
Next myth: it takes a long time to develop circuits. Again, not true. A
prototype circuit can be whipped up in anywhere from a few minutes to a few days
in most cases, and making a finished device with a case and printed circuit
board usually takes a few days to a week. Learning how to make circuits might
take a few months, but many medical school applicants will think that's a small
price to pay for something that will give them an edge over other applicants. In
my experience, most docs are enamored with gizmos. If you can show one that
you've created to the person who interviews you, you're almost bound to be a
Senator Bill Frist's roadside
Can endotracheal tubes migrate from the trachea to the esophagus?
As many of you probably know, Senator Bill Frist recently stopped to assist
victims of a car accident in Florida. Broward County Fire Rescue's Capt. Ken
Kronheim was quoted as saying, "He sneaked out before he could get any thanks or
glory -- a true hero."
Here is my question: I was taught that when a physician renders emergency
assistance, he cannot turn the patient over to a person with less training.
Thus, he is obligated to accompany the patient to the ER. This strikes me as
overkill for some situations, especially when the apparent "emergency" is
anything but. However, I thought I heard that Frist cleared the airway of one
patient, and perhaps two. Thus, it sounds as if these victims were in a bona
fide emergency situation. Granted, most paramedics are proficient at airway
management, but from my experience (having seen paramedics bungle several airway
cases), an average ER doc is probably more capable than an average paramedic.
Thus, by abandoning an airway patient and turning him over to a paramedic, this
doesn't seem to fulfill the dictum of transferring patients only to
practitioners of equal or greater training. Frist is reportedly a cardiothoracic
surgeon, but I assume he's been trained in ATLS.
Hence, I'd like to hear opinions from list members on whether they were also
taught this same dictum of patient transfer. I wonder if this is just an ethical
obligation, or if it is codified in law as something that, if not done, may
expose the physician to legal peril.
This prompted a number of opinions, and also one
response from a paramedic who took offense at the fact that I mentioned
paramedic mistakes. In response, I said:
Andrea, I think you're taking this much too personally. I simply stated a
fact, namely, that I've seen paramedics botch airway management (usually
intubation), sometimes horrendously. I try to make allowances for the often
chaotic circumstances that pre-hospital personnel work in (frankly, I'm
impressed that anyone can put up with that), but I've nevertheless seen some
inexcusable mistakes (such as a paramedic who esophageally intubated a patient,
then rode with her for 45 minutes in an ambulance, oblivious to the obvious
signs of esophageal intubation).
A discussion then ensued about whether it is
possible for a correctly positioned, inflated, and secured endotracheal tube to
migrate from the trachea to the esophagus. The consensus seemed to be that
this wasn't possible, and that paramedics sometimes use this excuse to explain
why an endotracheal tube was in the esophagus, not the trachea. In
fairness to paramedics, it can be very difficult to intubate some patients in
the controlled environment of the ER, and this difficulty is compounded in the
conditions that paramedics work in.
Bottom line? I think that paramedics
usually do a great job, but if I was so mangled in a car accident that a doctor
needed to clear my airway, I'd hope that doc would stay with me until I reached
the ER. Most paramedics are adept at intubation, but aren't usually as
skilled as docs are in surgical airway management, which trauma victims
A list member implied that President
Bush had no reason for asserting that there is a link between the medical
liability crisis and the availability of affordable health care. I
I think the nexus is clear: we live in the most litigious society in
history, doctors know this, therefore they take steps (CYA) to minimize their
risk. President Bush fingered this in his speech:
"And there's another cost driver. And if you're worried about getting sued all
the time, then there is the natural tendency to practice what they call
defensive medicine. In other words, you order tests that someone may not need,
to protect yourself in a court of law. And that's costly, and that's one of the
main reasons why costs are going up."
The only thing I disagree with is his estimate that defensive medicine costs $28
billion per year. I think the true cost is far higher. If my calculations are
correct, that approximately comes out to only $38,000 per physician per year in
defensive medical costs. I'm sure I spent that much per month in the ER with CYA
CT scans, CYA MRIs, CYA EKGs and blood gases and zillions of blood tests and
referrals and admissions. I think that American physicians are so inured to
defensive medicine that we often fail to appreciate how pervasive it is and how
much it influences our practice. Of course, Bush was just referring to the costs
imposed on the "federal government's health care cost(s)."
A list member asked for
cases at shift change time (when patients are transferred to the oncoming doc)
with a bad outcome. In emergency medicine, turning patients over is
generally viewed as something that increases risk. However, I know of
several cases in which it actually improved care, so I mentioned two of them:
Turning patients over does not necessarily create problems; it may also avert
them. For example, one of my former partners (board certified in EM) signed a
case out to me. I listened to his presentation, and said, "John, the guy has a
central cord syndrome." To make a long story short, John didn't believe me and
refused to re-examine the patient, so I did. It was obvious that the patient had
it, so I admitted him. I don't think I changed the patient's prognosis, but at
least I saved John from a lawsuit.
Another day . . . . I was coming on for the night shift to relieve my boss and
found him with a nurse and the respiratory tech in the room of a child who was
near death. My boss explained that he’d seen the child earlier in the day for an
ear infection and discharged him on antibiotics. The child was comatose, apneic,
and posturing. My boss said that he and the nurse couldn’t get an IV in the
child and that he’d also been unable to intubate him. Strangely, when I walked
in the room nothing was being done (the kid wasn't even being bagged!); it was
as if they’d already given up and were just waiting for the kid to die so he
could declare him dead. I inserted an intraosseous line, tubed the kid, and gave
him some meds, and he did fine. This story had a happy ending, but it likely
would not have unless this patient was being treated at shift change time.
Bottom line? I know about some of the horror cases that accompany change of
shifts, but I think we shouldn't overlook how turning patients over can
sometimes improve care by giving a fresh perspective.
A list member requested
citations in which a court issued an opinion in a tort case regarding false
imprisonment versus the duty to act to protect an intoxicated patient who
refused treatment, eloped, or attempted to elope from the ER. My response
I don't have a court case for you, but I was involved in a case in
which an intoxicated (& stoned) patient tried to leave the ER for a 10-hour walk
home in the middle of the night. We had no security guards, and the nurses
refused to help restrain her (citing some idiotic new hospital policy in which a
quorum of five personnel were needed to attempt a restraint, but we never had
that many people working during the night shift). To make a LONG story short, I
restrained her, which angered my boss and the hospital CEO, who claimed that I
"just should have let her go." I analyzed this decision from every possible
angle (what was best for the patient, her daughter, me, the company I worked
for, my insurer, the hospital, and its insurer) and concluded that my boss and
the CEO were stark raving mad. The road from the hospital to her home was
frequented by a bunch of drunk yahoos, and I didn't think that she would make it
home safely. On that moonless night, being hit by a car was a distinct
possibility, and so was a number of other unfortunate outcomes. I felt that I
had a legal duty to protect her, and had I not restrained her and she were
injured or killed, I bet that some lawyer would have agreed with me. My brother
used to work for a firm selling case law products to attorneys, and he told me
about several similar cases. I forgot most of the awards, but one was $7,000,000
-- and that was back in the days when 7 mil was a lot of money!
Money aside, the think the best way to handle all such cases is to think what
you'd do if the patient were your sister. Would I let my sister walk 40 miles
home at night with a recent BAL of 269 and having multiple drugs on board (she
had 84 bottles with her and, strangely, one jar of Gerber baby food)? Never. In
cases like this in which there is an imperative need to protect the patient, I
think restraint is a no-brainer.
Emergency physicians typically work for
a company that provides ER doctors to staff a hospital's ER. Some of these
corporations are small groups that distribute the profits fairly to its
physicians, while others are the modern-day equivalent of slave owners who keep
the majority of the profits. Is that an exaggeration? Judge for yourself. I
posted this in response to a discussion about how one corporate owner (who I
once worked for) sold the business for $212 million.
I wholeheartedly agree with Dr. McNamara's posting ("Q: Where do these
millions of dollars come from that fuel these deals? A: From the profit off the
professional efforts of AAEM and ACEP members."). I used to work for Sterling
and made a whopping $70 to $75 per hour, with no health insurance, dental
insurance, optical insurance, sick pay, personal days, retirement, unemployment
insurance, life insurance, or other benefits. As an "independent contractor" I
didn't just pay the Social Security contribution that everyone else pays; I paid
the portion normally contributed by the employer. I knew there was a lot of
money in emergency medicine (not that I reaped much of it), but $212 million? So
that is where the lion's share went — to one person. OK, this is America, and
the profit motive isn't iniquitous. Nevertheless, it still rankles me. Why?
Because I think that profit should be commensurate with job performance. Perhaps
some elements of Sterling were well-run, but the part of it that I was familiar
with was not, in my opinion. I used to quip that the name "Sterling" wasn't
apropos. In truth, I am bending over backward to be kind to Sterling. If I said
what I truly think about it, I could fill many pages with blistering criticism.
I worked dozens of jobs in my life before I became a doctor, sometimes working
for myself, and sometimes working for others, and until I worked for Sterling I
never encountered a company that I thought was loathsome. I've worked for other
ER bosses/corporations that were good to superb. But not Sterling — or at
least the segment of it that I saw.
I graduated in the top 1% of my class in medical school, the director of my
residency program once commented that I was the smartest resident they ever had,
and one of my former bosses told me that I was the smartest doctor he ever met.
I am NOT mentioning this to brag; I'm mentioning it to segue into a rhetorical
question: why should I, and other members of this list who are highly educated
professionals, have to take orders from corporate bosses with less aptitude and
less education? I am not referring to Dr. Dresnick, but rather to some
simpletons who worked for Sterling.
Considering my experience with Sterling, when I see Dresnick become a
multimillionaire, I wonder if the American economic system is truly rewarding
excellence, or if it just allows for undeserved profiteering. I don't know if he
had anything to do with hiring and supervising the goofballs who earned my ire,
but if he did, then I think he may have received a fortune for presiding over a
corporation that was, in my experience, anything but sterling.
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