Category Archives: Deep Thoughts

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I think that one of the best things we do in the ICU is when we allow people to die with some degree of peace and respect. We recently had a Cambodian patient, on life support, with no hope of recovery. Discussions were started with family about withdrawal of care. And while they were in support of the idea, their concern was that he somehow had to die at home, and not on a Tuesday.  I understand the dying at home part, but I was never clear on what it would be bad for him to be allowed to pass on a Tuesday. It had something to do with his Buddhist religion, but I was never informed of the specific reason. I would have asked all the monks that where there in their orange robes, but none of them spoke English. So when Wednesday morning rolled around, the monks and family gathered in the room, the ambulance crew showed up. We loaded him onto the stretcher and literally pulled the breathing tube out as he rolled out the ICU doors. Medics were instructed to NOT check a pulse, NOT check for breathing, not to do anything other than get him home as quickly as possible. And, under no circumstances, where they to come back to the hospital. It was the best thing we did in terms of patient care all month.

The Beautiful People

People talk about burn out all the time in this field. I know I’m only two years into this, but I’m pretty sure it’s not the job that burns people out, its the asshole patients. Those people that are just unkind, cruel, self centered.  I fully admit, that I have positively loathed some of my patients.

“Hey there, I’m Dr. X, how can I help you?”  “Fuck you, fix my arm”  Ohhhhh kayyyy then.

But these people aren’t anything new. They exist in every ED. They suck your good will out and just pour it down the drain. But fine, whatever, I’ll deal. But everyone once in a  while…. you get that one guy….

There is this guy that comes into our hospitals about every two months. Always an overdose of his calcium channel blocker, usually a half assed suicide attempt, always goes to the ICU, gets tuned up, set up for out patient support, psychiatric follow up, never goes, comes back two months later, rinse and repeat. The thing is though, he is the most racist, sexist human being I have ever met, or even heard of for that matter. Once he comes to, wakes up, he runs his mouth constantly, spewing forth the most vile things you’ve ever heard. When I was in the unit with him one time, he had this kind, sweet nurse, one of the good ones, whom he quickly sent out of the room by calling her a “cunt nigger”.

Everybody hates this man, loathes him, wishes one of these times he would just get it right and come in as a code blue.  How horrible is that, to think that, and then having to perform life saving medicine on him. That’s what burns the docs and nurses out, that’s what eats at the fiber of your soul.  It takes 50 happy, kind, thankful patients to replace one of the scars left by these horrible people.

I wish more than anything, we didn’t have to put up with it. I’ll treat you, quite happily, but only when you act like a human being.  Fine, I’ll come back in 20 minutes and you can try telling me about your arm again. But nope, not allowed to do that, cause door to dispo times matter more.  We have to take it, to the let the patient smear all their vile feces all over our faces, while we stand there and take it. THAT’s where the burnout comes from, not from the long hours, not from the over crowding, lack of resources, or what ever other factor experts say makes us burn out.

It IS a problem though, even in residency. A poster that was presented at ACEP showed  that 50% of EM residents experience mild burnout, 25% of them have SEVERE burnout (Ironically, 50% of participants failed to respond to the follow up survey)

And deep breath. I’m not saying I am in any way burned out. Far from it. I am a little angry about it, but beyond that….well, just keep doctoring on,  and doing my best to not stab these patients in the eye with a angio cath, at least for the time being. There are days when that is a distinct possibility. And I think I’m better than most at keeping my cool. One of my other residents almost came to blows, patient telling the resident “GIRL I WILL FUCK YOU UP IF YOU DON”T GIVE ME A SCRIPT FOR PAIN MEDS” and her in response… getting right in the patients face and going all calm and quiet Clint Eastwood like…. “Go ahead, hit me, I dare you”…..    Yup, let’s just keep packin’ powder into that keg.

I’m not sure what I’m going to do about, other then just vent about it anonymously for the time being. And a good vent always helps. Ahhhh, much better.

I’m always getting these advertisements for jobs, even though I’m a year away from serious starting to look. I got a post card today extolling the virtures of one particular opening.  They claim that you work one 24 hour shift and then have 3 days off…  Really? A 24 hour shift? I couldn’t imagine.  Maybe life as an attending is different, but when I work an ER shift, I’m pretty much husltin’ the whole time.  At the end of a 12 hour run, I’m pretty much spent. I couldn’t fathom doing a 24 hour shift. Much less the overnight part… AFTER already working 18 hours!  (I can handle them okay now, but that’s with a three hour nap before my shift starts…) Now the ER was some where in the state of Maine, so maybe it’s a podunk little ED where the attending actually goes to bed over night since no one comes in. If that was the case… that actually sounds kinda sweet.

Anyone know anything about these 24 hour shifts?

Mondays

 

Oh Monday’s, how I loathe they…. Let me count thy ways…1…2….45.

Oh, and mom, if I am trying to suture the lip of your screaming two year old, you getting hysterical and crying too, doesn’t help, not one bit.

Happy Flower is Sad

 

One of our patients in the ICU was discharged home under her own power, which is a pretty rare thing in the unit. One her way out, she dropped of this flower. It’s solar powered, and dances when the sun light hits it. But….there is no sunlight in the unit. Whomp whomp.  So our happy little flower has never gotten to dance. Happy flower is sad.

Ouch.

A few weeks back, I had to take Mrs. ERJ to the ER. She’s just fine, but now about a month out the bills from her visit are starting to come in, and frankly, it’s a bit of an eye opener. Even though we are both gainfully employed, with “good” insurance, we ending up paying about $700 out of pocket for the visit. I’m not really complaining about this amount, for good care and peace of mind, it seems worth it. But what was really shocking, is the cost that is billed for some of the most routine parts of a ER visit, things we often “shotgun” without really thinking through what we hope to gain by ordering it.

  • $101 Urine Pregnancy test
  • $430 – LFTs ($86 per individual test)
  • $133 – BMP
  • $138 – CBC
  • $1,997 – CT Head (this prices does not included the separate bill from radiology for reading the study)

 

Round and Round

 

I’m reblogging this from EP Monthly, as it’s a great summary of one of the major problems facing emergency medicine today. And it’s something I haven’t really heard anyone address in residency as of yet, and I’m curious if anyone will. A few personal thoughts at the end.

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The article below was forwarded to me by a reader. It was originally published on the Student Doctor Network by an anonymous poster who goes by the handle “BirdStrike” and was made free to republish. For those of you who want further insight into how patient satisfaction rankings adversely affect medical care in the emergency department (aside from the fact that highly satisfied healthy patients are twice as likely to die from their medical care – it will be interesting reading.

What you’re getting at, is the core of why patient satisfaction scores in the ED are so soul crushing to some of us and what is so fundamentally different psychologically and philosophical about being a physician in the ED, compared to any other setting.

Outpatient physicians have always had their own version of “Press-Ganey”. So does every business in a free market. In their case it’s “name”, “reputation”, and “practice building”. If their patients don’t like them and aren’t “satisfied”, they go elsewhere and the practice, and ultimately the docs pocketbook, suffers. If their patients are satisfied, the physician benefits with a more robust practice and fatter wallet. This is like any other “business”. The better a business is at providing a product or service, the better off the business is. This is how it should be. Doctor makes patient happy, happy patient makes doctor happy. It’s a positive feedback loop. (Although a physicians practice is more than “just a business”, it is a professional practice held to ethical standards, it has to pay the bills, with dollars and cents, according to the rules of business.)

However, the ED is like no other business in the world. In the ED, you’re swamped no matter what. You have no control over your workflow. There’s essentially no risk, ever, of not being busy enough to “put food on the table”. Being overwhelmed with patients is the rule. Whether or not there are too many patients to see, or twice as many patients than you can see, or three times as many patients as you can see, does not affect your pocketbook, and does not increase your job satisfaction. In fact, the busier it gets in the ED and the more”customers” there are, the worse the job satisfaction. It’s a negative feedback loop. Unlike the outpatient doc, where the more satisfied the patients are, the busier the practice is, the healthier the pocketbook is and the happier the doc is. In the ED it is the exact opposite. In fact, you are grinding the machine to increase the job satisfaction (and profits) of someone else such as an administrator that you might not have even met or barely know.

This is why outpatient physicians in private practice (and all good businessmen including hospital CEOs), especially ones in their earlier years building a practice (or business), just don’t see what all the complaining is about. To them, “patient satisfaction” is their lifeblood. Without it, they can’t pay their staff, their practice overhead or their own salary let alone have any profits left over. This is a crucial difference. Another crucial difference is that when they reach the point of saturation, there are several protective mechanisms not available to ED physicians, that keep the work load and stress load to a manageable level:
1. “Office closed”.

There is no law stating that the overwhelmed pediatrician, plastic surgeon, dermatologist or business owner has to keep the office open after 5pm, through 2am and until 7 am and around the clock because there is a line of patients with no ability to pay him or with government insurance that pays $0.08 on the dollar lining up around the corner. There is no contract with the hospital corporation stating he and his partners MUST find a way to provide coverage to all customers, no matter how rapid and unmatchable the increase in volume all the while meeting some arbitrary “door to doctor” time-, and patient satisfaction goal.

The legal burden, at the threat of $50,000 dollar fines, to ever expand your workload to non-urgent patients, regardless of the ability to do so, and regardless of the support staff provided, while being held to a “boutique standard” of satisfaction is an oppressive burden.

2. The ability to tell an abusive insurance provider, “Your payments aren’t worth my time” and go “non-par” (non-participating).

The fact that EMTALA makes this option almost impossible, even for non-emergency patients that abuse the ED, is further oppressive. The only thing providing any significant upward pressure on the payers in this country to pay physicians acceptable wages, is the ability of physicians to individually opt out or insurances that arbitrarily, and unfairly cut or eliminate payments for services to an unacceptable level. This dissatisfies the customers (patients), who switch insurances to companies that have more doctors in their network since they pay doctors more fairly.

It’s like walking into a convenience store paying for your groceries and being told even though you paid for a gallon of milk, you only get a quarter cup. Even though you paid for 10 rolls of toilet paper, being told, “From now on, you only get two for the price of ten, and we reserve the right to give you even less, for any reason, at any time” and being bound by a law that prevents you from taking your business to a company that treats you ethically.

Not having this ability, in relation to non-emergency care, and being bound to “satisfy” such “customers” who use EMTALA as a means to pillage your services to have to keep your job, is wrong.

3. “The schedule is booked”.

A human being should know that there’s some limit to his potential daily workload. What other profession expects you to show up at work and be told upon arrival, “Here, you have twice the work to do today,” then before you can get halfway through the first part of the days double workload, “Here you go, here’s four times the work. Get it done. Get it done as fast as you would get a single days work done. Don’t cut corners because that could be devastating and dangerous and keep a smile on your and the customers faces. Yeah, I know it’s tough but you can do it. If not, that’s okay too because we have a mega-group that wants your job for 20% cheaper anyways”?

Ever walk in for a shift and there’s 4 patients waiting? You go see those four as fast as you can and when you come out of the fourth room, there’s eight on the board. You and your wing man dig your heels in deeper, dive in and see those eight together and when you resurface, there are 12 patients on the board. As the shift goes on, the harder you work, the worse it gets and the sicker the patients get? Of course you have. Do administrators work under these conditions? Hell no. Only a fraction of a fraction of a fraction of people reach this level of education, knowledge, professionalism and ability to handle stress that would leave most people naked, in tears, shivering in a bathtub. Yet administration doesn’t even have the respect to evaluate physician performance with something other than a sloppy, unqualified patient satisfaction survey, that out of context and in numbers not up to scientific standards, means nothing.

Treating all patients with respect and dignity is part of being a physician and a professional. However, being expected to function within this model, while following the standards of medical care and ethical practice, while being expected to take care the multiples of the sickest and most critically injured patients in the medical world, yet be subjected to standards of “customer service” designed for luxury product salespeople standing around showrooms waiting for customers to arrive……is just plain wrong.

4. Abusive, non-compliant and insatiable patients can be turned away, permanently, and discharged from non-EMTALA bound practices like any other free business.

Plain and simple, it is basically humane to allow physicians this ability. Yes we all know ED physicians signed up to take care of such patients. It is well known that ER physicians cannot turn away people that are drunk, violent, abusive or rude. All other doctors can. All other businesses can. You can’t walk into the hospital CEO’s office drunk, violent, abusive and rude and have you’re a-s kissed. ER physicians cannot turn away patients who have threatened to kill their staff and coworkers. All other doctors can. Hospital CEOs can. ER physicians have to take care of the child run over by the drunk driver, and turn around and treat the drunk driver in the next room, and stay professional and keep their cool, then suffer the consequences of a negative patient satisfaction survey of a patient who is upset they waited “too long” while the physician ran the trauma codes.

As far as I’m concerned, the least society and hospital administrators could do, to thank us for routinely handling some of the worst situations in the medical world, under the worst conditions, with a huge portion of services provided for free, is to qualify patient satisfaction scores?

Is this asking too much? If a patient comes into a family practitioners office, is late, rude to staff, hasn’t taken his medication, and writes a complaint letter to his doctor complaining that his blood pressure is still high, that he’s upset and switching doctors, the physician has the ability to qualify this complaint and verify its validity. He rips it up and throws it in the garbage. He knows this patient likely can’t ever be satisfied and puts very little weight on it. He does not question his own performance as a physician and shouldn’t, nor does anyone else.

On the other hand, a complaint such as this: “Doc, your staff is rude. I always have to wait 2 hr to see you and when I finally do, you’re out of the room in 5 minutes. You don’t listen. I’m feeling sicker. I’m thinking of switching doctors” has great value. The physician may be offended at first, but after thinking about it, he realizes there is an element of truth to it and he actually thanks the patient for letting him know. It’s qualified. It’s given much greater weight than the complaint of a patient who has unrealistic expectation and makes inappropriate demands.
The outpatient private practitioner serves a master: the master is his patients and the master is himself. If his patients dislike him, he suffers. If they’re HAPPY, he GAINS. It’s a positive feedback loop.

In the ED, if patients dislike the ED doc, and his ED, it’s no loss. There’s a waiting room full of desperate people waiting to fill the void. There’s no loss. In fact, there’s often a subconscious (false) belief that if a few patients are steered away, it just might lighten the load.

This is wrong. The revolving door never stops bringing in work. There’s often also a false belief that, “If I just push it a little bit more past max velocity that I’ll get a break”. The faster you go, the harder you work, the more the billboard says, “one hour wait………45 minute wait……..15 minute wait…….13 minute wait” and sends more piling in. As more masses pile in, the ED physician won’t ever earn more, he’s working at or very close to maximum capacity all of the time. It’s a negative feedback loop: the faster you cut through the never ending workload, the more satisfied you keep the many times insatiable patients, the more pile in to generate money for the corporate suits bonuses. It is exceedingly unlikely that any “increase in customers” will increase the ED physicians “business, paycheck, job satisfaction or livelihood”, because as I stated before likely he has already settled in to his maximum sustainable pace and has an oversupply of patients to begin with.

Making matters worse is that there is NOT a linear correlation between “quality of medicine practiced and patient outcomes” and “patient satisfaction scores”. In fact, often times it is the opposite (see thread on topic). Telling someone they may have cancer is not “satisfying” to the patient, but it may be your job to do it. How do you send someone a satisfaction survey after that? Telling someone you have the ability to do their ingrown toenail repair, but don’t have the time, because it’s 3am, you’re working single coverage, have two critical care patients in your ED and have a ped vs motor vehicle coming in, and that a podiatrist can take his time and do it much better Monday morning is not likely to ever “satisfy” a patient, but it’s the right thing to do. How do you send that patient even a level 1 or 2 bill for your time spent evaluating them and their toe and ruling out infection/abscess/osteomyelitis and explaining the situation and treatment options, knowing that the patient going to say “he did nothing for me”, when in fact your decades of training allowed to rule out life and limb threatening causes of the toe pain within seconds of looking? (Yes, toe pain can be life and/or limb threatening.)

A lay persons view of what “feels most satisfying” often has no correlation with proper medical practice, and in fact, often is the opposite. This is what makes the application of the current model of corporate centered patient satisfaction to the ED setting immoral and unethical and incentivizes the physician to perform outside of the standard of care to support not better patient outcomes, but corporate revenue.

The current corporate model of “Patient satisfaction” in the ED goes like this:

You can tie, you can lose, but you can never win.

An A+ is the only grade accepted. A “5 out of 5″ is expected. A “4 out 5″ is not a “B” grade. It drops the “B grade” physician, not down a rung, but to the very bottom of the not bell-shaped, but steeple shaped curve. Also, it dis-incentivizes good medicine, it incentivizes catering to unhealthy demands by many patients, it is fueled by non-physician administrators desire to generate money for themselves with no regard to proper practice, and is powered by coercive threats to physicians that if they truly do the right thing, instead of “getting in line” for administration that they lose their contract and jobs.

The reason that the application of patient satisfaction surveys to yourself in the ED feels disturbing and wrong, is because it is. It’s unethical, bad for the patients and bad for the physicians involved.

For those of you that demand proposed solutions:

1. EM leadership (ACEP, ABEM, SAEM) should have the courage to support their own and make a statement that current patient satisfaction surveys are ill suited to ED setting and promote substandard care, and are fundamentally unfair to ED physicians as currently applied to the ED setting.

2. EM physicians should demand that their leadership be allowed to construct their own model of monitoring patient satisfaction that qualifies cases of inappropriate patient expectations (for example, unsatisfied because ED physician refused demand to violate standard of care, order inappropriate CT, prescribe inappropriate antibiotic/pain medication, etc). This could involve anything from reverting to “the old fashioned way” of dealing with complaints such as ED director addressing complaint with ED physician based on merit, to developing a new model of formal patient satisfaction surveillance as a joint project between EM leadership and polling companies.

Any solution should center on EM physicians being active partners in developing and applying any patient satisfaction monitoring systems that apply to ED settings. EM physicians need to take this specialty back. This could be one small step.

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I agree that changes need to be made. But this seems almost impossible to change on an individual level. I suppose I am lucky that I work at a busy urban hospital where 20 waiting to be seen is the norm, so I am conditioned to the idea of always having to be moving, always someone needing something now rather than later. In my mind this is just another example though of how our whole health care system is so damn broken. Such that I don’t even want to try to fix it. I imagine THAT would be far more frustrating, far more making me want to pull my hair out, then dealing with things like Press Gainey Scores. Maybe that’s me burying my head in the sand, but at the same time you have to pick your battles and know what fights you can win. Maybe at some point in my career I’ll have the time and interest in want to take on the big fight, but not right now. But I’m happy to pay my ACEP dues so others can carry on the good fight.

“Stickin” with it.

 

Been squirreled away in the ICU for the past 10 days or so, which leaves little time to post, much less stop and think of something to post about.  A few ideas of things to write about did pop into my head this past week, but I invariably wrote them down on my rounding list, which invariably got thrown out at the end of the day as some cathartic gesture, so instead I am left with a few random thoughts from the past week or so.

  • It’s become a bit routine at this point. Those things that used to be terrifying, aren’t so much any more
  • Except for heart rhythyms. Espeically the tachy arrhythmias. Just once I might actually like to have a patient with true V tach so I can see it be like, YES there it is Mr. Cardiac Monitor, that is what true V tach looks like, so stop trying to get me all worked up with your fake V Tach alarms in the middle of the night.
  • I got a needle stick this week. It was probably both my fault for going to fast and the movement of the patient that combined for the teeny tiny little prick, but mental note made that even though I’m getting good enough to sink a central line in under 10 minutes, go slow on the needle parts.
  • People in the ICU have some fairly legit problems in their life. No quite third world problems, but pretty close. Which put things in perspective when a lady in the cafeteria was pitching a fit because the toaster was not toasting both sides of her bread equally. Definitely a first world problem.

Love or Hate

So the ICU …I may…actually like it…at times. Like the weekend or at night. In general, I love being at the hospital when it’s late at night, or on weekend mornings. I love when no one else is there. Just you, your fellow residents, usually the more chill attendings, the nurses are a little less stressed, more likely to be crackin jokes. Its just you and the patients basically, you and medicine. Not all the administrative crap, support staff, extra people, visitors. It’s just quieter. No distractions. Even the beeps of the monitors seem quieter at night.

Those little bastards…

 

…got me sick. I suppose I should have seen it coming. Working around sick kids all day, one is bound to get sick themselves. But damn, I have never been sick like this. Mid shift, my mouth went all dry and ten minutes later I’m in the bathroom erupting from both ends of the garden hose. Felt better for a short while after, but then things spiraled down and I was promptly sent home. I always ask my adults patients “Any fever or chills?” And you know what, every single person on the planet has had chills in the past 24 hours. I don’t think I’ve ever actually had a patient say “you know what doc? as a matter of fact I have NOT had the chills”.  But if you had had chills like this… you’d know better than to answer yes. I damn near collapsed in the parking lot I was shaking so bad. I think I scratched the paint job up on my car something fierce trying to get the key in the lock. It definitely didn’t help that it was 22 degrees outside, but this was WAY more than “brrrr, it’s cold out”, more like “MUUUSSST HAAAAVVVEE HEAT!!!!!!” as I am spewing ice chips from my 32oz cup all over the parking lot and inside of car as my whole arm stacattos  back and forth.  I felt lucky that I was able to make the 30 min drive home in one piece, my arms started going numb towards the end of it. Luckily I was slipped some Zofran on the way out of the ED, so I managed to avoid having to pull over mid drive.  I more or less curbed the car and made Mrs ERJ park it for me as I just couldn’t make myself do it. The thought of searching for a parking spot seemed more daunting the having to climb Everest at the time.  Double sweat suit and 3 blankets later, I was finally warm in bed, and now 48 hours later I am back to work and right as rain. But, I have new respect for the “Fever and ____ ” I was lamenting in my last post. Lesson learned.

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