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I once had a patient who came into the ED with some respiratory complaints. While I was treating him, a couple of times he muttered “I feel death”. I assumed he was talking about himself as he wasn’t doing too hot initially. But maybe he wasn’t. His wife pulled me aside at one point and told me that she just got a phone call saying that the patient’s twin brother had just died, but that the patient didn’t know yet. Perhaps it was not his own death that he was sensing.
Nurse giving report: “He”s aao x 3 so long as you keep his sugar above twenty”
Attending, listening to a patient being presented: “Once you said he skipped dialysis I stopped paying attention”
Nures 1: “Don’t you feel like a farmer sometimes?”
Nurse 2:? “What do you mean?”
Nurse 1: “You know, just watering all the vegetables?”
Attending commenting on a surgical resident: “PGY-1? AAO x1!”
On an ICU overnight, we’re all busy in a room dealing with some issue. From down the hall, another patient’s starts to scream bloody murder. We go charging down the hall to render whatever aid is causing this patient’s obvious distress
Patient: AHHGGGHHHH!!! I CAN’T BREATHE! I CAN’T BREATHE!
Us: What’s going on? Why can’t you breathe?!?
Patient: BECAUSE I NEED A FRUIT CUP!
My solution to the medicaid debacle is this; incentivize people to be healthy, and they will need less health care. Less heath care equals less burden on the medicaid system, equals more money for paying physicians and providers, equals better coverage for those that need it. Now, I say all this having done absolutely no research. I admit this up front. But I’m an intern, and don’t have the time or energy to do that at the moment. But my plan is based on the presumption that a super expensive procedure, or stay in the ICU, cost more than a few thousand dollars (which it certainly dose)
Gist of the plan
- Pay people for being healthy – Its often stated that those in low socioeconomic classes have the hardest time leading a healthy lifestyle, for all the various reasons that are better discussed elsewhere. It has also been shown that minimal financial compensation is enough to significantly motivate people to change their behavior. What if you paid someone $10 to go for a checkup? Paid them $5 for every month they took their medication as prescribed? $25 for a colonoscopy. Lose 10 pounds? Here’s $10. Make healthy lifestyle changes and no longer need to take insulin? Here’s $50 my healthy friend. By medicaid paying money upfront to the consumer, to promote healthy living, they avoid paying buckets more money downstream when this same person, who was bound for a triple bypass in 20 years, eventually shows up at the doors of the ER having not seen a doctor for 15 years and is now having crushing chest pain. Now, with a simple bit of financial motivation, people who could most use a few hundred bucks in their pocket are getting both a little extra walkin’ money and the benefit of increased health. Some smart guy with a calculator would have to do all the math, but I’d be willing to bet you could pay someone $500 a year in incentives and it would still be cost beneficial compared to what medicaid is shelling out now. And $500 might be enough to get someone to walk to work. To take their pills. To eat healthier food (and pay for it at the same time).
- Those that “buy in” get access to the best health care – Despite the above plan, we still need to cut back on medical spending. But we need to do it smartly and justly. If you smoke for 40 years, I don’t think its fair or right to expect the taxpayers to pick up the tab for your radiation therapy. That sort of bullshit has to stop. Your cholesterol is 4 billion and you had an MI? And we have to pay for it? F-that! Rather than this, where anyone can get “top level care” regardless of their past interest in their personal health, I’d propose that only those earning X dollars in incentives qualify for “top level care”. Sure, you could not earn a penny, and still get top level care, but it would be more like other countries. It would be rationed. You’d be put on a list, and have to wait until it was your turn to receive it. If 2,000 (just making this number up) cardiac bypasses are performed annually in this country the way it stands now, 400 bypass “slots” would be set aside for those that didn’t get on board with the program. The remaining 1600, or how ever many were needed, would be given to those who “earned” it in incentives. But guess what, since these people are now healthier, that number is only 1000 bypasses all of a sudden. So we just cut 600 bypasses that medicaid has to pay for. So now there is extra money to fairly compensate medical providers, money to pay those that are “earning” it and probably some left over.
- So now you are fairly compensating providers? Guess what, more providers start accepting medicaid, which increases access to health care, which increases opportunities for John Doe to earn incentives, which increases the likelihood that he gets healthy, which decreases the chance that he needs expensive medical care, which increases the savings to medicaid, which increases their ability to compensate providers…. see where this is going? Its win win.
I realize that some may have read my last post and read “Only rich people can afford Johnny Cockran, so ERJ, are you saying only rich people should get good healthcare?”. No that’s not what I am saying at all. I’m SAYING that only people who murder their wives should get health care. But seriously, I’m a firm believer in the saying “Failure to plan on your part, does not constitute an emergency on mine”. If you choose to lead a lifestyle that is not conductive to good health, whether it’s being sedentary, smoking, eating fast food, I don’t think its fair or right for you to expect to have the full medical kitchen sink at your disposal, especially free of charge. You have to do you part, in what ever form that takes, if you want to reap the medical benefits.
I also firmly believe, that you are not allowed to complain unless you also have an idea to address the thing you are complaining about. Bring me solutions, don’t bring me problems. That said, I do have solution for our national health care problem, which works for the capitalists, the socialists, and is most beneficial to those of lower social economic status. Stay tuned.
So to be honest, come this last week of peds, I was pretty much over the whole rotation. These 8 hours shifts were dragging such that they felt like 12 hours. I’ve only been here an hour and a half? FML! I don’t know why I didn’t like it… it was easy… which is good. But it was also just… kinda boring. I was never getting that high I do with adult EM where I’m essentially floating out the door at the end of the shift. I caught myself actually looking forward to my ICU rotation which starts in two days, and that’s kinda disturbing. To actually prefer the beast that is the ICU over peds… weird. Anyways, last night was my last shift and it managed to be a pretty good night, the best of the whole month. Actually had some sick kids. And there was only one other resident and myself, which meant I was busy and moving the whole eight hours, which I SO much prefer. I’d rather be stressed and harried over idle and thumb twittling any day.
My own little personal goals for the past month were to hear the classic barky cough of croup, and to see a nurse maid’s elbow. Two things you hear about in medical school a thousand times each. And I was 0/2 going into my final shift. Low and behold though, my second kid last night was a 2yo complaining of arm pain after being helped up from sitting by a gentle tug upwards, and now was crying with the slightest movement of the arm. One gentle hyperpronation of her arm, one little pop under my thumb later, and she was all smiles. So that felt pretty good, and was probably my personal highlight of the month.
Walking out to my car last night, and thinking back over the past few weeks, I realized a few things. Most of these kids are pretty tough. Most of these kids are pretty resilient. Never once did I hear a kid complain, even the older ones. So in that respect, peds was pretty awesome. But I think I definitely prefer adult medicine, even despite all the bitching, moaning, retarded complaints and drug seekers.
I’m spending the next few weeks working shifts at one of the ER’s at a local children’s hospital. Before I started my first shift, I have to admit, I was pretty nervous. For obvious reason, this was something I was not familiar with, which made me a bit uneasy. I was worried I’d feel more like a veterinarian (their patients can’t talk either) than a doctor. In a panic, I read through all the Peds chapters in Rosen’s emergency medicine and crammed in a few pod casts just to hopefully get a few basics down. The reading definitely paid off as I knew what to say when the attending asked “So, what do you want to do?” after my first patient. And most of the ones after that too.
A few other thoughts after just a few shifts
- I’m actually really enjoying this. I didn’t think I’d like treating kids as much as I am. I don’t think I’d ever want to do it full time, but its a nice change of pace from our urban ED and ICU
- Maybe it’s because I don’t have to worry that any of my patients are just trying to scam narcotics out of me
- I hate congenital disease. All these rare one and a million things you read about in med school and cross your fingers you’ll never have to deal with cause who can actually remember this stuff and what all these eponym’s are about. My last patient of my first shift had VATER syndrome. And yes, I had to look it up too.
- 8 hours shifts are SOOOO much better than 10 hours shifts
- There are 3 residents covering 13 patient rooms, unlike the adult ED, where there are three residents for 28 rooms. At the most, I’ve had 4 patients at once, versus 10 or 11 in the adult ED. Again, world of difference in stress and time to relax, talk about patients, look stuff up.
Just a thought for the day. When a person goes into drug treatment, gets clean, but then has a relapse, its generally considered by most people to be a treatment failure. But if I person has high blood pressure, starts taking an anti hypertensive, gets their pressure under control, but then stops taking their meds and has high blood yet pressure again, the treatment was still considered a success, the failure was with the person. Point being, I think may people expect to be cured by going into rehab and fail to realize that drug treatment is a life long process of treatment, just like blood pressure. If you stop taking your “medicine”, you are going to relapse.
For the next few weeks, I am on an anesthesia rotation. So the ER related stories might be far and few between, at least until January. I’m using this down time to finally get around to checking out twitter (check out the new Twitter integration in the sidebar). I’ve resisted for as long as I can, as I really am not a huge fan of the whole social networking thing. To many people are just posting stuff that I could really care less about. (Really? You cleaned your garage today? Thank you for sharing that.) But I figure with Twitter, I’ll only follow those people who post about EM, at least the majority of the time. Likewise, I’ll only post things related to the world of EM. So, here’s to trying something new. If you read this, and think I should follow you, please leave me a comment and I’ll be sure to check out your stream (that is what’s it’s called right? haha. Noob Tweeter alert!)