Wednesday, January 29, 2014


Has it only been a year? Really?

Seems like three.

And looking over to the right, as noted earlier, four more blogs have pretty much died (I removed GuitarGirl RN, the link is dead and it's gone).

Swear to Buddha, blogging the Emergency Department is like crossing the plains and following the bones of the unsuccessful pioneers.

Ever a glutton for punishment, after doing ass-kicking Level I Trauma to start my career, I may be returning to it again soon. It should at least give me even more to write about, as the second time around I'll take better notes. And no discernible uptick in human intelligence nor behavior has been noted, whether one refers to patients, family members, staff, or management.

See you in the trenches.

Monday, January 20, 2014

Permanent Solutions To Temporary Problems

That's what suicides are, in case nobody told you.
It's the most brilliant summation I've ever read, and it stabs my soul every time I see another try.

Some people I work with get annoyed at suicide attempts.
I can understand that, and share the sentiment sometimes.
Like when you've attempted to slit your wrists with a dull plastic picnic knife, just to get 3 hots and a cot.
Like when you find out your crippling chronic inability to get gainful employment or panhandle enough change for another bottle of vintage Boone's Farm or Everclear doesn't equal a pressing need for admission to the Callous Bastard Hospital Hotel Bed and Breakfast Inn.
Like when you pull the "I'm suicidal" card out to keep from being bounced out of the gurney by Security at 3 A.M. on a cold, rainy night.

Those times, I pretty much wish they'd let me close the door and kick your ass for a few minutes, and see just how badly you really want to die. Because no one, the doctors, nurses, nor anybody else, has time for your pathetic histrionic shit, and the best prescription for you is about 5 minutes of crotch-kicking and a gratuitous measure of bitch-slaps.

All too sadly, both mostly unethical, and generally against hospital policy.

Then there are the other kind.
The people who really mean it. (Which, if you're keeping score at home, is probably less than 10%. Probably even low single-digits.)

But I get them.
Life will really try to grind you down. Some of us, more than others.  A philosopher once said "Be kind, because everyone you meet is fighting a hard battle." He knew what he was talking about. Whether it's physical or emotional pain, one of the things about it is that after a couple of minutes, you can't remember life without it, and you don't know when it's going to end. You just want to make it stop hurting. And in the absence of therapeutic alternatives, when that pain becomes too much to bear, people will do anything to make it stop.

Including kill themselves.

Part of the hidden fail in my job, is that the people I see (mostly) are the ones who aren't serious. The folks who eat a shotgun, jump off the 7th level of the parking structure - helpfully head first - or step in front of a freight train going 60MPH are deadly serious, and 100% successful. So I see the people making either a desperate cry for attention, or the incompetent. By definition, because they make it to the ER.

But the worst are the ones who are serious, and are only semi-competent.
Like the 15 year old girl, who was living in shiny SoCal splendor with a family that loved her, in a house near the beach, with no physical wants on earth, and stunningly model-gorgeous beautiful, who got dumped for someone else by her douchebag boyfriend the week of the prom. So, in a permanent solution to a temporary problem, she decided the remedy to make everyone pay, was to eat an entire 150-pill bottle of Extra Strength Tylenol. On Friday.

And then not tell anyone, like her mom, until Monday.

Seventy two hours later, there's nothing on the planet that will fix the ingestion of 75 grams of acetaminophen by a 45kg teenager three days after the train left the station.

But unfortunately, it isn't a right away solution. She came to us normal, scared, sorry, and a thousand other things. She left the same way, admitted for observation, and then discharged home. Over some months' time, her liver failed, and she got to die a long, slow, agonizing death, with her family at her bedside every step of the way, until long, long after she'd forgotten the pain of being snubbed by another 15 year-old juvenile jackass at school, she died, wasting the promise of her entire life, and emotionally wiping out a loving mother, father, brother and younger sister, and countless friends, with one agonized moment's thoughtlessness that will bear a lifetime of pain long after her passing.

Some things in life you don't get to do over.
So if you're hurting that much, long before you decide on that permanent solution, talk to somebody about other choices.
For the love of God.

Thursday, January 16, 2014

Pest Control

Sign TPTB made us (me) take down from the Triage window:

The common cold likely won't kill you.
We cannot make the same promises about the triage nurses if you keep coming back to the window to ask them about the wait to be seen for it.

I'm betting if I put it up by the TV set outside, it'll last a lot longer.

Tuesday, January 14, 2014

We Do Not Know Everything

Sorry if that's news to anyone, but sometimes, the truth hurts.
Or more specifically, you hurt, and us not being able to figure out why just pisses you off.

We do science here. If you want omniscience, the chapel is behind the gift shop.

It's why docs - hell, everyone - loves being able to point to that whatsis on an x-ray, CT scan, MRI, or ultrasound and say, mentally or out loud "A-HA! Got you, you little s.o.b.! That is the problem!!" and then merrily set about treating it with all dispatch.

It's why working in fast-track breaks your back while turning your brain to jello: 99% of the time we know what the problem is, because there's either blood oozing out or a bone poking someplace where it shouldn't be. Thus the work there generally devolves to how fast we can do an Indycar pit stop on your problem, rather than trying to figure out why something isn't right.

But even at that, and with all we know, we're still at Rumsfeld's Conundrum on what we don't:
there are known unknowns - the things we know we don't know;
and there are unknown unknowns - the things we don't even know we don't know.

And while what we know grows geometrically, the number of unknowns grow exponentially.
One bare example is ulcers. They finally gave a Nobel Prize a few years back to the doc from Oz who was telling them for twenty years that bacteria play a large part, and to try treating it with antibiotics. Unfortunately, he was telling surgeons, for whom the primary ulcer treatment was surgical at that time. The happy ending is that eventually science won out over self-interest, but it took decades of ridicule and needless patient suffering. In any event, I can now rip out the chapter on ulcers from the late 1970s, and throw it away.

Medicine, as a whole, is not populated by heartless morons, rather the reverse. In point of actual fact, an EMT or paramedic today has more medical knowledge and expertise than what most doctors had through the end of the Civil War, or even to the turn of the century in 1900. This is the reason army medics and navy corpsmen save so many lives today, compared to the casualty rates at Gettysburg. Rapid transport, aseptic technique, and antibiotics do most of the heavy lifting, but unlike Col. Anyone, M.D. in 1863, today's medics know all that.
We still don't let them take off limbs or do appendectomies in the field (with certain specific exceptions, and only in the military, or catastrophic situations like under collapsed freeways during an 8.0 earthquake).

And what we do know, in about 98% of cases, you can take to the bank. I may not know why you're making your 9th kidney stone in 12 months, but I can darn sure show you where it is, whether it will pass easily or not, and make the pain significantly better in a few minutes until it does.

But sometimes, some things we simply can't suss out. Sometimes the technology/pharmacology isn't good enough. Sometimes, the technology hasn't even been invented. And sometimes people lie to us.

But the problem is astronomically rare that we'll tell you we can fix anything. It's usually a case of you thinking that, beyond all rational expectation, and usually a good bit of reversion to the magical thinking of childhood.

We know you're the hero of your own internal monologue, but before you make us the villains, listen to what we do know, and give it a shot, before you start rewriting history to all the subsequent audiences for whom you recount your tales. Especially if it's us again, and we remember you from the last ten visits.

So take the pain med for the pain, and the tetanus shot for the prophylaxis of not dying a horrible death paralyzed in rictus bent back like an English longbow while you slowly dehydrate and suffocate when your breathing muscles are overcome by terminal tetany, staring back at the wall through unclosing eyes. Or ignore what we do know, go home in pain, and die like that, thinking silent unuttered curses on the imaginary medical training and dubious wisdom of your current hero, "Dr." Jenny McCarthy.

Thursday, January 2, 2014

Reality Rears Its Ugly Head

"Supporters of President Obama’s health care law had predicted that expanding insurance coverage for the poor would reduce costly emergency room visits because people would go to primary care doctors instead." Link

And then someone - clearly not properly briefed on the Party Line - went and conducted an actual proper survey, because Science, and lo and behold, HopeyDopeyCare's HappyGas promises got gobsmacked by the Reality Fairy:

"Those who gained coverage made 40 percent more visits to the emergency room than their uninsured counterparts during their first 18 months with insurance."

Suprising no one with a lick of common sense, and/or 5 minutes' work experience in any American ED in any town or city with a population larger than a list of who Paris Hilton has slept with. Which, uncoincidentally, didn't include anyone who voted for this Mother Of All Boondoggles.

Who will doubtless be shocked, Shocked! I say! to find out

"The findings cast doubt on the hope that expanded insurance coverage will help rein in emergency room costs just as more than two million people are gaining coverage under the Affordable Care Act. And they go against one of the central arguments of the law’s supporters, that extending insurance to large numbers of Americans would reduce emergency room use, and eventually save money."

{Nota bene that it's closer to two thousand people who are gaining coverage - to date - but it's only been a few months. Nonetheless, the point in the article is still valid.}

Biggest shock of all?
That this story was published today by the NYTimes.
Two possibilities:
1) Someone in HR at the NYT screwed up, and they accidentally hired someone who knew how to actually report a story based on facts and evidence using techniques of accepted journalistic practice everywhere else in the free world. This story isn't "Blind pig finds acorn"; it would be more accurately titled "Pig finds entire forest of acorn-bearing trees".
2) Someone didn't read the paper's Style Manual regarding following DNC talking points, and is imminently to be reassigned from writing Medical stories to writing Obituaries.

Either way, since this came from Science magazine via the NYT, the cat is well and truly out of the bag, but it's really curious that it took them 5 years to collate and publish the data from 2008-2009, helpfully long after the plan had been not-debated, rushed to a vote, passed, and then the architect of its passage successfully re-elected before it found daylight.

Nothing to see there, certainly just a wonderful string of coincidences.

If this were 1996, the authors of the column and the study would be found dead in a city park after committing suicide by shooting themselves in the head three times each.
In 2014, I expect they'll shortly disappear, and their next stop will be some Third World dungeon used to render confessions from suspected terrorists, never to be heard from again. After all, midterms are coming, followed by the race to pick the next president, and boat-rocking is viewed dimly under the current regime.

Try not to notice that your ED is busier, especially now that most of them have cut staff due to expected government underpayments.

Once again, the problem with Obamacare isn't that the website is broken, it's that it will eventually work as was intended. And here we see the cognoscenti who foisted it upon us focusing on predicting whether a cat will land on its feet or not, when the real problem is that they also predicted the cat would land on the ceiling.