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Some of my EMED-L postings

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 follows:

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 ER.

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?

Predictably, the 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 this subject.

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 crosshairs.

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 Mount Rushmore alongside those of Presidents Washington, Jefferson, Roosevelt, and Lincoln.

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You know that writer's block you get when you sit down to write the essay portion of your personal profile for online dating? And you know the difficulty you have trying to think of a catchy headline? Well, MyProfileWriter allows you to create a profile essay and headline without typing, just by clicking!

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 site:

"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 the system.

How to dissuade misutilization of the ER?

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 meaningless.

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 follows:

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 step-parents?

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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 entirely.

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 expropriate?

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 and cons.

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 wound.

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.

A list 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 electronic 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 most dreams

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 commercially available.

-- 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 professional titles

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?  Appropriate?  Inappropriate?

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 my response:

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 sensibilities?

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 continued:

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 justified?

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 shoes.

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 terrorists
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 responded.

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 MCAT?

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 shoo-in.

Senator Bill Frist's roadside emergency assistance
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 sometimes need.

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 responded:

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 follows:

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!

An extreme example of polypharmacyMoney 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.

Organize your garage beautifully.

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