ndab Ah Yes, Medical School: November 2006

Thursday, November 09, 2006

ERrrrrrrrrrrr

A Pirates Guide To The Emergency Room

Editor’s Note: Two posts in one day? He must be mad! Not really, but I got so depressed writing the first post of the day I had to cheer myself up, and since I’m all out of alcohol and I’ve seen Erotic Survivor 2 about 46 times already (thanks Patty!), I thought I’d put this together. I hope you don’t mind. But if you do, please send me some new porn so I have something else to watch. And I hope you appreciate the irony of me putting in an Editor’s Note here, as if to signify that there are two separate people working on this. I’m losing my mind.

Ahoy pirates, welcome to the grimiest ship in all the sea, the emergency room. OK I’m done (for now). Rather than change the slogan of every ER (or every medical school, for that matter) to “Abandon all hope, ye who enter here”, I thought it’d be fun to recap some of the things I’ve learned about the ER from the pirate perspective because…well…umm…pirates are fun. I feel like that needs no further justification. So please enjoy the guide that follows, and if not, it’s off to Davy Jones’ locker for ye, arrrrrrr! (See how much fun this is? There’s no way I’m not starting a patient interview tomorrow by saying “How arrrrrrrr’ ye doin’ mate?”)

Most of ye patients, they not be chum free. Aarrr.
I’m sure the rules of personal hygiene apply to most people in this world, rules such as “Clean oneself once every two to three weeks at the absolute minimum”, but it seems to me like people who go to the ER actually know they are going about 4 months beforehand and choose to stop showering, shaving, brushing teeth, or doing anything that might resemble cleanliness before entering, almost out of spite for having to wait so damn long before we see them. I mean, we get trauma patients (who, presumably, had no plans of coming to the ER before being hit by a car or something) come in who are homeless who smell a hell of a lot more fresh than other housed people with less urgent problems who have no excuse. So, please, unless you’re being brought in by an ambulance, throw on a little deodorant before coming in. Or at least try wiping the urine off your pants.

Avast, ye silly tricks be too strong for a lubber. Aye!
People do the strangest things. In the ER, that means taking us by surprise and showing us things we never thought the human body was capable of doing. Whether that be discovering that a Johnny Walker bottle can indeed fit up ones rectum or that it is possible for one to squeeze skin near ones thigh and express a milky white discharge through a hole created by a botched hip replacement surgery 12 years ago, these tricks are simply disgusting. Next time, just say you can do it and not actually feel the need to show us, we promise to believe you.

Scraping barnacles off me rudder be worse than dropping anchor in a storm.
You haven’t lived until you’ve scraped a live cockroach out of someone’s ear. I have nothing further to add here.

Shiver me timbers, swabbie be bleeding more than a scurvy dog!
It never ceases to amaze me how many people show up to the ER teetering on the edge of death, bleeding out of all sorts of orifices most people don’t even know exist (except for those of you into the really cutting edge art-house porn – that’s two porn references in one post, I’m on fire!), and not having any clue how sick they are. No, ma’am, you shouldn’t be bleeding like that, the blood is supposed to stay…inside of you. But thanks for asking, and I’m really glad you are enjoying your fifteen hour wait. Please enjoy our complementary reading material, a 1985 Time magazine.

Everthin’ be faster than a wench on me jiggers.
I never really appreciated how fast one needs to work until I started my rotation in an ER. Everything has to be done at breakneck speed, from interviewing the patient, doing procedures, and shipping him or her off to somewhere else, because there’s another 50 people in the waiting room, two gun shot wounds coming in from ambulance, and one of the patients just crapped her pants all over the floor. In other words, it’s total chaos. It’s great that some people thrive in this sort of working environment, but me, I don’t think I function all that well after 7 straight hours of chaos, which is probably a big reason why I plan on staying as far away from the ER as possible in my future (assuming I haven’t managed to extract myself from the hospital in the near future – c’mon, someone has to want to give me some money for this crap?!). It also should be noted that I like my poop to remain in the toilet. But hey, that’s just me.

Not even the scallywag can see the end of a bilge rat.
Highlighting what I find to be the most frustrating part about emergency medicine, this bit of pirate wisdom points out to a key characteristic of the ER: no patient continuity. This means that the vast majority of the time you evaluate the patient, initiate a work-up of the problem, and then transfer the patient to home, clinic, or the inpatient ward for further investigation, often never really knowing what happens to the patient. Now, for people in ER this serves as one of the perks of the field, but personally it drives me nuts. It’s like only being allowed to watch the first twenty minutes of every movie you watch. Sometimes, as in the case of just about every piece of crap movie that came out this summer, this strategy works in your favor, as by minute twenty you are about ready to kill yourself anyways. However, every once in a while The Godfather comes on, and it would be a crime, a travesty, an affront to Al Pacino’s glorious overacting to turn it off after only 20 minutes. And that’s why I cannot be an ER physician. Aye, ‘tis true.

That be the last, me hope ye liked ye trip. If not, it’s the plank for ye. Aarrrr!

Seriously this is too much fun. And can you believe I made it through an entire post about pirates and didn't make attempt to combine the word "pirate" with the word "butt"? Me neither.

(I would like to thank the folks at talklikeapirate.com for enhancing my linguistic abilities in all things pirate. FYI, Talk Like A Pirate Day is September 19th.)

Shande

Somewhere between Einstein and Gene Simmons in the list of Jewish contributions to mankind, Yiddish, a mutt language that is sadly fading away with each generation, is arguably one of the most fascinating and lasting because of its richness and knack for having just the right dour expression for any situation. I thought of Yiddish today, motoring around a packed county emergency room, because I cannot stop thinking about one expression in its repertoire: shande fur de goyim. Literally, this means “shame for the gentiles”. It is an expression used by Jews to describe a person or event that brings a collective shame to the Jews, something that makes us think the gentiles (that’s you people) will think less of us and, as was often the case not too long ago, proceed with a pogrom or other form of mass extermination to display their displeasure with our actions. For instance, Jack Abramoff is a shande fur de goyim. It is a sense of communal embarrassment, collective shame, for someone or something that makes us shake our heads with a combination of disgust, fear, and sadness.

I couldn’t stop thinking about that phrase recently, not so much as it relates to Jews, but as it relates to the health of our country. You see, I am about halfway through my emergency room rotation at an extremely busy county hospital in a very urban (i.e. poor) area, and I feel like I keep seeing the same thing over and over again. The typical patient encounter goes something like this:

Hi Doc, I’m here because I have chest pain. It started this morning, and it feels like an elephant is on my chest. What’s that? No, I don’t have a regular doctor. I don’t have insurance. What’s that? No, well, I had some medications given to me the last time I felt like this and came here, the doc said it was important I take it every day. But I ran out and each time I come to get a refill the wait is more than 12 hours here, and I can’t stop working for that long because I have to support my family, so I just kept putting it off. I mean I work 14 or 15 hours a day just to get by, I can’t afford to pay for the drugs. I have to put food on the table, doc. You understand, right? No, I don’t have a regular doctor, I can never get an appointment, and I can’t afford an outside one.


The story ends one of three ways:
1) The patient ends up being fine, gets a refill of his medications, and maybe fills the prescription before walking out the door.
2) The patient is having symptoms of a heart attack, gets seen early enough, has a corrective procedure done, and has a protracted hospital stay at an exorbitant cost to the taxpayer.
3) The patient has a massive heart attack and dies either in the ER or soon thereafter in the intensive care unit, also at an exorbitant cost to the taxpayer.

I bring this story up not just because it keeps happening over and over again, but more because I was thinking about it today in the context of how embarrassed it made me feel, how each day I come home and take a moment to myself to simply shake my head in disgust. Not for myself, or for the doctors, nurses, and other ancillary staff at the hospital. But for my country. See, just like all of you, I was brought up to believe that America is the greatest country in the history of civilization, the land of opportunity, of equality and freedom and on and on. While there is clearly a fair amount of jingoism going on with this sentiment, I genuinely believed in this concept in a general sense, especially after being lucky enough to travel around much of the world over the last 4 years and seeing what other “first world” countries have to offer in terms of basic transportation, amenities, and other basic societal services. (One need only compare the ease in finding a street sign at a random corner in a random city in the U.S. versus just about any other country to see the difference.)

This sentiment even extended into medicine. Much of my medical career has been spent seeing the cutting edge of medical technology (i.e. the most expensive new stuff out there), provided at both county and private hospitals. I presumed and initially observed that even the county system, with all its flaws, worked well enough to provide basic medical care for everyone at minimal cost to them and independent of the patient’s insurance or citizenship status. A noble effort, indeed, despite the obvious disparities between care provided to insured and non-insured patients, as all were treated adequately by competent physicians even if the hospital surroundings differed dramatically. Sure, things didn’t run as smoothly at a public hospital, but all patients were still given the care the needed when they needed it, or so I observed on various inpatient rotations, such as neurology or general surgery.

However, it has taken only about two weeks working in a county emergency room, at the front lines of medical care, for me to realize how ridiculously wrong I was, and I am astounded at myself that I didn’t fully appreciate this earlier. The one aspect of medical care I was not able to compare up until this time was the emergency room, and I was unaware of the magnitude with which people depend on the ER for the entire spectrum of medical care that they need. People go to the ER for everything from medication refills to heart attacks to the most obscure disease you could conjure up, the ER serving in place of having regular doctors. Regular doctors who would follow these patients and do their part to contribute to preventative medicine by providing them with cheaper earlier interventions that are easier on the patient and the system as a whole. But our system does not provide for such basic services at levels necessary to cover even a remote number of the people who need such services. As a result, people show up to the ER sicker, require more involved (and, therefore, more expensive) care, and have worse prognoses, all a drain on the patient, the hospital, and society at large.

Put simply, the American health care system is broken. But I don’t mean that the way people throw that type of phrase around, as it has been used for some time now and as I have joked about in the past. Not “broken” in the “we should probably maybe do something about it but it sort of works so it’s ok for now as long as you’re insured” way. It’s embarrassingly broken. Shamefully broken. Broken to the point where thousands of people are dying solely because as a society, the presumed greatest society, we can’t institute a system to provide basic simple preventative medical care for everyone. We’re not talking invasive neurosurgery here; we’re talking cheap blood pressure pills, quick clinic visits, simple follow-ups. It’s broken to the point where, for the first time in my life, I came home from a shift a few days ago feeling embarrassed. Not just for myself, or for the medical community, or for the vast amount of people waiting for ages in the emergency rooms across the country that haven’t been closed down yet begging for medical care…but for the entire country, for America, that we can’t do better than this. I know about the statistics, pointed out in a similar rant by Bill Maher on his cable show two weeks ago, how we rank somewhere in the 30s or 40s among all nations in terms of things like quality of care or infant mortality, but I never really believed it. I never saw this played out before my eyes this frequently to this level of magnitude before, and it is simply shameful.

Now before I get barraged with hate mail calling me un-American or a communist or whatever else you have in store, keep in mind a few things. First, make sure you have any clue what you are talking about before you start screaming at me, because I defy anyone who’s actually worked in this system to tell me it works. Frankly, it’s a miracle it works at all, and this is only because a few good doctors, nurses, and ancillary staff take significant pay cuts to work with the poorer segments of society in these crowded and understaffed public hospital environments. Second, know that it is actually painful for me to write in print that I’m embarrassed for my country, because despite all the crap our country has been involved with of late, I have never taken pleasure in it, never found any sort of joy in what I’m seeing, and never felt embarrassed enough to actually say something about it.

But most importantly, remember this: without enough people from all segments of society screaming about this, complaining, being ashamed, it is not going to change, because as this most recent election has demonstrated, things only changed when people get so dramatically upset about a unifying issue they find so repulsive that they decide to clean slate and elect new leadership that will presumably change things. I don’t know what would be better, whether we need a national health care system, whether we need more incentives for businesses to provide adequate insurance plans, or what, but it is painfully clear that something needs to change, because the system as it currently exists is a disaster.

So if we want to parade around the world telling everyone how amazing we are, how genuinely attractive a society we have built, how we are the greatest country in the world, we damn well better start acting like it. And one way to do so would be to not let this shande persist, because the whole world is watching, and they’re probably having a laugh at our sickly expense. Shame on you. Shame on me. Shame on all of us.