Dear readers,
This month I have a column in the widely read magazine, Medical Economics.
I hope you enjoy it! Here’s the link:
I’ve met some nurses in my day. Nurses are a force of nature. I say this having worked with untold numbers of the species, and most important by being raised by one of them. My first memories of any nurse at all were of my own mother in her white, starched nurse’s uniform with white shoes, stockings and cap. Yes, I’m old enough to remember nursing caps.
I remember that she worked a great deal, and that despite her schedule, and despite the fatigue that often left her unconscious on the couch (or semi-conscious, which was way more fun), she always gave me time and took care of me. She kept me healthy in the days when my childhood respiratory illnesses were treated by prayer, humidifiers and in the end, oxygen tents. She kept me fed when she barely had time to eat. And she kept me comfortable, safe and inspired with her constant, open and unreserved affection and encouragement. And when she could, or when I asked, she bought me little things; an action figure, a matchbox car, the sorts of things that cost so little but mean so much to the heart of a child.
Little did I know she was watching me and looking far into the future. Mom was, it seems, a little bit of a prophetess; like all good mothers, I suppose. As my years rolled along, she always spoke highly of me, to me. She saw good in me; she saw the promise of what I could be, and reminded me of what I should be. And, when I went to college with the intention of being a journalist, she waited patiently for my boredom to develop, then pounced like a cat in a starched white hat. Those fateful words…’you know, Edwin, I think you’d make a good doctor.’ The were well-timed and well-aimed.
I hadn’t even tried to accomplish anything that required science. My high-school C in chemistry was a combination of good writing skills, minimal interest, an engaging personality, prayer and a very tolerant chemistry teacher.
So, imagine my surprise when I agreed with her. Or at least, agreed to try. So I began taking science classes; chemistry, biology, organic chemistry, physics, and all the rest. Imagine my further surprise when I…gasp…did well! She sat back, smiling, I suspect. She saw it all along.
My mother took care of me in the beginning of my life, and by watching me, knowing me, shaping me and loving me, she ultimately enabled me to take care of myself, my wife and my children later in life as I entered medical school, residency and practice.
The good mother, my mom took the stone and the pond, cast the stone in and knew long before that the ripples would be good ones, not destructive. I don’t know if she realized the other effects. If not, I’ll explain. See, over the years, I have helped thousands of people of all ages. I have saved some lives, prolonged some lives, closed some wounds, protected some airways, found care for the mentally ill, helped the abused and tried my best to be a man of Godly character in my workplace, so that others would feel safe and happy as co-workers.
But there’s more. I returned, if not to journalism, to writing. My mother’s prediction of my future landed me in medicine and thereby gave me a wealth of topics for writing, and a rich look into the hearts, minds and bodies of mankind. The sort of thing that writers, to be proper writers, need so very much to have. Hemingway was of the mind that war was the best education for a writer. If it is, then medicine is surely second best. That was another gift of the direction my mother sent me off into as an adult.
She encouraged my faith and prayers, my devotion to church and scripture, and taught me that vital lesson, that all men must learn in order to be truly good…the lesson of kindness. And that lesson helped find me a wife, who gave me children, and my mother grandchildren, and a wife who is even now watching and molding our children as my mother molded and watched me.
So, to all mothers, thank you. And to Sharon Leap, my nurse mother, who like all good nurses knows how to manipulate doctors (present and future), thank you. Thank you for the gifts that made me who I am. And thank you from all the lives I’ve been able to touch as a physician, writer and most importantly as a husband and father.
You’re the best!
Edwin
EMTALA, the Emergency Medical Treatment and Active Labor Act, was passed in 1986. For those who aren’t familiar with yet another acronym, EMTALA is a federal law that was enacted to keep poor, uninsured patients from being ‘dumped’ on indigent-care hospitals, or any other facility, for financial reasons. Although it was a good idea, it soon grew fangs, tentacles, claws, rose up to several hundred stories in height and developed a surly attitude and bad breath. It is, in fact, one of the largest unfunded mandates the US legislative branch has ever gifted on its subjects.
For those of us who practice emergency medicine, and by now any medicine in a hospital that accepts Medicare payments, no one can be turned away for financial reasons. On the surface, this seems fair. Certainly, the potential exists for gross harm and injustice if we refuse to care for the most needy in our populations because we aren’t getting paid. ‘Your child is having non-stop seizures, eh? Well, pony up $400 we’ll see what we can do!’ It makes sense to have a provision of protection.
However, because this law basically forbids hospitals and physicians from saying ‘no,’ (without a complex, time consuming, legally perilous screening exam that is rarely worth the effort), we see all those who come through the door. And because the ‘cat is out of the bag’ and has been for a while, many of our patients know this. So, we have these conversations.
Doctor: ‘I see you have a toothache. Have you seen your dentist?’
Patient: ‘No, I owe him money.’
or
Doctor: ‘You know, you’ve been here every week for the last six months for chest pain, and you’ve had every test we can do. It isn’t anything dangerous, yet you keep asking for pain medication, you refuse to follow up with anyone, and now owe our group $7000.’
Patient: ‘Right, interesting. So, today it goes around my back, to my ear, down my arm and into my testicle. What do you think it is?’
It isn’t that we don’t take people seriously, because we do. It isn’t that we don’t want to help, because we do. But medicine being our business, money is often part of the transaction after the smoke has cleared.
Equally problematic, surgeons, neurologists, cardiologists, otolaryngologists and just about every other ‘ist’ is burdened with the same issue. The people they see in the ER, admit to the floor, or take to surgery or the cardiac cath lab will frequently be unable to pay anything, but then still be able to sue for millions of dollars. It’s hard for specialists to run practices when large numbers of patients pay nothing for their care. I understand their issues here. I don’t blame them a bit for being angry.
And of course, hospitals are providing care that isn’t reimbursed to patients who can’t, or intend never to pay them. Nurses and other staff are cut. Rooms aren’t available, needed additions aren’t built, new technologies are hard to afford, other specialists can’t be recruited, and before you can blink a hospital is closing or reducing it’s capacity. And to top it off, we can’t even get the Smucker’s peanut butter cups we all used to scarf from the patient supply cabinet while seeing sick people! Woe is me!
Across America, small and medium sized emergency departments and hospitals are closing. Trauma centers and teaching hospitals are struggling and overwhelmed. And specialists are simply leaving hospital care in order to avoid being on call, and the attendant EMTALA responsibilities that call entails. They’re working in surgery/outpatient centers. They’re leaving the setting where they are compelled to give care away, and where they are constantly overwhelmed by more and more demand, less and less payment.
Our own group sees increased volume every time we increase staffing. The numbers, the lack of control, the degree of genuine illness, and the degree of ridiculous visits for life crises, narcotic abuse, work excuses or just ‘because I was here with my friend anyway,’ keep rising. Can we say no? Not much, not often.
You see, the federal government thought EMTALA seemed like a nice, friendly, warm-hearted way to help America’s indigent populations. It also thought it seemed like a cheap way to do it, since EMTALA didn’t come with any money for providers or hospitals to do this epic work of securing the ‘health-care safety net.’ Like so many government programs it consists of untold numbers of legislators and government functionaries patting themselves on the back for helping the poor by having someone else pay for it and do the work; that is, America’s hospitals and physicians.
But here’s the final irony. EMTALA has created the very conditions it sought to avoid. Now, with specialists unavailable, hospitals full, transfers always difficult and no lack of genuinely sick and dying patients, there’s often 1) no one to care for them and 2) no place to put or send them. EMTALA, the federal mandate to save the poor from sickness has begun to crumble at its foundations, and leave untold numbers of patients, poor and paying, without care.
This isn’t meant to be a tirade about payment, though non-medical readers may see it that way. What I’m getting at is that our system, our government mandated system, is a failure.
You might make the argument that nationalized health-care can fix this with money, but as we see in so many problems, money doesn’t do much. Money in the school system still leaves us with staggering drop-out rates and high-school illiteracy. Money, in the hands of an irresistible, un-yielding, entitlement crazy, grandiosity-leaning government system will probably result in an even greater disaster than EMTALA.
My suggestion? Get the government out of it all. If you do, the poor will likely get better care, since we’ll be able to screen out and turn away those who abuse their privilege. And doctors, that pesky, generally unimportant part of the medical equation, will actually return to hospitals and be available; out of a sense of duty, professionalism, entrepreneurial spirit and genuine compassion without federal compulsion.
It’s unlikely to happen, but a doctor can dream. ‘And then I saw a scarecrow and some flying monkeys and a witch, and a hospital where I was in charge and could always do what I thought was right, oh Auntie Em, it was wonderful!’
Yours,
Edwin
I’ve been slack and forgotten my blessings!
‘May the almighty God, Father of our Savior Jesus Christ, who through his gospel is gathering an eternal church among men and women, strengthen you in body and soul, and graciously keep and guide you, world without end.’
Philipp Melanchthon
From Classic Christian Prayers, edited by Owen Collins, published by Testament Books, 2003.
Edwin
The ups and downs of a complete education
Published by April 30th, 2008 in Uncategorized. 2 CommentsMy wife and I home-school our four children. It has, over the past two years, become a wonderful experiment in learning and family cohesion. The children have bloomed academically, and even as we find bumps in the road, it always seems to get a little bit better.
However, now and then you get a real eye-opener. Like today, when my daughter exhibited that her vocabulary far out-strips the average seven-year-old. She was talking about her imaginary friends, the ones that make appearances every six months or so. Their names are ‘Bloody and Daisy.’ She can’t describe them; that would put a hex on the wonder; it would put into concrete something so wonderfully ethereal and full of possibilities. I understand. She’ll describe Daisy’s dress as a lovely green affair, that flows when Daisy flies, but she won’t describe Daisy.
However, she did describe Bloody today. Bloody has short, brown/black hair and is…I pause to take a breath…’a hermaphrodite, Papa. Sometimes Bloody is a boy, and sometimes Bloody is a girl.’
A hermaphrodite? As Scooby Doo would say, ‘ruh roh.’ Maybe her older brothers have been more of an influence than I realized. They teach her all kinds of things, from history to science, personal combat to family stories, but this was a unique one. A hermaphrodite? Dear, dear Elysabeth. I’m glad we’re homeschooling you. That one would have raised some eyebrows at the Christian school, now wouldn’t it?
An education and a vocabulary are powerful. They allow my eight-year-old boy to say he finds something ‘irksome.’ They teach my oldest boy, at 13, to connect the occipital lobe with vision, because oculus means eye in Latin. They keep my 11-year-old male progeny looking for a way to marry magnets and perpetual motion. But hermaphrodites?
What can I say. She is God’s child. He clearly has a plan for her that involves a sharp mind. And after all, God certainly loves hermaphrodites, too.
But couldn’t Bloody have just been an anthropologist or cellist?
Have a fun day,
Edwin
Dear readers, this is the text of my column in today’s Greenville News. I hope you enjoy!
Some things make you stand out from the crowd. I’ve been paying attention for a while, and frankly, being different isn’t so easy. In fact, there are a few things I wish I could do just like everyone else.
Case in point: while flying back from a hunting trip in Alaska some years ago, the steward on the airline asked me what I wanted to drink. I had been outside, cold and wet for part of the week, so I said, ‘hot tea, please!’ ‘Are you sure? Tea is such a production,’ he said, hoping I’d ask for the coffee that sat so easily within his grasp. I wish that I could drink coffee. I’ve tried. I just don’t like it, whatever I add. Unless it tastes exactly like hot chocolate, in which case it’s hot chocolate. But there’s always coffee! It’s at every meeting, restaurant and airline concourse. Coffee is a universal. I suspect, without any substantiating proof, that alien life forms intentionally come to earth for coffee.
But it isn’t just coffee. How I wish I enjoyed football, basketball, baseball, soccer and golf. How wonderful to be able to flip on ESPN and laugh with the guys, recounting the recent stats on my favorite player or NASCAR driver, the way my brother-in-law Dave can; without any effort, fluid and fluent as if sports were a second language.
As a guy, this is very disconcerting. Go to a party and you’ll find ladies discussing men and men discussing sports. ‘So, Ed, what do you think about the Tigers’ chances next year?’ They ask me this as if I have some reason to know. ‘Well, I think encroachment on habitats is a real problem, but conservation efforts are going pretty well, except of course for the Siberian ones.’
I’m directed to go talk to the women. To save my status I tell an ER story of blood and gore and I’m back in the circle, though watched cautiously. I wish I could recount to them my glory days of high-school football; I just never cared about it, or any other sport for that matter.
I also wish that I really cared about how to build things or work on cars. I just don’t. I work on humans, but buildings and vehicles are twin universes of unimaginable mystery to me. I’m happy there are those who can do what they do; I’m also happy they get sick and hurt, so I’ll have a job. (Figuratively happy, that is.)
Unfortunately, being different is harder now than ever. The world has expectations of us, and if we stray from those expectations, we get smacked down and quite literally called names. The ideas of diversity, intellectual honesty and free speech are ironic inventions in a time when dissenting opinions can get you branded a right-wing nut, a fascist or worse…intolerant!
This is a tragic development. I now watch as like-minded people stand together and whisper their opinions about politics or cultural issues. They don’t speak out loud because they might offend, or be offended; or may be branded different; which feels a lot like being told you’re ‘just special.’ A left-handed compliment at best.
I feel the pressure, too. However, as much as I would like to be accepted by everyone, there are still things I don’t like or can’t agree with. Like nationalized health-care; you see, I want everyone to get the best care possible, I just doubt if that will make it happen. Furthermore, I so wish I could get on board with (here come the e-mails) global warming and the tragedy of human existence on an otherwise nice planet. It isn’t that I don’t want to make the planet nicer. It isn’t that I don’t think the world may be warmer. I just don’t know if it’s entirely human in origin, or if it’s catastrophic enough to propel us into a green frenzy. Still, I’m ‘green with envy’ towards those who can simply be moved to tears by films and commercials about the fate of the earth.
I guess my point is that it’s good to be different, but there’s a price to pay. You get called names, like ‘ignorant,’ or ‘heartless.’ You get told that ‘people like you are the problem.’ You don’t get invited to sports events, and you don’t always get your cup of tea.
That’s the price of being different; and the price of dissent. But I’m convinced it’s a price worth paying.
Cup of tea, anyone?
I worked two nights this week. It was the middle of the week, Wednesday and Thursday. It was April. And it was insane. Standard stuff, suicidal thoughts, alcohol binges, violent outbursts, dog-bites, etc. I thought, for a while, that it was Memorial Day, and I was just out of touch with the calender.
I was very tired and slept poorly before working both nights. For all that I felt miserable, and got by on my prayers, my wife’s prayers, God’s grace, tortilla chips and sweet-tea, I strangely enjoyed my shifts.
I have to admit that I still find night-shift patients fascinating. So often they’re part of a subculture that simply comes out after dark.
You know the old saying ‘there’s nothing there in the dark that wasn’t there in the day?’ That’s a lie. I know a little about animals and humans and there are plenty of things out at night that weren’t there in the daylight. Sure, they exist in the day, but daytime is when they rest in dark dens in preparation for the nights predations.
Granted, there are some very ill, and very badly injured, people who use emergency rooms at night. But there are some to whom the ER is just another place to go, another box to check off on the ‘to do list.’
In envision the cheese-dip and white-powder covered Day-Timer lying around a cluttered apartment, with unopened mail and opened beer cans. ‘April 22, 2008: My list: Buy cocaine, drink case of beer, hit neighbor with tire-tool, key car in parking lot, hit on neighbor’s teenage daughter, hurt back in Wal-Mart, get arrested yelling at manager, fake seizure, insist on being taken to ER instead of jail, climb off of backboard, urinate in corner, ask for coffee and ice chips, hit on nurse, call doctor ‘SOB,’ spend two hours calling for ride home, stumble out the door in the dawn’s light like an unhappy vampire. Go home to sleep after breakfast of potato-chips and Mountain Dew, sleep, repeat.’
For some of our female patients the schedule book has the words ‘Redneck Woman’ in feminine pink on the cover, but list goes as follows: ‘Go to Taco Bell for late dinner. Go to ER and complain of vague pelvic pain for Lortab, pass out after argument on cell-phone with boyfriend, call boyfriend to come to ER while crying with either pain or emotional distress, have boyfriend yell at ER doctor for not giving pain medicine fast enough, call nurse suggestive and angry names, threaten to call administration, call angry parents to come yell at doctor, get obligatory pregnancy test, ask for crackers and soda because ‘my sugar gets low.’ Stumble home in the morning after meeting cool guy in waiting room with back pain and Lortab prescription. Get phone number. Leave with work excuse in hand, watch movies all day, sleep briefly, repeat.’
I’m not being cruel, I’m telling it like it so often is. Ask the people who staff America’s EMS systems and emergency departments. But the truth is, I like these folks. They’re bold, they’re unashamed, they know what they want and they go for it! Like the overdose with slurred speech who looked at me and said ‘cannn I havvvv sommthinnng for pppain, my tooootttth is kkkkillinggg meee.’
Hands on hips I said, ‘You’re joking, right?’ ‘Well,’ she recovered, ‘maybe after all of this is over?’
These patients give us our best stories, they keep us constantly entertained, and truth is, they are in deep need. They need normality, they need healing for the brokenness of generations of dysfunctional families. They need pride and sobriety and goals. They need to decide to raise their sons and daughters well, without night-time wanderings and family-court drama. I consider many of them my favorite patients. I know them, medical history, allergies, surgeries, medications, genealogy and all. I don’t always want to see them coming through the door, but I like them all the same.
As I thought about the crazy morass of night in the ER, I realized that many of my Christian physician friends feel inadequate because they aren’t in distant mission fields, or because they don’t work in environments that are uplifting. It occurs to me that the emergency department at night is a place of so much need that Jesus probably wants me there. If he were walking among us in the flesh, he’d hang out there too, along with every other locale of pain and misery in the world. Since he dwells in those of us who call ourselves his disciples, he must want me and other believing doctors to go to places like our emergency department, a certified place of enormous need.
He said, ‘it isn’t the well who need a physician, but the sick.’ That being the case, the sick rise up in the night and come to the ER. They drink and fight and get arrested and call me names. And I don’t always have to like them, and I sure don’t have to enable them, but one thing I’m duty-bound to do is to try to treat them with love and respect, for the sake of the Physician I hope to emulate. God help me, they drive me crazy. But Jesus knew they would.
I like to think that he laughs along with me. I like to think he’d roll his eyes too, when they do all of the silly things they do. But where I can place stitches and take x-rays, intubate and transfer, lecture and observe, he can heal.
As I go from madness to madness, I hope that my anger and frustration doesn’t drive Jesus away. I hope that when I walk into the room and out of it, he lingers and works some hope, some miracle I can’t. I believe he does; despite my humanity and incapacity as a healer. I don’t have much time to talk to them. I’m not sure I could explain to them that all their sins can be forgiven, all their past healed, all their futures transformed. But even if I can’t, he can whisper it to them, head injuries and all. And if I’m a little kind, if I joke a bit, if I smile at the sad-eyed children, I may plant a seed of hope in the lives of people who have known so little of it.
But if that’s how it is Lord, if that’s how it’s going to be, go ahead and get ready to forgive me for my snippy remarks and cynical outlook. I’ll try harder. And how about making me a little more rested before I take care of all your assorted fruit-loops, OK?
I know he understands what I mean.
Edwin
‘
‘I’ll be back in a minute.’
Reality? This is a reflex statement usually followed by several hours of labwork, x-rays, CT scanning and consultation.
‘Hey, I have this fascinating case for you…’
Reality? This is what we say to other doctors when we don’t know what to do. Sometimes it really is interesting. Actually, after about 10 PM, nothing is interesting at all until the sun comes up.
‘Just a little pinch and a burn.’
Reality? ‘Ouch! Ouch! What are you doing? Is that a hot iron? It’s a 10! It’s a 10! Morphine!!!!’
‘You have very rare, and I must say fascinating, condition.’
Reality? ‘Better you than me. I don’t know who to call first, the infectious disease consultant or the coroner! Don’t breath on me please.’
‘It might be a little while before we have a room for you. You know how busy the ER can be!’
Reality? If the staff doesn’t get to eat a little bit, everyone is going to hit the floor. You can wait a few minutes.
‘I know you’re having pain, and I appreciate that it’s a ten out of ten; but let’s look a little further so we’ll know what to treat.’
Reality? ‘You’re pain isn’t even a 0.10 out of ten. And I don’t intend to treat your hangnail with Demerol, so just let go of that little dream.’
‘So, you have chest pain? Well, let’s look and see if your EKG and heart labs are normal, shall we?’
Reality? ‘You and the rest of the free world have chest pain. Odds are, at 19, your chest pain has more to do with the argument you had with your girlfriend than with any real disease.’
‘I can’t imagine why you’re still short of breath!’
Reality: Quit smoking, goofy-head!
Just a few that came to mind on today’s shift! Liars all of us, I guess.
Edwin
I love taking care of patients. I don’t mind blood or gore, screaming children or protruding foreign bodies, unpleasant odors or spewing drainage from abscesses. It’s bread and butter.
But I hate charting! I especially hate dictating. I don’t know why, but something inside me doesn’t enjoy doing it. Consequently, I’m always behind, and tend to get my charts done at the end of each shift. Or I’m busy and miss the chart, and it shows up in a yellow or red folder days later, handed to me by the long-suffering ladies from medical records.
Call it a character flaw. Call it procrastination. Call it ADD. I don’t know, I just don’t like doing it. I wish I had a scribe following me from room to room, recording my actions. Or an orangutan or chimpanzee who could take dictation and dictate for me. That would be, I suspect, the most enjoyable solution. ‘I’m doctor Leap and this is Shotzie, our ER Ape. If he stares at you, look away or he’ll scream.’
On the other hand, I think I hate charting because it’s so unrealistic, so ridiculous now. We go overboard on everything, and charting is no exception. So, I can’t just dictate what happened and what I did. I have to dictate for at least three reasons, and each has slightly different requirements.
I dictate for the medical record, so that we’ll know what to do next time, and what was done before, and so my partners can curse me for giving Percocet to the guy they refused it to last week.
I dictate for medico-legal protection, to demonstrate that I did everything and asked everything necessary for the safety and well-being of the patient; and the ultimate satisfaction of our insurer.
I dictate in order to bill the patient. And in so doing, I am forced to use an internal medicine template that involves examining the sickest emergency department patients, the ones who are going to be admitted, as if they had stumbled into my medicine office for a new patient visit and need me to document their nose-hairs, crooked joints, liver-spots and spleen size.
This is all ridiculous. It forces me to document the things that are absent. That is, in dictating on the chest pain patient, it isn’t enough that his past medical history was negative. I’m supposed to say, ‘denies heart disease, denies diabetes, denies stroke, denies family history.’ I can’t just say ‘past medical and family history negative.’ Talk about a poor use of space and time!
So, I’m dictating what I actually did, how thorough my exam was, how thorough some lawyers and corporate doctors think it should be, everything I might want to say if I end up in court someday, as well as unnecessary information deemed necessary to prove that I deserve to be paid more than someone hanging drywall.
We do this all the time! We document the most inefficient way possible. We record vital signs on young ankle sprains. We write unnecessary statements that could have been covered by the word ‘negative.’
We do a ‘review of systems’ that has no place in emergency medicine and that could just as easily be covered in ‘history of present illness.’ We have to dictate the indications for our labs and x-rays, which should be adequately covered by the statement, ‘because I said so.’ We say so much that all we do is extend the long legal rope that someone will use to hang us.
But not just doctors, oh no. In a time when we’re short of nurses, and when patients often say they don’t get enough time with those ministers of mercy, regulatory bodies take nurses away from sick humans and plant them, like us, firmly in front of computers. Our nurses template ‘no drug or alcohol abuse,’ on infants, or ‘non-verbal’ for newborns. Our nurses document screening exams about nutrition, physical abuse, substance use, immunizations, home medications, medications being sent home and on and on.
Then they drive the dagger home by documenting their physical exam which frequently conflicts with our own. I’m glad they like doing exams, and some are good while some are bad (just like physicians) but the potential for each of us to hurt one another in court is very high.
In fact, our nurses document so much, from physician visits to problems reported to physicians, to wasted medicines to ‘patient visited, call light within reach, physician notified of crushing chest pain,’ that I’ve actually seen the reason for the visit lost in the sea of words.
Example: I have seen patients who came with simple wounds, who came to the ER for a laceration repair and tetanus immunization, but whose chart lacked any description of the wound itself or the repair of said wound. They were asked about past history, medicines, allergies, family, spouse abuse, alcohol use, and all the rest. JCAHO did a good job of frightening the nurses about screening. But the wound? Described by the nurse? Hardly. The wound was a secondary concern to the social engineering being foisted upon hospitals.
(In the larger sense, the sick as a whole are the secondary concern, and lie in the shadow of the looming inefficiency of further social engineering that may visit us next year. But that’s another topic altogether.)
So, charting makes me crazy. We waste time and money. We waste brain cells. And it could be so simple.
Patient name: John Doe
Age: 45
Complaint: Chest Pain
History: One hour of heaviness in the left chest, radiating to the left arm, with shortness of breath, sweats and nausea.
PMH: Negative
Meds: None
Allergies: None
Family/Social: Smokes one pack per day. Father had MI.
Physical Exam: Vital signs normal
Lungs clear bilaterally
Heart Regular rate and rhythm, no murmur, gallop or rub.
ENT: No neck mass or JVD
Extremities: No edema
Abdomen: Soft, non-tender, no mass
Rectal: Heme negative
Decision making: EKG showed acute inferior MI. Aspirin and nitroglycerin drip administered. No contraindications for thrombolysis. Chest X-ray negative. Cardiac markers pending. TNK administered. Patient did well, hemodynamically stable, ST elevations resolved, pain free, admitted to CCU to Dr. Heart.
Diagnosis: Acute inferior MI
Disposition: To CCU. Care assumed by Dr. Heart at 1645
Wasn’t that simple? No nutritional screening, no abuse screening, no reasons for anything I ordered, no nurse’s exam to ambush me later by saying ‘patient had pulsatile mass in abdomen, doctor aware.’ (I was not aware!)
Maybe that’s why I hate charting. It involves so much charting! So many extra words, and so little actual useful information. So, that’s that. I’ll sign off now. I probably have some lost charts to dictate.
Quick, hide me! I hear the medical records lady on her high heels, clicking around the corner with a folder in hand! Someone document that I don’t feel safe in the ER! And I’m hungry! Document my nutritional screening!
And be sure to document that I hate, really hate, dictating and charting.
Edwin
Kids love sleepovers. My children seem to have one every other weekend. It begins on Thursday or Friday as a friend starts calling, whispered conversations occur, then a child comes to me and asks, ‘can my friend sleep over tonight?’
Negotiations occur. Other parents are involved. Travel routes and schedules are developed, and before you know it, masses of children are camped out in front of the X-Box, or are screaming at the top of their lungs on the trampoline…or tramopoline, as Homer Simpson put it.
This is known as the sleepover, but it’s a trick. No one actually sleeps. Last night my children were in the basement with friends, watching the television at 11PM when I told them ‘good night, I love you, sleep well.’
(Incidentally, I was so proud…they’re finally watching Monty Python’s Flying Circus on DVD. They grow up so fast!)
Anyway, it turns out that they didn’t go to sleep until 5 AM. That accounts for the general surliness and fatigue all of them are exhibiting. And for the fact that several boys were too tired to shoot pellet guns or .22 rifles, even when I offered to be range-master and let them. A sure sign of exhaustion in a boy.
So all I know is, sleepovers ain’t sleepovers. They’re food-fests, in which entire pizzas are consumed for breakfast (as one was this morning in our kitchen). They’re caffeine parties, during which the children manage to suck down every molecule of stimulant they can find. They’re holy sacraments of destruction, in which the house becomes strewn with shoes, socks, underwear, soda cans and potato-chip bags. Sleepovers are movie festivals and video-game competitions. But they are not, in fact, times of sleep.
They’ve duped us! The children, by using some kind of Orwellian ‘newspeak’ have managed to convince us that their friends come to our homes to sleep. Be aware, dear fellow parents.
Many things will happen, but sleep is not on the schedule.
Watch out! Grumpy children on the horizon!
Edwin
