30 April 2007

Happy Mission Accomplished Day

Four Years Later.

Just for reference, that is three months longer than it took the US to arm itself, invade Africa, Italy, and France, island hop through the Pacific, liberate the Philippines, drive to Berlin, and defeat the Japanese Empire. Granted, that says more about the absolute stunning mobilization the US went through for World War Two than it says about this military expedition. In the grand scheme, WWII was amazingly short, especially when you consider the sheer amount of geography reconquered, and the fact that the weapons the US relied on to win the war not only did not exist at its outset, but in many cases had not yet been invented.

But it is still a remarkable perspective, that the time from Mission Accomplished Day to today is longer than the time from Pearl Harbor to V-J day.

What I do with my time

I see, on average two patients for every hour I work, give or take some. This is about average for ER docs in general. I am a little on the fast side for our group. This breaks down to about 30 minutes per patient; simple patients take much less, while complex or critical patients take substantially more. Yet when we review patient complaints, one of the most common themes is "I only saw the doctor for a minute." I think that's a underestimation, but not too far off the mark. A complex patient, I may be with them on and off for half an hour, cumulatively. Moderately complex patients I may spend five to ten minutes at the bedside. Ankle sprains and simple matters may truly get a minute or two, depending on whether they need much in the way of instructions.

So, you may wonder, what is it I do with the other 25 minutes for each patient? Here are the common tasks (in no particular order):

  • review old medical records
  • enter orders in the computer, and via the unit clerk
  • write up the chart -- history, exam, medical decision-making
  • chase down labs
  • chase down x-rays
  • call answering service to page primary care doc, consultants, admitting docs
  • wait for call-backs
  • phone conversations with primary care doc, consultants, admitting docs
  • receive phone call from outside doctor or clinic
  • base station control for ambulances
  • conversations with nurses (patient care-related)
  • conversations with nurses (social)
  • write up discharge instructions and prescriptions
  • field phone calls from pharmacies about prescriptions written by other providers
  • write up admitting orders
  • bother charge nurse about when inpatient beds will be ready
  • visit bathroom (maybe)
  • follow up abnormal culture results
  • consult with psychiatric social worker
  • dictate records in some cases
  • fend off approximately 24 interruptions per hour (really)
  • eat (maybe)
So, yes, I am sorry that I only had a couple of minutes to spend with you. I know you spent a long time in the ER waiting for the test results, and you felt cheated that I was in and out briskly. I tried to communicate a lot in that short time and maybe you didn't follow it all. There are so many things to do that I wonder how I manage as it is. I can't omit (or escape) any of the above tasks, and I routinely go an entire shift without eating and sometimes without voiding. It's not as if I was lazing around. But you didn't see any of it, and you overheard an extended personal conversation between two nurses in the hall, so you have concluded that we were all too busy socializing to take care of patients. That is very frustrating, I understand.

But we are, after all, very busy.

Advice for Emergency Medicine Interns

I thought I would steal a page from the sadly departed but still remembered Barbados Butterfly, and give some sage advice to those still in training.

I will pause a moment here for those who personally know me to recover from their shock and horror at the notion of someone like me providing anything approximating “sage advice.” They may need to clean the coffee off their monitors. . .

There, all better now? Off we go, then.

How to deal with consultants:
The last couple of posts involved exchanges in which I presented an uncommon or hysterically improbable set of facts to a surgical colleague, and they took the case as presented. Charitydoc alluded to a similar experience in the comments. This sort of thing pretty much never happened in my training. For one, the ED and surgeons regarded one another as natural enemies. Also, more than half the time you didn’t really know the person on the other end of the phone. I have been in private practice now for about seven years. There are a number of critical differences between training and private practice. One is that you tend to work with and refer to the same individuals over a prolonged time, rather than the rotating groups of short-time consultants you get in academic institutions. You build relationships, view one another as colleagues and (gasp) friends, and develop a history with your consultants – be they hospitalists, surgeons, what-have-you. They come to know you, and hopefully trust you, and their response to your requests is predicated on their opinion of you. I cannot emphasize this point enough:

Credibility is the sole currency you have in this relationship. Hoard it carefully and spend it wisely.

You, as an ER doc, have one and only one job: to keep your patients alive long enough for them to become someone else’s problem. To accomplish this end, you are entirely dependent on the good graces of your consultants. I have many times watched my partners, especially some of the junior ones, chase their tail for hours trying to get a patient admitted, because they couldn’t get their consultant to bite on their presentation.

This my patented recipe for success:

1. Never call without first knowing exactly what it is that you want. If you call with a wishy-washy “do you think that you should get out of bed and do a lot of unpleasant work?” then human nature dictates that in many cases the consultant will seek out the easiest solution, which may not be appropriate, since you have seen the patient and they have not. They may well embarrass you by asking irritably “Well, you’ve seen them, what do you think I should do?” It’s quite deflating to have no ready answer to that question. Know in advance what the desired outcome of the conversation will be.

2. Be direct when presenting on the phone. The consultant doesn’t want to chat, especially if it’s after midnight. The FIRST thing they think when their pager goes off is “Oh, shit, it’s the ER; what the hell do they want?” So answer that question first: “Hi Dr Jones, I’m sorry to bother you but I have a patient for you to admit/consult in the ED/take to the OR/see in the office/give advice on.” Don’t make them wonder; if they know where you are going from sentence one, they can prepare a response as you talk and are much less annoyed than they would be by a rambling presentation.

3. Make a compelling sales pitch. You are calling them because you have already decided that you need something from them. (See #1) You need to convince them that what you need is in fact reasonable. I begin with the diagnosis, present the supporting facts in an order designed to logically lead to the conclusion I have already reached, then reiterate the diagnosis and required action. Don’t present a rambling review of systems, and don’t lead with the chief complaint or narrative history. We love to “tell the story” but at 2AM with a sleepy surgeon on the phone, he or she does not care about the story. Just make the sale and convince them as succinctly as possible. Three sentences is as long as this should take:

“I have a patient with Pneumonia. 66 y/o, fever and cough.
Needs to be admitted because the O2 is 88%.”


4. Never lie or shade the truth. They will find out. If there are facts counter to your working diagnosis or proposed plan, you must acknowledge them up front. It’s tempting to try to pull a fast one, especially on those borderline cases – just get the internist to agree to admit and send the patient on up, right? Wrong. You may or may not get an earful from their department director later, but even worse, the next time you try to admit to them, they’re not going to believe a word you say, and you’re fucked, me boyo. In some cases you need to be very up front. I frequently begin the conversation with “I am sorry but this is a social admission, and it is necessary because…” or “I do not know what is wrong with this patient but they need to be admitted because…” The nice thing about this is not just that you don’t have to contort yourself to make a medical case out of it, but you get a reputation for not trying to put lipstick on the pig, which pays dividends when you have the more genuine medical admissions.

5. Don’t shoot yourself in the foot. If you start off your presentation with the adverse facts, you are making it hard to convince your consultant. Start with the case FOR your diagnosis and plan, then acknowledge the countervailing facts. When possible, do so linked to an immediate explanation why those facts do not negate your overall impression. Be assertive and speak in short declarative sentences. If they hear uncertainty or ambivalence in your voice, they will pounce and you are lost.

6. Anticipate and pre-empt obstacles. It’s no secret that some consultants are hesitant to see/accept an ER patient until they have been fully worked up. You want to get them upstairs as quickly as possible. Figure out what the roadblocks may be, address them in your presentation, and have an answer for the objection before it is even uttered. Examples:

  • Blocker: Have you ruled out PE? Preempt with: I considered PE, but they are not tachycardic and have no risk factors (blah blah) and so my clinical concern is low.
  • Blocker: Altered mental status? What about an LP? Preemption: I think meningitis is unlikely because of (insert clinical reasoning), so I did not do an LP. After you have seen the patient I am sure you will agree with me.
  • Blocker: Did you order (insert reasonable but obscure and time-consuming test)? Preemption: Yes (as I write it on the admitting order sheet) and it should be resulted by the time you see the patient on the floor.
  • Blocker: Can you hold the patient in the ED until (sometime in the future)? Preemption: I have ordered tests X, Y and Z, but the patient is stable and I have 40 patients in the waiting room, so with your permission I will write holding orders, and you can see him on the floor.
  • Other popular ones are “Is the patient stable enough for the floor/sick enough for the ICU/well enough to go home?” (Often all of the above amusingly applied to the same patient) Or “shouldn’t this be admitted to (some other specialist)?” If you can anticipate the concern and address it in advance, you are much more likely to move the patient out of the ED in a timely manner.
7. Be reasonable. Don’t try to admit an abdominal pain to medicine without a CT (or surgical consult, as appropriate). If there is reasonable concern for PE, rule it out or at least get the process started before you make the call. Sometimes the specialists know more than you do (really!) and may legitimately have an alternative strategy which may be effective. Listen to them.

8. Close the deal. Once you and the consultant have agreed upon a plan, be very concrete in defining the next step. “I will write holding orders and you can see them in the morning,” “I will see you in the ER shortly,” “I will send the patient to the cath lab/OR/ICU and you will meet them there.”

9. Be pleasant. Get to know their names, chat and joke as the situation and time of day allow. Social niceties lubricate and facilitate these interactions. You may even become friends(!).

10. Become involved in your hospital medical staff. The better your consultants know you, the more credibility and trust you will accrue. Many docs view the ER docs as itinerant locker-docs and glorified paramedics. When they work with you on the medical staff, they are much more likely to view you as a valued colleague. What’s more, they are much less likely to be a dick to you over the phone when they know that you will sit next to them at the X Meeting tomorrow. And if they know that you will be reviewing their credentials the next time their appointment comes up for renewal…

I had a nice interaction with a hospital internist recently. I had a really borderline case where there was no clear indication for admission, and I apologized for that as I presented it to the hospitalist (who was a notorious blocker). She responded, “That’s OK. We don’t mind because with you we know that you’re not going to admit for a stupid reason, and when we see the patient on the floor they will be exactly as billed.”

I felt really good about that.

29 April 2007

DC Blogging

I had forgotten how beautiful DC is in the spring.


If you look carefully at the high-res image, you can see there's an "event" taking place on the West lawn. There is a huge PA set-up and a couple of thousand chairs. There are more people on the stage than in the audience.

I felt kind of sorry for the folks on the stage. They were ranting about something - the details were not exactly clear but they seemed to be decidedly pro-god (who isn't?). But I am sure they put a lot of work into setting this up and it was a really bit event for them -- all to preach to the empty chairs and confused tourists.

26 April 2007

Hubris, continued

Oh, what the hell. It's fresh in my mind after the last post and I can never resist telling one of my favorite stories. And you will see why I deserved my comeuppance.

A couple of years ago I came in to the evening shift and took sign out from my partner who was going off-shift. There was one case signed over which made my eyebrows go up a bit. I was a woman, early middle-aged, who had a story which weakly suggested appendicitis: right lower quadrant pain, no rebound, mild tenderness on exam. They got a CT scan on her and the radiologist did not think it was an appy, but was a little uncertain. So he consulted with one of his colleagues who had suggested (for reasons which to this day are beyond me) that the CT scan be repeated with the patient in the left lateral decubitus position (picture). I had never heard of such a thing, but I'm not a radiologist. Then the second CT scan was also indeterminate. So they decided to get another CT scan, in the right lateral decubitus position. The results of this CT were pending when I took over the case. My partner wryly informed me that his suspicion was kind of low anyway, so once the radiologists quit screwing around and decided this CT also was negative, the patient could go home with a diagnosis of "Abdominal pain, uncertain cause" and the standard precautions.

Sure enough, an hour or so later, I got the final results which were negative for evidence of acute appendicitis.

So I went in to tell her about the diagnosis and plan. She was a little anxious about the uncertainty, but I reassured her and went to re-examine her in a rather cursory, desultory fashion. Her abdomen was modestly obese and soft, and she did not even wince as I palpated deeply in the right lower quadrant. Idiots, I muttered to myself, all this fuss and not even pain on exam. I let go and stepped back, and as I let go, she gasped in sudden pain and sat up bolt upright. Okay, that was unexpected, I thought. Something just happened. I examined her again, a little more carefully, and again, though she really had no pain when I pushed on her belly, she had classic and severe rebound tenderness.

I hate it when this happens with a sign-out. Supposed to be a simple discharge, and now I have to look at the chart and re-think the whole thing. Hmm. She does have an elevated white count, and she has been in the ER eight hours getting her scans, so that's long enough for the rebound pain to have evolved -- you classically want a twelve-hour serial exam to rule out an appy, and eight is getting pretty near there. It was getting close to midnight, and I called the surgeon, who was a nice guy and a reasonable fellow, but unsurprisingly skeptical.

"So Brad, I have a lady here with an unusual presentation of appendicitis."
"Okay, what did her cat scan show?"
"Well, that's the funny part. She had three of them, one supine and bilateral decubitus CTs."
"Are you kidding me? That's insane. What did they show?"
"Well, they were all negative. But she's been here for 8 hours and clinically she has an appy on exam."
"Now I know you are kidding me. Three negative CT scans and you think she has an appy? You're on drugs. Send her home."
"Brad, I know it sounds bad, but really, you have got to see this lady."
"Fine, send her home and I'll see her first thing in the morning in my office."
"Brad, I can do that, but I don't recommend it. She'll have ruptured by then."
"You're killing me. Can you just admit her to me and I'll see her in a few hours on the floor?"
"I can do that if you prefer, but you'll just be taking out her appendix at four AM."
"Oh God. Fine. Send her up to the OR then." [click]

A couple of hours later I got a phone call from the surgeon.

"You know, I was really pissed at you for sending me that stupid case. And the thing that really pissed me off when I opened her abdomen and saw her black, necrotic appendix lying there, was the realization that the next time you call me with some stupid consult in the middle of the night, I am going to have to take you seriously and listen to what you have to say."

I should say that we have some really great surgeons and have a great relationship with them. I portray them as gruff but they are not in any way unpleasant or jerks, so don't read it that way.

I was very proud of my cojones that day, calling the diagnosis in contradiction of not one but three scans. I strutted around for quite a while after that. Which, as I said, is why I undoubtedly deserved my karmic comeuppance.

Pride goeth before the fall


So says the book of proverbs. You may recall the pride I expressed when I picked up a difficult appendicitis case a couple of months ago. Karma is a real bitch, sometimes, and this week has been payback time. It began in what is for me typical fashion:

It was a classic presentation. A young man, about 19 or so, with 36 hours of anorexia, malaise, low grade fevers, and generalized abdominal pain which subsequently localized to the right lower quadrant. He has a elevated white count, tenderness over McBurney's point, involuntary guarding, and rebound tenderness. Now, as a digression, one drawback of modern technology is that is it nearly impossible to get an appendectomy without a CT scan any more. It used to be that a "negative laparotomy" rate of something like 25% was acceptable. Now any negative laparotomy is viewed in much more negative terms, and the surgeons almost always demand a CT scan before even seeing the patient. So it goes. This was, I thought, one of the few cases which was clear cut enough to justify skipping the CT scan and going straight to the OR. And the surgeon on was one I knew well and who trusted me. I called her up:

"I've got an appy here for you."
"What did the CT scan show?"
"I actually think you may want to just take this one to the OR. I am sure this is an appy. I don't own a hat, but I will go out, buy a hat, and eat it if this is not an appy. I'll get a CT if you like, but I think it'll be a waste of time."
"If you say so, it's good enough for me. I'll come down and see him now."

She examined and interviewed the patient, agreed, and up to the OR he went. An hour later, I got a call from the surgeon. With barely-disguised malicious glee in her voice, she said, "It's time for you to go shopping. What's your hat size?"
It turned out the young man was experiencing a first presentation of inflammatory bowel disease and had terminal ileitis, which is notorious for mimicking appendicitis. (and the surgeon was very nice about it -- we are friends and she too, had been convinced enough to take him to the OR.)

So then the next day when I saw another young man with a classic case of appendicitis, I was more cautious. I told the patient that I was quite sure it was an appy and he would need to go to the OR, but to be certain, he would get the CT scan before I called the surgeon. His CT came back showing epiploic appendagitis, a bizarre and rare, but benign condition which mimics appendicitis but does not require surgery. I have seen it maybe three or four times in my career.

Thoroughly snakebit, I saw yet another "classic" case of appendicitis last night. Once again, it couldn't have been any more obvious, as if from the textbook, in a young male. (It's never straightforward with females. Um, I say that in reference to appendicitis only. Really.) He also got a CT scan, and at this point I was no longer even surprised to have an unusual and rare thing turn up on the CT scan. In this case, it was cecal diverticulitis, which I have never seen before, let alone in a 22 year old (diverticulitis typically occurs in the sigmoid colon and in patients 50-60 years old).

It's almost is if I was living in some Greek tragedy in which the fates were eager to punish me to the crime of hubris, of which I am undoubtably guilty. Enough, already!

If I get a chance, one day I will tell you about the case that truly set me up for this karmic payback. Here it is. I can't argue that I don't deserve it.

24 April 2007

Roger Ebert - Not hiding his cancer

Good for him.

I grew up in Chicago, and film critics Siskel & Ebert were local celebrities who had been around my whole life. I was terribly sad when Gene Siskel passed away from an unspecified brain tumor. I saw Ebert on The Daily Show about a year ago, and I was shocked at his appearance -- his face looked plethoric and his neck far too thin. I think he may have made an oblique reference to some illness, and I surmised that he may have had a radical neck dissection. I had no clue till today of the true nature of his illness. It turns out he had a papillary thyroid cancer, which spread to a salivary gland and required removal of part of his mandible. Some truly horrible complications followed. Is sounds like, after a very rocky course, he is improving, and despite a radically altered appearance and the inability to speak, he is ready to resume some elements of public life.

He retains his trademark wit "I ain't a pretty boy no more," he says, paraphrasing the film Raging Bull.

Good for him, and I wish him well.

23 April 2007

Grand Rounds

Up over at Med Valley High. See you there!

Well said, young turk!

"If you’re a Democrat when you’re young, and a Republican once you get a mortgage, then you’re for private health insurance when you’re well, and you’re for health care reform when you’ve developed chronic disease."

Graham

The Greatest Living American -- it's official

Apparently the greatest living American is Stephen Colbert. It's official -- Google says so. Apparently Google-bombing is still possible.

Amusing back story here.

Victory Speech by the Alchemist here.

22 April 2007

Meeting a hero

The triage nurse's note was not encouraging. Something to the effect of "85 year old male, fell, severe low back pain, unable to get out of chair x 3 days." These things are frequently nightmare cases -- either you have someone severely dehydrated and in kidney failure, septic, and terribly sick, probably moribund, or they are uninjured and well but you can't get them out of the ER due to pain, and nobody wants to admit them because there's no "medical indication" for admission and they don't want to deal with a case that medicare refuses payment on. Not the case one would choose to end the shift on, and didn't bode well for getting home on time.

Well, that's why I get paid the big bucks, right? I took a deep breath, squared my shoulders, and headed in. . .

The first thing that greeted me in the room was the strong odor of stale urine. Not a good sign. And the grizzled, unshaven face atop squalid clothing. Expectations met so far. But a pair of keen, bright eyes peered out at me from under bushy eyebrows and a big, albeit toothless, grin. He had been reading a book while waiting for me to come in! A book! After chatting with the fellow for a couple of minutes I determined he was a pleasant, extremely sharp fellow, neither terribly ill nor a complainer. He had never been ill a day in his life (a good recipe for living to 85, it must be said). After concluding the history, I went to examine him and gently picked up his book and put it aside, careful to mark his page with the bookmark. I forget the title of the book, but the bookmark was a large, glossy 4x8 photo which looked like this:"Nice plane," I commented.
"I used to fly it," he responded.
"What? Really? That exact one?"
"No, no, I flew a F model, that one's a G, but you couldn't really tell."
"Wow. What did you do on it?"
"Pilot. 17 missions."
"Damn."

It's hard to explain how he was transformed in my eyes after that. I so wanted to sit down with him and talk about his experiences. I am a pilot, and have nothing but awe for the guys who took off from England, flew these big beasts of aircraft, loaded with tens of thousands of pounds of bombs, across the Channel and over Germany with no navigational systems beyond a compass and a watch, dropped the bombs more or less on target, and returned home. Oh, yeah, and there were people shooting at them the whole time. They were real men.

I try to treat every patient with the same level of courtesy and compassion and all that humanistic bullshit, whether they are homeless scum or the wife of the hospital CEO, and I think I am pretty good at it. But it's pretty rare for me to really truly feel a sense of respect and indebtedness to a patient. In this case, it actually helped make the disposition easier. He turned out to have a couple of compression fractures in his lumbar spine, and despite pain medicine and his best effort, simply couldn't get up and walk. So I called up our hospitalist and began the conversation with: "Hi Jim, I have an interesting guy here. 85 years old with a couple of compression fractures in his back. He actually used to be a B-17 pilot in WWII."
"No shit?" asked the hospitalist.
"Yeah, really. Anyway, he's in pain, so I'm admitting him to you."
"Oh, of course. Send him up."

Good karma. And I got to meet a hero.

19 April 2007

Impress me

From the Seattle P-I:

Woman’s blood alcohol level 6 times legal limit
DUI suspect registered 0.47 in test

OK, that's pretty impressive. On any given night in our ED, being >400 on the blood alcohol scale (or >.400, depending on the units you prefer) will probably win you the gold star for the evening. I've seen someone walking and talking at >500. He was acting more sober at that level than I would have at 100, and in fact I might not have noticed that he was drunk at all, if it were not for the slightly slurred speech and distinct odor of ketones. I've seen 800 as the highest level I have personally witnessed, and that was a chronic inebriate who managed to get himself well and truly comatose (and intubated). Some of my partners report having seen levels over 1000, which stretches credulity, but I believe it.

And just for reference, legally intoxicated is 80 (or 0.08). Yeah, 400 is pretty high.

17 April 2007

Some days I don't want to listen to the news

It just makes my heart ache. I spent an hour and a half listening to NPR while driving this morning, and I eventually had to turn it off and listen to music instead. I saw this headline on CNN:

ER Doctor: "I've never seen anything like this."

I can only imagine. Maybe I should volunteer for that upcoming mass casualty drill our hospital is having.

15 April 2007

I have a four year old son

This little boy looks to be about the same age. Maybe a year or two older. Hard to say. My little boy went to T-ball this morning and is watching cartoons now. Nothing blew up. This one went to the marketplace. Something blew up there. I wonder if his parents are still alive?

Some people, mostly conservatives, don't understand why we on the left are so angry. They think we just hate Bush so much that we have become unhinged and are just deranged moonbats. It's true that I hate Bush and all his henchmen, but I hate him not just for being a callow, petulant, incompetent, messianic ideologue. I hate him because I see these pictures, and because I read heartbreaking letters like these, and because I think of my little boy and how my heart would break if he were killed in a stupid, senseless, wicked war like the one Bush started. I think about the fact that some of the letters written by the troops were written by soldiers who were 13 years old on 9/11, and now they are 18-year olds coming home in flag-draped coffins. It makes me weep with frustration and rage and a deep and profound sadness.

I hate George Bush for many reasons. I hate him for making America a country of wiretaps, terrorist watchlists, and indefinite detention. I hate him for condoning torture and compromising America's moral authority in the world. I loathe so many of his policies and the things he has done that it's hard to list succinctly, though I have tried. But mostly, because of all the innocent blood on his hands.

3300 Americans. Tens of thousands, possibly hundreds of thousands of Iraqis.

If you're not angry, you should be.

I'm gonna go hug my boys now.

14 April 2007

Draining the swamp

I have never listened to Imus in my life, and have managed to ignore the whole "nappy-headed ho" imbroglio -- to the degree that it is possible, given the saturation media coverage. Yet there has been a bright spot because I have heard much less about someone named Sanjaya in the interim.

Vaguely annoying though the media circus has been, yet another bright spot has been the focus on bigoted language in public discourse, and the clarification of the bounds of what is acceptable. There are a whole host of right-wing hate-mongers to whom the standards should be applied and from whom accountability should be required. Just to start, I refer you to Media Matter's compilation of just a few of the more egregious comments of Messers Limbaugh, Beck, O'Reilly, Savage, Bortz, and Coulter. Selected highlights:

  • Boortz: Rep. McKinney "looks like a ghetto slut"
  • Boortz also declared Islam a religion of "violent, bloodthirsty cretins" and called Prophet Muhammad a "phony rag-picker"
  • Boortz suggested that Katrina victim turn to prostitution
  • CNN's Beck to first-ever Muslim congressman: "[W]hat I feel like saying is, 'Sir, prove to me that you are not working with our enemies' "
  • CNN's, ABC's Beck on Clinton: "[S]he's the stereotypical bitch"
  • Beck has a warning for Muslims "who have sat on [their] frickin' hands" and have not "lin[ed] up to shoot the bad Muslims in the head"
  • Coulter refers to Edwards as "faggot," has smeared Dems in similar fashion many times before
  • Savage: CNN's Blitzer and King "would have pushed Jewish children into the oven"; "curry favor with the turbanned hoodlums"
  • Limbaugh handicapped races in new Survivor series, suggested "African-American tribe" worst swimmers, Hispanics "will do things other people won't do"
  • O'Reilly to Jewish caller: "[I]f you are really offended, you gotta go to Israel"
And these are only comments from the past eighteen months or so. Limbaugh and Coulter have a track record of racism and slander going back well over a decade. As long as cretins like these are considered credible and praise-worthy on the right, they incriminate by association, by their silence, and by their implied support all the reasonable conservatives (and they do exist) who shudder at such brazen attacks. Kos has asked "what does a conservative have to say to not get invited back on the TV as a pundit?" I don't know - I can't think of it happening. You can advocate the assassination of supreme court justices, the destruction of the New York Times, the execution of journalists, and on and on, and the conservative establishment will support you and ensure your meal ticket continues to get punched.

Conservatives who fail to denounce these vile human beings are at the least complicit.

PS: Just for the record, if anyone would like to bring to my attention comparable slanders by liberals, I will be happy to add their names to the list of shame.
PPS: And, no, anonymous commenters on blogs, vacuous celebrities, and obscure university professors don't count. I am referring to major media figures and respected pundits.

13 April 2007

JCAHO Again!

Sorry for the prolonged radio silence. Real life gets in the way of blogging sometimes. As my hero, Monty Burns said: "Family, religion, friends.. these are the three demons you must slay if you wish to succeed..." Well, I'm back with an annoyed rant, yet again on the Joint Commission. Apparently they have recovered from the temporary bout of sanity which caused their earlier hesitation and reinstated this odious rule:

Joint Commission Reinstates First Dose Medication Review

Medications administered in an emergency department must once again be reviewed prospectively by a pharmacist, according to a notification sent to hospitals last week by the Joint Commission. But a conversation with the Joint Commission president indicates that the reversal may not be permanent.

ACEP President Brian Keaton, MD, spoke with Dennis O’Leary, MD, the Joint Commission president, on April 13. According to Marilyn Bromley, RN, Director of ACEP’s EM Practice Department, Dr. O’Leary indicated that he would convene an internal task force to revisit the many concerns presented to the Joint Commission.
You can read the proposed rule here. Once again, the bureaucratic mindset took control of the residual brainstems of the great thinkers at the Joint Commission, and heedless of the lack of qualified pharmacists to review the volume of orders for meds in the ER, mindless of the needless delays in dispensing critical medications, mindless of the obligate delays in care, increased length of stay, increased waiting times, impact on patient flow, etc, they reinstate a stupid rule which not only unnecessary but potentially detrimental to patient care.

You will note that ACEP is opposing this. Never say that your college doesn't do anything for you.

04 April 2007

Leadership is hard


We had the physicians' retreat for our practice today. I found myself, for the first time, in the uncomfortable and intimidating position of being the guy in the front of the room, facing the 30-40 physicians there, expected to speak the words that will inspire and motivate them.

Sometimes I wonder how I got here. It may come as a surprise to the readers of this blog that I am a man with opinions. They range from politics to the practice of medicine, to the business of medicine (and well beyond). I had historically been content to shout criticisms and witticisms from the back bench. Nobody looks at you there, and if you're disastrously wrong the consequences are lesser. But a couple of years ago I was put in a "put up or shut up" situation. And now I run the group. Funny old thing, life.

It's turned out well, so far, and I am proud of what we have accomplished in the time I have been involved in the leadership team. We pulled the practice from the brink of insolvency and closed the rotating door on staffing. Now we recruit from top-tier residencies and have great retention.

But nothing sobers and intimidates like facing your partners in the flesh, and the expectation that you are going to have something stirring and inspirational to say, which will motivate them, make them excited and cheerful to go to work, and rekindle their love for the art of medicine. No pressure.

I'm not ready for a career as a motivational speaker just yet. I got through it OK, though. There was a lot to talk about and now I am just burned out. I think I will have a beer and soak in the hot tub. I have a lot of tension in my neck just now.

02 April 2007

The Least Funy April Fool's Ever

Susan over at How Can I Keep from Singing? tells the gutwrenching story of when her son Nathan was diagnosed with Neuroblastoma four years ago. She summarizes her feelings:

I am so very grateful for these four precious years! They have been filled with terrible things, but mostly, they have been witness to a toddler growing up into a school-aged boy and I am so thankful we have gotten to see that happen.

I can't put into words how much I wish that this anniversary could be joyous, that Nathan was cancer-free, but I am full of joy that Nathan is here today. I am listening to him sing as I type this. He is happy and so am I.
I think about Nathan every day. I remember vividly when she called me (we are old friends) about Nathan's swollen eye, and I still harbor some irrational guilt that I too thought it was just a viral conjunctivitis. I saw a three-year-old in the ER yesterday who was complaining of nontraumatic hip and knee pain and I immediately thought about Nathan. I routinely weep when I read Susan's blog, as well as Luke's (Nathan's Dad). What else is there to do?

Thanks for sharing, Susan.