Shortness of Air? Are you joking?

The strange land of Emergistan is full of even stranger ideas.  It seems that the people in charge of medicine (by which I mean everyone but physicians, nurses and mid-levels) are simply losing their ability to focus on reality.  Thus, they focus on anything and everything else. 
 
Case in point.  I work in one facility which no longer uses the term Short of Breath in its charting templates.  The new, updated, customer friendly phrase is 'Shortness of Air.'  Nobody comes in with SOB; they present with SOA.  Pourquois, you ask?  Good question.

I envision it like this.  Somebody looking over a chart in this small town was shocked (shocked I say) to learn that their dear old grandfather is described as SOB.  (Probably by some damyankee locums doctor from the North.) Of course, we all know it had nothing to do with either the character (or species) of his mother.  It simply meant he is short of breath. 

Offended person complains to hospital administration;  thus, a committee is born.  Now, with all due respect, hospitals are generally run by nurses these days.  So I envision a room of former clinical nurses, turned administrators (and dressed quite sharply, by the way) sitting around a conference table and fanning themselves over the vapors they develop when they consider the fact that for years they, too, described old ladies and small children, young men and veterans and all the rest as SOB.  Scandalous! 

Granted, it may not be the case. This committee might have been populated with practicing clinicians (but they usually don't have time for meetings like that), or former lab technicians, xray technicians, security officers, or even current CEO's, CFO's, nurse managers, IT employees, etc.  Without the slightest doubt, there was also someone from risk management who realized the enormous legal peril of slander, should anyone else be described with the ages old moniker, SOB.

Other options were likely bounced around over coffee and pastries.  Dyspnea?  Too many letters.   Trouble Breathing?  TB?  (Nobody wants their chart to say TB).  Breathing Problem? (Too much like Blood Pressure).  Ultimately, someone came up with Shortness of Air.

Not to be a stickler, but Short of Air suggest a problem with the atmosphere rather than the body.  The sort of thing that happens when an alien species decides to take the oxygen off of our planet for their own.  Or when an airplane depressurizes.  It suggests a rather collective problem, not the intimate individual trouble of Shortness of Breath.

Long and sort, when I chart at this little garden spot of Emergistan, I have to use Shortness of Air on the template.  Sometimes I use dyspnea, just to show off.  And often, I still free text Shortness of Breath or SOB.  Because that's the kind of guy I am.

But I have to ask, of all the issues in medicine today, this was the one that had to be addressed?  I guess when it comes down to it, customer satisfaction (or the fear of dissatisfaction) trumps all common sense and nearly all other concerns. 

Tragic.  Why, it makes me feel all SOA just thinking about it all!

Edwin Leap
President of Emergistan (self-appointed)

Doing more with less

One of the biggest lessons I've learned in traveling throughout Emergistan is the remarkable differences in what hospitals can do.  There's a certain perception on America that every hospital can do what any other hospital can do. 

I once had a young man come to me in my original job, stating he had moved to rural SC and needed a local doctor to manage his late-stage AIDS.  He seemed surprised when I told him he would have to be seen in the next town.  But that's life in medicine. 

Small hospitals serve a great role, but they can't do it all. And big hospitals can do amazing things, but simply can't see everyone for all of the very real but relatively mundane problems that they have.

But to illustrate the point, I recently had to transfer patients out of  Tiny Rural Hospital for:  spinal fluid analysis, which my facility couldn't do.  An eye evaluation because we lacked a slit-lamp.  For an ICU bed because we lack ventilator capacity.  And for a pelvic ultrasound in a woman to rule out ectopic, because we could only do males.

Of course, I could still identify the problem and stabilize.  Start lines, get labs, intubate, etc.  But medicine in 'the sticks' or in the poorer areas of large cities, isn't the same as it is in the large teaching centers.  And that's probably OK.

It takes all kinds in Emergistan!

Semper A Decem, brothers and sisters!

Lacerations, alcohol and Star Trek

Last night, around midnight, I was sewing up the head of a young man who had been in a fight.  He was a little 'intoxicalated,' and angry about the fight.  He had other injuries, less severe, but was frankly a bit of a mess. 

And he and I had a great time.

I have no idea how it happened, but we stumbled onto Star Trek.  With my instruments pulling his scalp and skin back together, and blood dripping down his forehead (which he accepted with casual grace), we bonded over Sci Fi.

We both agreed that Jean Luc Picard conducted himself more like a Captain should, but that you have to love Jim Kirk and his tendency to get green chicks. 

We both thought that the latest incarnation of the Star Trek franchise was truly awesome, and that we honest to goodness wanted to like Khan.  Until we remembered who he was, and what he was capable of doing.

With his head sewn up, and swollen from local anesthetic, he had an appearance that prompted me to say, 'dude, you look like a Klingon!'  We had a good laugh about that.

It would have been easy to dismiss him.  Just another drunk.  Just another crazy young man in another fight.  But I would have missed his charm, would have missed that essential connection.

Sometimes the ER and its denizens can make a sane person crazy.  But other times, all of the weirdness, all of the surreal stories, the drama and smell of blood and alcohol; all of the pain mixed with hope, it's simply...

Wonderful.

When we learn to love everyone (by which I mean the verb love...not always the emotion love), then our work becomes a daily delight, no matter how challenging.

Because we see the hurt and the broken. And we can reach them far better with love, gentility, laughter and heck, Star Trek, than we ever will with policies, procedures and sterile professionalism..

Edwin 'Bones' Leap
Chief Medical Officer, Starship Emergency

Residency flashbacks and a new experience

I recently did some locums work in a very small emergency department (four beds) in a very small hospital (26 beds).  It's so small, in fact, that I acted as hospitalist as well. While this is the stuff of a much longer post, I can say that I had flashbacks to residency.  I had to round.  I had to write orders and dictate discharge summaries.  While it has indeed been a while, I must say that it does come back...not exactly like riding a bike, but not terribly difficult on the surface.

Two things, however, were particularly odd.  The first, that I stayed in the hospital for 72 hours (except for quick drives to get carry-out).  I haven't been 'on call' for a very long time.  And the longest I was ever truly on call was about 24 hours (with 12 hours of subsequent rounding on the trauma service in residency).  It was surreal to stay in one place that long; to be 'on' that long. Fortunately, it was low volume and not stressful.  But when one is sleeping in the hospital, covering the emergency department, the threat of a phone-call always looms and seems to banish deep sleep.

The other, however, may be more bizarre.  In that 72 hour period, other than hand off from the previous physician, I did not see a single other doctor.  Nurse?  Sure.  Social worker?  Absolutely.  Case manager? All day long.  But no other physicians.  I can't recall a time in my medical life when I experienced that sensation.  And it wasn't all bad.  It was just different.  And oddly validating!

I hope that whatever and wherever you are practicing, you find new ways to stay fresh, sharp, engaged and interested.  To me, this work is what puzzles are to others. A way to challenge and stretch my mind. 

Because in medicine, ruts are easy to find.  But there are plenty of ways to climb out.  And one sure-fire path is to work off the beaten-path, and to do it all alone.

Edwin

I am the Kwai Chang Caine of Emergistan

Good morning Emergistan!  I haven't posted in a long, long time.  But I'm going to try harder to post here, in addition to my www.edwinleap.com/blog site.  The reasons?  Well, there's a lot to say about Emergistan these days.  As the ACA collapses all around us, refugees are streaming across the border to Emergistan.  It's because they still can't get insurance, or because they have it but can't get doctors, or because their doctors always press the default 'we're too busy so just go to the ER' button.

Furthermore, there's always plenty of silliness to report here in Emergistan.  For instance, Electronic Medical Records increasingly causes misery.  I know of a hospital that changed to a new system, and the nurses were on the verge of tears and one of them was having violent dreams...all consequent to the shiny new system.  Charts done on EMR are beginning to resemble hieroglyphics but less decipherable.

In addition, I'm doing full-time locums work now, taking sabbatical from my job of 20 years.  I consider myself a reporter, roaming the land to look for wonderul stories, for shared goals and difficulties among healthcare providers, for clues on how to make it better and for problems and toxic policies that need to see the light of day. I'm the 'Kwai Chang Caine' of Emergency Medicine now.  (If you're old enough to remember the show Kung Fu with David Carridine.)

'When you can snatch the Lortab from my hand, grasshopper...'

And there's one more.  If all goes well I'll have a new book this year, a compilation with Emergistan in the title.  Something that will continue, I hope, to show the world what we do, why we do it, and give hope, laughter and insights to my fellow travelers.

So welcome to 2014 Emergistanis!  Let's travel the new year together.

Semper a Decem!

Edwin

Emergistani dietary habits:

The official food of Emergistan may well be MacDonalds.  In fact, there should be a special meal, the 'McEmergency Meal.'  It would have large fries, two double cheeseburgers, two milkshake and two large sweet teas.  The idea being, when you take a friend or family member to the ER, you'll want to eat.  And so will the patient!  I mean, a person can't be expected to wait around with 10/10 abdominal pain but without a snack, right?  Anyone who works in Emergistan has observed this phenomenon.  Followed by the negative labs, negative CT and most important question:  'How much longer?  I'm starving!'  (Meal would include a work-excuse prize, or coupon for disability evaluation.) 

Unique revenue streams in Emergistan

It's evident that America's emergency departments need some relief.  Perhaps the best 'relief' would come in financial support to increase the physical dimensions of the departments, as well as increasing staff, both nurse and physician.  But how to do it?  I have some thoughts.

Narcotics being one of the more cherished currencies of Emergistan, I submit that video poker machines with payouts in Hydrocodone or Oxycodone would be very effective at generating revenue.  The could also pay out in work excuses.  Or, for the big spenders, like the 'Million Dollar Slot' in Vegas, there could be machine now and then that pays out in the greatest gift of all:  complete disability.

If you think folks wouldn't plug their money into those machines, you haven't spent enough time in the ER.  They'd pass up Big Macs, Bath Salts and Crystal Meth for a shot at that golden ring!

Yes, I know, laws, rules, taxes, illegal, etc.  Blah, blah, blah!  A great idea is a great idea, no?

Any thoughts of your own? 

Edwin, Ambassador to Emergistan