doctors,lawyers,physicians,attorneys

The former undisputed champion professions; short of being a pro athlete or a star entertainer, medicine and law were the path to money, prestige, and upward mobility. Dentists were premeds who couldn't get into medical school. Lawyers were always plentiful, but where you went to law school was the determining factor as to your rep and earnings.

Today there are many lucrative career paths open to college grads. In the 1970's only one in four premeds metriculated to medical school, today the odds are better than one in two. Your specialty is the key to big bucks. Thus we have too few primary care physicians and too many doctors with mechanical devices that they can insert into patients for fat fees. Emergency Medicine has become more a life style choice. Decent money for 36 hours of work per week and your free time is unencumbered with beepers or pagers. The down side is that ER's are open 24/7 and have become the safety net for all things medical in our chaotic health care system.

My thoughts today concern the relationship between ER docs and lawyers. There are 2 main divisions in law: civil and criminal. ER docs must coexist with both.

We often treat both the victims and the perpetrators of crime. Gang war casualties end up in the local ER. Victims of assault, child abuse, domestic violence, rape, DUI's, and barroom brawls all find their way into the ER. We treat their injuries, try to alleviate their physical and mental anguish. The state, county, city, and federal authorities also must dealt with by the ER doctor. Evidence gathering, physical examination, and verbal accounts all are required by the legal system. Mandatory reporting and privacy requirements must be carefully navigated. We are expected to meet with prosecuting attorneys and to testify in court regardless of our work schedules. I have had good relations with the local district attorney's office for many years. They go out of their way to try and accommodate my night schedule. When called to court, I dress as a professional. My testimony has secured many convictions, including a murder one against a baby killer. I have enjoyed the good will of the DA's as they do the messy job of keeping us all safe for little pay.

Civil lawyers are a very different beast. Our adversarial legal system is terra incognita for MD's. Doctors are trained to arrive at a truth, a correct diagnosis, a useful treatment. We work together as colleagues to cure or at least ameliorate our patients' suffering. Civil litigators are adversaries. They try and discredit the other side. Plaintiffs lawyers, also sometimes refered to as ambulance chasers, are motivated to prove how unskilled, uncaring, and incompetent a treating physician is in the care given to their clients. If they win they get about 1/3 of the malpractice award, plus expenses. If they lose they get nothing. This motivates them to be less than cordial in the way the approach the defendent physician. The malpractice defense attorney is our knight in shining (?) armor. They take our hand and try and lead us through the mine field of a malpractice trial. I would rather have a colonscopy than be deposed by a malpractice attorney.

I now share with you my secret. I am very happily married to an attorney. Many of my closest friends are attorneys and judges. Our legal system has many flaws but it still the best and fairest in the world. Malpractice reform is necessary. Doctors are human and "to err is human". We make mistakes and our patients and their families suffer the consequences. Given that mistakes will happen and that doctors are trying to do their best, I support a no fault, mediation system to deal with malpractice. Patients will be compensated, doctors will be less pressured to practice "defensive medicine", only the lawyers will be unhappy as their fees disappear.

holidays in the ER

Holidays in the ER are stressful for the patients, their families and the ER staff. Illness and death are the worst experiences in most peoples' lives, but this emotion trauma is heightened when it occurs around Thanksgiving or Christmas. The doctors and nurses are also dealing with the fact that they have to work when most people are home with their families. Our spouses, children and relatives may not be as sympathetic, as we might wish them to be, concerning the sacrifice ER folks are making.
Over-eating, excessive drinking and the frequent emergence of old family conflicts add to the cases of congestive heart failure, vomiting, and trauma, not to mention the jump in psychiatric complaints. Nothing like a suicide attempt to brighten the mood of an ER doctor. The volume of the ER is very predictable with regards to holiday weekends. Christmas Eve is pediatric clinic, as parents want little Johny or Mary cured by Christmas morning. The last day of a long holiday weekend is non-stop as those injuries, overindulgences and assorted coughs, aches and pains loom large with the first day back to work or school in sight.
Please, enjoy your holiday. Remember those who work to provide the safety net that you need, nurses, techs, docs and our friends the police, firefighters, EMT's must give up their holiday time to keep you safe and secure.
I will be home tomorrow with my wife and family. We will eat turkey, turducken, mashed potatoes, stuffings, veggies, and drink wine made by my nephew. Toast to your health, a votre sante, prosit, skole, gumbay...

sleep deprivation

Another week of nights completed. 2-3 hour naps twice a day is not conducive to the health of my patients or me. ER's are open 24 hours a day. The night staff is usually self selected, but we still are tired. Patients have decided over the years that ER's are 24-7 walk in clinics. I have been told that a patient chose to come in at 5:00 AM for his one month of back pain because he knew it would be less busy. Having pain at night is significantly more urgent because it interrupts your sleep.
I often share information about circadian rythyms with my patients. I explain changes in body temperature as they relate to time of day. The early morning MI, CHF is a well recognized phenomenon.
For the doctors, nurses, clerks, techs and secretaries who work nights there is a price to pay. Night pay differential does not adequately compensate for the statistically significant shortening of our lives that has been shown to be a consequence of shift work. The fact that our significant others are almost always day people adds another stressor to nights. A nurse I worked with for many years determined that she and I spent more waking hours together than we did with our respective spouses.
I will get my "make-up" sleep in the next few nights. Dr Jekyl and Mr Hyde except Hyde is the calm persona in my autobiography.

ER patients

Why does someone choose to go to an ER? Chest pains, trauma, vomiting blood, labor.. all good reasons to seek emergency care. Vague abdominal pains for 6 months, chronic back pain for 10 years, the dog ate my script.. not so urgent.
NCP, non coping patients. If your child is cranky and has a fever, give the kid some acetaminophen or ibuprofen. It is not necessary to see an ER doctor because of a simple febrile illness. Similarly if your child vomits twice, don't keep trying to feed him or her and then come to the ER because Jonny or Susie isn't keeping anything down. I often find this child with cheetos powder around his well hydrated lips.
ER docs are not dentists. A tooth ache not accompanied by fever and severe facial swelling can wait to see a dentist the next day. One's lack of dental insurance will not change the fact that you need to see a DMD or DDS not an MD.
We are also not WEBMD. please don't call the ER for medical advise. We cannot make assessments by phone. In the same vein, don't call to see how busy we are. An ER is not a bakery. Patients are seen by the severity of their illness, not who arrived first. Family and friends should not ask your overworked ER doctor for free medical advice concerning their own ills.
Being old I also would like a make a case for civility. My name is not dude, man, bro, doc, or pal. I spent 12 years to become an ER doctor. Doctor is my title and my preference when addressed by a patient or family.

foreign bodies

Welcome to the fascinating world of objects inserted into various body openings. Light bulbs, vibrators, small animals, candles, assorted produce (organic?), beverage containers (glass, plastic, 8 ounces to 2 liters, recycling taken to a ridiculous extreme) all have been visualized, x-rayed and removed by your humble medical provider.
In the ER, not telling the surgeon that the vibrator is still running and watching he or she jump back in surprise passes for humor. Keeping a non-judgemental facial expression can be more difficult than the actual removal.
The back story can be like a fractured fairy tale. "I was walking in the kitchen nude, slipped on a wet area and came down on the candle that just happened to be on the floor pointing up." "My pet gerbil was sleeping in the bed with me and must have thought my posterior was his den."
"I love my boyfriend but he needs a penis extender 'cause' he's so small."
I took an oath, Maimonides not Hippocratic. I try to respect the humanity of my patients. Don't judge, just treat.

In the Beginning

H1N1 in the ER,
The waiting time in the ER has gone from 2-4 hours to 4-6 hours. The medaid taxi service (ambulances) are arriving in bunches with masked patients and EMT's. The triage nurses are trying to separate the truly sick from the merely miserable. Yours truly, an ER doc since 1978, spends my entire shift trying and failing to make a dent in the wait times.
This blog is called BONER doc not for the graphic image but for the acronym Brotherhood Of Nocturnal Emergency Room doctors. I am the self appointed Yoda of the night shift. I mainline Starbucks blackeyes (venti with two shots of espresso). My sleep schedule is disjointed and is probably shortening my life. I did a residency in Emergency Medicine when Jimmy Carter was pres. I am board certified in EM and have recertified three times. When I started in the ER there was no AIDS, no CT scans, no MRI, penicillin was an effective antibiotic, the ER was not the site for primary care medicine.
I have punched, wrestled, hugged, cried with, cursed at, laughed at and with more than 100,000 patients in my career. Doctors actually ran the ER and the hospital when I started. Now the nurse managers and the masters of hospital administration micromanage health care.
This blog will contain anecdotes, case histories (sanitized in accord with HIPPA and decency), rants, and always the truth.