Hype

All Irene, all the time. Hype. Snow storm, hurricane, heat wave; local news stations love a good/bad weather story. People are encouraged to prepare for Armageddon. The ER is effected by this hype. Every child with a fever must be checked out before the winds/ snow/ rain arrives. Local media hype medical issues as well.

Years ago I was in my final hour of a busy 10 hour shift. A mother arrived with her school age child and said she wanted her offspring to be checked for meningitis. There had been a recent local case of a teenager dying from bacterial meningitis. This distraught mother's child had not been exposed. Her concern was because the child had vomited once. She pointed out to me that vomiting was one of the signs of meningitis. She had watched the news broadcast the night before. I bit the inside of my cheek to keep from laughing. I asked the child, who was happily sucking on a popsicle, if he had a headache, or any pain, and if he felt nauseous. The answers to all my questions were in the negative. I was finally able to convince the mother that her precious did not need an lumbar puncture. I assured her that we would be ready if junior developed the headache, neck stiffness, fever, and vomiting that might indicate a diagnosis of meningitis.

The recent medical hype concerns the discovery of mosquitoes carrying the West Nile Virus (WNV). Lots of cans of insect repellant will be purchased to protect the citizenry from this disease. Some years, the mosquito-borne disease being hyped is EEE (eastern equine encephalitis).

Lets look at the facts. In 2009 there 720 cases of WNV in the entire US. The incidence of neuroinvasive disease (meningitis/encephalitis) was 0.13 per 100,000 people. The incubation period after exposure from an infected mosquito is 3-6 days. The number of cases of infection is very low compared to the number of people exposed. When someone develops encephalitis/meningitis, the fatality rate is 5-10%. The fatalities are mostly in the elderly. If a patient is in the 90-95% survival group, they usually make a complete recovery.

EEE tends to occur in outbreaks that may last for years. In 2005 Massachusetts and New Hampshire had a combined 11 cases of EEE. The 7 human cases in NH were the first cases in 41 years. Of the 11 patients who were diagnosed with EEE, 4 died. The incubation period for EEE is 5-10 days. There are about 20 cases in the US per year. The case fatality rate is 1:1000 for adults, 1:50 in children, and approaches 1:1 in infants. The overall case fatality rate is 50-75%. Most patients who survive EEE have permanent disability.

The treatment for both WNV and EEE is supportive. There is no specific medication or therapies. How high on one's list of health care problems are these 2 diseases? Next weekend is Labor Day. I predict that more people will die from accidents on the road and waters of Massachusetts than will be diagnosed with WNV and EEE combined.

I am in favor of educating people as to the risks of infectious diseases. Wearing long sleeves and long pants, using DEET containing insect repellants, and avoiding the peak times for mosquito activity are all good practices. When I walk my old pooch in the woods, I wear white scrub pants, and a long sleeve shirt that contains insect repellant. I tuck the pants into my white socks. This outfit serves the additional advantage of reducing my exposure to the deer ticks that carry Lyme disease (please refer to a recent blog on Lyme disease).

My concern is that exposure to the pesticides used to control mosquito populations may in the long run cause more wide spread neurological sequelae. There will always be risk. We must assess the degree of risk. The actions taken to mitigate the risk should be cost effective and not cause excessive damage to the environment or the people and animals in the area. As I have tried to stress in my blogs, be prepared. Read and listen to the media sources. Do your own research into the actual risks. Common sense approaches are your best protection.

Irene is now being downgraded as to wind velocities and rainfall amounts. The local food and home supply purveyors are counting the recent purchases made by the people who believed the hype. My wife and I have lots of snacks ready. We have a generator that runs on the natural gas. The ice/rain storm of December 2008 was not hyped as a severe storm. The power outages were devastating being both widespread and long lasting. Our house flooded because our trusty sump pump runs on electricity. Ready; come on Irene.

Nosce te ipsum

Nosce te ipsum, know thyself. Self-knowledge seems so obvious. Look in the mirror, et voila! We  have all seen people on the beach or in the workplace who made us wonder if they even owned a mirror. Being self-aware is much more complicated than mirror gazing. How do others view us? Coworkers, family, friends may all contribute to the portrait we carry in our mind. Check list: man, middle aged, thin, tall, husband, son, brother, uncle, cousin, friend, ER doc. The shading in my portrait contains experiences, education, books, music, art, travel...life.

Why the existential angst? The new job and my place in the medical community. What is an ER doc? The American College of Emergency Physicians would define an ER doc as one who has completed an approved residency in Emergency Medicine, been board certified by passing the written and oral parts of the American Board of Emergency Medicine examination, and who works in an Emergency Department. Paying your yearly dues is also important to ACEP.

I have met the above criteria and have recertified every 10 years to maintain my status with the ABEM. When I worked at LGH, I never questioned my professional self as an ER doc. I saw lots of patients from neonates to the very elderly. I treated patients in labor, having heart attacks, in respiratory failure, with traumatic injuries, suicidal depression, psychosis, and life-threatening infection at both extremes of age. I supervised PA's, taught PA students, mentored young ER docs, and tried to impart some of my thirty years of ER experience to the nurses, EMT's and paramedics who worked on the patients in the ER. Arriving at 2030 hrs for my 2100 hours start time, I would scan the lists of 20-30 patients waiting up to 5 hours for treatment. After a ten (shortened to 8 just before my forced exit from LGH) hour slog, the waiting room would be close to empty.

Tonight I will leave my house at 2230 for my 2300 hour start time. There may be a few patients waiting. I will see an average of 5-6 patients during my 8 hour shift. In the month since I began working at NMC, I have treated few children and very few infants as NMC has no in-patient pediatric beds. I have seen so major trauma patients. Pregnant patients do not use NMC as there is no obstetrical services. NMC is a small community hospital in a somewhat isolated location.

Am I still an ER doc? The nurses, secretaries, (lab, radiology, and respiratory) technicians and other physicians in the ER, the hospital and in the community are smart, hard working and dedicated to providing great patient care. I have been welcomed with friendship and respect. My patients look to me as an ER doc. They wish relief from their pain and answers to their questions. The slower pace and lower acuity allow me to spend more time talking with and examining my patients. Maybe I am still an ER doc.

Whether in a 9,000 per year ER in a small town or a 250,000 visit per year ER in a large city, if you provide care to ER patients, you are an ER doc. Listen, empathize, comfort and use all your self knowledge to be the best ER doc you can be.

Adjusting

I have worked two doubles, a triple and a quadruple at my new job. At LGH I had stopped working 4 nights when I turned 55. By the fourth night I would be physically,and  mentally spent and rather cranky. Not so at NVMC. Average night shift census is about 6 patients. Although I have not been sleeping any better between shifts, I am not STRESSED as before. I do miss my friends and coworkers at LGH. I received a call from Robin, my trustworthy PA today and my sense of loss was palpable. Don't we all feel that we are irreplacable? The staffing of the ER at LGH has been difficult since my forced departure. The remaining docs have had to go back to longer shifts. I like to soothe my ego, by thinking that the powers-that-be regret their active or passive complicity in my termination.

My daily routine has been adapted to my new circumstances. I have a snack and my coffee before I leave the house. My wife and I now have some quality time together even on my work nights. The drive is a pleasant 10.3 miles of countrified roads with a single traffic signal. Leaving the house at 10:25 PM allows me to listen to jazz on WGBH-FM on the ride into work. There is a fair amount of time to pass during the 8 hour shift. My newish 4G phone has been packed with 2 versions of "Angry Birds", "Bejeweled", "Scrabble", Mah-jong tiles, poker, backgammon, multiple solitaire variations, newspapers, magazines, etc.

The patient population is quite different from LGH. I have yet to use the translation phone. In three weeks, I have only treated one child under the age of 2. There is little trauma. The patients have been as pleasant as any at LGH but I am able to spend much more time with the patients and their families. If NVMC uses Press-Ganey surveys, I feel that I will consistently be in the top percentile. The fact that my patients are not waiting 2-5 hours before being evaluated by a physician, makes them much less cranky.

The nurse and secretaries have been most welcoming and are very good at their jobs. Last night the nursing supervisor brought in a cake to celebrate the birthday of one of the ER night nurses. I have made friends with the security guards, night housekeeper, and the sargeant of the local town police department on the overnight shift.

After the last 2 weeks of financial shock to my retirement funds, I will be working for the next 8 years. Is NVMC my final destination? Only time will tell. For now, I will improve my gaming skills, enjoy spending time with my patients, and be a relatively stress free "world's oldest ER doc". Thanks to my friend Wendell for his sage wisdom, when he told me that would be life after LGH.