Swear Words in the ER

I recently arrived at the ER to see a patient who repeatedly swore at anyone within eyesight, “Listen, you #@%s!!  I want some %##$ing serivce before I rip someone’s head off and ##$@@% this place up.  I’m dying in here!”  From my nook at the doctor’s station I watched my soon-to-be patient as his demands repeatedly met with the exquisite uninterest only an experienced ER nurse can master as they replied with some version of, “You want some Tylenol?”

I felt a twinge of – well, I won’t call it pity, but some sort of desire to get this guy caught up on the New World Order of the ER.  He had the right idea, using swear words to get what he wanted.  But what he clearly didn’t understand was that ER vulgarisms differ substantially from your average, garden-variety verbal swill.  He certainly needed to cuss, but with a decided ER twang.  He wouldn’t even need to yell.

I felt like sidling up to him, kindly putting my arm around him and saying, “Dude.  Tomorrow night, when you show up here again, try this line… I have chest pain.

Try it.  See how long you wait then.  If you’re still watching “America’s Got Talent” after 10 minutes, use the words shortness of breath and mix in that you’re feeling dizzy and seem to be sweating.

Front of the line.  You’ll be seen in 2 minutes.  Or less.  Putting those words together in an ER is worse than a creative spew of explectives strung out like Christmas lights glowing through the weed-haze of a freshman dorm room.

The truth is that ER staff get sued so often they don’t really have the luxury of thinking much.  They have to react to what they’re told so that if someone dies, they can say they did everything.  Never mind whether or not the claim has any merit to it.  And never mind the fact that a thoughtless workup leads to stratospheric medical costs and just might get a guy some rather intense medical interventions based on a FALSE positive test.  Every test has a statistical rate of false-positivity.  Every time you get a medical test, there is a possibility it will tell you you’re sick when you aren’t.

It’s lawyer thinking that got us to this point, by the way.  Lawyers don’t necessarily understand medicine, but they sure comprehend theatrics.  No doctor wants to try to explain to a jury why they didn’t order cardiac enzymes on some guy who had the drug-munchies reeely reeely bad and also vaguely hinted that he had chest pain when he was told to go find a sammich at the local mission.  So, he gets the work-up (and some dinner).

Watching that guy sitting in the EMERGENCY room with his back pain or a cold or any of a thousand not-actual-emergencies, I could see he had reached his limit.  All he needed was to use some ER swear words.  He may not get his back looked at…but he could just end up with a cardiac catheterization, which I guess is almost as good.  And he wouldn’t have had to wait so damn long for it, either.

Instead, I walked into his room and doggedly launched into my familiar mantra, “Hi Mr.–.  Sorry for the wait.  I heard from the nurse that you have back pain…”

Ode to McDonalds and Cigarettes

You can say you saw it here. This family medicine doctor – supposed bastion of all that is healthy and wholesome – recently found himself encouraging a patient to keep up the McDonald’s and smoking. Instantly after proclaiming my support of these two great sins of the developed world, I heard my program director’s voice in the back of my head saying not unkindly, “Nice job, doctor, good work…we’ll most likely kill you in the morning.” Although never tempted by cigarettes, I frequently fight the urge to hit a McD’s and constantly rail against both as all that is disjointed and wrong with our society (celery is another problem, IMO, but that’s another discussion entirely).

I saw a patient this weekend who unabashedly describes smoking about a half-pack of cigarettes a day, and has been doing it for “goin’ on 50 years now, and I ain’t quittin’ no matter what you tell me.” The patient is 78 years old with advancing COPD. When she inhales, the wispy flimsy breath she drags down into her rapidly deteriorating lungs rattles around aimlessly like a blind baboon in Grand Central Station. She then forces the air back out; little of the oxygen actually used. She is on 14 medications to treat everything from her diabetes to the high amounts of fat in her blood.

“Smoking makes me feel…” She closes her eyes, her face taking on a distant, faraway look as if she just lost herself in recollections of her torrid love affair in Paris on a college philosophy tour, “like I’m surrounded by friends when I’m actually all alone.” How can I beat that?

This patient lived a full life, been smoking for a good majority of it. Now she is stuck in that impartial vice-like vortex of half-life and half-death that American medicine has so expensively provided us. Historically, people just died when they got as sick as her. Today, people linger, in a sort of daily, living suffering. The institutions they inhabit have innocuous-sounding descriptions like “assisted-living communities”, but everyone knows what they really are. Places where the clock of mortality hangs largest on every wall, where the clanging metal hammer pounding on anvil cannot go ignored, but can’t be rushed. It pounds in measured, inexorable rhythms, indifferent to anguish it causes. Hundreds of thousands of Americans waste away in these communal halls, most abandoned by their families, waiting for that final insult and staring droolingly at the wall in the meantime. But when this insult finally does arrive – a heart attack, hemorrhagic stroke, maybe a pulmonary embolism – it shows up with a slouch, hands in pockets, irresolute, nuanced and often as slow as a sadist. These days, the Reaper arrives in a robe of gray, eschewing the dramatic and abrupt pitch black somewhere around the time we invented beta-blockers.

So, go ahead, lady. Smoke to your heart’s content (or infarct). The damage is done, really. If you did stop today, the additional few weeks or maybe even year would be so miserable for someone who loves smoking this much it wouldn’t do much for you. Mortal time isn’t everything. There’s such a thing as life quality, too.

“The other thing I love,” She continued, “is Saturdays.”

Her face, looking like gravity used physical hands to pull her face to the ground for the past 200 years, suddenly filled with a smile. Her losing battle with age suddenly clamoring to a standstill. “My wonderful daughter comes every Saturday and brings me a McDonald’s egg McMuffin sandwich and coffee. I just love that. I look forward to it all week. Say, what day is it? Maybe she’s coming today. Do you know?”

“Well, it’s Saturday night at 11. Maybe she came earlier before your care facility staff thought you needed to come to the hospital.”

“Yes. This could be. You see dear, I can’t really tell the difference between days and weeks and months and years anymore. They’re all sorta the same to me anymore. I just know my Jerry comes on Saturday and we have breakfast together. And you know…that McDonald’s does a lot of good for other people, too. They hire young kids, old folks…give people a start in life, or help them do something worthwhile. The buy all kinds of ingredients from local grocers and farmers. Why, when they moved in here 30 years ago, my son was one of the first they hired. He has his own business today. Employs 30 people.”

“Wow. I’ve never thought of them that way.”

“And them McMuffins…ain’t so bad for you, either. They fill you up, keep you fed through almost a whole day. It’s good food.”

By any primary health care measure, someone who smokes daily and eats fast food at least once a week, is not healthy. But exceptions to every rule emerge in unlikely places. This woman did not come to the hospital to make me re-evaluate my unbending belief in the immutable evils of fast-food and smoking. But her defense of their place in her own life was unassailable. This woman won’t live to be 90 years old. The end may come in the next few days, in fact. But this is true for all of us. This very moment, our lives could be required of us. Should this happen, could you depart with the same gentle serenity?

If deprived of her simple vices, could she?

I found myself answering no to both questions. So this family doctor ended up departing the room, encouraging an overweight patient with COPD and hyperlipidemia to “keep up the smoking and enjoy your McDonald’s.”

I’ll start typing my resume. I hear there’s good jobs in the restaurant business.

Moral Monsters

There’s lots of reasons why the lawsuit over John Ritter’s death (the “Three’s Company” actor, if you remember that show) is categorically asinine.  You can read about the latest here.  But here’s one of the biggest problems with the case:

The suit is for 67 million dollars.

The jury are being told that the doctors did everything wrong, largely because they treated Ritter for a heart attack when in fact he was having an aortic dissection.  Only mildly important in this case is the fact that the dissection actually did lead to a heart attack and that, in general, they are extremely easy to miss.  There’s lots of ways to interepret the actions of the medical staff and lots of mistakes that can be identified now that we have all the information about the case.  But note who is making the claim – lawyers.  Not doctors who have been in these situations.  Not doctors who have made similar mistakes.  Sure, they’ll get some doc to say exactly what they want on the stand, but the argument is being made by lawyers.  These are people with no training in medicine and who probably had to look up ‘aortic dissection’ before they took the case.  They aren’t in this game for truth, or to improve the medical system.  They want one thing:

Show them the money.

As I’ve mentioned before, the major problem with medical litigation in the U.S. is the financial incentive.  Ritter’s lawyers have already successfully sued the hospital and 8 medical personnel for close to 14 million dollars.  Now they’re suing two doctors for an additional 67 million.  These lawyers stand to make a fortune on this case.  They’ve hit the jackpot.  A typical John Edwards haul.  Soon, after the minor detail of catastrophically destroying the emotional and possibly professional lives of two doctors, these lawyers will be able to enjoy their 26,000 square foot homes, $400 haircuts and send their kids to the best schools in the land, just like our earstwhile presidential candidate who also sued doctors to ascend to his upper-class life.

You can say that people are basically good; that common decency would dictate that you don’t excoriate someone for an honest mistake, especially if the truth is murky and unclear anyway.  You might assert that we all need grace in the harsh light of hindsight and you might be honestly grateful for the times when this kind of grace has been extended to you.  Most people believe these things.

But I bet you still wonder at times – while living out your grim job day after day with no hope of real financial freedom – just what it would be like to live in a mansion and never have to worry about money again.  What would it be like to get the best service, own nice cars, have the ability to take care of your financially ailing family?  We’d all like to live that way…the allure of a life like that is intoxicating even for good people who generally want to do good things in the world.  This is why the system is broken.  When it comes to medical litigation, the very rules  we follow entice even the moral among us to become monsters.