NaBloPoMo - Day 18 - Seriously...?

I haven't watched "Grey's Anatomy" in the longest time, 

but one of the taglines from the show that I remember vividly

was "seriously..?"

It covered everything from boy problems, to work problems, to all general life problems.

Often, when I pick up a chart in the ED, I read the presenting complaint of

(what the patient came into the ED for) and immediately go "seriously?"

Others, I go in and interview the patient then walk out and go... "seriously?"

Still others are given the benefit of the doubt, worked up,

found to have, um, something like meth or cocaine in their system,

to which I say, "Seriously...?"

I really wish I could say it to the patient...

As in,

"Seriously..? You came in concerned that you were having a stroke because

you "couldn't think straight," or couldn't "find the right words,"

and your head and your body hurts and you're not sure why...

Well, let's see... your CT of the head was negative...

your EKG, labs, vitals are all normal...

oh, but let's focus on that drug test:

positive for cocaine

positive for methamphetamines

positive for benzodiazepines

positive for methadone (which you're not prescribed, by the way)

and you wonder why you alternatively:

don't feel right...

have been really tired...

can't seem to focus...

etc...

Seriously...?

People wonder why health care costs are so high...

I think it's in part because of all the patients like this I see on a daily basis...

Today it was like this for three different patients...

All different genders and age ranges...

I can't discount you're not having some physical symptoms which are bothering you,

but if you had initially just been a little honest about your social habits

I probably could have avoided about $5000 worth of a work-up.

Don't do drugs, seriously...

And, especially, don't do uppers which you then take downers for

which leads to more uppers, then downers, then uppers, etc, ad nauseum...

I wish we did have levels instead of just positive/negative for drugs

because I think some patients have perfected the meth/heroin ratio...

However, combining uppers and downers can 

lead to a potentially lethal combination...

Then there's the "what's this on my body...?"

Seriously, you came in for that...?

November Notes, Day 21

"FOS - or Why I Want You to Eat Your Veggies"

As I was doing a rectal exam on my last patient today, ending up with my hand almost entirely into his rectum trying to get out a fecal impaction (big poop ball from severe constipation), I thought it might be time to readdress one of my "how to stay out of the ED" lectures.  The one about constipation.

The U.S. could save MILLIONS and MILLIONS of dollars if people would just do a little bit of preventative care.... like eating a vegetable-based diet, drinking plenty of water and exercising.  I see so many children (and many adults) with abdominal pain who are FOS (full of s&*^).  Kids that are brought in with "I think Timmy might have a appendicitis" even though the pain is on the left, they're chowing down Cheetohs and Mountain Dew in the waiting room, and they haven't had any fevers or chills, nausea or vomiting.  Or the kids who are brought in at 3 in the morning with the "bad tummy ache" who went to a party the night before where they chowed down on pizza, coke and boxes of Ike and Mikes.  

Yes, I know that appendicitis can present atypically, but let's give it a couple of hours at least.  Or, you could do what my grandmother used to do when I complained of a stomachache... she brought out the fish oil medicine.  That was her test... if you still complained of pain after you were completely flushed out, then something might actually be wrong.  I've given parents the "if they continue to have pain or develop a fever after giving them this laxative then bring them back for re-evaluation" instruction many times, and maybe one or two has actually returned, and neither had appendicitis.

And, yes, you can poop daily and still be constipated because if you imagine 4 feet of large intestine being filled like a sausage casing, only a small amount may come out at a time, but it's still full.  And, that continued fullness leads to other problems... like diverticular disease and when that gets infected then it's diverticulitis.

Basically, if you've seen a blow-out on a tire, that's the same thing that happens inside of the large intestine.  It's trying to move your digested food stuffs, but there's not enough fiber and water to push them through without having to strain, so the bowel wall weakens and you get a diverticulum.  If that gets infected then it's diverticulitis.

Diverticulitis used to be a disease of the elderly, but I recently saw my first 20 year old with the disease who needed IV antibiotics and then oral antibiotics.  Yes, while antibiotics can cure this, complications include a ruptured diverticulum with abscess, and sometimes that means getting a part of your colon taken out.  If the infection is really bad, you get a colostomy for six months before they can reconnect the parts.  Imagine showing that to your date in your 20's, 30's and 40's.

So, let's practice a little preventative medicine shall we?  Eat a high fiber, vegetable-based diet.  Drink plenty of WATER... not soda;  soda has no nutritional value and is bad for you even if it's diet.  Why would you put anything into your body that does more harm than good?  And why would you give it to your child?  And exercise.  The colon likes motility.  We're not rest and digest kind of creatures like snakes that crawl onto a hot rock after a big meal, we're moving on, moving on kind of creatures that should be active.  

***Caveat:  do not sue me.  I'm not telling you to not come into the emergency department or not to bring your child into the emergency department if they are having abdominal pain.  People can have abdominal pain for different reasons some of which can be life-threatening.  I'm here telling you about preventing disease with some simple things that don't cost a lot of money, but can save healthcare a lot of money, and also save me from having to put my hand up your rectum.

November Notes, Day 7

"Flash Back to the Future"

It's funny how things never really change.  While doing research for one of my blog posts, I came across an older blog post that I wrote while in residency.  Re-reading it, I'm amazed at how much is still true to this day... so I thought I would share it... enjoy!

17 August 2009

Lowered Expectations

(**Warning: venting today... warning! warning! warning! High pressure release! warning! warning! warning!)

And, I had such high expectations for today because we started off with three patients on the board...

I have goals for the year. Every day I strive to improve my efficiency. Every day I set a goal that I will succeed in learning one new thing about a disease process. Every day I will treat my patients with the honor and dignity due to a member of the human race. Today I failed miserably on the last.

I went to a private Catholic parochial school. Somewhere around 5th or 6th grade we were visiting neighboring churches (Lutheran, Methodist, Jewish, etc.) to learn about the similarities and differences in our faiths. At the Jewish temple, the rabbi asked us what the worst word in the world was. My naive brain could only come up with one or two words that are tame compared to some of the words used on network TV these days.

Then the rabbi told us that "weird" was the worst word in the world. He said we should never call anyone "weird." Just because someone does something in their culture or faith that you don't doesn't make them any less deserving of respect. This started my understanding of the idea of tolerance. I never forgot that.

My husband feels that the word "stupid" is the worst thing you can call a person. It implies, to him, that you are the lowest, most ignorant being on the planet. Worse than "retarded" because "retards don't know any better." When you're stupid you have brains, you just can't use them. You are, in a way, "low class" and uneducated.

Unfortunately, my first round of patients this morning were seriously stupid. And, then they just got weird. So much so to the point that I got very frustrated this morning with what I was doing during my shift. And, to add to the mess, there was a situation with a sick patient that was signed out to me from the night before that just pushed me over the edge.

I was lamenting, in part, to an unsympathetic ear who told me that I needed to lower my expectations. Once I did that, they said, I would be able to survive my shifts in Emergency Medicine. Seriously? Really? Seriously? I'm about a year from starting my career and you're telling me this?

I went off in need of a break. I considered my options: try to match in surgery, take a year off and do a fellowship, move to Mexico and be a beach-side doc-in-the-box catering to tourists, get a new career, maybe something in retail or truck driving.

I pictured myself at a town hall meeting standing up and saying, "You know, instead of spending my hard-earned tax dollars on taking over medicine with a potentially corrupt and inexperienced socialistic government Health Czar, why don't you take those billions of dollars and educate people on the importance of preventative medicine, on seeing your doctor on a regular basis, on taking medication as directed, on not cutting off your cast every two weeks because you think it smells and you want a new one, on not treating the emergency department like a drive-through that will provide services on your time schedule? How about that? Why don't you tax them for taking up valuable time in the E.D. and wasting, oh yeah, again, my small resident's salary tax dollars? Instead of Hope and Change how about Personal Responsibility and a sense of agape (ἀγάπη)?" Huh? I can't hear you....!

At what point should I expect nothing of my fellow human beings? My colleagues in medicine? I was very surly. I was thinking I would like nothing more than to pack it all up and go home. Start again in the morning.

Anyway, my foul mood might have continued had my attending not come around the corner at this point and, seeing me, started singing, "Don't go changing... to try and please me..." in the most honest and sincere voice I think I've ever heard out of him. I had to smile and then laugh. I was still snickering to myself as I continued to work my way through the flood of patients that came in this afternoon.

Somehow, it didn't seem so bad after that....

Early in our relationship my husband and I discussed an email that was circulating around the web at that time. It had to do with a man who went home every night and touched the tree that stood just outside his door. One day a neighbor asked about his ritual. He said that the tree was their "Problem Tree." Before walking in the door, any problems from the day were "hung on the tree." The neighbor asked what happened when he left in the morning. The man answered that somehow the problems never seemed to be there.

We made a promise to leave any problems "hanging outside" and not bring them in. Tomorrow I will wake up and head into my shift. There will be a clean slate and anything from today will not be carried forward. Sure lessons will be learned, but I will again try to achieve my goals, especially the one that can be restated simply as, "Love thy neighbor." Lord, love it, but it's hard sometimes...

Day 17 - Prompted

I couldn't think of anything specific to write about tonight, so I decided to see what the NaBloPoMo topic was.  Last year, close to this time, I wrote what I thought would be a post that would get a lot of comments.  A year later, close to a thousand reads on both my blog and on BlogHer and two comments...

You see, being an ED physician, we're on the front line of medical care.  We are the "gate keepers" to the hospital.  And, on occasion, we get very frustrated with what we see come into the emergency department.  We see the good, the bad and the ugly.  We see the best of people, and we see the worst that people can do to each other.  There are times when we wish for mandatory sterilization and the requirement of government permits to allow people to have children.  There are times when we wish we could enact frontier justice, but we can't... because we are bound by a higher oath to care for others.

Regardless, here's a link to the post I wrote.  Let's see if this time it garners a little more discussion.  Talk amoungst yourselves.

Weeping for the Future 

Day 8 - Resurrecting an Oldie but Goodie

I was trying to think of what to write about today, and I came across a posting by Heather who writes "The Waiting is the Hardest Part."  She participated in "Resurrection Blogfest III" yesterday where her fellow bloggers brought back a post from the last year.  I thought I would borrow her idea and repost one of my favorite posts from the last year.  Seriously, I tell patients this on a daily, so I am resharing this blast from the past... well, from 2/10/14 anyway....

A Healthier Lifestyle: Just My Opinion

 As an Emergency Medicine physician, patients frequently ask me what to eat when I am in the process of giving them instructions for discharge.  Especially when I tell them to "lose weight, " stop smoking," and get maintenance check ups from their primary care provider.  It's funny how often it seems I am the first person to address their health and eating habits.  

They are surprised when I tell them to stop smoking because it cuts oxygen supply to their blood vessels by about 50% every time they light up.   They seem sincerely amazed that I recommend exercising in a pool when they tell me that because of their chronic back/knee/hip pain they can't follow the simple walking plan I lay out for them. (And, it is very simple:  15 minutes three times a week, then increase to 30 after several weeks, then add a hill, then try to go farther faster, then the possibilities are endless.)   As for seeing their primary MD;  well, isn't it easier just to come into the ED when I need something?  I'll save my answer as fodder for another post.

But, let's get on to  the, ahem, meat of this.  To eat right you just need to follow three simple rules:  nothing in a bag, nothing in a box, nothing in a can.

Nothing in a bag:

Bags include fast food, snack foods, any prepackaged food.   Top Ramen anyone?  This goes to the ideals also set out in Michael Pollan's "Food Rules:  An Eater's Manual."  You should only eat things you can pronounce.  Lower ingredients = healthier eating with a goal of 1 for everything.  The more the food is in its natural state the better.  I follow a mostly raw food diet and have never felt healthier and with more energy.  On one of my allowed "cheat days"  I was craving McDonald's french fries.  I honestly tasted every molecule of rancid oil along with several flavors I couldn't quite identify.  After about 2 or 3 fries, I threw the rest of the pack away and went to the grocery store for some kale and jicama to make into an awesome salad later that night for dinner.

Nothing in a box:

Again, think prefab foods.  Now, I know it's so much easier to get a Lean Cuisine and throw it into the microwave than to take 20 or 30 minutes to prepare something healthier (one of my mixed salads can take almost an hour to prepare.)  Not to mention, I had to run to grocery store about 2 - 3 times a week, because when you eat healthier, you need to maintain a large stash of fresh ingredients rather than a collection of boxes in the freezer.  Also, boxes generally mean breakfast cereals.   Even Special K cereal contains rice, whole grain wheat, sugar, almonds, wheat bran, then "2%  or less" of other ingredients including maltodextrin and BHT "for freshness."  I don't know about you, but I've never seen a maltodextrin tree, and what is BHT? 

On the other hand, meusli contains a mix of rolled oats (uncooked), wheat, rye, triticale, barley, and usually nuts like almonds, sunflower seeds and walnuts.  Some include some fruit like dates or raisins to add a little touch of sweetness.  Add some coconut or rice milk and have a healthier, low glycemic index breakfast.  I usually cut up a banana for added fiber and potassium.

Nothing in a can:

Before you start jumping all over me about things like tomato paste or canned vegetables, this is a place to read the label and remember my argument about the fresher the better.  How much healthier for you are green beans that come off the plant and to your grocer's display than a can of green beans that is packaged in some kind of liquid, usually with some kind of salt preservative;  that have lost their crispness, broken down their fiber, and taste like the can?  And, at the risk of sounding too "green," think about trash and recycling.  Fresh vegetables come in their own packaging.

Cans also include sodas.  Other than tasting good, sodas have no nutritional value.  And, you have to think about the sugars, phosphates and caffeine that they contain.  Caffeine is a diuretic (it makes you pee more.)  As it is, most people don't drink the recommended gallon of water a day they should be drinking.  (Eight glasses of water = 8 x 8 oz = 64oz = 1 gallon or four 16 oz bottles.)  Add a diuretic and now you're at a water deficit.  Your body needs water to perform many vital functions especially digestion.  And, we're seeing changes in patient profiles because of it.  Whereas diverticulitis used to be a disease of the elderly, I'm now seeing diverticulitis in 30 year olds.  The disease comes from not having a high fiber diet and increased pressure on the colon to expel the digested food stuffs.  Lots of water helps.  And exercise... just saying.

So, there you have it.  I can usually give this talk to my patients in about 5 minutes, answer all their questions and send them off to, hopefully, lead healthier, happier, and more flavor-filled lives.  Yes, I know it costs more.  Yes, I know it takes longer to do.  But then, isn't anything that's worthwhile worth doing right?

**I have no financial ties to any of the companies I've mentioned.  One of the best books I read on the raw food movement is "Raw Food/Real World" by Kenny and Melngailis

#1611 - On Offspring

We get a lot from our parents.  Not just our genetic makeup, but our values and traditions.  Our self-esteem and our value.  They help us gain confidence an set the example for how we should live our lives.  I've been thinking about my mother a lot recently.  Especially since I started counting calories and working harder on living a healthier life style.

My mother was diagnosed with diabetes in her 40's.  By her 50's, she was suffering from peripheral neuropathy and could no longer wear the heels she so loved because of the danger of falling.  But her shoes still defined her style that was anything but sensible.  She started to develop diabetic retinopathy that caused her to quit driving for fear of being in an accident because of her sight problems.  And, around the time I was going to graduate from medical school, she was told her greatest fear.  That she was going into renal failure and should start planning for dialysis.

We talked at great length about what this would mean, and she asked me what it would take to stay off of dialysis.  I talked to her about medications that would help to remove the buildup of impurities and electrolytes (especially potassium) in her body.  I talked about low protein diets and drinking plenty of fluids.  I talked about exercise and doing whatever the doctor told her to do.  She went to her kidney doctor then and told him in no uncertain terms that she did not want dialysis, and that she was willing to do whatever he told her even if it included killing puppies, making them into milkshakes and drinking them on a daily basis. (Momma and I have a warped sense of humor)

He laid out a pill regimen (about 9 different ones) and told her that they would check her blood on a regular basis.  And so it went.  From 2003 to 2013, she continued the plan.  You couldn't get her to take a bite of anything that wasn't good for her.  She's a low meat, water-drinking, no sweets seriously disciplined patient.  And, her kidney function didn't worsen.

Over the last 6 months, however, the doctor told her that he's starting to see some changes in her lab work that concerns him again that she might be approaching the need for dialysis.  Again, we talked about it, and she says she doesn't want it.  Her kidney doctor told me to talk her into it.  And, I told him I have to respect her wishes.  I am sad to think I might lose her sooner without it, but proud and supportive that she wants to live life on her own terms.  Like she has always done.  And which inspires me on those days when I just want to throw away my salad and have a stack of pancakes, or french fries, or a Starbuck's caramel macchiato or any of the other 100 foods I love that I can't have right now.

If a woman can be so disciplined and focused that she has literally willed herself and her body into staying off dialysis, I know that as her offspring I have that within me too.  And, together we'll conquer any challenges that come along.  For hopefully many years to come.

Happy Birthday, Momma.

I love you and am inspired by you daily.

2013 A to Z Challenge Post:

O is for Oh, Momma, That'sa What I Like

#1639 - On Lent

For Catholics, and a lot of other Christians, this is the time of year known as Lent.  It's a period of prayer and reflection in the 40 days prior to Easter.  Traditionally, you fast and don't eat meat on Fridays (hence all the fish frys and McDonald's specials on Filet-o-fish), and you also give up something as well.  Something you really like... Like chocolate... or red velvet cupcakes.  

Several years back, I also started doing something which was considered a "hardship."  Like being nice to that co-worker that really grates you.  Or saying a Rosary every day.  I had read somewhere that doing things like that was more of a sacrifice than simply giving up your favorite food or even Facebook like some of my friends do. (Although for me, Facebook would be a huge sacrifice.  How can you not log on for forty days!)  Regardless,  you do it in the spirit of Lent, and you come out a better person on the other end.  Purified of mind and body and spirit on Easter Sunday.  Not to mention, after 40 days that co-worker might not seem so bad.

My mother and I give up meat for the entire 40 days of Lent (except for Sundays which are "free days" or so I was always told).  I've written before about doing PETA's "Pledge to be Veg" and also about my raw food diet, so for 40 days it's not much of a stretch to not have meat.  What I find funny is so many people ask how I can do it.  Don't I miss it?  What do you eat?  And, it's simple...

Instead of this:

I have this:

And instead of this:

I have this:

And, I replace this:

With these:

Forty days is nothing.

Like I've said in the past, I could be totally vegetarian,

but I keep coming back to ribeyes... yum!

2013 A to Z Challenge Post:

L is for Lazy

#1709 - On Healthcare

I've been really busy over the last couple of days

so today's post is going to be a little short.

Here's an interesting article that came out on

CNN today.

I think it's pretty close to what I've said before...

2013 A to Z Challenge Post:

H is for Hungry

#1789 - On Calories

I've always had a love/hate relationship with my body.

Although it's always been a mostly

"if you loved me, you'd love all of me"

kind of attitude.

Then earlier this year my husband and I went to a conference

in Yosemite and I faced this trail...

After huffing and puffing uphill for 45 minutes

and thinking that my heart was going to explode

even after multiple stops to rest

I knew I had to make a drastic change.

So I bought a FitBit.

We'll talk about that on another day...

can you guess which one...?

Regardless, along with counting steps

one of the features is a calorie counter.

I didn't think much of it initially as I cut down

on my eating and measured my daily steps.

With no success.  WTH?!?

So I started playing around with the calorie counter

and kept track of every meal.

And what I realized is that my calorie intake count

went way beyond my burned calories.

Upon further investigation, I found out

this little watchband can set a daily calorie goal

based on how fast I want to lose X amount of weight.

I didn't go uber restricted, nor the way easy, 

I chose moderately difficult

with a goal to lose the weight by November.

So it set these goals.  A 750 calorie deficit.

Woah!

Day one: I did a bit of juice fast just to try things out

Day 6: Came out just about even

Day 12: Ok, seriously, the pizza spoke to me; come on,

man can't live on kale alone

Day 17: Wait, what? If I exercise I get to eat more..!

And here's where it matters most...

In case you're confused, I do my weight in kilograms;

it's doesn't sound so bad when I do it that way

(divide pounds by 2.2)

and, all I care about is the downward slope...

What will you do today....?

I have my game plan set....

**based on age, weight, height and sex your

basal metabolic rate is set and you can 

add activities like driving, or shopping

or yardwork throughout the day

Need a kickstart?  Read my recent post

on eating right...

2013 A to Z Challenge Post:

C is for Cats

What Does Your Fridge Say About You...?

I'd like to think that mine says:

world traveler

art lover

likes cows

currently working on home remodel

somewhat organized

inspired

and health care professional (pharm rep magnate)

And, this is only a quarter of my fridge...

What does yours say about you?

A Healthier Lifestyle: Just My Opinion

 As an Emergency Medicine physician, patients frequently ask me what to eat when I am in the process of giving them instructions for discharge.  Especially when I tell them to "lose weight, " stop smoking," and get maintenance check ups from their primary care provider.  It's funny how often it seems I am the first person to address their health and eating habits.  

They are surprised when I tell them to stop smoking because it cuts oxygen supply to their blood vessels by about 50% every time they light up.   They seem sincerely amazed that I recommend exercising in a pool when they tell me that because of their chronic back/knee/hip pain they can't follow the simple walking plan I lay out for them. (And, it is very simple:  15 minutes three times a week, then increase to 30 after several weeks, then add a hill, then try to go farther faster, then the possibilities are endless.)   As for seeing their primary MD;  well, isn't it easier just to come into the ED when I need something?  I'll save my answer as fodder for another post.

But, let's get on to  the, ahem, meat of this.  To eat right you just need to follow three simple rules:  nothing in a bag, nothing in a box, nothing in a can.

Nothing in a bag:

Bags include fast food, snack foods, any prepackaged food.   Top Ramen anyone?  This goes to the ideals also set out in Michael Pollan's "Food Rules:  An Eater's Manual."  You should only eat things you can pronounce.  Lower ingredients = healthier eating with a goal of 1 for everything.  The more the food is in its natural state the better.  I follow a mostly raw food diet and have never felt healthier and with more energy.  On one of my allowed "cheat days"  I was craving McDonald's french fries.  I honestly tasted every molecule of rancid oil along with several flavors I couldn't quite identify.  After about 2 or 3 fries, I threw the rest of the pack away and went to the grocery store for some kale and jicama to make into an awesome salad later that night for dinner.

Nothing in a box:

Again, think prefab foods.  Now, I know it's so much easier to get a Lean Cuisine and throw it into the microwave than to take 20 or 30 minutes to prepare something healthier (one of my mixed salads can take almost an hour to prepare.)  Not to mention, I had to run to grocery store about 2 - 3 times a week, because when you eat healthier, you need to maintain a large stash of fresh ingredients rather than a collection of boxes in the freezer.  Also, boxes generally mean breakfast cereals.   Even Special K cereal contains rice, whole grain wheat, sugar, almonds, wheat bran, then "2%  or less" of other ingredients including maltodextrin and BHT "for freshness."  I don't know about you, but I've never seen a maltodextrin tree, and what is BHT? 

On the other hand, meusli contains a mix of rolled oats (uncooked), wheat, rye, triticale, barley, and usually nuts like almonds, sunflower seeds and walnuts.  Some include some fruit like dates or raisins to add a little touch of sweetness.  Add some coconut or rice milk and have a healthier, low glycemic index breakfast.  I usually cut up a banana for added fiber and potassium.

Nothing in a can:

Before you start jumping all over me about things like tomato paste or canned vegetables, this is a place to read the label and remember my argument about the fresher the better.  How much healthier for you are green beans that come off the plant and to your grocer's display than a can of green beans that is packaged in some kind of liquid, usually with some kind of salt preservative;  that have lost their crispness, broken down their fiber, and taste like the can?  And, at the risk of sounding too "green," think about trash and recycling.  Fresh vegetables come in their own packaging.

Cans also include sodas.  Other than tasting good, sodas have no nutritional value.  And, you have to think about the sugars, phosphates and caffeine that they contain.  Caffeine is a diuretic (it makes you pee more.)  As it is, most people don't drink the recommended gallon of water a day they should be drinking.  (Eight glasses of water = 8 x 8 oz = 64oz = 1 gallon or four 16 oz bottles.)  Add a diuretic and now you're at a water deficit.  Your body needs water to perform many vital functions especially digestion.  And, we're seeing changes in patient profiles because of it.  Whereas diverticulitis used to be a disease of the elderly, I'm now seeing diverticulitis in 30 year olds.  The disease comes from not having a high fiber diet and increased pressure on the colon to expel the digested food stuffs.  Lots of water helps.  And exercise... just saying.

So, there you have it.  I can usually give this talk to my patients in about 5 minutes, answer all their questions and send them off to, hopefully, lead healthier, happier, and more flavor-filled lives.  Yes, I know it costs more.  Yes, I know it takes longer to do.  But then, isn't anything that's worthwhile worth doing right?

**I have no financial ties to any of the companies I've mentioned.  One of the best books I read on the raw food movement is "Raw Food/Real World" by Kenny and Melngailis

Day 23 - I Weep For the Future

One of the best lines from the movie "Ferris Bueller's Day Off."



I worked triage over the last couple of days during my ED shifts.  No where can you see the failure of the health care system, and society in my opinion, so readily as on the Front Line of medicine... the Emergency Department triage room.

- patient with three year history of stomach pain who came in because it hurt more the day before while they were driving but they couldn't get a ride to come to the ED until tonight and they came because their mother told them they should have it checked out because there might be something wrong.  Um...

- patient with very high blood pressure can't get needed prescription because insurance won't cover combination med.  Pharmacy has been calling cardiologist for over a week to get new prescription but no one returns their calls.  Insurance will cover meds separately so I write a prescription for them.

 - pregnant patient can't get doctor because they don't have MediCal yet and has to wait to be able to get into a practice that accepts MediCal.  She goes to a free clinic where she can get prenatal vitamins but none of the recommended blood work or other prenatal tests.  She's now almost 5 months' pregnant.

 - patient with kidney stone blocking their ureter gets sent home with scripts for antibiotics and pain medication and told to follow up in urology clinic to have stone removed.  They never get a follow up appointment because they don't have insurance and their MediCal application wasn't filled out because they neglected to do it.  They didn't fill their prescriptions because they "don't have any money to pay for medication."  Crystal meth, alcohol and "pain medication they borrowed from someone else with kidney stones" are what they've been using to help with the pain until tonight when 3 weeks later "the pain is like the first time."

 - patient with gallbladder pain who tells me they "can't just change my diet that easy" and who wants to see if they are "sick enough to have it taken out" because they are "tired of waiting for the referral from my doctor" to see a surgeon to schedule surgery.

 - child brought in with a cold.  They have a "runny nose and are congested."  Do they have a fever? "No."  Are they eating/drinking/peeing/pooping normally? "Yes."  What are you concerned about? "Well, I wanted them checked out."  Did you call your pediatrician? "Yeah, but they can't see them until Monday, and I didn't want to wait."

 - patient with chronic pain who was upset that they had to change doctors and insurance because of the ACA (affordable care act) and who now can't get the pain medication they were used to because it is no longer on their insurance formulary.  "Can you write me a script for it?"  Are you going to pay out of pocket for it?  "No, I don't have any money." Um...



**please read my disclaimer that these views are my own and do not reflect the medical groups for whom I work nor the professional organizations with which I am affiliated.

#563 - K is for Kum Ba Yah

There's a big push in the ED recently to get our patient satisfaction scores higher.  When asked, I said the only thing to add to what we're already doing is to serve drinks and offer a moist towelette.  A little tongue in cheek, I know, but now with the government trying to get into the business of managing healthcare, they are trying to cut costs by all means possible.  And, that includes not paying ED's that fail to meet a certain standard of patient satisfaction.  Imagine that, you provide a service that you are legally required to perform and you don't get paid even when you do everything right because someone decides to give you three stars instead of five.

What they fail to realize is that when someone gets something for nothing, and has no responsibility at all for the privilege of taking someone else's money and using it as their own, everything from their EBT card to medical care becomes an expectation.  I work in an area where something like 65% of our patients are on some sort of government assistance.  They come to the ED for their coughs and colds and pregnancy tests because they can, and they're not expected to give so much as a $5 co-pay.  They come in demanding their CT scans, MRI's, antibiotics with a twist of lime and a pillow because they don't have to pay for it.... ever... if a bill comes, it doesn't matter.  They HAVE to see me in the ER.  I can't go to the doctor's office because I owe money, but not the ER.  They HAVE to see everyone.

They get upset because they're made to wait 30 minutes, an hour, maybe two.  I know of ED's that have 5 hour waits on a regular basis.  They get upset because I didn't give them the antibiotic WebMD told them they have to have for a condition they read about.  They expect to come in and have a full physical, lab work, and imaging done because their primary is "taking too long," "has it ordered for a month from now," "thinks I should have this other test first and I think I need to have it done now for this chronic problem I've had for the last 6 months."

So we get poor patient satisfaction scores and comments when we say no.  When we remind them it's not an emergency.  When we tell them that we're not a pharmacy, radiology suite, lunch counter or hotel.  When we ask them to be patient because someone else's family member is dying, and they can't be seen right this minute for the viral illness that's been going on for the last week and for which they haven't taken even a Tylenol because "I don't get my check for another week, and I don't have any money right now, but hey watch my kid play on my new iPad mini while I go out and have smoke."

So while I face the prospect of getting paid even less per patient while still trying to maintain the same level of service and face the real possibility of losing even more staff because the hospital can't afford that extra nurse because it's not getting paid or collecting as much per patient, we're all expected to come together and hold hands and keep the cheery smiles going.  If you think about it, the ED really is a "come by here" kinda place.

Sorry about the rant coming at the end of working the last 6/6, but sometimes you just gotta vent.

And, as always, the views expressed here are my own and in no way reflect the views of the physician's group, hospitals or professional organizations with which I am affiliated.

How Long Has It Been...?

 Wow, after a feverish month of blogging daily, I have gotten lazy, haven't I...?

Let's wrap up:

On the 30th we had, what's becoming, our annual Wine and Mushroom party.

It was wet, sloppy weather and the chanterelles were a bit waterlogged,

but I made a fantastic sangria, plus opened several other special bottles I had

laying around the house, and we had a lot more people show up than last year.

All in all, a LOT of fun, and it really highlighted my lack of seating

since everyone chose to sit around the kitchen table and eat appetizers

instead of milling around.

That weekend I started my decorating for the holidays.

Here's the trim for the fence at the end of the driveway.

I love those big ornaments, but somehow 2 have disappeared, 

and I can't account for how that happened.

I have a thing for silver reindeer, and I added a couple more to the collection.

The slender deer in the middle of the picture is one of the new ones.

He's looking very handsome and is a nice addition to the herd.

We have green eggs!  

This means that at least one of our latest 2 hens are starting to lay.

As you can see, there are 4 different colored eggs, so at least 4 of the 13

(well actually 10 since 3 are roosters) chickens are laying now.

This will be great and I won't have to buy as many eggs when I start

my massive holiday baking projects.

I tried my hand at Southern Fried Pie.  Here are two attempts next to my final

all American apple pie.  My husband performed the taste test.

Not quite like his aunt used to make, but still deemed yummy.

Having done this, now I know what I need to do for the next trial.

But, first we've got to dry some more apples...

Our county is one of the "pilot" counties in the state for the California Medical Foundation "Walk With a Doc" program.  I led last weekend's walk in my town, and despite the rain and 38 degree weather, almost a dozen people showed up to walk the almost 2 mile route I had planned.  I brought the dogs which helped keep us at a brisk pace.  All in all pretty successful, and if anything it got me out of the house to exercise.... and, so should you!

Speaking of the dogs, they really do travel well.  We went on a 12 hour car ride to pick up my mother for the holidays.  The dogs slept most of the time.  They behaved well during our pit stops.  And, they didn't get annoying during those "drive thru" meal stops.

 

Then twelve hours back on the road, which leads us to the present.  

Momma's here to spend the holidays with us, and Dillon just loves his Gramma.  

Cheers to you and hoping you're able to spend time with loved ones

during this holiday season!

NaBloPoMo Day 6 - State of Disbelief

Still in a state of disbelief...

... will post tomorrow when I have recovered...

I feel, though, that our country never will...

NaBloPoMo Day 5 - 47 Percent

"There are 47 percent of the people who will vote for the president no matter what," Romney said.  "There are 47 percent who are with him, who are dependent upon government, who believe that they are victims, who believe that government has a responsibility to care for them, who believe that they are entitled to health care, to food, to housing, to you name it."

Although I couldn't put a number to this, before I even knew that Romney had said this, there were a lot of people saying this;  especially those of us in healthcare.  As an Emergency Medicine physician, my colleagues and I are on the front lines of the healthcare battle.  We watch while others make decisions on the type of medicine we are allowed to practice.  And, we deal with the consequences of a societal collective unconsciousness that feels that they are entitled to whatever they want, whenever they want it.

As residents, we scoffed at the patients who called ambulances for medication refills.  We balked at the parents with their manicured nails, blinged out cell phones and designer handbags who asked for prescriptions for tylenol because that way they wouldn't have to pay for it.  We lamented taking care of baby number 7 or 8 whose other siblings were in child protective services' custody because of drugs, or poor living conditions, etc. but whose parents were allowed to continue collecting support as long as they continued to have children.  I have been angered by patients on "disability" who use their money to feed their drug and alcohol habits, and who complain that they don't have enough money but "can't work" because then their support is going to be "cut off."

No, I did not spend the last 10 years of my life studying and working, at times three jobs, so that I can now be living paycheck to paycheck because taxes take away almost a half of my income so that you can have "free healthcare, free medications, and free childcare."  I don't want to hear you complain about how you couldn't afford medication that was necessary to your continued recovery but could afford a pack of cigarettes and beer to help wash down the narcotic medication you demanded and which was the medication you did fill.  So, now your simple infection is a full blown infection for which you will be admitted, given high cost antibiotics for, take up a hospital room for and during which time you will leave AMA (against medical advice) because you couldn't smoke/sleep with your boyfriend/feed your dogs/make a meeting that you just had to get to.  And, that will be "free" as well.  After all, you're not going to pay a bill when they didn't bring you water with ice and a lemon slice like you demanded.  Or you didn't get your next dilaudid shot at the moment you pushed your call button.  Why should you pay for bad service like that?

Today I read a post from another ED doc in Nebraska who said the same things I know a lot of my colleagues and I say often.  And, lately, more often than not.  No matter who you vote for tomorrow, I hope that as a country we can begin to see a shift in the mentality of this country.  I was raised to work hard, to get ahead, to make a difference.  We are propogating a society where a set of the population feels that it's "nice that people that have money share it with those that don't have as much so that way we're all equal."  That's an actual quote from a patient just a couple of days ago, and I was angered by it.  I hope the other 53% of you are too... and will vote to make changes happen.