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Author Archives: Birdstrike

Bloated Healthcare Costs: Are Emergency Physicians to Blame?

By Birdstrike M.D.   In an article entitled, ”Why the ER Admits Too Many Patients,” Dr. Michael Kirsch tries to explain that Emergency Department admissions are inflated due to Emergency Physicians acting in their own self-interest.  Many Emergency Physicians have read this and taken offense, feeling that his assertions point unfair blame on them for a significant portion of excesses in medical care and costs.  I share this visceral reaction in part, but such a reaction blurs some very important points worth examining.  Let’s give the benefit of the doubt for a moment, that the author may in fact be pointing the blame not at Emergency Physicians personally, but at a broken “system” instead. First, he claims that due to fears of potential lawsuits, Emergency Physicians when in doubt, cautiously err on the side of admitting a patient and ordering tests, rather than discharging them with minimal work up.  How any Emergency Physician can deny that this happens baffles me, as almost every one I’ve ever known will say in private they think about, and are motivated to avoid the threat of lawsuits (except for possibly a few in the handful of states with strong tort reform).  Physician surveys seem to support this, with at least one showing >90% of physicians across multiple specialties admitting to such.  This speaks to the greater issue of defensive medicine and the need for tort reform, and should not be seen as an indictment of Emergency Physicians.  Tort reform is an issue where the American people just plain need to decide.  Do they want to keep their cake uncut, or to eat it?  You absolutely cannot cling to the pipe dream of reducing unnecessary medical testing and expensive overly-cautious admissions while holding true to the good old-fashioned American past time of suing the pants off of a doctor who sends a patient home, only to have something unexpected go wrong.  Decide: Do you want, A-Doctors to send you home, cancel your test, and throw caution to the wind when you might be sick to save costs for the “greater system,” and give up the right to sue if something goes wrong, or, B-Do you want to retain the right to sue in court for hundreds of thousands of dollars (or even millions) if you have a bad outcome and have doctors admit you when in doubt and order every test (expensive or not) that they think they need to keep that from happening? You cannot have both A and B.   For the most part, and in most states in the land, the American people, their elected politicians and the plaintiff’s attorneys that support them, have already decided in favor of option B.  The right to sue has always come out on top (in most states) and there’s no sign that’s about to change any time soon.  To those who will respond with “science,” “data” and articles claiming the threat of medical malpractice doesn’t alter doctors’ practices or inflate healthcare costs, don’t bother.  Most physicians are not interested in hearing evidence or “data” to show oxygen isn’t needed for breathing, or that 2+2 isn’t 4, either.  There are some things we as doctors know to be self-evident.  To the extent that one blames such a drive to err on the side of admitting patients on a dysfunctional medical malpractice system, is the extent to which he is correct.  To the extent one points the finger specifically at Emergency Physicians, who have no choice in this day and age but to admit patients with the utmost of caution when in doubt, is the extent to which ...

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Cat Lady

By Birdstrike MD   “She talks to angels, they call her out by her name.” – The Black Crowes. . . The radio crackles alive, “County General…we’ve got a 20-something female……just picked her up…..bagging….we’re at your back door…” Boom! They slam through the double doors, and roll into room 8.  Lying on the stretcher is a young thin woman.  Beneath the mask over her face is a full head of golden wavy hair.  I get to the head of the bed, and get ready to intubate her.  I grab the bag and mask and start bagging her myself.  “What have you given her, so far?  Any narcan?  D50?” I ask. “No,” the paramedic says.  “We just scooped her up and had just enough time to get her here and pop an IV in.  Just lost pulses a few seconds ago.  PEA.” “Okay, give her some narcan and D50, while I get ready to intubate.  Resume compressions!  Etomidate, sux, scope…” roll off my tongue.  I look down at the patient’s face again……blond, so young, hair and face like a movie star, except for the pale-bluish dying hue.  She reminds me of Cat Woman from the old Batman comics.  She’s just about dead and much too young to die.  I don’t think I can handle another young patient death this week.  I’m filling with dread, not from anything that has to do with the medical “case” in front of me, but because somewhere out there is an unsuspecting mother, husband or child that I’m going to have to tell that she is dead.  There’s no way to candy-coat that news, and no matter how many times I do it, it still gives me chills. The nurse has just given narcan.   She starts to move.  Is she trying to breath?  I look at her face, it’s pinking up.  Did we restrain her before the narcan?  Damnit….we didn’t! She VIOLENTLY sits up, blasting upwards towards my head, ripping the mask off her face, ripping out her IV and heaves forward.  I’m looking straight at the back of her head and torso and she’s heaving forward violently grabbing at her own neck, making an awful guttural noise, contracting rhythmically.  That noise, what’s that noise?  I’m hearing my cat, she’s trying to vomit.  Is this lady trying to gag up a hairball?  Cat Lady. “Blahhhhaaaaaacghck…..blaaa…..ughggh!” I look beyond her and the nurses are staring back mortified, at the patient.  “Ahhhhhh!     Ahhhhhhh!    Ahhhhhh!” this Cat Lady is screaming.  “I’m dying here!  Help me!!!  Oh, the pain, s—t, the pain!!!” I step around out from the head of the bed to the front of the patient to see what the nurses are looking at, and on the patient’s lap is a big, gooey, mucous-covered ball of something on her lap.  Whatever it is, this patient was choking on it, it almost killed her and now she’s alive and well, though ready for vengeance. Why the heck is she screaming, now?  This thing, whatever it is, is out of her, and she’s awoken from the dead. I pick up the ball of goo and examine it.  I start picking it apart.  Why do I have to do this, this is disgusting?  I should’ve been an accountant.  Hairball, I think to myself, laughing a little bit inside.  Just like my cat.  It seems like a ball of wadded up plastic.  What the heck is this thing?  There’s writing on the plastic.  What is it? Is that an “F—–, Fe—“? “Fentanyl!  Fentanyl!” yells one of the nurses looking over my shoulder, who can obviously read through bloody mucous much better than me.  Fentanyl ...

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The Day This Doctor’s Best Friend Died

By Birdstrike MD “Would you know my name, If I saw you in Heaven?” -Eric Clapton, Tears In Heaven Pete was my best friend.  I had known him for over 10 years.  Pete was more than just a friend.  Pete had become part of my family.  All of Pete’s relatives had died.  He was born in a different state, and when he came into our lives, Pete had no one but us.  You could say my family adopted him. Pete was quiet.  I swear it seemed like he never talked.  I’m quiet, too.  I think that’s why we got along so seamlessly, and without drama or complication.  We had quite the connection.  Words were overrated to me and Pete.  Pete and I liked to do the same things.  We both loved to run.  We went on countless runs together.  I preferred to run alone, and Pete was the only real training partner I had ever wanted to run with.  Pete had even helped me train for a marathon.  Pete just liked to run with me.  That was enough.  Pete didn’t care who was faster.  I liked to think I could outrun him.  I was kidding myself.  He never went ahead, though.  The truth was, if he wanted to beat me, he could have run twice as fast, twice as long, but he always held back out of respect, I think.  Pete was significantly younger than me.  My only hope of beating Pete in a race was to wait for a 90 degree day.  The heat was his Achilles heel.  Pete’s speed disappeared in the heat.  Nevertheless, we bonded over countless miles, during many great runs together. Pete was a super loyal friend; in all honesty, much more so than I.  I don’t know that I ever did anything to deserve how loyal and dedicated a friend Pete was.  That’s just how Pete was.  You almost got the sense he’d lay down his life for anyone of us.  Most of what I gave Pete was just someone to hang out with.  Other than running together, we spent lots of time outside.  We shared a great love for grilling steaks, and we’re both suckers for any sport involving a ball.  No one loved a great juicy rib eye as much as him.  Pete also had a strange liking for popcorn. In all the years I knew Pete, I never knew him to have any career in the traditional sense, like a doctor has.  That’s unless one considers being a boxer that never received a real paycheck a “career.”  He also worked as a volunteer security guard.  Some would say that made Pete a free-loader.  Sure, he was a sucker for a free steak and a rent-free roof over his head, but I never held it against him.  He more than made up for it in the intangibles. My wife and kids had bonded with Pete as much as I had, since we were his adopted family.  My kids had grown up with him.  Many times in the summer, we’d hang out at the pool.  He’d play ball with my kids.  Pete loved kids.  Pete was in as many family photos as my own kids.  Brown hair, brown eyes, there’s Pete again! One day, Pete was tagging along as my wife pushed my youngest in a stroller.  A viscious dog had aggressively lunged at the stroller.  Pete threw himself between the baby and the dog, without hesitation.  Pete could have been eaten alive.  The viscous dog backed down.  Pete was forever a hero to our family after that day.  From that moment on, ...

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Blown Away

By Birdstrike MD I was a work today and I was given this message, “ —–‘s husband called and wants you to call back right away!  He sounded very upset.  His wife died.” Uh-oh, I thought to myself, this is never good.  It was a patient I remembered well, that I had seen repeatedly for a chronic problem, and who always came with her husband.  We seemed to get along well.  I didn’t recall any conflict, unpleasant interactions or any immediate life threat that might have been ominous. There were no complaints to administration.  I looked in the computer, and I hadn’t seen this patient in over 3 months.  I debated whether or not to call back, not knowing what beehive I would be getting into.  Did I do something wrong?  Am I being sued?  Surely I am going to be blamed for this in some way?  Maybe returning this call would not be such a good idea. I decided to call back.  After all, I knew the curiosity of not knowing what happened would torture me more than simply calling and facing whatever was coming my way.  I had a few extra minutes, so I dialed the phone and called. “Hello,” answered the familiar voice of Mrs. —-‘s husband. “Hi, this is Dr. Bird.  I got a message that you had called.  I’m sorry about the terrible news,” I said. “Yes, she died 2 weeks ago,” he said, his voice crackling and wavering.  “I thought you would want to know.” “Yes, absolutely, thank you for calling.  Again, I’m very sorry about your loss,” I said.  “What happened?”  I was afraid to hear the answer. He went on to explain that 3 months after I had last seen his wife, her condition began to deteriorate (from something unrelated to what I saw her for).  He paused and choked up repeatedly in telling the story, the tears and emotions still raw.  She ended up in the ICU and on life support.  Her condition worsened, beyond any hope.  To respect her wishes, he decided to withdraw support, as she requested.  As a result, she died.  This concluded many long and painful years of an excruciatingly painful illness.  Nevertheless, he was crushed. “She was a very strong woman and she went through a lot,” I said.  “I’m sure you miss her very, very much.” “Yes, I do,” he said.  I could hear him now choking back full tears.  “Most of all, I wanted to call and tell you thanks, for all you did trying to help her.  I want you to know she thought the world of you.” Wow.  That was a shocker.  After all the years of hurried patient interactions, the long nights, the grinding day shifts, and the routine ins and outs, unexpectedly, this one stopped me in my tracks.  I have to admit, he got me.  I was totally caught off guard, by the appreciation in the face of such a hurtful tragic loss.  I had come to expect utter negativity and un-appreciativeness at all turns. “Wow, sir.  Thank you.  Thank you for calling.  I really appreciate you letting me know,” I said, in disbelief, and humbled.  After years of being a doctor in various setting, with 30,0000 or more patient interactions and counting, I can honestly count the number of times I have received this type of thanks on one hand.  At least for the moment, this one “thank you” seemed to have made up for many thanks that likely were felt, yet not necessarily sent or expressed, and likely drowned by a much noisier negativity more demanding of ...

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What I Can Tell You Is, “Thanks”

By Birdstrike MD I can’t tell you that the “patient satisfaction obsession” is suddenly going to focus on patient health over profits and start being applied fairly to doctors and nurses. I can’t tell you that someday politicians, administrators and insurance companies will wake up and see things the way you and I do. I can’t tell you that someday, all the demands for inappropriate medications, tests and treatments will end. I can’t tell you that all of a sudden the government will stop making cumbersome and nonsensical rules and regulations, stop crushing private practice and start increasing instead of decreasing doctor pay. I can’t tell you that all of a sudden you are going to stop taking hits in the line of duty for doing the right thing for your patients. But what I can and will tell you is that I appreciate every time you or any other doctor, nurse, physician’s assistant, paramedic or tech laces it up for a shift to take care of the sick and injured. I can tell you, “thanks” for everyone too sick, too short of breath, dizzy, psychotic, weak, unconscious or too intoxicated to say it or realize it themselves. I can tell you that I appreciate all the blood, sweat, tears and REM sleep you leave on the floor during your days and nights on the front lines treating the sick, bleeding, broken, bruised, and destitute. For what it’s worth, you are a hero to many, whether they say it, know it, or not. I’ve been there, done it and still face the same battles.  What you do is not easy. It’s incredibly difficult. Don’t ever let anyone tell you otherwise, including yourself. You make a damn big difference to this world. For anyone who steps up to the plate in an Emergency Department, hospital, OR, or doctor’s office to be there when no one else can or will, to wait for me, my family members, your own friends, enemies or complete strangers to pass out, get run over, to arrest or stop breathing, keep your chin up. For what it’s worth, you’re a hero to me. Happy Holidays, Birdstrike MD . . .

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“You’re Next”

By Birdstrike MD I saw a story in the news about something that happened to an ER doctor.  It reminded me of something that had happened to me before, so I started writing about it.  Then my imagination got a little bit carried away.  So, let’s just say parts of this story are absolutely true, and other parts are, well…just read along.  I walk in for my ER shift.  There’s a letter in my department mailbox.  It’s a hand written letter from a patient.  I open it, “Hey doc!  I just wanted to thank you for taking care of me last week.  It was one of the low points of my life and I really had hit rock bottom.  You’re the first one to talk to me like a human being.  You convinced me to get help.  They finally let me out.  Thanks, again.  You saved my life.  You’re a great doctor.  We should hang out sometime.” Sincerely, Jerry —– Cell: XXX-XXX-XXXX” I remember the patient.  I admitted him for severe alcohol intoxication, depression and suicidal thoughts about 2 weeks ago.  It’s not that often that you get to start out a shift with a “thank you” letter, albeit with a bizarre request at the end to “hang out sometime.”   In this ER game, you take every pat on the back you can get, because they don’t come every day. I walk to the pit to see my first patient.  First up is, “Broken wrist.”  I walk into the room and it’s him, Jerry, the letter writer.  “Hi, Jerry, what can I do for you today?” “This,” he holds up his mangled right hand and wrist.  “I got pissed off and punched a wall.” “Wow, you sure did a number on yourself.  What happened?” I ask. “Did you get my letter?” he asks. “Yes.  Why do you ask?” I wonder aloud. He stares at me silently, and uncomfortably long.  “Oh, I don’t know,” he trails off, staring through me.  “Just fix me up, and we’re good.” I walk out of the room.  That was weird, I think to myself.  I put in an order for x-ray of the hand and wrist.  I put that plate up in the air to spin, and move on to: Chest pain, Migraine, “Can’t see,” Sprained knee, “Menstrual,” “Sick still,” Split lip, “Vag drip.” Jerry’s x-ray is done.  Wow.  He’s completely shattered his wrist and 4th and 5th metacarpals in his hand.  I haven’t seen a one this bad in a long time.  I walk into his room.  “Jerry, you’ve badly fractured your hand and wrist.  You’ll probably even need surgery.  I’m going to call the orthopedic surgeon.” “No.  I want you to fix it.  You owe me, big time,” Jerry says. “No, you don’t understand.  It’s badly fractured.  You need a surgeon for this, a specialist,” I explain. “Did you hear me?  I said, ‘NO ’,” he says, gritting his teeth so hard they could shatter. After years of seeing anything from little old ladies to psychopathic criminals, it takes a lot for a patient to truly bother me, but this guy is truly disturbing in a way that’s hard to describe.  It’s time to get out of this room.  “That’s the way it has to be for you to get the best care,” I say and walk out of the room. As I get to the door, he yells, “This s—t is your fault mother f—-r!  You should have called me back.  I left my cell number on the letter for a reason.  YOU shattered my hand and wrist.  This is because of ...

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