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Letter To Doctor That Lost A Patient

By Birdstrike M.D. We all went into medicine to save lives. Deep within even the most cynical of us, is still that pre-med hopeful that believes we can and should restart each non-beating heart, make the non-breathing breathe and fill with blood those who’ve bled, filling them back with life. We expect that a patient’s condition will improve while under our care, or at least not worsen. Intellectually, we know we’ll not be successful every time. None of us became doctors to helplessly watch others die. Yet, we know there will be times, that no matter what we do, nor how perfectly we do it, that’s exactly what we’ll be forced to do, though not for lack of trying. Ultimately, regardless of what any of us says, you’ll go over the case ad nauseum to determine “What could I have done differently?” Ultimately you may conclude you could, or couldn’t have, done something different. But the crux of it, is that the answer to that medical question is irrelevant to the what is ultimately a human experience we can’t fully control. As medical as we try to be, it hurts to watch someone die. And the thing very few understand is the tremendous emotional risk we take as physicians, in having to be part of that, while at the same time charging ourselves with the responsibility of not allowing it to happen. Ultimately, we set ourselves up to fail. Some we can save. Many we can’t. Uniquely, we bear that emotional burden. The hospital CEO doesn’t feel that. The insurance adjuster who pays (or refuses to pay) the hospital claim doesn’t feel that. We share the burden with the family. I’ve seen fellow doctors, grown men, cry over patients lost. What you have to do, after you’ve done the analysis, ultimately are two things: 1-You first have to give yourself permission to be, and forgive yourself for being, human. You have to have compassion, not only for your patient and the family, but allow some for yourself. 2-You have to remind yourself, regardless of whether or not you ultimately decide you could/should have done some thing different, that by your being there, you took a large risk (an emotional one) and by doing so gave your patient a much greater chance of surviving, than if you hadn’t taken that risk. Even if the outcome wasn’t what you or the family would have hoped, you took a great emotional risk by choosing to be there if and when that patient would need you, and increased their chances much greater than if you weren’t there. Sometime their chance was never more than zero, but you did what the rest of the world didn’t have the courage, ability, or desire to do. You placed yourself there and were willing to risk taking the emotional bullet. Why? Because you’re a good human being and you care. I don’t know if that helps, but either way, I can assure you I’ve been there. I have cases that I think about years later; not all the time, but when something, or nothing at all, triggers the vivid memory. For what it’s worth, I feel your pain.   “Midnight, our sons and daughters, Were cut down and taken from us, Hear their heartbeat, We hear their heartbeat.” -U2 (Mothers of the Disappeared)

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Medical School in the Big City, Vol. II: A Month in the Morgue

  By Birdstrike M.D.   “So, I grabbed up my suitcase, and took off down the road When I got there she was layin’ on a coolin’ board” – Son House, Death Letter Blues   Fourth year of medical school is great.  Finally, I get some elective time.  Last month was great: Dermatology, ahh…….Sleep, rest, low stress and drug rep lunches: Yum.  I can still smell the delicious smoked ribs the rep brought for lunch, just last week.  I’m already hungry as I drive to start my second elective month in a row.  This month is going to be even more relaxed.  The patients might have >gasp!< pimples and rashes like last month, but this time they probably won’t even move!  After getting worked to death on 6 straight months with hospital call, this is the break I need. I walk into the building and as I get close to the bottom of the stairs, I smell something.  Is that ribs, again?  Wow, drug rep food already?  It’s only 9 in the morning.  That’s weird?  Oh, well.  I guess life really is good on these elective months, when you’re not getting called at 2 a.m. for a patient who might be dying.  I look at the clock.  Shoot, I’m a few minutes late.  I open the door. A group of students and residents are standing around a table that is covered by a sheet.  The smell of barbequed ribs hits my nose stronger.  A bearded man on the other side of the table, waves to me to come over.  That must be Dr. Black.  I creep toward the others around the table as Dr. Black pulls the sheet off of the table.  The overwhelming smell of smoke chokes my nose and as I see what is lurking under the sheet, I feel my stomach drop and my head get dizzy.  There laying on the table is a charcoal-black human body, burned to a crisp, arms drawn up to the face in a fetal position.  A few of the others turn away.  I hear a gasp, and a few deep breaths as we look at each other.  Oh my god, that smell!  I feel like vomiting.  It’s the smell of barbequed ribs, alright.  Human ribs.  Welcome to Forensic Pathology, I think to myself. “One thing we always do with burn victims is to x-ray them.  Does anyone know why?” asks Dr. Black. “To identify them by dental records,” chirps Gunner Boy with the bow tie. “No, although we do that occasionally,” says Dr. Black.  “It’s to see if there is any lead in them.” “Huh,” Gunner Boy seems puzzled.  “This person died in a fire.” “Are so sure?  Why might such person have lead in them?” asks Dr. Black. Now it’s my turn.  “It’s because they’ll shoot them full of lead, then light the house on fire to try to cover up the evidence,” I blurt out. “Yes sir,” nods Doctor Black. Betsy, the mousy-haired girl that was in my Anatomy group looks at me disturbed, as if to ask, “How’d you know that?” “Welcome to Big City Morgue, Betsy,” I shoot back. I look down at the burnt corpse and despite the whole body being as black as a charcoal briquette, for some reason there’s a patch of skin on the right arm that’s completely unburned.  It’s a tattoo that says, “Mom, I love you forever.  R.I.P.”  Below that is another tattoo that says, “Straight to Hell.”  How unbelievably ironic, I think to myself. We move to the next table.  Dr.  Black pulls back the sheet.  It’s an 18 year ...

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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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Dear Diary

It has been a long time, diary. I can’t even think of all the things that happened since I last wrote. Last time I left off, it was the squirrels. I’m happy to say that they’re gone. Mwuuuuuuhahahahaha. Actually, I’m a chicken shit. I got two types of traps. When I put peanut butter on to the lever of the live trap, I was able to catch a couple of squirrels. The other ones would simply knock the trap over and then grab at the peanut butter through the holes in the cage. So I got a couple of Ortho rat traps and caught the three remaining squirrels using those. One of them died. Two of them just got their legs caught. I made the mistake of telling my youngest daughter that I was going to go and “finish them off” after I caught them. She had nightmares for two days that daddy was killing the squirrels. In reality, I took them a half-mile away and let them go in the woods. What a sucker I am. But at least they’re gone and not chewing holes in my roof. Cracked a tooth while chewing a peanut. That was an experience. First, it happened on a Friday at work, so I couldn’t get into the dentist. I happened to have a temporary filling in my bag that I had purchased over the counter at a pharmacy. It worked amazingly well, and in fact I was considering just leaving it like that. Unfortunately, after visiting the dentist I needed a root canal. That was fun. Also had to have a superficial cancer burned off of my face. I went into the dermatologists office to have it looked at. Two minutes later, she’s putting on gloves and coming at me with a scalpel. That wasn’t too bad. Then she turns around, pulls some canister out of the closet and starts spraying me some Despicable Me – looking freeze ray mist. I think she called it “liquid nitrogen.” That stuff burns like a mother. Imagine the worst case of brain freeze you’ve ever had and then multiply that by about 10. That’s what this stuff felt like when it hit my skull. I could see this being used as a torture tactic when waterboarding stops working. So I got to make up about 15 or 20 different excuses as to why I had a chunk of skin removed from the side of my face. Dog bite. Squirrel bite. Patient attacked me. Son’s lacrosse coach at me with a stick. Shooting accident. Improvised explosive device prematurely detonated (don’t use that one at the airport). Most importantly though, when my fair-skinned kids argue with me about going outside without using sunscreen, I point to my face and ask them “do you want to look like this?” I don’t know whether their immediate assent to sunscreen use is a testiment to my good parenting skills or a reflection of their fear of growing up to look like me. Whatever. It works. Oldest daughter has now started driving. Dad has now started drinking before he takes her out driving to calm his nerves. Seriously. I just sit here and wonder whether or not I was as bad of a driver when I was starting out. I don’t ever recall running over curbs when turning a corner. I distinctly remember stopping very quickly when a crash is imminent. In our short time driving together, we’ve had several near misses. It is going to be a long time before she drives alone. And fortunately my life insurance is up to ...

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Blog Feedback

This new WhiteCoat Version 2.0 blog has taken a back seat for a month or so as my attention was focused in several other places. I’m finally getting to a point where I can start focusing more on this blog again. I’m going to ditch this website layout and set up another one. But I want to get WC 3.0 right. And I need your help. I need to know from all of you what works well and what doesn’t work well for you with this blog the way that it is set up now. The math problem CAPTCHA login for comments is a source of a few negative comments. Here’s the problem: I get so many spam comments that I can’t keep up some times. It was getting to the point that many spam comments were getting through the Akismet filters and ending up in the legitimate comment queue. The spam comment folder previously had several thousand comments inside. Using the math CAPTCHA, it’s down to a few hundred comments – and that’s including use of the Akismet plugin. I haven’t had to remove any spam comments from the legitimate comments queue since adding the math problems plugin. The more time I spend deleting spam comments, the less time I have available to write posts. So that’s a tradeoff I have to make. The other option is to prevent people from commenting unless they register on the site and confirm their e-mail – which is another option. However, I think that may effect the willingness of people who wish to comment anonymously. What’s better? [poll id=”2″] I’m aware about the “read more” links and the frustration with clicking several links to get to a page to read content. I tried fixing that within the theme I’m using, but wasn’t able to do so. In retrospect, the theme I purchased seemed geared less toward a blog and more toward a static web site. I was having problems implementing the picture slider because it kept crashing older browsers (something about HTML 5 instead of HTML 4), so I removed it. Now the site is kind of bland. I’m testing out other WordPress themes now. Trying to focus more on “magazine” formats. Have a couple that look promising and will hopefully have a new one in place sometime in the next week or so. When that happens, the site will be offline for a day or two and afterwards will hopefully look different and better. I had a couple people write me that they were getting frustrated with all the clicking they had to do from an RSS reader in order to get to the post they want to read. I’m hoping that the theme update will make it less of a hassle. To fully address that issue, though, I need to explain a few things. Right now, the only way that the site earns income is when readers view and/or click on ads. That can only occur when people visit the site. On one hand, I want to make it easy for people to read the content, on the other hand, I’m going to start paying authors to write content. So to encourage more good authors, I need people to visit the site to make that happen. I also want the site to be interactive and want people to comment on posts. Part of a blog is establishing a community – kind of like hanging out at a bar and watching a game and talking about things that interest you. Sure, there’s that guy that always has good stories, but after ...

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