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Tag Archives: Guest Posts

Homeless Elvis

By Birdstrike M.D.   I think every Emergency Department has a patient like this.  Homeless Elvis came in to our ED at least once per day, for many years.  Sometimes he’d see each doctor, on each shift in an entire day.  By sheer numbers the amount of uninsured ED visits he accumulated over time was unbelievable.  None of us ever knew his real name, because he never had ID, and he insisted we call him “Elvis.”  His last known job was working as an Elvis impersonator, and due to his uncanny resemblance, this would have been no stretch.  We all knew “Elvis” had no real home, other than possibly our ED.   On one particular day, he surprised us all. I had taken care of the guy, probably 500 times.  He had an extremely bad heart.  He was told that after a heart bypass, repeat bypass and multiple heart stents, that there was absolutely nothing anyone could do for it.  It was amazing he was even alive.  He would come to the ED, every day with the same complaint: “Chest Pain.”  Sometimes he actually had chest pain, sometimes he didn’t.  Sometimes his chest pain was from a heart attack, sometimes it wasn’t.  More often, Elvis wanted food, clothes, or shelter from the elements and most of all, company.  In our ED, he almost always got it.  He would routinely agree to an aspirin, EKG, and sometimes labs.  Almost never, anymore, would he agree to hospital admission, or stress testing, let alone a heart cath.  He must have politely signed hundreds of “against medical advice” release forms.  He never argued with anyone, made any demands or caused any trouble.  He had been coming to our ED longer than anybody that worked there.  The guy was a fixture of our ED and part of its soul and personality.  Some of us spent more Christmases, New Year’s Eves, and other holidays with Elvis, than with our own families.  I once overheard one of our veteran nurses tell a new employee, “Oh, don’t worry about Elvis.  He’ll grow on you.  Like mold.” Not surprisingly, Elvis also had depression, in its most severe and chronic form.  Whether his situation led to his depression, or his severe depression rendered him unable to function, it is hard to say.  Rumor had it that he was married with children at one point and that they had left him and that he had lost all contact.  He refused to talk about any of it.  The only thing that helped his mood other than a warm blanket, meal tray and something for his pain was his antidepressant medication.  He had been on it for years.  Nothing else worked.  Sometimes he had a little bit of money to buy it, sometimes he didn’t.  Sometimes he’d get samples, sometimes he didn’t. I actually liked seeing Elvis as a patient.  I knew him well and I knew exactly how to take care of him, since I had seen him so many times.  Seeing him was, in a strange way, a routine and comforting break during many a chaotic shift.  He was an easy patient, really.  Others got irritated, especially if they were new and didn’t know him well, and especially when the ED was busy. One shift, we were incredibly busy with 30 or more patients waiting and only two doctors on duty.  The acuity was high.  We had traumas, and we weren’t a trauma center.  We had STEMIs and we had no cath-lab. We were buried. In comes Elvis by ambulance, with his usual chief complaint of “Chest pain.”  I purposely let my ...

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By Birdstrike M.D.   I was driving home from a night shift and the scorching sound of Texas guitars flamed out of my car speakers.  The group ZZ Top was old, but the song was new.  It went like this, “25 lighters on my dresser, yessir.  You know I gotsta get paid.”  Mostly, I was shocked that any members of the band ZZ Top were still alive, let alone putting out new music that was actually getting airplay.  Also strange, is that the song is a remake of an old rap song.  The lyric reminded me of a patient who I won’t name.  It would be a safe assumption that he was a gang member.  He wore saggy, baggy pants, and was heavily tattooed and shirtless.  He either spent 8 hours a day in the gym lifting weights, or ate a healthy diet of steroids.  If he had killed half as many people as his tattoos indicated, it was certainly in my best interest to keep him happy.  This was one patient satisfaction score I would ace.  I’ll call him Lighterman. “Yo doc!  You gotta fix my hand, man,” Lighterman said in his gang accent.  He held up his bleeding hand. “What happened?” I asked. “I used my knife to open a bottle of some Robitussin to put in my beer and I slipped,” he said.  “My brother is home right now getting wasted on my stash.” “Robitussin in your beer?” I asked, half amused.  “That could kill you, you know?” “Aw yeah, boy.  It’ll light you up, man.  You should try it.  You a doctor!  You can have all you want, anytime, man.  You got it made,” he said. “Uh, no.  I would never do that.  Let’s take a look.”  He had a 2 cm laceration on the back of his hand.  I prepped, draped, anesthetized and explored it.  “Looks like you’ve got a partial extensor tendon laceration,” I explained.  “It would be best to have it repaired by a hand surgeon.” “No way.  I got deals to make and hearts to break, man.  Ha!” he laughed. “I’ve heard that one before.  I’m not joking, though.  This is serious,” I said. “You got 10 minutes and I’m gone, dog,” he said. Suffice it to say that my best “against medical advice” warnings about limb-threatening bad outcomes and signed paperwork did nothing to dissuade him.  He showed no outward signs of drug or alcohol intoxication and certainly would not have consented to blood or urine testing to prove otherwise.  Although, his judgment was clearly very poor, he understood the risks of not getting the best treatment for his injury.  He just didn’t care. “I don’t got time to go see your specialist, either,” he added.  “I trust you, man.   You look like that TV doctor from back in the day, Doogie Howser, only younger, smarter, with a bigger head and skinnier neck,” he said laughing.  “Sew on, man.  Get on it.  Plus, if you don’t do it, I’ll shoot you.” “What?” I asked. “Just kidding, I’d never shoot a doctor as good as you.  Ha!” said Lighterman.  “Here you go, man,” he said and pulled a handful of cigarette lighters out of his pocket.   “A little somethin’ for the effort.” “No, that’s okay.  I don’t smoke.  I don’t drink or take drugs, either.  Neither should you.  I really don’t need a bunch of cigarette lighters.  Plus, we don’t accept tips here in the Emergency Department,” I answered. “You don’t drink, smoke or take drugs!?  What do you do?  You’re a tough negotiator, boy!  You’re playin’ dumb.  It’s not enough is it?  Here you go.  ...

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Those Shoes

By BirdStrike M.D. Some cases burn into your brain like a hot branding iron, for whatever reason, and never really leave.  This was one of those cases. One hectic morning before my shift, my wife and I rushed around the house trying to get our kids ready for school.  On this day, my daughter was to go on a field trip where the teachers would walk the kids through the city to the local park to study the small oasis of nature in the “concrete jungle”.  Before such field trips I would always wonder, how the teachers can corral all those little kids safely through such a crazy city, crossing such busy streets.  “We are super careful,” the room Moms would ensure everyone.  My wife had gone on a couple of these field trips and she remarked at how organized they were and how good the kids listened, holding hands and singing as they walked in a long hand-holding train through the city.  “Okay,” I would say, “sounds like they’ve got it under control”. Working in the ED, I knew better.  At this point in my career, I had already seen most forms of human tragedy up close and personal.  Sometimes I wonder half-joking, half serious, if there is something called “PTS-ED-D”, or “Post Traumatic Stress Emergency Department Disorder”?  Of course, not, that’s nonsense. As we rushed to get the kids ready for school, my 5-year-old daughter beamed her baby-blue eyes up at me, hair curly golden-blonde and said with a life loving smile, “Daddy!  Can you put my shoes on, please?” She proudly raised her adorably tiny and favorite new hot-pink glitter shoes and handed them to me.  I put them on her and she blew me a kiss.  “Bye Daddy!  I love you,” she said. “I love you, too.  Have a great day at school,” I said.  At light speed, they rushed out the door and I rushed to work for the early shift. Two hours into my chaotically routine shift the charge nurse gets off the phone and says, “Buckle up guys.  We’ve got a pretty bad one coming in.  EMS will be calling in any minute: Trauma, level I, no vital signs.” “Alright, guys.  Trauma room one.  Let’s go,” I say.  Before any radio call, the ambulance doors blasts open and all I see is a blue swarm of huge EMS men around a rolling ambulance stretcher, one up high doing chest compressions with sweat pouring off his red face like Niagara Falls, and all the others busily working this trauma looking notably more stressed than usual.  As they roll down the hallway towards us, still I see nothing but a sea of big burly EMS men and haven’t seen even a glimpse of an actual patient yet.  As they roll around the door and make their left turn towards me, a tiny but searing flash of hot-pink and glitter explodes into my eyes through the sea of blue uniforms.  “Oh… My… God…” I think to myself. T  H  O  S  E     S  H  O  E  S Hot-pink.  Glitter.  Tiny.  Time stood still. . . . I felt my heart rate dropping.  I was getting dizzy.  Was my worst nightmare about to come true, right here in my own ED, on my own shift?  I needed to see the face.  NOW.  I was afraid the see the face.  As “clinical” as I could be to get through the most difficult parts of my job, this was too much.  As the stretcher came towards me, the sea of uniforms parted and I saw her. A girl 5 years old, ...

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Obama vs. Romney vs. Honey Boo Boo

By Birdstrike M.D.   Once again, our upcoming election will have great impact on future health care policy.  Obamacare will either be kept intact, repealed or altered.  This will have great impact on patients, physicians in general, and especially Emergency Physicians.  By whom they choose to lead us, the electorate will decide whether treatments are rationed or not, and if so, to what extent, by whom and on what basis.  They will decide whether doctors are free to choose what tests to order, and if so which ones, how many and for what reasons.  Also, they will influence physician salaries, by choosing the leaders who will determine Medicare and Medicaid reimbursement, which generally lead with reimbursement cuts that private insurers follow.  Our electorate will determine our malpractice liability by choosing our leaders who will either, strengthen, weaken or ignore tort reform.  They will influence which charting systems we are required, or not required to use, given that Obamacare has already written into law penalties for failure to implement electronic health record use.  By whom they choose to lead us, the electorate will influence how much we are, or are not burdened by regulations, and whether these regulations will be logic based, or cumbersome and irrational. The choice of the electorate will affect which pay for performance measures we and our salaries are subject to.  Likely, they will also influence which form of patient satisfaction surveys we are or are not subject to.  Also influenced, will be our overall workload depending on whether patients are adequately insured, by which doctors and in which settings.  This will influence who is most, or the least burdened by the overall shortage of healthcare providers, and whether or not the millions of newly insured will end up in primary care physicians’ offices, shunted to emergency departments with growing wait times, seen in specialists’ offices or remain uncared for.  How informed, or uninformed our electorate is, particularly as it relates to health care policy, will affect the health of our patients, our livelihoods as physicians, not to mention the health of our families and ourselves as patients. Since the end our nation’s two major party conventions, it caught the attention of several major news organizations that on any given night of the week of either the Republican or Democratic National Conventions, that both parties faced stiff competition for viewers from the new and controversial TV show on TLC called “Here Comes Honey Boo Boo,”  which TLC describes on its website as a show where a “six-year-old pageant sensation proves that she is more than just a beauty queen.” As said by the child’s own mother, June Shannon on ABC News, “We are a little redneckish, and we live in Georgia and that’s what people do in the country — get muddy and have fun with the family.”  In the first episode they take part in the “Redneck Games,” bob for pigs feet and take part in a “mud pit belly flop.”  Although fortunately the overall viewership of the conventions was greater according to ABC News, this show did draw more viewers than Fox News’s coverage of the Republican National Convention on at least one night and tied the ratings of the Democratic National Convention during Bill Clinton’s speech.  Does anyone know where Honey Boo Boo stands on health care? Apparently, a large part of our electorate would prefer to watch a show like TLC’s “Here Comes Honey Boo Boo” over either convention.  Whether this is more of a reflection on our political parties, our electorate, our “Democracy” or (hopefully) none of the above, I am not sure.  However, two months before an election where we will choose a ...

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What Is Your Life Worth?

By BirdStrike M.D. “Good, it’s about time that these greedy doctors get smacked down for being the financial rapists that they are.  Medicine in this country is the biggest, most destructive SCAM going on today. Doctors think they are entitled to RIDICULOUS amounts of money for simple routine procedures.”- Johnathan Blaze August 27, 2012 at 4:54 pm It is generally agreed upon that the more one values a good or service, the more he or she is willing to pay for it.  Most will agree that shoes are important.  They keep your feet from bleeding and hurting when you walk on the street.  People seem happy to pay anywhere between $20-$150 for them.   Some will clamor to pay without complaint as much as $315 for sneakers that mimic those of their favorite basketball hero, or $865 for designer Manolo Blahnik “BB” Snakeskin Pumps.  Many place great value on a youthful physical appearance and sex appeal and will gladly pay up to $15,000 cash for a new pair of breasts with little if any sense of resentment for the doctor providing the service and metering the charge.  Having a car, most of us will agree is very important, and therefore paying around $30,000 is pretty average.  Though it seems that many are outraged at a Plastic Surgeon charging $12,000 to repair a fingertip, most people consider their limbs and appendages important, and being able to use them of significant value.  Therefore, it follows that a total cost of approximately $40,000 for a hip replacement tends be generally well accepted and frequently paid by insurance companies along with the physician portion of $1,505 (CMS CPT 27130.) So how much is your life worth to you?  Clearly it is worth more than a pair of shoes.  Are we still in agreement?  Certainly you would be more than happy to pay $20-$150 to have it saved, if you or your insurance company had the finances.  Is a human being’s life in total worth more than the $15,000 pair of augmented breasts on the human being?  I’m sure most would agree it is.  I’m sure as a society we must pay more than this for a human life saved, correct?  I’m sure we all similarly agree that the entire value of a human life saved is greater than the value of a “spare replacement part” such as a $40,000 hip.  We must certainly and gladly pay those who save our lives at least as much as we pay for sneakers, designer shoes, our cars or a spare hip, correct? No.  We don’t.  It’s not even close. In the field of Emergency Medicine, there are only a few situations where the physician can truly walk in a room and walk out a few minutes later absolutely certain he saved a life.  One is an emergency intubation (making a non-breathing person breath again) and another is cardioversion/defibrillation (restart a non-beating heart.)  It doesn’t always happen every day, but it is what Emergency Physicians and other critical care providers are paid to do.  To be an Emergency Physician is a paid position.  It is not a volunteer position.  It stands to reason that Emergency Physicians would be paid at least as much as for a life saved as for the aforementioned goods and services, correct?  Let’s break down what a true life-saver gets paid to save an entire life, not just the hip, the breasts, the fingertip or the shoes. What an Emergency Physician actually gets paid to save a life- 1)      Emergency intubation: $112  (CMS payment for CPT 31500) or, 2)      Cardioversion/Defibrillation: $131  (CMS payment for CPT ...

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Tony the Doorman

By BirdStrike M.D. I’m sitting in my apartment on the West Coast starving, listening to my stomach growl, waiting for my pizza to be delivered.  It is taking unacceptably long.   I’m going back and forth on how little I can tip the pizza delivery man without feeling too guilty to actually enjoy the pizza if and when it ever arrives.  There’s a knock on the door.  Thank God, I think to myself, it’s about time. I open the door, “Pizza’s here,” says the pizza man.  “You’re the best doctor in the world!” “What?” I say.  “Yeah, the doorman says you RULE!  He said if I ever need to get checked out, to go see you.  He says, ‘You da man!’” “Oh, that’s just Tony the doorman,” I say shaking my head.  “Don’t listen to him.  He says that all the time.” ………………………………………………………………………………………………………………………………………………………….   I pick up a chart in the ER, back when there still were things called “charts”, and it says: “Tony ***** 37-year-old male.  Chief Complaint: Back Pain.”  I walk in the room and it is Tony the doorman of my apartment building, nervous, sweaty and pacing the room, with his jet-black hair slicked back and his gut as huge as always. “Tony!  How are you doing?  Good to see you.  What brings you in here, today?” “Doc.  You gotta’ do somethin’.  My back’s killin’ me.  I’m dyin’ here,” he says in his tough-guy accent, as he nervously paces the room. “Where does it hurt?” I ask. “Right here,” he says, pointing to his upper back, “right between da shoulder blades.” “When did it start?” I ask. “Just a couple hours ago.  I didn’t do nuttin’.  I was just sittin’ there and it hit me like a ton of bricks.  I didn’t fall, lift anything heavy or hurt myself at all.  I’m dyin’ here doc.  You gotta help me.  I need something for this pain,” says Tony. “What does it feel like?” I ask. “It feels like someone’s got a sledge-hammer on my back.  Seriously, man.  I’m dyin’ here.  Come on.  Do something doc.  Make this pain go away.  I need something for this pain.  Please.” “Is there anything that makes it any better?  Anything that makes it hurt worse?” I ask. “Nope,” he says. “Does the pain move?  Does it radiate?” I ask. “No,” he says, “it’s just right there in da middle of my back?” “By chance, is it a ‘tearing pain’ right between your shoulder blades?” I ask. “Not really,” he says, “it just hurts!” My gut is telling me that something is not as it appears.  I have the nurse give Tony a dose of Morphine while I continue to get the history.  Tony proceeds to tell me that he doesn’t drink, smoke or use any illegal or prescription drugs.  Also, he reports no significant medical problems, and no significant family history.  He also denies any history of chronic pain of any kind.  His physical exam is completely normal including his vital signs with equal blood pressures in both arms. “Alright, Tony, the nurse is going to give you another dose of the pain medication.  We’re going to get a chest x-ray and see what that shows.  I’ll be back in a few minutes,” I tell him.  My gut is telling me, that there is something Tony is not telling me, but my brain is telling me that if Tony’s upper midline back pain is from a thoracic aortic dissection, and he dies from it, I’ll never forgive myself. “Doc, it’s starting to hurt right here,” Tony says, pointing to his chest. Bingo, I ...

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