From the monthly archives:

March 2009


I just returned from an emergency medicine conference in San Diego.  Outstanding place for a conference, depressing to leave actually.  The prevailing theme at the conference was avoidance of law suits, and how to defend against them.  I strongly feel that any efforts by our government to reform our health care system has to include liability reform.  Every ER doc worries about this problem on a daily basis.  Every patient is a potential plaintiff, every complaint a potential disaster.  All of us are aware of cases where the ER doctor simply did their best job possible, and got sued anyway.  There are many cases where juries award huge sums of money to plaintiffs simply because they felt sorry for the defendant, even if there was nothing wrong with the medical care.  Plaintiff’s attorneys often file cases on contingency, so that the plaintiff doesn’t have to spend any money on the lawsuit, and the attorney is heavily motivated to acquire a large judgement.

As a result, physicians often practice defensive medicine–ordering lots of tests, CT scans, and admitting lots of patients who could probably be discharged home, for fear of liability.  They also have to pay huge liability insurance premiums.  On top of this, ER doctors are required by law to examine and stabilize any patient who arrives at their ER, regardless of the patient’s ability to pay.  All of these factors result in increased costs to patients, and unhappy physicians.  I know that unhappy ER docs are not a primary concern of the general public, or the government, but they should be.  I for one, would like to have the best people available in the ER when I arrive with my heart attack, broken leg, stroke, or meningitis.  I have personally seen many ER docs hang up their stethoscope for jobs with lower liability, where they can make more money.  If the trend continues, quality will go down.


irobot-glanceWhen I was told recently that our emergency department would be getting a robot to help us, I must admit I was a little nervous.  What exactly would this robot be doing, I wondered.  Perhaps it has every medical fact from every specialty downloaded onto its hard drive, and a better bedside manner than me.  Perhaps in a few weeks, my services will no longer be required.  The day arrived, and the robot was delivered to the ER.  It stands about 5 feet tall, and its head is a flat screen monitor.  Two video camera lenses gape at you like oversized fish eyes.  There is a speaker in the center of its chest and it moves around on wheels.

Now here’s the good part.  It can’t do anything without a doctor.  Pheww!  What happens is I call up another doctor who is not anywhere near the hospital, and he can talk to me (and presumably a patient) through the robot.  That’s it.  That means my job is safe.  However, I don’t want to understate how valuable this tool could prove to be.  If I need a specialist that we don’t have, I could get a consultation from a doctor anywhere in the world as long as they have an internet connection.  Totally cool.  Now if I could just figure out a way to see patients myself while I hang out in the hot tub I’ll be set.


Don’t parents know that rashes can be caused by food?  I had a young girl, about 4, brought in by her parents for a rash a while back.  She had eczema, and had been sufferingdairy-allergy from it pretty much her entire young life.  I launched into my quick question mode and found out that no one had even considered various allergic causes of the rash.  I asked if she seemed particularly sensitive to any foods, and the mom said, “Oh well when she drinks a glass of milk, she has terrible diarrhea and bloating, and maybe her rash gets worse.”  Trying to lead them a bit, I asked if they thought she might be sensitive to milk or dairy.  They weren’t sure.  I asked if they had ever tried a dairy free diet.  No.

It’s hard to imagine having a child with these symptoms, and not trying a couple diet changes to see if that would help.  Unfortunately for this child she has suffered now from fairly severe allergic symptoms for several years that were most likely preventable.


overdose drugsNarcotic medications are a big problem in every ER I’ve worked in.  They are powerful medications, and can cause tolerance when used chronically.  We get a lot of patients in the ER who want refills of their pills, and I have heard some far-fetched reasons why.  Lost or stolen pills is pretty common, and one that I hear occasionally is, “I accidentally spilled my pills down the toilet.”  Come on.  Does that really sound believable to anybody?

One thing that continues to surprise me is patients who come in to the ER with a narcotic overdose, but are just awake enough to ask for for more pain medications, usually by name.  One moment completely asleep, then, eyes barely open, asking for a dose of dilaudid.  Umm, no.

Like most ER’s, we use a pain scale from 0-10, to gauge how much pain patients are having.  Seems like 10/10 is the most common response, but sometimes it’s even higher.  One of my former colleagues (not known for subtlety) would become irritated when he got a 10/10 pain level from a patient.  He would roll his eyes and say “Oh really?  So I could take a chain-saw and chop your legs off, and you wouldn’t even notice because you’re having so much pain?”  Really sensitive.  He had various other horribly painful examples to use depending on his mood.  “So if I dropped you into a bathtub full of scorpions, you wouldn’t even notice because of your ankle sprain?”

This same doctor liked to sneak up on patients to see if they appeared to be in pain when they did not think they were being watched.  He would literally creep around the corner, on his tip-toes and then pull back the curtain just a smidge.  If he thought they were faking their pain just to get narcotics, he would be livid.  Come on man, what are we?  Twelve?