Mr. Hassle’s Long Underpants

Is his healthcare advisor’s attitude toward’s Emergency Departments:

 In the Los Angeles Times’s (8/28) Booster Shots Blog, Shari Roan wrote that this week, “John McCain campaign advisor” John Goodman “said, in effect, that as long as there are emergency [departments], no one in America is really uninsured.”

And…

Op-ed columnist Paul Krugman writes in the New York Times (8/29, A21) that according to Goodman, in America, “there’s no such thing as being uninsured. After all, you can always get treatment at an emergency [department].” Furthermore, Goodman “the president of the National Center for Policy Analysis, an important conservative think tank…wants the next president to issue an executive order prohibiting the Census Bureau from classifying anyone as uninsured.”

Understand that there are a few issues here:

1)  An unfunded government mandate that requires that anyone presenting to an ER requesting medical evaluation, or someone requests a medical evaluation on their behalf, must receive screening for an emergency medical condition regardless of ability to pay.

I have no issues with screening people for medical problems…but the government provides no compensation or liability coverage for hospitals or physicians following this mandate.

Why should this concern you?  When the ER is full of uninsured people demanding an evaluation for their chronic pain or made up medical conditions, or just because they are bored and it’s your hospital’s turn for their daily/weekly/monthly ER visit (yes, it happens…over and over and over again)…YOU or your LOVED ones, who are responsible users of the system will be a) waiting for an ambulance to return to service after transporting the “sprained ankle” who didn’t have money to call a cab or b) waiting in the waiting room because all rooms are full…

Problem #2

Going to the ER to be screened for an emergency medical condition is no substitute for primary preventative care.  People come to the ER only AFTER they are ill, or well advanced into a serious medical condition for which the might have sought treatment had they had insurance.  In addition, the ER is only required to screen for an emergency medical condition and provide stabilizing treatment.  In other words, if the patient does have a medical condition, but it is not an emergency (long term treatment of hypertension, for example), the ER is a horribly inadequate place to be seen and evaluated.

A patient like that will fall through the cracks, not follow up, not be treated for his ongoing medical problem until he shows up in an ER years later (if he can get in) with a heart attack, stroke or flash pulmonary edema.

The stance of the McCain advisors is flat out abuse of the existing Emergency Medical System, which will ultimately hinder your ability to receive appropriate and timely emergency medical care when you or your family needs it most.

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I see a lot of Horse injuries up here in the rocky mountains.  Mostly tourist stables and stuff, but when there are horse shows in town, we seem to get a lot of hunter-jumper injuries…girls getting thrown headfirst from their horse.

Which is wierd, because during the rodeo, when guys are deliberately riding horses & bulls getting thrown off, we never see them in the ER.  Those cowboys are tough and refuse to go to the hospital, even if they can’t breath or walk.

So my new motto is, “If you’re not a Cowboy, don’t get on a horse.”

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I rounded the nurses station to drop off a chart only to by confronted by a clown.

I did a double take…yes, it was a clown, sitting in a wheelchair. A Pink curly wig donned his head and billowing teal pants with red and pink polka dots spilled through the spokes of the wheels.

He sat staring straight ahead. The droop on one side of his face pulled his make-up over to one side and made his painted red nose even more prominent. But it didn’t make me laugh.

I quickly examined the clown from head to toe and added some new parts to my neurologic examination.

“Raise your eyebrows for me,” I said.

His rainbow painted eyebrows tilted his whole forehead to his left as he struggled get them up.

“Show me all your teeth.”

The cognitive dissonance between a clown with rotten teeth and halitosis augmented the irony of his presense.

A short thin bobbing woman who resembled a toothpick came skipping down the hallway. Her bright orange wig somehow made me smile and she thrust her hand out to introduce herself.

“I’m Jellybean,” she squeaked. “How is Riggles doing? The rest of the group will be here shortly”

“Hi Jellybean, I’m Doc Shazam,” I replied. The words that came out of my mouth were, “It looks like Riggles has had a stroke.” But inside my head I was thinking, “A whole group of clowns arriving in our ER will make everyone happy.”

I’ve learned to emotionally separate myself from the personal details of my sickest patients, but internally, this seemed ot me to be a step too far. As I put in the alarm for a stroke alert, I was smiling inside at the thought of a hallway filled with bobbing, squeaking, smiling, polka-dotted, wig topped, red-nosed adults in Urban Blight Memorial.

I forgot that people who live in this community still reach out to their neighbors. Ghetto Clowns. Nice.

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Rather than write my own version of the night, I’ll just post this group poem that was written the next day.

Once upon a midnight dreary
There I pondered, weak and weary
About a hound named Lola
Covered with bumps of curious lore.

When all at once I heard a knockin’
Lee-Ann cried, “Shazam! This dog is Talking,
About an oozing bloody mass that’s
Spewing pus upon her fur!”

Then the puss soaked, slimy rustling of each fur
Sickened me-left with a queezy feeling never felt before
My Soul grew stronger, hesitating then no longer
“L-A I will help you ferry, and in the process make more merry
The journey to the vet, to ensure the health of the ‘lords pet
Route 8 and nothing more,

Now Dasher, Now Dancer, Now Prancer, Now Vixen.
On Comet, On Cupid, On Doner, On Blitzen.
Grab a cat leash, your pal Shazam and jump in the CRV
Wait we do and patiently.

We arrived upon the clinic so dark
and pounded on the door,
“bark, bark!”
The entrance swung open slowly
and creaked a lonely sound.

We entered, females three,
Lee-Ann, Lola and me.
And lamented that there were only
two humans to laugh out loud.

When suddnely the door swung open,
“CARL!!!” Shazam shouted with emotion.
The waiting room got quiet and all eyes
darted from the floor.

On the road they had phoned, explained and bemoaned
and dreams of ice cream roused him twisting turning speeding toward them
Deep in the darkness came a beac’n not without a certain reak’n
Eat n’ Park!! was the source to spurn this man upon his course
surrounded by “smiley” faces awaiting patiently his bounty
Twas 3 shakes. Who could ask for more?

Text at 11, replies of fright,
“a leaky bassett hound you say?”, not such a delight
but how, but when, but why, you might ask?
no explanation given, just focus on the task
poor lola the bassett, she can barely see
but rest assured in better hands she could not be….

Upon his arrival, barging through the doggy door
There erupted from a patron a heartfelt gutsy roar
Joyous their reunion, cold and creamy their communion
cheery banter filled the air , those around tried not to stare
who are these interlopers disturbing their morbid lair.
Shakes by Jamaal and nothing more

Deep in the darkness, the talk turned to canines, cycling, appendix, cogs
lawyers, patrons, friends, hats and puss filled dogs
A feline hit by a car, and a Husky too drugged to walk far
amidst the downcast faces surrounding them in these morbid places
They found laughter and sun- the clock steadily approached one
350$. Nothing more

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I was trying to quickly wrap up my patients for the afternoon, since I had someplace to be at 6pm (a bike race to be specific), when  the nurse taking care of the woman in room F told me that her son had some questions for me.

I sighed.  I always want patients and family to understand what is happening, but sometimes I feel like i explain the same thing over & over again (because I do, most of the time).  But this time the questions were different.

“I need you to be frank with me,” her son stated solemnly, but peacefully at the same time.  I actually felt soothed by being in the room with the woman whose blood pressure was 88 systolic and her pulse ox was 85%.  “Is my mother in imminent danger of dying?” he asked.

I wasn’t quite sure how to answer his question, so I probed further in to why he was asking.

She was a “no code”, “Do Not Intubate”, “Do Not Resucitate”, etc.  Generally, I know what that means, but far more important than what boxes are checked on the “DNR” form is what the patient wants from their quality of life.  I feel that it is the onus of the physician and healthcare team to determine what “boxes” to check, based on the patient’s and family’s stated wishes for end of life.

After discussing his mother’s quality of life, I gave him my recommendations.  I didn’t feel comfortable withdrawing all care until he had the opportunity to talk to his sister in North Carolina, and to talk to his mother’s physician.  While I was flattered that he asked for my opinion, I explained to him, “I’ve only known you and your mother for less than two hours.  I don’t feel comfortable telling you stop all treatment right now, but I will give you my advice about what you should do tonight.”

I suggested that we continue fluids, antibiotics and humidified oxygen through the night to maintain her present state of health, and possibly improve it.  This evening he could discuss the case with his sister and in the morning talk about it with his mothers physician. I told him that there was nothing that we were doing tonight that could not easily be stopped in the morning and this would give him and his sister time to discuss her care.

Was it a cop out on my part?  I don’t think so.  I’ve recommended to families that they stop all treatment in the past, especially when it’s clear what the patient’s wishes are.  I wasn’t certain that this lady would die tonight if all treatment were stopped…I was pretty sure she would linger for days to weeks, getting progressively worse every day.  I wanted him to at least enjoy her company for one more night.

She said to her son just as I was leaving, “Matthew…I’m not very good company right now.  Why don’t you go home.”  Matthew didn’t seem to mind just sitting there in his mother’s room.  Enjoying her quiet serenity one last time.

Matthew didn’t mind it at all, and neither did I.  It was better than the bike race would have been.

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