There are some people in the blogosphere who have to chill. I have received a boat-load of vociferously angry comments on this site over the last two days – it appears that many of these commenters are either: A. Overly sensitive to any discussion of obesity that does not remove all blame from the patient. B. People who suffer from chronic pain conditions (legitimate or otherwise) and Cushing’s disease/syndrome and C: People who just don’t get what it is like to work in an ER. Some are all of the above.
Thus, in this post, I will address my view (and very likely others’ in the health care field – especially those who work in the ER) on obesity, chronic pain, psychiatric illness, and what it is like to work in an ER. Take this into account when you read any future posts that concern these issues – and don’t immediately jump down my throat saying things like “You are not compassionate”, “You should be a garbage man, not a doctor” and “I would report you to the medical board if I knew who you were”. Please try to keep comments at least somewhat constructive or they will be deleted.
Any other health care providers please feel free to chime in.
A. Obesity. Everyone agree that it is an epidemic in this country now. Just take a look at the average personal health record. Unfortunately it is getting worse and worse in our youth for a myriad of reasons. The other sad fact is that our obesity seems to be spreading across the oceans to other countries as well. Our country’s obsession with fast food apparently is being exported. Even in France all places, American-style fast food is making inroads, bringing obesity along with it. So, with that said, what to make of obese patients. First, any patient who is having an emergency will be treated appropriately with compassion in my ER. This of course includes those who are obese. However, the sad fact is that many people feel that obesity itself is not at all in any way even at least partially the fault of the obese patient. I do not believe this. Yes, there are a minority of patients who suffer from conditions where they are bound to be obese no matter what they do. Those who have adrenal diseases (like Cushing’s disease or syndrome), are severely disabled, have hypothyroidism, fat storage and metabolic diseases, etc really cannot do much to prevent themselves from becoming overweight unless they starved themselves. People who really have these conditions have truly been dealt a very bad deck. Many others are obese at least partially for psychiatric reasons. They eat because they are depressed – food is their drug of abuse. However, many, many people are obese because they simply eat too much unhealthy food and do not exercise enough. Many of these people live in subcultures within America where obesity is not only tolerated (mostly in women), but is praised, despite the well known health hazards. Obese patients are treated with respect in my ER – however, if they are disrespectful to the staff, demanding, and make a nuisance in my shop, they will get rebuked,just like any one else. Additionally, just like with smoking, I feel it is a doctor’s duty to reprimand patients for unhealthy behaviour – and this includes unhealthy eating and subsequent obesity.
B. Chronic Pain. Here is hot-button topic if ever there was one. Chronic pain is HORRIBLE. Chronic pain is debilitating. Chronic pain is sad. However, chronic pain is not to be managed in the ER! If truly have chronic pain, go to a pain management specialist! Often they can recommend many treatments besides narcotics to control it. I am sure there are millions of these sufferers who do indeed go to specialists and guess what – we never see them in the ER! Or, if they do come in, it is only once in a blue moon. The ones that come in day after day after day with diagnoses like “tooth ache”, “migraines”, “fibromyalgia”, “back pain ” (often with no documentation of getting any real work up for the cause their pain) , etc and claim to be “allergic” to everything except Demerol, alter our Rx’s, and overtly fake or exaggerate symptoms are a different breed. They are manipulators and often criminals. The should be arrested. They are lucky they just get thrown out with Naprosyn. They may be a minority of chronic pain sufferers but they drain our resources, waste our time, and cost the taxpayers money.
C. Psychiatric Conditions. Psychiatric disease is widespread. Many, many, many people have some form of it. In fact, I cannot recall the study but I remember reading one a while back where where the investigators went to a busy ER waiting room. The did not ask what the people sitting there were there for – they just asked them to fill out a professional questionnaire used by Mental Health providers to screen for anxiety disorders. About 40% of the people that responded there were determined to be suffering from some anxiety disorder! So, you can see how often we in the ER have to deal with it! Anyway, people who suffer from these disorders need help. In fact the ER is a great place to come when you are truly down to the point where you are suicidal or at your wits end. It is not a great place however if your symptoms are milder. We are simply not trained for and do not have the luxury of time to spend with each person who has a complicated psychiatric history. We have to juggle an ER with sometimes dozens of patients, some of whom are in danger of dying at any moment. We cannot do much for you except admit you or make a referral.
D. Life in the ER. Simply put, if you have not spent any significant time either working or volunteering in an ER, you really don’t know what it is like. People are at their WORST in the ER. Sometimes it is because they are sick or a loved one is sick. Sometimes it is just their true colours coming out. If many of you extremely touchy-feely types actually had to work a shift in the ER you would probably want to kill someone. Why? Because you don’t realise it but much of the population is either nasty, manipulative, violent, malingering, antisocial, and or disrespectful. Of course the majority of people we treat are not, but I guarantee if you have to deal with even 4-5 out of the 20-30 you might see on a given shift, you will re-think things. Imagine getting threatened by people who you are trying to help. Getting spit on. Getting told what do by people who don’t know anything about the practise of medicine except what they read on blogs or in newspapers. Witnessing the gross indifference people have for sick loved ones. Witnessing child abuse regularly. Dealing with intoxicated persons who want to kill you. Listening to people bullshit you about their medical conditions so they can either get out of work, get disability, or get narcotics (often for resale). Imagine getting zero respect from people for the years of training you have. Our oath forces us to deal with and treat people the rest of you in the outside world would just walk away from, ignore, or call the police about. I signed up for this so I know I have to do it so don’t accuse us of whining. This is whining. And on top of all this, you have to treat the TRULY sick people – ie people have to be intubated, recussitated, cardioverted, sutured, and transfused. Those 4-5 “bad” patients severely inhibit you from what you are trained to do – take care of the sickies. They waste your time, sap your energy, and burn your resources. How do we cope? We develop morbid senses of humour. We develop tough exteriors. We tell those off who need to be told off. Nowadays we vent on the internet. (this blog partially serves this purpose for me) You won’t last a month if you don’t develop these survival skills. That said, I would not change my job for anything. Why? Because there are also always some people per shift who really do appreciate what you do for them (even if it just telling them they are OK and they have nothing to worry about). There are people you bring back from the dead who look back at you in thanks. There are people that make you laugh. There are people who help restore your hope for humanity. That and the fact that you never get bored working in the ER -which I consider worse than dealing with drunks! And finally, we don’t get rich working in the ER. We do all right and I am grateful for the living I earn, but don’t lump us in with high profile surgeons like Dr 90210.
All that said, it really comes down to respect. If you are not in true extremis (ie about to code, severely short of breath, just got shot, or have a bad fracture in which case I will of course forgive you), then I will do almost anything for you when you come to my ER as long as you can show some respect and thanks to me and my staff. I have gone on the internet to help people figure out their insurance and find them a provider that takes it, I have called 10 relatives all over the patch to keep them informed as to a patient’s condition, I have spent hours arranging a transfer for people not out of medical necessity, but for their personal preference. I have given people money to get home on the bus. I write generous work notes. I have spent eons explaining a diagnosis to patient while the whole ER backs up. I will give you 25 percocets just because I don’t want you to run out over the weekend. I have spent 30 minutes with families who just lost a loved one.
Don’t say I am not compassionate
However, if you try to pull a fast one on me by lying, faking illness,exaggerating symptoms, or making threats, or you are just plain disrespectful and nasty, don’t let the door smack you on the ass on your way out. (Cushingoid, or not)