Good evening everyone, and thank you for coming to my talk. This is “Travels in Emergistan,” and I’m Edwin Leap.
So, a few years ago, I was at the doctor’s office, and because I don’t want to implicate this one physician of mine, I won’t say his name, but he said to me one day, “Ed, do you do any mission work?” And this guy is a fantastic man who does lots of mission work overseas with his children, and I said, “No, I don’t,” and then I left.
And then you know how you have that discussion, and after you’re done, you think, “Oh! I should have said that!” And I said I should have said, “I go to the emergency room,” but what is that? And then I thought I need to make a name for the place I go, the place you go, the place we work. So I decided to call it Emergistan, without the intent to insult any particular country, but it just seemed like an exotic-sounding name, and frankly, we go to a sort of exotic place.
So now I will share with you the flag of our noble land. It says, “The Republic of Emergistan.” I have it on my pin here. “The Republic of Emergistan,” where our motto is “Semper A Decem.” The vulture, I think is self-explanatory. Red is for blood, green is for infection, blue is for blood, and “Semper a Decem” in reference to the pain scale is, “Always a 10.”
The Emergistan as we know it really began in 1986. For those of you who know about EMTALA’s history, that’s when EMTALA came into effect, and I believe at that point, we became who we are today, the beginnings of who we are today. So let me just say a big thank you to Washington for what we deal with every day of our lives.
And we have our pledge, right? Every country has a pledge, right? “I pledge allegiance to the flag of the Republic of Emergistan. And to the chaos and hope for which it stands. And to the brave souls who work there / facing suffering, stupidity, and never-ending need with science, compassion, and cynicism. Doing the impossible in the worst of situations with pain scales, work excuses, and ridiculous regulations for all.” Amen.
If any of you are musically inclined, I’d be happy for you to write an anthem for us, and I’ll put it on the website, and we’ll publish it. I had an idea: “Emergistan, Emergistan, doing the things nobody can. Is it dumb? Is it tough? Everyone wants more drugs and stuff. Oh, yeah, this is Emergistan.” But, you know how those Marvel comics people are.
So, some of you are nurses, some of you are not emergency physicians. You may be intensivists or what else, so I want you to understand that today you’re all Emergistanis. We are all affected by Emergistan because you admit patients for Emergistan, you come down to the department, so just like John Kennedy said, “Ich bin ein Berliner!” Today, “Ich bin ein Emergistani!” We’re all one with the people of Emergistan.
But it isn’t really a place; we’re certainly not limited by locale. Every emergency department from around the country is sort of a state of mind; it doesn’t matter so much where you are. I’ve been going to Locumstan lately, as a part-time job, and I can tell you, emergency departments are the same in every place. It doesn’t matter if they’re in Indiana, it doesn’t matter if they’re in West Virginia or South Carolina or Nevada; people do the same things and they say the same things. The doctors face the same struggles, and the nurses face the same struggles, for those of you who are nurses.
The problem is when, at the end of the day, when we go home, and we talk to people about it, people don’t believe us. Have you faced this phenomenon? When you try to talk to people about what you do, you try to explain how it is, sometimes even to your family, they sort of, like, shake their heads and think that there’s something wrong with you. Your friends don’t believe it, your administrators certainly don’t believe it, and your politicians frankly could care less. Now they think you’ve taken crazy pills.
So, I was called to testify for a friend who was brought before the state medical board on some spurious charge that had to do with missing a BUN:creatinine in a hospital. So he was charged with unprofessional behavior. So the attorney who was trying to “prosecute” him, as it were, said to me, the patient came by ambulance and, “Dr. Leap, I’m well aware that patients who come by ambulance always require immediate attention for life-threatening problems.” Really? So I said, “No, sir, that’s not true.” “Well, it…” “No, sir, but it’s not.” And so had a little impasse there, as he had to reconsider his strategy.
But if you do try to explain, people call you bitter, or they call you small-minded, or they call you a liar, or they say you just need a break, you just need some time off. I’ve written some columns about this before, and people said in response, “You need to get out of medicine for a while because you just need a break,” and “You shouldn’t practice medicine.” Well, OK. They call you hateful or judgmental. And, of course, the worst thing you can do in our society today is make a judgment about something. But don’t worry, at the end of the day they’ll still call you for Zithromax because everybody has a cold now and then.
But… those who don’t believe you, you let them sit in the waiting room for just about an hour or some time. Your friends, your family, your politicians, and they will believe everything you say. I’ve been there, though. I believe you. I believe all of the stories you tell me. You could tell me the strangest story imaginable, I would believe you because I know you’re not making this up. But, as strange as it is, we have to analyze it. We’re scientists; we want to catalogue, and we want to record the phenomena we observe in Emergistan.
So, I want to think of this as a travelogue. This [lecture] is some of my notes to share with you. And you may have notes to share with me. I’d love to hear from you if you want to write to me, you want to post things on my website or blog, I’d love to hear it. So, I’m going to be talking about the biology, anthropology, culture, and customs of Emergistan.
So I guess that makes me like Jane Goodall, except the chimpanzees weren’t quite as difficult to deal with. They had hair on their bodies, they didn’t ask for drugs, or ice chips. Ice chips, what is that all about? You get this? People ask for ice chips all of the time? It’s like the most important thing in the ER. Crushing chest pain, and “Doctor, can I have some ice chips?” So, it’s a strange place, I mean there’s rich culture, a lot of diversity of thought, and ideas, and people, and half-truths, and dysfunction. But even some physical laws are a little odd in Emergistan. I mean, it’s like a parallel universe in some ways.
Time. … Time expands and contracts oddly in Emergistan. Sometimes, when you’re doing resuscitation, 20 minutes can feel like five hours. And sometimes, when you’re doing something really good for a patient for a couple of hours, they think that you’ve taken forever, right? “I’ve been here 12 hours, and nobody’s done nothing for me, or said a word to me.” Except, what actually happened was you got a CT scan, you got Morphine, you got surgical consult and labs; that was about three hours. So, somehow, there’s a disconnect in the way people receive time in the emergency department.
Also, sound waves are different. When an appendix ruptures, it makes a sound like a shotgun. Have you hear that story before? People say, “My appendix ruptured, and I swear to God, it sounded like a shotgun going off.” Really? OK. Who knew? That is not, by the way, covered in Cobb’s Diagnosis of the Acute Abdomen or Sabiston’s surgical text.
There is also electrogenitalmagnetism. Heard of this? Maybe not. I may actually get to diagnose this myself. I may get to call this, “Leap’s Electromagnetism of the Genitals” or something. So, here’s what happens: A man comes to me in the middle of the night one day with his pregnant wife in tow, and he has two rare earth magnets pinching together his scrotum, causing pressure necrosis. As you might expect, it’s a little bit difficult to remove them. People don’t want things like that yanked or pulled on.
So after some propofol, some anesthesia, and a Schrade super tool, like that, we were finally able to remove the magnets from his scrotum. He left, and never said another word, his wife went like this and shook her head. So I got this idea later, and I contacted Schrade Corporation, and said, “I’ve got a great motto for you.” And without using his name, obviously, I said, “Here’s the story. This man had magnets on his genitals, and we used your device to get them off.
‘Schrade: the tool for your tool.’” Would you believe that Schrade Corporation sent me two T-shirts and two ball caps?
Nutrition is different in Emergistan, isn’t it? Right? In Emergistan, narcotics are like nutrition. Narcotics are vitamins, right? And benzos are co-factors, and antipsychotics give you a quiet night, but when the crazy guy in 20 is … is making a lot of noise. And Tylenol? Are you kidding me? Take some Tylenol and Motrin for your pain, and I quote, “Tylenol don’t do **** for me. It’s like taking candy.”
Immunology? Different. Anyone ever heard of this one? “I’m allergic to 5 mg Lortabs, but I can take those 10s. OK.” Right? Immunology is odd. I’ve had people tell me they’re allergic to saline, to potassium, to electricity, to oxygen, to epinephrine, all the things that you wouldn’t really think an allergy should develop to, since, you know, they’re serving your body. But, hey, it’s Emergistan! Who am I to say? Maybe those things are real allergies.
Interpersonal relationships. Boundaries are for sissies. So a patient of ours came to the department one day rather intoxicated, and my partner walked in to see her, and he said, “What can I do for you?” And she said, “What do you think of these?” and lifted up her top. He walked out. We also had a patient and another patient who were being held on psych papers who managed to meet across the curtain in the fast track, and actually have sex. I don’t know what the patients’ sitter was doing during that time. I don’t want to know. By the way, points if you can name the movie [points to picture on screen]. Thank you, “Wedding Crashers,” yeah.
Relationships in Emergistan are something that’s fiery. Right? We do see violent outbursts now and then, don’t we? We see people who have come in a little crazy. A [base]ball bat to the head is just another way to say, “I love you!”
In Emergistan, let’s face it, it isn’t just people who suffer, it’s the animals. So, a man comes to me one day, and says, “Listen, now.” Now people in the South, you understand, people start sentences like this — “Now, listen” — this is what we do, it’s like, “Bless your heart.” “Now listen here; the thing is,” he’s 45 years old, he said, “The thing is, my mom and me live with her boyfriend.” OK. Right off the bat, problem. “And the other day her boyfriend had a cardiac arrest.” OK, I’m sorry. “And when he had the cardiac arrest, he rolled out of bed and crushed the Pomeranian.” Only in Emergistan.
Even had a guy run into a groundhog on a moped. How do you run into a groundhog on a moped? Right? I just had this vision of the little groundhog eating grass and [imitates moped sound] like the moped’s like 5 mph, and they keep looking at each other. Somebody had to be pretty drunk. I think it was the groundhog actually. In South Carolina, our state bird is the Carolina Wren. In Emergistan, the state animal is the Mullet. But, not the fish, right? And that’s from [points to movie picture on screen]. And that’s from? [Audience: Joe Dirt.] Thank you, OK.
Economics. Keynes? Hayeck? Marx? Reagan? Nope, just free. Now how about trauma care? Well, you know, we know a lot about trauma. But things are different in Emergistan. I have this axiom: “If you can text from the backboard, your cervical spine is probably just fine.” Right? [imitates texting] “In car wreck, please send McDonald’s.”
And professionalism varies a bit. Remember, a lot of what you learn in medical school isn’t really true in Emergistan. It might be true in the clinic, I don’t know, but in Emergistan, it’s questionable at best. Like open-ended questions, right. You don’t ever want to say, “Do you have any pain?” What are they going to say? “Absolutely, I have pain.” Or how about this one. You know, we’re not supposed to lead them. “You don’t have chest pain, do you?” I know, it’s wrong, I know, it’s wrong, but sometimes you have to do it.
Now, the other thing about Emergistan is that people are just hard to kill. I’ve known people who had terrible injuries that surprised me. In fact, some years ago, and I’ll tell you a great story. We had an individual who was playing with his pet rattlesnake — I’m not lying — he had a pet rattlesnake. It was a canebrake rattlesnake, and it was [gestures about 4” in diameter] this big around because I saw it later. OK. So he reached in at night to kiss it goodnight and pick it up, and it bit him. OK, yeah. So guess what? Guess what was tattooed on his arm — a snake. So he’s very intoxicated. He actually experienced cardiac arrest on the way to the hospital. And there were paramedics who resuscitated him. And we ended up giving him 36 vials of antivenin … 36 vials. That’s about $72,000 worth. He lived actually. These people are hard to kill.
Here’s a classic Emergistan quote. The overdose patient says, “I took 26 Klonopins, 10 bars of Xanax, 30 Lortabs (10s, not 5s, because I’m allergic), all my momma’s Neurotins, five of daddy’s Cardizems, and drank a gallon of whiskey. I ain’t staying here; I feel fine.” Great. Great. Notice also, though, the plurals. I’ve never understood that. The Xanaxes and the Lortabs thing. This is a quintessential Emergistani, and he’ll be fine. And you know how you’ll know he’s fine? The next day he’ll be doing your roof with a nail gun. Right. “Hey, Doc! I remember seeing you last night! Remember I was drunk. Remember how drunk I was?” Yeah. Yeah, I do.
In Emergistan, physiology is very different as well. There is nothing better for a gallbladder attack than a Big Mac. Right? No matter how bad the abdominal pain, there’s a Big Mac in the room. Or, maybe at our place, maybe a Bojangles or a bag of fried chicken, or something like that. KFC. And there has to be a giant Big Gulp drink. They get better. By the way, in Las Vegas, that costs $50.
In Emergistan, two beers means two beers! I mean two big beers. This is a conversation I had with a guy one time. He said, “Now, doctor, I am drunk. I’m going home to babysit my nephew and niece!” His blood alcohol level was about 500, literally 500. And that’s how he walked around. And this is for you, Larry. [Blows kiss.] Because he later died of liver failure. But, that guy, every day he was in, he was that drunk. And he was fine, well, until he wasn’t. Social tip. If you go to Emergistan and hang out with the people, just be careful because they will drink you under the table.
Now, the other thing. Disability. Regular people, like you and I, the people I assume that we hang out with, we get fired if we don’t get along with people, right? We had this discussion earlier on before the lecture that, you know, employers have certain expectations about the things you do and say. So, having a bad attitude might end your career, or certainly that job and land you in another location. However, in Emergistan, there’s a thing called “disability.”
Travel tip on economics: bad attitude or pseudo-disease equals disability check. Right? Pseudo-seizures. What is that, right? I don’t understand. I never understood that. I take Dilantin for my pseudo-seizures. I don’t understand this. I’ve had the most bizarre people tell me the most bizarre things about disability. I say, “What are you on disability for?” “Uh, honestly, I don’t remember. My daddy got me on it.” OK. Um, “What are you on disability for?” “I can’t hold a job.” That’s intriguing, OK. “What are you on disability for?” “I’m just nervous a lot.” OK. So, in Emergistan dysfunction like that is actually very much a survival advantage.
To most people, a visit to the ER is to be avoided. I mean, I’ve been to the ER myself as a patient maybe four times in my life, maybe. Twice for kidney stones, and once for getting hit in the eye or something like that. These people, it’s like an event; it’s like a social outing. Have you noticed this? Now that’s when you have the multiple people in one thing that the nebulous complaint. It’s a family outing. “Hey, you got back pain again? I’m out of my methadone. You might want to come with me. It don’t cost nothing.”
Emergistanis are resilient. As I said, they survive injuries that would kill mere mortals. But it is my contention that the people who frequent Emergistan may be a new species entirely. Emergistanis laugh in the face of Darwinian natural selection. Darwin himself was quoted as saying, “Emergistan keeps me up at night!” – Chuck.
Of course, Emergistan gives us other lessons. Like, for instance, how medical providers in Emergistan do the right thing for the sick and the vulnerable. That’s a great thing that you do. And for the people with no other recourse. Because you know, you understand, many of these people you see have no other place to go and no other option at all. So, it is a great service that you provide every day when you travel to Emergistan.
Of course, also, unlike the natives, doctors and nurses understand that you have to go back to work no matter what. So, day in and day out, you work in spite of devastating ankle sprains, sunburns, and head colds that keep your patients at home for days. “I can’t go to work. I’ve got an ankle sprain. Can you give me an excuse?” “No.” My partner walked around on a fifth metatarsal fracture at work for weeks; and he didn’t give a lot of work excuses.
We do have unique challenges. We have violence and drug-seeking and patient-satisfaction scores. Several years ago, we had a patient who was psychotic in one state, and the state police from that state graciously dropped him off at our rest area. He was brought to our hospital and nearly choked a nurse to death. That’s great. That’s Emergistan for you!
I don’t think you’ve ever had to fill out a satisfaction score, but let’s face it, satisfaction scores are a big problem for us, right? But the problem is, when you’re happy about a thing, you don’t fill out a satisfaction score, right? I bought a truck, and I never filled out a satisfaction score. I like the truck. It’s angry people who fill out satisfaction scores.
Now, when you read that, your heart rate went up just a little bit, didn’t it? Nobody’s evaluating you today; it’s OK. You can be upset; you can even criticize me if you want to. Don’t. Doctors in Emergistan are frustrated. Frankly, because of EMTALA and things like that, we do struggle, and departments struggle, and it isn’t just physicians because hospitals collect less money on the people they see for free, nurses salaries go down and everything else. It is a difficult thing. The economics of Emergistan are frustrating and bizarre.
And the government entities that oversee us, you know, like CMS and others, they believe we’re all very rich, and so do the patients. How many times have you heard this? I love this line: “I couldn’t afford to see no doctor, so I came to see you.” Awesome. Thank you. Now, there was a time in the past when people would bring you like a chicken or a pie. We had a patient who used to bring us day-old doughnuts. I was fine with that. Now they don’t even bring you a load of copper or any meth. You know, there’s some ways you could make money if people bring you little things like that. Nobody brings you gifts anymore.
We are endlessly harassed as physicians, aren’t we? To take more tests and pay more fees and get new merit badges. How many of you are frustrated with maintenance and certification? Where you have to take a test every, seems like every, what is it every week now, I think? Yeah. And then you take a bigger test every month, you take the big test once a year, and then you donate blood and, I don’t know, it’s just more and more complicated. By the way, as an aside, ABMS, do you guys know how much money ABMS brings in every year? I shouldn’t say this. Can you guess? $300 million. OK, moving on.
We’re told to see more patients, and get give more pain medications, and smile more, and sit down, and talk more, and follow every new rule that comes down the pike from every administrative body. And it’s difficult in Emergistan all the while working as data entry clerks. Does this drive you crazy? Entering data all of the time? And who’s doing the MR? Everyone’s doing the MR now, right? It’s almost inescapable now, and it’s very time-consuming. But it is part of the technological revolution in Emergistan, and we have to face it.
As far as I’m concerned, being willing to come to work in Emergistan everyday should be its own merit badge. I don’t know how much CME I need when I’m willing to come in and take care of psychotic drug addicts all of the time. I know I need CME, but still. No, the point is it’s a difficult job, and you guys deserve a great credit for what you do.
But, if there was going to be a merit badge, I would invent this one: “Physicians Tolerating Silly Draconian Situations” — PTSDS. So, students and instructors, courses are available this summer, so I’m going to make my living off of this now. I’m going to establish my own merit badge. Now, people sometimes do take me to task over my columns, and they do take you to task when you complain. But you know what, why do we complain? We complain to cope, right? It’s the way we deal with things. It’s the way we deal with it.
It’s a hard job, and it’s a scary place in Emergistan, so we say things about what we do, but at the bottom of it all, we love our jobs, and we’re proud of what we do, and we even like the crazy people we see. You find yourself bonding with them. Like, I see them in Walmart now, and they’re like “HEY!” and I’m like, “How’s it going? You out of jail? Good. Great, how are the kids?” “It’s great to see ya!” Awesome. Yeah, don’t rob me.
They become like you’re people, right? I always tell people, these are my people. All right. The sheep of my pasture. You know, we’re proud of what we do even though we’d like to hit it big in Vegas and go home and not practice because I’ll bet if most of you hit it big, you’d have a hard time quitting because it’s sort of in you now. It’s what you do. It’s how you relate to the world. Oddly enough, I thought about my kids recently, and my kids are about to start college, one’s about to start college, and I don’t know if he’ll be in medicine or not. And I sort of thought, how sad that he won’t have to experience what I experience every day. And then I thought, really? Is it sad? Because it’s what I do. It’s so much a part of my world to be the doctor in Emergistan, to see the craziness and the weirdness, that I can’t imagine my son would want to do a thing with a life that wasn’t like that. And yet, that’s a weird thing to think. So, it’s OK for them to do whatever they want to do. We all like what we do on some level, even though we wish we could have done better.
Emergistan does use a different language altogether, right? I mean, nobody recognizes the things that people say to us. “So me and my boys had just done some Ice when this dude pulls his nine and caps Rooster right through the tat just above his junk! So we called the 5-0, and Rooster was screaming for some bars, but we didn’t have none so I gave him some Special K to chill him out.” What? Well, that makes perfect sense to me, but most people don’t really get that. Most of you understand that discussion. It’s all fun and games until somebody gets shot, especially in the junk. That’s, that’s bad. I don’t ever want to have that happen.
But more than that, more than the sort of weirdness of things that people say to us, there’s this whole other side to Emergistan. There’s all this resignation, and there’s all this loss, all this cruelty that we see, and that troubles me, and I think it troubles you. That’s what makes it hard to understand what happens there.
It’s a hard place. There’s a lot of sorrow. You know, people often ask me, “What’s the worst thing you’ve ever seen?” because they want a story about a stabbing or an amputation or something. What I tell them is the worst thing I’ve ever seen is the face of someone when I tell them someone’s dead. That’s the worst thing. The loss is hard in Emergistan. We deal with it every day, right? How many times a year do you tell someone that some bad thing that has happened or is going to happen, that they’ve lost someone? That’s miserable.
And how many times do you wonder why people seem to choose incapacity? I don’t understand that either. That’s hard for us. And do you want to know why it’s hard for us? Because we’re high-functioning. And I’m not saying that arrogantly. Let’s face it. We’re in Las Vegas at a conference on resuscitation. You’re one of those people who gets stuff done. You’re a high performer. You’ve been a high performer your whole life. When you see someone who simply can’t get out of bed to go to McDonald’s to get a job, you have a hard time understanding that, right? It’s a disconnect between us and our fellow Emergistanis.
Some days, it seems like all that we see are patients with social drama and anxiety and depression, right? Have you ever seen so much anxiety in your life? It’s like anxiety is epidemic in Emergistan. That’s all people talk about. Everyone is on Xanax or Klonopin or Valium or Adapin, or all four, right? Now, I don’t know how you stay awake; I don’t know how you breathe. But then, since there is a lot of drama, we do work at a level one drama center.
Emergistan can be a sad place. A lot of people go there because they don’t know how to cope. There’s a famous pastor and writer named John Piper. You may have heard of him. And I heard John Piper talk one time on a podcast, and he said that he had gone to visit a girl in the hospital who was a cutter. And he said, “Why do you cut?” and she said, “Oh, well I like it when the doctors and nurses touch me.” Ouch. That hits home, doesn’t it? It reminds us of the pain that a lot of our patients endure in Emergistan. Notice what it says: “ugly, fat.” [Points to a picture of an arm carved with the words “ugly” and “fat.”] Somebody carved that on their own arm.
Of course, tattoos are sometimes attempts to cover up pain or a deep-seated loathing or a love of all things cat. Have you ever seen this guy on the TV? [Points to picture of man who has changed his face using plastic surgery and tattoos to make him look like a cat.] He really, he’s a real guy. I mean he’s actually, he’s actually had like nylon whiskers put in, and his teeth filed and sharpened, and surgery to pull out the lip. He’s actually trying to be a cat. [Whispers:] You’re not a cat. This guy’s got a problem. But we see those, right? See people who somehow their sense of self, their sense of self-worth is so skewed that they have to do things to mar their bodies and change their image. It’s a very odd and sad thing at times.
Some people come to Emergistan because it’s the only safe place in their world. We have a PA who had a great insight one time. He said, “I think that people come here, Ed, because it’s the only place where they have any control.” Right? They do, right? They can say, “I demand to see the patient advocate,” “I want a blanket,” “I have pain. I need to be admitted,” “I need some more pain medicine,” and, “I want a CT scan.” They have this ability to sort of push us because they know that we want to do the right thing, they know we’re afraid of lawsuits, they know now that we have satisfaction scores. So to some extent, some of that may be a reaction that there’s a lack of control in their lives.
You ever have the little kid that you treat, right? He’s in his mom’s arms, his mom’s clearly checked out, and the kid looks at you as you’re leaving the room and goes like this, like please, you’ve got to take me with you; these people are crazy. That’s what the kid is saying to you. You’ve got to take me away. But then, when your kitchen doubles as a meth lab, even Emergistan seems sane.
Emergistan is frightening for citizens and doctors because it seems like all the bad in the world ends up there, right? You ever feel like that? Like, you go to work, and you come home with a story of one more brain tumor, another PE, a cardiac arrest, and a burn, and you know, we store all of this stuff up inside us, and we sort of get this big bank account of suffering. I really do contend that maybe of the physicians have PTSD, but many of us just work through it, and we deal with it because nobody wants to talk about it. So we have this perception that because we saw it at work, it’s very likely to happen elsewhere. So we take it home to our kids and our wives, and when our kids and wives are on the road, we think that they’re going to have a car wreck. And, every time my kid has a headache, I think it’s a tumor. And every time my wife has a cough I think she has pneumonia. That’s what happens to us. And it’s the consequence of the work we do in the place we do it.
Emergistan. It gets inside of our heads. It’s scary. V-fib – God’s control+alt+delete.
No wonder everyone is anxious. People are anxious because the world is a scary place. I mean, yeah, they’re overanxious and they don’t cope well. I had a young lady one time who told me that she was just terrified of death, terrified of death. She just didn’t’ know what to do. She was crying. And I said, “Well, what do you watch on TV?” She said, “Well, the First 48, and CSI, and …” and all these murder shows. I said, “Well, you need to turn the television off, my dear. This is why you’re anxious.” But this is why the doctors are stressed because it’s very scary in the land we call our home, Emergistan.
Seriously, though, travel tip for you. The psychology of Emergistan. Remember that there is a border, and most of what you see in Emergistan is not true outside of Emergistan, OK. It’s there, but it’s not there in the same, distilled-down, concentrated amounts that you see it at work. We have to teach ourselves to leave it at the border, all right? All that baggage of pain and suffering and fear; it’s hard, but sometimes you have to learn to let it go and leave it behind because it isn’t reflective of reality once you leave Emergistan and go back into your lives.
Why is Emergistan hard for us to understand? Why is it hard for other people to understand? I mean, we get it, don’t we? We get it a little bit because we’ve worked there so long now. We understand a little bit about the guy who gets his head caved in who wants you to stitch it up so he can go get into the fight. I don’t agree with him, but I get it. I understand what he’s saying; he’s got an honor issue. I get it that people drink to cope with mental illness because they can’t go anywhere else. You know. Dave Chappelle once, he, one time said, “White kids have psychiatrists, and black kids have liquor stores.” Kind of Emergistan.
But our patient population is a lot of folks who were raised by people with no motivation and no coping skills, and people who had never heard a kind word until one of you said it to them. All right, maybe that’s why they come back all of the time. Maybe that’s why they ask for you. How many kids do you see who need simple things done? Sutures or x-rays, and they scream; they’re completely out of control because that’s what their parents do, right? That’s how everybody copes in their house; everybody screams. You take your kids to the hospital, and you can reason with them and talk to them because you reason and talk to them at home. Well, it’s hard to understand.
It’s also hard to understand because it’s a place where psychosis can seem completely normal and where suicide attempts are just what people do. Right? When you’re upset, you try to kill yourself or you think about killing yourself and tell someone or you get a pill bottle and shake it, and say, “I’m going to take these pills.” Or you cut, or whatever.
But it’s also a place where we ask crazy people to talk to the television, right? This is telepsychiatry. “I know you’re hearing voices, so what I want you to do is talk to the nice man on the TV.” “Really? He knows my name? That guy on the TV?” I’ve always wanted to say, “He’s from the FBI.” That’d be really bad.
It’s hard to understand because the lives of the people we see are so unlike our own. And so it’s all the more vital to remember this great saying, one of my favorites from the philosopher Philo of Alexandria. He said, “Be kind, for everyone you meet is fighting a great battle.” Isn’t that true? Everybody we see is fighting some great battle. It might even be about their work or their money or their drugs or their relationship or their kids or their sickness, but it is true. And we can couch it in these terms, I think it makes it easier to cope with the difficulty we see in the people we care for. You know I make fun, and we all make fun, but the truth is I really feel for the people we see, and I love them. And you’re allowed to make fun of the people you love, sort of, right? You have brothers and sisters? You make fun of them, but nobody else can? ‘Cause I’m from West Virginia, OK. Are you kidding me? Everybody makes fun of us. I make fun of us. But I won’t let anybody else do it.
Moving on. Emergistan is the place where good ideas go to die, right? You know that little law of intents and consequences? It’s so true. How about these? EMTALA, JCAHO, pain scales, time-outs, customer service, maintenance of certification, core measures. Core measures are killing us now, right? You’ve got to have everything done within, like, like you have to have the EKG done before the patient arrives, right? In the parking lot, in the car, or else you’ve missed something. We were going over this data at our hospital, and one of our partners said the place that he had been before, what they did was, they did the EKG, and then they started the registration process. It’s actually time-stamped before the registration is done in order to get around that. It’s pretty cheesy, but it worked. Raise your hand if any of these things have driven you crazy in the last month. I’m sure they have.
If you want to see how a policy really works, watch what it does 24/7/365 in our country, in Emergistan. And watch how the Joint Commission enforces it. A lot of ideas are great ideas to begin with, right? Like mandatory EMR. It’s going to make it so easy to chart everyone, and we’re going to connect to people, and we’re going to be able to store records and share records, and it’s going to be so much faster, and it really isn’t. It didn’t work out that way. Of course, that’s because the technology were using for the ER is a little bit behind what’s out there, right? Your cat can play an iPad game. Yeah, there’s an iPad game for cats. If EMR were that simple, then I think we’d be OK.
Billboards with wait times. I don’t like this. I don’t like to have people get tweets about the wait times in the ER because I think that suggests to me maybe it’s not an emergency room.
Restraining without restraints. We had a psychiatry issue in the hospital we brought with our risk manager because we’re trying to decide how to keep people. And they said, well, if you’re going to commit him then you have to really keep him. But you can’t really keep them because they’re not fully committed until they go. But you can’t let them go because they may kill themselves. But if they do go, you can’t hold them and restrain them because physically it might hurt them. If you do it that way, you’ve got to bring them back, even though you’re not keeping them. That’s pretty much how it went. Only in Emergistan can you have that conversation, and actually follow that conversation. So, what they’re saying is they have to stay, but if they leave then I have to let them go, and I have to try and get somebody to bring them back. OK, whatever.
So, what I’m saying is this: nobody believes us, but we do work in a weird place, and it is so different from most people’s experiences that it might as well be a foreign country. The Emergistanis may not always appreciate us, but we do very important work with fewer and fewer resources, and with lower and lower compensation. And I say compensation a lot. I’m not all about the money, and you aren’t either. I’m just saying that it’s one of the things that we have to deal with. There’s a great talk I heard that was given to senior residents, and it was about life at $250,000 dollars a year. And it basically said that by the time you take into account your costs of insurance and licensure, and your benefits and all of the things, what you make per month is not so much as it sounds. And it’s true. In medicine, people assume that large numbers equal large amounts of take-home cash, which isn’t necessarily true. And, we know this in Emergistan. That’s what they don’t understand about us.
But we do meet cool and very bizarre people. I will tell you this. You will never be at a loss at a cocktail party to tell a story, right? Your brother-in-law, the accountant, or whatever he does, and your friend, the lawyer, they got nothing. When you have a story to tell, you’ve always got the greatest story about, you know, amputations, the decapitations, and all of the other horrible things that you see like the tazings. Have you seen tazings lately? You know, I had a great tazing right in front of me in the ER a few weeks ago. It was wonderful. I mean, I can say that because this is what I do. It’s a beautiful thing because the guy clearly deserved it. No, he was fine, really, it was OK, it was nothing bad.
We have travel stories, and we learn all kinds of new words and skills and profanity and drugs and things like that. We make a difference; and this is what’s really key for you to understand. You make a difference. And I’ve said it before, you make a difference in lives of people that nobody else seems to care about. You know? If you’re homeless and dirty, you don’t walk into the doctor’s office most places. Right? If you have no money, you don’t for sure. That’s the upside to EMTALA. We do get to kind of take the high ground. And I think that’s a good thing on some level. I wish it were implemented better, and I wish it were funded, but we do get to take care of people who have no other recourse. It doesn’t matter if they’re immigrants or locals or whatever, we get to provide for them, and that’s a great thing. And also you get to take care of people that other doctors are frightened to see, right?
Listen, you can’t walk drunk and screaming into most places. If you walk drunk and screaming into Walmart, they’ll escort you out and the police will take you home. If you walk into the judge’s chambers in a county court house, and you cuss and you punch the guard, you will go straight to jail. And they will taze you to some principle. That’s how that works. And then after they’ve tazed you and taken you to jail, they’ll take you to Emergistan because you’ve had chest pain or you were too drunk, right? Because like the ancients used to say, “All roads lead to Rome,” right? All roads lead to where? Emergistan. Right! You can’t arrested without going to Emergistan, right? You can’t get committed without going to Emergistan. In our place, it’s hard to get direct-admitted. So if the patient has pneumonia, the doctor’s going to have to x-ray them and they’re hypoxic, and says, “Well, I’m not sure I can trust him. Just have the emergency room check him out first.” Check him out for what? Right? OK. Well, it’s fine. Ha, it’s Emergistan.
This is the guy [points to picture] that we see him all the time. You know what the great thing about this guy is? We’ve all seen this guy a lot. This guy will scream at you and threaten you, and then the next, after he’s slept it off a few hours later, nine times out of 10 he’ll say, “Hey, I am really sorry about the way I acted last night. I didn’t mean to be like that. I was just drunk. I was just mad. I’m sorry. Did I hurt anybody?” You know? Well, yeah, that’s the handcuffs, you’ll notice. By the way, if you want to make that transition happen faster, you know what to give him? To make the drunk nice? What makes drunk people nice? Food. But what drug? Droperidol. Yeah, it actually for some reason is just a mood stabilizer. I don’t know how it works, but they’ll go from calling you names to, “Pardon me, doctor. May I have a cup of water?”
Here’s the other thing. We save lives. We rescue children from abuse. We restore families. And as frustrating as it is, that is absolutely huge, right? I used to joke that we’re the mechanics of the human machine, and that’s sort of true. We do sort of fix people so that they can go back to the other things that they’re supposed to be doing. You know, people think of medicine as this highest, most important thing in the world. Medicine’s just about making sure everyone else can do the important things. We’re here to sort of get people back into the game. All right. We mustn’t think too highly of ourselves because our job is to restore people to mundane things like roofing and carpentry and mechanic work and doing teaching and all of the other things that they do. But it’s huge because we save them, we restore them.
It could be done better. It could be done with less frustration and less hassle. That’s great. I mean, I’d love to see that. That’s why I write what I write. You know, just to sort of be a gadfly, to say, “Why can’t we do this better?” And that’s what we should all be doing. We should all be saying, “Why can’t we do it better?” That doesn’t mean that it’s not an important place, that doesn’t mean that we don’t love going to Emergistan. It doesn’t mean it doesn’t matter. It doesn’t mean that we hate it. It just means that from the inside, from where we work, we see ways that it can be done better. I think that’s legitimate.
These are my kids [shows picture]: Sam, Seth, and Elijah, and Alyssa. Who may be watching right now – hey, kids, with their mother, hello, dear. I show this slide because a few years ago, my wife had been suffering from a protracted illness, and woke up in the middle of the night, and wasn’t feeling well, stood up and passed out, and was short of breath. So, that morning we took her to the hospital, and you know what she had? She had a huge saddle embolus. It was hypoxic and was tachycardic at about 140 and hypotensive and terribly ill. And my partner, who is a very good doc, Dr. David Heap, David diagnosed it, and we decided based on our location, not a big referral center, that the best thing to do was to give her peripheral tPA. And it was a scientific experiment. Her oxygen level rose steadily over 10 minutes. Her blood pressure got up, her heart rate went down, and she was completely fine. All right. So they got to keep their mom because somebody did a really good job, and that’s what you do. OK, I got to keep my wife because somebody did a great job. That’s where Emergistan matters. That’s why when you go off to Emergistan, no matter how crazy it is, it’s worth it.
So, my point is this, intrepid travelers and fellow Emergistanis: every day that you walk into that crazy emergency department, and somebody assails you with another stupid complaint, every day that you have to argue once again about Lortabs and Percocet, or why you can’t be allergic to 5s and not 10s, and every day that you say, no, I won’t give you a refill, every day that you have to tell someone bad news, every day that you have to wrestle an intoxicated person to put them on a backboard, every day that you have to fight with an administrator to do the right thing, every day that you really, really want to put your fist through the computer because the EMR is just about to drive you crazy, every day you come back to that, every day it feels like you’re holding up the world of medicine by yourself because all things seem to land in the ER, as all the other physicians stop taking calls, every day you feel like Atlas, every day you do the right thing for people who no one else will help. You are really missionaries to Emergistan.
That’s really something to be proud of. Really something to be proud of. Because, man, it is a freak show out there. You cannot make this stuff up. [Points to fetal skeleton tattooed on young woman’s abdomen.] And that is one awesome tattoo. You know. I’m not a huge fan of tattoos, but I’ve got to say, that one is cool.
This message today was brought to you by the Emergistani ministries of travel, tourism, disability, drug control, and mental health, where our motto is, “Can I get a sandwich and a work note?” Anyone here who is interested in cabinet positions in Emergistan should see me later as I am willing to accept bribes because my son starts college this fall. After all, “Ich bin ein Emergistani.” If you would like to have a pin with the Emergistani flag on it, I have some, and I have some that say, “Level one drama center” up front. So you can talk to me later. All I’m asking is a paltry dollar to help send my son to college. Come on.
So ladies and gentlemen, thank you for having me. And thank you for taking time out of this beautiful day, you know, you could be gambling right now and watching shows, and you came to hear me. I’m honored, so thank you, and have a great day. Keep up with your great work in Emergistan.