I'm back

A funny thing happened on the way to forty.

I have been asked more than a few times why I took a break writing. My answers have varied, if you did ask you likely got one of the following answers: "Writers block", "Kids, Summer, you know the deal", "It's complicated". The truth is: I don't know. But I think I've got a better handle on it.

I turned 40.

I would have told you it's not a big deal to me. It's just a number. Our traditional way of keeping track of time, nothing more. The Mayans invented the calendar, blame them. For new parents (who only speak of their child's age in months: I am a little over 480 months).

Let's say the average U.S male life span of productive life is 75 years (900 months). That's not very long, I'm over half way there. The ridiculous thing is I don't feel like an adult. Med school will do that to you. College done at 23, med school done at 27, residency done at 30, got my first real job then. I've only been in the work force for 9 years. I just got my loans paid off, I have a little in retirement but the sad part is :I'm halfway done! I've used half my months and I just now got to the place I want to be.

Life is fast. I have a great life but the pace is blinding. My kids aren't babies (mostly), my parents are getting older. Which leads to another reason for my writing hiatus.

My mom was diagnosed with malignant melanoma about 4 years ago. Her lesion was deep and ulcerated. She had a wide margin resection and did very well. Top shape. Life is good.

She had an axillary node recurrence at the beginning of this year. She had a second surgery, an axillary node dissection followed by 6 weeks of radiation therapy. Not a good thing but we'll get through.

She had a third recurrence just a few months ago. There are multiple lesions spreading from her spine to the arm pit. Surgery is not an option, radiation won't help, she's now on chemo. This has been a major blow to the family. Like most moms, my mom is the glue. The hell of the thing is that she is not "sick". She doesn't feel bad. I know the disease, I've read the statistics and I know the prognosis but I just can't get my head around it. My colleagues get an altruistic look in their eye and whisper "How's you mom? or I'm sorry about your mom." And I'm just like "Man you don't get it, she's not that sick". I feel like I'm one of those family members who are in denial about what's going on. I'm not ready for this. Life is fast. There is no slow gear.

I jokingly complain about Danielle all the time but the truth is she's great. She's great in the fact that she pushes me out of my comfort zone. Third kid-her idea. Sell our house all the time -her idea. Travel everywhere -her idea. Her shenanigans have gotten us in trouble before. We almost got killed one midnight on a deserted Costa Rican back road, we were stopped by machine gun welding soldiers in Macedonia, I thought we were done for in turbulence over Peru. But one thing is for sure, it's never boring. Now she's talking smack about moving to New Zealand or selling the house, taking the whole year off to travel the world. When we get back, no big deal, we'll just start over. Most of that's just talk but sometimes I'm not so sure.

She saw her mother suffer and die horribly from Alzheimer's disease. She was just patching things up with her father and then he suddenly died as well. Since then her attitude is "if she can't control the end, then she is damn sure going to make the best of this part". I know she's right in principle. I think about it this way: I know roughly about 2000 people. Meaning if you handed them my picture they could come up with my name. 900 months from now that number may be 200. 900 months from then maybe 20. And 900 months from then, well.....yeah. That's not depressing. That's just the way it is here on earth.

So why not. Why not move to New Zealand. Why not travel for a year. Why not take that job that guy has been hounding me about. Why not go deliver health care in a place that I can really make a difference. (I am not making a huge difference passing out Lortab and blood pressure meds here in Nashville). That's a stretch, I do make a difference about once a week. Which is more than most ambulance chasing lawyers can say in a lifetime. Sorry, swords shoot from the depths of my self pity.

That's it. Philosophy class is over. But friends the end is coming, let's get over it and over ourselves. No one is guaranteed 900 months so there is no point dwelling on it. That's no license to act stupid but there is also no denying that the clock is ticking. It's so corny but true: Each day is a gift. Live life every day. My goal is to hit the pillow each night knowing that I have made the most of the day. That's probably going to mean getting out of a rut and taking some risks. That's what it has taken me 480 months to learn. Alright, tomorrow is coming, lets get to it.

What Do We Do With The Pirate?

As you all know by now the U.S. Navy captured a Somali Pirate this month. Some say he was trying to escape others say captured. Doesn’t really matter, we’ve got him now.

So what do we do with him?

When I’m driving home late at night sometimes I pretend I am President and am preparing to address the nation about a problem we are facing. My constituency is the steering wheel. I’ll bet many of you do the same.

At this point I am going to have to disclose some things.

I really don’t have a political affiliation. I did vote, but I did not vote for Barack Obama. The biggest issue for me was taxes. Not that I am against taxes, I am not. It is the price we pay for a free society (Oliver Wendell Holmes). I like paved roads, providing education for our children, protecting our country, protecting our environment, caring for the truly needy. I do believe that government should stay out of religion and religion should stay out of government, but they are like two kids that can't keep their hands off each other. Maybe I am a Democrat?

I do however believe our government is lousy at managing its finances. The government lives in a way you and I could not. We have a budget. We stick to it.

I don’t think it’s the government’s responsibility to pay for my college, give me housing, provide my healthcare or childcare or really even deliver the mail. There are already so many government sponsored boon-doggles, I have lost my faith in government to be efficient at most anything. I don’t believe that government is going to solve any of my everyday problems nor do I expect it to. I do think we all pay too much in taxes for the return we get. Maybe I am a Republican?

At the end of the day I am more suspicious of government than I am trusting of it. I think the writers of the constitution were much the same.

Anyway, back to the pirate.

I’ve been taking a poll among friends asking what would you do if you were the judge? I say judge because the president is in a separate branch so factually he has no more say than you or I. Of course I don’t really believe that. President Obama’s wishes will go a long way here.

Here are the undisputed facts about the pirate as I know them:
He is a pirate.
He steals and holds goods for ransom.
He was not the mastermind but guilty nonetheless.
He was caught red handed.
He is a teenager.
He comes from a country of abject poverty and corruption.

So what are you going to do with him?

Here are your options:

Release him back to Somalia. This is probably the easiest thing to do. He’ll go back to his lifestyle. He’ll get his 15 minutes of fame but he won’t be much of a problem for us again. He may go back to pirating but that problem is still going to be there weather he is there or not.

We could put him in prison. Easy as well. We would forget about him eventually. He could do some hard time with some of our bad guys. After his release he would be deported. Too old to do much pirating. The problem is now we taxpayers have to pay for his food, lodging (as it is) and healthcare. It’s probably a step up for him compared to daily Somali life. But it is still prison, he is a teenager, surely we can do better.

We could have killed him. If he had actually shot that captain this is what the majority of American’s would have wanted. Don’t be so naive to think that wasn’t discussed at some level. This kid could be a problem. If we jail him he could become a living martyr. We could have easily been told he drowned or was shot with the other bad guys. The fact that we even know he exist means the government ruled this option out. I am glad about this.

Or lastly, we could do something good with him. This is my favorite option, probably because I soon will have teenage boys.

We could take this kid and give him an education. Provide him some type of family. He would get healthcare and security. He could discover a country that mostly has peace, because most Americans are peaceful. We don’t have to steal food. We don’t have to bribe judges or pay off the police. We believe we live in a country that provides our citizens the opportunity of a good life. A life we choose based on the choices we make.

This young pirate is truly guilty. But what were his options? I am not sure that I would not have made the same choices he made if I were a 16 or 18 year old Somali youth.

We could take this young man and show him what the U.S.A. is really all about. Not what he has been told. With a little love and some opportunity this kid could become something he never dreamed he could be. He could be a doctor, lawyer, school teacher, really anything he chooses. And when he turns forty, we pull the trigger.

By that I mean then send him back to Somalia. He doesn’t owe us a thing. He can do whatever he wants. We could support him as best we could from afar but it’s his choice. He can go back to being a thug or he can go be the leader that his people so desperately need.
If we do this job well, I know he will make the right decision.

Anyway, that’s what I would do. I would be interested in hearing your comments.

How I Remember It

It's a cold winters day in February. Friday exactly, the day most people pack it in, take it all home. I’m on the 2pm to 10pm shift. Not bad. Usually those are peak hours, a good time to work. But on this Friday afternoon it’s a little slow.

I working with one of our new docs. She just completed her residency last year. She’s green, nervous, frequently seen looking up doses for penicillin and the like. She has potential but needs some polishing. I know only I can help this young apprentice to one day be an ER Jedi.

At my hospital there is one thing every ER doc fears……..Delivering a Baby.

In our current health care climate, many hospitals have gotten out of the Labor and Delivery business. Mostly because of profit and liability issues. Anyway, not all hospitals have an L&D suite or staff Obstetricians. At my hospital we don’t have any ER coverage for OB/Gyn. So we don’t birth no babies.

Anyway back to me.

On this blustery Friday afternoon we are strolling along. Suddenly a red truck speeds to a stop outside our ambulance doors. A young man jumps out and appears to be yelling for help through the glass. Sometimes patients do this. We always go check it out, but it better be good.

It’s good......... His girlfriend is in labor.

Tension heightens as the staff help the 19 year old out of the car and checks out the situation. This could be an emergency, the next sounds from the room…

"We need a doctor in here."

The patient is screaming, obviously in the throws of a contraction. She says she is 5 and half months pregnant. That’s 22 weeks. A baby is considered full term if over 35 weeks. A non viable fetus is less than 20 weeks. 22 weeks is no mans land. 22 weeks is premature. 22 weeks is bad. If born, the baby could live, but at 22 weeks there will be complications. We are talking neonatal breathing machines, umbilical IV lines and feeding tubes.

This girl is 19 years old, this is her first pregnancy, she has had no prenatal care. To make things even better she is stick skinny. By that I mean she has a very small pelvis. In Alabama there is a thing referred to as birthing hips. Good birthing hips are wide and the misses can spread her legs far apart creating a wide opening. I’ve seen good birthing hips that you could pass Volkswagen through. Bad birthing hips are small framed girls, tight pelvis and it’s even worse if it’s your first pregnancy. Bad birthing hips define this young mother.

So the first step is to see where we are. I slip on a glove, add a little KY jelly and insert my fingers into the vagina hoping to feel a closed cervix. What I actually feel is a baby’s head. The nurses are staring at me in anticipation waiting on the news....... "We are going to have a baby here." is my response. "Oh sh*#!" is the general refrain.

Accounts of what happened next differ, but this is how I remember it….

The nurses generally begin to panic. There is confusion. Some of the staff are yelling, some are starting to cry, a few passed out and one or two are on their knees praying. This is a scary situation, they need leadership, they need a hero.

So I stand tall and brave between this young girl’s thighs. I take both my hands to my v-neck collar of my scrub shirt and rip it down the middle exposing my pectoralis muscles and 6 pack abdomen just beginning to glisten with sweat. I run my fingers through my perfect hair and raise my hands to shoulder height. "Gloves!" I call, and gloves are placed onto my steady hands. "Gown!" I call and I am draped like a priest giving his most holy service. In a calm, confident tone I look at the charge nurse, "Get me the delivery tray, I am going to usher in the miracle of life."

My young assistant doctor is panicking. "Excuse me Doctor Gibson, but her pelvis is too small! You will never get the baby out! No doctor in his right mind would even try this! What are we going to do?" I have no choice but to slap her firmly across the face. "Dr. Barnett, remain calm. I am no ordinary doctor." Ashamed that she has lost her composure, she quietly gathers herself.

I insert my index fingers into each side of patient’s vagina around the child’s head. I begin to stretch the vagina open with all the strength in my fingers. An IV has been started but I can’t give any pain medications. Narcotics in a preterm delivery could depress the child’s respirations. Mom is going to go naturally. Mom is pushing and screaming. I am stretching, a ER tech in the back of the room just vomited. The contraction subsides.

The baby’s head is facing the wrong direction. Meaning its nose is facing up. Usually babies come out with the nose facing the floor. Ideally I would like to try to rotate the baby but there is no time and the child is lodged into position. Another hurdle I must overcome.

This is getting bloody. I call for suction. I continue to stretch. I can see the head well now. If the baby gets stuck, I am going to have to start cutting. I must stretch, she must push hard!

At the crescendo of the 5th contraction the baby’s head pops out. One more good stretch and I reach my fingers under the child's armpit, rotate the body and with one more push the baby is out.

"Clamps" I state commandingly.

"Scissors!" The child is now free.

I am now holding the child across my right forearm and tap it on the bottom. The room is filled with silent awe.

The next sound we hear are the eeking of a newborn’s cry.

Elation fills the room. Tears of fear have turned into tears of joy. Nurses and complete strangers are hugging, music is in the air and as I listen closely, I can hear the sounds of angels singing.

View from the Other Side

I have a work routine. I dress in scrubs, sometimes a white coat. I talk with patients, extract their symptoms, do an exam and formulate a problem list. This is usually followed by ordering some labs, sometimes X-rays, and starting treatment. I chat with friends. I have my perspective, this is my side and that’s where I live.

I have never been a patient. I’ve never been on the other side. Until recently....

I was visiting my parents in Birmingham and we were having a "fun day". We ate greasy hamburgers for lunch, had afternoon coffee and met my sister and her family for some spicy Chinese food. Fun enough?

In the past few years I have had some stomach problems, initially self diagnosed as indigestion, later as gastritis and finally an ulcer. The cause of my stomach problem is all on me. Fast food is often my best option and I have a daily habit of a 6 pack of diet coke. Not to mention my job can be a little unnerving at times.

So on February 6th I woke up at two in the morning in excruciating pain. I basically felt like I had been stabbed in the stomach and someone was twisting the blade. I drank a half bottle of pepto, no luck. I took a Prilosec, no help. I drank milk. I drank water. I tried to make myself puke. Nothing helped and my pain was only getting worse. Changs sweet and spicy chicken is having its revenge. Damn the Asians!

It’s funny (not gay), when you are at your weakest moments, how your imagination can run away with you. Is it my stomach? It's never been this bad. Could be gall bladder. Could be a kidney stone. Probably not appendix, but could be. This is killing me. Could I have a gall stone lodged in my common bile duct? Possible. Could I be developing pancreatitis? That's really pain full and this is really pain full. That could mean surgery. Could I have a perforated ulcer? This is actually my worst fear. That's definitely surgery. This is not going well.

So I come to the first decision every person on the other side (the patient) makes. They decide to come to the hospital. This was not as easy as I thought.

It's the middle of the night. I'm not at home. I am about to ask my 74 year old mother to drive me to the ER. I'm in agony. This completely sucks. After 30 more minutes of anguish I decide there is no other option.

I have one friend who practices in Birmingham. I call and of course she is not on shift. At this point is doesn't matter. If I am leaking my stomach contents into my peritoneum there is only one place I'm going in Birmingham: UAB.

I arrive and am quickly triaged. I go straight back. (Usually not a good sign). I meet Dr. Buckman. He is about my age. He knows I am a fellow pit doc (that's slang for ER doc. If you really want to be in the know refer to the ER as "the pit". Usually because the ER is always located on the bottom floor of the hospital but also considered by many as a place of primordial ooze that some of the most basic forms of life miraculously survive. Anyway, it is 4am now and Buckman looks a little tired. I give him a succinct story about my symptoms but leave out my list of possible diagnoses. That's his job. I should stay out of the way.

He examines me and says "I think you've got a perforated ulcer". Oh great! This Buckman is a real wordsmith. So much for sugar coating.

That means major surgery. I'm 300 miles from home. I've got obligations this weekend and I'm back on schedule in the ER starting Monday. I am not prepared for this and my entire career is based on being prepared for an emergency. It's just not a good time.

Buckman plays his trump card, "Well, if you've got it, there are no other options."

I know he's right. There is an unintended psychological warfare going on in the hospital. I am in severe pain. I have on a hospital gown and a pair of boxers. One person walked in while I was changing and I'm pretty sure at least 3 people saw me naked. But since I've got this burning fire poker in my belly, I could hardly give a care. I'm pale and feel lousy. I don't know any one's name. Someone whom I have never met and who has never met me could be opening my abdominal cavity in the next few hours. I am at their mercy. I feel helpless.

So to make a long story short, I ultimately did not have a perforated ulcer, just an ulcer. I got outstanding treatment and was discharged in a much improved condition.

As for my treating physician, Dr. Buckman was a flat out stud. I knew he was concerned. Not by what he said but by what he did. He showed up in X-ray after I had my films done. Later I saw him again in the CT scan control booth looking at my images as they were being developed. He didn't have to do that, but he knew that something could be bad and he didn't sit around and wait on the answers to come to him. He actively sought them out. It's those kind of actions that separate the great from the good.

Barbara, my nurse, was fantastic. Like all great ER nurses she has the most face to face time with the patient. She started an IV, was quick with the meds and double checked the doses at the bedside in my clear sight. I only got a small dose of pain medicine (my request) but she hooked me up to the monitor just to be safe. I (and she) knew that probably wasn't necessary but still it was comforting. She wasn't taking any chances and I really appreciated that. I joked with her and she joked back. I was facing a crisis but I was confident she knew my case and was looking out for me. She was a pro.

There is a thing called "The Patients Bill of Rights". As a physician, I have always rolled my eyes at this idea, thinking what is the point? I am on the patients side. I want to get the diagnosis right. I want them to get the right treatment. But now I know the Patients Bill of Rights is not about me, it's about the patients' trust.

So I have written the ER Patients Bill of Rights:
1. The Patient has the right to be afraid. We know that you don't know us and that is naturally frightening in this critical time.
2. The Patient has the right to be believed. I will believe you are sick.
3. The Patient must know that the doctors and nurses are asking them for their trust.
4. The Patient must trust that I will do the best for you to come up with the right diagnosis. Not of of fear of being sued, but because I want you to get better.
5. We (including you) are part of a team. We must all work together and do our best to solve this problem.

*This Bill of Rights may not apply to everyone. If you come in weekly and have cried wolf too many times, you have betrayed our trust. And this is a two way street.

So what have I learned from being on the other side?
It's miserable. But when it's miserable I want to be the kind of doctor that (and I can't believe I'm saying this) is a comforter. It's not just getting the diagnosis and providing treatment. It's about reaching out and really helping someone in a time of need.

Surreality Show

"Most people you meet are asleep, and the ones that are awake live in a state of constant, total amazement" -Joe versus the Volcano

It’s a Saturday night and I’ve got the late shift in the ER. Weekends always bring interesting patients to the mix.

Those of you who aren’t in the medical business would be surprised at the number of people we see who actually don’t want to live. Everyday (and I mean everyday) we see at least one patient and usually more with the complaint of “depressed, wants to commit suicide”. For everyone one of these we see five more with “waste basket diagnoses”, examples of these are: chronic fatigue syndrome, myofascial pain syndrome, hypoglycemia, mitral valve prolapse, there are many more. These patients take many medicines, herbs, therapies and the like. Their doctor doesn’t know what to do with them but feels obligated to come up with a diagnosis so they get one of these labels. They are sick, they have “poor health”.

Back to Saturday, I’m working with 10 patients and 3 have intentionally overdosed and one is thinking about cutting her wrist. Not a good mix.
My suicidal group ranges in age from 20 to 60. None of them want to live.

On the other hand my partner has a patient. Her patient is 37 years old and has terminal lung cancer. Diagnosed originally two years ago, he has undergone numerous operations, chemotherapy and had little success. His tumor is adenocarinoma of the lung (not necessarily caused by smoking) and is very aggressive. He is down to 90 pounds, has a feeding tube and bed sores. He is dying and there is nothing more we can do. He has come to the hospital tonight because he has fired his Hospice nurse and has thrown out his home health team. He is angry with his parents, doctors and family. He is not ready to die. He wants to live. “I’m just not ready”.

It was a surreal moment. I am surrounded by relatively healthy people who want to die and looking at a very sick guy who desperately wants to live. Life is unfair.

It makes me think of one of my favorite movies, Joe verses the Volcano. Basically it’s about a guy in a dead end job, living a dead end life. He finds out he has a terminal illness (brain cloud) and only has a few months to live. So for the first time ever he chooses to live. The movie has moments of great dialogue and symbolism. It has a silly ending but the message is wonderful. I highly recommend you watch it.

The best part is that it’s message is true. So few people actually live life. I have met many people in my 39 years and I have learned this: money won’t make you happy, power won’t do it either. I think it comes down to doing a job you love, having real friends, and not taking the rest so seriously. I think it’s about trying new things without a fear of embarrassment. Most importantly don’t waste a day, you’ve only got a few.

Now “Take me to the Volcano!”.

http://www.youtube.com/watch?v=oGLKnAvzlg4&feature=related

Complaints

Believe it or not, sometimes we in the medical profession get complaints. We always have a response to these complaints. When this happens to me, I tell my side of the story. It’s usually the truth.

The problem is that the patients who complain usually have no grounds to complain. The patients who have a legitimate gripe usually don’t bother. They figured they survived their Emergency Department trip and that’s enough.

Complaints usually break down into three main categories:

Common BS complaints.

You/They didn't do anything for me. If you see any doctor you are guaranteed to get a history and physical. Sometimes that's all that's needed. Somethings can't be fixed in the ER. Long term illness, chronic problems, mental illness, the flu. Sometimes all patients need are a few Tylenol and a big shot of "suck it up". There is just no magic bullet.

I saw a patient 2 weeks ago who had advanced Alzheimer's dementia. He fell at his nursing home and bumped his head. His wife accompanied him to the ER. I could have run a battery of tests and spent thousands of dollars. But the bottom line is it wasn't going to change anything. His wife was frazzled, struggling, watching her loved husband slowly become a victim to this horrible disease. (My wife had to walk down this road with her mom.) I talked to her about our options and we decided to send him back to his unit. No prescriptions, no test. I didn't really do anything other than talk and listen. After our discussion I walked around the bed, put down my clipboard and stethoscope and held her in my arms. She cried for about 5 minutes. The best care I provided that day was giving this lady a hug. No charge for hugs.

The doctor didn't take me seriously. If we aren't freaking out, you shouldn't either. We are trained to identify what "sick" looks like. It actually takes years of experience. One bubble in the IV tubing is not going to kill you. If the monitors start beeping (and you are conscious) it's usually not a big deal. This frequently comes off as callous, but what it really means is everything is okay for now. If your kid got hurt and is crying that's actually a good thing, but it makes mom terribly anxious. If your kid gets hurt and is not crying- that's the kind of thing that gets me anxious.

Insider Heath care tip: If you only see one nurse and your ER doc is acting casually, that is good. If you look up and see more than one doctor and three nurses in your room, things are not going well.

Middle ground complaints

The doctor wasn’t friendly enough. This one really gets under my skin. Most doc’s are polite. The point is we are trying to get some important information out of you. So occasionally I will interrupt a patient to keep them focused. It probably doesn’t matter if you had your tonsils out when you were kid. It probably doesn’t matter that your great grandfather was allergic to shellfish, vitamins are not medicine and cats make you nervous. None of those things ever matter unless we develop some new therapy that involves cats. So if you, as a patient, start rambling, I’m going to cut you off. No offense, but I'm trying to stay focused on your emergency today. Don’t take it personal.

Legit complaints.

It was too cold in the room. Patients are right on this one. The nurses are working hard, walking at a fast pace, usually with a little adrenaline pumping. They sweat easy. The patient on the other hand is forced to strip down to a paper thin gown and sit on a cold examination table. Occasionally we run cold IV fluids and sometimes you have a fever which makes you feel cold. We can really poor it on here. If you ask for a blanket, most times you’d do better knitting one. People are dying in here! And you want me to stop to get you a blanket. Ask for one and you may get a eye roll. Actually my nurses are pretty good at this. I myself have gone and fetched a blanket or two. But we don’t do it consistently so don’t get your hopes up. No kidding people are dying in here so we keep our priorities. For the life of me I don’t know why we don’t keep blankets in the room. I’m sure it’s a cost saving measure. Less linen means less laundry fees.

By the way don’t get cute and bring your own blanket. You will be made fun of for this and all will think you’ve been in the ED a little too much.

We will starve you. There are many reasons why we don’t let you eat. Primarily we want your stomach empty in case you decide to become unconscious for some reason and vomit. You could choke on your vomit and suffocate. You don’t want me to suck vomit out of your trachea and frankly I don’t want to. So it’s really a win/win.

I was kept in the ER too long. This is the king of legit complaints. After I see you and decide you need to be admitted, I do a little paperwork and have the charge nurse request a bed. You think it’s all down hill from here, but wait. Many times there is no bed available. The nurse has to copy the chart, do some more orders and call report to the nurse on the ward. Sometimes the nurse on the ward is available, sometimes not. Your room has to be cleaned. Then you have to be transported (usually by a transport tech who may or may not be available). This can drag on for hours. At our local university hospital some patients have been kept in the ER for days. Patients get angry with me about this but there is nothing I can do. I can crack open your chest and massage your heart, but I can’t seem to get the floor mopped in room 509.

I used to not always feel so powerless. Once I had a tantrum. I went up to the ward found the nurse, the unit manager and the bed and called down to the ED to have the patient immediately transported. This did not go over well. I did get a phone call from the "doctors behaving badly committee". But for a few months things did seem to improve. I tried a similar trick the other night and got a tongue lashing from my fiesty charge nurse and the nursing supervisor. It does amaze me how I can go to hotel without any advanced notice, ask for a room, and the zit-faced, high school educated night clerk can get me in a room in about 10 minutes. Why can't hospitals do that? Hospital administration does not like that question and they don't think my zit-faced clerk analogy is cute one bit.

What people don't complain about.

Whats up with all the cussing and nudity? I have to say the ED is R rated material. We see a fair amount of drunk, drug addled, nut jobs. They scream profanities and have no problem at all walking around naked. You can hear them all over the hospital and I know the deacon and his wife in the room next door are getting an ear full. Sometimes I'll even apologize to patients and their families for the show they are getting but amazingly they all seem okay with it.

The Bill. The cost of health care is insane! Yet people who have insurance seem to willingly pay their copay thinking that their insurance is going to take care of the rest. Keep dreaming. Your insurance company will deny everything they can and ultimately pass this cost on to you. I sutured a kids leg the other day. Took about 4 stitches and about 10 minutes. We hit them up for about 400 bucks. I got about 30 for the gig. I have no idea where the rest is. There is a laundry list of explanations but that's for another time.

The food. Hospital food is a cold, saltless, sterile mess. Yet patients suck it down like it's prime rib. We often see the complaint that "grandma has just stopped eating". Then I'll watch her inhale a Salisbury steak, a carton of room temperature milk and pimento cheese spread like it's the last meal on earth. For what you paid for that meal you could have taken the whole family to Ruth's Chris.

In summary there is an art to complaining in the ER. Basically keep your complaints realistic. If someone is being a real A-hole, call them on it. But keep in mind we only partially control the environment. For some reason, you've wound up in the ER, and that was not your plan, so you're already having a bad day. Expect the staff to be professional but don't expect a lifelong friendship. We do see people in crisis everyday, so it's only natural to get "dumbed down" to all the emotions. It doesn't mean we don't care. Help us out and we will go the extra mile to make sure you get what you need.

The Evil Empire. Girl Scouts!

There is badness in the world.

On Wall Street, on your street, you can see it at a number of levels. Explotation is a fact of life. You could argue that since the industrial revolution everyone gets exploited some.

One day, I bought a car. A group of people designed and built that car. They had incurred cost: materials, labor, shipping, advertising, etc. They sold that car to me for more than what the car was worth. They made a profit. Was I exploited? To a degree the answer is yes. The alternative was I could walk everywhere, or build my own car, but that’s really nonsense. But was I morally wronged? No, I knew the deal going in.

Here is a different example. My oldest son doesn’t really like candy. My middle son loves candy. On November 1st last year my oldest son, Wyatt, “sold” his Halloween Candy (retail worth about 8 bucks) to my middle son Graham for 20 dollars, (money he earned for his household chores). Was Graham morally wronged? Yes. He got a lousy deal (not morally wrong in itself). He was wronged in the fact he did not have the insight to see he could have bought 5 times the amount of candy for the same price. They were 8 and 7 years old, so no big deal. Graham learned a valuable lesson and won’t be making that mistake again. But what if Graham had been conned by an adult? That would have been reprehensible. Surely no adult would do that to a child, right?...... Wrong. Enter a little group called The Girl Scouts of America.

Every year at this time, I get a knock on my front door by a hapless pawn of one of the biggest exploiters of children in America: the Girl Scout. Dressed in their drab little uniforms, they stumble out of their mom’s minivan, slouch up to my door and eek out “Mister, do want to buy some cookies?” This starts the exchange.

“Let’s have a seat here on the steps.” This usually gets the window rolled down from the minivan.

“Why should I buy your cookies?”
“I am selling them for my troop.” Toothy grin.
(I guess these troops form companies then battalions and so on, but I don’t know that for sure and don’t ask. It’s already kind of para-military. I admit it would be much cooler if they dropped their cookies out of C-130’s)

“Why are you selling them for your troop?”
“They told me to.”

“Are you getting paid for doing this?”
“They cost 3 dollars a box.”

“No. That’s not what I asked. How much of the 3 dollars to you personally keep?”
“Huh?”

My questions continue.

“What’s your cut?”

“What are you getting paid per hour for selling these?”

“Does your employer provide you any benefits?”

“Are you getting mileage?”

“Are your time and energy valuable?”

“Are you valuable? Are you not valuable?”

This barrage usually gets tears but I am making a point here.

So I cut her a break and make the girl scout a deal.
“Here’s the deal. I am not going to buy your girl scout cookies. Not now, not ever. But if you go home and make me some cookies, we will work out a price and you will have the money to spend how you want. You can keep it, you can spend it, you can invest it, you can give it away. It’s your money and you get to decide what to do with it. The bottom line is this: You produce something of value to me and you get paid.”

Fighting back tears, in a whiny voice: “But I don’t make the cookies, I just sell the cookies.”

“Well I’m not going to let you make a fool of yourself, so get off my porch”.

Here comes mom.

“Why are you being mean to my daughter?”
“Why are you teaching your daughter to be a loser?”

Mom grabs her snotty kid and storms off. They will be back next year. Still not knowing a thing about how the free enterprise system works.

Here are some facts:

Your local GSA “troop” gets about 50 cents a box. The GSA’s own sources say about 17% of the money goes to the troop. The “troop” is loosely defined and not necessarily your child’s troop.

The GSA is genius. They make average cookies. (Okay, the thin mints are above average). They have a sales force of several hundred thousand children. (I thought there were laws against that) And they pay their saleswomen a giant sum of ZERO! For emphasis, they pay their sales force ZERO. Think about that.

Even better, their advertising is minimal. Retail delivery is not their problem and there is no return policy.

My neighbor Girl Scout has to buy her own lousy uniform, pay dues to join and even has to purchase her merit badges. The field trips are subsidized by parents and supervised by parents who also get paid a big fat ZERO!

Why didn’t I think of this!

Nothing is more un-American than the Girl Scouts of America. Believers are teaching their daughters to work hard for someone else and then give their earnings away.

Did you know the GSA has several national and international head quarters. They have a multi-million dollar budget. The main headquarters is on 5th avenue in Manhattan and the CEO makes $650,000+ per year. The best part of all: it’s a non-profit organization. That’s all well and good if you plan on raising non-profit kids.

Oh but wait, the top sellers for each troop get a prize, usually a t-shirt and a certificate. The certificate says in old English “This is to certify on this day that Molly is the biggest sucker of all her friends. Sincere thanks from the Girl Scouts of America.”

Well that’s what it should say.