Gerald O'Malley, DO: Sadao

My father-in-law passed away on Saturday.

Sadao Nagakuni was born in 1942 in Katsurahama, Kochi Prefecture on Shikoku, the smallest and least populated island in Japan. He lived through the occupation of Japan following World War II but he was too young to remember much of it. He loved to swim in the ocean when he was a child, even though it was prohibited because of the rough surf. He put himself through school as a guitar player in a “Hawaiian band” that would play in beer halls. He loved classical guitar and his favorite artist was the Spanish guitarist Andres Segovia. Nagakuni-san developed a method of playing traditional Japanese melodies with a flamenco/Spanish styling that was exquisitely beautiful and quite unlike anything I had ever heard.
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As a young man, Nagakuni-san was forced to work in his father’s factory making water tanks to hold fresh seafood. My father-in-law didn’t get along with his father and moved away from Shikoku to Tokyo where he met his wife. They settled in Osaka, the second largest city in Japan and started a company that designed, built and serviced water tanks to hold live seafood, mostly for restaurants and seafood suppliers.

In the early days of their marriage they had no money to rent a house so they lived in the workshop where they built the water tanks and slept on a futon in the corner of the building.

In Japan, you can judge the quality of a restaurant by the way they display their fish and seafood, Nagakuni-san created elaborate and beautiful and functional water tank/display systems for clients all over Japan. When Rika introduced us, her father treated me to many wonderful meals all over Osaka. He knew all the owners because they were his clients and we received VIP treatment wherever we ate.

Japan remains a very culturally closed and homogenous society. At the time that Rika and I became engaged I was stationed at the US Naval Hospital in Okinawa and relations between the Japanese and the US military were very strained because of some heinous and criminal behavior by one or two members of the more than 40,000 active duty members stationed in Japan. US military members were spit on and harassed by the Japanese in the streets of Okinawa.

None of that seemed to bother Sadao. I remember sitting at a lunch counter with him eating teriyaki and beef bowls surrounded by muttering construction workers and clucking housewives while we tried to communicate through his limited English and my nonexistent Japanese. We must have made a strange duo. I’m left to wonder if he ever wished that his daughter had fallen in love with a Japanese guy because he only ever treated me as his son-in-law.

Sadao suffered a cerebral aneurysm bleed in 2002 which robbed him of many of his cognitive faculties. Physically he appeared fine and he was even able to still play the guitar although not as easily or fluently as before and he would often play the same song over and over again for hours. It still sounded beautiful to me.

For the past several years, Nagakuni-san required around-the-clock supervision for his own safety. We saw him last March and visited with him several times and he remembered me and our daughter and surprisingly our son, whom he had only met once before. He reportedly woke up Saturday morning, walked out to the lounge area, sat down in front of the TV to watch the morning news show and didn’t respond when they called him for breakfast.

Sadao Nagakuni was a quiet man with an easy smile and a deep laugh. He worked hard, helped neighbors and strangers alike, was honest and generous to a fault and raised my wife and her brother in a loving and disciplined home. He was one of the millions of men that live their lives honorably and productively with a quiet nobility that are the soul of the family and the engine of the world. I will miss him.

Sayonara Nagakuni-san.

Gerald O'Malley, DO: On Precious

The other night my wife was working the overnight and I was tired of reading, so I took a break and bought and downloaded the movie “Precious” from the On Demand channel. Since the kids came along I rarely go to the theater — unless the movie has Hannah Montana or a talking fish, I’m usually watching it on my couch.

I watched about half the film but I couldn’t finish it. There is only so much brutality and cruelty and psychopathology that I can take outside of the ER. As I got deeper and deeper into the movie, I recoiled from the hyper-real depiction of violence and depravity.

Finally, as I literally became nauseated, the thought dawned on me – why and I subjecting myself to this? Don’t I get enough of this at work? Don’t I get enough ignorance and hostility and violence from the residents? Just kidding.

The movie was just too good. It was too real.
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To those that aren’t familiar with the movie “Precious” is about a very unattractive and unsympathetic young black woman (ironically named Precious) living with her sadistic, mentally unstable mother in Harlem. Precious is surrounded by ignorance, violence, and antisocial behavior by dysfunctional and psychotic characters including her father, who rapes her repeatedly and impregnates her twice. As the movie opens, Precious is dismissed from her public school because of the pregnancy. A dedicated counselor finds a place for her in a special school for girls with extracurricular obstacles, but every where she turns Precious is berated, beaten, and bullied.

Most of time, despite her enormous size and obesity, Precious is invisible to other people and when she is noticed, she is tortured. The major antagonist is her mother, played by an actress named Mo’nique, who, when she isn’t beating her with pots and pans, is drunk and high, smoking cigarettes and screaming at Precious to forget school and stay home and collect welfare.

After the third or fourth scene of Precious being beaten and seventh or eighth scene of illiterate black characters engaging in irresponsible, immature behavior and substance abuse, I just couldn’t take it anymore. Who wants to see a movie about this crap when I have to deal with this exact same set of problems every time I walk into the ER?

I’m sick of seeing the effects of drug and alcohol abuse on abused wives and children. I’m sick of trying to explain simple concepts of health maintenance like the importance of not smoking crack when you are pregnant to young women (who are generally more interested and engaged in texting while I’m trying to speak with them) that already have two other children from different sexual partners and haven’t read a book or magazine that doesn’t have a menacing tattooed hip-hop rapper thug felon on the cover. Does this have to be celebrated with a movie?

“Precious” the movie does an incredible job of realistically depicting the worst behavior of black inner city inhabitants. I watched as much of the movie that I could stand and I didn’t see a single heroic or even sympathetic character. That is not my experience.

In my years of practicing emergency medicine in the ghetto I have witnessed breathtaking examples of selflessness and honor. Instead of the disgusting and depressing “Precious,” give me a movie about a heroic inner city math teacher or a grade school spelling bee champ or basketball team that beats the odds any day.

Gerald O'Malley, DO: Diet

Like most ER docs, my diet is atrocious. Shiftwork, the scheduling demands of raising two elementary school-age kids with a working wife and the unpredictable nature of the job conspire to interfere with a normal three-well-balanced-meals-a-day nutritional game plan.

My friends and colleagues that I work with all have the same excuses. Fried cafeteria crap for breakfast, lunch and dinner and fast food delivered to the ER all night to feed the graveyard shift. There is even a Chinese restaurant down the block that delivers until 5:00 a.m.! (We boycotted the place a few years ago when they sent out a 12-year-old kid at 3:00 a.m. on a school night to deliver our egg foo young. The boycott lasted nine days until, starving, we broke down and sheepishly ordered our 4 a.m. fried rice fix.)

Over the years I’ve tried to eat healthy, but have you ever tried to find a salad in the ghetto at 3:00 a.m.? You usually break down and feebly hunt through the left-over tuna sandwiches in the out-of-date box lunches that the ER keeps for the homeless, or the last resort of the starving – the vending machine.
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Before leaving for work I make sure to stuff my pockets with quarters for the gee-dunks (old Navy term) in the hopes that I might snag the last packet of trail mix but I usually have to settle for the pop-tarts or peanut M&Ms or little chocolate donuts.

Once I entered my 40s and the inexorable rise in my total body mass became hopeless to halt or even slow down, I tried a series of desperate and crazy diets – all miserable failures. But I started a new one on March 1st of this year and I think this one might actually work.

I stumbled across this diet while reading another blog. An advertisement on the side of the page showed a series of pictures of the diet developer beginning on the left with an old photo when he weighed 300+ lbs. and ending with a photo on the right in his new, svelte 165 lbs. chassis.

His story is amazing and inspirational and his reasoning and philosophy seemed to make a lot of sense – we eat too much processed food which is absent of omega-3 fatty acids and assimilable proteins, so incorporate foods and supplements with these elements in them and the weight will fall off you (I’m oversimplifying here – the name of the diet developer is Jon Gabriel and you can look him up yourself).

I thought – well, maybe this is worth a try. Mr. Gabriel extensively references his book with genuine scientific articles from biochemistry and hard-core physiology journals. So I bought a bunch of fish oil capsules and probiotics and digestive enzymes and flaxseeds and I incorporated them into a diet consisting of lots of raw greens, fruits, and vegetables, and I’ve been pretty compliant with the program (much to my own surprise).

St. Patrick’s day was brutal and I cheated with beer, soda bread, Irish beef stew, and my wife’s amazing whiskey tea brak, and I broke down a couple of weeks ago and savored every bite of one of famous Ray’s mushroom cheesesteaks, but I discovered that when you eat a ton of lettuce everyday, you really don’t have cravings for sweets or desserts.

My wife helped me by filling up the fridge with fresh vegetables and fruit and packing delicious salads for me while I napped before a night shift. I haven’t eaten this well in a long time and I actually feel great – I feel light and I’m sure I lost some weight, so I’m going to get up from this essay and weigh myself right now….

Six pounds? That’s it? In 5 weeks of dieting? I went from 234 lbs. to 228 lbs. (actually 228.5 lbs. so it’s not even 6 pounds!). Huh. What a disappointment.

Oh well, I feel like I’m doing something good for my body, so maybe I’ll continue with this diet for awhile more. Then I told my lovely Japanese wife that I lost 6 lbs., she said, “I can’t believe you weigh 230 lbs. – that’s as much as a sumo wrestler!”

I think famous Ray’s is open until 10:00 tonight.

Gerald O'Malley, DO: Secret myths and quiet truths of the ER

I was in the grocery store the other day and something caught my eye as I pushed the bananas and Ho-Hos through the price-check scanner. Reader’s Digest had an article about my childhood hero, Willie Mays (I know he was a Met, but even Yankee fans recognize greatness), but that wasn’t what made me buy the magazine.

It was the picture of the young woman dressed in scrubs accompanied by a headline like: “50 Secrets ER Doctors Won’t Tell You (Read This Before You Call 911).” I couldn’t resist.

The American ER (and the people that work in ERs) has always been fertile ground for urban myths and legends. I’ve heard the same outrageous stories told in ERs from Virginian Beach to Los Angeles: The violent PCP patient tossing around security guards after being tazed, the guy with the vibrator in his rectum, the “dead” patient that sits up and moans…

ERs all have similar stories and sometimes it gets hard to separate truth from fiction. Reader’s Digest actually picked some uncomfortable but undeniable truths to reveal as “secrets.”

Some of my favorites from the March issue of Reader’s Digest include:
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• Never, ever lie to your ER nurse. Their BS detectors are excellent and you lose all credibility when you lie.

• Standing in the doorway and staring at us while we work won’t help your loved one get treated more quickly. We’re pretty used to people trying to intimidate us.

• The busiest time starts around 6 p.m.; Mondays are the worst. We’re slowest from 3 a.m. to 9 a.m. If you have a choice, come in the early morning.

• If you come in with a bizarre or disgusting symptom, we’re going to talk about you. We won’t talk about you to people outside the ER, but doctors and nurses need to vent, just like everyone else.

Harsh to read, but I had to grudgingly admit that there was some truth to the “secrets.” The reality is that this can be a really crappy job a lot of the time. For every good, happy, positive outcome, there are a dozen that are heartbreaking and terrifying.

The first of the 50 secrets in the article seemed a little obnoxious and condescending. It read: “Denial kills people. Yes, you could be having a heart attack or a stroke, even if you’re only 39 or in good shape or a vegetarian.” Seemed a little self-evident to me.

Tonight I tried everything in my power to resuscitate a 43-year-old woman that I pulled out of the front seat of her boyfriend’s car. I remember smelling and seeing the burning cigarette in the car ashtray as I wrenched my back trying to untangle her feet from under the dash, lift her out of the car and drag her out onto the ER gurney. The boyfriend took the time to light and smoke a cigarette while he drove this dying woman to the ER.

I thought of the first secret as I sat to explain to her 13-year-old son why I couldn’t save his mother.

Gerald O'Malley, DO: Legislative tyranny

I wanted to write an essay this week about the residency match and the excitement (and disappointment) that happens this time every year along with St. Patrick’s Day in the ER. We celebrated in the hospital by sharing several big pots of traditional Irish stew (my dad’s recipe) and my wife’s soda bread and tea brack with the Pogues and Clancy brothers on the CD player. I started to write that essay, but the words just wouldn’t come.

The congressional approval of the healthcare takeover bill is so profoundly unjust I can’t not write about it. So much has been written and said about the legislation that the House approved late Sunday night – what more is there to say?

From an emergency medicine perspective there’s a lot to say. Every ER doc that I know desperately wants healthcare reform. We went into this line of work to help people. It’s really hard to help people that have no insurance. They don’t practice routine health maintenance, they can’t afford the medications we prescribe, we can’t get them in for follow-up appointments, and forget about seeing specialists. Patient advocacy is ten times more difficult for people with no insurance. The people of this country deserve a better system, but this massive government entitlement is not the fix. In the words of my father, this thing is a dog’s breakfast.
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I had a lot of trouble figuring out which bill was the relevant one. Try Googling “I want to read the healthcare reform bill” and then sift through all the variations of the bill that have been posted online. I finally found the relevant reconciliation amendment and my computer crashed three times while attempting to download a pdf of a summary of the bill. The Table of Contents is 14 pages long! I read as much of the original bill as possible but when a document is filled with this much gobbledygook, no one can possibly understand what is being said, and I can guarantee that most members of Congress didn’t read the damn thing. (You can read all 2,310 pages of H.R. 4872 plus the 153 pages of the reconciliation act at http://thomas.loc.gov/.)

Why does this need to be so dense and complicated? Why didn’t Congress entertain smaller and less intrusive fixes that will serve to bring down the cost of healthcare but not set us on the road to a single payer (i.e. governmental) system? Why not allow consumers to buy health insurance across state lines? Why not allow for health savings accounts that can serve as investment vehicles? Why not allow for a variety of healthcare insurance options that provide for catastrophic coverage with flexible premiums depending on the deductible that we want to pay? Why can’t we buy our health insurance the same way that we buy car insurance? Congress and the President seem determined to establish a national healthcare system similar to the British National Healthcare System, which is the third largest employer in the world, behind Indian Railways and the Chinese army.

I’ll tell you one thing that you won’t find anywhere in this bill — tort reform. The trial layers saw to that.

There is an avalanche of legal challenges to this monstrosity and I’ll probably financially support several. I feel like I have to — the national deficit is so huge and the debt is so massive I’ll probably wind up paying close to 50 percent of my income in taxes as will my children and grandchildren. Medicare and Medicaid and Social Security are broke and we cannot afford another massive entitlement. I don’t believe what my government is telling me about how this action won’t negatively affect the economy. This is so unfair to taxpayers and future generations of Americans.

In New York, bricks were thrown through the windows of legislators that voted for the bill. I’m truly afraid for my country.

Gerald O'Malley, DO: The mushroom mystery

On Tuesday morning I received an urgent phone call from a colleague who works in another ER. He told me about a patient who he saw with a possible severe mushroom ingestion and poisoning. The patient was a friend of his. My colleague had secured emergency consulting privileges for me from the medical staff president and asked me to see the patient. I was scheduled to work a moonlighting shift that evening at my friend’s shop, so I promised to stop in and see the patient before work.

Thirty minutes later I received an urgent e-mail from Dr. Kevin Osterhoudt, the director of the Philadelphia Poison Control Center about a mushroom-poisoned patient somewhere in the city.

My first thoughts were “My God – are there TWO patients? Is someone selling poisoned mushrooms on the streets of the city? Do we have a public health crisis on our hands?”

A quick phone call to Poison Control clarified the situation. One patient. No epidemic. No need to call in the health department or to shut down the farmer’s market where our patient bought her mushrooms. At least not yet — but the chase was on.
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I saw the patient a few hours later. The patient was a professional and a very health-conscious individual who rarely ate meat and bought her produce at the organic food market. Her symptoms began about three hours after eating the morels that she bought at the Reading Terminal Market. The patient and her husband were both in the ER at midnight — he was on death’s door; she was a lot worse. There were no more reports of mushroom poisoned patients in the Delaware Valley in the interim.

Abdominal pain, diarrhea, bloody vomiting, volume contraction, hypotension, dysrhythmias, acidosis…everything needed to kill a young woman. Except mushroom poisoning. There are seven or eight known toxic syndromes associated with poisonous mushrooms, but neither this patient nor her husband showed the characteristic signs of any of the known syndromes. No liver toxicity consistent with Amanita phylloides, no renal toxicity to suggest Cortinarius species or Amanita smithiana, no central nervous system toxicity to suggest Gyromitra species (the “false morels”).

What the hell was killing these people?

I called the Poison Control Center and consulted with the brilliant Dr. Fred Henretig. He agreed — didn’t sound like any mushroom he had ever heard of. I felt reassured when Fred concurred that this wasn’t a mushroom — this sounded more like some kind of pre-formed toxin like a Staphylococcal toxic shock syndrome.

The patients improved. The first 36 hours were terrifying. The next 36 hours were tense but hopeful — double and triple checking hemodynamics and fluid status and pressor dosages. The fourth and fifth days were joyful, watchful, prayerful. The critical-care specialists were heroic and never left her side. God watches out for drunks and doctors.

The mushroom questions never stopped. For the past week I’ve answered dozens of questions from family members, nurses, doctors, and Poison Center personnel about the mushroom poisoning that never was. Amazing how stories take on a life of their own.

Drs. Osterhoudt and Henretig think that it is worthwhile discussing this case at the next Poison Control Center Grand Rounds in the context of mushroom poisonings in general (rare but terrifying) and more specifically when we, as a Poison Control Center and a public resource, should pull the trigger to initiate a public health alert.

I’ve invited the patient and her husband to attend.

Gerald O'Malley, DO: The heroes of Haiti

This post is dedicated to the men and women of the U.S. Naval Medical Corps serving aboard the U.S.N.S. Comfort.

One of my former residents came to the hospital last week to visit. His name is Adam Cooper, and he graduated from residency three years ago, tried a couple of different jobs, but made the decision to enter the U.S. Navy as a medical corps officer about a year ago, so now I have to call him Lieutenant Adam Cooper. Recently, Adam was mobilized as part of the largest relief effort ever conducted in the history of the U.S. Navy: the rescue effort in Haiti. Adam wanted to come back to the hospital and “hug every one of the attendings for the four years of torture” that we put him through during residency.

Adam shared some of the 3,000 pictures that he took of his time on the U.S.N.S. Comfort and on the devastated island itself. Horrific images of severe trauma, necrotizing infections, and gangrene against a backdrop of collapsed buildings in a broken country. The pictures also told a story of heroism, valor, and tenacity by the members of the U.S. military — the true heroes of Haiti.

Adam kept his promise and hugged all of us amid backslaps and high-fives, and then we all sat down as he gave the details of his mission to rescue and aid the victims of the earthquake and provide 21st century medical care to a country with a 17th century infrastructure in an environment of biblical destruction.
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Adam was the only emergency medicine trained physician as part of a team consisting of family practitioners, surgeons, pediatricians, nurses, and naval corpstaff. The team treated over a thousand patients in 12 days, moving critically ill and injured people from the rubble onto helicopters and boats to the operating rooms on board the Comfort, recovering them and getting them back to some level of definitive care. The team worked under the most extreme conditions — an aftershock knocked out the CT scanner on the ship for four days and several of the portable X-ray machines burned out. Suddenly, Adam and the team discovered what bedside diagnosis was like in the 1950s.

The diseases and trauma that the team saw would give any physician nightmares. Among the fractures and amputations and solid-organ injuries and dehydration and sepsis and abandoned children, the team treated six cases of tetanus, cerebral malaria, and delivered a half-dozen babies, the births of which were complicated by seizures, eclampsia, and open pelvic fractures in one of the mothers. According to a study by UCSF, in 2007, approximately 15 percent of the population of Haiti was living with HIV/AIDS.

The team coordinated with members of the international relief effort including military representatives from Israel, France, England, and other countries as well as NGOs like the Red Cross and Doctors Without Borders.

Adam said that every member of the team work 20 hours each day for two weeks straight. He compared is to “the worst shift you’ve ever worked in the ER — all day every day” and he thanked us all again for the time and teaching.

I’ve never been so proud of one of my former residents. In a small way, I almost feel like I spent some time in Haiti with Adam — just like the old days.

Gerald O'Malley, DO: Some thoughts on the healthcare summit

Today, I worked a 7-3 shift in the ER while our political leaders were meeting to talk about what to do with healthcare. Ironic, considering there are roughly two dozen physicians in Congress and not one was seated at the table. Can you have a serious summit on energy policy without engineers? Can you have a serious summit on national security without law enforcement experts? The only members of the government that actually have any experience with the actual delivery of healthcare were absent, which should tell you everything you need to know about the healthcare summit of 2010.

As the snow swirled around outside in the most recent snowpocalypse to affect the city this winter, we struggled to get our patients out of the waiting room and into an exam room as quickly as possible. We waded through their poorly described complaints and tried to identify any life threatening problems quickly and efficiently.

We probably saved a half-dozen lives in eight hours; an acute myocardial infarction and a stroke, an ectopic pregnancy, an acute appendicitis, and a septic old lady were all “rocked and locked” — a euphemism for getting the job done quickly and expeditiously. In addition, we treated a number of “non-life threats” — broken bones and lacerations and asthma attacks and strep throats.
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We tried to follow the proceedings on TV and online whenever we could, but I had to wait to get home to watch the news in order to digest the proceedings.

I heard a lot of sound bites (mostly from Republicans) asking for tort reform, but beyond the sound bite, there was no follow-up discussion. The trial lawyers have spent so much money buying access and influence that I doubt any meaningful tort reform is possible.

Some idiot congressman actually suggested that a plan for “stealth patients” be written into the bill in order to “root out Medicare fraud.” He said that we should send “fake patients claiming to have broken legs” to MRI centers and if “they continue to treat them like broken legs, then we know there is fraud going on.” There are so many things wrong with that statement, including the fact that broken legs are not diagnosed by MRI, that I don’t know where to begin, and what’s worse is that this half-wit congressman was actually describing something that had been proposed by Senator Tom Coburn, who is an obstetrician! Maybe the physicians shouldn’t be at the table, if they are going to make ridiculous suggestions like that!

After work I picked up my kids and was driving home when I received a “remember that patient you saw the other day” phone calls from my vice chairman: “Gerry, you need to meet with risk management next week to talk about this case.” You don’t actually need malpractice to be sued — all you need is a bad outcome.

What are the odds that this patient was a “stealth patient” or someone that is already talking with a lawyer?

Gerald O'Malley, DO: Pattern recognition in the ER

ER doctors (and nurses) rely on pattern recognition to practice the type of medicine that is forced upon us when we take control of 75 patients all crammed into a space designed to hold 48 (with another 30 in the waiting room).

As Malcolm Gladwell described in his wonderful book “Blink,” good ER physicians develop reliable intuitive senses regarding the myriad ways that different diseases can present in different people and subconsciously search for patterns that guide clinical judgment. Many times, ER physicians “blink” instead of “think” (although I like to believe that we spend an awful lot of time thinking) and we learn to rely on and to trust our clinical judgment and our ability to recognize subtle patterns while caring for our patients.

What becomes really difficult to do over time, is to not bring that habit home and begin making instantaneous judgments about our spouses, our families, friends, and neighbors.
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I can recall many times that I’ve been introduced to someone outside of the ER and my first thought is, “My gosh, this guy is a tool. I bet he loves to watch grass grow, believes in global warming, and picks at mosquito bites until they bleed.” All that from a handshake and a “How do you do!” I genuinely feel sorry for any guy that my daughter brings home (I’ve got a couple of years before that becomes a serious concern) because the guy has about 11 seconds to convince me that I shouldn’t squeeze his head like a zit.

Pattern recognition is an inexact science and some are better at it than others. As a resident I used to think, “I can smell diabetes as soon as I walk in a room.” That’s not really true, I can’t “smell” diabetes, but I learned pretty quickly how to recognize the subtle clues of poorly controlled occult diabetes that might escape a non-emergency medicine trained or less astute clinician; the sticky film of sweat on the back of the neck, the two or three soft drinks consumed while waiting for me to get in the room, obesity, the general state of being unkempt and sloppy (because the constant interruptions to the daily routine caused by the disease do not allow for meticulous grooming), the thin film of greasy sheen under the eyes. There is no science behind this – these are observations that I’ve made over the course of a 15-year career in emergency medicine and caring for dozens of patients that have not yet received the diagnosis of diabetes mellitus.

During emergency medicine residency, the young physician is trained to do amazing things. One colleague told me that when he graduated residency, he believed he could sew somebody’s head back on (he has since modified his own inflated sense of his abilities). One of the most valuable things we can teach young ER physicians is to apply their intuitive ability to “blink” instead of “think” correctly, because, according to Gladwell, good clinicians are more often than not correct in their “snap judgments” which can probably lead to less testing, less time wasted, and less cost to the healthcare system. A good “blink” reflex comes in handy outside the ER when dealing with salesmen, auto mechanics, and (especially) lawyers.

What is not so easy to learn is how to turn off the “blink” and getting to know friends and acquaintances outside of the ER on a deeper level. Forming opinions of people with little or no exposure to them is not a great way to develop long-lasting and meaningful relationships.

Gerald O'Malley, DO: Philadelphia ER in the recent snowstorms

During the recent snowstorms in Philadelphia, the ER staff was sequestered for about 36 hours as part of the emergency disaster planning. Being required to stay at work caring for strangers while your own family is at home in the middle of the worst snowstorm in history, in some cases with no electricity, should bring out the worst in most people — but ER people are a strange breed.

Throughout Wednesday afternoon, as the blizzard progressed and the blanket of snow became thicker and heavier, nurses, techs, and doctors straggled in and arrived early, to be sure that they could make it in for their night shift. The mood was one of genial complaining and fatalistic good humor.
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“What are all these drug addicts doing here?”

“The methadone clinic across the street is closed. They put a sign on the door to go the ER. They came here for their methadone and now they can’t get home.”

“Can’t we stick them all in one room - the waiting room for instance - instead of having them lying around underfoot?”

The ER staff cared for the patients and paramedics that managed to make it into the ER and passed the downtime having snowball fights in the parking lot and using cafeteria trays as makeshift toboggans to slide down the snow-covered concrete steps of the hospital. Those that brought food shared it with their colleagues and patients and the rest ate whatever the cafeteria served up. The cafeteria stayed open all night serving up hamburgers and cheesesteaks while the salads got soggy. The staff worked and slept in shifts, finding an empty gurney wherever one was available.

Nurses, techs, and residents that couldn’t sleep entertained each other by gossiping and telling stories or watching TV (the most common request from the staff after the storm was that they wanted the hospital to provide Cinemax for the TV in the lounge for the next blizzard).

As the night progressed and the general volume decreased, conversations became hushed and more intimate. The wee hours of the cold night led to the revelation that You-know-who and So-and-so hooked up at the holiday party and What’s-his-name’s son is back in jail. We also learned that my colleague (that I’ve been working with for three years) turned down a music scholarship to Julliard to take on the burden of medical school debt, and two of our nurses were in Haiti helping with the relief effort.

Thursday morning arrived brilliantly and the whole city seemed like it was shining from the ground up. Every hard surface was nestled in a soft white blanket of silence. It was beautiful. Relief workers began to straggle in and tired nurses, techs, and residents were allowed to leave in a reverse-seniority order throughout the day.

During the winter of ’94-’95 there were several severe ice storms that crippled Philadelphia and left us stranded overnight several times. It’s funny how the long snowy day’s journey through the night always seems worse when you are actually living it. Some of my fondest memories of residency were those nights that we were trapped in the ER by our jobs and our duties. I suspect that this blizzard of 2010 will provide fond memories for another generation of residents and interns, although they probably won’t realize it for awhile.

Gerald O'Malley, DO: Violence in the ER

My job as an emergency physician is analogous to my brother’s job as a NYC police officer in that it is often defined by hours of monotony punctuated by moments of sheer terror.

We deal with the consequences of brutality every day and sudden, explosive violence is never far away. My ER is located in one of the worst neighborhoods in Philadelphia and we have very large but unarmed security guards that provide protection to hospital employees, patients, and visitors. They don’t get enough recognition.

Despite our best efforts, a determined assailant can threaten the entire ER.
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Recently, a man caved in his wife’s skull with a claw hammer because she smoked up all his crack while he was out. She suffered multiple skull fractures and brain injury, and while we were working with the trauma team to stabilize her, the assailant posed as the patient’s brother and tried to get through security into the treatment area of the ER in order to do…something. Fortunately, a Philadelphia police officer recognized him and arrested him before he made it into the trauma room.

Another guy broke his girlfriend’s neck, her jaw, her nose, and three of her ribs and while she was in the CT scanner, he checked into triage under a fake name with a complaint of an injured thumb. He sneaked out of the FastTrack, where he had been triaged and was moving through the ER going room to room and peeking through curtains looking for our trauma patient in order to do…what? One our techs noticed him, approached and challenged him, and after a few minutes of excuses, he bolted through the ambulance doors into the Philadelphia night.

We have discussed the hard economic realities of installing, maintaining, and manning metal detectors in the ER, but we all agree that a realistic cost-benefit-threat analysis concludes that it makes no sense. As a faculty, we thought that metal detectors would send the wrong message to the community we serve – that we don’t trust them or we feel threatened by them. Interestingly, a pair of surveys from 1997 (one of them conducted right here in the City of Brotherly Homicide) suggest that patients in an urban ER waiting room actually feel safer with metal detectors and do not feel that their privacy is being invaded.

I was robbed at gunpoint in high school while working the night shift at an ice cream shop. I’ve never had a gun pulled on me in the ER. Yet.

Gerald O'Malley, DO: I can't help you, part 3

In the ER we are frequently tasked with trying to help people that really don’t have emergency problems.

The system just isn’t designed to accommodate satisfactorily individuals with nonemergent problems, and my patients frequently become frustrated at my inability to assist them, although occasionally I have a small victory.

A patient showed up at 9:00 a.m. one day complaining of ringing in her ears for the past two months. Her primary-care doctor had made an appointment for her to see a specialist — in another three months. The high-pitched ringing was worse at night. She couldn’t sleep and was nearly suicidal. Read more
I spent 45 minutes on the phone with her insurance company and her primary-care doctor securing a referral and pleading with the specialist, and I got her an appointment at 1:00 p.m. that same day. During those 45 minutes, another six patients showed up in the ER and their care was delayed for hours while I negotiated on the phone. My patient was lucky — the specialist agreed to see her expeditiously.

As bad as things are now, I suspect that the day is coming when the specialist will just say, “I’m sorry. It is simply not worth it for me to take on this additional work and risk.” At that point it won’t matter how long I stay on the phone and no amount of pleading or bargaining or cajoling will matter. We have to savor these quiet triumphs.

Another patient wanted me to do something about the ganglion cyst on her wrist. It had been present for “a while” but had recently begun to interfere with her work, which was exotic dancing. The cyst rubbed against the pole and caused pain. She also wanted me to treat her hyperthyroidism.

“Who told you that you have hyperthyroidism?”
“Well that’s what causes you to do everything real fast, right?” she said. “Well, I talk real fast and I dance real fast too.”

She gave me a short demonstration of how quickly she can dance. The nurses loved that picture.

“So I figure that I have hyperthyroid and I need something to treat it to help me slow down.”
“Do you do a lot of cocaine?”
“Not a lot — only when I’m at work or at home.”
“I’m sorry, I can’t help you.”

Gerald O'Malley, DO: I can't help you, part 2

Some days in the ER, I just can’t seem to help anyone.

Here's the story of another patient, this one about 25 years old with chronic back pain who showed up requesting that I provide him with several different narcotics. He said he had recently moved to Philadelphia from another state and he had run out of his pain medication prescriptions.

You’d be surprised how many people show up in the ED complaining of chronic painful conditions that they had been suffering with for a long time that “suddenly run out of pain medications” and want refills. I never want to deny a patient pain medication if they are truly having pain, but my prescriptions have been forged and stolen and diverted to schoolyards. I have to be careful. My normal practice is that I require the patient to show me something to work with.
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It’s not fair to me for a patient to show up empty-handed and say: “I normally go to a doctor in New Jersey, but I lost my doctor’s phone number and I can’t remember his name but you couldn’t contact him anyway because it is 9:30 on a Saturday night and the office is closed and I don’t have any documentation of my chronic painful condition and I don’t have any empty pill bottles so can I have 120 oxycontin tablets please?” If you think I’m exaggerating, spend one Saturday night in any ER in this country and prove me wrong.

My patient today was a little more savvy than most. He showed up with a DVD containing all his X-rays and MRIs. They were all five years old, but at least he had the decency (or is it chutzpah?) to bring them with him. I contacted the last pain clinic that he had attended and, with his permission, they faxed over several pages of records including a letter from the director of the pain clinic discharging the patient from their care because he had broken the pain management contract numerous times. The receptionist at the out-of-state pain clinic told me that she gets several phone calls each week regarding this patient.

When I confronted the patient with this information, he became quite upset and defensive. He insisted that he could “barely stand up” and he needed to take several different types of narcotics, plus muscle relaxers every day in addition to an occasional percocet tablet just to enable him to do his job.

“What kind of work do you do?” I asked.
“I’m a roofer,” he said.

I called the pain center at my own hospital and they offered to see him and evaluate him in one hour. The patient declined and became testy. “I wasted two hours here, and you won’t help me at all. What did I gain from all this?”

“You got to eat lunch, watch Jerry Springer, and got a referral to the pain clinic. What more do you want? I’m sorry I can’t help you.” He muttered something under his breath and haughtily strode out of the ER.

It used to really bother me when guys like this would present themselves to my ER, but over the past 15 years, I’ve come to accept the fact that we are limited in our capacity to help certain patients because the system simply isn’t designed to accommodate their particular problem. It’s not my fault, it’s at least partially the patient’s fault, but it is primarily the fault of an increasingly inefficient system that is overburdened, overregulated, and unable to provide timely help for non-emergent but urgent problems.

Gerald O'Malley, DO: I can't help you, part 1

When I enter a patient’s room, I make it a point to demonstrate to the patient that I wash my hands or I squirt some hand sanitizer on before I touch them and my introduction is the same for every patient; “Hi, I’m Dr. O’Malley. How can I help you today?” I got into this line of work because I genuinely enjoy helping people. Today, I felt like I didn’t do such a good job helping anyone.

The first patient I saw today was a young lady that told me that she was losing weight. She wasn’t trying to lose weight and her appetite was good, but her mother and sisters told her she was losing weight. At one time she weighed 122 lbs.
“How much do you weigh now?” I asked.
“I don’t know,” she replied.
“Well then how do you know you are losing weight?”
“Because everyone tells me I am.”
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The patient wanted to be tested for a variety of different disease including but not limited to cancer and lupus. I told her that the ER isn’t really the place to begin a workup for any of these chronic diseases and I could provide her with a list of excellent primary-care providers that might help her. She was unconvinced and wanted something other than my reassurance. Having no insurance or source of income limited her ability to access a doctor that might help her.

“Well, let’s talk about this,” I offered. “How long have you been losing weight?”
“About five days.”
“You don’t need any testing. You need to go home and find a scale and try to figure out if you are actually losing weight or not. If you are losing weight, you need to make an appointment with a primary care doctor and get a check-up. If you like, I can have you talk with our social workers in order to begin your application for Medicaid. I’m sorry but I can’t help you.”

The patient became upset, called me a racial epithet under her breath and stomped out of the ER.

The ER has always been the great dumping ground for patients with no place else to go. Most ER doctors pride themselves as being strong patient advocates. I have argued, bullied, pleaded and bargained with other doctors to help my patients. Most doctors, when push comes to shove, will do the right thing for the patient even though it means that they will lose sleep, not be paid and increase their malpractice risk.

One recent case that comes to mind was the illegal immigrant that accidentally put his hand through a circular saw while at a worksite. He had presented to another ER (located on the “Main Line” – the southwestern suburbs of Philadelphia famous for the gorgeous old staid mansions and outrageously overpriced condos), was bandaged up, and given a map with directions to my hospital. He showed up in my ER with an injury that might have required an amputation had it not been for some gentle arm twisting on my part and a heroic effort on the surgeon’s part – all without compensation and with the shadow of the trial lawyer bribing OR nurses and techs for leads on possible malpractice cases. (I personally know ER nurses and techs that have been offered money from trial lawyers to “keep your eyes open” for information on any potential malpractice cases.)

Some days, I just can’t seem to help anyone.

Gerald O'Malley, DO: What is wrong with the PMS?

The Pennsylvania Medical Society (PMS) is arguably the most important professional medical society in the Keystone State. So why don’t they do something important to help the medical professionals in this state?

The medical malpractice situation in Pennsylvania is an unmitigated disaster for physicians and patients. The overt trial lawyer patronage on the part of the governor and state legislature at the expense of the citizenry is a model of corruption, cronyism, and racketeering that the rest of the country can study as a model of how not to run healthcare.

Unfortunately the PMS has, for years, tried to negotiate and cooperate with the state government. It took the theft of $808 million from the Mcare medical liability coverage fund last year to wake up the leaders of PMS that physicians can’t play footsie with trial lawyers or the politicians that protect them. As I have explained in previous posts, the Mcare fund is a pile of money collected from taxes applied to physicians, nursing homes, hospitals, and other health care agencies and was created for the specific purpose of compensating victims of medical malpractice.
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Late last year, the state legislature of Pennsylvania voted to take nearly a billion dollars from the Mcare fund to close a hole in the state budget (filling potholes, paying teachers, painting libraries, etc.), creating an unfunded mandate that will be paid by future generations of Pennsylvania physicians.

As a result of the theft of the Mcare money, the leaders of the PMS finally realized the futility of negotiating with the Pennsylvania state legislature. Recent e-mail communications and a “toolkit” pamphlet that was mailed to all members suggest that the PMS has decided to push back. Sort of.

The toolkit pamphlet is titled “Anatomy of a Raid – Challenge for Action”. Wow! Sounds like PMS got the message! They have finally figured out that there is no negotiating with the politicians in Harrisburg! Finally, our leaders are willing to get a little bloody on this! Let’s go! Let’s fight!

Excitedly I read the action plan to stop the legalized theft of my money and the hemorrhage of young physicians from the state:

Challenge #1: Learn more and pass it along
Challenge #2: Choose how you want to become involved
Challenge #3: Thank your legislators

Huh? Learn more? Thank my legislator? What the heck kind of challenge is that?
PMS joined the Hospital and Healthsystem Association of Pennsylvania to sue the state in October 2009 and challenge the theft of the Mcare funds, but as the Philadelphia Inquirer recently reported, the state judicial system is as corrupt as the legislative branch. The headline from the Inquirer from Dec. 28, 2009, was “Oversight of Pa. judges is wrapped in secrecy. The Judicial Conduct Board, created to protect citizens from errant judges, is criticized as doing just the opposite.” This fight will not be won in the courtroom. It should be fought very loudly and publicly.

How about a few more lawsuits? How about a few press conferences? How about organizing a physician strike, for crying out loud? The PMS is bringing a feather pillow to a gun fight. It should hire a few union bosses to advise them on tough-tactic collective bargaining.

This is war and the PMS is playing junior varsity paintball.

Gerald O'Malley, DO: Dreams from the 'hood, part 2

Our ER survey of 13- to 18-year-olds was reassuring in that most of the participants had some ambition and many of them were working toward their goals for the future.

The participants (and results) of the second part of our survey weren’t as optimistic as the first. The participants were older, between the ages of 22 and 27 years old. We chose that age range based on our own experiences; we believed that most people have some direction in their lives by the time they reach their early to mid 20s.
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One-third of the young people in our survey were unemployed or disabled, and the rest were employed in the service industry (waitress, limo driver, supermarket checkout-clerk) or were working toward their high school diplomas or technical trade certificate. When asked if there were any obstacles that had prevented or interrupted the goals that they had when they were younger, one-fourth of the respondents replied in the negative; half had children that had slowed the pace of their goal achievement, and the rest gave a variety of reasons for not being where they thought they might be when they were younger (including a war in one subjects’ native African country).

What can be derived from this summertime survey? Not much. It seems that young, primarily black individuals from the inner city have hopes and dreams for achieving success and career satisfaction, but their understanding of the process for realizing those goals is nebulous and unrealistic.

What happened to these young people in the decade from age 15 to age 25? Three-quarters of the respondents in our survey identified some obstacle that delayed or prevented them from being where they wanted to be — why were they not able to circumvent or avoid or overcome that obstacle? Many of the female respondents identified one or more unplanned pregnancies as the single greatest obstacle to their goals, despite all the financial supports that are available through social services monies and networks.

This seems like such an easy fix. Teenage pregnancy is a dream-killer — our respondents told us so. Instead of funneling lots of money on the back end, when the problem already exists, why not apply more resources to preventing unwanted pregnancies through abstinence programs and birth control education and measures? In my opinion, abortion counseling isn’t the answer because, again, the unwanted pregnancy (the problem) already exists.

Beginning at the age of 13, young men and women need to be taught not to impregnate or to allow themselves to be impregnated. Government provision of financial support to pregnant teens discourages families from doing the hard work that is necessary to work through the problems that accompany unwanted pregnancies.

Prevent the problem before it begins. Convince teenagers that getting pregnant when you are still in school is the surest way to not get what you want. Once the pregnancy occurs, the battle is lost.

Gerald O'Malley, DO, is the director of research in the largest, busiest emergency department in Philadelphia and an associate professor of emergency medicine at Thomas Jefferson University Hospital. He’s also the son of a NYC cop, die-hard Yankees fan, and a regular contributor to Practice Notes.

Gerald O'Malley, DO: Dreams from the 'hood, part 1

In my emergency room, I recently treated a 14-year-old girl that had been pregnant twice and was now on Depo-Provera birth control. While talking to this young lady about her sore throat, I became increasingly distracted by the small tattoo on the side of her face, by her right eye. Who would allow their 14-year-old girl to get a tattoo on her face? My 11-year-old still watches SpongeBob Squarepants. What happened to this 14-year-old?

I became curious as to what plans this girl and the other adolescents in my ED have for their future. Do they think about the future? What are their hopes and dreams?

Every summer we have medical students spend time in our ED to do research. I put them to work. We developed a series of five questions to ask people between the ages of 13 to 18. The questions were:

1. What are you doing right now? Are you in school or are you working or are you doing something else?
2. Where do you see yourself in 5 years?
3. Where do you see yourself in 10 years?
4. With whom do you live?
5. Do you have any children?

The results of our little survey were astounding.
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Almost all the teenagers — whether they were in school or not, working or not, had children or not — had some plans or goals. Some wanted to be doctors. Others wanted to be nurses or other healthcare workers. One kid wanted to be an astronaut. Of the two dozen teenagers that we spoke to, only one or two had no dream for their future. Only one teenage boy said that he expected to be in jail.

I must say, I was thrilled. Maybe things weren’t so bad. Maybe the girl with the tattoo was the exception.

The medical students were also excited. They wanted to know more. During a meeting, the idea came up to try to identify potential obstacles to the goals so the survey questions were amended. The results were slightly less reassuring.

Many of the teenagers in our survey had children. Several of the boys had no idea how many children they had fathered. Some 15- and 16-year-olds laughed as they tried to remember all the girls they had slept with and count up all their children; others didn’t want to talk about it and seemed almost embarrassed that they fathered children that they subsequently ignored.

The teenage single moms all seemed to be doing well. Many of them were in school learning some trade. Four of them lived alone, in their own apartments and had no contact with their families. Three of those four were enrolled in school to become nurses.

“How can a 17-year-old girl support an infant, have her own apartment, not work a job, and go to school and not have any financial or child-care support from their families?” I asked.

“State tuition assistance, city-supported child care, a housing subsidy grant, and WIC,” the students said. “From a financial or childcare standpoint, there really aren’t any obstacles for teenage moms to pursue their goals.”

This isn’t the case, of course. Our subsequent surveys (more on those later) demonstrated that even with enormous amounts of financial assistance, educational and career targets are frequently derailed by unplanned pregnancies.

I mentioned to a colleague that it seemed a shame that these girls had no contact with their families, and he said, “Family interaction is a two-way street. If the family isn’t willing to work through problems, then you can’t expect the teenage mom to do it.” That seemed like excuse-making to me. Why bother working through family problems when the alternative is to just move out and get your own place?

When I mentioned that it seemed remarkable to me that the city of Philadelphia is broke, shutting down libraries and fire stations and laying off cops and teachers, yet there is money to give to teenage single moms to pursue nursing degrees, one colleague actually said, “Well, I rather see my money go to support single moms than for other things – like supporting war.”

I could be wrong, but I don’t think that the city of Philadelphia has ever declared war on anyone.

Gerald O'Malley, DO, is the director of research in the largest, busiest emergency department in Philadelphia and an associate professor of emergency medicine at Thomas Jefferson University Hospital. He’s also the son of a NYC cop, die-hard Yankees fan, and a regular contributor to Practice Notes.

Gerald O'Malley, DO: Emergency surgery on a horse

One of the best things about practicing emergency medicine is the fact that people think you can do anything. Work at this job long enough and you begin to believe that too.

I spent two of the best years of my life stationed with the US Navy in Okinawa, one of the most idyllic spots in the world. I worked with a young corpsman from Oklahoma named Barbara who wanted to pursue a career in animal husbandry. She was enrolled in classes and planned to apply to vet school when her time in the Navy was up.

Barbara was incredibly persuasive. She became friends with a local Okinawan man who owned a pony that he would bring down to the beach and allowed tourists to ride. Horses aren’t native to Okinawa so Barbara convinced the man to purchase three horses from the local meat market and keep them in stables that she had built from driftwood.

Barbara and I became friends and I began to hang around the stables and help her care for the horses. The horses weren’t ill, but they were all damaged and old. One of them had injured its neck and its head was cocked at a 45 degree angle when you looked at it head-on.

One day I received a frantic call from Barbara.
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She told me that one of the horses must have fallen down overnight and sustained a large, deep laceration to its right front shoulder or haunch. Barbara was distraught. “I’ve seen horses have to be put down for injuries like this,” she said “The flies are already getting into it. Do you think there is anything you can do?”

“Why don’t we call a vet?” I suggested.

“None of the vets on this island treat large animals. They are all dog and cat practices. The Army has a vet but he has been ordered not to help me.”

I went over to the ER and collected up a laceration tray, heavy gauge suture material, a stapler and some cast material and drove to the stables. Sure enough, the healthiest horse in the stable had a large gash high on her right shoulder and the flies were laying eggs in it. I confessed that I had no idea what to do. I remember Col. Potter on M*A*S*H* saying that despite their size, horses are remarkably fragile animals. What was the appropriate dose of lidocaine for a full grown horse? Plus, there was the issue of how to not have this 800-pound animal kill me while I tried to repair the laceration. Barbara reassured me that she would apply a nutcracker-type device to the horses’ snout and keep the animal from biting or kicking or stomping me while I was underneath it. Barbara probably weighed 100 pounds soaking wet. “I should have my head examined,” I thought.

There was no way to get to the laceration without getting partially underneath the horse, so I said a prayer and crawled up under the beasts’ belly. I waved away the flies, Barbara applied the nutcracker, and I plunged an 18 gauge needle into the horses shoulder and injected 200 mg lidocaine all around the wound. The horse jumped, but Barbara held on and I managed to get the lidocaine into the wound without getting my head caved in by the rear legs or being smooshed by the animal falling over on me.

The real test came when I scrubbed the wound with a Hibiclens sponge. The horse didn’t seem to mind, so I cleaned all the dirt out of the wound and tried to staple it, but the staples just popped out when the horse moved, so I did a three-layer closure with absorbable sutures for the muscle and fascia and some heavy grade silk for the skin.

I tried to dress the wound a number of ways using tape and Plaster of Paris cast material, but the horse would just shudder and the whole thing would fall apart. Barbara had the great idea to make an elastic dressing by cutting the foot off of a pair of pantyhose and slipping it onto the horse’s leg and tying it to the other leg of the pantyhose, which we wrapped around the horse’s neck. It worked like a charm.

We took the dressing down a week later and the wound was healing well. We left the sutures in place for three weeks. We didn’t ride her for another several weeks and the first time that I got back on the horse, she threw me about 10 feet and I landed on my back, knocking the wind out of me. As I lay there with my face covered in dirt, gasping for breath, spitting out sawdust, I watched the horse gallop away to the far side of the pen, Barbara in hot pursuit one thought crossed my mind.

I don’t get paid enough for this.

Gerald O'Malley, DO: A rant on malpractice insurance

The state government of Pennsylvania is a corrupt failure. Over 40 different hospitals, health clinics, and surgical centers have closed in the last 10 years, all under Governor Rendell’s watch. I’m tired of reading about all the excuses. I’m not listening anymore.

My state representative from the 61st congressional district is a very nice woman. Her name is Kate Harper. She invited me to a constituents breakfast several years ago at which I was the youngest attendant (it was the social event of the week for the area retirement communities).
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Kate seemed earnest when talking about her passions like environmental legislation, and she was insistent that her votes supported doctors. But she couldn’t resist relating a grotesque story about a drunken OB/GYN that she had heard second- or third-hand (Kate is a Republican and a lawyer, so she seems to have an internal struggle with that existential inconsistency). We began an e-mail correspondence and Kate was kind enough to speak to my residents on the issue of medical malpractice. She even brought another lawyer with her, and the two of them put the fear of God into the residents with a mock med-mal trial. One resident participant, after being cross-examined during the mock trial, said, “I have never had anyone speak to me like that,” and he was visibly shaken. (Having been a defendant in two malpractice trials, I have been talked to “like that” for real).

Kate sent out an electronic update/newsletter recently. The newsletter described the process by which the Pennsylvania state budget was recently passed and detailed what will in all likelihood be the final nail in the coffin of our attempt to keep any resident physicians in this state.

This year’s budget approved the use of MCARE (Medical Care and Availability and Reduction of Error) funds for general purposes, rather than for what it was originally created for — settling medical malpractice lawsuits and compensating victims of medical malpractice (and their lawyers). General purposes include police overtime for the Phillies tickertape parade, trash collection, and libraries, among other things.

MCARE is essentially an insurance fund (run by the state) that charges an annual assessment on physicians, hospitals, nurse midwives, podiatrists, and nursing homes to pay current claims and operating expenses. In 2008, the fund paid out claims totaling $174 million.

Since 2003, high-risk specialties such as neurosurgeons, OB/GYNS, and emergency physicians were allowed to apply for an “abatement,” which eliminated their contribution to the MCARE fund. The abatement program allowed doctors that don’t practice in high-risk specialties to reduce their contribution by 50 percent (creating an adversarial situation among specialties). The MCARE abatement program was eliminated last year. The MCARE fund itself ended this year so that all physicians will be forced to obtain insurance privately at exorbitant rates (the average malpractice premiums for an ED physician in PA is $60,000 per year higher than in neighboring Delaware).

So the governor of Pennsylvania has collected money from doctors specifically for the purposes of paying lawyers that have sued doctors and now they want to take $808 million of the money that the doctors have already paid into this account and use it to pay for other things.

In addition, since the MCARE fund only covers expenses from year-to-year, eliminating MCARE and using the existing funds to pay for parks landscaping and school lunches creates an unfunded mandate for lawsuits and settlements currently in progress that equals $1.7 billion. Who will get stuck with that bill?

Never mind keeping resident physicians in Pennsylvania – I can’t afford to live here anymore.

Gerald O'Malley, DO, is the director of research in the largest, busiest emergency department in Philadelphia and an associate professor of emergency medicine at Thomas Jefferson University Hospital. He’s also the son of a NYC cop, die-hard Yankees fan, and a regular contributor to Practice Notes.

Gerald O'Malley, DO: Something special

I’ve worked for the National Board of Medical Examiners (NBME) and Educational Commission for Foreign Medical Graduates (ECFMG) as a patient note rater for the last five years.

Every medical student and international medical graduate that wants to train in a U.S. residency program has to take and pass a series of licensure exams, including a Clinical Skills Assessment in which the examinee interacts with an actor in a mock examination room setting and writes a note detailing history, physical, differential diagnosis, and proposed work-up. I, along with about 88 other physicians, get paid to rate about a half million notes every year.

The whole testing process is amazing. Read more
There are five testing centers in major cities throughout the U.S. Students and international medical graduates show up to examine fake patients. All of the patient encounters are incredibly realistic. Some of the actors have been portraying the same patient and the same illness for years and have a very good understanding of how a patient with renal colic or alcoholism or pneumonia or GI bleeding presents. The examinees receive instruction and then have a set amount of time to interview and examine the “patient” and write a comprehensive note.

This is a high stakes test. It’s expensive ($1,050 for U.S. students, $1,200 for international medical graduates), plus travel, lodging, and Pepto-Bismol. The anxiety level in the waiting area of the ECFMG testing center on exam day is palpably high. There is usually a table with bagels and coffee that remain untouched by the examinees as they sit around the room in silence waiting to be called to begin the exam. Each examinee has the look of a long-tailed cat in a roomful of rocking chairs. Given the complexity of the exam, the comprehensive nature of the monitoring, and the necessary integration of technology and human interaction to simulate the doctor-patient interaction, it is really amazing that testing goes so smoothly.

The first time I saw the testing center I remember feeling a certain pride. My wife is an international medical graduate and I’ve been involved in international medical education through my work as a Navy medical officer in Japan. The international medical graduates who come to this country and sit for this test cannot help but be impressed and maybe a little intimidated by the attention that is given to this test and the seriousness that surrounds the whole testing process.

This week, all the patient note raters attended our annual refresher training, which is a four-hour process and like everything else that the ECFMG does, it was highly organized and valuable. We sat in a large room and performed exercises and discussed problems with the rating process and ways to improve quality, accuracy, and reliability of our note rating. We received feedback on the notes that we have rated and we were given details about our statistical scoring averages and ranges and standard deviations and skew and kurtosis (tells something about rating bias - by the way, you don’t want to be too leptokurtotic — too peaked — or platykurtotic — too flat — but more mesokurtotic, in case you we were wondering) with histograms illustrating our rating history.

Some of us have already seen this data in private remediation sessions held with Tom the friendly physician medical director. The oversight and double and triple checking and analysis are endless. Each note is rated several dozen times by several dozen different raters. The first attempt failure rate for U.S. graduate is about 3 percent and for international medical graduates, it’s about 30 percent.

I think that every physician that practices in the U.S. should feel the same sense of pride that this program is run so competently. This is the face that we present to doctors all over the world. The fact that this whole process is so arduous and comprehensive and professionally administered demonstrates to the rest of the world that we take medical education and training very seriously and being a physician in the United States is something special.

Gerald O'Malley, DO, is the director of research in the largest, busiest emergency department in Philadelphia and an associate professor of emergency medicine at Thomas Jefferson University Hospital. He’s also the son of a NYC cop, die-hard Yankees fan, and a regular contributor to Practice Notes.