A New Way, DNR Tattoos, and the Paradigm of Presenteeism

Despite best intentions and numerous drafts just waiting to be completed, over the last few years I have not been able to write regularly.  The blog stagnated as I progressed through residency into attendinghood, took on a series of academic and administrative roles, and expanded my family together with my wonderful wife. And yet, it’s something that I think about constantly.

I recently had an opportunity to sit down with an ED doc who actually does write regularly, while still working, teaching, and, presumably, leading a normal life so I asked him how he finds time.  His answer was simple.  It’s one that I’ve seen over and over, and heard indirectly many times before – but somehow it carried more weight coming from him.  “Write something every day” he said.  Now I’m paraphrasing here, but the bottom line – more or less – was this: “Even if you only write a few lines about something that made you think, or something that you’d like to comment about, you capture the emotion.  Then, over the next few days, or at some point down the road, you can flesh it out.  Add references, background, expand the piece, and eventually you’ll have a completed item.”

So, with that in mind I’ve started writing privately again. Compiling ideas, starting new drafts, feeling out old beginnings, and now, also reviving EMIMdoc.org for the hundredth time.  I’ll be cleaning up the links and pages over the next few weeks. New writings will focus primarily on current events in medicine, personal reflections, and topics in medical ethics.  There will also probably be some FOAM, and I’ll still be using the site to post recent slidesets and associated materials.

Since my objective is to post once every week, despite the 3 kids and 5 jobs, some of it may be in rough draft mode, some may be off the cuff, and some may not be particularly interesting.  All the weekly posts will be written in one sitting with minimal editing. But I hope to write for writing’s sake and to use the space to process some of the challenges that come up as this combined doc rambles through life.

 

When I Die I’ll Have ‘Do Not Resuscitate’ Tattooed Across My Chest! 

This NEJM letter was making the rounds on social media today with some docs and nurses expressing disbelief (“Can you believe these people?!”) at the fact that an ICU team chose to obtain an ethics consultation in order to clarify the applicability of a patient’s DNR tattoo.  We expect all kinds of vehemence and vitriol on SoMe so the magnitude of some of the responses wasn’t particularly shocking, but I did find it surprising that so many people would feel comfortable taking such drastic action based on a tattoo.  Also surprising was the fact that the Ethics consultants apparently ended up recommending a DNR order based solely on the tattoo. Maybe mine is the minority view.

I’m not claiming any superior moral insights,  and I’m definitely not the arbiter of right and wrong in the world of medicine, but let’s reflect briefly on tattoos. The history of body art is probably just as long as the history of man.  People have been marking themselves up forever.  Some tattoos are purely artistic, while others carry personal or cultural meanings.  I’ve had friends who’ve saved money for years and spent months designing their tats, including some with incredible artwork that has been implemented in carefully thought out stages over decades.  But I’ve also known many people who ended up drunk one night with a friend or two and decided to “finally get that tattoo!”  What tattoos all have in common – for the most part – is permanence.  Sure, if you have enough time and money you can have a tattoo removed.  Success rates vary though and the cost can be prohibitive.

And then this guy rolls in to the ED.  You have no information about him except for what seems to be one very clear request scrawled across his chest. You also know he’s very close to losing his pulse.  What do YOU do? Maybe you see his chest and think back to that fateful night in Vegas when you and your buddies thought it would be great to get matching ankle tattoos.  Or perhaps you’re suddenly glancing at the name etched into the skin of your forearm, your mother’s, to whom you promised to stop drinking as she lay on her deathbed? We carry echoes of our past everywhere, even into the clinical setting, and these color our medical decision making. So he has a tattoo.  So what. Sure, most tattoos are probably done intentionally, and while sober (at least in the military, per this article), but some aren’t. And we all know that DNR preferences sometimes change, while the funds to constantly revise body art may not be readily available.

The case described in the NEJM ended as well as could be expected.  Turns out the patient had a valid out-of-hospital DNR form. He eventually died of his illness without the burden of a likely futile CPR attempt in accordance with his wishes.  But what if there was no form to be found, and the patient’s wife had come in later?  What if, while the physicians were allowing the patient to die naturally, in accordance with their understanding of the “proper” thing to do, she would explain that he got the tattoo several years ago after a cancer diagnosis with a poor prognosis, and that he had recently decided, after being in remission for a full year, to have the tattoo removed? Granted, CPR is often an almost futile intervention no matter what, especially in someone apparently as sick as this person was. But we generally protect patient autonomy and self determination to an extreme. And yet in this case we seem willing to make an irreversible decision based on very flimsy evidence.  Perhaps, lacking valid guidance, it would preferable to act in accordance with what seems clinically most appropriate at the time, while making every effort to contact family and next of kin. With an eye towards self determination we must remeber that death, unlike the decision to get a tattoo, cannot be reversed.

 

Sick of Work, But Working Sick

Healthcare professionals frequently share stories of showing up to work sick (aka Presenteeism).  When we do there’s usually more than a hint of pride in it.  Our colleagues’ responses inevitably fall either in the range of “Oh my god, you’re amazing!” or somewhere close to “Can you believe that you had to work like that, while all these patients come in for nothing?!” We hear stories of physicians working through labor until the very moment of delivery (unrelated: see this truly inspiring story about an Ob who helped deliver a distressed baby when nobody else was available, while she herself was in labor), docs working through appendicitis, or coming to work with various serious and sometimes contagious conditions, and I ask myself, “Self: Why?”

Single coverage is one answer.  There are places where the ED doc, for example, is the only provider available. In medicine, for some unclear reason, it is acceptable that the critical staff member – the physician – has no backup coverage.  And so, in a single coverage ED, if a doctor doesn’t show up the entire department has to close.  The burden then, unjustifiably, falls on the sick physician until they literally collapse.  It is their duty to provide medical care to others while in desperate need of attention themselves. There is a pride and nobility in this of course, but it should not be necessary.

People also quote “culture”. Fear of retaliation, or worrying about the inconvenience calling out sick would cause others, drives otherwise rational doctors to come to work with 102 degree fevers, while vomiting, and with a debilitating headache. Though I don’t believe there is any solid literature around this “culture”, it seems to be gradually changing – at least for trainees.  The ACGME appears to be taking an active and genuine interest in assessing local program cultures around acceptance of and support for sick residents. From my perspective though, screw culture.

A third reason is likely pride.  We are doctors, not patients.  We are caregivers to the extreme. We are well and, as long as we’re still standing, we can keep taking care of others. Physicians also like to think they know themselves better than anyone else and that they can judge their own impairment.  This is not the case. We just don’t want to admit that we, occasionally, also have to take time off to care for ourselves.  Even when coverage is available, many of us would rather complain about having to work sick than actually stay at home. And besides, the battle stories make for great conversation.

And yet, by coming in to work sick we are saying to the patients that our ego is more important than their health. If a physician is so dehydrated that they are vomiting through the shift and had to go to the lounge to get an IV – “Just to perk me up” – can they really provide high quality medical care to their patients? Is the doc working through her migraine able to operate at the same level of efficiency and safety as the rest of her colleagues?  The asthmatic nurse trying to place IV’s while shaking from his non stop albuterol on shift in not doing anyone any favors. As professionals we need to free ourselves from this absurd Superman complex.  Sometimes, not infrequently, we are called upon to make personal sacrifices.  Hell, medschool and residency combined are one massive masochistic endeavor (totally worth it!). And sometimes that’s OK.  All kinds of crazy things need to happen during mass casualty incidents or other extraordinary circumstances during which we are called on by society to sacrifice for the greater good.  But it’s not OK to tell our trainees or employees they should just take some Ibuprofen and “work through it” on a routine basis.

Administrators and educators need to do everything possible to avoid situations in which no back-up is available (I appreciate this is not immediately practicable for some). More importantly, though, sick-call shaming needs to go away. It’s simple: Your patients will do better with a healthy doctor. Use your sick call system if you have one, or try to find coverage if you don’t.  Yes, the threshold question can be tricky. Yes, some people will try to abuse the system.  Everyone is different. Just realize that physicians tend to underestimate the degree to which they are impaired.  Your colleagues will understand, and they’ll also expect the same from you when they’re sick. It sucks to be called in to work when you were planning a night out.  But still, those of us who are fortunate enough to work at shops with sick call systems understand that we all pitch in to help each other out.

Maybe it’s a coping mechanism, but we all need to stop pretending to be so damn proud of working ourselves to death.  It’s idiotic. It’s also teaching the next generation of physicians that this is just what we do. Glorifying presenteeism will inevitably reinforce this broken, pathetic culture.

The post A New Way, DNR Tattoos, and the Paradigm of Presenteeism appeared first on EM IM Doc.

A New Way, DNR Tattoos, and the Paradigm of Presenteeism

Despite best intentions and numerous drafts just waiting to be completed, over the last few years I have not been able to write regularly.  The blog stagnated as I progressed through residency into attendinghood, took on a series of academic and administrative roles, and expanded my family together with my wonderful wife. And yet, it’s something that I think about constantly.

I recently had an opportunity to sit down with an ED doc who actually does write regularly, while still working, teaching, and, presumably, leading a normal life so I asked him how he finds time.  His answer was simple.  It’s one that I’ve seen over and over, and heard indirectly many times before – but somehow it carried more weight coming from him.  “Write something every day” he said.  Now I’m paraphrasing here, but the bottom line – more or less – was this: “Even if you only write a few lines about something that made you think, or something that you’d like to comment about, you capture the emotion.  Then, over the next few days, or at some point down the road, you can flesh it out.  Add references, background, expand the piece, and eventually you’ll have a completed item.”

So, with that in mind I’ve started writing privately again. Compiling ideas, starting new drafts, feeling out old beginnings, and now, also reviving EMIMdoc.org for the hundredth time.  I’ll be cleaning up the links and pages over the next few weeks. New writings will focus primarily on current events in medicine, personal reflections, and topics in medical ethics.  There will also probably be some FOAM, and I’ll still be using the site to post recent slidesets and associated materials.

Since my objective is to post once every week, despite the 3 kids and 5 jobs, some of it may be in rough draft mode, some may be off the cuff, and some may not be particularly interesting.  All the weekly posts will be written in one sitting with minimal editing. But I hope to write for writing’s sake and to use the space to process some of the challenges that come up as this combined doc rambles through life.

 

When I Die I’ll Have ‘Do Not Resuscitate’ Tattooed Across My Chest! 

This NEJM letter was making the rounds on social media today with some docs and nurses expressing disbelief (“Can you believe these people?!”) at the fact that an ICU team chose to obtain an ethics consultation in order to clarify the applicability of a patient’s DNR tattoo.  We expect all kinds of vehemence and vitriol on SoMe so the magnitude of some of the responses wasn’t particularly shocking, but I did find it surprising that so many people would feel comfortable taking such drastic action based on a tattoo.  Also surprising was the fact that the Ethics consultants apparently ended up recommending a DNR order based solely on the tattoo. Maybe mine is the minority view.

I’m not claiming any superior moral insights,  and I’m definitely not the arbiter of right and wrong in the world of medicine, but let’s reflect briefly on tattoos. The history of body art is probably just as long as the history of man.  People have been marking themselves up forever.  Some tattoos are purely artistic, while others carry personal or cultural meanings.  I’ve had friends who’ve saved money for years and spent months designing their tats, including some with incredible artwork that has been implemented in carefully thought out stages over decades.  But I’ve also known many people who ended up drunk one night with a friend or two and decided to “finally get that tattoo!”  What tattoos all have in common – for the most part – is permanence.  Sure, if you have enough time and money you can have a tattoo removed.  Success rates vary though and the cost can be prohibitive.

And then this guy rolls in to the ED.  You have no information about him except for what seems to be one very clear request scrawled across his chest. You also know he’s very close to losing his pulse.  What do YOU do? Maybe you see his chest and think back to that fateful night in Vegas when you and your buddies thought it would be great to get matching ankle tattoos.  Or perhaps you’re suddenly glancing at the name etched into the skin of your forearm, your mother’s, to whom you promised to stop drinking as she lay on her deathbed? We carry echoes of our past everywhere, even into the clinical setting, and these color our medical decision making. So he has a tattoo.  So what. Sure, most tattoos are probably done intentionally, and while sober (at least in the military, per this article), but some aren’t. And we all know that DNR preferences sometimes change, while the funds to constantly revise body art may not be readily available.

The case described in the NEJM ended as well as could be expected.  Turns out the patient had a valid out-of-hospital DNR form. He eventually died of his illness without the burden of a likely futile CPR attempt in accordance with his wishes.  But what if there was no form to be found, and the patient’s wife had come in later?  What if, while the physicians were allowing the patient to die naturally, in accordance with their understanding of the “proper” thing to do, she would explain that he got the tattoo several years ago after a cancer diagnosis with a poor prognosis, and that he had recently decided, after being in remission for a full year, to have the tattoo removed? Granted, CPR is often an almost futile intervention no matter what, especially in someone apparently as sick as this person was. But we generally protect patient autonomy and self determination to an extreme. And yet in this case we seem willing to make an irreversible decision based on very flimsy evidence.  Perhaps, lacking valid guidance, it would preferable to act in accordance with what seems clinically most appropriate at the time, while making every effort to contact family and next of kin. With an eye towards self determination we must remeber that death, unlike the decision to get a tattoo, cannot be reversed.

 

Sick of Work, But Working Sick

Healthcare professionals frequently share stories of showing up to work sick (aka Presenteeism).  When we do there’s usually more than a hint of pride in it.  Our colleagues’ responses inevitably fall either in the range of “Oh my god, you’re amazing!” or somewhere close to “Can you believe that you had to work like that, while all these patients come in for nothing?!” We hear stories of physicians working through labor until the very moment of delivery (unrelated: see this truly inspiring story about an Ob who helped deliver a distressed baby when nobody else was available, while she herself was in labor), docs working through appendicitis, or coming to work with various serious and sometimes contagious conditions, and I ask myself, “Self: Why?”

Single coverage is one answer.  There are places where the ED doc, for example, is the only provider available. In medicine, for some unclear reason, it is acceptable that the critical staff member – the physician – has no backup coverage.  And so, in a single coverage ED, if a doctor doesn’t show up the entire department has to close.  The burden then, unjustifiably, falls on the sick physician until they literally collapse.  It is their duty to provide medical care to others while in desperate need of attention themselves. There is a pride and nobility in this of course, but it should not be necessary.

People also quote “culture”. Fear of retaliation, or worrying about the inconvenience calling out sick would cause others, drives otherwise rational doctors to come to work with 102 degree fevers, while vomiting, and with a debilitating headache. Though I don’t believe there is any solid literature around this “culture”, it seems to be gradually changing – at least for trainees.  The ACGME appears to be taking an active and genuine interest in assessing local program cultures around acceptance of and support for sick residents. From my perspective though, screw culture.

A third reason is likely pride.  We are doctors, not patients.  We are caregivers to the extreme. We are well and, as long as we’re still standing, we can keep taking care of others. Physicians also like to think they know themselves better than anyone else and that they can judge their own impairment.  This is not the case. We just don’t want to admit that we, occasionally, also have to take time off to care for ourselves.  Even when coverage is available, many of us would rather complain about having to work sick than actually stay at home. And besides, the battle stories make for great conversation.

And yet, by coming in to work sick we are saying to the patients that our ego is more important than their health. If a physician is so dehydrated that they are vomiting through the shift and had to go to the lounge to get an IV – “Just to perk me up” – can they really provide high quality medical care to their patients? Is the doc working through her migraine able to operate at the same level of efficiency and safety as the rest of her colleagues?  The asthmatic nurse trying to place IV’s while shaking from his non stop albuterol on shift in not doing anyone any favors. As professionals we need to free ourselves from this absurd Superman complex.  Sometimes, not infrequently, we are called upon to make personal sacrifices.  Hell, medschool and residency combined are one massive masochistic endeavor (totally worth it!). And sometimes that’s OK.  All kinds of crazy things need to happen during mass casualty incidents or other extraordinary circumstances during which we are called on by society to sacrifice for the greater good.  But it’s not OK to tell our trainees or employees they should just take some Ibuprofen and “work through it” on a routine basis.

Administrators and educators need to do everything possible to avoid situations in which no back-up is available (I appreciate this is not immediately practicable for some). More importantly, though, sick-call shaming needs to go away. It’s simple: Your patients will do better with a healthy doctor. Use your sick call system if you have one, or try to find coverage if you don’t.  Yes, the threshold question can be tricky. Yes, some people will try to abuse the system.  Everyone is different. Just realize that physicians tend to underestimate the degree to which they are impaired.  Your colleagues will understand, and they’ll also expect the same from you when they’re sick. It sucks to be called in to work when you were planning a night out.  But still, those of us who are fortunate enough to work at shops with sick call systems understand that we all pitch in to help each other out.

Maybe it’s a coping mechanism, but we all need to stop pretending to be so damn proud of working ourselves to death.  It’s idiotic. It’s also teaching the next generation of physicians that this is just what we do. Glorifying presenteeism will inevitably reinforce this broken, pathetic culture.

The post A New Way, DNR Tattoos, and the Paradigm of Presenteeism appeared first on EM IM Doc.

Ditch the Books or: How I Learned to Let Go and Enjoy the Flow

Presented at the 2017 Cohen’s Children’s Medical Center Pediatric Emergency Medicine Symposium

  • What PEM specific FOAMed resources are out there?
  • How can PEM specific apps be used in clinical practice?
  • Are there any useful PEM Just In Time Learning resources?

 

The post Ditch the Books or: How I Learned to Let Go and Enjoy the Flow appeared first on EM IM Doc.