The Devolution of Emergency Medicine

I will be seeking gainful employment for the first time in 21 years.

No, I haven’t been fired.

I also haven’t been involved in the following, which can get you fired:

  1. I haven’t been found in cahoots with a drug company.
  2. I drink only moderately (actually next to nothing for an author).
  3. The last time I did a drug of significance was in prehistoric times.


From the hospital end:

  1. My hospital has not closed.
  2. It hasn’t run out of patients.
  3. It hasn’t become a gigantic clinic.
  4. It hasn’t gone bankrupt or been accused of Medicare fraud.

With the above disclaimer in place the reason for my seeking a new venue can be summed up by:
a/b=c/d.

For someone who was never a mathematician my relationships with my past emergency departments are a mathematical equation. As administration policy is (a) and how it changes over time (b) is how my attitude is (c) and how it becomes (d) over time. This is not an original concept, but it may be the essential bedrock of a life that is lived.

We can see examples of this equation everywhere. We work at jobs because the institution has given us a sense of purpose. This is the a/b part. Time changes and institution goals change. We either accept those goals and work toward new areas of achievement or we wonder how the fuck the institution corrupted itself and work against those new goals, the c/d part.

If the living of life is constant change, why shouldn’t the institutions that we serve follow the same rules?

My current hospital is a community hospital serving a mostly poor population. This hospital serves a rough city that is small but very urban. Drugs, teenage pregnancies, domestic abuse, alcoholism, sexually transmitted diseases, and the un- and underemployed represent the majority of patients cared for. When you add no to little education you get Brooklyn… or at least a couple of acres of Brooklyn. Almost my entire professional life has been serving these kinds of populations.

I am no urban social worker, but I’m pretty sure in the 30 years trying to fix the medical consequences of inner-city patient choices I have a working knowledge of what the community needs. We will call this Doctor Taco’s Thesis of Problem Solving in urban America.

The younger generation needs a good education. Writings about the “special” impoverished child lifting himself up by studying hard, getting noticed by the “special” teacher, getting noticed by Harvard’s scholarship committee and finally escaping the neighborhood abound. Screw that piece of fiction. It does happen, but instead of the occasional child succeeding, all children will be educated rigorously and go on to higher education. Everyone from pre-K up from now on has a legal mandate to receive a good education. Get those kids in the school early in the morning, feed them breakfast, get them into classes, feed them lunch, more classes and then at the end of the day the school stays open for required help with their studies or the extra-curricular education that is the basis of a civilized world. Rich kids learn these necessary areas (now called educational enrichment) because their parents can afford it; violin lessons to appreciate classical music, art classes to understand Picasso’s Guernica and slam poetry to understand that the word can be mightier then the sword. Substitute the extras with whatever the child might be interested in. There is even education in studying crappy television, I know as I worked with a lot of TV writers driving Porsches.

“All this costs money, we can’t afford it,” I hear my brethren conservatives say. The truth is as a country we can’t not afford it. Ignorance is the cause of teenage pregnancy, which destroys futures, boredom which encourages delinquency and an inability to make correct choices, which leads to future housing in the prison system. This is very simplistic and I know I am not a Ph.D. social worker, but after 30 years of the poor and desperate, the wounded and the intoxicated and finally the young dead, I am convinced education is a great start as a prophylactic.

Health is another need and it ties into education. Drugs are bad if you personally can’t control their use and effect. Here is a message from the 21st Century to President Nixon, “Like so many things in your screwed up administration you were wrong about the War on Drugs. Billions spent and you lost this war like you lost in Vietnam. The Viet Nam geopolitics corrected after decades, but we still live with your crappy drug war. Most of the educated and busy pick a poison to get high. They do it under controlled circumstances, in a safe company and are ready to go to work the next day. Is this everyone? Of course not, alcoholism and drug addiction is found in every segment of society and is a disease. Diseases need treatment and monitoring so the patient can get back to a productive life. Take a patient with a diagnosis of drug addiction. Now substitute a diagnosis of congestive heart failure. Both these patients need work-up, diagnosis and treatment. This is medicine and how the doctor needs to approach any medical problem. Today’s social ills are a wholesale phenomenon born out of the uneducated being unable to achieve higher rungs in life because they don’t have the skills. The uneducated have no goals in life, nothing to do, so they create their own drug-induced worlds and detach from successful society. The government then treats them as mentally slow children, unable to care for themselves and give them useless Band-Aids like revolving door rehab. No problems are fixed, children begat children and the cycle continues.

The hospitals and schools are the institutions entrusted to help build the success of the community. When the boards of either of these institutions lose site of their common responsibilities our society fails. This is a basic truth and that truth must be served through all sorts of economies and faddish social mores. The boards must not falter because future generations count on the implementation of policy to not only maintain a civilization, but also improve the general wealth and happiness of the populace.

When a hospital loses its way, it is time to either fight that board or find an institution that supports the truth. When a hospital or school believes more in edifice building than in supporting the health and education of their charges it is time to replace that board because they glorify themselves and a building more than the community. Communities need their basic health care treated. We need more health care providers and clinics for the preservation of health on a basic scale; diabetes, hypertension, heart disease, prenatal and pediatrics. While recent literature seems to point out that fads such as gastric bypass can “cure” diabetes, if you don’t have the physicians to support the surgery, which includes room in your emergency room to deal with complications, the space on your medical floors to take care of a simple heart attack, pneumonia or urinary tract infection, you are building an institution based on waste. Programs that are conjured up without the necessary support staff just waste money and add to the problems at the hospital. Eventually these programs create more problems because the complications can’t be fixed and more money must be spent just to prop them up. Above all, programs such as these take money away from the basic needs of the community. We, as a society, don’t have unlimited resources so programs that are important and effect the most patients in the community come first, then if there is money left over… but there never is.

Money must be spent wisely based on the majority needs of the community. It may not be sexy like new operating rooms with operating tables built to hold 400 pound patients, but success will only be granted to achievements such as lowered blood pressures, decreases in COPD, lower lipid levels and the like. The lesser amounts of money outlaid for an interested internist with a couple of nurse practitioners helping comes to the assistance of so many more people than a program that supports relatively few.

Yes, doctors are needed for basic medicine. If society cares for these problems and rejects building the golden programs that are all gild and no substance, maybe we will not need the funds for the edifice.

I will find a place I can get back to the basics of doctoring for those in need, those that I can help.