Oh Henry
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This month we continue on our journey to understand what really happened at the 2013 ACEP Council, as expressed in the resolutions which were sent to the Board of Directors. I act as Virgil to your Dante in this quest, but the journey is neither allegorical or metaphysical. These resolutions are real. It’s your money. It’s your leadership. It’s your profession and your life. If you have no interest, fine. Then live with what you get. But to the rest of you, pay attention.

First, a recap of the ground rules. Number one: every issue has a secondary or hidden agenda. Second, whenever a resolution contains the term “further studying required,” somebody or some group of somebodies wants to get money for the project, which will allow them to do something other than see patients. And third: there are Quixotic issues on which people are willing to break their lances for no particularly good reason. A zealot is someone who redoubles their efforts even when they’ve forgotten why they’re in the fight. Now on to the show. 

Resolution 9 – Criteria for inclusion of organizations into the ACEP Council – falls into the category of “Who are we anyway?”. Who should be able to have a seat and vote on issues and help elect leadership in a professional society? Should AAEM, CORD, and SAEM have proportional votes? The question of who is allowed to make the rules never seems to go away, yet this ultimately serves as a distraction. We foment a crisis of decision making while ignoring the biggest healthcare issues breathing down our necks.

Resolution 18 – Creation and funding of a national prescription monitoring program – dealt with a desire for a federally funded nationally accessible databank to see who is ripping off the system for Vicodin. This would allow you to triumphantly stride into the room and unmask the villains for getting a script in Las Vegas last weekend and one in Tupelo, Mississippi this weekend. This might be helpful, but it is mostly a feel-good resolution: Medice, cura te ipsum. This will only be a Band-Aid on the cancer of medication abuse, a stopgap until everyone starts writing for fewer pills. People now believe happiness, success and the ability to cope with the vicissitudes of life come out of a bottle. How incredibly sad. 

As a short aside, I must comment on Resolution 40, which is entitled “Golden Care For The Quality Of Life.” This is about palliative and hospice care, which mostly has to do with old people. Let me be clear. I am absolutely in favor of excellence in palliative and end-of-life care. I just hate the euphemism of referring to my rapidly advancing senescence as the “golden years.” This is total crap. My golden years were when I was about 21, when I could stay up all night, drink heavily, have sex three times and still make it to work and/or class the next day with no problems. Resolution 40 is great, but “golden” is a term which simply needs to be dropped from the discussion. 

Resolution 34 represents an area of deep water which will require serious discussion and debate. It has to do with “community paramedics” and what we mean by this term. Is this a junior doctor concept? Is this like the Chinese barefoot doctors program of the 50s and 60s? Will pre-hospital providers be trained differently? Will this increase response times for the critically ill? What will they do and what do we want them to do? Of all issues being sent to the Board from this meeting, this one requires thought and substantive action. This is in our bailiwick. Our members are involved, our expertise is required and we may be impacted by the outcome. Now that we have proven that no drug in the ACLS box really works and intubation has minimal affect on outcome, what should paramedics be doing? This question isn’t going away and we need to act.  

There was a resolution on the “virtual milk carton” which declared that we should put missing children’s faces on our screen savers in the emergency department work areas. There are real pros and cons about this, but I’d add one revision. Rather than showing the images in the work area – where providers are overloaded – display them in the waiting room. After three or four hours, these images will be burned into the patients’ brains. “How do we keep their attention?” you ask. “Simple,” says I. “Intersperse the pictures with winning Powerball lottery numbers.” Done. 

Resolution 32 is not a joke. It is a reaction by the Council to an action taken by the Board of Directors on the TPA for stroke policy. It reflected the stark feeling by the Council that the stroke TPA issue is not resolved. But most importantly, it suggested that any subsequent ACEP policies must be open for a 60-day comment period before adoption. This was a direct rebuke of the Board and should be not interpreted as anything else. 

This debate about TPA went way beyond science, taking on an evangelical framework in that “sweet spot” between warring theologies and thought metaphysics. Both sides lack Nietzsche’s aphoristic brevity or Shakespeare’s lyrical poetry. There is a near-religous intensity here that harkens back to Calvin at the Synod of Dort. Stand back everyone! Stand back! Everyone hold out their “analogia entis”. While theirs was a fundamental dualism, we are forced to choose sides, and the intensity of this discussion has reached almost unbelievable heights. 

Added to the hyperbolic caldron is the lawyer/lawsuit factor which doesn’t give a wit which side is correct. They only want to be able to make money, no matter which way this battle goes. “God, defend us from what men do in the name of good.” 

Before concluding this piece, there are two resolutions on which I feel compelled to vent my spleen: Resolution 42: Resolved, that ACEP develop a policy statement regarding the role and training of the patient advocate in the emergency department. Excuse me, did I miss something? Maybe I didn’t hear them right in medical school. I thought I was the patient advocate. It’s my job to know what the patient needs and get it for them. 

Perhaps we should start the doctor/patient interaction like we begin college football games. A neutral party, if one could be found, would introduce us all. “Doctor Henry, this is the patient, the patient’s advocate, the patient’s attorney and their governmentally-mandated assistants. Mr. Patient, this is the doctor, the nurse who will not, I expect, undress you, the techs, the desk clerk and the pizza delivery man. Now the coin flip. The doctor team wins. The doctor team chooses to defend the exam room, their pride, and the stuff you intend to steal from the drawers and their right to say ridiculous stuff like: ‘It will only be a few more minutes.’ The patient team will defend their right to follow only the directions they want, not get follow up care as directed, and to throw a huge shit fit if they don’t get Percodan. The patient advocate maintains the right to run interference on any and all issues.” Let’s get real. We are the patient’s advocate. And if you need someone of lesser medical training to assume this role, you need a different job.  

Lastly, Resolution 36: “ACEP develop of a rapid integration of care toolkit.” First off, I hate buzzwords like “toolkit.” I have tool kits. They have wrenches, tap and die sets and well-worn hammers. Listen to this and tell me what it says that we have not already been doing for the past 40 years? “Resolved that ACEP develop a rapid integration of care toolkit that would focus on both transitions of care and care coordination, provide best practices based upon hospital type and location, tools/resources for the design and implementation of the rapid integration of care programs and measures to report positive sources of effort.” Maybe they want us to have more patient advocates. I can’t be for or against this resolution because I have no real idea how this varies from what we have been doing since I started medicine. God defend us.

“I firmly believe if the whole materia medica could be sunk to the bottom of the sea, it would be all the better for mankind and all the worse for the fishes.” 

—Oliver Wendell Holmes
(Harvard Med School Lecture)

Greg Henry, MD is Founder and CEO of Medical Practice Risk Assessment, Inc.; past president of ACEP.

 

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