MediSin: Losing the Heart and Mind of an ER Provider – What he thinks of his patients, the American people and America’s healthcare system

Before I start I must apologize. Unfortunately this book is the recollection of a good portion of my life. And it is a life truly un-extraordinary. There may be a few who disagree, such as my wife and parents, but they are biased. Even this book symbolizes my lack of greatness. I’m fine with that.

By all standards, I am lucky. I have no right to complain about my life. I have made mistakes, and hopefully I have learned from them. I may tell others that I would make changes if I could, but looking back on where I am now, if by some miracle I could alter my past, therefore changing my future and the life I live now, I would not change a thing. I have a beautiful wife and three amazing children, children that are a paradox to me. I find it amazing that I would sacrifice my life in less than a heartbeat for any of my kids to ensure that they are safe and happy; yet I spend 99 percent of the time wanting to kill them, because they drive me absolutely crazy. But that is another book in itself. For this story, my only point is that I make no claims of despair.

I am a PA. A physician assistant. I am not a doctor. I am not a nurse. And more importantly, I am not a medical assistant, nothing against MAs. A physician assistant, or as I tell my patients, a ‘wannabe doc,’ is a licensed medical professional who is recognized by the government to practice medicine.

The practice of medicine is limited to a few medical professionals. In the past it was limited to Medical Doctors (MDs). When we think of a doctor that is who comes to mind for most people. However, there are other fields of medicine that the general public is often unaware of. There are other types of ‘doctors’ treating patients in offices, operating rooms and emergency rooms throughout the world and their training is different than that of the traditional MD. The closet relative to the MD is that of the DO. A Doctor of Osteopathic Medicine. A DO is a doctor and by all rights deserves the same privileges an MD is given. Traditionally a DO’s training is hybrid, combining the medical applications of the medical doctor and the manipulative training of a chiropractor, to obtain the most versatile physician caring for a patient. In truth, few DOs actually apply their dual nature and instead focus their treatments primarily on the medicinal side of patient care. In my opinion, it is a loss we all suffer.

Other ‘doctors’ include DPMs (Doctors of Podiatric Medicine) foot doctors of which my mother is one. They spend the same amount of time as MDs and DOs in training to care for smelly, crusted and decrepit feet. They deserve sainthood. Another saint of a doctor is the dentist (DDS). The thought of working inside the mouths of the average American everyday—OMG! Other doctors who receive little acclaim are chiropractors (DCs). I was originally on the path to becoming a ‘back cracker.’ A DC spends three years in training, and is by far the best manipulator around. I have never found a DO that can come close to the adjustment capabilities of the average chiropractor. Despite what a majority of the medical community claim, chiropractors have a valuable role in treating overall patient wellbeing. However, after six months at a chiropractic college I came to the realization, that ‘snapping spines’ was not the path for me.

I left Chiropractic College and applied my undergraduate degree for a few years. I worked as a clinical dietician in a nursing home for two years. Simply put, it was horrible. A career of implementing puree, low sodium diets would drive me to unspeakable acts. I knew I needed something else. But what?

I struggled for a few years. I debated going back to chiropractic school, and was reminded a few times a year when a chiropractic school’s admissions office would call me to inquire about starting my training in the upcoming semester. Maybe it wasn’t so bad. Maybe I was destined to be a ‘quackerpractor.’ I wasn’t one of the lucky ones growing up. I never found my niche. I never knew, even in college, taking a variety of courses, what my ultimate path was going to be. Nothing rocked my world. All I knew was that the current path I was taking would lead me to unhappiness. I needed change.

At 25 years old, and feeling that I had wasted the first half of my 20s, I made a pledge to myself that I would not waste the second half. By the time I was 30 I would have a career, or at least have my feet on the path to getting one. I wanted a family, and a home (my parents were life long renters), and I was going to make sure that I had a future I could mentally live with.

I made my decision, and no matter what happened I was going to see it through. No racking spines for me. I was going to be a doctor. I was going to medical school. That was the plan until I ran into my mother.

I was spending the night at my parents’ house, for reasons that have since left me. I was in my childhood room, application papers spread out across my old bed when my mother entered. She said with a smile, It’s been a long time since I have said this and it feels good to say, dinner will be ready in a few minutes. I looked up at her, oblivious as most kids are, no matter how old we are, to the inner thoughts of our mothers. She gave a subtle, inquisitive look at the mess of papers spread out in front of me and then casually left. I paid it no mind, until she returned, less than five minutes later, and asked me what I was doing.

I looked up at her and stared straight into the eyes of the woman who spent years of time and energy, sacrificing her sanity, like the time I crashed my friend’s car at 16 years old, when the legal driving age in my state was 17. I met her gaze, and with pride in my voice, I told her that I had made a decision. I was going to go to medical school.

I immediately saw the disappointment in her eyes, and it was reaffirmed with a disappointed Oh. She said nothing more and then left my former room. I questioned what had just transpired for a moment, then blew it off and reassumed the work toward my future endeavors. I was deep in thought, until another knock came at my door. It was soft, almost uncertain if it truly wanted an answer. Of course I responded, Yeah?

My mother entered. This time she had a look that expressed the need to tell me something, but fear that it was something that I would not want to hear. She summoned the courage and asked if she could give me some advice. I answered, Of course, and put my pen down. My mother was probably unique. Growing up she would give me advice. She would intervene when I asked her, which looking back was not often enough, and also when she thought I was really about to fuck up. Otherwise, she would let me make my own little mistakes. She let me live my life. What a wonderful mother. I love her for that.

Anyway, I was all ears. She hesitated for a moment, probably trying to collect her thoughts. Then she started, I have been in medicine for over 25 years. First as a nurse and then you saw me go back to medical school. I have seen medicine from all sides, and I can honestly say that I have no idea where healthcare is going. It is not anything like what it was when I first graduated. As a doctor, I am frustrated. Reimbursement is constantly decreasing, while my overheard continuously rises. My liability insurance is skyrocketing, because patients see physicians as lottery tickets for any failures we make. We are human, and medicine is an inexact science, constantly evolving. We are unable to know everything, let alone be perfect. We are doomed to failure, and society can’t accept that. That is why it is called ‘practicing medicine.’ In addition, you are planning on getting married. Having children I hope. I am afraid that you are going to spend the next four years in medical school, followed by three, five or seven years of internship, residency and possibly fellowships, learning your specialty, only to come out with $300,000 in debt. A good portion of my friends in medical school got divorced, and those that survived, either put children off, or if they had them, they never saw them grow up. I don’t want to see you sacrifice your youth and potentially your family, to emerge after ten years and come to the same certainty I have concluded after all my years in health care. She paused again. I was waiting. I needed to know. What was she certain of? She continued, In over 25 years, the only thing I know 100 percent, is that I HATE PATIENTS! I hate all of them. Even the nice ones. I do not want you to come out of all of this, after losing so much, and after a short time realize that you hate the very people you have sacrificed your life to learn how to care for. It would break my heart.

I was stunned. All I was able to think was, ‘What the fuck!’ What the hell are you doing you insane woman? Have you taken your medication? Wait, you’re not on any. Get on some. You are the quintessential ‘Jewish Mom’. You’re supposed to encourage your son to go to medical school. Then when talking to all your friends about me you can start out with, Oh, my son the doctor …

In less than a minute she killed my plans. It wasn’t difficult, because as I said earlier, I had never found my calling, and at that point any path I chose was one of compromise. But, in her perspective, with all the time, money and sacrifice, was it one I should make?

I spent the next few weeks contemplating everything I had come to accept. I even thought she was becoming insane in her aging years and what she claimed was crazy. I worked with doctors; I thought I would ask them. It was a great plan, until every physician I spoke with had practically the same grim outlook on their professional life. It was almost unanimous, with the exception of a fluffy new graduate who was ready to save the world. She’d change. It was just a matter of time. What the hell was I going to do with my life? I was about to run out of the nursing home screaming when a ‘resident’ (nursing home patients are called residents) with no teeth and refusing to eat a puree diet hacked up a solid pea, complaining that the food was too hard. I felt like screaming at her, You need teeth you senile old bag. The though rang within my head like a huge bell, I hate patients! Will that be me?

After dealing with Mrs. Gummybear, I continued my charting and came across a drug food interaction. A new doctor was sitting next to me. I had never seen him before. He was wearing the long examination jacket. The stethoscope was tapered around his neck. He had a small library of miniature books in his pocket (this was long before the IT boom). He was the real deal. I asked him my question, and without pause, he stopped what he was doing and gave me valuable insight into my problem. Problem solved. I went back to my work and gave him a Thanks Doc.

He turned to me and informed me, I am not a doctor. I simply stared at him. Well then who the hell are you? What, did the janitor just give me some bullshit answer? He saw the concern on my face and gave me a subtle smile, I am a PA. Still there was no understanding on my part. He picked up on it and elaborated, A physician assistant. He then went on to tell me what a PA did. I came to find out that it is in a family of medical practitioners called ‘Midlevel Providers’ (MLP). Midlevels are another branch of medicine that is licensed to practice medicine. Up until that moment I only knew doctors could practice medicine. Nurses are not allowed to practice medicine; they carry out the orders written by ‘providers.’ I suddenly learned that there were other providers, other than doctors, and they included Nurse Practitioners (nurses that advanced their education), and Physician Assistants. I talked to him a lot longer than I should have, but he educated me on his role and the training involved. It was less than the doctor route. He also told me the hospital I was working for had a PA program right on campus.

The next day I checked it out. It was interesting, but I still had my doubts. I hate patients! echoed in my mind. I spent the next few weeks hunting down other PAs. They were easy to find, now that I knew what to look for. I asked them about their job and their feelings about what they do, and unlike the doctors, an overwhelming majority of them truly liked what they were doing. Wow! Within the month I found myself applying to the hospital’s PA program.

PA school was the most difficult mental challenge I have ever had to face. The education was intense. In fact, it was too intense. It was described to me as taking 85% of what is taught in medical school and cramming it down your mental throat in half the time. It was TMI—too much information to properly ingest. Even throughout my PA training, I still struggled to find a specialty. I finally chose a career, but I was continuing to struggle to find my niche for the rest of my life. One rotation after another, I would return home disappointed. Disappointment became frustration, and frustration eventually turned into fear. I was coming to the end of my medical training and I still didn’t know what I wanted to be when I grew up. Surgery was terrible; too many hours, standing in one spot, wearing a suffocating mask choking on each hot breath. Not to mention that most surgeons are assholes. Maybe it is only me, but I don’t get along very well with assholes. ObGyn, internal medicine, family practice, pediatrics, geriatrics, all passed me by without a spark. Psych was the worst. I wanted to back slap the crazies, a.k.a. patients (even most of the staff were Looney Toons), and scream at them to snap out of it! I was dying. I wanted someone to slap me and knock some sense into me.

My next to last rotation was Emergency Medicine. I dragged myself into the ER that morning without any great expectations. I got the 30 second tour. That is all the allotted time given to new people in high volume urban ER’s, especially students, who are typically more of a pain in the ass than an asset. It is nothing against students. Every experienced health care worker started out the same. Even after more than ten years of experience, I am still learning new things every day. It is the nature of the profession.

I slumped in my designated seat, everyone racing around me, lost and alone, wondering what I should do. I played with the computer in front of me, figuring out how to check on test results. I looked at the charting system, and tried to get a feel for it. Even though I had been charting for almost a year in other departments, it still seemed Greek to me. It is very hard, especially in the beginning.

For the most part I sat there. Occasionally I’d get the fleeting hello or inquisitive Who are you? I’d tell them, and then get the truly uncaring Oh, welcome, and then they would race away to whatever they were doing. It was going to be a long eight weeks.

I sat there for about 20 minutes, dazed and confused. The room spinning around me, my educational vertigo was cured by a physician who sat next to me to check on some test results on the computer next to me. Like everyone else he inquired who I was, but unlike the rest he told me his name in return. He finished his query, and then stood up and said, Come with me. Looking back at that moment I think of the movie Terminator II, when Arnold Schwarzenegger playing the Terminator reaches down to a terrified Sarah Conner and says to her, Come with me if you want to live. I was drowning and this doc was throwing me a lifeline. I didn’t realize it at the time. I never got the chance to thank him.

I stayed on his heals. We walked into a few patient rooms and I listened to everything he said and watched everything he did. He’d always introduce me to the patient, and then let me get involved in the patient’s care. He let me auscultate (listen to) the patient’s heart and lungs, palpate (touch) patients abdomens, and pointed out what I was hearing and feeling. He’d especially stress any abnormalities, especially clinically significant ones. The origin of the word doctor is ‘to teach,’ and that was what this physician was doing. He was a teacher, and I have learned over the years to cherish those who are willing to take the time to teach you something.

About an hour and a half of shadowing my new mentor, and a half a dozen patients later, a truly critical patient came in. The nurse called the doctor over, and off he went. I was uncertain if I should follow, but he quickly answered my question, when he turned and said, Let’s go. Off we went. I had no understanding; therefore I had no expectations of what I was about to experience. We arrived at the patients bedside, and before me was a middle aged man, poorly groomed, unshaven, partially naked with wires attached to him and machines recording a bunch of information, about most of which I had no understanding. I heard bits and pieces of what was being discussed. Terms such as ‘chest pain,’ ‘tachy,’ ‘ST elevation,’ danced through the air. Orders from my new doctor friend fired back, such as ‘aspirin,’ ‘Tridal’ and ‘Heparin drips.’ The team quickly organized a ballet to save this man’s life. Unlike most emergency room visits, including most patient complaints of chest pain, the gentleman before me, at the center of this performance, was the real deal. He was a true medical emergency and his life was in jeopardy. He was having an acute MI (a heart attack). The muscle of his heart was dying, therefore so was he. Time was essential. The ER team knew this, and they worked together perfectly. I simply stood off to the side, near the head of the bed, watching this man die, and helpless to do anything about it. I watched in admiration as the staff performed as they were trained to do.

Suddenly, something went wrong. I heard it in a nurse’s voice as she screamed, V-Fib. I looked at the patient and he was no longer conscious. He wasn’t moving. Was he dead? I realized he wasn’t breathing. The doctor slapped me on the shoulder and ordered me to begin chest compressions. My first thought was, ‘You want me to do what?’ But before I knew it I was pumping up and down on the patient’s chest. He then told the staff to get out the paddles to cardiovert (shock) the patient, which the staff had already been readying. Harder, the doctor ordered at me. I want to hear ribs cracking. Ribs heal, hearts don’t. Compress that heart! I began to beat the senseless patient senseless. I heard, and even worse, felt the first rib pop. My instinct was to ease off, but I quickly overcame my hesitation and continued to assault the dying man. Then another and another. In my adrenaline-induced frenzy, I counted at least four ribs a cracking. I thought, If this guy survives, he’s going to feel like shit. I guess it is better to feel pain, than to feel nothing at all.

A nurse charged the unit to shock the patient’s heart back to a normal rhythm. The doctor told me to hold compressions. Another nurse gave me a body check any hockey player would have been proud of, knocking me out of the way so she could squirt conduction jelly on the patient’s chest. This helps conduct the electric charge into his chest cavity. I then heard a scream Clear! Everyone backed off, including myself, even though I was knocked across the room by the hockey nurse. Nurse Gretsky then pressed the button on the side of the electrified paddle; it was followed by a confirmatory beep from the machine, and a violent jolt from the patient. I looked at the middle-aged man on the gurney; he fell back flat, and then suddenly opened his eyes, sat straight up and looked directly into my eyes and screamed, What the hell are you doing to me! The nurse laid the patient back down. She told him to relax and then noticed he was unresponsive. V-Tach was called out again and the Doc told the nurse to hit him again. The middle-aged man was shocked a second time, followed by a second scream, this one not directed at me, and he remained flat on the bed. Normal sinus rhythm (NSR) read across the monitor, a normal heart rate, and the middle aged man continued to let out a series of low pitched moans. That was a good thing. Dead people don’t moan. (FYI—The louder you bitch, the less sick you are!) I am pleased to inform you, the middle aged man survived; at least he was alive when he left the ER in the hands of the cardiology team.

The doctor and I went back to our seats. I was shaking. Not due to fear or anxiety, but from the adrenaline that was pumping through my veins. I was hooked. I found it. ‘X’ marks the spot. I went home to my wife that night, with a smile on my face and relief in my heart.

A NEW HOPE

After that first day in the ER I had hope. Hope that the rest of my life would not be one of employment misery. I had a beginning, and my future had a sliver of optimism for the first time in my life. I had a plan, and if I was able to see it to fruition, the promise I made to myself that fateful day might actually come true.

I spent the rest of the eight weeks of my emergency rotation with a purpose. I worked hard at not only learning everything I could about patient care, but I worked to make new relationships. I networked myself.

When I finally graduated, it wasn’t easy. Emergency medicine is difficult to infiltrate for someone fresh out of training. Unlike MDs or DOs that are required to go through a residency-training program in their field of practice, PAs are simply thrown into the fire. Our residency is on the job training, and many employers are reluctant to take the time, resources and malpractice exposure to train a new graduate. Who can blame them?

After months of pounding on doors, my wife and I decided to take a risk. We relocated, hoping that more opportunity existed outside the heavily populated area we lived in. It was a time of great excitement and stress. This move was costing us our minuscule life savings. My wife left a job with a global company and a lifetime of potential, and I didn’t even know if hospitals actually existed outside of my home city. We were young and stupid, but old enough to be scared of failure. Our future was wide open, for good or bad.

We arrived at our new home in late September. It was still hot outside, and that felt wrong. We weren’t in Kansas anymore. Despite our fears that grew as we traveled away from the life we left behind, we quickly got to work, or to be more exact, tried to find work in our new city. My wife started networking and I began to pound on doors. My wife found a job first. It was a huge relief, but was the trip worth it? Was I going to find a job, and hopefully in the emergency room?

After a few weeks, and increasing doubt, I decided to broaden my wish list. I was coming to the realization that the same problem existed in our new city. Getting a job in emergency medicine, without experience, was difficult. I decided to look into Urgent Care Centers. I hoped a year or two of experience in an urgent care would make me more marketable for a position in an ER.

I set out that morning and headed to an urgent care that I noticed on my way home the day before. That decision set forth a series of events that changed my life forever. The urgent care was not looking for any help, but they referred me to someone across the street at the hospital. I immediately followed up the lead. They were not hiring either, but they sent me down the hall to Human Resources. Human Resources deflated my hopes once more, but one of the employees, a beautiful woman, I can’t remember what she looked like, came out of her office. She overheard my conversation, and informed me that she knew a doctor who ran a freestanding emergency room and he was looking for a PA to supplement his provider group. She knew he was having difficulty because of the remote location of the center as well as the hours of coverage he was looking for. I told her I didn’t care, and she was kind enough to make a few phone calls for me. She returned a few minutes later with a phone number, an address, directions to the ER and a scheduled interview. It was in an hour.

I had hope again. This was an opportunity to work in an ER. It was what I wanted and I didn’t want to make any mistakes.

I met with the medical director. He had practiced medicine longer than I was alive. He interviewed me for over two hours. Although it was an official interview it felt more relaxed. We laughed and exchanged stories. He was from where we just left. After everything appeared to be said he stood up, stuck out his hand and said, I usually don’t do this so fast, but if you want the job, it’s yours. I shook his hand, and thanked him as I accepted the offer. He became a friend and a new teacher.

That was it. I had my chance, now the real work began.

As a side note, my new mentor recently passed away. Unlike before, I had the chance to thank him for everything he did for me. He will be missed.

NEWBIE

So here I was. I had the job I wanted. My career had begun and along with it, a new life. November first was my first day. I was excited. All the sacrifice and hard work was about to pay off. I had more than doubled my salary as a dietician and the potential seemed limitless. It appeared I had come into my own.

I mentioned I was excited, right? Excited may not be the perfect expression for what I was feeling. To be more exact, I was terrified. I had butterflies in my stomach that were being hunted by bats. I thought I was going to throw up. All I hoped is that I didn’t shit myself. I had a bad case of Irritable Bowel Syndrome (IBS) and it tormented me for the two years I was in PA school. Please don’t confuse IBS with Inflammatory Bowel Syndrome. Inflammatory Bowel Syndrome is a real disease and includes such names as Ulcerative Colitis and Crohn’s Disease. These are horrible, painful and often debilitating diseases that plague thousands of people, and I sympathize with their condition. IBS is due to the fact that I am a pussy. My fear of failure and screwing up get me so uptight that my bowels blow a gasket. No sympathy, no glory. Many mornings I missed the early train