Doctor

If you are seeing this then you are in the wrong blog. Come to my new blog called Doctor.

The Chronicles have come to an End

I can be found in my new home. Welcome to Doctor.

Ruined by Reality

Was that me, dressed up in a dark suit doing my best not to look intimidated?

Three years have changed and these fourth year students filing into our conference room remind me of a younger self. How they shine bright with curiosity for answers only their future will tell. The prospect of a career in medicine is exciting for them now. It is the beginning of a new world. Everything, it was all for this. Again, with another September starts another match.

It is that time of year again, when a competition ensues to capture the most valuable of prizes, a medicine residency in a prestigious institution. There are only a handful of these and that makes each and every position precious. Each of these students knows it will be a critical steppingstone to a future glorious career, and so did I.

I had survived a breakup with my fiancé, struggled through four years of medical school in a foreign country, even found the love of my life while there and got married. I came to the Mad House is 2002 anticipating a day of sweating and squirming as I attempt to guess the most desired answer. I had the future in my hands, they wanted me, and the prospect of a career as an internal medicine doctor was exhilarating. I remember running home to tell my wife that I was offered a position, hardly able to contain myself.

So what happened?

That young man and this seasoned resident, they are such different people. In between them three years of an internal medicine residency that drove that same young man on a path to…well, you read this blog don’t you?

Unfortunately, the real world happened.

Saving a troubled father of two from a severe bout of congestive heart failure was rousing. Saving that same father from another bout and yet another simply because he refuses to take medications can be downright depressing. They say memory is selective, I find mine tends to select for depressing moments.

This is one of the reasons I never delete negative comments. They ground me. Often, they allow me to reflect on the true magnitude of what it is that we do. Somewhere and sometimes I make a difference. And that is essentially one of the greatest things anyone can do. But I’ve lost a large part of my former compassionate self.

At times though, I do miss that young fourth year. Would he disapprove of what he has become, a new breed of healer and warrior struggling with himself to survive?

Reading this you probably think my patients don’t appreciate my efforts. But, my patients actually do like me. I know you wouldn’t think so from reading this blog but judging from the comments and gifts I get at my clinic, they must.

So to all the fourth year students who have that jazz in their step, bouncing on clouds, hoping to high-heaven they do well. I wish you all the best. Moreover, I wish you the wisdom to know that what you are doing, as depressing and downright useless as it may sometime feel, is immeasurable good, even if your patients don’t know it.

Like well trained warriors, don’t let your compassion run dry, but do learn with who it’s worth fighting your battles.

Future Intern Wishes You a Happy New Year

From inside my investigational lab where I can assure you we are making progress in the ultimate battle against some of the worlds’ greatest health threats, I wish you a Happy and Healthy 2006.

First order of business, this new anti-madhousemadman antibody. That should save a few thousand from that internal medicine doctor.

Carnivals

Grand Rounds is here.

COTV here

Bonfire of Vanities here.

Merry Christmas and Happy Chanukah

As 2005 winds down I am once again amazed at how fast goes the passage of time.

There is a sign posted on the stall room door in the Mad House. It reads “They can always hurt you more but they can’t stop time”. It’s a grim reminder of how demanding and grueling this job can be both physically and emotionally, it’s also derogatory. Such as the resident who complains of the patient who “dropped his pressure on me”, as if it was something he was consciously in control of. It’s like this blog, mis-directed anger written in a comical and sarcastic fashion.

One year and four months later I am still writing. This blog has allowed me to vent my anger and my frustrations. It has been a medium through which I have been able to connect with some of my readers and establish new friends. And it has allowed me to write, something I enjoy. Also, I was able to share with you my experience of an internal medicine doctor. It is something I will be able to reflect upon later on.

The holidays are upon us. Christmas is here. I am late with my warm wishes but that has never stopped me before.

It’s been an opportunity to read up on what I’ve written over the last year. I thought of including a top ten list. Reading some of the entries I was amused at my sense of humor. It’s not too bad, wouldn’t you say? I can write too. No wonder you read this blog.

Reflecting upon my blog is sort of funny. I was able to review some of my insane attempts at gathering readership. These included, but are not limited to, my blog parodies and my Gray’s anatomy reviews. They were entertaining but exhausting and I will never commit to staying up until 11 pm on a regular basis, during a medical residency, again.

But there was more. Remember the traveling story, or the introduction of the Madman that stands above, or the one before him.

I realized that during summer I shouldn’t write. For one, I don’t feel like it (During August I had two entries, both two lines long) and also I don’t write well when I want to get out.

But for now I will continue writing. Because I love to.

Mad House Top 10 of 2005: (as chosen by the Mad House Madman)

Recommendations for Personal Statements
A guide to AMA. And follow up.
Room 422
Problem Solved
CD4
Gotcha
Spectrum
PTT
A Small Percentage
Dangerous, Do Not Touch

And of course not a post, but, by far this is my most favorite entry this year.

Most of the wonderful comments you guys made have been erased by my attempts with Blogger/Haloscan/blogger. I'm sorry for that.

Merry Christmas to everyone and a Happy and Healthy New Year.

COTV

chekc out the COTV at Ravenwood's Universe

Grand Rounds

I've officially requested to host Grand Rounds again but until Nick approves my request you'll just have to go enjoy them somewhere else. Today, Medpundit, one of our first medical bloggers has the honors.

Unpeople Person

I find it troubling that almost all the fourth year graduating students in our affiliated medical school have no intention of entering primary care, or for that matter, internal medicine. What’s more alarming is the reason that they most often cite: “I found out I really hate to deal with patients/people”.

“So it’s not the money?” I ask.

Of course, it’s also the money, or lack thereof. Is it me or does the general trend go something like Jerry McGwire:

“Show me the money!”

I’ve heard so many lame excuses as to the sudden un-popularity of primary care among US graduates. Everything from blaming the medical schools for not promoting the specialty enough to citing residents for not making it exciting. Let’s cut the crap, bring some of the money back and watch how fast these graduates become people friendly again.

Haloscan Out

I am contemplating getting rid of haloscan and going back to good old blogger comments. I just have to figure out how to un-install.

Of course this means that a lot of comments will disappear, never to be seen again. Sorry guys, I can't stand this haloscan thing any more.

Too Many Ways to Die

Over the last three years I’ve developed a not so healthy case of generalized anxiety. It’s official; there are too many ways to die. Six million may be just a small exaggeration, but the point being: I know way too many of them now.

It seems I can invoke three climactic death scenes for anyone I know. You name a medical condition and I can think of ten horrible terminal scenarios that will part one with dear life. Diabetes, for example, causes complications ranging from a simple hyperglycemic coma to Diabetic Ketoacidosis, both potentially deadly. Even as I write the prescription for diabetic medications my mind trembles with fear at the thoughts of further potential complications.

“We tried to save him Dear Internal Medicine Doctor, but when we got there he had blood glucose of 10. By the time we finally got access it was negative 50.”

While most drivers worry about a high speed crash switching lanes on an interstate highway at 60 MPH, I worry about the driver in front suddenly having a tonic-clonic seizure. In a word, I find this new diversion “unhealthy”.

No one can accuse me of lacking imagination, or hypocrisy; after all, I’ve all but terminated myself a hundred thousand times over. I figure if things go well I’ll die of septic shock while my wife tries to urgently call paramedics. God will support my cause and due to unexplained reasons the four tires on the ambulance will go flat. I plan on having my jaw wired to prevent myself from being intubated, just for giggles. Maybe I’ll tattoo “DNR” on my forehead.

Of course, I’m anxious things won’t go as planned and I’ll get in the line of a perfectly good bullet, meant for someone else, on my way to an anti-gun rally. Each scenario just keeps getting more and more sarcastic and ironic, not to mention painful.

The next young man who complains of being abducted by aliens on his way to Pluto will surely get a STAT ride to psychiatry on my ER shift. It’s just that next time I may do one of two other things. First, I may congratulate him on a death scenario that even I could not have fathomed for such a healthy young soul. But in addition to doing this I may just ask him to “scoot on over” and make a little room for me on the stretcher. I think I need to come along for the ride.

Chalk another one up for the ER- Wait, I have to vomit first

Its moments like these that made me want to become a doctor in the first place. The strange thing about all this is how these rare moments happen whenever I’m doing my ER rotations. Strange, because I find I am able to spend very little time with patients, much less than I would as an internist, and yet there are these little sparkles of light. Maybe this is what draws emergency physicians to their specialty. Although, I’m betting it’s the fact that they get to intubate.

I’ll set the stage. It’s five in the afternoon and I’m preparing to draw blood on one of my patients when the receptionist pages overhead “Medical notification is HERE!”. Normally, a notification is announced minutes in advance thus notifying the physicians of the severity of a particular case that is on its way to the Emergency department. This notification was slightly late.

Suddenly, I see a young girl; about 26 years old, being wheeled towards the back while Emergency technicians are trying to give her oxygen with a bag. She is not moving any air. I can’t hear any breath sounds. No time to react. We establish a line and she is intubated almost immediately.

After the intubation a careful exam still reveals clear breath sounds, no wheezing, normal peak pressures on the ventilator. While before the intubation this was likely a case of horrible asthma, it doesn’t seem to be the case now.

A further probe into her past reveals this patient suffering of a condition called paradoxical vocal cord movement. A cause was not yet found but is probably psychiatric in nature.

She is extubated one hour later.

Now she begins to wheeze heavily and we re-assess our initial impression.

She spends the next four hours wheezing heavily, looking like she needs to be re-intubated. But, all the blood gases and the monitor shows she is oxygenating perfectly. I think I may be going on too much about this case but here’s why I decided to write about it.

Before my shift was about to end I went to check on her. Having looked to me like she was tiring I decided to attempt another blood gas. While I was obtaining the test I started asking her about her life.

“I have four kids” she said.
“Four kids?” I answered, surprised. “If I had four kids I would be here getting intubated every night”. She laughed.
“Where’s your husband?”
“At home with the kids”
“How are things at home?”
“They’re great she answered” She was calming down. No more wheezing.
“Are you sure?” I continued.

And she nodded. We continued our conversation. I was trying to make as many jokes as I could, this was definitely working.

Within two minutes even the non-rebreather was off, the legs were crossed and we were having a nice little chat. No more wheezing.

“What causes this I asked her?” She didn’t know. She’s been to therapy, is on medication and still she’s been intubated five times. We talked for a while, no wheezing, no intubation, no blood gas. Just words. She began to breath normally because we were talking.

I went home happy that night. And that’s why I became a doctor.

This week's Rounds

Go check out the best medical writing of the week.

Grand Rounds

This week's Grand rounds are at the Examining Room. Charles has been doing so many carnivals you'd think he put a picture of a ferris wheel somewhere on the page.

Hail To The Chief

Two days into my rotation as ER chief. That means that every patient who walks/is wheeled into the Emergency Room has to be seen by me first and then I hand it out to a junior resident.

“What part of Emergency did you not understand?”

Shame on you! You probably tuned in to hear me bitch about how bad Emergency Medicine is. Me, complain about the Emergency Room? You must’ve been reading another blog. Now wait here while I go fetch this guy a clean catch, I need urine.

“This is a level 1 trauma center. What level would you rate your arthritis pain and do you believe it really belongs here?”

I walk into another room as the twenty year old patient in the paper gown informs me I should remain quiet. “We’re in grave danger” he says. “I need a one-to one here” I announce to one and all as I storm out of the room to intubate the asthma exacerbation next door. Figures! He suffered blueberry poisoning last month and his parents tried to have him killed, in Europe, when they found out he was a double agent for the Israeli’s.

“I say Mazal Tov my dear friend. Please don’t let the door hit you on the way to the Psych ER” “And stay away from those blueberries”

The first day I was ill prepared. Guess what? It can get pretty busy here. Handoff rounds were of the brutal/ugly variety as I try to remember who these patients are, why they came and how old were they. I went with a ballpark figure.

“Senior citizen man here for pain in the abdomen”, “No, I have no idea, ask the junior what he found.”

The shift was over. I felt like I’ve been raped. Yes, I know this isn’t funny.

“Let me introduce you to the medical clinic. Sorry you waited so long in the waiting room but you see this building next door? You could have seen a doctor there ten hours ago in walk-in.”

Why the long-face? Did you not appreciate the Lumbar Puncture I did for your perfect tension-headache?

I love Emergency Medicine.

Grand Rounds

Tomorrow I start ER chief. That's right, you guessed it, that means there's going to be a lot of ER bitching going on really soon. So while I get worked up why don't you go enjoy this week's Grand Rounds.

Dear Bluedude Please Consider This

Recently, I wrote a post about being names in a lawsuit which was brought forth by a patient I had cared for in the past. The patient had a bad outcome and felt that this was due to the medical care he/she recieved or did not recieve. I've written similar posts about others before and usually what happens is that a med-mal discussion begins to brew in the comment section. It did this time as well and I put an end to it early, honestly, because I'm tired of hearing about it and arguing about it.

So why am I writing this post? Well, I've observed that the readers who are drawn to medical blogs are either people in the field or patients who have chronic disease and do a lot of research on the web about their own disease. These readers like to pick physician's brains or are interested in hearing something that validates their pre-concieved notion about their prognosis or other concerns. Of course, there are the occasional readers who are just interested in medicine as a field. But I digress.

Whenever one of these posts gets written, and this discussion begins, there is always one or two comments from readers who are truly convinced that their physician made a mistake, or missed something or just plain didn't know. This time the reader goes by the name "Bluedude". As they say "if you live in a glass house don't throw stones" so I will be happy to address him as "Bluedude".

Bludude writes:

"My father died very suddenly, and it was revealed that his doctor, also personal friend, missed the spot on his lung on the xray. We are not a litigious family and people do make mistakes. But what infuriates me is the way each doctor consistently stood up for each other, and my dad's friend kept reassuring my mom that there was no way he could've been diagnosed by the xray. Everytime he said that, it made me angrier and angrier. If doctors make a mistake, which they will, since they're only human, please don't lie to my face. Also, we asked the oncologist, and he just kept stating he didn't have a chance to review it. Be honest, be remorseful; show that you care about this patient, at this time. There would be less law suits if doctors didn't circle the wagons so readily."

This is not the first time I recieved this kind of response. I believe that Bluedude really is upset by what he believes are "physicians covering up for each other". I do understand how the situation can appear to be as such but please allow me to offer some counter-arguments you may have not given any consideration to. The reason I am going to do this here is because if I were the one being confronted by this family memberI would probably not point this out, in fear of being misunderstood, further worsening the situation and infuriating the complaint or because it would simply take wayyyyyy too much time and the person with whom I am having the discussion does not have the approprate background knowledge to begin to understand the full ramificaions of what I am saying. Especially when they are angry and more closed minded. I believe this phenomenon occurs because on television decisions seem much more straightforward. X-rays always tell the truth. CAT scans are perfect, an MRI, undeniable! If only things were that simple in REAL LIFE medicine. Please don't forget that television shows are aimed at the general public and have to be extremely simplified. A shame, since the general public gets most of their impressions about medicine from a very simplistic version.

Here is my response:

Dear Bluedude, My deepest condolences on the passing of your father. I do understand how you came to believe that your father's physician made a mistake and, inferring from your response, he ultimately was diagnosed with lung cancer (I am not sure of this, however, you do mention an Oncologist being involved).

First, please allow me to discuss a personal story:

My father, then 49, continued to complain about chest pain radiating to both arms for about two months. He continued to return to his PMD with the same complaints however all the EKG showed nothing. I was still a student in college and did not understand medicine and certainly not interested. His doctor repeated an EKG on each occasion which (according to him) did not show anything.

When my father, finally, was reffered to see a cardiologist he went straight to cardiac catheterization (after the Cardiologist saw his EKG) which showed severe obstructive disease of the arteries to his heart. He needed an immediate triple bypass surgery.

For a long time we were very angry at our PMD for what we believed was ineptitude at reading an EKG. We never sued him although we didn't return and changed PMDs soon afterwards.

Now, after having studied medicine I do understand that what he was looking for was a CHANGE in the EKG. Which is medically legitimate. Although, I certainly feel a stress test was in order earlier I do understand that what he was doing was appropriate, if for example, he did not think the pain was truly cradiac.

Now, let's discuss your father. You believe that his doctor "missed" a spot on your father's CXR. OK. But have you thought about this:

1. Are you sure that the spot was truly lung cancer? (in your case it may have been but I am just making a point)

2. Was that same spot there before and therefore there really was NO CHANGE on this Chest-X-Rays from previous ones, something that would go against this "spot" representing a cancer?

3. If this WAS cancer, was it what really caused his death? Cancer usually causes a slow deterioration, therefore, dying suddenly is more uncommon (not to say it doesn't happen). Could your father have died with lung cancer, instead of, from lung cancer?

4. Where was this "spot" on the x-ray. Could other things have explained it in the medical history of your father, maybe it was an Aspergilloma (I know you probably never heard of this diagnosis but it goes to further point out that people not trained in medicine lack the knowledge needed). Maybe things he didn't ever tell you but did tell his physician. This may have caused your father's physician to choose observing this "spot" for growth as opposed to subjecting your father to a dangerous biopsy that would have caused his lung to blow and then really cause him to die.

Just understand that medicine is not as straight forward as it looks on TV. Chest X rays are imperfect, so are CAT scans (they sometimes show results which only cause further unnecessary workups- One, put the patients at further risk for procedure complications and are expensive). So are MRI's for that matter. Medicine takes EXPERIENCE and association of SYMPTOMS WITH results.

You can always second guess your physician. That doesn't mean you have any clue about what was really going on OR what were his considerations at the time. He may have only been trying to protect your father from a painful and unnecessary workup. You've never seen a complication from a procedure cause a patient's death, I've seen many. So has your father's physician.

5. Finally, By the time a mass appears on a CXR (if it is lung cancer). The disease has usually allready metastisized and the cure rate is EXTREMELY low!!!Meaning, chances are that even if he did pick this up and did subject your father to a painful workup and chemotherapy it would not have changes the ultimate outcome.

Furthermore, most likely your father's physician never even saw the x-ray, the radiologist who read the Chest X-ray may have missed it. Your PMD usually only recieves a report of the reading.

I've tried having this type of conversation with others who have similar beliefs but it's really too emotional for the other side and their view is too narrow and set on blaming someone. Again, I am truly saddened for your loss. I don't know if anyone is to blame after all but I'd like for you to consider that maybe nobody is to blame and everyone lost someone they loved (including your father's physician and good friend) because everyone dies sometimes and life is unfortunate and cruel in that way.

Happy Thanksgiving Everyone

I'm thankful my residency is over in 7 months. I'm thankful I'm no longer a second year or an intern. I'm thankful my residency is almost over. I'm thankful for a wonderful healthy girl and a loving wife. I'm thankful my residency is over in 7 months. I'm thankful for a beautiful world full of beautiful sights and gorgious women. I'm thankful my residency is over in 7 months. I'm thankful I'm a third year resident. I'm thankful that interns do my scut work. I'm thankful for not doing one guaiac exam myself this year, not one. I'm thankful my residency is over in 7 months.

I'm thankful my residency is over in 7 months.

Happy Thanksgiving everyone.

Sincerely,
Joe

I'm Getting Sued

Or Shall I say "We are getting sued".

It's about a patient I've cared for as a resident who had a bad outcome. The lawsuit is by no means a surprise. I had a feeling it would head in this direction from the beginning.

I know you don't want to hear me bitch about this. Neither would I, so I won't do any of that. I would like, however, to document a few things that I can take away from this lawsuit that may, still, make me into a better physician or, at the very least, prevent me from being sued again.

For one, when things with the family appear strained, or tense, make a strong effort to document everything. Everything that they say and all of your responses. This does, however, become difficult because it will eat up a lot of your time.

Two, when the situation is heading in the wrong direction make a strong effort to document everything. Today, the impression is that an unfavorable outcome is automatically the physician's fault.

Three, get the family involved early. In fact, a good question to a patient when admitting them is if you can discuss the situation with the family. I suggest calling the family on admission so that they understand what is really happening. Try not to commit any HIPAA violations in the process.

Never say that things are looking "great" or "good" or "wonderful". You may use words like "Better", "Improving" or "Heading in the right direction" but make sure to mention that the overall situation is still bad. This will cushion the shock if something doesn't go as planned.

Never ask about a DNR the first time when speaking to a family even if the patient is crashing. They will become paranoid that you are not doing your max to cure their loved one. People really are distrustful of doctors these days. That is real! Wait at least 24 hours before asking about a DNR.

I have to face how this makes me feel. The truth is that I have no idea what exactly went wrong. I've had a chance to look through the chart and I am still unsure. But it doesn't mean I'm a failure or that I made a mistake. And even if I made a mistake I was hoping to take some lessons away from the experience. Unfortunately, I can think of other cases where I did make a mistake but the only thing I can really learn from this case is how to prevent myself from being sued. Which won't make me into a better physician by any stretch of the imagination.

I'm mostly nervous about having someone look at all of my decisions under a microscope. Can my judgement really withstand that sort of scrutiny? We all make decisions and many times those decisions are based on instinct.

Since that case I've been a better doctor. That's the simple truth. Much more careful about every single decision I make. Many of my decisions are based on my own welfare and not necessarily the patients. They are based on what someone may say in court. They are based on my need for future employment and malpractice insurance. I do, however, feel that ultimately the patients are better cared for and that is what counts.

Residency teaches more than just medicine.

It's My Blog, Whaddayagonnado?

I've been thinking about money lately. I think the reason is simple: I love money! There I said it. Finally, it's such a relief, I'm out of the closet.

Naturally, I've been doing a lot of reading about the topic. Mainly, reading about buisness and investing through various blogs that deal with...'buisness and investing'. I happen to find some of these pretty helpful. Not in that 'How can I help a fellow human being' helpful but more in the way of 'How can I make myself rich' .

Some of the most interesting things I found were quite discouraging. For example, did you know that had I not attended medical school the odds that I will be rich would have been much greater. Do you know how much compound interest can add up to given an extra ten years head start.

The lifestyle that physicians need to maintain can also add up to a lot of cash. Those Armani suits aren't cheap you know.

Now, I know most of you will say that my future salary should more than make up for the lost time. Possibly. But, don't forget that I am starting in the minus. Medical school loans will haunt me probably for the duration of my physical being. Should I die, I'm convinced the collection agency will find a way to contact me. they will ask that I work out an alternative payback plan. Maybe I'll be the collector's guardian angel, for a fee.

Recently, I read Rich Dad Poor Dad, and you might say it certainly made me think. There are also tons of blogs out there that deal with money and many of them will be popping up on my sidebar soon enough. Not so much so you can go and check them out but more so for me. I do recommend the rest of you residents spend some time reading up as well. We can all use a little education about money and it would be quite refreshing to take care of yourself, once in a while.

I apologize that the medical comedy you come here for has been noticeably absent recently but I have other things on my mind. This is a blog about a journey through residency and finance is certainly part of that journey.

Enjoy:
Wealth Junkie: A young man's journey to becoming a billionaire.
Phil Town, Rule #1: Attempting to teach a special method of investing. That is Rule #1.
Fat Pitch Financials: Currently covering 30 days to becoming a better investor.
Frugal For Life: Currently hosting the Carnival of Personal Finance.

Of Course, I take no responsibility for any of the advice on any of these blogs. I do however encourage learning about investing. This is certainly one course I unfortunately never attended.

If any of you know other sites I should be reading please metion them. I'm always open to suggestions.

Things To Do For My "Inner Child"

Recently, Misha (sorry no address) wrote a response to one of my posts:

"madman--you sound depressed. I think you need a diversion. How about a post of things you promise to do for your inner child.....Kind of a "to do" list. Not important achievement kinds of things....crazy things...fun things....things you have never done. You are clever....I trust you can come up with some good ones"

I thought "Heck, I spend half my day day-dreaming anyways so why not actually write down what I would love to do. So here it is, a list of what the 'little me' would really enjoy doing and then things I promise to actually do: (Some of these will get me in trouble)

Things I Would Love To Do:

1. Fly in a hot air balloon
2. Take a submarine trip
3. Scuba Dive in the Sainai
4. Try Cocaine
5. Learn to Tango really well
6. Perform in a play
7. Take a home renovation course
8. Make love to Adriana Lima
9. Meet Some of My Readers in Person
10. Fly a plane

Things I Promise to Actually Do:

1. Take a submarine trip
2. Scuba in Sainai
3. Perform in a play
4. Meet some of my readers
5. Learn to tango
6. Make love to Adriana (If she lets me)

I guess that's a big "If"
Have a great weekend

The COTV

Over at Charles. And...He placed me first, I love you Aiden!

Possibly the Most Hysterical Thing I've Ever Read In a Medical Journal

I feel so badly pouncing on this when really it's so much more ideal for the blogs of my emergency physician friends. the Annals of emergency Medicine October 2005 issue published an Article titled "The Next Generation of Emergency Medicine Reality Television". It's possibly the funniest thing I've ever seen in a Bona Fide medical Journal (if you consider EM medicine???). Props to Jeffrey Freeman who wrote the piece. Truly Mad my friend, I love it. Please excuse me for publishing it here. I have no money, really, I promise, none. Forgive the EM joke, that's mine, figures right?

As any emergency physician knows, it is normal to ride through the hallways of the hospital doing CPR atop the chest of a dying patient while shouting out orders to nurses at the top of their lungs—at least on television. And, while miracles occur in emergency departments (EDs) every day (such as a specialist coming in to see a patient), they are not always sufficiently dramatic for prime time. Like it or not, the American public learns more about emergency medicine from the television than from their personal experiences. ER has just finished 10 seasons; Trauma: Life in the ER has finished 7. Since it's only a matter of time before these shows fade from the airways, a replacement will soon be necessary. In this era of reality television, something that will grab the public attention and let them feel the true grit of today's ED is needed.

The following are reality television proposals for the next generation of emergency medicine viewers:

The Resident—A powerful and omniscient residency director starts with 12 emergency residents and each week fires one resident and gets all the remaining residents to work the extra shifts vacated. The last resident working gets hired to a large contract management group, but not as a partner.

Joe Emergentologist—Ten patients compete for the attention of Dr. Joe, the only physician working in a small rural ED. Each hour, Joe transfers off 1 patient to an alternate facility. Imagine the patient's surprise when it's finally revealed that Dr. Joe is only a moonlighting first-year dermatology resident, with no experience in any ED. Will the last patient standing still accept the loving care that Dr. Joe offers when they find out the truth?

Waiting Room Survivor—Twelve patients are stranded in an isolated, barren waiting room, and triage is closed. Who will survive? Without water or food, they have only their wits and the will to survive. Each week a patient is voted out of the waiting room. As they form tribes and win challenges, they struggle for the ultimate goal: any available treatment room.

ER Jeopardy—In this game show variant, 3 emergency physician contestants try to guess a patient's diagnosis, but the answer to every question is another question. Categories of answers include such puzzlers as: “What Language Is That?,” “Nominal Aphasia,” “Geriatric Confusion,” “In2bated,” and “Toxic Delirium.” Losers get sued, and the winner gets no actual cash or prize, but does get to come back for another shift and the satisfaction of a job well done.

The Mole—A high-volume ED, and one of the staff is sabotaging patient care. The Mole changes lab results, erases orders, and gives wrong doses; each week another abbreviation is cut from the list of accepted abbreviations. Can the emergency physician find the Mole before another patient calls their attorney? Sponsored by the Institute of Medicine.

Patient Extreme Makeover—A team of top-notch support services: social worker, physical therapy, occupational therapy, and dental hygienist, take a frequent ED visitor each week and work their wonders. Consultants are called in for bariatric surgery and laser tattoo removal; clothing is donated from the local thrift store. The patients return after their complete makeover with a new chief complaint, and the ED staff can't recognize them until they ask for Dilaudid…

The New Price Is Right—Forty-five million uninsured audience members are invited to the television studio ED waiting room, where 4 contestants are chosen to possibly win some medical care. To win, they've got to guess the price of industry-sponsored drugs and medical procedures. Those who guess closest are invited to a final showcase, where they try and guess the complete cost of their medical treatment before succumbing to their disorder. “Come on down!”

The Simple, Poor Life—Two consultant physicians, both from fabulously wealthy subspecialties, are sent to live and work in an ED for a month. Each week they are given a different job, from unit clerk through transport and housekeeping. Can they get through one last shift without getting their clothes dirty? A laugh a minute…

Who Wants To Be a Millionaire?—Two physician CEOs compete for an ED contract, trying to underbid and underpay their employee emergency physicians without going over the contract price. Three lifelines are given: “Noncompete clause,” “Restricted access to billing information,” and “Call a Friend.” Winner gets a million dollars and retires early from medicine.

American Idle—Each week, 12 patients wait hours for lab and radiograph reports while their medical conditions deteriorate and inpatient beds are unavailable. Radiologists and audience members can text message their vote for favorite patient to be admitted.

And finally, Fear Factor—This could be the ultimate ED program. It's apparent that the potential for an endless series of reality-based episodes of pain, terror, and inedible food is available. Just like a career working shifts in any ED.

Note 1: If anyone wants to consider hiring an emergency physician as television producer, please contact the author immediately.

Note 2: JCAHO has reviewed this article and would like to remind emergency physicians who shout out orders while performing CPR while riding stretchers down hallways, that for verbal orders, please verify the order by having the person receiving the order “read-back” the complete order. Thank you.