Thursday, May 21, 2015

Breaking and entering

Apparently, we missed the memo about yesterday being an early release day for a teachers meeting.

So the twins texted me while I was with a patient to say they were locked out, since neither of them had brought a key.

Fortunately, my last 2 patients of the day had cancelled, so we were able to close down early. On the drive home I ignored the text fight that broke out between the kids over whether the front or back yard was a better place to wait.

So I got home to find Craig planted in front of the garage, staring at his phone. He told me Marie had gone into the back yard to wait on the patio, and he didn't think that was a good idea for whatever reason. They were continuing to text insults to each other over which yard was better.

Such are the conflicts that shape our lives.

Anyway, I opened the garage, unlocked the door, and we went in.

To find Marie sitting in front of the TV, eating popcorn, and texting Craig back.



Dr. Grumpy: "Marie, how did you get in here?"

Marie: "I picked the lock on the back door."

Craig: "How did you do that?"

Marie: "I used my student ID to push the first lock in. Then I got Frank's old croquet set and bent one of the hoops around, so I could fit it through the crack and slide the second lock over."

Dr. Grumpy: "How come the burglar alarm didn't go off?"

Marie: "I twisted the croquet hoop the other way, like this, to reach around the corner and flip the alarm switch off."

Craig: "You didn't tell me you were inside! Why didn't you let me in?"

Marie: "Because you called me a bitch for going to the back yard."


We've lived in this house for 12 years, and this is the first time anyone's broken in. My neighborhood must be safer than I ever imagined.

Wednesday, May 20, 2015

Wednesday reruns

Dear Dr. Dipshit,

You sent a fax over to my office this morning that only said "PLEASE CALL ME ASAP TO DISCUSS MUTUAL PATIENT IMA DINGDONG!!! I'M AT 867-5309!!!".

I can only assume you did this because you are incapable of actually dialing a phone by yourself. Obviously, if someone at your end can look up a fax number, they could have found my phone number, too.

Mary brought it back to me about 3 minutes after it printed, and interrupted me while I was with a patient because it looked urgent.

I don't mind being interrupted, because a patient emergency should always take priority. So I called 867-5309.

The call was immediately transferred to your answering service, who told me your office was closed and offered to page another doctor on call, who likely had no idea why you were trying to reach me urgently. I begged the operator to see if your office had a backline she could connect me to, and she kindly did.

The lady (Jenny, I assume) who answered your back line obviously didn't give a shit. I told her I was Dr. Grumpy, and I was returning YOUR fax about Mrs. Dingdong. She told me the office was closed, and I should leave a message with the answering service. When I repeated that YOU HAD FAXED ME, she said you were having coffee with a drug rep, and didn't want to interrupt you (I guess it's better for a doctor to be interrupted when with a patient, huh?).

I told her that the fax said it was an emergency, so she sighed heavily (I could hear her rolling her eyes), whined, and said, "okay, let me go see if he's done".

I was then placed on hold for 2 minutes and 38 seconds (while I'm with a patient at my end) before another of your staff came on, said you were still with the drug rep, and asked me which patient it was on, what their date-of-birth was, and why was I calling in the first place? Could it wait until your office opened after lunch?

Sorry I hung up at that point, but I didn't want to scream and swear at some poor staff member that you'd stuck between us. Obviously, you and I have a different definition of "emergency".

And you can call me back if you need me. Or, better yet, just tell the patient to.

Tuesday, May 19, 2015

Brevity

Seen in a hospital chart. This was the entire physical exam performed by a neurosurgeon:


"Wait, he left out cyanotic."
For non-medical readers: NAD = "No apparent distress."




Here's another thorough note, this time by an internist:



"Pregnant or non-pregnant. Are there any other human health conditions?"




For all these years, I thought the neurological exam consisted of checking multiple subsystems covering cognition, Cranial Nerves, strength, coordination, sensation, reflexes... and other stuff. Apparently I was wrong, as this hospitalist's entire neuro exam shows:


Monday, May 18, 2015

Sunday night, 11:52 p.m.

Dr. Grumpy: "This is Dr. Grumpy, returning a page."

Mr. Levodopa: "Hi, I'm a patient of Dr. Brain's, and I have Parkinson's disease."

Dr. Grumpy: "What can I do for you?"

Mr. Levodopa: "Well, he has me on Sinemet, one pill four times a day. Is that okay?"

Dr. Grumpy: "Are you having any problems? Or side effects?"

Mr. Levodopa: "Nope. This dose has worked great for me since 2012."

Dr. Grumpy: "Then I'd leave it as it is."

Mr. Levodopa: "Okay. I just call his office every week to make sure, and he's out of town right now."

Friday, May 15, 2015

Patient quote du jour

"I'm allergic to any and all manufactured products, regardless of what it is or what it's made from."

Thursday, May 14, 2015

Class




Mr. Skoal: "Then the pain radiates from the wrist to the thumb and..." (pauses, reaches onto my desk, and picks up my Diet Coke can) "Hey, doc, is this can empty?"

Dr. Grumpy: "Uh, yeah, mostly, w..."

Mr. Skoal: "Good, I need to spit out my chewing tobacco."

Hock


Wednesday, May 13, 2015

Top secret

Dr. Grumpy: "Hi, this is Dr. Grumpy. You guys referred Mrs. Spazzo to me, and I'd called earlier to have her most recent labs faxed."

Ms. Desk: "Yes, I sent them over a short while ago."

Dr. Grumpy: "I got them... but there's no lab results here. It just says they're 'abnormal'."


"How much more helpful can it get?"


Ms. Desk: "Well, that's because they're abnormal."

Dr. Grumpy: "Okay... but this doesn't tell me what's abnormal. Or even if they're high or low. The CMP has roughly 10-15 different things on it. Which ones are abnormal? Or is it all of them?

Ms. Desk: "Well, you're not the ordering physician. I don't see why you need more information."

Dr. Grumpy: "Because I'm trying to figure out what's wrong with the patient, and knowing which of her labs are off would help me. A lot."

Ms. Desk: "We have to protect patient privacy."

Dr. Grumpy: "But you referred the patient to me."

Ms. Desk: "Obviously, that was a mistake."

Click

Tuesday, May 12, 2015

"I'll have what he's having."

Seen in a hospital chart:



Monday, May 11, 2015

A very bad nut

Veruca Salt is the poster child for spoiled kids. With her demands, manipulative behavior, and spineless father, she's one of the most hated children of all time. Certainly, any parent (except her daddy) was thrilled to see her dumped down a garbage chute.




That's what you get when you give children everything they ask for. Trying to raise them to be responsible adults involves saying "no." A lot.

But, in today's world of health care, spoiling patients is apparently the goal. Even when it's against their own best interests (such as keeping them alive).

In case you haven't been near a hospital recently, "Patient Satisfaction Scores" are now the big thing. This isn't just some bullshit public-relations crap. Under the Medicare guidelines, 30% of a hospital's reimbursement is based on them. As opposed to, say, surviving brain surgery with a good outcome because of excellent care.

30% of Medicare money is a pretty decent chunk of change for any hospital. So they go along with it.

Because, ya know, if you hit the ER with crushing chest pain it's more important that someone immediately offers you a light snack than slaps an EKG on you and calls a cardiologist.

Of course, patient surveys don't ask questions about "are you happy that you had a complete recovery after your cardiac arrest/massive stroke/traumatic high speed rollover accident?" They ask if you were pleased with the food service. Or if the nurse smiled enough. Or if the call light was answered quickly.

Perspective is important. If you've suddenly lost vision in one eye, or can't move your leg, I'd hope they answer the call light quickly. If you're ringing it because you can't reach your iPhone, or your roommate is snoring too loudly, then a prompt response isn't as critical. But try telling that to the whiny person who's upset that no one answered her 5th call light in an hour (this time to ask when Survivor comes on) because the staff has been running a Code Blue across the hall. Minor things like someone elses health, or even their own, are beneath them.

The question about call lights is, really, on the survey. According to a recent article in the Atlantic, patient comments about "quality of care" have included:


"My roommate was dying... his breathing was very noisy.”

“The hospital doesn’t have Splenda.”

"I didn't get enough pastrami" (from a guy recovering after coronary artery bypass, FFS)



"This is a hospital, and you can't have it your way."

This experience was drilled into me over 20 years ago. I was a 4th year medical student doing an ICU rotation at a VA hospital (not known for having a big budget). One patient who'd been brought in for unstable angina the night before was yelling at me and a nurse because - get this - he hadn't gotten enough eggs for breakfast, and wanted more sausage links, too. My resident, a guy named Ivan, came over and said "this is not a hotel. We're trying to keep you from having to eat through a tube."

Of course (as is common at the VA) the guy yelled back that he was going to write to his congressman, and left AMA. But I digress.

The goal for us (the people on this side of the bed rail) is that you leave the hospital as reasonably intact as possible. This isn't always possible, but we do our best. But that doesn't mean you're going to get cronuts. Or HBO. Or someone to fix your TV at 2:00 a.m.

Getting you better (at least enough to go out and destroy your health again on your own watch) is our long-term goal. The guy recovering from diabetic coma may be pissed we won't give him cake and ice-cream, but that's not in his own best interests. So we have to say "no." He can go hit Baskin Robbins after leaving, but we can't control that. Like any parent trying to raise a child into a decent adult, saying "NO!" is critical here. As opposed to Veruca Salt's sniveling daddy who gives her whatever she wants and is raising a horrid brat.

Sadly, with patient satisfaction surveys, care takes a back seat. The guy who made it through a messy brain surgery may not be in a condition to fill it out, even though he had excellent care. But the junkie who didn't get Dilaudid as often as he wants? You can be sure he'll be ripping the hospital and nurses a new one.


"Look, bozo. You can't always get what you want."


Of course, the sword swings back at us, too. Let's say I give in to the "customer is always right" attitude they're pushing and let the patient have a little more bacon, or Morphine, or a cigarette. When they have another stroke you can bet they (or their heirs) will come after me with a lawsuit.

Patient satisfaction isn't necessarily the same as good patient care. In fact, it may be the opposite. One study found that the patients who were the most satisfied also had higher rates of medication use, hospital admissions... and death.



"Botched my surgery, but at least they had Splenda."

The hospital CEO's in their 25,000 square-foot offices, however, don't see it this way. They usually don't care about anything but revenue and getting that 30% out of Medicare's coffers. So a nurse who provides excellent care and catches early stages of an MI is going to be worthless compared to one who mixes up the wrong medications but has a nice smile and gives the diabetic extra ice cream. THAT'S the nurse who'll get the hospital a good survey score.

I suspect that, when this was written into Medicare law a few years ago, no one saw this as the end result. They likely believed patients (or "health care consumers") would be able to see the difference and judge accordingly. Unfortunately, human nature dictates otherwise.

I've bitched about this before, how completely worthless these online rating services are. Granted, the patient satisfaction surveys aren't quite the same, but they make the same mistake. Confusing personal satisfaction (which is subjective, variable, and wildly different from person-to-person) with good outcomes and quality of care (which can at least be somewhat more objective).

Your doctors, nurses, and all the others involved in your hospital care, are doing their best to make sure you get out of there in as good a condition as possible. But, like saying "no" to Veruca Salt, that doesn't mean it will always make you satisfied with us. But, for her own good, it would have made her into a better person. Or, in this case, a healthier one.



Thank you, SMOD!

Thursday, May 7, 2015

May 7, 1915





100 years ago today, in a factoid well known to school children, the R.M.S. Lusitania was sunk by a German submarine with a loss of 1198 lives.

And... that little snippet is pretty much all most people know about the disaster.

The details are forgotten compared to her erstwhile competitor, Titanic. Nobody made a blockbuster movie about her. Plenty of books have been written, but they often focus on the debated aspects. Was the ship a legitimate target? Did the British admiralty intentionally put her in harm's way? Was she carrying priceless paintings? These questions will never be settled, and I won't debate them here.

Americans are taught that the sinking is what brought the U.S. into WWI. Horseshit. It certainly contributed, but was only a small part. In fact, President Wilson fought like hell to stay out afterwards, and the U.S. didn't enter the war for another 2 years. The resumption of unrestricted submarine warfare in 1917 was a bigger factor. And, although mostly forgotten now, the Zimmerman Telegram was likely the event that finally pushed America into hostilities. Except for those of you who (like me) are fascinated by history, you've probably never heard of it.

A voyage then was a far cry from cruising now. Today's ships are designed for entertainment, with shows, games, shopping malls, climbing walls, mini-golf courses, and countless activities. They're rarely at sea for more than 2-3 days (at most) and frequent port stops are part of the attraction.

That wasn't the case in 1915.

To get some idea of intercontinental travel in the pre-flight age, think of this: You were in a large hotel for 10-20 days. You couldn't leave. You didn't stop in port until the end. The restaurants, though opulent, were the same. Your fellow travelers, and the crew, never changed. The only entertainment provided by the ship were small orchestras for 1st and 2nd class, an exercise room, and a meagre library. 3rd class slept in large dormitory-like rooms that doubled as their dining areas, and their only entertainment was whatever instruments and reading they'd brought. The North Atlantic crossing, arguably the busiest and most economically important of the era, was rainy, cold, and windy. The ships didn't have the stabilizing systems we take for granted today, and rolled with the choppy seas.

The Lusitania's stories are mostly forgotten (like the Empress of Ireland) probably because of the time scale involved. From start to finish the sinking took 18 minutes. In that sort of time, on a rapidly foundering ship, the overall reaction is rushed panic. The Titanic, in contrast, floated for 2 hours and 38 minutes after striking the iceberg. Enough time to avoid panic and for the norms of Edwardian society to dictate the events. Women and children first. Rich before poor. Americans & Britons before immigrants. Stories of the band playing to the end, of Isidor & Ida Straus choosing to die together rather than get in a lifeboat ahead of younger people, or the chief engineer who went back to carry out a crewman with a broken leg - with neither ever seen again. Thousands of stories in 158 minutes that immortalized the disaster.

In just 18 minutes, those on the Lusitania didn't have time to do much but try to get in a lifeboat. Most failed. Although (unlike the Titanic) she had enough lifeboats for all, the slope of the sinking hull, and the rivets holding it together, made it difficult to launch them. Many dumped people out before hitting the water.

But stories are there, you just have to look for them.

The Lusitania herself was a technological marvel. The first liner fitted with the revolutionary new steam turbines that today run everything from nuclear submarines to power plants. The first ship to have a central climate-control system (the ancestor of air-conditioning) to keep the interior at a steady 68°F, regardless of outside weather. The system also exchanged the air inside the ship 7 times every hour, eliminating the need to open portholes on a cold day. And, for a time, she was the fastest liner to ever cross the Atlantic.

On the antagonist in the tragedy, the submarine U-20, was a story. The ship had been identified as a large passenger liner, and Kapitanle├╝tnant Walther Schwieger still had every intention of sinking her. He gave the order to fire, and it was the job of Quartermaster Voegele to relay it to the torpedo room.

But Voegele wouldn't. He told Schwieger he refused to carry out an order that would kill innocent civilians. Schwieger immediately relieved him of his post and had another officer do it. After returning to land, Voegele was court-martialed and spent the rest of the war in prison.

Very few stories are as popular, or been "re-booted" as much, as Peter Pan. From the Walt Disney cartoon, to Dustin Hoffman's "Hook," to 2003's "Neverland," the tale has been imagined and re-imagined, both in movies and theater, many times. And Tinkerbell now has her own spin-offs.

But the odds are you'd never have heard of Peter Pan or Tinkerbell if it weren't for a man named Charles Frohman. One of the leading theater producers of the era, he was instrumental in bringing the story to stage. First in London, then in America, he put J.M. Barrie's once obscure story in front of live audiences night after night. Frohman even had the title changed, from the original "Peter Pan - the Boy Who Hated Mothers" to the one you know: "The Boy Who Never Grew Up." It's as immortal as a tale can be.

Frohman died on the Lusitania, at age 58. Unable to jump into a lifeboat due to severe arthritis, and not knowing how to swim, he knew his life was coming to a close. He spent his last minutes with the wealthy Alfred Vanderbilt (age 37, also couldn't swim, and refused to get in a lifeboat ahead of women), tying life jackets to the nursery's baby baskets to make sure the infants would float. As the end approached Frohman turned to actress Rita Jolivet (who survived), and quoted from Peter Pan “Why fear death? It is the most beautiful adventure that life gives us." Then he disappeared under a surge of water.

As Margaret Mackworth and her friend Dorothy Connor watched the frantic rush for the lifeboats, Margaret commented that "I've always thought a shipwreck was a well-organized affair." Dorothy replied "so have I, but I've learned a devil of a lot in the last 5 minutes." An hour earlier, at lunch, Mackworth had told others at her table "It's been such a dull, dreary, stupid, trip. I can't help hoping that we get some sort of thrill going up the channel."

In Chicago, Illinois is Ambrose Plamondon Elementary School. Mr. Plamondon was a major American steel industrialist of the 19th century. When he died his son Charles took over the vast company... And, along with his wife, died on the Lusitania.

Another survivor who ran down to get her lifebelt remembered passing an open door, where inside a middle-aged woman cheerfully arranged and re-arranged her suitcase unconcernedly, as though they were about arrive in port.

In New York, Cunard's local director watched a crowd gather outside his office as news drifted in. He remembered watching a similar crowd outside the rival White Star Line office across the street 3 years earlier, and hoping it would never happen to him.

The worst of human nature was on display that night through America, Ireland, and Britain. Mobs attacked and burned business and homes owned by families of German descent, or even those with vaguely German-sounding names.

To the people of Queenstown (now Cobh), Ireland, fell the rescue. As the first S.O.S. crackled from the Lusitania, local fisherman (who'd just come in to unload from the morning) frantically untied their boats and headed back out to sea to save as many as possible. It was a motley collection of mostly sailing boats, a few faster ones with engines, and even some that were being paddled. Boys standing on the cliffs of Kinsale to watch her pass saw the explosion, and helped spread the alarm to local life-saving patrols. The exhausted fishermen worked into the evening to save as many as they could.

As the 767 survivors came into town on overloaded boats, the townspeople rushed blankets and food to the docks. They found places to shelter the fortunate ones - in homes, hotels, warehouses... anywhere there was space - until Cunard was able to make arrangements.

To the locals also fell the unenviable job of handling bodies that were picked up by boats or washed ashore for the next several weeks. Those that could be identified were sent home, but many were beyond that. So three large mass graves, with coffins stacked 2-3 high (some with 2 children put in them) were dug at the Old Church Cemetery. More were buried in Kinsale, at the Church of St. Multose.




Some of the victim's names were known only to their families, sadly being listed on the roster just as "Mr. Stanton's manservant" or "Lady Adam's maid."

In 1912, as the Titanic was about to leave port, the suction from her powerful propellers pulled another liner, the S.S. New York, away from the dock. The 2 ships missed colliding by roughly 3 feet before tugboats could push them apart. Now, 3 years later, the New York was linked to another tragedy. The American government chartered her to bring citizens, living and dead, back to the states. She carried the bodies of Charles Frohman, the Plamondons, and many others.

Survivor Herbert Ehrhardt took off his shoes and gave them to a shivering man in his lifeboat while awaiting rescue. They didn't quite fit, but the man said they'd do. The next day Ehrhardt (and many others) went to a Queenstown shoe store to replace them. As he waited to be helped, he noticed his original pair lying discarded on the floor. He laced them back on and left.

U-20, the submarine that sank Lusitania, ran aground off Denmark in November, 1916, and was subsequently demolished. What's left is roughly 1200 feet from shore, under sediment. The conning tower was removed and is at a local museum.

Captain William Turner of the Lusitania survived the sinking when a wave washed him off the bridge. He was pulled from the water, unconscious, by the crew of a fishing boat. Although exonerated by the inquiry, public opinion held him to be at fault for not taking preventative measures. His wife and sons left him, and he never saw them again. He was assigned to command the ship Ivernia in 1917, which was sunk in the Mediterranean by a submarine. He survived again, but never returned to sea and died in 1933.

Kapitanle├╝tnant Walther Schwieger was killed in September, 1917, when his next submarine struck a British mine.

The last survivor of the Lusitania, Audrey Lawson-Johnston, died at age 95 in 2011.

The once-beautiful Lusitania lies, collapsed on her starboard side, in 300 feet of water off Ireland. While the bow section of the Titanic still evokes a sense of grace and majesty, the Lusitania is little more than a large scrapyard. Her much shallower depth makes her susceptible to the effects of tide, weather, and temperatures. The attack by U-20 was also just the beginning. Countless times in WW1 and WW2 there was concern U-boats were using the wreck to hide, and so it was aggressively depth-charged by destroyers to scare them off.

The hundreds in the mass graves, whose identities will never be known and whose families never saw them again, are marked at the Old Church Cemetery by a single large stone.




Wednesday, May 6, 2015

Reportable case

Seen in another doctor's note:


Tuesday, May 5, 2015

Nudge, nudge, wink, wink

Apparently, the Shipley School in Pennsylvania held a spring fundraising auction this year.

Which included this item:


"Is that why they call them blue movies?"
Thank you, W!

Monday, May 4, 2015

Skool Nerse Time

This is Mrs. Grumpy.

Today, as I was leaving for the day, I was accosted in the parking lot by a wild-eyed mom.


Wild- Eyed Mom: "DO YOU WORK HERE?!!!"

Mrs. Grumpy: "Um, yes..."

Wild-Eyed Mom: "YOU'VE GOT TO HELP ME! MY SON IS MISSING! PLEASE!"

I text the twins I'll be a few minutes late. I take her to my office, turn the computer back on to get records (which takes effing forever, thanks Windows), and dial up a security guard to come help.

Mrs. Grumpy: "Okay, what's his name?"

Wild-Eyed Mom (hysterical, but trying to calm down) "Claude Rains."

Mrs. Grumpy: "All right, let me see if any reports are in... When did you last hear from him?"

Wild-Eyed Mom: "When he got home from school."

Mrs. Grumpy: "Wait... So he's already been home?"

Wild-Eyed Mom: "Yes. He got home from school, and was watching TV, and I went to go shower. When I came out he was gone!"

Mrs. Grumpy: "Okay, so you came back to the school even though you knew he'd gotten home safely from there?"

Wild-Eyed Mom: "Yes! Isn't this what you people do?"

Before I could answer the computer stopped searching.

Mrs. Grumpy: "You said Claude Rains? We don't have a Claude Rains in the database."

Wild-Eyed Mom: "Oh... He just texted me. He's back home now. He went to help a friend who had a flat bike tire. What did you say?"

Mrs. Grumpy: "He's not in our database."

Wild-Eyed Mom: "Well, he doesn't go to this school."

Mrs. Grumpy: "Then why..."

Wild-Eyed Mom: "He goes to Daniel Simpson Day Middle School."

Mrs. Grumpy: "That's not even in this district... Why did you come here? Do you live nearby?"

Wild-Eyed: "No, I figured you guys had better computers and stuff that could find him."

Mrs. Grumpy: "We..."

Wild-Eyed: "Obviously, I was wrong. I wish you'd have just told me that in the first place."

She left.

Monday, April 27, 2015

The Out-of-Towners

Due to family visiting this next week, I'll be taking time off from the blog. See you next week!

IG
 
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