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!

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 Kapitanleütnant 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.

Kapitanleütnant 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.

Reportable case

Seen in another doctor's note:

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!

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.

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

Zzzzzzzzzzzzzz

Dr. Grumpy: "Let's check the list... Lipitor, Atenolol, daily Aspirin... Are you still taking Ambien to help you sleep?"

Mr. Nicklaus: "No, I stopped it a while ago."

Dr. Grumpy: "What do you do for your insomnia now?"

Mr. Nicklaus: "I turn on the golf channel. Works better."

Dinner theater

This was left on the office voicemail yesterday:

Him: "No one is answering."

Her: "I heard. It says they're helping someone else."

Him: "Should I leave a message? Or call back later?"

Her: "Just call back later. Did you find that recipe?"

Him: "Yes, I emailed the link to you."

Her: "That one sucked. You can't make lemon chicken like that!"

Him: "How do you know? Have you ever tried?"

Her: "No, but anyone with half a brain can see it was crappy recipe. You'd need more chicken than that."

Him: "It made perfect sense. I went to cooking school, you didn't. Trust me."

Her: "Really? Have you ever used it? All that tuition, and I don't think you've set foot in the kitchen except to make chips-in-a-bowl with a side of beer."

Him: "Oh, like you're capable of anything more complex than eggs."

Her: "At least I know what a good lemon chicken recipe looks like. You don't."

Him: "Okay, what?"

Her: "It should have, um, chicken, and, uh, lemon."

Him: "It had both."

Her: "It didn't have enough chicken."

Him: "Fine. Why don't we just do take-out?"

Her: "Whatever. Why don't you call the neurologist back and see if you can get through now?"

(click)

Knowledge

 

Recently a patient brought his daughter, a 4th year medical student, to the appointment with him. She nervously asked me about making her imminent, and bizarre, leap from medical student to doctor. She felt like someone was going to tell her she wasn't really qualified to be a doctor, that her whole 4 years of med school were some sort of trick, and that she was really a fraud.

And... I agree. Not that she's a fraud, but that it's how I think most of us feel at that point. Actually, it's how ALL of us feel. It's just that some won't admit it. I will.

Attention medical students and residents: THIS IS NORMAL. You just don't realize it until you're actually going through it.

As a 3rd year medical student this terrified me. I was seeing REAL (OMG! REAL!) PATIENTS and had no idea what I was doing. The attendings would point out the substantial gaps in my knowledge and I'd feel like there was absolutely no way in hell I'd ever know that much.

Toward the end of my 3rd year was a rotation with Dr. Griffith, an absolutely brilliant internist. He was a nice guy, but always made me feel like I knew little, simply because he had all the answers I didn't. Seated next to him at an end-of-year lunch, someone pointed out to him that he'd now been an attending for 6 years (yeah, in retrospect, he's not that much older than me). I quietly asked him "and do you still feel like you don't know anything?" He laughed and said "I don't know anything."

And, folks, it never goes away. I've now been an attending physician for over 15 years, much longer than Dr. Griffith was at that time. And I still feel like I don't know anything.

I think the issue is that inwardly we're still the same people who went to college, made it through medical school, survived residency... but we're still ourselves. Somehow we expect that, by being given the title of "Doctor" we're suddenly endowed with a sort of medical omniscience... and it doesn't happen. I don't feel any smarter today than I did when I stepped out of grade school, or high school, or college. Even though I KNOW that through learning and training I've amassed a decent amount of medical knowledge, it's not something that any of us is consciously aware of.

In my experience, the only way any of us realize how far we've come is when we compare ourselves to someone at a previous stage in our training. When I have the occasional medical student or resident spend a few days with me, I'm amazed at how much more I know about neurology than they do, even though I don't feel any different than I did at their stage. It's only in comparison to those behind us that we realize how far we've come.

And, if they ask me if I ever feel like I don't know anything, I tell them "always."

Good luck, Haley!

I'm a magnet

I stopped at the bank to deposit some checks. They know me, and so the teller and I are chatting a bit. While we're talking an elderly woman steps up to the other teller.


Teller: "Hi, Mabel. How are you doing?"

Mabel: "I need to know if my debit card was activated. It doesn't seem to be working."

Teller: "Let me see it..." (Mabel hands her a card) "Mabel, this is a library card."

Mabel: "It is?" (opens wallet) "What about this?"

Teller: "That's your driver's license."

Mabel: "Well, it's still not working at the ATM."

Teller: "It's not supposed to. Let me check your account."

Mabel: "Can you see if I have any overdue books?"

Beware of the Dragon

Seen in a hospital chart:

For my non-medical readers: it was supposed to say "hemorrhage." The joys of Dragon software.

FRANK!!!!!!!!!!!!!

"I didn't do it Dad." (snicker) "Really!"

1:58 a.m.

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

Mrs. Call: "My husband is having a seizure. He sees Dr. Nerve for epilepsy."

Dr. Grumpy: "Okay, do you have a medication to give him for seizures?"

Mrs. Call: "It's in the bathroom. Can't I just hold the phone next to him and you tell him to stop?"

Scum

One of my patients is dying from a brain tumor. He has severe pain from a number of related and unrelated issues, and since I'm the doctor he sees the most I've ended up prescribing his narcotics.

Recently, though, his pain has been worsening, and nothing I've given him is touching it. I've tried increasing pill strength and changing narcotics, to no avail.

Because of his severe pain, I finally admitted him directly to the hospital, to try and get things under control with injectable narcs while I decided on the next step. As always, I told his wife to bring in his pill bottles for me to review.

Sitting in the room with them yesterday, I began making my usual notes on what pills, how many were left in each bottle, etc., to make sure he was taking them correctly. As I opened one narcotic bottle after another I found that, in spite of different labels, they all contained the same white tablets with the same number stamped on them.

So I took out my phone to look up the number.

All the bottles were full of generic Tylenol. No wonder nothing touched his pain.

Further investigation revealed his daughter, who was the one picking them up, was selling the pills and replacing them with Tylenol before taking them to her elderly parents.

I hope you rot in hell.