Friday whatever

Dr. Grumpy: "Are you right or left handed?"

Mr. Vocab: "I can write with either, I'm bisexual."

Dr. Grumpy: "Um, you mean ambidextrous?"

Mr. Vocab: "Yeah, whatever it's called."

Memories...

Dr. Bond was an attending physician where I trained, known for insanely long wait times (like 3 hours or more). Although I never really understood why (and still don't) he had a loyal following of patients who put up with it and came armed with books, magazine, and coolers.

They'd wait in the lobby, then get taken back to an exam room where they'd wait a few more hours... and at some point he'd see them.

Until one night.

I was the neurology resident on call, and around 11:00 that night was paged by the head of the hospital's janitorial services.

Apparently, Dr. Bond's 4:45 patient had been put in a room... and forgotten. The staff left around 6:00, and the patient, used to Dr. Bond's usual waiting times, just stayed in there. Eventually he fell asleep (the badly-rattled cleaning lady actually thought she'd found a body).

So I walked across the street to the clinic (not exactly a great idea in that area) and briefly met with the patient. After determining that he wasn't dead (he'd just left his hearing aids at home) I called Dr. Bond to ask him what to do.

To his credit, he drove in to see the patient for the regular appointment that had been scheduled for that afternoon.

Maybe

Dr. Grumpy: "Any other questions?"

Mr. Rem: "Do you think I'm so tired because of all the Oxycontin I'm on?"

Dr. Grumpy: "That could do it... Um, I don't have you listed as taking Oxycontin."

Mr. Rem: "That's because I didn't tell you. I'm on 80mg three times a day."

Dr. Grumpy: "Um, yes, that could make you tired. Why didn't you tell me that?"

Mr. Rem: "I didn't think it was relevant."

"I'll be damned if I'm buying the next round."

Seen in a chart:

Memorial Day

Howard Gilmore was born in Alabama, and joined the navy when he turned 18. For an enlisted man to become an officer was a rarity at the time, but after 2 years he was appointed to Annapolis following competitive examinations.

He was, as a fellow officer described him, "one of the finest men I ever knew, but he was born under an unlucky star." While ashore in Panama during the shakedown cruise of the submarine U.S.S. Shark, he was attacked by local thugs and had his throat cut. He survived, but was left with a bad scar.

A few years later his first wife died, at a young age, from a disabling disease.

The day after the Pearl Harbor attack he was assigned to command the U.S.S. Growler, a submarine that was nearing completion. He supervised her during commissioning, and then took her through the Panama canal to fight in the Pacific.

Through 4 patrols, he led his crew on a series of successes. In July, 1942 Growler single-handedly attacked 3 Japanese destroyers, sinking one and badly damaging the other two. He was awarded the Navy Cross for this action. On a second patrol later that year he sank 4 Japanese merchant ships.

Shortly after Growler left on her 4th patrol, his 2nd wife fell down a flight of stairs and was in a coma for several months. Because his sub had already left, this information wasn't relayed on.

In early February, 1943, Growler was hunting off the Solomon islands, sinking one freighter and damaging another. Just after 1:00 a.m., in the early morning of February 7, 1943, she was stalking a Japanese convoy and preparing for a surface attack. Gilmore and 6 others were out on the bridge, planning strategy, when they were spotted by the enemy.

A convoy escort, Hayasaki, came after them, intending to ram the sub. In the darkness the course change wasn't immediately seen, and the enemy vessel got quite close before being detected. Gilmore ordered a sharp turn... but it was too late.

Growler struck the Hayasaki amidships. The collision bent the submarine's bow sharply to the left and destroyed her forward torpedo tubes. As Gilmore ordered the crew to clear the bridge and get below, they were raked with machine gun fire. Two crewmen were killed, and Gilmore was wounded.

The Japanese vessel, undamaged, raced away and turned around, intending to ram the submarine again and send her to the bottom. Gilmore, wounded and now the only living person on the bridge, couldn't get to the hatch quickly and realized the submarine had to dive immediately if she were to have any hope of surviving. He yelled "Take her down!", repeating the order to make sure he was understood. He knew this would leave him on the surface to drown.

Growler's executive officer, Arnold Schade, hesitated for a few seconds, but realized the situation, too. He followed the commander's last order and submerged to avoid the oncoming ship.

After hiding deep to escape Hayasaki for several hours, Schade brought Growler to the surface. The Japanese ship had left, and the submarine slowly cruised around the area looking for Gilmore while the crew carried out makeshift repairs. Though badly damaged, she was able to make it to Brisbane.

Commander Gilmore was never found. His posthumous Medal of Honor was presented to his widow when she recovered from her injury.

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 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.

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:

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."

Patient quote du jour

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

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

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

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

Seen in a hospital chart:

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!