Confessions

You ever killed someone?

I have.

Of course, "kill" is too strong a word for what most doctors have done at some point, but still, he died because of my direct actions (a nurse and respiratory tech were involved, too).

He was a retired farmer, around 80. Strong and healthy for his age. I was in my early 30's, just out of residency and starting life as a newly-minted attending physician.

He'd fallen from a ladder and severed his upper cervical spinal cord. He was awake and alert, but completely paralyzed from the neck down. He couldn't breathe on his own, so was facing the rest of his life on a ventilator, requiring complete care for everything. There was no hope for recovery.

In the first days of the injury the trauma and neurosurgery people worked their magic, stabilizing what was left of his neck, converting him quickly from a ventilator tube to a tracheostomy for comfort, getting a feeding tube in.

As the days went by and we began decreasing his medications it became clear that he would live, was mentally intact, and could communicate with us.

In spite of what his family had told us, he wanted to be let go. He'd led a robust life and didn't want to spend the rest of it in this condition. He was ready to have things turned off so he could pass.

This sort of thing is (comparatively) easy in someone with advanced dementia, or severe brain trauma, or end-stage cancer. But in a guy who was fully awake and who'd been healthy and vigorous a few days earlier it was a whole different matter.

The family was unhappy, but acquiesced to him. To cover myself I had a psychiatrist interview him and ordered a consult from the hospital ethics committee. All agreed that he was pleasant, had a good sense of humor, and was fully capable of making this decision.

The family didn't want to be in the room when it happened, so we gave them all the time they needed to say goodbye.

When the time came we chatted briefly, and he thanked me and the team who'd taken care of him. He even asked that we shake his hand.

I had the nurse give him megadoses of morphine and Ativan, to put him to sleep and take away any pain that might still be there. Once he was out the respiratory tech disconnected him from the ventilator. Between the medications and his non-functioning diaphragm he went pretty quickly. I wrote a death note and moved on to another case. There are always more consults.

What would you call it? An execution? Physician-assisted suicide? Compassion? I'm sure some out there would love to have me tried for murder, but I don't care.

To me, my responsibility is to the patient. This man had lived a good life, wasn't suicidal in the sense of someone who's depressed, and made a rational decision about his own existence. I did everything I could to make sure there wasn't a good reason NOT to end his life, and did what I could to respect his wishes and relieve his suffering.

That was the first, though not last, time I've had to face this situation. We may become more experienced, but it never gets easier.

It's been 20 years, and I'd still say the same thing: In the end it wasn't my decision, it was his. I just did what was right for the patient.

Neurology humor

Two neurologists were walking along the street when they saw an old-timer veteran cop walking a beat with his legs wide apart. He was stiff-legged and walking slowly. One doctor said to his friend: "I'm sure that poor old cop has Peltry Syndrome. Those people walk just like that."

The other neurologist says: "No, I don't think so. The old cop surely has Boyd Syndrome. He walks slowly and his legs are apart, just as we learned in training."

Since they couldn't agree they decided to ask the cop. They approached him and one said, "We're neurologists and couldn't help but notice the way you walk, though we couldn't agree on the syndrome you might have. Could you tell us what it is?"

The old-timer said, "I'll tell you, but first you tell me what you two fine upstanding neurologists think." The first doctor said, "I think it's Peltry Syndrome." The old-timer said, "You thought - but you are wrong." The other neurologist said, "I think you have Boyd Syndrome." The old cop said, "You thought - but you are wrong."

So they asked him, "Well, old timer, what do you have?"

The old-timer cop said, "I thought it was just a fart- but I was wrong, too!"

- Thank you, Officer Cynical!

Friday morning, 12: 38 a.m.

This message, left on the on-call emergency voicemail, woke me up:


"Dr. Grumpy, you can cancel all my appointments. I'm very hurt. This is the 2nd year that your lousy practice hasn't sent me a birthday card, like my dentist does. I think you're an asshole. Goodbye!"

No kidding

Dr. Grumpy: "Are you allergic to any medications?"

Mrs. Ambu: "Succinylcholine"

Dr. Grumpy: "What happened when they gave you succinylcholine?"

Mrs. Ambu: "I stopped breathing."

Snow

Mary: "Dr. Grumpy's office, this is Mary."

Mr. Flurry: "Hi, I have an appointment later this morning, but am trapped at home by all the snow."

Mary: "I understand, we can certainly reschedule it for later this week, or next. What times of day work best for you?"

Mr. Flurry: "No, I'd really like to make this appointment. Isn't there some special doctor's line you can call or something, where they direct snow plows to my house and clear a route so I can get to the appointment?"

Mary: "No sir, there is no such phone number."

Mr. Flurry: "That's ridiculous. He's a doctor. Doesn't he know the governor, or mayor, or someone who can do that?"

Mary: "No."

Mr. Flurry: "This is stupid. I thought he was a good doctor, but obviously my appointments there have been a waste of time."

Grammar

Seen in a veterinary orthopedic course brochure:

 

Thank you, Webhill!

Bagels

I recently was at a hospital staff meeting where one of the administrative clowns got up to speak. He was trying to show us how grateful the hospital is to have all of us, and mentioned that the food in the doctor's lounge costs the hospital $350,000 a year, so we should be thankful.

I know this sort of thing varies between hospitals, but here's what mine supplies to doctors for that $350K:


Morning: bagels and donuts. Boxes of cereal and instant oatmeal. Granola bars. Little milk cartons in the fridge.

Lunch: Tray of deli meats and cheeses in the fridge. Irritatingly small cans of soda. A tray of cookies.

Dinner: Not supplied. Whatever is left over from breakfast and lunch.

Always available: coffee, tea, sliced bread, English muffins, little packets of peanut butter, jelly, butter, and honey.


So, I guess that's what $350,000 a year gets you. I'm sure you also have to figure in there the salary of the person who restocks & cleans it each day, frequent repairs to the heavily-used coffee machine, and a few other items. Plus, they probably fudge in how much money they're losing by not giving us the finger and turning the lounge into another endoscopy suite.


That's not a huge sum of money in the modern healthcare world, but since hearing that figure, I keep wondering how it might be better spent. Maybe a few more nurses in the rotation. Or respiratory techs. Or physical therapists.

I'm sure some doctors would whine, but realistically I think most would be happy with coffee and a bagel in the morning, since that's when most round, and the hospitalists buy their own stuff for lunch anyway.

There are certainly bigger wastes of money in modern healthcare: CEO bonuses (at my hospital his was around $7 million last year) and paying Press-Gainey to do surveys, to name two of them. And the people involved in those things don't care about patients, anyway (regardless of what their PR staff tell you).

But I do care about patients, and would be more than happy to give up a deli tray, cookies, or even a bagel, to improve their care.

That's provided the money actually went to that use. Realistically, it would probably just go to some administrator's year-end bonus for the money he saved by cutting coffee and bagels out of the doctors lounge.

Survey says

Dr. Grumpy: "So, I last saw you a week ago, when you were in the hospital for Transient Global Amnesia. How have you been doing?"

Mr. Percheron: "Fine, I guess, everything seems back to normal. I've returned to work."

Mrs. Percheron: "He's back to himself."

Dr. Grumpy: "Good."

Mr. Percheron: "I have a question, though."

Dr. Grumpy: "Go ahead."

Mr. Percheron: "What am I supposed to do with the survey the hospital sent me? It has all these questions about my stay, but I don't remember any of it."

Overheard on rounds

Nurse: "Have you had any previous heart issues?"

Patient: "I have a porcelain heart valve."

Nurse: "You mean porcine heart valve?"

Patient: "Whatever."

And now, music

Seen in a chart

This isn't the first time I've put up stuff like this, and it won't be the last.

But you know what? Crap like this is no longer the exception. It's the rule. I'd say at least 50%-60% of charts I read from hospitals and practices that use computer charting systems (which is pretty much all of them) have errors of this kind.

And these are what the world is pushing us to use more and more of.

I'm not saying computer chart systems are bad things. They have a lot of advantages. But they also encourage the slacker inherent in all of us. It's easier and faster to check boxes, cut & paste, and use templates than it is to actually type out what's correct. Especially if you skip the critical step of proofreading what you've just done. Most do.

The majority of these errors are just amusing. This one is just stupid, but likely won't cause a serious patient outcome.

But if it can make an error about smoking, it can also make them about your allergies. Your current medications. What conditions you have. Your past surgeries.

And one "minor" error in any of those could lead to a disaster in the right setting.

Cole slaw

I'm in the emergency room, talking to a patient's wife:



Dr. Grumpy: "When did this all start?"

Mrs. Concern: "Last night. He fell down in the bathroom, and said he couldn't move that side."

Dr. Grumpy: "Then what happened?"

Mrs. Concern: "I figured he was just angry at me, and trying to get attention. We'd had this big argument over cole slaw at lunch, because..."

Dr. Grumpy: "Okay, but last night..."

Mrs. Concern: "Oh yeah, anyway, so I watched some TV in bed - there's that new detective show I like - until I fell asleep. When I woke up this morning he was still on the bathroom floor, and boy, was he angry. So that was when I called paramedics."

New year's day

10 years

This post wraps up 2018. I'll be taking 3 weeks off, and will see you guys in January.


December 21, 2008, was, apparently, a slow news day. In looking backwards I really can't find any articles of note from the major news outlets on that date's happenings.

But to me it was a big day as I published my first post here.

A lot of factors had led up to it. For years I'd been collecting stories hoping to write a book... someday. But life, work, and kids get in the way of those things. At some point I realized the book was never going to happen.

Then, in 2008, a change in my practice led to me having a bit more free time. So, instead of a book, I decided to share my stories on this blog.

And here I am, 10 years out. My numbers have gone up and down, but I still seem to have a following. For that I'm grateful. If it wasn't for you guys there wouldn't be a reason to do this. My posts have dropped from twice daily to 2-3/week, but I'm still cranking them out and hopefully will continue to do so.

I appreciate those of you who have stayed with me and written comments. I've only been mentioned once in the general media, but knowing you guys are reading makes it worthwhile to keep doing this.

At 10 years out I want to thank my wife, for putting up with me, and my kids, who've grown from small rug rats to young adults heading for college since I started this.

I also want to thank Mary and Annie, also for putting up with me and supplying me with stories to share. Without you guys I wouldn't have a real job.

My patients deserve a big round of applause. Without them I wouldn't have this blog. Most of them are good folks, and I genuinely appreciate them making my job a fulfilling one. Medical blogs may give you the impression that most patients are insane, or stupid, or both, but that's far from true. The vast majority are good people, but stories of normal patient encounters are boring and aren't why you come here.

Lastly, I want to thank all of you guys for sticking with me over time, sharing your thoughts, and making this fun.

A special thank you is deserved by those I've met through the blog and who I'm now proud to call friends. We may never meet in person, but knowing you're out there is good enough for me.

Thank you all, have a great holiday, and I'll be back on January 14, 2019.

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