Monday, September 14, 2015

Hungry? Bow bow bow...



At Local Hospital, about 30 minutes before mealtime, someone from "Dietary Services" (previously known as the cafeteria) walks into a patient's room to take their order, entering it on an iPad.

Obviously, the staff hired to do this are not medical people. They're usually teenagers. Some are doing it as a job, others to get some background in hospitals for a college application, some are even volunteers doing it because their school requires community service.

Generally they're a fairly upbeat, happy, bunch. It probably beats flipping burgers and asking "do you want fries with that?" Hell, some days I wish I had that kind of enthusiasm for my job.

Anyway.

I was on call this past weekend, and yesterday morning saw a sweet old lady, who'd suffered a stroke the night before. Her language function was limited to saying "yes."

After examining her I sat down at the station to review her tests and dictate a note. The nurse came over and we talked about my orders.

As we chatted, one of the perky cafeteria staff went into the room and began her spiel.

Miss Chipper: "Hi, Mrs. Broca. I'm from dietary services. Would you like scrambled eggs for breakfast?"

Mrs. Broca: "Yes."

Miss Chipper: "We also have vegetable omelets today. You want one of those, too?"

Mrs. Broca: "Yes."

Miss Chipper: "Pancakes?"

Mrs. Broca: "Yes."

Miss Chipper: "My, you're hungry today!"

Mrs. Broca: "Yes."

Miss Chipper: "We have plain, chocolate chip, and blueberry pancakes. Any of those sound good?"

Mrs. Broca: "Yes."

Miss Chipper: "How about I bring you one of each?"

Mrs. Broca: "Yes."


The nurse and I were hysterical, leaning against the wall and each other, trying not to start cackling aloud. She bit her tongue. 


Miss Chipper: "We have turkey bacon and sausage."

Mrs. Broca: "Yes."

Miss Chipper: "I'll get you a little of each. Would you like coffee?"

Mrs. Broca: "Yes."


The nurse and I are envisioning this immense Las-Vegas-buffet sized cart being pushed up to the room.


Miss Chipper: "Now, for juice, we have apple, tomato, orange, and prune."

Mrs. Broca: "Yes."

Miss Chipper: "You like them all? Is one of each okay?"

Mrs. Broca: "Yes."

Miss Chipper: "Do you want sugar and creamer in your coffee?"


The nurse couldn't take it anymore. With tears running down her face from laughing, she called Miss Chipper out and explained the situation to her.

It was a while before I was able to dictate a note.

Thursday, September 10, 2015

Thank you

He's also a doctor. Retired, but still relatively young.

He came to me for back pain, which sounded like fairly benign stuff. But when he worsened dramatically after 2 sessions of physical therapy, it was time to look further.

Unfortunately, the MRI showed a malignant tumor, leading to a bigger work-up. It was quickly obvious that he had widespread metastatic disease.

We put him in the hospital, and he went through chemotherapy, radiation, and back surgery. Fortunately his disease responded to treatment and he got better. His back pain improved and his leg strength returned. My job was done, now it was up to the oncologist. I signed off his case, wished him good luck, and told him to call me if any new neurological issues came up.

Time went by. His oncologist kept sending me copies of her notes, so I peripherally kept up to date. I'd scan them to see how he was doing, make sure there weren't any neurological issues I needed to deal with, and put them in his chart.

This went on for 2 years, when his notes showed he'd taken a turn for the worse. He had more difficulty breathing, and they found the cancer was back. Further chemotherapy and radiation weren't as effective, and he kept going downhill. I watched, sadly, as his weight and health declined in the increasingly frequent notes from the oncologist.

Then, yesterday, toward the end of the day, Mary handed me a piece of paper. He'd called, looking to speak to me, and asked that I call him at home. He said it wasn't urgent, so I stuffed it in my pocket and wrapped up the day. There were kids to pick up, homework to supervise, tomatoes to buy.

After dinner, when the evening had settled down into the usual quiet chaos, I went to my desk, brought his chart up on my laptop, and called.

Dr. Grumpy: "Hi, it's Ibee Grumpy. You were looking for me?"

Dr. Good: "Hey, thank you for calling me back. Haven't talked to you for a while. Have you been following my notes from Dr. Onco?"

Dr. Grumpy: "Yes."

Dr. Good: "Good, so you know what's going on. She's a damn good doctor, glad you sent me to her."

Dr. Grumpy: "Yes, how are you..."

Dr. Good: "Look, Ibee, I'll get to the point here. I've had enough of this shit, and it's time. I've decided to stop treatment, and signed up with hospice today."

Dr. Grumpy: "I'm sorry..."

Dr. Good: "Let me finish. Anyway, I know I haven't needed you since this all started, but I just wanted to call and say thank you for everything. I know you and everyone else did your best, and by catching it when you did you guys bought me an extra 2 years I wouldn't have had. You're a good doc, and I know you care. I think of all the patients that I saw, and I hope they feel the same way about me."

Dr. Grumpy: "Thank you, I..."

Dr. Good: "That's all. Thank you for everything, and good luck. Maybe we'll meet again out there."

He hung up.

He called to say "thank you."

I stared at the phone for a long time.

Wednesday, September 9, 2015

Texts you don't want from your teenage daughter

Earlier this summer, a pregnant rabbit decided to raise her young in our backyard.

This was a really terrible idea, as Mello is, by nature, a hunting dog. So when she discovered them... it wasn't pretty.

Most managed to get out under the gate, but during a Crime Scene Investigation (CSI: The Oleanders) Marie discovered an injured one hiding under a bush.

She took it to her room, named it Phil, googled a few things, and set up a bunny infirmary. This went well for 2 days, but on the third morning, when I asked her how Phil was doing, I got this back:




Tuesday, September 8, 2015

Casual Friday

With it being a holiday weekend and the de facto end of summer... me, Pissy, and our staffs decided to all wear Hawaiian shirts last Friday.





Mr. Collar: "I can't believe you're wearing that shirt."

Dr. Grumpy: "I know, but it's Friday, and I have the long weekend off, so I thought I'd wear something relaxed."

Mr. Collar: "That's not the kind of agenda I think a doctor should be pushing."

Dr. Grumpy: "Um, that I wore a Hawaiian shirt on casual Friday?"

Mr. Collar: "No! That you're promoting marijuana use!"

Dr. Grumpy: "Huh?"

Mr. Collar: "On your shirt! You think I don't know what those are?"

Dr. Grumpy: "Um, they're palm trees."

Mr. Collar: "Do I look stupid to you?"

Monday, September 7, 2015

It's a holiday, here's a video







Thank you, Tab!

Friday, September 4, 2015

Rimshot

Mrs. Osteo: "I take a daily calcium supplement."

Dr. Grumpy: "Do you take vitamin D, too?"

Mrs. Osteo: "No, it's vitamin D3."


Say it aloud if it doesn't make sense.

Thursday, September 3, 2015

Skool nerse memories

This is Mrs. Grumpy.

Many years ago Local Hospital built a new wing, which had quite a few delays (the main one being that about 1/3 of the way through they discovered they'd forgotten to budget money to build it, and didn't have any).

Anyway, the day they opened the new building was, coincidentally, the day I'd scheduled my hysterectomy. So I was in the first batch of post-op patients that were put in rooms in the wing. They were bigger and more modern than the old building, so seemed like a nice idea.

After I settled in I turned on the TV in my room... it didn't work, but the nurse came down to answer my call light. Which I hadn't pushed. It's just as well, though, because she had to go into the room next door because the TV in there had just switched on even though the occupant hadn't touched it.

When I turned on the sink both it and my shower came on.

They eventually got my TV working, and I sat back to watch something. About 15 minutes later the fire sprinkler in the room randomly switched on, dousing me and shorting out the TV. Which gave off a huge cloud of smoke and triggered the fire alarm.

As they rolled me and several other post-op patients back to the old wing, the nurses were talking about how they'd installed computers for them, but no monitors.

Awesome planning all around.

Wednesday, September 2, 2015

Mary's desk

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

Mr. Robichaux: "Hello. I need to make an appointment with Dr. Grumpy."

Mary: "Sure. We have an opening for 8:00 tomorrow morning... What's your insurance?"

Mr. Robichaux: "U.S. Veterans, Inc."

Mary: "Oh, I'm sorry. We're not contracted with USV."

Mr. Robichaux: "What the hell? You guys have something against veterans?"

Mary: "No, not at all. We've just never been contracted with USV, as long as I've been here. There are several insurances we don't take."

Mr. Robichaux: "I risked my life so people like you could have freedom, and this is how you treat me?"

Mary: "I respect that you did that, sir. Let me give you the names of neurologists who do take USV... Down the street there's Dr. Techie, and her number is..."

Mr. Robichaux: "Fucking communists."

He hung up.

Tuesday, September 1, 2015

Nice try

I'm at the nursing station, writing a note. A nurse comes over.


Nurse: "Hi, Dr. Grumpy. A family member for room 8 is on the line and wants to talk to you."

Dr. Grumpy: "Okay" (picks up phone) "This is Dr. Grumpy."

Mr. Little: "Hi, you were just in to see my brother, in room 8? How's he doing?"

Dr. Grumpy: "Seems to be getting better, I think he'll do well with time and physical therapy."

Mr. Little: "Is there anything I should know that you haven't told him?"

Dr. Grumpy: "No, I've gone over things pretty thoroughly."

Mr. Little: "There must be some secrets you're keeping from him that we need to be aware of."

Dr. Grumpy: "No there aren't."

Mr. Little: "I think..." (coughs)


Oddly, the patient in room 8 is heard coughing at the same time.


Dr. Grumpy: "Who is this again?"

Mr. Little: "I'm Dave, the brother of the guy in room 8."

Dr. Grumpy: "Okay, I..."


Guy on phone and patient in room 8 both have another coughing spell.


Dr. Grumpy: (sighs) "Mr. Little, I'm not hiding anything from you."

Mr. Little: "I told you! I'm not Mr. Little! I'm my brother!"


Monday, August 31, 2015

P4P

For those of you not in the field, quality medical notes in the U.S. have been replaced by bullshit "Quality Metrics."

Instead of an intelligent statement on the patient's condition, you have to make sure that your note includes specifically worded stuff - which usually has absolutely nothing to do with what's going on.

The idea is that if you don't say these required phrases then you must not care, and (also importantly), may not got paid by insurance. So docs have to put crap like this in their notes.

Anyway.

Last Friday I received a consult on an 89 year old guy who suffered a cardiac arrest at home on Monday. He'd since been on a ventilator, and clearly wasn't waking up. So neurology was needed to decide if he'd recover (yeah, I know, but that's a whole 'nother post).

Leafing through the chart, I saw this note, written on Thursday night by an internist:


Sigh.

Thursday, August 27, 2015

Sharper than a serpent's tooth

Compassion.

Once upon a time, I had a lot of it. I guess I still do, or I wouldn't be at this desk.

I think most medical students start out that way. We want to help the sick, heal the wounded, decrease suffering. All that stuff we once wrote in the "personal statement" section of the universal med school application. And believed.

A friend of mine, an OB/GYN, and I were chatting about how this job can suck the compassion out of you. There are some people you just can't help. She recently had to do emergency surgery on a 15 year-old girl for an ectopic pregnancy. The girl had had upwards of 20 sexual partners already, and was, of course, angry at the doctor for having emergently done something that might prevent her from having kids, even if the goal was to save her life.

We all have stories like that, little knives that cut away part of our compassion. They add up over time. And, for most of us, we remember when it started.

Mine began over 25 years ago. I was a 3rd year med student, working at the school's clinic. That day the resident and I were doing a routine pregnancy visit on a 19 year old who already had 3 children. Her other kids were there, undisciplined and destroying the exam room as we tried to work. None had the same father. Of course, they were on welfare and food stamps, and the unemployed mother had brought paperwork to get her amounts increased.

It hits you hard that first time, when you realize where some of your tax dollars are going, and that I was supporting her. Walking home that night, at the end of 17 hours at the hospital, I realized that, if her welfare money were cut off and she and her kids died of starvation and exposure in the street... I probably wouldn't lose any sleep over it. None. Zip. Nada.

Terrible thing to feel that way, huh? It's not like the kids had asked to be in this situation. And then I was angry at myself for even having such an awful thought. But I've never forgotten that moment, when I first realized that, at some point, even my concern for others ran out.

That was the first, and they add up over time. The patient who's in for yet another drug overdose,  knowing that, after me and the ICU team patches them together, they'll go out and do it again. Often they're on welfare, but even if they're not, the bottom line is that we're all paying for them one way or another, either through our taxes or insurance premiums.

The epilepsy patient who doesn't take her meds, and several times a year I have to go in at 2:00 a.m. to pull her out of the fire. She might be pregnant, too, and the repeated effects of uncontrolled seizures will damage the next generation.

The anxious guy who thinks he's dying of something, who you agree to "squeeze in" and give up your 15 minute lunch break for... and then never shows up. He calls later to say he'd forgotten, or been busy, or had to wash his hair,  then screams and threatens legal action when Mary refuses to work him in the next day.

The obviously bogus disability claim, who wants lifetime payments for exaggerated or fraudulent problems, and is bringing you the paperwork demanding it be filled out in his favor.

The guy you went the whole 9 yards for, filling out forms and writing appeals, to get his $800 per month medication covered. Then sends you a nasty hate-filled letter because your staff charged him the $15 co-pay his insurance requires you to.

The lady whose neurological issues you finally get controlled after 2 years of frequent appointments, medication changes, pharmacy coverage appeals, and late night emergency phone calls... who ends up in ER after stopping treatment because she took some TV charlatan's advice over yours.

Don't go thinking all patients are like this. Most aren't. They're decent people who want your help, and are grateful for it. The problem is that the one crappy person in a day of 10 good ones can dwarf the nice people to nothingness and make you forget about them.

It becomes a political issue. The conservatives would have you believe that all people on welfare are like this, and deserve to starve and die. The liberals claim that as a society we have to support all our members, regardless of cost or lifestyle decisions. The real truth varies from case-to-case, and is always somewhere in between. There are plenty of other sites where you can argue those points, and this ain't one of them. So I'll leave that there. You want to post a political tirade about this? Go troll elsewhere. That not the point of this post. This is:

What does it do to your doctors? And nurses? And all the others in healthcare who have to deal with these cases?

It sucks the compassion out of you. You came here believing that somewhere, somehow, you'd be able to help people. To make a difference in the lives of others. To care.

And, for the most part, we do. But the thing that slaps you hardest is learning that you can't help everyone. There are always going to be the ones who don't want to be helped, or don't believe you can help them, or are only there to game the system. A million reasons with the same end result. You watch your best efforts, midnight runs to the hospital, your own health, family time, and sanity, and a fuck-ton of your own and everyone elses money, all go down the drain because the person you're trying to help doesn't care.

And, every time this happens, a little piece of you dies. You never stop caring, but it gets harder and harder to do so. Some of your compassion and fire goes away. Occasionally you meet a medical student with the fire you once had, and wonder what happened to it. They probably look at you and wonder the same.

This is where it goes. Cut out of you in little pieces by years of working hard to help people who don't want your help. Or who take advantage of your concern for their own greed.

At the end of some shitty days I think back to the 19 year old with 3 and 1/2 kids many years ago, and how I felt after leaving that day. Sometimes I hate her for being the first cut. Sometimes I hate myself for feeling the utter contempt for her that I did. And most days I'm just too tired to think about it at all.

But when the alarm goes off in the morning, or my iPhone rings at 2:00 a.m., I still go back and do it, and give it my best shot, all over again. Just like a million other doctors and nurses around the world every day. Because, win or lose, that's why we're here.

Wednesday, August 26, 2015

Face palm

Dr. Grumpy: "How are the hands doing?"

Mr. Carpal: "Since wearing the brace my right hand is much better, but the left hand isn't. Is this the correct kind of brace?"

Dr. Grumpy: "Yeah, I'm surprised the left isn't any better. Did you get the same kind of brace for that side?"

Mr. Carpal: "I only got one for the right side."

Dr. Grumpy: "So... You haven't been wearing one on the left side at all?"

Mr. Carpal: "I figured wearing only 1 brace was supposed to help both hands."

Dr. Grumpy: "No... you need it on both wrists."

Mr. Carpal: "I tried, but both hands didn't fit in it together."

Monday, August 24, 2015

Rimshot

Dr. Grumpy: "How are you doing with the new medication?"

Mrs. Patient: "It's terrible! Ever since I started it, I haven't been able to have an orgasm!"

Dr. Grumpy: "Okay, let's stop it and see how you do before trying something else."

Mrs. Patient: "Do I have to back down slowly?"

Dr. Grumpy: "No, it's easy to get off."

Mrs. Patient: "Not when you're taking this medication!"

Friday, August 21, 2015

Allergies

Paramedic: "Are you allergic to any medications?"

Mr. Emesis: "Yes. Ipecac makes me vomit."


Thank you, Firefighter Tom!
 
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