Wednesday, February 29, 2012

Entitlement rears its ugly head....again...

I try my best to be mindful about costs when dealing with self-pay patients.  Most of them are hard-working and want to pay their bills like responsible citizens.  We do get the occasional absolute deadbeat who thinks that the world owes them everything and makes sure that you understand that.

Antibiotic choice is one of those things that can really make a difference in terms of costs at discharge.  Generic drugs can really save the patient money (and increase compliance), providing they are feasible to use.  However, whenever you get an infection in which we have cultures showing resistance, we have no choice but to choose something that is often very expensive.  Whenever this occurs, I usually get our case managers involved to see if they can get them in an assistance program.  Some people don't even appreciate this, however....

Me:  "Ok, I've got you in an assistance program for the medication.  You should only have to pay about $20 for the whole prescription."

Patient:  "Why can't your pharmacy just give me all the medicine I need to go home with?"

Me:  "Sir, this is a $100 a pill medication.  I'm getting you a $2000 course of antibiotics for $20.  I'd say that's more than fair."

Patient:  "But if I get it from you, it's free."

Me:  "Our pharmacy is not going to give you $2000 in medicine from our own supply."

Patient:  "Why not?  I'm not going to pay for this visit, anyway."

Me:  *sigh*


Tuesday, February 28, 2012

Gangsta Granny....

Me:  "So the GI doctor will be coming by later and explaining the procedure..."

*Tupac's "How do you want it?" starts playing, muffled*

82 year-old (white) female patient, picks up the phone from under her leg.  The music is suddenly unmuffled.  "Love the way you activate your hips and push your ass out..."  Patient looks at readout on phone and presses ignore.  Music stops. 

82 year-old patient:  "That was my grand-daughter calling.  I'll call her back later.  Now what were you saying?"


Monday, February 27, 2012

Overly sensitive...

Me:  "I need to find a place for this patient to stay, she can't stay home by herself anymore."

Nurse:  "Well, she has a daughter that might could take care of her..."

Me:  "No, that daughter is retarded."

Nurse:  "That's not very nice!"

Me:  "No, I mean she is literally retarded.  She has Down's syndrome."

Nurse:  "Oh...never mind then."


Sunday, February 26, 2012

Sunday Vet story...

Once again I have forgotten to post a video before leaving the house and I'm subject to the iron-fisted rule of the hospital YouTube ban.  So instead I'll tell you a story that happened about 3-4 years ago.

Every once in awhile we get to meet people in this profession that have done amazing things.  One of my patients when I was just out of residency was a WWII vet whose first encounter with me is one I'll never forget.  It all started when I mentioned how interesting his cane was that he came in with.  It had what appeared to be an ivory handle on it, but with a beautiful sheen to it.  Hoping that it wasn't elephant or rhino ivory, I asked him what it was made of.  "A baleen whale's tooth," he replied.  He went on to tell me that when he was picked up from Iwo Jima after the battle was over he'd found these on the beach, a total of seven in all.  He'd made canes from all of them and given three of them to his fellow survivors from his unit.  At this point, I stopped him and said, "Wait, you and three others were the only survivors from your unit?"

Patient: "Yes."

Me:  "How many people were there when you started the battle on the island?"

Patient:  "In my company there were over 200, six platoons."

Me: "And only you and three others walked off the island?"

Patient:  "Yes."

While I took a moment to consider myself in a group of 200+ people and watching 98% of them die horrible deaths, he cleared his throat and said, "And the best thing about these canes is..." In one swift motion, he twisted the top of the cane and drew a sword from it!  Before I could even react, he had it about an inch from my right eye, unwavering.  He held it there for a moment before handing it to me, hilt first.  Not only had he designed the cane, he had smithed the sword himself and had a concealed weapons permit for it.  I was, in a word, impressed.  Ask anyone who has worked in a VA hospital in the last 10 years, they will all tell you:  WWII vets are hard to kill.  It will be a sad day when this breed dies out.


Saturday, February 25, 2012

Touched by an angel...

Elderly woman, grasping my hand:  "Oh, your hands are warm...are you an angel?"

Me:  "Yes, but I'm married to the devil."  (sorry, sweetie)


Friday, February 24, 2012

Done with that...

Personally, I can absolutely understand why a 90+ year-old person is ready to die.  When a lot of them choose to do so, I have zero problem with that...they've lived their lives and most of them are ready.  Families, however, are another story.  They often push elderly patients into treatments meant to prolong their lives despite the patient's objections.

Family:  "Mom, you need to get up and work with physical therapy or you'll never be able to walk again."

92 year-old patient:  "No, I think I'm done with that."

Family:  "With physical therapy?"

92 year-old patient:  "No, I think I'm done with walking.  I'm just not going to do it anymore."


Thursday, February 23, 2012

Lies and more lies...

People lie to us, all the time.  It is a phenomenon that is as ridiculous as it is pointless, because the only person you're actually hurting is yourself.  A classic example is how people lie about their sexual behavior.  Odds are, if you have a male age 30 or younger who comes into your office for a "checkup," that is code for "I bagged a skank last weekend and think I caught the clap."  Everyone in the office knows it, the secretary knows it, the nurse knows it, the mail guy knows it.  You're not fooling anyone.  We're all freaks, quit lying to yourself, because we're not buying it.  Anyway, I digress from that minor point, but the larger point I am making is that people most often lie about things they know they shouldn't be doing.  Take the following three quotes from dictations on the same patient this week....

Pulmonologist:  "Patient has not smoked in the past 10 years."

Hospitalist:  "Patient states she smokes approximately 2 cigarettes per day."

Cardiologist:  "Patient has smoked two packs per day for the last 20 years."

We do all talk to each other, you're not fooling anyone. 


Wednesday, February 22, 2012

D performs an exorcism....

I have spoken about D before, he is our ubiquitous chaplain in the hospital.  I have referred to screaming patients in the hospital before as the heads of the hydra -- stop one from screaming, two more arise to take their place.  By the way, if you've never read The House of God, I highly suggest it as there is an entire section devoted to GOMERS, who you can identify by their individual screeches.

One evening, I walked into the CCU to see my new admission and was quickly approached by the nurse, who exclaimed, "You'll need an old priest and a young priest for this one."  I learned what she was talking about fairly quickly, as I heard what sounded like a cat in heat coming from one of the rooms.  My interview with her went something like this....

Me:  "So what brought you into the hospital today?"

Patient: "Rawrawrawrawrawrawrawrawr!"

Me:  "Ahh, so you came in by ambulance."

Patient:  "Rawrawrawrawrawr!!"

Me:  "I see..."

At this point I concluded the interview was useless and tried to examine her, at which point the cries became screeches with the slightest touch.  So, both history and physical were almost pointless.

Nurse:  "What do you think?"

Me:  "Get D down here, but don't make it an official consult, just tell him we need his services."

I wasn't there for it, but the nurses say that he actually tried to have a conversation with the patient for about 20 minutes, to great hilarity.  When he came out of the room to find all the CCU nurses laughing, he loudly exclaimed, "All of you are going to Hell!" before storming out in mock anger.


Tuesday, February 21, 2012

Don't make 'em like they used to....

When I was growing up I used to hear the adults talk about how much tougher they and their parents had been growing up and I wasn't ever certain it was true that children were getting soft....until recently at least.

16 year-old boy:  "I need physical therapy before I can go home, I'm too weak."

Me:  "You've been in the hospital one night."

Boy:  "I really think I need it."

I should point out at this time that the kid was in on observation status for a presumed (not confirmed by testing) flu.  At the time I saw him he was playing Angry Birds on his iPhone and did not appear at all ill.  He was on some sort of break from school, so I can probably rule out trying to get out of class another day as an excuse.  As a counter to this, when I was 17, I broke my ankle (both tib/fib) at church camp.  I was so angry about it that I refused crutches and hopped around the entire facility, sometimes over a half-mile at a time.  To prove a point, I entered the swimming races later in the week and WON THEM.  And I am from the same generation that grew up with Nintendo (the original) and Playstation and eventually the Xbox and beyond.   I think when I finally decide to have kids, I'm just going to start beating them at birth to toughen them up (for the record, I am absolutely, 100% joking).


Monday, February 20, 2012

Nom, nom, milkshakes...

Whenever someone comes in for a suspected infection of the colon (colitis), we usually keep them from eating anything for awhile both to avoid exacerbating it and to keep them from vomiting everywhere.  Incidentally, we have no idea if this actually makes it worse or helps as (to my knowledge) no one has ever done a study to see if it works.  Once you're in medicine for awhile you'll realize we do this A LOT.

A few weeks ago, I admitted a young woman with a suspected colitis and made her NPO (no food or drink) overnight.  The following morning when I went to see her she thanked me profusely for the strawberry milkshakes I had sent over, that she had been very thirsty.  I was confused about what this was until the nurse showed me the empty canisters of strawberry-flavored barium they had given her prior to her CT.  Evidently she had been asking for more ever since coming back from the CT scan.  The usual amount you are required to drink for the study was one canister and most people had a hard time with that due to the taste. 

She had drank a full four. 

No one could explain where the extra 2-3 canisters came from. 


Ad Code fixed...

Ok, I have removed the ad code that was causing some people to get virus warnings.  There was no actual virus, just a few of the ads caused the warning.  I should point out this was only affecting people who used Internet Explorer (mother) and not some of the newer browsers such as Firefox and Chrome.  If you are still using IE, welcome to the internet!  Pick a safer browser, please and you will avoid a lot of headaches.

Sunday, February 19, 2012

Quick Question...

Anyone viewing the blog, are you getting virus warnings whenever you load the page?  I think the ad program I'm using may be triggering some virus scanners.

Sunday Hero...

If you haven't seen Drive, I highly recommend it.  Welcome to Sunday...

Saturday, February 18, 2012

Locked, cocked and ready to rock...

Seen in chart: "Patient is fully optimized for surgery."


Friday, February 17, 2012

Physical exam time...

Believe it or not, the vast majority of reasoning out the causes for an illness are done in the conversation leading up to the exam.  The physical exam portion serves mainly to confirm or refute what you suspect is going on.  In the past 20 years, however, a lot of our technology has replaced what are considered to be the cornerstones of physical exam.  Our stethoscope, a ubiquitous symbol traditionally associated with the profession was cutting-edge technology....80+ years ago.  Nowadays, we rely more on technology to protect us in our diagnoses in legal cases than our own physical exam findings.

When I was a third-year medical student, I had as one of my teachers a man who had been in medicine I think since sometime around the Middle Ages.  He was still brilliant, a contributor to multiple textbooks and took great pride in his work.  He (over)emphasized physical exam as a key in our training and would often examine the patient extensively in front of our rounding team to try and prove some point.  Whenever we presented a patient with known lung cancer, we were forbidden to tell him where the cancer was.  He wanted to examine the patient and make the diagnosis himself before hearing about the chest x-ray or CT scan.  After the first week of this, he was wrong roughly 75% of the time, worse than even blind luck which came in at a 50% coin toss.  At the start of the second week, I presented my patient, being careful not to reveal where the mass was and we all waited as he went to examine the patient.  He put the ear pieces from the stethoscope in and approached the patient, but stopped with the bell of the device about an inch from the patient's chest.  He sighed, removed the ear pieces and turned to the rest of us before exclaiming, "Just tell me what the damn x-ray said, already."  He fined each of us a dollar for laughing.


Thursday, February 16, 2012

Lunch time...

Me:  "Ok, well I think you're ready to go home."

Patient:  "Oh, let me have lunch first."

Me:  "Ok, we'll send you home after lunch then."

Patient:  "Well, I don't want to just eat then leave."

Me:  *sigh*

Wednesday, February 15, 2012

Chaplain blues...

Yes, this post deals with white people and black people.  Deal with it for a minute and don't get all huffy...

Our hospital chaplain is a black gentleman we'll call "D."  We often call on him whenever families are grieving for assistance and he does a great job at comforting them.  Some families are inconsolable, however.  Anyone who has ever worked in a Southern hospital knows that black families down here are a little more animated than white families when it comes to dealing with death (or church, for that matter).  In the hospital, informing a large family group of black people is tantamount to screaming "Fire!" in a crowded theater.  Furniture gets turned over, wailing commences, Kleenex stock goes up, nearby pets burst into flames, frogs rain from the heavens...typical doomsday scenario.  One night in the CCU, a very ill elderly black woman died after a protracted struggle with heart disease.  Rather than brave the crowd, we asked D to go out and assess the situation first.  He left us for about 30 minutes, then finally walked back into the CCU.

D:  "You didn't tell me they were black!"

Nurse:  "Uh, D.  You're black."

D:  "I know, black people are crazy, didn't you know that?  I'm out of here."


Tuesday, February 14, 2012

It's a little dry...

Me:  "How did that fiber supplement the GI doctor gave you work?"

Patient:  "I tried taking it once but it was incredibly dry, got stuck in my teeth, made me gag."

Me:  "Uhh, you know you're supposed to mix the powder with water or orange juice, right?"

Patient:  "Well I do now."


Monday, February 13, 2012

Conversations of the mortal variety....

Yesterday, 3:30 p.m.:

Nurse:  "I'm worried about your new admission."

Me:  "Why are you worried?"

Nurse:  "Well, he keeps saying he's here to die."

Me:  "Is he stable?"

Nurse:  "Yeah, all his vitals are fine, he just keeps saying he's here to die, that Jesus is coming for him."

Me:  "How old is this guy?"

Nurse:  "85."

Me:  "Ok, let me put this in perspective for you....if Jesus showed up at my house tomorrow morning and gave me the option of either showing up to work or going with him, you can bet your ass I'm riding the J-train to H-town."

Nurse:  "Fair enough."

If you can't already tell, I've been on for 22 days in a row now.

So, I walk up to the patient's room, he's comfortable in the bed.

Me:  "Do you know where you are?"

Patient:  "I'm in this bed, about to die."

Me:  "No, do you know what building you're in?"

Patient:  "I'm in General Hospital, Room 555, the date is February 12, 2012."

Me:  "Ok, something I need to know, if your heart stops do you want us to press on your chest and shock you to restart it?"

Patient:  "Why in the world would anyone want that?  The answer is no."

Me:  "Ok, that's what I needed to know, I'll be back here in a bit to see you."

Patient:  "If I'm not dead, I'll talk to you then."

Me:  "If not, I'll catch up on the other side."

Patient:  "I'm pretty sure I'll beat you there."


Sunday, February 12, 2012

Saturday, February 11, 2012

Stuffed and mounted...

We often get in enormous arguments with families who have unreasonable expectations about their family member's outcome.  We can't cure a very large number of things, but at the top of that list is ADVANCED AGE.  Yet, Hollywood, with its infinite wisdom, has instilled a delusion in the American populace that everything can be cured if you want it bad enough.  Here's the deal, though:  I can't fix a machine that is 30 years past its expiration date.  Nature just doesn't work like that.

Some time back, we had an extended argument with a man about his 102 year-old mother.  He insisted that she was in perfect health and we were just incompetent.  Yet, she continued to decline and, despite our repeated attempts to make her comfortable and quit torturing her, her son would not relent and make her comfort care.  He absolutely insisted that she was going to live to 110 and we would not stop her from doing that.  When I told one of the ER guys the story, he came up with a novel solution:

ER Doc:  "Has he considered a taxidermist?"


Friday, February 10, 2012

Foreign bodies...

It always seems whenever I meet someone new or see someone I have not seen in a long while they usually want to know what I do for a living.  When they find out I'm a doctor, inevitably, the conversation leads to things removed from peoples' rectums in the ER.  I doubt any other profession can claim such an obsession with a person's ass.  So, to satisfy your curiousity briefly, I will occasionally be telling these stories I know you are dying for...

I was reminded of this story when I was retelling it in the ER the other night and I uttered the phrase "And that's when I realized I knew a lot more about dildo anatomy than I thought I did."  Off-hand, this phrase is an excellent one to speak aloud if you ever want to get the attention of everyone in a room at once.

Some time ago, I walked down into the ER to admit a patient and found our GI doctor and one of the ER docs leaning over a radiology viewing screen.  They were pointing to an obvious foreign body buried in an abdomen.  A quick glance told me that it was VERY large.  I watched for a moment before I realized they were making a mistake in determining where it ended.  The internal components of a dildo are all radiopaque (they show up on xray), while the plastic or rubber coating does not.  The GI doc pointed to an area about half an inch above the gyros that were visible as to where he thought the device ended.  I walked over and traced a line about 3-4 inches above that, pointing out the very slight line the rubber made on the film.  Looking at it anew, this meant that the thing was shoved up to the splenic flexure.  Now, to illustrate where this is, take your left hand and cup it just under the lower border of your left lower ribs.  Yeah.  There.  Things like this create incredible suction when you attempt to remove them.  The last view I had of our GI attending was of him standing on an ER exam table above the guy who was on his stomach, leaning back with the effort.  I later learned they had to take him to the GI lab to get it out.  When it was removed it measured 11 inches long and had been buried 25+ cm inside this guy.  I later learned it was bright purple. 

The GI guy named it Barney.


Thursday, February 9, 2012

The digital age...

Every man knows that a trip to the urologist = one-finger salute.  It seems some people still try and weasel out of this, however.

Man (watching urologist put on glove):  "Uhh, I was told I need a digital rectal exam."

Urologist:  "That's what I'm about to do."

Man:  "No, I need a DIGITAL one."

Urologist:  "This is my digit *waves finger* and that *points at man's backside* is your rectum."


Wednesday, February 8, 2012

Family history...

Two smaller posts, for your viewing pleasure, both occurred this week.


Me:  "Did your mom and dad have any medical problems?"

Patient:  "I'd say so, they're both dead."


Me:  "Did your mom and dad have any medical problems?"

Patient:  "Oh no, they were both very healthy."

Me:  "How'd they die?"

Patient:  "Well, dad died of a heart attack at 35 and mom died of a stroke in her 40's."


Tuesday, February 7, 2012

Recruiting time...

I loathe physician recruiters.  I usually try to be cordial to them, because I realize they are just doing a job, but sometimes they push the wrong button....

Yesterday, 12:30 p.m.:

*phone rings*

Me:  "Hello?"

Guy:  "Yes, my name is Brandon and I'm calling from Company You've Never Heard of Recruiting firm.  Are you currently looking for a new position?"

Me:  "No."

Guy:  "Well, let me get you in our system so that in case you do ever look for a new job we might be able to help."

Me:  "That's not really necess...."

Guy: "Great.  Now, let me ask...are you just a family physician?"

Me:  "Uhh, I don't know.  Are you just a telemarketer?"

Guy:  "I'm not a telemarketer, sir.  I am a recruiter with..."

Me:  "But you sit in a cubicle, right?"

Guy:  "Well, yes."

Me:  "And you make unsolicited phone calls to people, trying to get their business?"

Guy:  "Yes..."

Me:  "While they are at lunch..."

Guy:  "Well..."

Me:  "And you're not a telemarketer?"

Guy:  "..."

Me:  "That's what I thought." 

Guy:  *hangs up*


Monday, February 6, 2012

Just here for the commercials...

Chief complaint of the week:  "I don't have a place to watch the Super Bowl, so I came here."  -- chronic psych patient, on why he showed up to the inpatient psych unit.


Submitted by Jennifer.

Sunday, February 5, 2012

Phones are for phone calls....

Forgot to post my usual Sunday video today and can't access YouTube at the hospital, so I'll just post something brief.

Patient (approaching nurse's station):  "Excuse me, do you have a phone book back there?"

Me:  "Ma'am, you're holding an iPhone."

Patient:  "Yes, that's why I need a phone book."


Saturday, February 4, 2012

God's work...

"She's still doing God's work."  -- Family, explaining why they would not take their 98 year-old, brain-dead grandmother off the ventilator.


Friday, February 3, 2012

No added sugar...

Patient:  *munch, munch* "I also have diabetes.  They can never seem to get my sugars under control." *munch, munch*

Me:  "Ma'am, you're eating McDonald's."

Patient:  *briefly stops chewing, looks down at McNuggets*  "These don't have sugar in them, they should be fine." *munch, munch*

Me:  *sigh*


Thursday, February 2, 2012

Fight fair...

This is not a funny post, be warned.

Doctors (and nurses) are often given the additional role of counselor/pastor/friend when talking with families.  Indeed, patients and their kin often tell us things that should probably be reserved for someone who has the right NOT to tell authorities, but I digress in that regard.  This story is a warning for anyone with a spouse/significant other/boyfriend/girlfriend/relative, so everyone, basically.

I recently admitted a gentleman who was brought in by ambulance after collapsing at a poker game with his buddies.  He'd had a massive heart attack which caused him to immediately lose consciousness (inferior ones often do this, dropping the blood pressure precipitously).  CPR was started (fairly) quickly, but the end result was that he had a severe anoxic brain injury which made him a suitable organ donor, but realistically not much else.  The man's wife was inconsolable.  She kept trying to get him to wake up while he was intubated, to no avail.  When I was examining him during rounds she stood next to me.  After I was finished, she very quietly whispered, "The last thing I ever said to him that morning was, 'I wish you were dead'."

I can't fix the situation.  I cannot absolve this woman of her sins, but I feel that I can warn others.  When you fight with someone you love, choose your words very carefully.  Don't say things you'd absolutely regret later if something happened and you could not apologize.  From my experience, I've learned that the one who apologizes first is often the one who "wins" the argument.  Most arguments with my wife are over in 10 minutes and forgiven shortly thereafter.  Fight fair, love hard.


Wednesday, February 1, 2012

Irony at its finest...

Patient:  "You guys always take forever to see patients, I had to wait 30 minutes past my appointment time."

Me:  "I apologize, sir.  Tons of things can go wrong that make us run behind schedule."

Patient:  "Well, let's hurry this up, I have to be back at work."

Me:  "What do you do for a living?"

Patient:  "I'm a construction worker for the state highway department."


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