Pour a lil' cider on it....

Awhile back, I had a patient in the hospital with aggressive bladder cancer that was considering chemo after her surgery to remove the tumor.  I told them everything I knew about the cancer and what the odds of survival were with chemo and whatever else I could.  The family wished to discuss it further with one another and I told them I'd check back tomorrow.  As I was walking out the door, I heard one of the sons say, "I'm going to run home and get you some apple cider vinegar, Mom.  Couple of shots of that will fix anything wrong with  your bladder."

#sigh

SCOTUS

On the backs of the SCOTUS decision today to uphold the individual mandate and all of the health care law, I'm going to say something that would not endear me to my colleagues....

I'm actually FOR the requirement to have health care AND a means to provide it for those who can't afford it.  Why?  Because I think we are supposed to be our brother's keeper, to quote a rhetorical question from the first murderer of the Bible.  I've seen people using the Bible as an argument against this bill, much to my confusion.  Jesus did not only help those who wanted to help themselves.  He helped cripples, the blind, the poor...EQUALLY.  He never asked if they were willing to work for a living, he gave everything to give them a better life, to the end that he gave his own life, if you believe the stories of the Bible.  If forgiveness and mercy were given only to the deserving, we'd all be in trouble.

My reasons for supporting this may have roots in my own (white) guilt.  I was born a white, male American to a middle-class family with two doting parents (still married), which automatically makes me better off than 99.9% of the world.  I didn't have to walk two miles twice a day to get water, I didn't have to worry about whether to pay the electric bill or put food on the table.  I was taken to school daily on tax-payer supported roads and went to a (public) school which put out a disproportionate number of very intelligent people of similar color and background to myself.  I recognize this in myself and know (to the extent that anyone can recognize their gifts in life) that I was given more than anyone should ask for.  The irony here is that many people of similar socio-economic class to myself think that they got where they are in life on their own merits, when in reality, we woke up on third base and were told we hit a triple.  My father is an example of someone who actually worked his way through life, but he had the advantage of a father who knew that education was the way to get ahead and pushed his son along the path.  That is a huge advantage.  I will not deny my father's drive, his temerity, his determination to get where he is today, but he also benefited from those same roads, those same schools.  No one in a high-paying job in this country is exempt.  At the risk of alienating some of you, we all owe a debt to those less-fortunate.  I don't like paying taxes anymore than anyone else and I do all that I can to decrease my tax burden, but I owe a debt that cannot be repaid and we've taken a step toward putting us in the black today.

I have my doubts about the bill, but I hope for a good outcome to this.  I welcome discussion/dissension, but I will not allow hateful comments to be posted, so use that as a guideline.

For reference, I'm not a Democrat or a Republican, I'm just....awake.

Trippin'...

One of the hardest things for families in the hospital to understand is that there is literally nothing they can do to help if something goes wrong.  Indeed, any physical aid they render is more likely to do harm than good. 

While standing over an intubated patient in the CCU the other day I had the following conversation:

Family:  "So what do we need to watch out for in him."

Me:  "What do you mean?"

Family:  "I mean what warning signs do we need to look for to see if he's having trouble breathing?"

Me:  "We're breathing for him; there is nothing for you to watch out for."

Family:  "Well what about his blood pressure?  Do I need to alert you if that drops?"

Me:  "You need to do absolutely nothing.  We are monitoring every parameter that needs watching."

Family:  "So, what can we do to help?"

Me:  "Umm....try not to trip on any cords when you leave?"

#helpful

Parasites...

It's still fun to mess with the younger nurses....

Nurse:  "I need you to do something about this blood sugar."

Me:  "I'm not talking to you while you have that parasite growing in you."

Nurse:  "My baby is not a parasite!"

Me:  "It's growing inside you, right?"

Nurse:  "Yeah."

Me:  "And it's stealing nutrients from you to feed itself..."

Nurse: "..."

Me:  "...and tweaking your hormones to make you think you love it.  And after it's 'born' *air quotes*, you'll continue to feed it from glands in your body."

Nurse:  "I have noticed my boobs getting bigger."

Me:  "And it's not a parasite?"

Nurse:  "Damn it.  I'm having a tapeworm, aren't I?"

#bingo

Oh, bartender....

This alternatively could be titled, "How I know you're a drug-seeker."

Patient:  "The only thing that works for my pain is Demerol 75 milligrams mixed with two mgs of Ativan and 25 mg of Phenergan rapid i.v. push, with 50 mg of Benadryl given 10 minutes later to prevent itching."

That is a real quote.

The classic of course is, "I'm allergic to everything but Dilaudid."  I did have a patient tell me once that she was also allergic to Dilaudid given slowly, it had to be pushed quickly.

#mixologist

Sunday blindness...

Search term of the week:  "can silvadene be used in anus?"

Playing doctor...

We try to extend common courtesy when speaking with relatives with medical backgrounds and we ease our language a bit to accomodate them, since we assume they know what we're saying in medical speak.  However...

Me:  "Well, when someone is withdrawing from narcotics and alcohol we'll usually start seeing them show symptoms of confusion, anxiety and such around 24-48 hours after the last ingestion.  I'm sure you heard of delirum tremens.  Well, what happens there is..."
Patient:  "You don't have to explain it to me, I'm much smarter than the average person.  I'm also a doctor."

Me:  "Oh, ok then.  Well, we have him on scheduled ativan to prevent any problems and we'll be monitoring him for autonomic instability over the next several days.  Do you know if he was taking any benzos?"

Patient:  "Umm....what are benzos?"

Me:  "What kind of doctor are you again?"

Patient:  "I have a doctorate in philosophy."

Me: "..."

#pseudodoctor

Donations...

I have taken to wearing blue scrubs at the hospital because it makes me blend in with the nurses and keeps families from pestering me too much when I'm trying to work.  While working at the desk the other day a voice above began to speak:

Man:  "I'd like to donate these flowers from my wife's room to the decor."

Me (without looking up):  "That's fine, just leave them on the counter there."

Nurse (a few moments later):  "Who left all the dead flowers on the counter?"

When I lifted my head to look up, I noticed that the guy had "donated" four vases full of brown, crispy, dead flowers.

#thanksalotman

Short-staffed...

We are short several members of our group at the hospital, meaning we're having to hire locum tenens docs to fill in.  It has its downsides....

The Sixth Sense...

I have a confession to make:  I think it would be kinda cool to talk to dead people.  This makes it rather hard for me to take nurses seriously when they call me about patients doing the same.

Nurse:  "The family wants a neurology consult.  The patient is in there talking with dead people.  They say she's been doing it for months."

Me:  "Do the dead people talk back?"

Nurse:  "It's weird, when you watch her it's like you're only seeing half a conversation, so I'd say yeah."

Me:  "Why would I want to fix that?  That's like the coolest thing ever.  I'm coming by to talk to my grandmother."

#brucewillis

Hearing voices...

On my psychiatry rotation during M3 year, we had a schizophrenic patient we were treating for acute psychosis.  One morning on rounds the attending physician asked the patient if he was still hearing voices.

Patient:  "Yes."

Doctor:  "When was the last time you heard voices?"

Patient:  "This morning."

Doctor:  "And what did the voices say?"

Patient:  "Patients, please go down to the activity room for your morning snack, and don't forget to wash your hands first."

Perhaps the intercoms shouldn't be used on the psych ward.

Submitted by Phil.

#Ihearthemtoo

Why the Medicare "pay for patient satisfaction" is a lie...

One of the newest trends in insurance payments is a "pay-for-performance" where the government sets up a payment schedule based on how well you meet certain core guidelines regarding treatment.  To be clear, I am in favor of increasing compliance for treatment.  However, I am NOT in favor of the other part of this plan, which involves paying providers based on Press Ganey scores, which are, in essence, a grade sheet filled out by patients about their care.  To illustrate why I am against this, see the following adage:

Patient:  "This is the worst hospital I have ever been in."

Me:  "Well, ma'am, we managed to save your life, despite that."

Patient:  "I'm not talking about that.  That nurse took 30 minutes to bring me a refill on my water.  I could have died of thirst."

Me: "..."

You see, the average American only cares about the minutiae in their care.  They nitpick over the things that they think they are capable of doing themselves and use those as a basis to judge the entire stay on.  These get translated into a worse Press Ganey score and thus, a lower payment to the provider.  Because we took too long getting her a fucking glass of water.  We quite literally saved this woman's life and her only concern is about the length of time it took for us to play waiter.  Not that we have other people with their lives in jeopardy that we are caring for, only for her immediate physical desires. 

Now, all of these changes are dressed up in the guise that they are in the patient's best interests and, to the extent regarding core measures, I agree.  But what lies at the heart of this is money.  You see, the government plays a game with providers where, every few years, they change the way you have to bill in order to get paid.  A prime example of this is the term "urosepsis."  A few years ago, writing this in the chart allowed you to bill at a higher level for a urinary tract infection, plus sepsis.  Then the government randomly decided that urosepsis only coded to the lower level "urinary tract infection."  It took months to years for physicians to catch onto this so the government saves money by paying out lower reimbursements until the doctors catch on, at which time they change the rules again.  These new enactments are no different.  It is an excuse to pay less to hospitals and providers, only this time using the patients themselves as a weapon.  Hospitals are under-staffed and overcrowded so they rely on this dissatisfaction with the whole system to work against us.  It's a ruse, don't be fooled.

Now, if I have misunderstood any of the plans to use Press Ganey and you have better information, please enlighten me (I'm serious).  This is just the way I understand what is happening and I work far too much to read through the whole plan.

Big baby...

Overheard:

Aide:  "The big guy in 25 threatened to hit me if I kept messing with him."

Nurse:  "I wouldn't worry about him too much."

Aide:  "Why?"

Nurse:  "He cried like a baby when I put his I.V. in."

#teddybear

Just throwing that out there...

I'm also left-handed...

Family history...

Me:  "Do any diseases run in your family?"

Patient:  "Well, there's diabetes, cancer, and heart disease on my husband's side."

Me:  "No, I mean family by blood."

Patient:  "Well, I received some of my husband's blood in a transfusion one time."

Me:  *sigh*

#retakebiologyplease

Why I hate transferring patients to academic centers...

Academic physicians live in a protected bubble inside their institutions.  They have residents, interns, and a whole plethora of support staff who do most of the work for them.  Additionally, they rarely have to worry about insurance when planning for patients, since academic centers usually absorb a large percentage of non-insured patients.  In short, they don't live in the real medical world.  When many of them try to go into private practice, they find out exactly how ill-equipped they are, which is why they usually end up back in academia.  My issue with them doesn't exactly involve that, but instead has to do with the grilling I usually get when I talk to them over the phone.

Me:  "I need to speak to a neurosurgeon about possible transfer to your facility."

Neuro:  "Yes, what is the problem with the patient."

Me:  "The patient has a large bleed in his brain and we do not have the capability to adequately monitor him."

Neuro:  "What is his GCS?"

Me:  "Eight.  He currently withdraws to pain appropriately, no posturing and is stable on the vent."

Neuro:  "Does he have Bieber's sign?"

Me:  "What?"

Neuro:  "How about Kardashian tremor?"

Me:  "Uhh..."

Neuro:  "Does he have Peter Griffin pupillary response?"

Me:  "His left pupil is blown, if that's what you mean."

Neuro:  "Hmm, that's a negative Peter Griffin, then."

Me:  "Oh, ok."

Neuro:  "Have you tried performing a reverse Matthew McConaghey maneuver on him?"

Me:  "Dude, WTF are you talking about?"

Neuro:  "You need to know these things, I can't believe they let you pass medical school without..."

Me:  "I am not one of your residents or a med student.  Let me put this in perspective for you:  I have a currently stable patient in my CCU who is intubated with a large brain bleed.  We do not have neurosurgery here so the next words out of your mouth better be, 'We will take the patient' or I am reporting you."

Neuro:  "Oh, we'll take the patient.  I just need you to tell the complete story to our Neuro ICU fellow who will ask you to tell it to the intern for the general medicine team who will then send you back to me for a recap."

Me:  "F*** you!"

The converse of this is when I tell the story to the private hospital here:

Me:  "Yes, I have a patient with a brain blee..."

Neurosurgeon:  "We'll take him."

#thankyou

Shake on it...

While I was working in a clinic recently, I saw an elderly man who came in for a "skin infection."  When I walked in to examine him, I noticed that the man's hands were covered in a thick fungal infection.  I talked with him for a few minutes and wrote him a prescription.  On his way out of the room I overheard him say to his wife, "That doctor was very rude.  He didn't even try to shake my hand."

#mindyourmanners

More beer brewing + Sunday Vid....

This is what I spent yesterday doing with my youngest brother (I'm the oldest of three):

These are mash tuns, used in whole grain beer brewing.  You can use extracts to brew, but this way is cheaper, but takes more time so there's a trade-off.  Those are my sandaled feet in the pic.

Welcome to Sunday (drink a beer)...

Off work...

If it wasn't already apparent, I'm off work today.

I believe...

One of the running themes you can see in this blog is the inability of people to grasp the truth/reality of a situation and deal with it appropriately.  Family members are by far the most guilty of this.  Some would call that a testament to the human spirit.  I would call it a blindness to reality.  Take the following guy, for instance...

I recently explained to a man that his mother's dysphagia had progressed to the point that she wouldn't be able to eat through her mouth anymore.  Additionally, she was so weak from lack of nutrition that she could not walk.  In what I thought was a well-understood conversation, I gave the man the options of either placing a feeding tube and feeding her in that manner or feeding her what she wanted with the understanding that half of it would go into her lungs, causing pneumonia.  It's a fairly common scenario.  In the latter instance, I usually suggest hospice care as it's only a matter of time before they develop a fatal pneumonia.  The man stated that he understood and that he wanted to talk to someone about placing a feeding tube.  I put in the consult and left for the day.  The next day when I arrived on the floor, the plan had evidently changed, as the man had sent the GI doc away and claimed he would feed her today (by mouth) and have her walking by this afternoon.  I chuckled when the nurse told me this and asked her to call me so I could find out how that worked out.

Nurse:  "Ok, well, he tried to get her to walk a few minutes ago."

Me:  "How'd that turn out?"

Nurse:  "He immediately dropped her in the floor.  I think she hit her head."

Me:  "He might as well have pushed her out the window and asked her to fly."

Nurse:  "Yeah."

Me:  "And the feeding?"

Nurse:  "He gave her a few spoonfuls before she started coughing and turning blue."

Me:  "So now what does he want?"

Nurse:  "He thinks she'll get better at rehab."

I refrained from asking if they take Smurfs at rehab.

#lalalalalalaaa...

Spam and search terms...

I like reading the spam comments that come through, here is one of my favorites:

i love OPI. Old people holding fingers. Assuming enough time they've been married is relative to their age group then it can be sweet people still become young enthusiasts. what pertaining to revisiting the elementary education, and witnessing your kindergarten instructor, and the lady still remembers you actually!
Hey Jeremy... I simply just tried dialing in on the live opportunity need today. No the first is there... has the particular schedule changed? Cooking together with someone you adore. I have got five littermates and many of us spent considerable time in your kitchen together expanding up tossing apple cores at the other person, snapping one another with wet towels, teaching ourselves the awesomeness of the meal prepared with love. Then We moved out and about and married men who likes to cook far too. One of my favorite things is to spend an hour or two with him from the kitchen pinching his butt if he won't re-locate of my way, reading recipes together, and commonly not to be able to eat the meal when it is really done due to all the actual sampling many of us did through the cooking procedure! HA! And just today I appeared to be congratulating personally on memorizing the actual spot that we place my personal Ipod Ihome remote to ensure I can grab them, feel out the doze button after which press it to obtain an more ten a few minutes of doze bliss almost all without going over or opening my personal eyes. Good for you!

"Opening my personal eyes."  Lol.

Another very short one simply stated, "Lofty bye, sweet friend :)" with the companion spam of "Honorable bye, considerate chum :)."

Additionally, here are some of the search terms that have led to this blog this week:

barbie casovnici

funny quotes in text message form

how to become a med school gunner

let me get those digits horse cum flavor vampire signs

med school gunners arrogant

perfect body +"powered by blogger" "post a comment" -inurl:blogspot

phrases to say to patients

silly things patients say

The mere fact that someone typed the phrase "horse cum flavor" into a search engine is enough to make me lose what faith I have in humanity completely.  The fact that it led to my blog is a point of personal pride.  People are weird. 

Foxholes...

Unstable patients who come through the ER are often intubated and had initial orders set up before we see them in the CCU.  A few nights ago, I had one individual present in such a manner.  By the time I saw him in the CCU, he was intubated, on pressors, with tubes coming out of his nose, mouth, and rectum.  We were breathing for him, keeping his blood pressure aloft and giving him antibiotics and fluids.  The very first thing the family said when I walked into the room was, "He doesn't believe in doctors."

Me:  "Oh, well we can just un-hook all of these, if you want."

Family:  "NO!"

I'm trying to think of an adage similar to the war saying that "There are no atheists in foxholes," but using doctors instead.  No one believes in us...until they need us.

#fullcode

More elevator weirdness...

One of the common misconceptions about the South is that we're all drunken, illiterate rednecks.  This stereotype persists in people who have never been here.  Got news for you:  we're not all like that.  That isn't to say those people don't exist, but we're judged by our fringe groups far more than other areas of the U.S., at least in my opinion.  Still, we know when those people are present because they stand out, we often refer to them as "country" in polite company, which carries the connotation that these individuals are of the backwoods, Deliverance type. 

Saturday, 2 p.m.-ish:

I got on the elevator on the fourth floor of the hospital and was joined by several, very "country" individuals, ranging in age from about 14-19.  The moment we all got on, the youngest one, a 14-15 year-old male, turned to face me wearing a tattered flannel shirt (in summer) and raised his fists in a pseudo-boxer's stance toward me.

Kid:  "C'mon, I think I can take you."

I should point out at this juncture that the kid was about 5'3", weighing about 120 lbs, at most. 
While I'm not a big guy, I still outweighed him by over 50 lbs and was six inches taller.

Older (assumed) brother:  "Uh, I don't think you can take him." 

Kid:  "Nah, I can do this.  C'mon."  *edges toward me*

The two 16-ish girls with them titter, a bit nervously.

Me:  "Let me put this in perspective for you.  Even if I was going to fight you, I certainly wouldn't do it in a small, enclosed metal box with four of your friends standing by."

Kid:  *lowers fists*  "That's a good point."

The doors opened and they walked off without another word.

#country

SilverSunday...

Welcome to Sunday...

Area codes...

If you're wondering what sparked the following to be running through my head at work, my wife and I had a discussion the day before about which rapper sang the song I was humming.  I lost the argument.

Yesterday, 2:15, in the elevator:

Me:  *humming*

Gray-haired woman, probably in her mid-50's:  "Are you humming, 'I've got hoes in different area codes'?"

Me:  "Umm...actually, yes."

Woman:  "It's ok, I love that song, too."

#ludacris