The Placebo Chronicles: Strange but True Tales From the Doctors' Lounge
Page 19
I don't know about you,
but I am sick of being the zookeeper.
When such patients arrive, they have the monkeys well hidden. Other patients in the waiting room hardly notice. The front staff is usually oblivious to them. Your nurse, however, usually gets a whiff of them. She senses that there are monkeys about. By the time the patient enters the room, their monkeys are all over the place. As soon as you walk in, you realize that the place is a menagerie.
These patients live with these monkeys all the time. They feed them. They take care of them. Now, since you are the doctor, they think they can just hand them over.
It starts with a list.
Complaints of dizziness, fatigue, or headaches are just little monkeys that got the patient to come in. Pretty soon the big monkeys come out. You may know them as depression, situational anxiety, or polysubstance abuse.
There are a lot more monkeys I could name but does it really make a difference.
You get the point.
For some reason, these patients think that you deserve their monkeys. They don't want to take care of them anymore. They are tired of them. Their monkeys weigh them down and since they don't want to deal with the issues themselves, they are kind enough to let you do it.
I want to be the first to say,
“I don't want your damn monkeys!”
I've got enough monkeys of my own. It took me a while in private practice to realize that each time I left a patient's room, I had one, two, or three monkeys on my back. The patient would say things like, want you to get me to quit smoking” ‘ or“I have no energy and I want you to address that.” Other bombshells of relationship problems, run-ins with the law, or problems with money got laid on my back. These monkeys were all over me by the end of the day. I was becoming the Quasimodo of Medicine. Sure, the patient felt better, but I was getting burned out feeding all the monkeys they'd left with me.
My answer to this quandary
is to turn the tables on the patients.
You must make them take responsibility for their own monkeys. They have to kill the damn things before they make a mess everywhere. Give them assignments to fulfill. Make them jump productive hurdles that will get them to the right place and without a monkey in sight. They need to show some accountability to you because the next time they come in, you will ask them if they followed through. When they say no, you can end the visit and walk out monkey-free.
This is the bottom line -
Either they kill their own monkeys
(or at least show some effort trying to)
or they take their pets somewhere else.
A COPD Terrarium is a collection of both plants and Lungers living in a single container, one that is completely enclosed. These gardens are an excellent place to grow plants, which require a high degree of humidity, and “COPDers” who pro-2 duce so much extra of that pesky CO. Togethe rthey will live in complete symbiosis; freeing your patients of their home oxygen needs and you from those recurring hospital admissions.
COPD Terrariums are fun and only require a minimum of care if they are kept sealed. They usually demand little attention and will grow successfully on their own for several months or even years. Regular input of food for the Lungers, as well as a TV guide now and then, is all the hassle you will get.
The following is a list of
what is required to create your own
COPD Terrarium:
The Container
and How it
Works
The containers must be large enough to hold a minimum of three inches of soil and should be roomy enough to hold a reclining La-Z-Boy chair, a small refrigerator filled with beer, and a TV with cable. Any very large clear or tinted glass or plastic container can be used if it will admit light and allow plants to be seen. The moisture that the plants absorb from the soil is given off through the leaves by the process of transpiration. This condenses on the container walls and runs down to moisten the soil again. The atmosphere also remains balanced through the combined plant processes of photosynthesis and respiration. A well-constructed terrarium requires only light and warmth to flourish.
Choice of Plants
The arrangement of the plants within the COPD Terrarium should be determined before putting your patient inside. The physician should trace the shape of the container onto a piece of paper and arrange the potted plants to test possible arrange-22 ments for optimal CO and O transfer. A regular ceiling fan can be used for air circulation. Most plants recommended for terrariums are moisture-loving types which never become large. Because most houseplants are of tropical or subtropical origin, they thrive in the COPD Terrarium environment. Correct selection of the plants to be incorporated into the garden is vital to its longevity. Since your patients with emphysema have little more than blebs for lungs, small plants of varieties that do not grow quickly are the best choice. Plants of assorted growth habits create a natural landscape, and the garden may be structured from the viewer's point of view. Do not obstruct the TV screen of your patient or they will become irritated if not violent.
Choice of Lungers
We recommend using those patients with a CO2 greater than 70 mmHg. They seem to blend in well Cigarettes with your new agricultural environment. Be careful to not put more than two Lungers in the same COPD Terrarium. Many times they will fight which will cause an excessive use of the plant-2 produced O. Since some Lungers are also bitter and depressed people, the chance of having two get along are very small. Do not risk the wrong combination!
Planting
You may wish to create a landscape effect by making the plants and soil look like a normal living room. Different types of grass can be used to give a carpet effect.
Avoid clutter as this may confuse your Lunger. Often the simpler arrangements, which make use of a few well-placed, attractive plants are much more pleasing to the eye than miniature jungles which appear about to burst through the glass.
Watering
Well-constructed COPD Terrariums do not need to be watered because plants recycle the moisture they use. Lungers do not recycle their fluids so an emphasis on beer and coffee is needed. A completely enclosed terrarium requires little or no extra watering. Your Lunger, however, may need a shower now and then.
Sunlight and Fertilizer
Do not forget the importance of sunlight for both the plants and the Lungers. The former needs it to grow and the latter needs it to stave off Seasonal Affective Disorder.
Fertilizer is also very important but with the new and improved FECAL-IZER, your patient's stool can be your plants’ best friend.
Cigarettes
This is the beauty of the COPD Terrarium. How many times have you seen your patients blow their faces off because they smoke while on home oxygen? There is no chance of combustion in the COPD Terrarium. Now your Lungers can grow their own tobacco right at home – and smoke it too! Bad for their health you say? With such little lung tissue left, does it really matter anymore if they smoke? And that's not all! The COPD Terrarium is actually self-regulating. The more the patient smokes the more oxygen they use. Over-users will choke and pass out and the plants will just replenish the oxygen once again until they wake up. No one gets hurt.
They do very little for anyone but their stockholders. If I was smart enough and had had the money to invest in them fifteen years ago, I would be rich and I wouldn't be writing about HMOs today. Unfortunately, I didn't make a dime by buying their stock and that puts me in the precarious situation of having to live in their world. I am also bitter about the missed opportunity.
HMOs do not help me.
Let's do a little math problem. Pretend you are taking the SATs all over again. Your first problem is as follows:
You are a family doctor who has to take $12 per member per month. If your patients and their employers are paying approximately $1,000 per family member per year and you have 2,000 patients in your panel, you would be making a whole lot of coin if it was all going to you. Check One: Y
ou should
Enjoy medicine again
See fewer patients in a day and spend more time with them.
Stop seeing your therapist for burnout
See your family again
All of the above
By using the calculations above, you gross $144 per patient per year or $288,000. That is before overhead and doesn't include Medicaid or the freebees of self-pay. Is that:
□ Good □ Bad □ Ugly
The HMOs, on the other hand, get $2 million. Take away what they pay you, and they receive more than $1.7 million. Do you think all that goes to:
Labs?
Hospitalizations?
Procedures?
CEO bonuses? ($40 million on average)
Medicines?
Specialists?
Administrative costs?
Answer key: You get my point.
HMOs do not help me.
HMOs do not help my patients.Or my patience.
The way they bank on people not using their product is perverse in a way. It is kind of like a big health club that banks on its members not showing up and eventually quitting. If everybody showed up to the gym, it would be a mother of a sardine can. It's the same way with HMOs. When people do use their product they block as much as they can. The doctors don't want the patients there because they were paid already. The HMOs don't want referrals (and neither do the physicians) because it comes out of their pockets. HMOs also try to block every procedure, test, or medication they can. My patient can't have Celebrex without a pre-authorization and their first born. My patient can't have an MRI unless the tumor truly causes grand mal seizures because petit mal seizures are, after all, pretty subtle. I exaggerate a bit – or do I?
HMOs do not help my patients. Doctors do.
I was the local hospice's medical director, and as such, was responsible for providing comfort care to the terminally ill, often without direct interaction with the patient. Instead, it is often the case that the nursing and psychosocial staff become my only eyes and ears on the case, apart from the referring physician or any family who I may have encountered outside of the home setting. It is neither necessary nor possible to have seen new patients when they are initially presented to the hospice interdisciplinary team at the weekly meeting and intake rounds.
Cathy was an experienced hospice nurse who was presenting a new hospice referral thought to have severe diabetic peripheral ascular insufficiency, especially in a leg that was being called gangrenous for which only amputation was possible, but was being refused by the patient. Such patients would presumably die of septicemia within days to weeks barring surgical intervention, and since surgery had been barred as an alternative, the patient was probably appropriate for hospice care.
Assessing for appropriateness of a candidate or recent admission to hospice can be done vicariously by the medical director in such a case, as long as it is wet (purulent) gangrene and not just digital infarction without bacterial infection, so-called dry gangrene, characterized by distal blackening of the digits in the absence of pus, gas, or odor. Cathy's description of the limb in question had been unclear, and I was uncertain that the patient had either lesion after her jumbled presentation that alluded to dark coloration of the dorsum of the foot.
“Was the area dark or black?” I asked.
“Black,” was the reply.
“Is the foot black on the toes, too?” I followed, assuming that ischemic or embolic infarction could not spare the toes and therefore needed to be present to accept the diagnosis of gangrene, wet or dry.
“Yes, the toes, too.”
“How far up does the blackness extend? Does it include the heel or ankle as well?” I asked.
“Yes. The whole leg is black. Both legs are completely black except for the soles of the feet,” Cathy offered.
Now I was very confused. This didn't sound like gangrene, and if it wasn't, the patient may have had six or more months of natural life remaining, a disqualifying factor in most cases when judging initial hospice admission appropriateness. I was beginning to sense that I was going to have to lay eyes on the “lesion” myself. But what could Cathy be describing?
“I'm stumped,” I admitted. “I don't know what makes both legs black but spares the soles.”
“Her hands are the same,” said Cathy. “The whole body is black. Did I mention that she was African-American?”
No. Nice presentation, I thought. The patient was discharged. Being black is not a terminal diagnosis, even in Missouri.
From there, I made my hospital rounds to see my new internal medicine admissions. One was a gentleman who was admitted with post-traumatic, lower extremity deep vein thrombosis, chest pain, and productive cough. Suspecting pulmonary embolism and perhaps infarction as well, I asked Ron if his mucous contained any blood or red discoloration. “No, but it's dappled with black flecks,” he stated.
What now? I thought. Incidentally, Ron was white, so these weren't pieces of himself that he was coughing up. At least, not melanotic pieces. Once bitten, twice shy I thought, still reeling from the bizarre events of hospice rounds earlier in the morning. No coal history. What else gives black color to sputum if not necrotic tissue? Blood is never darker than maroon in phlegm. I was stumped again by a history of atypical black discoloration.
I returned to see this same patient that evening while rounding again, and Ron informed me that he had saved me a specimen of his blackened mucus in a tissue on the bed stand. I unwadded the mess i and peered at the contents within. Bright red blood. Garden variety hemoptysis. i “Does this look black to you?” I queried in amazement.
“Yeah, it does, Doc. I'm color blind.”
My fault. I forgot to ask this man what his complete chromic visual spectrum was, and I slackened on the physical exam, having omitted the Ishihara color vision test required i by Mediocre, er, Medicare, to qualify for the coveted 99223 reward (code for average office visit bill): thorough. Boy, was I feeling stupid. Color me red - or, black in the eyes of some.
I fondly recall the time that two other anesthesia attendings and I were walking out to the parking lot along with one of the residents. We saw a guy collapse on the corner and rushed over. We all knelt over him. One of us said, “I think he isn't breathing.”
At that point, reaching deep down into our collective wisdom and experience as board-certified anesthesiologists (I also have fellowship training in critical care), and with lightning-like reflexes, all three of the attendings, myself included, stood up as fast as we could. This left the resident kneeling on the ground next to the apneic man.
We all stared at him expectantly. Like a fraternity pledge swallowing a goldfish, he dutifully started mouth-to-mouth on the stricken man, who promptly vomited all over the place. We're talking Old Faithful here! The resident started gagging and retching. Naturally, we stepped in to help by using the man's coat to wipe off the vomit so the resident could continue his life-saving maneuvers.
We got the man over to the ER, where unfortunately he later died. As “Thoughtful Attendings,” in gratitude to this heroic resident who performed such a selfless and nauseating act, we remembered to ask the ER staff to send off serology for communicable diseases, which was negative.
You can confirm this independently by contacting a renowned attending at Duke, who was the resident. I'm sure he will enjoy reliving the experience.
Here are some reasons given for requested radiology studies.
Sometimes they are the study that was ordered. I will give you our
interpretation in parentheses when I think you may need it.
Reason for Study for Chest X-ray: SOB/Resent Cabbage
Reason for Study for Chest X-ray: Failure to Breathe
Reason for Cspine X-ray: R/O Oreochitis (I guess arthritis)
Ballistic Metastases Metrogagia (Menorrhagia)
We Need It
Post Thorus Synthesis (post thoracentesis)
Mummer (murmur)
Pre-op RED ALERT
&nb
sp; Injured Groins while tightroping
Patient known to you
Tub placement
Assault with high heels
Left total lip replacement
Stag Wound to Chest
R/O Lung Absence
Weightless
Shot with Taser by SWAT team
R/O Phewmonia
Allergic to “red food”
S/P Chest Ache Removal
Shortness of Breast
OR S/P Post liver transplant, missing needle and bootie
OR S/P Post-op nephrectomy, missing sponge and nut
Face Vs. Ground (I guess the patient lost that battle)
For L-S spine series: Pt. c/o pain with radiation (Time to stop ordering X-rays)
Reason for CT Brain: Mass in chest - to see if it has climbed up into the brain
R/O Os Good Shlottess Disease (and a similar one) R/O Oscar Shlatters
Lumbar spine with erect penis (Lumbar spine with erect pelvis)
Reason for Cerebral Angiogram: R/O Subarachnoid Hemorrhoids
Reason for Pregnancy Ultrasound: Spootin (Can't even guess on this one)
Anal X-ray (Annual X-ray)
Reproductive chest pain (Bummer!)
“End of Life” Mode
Examples of Cultural Nuances
Always say the person's name; (“Well, Jim, I believe …”) as it makes them feel important.