white elephant – Weary Wretch

Live by the word, die by the word

A colleague and I were talking at work the other day. The secretary came up to us and addressed my colleague in a hushed voice, “Did you happen to drop the “F” word in room x?”

Blushing, he replied, “I don’t think I did, but I guess it could have happened.”

The secretary then stated that she was on Facebook and the patient was ranting that a Doctor had just dropped the “F-bomb” in front of him and his family. Her sister was a friend of this patient which is why she happened to notice the Facebook post.

It’s going to happen. If you use obscene or offensive language of any kind, sooner or later you will say the wrong word at the wrong time. Sure, use of language will, by definition, contain some words that are offensive to somebody, somewhere eventually.

But we are talking the commonly known 4 letter, English-words that are generally considered “offensive” in general public, the ones that would get you thrown in jail, if said to a police officer.

Yet, these words are also heard, occasionally, on children’s networks and in lesser rated (pg-13) movies. Huh, society?

Continuing with my story, my colleague and I talked some more. He is relatively new to private practice and I thought I would lend my advice. Yes, it is tried and true advice, deep from the well of experience.

I suggested he humbly return to the room and express his apologies in as sincere a fashion he could muster. If the patient rants and lambasts him mercilessly, take it like a dog with his tail between his legs. At the next opportunity during working hours, inform the department head of what happened and how it was handled.

He did.

When he came out of the patient’s room, he told me that it went well.

I asked, “Oh, how was that?”

Colleague, “After I apologized, they said there was no need to and that they thought it was cool. They said they were sick of Docs that pussy-footed around and wouldn’t come to the point!”

Still, I recommend following the above advice if you want to keep your job.

Your Grumpy Uncle Dave.

Weary

The complexity of Death Panels

For those that don’t know, I have asthma. No biggie, I just use my medicine as I should and I’m OK. The symptoms come on, seemingly in a random fashion. In other words, I can’t (nor can doctors) predict when or why I have a flare up and have to have these medicines at hand.

Want to know why that matters to me, and will to you, eventually?

The first issue came about on obtaining the medicines. In an effort to curb the rapid rise of health care costs and to stop evil patients from abusing the Medicare/Medicaid/private insurance industry, Congress and Obama decided to put the crunch on wasteful prescribing and use of medicines.

This is the pharmaceutical side of death panels, by the way.

This is how it works. The doctor sees the patient and prescribes medications that are felt to be needed for up to the next 3 months. At the time of the doctor-patient visit, the doctor is under pressure to prescribe for the symptoms or diseases that need treatment, and in some cases, may need treatment in the next 6-12 months. As I pointed out to my doctor one year, he/we were dead wrong in our predictions on the degree the asthma would affect me that spring. I ran out of medicine, couldn’t get an appointment to see my doctor and had to resort to all manner of probably illegal methods of obtaining what I needed. I survived and we talked about this and he offered a solution.

Horde!

So my doctor’s solution to this congressional-caused chaos was to cheat the system. So I did. I insured that I had several inhalers on hand, in case the asthma symptoms returned at an inconvenient time for my doctor. But, here is a white elephant in the room. Packaged medicines don’t have an infinite shelf life. They expire. The co pay for the drug may be nothing or $75. Now what does one do? Use the expired drug and hope it works, or at least doesn’t kill you? Or, try to replace the expired drug with an unexpired unit?

The prescribing pharmacy refused to replace the unopened, unused and expired drug.

Enterprising fellow that I am, I decided to trace down the manufacture. In the old days, whenever that was, it was common practice for the pharmacy to replace expired, unused medications. The manufacture of one particular drug that I needed was GlaxcoSmithKline of Canada. I googled (which makes it official that I’m a google doc) GSK and read their online replacement policy.

Great, “No return authorization required.”

Just send the drug(s) to the address provided. So, I grabbed up the 4 unopened, unused units of medicine and went to the post office. That’s the United States Postal Service. The one that requires me to fill out a United States Customs Service form to declare what I was sending to this foreign country. Oops, another white elephant in the room. As of just recently, they, the USPS, will not ship prescription drugs through their service, by act of Congress. Sorry bud.

Do you know why our august Congress decided to make it illegal to ship prescription drugs?

Well, let me tell you. It’s for a variety of reasons but the last straw is the opioid crisis. Truthfully, a little more than just opioids, but drugs of abuse in general. See, one of the major avenues of illegal drugs into the US is only partly due to the absence of a wall on our southern border. Other major avenues include the USPS, UPS, FedEx and the like. The WWW, the Internet, Google. K2 (synthetic marijuana), anabolic steroids, opioids, Viagra and a host of other medications have been flowing south for years. It’s a cost issue as well as an access issue.

My expired, unused asthma medication cost me a pretty penny in co-pay ($300). It was prescribed by a US doctor, dispensed from a US based pharmacy (probably the largest in the US) that had obtained it from a Canadian based USCS approved importer of pharmaceuticals into the US and I can’t get it replaced through the company approved system because our US Congress thinks I’m importing (exporting?) illegal drugs, or at least facilitating others to do so!

Now we are down to the point of all this. We’ve all heard the phrase, “Be careful what you ask for, you might get it and then what would you do?” There are versions in all the major religions and folklore. In the mid-twentieth century, Robert K Merton, an American Sociologist, coined, “The law of unintended consequences.” Plagiarism at its best.

Another witticism. We want to stop illegal drug abuse, illegal immigration, gun violence, rolling stops at busy intersections or whatever. Just pass another law, that’ll fix it.

Your grumpy Uncle Dave.

Weary.

Informed decisions against medical advice

Signing out AMA is a legal term used in Emergency Departments (and other healthcare areas). It is a paper that the patient signs when they are leaving against medical advice so that the lawyers don’t sue the doctors or facility for letting the patient leave without being properly informed.

For instance, a patient that may be having a heart attack might come to the ED complaining of chest pain, like my patient tonight. If the patient wanted to leave before any testing or a diagnosis is made, I would inform him that he may be having a heart attack, a blood clot in his lungs or other severe intrathoracic event that might be fatal without treatment.

Tonight’s case was standing on the sidewalk by a building not doing nothing. The police arrested him and took him to jail. He told them he was having chest pain and he ended up in my ED. Before I finished saying hello, he wanted his IV out and wanted to leave. The police cited him but didn’t want him back. So he signed out AMA and left the ED.

About 2 hours later we get notified by EMS that they are coming in with a gunshot wound to the chest. It was the same patient. Unfortunately, the GSW was fatal.

Now, the revised AMA instructions for leaving AMA with chest pain include the following.

Death from;
Cardiac ischemia
Pulmonary embolus
Pneumothorax
Gunshot wound

I figure it was another drug deal gone bad. The police unknowingly interrupted him receiving drugs that he didn’t pay for or him delivering drugs that somebody didn’t pay for.

Your grumpy Uncle/Brother Dave

Weary

Alarm clocks, the bane of mankind

It seems that the world has gone crazy. Divorce is at an all-time high, over 50%. Mass shootings, suicide bombings, genocide, postal workers going “postal”, and all sorts of murder and mayhem. What has this world come to? It seems that these things didn’t use to happen, or at least happen with such frequency. Why are these terrible things happening? Is it global warming? Is it too many nitrates in the foods we eat?

No, its the alarm clock.

There is a direct correlation with the invention of the alarm clock, the increased use of alarm clocks in general and enforced punctuation of time on society and these awful travesties.

The industrial revolution has brought a form of scheduling to society that does not correspond to nature’s calling. A 7 am – 5 pm workday may be compatible with the circadian rhythm’s of some (larks) but not all (owls). Throw in 1, 2 or 3 shifts per 24 hours and compatibility is about 100%, not.

So what happens when a human is sleep deprived? Besides being grumpy, inattentive, short-tempered, confused and generally in poorer health. There are a lot of opinions as well as differing experiences. But, because of societies mores, we don’t know because experimentation on human subjects to a degree of permanent damage is not too common. But, we do know that there a lot of researchers that consider sleep deprivation to be a form of torture. It has been used since the beginning of time and only recently been outlawed for human rights reasons.

Think of primitive man. Eat when your hungry and have food, sleep when your sleepy and have shelter. Yawn, “I’ll go slay the dragon after a couple of hours sleep,” says primitive man safe in his cave. No supervisor to demand that he do it at 7:18 am every morning, Monday through Friday, so that the rest of the clan can get on with this year’s worth of meat-processing assembly line.

Alarm clocks are thought to have been around since Plato’s time (circa 400 BC). An alarm clock, most of the modern ones anyway, are very accurate in waking us up at the preselected time we set. Chronologically. But, they are almost always wrong with regard to our circadian rhythm. We either wake up before the alarm goes off or we are dragged, painfully, up from deep slumber nirvana to the explosively and irritatingly obnoxiousness some engineer somewhere thought could not be ignored by most sleeping humans.

Now do this 5+ days a week for 50 years. About 13,000 times in our life. It’s no wonder that humans are a bit touchy, at times.

From your grumpy Uncle/Brother Dave.

Weary

Death Panels

I received a 7 page double sided letter from CMT. Care Management Technologies, which sounds real official. It is part of Missouri Department of Social Services that monitors drug claims, diagnoses and ER visits. It is also part of Missouri Medicaid Audit and Compliance Unit (MMAC, read Death Panel). Probably a whole lot more, but I’ll come back to that.

The purpose of the letter was to bring to my attention that a patient I saw and gave narcotic medication (opioid narcotic, gasp) to who had also received narcotic prescriptions from 5 other doctors. Of course 2 of the others were hospitalists that had taken care of the patient while he was in the hospital.

I had given the patient one hydrocodone tablet while we were waiting for lab results in the ED. No other medication was given by me and no scripts were given by me.

In contrast, he received 334 tablets from the 4 other physicians over a 3 month time frame. That sounds like a lot, but it is 25% less than the maximum recommended dose over 98 days.

And, the pain the patient was being treated for was metastatic prostate cancer. Prostate cancer metastasizes to bone and is the most excruciating cancer pain known. There is no cure and treatment options include estrogen hormone supplement and castration to lessen testosterone which stimulates the prostate cancer to grow. Otherwise the only thing modern medicine has to offer is relief of pain.

So, you must be wondering why I am going on about all this trivial and complex issue. If you remember, we have suffered a few years of Obama Care and the rationing of health care that was predicted to result. Here is evidence that the pundits were right to predict that the “Death Panels” were coming. And, they are here. Actually, they’ve been here for a lot longer, they are just more functional since Obama.

And last week, President Trump signed the “Omnibus Budget Act” leaving Obama Care intact. And, President Trump vowed to stop all the opioid abuse, like my giving this patient one pain pill in the emergency department.

I have been writing about the pending doom of this opioid hysteria for a couple of years. Again will I stress;

There is no opioid crisis, there is only opioid hysteria.

There is a crisis of poor law enforcement, poor government regulations, poor prescribing habits and poor management of psychiatric health issues in America.

There is no opioid crisis.

Venting from your grumpy Uncle/Brother Dave.

Weary