Month: April 2023

One thing I’ve never gotten used to is being caught up in a no-win scenario.  The no-win scenario is a common occurrence in the medical world (even more so in today’s hospitalist environment).

Let me explain. Patient X presents with high-risk symptomatology, and you recommend he/she go to the ER and be admitted for further testing and monitoring.  The differential diagnosis is lengthy with the potential for permanent damage or even death.  The patient insists that nothing is wrong and does not want to go to the hospital.  After some arm twisting, the patient relents and goes to the ER by paramedics.

In the old days, I met my patient in the ER and controlled the workup and the referrals.  Things moved quickly. In today’s world, the ER doc runs the show until the hospitalist takes over and both the ER doc and hospitalist are incentivized to send the patient home for outpatient workup. It’s a win for the ER as the patient didn’t want to be there in the first place. Unless, of course, the patient worsens or dies while awaiting the outpatient workup.   

Prior to retiring, I sent a patient to the hospital ER and requested that the ER doc order a CT scan.  The ER doc called me to tell me that he refused to order the CT as he had been “dinged” too many times for ordering CTs.

I got out of bed, drove to the hospital at 3 am and ordered the CT.  The CT showed a bowel rupture as I suspected it would.  By the time the ER doc saw the patient, the bowel had ruptured, temporarily relieving the pain and, rather than believe the patient and my assessment, was ready to discharge the patient. The patient went to surgery and did fine. There is often a calm before the storm as the pressure is relieved by the rupture and pain goes away, then infection sets in.

So, back to the original story, my patient is pissed off that he is in the ER.  The ER doc and staff want to send the patient home for further workup but ultimately do the right thing and order some tests.  The tests are positive requiring specialty care.  It’s decided to transfer the patient to another facility for specialty care, but the transfer never occurs.   Communication between the docs, patients and hospital is poor.  Ultimately, the patient is discharged several days later and is frustrated that he stayed in the hospital and perceived no benefit.

In the latter years of my practice, the above scenario became more and more common.  Frankly, it made me think twice about sending my patient to the ER. I, too, was being incentivized to send patients home and do outpatient workups.  Experience trumped the hassle factor; and, to this day, if any symptom could be associated with permanent injury or death, I advise people go to the ER.             

When I’ve advised that my friend or relative (I am no longer a practicing physician so I no longer have patients) go to the ER, I hope and pray that nothing serious is found, knowing full well that they may be mad at me if they turn out to have nothing.  I often pray that I am wrong.  However, in most cases, I am right.

So, what do you do if things are not going well in the hospital?  If communication breaks down?  If you need assistance, ask to speak with the DON (Director of Nursing) or the CEO. They can usually help. Which brings me to my favorite blessing.  May you be so blessed as to never know what disease or injury you prevented by going to the ER in a timely manner.

I usually write about this subject once a year. Women will tell you that men are stubborn, and men will tell you that women are.  Really, stubbornness is universal.  How you handle the spouse who refuses help is dependent on sex.  The answer is highly dependent on the severity of the consequences of inaction that could result if care is not sought. What do you do when your loved one needs help but refuses to acknowledge it? I

In the case of chest pain and neurological problems,. a trip to the ER is best:

 You’ve got bad indigestion.  Why not see your doc?  How likely are you to speak to your doc on the first call?  Not very!  If you’re lucky enough to speak with a triage nurse, he/she is most likely going to put you on hold while he/she confers with the doc on call. Forty minutes later the nurse sends you to the ER or makes an appointment for you to be seen in 1-2 weeks.  Medicine is called into your local pharmacy.

Did you know that heartburn and heart attack can be indistinguishable? Yep! One eighth of my patients with indigestion ended up with a diagnosis of heart attack/heart disease.  Mr. X sat in my lobby for 2 hours before he was seen.  He was asked about chest pain multiple times and denied having pain in his chest.  He did have “indigestion” he attributed to spicy Mexican food.  His indigestion was a heart attack.

Had he called the paramedics, he would have been seen immediately.  There is a “golden period” of 4 hours during which the ER can reverse the effects of a heart attack or a stroke. Once you are in an ambulance, you’re really in the ICU.  Assume that this patient did not come to the office but stayed home. 

His wife says, “Darling, I’m going to take you to the hospital.”

 A typical response from her husband would be, “Its just indigestion; do we have TUMS?  I’m not going to the ER!” 

Wife says, “I’m calling the paramedics!”

 Classic response from her husband, “If you call the paramedics, I’ll never talk to you again!” Four hours later, in the cardiac intensive care unit:

I ask the wife, “Did it dawn on you that if he died, he’d never speak to you again?  Better he be mad than dead.”

Unexpectedly, the wife responds, “I did, I thought about it and decided I’d call the paramedics and pray he lives and never talks to me again.”

These days, ER (actually all docs) docs are incentivized to send patients home for out-patient management. The formula for catastrophe is a patient who belittles his indigestion and sees a physician who is tired of being admonished for admitting patients to the hospital.

On the TV show, Dragnet, Detective Joe Friday’s signature line was “The facts, ma’am, just the facts.”  In the ER, the doc needs the facts and more than just the facts.  He/she needs to know everything leading up to and through the present. The ER doc needs an accurate history of prior illness, surgery, medications and allergies.

As a patient, you should have several documents on your computer.  Documents should be entitled past medical history, current medications, allergies, surgical history, family history and review of systems.  If you keep them current, then printing and taking them with becomes a simple task.  

If you are worried about being sent home, pack a suitcase.  It’s hard to send a patient home with a positive suitcase sign.

Here’s your joke- Q: Why was the insurance company refusing to pay after lightning struck the church?

A: Because they said it was an act of God, therefore, deliberate destruction by the owner.

Do as I say, not as I do! There are certain prerogatives to having practiced medicine for years.  In medical school, we were told that the doctor who treats him/herself has a fool for a patient.  After 45 years in medicine, it’s my opinion that the doctor who does not take an active role in his/her own treatment is a fool.

My doctor/patient relationship is excellent since I’m both doctor and patient.  I know what I know and what I don’t know. My trust level is as high as you can get. My relationship to myself allows me to pick treatments that are more likely to be successful.

So, when I talk about the treatment of my depression and my refusal to take medications, I have 45 years of diagnosing and treatment depression.  An example will help you understand. 

My gerontologist referred me to a psychologist.  During the initial eval, the psychologist started questioning me.  I said “17”.  The shrink looked at me and said, “What is 17”?  “17” is the score I’m going to get on your screener.  I administered the screener so many times over the years that I memorized it.

Right or wrong, my treatment is not the standard treatment.  It has the approval of my MD and I strongly suggest that you follow your doctor’s treatment plan. By the way, a high-end sports car is an expensive treatment and is not covered by insurance. Medication is both effective and safe if your doc wants to medicate you.

Here’s today’s joke:

A dad was depressed, so he went to the liquor store.
He bought some whiskey and tequila.
When he got home, he set them on the table.
His son immediately picked up both bottles.
The dad asks, “What are you doing?!”
The son responds, “You were sad, so I’m lifting your spirits.”

By the way, alcohol is a depressant.

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The votes are in and the results are definitive.  My readers say my articles are too depressing.  In other words, my depression is showing!  As I’ve become less mobile, I’ve become more depressed.  I had to sell my convertible and Thursday will take delivery on a handicapped van.  What a change!

I’m hopeful that being able to get out and travel some will brighten my days.  Actually, just knowing that I’ll have the ability to take my electric wheelchair with me already brightens day.

I’ve decided that my moratorium on flying has been getting me down.  My best buds leave for Ireland this coming week; and, for a multitude of reasons, I am not. I normally go to Paradise Village in October and have been bummed out by the idea of not being able to spend 2 weeks in my favorite place on earth.

One thing depression does to you is blunt your ability to problem solve.  The airlines and Prospect really did a number on me.  The abuse I took in Houston (United Airlines) and then again in Dallas (American Airlines) made me never want to step foot in an airport again. Knowing how I feel now about traveling by air, I can’t imagine how bad PTSD affects people.  None-the-less, I spent a lifetime solving other people’s problems but couldn’t solve my own.

The answer was a simple one.  I’m looking forward to going to Mexico in October of this year.  I’ll travel to Dallas on day one and stay overnight, flying out the next morning.  On the way back, I’ll stay overnight at my port of entry into the United States, flying out the next day.  The stress of making the connecting flight will be gone.  I’ll expect to be dumped in a holding area and just have to put up with a system that routinely ignores the rights of the handicapped.  This time I’ll wear a diaper.

It’s a pity United and American no longer fly non-stop to Puerto Vallarta.  It’s also maddening that they’ll charge me extra for the longer layover despite the fact that they can’t service their customers with shorter layovers.

The long and the short of it is I’m going to look forward to whatever life I have left.  I’ll adapt to whatever changes are coming and use good old fashioned ingenuity and technology to mitigate my losses.

Thanks for your feedback on my journey to the darker side.  Now I really want to hear from handicapped travelers who have been abused in our airports.

Here’s today’s joke:

A woman told her friend, “I feel like my body has gotten totally out of shape, so I got my doctor’s permission to join a fitness club and start exercising.” “So, I decided to take an aerobics class for seniors. I bent, twisted, gyrated, jumped up and down, and perspired for an hour. But, by the time I got my leotards on, the class was already over.” (Copied from scary mommy jokes)

Last night I told Renee I was going to have a lousy week or 2 as I finally decided to take my weight off.  I apologized for being grumpy in advance of being grumpy. I’ve spent today talking to myself.  I’m hungry!  Today is Renee’s and my shopping day.  We went to the kosher grocer for fresh Challah.  If you’ve never tasted Challah, you should try it.

Challah is a braided loaf of a soft egg bread with a dark crust.  Renee slices hers.  If she is not around, I pull off a hunk. My conversation with myself goes like this:

Me – “Go ahead.  Pull off a hunk. You deserve it”.

Me- “No, you don’t!  You’re going to break your diet after only 12 hours?  You know better than that!”

Me –“It’s fresh, you can’t always get fresh Challah.  A chunk of Challah, a smear of cream cheese, a slice of lox, lettuce and tomato”

Me- “What a schmuck.  Either shit or get off the pot.  It’s now or never!”

I DID NOT EAT THE CHALLAH. For me, losing weight requires a change of mind set.  “I live to eat!”  needs to change to, “I eat to live.”  Anyone who knows me knows that my motto is “Go big or go home.” I need to change my motto to “Go any bigger and you won’t be able to fit into your home!”

Writing this article is my declaration of independence from my refrigerator.  Now that I have publicly challenged myself to weight loss, I succeed or embarrass myself.  So, say a prayer and send suggestions. 

Here is today’s joke:

Her husband was so obese that when he weighed himself, the scale said, “Please tell your family members to wait their turn.’

Last night, I re-read Diets and Other Unnatural Acts.  I enjoyed reading it and still think it’s relevant and fun.  Unfortunately, Diets and Oher Unnatural Acts teaches and relies on eating healthy, exercise and a healthy attitude.

As my Parkinson’s worsens, exercise becomes next to impossible. On top of the Parkinson’s, I now have a Baker’s cyst (causing knee pain) and a lousy attitude.   My day starts when I stand in front of my bathroom mirror and marvel at how fat I’ve gotten.  I joke that the post office is considering assigning my own personal zip code.  I brush my teeth and resolve to take my first chicken steps toward improving my diet.  Then, I go to the kitchen and eat breakfast.  It’s 7 am and I finish breakfast at 10 pm. 

I count my blessings: my children, grandchildren, siblings and friends. I save my biggest blessing, Renee, for last.  I debate whether she belongs in my family list or breakfast list. On a good day, she makes both lists.  Talking about a good day, this week’s bad day is next week’s good day.  Anyway, my attitude of gratitude lasts a short time and is replaced by depression.

I’m hoping that my new handicapped-accessible van will make travel possible.  The thought lifts my spirits for a short time.  I turn on the news and am immediately bombarded by bad news.  By 9 am, my joints have loosened up and my meds are kicking in. It’s sunny so, at the risk of falling, I venture out to look at my garden. I’ve got lettuce, radishes, chard, parsley, celery and parsnip.  I smile realizing that I hire out my garden work.  A bunch of chard costs me $15 to grow. It truly is organic.  Next, I sit down to write.  My readers tell me that my articles are depressing.  Really? As I spit this stuff out on paper, I start to feel better.  Unfortunately, I have writer’s block which accounts for this article.  While I sit at the table typing, my refrigerator calls.  “Hey, come here, I’ve got food for you.  You’re not fat! Eat!

The doorbell rings.  There are ribs from Rendevous in Memphis.  I smile.  It’s going to be a good day after all.  I’ll start my diet tomorrow!

Learning to accept and live with a disability is not easy.  As a matter of fact, it’s much harder than I thought it would be.  Looking back in time, I thought I was good at counseling people with new disabilities but obviously was fooling myself.  I now believe that, to counsel a patient with a newly diagnosed disability, you have to have a similar problem yourself.

In other words, I underestimated the impact of being disabled.  I want to visit my brother in Tennessee when my handicapped-equipped van is ready.  My van has been converted by Braun with an in-floor ramp and a floor designed to lock in my motorized wheelchair.  So, step number one is done. I have transportation that will carry me and my 350-pound wheelchair wherever I go.

Step one gets me to my brother’s house.  Step number one was easy; it just cost big bucks.  Step number 2 is not so easy.  When I get there, how do I get into the house. Alan has steps at all entrances.  To get me into the house, Alan would have to build ramps.  Another expense.   Let’s assume that he goes through the expense of building ramps, I’ll need a handicapped bathroom. 

I’m in luck.  Alan has a handicapped equipped bathroom.  The catch is that it’s on the second floor.  No sweat!  He has a chair lift.  While the chair lift will take me up the stairs, for the most part, I can’t walk.  Now we have to get me from the chair lift to the bathroom and from there to the bedroom.  Point made! 

The logistics of dealing with a handicapped individual are near impossible to imagine.  I think my travel days are over.  Or are they?  I had to cancel my trip to Ireland.  My friends leave next week.  They’ll send pictures and we will Facetime.  I’ll use Google earth to follow their trip.  I’ll use YouTube as well.  Cyber travel is about the best I can do.  Google Earth will further expand my ability to walk the same streets they walk on.

Being handicapped is costly emotionally, physically, and financially.  I guess my advice should have been to be born to rich parents or work hard, save your money and invest wisely.  In other words, good luck!  I worked 7 days a week, sometimes putting in 16-hour days.  I did that for 35 years and still worry about the expense of a handicapped van, in-house assistance, etc.  In retrospect, long term care insurance would have been a wise investment.  And going to the gym on a regular basis would have built physical reserves I could sure use now.  On the bright side, cyber travel is now possible and I intend to use it liberally.

Today’s joke:  I’m going to rename my bathroom substituting Jim for John.  Insead of saying,” I’m going to the john,”  I’m  going to say, “ I’m going to the Jim.”  I may go to the Jim 3-4 times a day.  Impressive! I started a new exercise routine this week: do 100 crunches in the morning and again in the evening.
My favorites are Doritos cheese supreme and Lays

I’m invisible.  That’s right, most people don’t see me or any of my kind. When I say my kind, I’m referring to the handicapped.  You think that’s a ridiculous statement?  You want proof?   Let me present the case of the handicapped parking at our local Costco.  All you have to do is sit in the parking lot for 20 minutes and watch the able-bodied park in the handicapped spaces, easily exit their cars and march into the store.  Where are the cops when you need one?

Worse than taking up a handicapped parking space is taking up a handicapped toilet stall.  The next time you’re sitting in the handicapped toilet stall, look around.  See all the bars?  They aren’t there to play on like a child’s gymnastic set!  They are there to help a person with mobility problems get on and off the toilet.  The extra space is there to allow wheelchair access.  Yesterday, employes at Costco cut in front of me and occupied the handicapped stall.  Again, where are the cops when you need them?

When you sit in the “bellies and butts” section, the world passes you by.  The next time you’re tempted to park in the handicapped space or use the handicapped toilet, think of me and all the people who need those spaces and feel blessed that you don’t. 

Yesterday, several individuals spoke up, chastising the offender who was taking up space in the handicapped stall.  While I appreciated their support, I couldn’t help but wonder if any of the jerks who were violating the handicapped space had an AK and we would be on the 6 o’clock news.

Here is today’s joke:

Today I was offered sex by an 18-year-old female…Now, I’m not gonna lie. This chick was smoking hot. In exchange for the sex, I was supposed to advertise some kind of bathroom cleaner for her. Of course, I, being the great person that I am, declined because I have high moral standards and my willpower is very strong…..but not as nearly as strong as Ajax, the safe and affordable bathroom cleaner, now available in lemon and vanilla scents.

It’s time to reorient myself and get back to tackling the mistreatment of the handicapped in US airports.  Humanizing the plight of the handicapped in our transportation hubs is going to be near impossible.  That the task will be daunting it is still necessary!  We are going to need every passenger who has suffered the indignity of our present system to cry out and be heard by Congress.

First, a little story that will help you understand the reason that I believe changing the system will be almost impossible. When I computerized my office, I bought:

1. Computers
2. Network Hardware
3. Network Software
4. Medical Software

Whenever my program/computer crashed, the software engineers blamed the hardware engineers or the network hardware and vice versa.  A typical conversation sounded like:

Me: “My system is down.  We can’t input patient demographics.  I think the problem is in our medical software.”

Medical Software Engineer: “First have your hardware inspected, reboot the system, replace your keyboard, . . .  If you fail to resolve the problem, call your network engineers.  It could be a network problem.”

The absurdity of shifting blame has worsened over the years making it almost impossible to fix anything.  In the case of my office, I learned how to build and program computers, eliminating one player.  The remaining three still drove me crazy and wasted my money.

In the case of the airport’s abuse of the handicapped, the players are:

1. Prospect – the pushers
2.  The airport authority
3. The Airlines

The three play the game like experts, shifting blame constantly.

United Agent – “Prospect is responsible for having pushers and equipment in place when the plane arrives at the gate.”

Prospect pusher – “Our pay is so low that no one wants the job.  We are handicapped due to having to depend on old broken wheelchairs.  The customs agents work at a snail’s pace and can be downright mean. The airlines are booking connecting flights closer not allowing enough time to get to your next flight.

The airport authority simply fails to respond.

So, what can we do?  I think our best hope is to get 60 Minutes or 20/20 involved. I’ll send a copy of everything I have to their producers.  I’m asking that y’all do the same.  If you or a friend has had a bad experience, please write about it and publish it to the internet.  Please write 20/20 and 60 Minutes.  Complain to the airlines, Prospect and the airport authorities. 

Here’s todays joke:

The police just pulled me over, he came up to my window and said, “Papers?”  I said, “ Scissors, I win” and drove off.
I think he wants a re-match. He’s been chasing me for 45 minutes.

Over the past months, I’ve written about the loss of bodily functions caused by neurodegenerative diseases such as Parkinson’s.  Yesterday, I wrote about the stigma of suicide or a more dignified end to a life ravished by neurodegenerative diseases.  So, how does a person decide when to call it quits?

From my point of view, it all boils down to how you describe “quality of life.”   As everybody assesses quality differently, the answer to “when to call it quits” is different for everyone.  Quality of life should be high on the list of items discussed with your family and your physician.  As it stands right now, my “quality of life” ranges in the “it sucks” range.  It’s about to get better.  The movement disorder doc I see referred me to a specialist in adaptive devices. 

In a 2 ¾ hour session, she assessed my need to be mobile and measured me for a customized motorized chair.  I’m currently using a loaner and the quality of my life has already improved.  It has made functioning in the house a less exhausting and less painful experience.  I’ve sold my BMW and I’m outfitting a van so that I can take my chair with me.  It will be great to get out of the house.

The word, disease, breaks down to “dis” and “ease”.  In other words, it stands for lack of ease.  Anything you can do to make life easier is worth it.  If you have a progressive neurologic disorder, talk to your doc about ways to make your life better.  If you’re at the end of your rope, discuss that with your doc and family as well.

End of life conversations were among the hardest things I had to do as a doctor.  Patients were always surprised when I found them a longer rope.  When no additional rope was available, prepping the family and my patient often made a big difference.  Most people think Hospice is for cancer patients.  Hospice is for all end-of-life situations and can be a great asset in helping people die with dignity.