Fabulous Prizes II

As brothers our troubles are 
Locked in each other's arms
And you'd better pray
That they never find you
'Cause your back ain't strong enough
For burdens double-fold
They'll crush you down
Down into nothing.

-Townes Van Zandt

There is no alternative to black humor at the county hospital.  Rather, there is no survivable alternative.   If you are too sincere in your pursuit of the monster, you might actually catch it, and then you would have it in your arms.  This is clearly what happened to Townes in the epigraph above.

Morbid jokes supply an artful way of perverting the awful clarity with which you might see your patients, their situation, and your implication in it.  There are better and worse ways of executing this caper, this feigned stumble in pursuit of truth.

One of the worse ways to do it is to make jokes at the expense of patients - to mock the loud demands of the drug-seeking patient for i.v. Dilaudid (tm) or his implausible claim that he's allergic to the oral preparation.  I try not to do this, because in addition to being prima facie disrespectful, people who develop a facility for these jokes become calloused and uncouth.

A better way is to find the joke - this is the equivalent of dumpster-diving veal.  You're not actually paying for the calf to be shut up in a box; likewise, you're not actually mocking suffering, you're just noting its occasionally intrinsic comedy.  You can enjoy the surplus products of institutional cruelty without financing it.  You just need a morality which is more concerned with contingency than with essence.

Anyway, I found the best awful medical joke I have yet discovered in a chart in clinic the other day.  It was so good, in fact, that after close review by the Committee the author has been awarded another of my unsolicited prizes, the widely coveted "Most Concise Argument for Healthcare Reform" award in the Medico-Legal Documentation category.

I was seeing a patient for a colleague on leave, and I came across the following sentence, which she had written without any apparent irony:

Pt is a resident of the US but could not wait for appt with Adult Medicine so he went to Korea for diagnosis.

But this is not quite the best part - it's wildly hilarious, of course, that the waiting list for our clinic is so long and the private hospital alternatives so expensive that somebody would fly to Asia to avoid both.  But what swayed the Committee was the fact that the diagnosis the patient received in Korea was one of papillary thyroid carcinoma in situ, which is to say that he had a very dangerous tumor in his thyroid gland which had not yet spread.  The difference between papillary carcinoma in the thyroid only and metastatic papillary carcinoma is the difference between a minor operation and probable death.  He was smart to go to Korea; he waited "for appt with Adult Medicine," he might well be getting palliative radiotherapy right now instead of enjoying his cancer-free life with his wife and young children. 

He returned with his diagnosis and had his operation here, although I'm not entirely sure why.  He was taken a little more seriously when he presented his pathology report from the Seoul University Medical Center.  I'm thinking of advising my uninsured patients who can afford the initial investment to take their health problems to Seoul.  As a matter of fact, when I finish residency and lose my employer-mediated health insurance, I may join them. 


안녕히계세요!



  

The Archivist

Everybody knows Dr. T..  He has been at the county hospital, minus some stints at other facilities, for around forty years.  He came here from Brooklyn after finishing his pulmonary fellowship in 1962.  Forty years have not dulled his strong accent.  He is recognized as a deep well of knowledge and experience and frequently consulted about inpatient cases.  He is also to varying degrees notorious for being, as he proudly proclaims, "the only conservative" at the county hospital, and for baiting his liberal colleagues relentlessly with various conservative talking points.  He was most recently reviled for his vocal support of Sarah Palin, which he taunted the more progressive members of our already left-leaning faculty at every public opportunity.  I was on his service once before, as an intern, and when he found out I went to medical school in England he was delighted by the opportunity to explain the pitfalls of socialized medicine to our team.  At the end of my rotation he gave me a generally positive evaluation then handed me an two articles - one on the great global warming conspiracy and one on the inevitably Stalinist destiny of any government-run healthcare program - and said, "You don't know this yet, but you're a project of mine."  (I didn't mention that he is also a project of mine, in that I am still trying to figure out why a man so dedicated to free-market economics and living with the consequences of the choices you make has chosen to spend his life treating the unemployed, the homeless, the addicted, and other "non-productive" members of society, for which service he is mainly reimbursed by Medi-Cal and other government-run systems.)

He is also famous for his apparent immortality.  He is in his early seventies, but looks about sixty.  Only if you look closely at his hands can you detect the slight wasting of the small muscles that comes with old age.  His skin is relatively unlined and his hair and beard are still very much more pepper than salt.  His constitution and conduct of his daily activities seem unfazed by seven decades of active life.  He can still deliver two-hour extemporaneous lectures on most subjects in his field which are focused and coherent, and his appraisal of the cases he consults on is always clear and subtle.  When people comment on his miraculous mental and physical preservation, he attributes it to his diet, which, as far as I can tell, consists mainly of blueberries, strawberries and green tea.  He always has a large tupperware container full of the former in the battered backpack he brings to work, and a box of the latter on his desk.

But these are all relatively minor features of his repuation.  What Dr. T. is really famous for is his free-standing, completely illegal one-man Medical Records Department.  Everybody who works at this county hospital, and probably any county hospital, is engaged in a constant, losing war of attrition with Medical Records.  Every doctor has had the experience of seeing a patient for a return visit after seeing them a month before, opening the chart to where the last note should be, and finding nothing.  The unreliability of Medical Records in their ability to produce the patient's chart, and even in that event, to produce it in an unmangled condition containing the information that was in it the last time you saw it, is so widely known that almost all clinics maintain their own "shadow files" on their patients.  These are simply photocopies of clinic notes or hand-written summaries - they contain no information about what has happened in other clinics, but at least they save you from having to ask somebody you saw two weeks ago what the plan was at that point.

Dr. T. decided a very long time ago that this was inadequate.  He maintains a comprehensive library of shadow charts for every patient he has ever seen.  He makes them himself out of scratch paper which he tears into corners and sticks together with scotch tape.  These "pages" are then covered with his characteristic scrawl.  New pages are added every time he gets new information about the patient, which is as often as possible, and as much as possible.  New interns on the service are often shocked by the volume of data they're expected to record, duplicate, copy, and present for every patient.  Dr. T. stops them continously as they present patients they have seen to him in his office, asking for pieces of data they never thought to collect:

Intern: So Mr. Jones has been doing well overnight.  His temperature this morning was 98.6, although he did spike to 102.1 last night.

Dr. T: Uh huh..., and what time was that?

Intern: Last night.

Dr. T: Yeah, you said - but what time was it?

Intern: Um...I'm sorry, I didn't write that down.  He also had a chest X-ray this morning that showed -

Dr. T:  Oh, good.  Do you have the report on that?

Intern:  No, but it showed -

Dr. T:  Too bad.  When you getta chance, could you print out the report on that for me?

Gradually, they learn to collect every number within twenty feet of the patient's bedside and print out every piece of data that has been entered into a computer.  The difference, they realize, is that while other attendings they have worked for are content to know that a chest x-ray report is uploaded to the data reporting system and they can look at it whenever they want, Dr. T. has adopted an attitude of radical mistrust towards all hospital data.  If it's not printed out and scotch-taped to something in his office, it is in danger of vanishing into thin air at any moment.

Because of this obsessively acquisitive orientation to data and his...organic style of organizing it, his office is a mess.  Actually, it's more like a Superfund site.  It's the kind of mess that can only be made over a period of decades.  There are two large bookshelves which are completely stuffed with old journal issues, ancient textbooks, and innumerable scraps of apparently irrelevant paper.  The desk has only one small clearing near his chair where he keeps the scotch tape and his scratch paper - the rest is piled about a foot high with loose leaf.  These strata are mainly composed of journal articles he's used for teaching and redundant data which didn't make it into the charts.  They grow every day and every day become more precarious, until there is a predictable but always dramatic landslide.  An intern gets up to hand him something, catches their scrubs on the corner of a stack, and swoosh, an avalanche of disjointed confidential medical records come sliding down around their feet.  At this point he usually makes some joke about how carefully organized it was, and how long it will take him to put everything back in order, before adding the debris to one of the even more extensive piles of paper against the walls.  Because they are stabilized, some of these have attained heights of several feet and because they have been built up a few sheets of paper at a time they are extremely old.  So old, in fact, that there is a noticeable color gradient from the new, white sheets at the top to the yellow, cracked ones at the bottom. 

The fact that he has been doing this for years is also apparent from the frayed, yellow edges of his little coverless charts, and the presence of type-written reports towards the back.  He takes those pertaining to current inpatients home with him every night and on the weekends, and he keeps the rest in two enormous filing cabinets which dominate what would otherwise be a spacious office (although one assumes that if they weren't there their place would be taken by stacks of paper big enough to actually hurt people when they eventually fell over).  There is no apparent system to the charts' disposition in these cabinets.  When he opens them, all anybody besides him can see is a mass of indistinguishable shreds of highlighted paper.

But not only does he know where everything is, his completely insane, time-consuming, ad hoc medical records system actually does work better than the official one.  I'm currently the pulmonary resident, and I've been approached by residents on other services several times saying something along the lines of "Hey, we got this lady last long call - she's got bad pulmonary hypertension, and I know she's been here before, but there's no reports in the computer and Medical Records say they don't have a chart.  Would you ask T. if he's got anything?"


When I do, he rises slowly from his chair, repeating the name a few times to try to jog his memory, and then after a moment of shuffling, triumphantly draws a ripped, tattered collection of quarter-sheets from the depths of a creaking drawer.


"Ah yes," he says with a triumphant smirk, "Mary Johnson.  So, this is a thirty-five year old lady with a history of diabetes, who we first saw in clinic in 1998.  We did some pulmonary function tests," he unfurls a full-sized sheet that had been carefully folded into quarters and taped into the chart, "and we found that she had a normal FEV1/FVC ratio but markedly impaired diffusion.  She was supposed to come back to clinic in two months, but she missed her appointment, although she did get her outpatient CT done in April of that year.  Then, in August...."


I scribble down the things I think will be relevant to the other resident, and thank him.

"Yeah, well," he says, "this is my cawling, ya know?  I coulda been a great baseball player, I coulda been a great cardiac surgeon, but I decided, when I was a boy playing stickball in the streets of Brooklyn, I said, 'I wanna be the Chief Librarian at the county hospital.'

"As a matter of fact, Ben Bernanke was on the phone this morning," he continues, "To see if I knew anything.  He wanted to know if I had any records of what happened, you know, back in October."

I admire the commitment to a clear and comprehensive understanding of his patients that's implicit in this continual frenzy of data collection and collation - but I'm fairly horrified by what its necessity implies about our organization.