Doctors -- especially surgeons -- are expected to maintain a sense of decorum and professionalism at all times. I'm a board-certified neurosurgeon at a major American academic center, and while medicine is an incredibly rewarding career, it puts you in contact with a lot of people doing dumb, terrible things to their bodies. So, on behalf of frustrated doctors everywhere, here are a few things I'd love to say to my patients' faces if it wouldn't land me in another sensitivity seminar.
Every ER has its stories. And, yes, there are all kinds of anal-insertion stories. Thanks for asking. I'll give you one:
An enterprising young man soldered a long steel rod to the end of a surprisingly large dildo. We assumed it was so that he could still grab it when it was, well, inserted. But apparently it didn't help, because the dildo got stuck. Really stuck. And now the guy had a metal rod protruding from his anus.
If you're wondering how we get something like that out, well, we have tools ...
They may scare you, but this guy had an orgasm as soon as he saw one.
... but you're skipping the hard part -- how did he get to the hospital? He certainly couldn't sit down -- so no car or taxi. It's not the sort of thing you call an ambulance over (you get stuck with the bill if your insurance judges the situation not to be ambulance-worthy). So, he found the baggiest pants he owned and walked/limped miles to the hospital, presumably contemplating all of his life mistakes with each painful step. It's the kind of thing he'll probably leave out of his biography if he should ever run for office.
It's always males who have the anal-insertion disasters, by the way. Ladies, you're welcome to prove me wrong, but please don't, actually. I see way too much of that with just the one gender.
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But it's females who get humans removed through their vaginas, so I guess it evens out. Not really.
Here's one of my personal favorite stories from my time in the ER: A couple was seen by their family practice doctor earlier in the day for the wife's constipation. The doctor gave her two boxes containing enemas. For those fortunate enough to not have used these, each box contains enema fluid in a bottle with an uncomfortably long spout. This poor, hopefully illiterate woman took one look at that spout and knew exactly what it was for: drinking.
But that's not why she came to the ER. No, she only saw us because she hadn't wanted to drink the second bottle and wanted to see if she could get by with just the one.
I asked the husband: "Did these come in a box?"
"Are there any instructions, say, with pictures, on the side of the box?"
Long pause. Then:
"So is it a problem if she drank the enemas?"
"Hers and the public education system's, yes."
Professionalism. I didn't crack. In fact, because I'm a good doctor, I called poison control, and because I'm a better human being, I immediately muted the phone to hide the peals of laughter ringing on the other end. But hey, laugh all you want -- the enema still worked. But the woman suffered horrible, horrible abdominal cramps. In this case (in this ONE case), anal insertion is preferable.
There is a specific code in our manual that means "Patient was injured while landing a spacecraft."
Why? Well, medicine is like everything else on the planet -- it all runs on computers. We have to carefully catalog every little thing that's wrong with a patient, and, since this is all getting entered into a database somewhere, it needs to be done in the form of a code, so the insurance company and the government know what we're asking them to pay for. Makes sense, right?
Why describe the illness? The seven-character code saves so much space!
Well, give me a moment to explain the utter insanity of this system. First of all, there are a lot of fucking things that can happen to a person (see: Modified Dildo Accidents). Right now, we use a list of codes called ICD-9 (International Statistical Classification of Diseases, Volume 9). That little beauty contains roughly 15,000 codes. And if you think that surely covers every possible scenario a human body can encounter in the natural universe, well, the government disagrees. They're about to unleash ICD-10, and for my profession, it's Y2K (look it up, kids) and all the bad parts of the Rapture blended together and then spiked with a shot of Mayan Apocalypse. You see, ICD-10 has roughly 155,000 codes. There's a code for everything, and I mean everything. Examples:
T63622A -- Suicide by jellyfish
V9542XA -- Injury during forced landing of a spacecraft, initial encounter
V9107XA -- Burn from water skis catching on fire
V9840XB -- Genital injury sustained from Klingon Mating Ritual
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"Neck injury while attempting oral on a dryer" of course falls somewhere under "W231XXA."
I'm not whining about having to do complicated paperwork -- I know nobody is going to feel sorry for anyone making a surgeon's salary. But if I code a Medicare patient incorrectly, it's fraud. Against the federal government. I could go to jail, and while I make good money, it's not enough to pay for one of those fancy prisons the guy got in Wolf of Wall Street. What if I code for a lesser amount of money, just to be safe? That's fraud, too! It has to be perfect, every time.
And soon everything will be based on this new system, and it will be virtually impossible to do it right. Insurance companies don't know what to do with it. No one knows how it will affect billing. We've actually been told to expect to not get paid for three to six months once it starts. And we're not alone. Hell, 65 percent of clinical documentation doesn't include enough data for doctors to even make a code under the new standards.
Don't ditch your hospital and try your local shaman. She doesn't know the codes, either.
The conversion happens October 2015. So yeah, party your asses off this Halloween. Break out the vodka-soaked tampons and start all the fights you want. But next year, maybe just stay inside and avoid injury until we get this sorted out.
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For a doctor, back pain is a nightmare.
See, there's no way to "prove" pain -- it's not like blood pressure, where we can hook you up to a machine and generate an objective number. We can't just go by the amount of detectable inflammation or damage, either, because if you have a low pain tolerance, you might really need the pills, whereas someone with a high pain tolerance would be just fine without them. Have I mentioned that those pills are habit-forming narcotics? Yeah, now you're starting to see the problem. When you hear that back pain is one of the leading complaints of people seeking disability payments, you see it even more clearly:
Some of these people are lying.
Maybe not this guy, but some of them are for sure.
So, I'll look at one MRI and see what looks like a big herniated disc and have the patient skip right out of the room, insisting they feel fine. Then I'll get a young, otherwise healthy man with a normal scan who's limping in like he's fresh out of the opening scene of Saving Private Ryan. So, us doctors are forced to make huge decisions that impact these people's lives -- proof of disability for benefits, and prescriptions for addictive medication -- and in many cases it is impossible to know who's being honest.
I've had people whose immediate response to "You need surgery" was "Does this mean I can go on disability?" And they never ask that with the tone of dawning horror you'd expect from someone who just suffered a life-altering injury. No, they take the exact same tone as a 5-year-old asking if Santa's going to come tonight. But just because that person exists, it doesn't mean the next one isn't telling the truth.
When they jump out of the chair and start dancing, I get skeptical.
And it's hard not to let your feelings toward one patient carry over to the next -- I'll see a little boy who has just come out of surgery to have a tumor carved out of his spine excitedly talking about how all he wants to do is be well enough to get back on the playground, then I'll see a 40-year-old man demand narcotics ("Other medications just don't work, Doc! I'm allergic to Motrin and Tylenol! I can only take Percocet!") and weave a sad story about how he really, really wants to work, but just can't. Think Cousin Eddy from the Vacation movies.
And this becomes part of the diagnosis. In elective back surgery, we all look for red flags like chronic unemployment, a long history of workman's comp claims and frivolous lawsuits, and a fine, connoisseur's appreciation for methamphetamine. It's actually scientifically reproducible that candidates with those factors in their background are less likely to recover. Because they don't want to.
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"And give up all this?"
But I have to be professional and empathetic, and hey, maybe this next guy's not lying about how much pain he's in. I can't start spewing sarcasm, Dr. House-style, or sign my name on the prescription pad as a little drawing of a hand giving the middle finger. But I still want to say ...