Solstice 2021


Solstice, 2021

Washington, Pacific NW





Dear Ones:



—“It was the best of times, it was the worst of times…”
  

  Welcome, Friends, to my 30th Annual rueful ruminations on the occasion of the Winter Solstice.  You may harken back to High School, and your last known exposure to Dickens in actual print, as told by that helpful feller, Mr. Cliff Notes. (No, watching a Hallmark version of “A Christmas Carol” doesn’t count.) The year 2021 may inspire future Dickenses to write ‘A Tale of Two Cities’, except that George Orwell has already written this version, with a post-script and commentary by Margaret Atwood.  We started this year well enough, looking forward to a peaceful transition of power, a proud American tradition, even as we died like flies, or more aptly, like lemmings, of a plague we know how to control, but just won’t.  More than 800,000 of us have died thus far, perhaps half of that number preventable.  Then, only 6 days into the shiny new year, we witnessed the storming of the Bastille, by minions of a fascist, antidemocratic conspiracy, which hoped to topple the world’s oldest democracy from within.  As I have said here before, no country or group of countries on earth could prevail over us from without.  If America dies, it will be from a self-inflicted wound.  We were grazed by our own bullet.



—“It was the age of wisdom, it was the age of foolishness…”
   

    Even the victims of the mob attack, after cowering in the House chamber and escaping out the back door, have closed ranks around the conspirators, made lame excuses, laid false blame elsewhere, and generally ignored and hidden the plain facts, in an effort to regain power. This violation of their solemn oath to “defend the Constitution, against all enemies, foreign and domestic,” has no apparent cost, neither criminally nor politically, and has happened without hesitation, as they protect tribe over country, and power over the rule of law.  Despite many subsequent faults, I must commend Mike Pence, for doing the right thing when it mattered.  Also, Liz Cheney, and Adam Kinzinger, my two new favorite ‘Pubs', deserve hearty praise.  I propose that Joe Biden give each of them a Presidential Medal of Freedom. I love awkward moments.



—“It was the Epoch of Belief, it was the Epoch of incredulity…”
    

    Here, Dickens and I diverge, or perhaps converge, as blind belief has led to incredulity. A US Senator announces that mouthwash will prevent COVID. Thanks, Ron Johnson, for this Nobel-worthy discovery.  Except neither his hogwash nor anybody’s mouthwash do any good. Religious hucksters proclaim to their flocks against vaccines, masks, and social distancing, the top three weapons we have against the plague. (Really?? And you call us ’Sheeple’??)  They flog ivermectin, vitamins, hydroxychloroquin, prayer, herd immunity, and God’s personal protection, secured by cash donations…And their flocks are dying at thrice the rate of the rest of us.  That does not make me glad.  The real problem is that many innocents exposed by the credulous anti-vaxxers also die, so these ‘personal choices’ have lethal consequences for others.   ‘Do unto others’ takes on a new meaning, I guess.  But send us 10% of your income, or all of your income, and be saved. Operators are standing by.   Nobody has any sense of irony anymore…Nobody has any sense of common purpose or public duty anymore either.  Prosperity Gospel means Devil take the hindmost.  Run, Forrest, Run!  Devil gon’ getcha!
 

—“It was the season of light, it was the season of darkness…” 
    

      It is indeed dark here in this season, at least here in the frozen North.  That is why god invented Snowbirds. And Arizona.  It is an excellent time for taking stock, doing small, neglected projects, and counting the days until the return of the sun.  With that return may come common sense and purpose, and enough daylight to actually get something accomplished. We do have our little routine here, with an hour of 40hz light and sound, to ward off Alzheimer’s disease, while doing email and whatever, (this works in Alzheimer’s-prone mice, so we call it ‘Mouse Disco’.) Then come the actual chores of the day, followed by a survey of the news in the afternoon, with legal commentary from a variety of folks, including former Federal Prosecutor Glenn Kirschner.  I am really appreciating my law degree these days, as I can follow and anticipate the commentary better with it, than without.  Darkness is definitely present, in so many ways.
 


—“It was the Spring of Hope, it was the Winter of Despair…”
    

    I am doing my level best to cling to the spring of hope, and ride out the winter of despair.  I cheer myself with the latest adventures of ‘Florida Man’, and Karen, and I avoid tabloid press and celeb ”news” almost as much as I do COVID. I do follow the real news, and await the slow grind of the DOJ and justice for all.  WTF is up with all this shooting??  Everybody is mad as hell, and they ain’t gonna take it no more…I sure don't cross anybody in traffic these days, mindful of armed road-ragers among us. Well, anyway, with the arrival of Spring, I look forward to the release of Trump-branded Soap-on-a-Rope, Trump-designed rubber prison slides, and a Trump line of personal lubricants. I suspect he will have more chance to read mattress tags, than ever he had to read the Constitution.
 

   
    In my little tribe, no major disasters have occurred.  Two kids have had and survived COVID,  pre-vaccine release, and now all are vaccinated.  Mom is nearly 92, and doing reasonably well, living in her own apartment, with lots of help.  My sibs are likewise well and good, all things considered.  Michele (44) has sold her Yoga Studio in Columbus, and is enjoying part time work, and more family time.  Husband Eric has bought a Cessna, and is flying them about.  Lily (14) is a high school freshman, and is taking flying lessons(!) while older brother Jack (16) is driving and looking at colleges.  Nathanael is employed in San Diego, doing personal training, and doing his drawing in his spare time.  Mickey the boxer keeps him company.  Hannah (35) is in Phoenix, in her last year at Mayo Med School, interviewing (Zooming) at Emergency Medicine Residencies.  We will discover where she lands in early March, on ‘Match Day’, when the Match Computer will decide matters.  She has a  little rescue cattle dog she loves, and who loves her back.  Everett (33), our award-winning poet and author, continues his work in DC for a VA contractor, editing grant applications and the like.  Catherine is becoming a ‘Master Knitter’, requiring exacting precision, following directions (never her strong suit) and submitting samples for criticism, and then re-working them.  This requires, apparently, a lot of cursing.  You wouldn’t believe the strings of sailor-worthy expletives she belts out. Think Barbara Streisand not getting a table at Regine’s. Think Ethel Merman at the end of Mad, Mad, Mad, Mad World.  Does our sailor Hannah proud, she does.

      As for me, I have spent much of the year in boat husbandry.  The plan was to go to SE Alaska last May, but various unsolved and unanticipated problems prevented that, so that plan is deferred to this coming spring. I/We have done tons of upgrades, and tons more to go.  None critical, just home improvement stuff. I have recently had second thoughts on the name of the boat.  'Tortuga' is sweet, and descriptive as to speed, but another name has occurred to me:  'Pole Dancer'-- Because, she works for you as long as you keep throwing hundred dollar bills at her. It would be better still, if I had some Polish ancestry, but I cannot claim that honor.  I must also note, I have officially retired, as of December 7, 2021, a day that will live in infamy.  I am keeping my licenses for now, in case the stock market goes to hell, but I have no plans to work, and I love, love, love getting up each day and doing what I want to do.  In celebration of the day, I had a glass of $2,000.00 wine.  It started out as $10.00 wine, but after I dumped the fresh glass onto my MacBook Air keyboard, it was $2000.00 wine.  A little bitter, at that price point.  I will miss my work mates, and the fount of bizarre stories that work always provided.  So, indeed, might you, as my life becomes old and dull, and this letter just another Xmas letter-bore. I do have some collected sayings for anyone of the not politically correct persuasion, available as “Shit My Doc Says” on bobchristopher.blogspot.com .   I deny in advance, any and all of these quotes attributed to me by wily scribes.  Fake news, nothing but fake news. 

    Also on the work front, on my last shift, it was relatively “Q” , and I therefore had time to talk to patients.  I had to give new cancer diagnoses to two patients, one who suspected as much, and one who did not.  I had the 30 minutes each to sit down, prep them up a bit with the coming bad news, tell them, and then answer questions.  One was hard of hearing, so that was excruciating, repeating everything in a holler. "I THINK THIS MAY BE CANCER!!"  But it was worth the effort, and worth the time I was fortunate to have with him and his wife. The other was a very intelligent émigrée, who had escaped from the Communists just after the war as a child, and became an Ivy League nursing researcher.  She knew the news would be bad, and we talked a long time about controlling one’s ending, about dignity, about pain and anticipation, and about the opportunity many never get, to seek closure, to say farewell, to say I love you.  What a privilege, on my last working night, to talk with such an accomplished and intelligent person on such a deep and personal topic.  Yes, I will miss all that and more.  It has been a good run for me.

      I pause, as every year, to note the passing of some luminaries, and some blots on the landscape of our lives.  First, a sad farewell to the 800,000 lost so far from COVID.  There is a long list this year, but I will spare you.  So many entertainers, so little time.  Farewell to Cicely Tyson, Hal Holbrook, Ed Asner, Cloris Leachman, BJ Thomas, Yaphet Kotto, Helen McCrory (NOT Narcissa!), Jackie Mason, Michael Nesmith of the Monkees, Charlie Watts of the Rolling Stones, and Dusty Hill, of ZZ Top.  Politicians Bob Dole, Max Cleland, Colin Powell, Ruth Ann Minner , and Walter Mondale are history.  Public scoundrels Phil Specter, Bernie Madoff, Rush Limbaugh, Larry Flynt and Televangelist Marcus Lamb have made their escape, and good riddance to all of them.  Sportin’ Lifers included Tommy Lasorda, Hank Aaron, Al Unser, and Lee Elder, first Black golfer to play in the Masters.
    

    And so, Friends, Neighbors, and Countrymen, whether we agree or not, the earth continues to orbit on its slanted axis, and the light returns to our hemisphere in the spring.  No matter, whatever else transpires in our little tempest, the Universe don’t care, the Universe don’t give a shit.  Only we do. Or at least we should.  Let us draw together against the madness, hew to the truth over purposeful, evil fiction and alternative facts, reassure our youngsters that all is not lost, reaffirm the better angels of our nature, and forge into our future with purpose and stout hearts.  I wish you all peace, prosperity, health, security in insecure times, and most of all, courage to see, and to do what is right.  You WILL know it when you see it, but it may be hard.  Hard times require hard choices, but I trust you all to remain in the light.



—“It is a far, far better thing that I do, than I have ever done; it is a far, far better rest that I go to, than I have ever known.”

   

                

                            Bye, Best, and
                               

                                 Better times ahead,

                                        B
                                     




                           

I have a theory I want to record, just for the sake of recording clinical observations.
 
There is a neural reflex within the sensory fibers of the Fifth Cranial Nerve, and the sympathetic and parasympathetic supply to the nose.  When you have a cold or other cause of nasal congestion, and you lie on your side to try and sleep, there is a sympathetic reflex which causes vasoconstriction in the superior nostril, opening up the nostril by inducing vasoconstriction.  When you roll over, the formerly superior nostril becomes congested, and the newly superior one experiences vasoconstriction, again allowing you to breathe.  This happens in the absence of significant mucus (or with mucus), but is not simply the result of gravity-driven mucus flow. It happens in a dry, allergic nostril, just as it does in a wet, secretory nostril.  This is an “N” of one, but I am sure it is true.

SHIT MY DOC SAYS
A long-time collection of various utterances from the mouth of the doc of the night, recorded in real time by scribes.

    •    Re: Manipulative Therapy.--"I'm not paying $100 for a neck massage. You could get a happy ending for that.
"

    •    "Let us go and snatch her from the jaws, nay, floss her from the very teeth of death." 


    •    "I guess they could do an assay for serum bat shit level."

    •    "Huzzah, Dr. Geargrinder actually did something useful!   Be still, my beating heart." 

    •    "Let's get Cray-Cray outta here. She gon' need an exorcist. We don’t have one of those on call.  A padre, but no exorcist.
"

    •    "No, I can’t do your toenails.  You’d need a farrier anyway.
"

    •    "First thing is to give her a cold vinegar douche and we'll go from there."


    •    "That's another one I'd like to haul through the phone and beat the fuck out of. 
"

    •    "I've gotta go download some nitrogenous waste and then I'll be back."

 
    •    On being “butt dialed” on voice page device: "No, I do not want to listen to you breathing heavily. It's an obscene Vocera call. (voice rises an octave) What are you wearing?
"

    •    To the resident: "You might not want to pick this one up, this late in the shift.  She usually comes in near death stewing in her own juices."


    •    "He looks like he escaped from Dachau." 


    •    "He looks like death warmed over. Just put him in a brown paper bag and microwave him. Keeps the moisture in."


    •    *referring to a totally sedated, comatose, intubated patient* "What a chatterbox. God, I thought we were never gonna get out of there." 


    •    Talking to the hospitalist, on the phone, awaiting another ER doc to take the call, a former Big 10 All-American linebacker—“I'll transfer you as soon as I see the continental drift approaching… Here he comes. I feel the earth move.”


    •    *Speaking to an alcoholic patient* "When you die they’ll bread-slice your liver and make sandals out of it.
"

    •    "We could just lace her Vodka with Coumadin. Here, Bitch, have some rat poison."


    •    referring to Dr. Bogart’s 'nurse-canceling headphones':  "Don't borrow them though, you'll catch hearing AIDS."


    •    "That one’s BATL: Been Alive Too Long."

     •    "Say you've got 100 lesbians and 100 Congress members in a room. What do you have?  200 people that don't do dick."

 
   •    Me-- seeing a patient’s name show up on the tracker— "Oh yeah that guy comes in all the time self-diagnosing. He always thinks he has pneumonia". - Dr Jones—“He hasn't been here for a year!". Me - "I still remember his name, and once again, his chief complaint is, ‘I think I have pneumonia.’”


    •    Talking about how he hates Dr. Y:  “I looked up Y in the Hindi dictionary and it means 'dick'.
"

    •    Talking about Dr. X:  "Look that one up, too.  It means 'Lazy'.
"

    •    "This rotund 65 year-old troll rose tonight from beneath the dank, dreary depths of her bridge to plague us tonight with her many unrelated complaints."


    •    "He’s just a case of acute on chronic asshole." 


    •    *referring to Nurse Ratched*  “She’s markedly improved, to sub functional.”

 
    •    Scribe—"What’s this one's diagnosis?"  
Me—"Death, acute on chronic." 
Scribe—"Epic probably doesn’t have that one." 
Me—"Unlucky bastard?
"  Scribe—"Don’t think Epic would have that one either." 
 Me—"Snake bit, then. I know they got that one.
"

    •    "That is one snake-bit motherfucker.
"         

    •    Nurse—"You gotta do something about that patient screaming in the back."   Doc—"We’re gonna order a muzzle and a ball gag."

 
    •    "Yes my handwriting was terrible. I had pee from the urine sample cup on my hand, and was trying not to get it on my pen." 


    •    *Referring to playing videos on the TV the tracker board:  "Bad idea.  I used to work with a guy who got us in trouble over that. - He wouldn’t play Disney movies on there, he would probably play Debbie Does Dallas; he had no shame.
"

    •    *to Dr Z* *** "You, being disgusted? That’s like a maggot gagging." 


    •    *loudly retching patient passes on a gurney* "You know what that is? That’s T. Rex for 'I love you!'-- Raaaawr!"

    •    Referring to an unseen patient in a room, retching audibly:  “It’s Ralph!”

    •    "I don’t know what it is about loud retching.  It just makes me laugh uncontrollably.  I can barely stifle my laughs and tears, as I stand there and say, “There-there, There-there .” It is sort of like watching dogs fucking.  Nothing to do but laugh.
"

    •    "Dr. Y? Oh, he underwent a personality bypass a long time ago. Complete success.
  That Neurosurgeon was a genius"

    •    Referring to an 84 year-old female drug seeker chronic pain patient - “She is a crusty nasty old gargoyle. If you went to the downtown cathedral and look up, you would see the left tower gargoyle is missing”. Also:  “You could stick her in a shallow pool with water streaming out her mouth and people would throw pennies at her”. 
 

•    Referring to a patient with an ankle injury  in a cast-splint:  “I doubt if she’ll be able to clump around on that thing, she may need a walker.”


    •    "Glasgow Coma Score of three? A bowl of jello has a GCS of 3. Hey what’s the difference between a bowl of jello and your wife? A bowl of jello moves when you lick it."


     •    "This is an acute exacerbation of chronic tortoise inversus. You find a tortoise on its back, waving its flippers, saying "Help me!  Help me!",  so you flip it over.  It right away flips back over and starts waving its flippers again."


    •    "Worst case of Dramatic Fever I have seen in years.


    •    "Positive for cocaine? How ‘80s."

 
    •    "All I’m saying is that there is a clinical correlation between homosexuality and how far a man’s shorts are above his knees."


    •    *referring to a patient positive for meth, MDMA, opiates, and cocaine, who was asking for Ativan for withdrawal and also wanted him to look at his genital sores*   “This one’s going to change the world. I can already see it.”


    •    "What do you think? Is the iPhone 4 that is disabled for two days a fair trade for Percocet and codeine? He said he has a back thing, I bet it’s really been bothering him."

 
    •     From a Nurse complaining about a patient at the end of her shift:  "I still have one more hour with her…"  Doc:  "Well she might die sooner than that. You have to be optimistic."

 
    •    Patient:  "I don't know the names of my medications...one pill is blue."  Doc:   "Hmmmm well I don’t know of many blue pills. The only ones I know of are naproxen for when you’re stiff, and Viagra for when you’re not." 


    •    *referring to Dr. Prattmonger* *** "Man when he started here he was god awful. Luckily now he’s just awful."


    •    *Third patient in a row comes in for some form of chronic pain*  "Well, I’d say it’s about time I go anger another narcotic seeker. Maybe if I suck his dick instead, he’ll give me a 5 on the Press Ganey Survey. That’s basically all I’m here for nowadays, not prescribing narcs and sucking dicks. Now that’s what emergency medicine is all about."

 
    •  "Dr Mandrake’s got two patients,  Dr. Mapplethorpe’s got four. They have all been back over three hours.  There are nine in the waiting room that have all been here over an hour and a half, and there isn’t an order to be found. Huzzah. I see we’ve really been working hard this evening."


    •    "My exam? Look at this prior visit note! Well first of all I disagree that she’s pleasant. Jesus fuck. That bitch is a troll,  an asshole, hell, I’d even say she meets See You Next Tuesday criteria. (Later) Hangs up the phone after hospitalist accepts the patient:  “Oh, you fool.” 


    •    "He doesn’t even inject, he just snorts heroin. What a pussy."


    •    "Fucking  *** (frequent flier)… Actually you should never say ‘fucking’ and ‘***’ in the same sentence. It demeans fucking, which is high in my pantheon of good things."

 
    •    (Quoting Dorothy Parker):   "Can you use horticulture in a sentence? You can lead a horticulture but you can’t make her think."


    •    (Regarding a rather large woman coming in by EMS) “Here’s the new one. She’s short of breath.” “Yeah, breath tried to sneak up on her and got scared away. Took one look and it was like ‘Aaah!’” 


    •    Discharge instructions dictated, not sent. “Return for any worsening of dramatic or traumatic adolescence.”


    •    "Sarah Vocera’s voice is quite suggestive, but she’s probably a 500 pound troll with more facial hair than I’ve got. But hey, you never know what you’ll get with a nine-hundred line."


    •    "Well the coffee’s going through me like a greased weasel, I’ve gotta go drop some urine off--give me a second."


    •    talking about the time he delivered a baby from a 12 year old. “Well, it turns out her uncle was playing hide the sausage with her. But at least we don’t have to start a new religion.”


    •    "How the fuck is Nursing Supervisor X still employed? —It ain’t for her administrative or clinical skills, that’s for sure. Either she has some serious blackmail going on, or maybe she can suck the chrome off a trailer hitch."


    •    referring to a massively obese patient-- "If she got infected with flesh-eating bacteria, I’d only give her a year to live."


    •    after a nurse asks him a question about a patient in a specific room, "See, you have to remind me about who’s in what room, because you guys only have three of them and I’ve probably seen like 15 already. It’s like, which whore is by the bedpost now? There’s just too many of them."

    •    referring to a patient who has been constipated for the past 7 days: “You’ve gotta BE the turd, you can’t fight the turd.” 


    •    speaking to three County Sheriff officers who brought in a patient for a fit for jail exam: “I seriously commend you guys for not shooting more people. No really! If I were you guys I would be poppin’ motherfuckers left and right.” 


    •    To the cops:  "I was a policeman for one day.  Came back halfway through that first shift, and they said I had another 4 hours to go.  I said, I know, but I am out of ammo. Came back to reload.
"

    •    To a smoker: "Quit smoking or die trying!"  (he committed suicide 2 days later)


    •    To another smoker:  "You are standing on the edge of the Grand Canyon. The Marlboro man has his boot on your ass and he is about to kick you off. Either quit smoking, or enjoy the view on the way down.
"

    •    To a constipated patient: "Use a suppository AND an oral laxative. I generally suggest that whenever you squeeze the toothpaste tube, you take the cap off first.
"

    •    To a vomiting patient:  "Use the suppository.  I don’t prescribe them because they are aesthetically pleasing.  I prescribe them because no one has ever vomited one up.  If YOU do, let me know.
"

    •    To a young woman needing a pelvic exam:  "I have done almost 20,000 pelvics in my life.  If you think I can remember one face to go with one specific bottom, you are mistaken.  It is a blur to me.  Like looking at an elbow. That is why we write this stuff down.
"

    •    "You are the captain of your ship. If the anchor is down, and the birds are chirping, nobody cares if you smoke a joint or have a couple of beers.  But if there is a storm, and brother, your life IS a storm, you can’t drive shit-faced. Didn’t work for the Exxon Valdez, and it won’t work for you.
"

    •    To a patient who says “I’ll try!” —(in Yoda growl):  “Try not.  Do, or do not.  There is no try.”


    •    "Oh, man...Those two obviously did not apply for their breeding permit in person.  Must have done the online option.
"

    •    "Further evidence for why cousins shouldn’t marry."

    •    "Charter members of the 'Greasy Glasses Guild'."


    •    "That poor kid...Bad Wigglies, Bad Eggs, Bad Upbringing...the Trifecta!  Never had a chance."


    •    To a mumbling drunk we can’t understand at all:  (in hoarse Klingon growl) "Dar ne baath ‘takk Klingon!!
"  (Drunk opens eyes wide, and shuts up.)

    •    "What is his malfunction?
"

    •    "Oh Fuck.  The short bus just unloaded.
"

    •   " Nursing homes have us zeroed!  Return fire!  Gomer mortars sighted and registered.  Fire when ready!  Rounds complete!
"

    •   On noting 5 simultaneous check-ins in triage:  "Torpedoes in the water!  All engines ahead flank, helm hard to starboard! Battle Stations!
"

    •    To sign out doc: "I have the con."  (sign out doc) "You have the con.
"

    •    (In British Sea-Captain accent) "Recheck on room three, at four bells of a late watch. Make a note for the log, if you please, Mr. Lamb."

    •    Still in British Sea-Captain mode:  "Oh, Huzzah!
"

    •    To the Tech: "Set up for a Cooter-gram.
"  Tech:  "What's a Cooter-gram?"  Doc:  "Oh My God!  Has no one oriented this poor child to night shift?"

    •    "Send a party to check on the lab. They haven’t been heard from in hours.  Perhaps they are overcome by fumes, or trapped under something heavy!
"

    •    Discharge instructions:  "Stop smoking. Seriously.
"

    •    "We're only waiting for a Party-Pack from Pharmacy, to discharge this patient.
"  Pharmacist approaches, laughing:  "I have your Party-Pack!"

    •    Me: "This patient needs a Dog Scan."   RN: "What’s a Dog Scan?"  Me:  "I’m not a cat guy.
"

    •    "We don’t need an IV, just call the phlebotomist for the bloods."  Patient:  "What’s a Fullbottomist?"  Doc:  "That is someone who likes big butts and cannot lie.
"

    •    "Had a C-section?  That’s just a womb with a view…
"

    •    lady actively having a miscarriage* *on the phone with OB* “she is passing a bunch of baby parts, and big clots.” “I’m not entirely sure, she definitely passed a thingamajig though.”

 
   •    In full sterile surgical gown, mask and gloves, attempting a sterile central line insertion while patient is trying to sit up under the surgical drape, and is actively heaving,   “It’s fine,  just squirt it (phenergan) in her mouth.”

    

    •    "What does 80 year-old poontang taste like?  Depends."

    •    “He has his head so far up his ass, he can only see when he opens his mouth.”

    •    “He has a brown ring around his neck, but you can only see it when he pulls his head out of his ass.”
 

    •    “Worst pseudo-seizure performance ever—He was flopping around on that gurney like a tuna on a short gaff.”


     •    “Can you outrun a Saber-Toothed Tiger?  Me neither.  Nobody lived to be this old 10,000 years ago.  If you couldn’t run faster than a Saber-Tooth, you were tiger poop.  We killed all the large predators off, so nowadays we age, accumulate aches and pains, and wait for bacteria and viruses to kill us.”

    •    "He’s a troll."  or, "He's a Common Bridge Troll."

    •    "Do you believe that last guy?  Just discovered the secret of fire, and knuckle-walked all the way down here to share his discovery."

    •    "If you need any proof of evolution, look no further.  There is your missing link."

    •    "And this fellow, my friends, is THE stunning counter-example to any assertion of White Supremacy.  Case dismissed."

    •    To a complaining nurse:  "What is the point of drawing a breath, if you can't bitch on the exhale?"

    •    "What is an adolescent male?  Only a mobile life-support system for an erection."

    •    "And the female counterpart?  Just mobile life support for pussy."

    •    "My job is to oppose the laws of nature, to battle and undo Darwinian Evolution. Sometimes I hate my job."

    •    "I am nothing but the lifeguard in the shallow end of the gene pool."

    •    "I am really just doing this for the stories they tell.  Every now and then someone even tells the truth. But, apparently, you CAN make this stuff up."

    •   "I usually just take the first three versions I get taking the history, and then average."

    •    "15 nights is not a long stretch.  35 is a long stretch.  But like eating an elephant, you do it one bite at a time. The trick is to develop a liking for elephant."

    •    putting down the phone after a Specialist consult: “How do I hate thee?  Let me count the ways…”

    •    "I’m sorry, but,  “I am not comfortable going home.” is not a diagnosis the insurance will accept to cause them to pay for your hospital stay.  You are welcome to stay, but at five grand a night, you could have had a pretty fantastic suite and room service at the Ritz."

    •    "Your admission is not up to me.  I give the story and findings to the Hospitalist, and they decide to admit or not.  I don’t even get a vote."

    •    Patient:  "I don’t want to be part of your ‘Experiment’."   Doc:  "You already are.  You are just in the volunteer Control Group.  Good luck with that."

    •    "Every single COVID variant arose in an individual patient, and spread from there. So each unvaccinated patient is nothing but a petrie dish to the virus.  Don’t be a petrie dish."

    •    "OMG, thank god those last two patients never mated…Can you imagine the spawn of THAT?"

    •    "I don’t think that child ever hears the word “NO!” They are raising a terrorist."

    •    "They did not, apparently, read the manual that came with the baby.  These things cry, puke, shit, pee, and will break your fucking heart." 

    •    “What did Dr. Google say?  Great! Thanks for saving me the head-scratching. I really don’t want to think today."

        "With everybody confined together at home, due to Covid, and with all the supply chain issues, it has become impossible to find a wife-beater shirt at Wal*Mart. Look, that guy's wife-beater is brand new.  He must have bought ahead. I bet he has a closet full of toilet paper, too."

        "That hand sanitizer in the wall dispensers is disgusting.  It doesn't go away, no matter how long you wipe your hands.  I think it is robot spooge."

        *grimacing after a bite of a hospital 'Sammich', Scribe:
"Was it good?"  Doc:  "I've had worse things in my mouth, but I can't actually remember an example right now."

         "Well,  another night, shot to hell.  See ya again tonight."

         On catching a totally unexpected, precipitate delivery baby, the patient with 'belly pain' looked over her abdomen and said, "That's not my baby!"  Me:  "Well, it is not mine, either."

        Upon extracting a studded silicone device from the vagina of a patient with a complaint of a month of malodorous discharge, she looked at it and said, "What is THAT??"  Me:  Well, colloquially, it is known as a 'cock ring'.  Patient: "Where did it come from??"  Me:  It was in your vagina.  Patient: "But I haven't had sex in a month!"  Me:  Well, that does explain the odor.  Patient: "Oh My God, I am going to kill that bastard!"

        Coming back from a particularly horrifying and accidental view of someone's genitals:  "Give me the retinal Brillo pads!  I have to scratch that off my retinas!"

        "Here, hold this pencil up for me.  I am going to poke my eye out."

        "Don't make me stab you in the eye with my pen!"

        "Don't make me take my earrings out.  Girlfriend,  I will FIGHT YOU!"

        Upon finding the last small Diet Pepsi at 0300 in the EMS fridge:  "America, Fuck Yeah!"

        At 0200, on first contact, "I want to see the Cardiologist!"  Doc: "I'd keep a watch for unicorns.  They are much more common at this hour.  But if I see a Cardiologist, I will let you know."

        Examining a young male gunshot victim with multiple gang tats:  "What happened?  Wait, don't tell me--you were minding your own business!"

        "Who is on for Urology?"  Sec'y: "Dr. Nastiness.  Do you want me to call her?"   "Oh, fuck....  No,  I would rather vomit blood. I will figure out another way around this."     

        After an Admin briefing on why we are out of beds, and nurses, but cannot call an internal disaster  code to get help:  "OK! That was inspiring. We will fight on, we will cope, we will prevail!  Am I the only one with a little vomit in the back of my throat? "

        On examining a patient under arrest, to certify as 'fit for jail'.  "Fit for jail, and not much else.  He should fit in just fine."

        Asking a patient with a tummy ache about bowel habits: "Are you an every-day pooper, or a skipper?  A skipper?  Ah, I thought so."

        On a surprisingly non-busy Friday night shift: “I always know, if it is raining too hard to keep a cigarette lit on the way to the car, it is gonna be a 'Q' night.  This is 'Christopher's First Law of Acuity.'”

       "Welcome to the Shit-show!!"

       Quoting Monty Python's King Arthur, "Run Away!"

       On hearing that Child Protective Agency personnel are coming in:  "Naah.  I don't believe that for a minute. I don't believe in Unicorns, either.  I have seen just as many unicorns as CPA personnel, which is none, and I don't expect that to change."

    In British Naturalist voice:  "Bless my soul, but I have beheld a rare Consultant in the flesh! This is a diurnal creature, rarely seen, even by day, and never seen at night!  I shall record this in my field notes for Posterity!  Rather drab, in non-breeding plumage, wouldn't you say?"

    Quoting Dorothy Parker, "What fresh Hell is this?"

     Awaiting an almost certainly failed resuscitation coming by ambulance:  "You might want to save some time and lifting work.  Just put a body bag on the gurney, cover it with the sheets, and we'll be ready to go when we call this code." 

    "Tag 'em and Bag 'em."

    Doc:  "You said in the triage that your pain level is a 'Ten'. I need to understand that better.  So you feel this pain is the worst you can imagine?  Can you imagine crapping out a 10-pound bowling ball studded with razor blades, and then sitting in a hot vinegar bath?  Is it worse than that?"

    Patient: "They gave me a shot last time.  It started with 'D'."  Doc:  "Hmmmm, a 'D', eh?"  Strokes chin and gazes off in the distance..."I can't think of what that might have been..."  Patient: DeLaLa or something."  Doc:  "Hmmmmm. Not ringing any bells for me.  Well, anyway, we have a new cocktail for Migraine, and we are going to go with that."  Patient:  "Dilaudid, I want Dilaudid!"  Doc:  "Sorry, that is not on the menu tonight.  But thanks for clarifying what you came here for." 

    "This is the worst pain I have ever had!"  Doc:  "You are young still.  Worse, much worse is in store for you."

    Seeing patient 'X' on the waiting room list, with 4 hours of waiting time already logged:  "I can see my colleagues have been anxious to see this one.  I cannot face a night starting with that one.  He is just going to have to wait a bit longer, until I see a few other worthy supplicants."

    Patient:  "If you don't give me a Dilaudid shot, I will kill myself."  Doc:  "Uh, we will be taking this up after we move you to the psych holding area."  Patient:  "You can't do that!"  Doc:  "You took the decision out of my hands.  I take all threats of suicide seriously."  Patient:  "I was lying!"  Doc:  "Shoulda thought of that before you said it. At this point, I have a credible threat of suicide, an admitted liar who will say whatever he thinks I want to hear, and no choice at all."  Doc to Scribe: "Hashtag: SorryNotSorry.  Hashtag:  GoAheadMakeMyDay." 

    Also to Scribe regarding the suicidal drug seeker:  "Killing yourself is the LAST thing we want you to do."

    "We need the interpreter for this next patient. (looking for the portable video interpreter on wheels)  Where is the Confuserator?"  "Where is the Hispanicator?"

    "I have developed a new machine for the measurement of pain.  We have a box that generates DC current, and a rheostat dial that increases the current steadily, marked with a scale of zero to ten.  Then we place alligator clamps on the nipples of the patient, hooked up to this device, and ask them to dial up the dial until the pain equals their complaint pain.  When they stop at three, or whatever, we record their pain scale.  Genius, eh?  I call it, modestly, the Christopher Excruciometer."

    On leaving the room of a shouting, skeletal, nearly toothless, disoriented patient, writhing violently in handcuffs, with multiple self-inflicted excoriations on the face and body, "Mmmm, I have got to try some of that Meth.  Seems like good stuff."

    On his first day on the West Coast, seeing his very first patient with Methamphetamine-induced psychosis:  "Ahhh...So that is a Tweaker! I can honestly say I have never seen one before.  Huzzah, I have beheld a Western Tweaker!  I shall record it in my field notes."

    On the importance of discharges as a priority:  "Get 'em OUTTA here!  Discharge takes priority over everything but CPR in progress, and knife in the eye.  I hate knife in the eye."

    To a patient:  "Anything else you need?  I will be right  back with a warm blanket and a glass of water."  To the scribe:  "That will give them that 'Illusion of Caring'.  That is what we purvey here.  It is important that you sell it properly."

    After seeing a well-appearing, picture-of-health child with a runny nose and anxious parents: "Another dyin' baby...Throw it on the pile out back when it stops moving around."

    "Antibiotics? Antibiotics won't help this viral infection.  They will only give you side effects.  I can give you a nice case of diarrhea, and a yeast infection, so you can sit on the toilet pooping and scratching, but you have troubles enough as it is."

    "These are some pretty potent laxatives, so you are gonna be on a short leash to the potty for the next 12 hours or so. Bring a good book." 

    To a youngish  smoker with chest pain, worried about a heart attack:  "You are worried this is a heart attack?  Let's see...You are young, have some family history of heart disease, and you smoke.  You can't pick your parents, and you won't stay young.  The only risk factor you get to choose is smoking.  That one factor is in your hands.  Quit smoking.  If you won't do that, you are not worried ENOUGH."

    "We can bail you out from disaster for today, but if you keep smoking, it is like me bailing, and you shooting holes in the bottom of your own boat.  Not a lot of point to it.  But the good news is,  I can swim..."  

    To a patient with a threatened miscarriage:  "You need to rest.  Be the Queen of Sheba.  No lifting, no cleaning, stay home on the couch.  You need pelvic rest, too.  That means no sex, no tampons, no douching.  Don't even read "50 Shades of Gray".  You don't want to stir anything up."     To the boyfriend accompanying the patient:  "Sorry about it, Dude."

    On seeing a patient lining up at triage:  "Ah, another Player steps to the window for chips...Welcome to St. Cuthbert's Casino-Hospital, where the stakes are high, the odds are pretty fair, but nobody goes home rich, and some players don't ever go home."

    "Welcome, Ladies and Gentlemen!  It's time to play 'Beat the Reaper!' "

    Scribe:  "You really got that one right!"  Doc, in fluent Redneck: "Naaah.  Even a blind pig'll find a acorn sometime."

    To a young child while looking in their ears during an exam:  "Hey, you got some pretty good brains in there!  Hope you use them!"

    Usual review of systems question:  "Have you coughed up any mice, or worms?"

    After hearing an unusually convoluted and made-up Rube Goldberg story of self-inflicted, unintended trauma:  "I hate when that happens!"      

    Scribe:  "That nurse is an Angel!"  Doc:  "Yeah?  Ya Think?  Well I just want to remind you that Lucifer was an Angel.  And good-looking, too!"

    It is the nature of people to worry.  If we were more like dogs, we'd be better off.  We worry about the meaning of everything, and IS THIS THE END?? A dog will limp in with an obviously broken leg, and worry only about the next butt to sniff.  We need to be like dogs. But we just can't. We just worry. We are failures."

    Scribe:  "That guy is a dream."  Doc:  "Nightmares are dreams, you know.  Be careful what you wish for..."

    "Never marry a mean drunk."  

     "Room 6 is here because he’s had less than half an hour of belly pain, and apparently needs a gynecologist. He’s a pussy."


    Review of systems question when the line of answers is 'Pan-Positive':  "Do you get a burning pain between your eyes when you urinate?"  To Scribe:  "That is 'Retro-Bulbar Micturalgia'.   No shit.  I did not make it up.  It is totally bogus, but when someone answers 'Yes' to that, you know they are full of shit."

    "That is what 10 pounds of bullshit in a 5 pound bag looks like." 

    Patient receiving numbing injection and reacting to the pain:  "Oh my GOD!"  Doc:  "Just call me Doctor.  I get a little embarrassed when patients put me on a pedestal like that."

    Doc, noting the time at 0400:  "Ah, eight bells at last. Send the larboard watch to the crosstrees and set a reef in the t'gallants.  Still an hour to go on this tack before we turn for home."

    Doc:  "It's 5:00, finally.  This shift has crawled by.  In this last hour, you will need to be dying to get any interest from me."  Nurse:  "Doc, we need you STAT in the Trauma Bay."  Doc:  "Fuck.  Your timing is exquisitely bad,  Sir.  No consideration at all...What the fuck were you doing on a ladder at oh-three hundred, anyway?"

    "They can hurt us, but they can't stop the clock."

    Call bells are ringing constantly, unanswered by skeleton crew on nights of late.  Doc:  "Let me struggle into my white panty-hose and Nursemates white slides, and I will go answer that call bell."

    On seeing a patient in severe respiratory distress:  "Jeez, did you see that guy?  His face looked like a galvanized bucket."

     Doc:  "His skin was the color of a can of 'Dap' window putty."  Scribe:  "How do you want me to record that?"  Doc:  "OK, no room for simile or metaphor in a chart, god forbid.  He was gray, cyanotic, pasty.  That medical enough for you?" 

    "That guy had the complexion of a galvanized bucket."

    "That guy was dumber than a potted plant."

    "Is your mother still taking complaints on your upbringing and behavior??  Because she and I need to talk."

    "Fair??  Did you just say that is not FAIR?  Life is not fair, son, and anybody who says any different is lying to you.  Did your mother fail to convey this to you at an early age?"

    Patient, on hearing there will be no narcotics given tonight:  If I can't get a prescription, I will have to use street drugs."  Doc:  "That is a choice you have, for sure."  Patient:  "So you want me to go use street drugs, is that what you are saying?"  Doc:  "No, I am not saying that at all.  I am saying you have choices.  One of these is street drugs.  That would be the worst of many choices, but it is a choice you can make.  I do NOT recommend it.  I do recommend you get into a pain clinic and deal with this with help and control.  But this is not a pain clinic, I am not a pain medicine expert, and I cannot prescribe narcotics for you."     Patient:  "Well,  I will be back to Heroin, and it is all your fault." Doc:  "Sigh...Your entire life is my fault, by that logic, but I am not taking responsibility for your entire life."

    Suicidal Patient post overdose:  "You don't care about me!"  Doc:  "We all care about you.  The problem is, we care about you more than you care about you.  I hope we can inspire you to care at least as much as we do." 

    Patient:   "Doc, what will happen to me with this COVID thing?"  Doc:  "Hard to predict, in your particular case..."  Patient:  "What good are you, then?"  Doc:  "Sir, we study herds, so I can tell you what a herd of people, with roughly your same appearance will do.  I cannot tell what any individual animal in the herd will do.  If three percent die, I can't say in advance that you will be one of the lucky animals or one of the unlucky ones.  I can only tell you what your chances are. But I cannot admit every one in the herd to wait it out, either. The unlucky ones get sicker, and we admit them.  You don't WANT to be in THAT group." 

    Respiratory Therapist prepping a patient for Doc to intubate, wheels in video GlideScope.  Doc: (in best Spaghetti Western accent)  "We don't need no STEENKIN' GLIDESCOPE!  HaHaHa..." (back to normal voice) "You should know me by now.  I will need a Miller #4 Laryngoscope.  For me it is always 'Miller Time'."  RT:  "You are Old School."  Doc:  "You know that's right!"

    Referring to new doc doing admissions:  "OMFG, she is setting the new standard for slow...Let's drive a stake next to her, and see if she is actually moving.  Consult the Glaciologist."

    After a resident records extremity exam as 'normal', on a patient with bilateral amputations of the legs below the knees:  "Nice pickup."

    "You couldn't kill that one with a hatchet."

    "That Chinese character tattoo on your left chest--did they tell you what it means?" Patient:  "It means 'Friend'.  Doc:  "No, actually, it is the character for 'Breast'." 脯

    "They are so damn cheap with the toilet paper here.  Every time you use it, you wind up with a brown-haired finger puppet, wearing a Dutch Masters ruffled collar."

    "That is hell, breaking both wrists at once. I don't know what he's gonna do for toilet hygiene.  Maybe he can tie a loofah-on-a-rope to a couple of eye-bolts in  his bathroom, and just throw a leg over."

    Just back from an obligatory med staff meeting:  "That went on way too long.  I usually pre-medicate for those meetings with a Compazine suppository, but mine was wearing off in the last hour.  I nearly blew chips by the end."

    Calling an older patient "Young Feller," the patient objects, saying, "I am older than you are!"  Doc:  "There I have you, because they print your birthday out on your chart, so I know how old you are.  Thanks for the flattery, but I was born in the first Eisenhower administration, went to High School in the 60s, college and Med School in the 70s, and I am on Medicare.  You are a Young Feller to me!"

    "The complaint says, 'Vomiting Diarrhea.'  I hate when  they vomit diarrhea."

    "That guy had it bad...he shit out his tonsils, and vomited up his asshole." Or, "He said he vomited up a chewy ring, with hair on it...Turns out it was his asshole!"

     On hearing a familiar voice, a frequent flier cyclic vomiting patient, vomiting and keening in triage, "Oh Fuck.  I hear Alphonse out there. Don't you recognize that song?"

      Upon hearing that a frequent flier of may years tenure had died:  "Really? Never thought that would ever happen. Oh, well, they are like sharks' teeth anyway.  One drops out, and another just like it rotates into place."

    "Some days you thank god for yoga pants, and some days you curse god for yoga pants..." 

    "People have to be reminded, Spandex is a privilege, not a right."

    To a tech, after a history, before going back for an exam, "Can you ask her to get her out of her clothes and into a gown, please?  You may need paint remover, though, because those are spray-on jeans."

    "Oh, look!  It is almost 0400, which is almost 0500, and that is nearly 0600.  We will survive this shift yet!"

    "I love when patients say, "Well to tell you the truth, Doc...", because I know what follows that is always a lie."

    "I need to calculate the Tattoo-to-Tooth ratio for that one. It may be the highest on record."

    "His IQ is lower than his belt size.  We'll need to use small words in the discharge instructions."

    "I need to go to the Necessarium.  Back in a few..."

    "Hang on a few minutes.  I've got to download some used groceries."

    "It is actually no use talking to these young people.  They have no capacity for abstract rational thought.  The electrician is not done yet, the brain is not wired fully, and won't be, until they hit 27 or so.  You are a work in progress, my fine  young Scribe,  just on the cusp of acquiring abstract frontal lobe function.  Girls are completed a few years earlier than boys, on average, but many times the electrician just quits in mid-job.  Then you have the average person, a case of arrested development, with no capacity for deeper understanding, and no hope of acquiring that capacity, either.  Mazlov's pyramid with the point cut off.  I myself was an utter mook until I was 28 or so.  Just sayin'.  Sad, but that is reality for our species."

    "You know why nobody cares about history?  Think back to High School...Who taught History?  The football coach. He had to teach something to keep his job, and it usually winds up being History."

    While sewing up a laceration:  "I am so glad I watched that YouTube video on how to do this just last night!  Everything is exactly the way they showed it!"

    "These Computer System Administrators are crazy.  The doc who is the 'Chief Information Officer' is a 30-something, and cannot understand why I can't log on from home through double-layer verification and 32-bit encryption, on the mobile device of my choice.  I am NOT a digital native.  I am not even a digital illegal alien."

    To the new Gen X or whatever residents starting a rotation:  "You see this?  It is an archaic device made of pulverized bleached softwood, mechanically imprinted with black pigment, containing the wisdom of the ages.  It is called a 'Book'.  I still use these to remember stuff, and to broaden my knowledge of other stuff.  I have a stack of them on this shelf here, full of useful bits of information.  You may use them any time you like."

    Coming out of a room after visits with a "three-fer", three kids of the same family all brought at the same time with a variety of complaints:  (in a Smeagol hiss and rasp) "We HATESES Hobbitses!"

    Coming out of another room with Mom, FOB and baby:  "Breeding Permit REVOKED!"

    On seeing the waiting room list over 20, and 3 hour waits the average, "Well, Troops, we are in a target-rich environment tonight.  I feel like I am in an Apache helicopter with a full combat load, cleared 'hot', and orbiting over a Taliban convention."

    At pronouncement of death of a John Doe, who happened to have an unusually large penis:  "Check his wallet for a driver's license." Nurse: "Do we still need a name for him?" Doc:  "No, I just hope he has an organ donor endorsement on his license."

    In reference to a haughty Consultant:  "He has delusions of competence."

    In response to an obviously insincere apology from a verbally aggressive and insulting patient:  Patient:  "I am sorry."  Doc:  "You sure ARE!"

    Walking out of a room after a visit with a massively whiny male patient:  (Doc does impressive lat spread in Gerard Butler fashion and growls)  "We are SPARTAAA!"

    "I don't care anymore...OK, THAT is a LIE!  ...I never DID.  I used to pretend better, but not anymore." 

    "Does this Isolation Gown make my ass look fat?"

    After asking a patient about frequency of bowel movements, the patient reveals she goes three times a day, and it is generally solid.  Doc:  "Hey, thanks for sharing."

    After a patient with a laceration asks, "What is that yellow stuff coming out of the cut?"  Doc:  "That is fat.  Doesn't mean YOU'RE fat, it is just your stuffing.  You are just Raggedy Ann with your stuffing coming out.  Gotta sew up that seam, so your stuffing doesn't fall out!"

    Patient:  "Boomer don't know nothing about Rap Music!"  Doc:  "I do too know what Rap is:  That's when 'Bad' goes to Verse."

    Referring to Rap:  "I get yelled at by angry youths all the time.  I get paid for that.  I do NOT pay angry youths to yell at me." 

    Referring to Country Music:  "I also don't ever pay rednecks to whine at me about how tough their lives are.  They have to pay me."

    To a young male patient with a swollen hand who gave the history, "I punched the wall."  Doc:  "I know, the Wall had it coming!  That wall said something about my Momma, I'd punch it, too!"  And in discharge instructions:  "Next time, speak harshly to the wall. Avoid physical violence with inanimate objects. Curse. Call it names.  Don't punch."

    A particularly large, ugly and frowning frequent flyer is brought in by ambulance, seated upright in lotus position on the stretcher, giving everyone the stink-eye on the way in. The ambulance attendants are eye-rolling audibly as they pass. After they pass and are roomed safely out of sight and sound, Doc says, in hoarse, entirely accurate Jobba-the-Hut impression, "HOH-HOH-Hoh-hoh Soloooo!"

    "Pro tip:  If you have to fart, go check on a demented or unconscious patient and do it there, so you can blame it on them."

    Asked by a nurse to help place a Foley catheter in an obese male, Doc asks, "What is the problem?" Nurse replies,"He's so fat, we can't find his penis. There is just a hole there."  Doc says, "OK.  You will press down flat on his belly with both hands around the spot, and I will grab it when it pops out, and do the catheter.  Time to play 'Whack-a-Mole!' "

    Nurse:  "Turn up the heat in here.  Aren't you cold??"  Doc:  "Are you kidding?  Look at me.  I am a bacon-wrapped scallop.  I never get cold."

    During a rectal exam on a 30-something man with a complaint of dark stools and bellyache, the patient exclaims, "Oh, my God!"  Doc says, "Just call me Doctor."  Patient says, "After this, I am gonna call you Daddy!"  Doc admits later that he was totally gobsmacked.  No response was even possible...

    "Life's too long."

    "OMFG, her ass looked like 55 gallons of cottage cheese caught in a hair net!"

    To a smoker:  "Listen,  This experiment has already been run a million times.  The smoking rats do much worse than the control rats.  This is not an experiment that needs repetition, and yet rats keep signing up for it.  Don't be yet another lab rat on the wrong side of this experiment."

    In a sweet southern accent, to the mother of a 5-y.o. child, cursing a stream of very adult language:  "How nice.  How very nice."

    After calling a code that was clearly futile from the start:  "This was such a waste of effort and emotion. I don't know what the fuck people expect.  We do resuscitation, not resurrection."

    Of an anxious Pediatrician:  "OMG does he ever have his bowtie on too tight!"

    To another Pediatrician:  "It helps to remember, 'Children are just small adults!'"  To the Scribe:  I love to make their bowties spin around..."

    "I am only a single species Veterinarian.  I could never be a Vet.  I am not as smart as a Vet.  They know how to fix a whole bunch of species."  

    "My theory is, the more evil a person was to their relatives, the more the relatives have to pretend to care that he or she has 'EVERYTHING POSSIBLE' done to keep them alive. Therefore, the patients we are forced to torture, long past all reasonable hope, are the ones who earned it."  ("At least I hope I am right.")

    "Holy fuck!  I have been in Covid Hell for more than 2 hours.  This isolation gown is so hot, I have pitted my scrub top out, to the point that my sweat from each armpit makes a Venn diagram in the front and back.  My Tommy Johns are in a wet knot, and I can't even sit down to chart without leaving a wet spot!  I gotta go shower, change scrubs, and just go commando."

    "Loved the conspiracy-theory t-shirts on those last two.  Don't believe in masks.  Don't believe in vaccines.  Do believe in "hydroxy".  Do believe in China Virus Hoax. Get up in my grill when I suggest a Covid test for their cough symptoms and fever.  Rat-Lickers.  Motherfucking Rat-Lickers."

    Responding to a patient's declaration that he won't take any "Big Pharma" prescriptions, Doc: "I am sorry, I am not sure what you hope I can do for you then, if I can't prescribe something to help."  Patient:  "That's all a scam."  Doc:  "Okay, so how can I help you? (long pause) Well, there IS a Christian Science Reading Room down on Second Street.  But, (looking at watch) they closed at 5, and they don't have an emergency room."

    Returning from a meet-and-greet with a new doc recruited to the staff:  "I had the experience of eating lunch sitting across from him.  He was, uh, enthusiastic, eating and talking at the same time.  It was like sitting in the front row of a Gallagher Concert!"

    After an encounter with a screaming, spitting adolescent:  "Sorry, my practice is limited to human beings.  I don't treat wildcats or badgers, or whatever the fuck that thing was."

    "They ain't made a machine yet that can measure how little I care about that."

    Coaching the people doing chest compressions during CPR:  "Faster! Harder! Deeper! Don't stop!  Yes!!! Just like that!" 

    In announcer voice:  "It is the final period in The Hockey Game of Life! Death has the puck on a breakaway, Christopher in goal!  Death fakes left and fires a vicious wrist shot low to the glove side! Christopher stops it with a diving catch, and the crowd goes WILD!!!!

    To a crying, stranger-shy toddler of a Spanish-speaking family, "It's OK.  El Viejo feo (the ugly old man)  is leaving!"

    To a patient with neck strain after an accident:  "I am going to give you a soft collar to wear.  It just keeps you in a neutral position.  You can wear it in the day if you want, or not. It is definitely a fashion statement.  But DO wear it to sleep for the next week or so.  At night you don't protect your neck when you sleep, and get into funky positions for hours,  which will cause spasm.  You wake up in the morning looking like Ray Charles." (rocks back and forth with head and neck held in lockstep with his shoulders, a la the late great singer).  "You will then be back here with 'Ray Charles Syndrome'."

    Returning from the rest room:  "OMFG, we need to get some fiber into Dr. Skidmark's diet!  He just dropped a gator-strangler in there, and then didn't stick around to see that the flush failed.  He lit it UP! I need to go back there with a forked stick, and make sure it is safe to enter."

    Returning from the restroom:  "I cannot go so long between visits to the Necessarium.  I hadn't had a moment to pee all shift.  I sounded like a Baptist Revival Tent in there. The people in the hall outside were shouting "Amen!" and "Yes, Lord!"  I still got goosebumps!  Say HalleLUjah!"

    "The best thing about work is, I come here, talk to nurses and get ignored.  At home I get ignored, too, but at least here, I get paid to get ignored."

    Upon hearing the nurses making 'AAawwwWW!' noises at the ambulance bay, Doc says, "Somebody brought in a baby or a puppy.  Nurses only make that noise for babies or puppies."

    Scribe:  "What a cute baby!"  Doc:  "Yeah, the mostly all start out that way, but they turn into assholes pretty soon."

    To a nurse requesting a med for a patient:  "I entered an order on the chart.  Wait, let me re-phrase that...I left a 'suggestion' on the chart.  We don't do 'orders' anymore, apparently. And you nurses just do what you want, anyway."

    At an Admin-called staff meeting regarding worsening overcrowding and boarding in the department,  and exhortations to work together to get through the rough times ahead, the Admin says, "Remember, guys:  There is no 'I' in 'TEAM'!"   Doc, in low whisper in the back:  "Yeah, but there are two 'U's in 'Go Fuck Yourself'!"

    Upon leaving a room with a loquacious patient, whose story of why she came to the ER tonight began from her childhood:  "OMFG, I thought we'd never get out of there.  That woman could talk the ears off an acre of corn!"

    "I always teeter on the knife edge between Humor and Human Resources..."

    Patient with belly pain, upon hearing that the evaluation is normal, except for large quantities of very prominent solid stool in the colon:  "Are you trying to tell me this is all just constipation??"  Doc:  Well nothing else serious appears to be the cause, and you DO have a large quantity of stool in your abdomen."  Patient:  I cannot possibly be constipated.  I have a bowel movement every day!"  Doc:  "This is a problem well known to anybody in retail sales.  You can have a shipment every day, and still have way too much inventory in the warehouse.  You need to have a yard sale, and clear out all that backlog.  We have the technology, tools, and weapons to get that done, but I wouldn't make any plans for the next couple of days..."

    To the constipated patient's wife, smirking at the news:  "I see you smiling over there.  I know you have been telling him he is full of crap for years, and it turns out your were right!"  Imitating the wife-to-husband, hands on hips:  "Told ya!"

    "I ADVISED that asshole to leave against medical advice."

    Patient:  "I am going to have a wicked hangover in the morning."  Doc:  "Good.  You've earned it!"  Patient:  "Don't you have something for a hangover?"  Doc:  "Sure, but I want you to remember this one."

    "Let's just prescribe a course of 'Azifayekaromycin' for this guy, and get him out of here.  And maybe a shot of 'Shutthefuckup' for the road."

    "That's the third time we have seen that guy with marijuana-induced vomiting.  He just won't believe us that marijuana does that to some people, and that they have to quit for a month, just to get better.  The literature refers to this syndrome as 'Scromiting'.  Seriously.  That's what they call it.  I think that is a word derived from the Latin for "Vomiting up your Scrotum."

    Just back from vacation, the doc says, "I went in a guide boat to go salmon fishing. It was all men on the boat, three big old guys from Nebraska, and the guide and me.  We were chatting with him about how he got into guiding tourists for fishing trips, and he said, "I made the worst mistake of my life.  I took what was my greatest passion and pleasure, and turned it into my business."  Doc said, "I know exactly what you mean!  I am a retired Gynecologist!"

    Just an hour into the shift Doc says, "Oh, Lord...that last patient done broke my Giveashitter.  And it is early."

    After leaving a patient who insists that 98.6 degrees is a fever for her, because she "always runs   96.0."  Doc:  "That one is shit outta luck.  I am not qualified to take care of extraterrestrial beings.  We don't have an Exobiologist on the call roster?  No?  I thought not.  A Quantum Mechanic, perhaps?  No?Pity." 

    Demonstrating the lancing of a large boil for a medical student:  "The experienced clinician will angle the blade like so." (entering the lesion from the side, producing a jet of pressurized pus that misses them both.)  "The Newbie just pokes it, and either becomes the Artful Dodger, or wears pus and blood until he or she can get a new scrub top." 

    "Science has just discovered that female snakes have clitorises.  More amazing than that, is that they have TWO clitorises!  It is embarrassing that this fact eluded us for all this time, but it does explain the forked tongue."

    Returning from a particularly malodorous patient's room:  "OMFG, that was rough.  I couldn't choose which was worse, mouth breathing or nose breathing, so I opted for straining the air through my teeth.  (imitates Darth Vader)  Fuck, that was a corn-studded fart.  I need to floss, STAT!  Let's go get some tic-tac before we go back.  It will take one in each nostril and an OSHA compliant N-99 mask to tackle that room again." 

    Sees a patient named 'Smith', with unaccented 'murrican speech, who has checked 'Hispanic' on his demographic box on the intake form. "Glad I didn't waste time dragging the translator machine in there.  I don't think he's Hispanic, do you?  Looked like an Average White Boy to me.  Maybe he's Hispan-ish."  

    Sees a massively obese frequent flyer and says:  "She was the annual 'Poster Girl' for the Anorexia Nervosa Foundation."  Scribe:  "What are you talking about??"  Doc:  "She battled Anorexia for years, and won.  The battle was a complete and utter rout.  She ANNIHILATED Anorexia."

    Upon hearing that the Nurse Manager wanted to meet with him later, doc says, "Damn.  I wasn't prepared for that.  I never meet with Admin without knee-high boots and a forked stick."

    "We have had unbelievable luck at Mullet-hunting this past week.  The annual rut must be starting."

    "He is such a fucking SLUG!  You don't need to take a history from him.  Just go behind him, pick up his slime trail, and you can follow his whole life backwards."

   Doc, stepping over a frequent flyer on the floor, staging an obvious pseudo-seizure:  "Michael, get up.  We don't have time for that tonight."  Patient stops and gets up. 

   "That one is clearly BSC--Bat Shit Crazy."

    "That case mysterified me completely." 

    A demented little old lady from a room down the hall calls out plaintively, "Hello?"  Doc says, "Hey, Adele is here!"

    Doc and scribe leave a room after seeing a patient with multiple vague complaints, who has determined that only Lyme Disease can explain her symptoms.  Doc:  "I am from the East Coast, where Lyme was common, and people with 'Flyme Disease', Fear of Lyme Disease' outnumber the real deal 3-4 to one.  Out here, it is quite rare, and it is more like 20-30 to one.  She wants testing, but she won't accept negative results, because we are all stupid uncaring doctors who never heard of a false negative test, and can't diagnose what is obvious Occult Lyme Disease.  She wants antibiotics, and when that doesn't work for her symptoms, she will want another three week course.  When she starts shitting actual blood, she will look that up, and blame me for her very real Clostridium difficile Colitis.  Then she will need a month of antibiotics for that.  Fear-mongering from Oprah Wifrey and her ilk are the cause of all this, and nobody is suing HER for disseminating disinformation...Arrrrggghhh.

    Patient says, "You are an OLD Doc!  I hope that means you know more than these young ones."  Doc says, "Yep, I am old, but must be the dumbest one in my medical school class.  The rest are all retired already!"

    Doc:  "That's an interesting name...Where's it from?"  Patient:  "I'm Italian."  Doc:  "Really?  I am half Italian myself.  But only from the waist down,"

    Patient:  "I need crutches."  Doc:  "We can sure try.  But given your weight, bra size, and the fact that you haven't lifted anything heavier than a Grande double mocha pumpkin spice Latte in years, I think it will be a walker that will serve you best."

    Nurse:  "Can I ask you a question?"  Doc:  "You just did."  Nurse:  "Can I ask you another question?"  Doc:  "Same answer."  Nurse:  "Can I ask you two questions?"  Doc:  "Now you are catching on."

    "That girl is harder than woodpecker lips."

     Doc, looking at belly X-ray with patient:   "You see all that clumpy stuff all over?  That's poop!" Patient:  I am having diarrhea.  I can't be constipated!  You don't know what you are talking about." Doc:  "You can definitely have both constipation and diarrhea.  That is just a trout stream burbling over the rocks..."

    Looking at a patient with multiple surgeries for skin cancer:  "The trouble is, after they take off so much skin, you get so tight that every time you squinch your eyes down hard, it pulls your foreskin back."

    Doc:  "I am just 'Redneck Dr. Spock' to these upriver gals with young-uns.  I generally advise Moms that when the child grows a full set of teeth and starts smoking, it it time to wean him."

    At first shift after a European vacation:  "Oh my god, I have returned to the land of female mustaches and back titties!"

    Chiming in with the usual earnest send-offs to the departing shift, of "Drive safe!" and "Be careful going home!!" from the nurses...  Doc: "Drive Fast!  Take Chances!"

    Nurse says, "Doc, you are so funny!  You should do stand-up comedy!"  Doc says, "I already do.  The definition of 'Stand-up Comedy' is me, in a men's restroom, at the urinal."

    "He suffers from terminal phallocephaly...He's a Dick Head." Or, "That guy is totally phallocephalic."

    "Women are immediately attracted to the man with the prominent lump in his trousers.  No, the one behind his right hip, not the one in the front."

    "Young fellas, you want to find yourself a gal that likes to drive on the rumble strip once in a while, just because it feels good on her taint."

    Discussing HIPAA privacy regulations with a colleague, Doc says, "This HIPAA thing is tough for everybody.  Even docs and nurses don't know how to spell it, and patients think there is a law against violating HIPPOs.  There might be a law, I don't know, but HIPPOs do make a god-awful noise when you violate them."

    On Pain:  "People think they understand pain, or can describe pain with a fucking 'Pain Scale'.  Until you have had chronic pain due to neuropathy, you don't understand pain. I understand.  I have had the kind of pain that would make you want to suck-start a Smith and Wesson." 

    Patient:  "Don't you condescend to me!"  Doc:  "Hold on there, little lady...that's a pretty big word you are using there.  Are you sure that means what you think it means?"

    "My wife is a saint, a saint among women, putting up with me.  She has the patience of a murder hornet."

    "The wife has moved past 'For better or worse,'  all the way to 'Til Death do us part.'  I am reduced to playing Beat the Reaper."

    "Oh, I just broke out in a fine sweat...that means I have enough coffee on board for now."

    Nurse:  "Do you drink your coffee black?"  Doc:  "Are you kidding me?  My blood type is 'French Roast'."

     Upon return from a room:  "OH MY GOD!  I heard a weird noise as I finished seeing the alcohol withdrawal gal in 7.  I turned around, just as she pulled a high-gravity tall boy beer can out of her vagina, popped the top and started to down it.  I had to get a paper towel and grab it from her and pour it out.  Her alcohol level was already over .400, and she is still walking and talking.  Now I HAVE seen everything."

    "I totally empathize with gender-queer people.  I myself identify as a Lesbian trapped in a man's body."

    "Gotta love the Upriver Girls...land of mullets, mustaches and back-titties."

    Doc to patient, as patient concludes a spasm of coughing lasting almost a minute:  "Gosh, I hope that cough doesn't interfere with your smoking!"

    Doc, referring to Dr. Weeniewaver:  "You know, some people have 25 years of experience, and some have one year of experience relived 25 times."

    "THAT, Kids, is an honors graduate from Suxtabee U.

    "It must be great living in the tax-free State of Oblivion!"

    Doc commenting on the infected tongue stud just observed in a patient with complaint of sore, swollen tongue:  “I don’t get the tongue-stud thing at all.”
    Nurse:  “They say they do it to improve oral sex.”
    Doc:  “Oh, I missed my invitation to THAT committee altogether.  ‘The Oral Sex Improvement Task Force.’  Because oral sex just isn’t good enough.  And that’s what they came up with?”

    

    

    

    

    

    

     

     

     

            

        

         

        

Time For Medical Malpractice Specialty Courts?

 

     Medical malpractice is an acknowledged problem in America.  Medical errors, whether negligent or not, are variably estimated to kill between 40,000 and 100,000 Americans yearly, and to injure four to five times that number. [1] Some expert students of the problem maintain that these numbers are underestimates.  Despite these numbers, whatever their accuracy, very few persons who are injured, and vary few families of the dead actually sue their doctors in tort for their losses.   Most of that very small percentage who du actually sue seldom reach trial, and of that small percentage, only a quarter actually prevail.[2]  Many suits are dropped after filing for lack of merit, or lack of likely success.  Many are settled, usually by negotiation between the parties’ lawyers, but some after agreeing to binding arbitration.  But overall, the “system”, as it is styled by the legal profession, compensates a vanishingly small proportion of actual injuries visited upon the patients by negligent care.  If the purpose of the tort system is to compensate the injured and restore them to their prior position before someone’s negligence injured them. If an additional purpose is to deter negligence because of the likelihood of facing personal accountability for negligent behavior, then by any outcome measure imaginable, the tort system is an abject failure.  It may well compensate a few fortunate souls, but that requirement of being fortunate leads inevitably to comparing the system to a lottery, a contention that cannot be put aside lightly.  Accessory goals of the system ought to be fairness, predictability, transparency, and availability to all deserving victims.  But unfortunately, after two hundred years of incremental development without oversight or plan, and with the pressures of competing vested interests working hard to insure their status quo, we have evolved a system that serves almost no one, except the lawyers who operate within it.
    What keeps the deserving victim out of the system?  Multiple factors exist, and are well documented.  Many people never realize that their bad outcome is the result of medical negligence or error.  A culture of silence has existed since the beginning of medical practice, and continues today.  Many people may know or suspect an error, but feel that such events are merely unfortunate, or to be expected, and do not choose to seek money damages.  Many people are simply forgiving of a doctor with whom they have a relationship, and against whom they would never speak out.  But many people who are injured do see redress, and are simply not served by the system.  They may have suffered only a moderate injury, worth small to moderate amounts of money.  Such cases have little appeal for plaintiff’s lawyers, since the potential judgment is small, and the contingency fee is therefore small.  This is no comment on the legal merit of the case, nor on the reality of the suffering of the patient, but a comment only on the realities of the market forces which drive the current system. Some cases, resulting in fatalities, are likewise unattractive from a market perspective, because the damages involved may be higher, but not nearly as high as the ongoing needs, pain and suffering of a severely injured, but living patient.  So the irony of this result is that negligence which is severe enough to cause death may go unpunished, while similar behavior not resulting in death, may bring multi-million dollar liability and shame onto the practitioner, who may, after all, have recognized the error, and done things to ameliorate it, and kept the victim alive.
    From the doctors’ perspective, somewhat surprisingly, the perception is that the numbers of suits are overwhelming, and the risk of suit to each doctor personally is very high.  This his hard to reconcile with the numbers outlined above, but this perception is very prevalent, to the point that the perceived risk by doctors has been estimated to be three times the actual risk to the physician. [3] What drives this perception?  Doctors live and die professionally, and even personally, by their reputations.  An allegation of malpractice, particularly when framed in a legal complaint and made public, is a direct, shattering blow to that reputation.  Doctors personalize the legalistic language of the complaint, detailing the “wanton disregard for the patient’s safety,” the “cruelty”, and the “reckless and callous neglect” of their alleged transgression.  Even if all is false, it is impossible not to be wounded and angered, and if here is any doubt at all on the part of the doctor, no matter how small and immaterial, the wound is so much the worse.  Then the wound is held in secret for the long lead-up to the trial, and festers, as the physician is admonished by his legal defenders to “discuss the case with no one.”  The physician waits helplessly, while people with an expertise foreign to him direct events and determine his fate.  It might be compared to the role reversal a doctor experiences undergoing exploratory surgery, with the outcome very much in doubt.   When, finally, resolution comes, it may not reflect in any way the actual fault of the doctor, and may involve large sums of money personal assets at risk, and the potential ruin of both the past and future for the defendant doctor.   And even if the judgment is in the doctor’s favor, as the majority of judgments actually are, this victory, after years and much expense and personal loss, is Pyrrhic at best.  It is easy to understand why so terrible a process should be feared excessively.  It is also easy to understand why doctors are so intractably opposed to the current system.  On the other hand, as fearful and motivating as the situation may be to doctors, the system has apparently failed by any measure to reduce the incidence of malpractice to anything approaching an acceptable level.  Rather, malpractice continues at an appalling rate, and doctors and hospitals bemoan their risks without addressing the problem of risks to the patients.  They may, and surely do, order more tests than are necessary, and pursue diagnoses to the bitter end, and intervene actively, rather than use clinical sense.  They injure even more patients with their bias toward excessive interventions and testing, and generate more expenses in excessive tests, and then in the additional tests, which are prompted by results of the first round of unnecessary tests.  Efforts to quantify this phenomenon have been unavailing, but there is no doubt that this occurs constantly, and accounts for a large portion of the waste in the medical system.
     In the 1998 book Damages, by Barry Werth, an actual malpractice case is followed from start to finish.  The various perspectives on the case are developed by interviews with the participants, and some of the inconsistency and unfairness of the process is made apparent.  The personal anguish of both sides of the dispute is likewise explored and acknowledged.   But what is made most clear is how dependent the tort system is on a confluence of a particularly poignant and ongoing misfortune, significant money damages at stake, and skilled legal practitioners motivated by their part of a potential large settlement.  The case develops as a child is born with a severe brain injury, attended by a doctor who has never met the parents before the delivery.  The child does not die, but is terribly impaired, and this becomes more apparent over the ensuing months.  A chance conversation between the mother and another woman, who bears personal animosity toward the obstetrician, sparks suspicion, and ultimately a visit to a personal injury lawyer.  The lawyer is a highly skilled and successful practitioner of the art, well respected by his peers, and feared by the medical community.  He must evaluate whether he can demonstrate the required elements of malpractice to a jury, in terms of a strange calculus unknown to doctors, or the general public.  There should, of course, have been some deviation from standard of care, and an injury.  There must be a causal connection, no matter how tenuous.  There must be a defendant with sufficient assets to support a judgment involving potentially millions of dollars, preferably an institution.  And there must be a live victim, requiring ongoing support, to push the settlement dollars into those potential millions.  The victim must be the sort that inspires sympathy.  The family cannot be too contentious, nor appear opportunistic.  They must maintain this appearance throughout a long and difficult period, during which they have no ongoing monetary support.  The victim cannot die in the interim.  The attorney must identify and hire expert witnesses to support his theory of the case.  He must front all the money involved in hiring and deposing experts, as well as the discovery and deposition of all the involved parties.  He does all this knowing that there could be an adverse outcome, and that all of his effort and money invested could be lost.  But, in the event of a successful conclusion, he stands a gain 30-40% of whatever unimaginable sum becomes the final dollar settlement.
    In the actual case, the life of a child is terribly altered, and reduced to a vacant, totally dependent subsistence.  There can be no more sympathetic victim.  The family, though dysfunctional, does pull together and maintain the needed sympathetic façade, through financial and personal details only partly revealed.  The theory of the case puts the blame on the physician, who probably did not violate any standard of care, but who is a distinctly unsympathetic player in the drama.  More importantly, the theory places blame on the hospital, which has more assets, and more insurance for a settlement.  And an institution inspires no sympathy whatever, when compared to a severely injured and permanently impaired baby.  The attorney strings this chain of events into causality, and a complaint, and then by skill and some luck forces the choice between trial and settlement.  The choice of trial might seem reasonable for the defendants, except for the uncertainties of what a jury might do in fashioning a dollar amount for this pitiful child.  The choice of a settlement is distasteful for one who feels she has committed no wrong, but the alternative uncertainty is a powerful force.  And in the end, a settlement is reached, which does represent a reasonable sum approximating the huge expense of caring for this child for a projected lifetime.  The physician settles for the limits of her insurance, rather than face a judgment after trial that exceeds that sum, and which would then be settled out of her personal assets.  It does not matter to anyone but the physician that the experts retained by the plaintiffs do not actually implicate her.  Those facts might have come out at trial, but the deal is done, and she has chosen certainty and closure over possible vindication.
    No one can claim that this system failed to compensate this particular victim and his family.   That this child and family need support is unquestionable.  However, the fact that under the current regime, fault must be found and blame assigned, and assets transferred from people and institutions who actually did nothing wrong is the real issue with the outcome.  The fact that it took years to achieve, and involved dozens of people’s full efforts to engineer, is a nearly unstated cost.  None of the negotiated result would have happened without the dedicated efforts of a skilled attorney, but it is also true that a third of the settlement went to the attorney, and not to the support of the child.  Just reward for risks taken, no doubt, but this is a cost of the system nevertheless.  What is left unstated is the more common result.  Had the child died outright, there would have been very little money at stake, and very little interest from this attorney.  Perhaps another would have managed to wrangle a small settlement from the hospital, and taken his portion, but the loss to the family would not have been compensated.  Had the family never pursued the matter, due to ignorance, or doubt that the system would help, the no compensation would ever have been forthcoming.  Or, had the matter gone to trial, and a verdict for the defense rendered, there would have been no “winner” at all.  The family would go completely unsupported, the doctor would be vindicated personally, but left permanently wounded and exhausted, and the attorney would be left to pay his costs, and await compensation in the next big case.  Given the complexity and vagaries of the system uncertainty is the rule rather than the exception.  The barriers are substantial, and the chances of success small enough, and most opt to suffer in silence.  Real injuries most commonly go uncompensated, and negligent doctors most commonly go unpunished.
    This unsatisfactory state of affairs in medical malpractice and compensation law has led to numerous efforts at “reform.”  These have generally been advanced by insurance companies and their political allies, and by physician organizations.  Opposing them are the trial lawyers and their political allies, and a loose group of  victim/patient advocates.  These reform efforts can be categorized as efforts to limit damages, limit access to courts, limit the chance of prevailing in a suit, or to force or encourage participation in alternative dispute resolution schemes.  Given their origin, there is no surprise in the observation that none of these proposals advance the interests or needs of injured patients.
    Damage limitations include statutory caps on punitive, and pain and suffering damages.  These have been adopted in multiple states, and some upheld, and some ruled unconstitutional by state courts. [4]  Efforts at limitation also include the abandonment of joint and several liability, and the allowance of inclusion of collateral source payments as offsets to the settlement.  Some states have also adopted statutes requiring scheduled payments rather than lump-sum settlements, to avoid the windfall of a large settlement of lifetime support to a patient who dies shortly after the settlement.
    Access limitations include reductions of lengths of statutes of limitations, requirements for identification of expert witnesses before filing, and pre-trial screening for merit.  These have also been tried in several states.  Pre-trial screening by a panel of physicians has proved to be largely ineffective, and has been dropped in many instances. [5]  
    Efforts to raise barriers to plaintiff success at trial have included exclusion of, or limitations of the use of res ipsa loquitur doctrine at trial, and also raising of standards required to qualify experts for trial testimony.
    Alternative Dispute Resolution (ADR) efforts are numerous, and spreading rapidly.  These differ from all the forgoing in that they have the potential, at least of increasing access and reducing barriers, while reducing the incidence of anomalous results.  Not all are equally successful in this regard, but ADR represents the coming wave of efforts to change the current status quo.  These range from private, institutional efforts at rapid settlements, (e.g. U. of Michigan’s direct settlement program) to state statutory requirements for mediation of settlements in certain types of cases, with statutory protections for disclosures or admissions associated with the process.  A significant downside for doctors is that mediation never results in vindication.  It is a process toward a goal of settlement, without admission of fault, but money will invariably change hands.  Arbitration also differs little from the current scheme, in that most cases settle rather than proceeding to trial, and settlements are already the result of negotiation, with or without a mediator.  The difference is that the settlement happens under the threat of trial, and after much of the expense and trauma of developing the case has already been suffered.  ADR offers a faster, cheaper path to what already occurs in the substantial majority of cases.
    Other alternatives proposed include workmen’s compensation style schemes, which would compensate the injured without regard to fault, but with scheduled, reduced payments, and expedited resolution.  These would have to be established on a state-by-state basis, but after experiments are tied and found successful, they might spread to other states.  The motivation for such experiments is high among the defense-oriented participants, but this has not spread to the general public, or their elected officials with sufficient force to be realized.  The main limitation of this type of scheme is that constitutional issues are raised in many states, due to guarantees of access to jury trials contained in many state constitutions.  The need for a constitutional amendment in any given state is a significant barrier to reform.  The great unknown in such schemes remains the numbers and sizes of settlements that will result, once current barriers are removed.  It is possible that such a scheme will be even more expensive than the current scheme, but it cannot possibly be less fair, transparent, efficient or accessible.  It will also have the undesired effect of shifting the costs from the private insurance sector to the public sector, and this fact alone may prove politically insurmountable.
    Examples of such experiments exist, limited to very specific types of injury.  The National Vaccine Adverse Event compensation scheme provides scheduled payments to children with specified adverse events occurring in a limited time frame after vaccination, without requirement of proof of causation. This advances the goal of encouraging universal vaccination, while taking compensation claims completely out of the tort system.  Virginia and Florida have instituted no-fault compensation schemes for birth-associated neurological injuries. These schemes compensate a very narrowly defined set of injuries associated with birth, without application to the tort system, and its inherent delays and expenses.  The purpose, from the states’ perspective, is to ensure that obstetrical care continues to be available in the state, by removing one of the most expensive and contentious areas of tort litigation from the courts, and protecting obstetricians from suit.  The narrowness of the criteria for inclusion has limited the range of application, and therefore the success of these experiments, but they remain works in progress.
    No-fault compensation schemes represent the most radical end of the spectrum of reform efforts, involving a departure from traditional rights to jury trial, and free access to courts.  As noted above, this fact alone makes the concept difficult to advance, absent a public and legislative determination that the goal of reform is worth the trouble of a state constitutional amendment.  An alternative concept, which preserves much of the familiar appearance of the current court system, yet offers hope of improvement, is the formation of specialty Medical Courts.  In concept, these courts would have exclusive jurisdiction over all tort matters involving allegations of medical injury and malpractice.  They would develop expertise among the judges presiding over them, and by virtue of that expertise, render more consistent and predictable outcomes.  Many of the proposals do away with jury trials altogether, and assign the determinations of standard of care, and questions of fact to these expert judges.  The courts would retain neutral experts to provide the required expert testimony as to standard of care, eliminating the need for adversarial experts, and the associated scourge of “hired gun” experts, willing to opine anything for a price.  At a minimum, the courts would use strict standards to qualify experts, including compliance with national standards of testimony by the experts, and reduce the variability of the competing theories of the cases.  These courts could, in theory, offer expedited scheduling and relatively rapid resolution of controversies, by pulling these matters out of the general court system, with its infamously long backlogs and procedural delays.
    The notion of specialty courts is not new.  Congress saw the need for specialty understanding and uniformity in the area of Patent Law, and in 1929 created the Court of Appeals for the Federal Circuit, with exclusive jurisdiction orer patent cases.  This court has reduced the variability of outcomes in patent controversies, and provided a consistent and predictable record of case law, upon which industries and inventors may rely.  Similarly, Tax Court was established to allow potential litigants to have specialized questions of tax law answered prior to imposition of taxes and penalties.  Litigants still have the option of using the Federal Court system, but the use of the Tax Court is incentivized by the fact that the determination in Tax Court will be made prior to payment, whereas payment must be made first, and the money recovered later, if the case is taken to Federal Court.  The result is that most cases are handled in Tax Court, and the resultant level of expertise and predictability benefits both tax practitioners and their clients.
    On a state level, similar examples exist.  Delaware is the smallest state in the Union, and yet is home to the majority of corporations in the US.  This state of affairs is largely due to the State Legislature’s establishment of the Court of Chancery, and the adoption of corporate-friendly state laws, which allow predictability of outcomes in questions of corporate law.  The Court of Chancery has decades of expertise and a tradition of consistency, while the corporate bar in Delaware has likewise developed a familiarity based on years of interaction with this specialty court.  Thus, the outcome of a particular controversy may be estimated with some precision by these attorneys, and the corporations they serve may proceed to do business with confidence in their advice.
    The establishment of specialty courts in medicine would most likely happen on a state-by-state basis, since state courts are the locus of most medical malpractice actions.  This evolution by local experiment has some advantages and disadvantages, as all evolutionary developments do.  States will vary the parameters of these courts according to local needs and customs.  Some might retain juries, and some not.  Some might allow adversarial experts, along with court-retained experts, and some not.  Some might assign exclusive jurisdiction, while others may retain access to traditional courts, but incentivize participation in the Medical Court with expedited access, simplified procedures, reduced need for expensive experts, and consistent judgments on finding of violation of standard of care, breach of duty, and causality.  As these experiments play out in the public arena, successes can be emulated, and failures modified to suit the primary beneficiaries, the people of the various states.  
    The legal foundation for these experiments rests with similar specialty courts, as described above.  The authorizing statutes will stand or fall on their attention to due process and right-to-trial issues, as found in their respective state constitutions.  Some of these concerns can be answered generically by framing these courts as elective alternatives to traditional jury trial, but heavily incentivizing participation, as is done in Federal Tax Court.  The advantages these systems could offer could include easier and more timely access, rapid resolution, simplified procedural rules, decreased expenses, and a reduction of anomalous, unfair verdicts.  The judges involved would become expert in this area of law, and to some extent, in the medical issues involved.  The absence of juries would allow considerable streamlining of presentations of fact, since the finder of fact would be relatively sophisticated.  Cases could be screened initially by the judge, and non-meritorious cases dismissed on motion for summary judgment.  The consistency of verdicts would result in lesser incidence of appellate review, since the inherent inconsistencies of jury behavior would be eliminated.  The larger consequence would be that overall perception of unfairness, of “lottery mentality” would decline, and confidence in the legal system would improve.
    Concerns over multiple potential problems have been advanced, largely by the trial bar.  These include loss of rights to jury trial, which can be addressed by elective participation, as above.  They contend also that a specialized court will become narrow, and not reflective of the public view and common good, which perspective juries are supposed to provide.  They contend, possibly correctly, that concerns over access are not addressed by merely changing he venue, and that all barriers now in place will remain.  They argue that in light of the large numbers of victims who are not now served, efforts which do not address this will merely be an extra layer of administration, and therefore wasteful.  They argue that the tendency to dismiss suits will rise, and that possibly meritorious suits will fare more poorly when facing a specialty bar on motion for summary judgment.  The argument fails against the fact that alternative access to traditional courts would remain an option, but they are likely correct that it is more likely that suits based on non-mainstream theories of causality will have larger barriers to proceeding on the merits.  Finally, and most correctly, such a scheme does essentially nothing to deter malpractice beyond what the current regime does, and given the miserable failure of the system as it is, any solution ought to address this aspect also.  Patient advocates also note, and probably correctly, that the market-driven barrier of requiring a substantial amount of money in controversy, before access is worthwhile, will not change under Medical Courts.  It may be true that the decreased expense of neutral experts, and the shorter time frames involved may lower the practical limits somewhat, but the primary driver will remain the motivation of the lawyer by the contingency fee system.  This will continue to favor the high-dollar cases, and offer no comfort to the walking wounded.  States might address this by instituting mandatory ADR at lower levels of damages, which might improve access overall, but this is unknown.
    A likely result of Medical Courts to be anticipated will be the fact that more of the cases will proceed to trial.  Currently, the expense and threat of trial motivates many settlements.  Under a specialty court scheme, with outcomes more predictable, and the jury wild card not in play, we may expect more parties to allow the cases to go to final judgment.  There may be more motivation for plaintiffs to settle, and less for defendants, but the net effect is unknown.  One outcome may be that the net administrative costs of the system may actually be higher, though the cost per trial will almost certainly go down.
    Though most efforts will occur on a state level, Congress has shown some interest in encouraging this activity.  There is very little likelihood that Congress will assign jurisdiction over malpractice to the federal courts. Congress may, however, induce states to create medical court, or institute other specific reforms, by tying federal funds receipt by states to adoption of the desired reforms.  Such an effort occurred in 2004, with the introduction of H.R. 4280 in the 108th Congress.  The Help Efficient, Accessible, Low-cost Timely Healthcare (HEALTH) Act of 2004 proposed to reduce statutes of limitations, cap non-economic damages, disallow joint and several liability, limit attorney fees to a set schedule of percentages, allow collateral source discounts in settlements, require a showing of fraud for punitive damages to apply, and require periodic payments for large settlements.  The bill proposed these changes as a minimum alternative, not to supersede state laws which provide greater protections for health care providers.  Congress asserted its Commerce Power within the language of the Act, stating that the current malpractice insurance affects interstate commerce.  This bill was passed by the House, but never reached to floor of the Senate for a vote.  A bill specifically encouraging medical courts, the Fair and Reliable Medical Justice Act, S. 1337 was introduced in the Senate in the 109th Congress.  It offered grants to states to develop alternative courts, which would “restore reliability to the medical justice system by fostering alternatives to current medical tort litigation that promote early disclosure of health care errors and provide prompt, fair, and reasonable compensation to patients who are injured.” [6] This bill met a similar fate, dying in committee without action.  It was reintroduced the following session, and again failed to reach the floor for a vote.
    Meanwhile, individual states are not sitting idly by, waiting for Congress to act.  The high and rapidly rising costs of malpractice insurance in various markets have forced some types of specialties in some states into untenable positions, such that obstetricians are closing their obstetrical practices, and neurosurgeons are leaving states with unfavorable laws and malpractice climates.  In Las Vegas, Nevada, trauma surgeons in the main trauma center temporarily ceased doing trauma surgery, necessitating helicopter transfers of multiple patients out of state.  They resumed only when the Nevada legislature passed certain malpractice reform provisions the surgeons felt were indispensible.  Pennsylvania, which has a suit rate among the highest in the nation, and a recent history of large judgments, has seen physicians leaving the state.  Its legislature has directed the Joint State Government Commission “to study the feasibility of establishing an alternative to the existing liability system with regard to medical liability actions. [7] Based on this study, the legislature has further directed in a resolution that the Commission consider new systems, and specifically that it consider a medical court system. [8] A bill creating such a system was proposed, but not enacted.  Illinois and New Jersey are considering similar proposals, though none has yet been enacted. [9] These states represent only the first wave of similar efforts.  Numerous states face local shortages of various specialties, most notably OB, Trauma Surgery, and Neurosurgery.  Virginia’s and Florida’s no-fault birth injury schemes are efforts to deal with this same reality in a more limited, goal-related fashion, but as the shortages spread from the subspecialties into the broader areas of Emergency Medicine, Cardiology, etc., broader efforts will be needed.
    The concept of Medical Courts has begun to have wide discussion in various state, and by various elements of the legal and medical communities.  While the passions are high, and the vested interests vocal in their criticism, the underlying problems are severe, and unlikely to go away.  No constituency, except a small contingent of trial lawyers, is served by the current system, and no amount of spin about “protecting the rights of the injured” can take away from the bald failure of the system to do just that.  A Medical Court system, properly configured, could achieve multiple goals for multiple constituencies simultaneously, even though it would not answer all problems alone.  It could preserve and even enhance access to the courts for citizens injured by negligence.  It could render reliable and predictable judgments, based on the law, and not on the vagaries of sympathy.  It could reduce the load and backlog of the rest of the civil court system.  It could screen cases for merit, and expedite settlements for the deserving, and take the compensation from the truly negligent.  It could differentiate bad medicine from mere bad outcomes, and shift the financing of these random risks to an appropriate forum, whether accident insurance, universal health coverage, or other schemes.  It could reduce the overall expense of the system by streamlined procedures and expedited settlements.  And, it could conceivably direct the improvement of healthcare training by identifying doctors at increased risk and requiring remedial training or other action as a condition of the judgment.  No proponent can claim that Medical Courts will solve all the problems with the current system.  They may or may not address access issues.  They may have biases which are different, but not superior to the current system.  They may cause a flood of suits for lesser injuries and lesser amounts, which might be a benefit, from a patient advocacy standpoint.  They may ultimately be more costly from a governmental expenditure standpoint than the system they would supplement.  They may undercompensate the most severely injured, and neglect traditional pain and suffering related damages.  No solution needs to be comprehensive and perfect, nor can one ever be, before it qualifies as a step in the right direction.  No one can demand that no step be taken until a perfect solution is identified.  There could hardly be a wrong direction, situated as we are, in the deepest darkest center of a quagmire.  The national experiment is about to begin, and the multiple laboratories of the states will work through solutions which will change the landscape as we know it.  The perfect solution will, of course, never be reached, since all human activity is dynamic, and our needs will change dramatically, as society, medicine, and the law undergo unanticipated and amazing changes.
    

Footnotes:

[FN1].  INSTITUTE OF MEDICINE, To Err is Human:  Building a Safer Health System 37 (1999).

[FN2].  Studdert et al., Negligent Care and Malpractice Claiming Behavior in Utah and Colorado,  Medical Care Vol. 38, 2000, p. 253.

[FN3].  Weiler, P. et al.,  A Measure of Malpractice:  Medical Injury, Malpractice Litigation and Patient Compensation, 124, 1993 (cited in Sage, W., Medical Malpractice Insurance and the Emperor’s Clothes, 54 Depaul L. Rev. 463.

[FN4].  States upholding caps on pain and suffering damages include:  CA, ID, IN, KS, LA, MA, MD, MS, MN, NE, OR, VA, WV.  Caps were struck down in IL, OH, OR. See Fink, D. Notes and Comments, Best v. Taylor Machine Works, the Remittur Doctrine, and the implications for Tort Reform, 94 NW. U. L. Rev. 227, 229 (1999), and  Light, M., Note Who’s the Boss?:  Statutory Damage Caps, Courts, and State Constitutional Law, 58 Wash. & Lee L. Rev. 315, 319, 31 (2001)  (Cited in Gunnar, W., Is There an Acceptable Answer to Rising Medical Malpractice Premiums?, 13 Annals Health L. 465).

[FN5].  Gibeaut, J., The Med-Mal Divide 91 MAR A.B.A J. 39, 42 2005.

[FN6].  Reliable Medical Justice Act, S. 1518, 108th Cong. (2003).

[FN7].  S.R. 160, 187th Gen. Assem., Reg. Sess. (Pa 2003).

[FN8].  H.R. 1199, 187th Gen. Assem., Reg. Sess. (Pa 2003).

[FN9].  AB 1972, 211th Reg. Reg. Sess. (N.J. 2004;  SB 93rd Gen. Assem., Reg Sess. (Ill. 2004).



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This article was originally published in edited form in Medical Economics