Category Archives: Humor

Our Icelandic Saga – Arrival

When you have the time, you won’t have the money.
When you have the money, you won’t have the time.
When you have the time and the money, you won’t have the energy.

I’ve been wanting to go to Iceland since my 50^th and 60^th birthdays. We decided to combine my 70^th with our 25^th wedding anniversary and take a cruise around the island. Better late than never

We left from O’Hare’s international terminal, whose recent $1.3 billion expansion just made for a longer walk. We got a quick bite at Rick Bayless’ (famous Chicago chef) Tortas Frontera before heading for a two-hour wait at the gate.

Our flight left Chicago at 10:15pm on Icelandair, albeit on a dreaded Boeing 737 Max. (We survived!) If you’re old and going to do a long flight, I highly recommend shucking out the extra money for business class; it is a very long, six-hour flight. The seats are comfortable and accommodated my fat ass nicely. Each seat had a pillow, a comfy blanket and a cute little welcome bag made of reinforced biodegradable paper with socks, a sleep mask, toothbrush, hand cream and other stuff.

The flight attendants were a hoot; a skinny Indonesian looking guy, wearing an ascot and apparently enamored with his style, and an equally skinny young Nordic man. They treat passengers like royalty. They offered us bottled water, caramel corn, and free headphones (main cabin passengers had to rent them) and menus.

The food was great; delicate portions served on real china plates with real silverware. I tried 64° Reykjavik Distillery’s Angelica Gin, which tasted more like paint thinner and less like the typical juniper-based gin. However, on the way back I discovered their Rhubarb Gin. Very tasty!

The LED screens in the seatbacks provided a map of the jet’s progress along with information on altitude (36,000ft.), cruising speed (600 mph), outside temperature (around -56°F) and departure/destination times. Entertainment options included movies, TV, and Icelandic classical music selections. Peg watched the Barbie movie. I tried sampling the Icelandic music in between glancing at her screen and the one the next row up who was watching The Hitman’s Bodyguard.

About two hours after takeoff, the horizon started to lighten somewhere over Eastern Quebec. The sun was up by the time we reached the middle of the Labrador Sea. We passed over Greenland, but the clouds made it impossible to see the terrain. Finally, we landed in Keflavik at 9:30am local time, a beautiful sunny day. That was the last time we’d see the sun for the rest of the trip.

Getting off the plane provided our first shock. Tourist traffic has completely overwhelmed Keflavik International Airport and the crowds are worse than O’Hare. We had to walk down aluminum stairs rolled up to the aircraft; only departing flights get a jet bridge. The Rollator we gate-checked at O’Hare and assumed would be at the plane was nowhere to be found; we figured it went to baggage claim. We hobbled over to the buses that took us to the South Terminal, where we funneled in through a single set of doors like cattle being led to the slaughter.

Once inside, we took escalators to the second floor and made the long walk to Customs, entering the maze until the crowd stopped. We saw several Automated Passport Control kiosks wrapped in plastic that might have made the process faster but they hadn’t been installed .We stood in line for about 20 minutes. We finally made it through and took a short break; Peg’s foot was killing her by this time.

There are no people movers in the very long corridor connecting the South Terminal to the Main Terminal. I ran ahead of Peg to find the Rollator, but there was no way to retrieve it and then re-enter the secure area, so I came back, and we just kept walking.

Baggage claim is one floor down; Peg and I took the elevator. The first thing we saw before we got there were the requisite shops, including two familiar American shops:

I picked up our suitcases, but I couldn’t find the oversized luggage carousel, so I asked the young woman at customer service. I followed her (it was in plain sight) and apologized for being so clueless. She said, “That’s all right. You just wanted to meet me.” In the meantime, Peg got cash from a nearby ATM; banknotes come in 500, 1000, 2000, 5000, and 10000 krónur and like most foreign currency, they are very colorful. If that seems like a lot of money, keep in mind 1000 ISK is around $7.25, more or less.

Customs authorities must be very trusting because there were no officials at the “nothing to declare” aisle, so we walked through and found ourselves in the main terminal near the exits, across from the currency exchange Peg had expected near baggage claim. I looked for a bathroom but the nearest facilities were down one floor in a rather secluded area.

We stepped outside to the taxi stands. We could get to downtown Reykjavik for about $68 each via Flybus Airport Transfer, but a friend of Peg’s who has been to Iceland told her it would let us off at a designated bus stop a few blocks from the hotel. We weren’t going to schlep two suitcases, a Rollator, and a carry-on bag so we opted for a cab.

The nice young man staffing the taxi stand told us there were fewer cabs than usual, which at that time meant none, except for an empty van with no visible driver. They arrived one at a time, several minutes apart. We stood in line with a few other passengers and enjoyed our first view of Iceland on the ground.

Predictably, there was one American asshole who pushed to the head of the line, thinking he should take priority. He wanted to go to the Parliament Hotel in Reykjavik and tried to bum a ride with a couple that was going into Keflavik. The next available cab was a full-sized SUV. Peg asked the driver, “Is the Hotel Konsulat near the Parliament?” The asshole quickly interjected, “No!” Seriously? Later Google maps indicated the two hotels are about 4 blocks apart. It’s probably better that we didn’t ride with him.

Downtown Reykjavik is about 31 miles from the airport. The landscape between Keflavik and Reykjavik looks like Eastern Montana; very rough terrain covered with moss, the first thing to grow on volcanic rock. The highways are two-lane and not as wide as our Interstate or major US highways. They were well maintained, without the abundant and often perpetual potholes in the Midwest.

We approached the outskirts of Reykjavik and, while most of the businesses have Icelandic names, signs on the buildings have a mixture of English and Icelandic. And Iceland isn’t immune from American influences; we saw Subway, Domino’s Pizza and KFC. There are no Starbucks in Iceland because, as this What’s On article notes:

“The absence of Starbucks in Iceland is not a sign of a lack of coffee culture; rather, it represents a conscious choice to prioritize local businesses and foster a thriving scene for specialty coffee. Icelanders value the craftsmanship and dedication of their local roasters and baristas, who treat coffee with the same reverence that they extend to their beloved natural landscapes.”

Gasoline in Iceland is expensive, about $9.60 a gallon when we were there. Most of the cars we saw were small, including an electric Nissan Leaf, but there were a few Beemers and Mercedes. The Orkan petrol chain, with its bright pink color scheme, advertises “Cheap Gas.” N1 and Olís stations tend to be more expensive

Our driver took us through narrow streets in the downtown area before stopping in front of the Reykjavik Konsulat Hotel, which one would miss it if walking by casually. There is no big lighted sign and no parking lot, and the door isn’t automatic. That is because it was formerly a department store in the early 1900s, owned by Konsul Ditlev Thomson.

The hotel is very charming. The reception area and the wine room off to the left are done in dark wood. The elevators are very narrow; one of them could only hold two people. The top part of the car is papered with old photos of a store or apothecary shop; the bottom was wood, looking like rows of small drawer fronts. You can see more photos of the hotel at their Facebook page.

Our room was on the 4^th floor, small by American standards, but typical of European hotel rooms and quite cozy. The first thing we noticed was the king-sized bed had two individual comforters and no top sheet! The bathroom walls had large tiles from floor to ceiling; the wall behind the sink was done in mosaic tile. The shower had two heads, and the body wash, shampoo and conditioner were in refillable bottles.

There was a very small balcony through a narrow door just to the right of our bed. I took these pictures of the Radisson Blu 1919.

Eimskip is an Icelandic shipping company.
(According to Google Translate eimskip is “steamship”, and eimski is “stupid.” What a difference a letter makes.)

We were exhausted. Bu this time it was noon local time and we’d been up for 24 hours, so we got comfortable and jumped into bed for what turned into a five-hour nap. Neither one of us had the energy to find a restaurant after we got up, so we went downstairs to the bar to the right of the reception desk. It was quiet and cozy, with floor to ceiling windows, comfortable chairs and an attentive bartender. Peg ordered Iceland’s domestic beer, Gull, and I had a glass of white wine. Prohibition in Iceland began in 1915 and, while wine and spirits were legalized in 1922 and 1935, respectively, beer only became legal in 1989.

Bæjarins Beztu Pylsur (The Town’s Best Sausages), sitting just outside the bar, is the iconic hot dog stand that’s been in downtown Reykjavik since 1937. Icelandic hotdogs, made with lamb, are longer than our domestic dogs, and can be customized with Remolaði sauce, Icelandic mustard, fried or raw onions, and a ketchup sweetened with apples instead of sugar. They are also relatively cheap, about ISK790, or a little less than six bucks. There are people lined up in all seasons, but they are served quickly. We noticed two things: everyone paid with a credit card and the soft drinks are small; no extra-large or Big Gulps. The straws are recyclable; Iceland banned single-use plastic in 2021. You can see the crowd over Peg’s shoulder.

There is no real night in Iceland during the weeks either side of the summer solstice, only a four-hour period of dusk. The downside is there’s only a four-hour period of daylight during the weeks around the winter solstice.

I opened the balcony door in the middle of the night; there isn’t any air conditioning, and the room was becoming stuffy. There’s a bar, Hornið (trans: the corner), on the street and the rowdies sitting outside were at it until at least 3am. Someone was singing, “I don’t wanna wait,” but my sleep-deprived brain kept hearing “Power 108” as in “KPWR 108.3 FM.” (Actually, KPWR is a real radio station in Los Angeles, “Power 106” – 105.9FM)

We slept in and missed the hotel’s breakfast buffet, so Peg had hot tea while we waited for the 11 am cab we had arranged. I considered going across the street to Joe & The Juice for a cappuccino, but I didn’t want to miss our ride. (I discovered Joe & The Juice isn’t exclusive to Iceland; there are stores across Europe and seven in Chicago!)

I regret we were about to leave Reykjavik without having visited Hið Íslenzka Reðasafn, The Icelandic Phallological Museum. Maybe next time.

Next: Embarkation (fancy talk for boarding the ship)

Memories

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It’s been a little more than two months since Baxter crossed the Rainbow Bridge. We miss his furry little face every day, but we have so many memories of him to ease the pain.

The Early Years
Baxter was a very smart puppy. We took him to an obedience class at Pet Smart soon after we got him. He impressed the trainer, learning the commands quickly while the other dogs seemed to struggle, although the training treats were a great incentive. He learned the usual tricks – sit, high-five, shake hands – and every new visitor to our house was an opportunity to show off.

Peg taught him some unique tricks, like “let us pray” and “sign of peace” so he could join Sunday Mass on the television. I taught him “Bang, you’re dead,” which he did with a dramatic flair. Then I’d tell him to roll over and give him two treats for an Oscar-worthy performance. One trick he never learned was “put your toys back into your crate,” no matter how many times Peg tried. He’d look at her as if to say, “Why should I? That’s your job!”

Baxter lived with a cat before he came to us and adopted many cat habits. He liked to stretch out on the back of our couch. Sometimes when we picked him up from the groomer, we found him on the counter next to Miz Laura’s cat who either tolerated or ignored him.

He got so excited when we took him to the groomer, Miz Laura for “Spa Day.” He’d start squealing and jumping around the car when he realized where we were going. He strained against the leash until we got inside, then ran around in circles when Miz Laura came out to get him. They often let him roam free after his grooming. Miz Laura always put a bandana or necktie around his neck, and he looked really handsome!

He figured out how to get to the island in the middle of the kitchen by jumping from the couch to the dining room table to the counter and then the island. I learned to put meat into the microwave to rest after catching him mere inches from the “spoils of war.” Peg didn’t believe me when I told her about Baxter’s acrobatic feats. “He can’t jump that high!”

Her skepticism bit her in the ass the first Halloween with him. I was out of town on a job and Baxter got into leftover chicken bones she had left on the counter, which led to an emergency visit at the veterinarian’s office and a $300 bill. When she called, I said, “Thank you, Jesus,” having avoided the royal ass-chewing I would have gotten if it was my fault.

He loved sharing our dinner, but we quickly learned he wouldn’t eat his dry dog food nuggets if he got people food first. He didn’t like eating alone, so we’d sit in the family room while he dined, then we’d adjourn to the dining room for his “Taco Bell Fourth Meal.” He’d sit on the floor between us, or he would jump on the dining room chair next to me if the handouts weren’t coming fast enough. He’d jump on the table if he was particularly impatient.

And he was very fast. Once evening he grabbed a stick of butter off the table and flew to the floor before Peg could catch him. Another time he sat on the chair at the far end with his paws on the table while he eyed Peg’s steak intently, calculating his chances of success. I imagined Ennio Morricone’s Spaghetti Western music playing in that little brain.

When he got bored with the nuggets, he’d toss a toy into his bowl. Or he’d say, “Fuck the nuggies! I want your food!” We eventually switched to four-dollar-a can dog food, mixing in a bit of dry food for adequate nutrition, but there were still evenings when I ended up tossing it in the trash.

Baxter was a carnivore who loved any kind of meat, but he was especially fond of my brother-in-law’s pulled pork, cooked low and slow on his beloved smoker. One summer the family gathered at our house for pulled pork two Sundays in a row; Baxter thought he’d died and gone to doggie heaven. He was positively miffed when, the next Sunday, the family brought pizza. He gave a snort of disgust and retreated to the family room.

Baxter also loved sweet things like whipped cream, Dairy Queen and Culver’s frozen custard. I’d take him to Dairy Queen in the afternoon and we’d share a soft-serve cone. Usually, he dove into it but sometimes he would wait until the third or fourth offer before remembering, “Oh yeah, I like this stuff.” We often took Baxter with us when we went to Culver’s for a sundae, rewarding him with samples on the way home. He also enjoyed the Pumpkin Shake, available only in October and early November.

Our local grocery store Jewel shares the same parking lot with Culver’s. One evening Peg drove to Jewel to pick up a few things, taking Baxter along for the ride. (If I recall correctly, he ran to the car as soon as Peg opened the door to the garage.) He kept looking at Peg as she drove past Culver’s: “Wait. You’re not going to stop? Why did you bring me in the first place???”

The Guardian of the Cul-de-Sac
The Tibetans bred Shih-Tzus (which translates to “little lion” in Mandarin) from the Pekinese. Pug and Llhasa Apso. The little dogs were initially used to warn the royal court of intruders but later became companions. Baxter appointed himself as our guardian, standing sentinel at the patio door for any riffraff that might pose an imagined threat.

He went ballistic when people walked by and became more incensed if accompanied by a dog, large or small. It didn’t take long for him to figure out that whomever he saw from the patio door would reappear on the other side of the house. He’d run upstairs to the guest room, jump on the bed and continue yelling until they were out of sight. If anyone walked on the sidewalk in front of the house, he’d run back and forth between the guest room and our room, sounding more like a thundering herd of cattle than a fifteen-pound dog.

The Daily Rituals
I took him out to pee every morning and then fed him breakfast, followed by an insulin injection once he became diabetic. He used to demand a walk before I could have coffee, but as he got older, he was content to take the early morning nap, followed by a quick stretch before the late morning nap. We settled into a predictable routine which included daily afternoon recreation.

He loved car rides. When he wanted one, he would stare at me or jump onto the couch and paw my hand. If I asked, “Would you like a car ride” he would bark and go to the back door. Sometimes he’d run to the car if I opened the door to take the garbage out. Occasionally he’d try to con me into a ride at 11:00pm. Sometimes he’d get lucky, and I’d indulge him since a short trip around the neighborhood was enough.

He liked going for walks up to the playground near our house and back. I started taking him to another park after he yanked a muscle in his neck playing “whose dick is bigger” with the dog behind the neighbor’s fence. He couldn’t see her but knew she was there. That turned into a midnight visit to the emergency vet during COVID.

The Nightly Rituals
Baxter wanted to go upstairs at 5pm during the winter because it was dark and, in his mind, time for bed. We resorted to putting up a gate in the hall because otherwise he would run upstairs and start barking for us to join him. He’d reluctantly stay with us if we were watching television, but his patience ran out around 9pm, when he started pulling my socks off with his teeth.

I started eating a mozzarella stick at bedtime to keep my fasting blood sugar at a reasonable level; Baxter soon expected me to share. Our nighttime ritual evolved into a protein snack, several Old Mother Hubbard cookies, a drink of water and four pieces of Pill Pockets. If Peg wasn’t fast enough with the Pill Pockets, he climbed on her and tried to snatch the bag out of her fingers. His attitude towards cookies was, “We’re done when I say we’re done!” One night when he started barking for more Peg told him, “You’ve had enough!” The little shit then jumped off the bed, ran downstairs to one of his many stashes, brought a cookie back to the bedroom and devoured it while looking directly at Peg.

He slept at the foot of our bed, but I would move him closer to us before we went to sleep so he wouldn’t roll off the end. He growled but never opened his eyes. He used to love curling up in bed under my chin when it was cold; I’d listen to little puppy snores through the night. If he woke up before me, he would stare at me, willing me to get up.

Toys
Baxter loved ripping the appendages off his favorite stuffed toys. He went through several Gorillas and Dragons. He liked to pull the stuffing out of Panda and ripped out Peg’s repairs several times. He had a pink rabbit who, after having his ears and legs torn asunder, became a blob we nicknamed “Stinky Bunny,” well-marinated with doggy saliva. We tried to send Stinky Bunny to the farm upstate, but Baxter managed to rescue him from the trash.

Flying Bear was another favorite toy. He loved to grab it with his teeth and whip it back and forth. We tried to find a replacement when Flying Bear became overly ripe, but didn’t have any luck.

Quirks
He liked to lay on the couch’s footrest and watch television with us; he’d lay very still and stare intently. Sometimes the only way I knew he was still awake was when his ears would twitch. But several things would set him barking at the screen while jumping against the entertainment center:

The Buick jingle
Any program in black and white
Black people on TV (though not in person)
Animated films (Peg gave up trying to watch Disney’s Brave because he’d go berserk)
Animals on TV, even if he’d never seen one in person.

When I left for a job, he would put several of his toys on my office chair or in my spot on the couch. I guess he was keeping my spot warm. When I came back from Springfield, he knew when I was about 15 minutes from home, because he’d sit by the door to the garage. Peg called me and we’d count down the streets until I pulled into the garage. Sometimes he and I would bark at each other over the phone.

I learned to devote the day of my return from a job to the happy homecoming and indulge his every wish/demand. “Your ass is mine!” We had to go for a walk or a car ride IMMEDIATELY! I had to walk him for a walk every morning before he would let me work in my office.

Later years
Baxter liked to greet anyone coming into the house until he got older. Then he’d run upstairs, coming down only when he thought it was time for people to leave. He turned into a grumpy old fart like his daddy.

Baxter couldn’t easily get up on the bed in the guest room to survey his kingdom the last year he was with us, so he spent his time in a day bed on the floor in Peg’s office. He developed some quirky habits like scratching anything that struck his fancy: the filing cabinet; a binder on the floor; the trash can. Sometimes he would drag a piece of paper off one of the numerous piles on the floor and shred it. Peg would yell, “Stop that!” He’d give her that “What?” look and then resume digging, sometimes deliberately looking at her. He started knocking over a box of beef sticks under Peg’s desk. She would put them back in the box and he’d knock it over again. Eventually, she gave up.

Sometime during the summer, he developed the habit of wandering down the hallway like the night watchman before he finally settled down. He didn’t want to sleep on the bed with us, so I bought another doggy bed for our room. Some nights he preferred the bed in Peg’s office.

I think the most remarkable thing about dogs is they live in the moment. They don’t appear to grouse about getting older and I don’t think they ever contemplate mortality. Every day is a good day, even when it isn’t.

Like a Rolling (Gall)Stone – Part Deux

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Wednesday

Morning started at 6 a.m. with the Procession of Medications, a pill to prevent reflux, and my nurse noting my lipase level was down to 2,000. A tech took my temperature, blood pressure and pulse oximetry. The day shift nurse, Katrina, brought more meds around 7:30 a.m. which I took with the water I wasn’t supposed to be drinking.

“Uh, didn’t they tell you not to drink?” Nope, this is the first I’ve heard.

She also injected a dose of Lovenox®, an anticoagulant to prevent a deep vein thrombosis (DVT), because it had been ordered, not because I really needed it. I didn’t have the presence of mind to question it because I was tired but it seemed superfluous. My risk for a clot was low since I hadn’t had major surgery, I wasn’t bedridden, I don’t smoke and I’m not pregnant. Yeah, I’m old and fat but so what? (I refused it the next day, which is good because that little sucker was $119!)

An hour later a woman from Respiratory Therapy, who looked and talked like the commandant at a German women’s prison, appeared with one of the newer brand name steroid/long acting bronchodilator inhalers. Remember what I said about hospital meds costing a lot more? This one retails for about $450 and lasts 14 days; the hospital charged $570. My generic version, which lasts a month, is $40 with GoodRx®.

“I have an inhaler for you and I’m going to teach you how to use it. You pull back the cover and it’s very important that you hold it correctly with the vent side up. Then you take a deep breath and hold it.”

I pulled out my albuterol rescue inhaler. “I’m a physician. I’ve been using inhalers for a long time.”

She snapped at me. “You should NOT have your own inhaler! We are responsible for you and must know every medication you are taking! Another respiratory therapist would turn you in.”

Now she reminded me more of General Burkhalter from Hogan’s Heroes. Turn me in? What is this, Stalag 17? Are you going to send me to the Russian Front?

She watched while I inhaled like toking from a bong, then put it in a plastic bag which she placed on the shelf below the TV. “Someone will come back tomorrow for your next dose.” You think I’m so stupid that someone has to watch me?

No, it’s because the hospital can charge $424 to “administer” the medication and $323 to “demonstrate” how to use it! What the hell do people without insurance do with those kinds of charges?

The Parade of the Grey Coats began around 9 am. Doctors (usually men) in white coats often cause spikes in patients’ blood pressures, so now most wear either grey or blue lab coats to minimize the psychological trauma. Or maybe it’s because white coats are a bitch to keep clean. (I have a royal blue lab coat with a Grateful Dead patch on the pocket.)

The internal medicine hospitalist showed up first. Now, I’m not sure what a hospitalist does other than generating revenue and confusion while making it possible for office-based internists to never set foot in the hospital. I’m sure I’ll get a lot of shit for that but my sister-in-law’s experience with hospitalists, who are usually much younger than the seasoned staff physicians, was exasperating.

He asked me to recount the events that ended with my admission, the third request if you’re keeping count.

“How are you feeling?”
“Better than when I came in.”
“Well, your lipase levels have come down nicely to around 2,000 with the I.V. fluid flushing it out. Do you mind if I examine you?”

He poked my abdomen in a few places. “Does that hurt?”
“Not much but you’re not as rough as the ER doc last night. Do you know Dr. Nell?”

He chuckled, “Yes, I like her, but she can be a little, uh, enthusiastic.” That’s a polite way of putting it.

“Your lipase levels suggest you have pancreatitis. You’re not an alcoholic and you don’t smoke so it’s likely caused by gallstones. That pain you had may have been a stone passing, especially since it didn’t last too long and you’re feeling better. I’m going to order an ultrasound of your gallbladder. We might be able to send you home later today, but we’ll have to wait for the GI guy to see you.”

We interrupt this tale for a moment of education and enlightenment.

THE PATHOPHYSIOLOGY OF BILIARY PANCREATITIS

The gall bladder is a pear-shaped organ that lies below the liver. It stores and stores bile, which digests fats. Bile leaves the gall bladder through cystic duct. The pancreas also secretes digestive enzymes through the pancreatic duct which joins the cystic duct, forming the common duct. Both empty into the duodenum through the hepatopancreatic ampulla, also known as the Ampulla of Vater (Darth Vater?), which is controlled by the Sphincter of Oddi. Sounds like something out of Norse mythology.

The gall bladder also provides a source of income for general surgeons when it becomes inflamed (cholecystitis), full of stones (cholelithiasis), or both. Stones form when, for unknown reasons, stuff in bile crystalizes and forms gallstones, in much the same way stuff in urine crystalizes to form kidney stones. If a stone gets stuck in the common duct, it blocks secretions from both the gallbladder and pancreas, resulting in gallstone pancreatitis, which is what I had. Pancreatitis can also result from excess alcohol consumption, smoking, prior abdominal surgery, obesity, infections, injuries, and pancreatic cancer.

Abdominal ultrasound is the easiest way of finding gallstones and often cholecystitis, as inflammation thickens the gallbladder wall. Other, and far more expensive, diagnostic methods include nuclear medicine scans, Magnetic Resonance Imaging (MRI), or Endoscopic Retrograde Cholangiopancreatography (ERCP), looking directly into the duct with an endoscope.

A common home test for cholecystitis is consuming a greasy meal which results in excruciating upper abdominal pain; however, this is not medically recommended.

Now, back to the program already in progress

Peg arrived around 9:30am.

Did I ever mention Peg hates hospitals? No, she REALLY hates hospitals. Her mother said, “Hospitals are where you go to die.” If Peg has the big one at home, she wants me to just hold her hand and stroke her arm until she passes. Then, and only then, can I go through her office looking for the lam money.

She also thinks there is a lot of waste and abuse, albeit mostly inadvertently because no one thinks about cost in a hospital. This is largely true. I worked for a staff-model HMO thirty-five years ago. “Managed care” was withholding care from patients for profit and employed physicians weren’t good enough to work with “real doctors.” Forty years later most physicians are employed by heartless entities, and I got the last laugh.

“So, what’s happened so far? I talked to your nurse about 5:30 this morning and she said you had a good night.”

“Yeah, my lipase level has come down to two thousand something. I saw the hospitalist earlier; he thinks I have pancreatitis from passing a gallstone. He ordered an ultrasound and said I might get to go home…depending.”

“Do you have any pain?”
“No, I feel pretty good right now.”

Just then a guy from Patient Transportation appeared in the doorway. He took me down for ultrasound on my bed, reversing the previous night’s course. I stared at the ceiling again as we went left out of my room, into the elevator, down to the first floor, out and a couple of left turns before backing me into a cramped ultrasound exam room. The ultrasound tech introduced herself, squirted warm ultrasound gel on my abdomen and started the exam. About fifteen minutes later she finished.

“And….?”
“You’ve got gall stones, but you didn’t hear that from me.”
“My lips are sealed.”

As the transportation guy wheeled me out someone from nuclear medicine said: “We’re going to see you later.”

Once back in the room I told Peg what we’d both suspected. Then the gastroenterologist showed up – not exactly a fount of wisdom. At his request I repeated the events of the previous 12 hours for the third (or was it the fourth) time. He pushed on my abdomen, and I winced.

“Well, at least it’s in the right place. Your ultrasound showed you’ve got gallstones. We’re going to get a CT (Computed Tomography) scan to confirm the diagnosis and a general surgeon will see you later today.”

“Ok, how about not giving me another liter of fluid? I’ve had three in the past ten hours, and I’ve been peeing every two hours.”
“Yeah, that’s probably a good idea. We’ll also try you on clear liquids.”

Peg and had a discussion after he left.

“You told me it didn’t hurt, and you told him it did.”
“It didn’t hurt when you asked me. It hurt after he reefed on it because it’s inflamed, not because I’m lying to you.”
“Getting a CT scan to confirm what we already know is a waste of money! The ultrasound showed you have gallstones; a CT scan is redundant. It’s not going to give any better information. And THIS is why healthcare is so expensive!”

Peg had a point. If you’ve already made the diagnosis with a $1,000 ultrasound scan, why tack on another $3,000 for a CT scan to tell you the same thing? If an ultrasound might be difficult because of extreme obesity, then just do a CT. (Side note: Later that day the general surgeon told me the CT scan was used because ultrasound can’t evaluate the pancreas very well for things like fluid collections or tumors, which is important when considering surgery.)

We saw the cardiologist next and recited my history for the fifth time. I recognized his name; he is the “electrician” who did my sister-in-law’s cardiac ablation. She absolutely loves him, and his partner is my cardiologist, so I trusted whatever he had to say.

“Your EKG and troponin levels were normal. You haven’t had a recent stress test and we’ll have to clear you if you’re going to have surgery.”

I had a stress test in 2017 because I’ve no reliable family history and I was going to start work as a hospitalist. Unfortunately, a normal stress test doesn’t mean you won’t drop dead a few weeks later like Tim Russert.

There are two ways to do a stress test. The time-honored tradition is to hook a patient up to a 12-lead EKG, run him or her on a treadmill until the pulse is at least 130, and see what happens. ST segment changes suggest coronary artery blockage. (So does grabbing one’s chest and having the big one.) The test runs a few hundred bucks.

The other way is a cardiolite stress test, injecting the subject with a radioactive tracer and scanning the heart before and after the treadmill. A decrease in uptake after exercise suggests blockage and may indicate which artery/arteries are affected. The tracer and scan add several thousand bucks to the procedure, even though it is of questionable benefit in someone who has no history of coronary artery disease. Coronary angiography, injecting dye through the coronary arteries, is still the definitive test for detecting blockages.

The charge for an outpatient study is considerably less than doing the same thing in a hospital:

Item	outpatient	inpatient
Treadmill	$325.00	$1,200.00
Tracer	$720.00	$918.00
Scan	$1,634.00	$5,532.00
Interpretation	$300.00	$300.00
TOTAL	$2,979.00	$7,950.00

Cardiolite Stress Test: Comparing outpatient and inpatient charges

A nuclear med technician came in with a syringe containing the isotope in a shielded container and transportation took me down in a wheelchair instead of a gurney. This time I could at least see where I was going. The cardiac evaluation unit was below the first floor and reminiscent of the Batcave.

One of the women in the scanning room explained the procedure, then had me lay on the slightly uncomfortable scanner bed. The initial images took about six minutes, then they wheeled me across the hall to the treadmill room. Another tech applied twelve more EKG leads on my chest and abdomen, on top of the six leads I had for the portable monitor. The woman running the test explained what was about to happen.

“You’ll be on an incline on the treadmill. It will start out slowly for a few minutes, and then I’ll increase the speed until your heart rate gets to 130. You’ll have to keep that pace for at least a minute. Try to go as long as you can. When you need to stop, I’ll slow the treadmill for a one-minute cool down phase. I see you have exercise-induced asthma. Do you have an inhaler?”
“Yes, I do but the respiratory Nazi told me I shouldn’t have it in the hospital.”
“Well, she’s wrong; we like treadmill patients to have their inhalers on hand.”

Left hand, have you met right hand?

The incline was fairly steep, more than I’ve ever tried at home. I held onto the bar across the front of the treadmill to keep from falling backwards. The pace was manageable despite feeling I was hiking up a mountain.

Then, to quote Emeril Lagasse, she “kicked it up a notch.” Actually, several notches. It didn’t take long for me to hit the target heart rate. I managed two minutes at that speed before I told her I had to stop.

“Are you having any pain or trouble breathing?”
“No, I’m just way out of shape and too old for this shit.”

I went back into the scanner for about three minutes before being wheeled back upstairs. I napped for a while, while Peg sat in the corner playing with her Kindle and looking at the news feed on her phone. I figured no news was good news.

The day nurse came in a little after 1pm to tell me the CT scan was scheduled for around 4pm and I’ll get oral contrast to drink around 3pm. The guy from transportation arrived a little before 4, followed by the nurse.

“Wasn’t I supposed to drink some contrast?”
“Uh, you didn’t get it?” Would I be asking you if I had?

She sputtered a bit and disappeared, possibly to give someone an ass-chewing, and to get the CT scan rescheduled. Peg rolled her eyes.

“If you were just a regular patient, you would have gone for your scan without asking any questions. They would have done the CT, discovered you didn’t have the oral contrast, and sent you back upstairs, and repeated it later. And you wonder why I hate hospitals.”

I saw the surgeon around 6:30, after Peg had gone home to feed Baxter. We hit it off immediately. He extolled the virtues of removing gallbladders with a laparoscope and I told him about assisting on an open cholecystectomy when I was an intern. Back then they made an autopsy incision from the breastbone along the right rib margin, then pried the muscles apart to get to the gallbladder. The guy I helped with was fat and needed a very large retractor called a Joe’s Hoe for exposure. Yeah, it looked like one could till soil with it.

“There are two options. The first is to have the surgery since you are already in the hospital, and you’ve gotten cardiac clearance. The other option is letting you go home and scheduling this as an outpatient. I’d recommend doing it now because we know you have gallstones and you’re likely to have another attack within three months. It’s better to take care of it now, because I’ve seen people wait and then come in with a necrotic gallbladder. They end up in ICU on I.V. antibiotics and sometimes a ventilator because they are really sick.”
“My wife works long hours. I need to talk to her and make arrangements. What is the chance of passing another stone in the next two weeks?”
“It’s likely pretty low but not zero. You might want to just get it over with.”

Well, that sounded good to me; I wouldn’t have a lot of time to think about going under again. We talked about my prostatectomy; he said taking out my gallbladder wouldn’t take as long, and I could probably go home a few hours later.

“I know your surgeon. We’re actually very good friends, even if he did go to Ohio State.”
Oh God, he’s a Wolverine. They can be sooo insufferable! But he seems like a decent guy.

“In the meantime, you can have a clear liquid diet tonight. Don’t have anything after midnight in case you decide on surgery. I have one case in the afternoon.”

I called Peg.

“He said we can do it now or do it later. I told him you had to work and could we do it in a couple of weeks. He said we could but there was a chance of another attack before surgery.”
“Well, what do you want to do?”
“He’s coming back in the morning and you’ll probably be here before him, so you can ask him any questions. If I do it tomorrow, I won’t have a lot of time to think about it.”
“I’ll go along with whatever you want.”

Katarina brought me two cups of contrast just before 7pm.

“Drink these now and I promise you’ll be downstairs for your CT scan around 8pm.” Well, this better happen!

Someone arrived just before 8pm and took me down to the CT room. It was cold, probably to protect the equipment which can become very warm. The tech who met me was a scruffy guy who reminded me of the dude that drove the school bus down to the water when a bunch of us went canoeing at Turkey Run State Park in Indiana during college. (His “mandatory safety instructions” were “If the brakes go out on this bus, put your head between your legs and kiss your ass goodbye!”)

“Marian will help you lay on this skinny bed while I get everything set up. I’ll let you know when I push the I.V. contrast because your head will start to feel warm and then you’ll think you’ve peed your pants. You’ll have to hold your breath a few times but that doesn’t last long. Do you have any questions?”
“Nope, let’s just get this done.”

The scan was as he described. I held my breath a few times while the scanner did its thing. The I.V. contrast created a brief sensation of warmth in my head and nether regions, passing quickly. I was back upstairs by 8:30 and I called home to say goodnight to Peg and to Baxter, who wasn’t taking this very well at all. He paced Tuesday night until 2am and this promised to be another fitful night.

Maybe tomorrow would bring a reprieve from all this fun and excitement.

JOIN US NEXT TIME FOR THE SERIES FINALE!

Illustration Credits: All © Can Stock Photo
Pancreas: Blambs
Pancreatitis: alila
Pear: yayayoyo
Burger and Liver: FabioBerti

Keynote Address

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Transcript
Society for Maintaining Integrity on The Earth
Inaugural Meeting
Opening Remarks and Keynote Address

Good morning. I’m Michael, the Chair of the Ethics Department at the Society for Maintaining Integrity on The Earth and I’d like to welcome you to this inaugural meeting. It’s good to see all of you who accepted our invitation, and I’m looking forward to meeting with all of you individually. These are exciting times for all of us as we embark on this new project.

I’d also like to introduce Peter, our database administrator and technical wizard. Say hello, Peter. (Peter smiles, waves, and mumbles a greeting.) Peter will be leading the afternoon computer training workshop. He will also introduce the new phone app for Android and iPhone. This allows much faster access to information you’ll need to assess any situation. We haven’t yet activated the function because we still want you allow time for deep contemplation before acting.

A few housekeeping items before we get started. Lunch will be from 11:30 am until 1:00 pm in the Grand Ballroom. Be sure to bring the tickets that are behind your name badges. A bus for your spouses’ slash significant others’ activities will leave from the main entrance at 1:15pm and return in time for dinner.

Joseph Stalin famously said, “Everyone has the right to be stupid, but some people abuse the privilege.” I’ve been active since the first Homo sapiens appeared, weeding out those whose excessive stupidity threatened humanity’s survival and progress. Sometimes it was so rampant that I’m amazed you’ve accomplished anything in the past ten thousand years.

My job was much simpler in prehistoric times. There were fewer people and natural selection – what you call Darwinism – was very efficient. If you were persistently stupid, some ferocious beast decided you might make a nice snack (with a little subliminal suggestion from yours truly). Irritating the rest of the tribe might get you thrown into a volcano, justified by the flimsy excuse of “appeasing the gods.”

Now and then Administration had to periodically step in and thin the herd. Destroying almost everyone and everything with The Great Flood was regrettable, but that instilled the fear of The Almighty in the survivors, at least for a few centuries.

Later I experimented in Ancient Egypt, using the more articulate among the masses – Moses, David and others – to provide blatant warnings. The Pharaoh got nine warnings before the smiting began. I think DeMille’s casting of Yul Brynner was genius and I must admit a certain fondness for that stunt with the Red Sea.

A millennium and a half later, Administration had a great idea. Why not send Himself to live among the people? You recall how well THAT worked out. After the Resurrection the stupid in power – it’s amazing how the latter attracts the former – treated the disciples rather badly. Even a well-written manual wasn’t good enough for some – yes, I realize men don’t like to follow instructions – but then using it to inflict unspeakable pain has been humanity’s most despicable perversion.

Earthquakes, fires, the Black Death – all managed to keep the great unwashed under some control. That is, until things improved over the next couple of centuries and people began throwing caution to the wind. We found ourselves back at square one. The Renaissance was but a brief respite from idiocy. Humanity been remarkably resistant to guidance and reason.

By the twentieth century I had to become less subtle in my messages. That guy on the street, the one dressed in rags who held the sign that said, “The End is Near?” He wasn’t crazy; he was a walking Public Service Announcement. Targeted individuals who noticed but ignored the obvious hint later met with an unfortunate “accident.”

But the burgeoning population made it difficult for me to keep up with the workload. Social media has brought out the worst in people and you can thank those media czars for record levels of stupidity. Administration decided I needed some help, and that is where you come in.

You’ve all been selected for various reasons, for the Lord works in mysterious ways. Some of the people close to you probably wondered, “Why him (or her) and not me? I could do a damn good job of smiting!” We appreciated their enthusiasm but there’s more to it than just summarily dispatching everyone who irritates the crap out of you. One of this morning’s sessions will cover the guidelines for choosing those most deserving. Our next session will discuss why you were chosen.

Thank you for attending and I hope you all find these talks illuminating.

Notes from Dr. Dave

Musings from forty plus years as an OB/GYN and a writer.

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Keynote Address