Like a Rolling (Gall)Stone – Conclusion

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Thursday

It started out as a repeat of Wednesday. A lab tech drew blood around 5am which turned out to be yet another set of troponin ($254.00) and lipase ($197.00) levels and a third comprehensive metabolic panel ($202.00) and CBC ($92.00) plus $37 just for the honor of sticking a needle into my veins.

Meghan arrived at 6am to give me my daily Protonix® for reflux; Katrina would bring me the rest of the medications after shift change. This time I balked at the Lovenox.

“Do I really need that? I’ve been out of bed several times and I move around when I’m in bed, so I’m not really going to throw a clot.”
“Ok, well, you don’t have to take it if you don’t want it. I’ll let the doctor know.”
“While you’re at it, how about asking him to get rid of the telemetry monitor since we know I didn’t have a heart attack and this thing is probably costing someone a lot of money.”

Telemetry was $122.00 per hour and the total charge was $2,074.00 with another $2652.00 “room charge” tacked on.

Then the Parade of the Grey Coats started.

I don’t remember much of what the hospitalist said, aside that my lipase level was back to normal, and he would be talking with the surgeon about our conversation. Peg arrived shortly after he left.

I’m really not sure why the gastroenterologist showed up because he had nothing useful to say. Probably it’s because he could bill $366.30 for the initial consult and $192.03 for the follow up visit. He told me to make a follow-up appointment with him in four weeks, advice I promptly ignored because I’d already made an appointment with my own gastroenterologist to arrange another colonoscopy.

My cardiologist, Dr. McGuinness, recognized me immediately when he arrived. He is also my sister-in-law’s cardiologist, in the same group as her “electrician,” and he is beloved by staff and patients. He should give seminars on bedside manner and patient communication.

“It’s good to see you. I wanted to let you know your stress test was negative. I heard you might be having your gallbladder out soon.”
“Yes, I talked with Dr. DeBouw last night; he should be coming around this morning so we can finalize a plan.”
“There’s nothing more for us to do, so we’re signing off. I hope surgery goes well.”
“Thanks. It was good to see you.”

 Peg was in a good mood. However, Katrina, who must have sensed a critically low level of turmoil, arrived to top off the tank.

“Dr. Warner, the hospitalist, said he talked to Dr. DeBouw who said he would talk to you downstairs in pre-op before surgery.”

Peg and I looked at each other.

“Where did you leave it last night?”
“He was going to talk to me this morning about doing surgery now or schedule it for a couple of weeks later as an outpatient.”
“He didn’t say ‘We’re going to take you to surgery tomorrow,’ did he?”
“Nope.”
“Well, I hope he’s better in person because right now I’m not happy.”

If momma ain’t happy, ain’t nobody happy!

This could have been problematic. Insurance companies don’t like to pay inpatient rates for outpatient procedures unless done as an emergency, in which case one has to have been formally admitted. Peg had called the claims department on Wednesday and, as of 3:40pm, they had only received notification of my emergency room visit. They weren’t aware that I’d been held for observation, nor whether I’d been admitted. The person in claims said, “Some hospitals are better than others.”

Peg asked Katrina: “Who can I talk to about this? Utilization management?”
“That would be a good place to start; you can call the operator and they’ll connect you. You can also talk to the unit manager. I think she is on the floor today.”

Hospital Utilization Management (UM) departments are the bane of every physician’s existence. Utilization reviews ostensibly increase efficiency in hospital care and decreases revenue loss from unreimbursed charges by reviewing care for “medical necessity” and decreasing “length of stay.”  Physicians see UM as people paid to tell us what we’re doing wrong and why we should toss patients out “quicker and sicker.”

Peg called UM and got voicemail, which didn’t improve her mood. I called Katrina back into the room.

“Would you do a couple of things for me? First, have someone get ahold of Dr. DeBouw and let him know we want to see him here in the room, not in pre-op. I don’t know if there’s been a problem with communication, but I think it’s tacky to assume someone has agreed to surgery without a final discussion. Then can you find the unit manager because trying to talk with someone in Utilization Management was a bust.”

I sensed some annoyance, but she agreed to contact him. A few minutes later she returned and told us he was on his way to the hospital and would see us before his first surgery.  I hated to be demanding, but this is why physicians and nurses need to be on the other side of the bed. It gives the perspective one wouldn’t get without being subjected to the indignities inflicted on the great unwashed.

Dr. DeBouw arrived about 30 minutes later. He reiterated what we had talked about the prior evening, including the risks of becoming seriously ill while waiting to do surgery as an outpatient.  Peg was happy again. 

Someone from patient transportation came to fetch us around 12:30pm and took us to pre-op holding where patients are prepped for surgery. If you’re lucky, you’ll be put into a 10×12 ft. cubicle with a sliding glass door and a privacy curtain. There’s enough room for the gurney, a small wall-mounted desk and cabinet, an I.V. pump and one family member sitting in an uncomfortable plastic chair. The back wall usually has a fluorescent light bar, a wall-mounted monitor screen, and a “medical headwall system” which has outlets for oxygen, “medical air” suction and electricity. Often there’s a self-inflating resuscitation bag and mask hanging on the wall just in case someone codes in the room. Otherwise, you’ll likely be in a ward with several patient areas separated by curtains, which is also how most Post Anesthesia Care Units (PACU) are set up.

A lively nurse peeked around the curtain and said, “Your doctor will come and talk to you before we take you back.”
“Uh, we talked with him upstairs about thirty minutes ago.” Geez, doesn’t ANYONE communicate around here?
“Ok then, that makes it easier. What’s your name and date of birth? And what are you having done?”

If I’d thought more quickly, I might have made some smartass comment about having a Cesarean section for twins, but I was really tired and just wanted to get on with it.

The anesthesiologist followed. Anesthesiologists range from gregarious back-slappers through personable, reassuring people to grumpy assholes who speak in grunts. The stereotype of anesthesiologists are physicians who, much like emergency room physicians, prefer short-term, intense patient relationships, minus the need for engaging or conversing.

“What’s your name and date of birth? And what are you having done?” He wouldn’t be the last person to ask me that.

After identifying my name, my quest and my favorite color, I told him about my paradoxical reaction to Versed (midazolam), a benzodiazepine used for sedation for procedures, such as colonoscopies or minor surgeries that don’t require general anesthesia. I’ve been given it for two colonoscopies and my eyelid surgery; apparently, I tried climbing off the table for the first two and a nurse had to hold my head for the third. I don’t remember any of this because Versed puts one in a little black room without anything to distract, like elevator music.

“They gave me 6mg when I had my eyelid done.” (The usual dose is 2mg.)
“What??? That was wrong! If the usual dose doesn’t work, giving someone more certainly isn’t going to help.”
“Well, they ended up giving me propofol.”

He made a note in my chart and left. A few minutes later the Certified Registered Nurse Anesthetist (CNRA) came into the room. For the uninitiated, a CRNA is a registered nurse who has gone beyond a Bachelor of Science in Nursing (BSN), earning a Master of Science in Nursing (MSN) and completing two to three years of anesthesia training. They’re often supervised by anesthesiologists in large hospitals, but often practice independently in smaller, rural hospitals. They are cheaper to train than physicians and their salaries, while substantial, are much lower than anesthesiologist salaries.
I like CNRAs because I don’t have to deal with an outsized ego. With few exceptions I’ve found them to be a joy to work with.

Then the moment of truth arrived. I kissed Peg as they wheeled me out the door and down the hallway. Then down another hallway. And another. By now we should have reached the next county. Finally, they pushed the gurney into the room, and I climbed onto the operating table. The anesthesiologist put a mask over my face and told me to breathe deeply.

I heard, “How are you doing?”
“I’m still here.”
Not for long, sweetheart.

I’m thoroughly fascinated by general anesthesia. You’re out like a light and before you know it, you’re in the PACU babbling like an idiot. My prostate surgery took three and a half hours, but it felt like ten minutes to me. This was no different. When I woke up in recovery, I asked myself am I dreaming? I’ve had fairly vivid dreams that are almost indistinguishable from real life until I finally wake up. I asked “am I dreaming” out loud but there was still no answer. Slowly things started to come into focus, and I suspected I wasn’t in the OR.

I saw a recovery room nurse next to the gurney, making notes in the laptop sitting on the bedside table. I put my hand on her shoulder to make sure she was real. She took my hand away and looked at me.

“You’re in recovery. Do you need anything?”
“How about a beer?”
“No, there’s no beer”
“I want a beer.”
“Nope, no beer.” Well, THAT sucks!

I became aware of a rhythmic beeping sound above my head and to the left, the pitch of which began to slowly decline.

“Take a deep breath.” 

I did and the pitch rose. I nodded off and the pitch dropped.

“You have to breathe. Take a deep breath”

The beeping sound was coming from the pulse oximeter, a device which measures the percentage of blood oxygenation saturation (also known as O2 sats) through a small sensor clipped to one’s index finger. Anything above 98% in a healthy person is normal. I’ve had lifelong asthma and chronic inflammation, so my sats run around 95% on a good day.

I looked over my shoulder; my O2 sat was 89% and going down.  I took a few deep breaths and it rose to 98%. Every time I heard the pitch going down, I looked at the oximeter and adjusted my breathing because I don’t like being yelled at even though I know I’m just fine. I’m not breathing deeply because I just had three tent stakes thrust through my abdominal wall and I was breathing anesthetic gas, which I could still taste an hour later.

“Would you like some ice chips?”
“Yes, please.”

She dumped a spoonful of ice chips into my mouth which I savored, waiting for them to melt instead of chewing.

“Can I have more ice?”

Another spoonful of cool, wet ice chips. I could hear several people at the desk discussing Portillo’s, a well-known Italian beef joint in the area. That sounds good. Portillo’s and a beer.

Dr. DeBouw talked with Peg after he’d finished. My gallbladder was “ugly” and there were more stones marching down the cystic duct, so taking it out was prudent. He said surgery was “textbook” and took about 20 minutes. If recovery went well, I could go home later in the afternoon and have anything I wanted for dinner, even steak.

That sounded good, but someone hadn’t bothered to tell PACU or the floor to which I was going to be transferred. Normally, one goes from PACU to another outpatient area where the staff assesses one’s fitness to go home. “What we’ve got here is failure to communicate.”

Patient transportation took me to the fourth floor and dumped me off in a room the size of a storage closet. There was barely enough room on either side of the bed for one person. Someone had dutifully filled out the white board facing the bed with pertinent information like my nurse and her in-house phone number, my physician and what tasks had been scheduled for the next 24 hours. My new young nurse, Ashley, and her equally young assistant bounced into the room, bright-eyed and bushy-tailed, even though their shifts would end in a couple of hours.  Ashley immediately hung a fresh I.V. bag (another one hundred fourteen bucks a bag and another $753/hour for the pump).

“Let’s get you settled in…”
“Uh, I’m not planning on staying here for very long. Dr. DeBouw said I could go home this afternoon.”
“Uh… Well, let me check on that. I thought you were going home tomorrow morning.”
“Not if I can help it. I’ve been here long enough.”

She left the room, presumably to call my surgeon and confirm that I was indeed getting out of Dodge and returned in a few minutes.

“Yes, you can go home but before that you have to eat something, urinate and walk without difficulty.”
“Ok, well I peed while you were gone. If you want me to walk, let’s go now!”
“How about I have you order something from the menu, and we can walk while you’re waiting for it.” (Being able to order something charitably called “room service” is a recent development in hospital management. It’s still hospital food and sucks more often than not.)

Surgeons often inject long-acting anesthetic into the tissue around the trocar sites; I wouldn’t feel any pain until the following morning. I got out of the bed with little effort, grabbed the I.V. pole and led my nurse and her assistant out the door. I went down the hall and circled the nursing station at a brisk walk, the two of them marveling behind me as if Christ had just healed the cripple

“Well, just look at you go!”

You’re young and you think I’m ancient, but your perspective of age will change in about forty years. People in their sixties are no longer hanging out on Death’s doorstep. Neither are many people in their eighties.

My “dinner” arrived shortly after we returned to the room: desiccated grilled chicken and that tasteless broth I’d experienced the day before. The only saving grace was a small carton of Luigi’s Lemon Italian Ice. Very tasty.

Ashley bounced into the room again.

“We’re trying to contact the hospitalist because he has to approve your discharge?”
“Why? The surgeon already discharged me. Why would the hospitalist care if I’m gone?”
“Well, we just have to do it, but it shouldn’t be long. He’s already left the hospital but we’ll page him.”

After waiting another 45 minutes for the hospitalist’s blessing and satisfied that I met the criteria that would keep them from being sued for discharging me too early, they gave me the requisite discharge and follow-up information. Patient transportation wheeled me to the main entrance, stopping at the canopied walkway leading to the parking lot pickup point. He must have been tired after a long day.

“Can you make it from here or do you want me to wheel you out?”
“Nope, I’ll take it from here.”

I got into the car and Peg drove off. We stopped by Walgreens and picked up my prescription for hydrocodone tablets (I used only one), then Portillo’s for a beef sandwich before going home to my own bed. But no beer.

Here’s the damage:

DescriptionCharges
Hospital$47,914.92
ER Physician $1,264.00
Medical Group Physicians $1,850.01
Outside GI Consultant $558.33
Surgeon $2,900.00
Surgical Assistant $1,450.00
Anesthesiologist $2,475.00
CRNA $2,475.00
Radiologist $488.00
Pathologist $73.00
TOTAL$61,448.26
Medical charges May 4-6, 2021

I have good insurance which paid for most of this. We still had to pay more than $2400 out of pocket, but Peg is fortunate enough to have a Health Savings Account (HSA), which is funded with pre-tax dollars. I reached my deductible before the anesthesia group submitted its bill for both the anesthesiologist and the CRNA, $2475 each. So much for CNRAs being cheaper.

I can afford this but millions more can’t. It’s unconscionable that the richest country in the world won’t provide universal health insurance coverage. I don’t see that happening until Millennials and women run government.

(If you are interested in seeing how a gallbladder is removed laparoscopically, check out this video: Laparoscopic Cholecystectomy for Symptomatic Cholelithiasis – Extended L. Michael Brunt, MD, Section of Minimally Invasive Surgery, Washington University, St. Louis, MO.)

Sad Gallbaldder Plushie from The Awkward Store, courtesy of my wise-ass daughter. Now why didn’t I think of this 20 years ago?

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:

Itemoutpatientinpatient
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

Like a Rolling (Gall)Stone – Part 1

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Tuesday

One minute I’m sitting on the couch watching 911: Lone Star and the next we’re hauling ass down 22nd Street on our way to Our Lady of the Suburbs Hospital thinking I’m gonna die from a heart attack.

I’ve had one hell of a case of reflux from three decades of stress, heavy caffeine intake and being fat, so occasional epigastric “discomfort” doesn’t set off alarms. But this time the slight ache turned into a constant squeezing pressure just below my xiphoid, that triangular bone below your sternum (breastbone) and pain that ran up to my right jaw. I went to the dining room table and sat for about 10 minutes and, like every other guy facing the prospect of a life-altering illness, hoped it would go away.

It got worse.

Peg was on the phone with her sister when I said, “I need to go to the hospital right now!” I was clutching my chest and had that I’m-not-pulling-your-leg look.

“Oh, shit, I gotta go!” She hung up and asked, “Do you want me to call 9-1-1?”

Hell, no. My first and hopefully last ambulance trip cost about fifteen hundred bucks and we could get there faster by driving. We got into the car and for once Peg didn’t drive like my grandmother. We were at Highland Avenue in about five minutes; the hospital was another five minutes south.

I thought back to the time Peg’s mom Gloria took Michele’s husband to the same hospital with his second heart attack. She didn’t like the maniacal drivers on Highland and took the back way through Finley Square Mall. Despite being potentially on death’s door, Dave still had the presence of mind to backseat drive.

“This isn’t the way to go.”

Gloria snapped, “Well this is the way I go!”

Best not to piss off the woman who has your life in her hands.

Peg pulled into the circular drive at the Emergency Department entrance. I got out and slowly walked into the reception area, still clutching my chest. The pain wasn’t as bad, but it hadn’t gone away. Peg said, “Possible MI here!” which impressed no one behind the glass.

“Have you been here before?”
Does it fucking matter right now?

Peg whipped out the all-important insurance card while I grabbed the nearest wheelchair. A few minutes later someone came out to reception and wheeled me through the ED double doors. The desk clerk, whose duties include traffic control, said, “They’re just finishing cleaning up nine. You can take him in there in a couple of minutes.”

Even though I’ve done it a couple of times, I’m still not used to being the one being wheeled into an exam room. Usually, I’m the one strolling in after all the folderol is over and the patient is prepped. Now I’m the one climbing onto the gurney while a couple of people swarm around me like worker bees around the queen. 

My shirt came off and someone put EKG leads on my chest, a blood pressure cuff on my left arm, a pulse oximeter on my left index finger, a thermometer under my tongue and an IV catheter in my right antecubital space (elbow joint), one of the worst places to put it. A lab tech took several tubes of blood before the nurse ran heparinized saline through the catheter before plugging the end. I put my gown on sometime during this onslaught. Someone else came in for a nasal swab for a COVID test.

A tech did an EKG and I figured I wasn’t having a cardiac issue since he didn’t go running down the hall for the crash cart team. Modern EKG machines print out a preliminary reading; mine was normal sinus rhythm. A radiology tech pulled a portable x-ray machine into the room, put a plate behind me and said, “Deep breath and hold it.” Imaging is all digital now; no more 55-gallon drums full of used x-ray film. The image appears on a computer monitor and the ability to zoom in and out means the radiologist doesn’t have to squint nearly as much.

The nurse started taking a history of my episode; this would be the first time of many that I’d recite the same story. This is not surprising since patients will tell nurses one thing and doctors something else. My story went like this:

“So, tell me what brought you to the hospital / what happened / what’s been going on?”
“I was sitting on the couch about a half hour after dinner and started to feel this pain right here (points to mid-epigastric area) that felt like someone was squeezing me really hard. I waited about ten minutes thinking it was going to get better, but it only got worse, so we came here.”
“When did it start?”
(Looking at the clock) “About 30 minutes ago.”
“Did the pain go anywhere else?” This is important because cardiac pain generally radiates to the left jaw and/or the left arm.
“It went up into my right jaw.”
“Any nausea, vomiting, sweating?”  The first heart attack admission I saw when I was a 17-year-old hospital orderly was sweating like a pig*. Some have nausea and/or vomiting, making them think “it’s just a little indigestion.”
“How do you feel now?”
“Better than I did before I came here but it still hurts!”

*Before someone says, “Pigs don’t sweat,” that phrase came from iron smelting. Molten iron poured onto sand forms “pig iron” which resembles a sow and piglets. Moisture from the ambient air condenses onto the “pigs” as they cool, which looks like sweat. I didn’t know that before, and now you know it as well.

The nurse left and the ED physician, Dr. Nell, walked through the privacy curtain covering the exam room doorway. She was short and stocky with short blond hair peeking out from under her surgical cap; her last name suggested she was of Eastern European descent. She asked me “So, what happened?” (Go up two paragraphs for the recap.)

Before I answered I made a point of telling her I was a retired physician. Normally, I don’t advertise but I’ve found it comes in handy since physicians don’t treat their brethren with the same dismissive attitudes and skepticism reserved for the great unwashed.

She began her examination by listening to my heart and lungs, then pushed on my abdomen REALLY hard, like one of the old Soviet Union’s female weightlifters.

“AAAAAH!”
“Does this hurt?”  Well, now it does!

She was quiet for a few minutes.

“You don’t have any of the classic heart attack signs like sweating or nausea and your EKG is normal, so it might be GI. I’m going to try nitroglycerine to see if it makes any difference while we’re waiting for your labs to come back.”

She left and a few minutes later the nurse returned with a small oval pill in a medicine cup.

“Put this under your tongue.”

Nitroglycerin is a vasodilator, a substance that relaxes smooth muscle and blood vessels, increasing blood flow to coronary arteries and is absorbed more rapidly from the mucous membrane under the tongue. The tablet itself irritating if left in one place too long and tastes like crap after disintegrating.

A few minutes passed and I didn’t feel any different. The pain had been slowly ebbing since I’d arrived, and my blood pressure dropped slightly. Dr. Nell returned.

“Did the nitro do anything?”
“No.”
“I didn’t think it would.”
“Yeah, neither did I.”
“Well, your troponin levels are stone cold negative, so I don’t think you’re having a heart attack.”

Troponins are proteins released into the blood when heart muscle is damaged. During my internship forty-some years ago we used to measure blood levels of lactate dehydrogenase (LDH) and creatine kinase (CK) when evaluating heart patients, but levels can be elevated with damage to other tissues. Troponins are much more specific.

She continued: “If it’s not cardiac, we start thinking of other causes, specifically gastrointestinal. Esophageal spasms (painful contractions of the esophagus) can mimic cardiac pain. We’ll have a GI evaluate you, but I want to try something else in the meantime. I’m going to give you a solution to drink.”

My nurse returned with a little turquoise container resembling a salad dressing packet, containing a solution of antacid and viscous lidocaine, a topical anesthetic. “We call this Magic Milk.”

I’m probably not going to like this, am I?

“It’s a combination of lidocaine and an antacid. You’re probably not going to like it.”

I’m used to downing Bicitra, something we gave to women before doing an emergency Cesarean section after a long, fruitless labor. It’s a solution of sodium citrate and citric acid with a fluorescent yellow-green appearance and tastes like thick, unsweetened Mountain Dew®. A friend of mine compared it to battery acid, but it cooled the burn expeditiously. It would probably be even better over ice with a little gin or vodka.

I tossed it back like a tequila shot, grimaced, and then roared, causing Peg to immediately panic.

“Are you OK??? Is something wrong???”
“Yeah, this stuff is really awful!”

Dr. Nell returned about 15 minutes later.

“Your labs are normal. Your EKG and chest x-ray are normal. I don’t know what’s causing the pain but it’s not likely cardiac. We’re going to keep you overnight and get consults in the morning.”

A woman from Admitting came in with a tablet and had me sign several forms, including “You’re responsible for any charges not covered by insurance. Don’t be a deadbeat or Vinnie will come visit you.” My nurse hooked me up to a telemetry EKG monitor. I got another wrist band and someone from transportation started pushing me down the hall.

I’ve seen friends and family in this hospital, so I knew my way around a bit, but that was walking upright. It’s almost impossible to know where you are looking at the ceiling, passing under fluorescent lights and acoustic tiles. Left, then right. Down one hallway, right and down another. A bell announced the elevator’s arrival; two bumps as the cart rode over the entrance.

A short trip up and I was on the 5th floor. The transportation dude wheeled me into the observation room.

“Can you make it to the bed?” Yeah, I’m not dead yet and I’m not as old as you think.

After I got settled I looked around at the luxury that was the observation room. I’d bet the Cook County jail had better holding cells.

There was a single hospital bed in what used to be a double room, a bedside table next to the bed, and a single utilitarian vinyl-upholstered recliner in the corner. A laptop was bolted to a mobile desktop between my bed and the bathroom wall. I think there was an unremarkable print on the wall, the kind whose eventual familiarity drives one insane. The walls were painted in either celery or baby diarrhea brown which, combined with the yellow tint of the fluorescent lighting, made the room even more dismal. The mattress was lumpy and about two inches thick; it alternately inflated and deflated in different spots, probably to prevent bedsores or blood clots in skinny, immobile old people. One could probably die from despair in here.

My nurse, Meghan, came in shortly to get me settled. She was tall with dark brown hair, grey eyes, not much of a butt and yes, I could be her father or grandfather. Just because I’m on a diet doesn’t mean I can’t look at the menu. What the hell else am I gonna do at 11:00 pm after thinking I was going to go to the Great Beyond?

We chatted a bit between the obligatory nursing documentation questions, including going through my medication list for the third or fourth time. Here’s a hint: if there are any meds you can do without for a few days before you get back home, don’t mention them. The hospital will give them to you while charging outlandish rates.

About 1am she came in and said, “Your lipase level came back 30,000 and the doctor thinks it might be pancreatitis, so we’re going to start I.V. fluids.” (Lipase is an enzyme the pancreas secretes to break down fats in one’s diet; an elevated level indicates inflammation from a number of causes, including alcoholism, gallstones or tumors.)

Pancreatitis? The only person I ever saw with pancreatitis was when I was a resident. She’d been deposited in our Labor Unit because some genius in the emergency room figured the woman in triage was (a) female and (b) in pain, so she must be in labor. She was actually 49 and had acute pancreatitis; and our nurse manager reamed someone a new one. I wasn’t in that much pain, but even I realized 30,000 was, if not an error, something terribly wrong.

Whoever gave the order also wanted me NPO, nil per os, meaning nothing to eat or drink. However, no one passed that on to me, so I kept drinking all night. And, not wanting to be a bother, I’d unplug the I.V. pump when I needed to urinate, wheel it to the bathroom, do my thing and hook it back up before getting back into bed, after figuring out how not to get tangle in the I.V. tubing. Two days passed and NO ONE asked why the bedside urinal was never used.

The bathroom was another disappointment. Commercial toilets are wall-mounted and, if done more than ten or twenty years ago, were lower to the ground than today’s “comfort height” toilets. Hospital toilets also have a rod connected to the plumbing that pulls down to spray out bedpans. Whoever does maintenance put in a six-inch lift between the bowl and the seat to raise the height but neglected to caulk the lower part of the lift. Anyone peeing sitting down (including me because it’s easier since my prostatectomy), ends up drenching the floor. It took a few trips to figure out why my feet were wet.

The lab took blood sometime during the night, but I wasn’t aware of it and figured they’d taken it out of the I.V. port.  I wondered what fresh hell daylight would bring.

TO BE CONTINUED…

Featured image: Chest Pain.  © Can Stock Photo / yekophotostudio

Bare Bones

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“And why do you worry about clothing? Consider the lilies of the field, how they grow; they neither toil nor spin, yet I tell you, even Solomon in all his glory was not clothed like one of these.
Matthew 6:28-29

“Naked I came into the world, naked I shall go out of it! And a very good thing too, for it reminds me that I am naked under my shirt, whatever its colour.”
E. M. Forster

We come into the world, cold, naked and wet. It’s downhill from there.
Some anonymous cynic

I’ve done two things in my life that might be described as adventurous, daring, courageous or stupid, depending on one’s perspective. The first was jumping out of an airplane at 3000 feet, not once, not twice, but three times. (I was sure I was gonna die the last time because I had to pack my own parachute.) I’ll write about it in a future blog.

But telling people I’ve been to a nudist resort raises eyebrows and prompts some tittering, no pun intended.

Little kids don’t have a problem with nudity. They’ll tear their clothes off without warning, which isn’t a problem unless Mom is in a ZOOM meeting with a two-year-old running around naked in the background. But as we get older, we learn, directly or by inference, that unclothed bodies are shameful and if you don’t agree, you’re a pervert.

Americans can’t disassociate nudity and sex, which isn’t surprising given they descended from the Puritans, a group that was so uptight it outlawed Christmas celebrations. That “nudist colonies” even existed provoked righteous indignation from some and snickering from others.

Public nudity enjoyed tacit acceptance briefly in March 1974. Much warmer than normal weather induced thousands of college kids to run naked across public spaces for the sheer thrill, a phenomenon immortalized by Ray Stevens’ hit “The Streak.”

Now, before I go any farther, I should point out I’m not a narcissist or an exhibitionist. Far from it. Poor body image and self-esteem isn’t restricted to women. I couldn’t look into a mirror from about 7th grade until my late thirties. I don’t recognize the reasonably attractive guy in pictures from decades ago as me. As I’ve gotten older, fatter, and greyer with far less hair, I’ve learned to accept my dad bod.

My interest in outdoor nudity, (naturism to the faithful) was born out of 25 years of life-sucking Midwest winters. I lived in Arizona until I was 11 where we had abundant sunshine, occasional rains, and the rare sun shower, an odd mixture of both. Snow was rare and exciting and usually melted by noon.

Then we moved to Illinois, the Land of Lincoln and the Never-ending Winter, when clouds obscured the sun from November through March. Clouds obscured the sun from November through March; snow a month earlier or later wasn’t unusual. I moved to Michigan for my residency and then stayed in the state to practice for another 13 years.  More snow, less sun and -30° in January. Strolling naked in a warm climate while everyone else froze their asses off sounded better.

I joined the American Sunbathing Association (which became the American Association for Nude Recreation – AANR – in 1995) in the early 1990s. I don’t remember how I connected with them since there wasn’t much of an internet back then and websites were more than a decade away. They didn’t advertise on the backs of matchbook covers like the “Learn to Draw” folks.

I bought Lee Baxandall’s World Guide to Nude Beaches & Resorts, back when we still had bookstores. I discovered that, with few exceptions, naturist resorts are family oriented. Some are permanent residents. Men do not wander around with a cup of coffee in each hand and stacks of donuts on erect penises. Women aren’t an endless parade of Playboy bunnies. Naturists come in a wide range of ages, shapes and sizes. They are just regular people who don’t wear clothes.

There are a few rules when visiting a resort:

  • No lewd behavior
  • No gawking with your tongue hanging out.
  • Don’t take anyone’s picture without consent
  • Carry a towel with you at all times, just in case you sit somewhere
  • Be a decent human being.

I planned to visit a resort outside of Tucson in 1992 during a trip to Arizona for a conference. The now-defunct Jardin del Sol (Garden of the Sun) lay off a dirt road outside of Marana. It was a modest place with a few wooden buildings, a swimming pool, a place to play volleyball and sites for camper hookups. I parked my rental car and checked in with the owner, a short older woman who looked at my AANR membership card.

“You’re here alone?”
“Yes, I’m on a business trip and my wife couldn’t make it.”
She eyed me for a minute and said, “Well, you look all right. The pool is down the hill, and there’s a group having a picnic.”

At that moment a guy in a well-worn white Chevy pickup, who looked and sounded like George Kennedy, stopped and excitedly said something to my host about pending naturist legislation before driving down to the picnic area.

I went back to my car, stripped down to my shoes, grabbed my towel, and headed back. Footwear is essential in the desert; desert sand can become very hot.  Goat heads, the hard, pointed seeds of an obnoxious weed that seems to grow everywhere, prey on bicycle tires and bare feet. And while crawling predators like the scorpion are largely nocturnal, one might run across the foot-long giant desert centipede.

And don’t forget sunscreen.

Thirty years ago, I was uncomfortable around strangers, nude or otherwise, and I wasn’t interested in small talk. I just wanted to sit by myself, work on a sunburn and forget about sub-zero temperatures back home.

I started on a foot path that led away from the pool and stopped at a miniature Boothill Graveyard. The tombstones bore amusing names and the nature of the departed’s crimes, namely violating resort rules (one took pictures without asking). They reminded me of a fake memorial in Boothill:

“Here lies Lester Moore
Four slugs from a .44
No Les, No more.”

Just then an older gentleman, short, bronzed and the spitting image of Buster Keaton, walked up to me.

“Hello, young feller! Can I help you find something?”

“I’m looking for a place to sit awhile and read my book.”

He pointed towards a trellis farther along the trail. “There are a couple of lounge chairs over there. Is this your first time?”

“Yeah, I was born here but I live in Michigan. I miss the sun.”

“Well, there’s plenty here. Welcome!”

I thanked him and headed for the loungers. I put the towel across the seat, lay back and enjoyed the desert, naked as the day I was born, as they say. I stayed for a couple of hours, reading, napping, and baking before driving back to my hotel.

A couple of years later I visited Forest Hills Club in Saranac, Michigan, just outside of Grand Rapids. The resort sits on a heavily wooded hill off a two-lane blacktop and isn’t visible from street level. I drove by it twice before noticing a small sign by a dirt road into the trees; there was an intercom next to the utility gate that blocked the entry.

I pressed the button and a young woman answered. “I’d like to visit for a bit.” The gate opened and I drove up to the site. I showed her my AANR card, and she gave me a brief tour. I went back to my car and took off my clothes and my shoes (no goat heads in Michigan), then grabbed my towel and a textbook. (A textbook? Seriously? How anal-retentive can one be?) I helped her move a large folding table before settling into a lounge chair.

The day was overcast and warm and I lost interest in the book. I lay back in the chair and closed my eyes, forgetting how burned out I was becoming being one of three physicians trying to manage a patient load that demanded five. I imagined spending the rest of my life sitting naked on a beach sipping margaritas and staring out at the ocean.

I haven’t had any further opportunities to indulge, although I maintained our membership in AANR partly to shock a family friend whom we call the Bald-Headed Stepchild. I worked as a traveler for more than twenty years; spending time at home decompressing with Peg was more important that trying to find the nearest resort (there’s only one in Illinois).

If I had my druthers, I’d buy a condo in Mira Vista Resort and try to establish my reputation as a renowned writer-slash-curmudgeon. For now, sitting naked in bed in the morning with coffee and my Kindle while my faithful companion (no, it’s my 15lb Shih-Tzu Baxter, not Peg) eats cookies will have to suffice.

For More Information

American Association for Nude Recreation

AANR: Social Nudism: Behavior Guidelines and Etiquette

Mira Vista Resort

Nude Hot Springs Around the World

Big Think: Nudist Beaches of Central and Eastern Europe

New York Times: Articles on nudism and nudity

World Naked Bike Ride

Featured Image © Can Stock Photo / chrisbradshaw

Writing Exercises

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Disciplined writers commit to writing something every day, but that’s been a struggle. This is my latest attempt.

March 15-16, 2021

Beware the Ides of March.
I admit to being a chronic master procrastinator when it comes to writing, which should not be confused with a chronic masturbator. I am not the disciplined writer who gets up at the butt crack of dawn every day and writes furiously for two, three or more hours.

I’m not a new writer; I’ve been putting pen to paper for more than 50 years. I don’t carry a Moleskine journal, furtively writing everywhere because a newly found voice and sense of outrage is brimming with ideas. My outrage started with an alcoholic stepfather and increased exponentially with the Vietnam War. I’m old and tired and cranky.

I often think of things when I’m driving or out for a walk, neither of which is conducive to putting pen to paper. (Also, my handwriting is so bad I have to ask Peg if she can figure out what I’ve scribbled: “You wrote ‘small Bailey’s’, not small barley.”) I roll things around in my brain, editing and revising until I finally have something to record for posterity.

That, and I’m a poor judge of my own writing. I’m never sure anyone will want to read what I have to say.

I’ve tried to analyze my reluctance with little success, but I can attribute a lot of it to two things: I hate trying to write when the muse isn’t there, because it just makes me frustrated and angry, and I hate being interrupted when I’m in the groove.

Until I alter my habits to something more productive, my days look like this:

I get up after a fitful night’s sleep made difficult by annoying and sometimes terrifying dreams (I was a psychopath being taken to a mental hospital in the last dream I remember). I shower, take my meds from the seven-day pill case I keep in my nightstand, and make coffee. If Baxter is still sleeping – sometimes he won’t get up until 10am or so – I will sit at my desk and try to write or waste time, knowing he’ll be up soon.

When His Lordship has awakened from his slumber, I will take him downstairs and out to pee, then we will negotiate breakfast. Sometimes he is hungry; other times he tries to run back upstairs because he’s just not interested. Occasionally I can entice him with sliced turkey but if he has a case of the fuckits, it’s an exercise in futility. If he does eat, I have to catch him to give him his insulin before he bolts. If I’ve thought fast enough, I put the gate up in front of the stairs.

That being done, I will sit in bed, drink coffee, and play Kindle games or read while Baxter buries, then eats cookies on the bed. I started doing this because if I go directly to my office to work, he yells from the bedroom until I return. When he finally settles down for his all-important early morning or mid-morning nap, I will go to my office and engage in the usual timewasters.

I approach Facebook as the 21st century morning newspaper. My FB friends and acquaintances post news links, often from sources outside the United States. I’ve contacts in the UK, Australia, and New Zealand, as well as one guy in Norway, but he doesn’t appear very often. Reading how the rest of the world sees us is sobering and sometimes infuriating, especially when some asshole here says we shouldn’t have universal health coverage because, “it’s socialism and I don’t want to pay for some illegal’s health care.” Presumably, his own financial ruin, the result of unpaid catastrophic medical expenses, is just dandy.

Then I’ll read the notifications for previous posts which, more often than not, draws me back to running arguments with die-hard contrarians. Common topics include:

  • how Joe Biden is wrecking the country, and how that other guy was so great,
  • people who wear masks are sheep, and coronavirus is a hoax,
  • how the Democrats are coming for your guns,
  • why the national debt is now a problem when it wasn’t during the past four years,
  • poor people are poor because they don’t try hard enough, or they are lazy.

I’m trying to limit myself to thirty minutes as I can spend hours foaming at the mouth.

Next, I’ll check my email and then the ADD kicks in. I get distracted, remembering something I wanted to look days ago, or something I’d promised to send someone.  Last Saturday my lack of progress prompted me to start reorganizing my office. I tossed some shit but just shuffled most of it around.

I’ll give some thought to what I’m going to make for dinner. If I’m really busy I’ll default to takeout. Famous Dave’s on Tuesdays when they have the Feast for Two deal. Popeye’s, El Famous Burrito or Chinese from the Golden Wok on other days.

I have my weekly routines. Tuesday is getting recycling and garbage ready for pickup on Wednesday. Thursday is towel day – washing all the dirty towels. Saturday is for changing and washing the sheets. Somewhere in there I’ll empty the hamper and do my laundry. Peg is particularly finicky about her laundry; for some reason she doesn’t like delicates dried on “incinerate.”

I’ve tried to do the shopping strategically. I’ll do a Costco run once a month, as soon as they open, because otherwise it’s insane. Same with Aldi. I’ll go to Mariano’s nearer to dinnertime when most people are home. Peg and I made up printable shopping lists for Aldi and Costco.

Housework is done as needed. I’ll empty the dishwasher if it’s been run. I vacuum the rug next to our kitchen island as it picks up crap from walking or eating. Getting the Dyson vac we keep in the family room was the best purchase we’d made in a long time. Light, quick and efficient.

After dinner Peg and I collapse on the couch and binge-watch something on Netflix or Amazon Prime until the master realizes it’s around 9pm and starts barking until we go upstairs to the bed.

This all brings me to “The Finite and the Tangible,” a blog post I started years ago and still haven’t finished. Medical school had no definable end in sight. We were expected to acquire useful information from textbooks numbering hundreds, if not thousands, of pages. (Harrison’s Principles of Internal Medicine was about 1,500 pages in 1975. It’s now a whopping 4048 pages in two volumes weighing 13.2 pounds!)  I felt like there was a mountain of books, papers and trash piled into the middle of a school gymnasium and I was the janitor with a whisk broom and dustpan.

Writing provokes the same anxiety and trepidation.

Long ago I learned to derive a sense of accomplishment from simple things like housework, laundry, and cooking. They are finite tasks with tangible results. I don’t have to wait months or years to see the final product. I especially like cooking because cutting things into little pieces is very therapeutic (and, unlike murdering one’s tormentors, legal). I’m a reasonably good cook but I am not a chef by any stretch of the imagination, even though Peg chastises me for doing “cheffy-chef” things like trying to flip a large pancake using just the pan. Hey, practice makes perfect and at least I did it over the sink instead of the bare floor.

A good friend of mine is an artist who, in retirement, has committed to finishing one drawing every day.  I spent the 30-40 minutes writing this when I started, another hour revising the following day, and about 20 minutes just before posting. I’m trying to force myself to write something every day, but it’s still a struggle.

Maybe I’ll ignore the call of the long list of timewasters and go back to “The Finite and the Tangible.” But let me check my Facebook page for just a minute…