Abbott, Costello, and Microsoft

After the serious stuff, and two very tiring ED shifts, I will freely admit to cheating on today's post. I got this from The Father with an infinite email trace, so nobody knows where it started...but I hope you think it's as funny as I did!

(If you are of an age that this dialogue makes no sense to you, please go to YouTube, http://www.youtube.com/watch?v=wfmvkO5x6Ng, for the original.)

You have to be old enough to remember Abbott and Costello, and too old to REALLY understand computers, to fully appreciate this. For those of us who sometimes get flustered by our computers, please read on...

If Bud Abbott and Lou Costello were alive today, their infamous sketch, 'Who's on First?' might have turned out something like this:

COSTELLO CALLS TO BUY A COMPUTER FROM ABBOTT

ABBOTT: Super Duper computer store. Can I help you?

COSTELLO: Thanks I'm setting up an office in my den and I'm thinking about buying a computer.

ABBOTT: Mac?

COSTELLO: No, the name's Lou.

ABBOTT: Your computer?

COSTELLO: I don't own a computer. I want to buy one.

ABBOTT: Mac?

COSTELLO: I told you, my name's Lou.

ABBOTT: What about Windows?

COSTELLO: Why? Will it get stuffy in here?

ABBOTT: Do you want a computer with Windows?

COSTELLO: I don't know. What will I see when I look at the windows?

ABBOTT: Wallpaper.

COSTELLO: Never mind the windows. I need a computer and software.

ABBOTT: Software for Windows?

COSTELLO: No. On the computer! I need something I can use to write proposals, track expenses and run my business. What do you have?

ABBOTT: Office.

COSTELLO: Yeah, for my office. Can you recommend anything?

ABBOTT: I just did.

COSTELLO: You just did what?

ABBOTT: Recommend something.

COSTELLO: You recommended something?

ABBOTT: Yes.

COSTELLO: For my office?

ABBOTT: Yes.

COSTELLO: OK, what did you recommend for my office?

ABBOTT: Office.

COSTELLO: Yes, for my office!

ABBOTT: I recommend Office with Windows.

COSTELLO: I already have an office with windows! OK, let's just say I'm sitting at my computer and I want to type a proposal. What do I need?

ABBOTT: Word.

COSTELLO: What word?

ABBOTT: Word in Office.

COSTELLO: The only word in office is office.

ABBOTT: The Word in Office for Windows.

COSTELLO: Which word in office for windows?

ABBOTT: The Word you get when you click the blue 'W'.

COSTELLO: I'm going to click your blue 'w' if you don't start with some straight answers. What about financial bookkeeping? You have anything I can track my money with?

ABBOTT: Money.

COSTELLO: That's right. What do you have?

ABBOTT: Money.

COSTELLO: I need money to track my money?

ABBOTT: It comes bundled with your computer.

COSTELLO: What's bundled with my computer?

ABBOTT: Money.

COSTELLO: Money comes with my computer?

ABBOTT: Yes. No extra charge.

COSTELLO: I get a bundle of money with my computer? How much?

ABBOTT: One copy.

COSTELLO: Isn't it illegal to copy money?

ABBOTT: Microsoft gave us a license to copy Money.

COSTELLO: They can give you a license to copy money?

ABBOTT: Why not? THEY OWN IT!

(A few days later)

ABBOTT: Super Duper computer store. Can I help you?

COSTELLO: How do I turn my computer off?

ABBOTT: Click on 'START'.............

Employer Mandates: No Good Choices

Yesterday I mentioned a new CMS report noting that the current health care reform proposals that have passed the House of Representatives would improve coverage, but increase costs. While that undoubtedly was the big news of the day, there was another finding that I thought was of interest:

"While some employers will offer insurance for the first time, because of new access to insurance plans, other small employers will drop coverage because paying a penalty to the government will be less expensive than actually offering coverage to their employees..."

Patricia Murphy, The Capitolist, November 16, 2009

For purposes of reference, the current employer mandate features in the House bill are that employers must provide insurance or pay a penalty of up to 8% of their total payroll. Companies with total payrolls under $500,000 are exempt, and the penalty to phased in for businesses with payrolls up to $750,000. Businesses with ten or fewer employees get tax credits to help provide coverage. (Erica Werner and Ricardo Alonso-Zaldivar, Associated Press, Novemebr 7, 2009)

I’m not a small business, but I hope I might be excused for trying, on occasion, to think like one. And if I’m a small business, my decision to offering a health care package probably depends on the type of employees I’m trying to hire and keep. If I need highly educated or technically skilled workers, employees who command higher levels of salary, I’m probably going to provide the benefit. I’ll do so simply because this is the best way to recruit the highly select staff that I need, in order to stay competitive and continue to profit, and I’ll probably continue to do so regardless of the presence or absence of any kind of government mandate.

But I would argue that it’s not these highly sought-after employees that are the focus of health care reform. The currently uninsured employees we’re really worried about are, by and large, those who are essentially unskilled or hourly workers employed by either a small business or a large corporate retailer. These are people who are relatively easy to hire and easy to replace, and there seems to be a ready supply of them. The market impetus to provide insurance for them simply does not exist. This seems especially true in the midst of a recession.

So here’s my decision point as a business owner. Let’s pretend I’ve got twenty employees and a payroll of a million dollars. The government is going to require me to either provide insurance to my employees or pay a fine. It’s uncertain if I will be required to provide a full benefit to the employee or if the employee will cost-share, if I will be required to provide single person or family coverage, or the limits of coverage included within the benefits package. So for purposes of my calculation, I’ve taken the annual cost of my own individual “real-life” family policy ($16,230, of which the employer pays roughly $9,890) as a baseline. (Granted, it’s a pretty good policy, but certainly not the equivalent of the “high-value” polices subject to taxation in the current Senate version of the health care bill.)

Let’s say my company has ten employees. For my workers, the total cost of coverage will be $98,900. This compares with a penalty of 8% of payroll, or $80,000. The disparity between the fine and the premiums get larger as the number of employees rises. For example, if I have fifteen employees my cost is 148,350, and the differential is $68,350; if I have twenty employees, the numbers are $197,800 and $117,800, respectively.

So if the two obvious choices are to pay a penalty to the government or provide health insurance to my employees, I might certainly choose the less costly option. I might be even more prone to do so if I know that there are expansions of Medicaid or other subsidies to help my lower-paid employees buy insurance on their own. But there’s a third choice as well. I could decide that health insurance is an important benefit, and make up the difference between the premiums and penalties by either tightening my worker’s wages and taking the difference out of their salaries, or by letting a few go so the remainder can have their benefit. Neither of these are good choices.

Given this analysis, why would any business actually want to provide health insurance for their employees? Some large corporations such as Wal-Mart have come out in favor of employer mandates as a way to level the playing field and eliminate the competitive advantage held by companies that do not offer insurance. One might be forgivien for wondering if this support is real or simply a response to the knowledge that the train is roaring down the tracks and it's best to be on board, but the support is there nonethless. Advocates can also point to the State of Massachusetts, where employer mandates within their 2006 overhaul of health care did extract compliance from the vast majority of affected employers. (To be fair, the employer requirements were less stringent than as proposed in the current House bill, but so too were the proposed fines.) It remains to be seen if the public spirit shown by employers in the Bay State is shared throughout the country. One hopes for the best, but has unfortunately come to expect the worst.

So what’s the solution? The goal should be for businesses to opt to provide health insurance, not be forced to do so. But if employer mandates are the way to go, it would make sense to raise the penalty to an amount equivalent to that of the health insurance itself in order to eliminate non-compliance as a cost-saving choice. But much better, I think, to either rely fully on an individual mandate with generous subsidies to truly make insurance affordable (I remain desperately troubled by the idea that a family, even with a subsidy, should be required to buy insurance instead of using the funds on other needs), or to accept that the best and most cost-efficient way to solve the problem is simply to establish a baseline level of benefit for all Americans.

(Author's Note: When I originally put this note down on paper, I was using an Associated Press article as a reference. This morning, I was flipping through the news and found another AP article by David Lieb about small businesses dropping health care coverage. This article said:

"Both the House and Senate versions would offer temporary tax credits to offset a portion of the health insurance costs for businesses with fewer than 25 employees and average wages of less than $40,000...

Legislation passed by the House would impose a tax penalty on businesses with payrolls of more than $500,000 that don't offer health insurance or fail to pay at least 72.5 percent of the premium costs for a health plan with federally mandated benefits."

Granted, the differences in the provisions may seem minor, but they are differences nonetheless. So is it any wonder that nobody really understands what's going on?)

Health Care Costs Money: Who Knew?

Noted online yesterday morning:

A report by the Centers for Medicare and Medicaid Services sent Democratic staffers scrambling over the weekend after the 31-page study revealed potentially damaging findings about the cost and coverage of the health care bill passed by the House of Representatives Saturday night. The report said, among other things, that rather than cutting costs, the bill would increase them by $289 billion over 10 years…

…the analysis from CMS's chief actuary, Richard Foster, found that the House bill will achieve its primary goal of significantly helping uninsured Americans by providing new access to affordable health insurance. However, Foster also warns that the expansion will come at a cost to the federal deficit, which will likely increase, and to seniors, who could lose access to some of their own doctors under the plan as cuts to Medicare force some providers out of the market.

Patricia Murphy, The Capitolist, November 16, 2009

I’ve always thought that out of every relationship, good or bad, you find something of value. Originally this thought came to me over an eel roll, when I recognized that were it not for being totally tossed over by a certain dark-haired girl, I’d still not know the joys of sushi, nor have anything but a passing acquaintance with female cosmetic paraphernalia such as the eyelash curler. (Such knowledge has served me well in understanding of the makeup toolkit of my bride.) And so I must thank the worst boss I ever had for at least introducing me to the following equation, one which effectively summarizes the entire problem of any health care system.

Access x Quality = Cost

(Access is the number of people who have entry into the health care system, while quality represents the number of services provided. Cost is, well, cost.)

Given that this equation is true…and while I could go into excruciatingly painful details as to why, just for the moment accept that it is…is the recent report by the Center for Medicaid Services really a surprise? You increase health care access to an unrestricted level of services, and costs go up. You could have seen this coming a mile away.

It seems to me that the fact that this report is somehow startling or controversial is simply because nobody wants to make any hard choices. Hard choices require hard thought, which is anathema to our increasingly polarized, sound-bite democracy. (One wonders if Henry Clay would have succeeded in holding the Union together given the current media frenzy.) The hard choice here is to figure out what we really want. We can’t have increased access to care, increased services provided, and cost containment. You can have increased access or quality of care, but only at increased cost. You can lower costs, but only at the expense of denying people access to the system or by restricting benefits.

My suggestion: Policymakers should listen en masse to the fifth cut on Meat Loaf’s legendary Bat Out of Hell.

Don’t be sad…in health care reform, two out of three ain’t bad.

Inner Rumblings

I have come to the conclusion that America is the most bowel-focused nation in the world. Scholars of health beliefs, those who put together models for the purpose of enlightening the masses and acquiring tenure…I think I got that backwards…may be able to prove that this is not true. Perhaps they have done surveys of non-Western cultures, cultures in which bowels are simply part of Tao, that they ebb and flow as a river. Perhaps they are considered a sign of karma, a symbol of regeneration as everything that goes in comes back out once again. Perhaps they are mere entrails, things to be tolerated as part of this worldly purgatory we know as earth. Perhaps I hold this mistaken belief because, by accident of fate, Northeast Florida and East Central Kansas are uniquely bowel-conscious, and that these regions are joined in some mystical fashion by the good offices of St. Bonaventura (the patron saint of intestinal disorders). Perhaps there’s grant funding out there for me to find out.

I have come to this conclusion because I have recently fallen victim to the same obsession. This is a direct result of the ED “swing shift.” One of these shifts goes from 5 PM to 1 AM. While that’s no problem for night owls like me (everyone who knows me understands that I’m essentially non-functional before the day hits double digits), it does mean that by the time you get home, eat, wind down, and try to go to bed it’s often pushing three o’clock. It doesn’t help that I do everything the sleep hygiene articles say not to do, including using the bedroom as a platform for television viewing. It’s in the effort to lull myself to sleep that I’ve discovered the late-night world of the colonic infomercial.

The best of the bunch, and the one that really captured my attention, featured a “scientist” being interviewed by “serious, skeptical journalists” before a “live studio audience” drawn to the show by their “interest in health” to hear “what doctors don’t want you to know.” (In fairness, the audience did appear to be alive, as evidenced by the applause they dispensed at regular intervals when the camera cut away to them after a particularly profound pontification.) The highlight of the show was where he showed a picture of what was claimed to have emerged from his colon after use of his cleansing elixir. It was a mass shaped in roughly a semicircle, a dark black serpentine creation that appeared frightened to see the light of day. And that night, and for nights thereafter, I mused upon this picture. I was fascinated by the question of how he got it to come out in one piece like that, and I was absorbed in wondering how and why he would chose to fish it out of its watery grave. (There actually is a third question involved…if it did not come out in one piece, how did it get its shape…but we’re really not going there at all).

(Interestingly, my late-night viewing habits have also resulted in a fixation with the work of Edward R. Murrow after happily watching “Good Night and Good Luck” on the movie channel for what has to be the fourteenth time. I wonder how he would have covered the issue of colonic hygiene on the renowned “See It Now”:

“We don’t eat fiber, our fruit intake is low, and our sense of fullness is exceeded only by our sense of seeming self-satisfaction. How that can happen in a land where nutrition is plenty, ripe for the taking? Murrow and Friendly can see no answer but in our own internal Harvest of Shame. And as we consider our nation’s colonic health, we find it true that, as Cassius said, “The fault, dear Brutus, is not in the stars, but in ourselves.”)

I try very hard not to hold myself on a higher plane than my patients. (Well, okay, sometimes I do, especially when the ED patient‘s chief complaint is “Been sick, honey, been sick since the Korean War.” First patient I ever saw in my residency. True story.) But for me, bowel movements are simply one of the less tasteful functions of life, and to consider them an object of inspection and contemplation is just another sign that somebody needs to get a life. As one of my nursing colleagues put it, “Bowel movements are a necessary evil, not an object of fascination.”

I can still vividly recall the dialogue with one the first patients I saw with a bowel complaint while working at the University Of Florida:

Q: “Any problems with your bowels?”

A: “Doctor, I had a BM this morning. It was loose, not like my usual ones that are big. There were just some little pieces that looked like a rabbit. It was floating, so I poked it with a stick and it came back up. I called the ambulance. Does that mean anything? I knew you’d want to see it, so I brought it in with me. It’s in the baggie in my purse. Do you want to see it? ”

In the interest of science, there is an answer to the question (two answers, actually). The first is that stools float when there is a lot of undigested fat in them. The second is that I have no desire to touch, let alone look in your purse, and that I will trust your description of the malodorous event without feeling any need whatsoever to conduct any further investigation.

So what happens when the person with irregularity (polite term) comes into the ED? Most of the time we take an x-ray to demonstrate that there is in fact stool in the colon, and that there are no signs of bowel obstruction. (Every scenario has an ED nightmare we try to avoid, and writing off an obstruction as constipation is the risk element here.) Back when x-rays were printed out on acetate films, you could hand-carry the snapshot up to the patient, hold the film up the light, and show them the pebbly cylinders that go up, around, and down in a reasonable imitation of a tuba. Now that everything is digital and the films can’t be lifted from the computer screen, patients just have to trust you when you tell them that they’re really full of…it. (Which reminds me of several jokes that I can’t tell you.)

Then there’s therapy. The United States is an action-oriented society, and when we want our bowels to move we want them to move yesterday. Traditional stool softeners, such as fiber, fruits, and increasing physical activity, do not fit our lifestyle. So we want powerful agents, and lots of them; agents that let us know they’re working not just through the production of the desired product, but through the suffering that lets us know we’re cleansing both the bowel and the soul.

So my prescription for those who want action, and lots of it, is a preparation called Go-Lytely. It comes in a gallon jug, which more than satisfies the American desire to supersize everything in sight. (Including the output.) This solution acts by drawing more fluid into the bowels through the process of osmosis. As fluid enters the colon it not only helps to soften the stools, but the resulting distension of the bowel lumen stimulates peristalsis to help expel the intestinal contents. (Got that? There's going to be a quiz.)

Personally, I think the brand name Go-Lytely represents one of the most creative marketing ploys ever unveiled on the face of this earth. Go-Lytely does no such thing. The person who takes it goes heavily, goes forcefully, and goes quickly in an eruptive fashion reminiscent of Mt. St. Helens (or, if you prefer a classical analogy, like Vesuvius). From what I’m told, it’s a miserable few hours. On the other hand, after the potion has done it’s duty, I understand there’s a sense of completion, a lightness of being, and state of happy exhaustion like that which overtakes one who’s done a good day’s work.

I may need to try this someday, especially as I push closer to fifty and the inevitable colonoscopy begins to rear (no pun intended) it’s head. But I’m honestly still working up to it, partially because I dislike pain, partially because I’m not sure I’ve got enough reading material to peruse while the vile agent does it’s work, and partially because I fear I’ll end up like the last excreting Kansan who made national news (“Kansas Police: Woman Pried From Boyfriend's Toilet After Sitting on It for 2 Years,” Associated Press, March 12, 2008.)

You know, I think I’ll keep a stick handy as well.

Villian Comparison: The Child Speaks!

VILLIAN COMPARISON

I am The Child, as commonly referred to on my dad`s blog. I am now twelve, and have gained permission to write on my dad`s blog. I promise that this blog will keep you entertained through the times. This column shall contain such myriad subjects as Candy, Neopets, puppies, yo-yo tricks, and…..

Um, this guy.-------

To start with, villain comparisons. This will list my favorite bad guys of all time, and their rating from 1 to 10.

Sepulchere: Found in the game DragonFable, this bad boy carries a doom blade and has a penchant for destruction. He also tries to rule the earth, but it doesn`t seem to work out, now does it?

Evil Rating: 9 out of ten. Who can resist a DOOM-blade wielding doom knight?

Drakkath: Sepulchere`s evil minion in DragonFable, and his slayer in Adventure Quest Worlds, this chaos lord-in-training never knew he was going to be his master`s killer!

Evil rating (normal): 4 out of ten. Just a worthless pile of scraps, really.
Evil rating (chaos): 10 out of ten. The chaos powers he suddenly gets are AWESOME. I mean, he beat the lord of evil himself.

Gravelyn: The daughter of Sepulchere, and also his best kept secret, Gravelyn is only a girl, but she vows to finish what her father started after Chaos Drakkath is gone!

Evil rating: 7 out of ten. Just a girl, but not a bad evil ruler.

Gnats: Blasted things! Can`t they just bug someone else for once?

Evil rating: 8 out of ten. I HATE GNATS!

Zorbak: The all-mighty Moglin wizard himself, creator of the dreaded Undead Kitten! Brothers with the dreaded Kabroz, who just hate each other. Oh, the irony.

Evil rating: 6 out of ten. He`s so narcissistic. Only cares about his little blue self. Sheesh.

Xan: An insane pyromancer, wanting to torch stuff for no apparent reason. And what`s with the flaming skull? That`s overkill. But he DOES have cool fire powers.

Evil rating: 8 out of ten. He`s powerful, and pretty cool too.

Sir Malifact: A cursed knight, he fell under a dark spell. In return for great power, he became a doom knight bent on destruction! Very powerful and dangerous.

Evil rating: 7 out of ten. He used to be a good guy, you know.

Twig: The EVIL moglin who loves fish and ice cream. Has a dreaded ice cream blast, and can summon whales. Very stupid, but dangerous. Keep your distance.

Evil rating: 10 out of ten. He`s awesome. Need I say more?

Deady: The most powerful evil ever, he comes from the planet Necros, which he blew up. Very, well, deadly. Anger courses through his stuffed body.

Evil rating: 17 out of ten. The awesomest thing since Adventure Quest Worlds!

Perspective

Mr. Baskin came in yesterday with a mass in his neck. He’s 42 years old, smokes a pack of cigarettes each day, and drinks a beer three to four times a week. It’s getting harder for him to swallow. He works hard for a living as a laborer and tends bar part-time to make ends meet. He has no insurance and has yet to see a doctor for this. He’s not eating and has lost twenty pounds over the last year. He’s got a large, rock-hard growth under the skin on the left side of his neck. It’s lumpy, irregular, and fixed to the underlying tissue. Looking into his mouth you see that something under the skin is trying to push his left tonsil out of place. Everything screams bad. I walk out of the room and look at the nurse, who has seen the same things. “He’s going to die, isn’t he?” she asks as a statement of fact. And because his exam is what it is, and because one of the prime rules of emergency medicine is “Nice people get bad disease; dirtballs live forever,” I simply look back at her and nod.

If you have insurance, what I do is arrange an outpatient CT-guided needle biopsy of your neck mass by radiology, and set you up to follow-up a few days after the procedure with an ENT for the results. If you’re uninsured, I tell you that at our hospital we care for anyone regardless of money, and admit you to have the procedure done so you don’t fall through the cracks of the system. And either way I have to tell you, a person who I’ve just met and who doesn’t have any reason to know or trust me, about the thing on your neck. I tell you I can’t be sure exactly what it is. It might be some infection or some glands might be inflamed, or it might be a growth of some kind like a tumor. I explain to you that the best way to find out is to have someone take a piece out of it and look at it under the microscope. You don’t understand, but then you do. Your eyes get wide, and when I ask if you have any questions you shake your head for no reason other than something to do.

I have no idea how health care reform would affect him. I have no idea if his employer would carry insurance or opt to pay a fine. I have no idea if he would opt to take the subsidy to buy insurance or choose to pay a fine. I have no idea if he even works for a salary or works for cash. I have no idea if he could have a doctor to see him weeks or months ago no matter what kind of coverage he has. And in the end, it really doesn’t matter. First he’s going to undergo an operation, to be followed by radiation therapy which will dry out his mouth and cause painful ulcerations. Later, when the cancer comes back as they always do, he’ll have a laryngectomy and use an artificial voice box. Over time he’ll be unable to swallow and need a tube in his stomach for food and water, and the only thing he'll be able to put in his mouth are soft plastic swabs saturated with lemon-flavored glycerin solution and an occasional ice chip. And despite all this, the best care anyone has to offer, he’s still going to die.

Health care has very little to do with policy and politics and insurance plans.

Health care is a 42 year old man who’s going to suffer and die and you can’t do a damn thing about it.

The Nose Knows

I’ve had people ask me from time to time what doctors actually talk about in the ED. I think the assumption is that, just like on television, we spend most of our time either talking about difficult cases, weighing critical medical decisions, or discussing relationships. The truth is much, much stranger than you ever thought.

Here’s what passes for intellectual conversation one day last week. One of my colleagues was trying to dictate the medical record of a patient with a nosebleed. Just for the record, nosebleeds (“epistaxis,” from the Greek meaning “really disgusting”) are one of the least favorite things to care for in the ED. I don’t know anyone who thinks it’s an interesting clinical challenge, and I think it’s because nosebleed’s don’t just bleed. They bleed in a particularly unpleasant fashion. Blood by itself is really pretty innocuous...a little thicker than water, it has a little sheen to look at it and slickness to the touch, but you get it on your gloves and you move on. (If fact, in some cases of vaginal bleeding you’ll intentionally break up a blood clot with your fingers to look for fetal tissues suggesting a miscarriage.) With a nosebleed, however, you get blood mixed with snot (“mucus,” from the Latin “also disgusting”) which results in a product of varying shades, the consistency of snail traces, and a tendency to stick to everything worse than internists on old people (there’s a reason that specialists in general internal medicine are known as “fleas”). Add to it that when this stuff comes out of the nose, it either flows down the back of the throat and results in gagging and occasional retching of the nasal blood and mucous plus stomach contents, or (if you’re in just the right place) it comes out the front, punctuated with sneezes seemingly designed to cause maximum damage to the physician, who is inevitably standing in front of the patient trying to see where the bleeding’s coming from at that exact moment.

Treatment just adds to the fun. Fortunately, the bleeding often stops on it’s own. Rarely you’ll be able to see the bleeding spot along the nasal septum and cauterize it with silver nitrate. More severe bleeding comes from the back of the nasal cavity, and can’t be seen by the physician without the special tools and toys of the ENT specialist. So to get the bleeding to stop, the ED doc goes on a fishing expedition which essentially consists of jamming things…pieces of foam, plastic balloons…of increasing discomfort into the nose until the bleeding stops. And you’re doing this in the face of continued hemomucoid (“blood and pus” from the Arabic, “that’s bound to ruin your shirt”) expulsions directly towards the operator, who has to lean into the line of fire to see what he or she is doing.

At this point, the patient will be in pain (it hurts to have stuff jammed into your nose), and will feel short of breath because they can now use only one nasal passage instead of the requisite two. They don’t like you very much for what you did, and you’re not too enamored of them for making you do it. Hopefully, though, the bleeding will stop. If it does, you call the ENT and arrange follow-up for the next day, because if someone’s going to pull that stuff out of the nose and make it bleed again it sure isn’t gonna be you. If it doesn’t, you drag the ENT out of bed. (To be fair, I will say that ENT physicians so rarely have to come to the ED that when they do, they actually have a pretty good attitude about it. The chance for them to do something acute makes them feel like they’re a golden retriever and you’ve just thrown them a new red rubber ball.)

So anyway, the other doctor is trying to dictate this chart and is trying to figure out the right adjectives to describe the nosebleed. This got us started on all the different adjectives that can be used to describe bodily fluids and the ways they emerge from the body. This became a large-scale discussion involving the entire health care team in a management-friendly collaborative process. The only rule was that it had to be an adjective that you might actually hear used, not something like “paralleling the national debt” to describe a volume of fluid. (Please note that we’re talking adjectives here. The fluids themselves are nouns. You can combine two nouns to make it an adjective…for example, a mixture of mucus and pus can be described as mucopustular… but we thought that was cheating.)

At the end of the day, we decided that there were really four categories we could use to describe bodily fluids:

Amount: Scant, rare, mild, moderate, large, copious, voluminous, massive, elephantine. (Nobody really uses elephantine. I just wanted to see if you were paying attention.)

Rate: Oozing, dripping, steady, profuse, gushing.

Quality: Clear, discolored, purulent, creamy, thick, viscous, foamy, frothy, foul-smelling, feculent, phlegmatic, gooey. (I would personally never use the latter term, because it would permanently ruin Starburst and Japanese Rice Candies and Jujyfruits for me for life. But I actually know a physician who uses that term…copiously.)

Method: Pulsatile, spurting, projective, explosive.

Taking these general categories, one can mix and match to describe the clinical fluid of their choice. (I actually started to write some examples here, but as I did I began to lose my appetite. I’ll let you string together some examples of your own and you’ll get the general idea. “Feculent,” “copious,” and “explosive” is particularly queasy combination.)

In my continuing quest for medical immortality, I would like this system to be known as the “Rodenberg-Other People Adjectival Classification of Bodily Fluids (ROPA-CBF).” I look forward to it’s immediate inclusion in curricula everywhere. And thank you for your support.