Guinness vs Bartlett

Once there was an employer that provided annual “Employee Appreciation” gifts. At first, these were items such as camp chairs, Thermos bottles, fanny packs, coolers. Then a new sheriff (CEO) came to town. Before she eliminated those gifts entirely, the last one was a tiny leatherette notebook with an equally tiny pen.

Unsure what to make of this, one employee used hers to record quotations (hence Bartlett) from patients. Alas, the book was lost to posterity in one of our numerous office moves. (In our latest office move, we are each allotted 32 inches of desk space – so much for social distancing – as we sit shoulder-to-shoulder and back-to-back along a series of long tables, facing a wall in a windowless room, that make us look like telemarketers in a call center.) Lest it sound like we are making fun of patients, we will provide herein a couple of quotations from doctors – eminently better to make fun of…but are we making fun of them, or celebrating their wisdom?

An attending physician, known to be tough on her residents, once told the assembled group, “There is no ‘I’ in team – but there are three ‘U’s in Shut the fuck up!”

A patient had been in the hospital for weeks with complex abdominal injuries. His nurses knew his needs and his day-to-day changes. An overnight resident became alarmed and ordered a barrage of unnecessary tests in a CYA move. The next day a senior resident, letting him know the importance of asking the experienced nurses for input first, said, “Just because you’re smart doesn’t mean you can’t be a fucking idiot!”

A surgeon friend was invited to join a sewing circle. She was told it was a fun group, they met in a bar, it would be low-key. She agreed to check it out. She went to a meeting and they asked her to introduce herself and say a few words about her sewing experience. She said, “I don’t have any experience sewing, except with flesh.”

Guinness is famous for his book of World Records. We keep informal records in our heads. The legal limit for blood alcohol level in most states is 0.08%. Evidence of impairment has been shown at 0.03%. We have had drivers come in at >0.50%, or more than six times the legal limit – a level that would be fatal for most of us, and a level that requires some serious training to reach without dying. These were no amateurs. [We normally measure alcohol intake in terms of “standard drinks”. This would mean 12 oz beer, 5 oz wine, or 1.5 oz hard liquor – these are estimates, as not all beer is 5% alcohol, not all wine is 12%, not all hard liquor is 80 proof. I have met drinkers who measure their intake by the “handle”. A “handle” is a 1.75 liter bottle – so named because of the handy handle to make pouring easier. I guess you could say “A handle a day keeps withdrawal at bay.”]

from (images are not to scale)

The human bladder holds an average of 500 ml. A patient who was unable to urinate on his own had a catheter placed which immediately drained 2.5 liters (more than a giant Coke bottle).

A normal blood glucose level is around 100 mg/dL. I have seen from the teens to over 1000.

A human normally has 24 ribs – there are a few variations. Some will have cervical ribs @C7, some will have lumbar ribs @ L1, some will lack a rib at one end (T1) or the other (T12). Most of us have 24. Flagel, et al (Surgery, 2005) found that “half-a-dozen ribs” are “the breakpoint for mortality”. In other words, if you break 6 or more ribs you are at significant risk for serious complications. (Four in the elderly, per a subsequent paper.) I saw someone who broke 22 of them and survived.

And finally, we can’t talk about healthcare without talking about COVID-19 and profit. While we’d like to think that vaccine development was a humongous humanitarian venture, the truth is a bit murkier. When it was suggested that the vaccine “recipe” be shared widely to enable faster and cheaper production, Pfizer CEO Albert Bourla called that “dangerous nonsense”. (He will make $24 million this year – a 16% raise over 2021, which was a 17% raise over 2019. [Ed. note: That sounds like dangerous nonsense to me.]) BioNTech (co-producer with Pfizer of their vaccine) forecasts a 2021 profit margin of 77%, while Moderna’s profit margin was 70% for the first nine months of the year (figures from Oxfam). The lowest estimate for profit from the vaccine seems to be in the neighborhood of 30%. (Compare this with the average grocery store profit margin of 2%.) The British Medical Journal (Hawksbee, et al, 2022) found that drug company profits have consistently surpassed other market sectors for the past 70 years, and have jumped during this century. Vaccine sales have largely gone to developed countries, the ones that can afford the high price tag, while less-developed countries have lower vaccination rates.

And so, I enter my last week of work. Is healthcare a basic human right, or the most lucrative profit center? (1)