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)


It’s time for my next round on a COVID-19 floor. This time it’s the ICU. I have been on General and Intermediate Care on my previous tours. ICU is for the sickest of the sick. My patients are on ECMO (Extra-Corporeal Membrane Oxygenation). This isn’t merely a ventilator that assists you to breathe or breathes for you. This is an artificial lung. Your blood leaves your body via a ½ inch or so diameter line, runs through a machine to remove CO2 and add O2, then sends it back into your body via another line. (That’s what “extra-corporeal” means – outside the body.) One line comes out of your neck and the other your groin. Mobilization is a bit tricky. You don’t want any leaks.

Ready for action as soon as you add gown and gloves. The conehead look isn’t the most comfy, but it’s cheaper than the 3M PAPR (Powered Air-Purifying Respirator). There is no patient information on the wall behind me.

Some of these folks have been in this hospital for two months. They came from smaller hospitals that didn’t have the means to provide the treatment they need, after exhausting all options available to them. At least one has been sick since August – 3 months and counting. They are young and unvaccinated. Will they survive? Beats me. Are they anti-vaxxers? Beats me. My job is to help them, not to second-guess them.

(But since you ask, let’s just say that, if I were a betting man, my money would be on “yes” to surviving. As to whether they are anti-vaxxers or just think they are immortal, that one’s a tossup. This batch of patients are young enough to be my children and have survived two months in the ICU.)

A friend and spouse are vaccinated. One of their two adult children is vaccinated. The other is not, along with spouse and kids. We’ll call my friend Vac and the child Not. Vac was at Not’s house and Not confessed (after several hours together) to feeling ill. Vac had a home COVID test handy – Not was positive, confirmed by another test the next day in a health care facility. Not’s spouse and children are all sick. Vac remains well and has tested negative twice since that exposure. Vac’s spouse and other child are also fine. Do you think maybe the vaccine works?

One of the anti-vaccine arguments is based on “natural immunity”. People want their own immune systems to fight it out with the novel coronavirus. Note that name: novel. Our immune systems work by developing antibodies against invaders. If an invader is known, we have the means to develop a specific defense rapidly. If the invader is unknown (novel), we toss stuff at it while we try to figure out what to do. If the virus is strong enough, we may die first. (Or, in the case of the polio virus, just some motor neurons die. If enough die, we die. If we’re lucky, we’re paralyzed.)

What does a vaccine do? It enables our body to recognize the invader and develop specific antibodies. If we then come in contact with the disease, our immune system is up to the task. The vaccine enables our natural defenses to work.

Did you go to public school? You probably had a bunch of vaccines before you were allowed to attend. We don’t want you to come into close quarters with others and infect them with measles, mumps, rubella, diphtheria, pertussis, poliomyelitis, etc. It’s what we call Public Health. That’s why you should get the COVID-19 vaccine. On one level, I don’t care whether you get the disease. You are “free” to get sick and die if you so choose. Should you also be free to infect others or use scarce resources by running to the hospital when you get sick? Should you be free to demand that said hospital treat you with horse dewormer or a “cleaning” with an injection of a disinfectant like bleach?

Don’t tell me you “did your own research“, like a certain professional football player. Those of us who use research in our lives know that research involves experimentally testing a hypothesis. Before you do your research, you do a literature review, to see what has already been done. Is that what you did? A lit review? Did you actually read the literature, or just listen to a talk radio host talking about the literature? When you do a critical review of the literature, you appraise it against a set of criteria. There are what we call “levels of evidence”. Some evidence is better than others. No study is worth a lot before it has been replicated by someone else. Did you believe one person who runs counter to the mainstream because they say they are a doctor?

If you’re against vaccines (or at least this one) because they’re “unnatural”, are you against soap and water or antibiotic ointment if you get a cut? Why not just let your body’s natural defenses go to work? Maybe you’ll live, maybe you’ll die. Maybe that cut finger will result in being faced with the choice of death or amputating the arm. Amputation is unnatural. Death is completely natural. Decision made.

After all, life is 100% fatal. Why wait?

[Editor’s note: Sorry, it has been a rough week at the hospital. The writer apologizes to those who do take care of themselves and others and is not wishing an early and painful death on anyone. He is tired of reading about people refusing help until it is too late and then demanding their own particular choice of help. He is tired of reading about people looking for lawyers to sue hospitals for employing the standard of care instead of listening to their half-baked theories. He is tired of reading about people who refuse to take action to protect themselves and others, then beg for your prayers and money for funerals and to raise the children of stupid people who refuse the vaccine, refuse to wear masks, and think they are standing up for freedom. He is sick and tired in general this week – and he hasn’t even finished the first week of this rotation.]