My Reederz Rite

I'd like to thank my reader Beverley, who sent this picture. She says it was in the window of a Tesco supermarket in the U.K.

Another fine patient quote

"It's such an unexplainable thing, because, you know, I can't explain it. It's like something that is totally, entirely, not explainable, because no matter how much I try to explain it, it's still unexplainable. Does that explain it?"

Dear Mag Mutual Healthcare,

Thank you for your catalog of spiral-bound medical coding notebooks.

I've been trying to save money. But when I saw that if I spend only $355.95 on your books, I get a FREE stuffed bear (I bet it's made in China, and only cost you a few pennies), I just KNEW I had to place an order. A deal on a FREE stuffed toy like that (with every order of $355.95) doesn't come along every day.





If I had any second thoughts about getting the books, they were immediately erased when I noticed Jennifer on your cover (with the bear in the background).





I'll call you to place my order later, Jenn. I just hope Mrs. Grumpy doesn't catch me.

Mary's Desk, March 30, 2010

(Lady in scrubs comes in, stands at the front counter)

Mary: "Hi! Can I help you?"

Ms. Tooth: "Hi! I'm Cindy Tooth! I work for Dr. Plaque, the dentist across the street, and we're doing free tooth whitening for all medical office staff, to get them familiar with the procedure."

Mary: "Oh, that's nice, but no, thank you."

Ms. Tooth: "Are you sure? It looks like you could use it."

Mary: "Get out."

Early morning at the office

Dr. Grumpy: "Did you call her back last night?"

Annie: "No. I'll do it this morning. I couldn't bear to do it at the end of the day. She's like a torture chamber with a mouth."

Gee, thanks

More grainy, faxed pictures from a GI doc of the inside of my patient's rectum. This will really help me treat his Parkinson's disease.

Dude, you're also a pig

Look, I think it's great that you, a busy man in his 50's, would take the time out of your day to bring your mom to her appointment.

And I don't mind (too much) that you farted, loudly, in my office. I'd rather you have done it elsewhere, but sometimes we can't help it.

But, in all honesty, you then smiling and saying "Boy, that felt good!" wasn't needed. At all. I am not one of your beer buddies, and we are not in your living room.

Dude, you're a pig

Us guys get a bad rap. And, in all honesty, we at least partially deserve it. I myself am recently guilty of selective hearing.

There are times, however, when I encounter a situation that makes me ashamed to be a carrier for the Y chromosome (like this, from last year).

Yesterday I had a consult on a 24 year old lady who'd been admitted for some pretty scary symptoms. I got to the floor while she was downstairs having an MRI, so I saw a few other patients while waiting for her to come back.

Her boyfriend showed up during this time, discovered she wasn't in the room, and made himself comfortable. He adjusted the bed to a cozy position, bought a bunch of chips and pop from the vending machines, stretched out, and turned on basketball.

After about an hour she was done with the MRI, but there wasn't anyone available to bring her back to the room. Since I wanted to get started on the consult, I went downstairs myself, put her in a wheelchair, and pushed her up to the room.

When I wheeled her in, I looked at Mr. Boyfriend, and said, "You'll have to move to the chair. I need to examine her, and she needs to be in the bed."

He didn't budge. Without looking away from the screen he said, "Dude, I'm watching the game."

Comedy on rounds

I'm evaluating a pleasant, but very forgetful, older gentleman. His family is in the room.

Doctor Grumpy: "He seems to be very forgetful. Is he demented?"

Wife: "Heavens no!"

Daughter: "Oh my God! Is he ever!"

Son: "Maybe just a little."

Patient: "What's demented?"

Sunday morning rounds

Looking through the chart on a new consult. 22 year old female, who suffered a concussion yesterday.

I went in to see her. She had a HUGE bruise on her forehead, a few stitches at the hairline, and looked vague familiar.

Dr. Grumpy: "What happened?"

Miss Concussion: "I was upstairs doing a student nursing rotation yesterday, and had begun throwing up after seeing a lot of blood, when I got really lightheaded and remember falling toward the sink..."

Career change time?

On call today, there was a batch of young student nurses (maybe they were student nurse aids) at the hospital.

I was sitting at a nurses station, when a patient call light went on. One of the nurses, who was filling out forms at a desk, glanced up at a student and said "Hey, can you please see what he wants?"

The student went into the room, and we heard this:

Student: "What can I do for you... OHMYGOD!!!"

Patient: "Sorry, it looks like I'm bleeding a little and..."

Student: "A LITTLE! HOLY HELL! NURSE!"

The student ran out of the room and into the bathroom across the hall.

The nurse went into the room, giggling.

The patient began laughing.

On call. And they do call.

Dr. Grumpy: "This is Dr. Grumpy, returning a page."

Miss Myelin: "Yeah, I see Dr. Cortex for my MS, and I woke up today with blurry vision, and I can barely walk."

Dr. Grumpy: "Have you had this before?"

Miss Myelin: "No, it's new. When my MS acts up Dr. Cortex usually admits me to the hospital for IV steroids."

Dr. Grumpy: "That's standard. I think you need to go to ER, and I'll likely admit you."

Miss Myelin: "Are you kidding? I don't have time for that shit."

Dr. Grumpy: "Excuse me?"

Miss Myelin "I don't have time for that. Can I schedule them for next week, like Wednesday or Thursday?"

Dr. Grumpy: "I suppose, but you'll have to call Dr. Cortex on Monday and... Look, if you're not going to let me help you, why did you even call on the weekend, anyway?"

Miss. Myelin: "Because I thought it might need urgent treatment."

Insanity

A grateful patient brought me a box of chocolates yesterday. So I took it home to share with my kids.

I got home, and they were all excited. You'd think they'd never seen freakin' chocolates before.

I opened the box, and they all peered in. I said they could each take one.

And immediately, a fight broke out.

Did they fight over who got the first candy? No.

Did they fight over who got which candy? No.

They fought over who got the bubble-wrap packaging.

Do you need a prescription for that?

Dr. Grumpy: "Do you take any other medications?"

Mr. Nike: "Umm... I like jogging."

I'm going to change my undies now

I'm with a patient. My cell phone rings. It's the most dreaded caller ID of all: Mrs. Grumpy.


Dr. Grumpy: "Hello?"

Mrs. Grumpy: "Hey, can you pick up Craig on the way home? He's at the police station."

Dr. Grumpy: "OMG! WHAT HAPPENED?!!!"

Mrs. Grumpy: "Nothing. The Boy Scouts are touring it today. I told you that last night."

(long pause)

Dr. Grumpy: "Yes. I knew that."

Mrs. Grumpy: "Idiot."

I'm not that crazy. Yet.

Like most doctors, we have a sign-in sheet. It's not much, people just write their names and the time they arrived.

Mary usually tosses the old one and puts out a new sheet for the next day when she leaves at night, but forgot to yesterday.

So today's first patient comes in, and looks at this long sign-in list of patients seen between 8:00 and 5:00. And she looks at Mary and says "Oh, I had no idea you guys were working night hours now. That would be better for my schedule, too."

Bon voyage

The following message was left on my office voice mail over lunch hour:

"Hi! This is Cindy Scatterbrain! I forgot to call you guys last week, but I'm leaving for France tonight on a 3 month exchange program and so I'll need 3 months of my epilepsy medicine, whatever it's called. Can you guys call that in to my pharmacy ASAP? Or, I'll be near your office later today so do you have 3 months of samples I could pick up? Or if you can't do that, do you guys know a pharmacy in France you could call it to and I'll pick it up when I get there? Thank you!"

Early Wednesday Rounds

I was at the hospital this morning, seeing a new stroke patient.

The head CT was read as normal yesterday afternoon, but when I looked at it I thought there was a stroke on the left side. And I didn't trust the person who'd read it, so I called the night radiologist (who I do trust).

Dr. Radar: "Night desk."

Dr. Grumpy: "Hey, it's Grumpy. I'm looking at the head CT on Mrs. Stroke. It was read yesterday as normal, but I think there's a stroke on the left."

Dr. Radar: "Hang on... No, that's not a stroke. If you look at the other images, it's just artifact."

Dr. Grumpy: "Are you sure? It really looks like a stroke to me."

Dr. Radar: "Positive. Definitely artifact."


I disagreed, but it's his specialty, and I respect him. I got off the phone and began writing my note. About a minute later a nurse came over to say Dr. Radar had called back looking for me.


Dr. Grumpy: "Grumpy."

Dr. Radar: "Yeah, it's Radar again. Did you say the thing on the right or the left?"

Dr. Grumpy: "Left".

Dr. Radar: "Sorry, I thought you said right. Oh yeah, that's definitely a stroke on the left."

Foot, meet mouth

Mrs. Sadd: "I'm sorry I'm late, my husband and I just got back from Hawaii last night."

Dr. Grumpy: "Awesome! That's a fun trip! What did you guys do while you were there?"

Mrs. Sadd: "We went to my father's funeral."

Think green

I was out of syringes and needles, so I ordered some.

They came in cardboard boxes that said "Made from recycled materials."

I really hope they mean the boxes...

Wow! What a great policy!

I noticed this authorization in a patient's chart yesterday. Isn't it awesome?

The patient is only 44, and yet his insurance has been covering him for over 110 years, just waiting for his visit with me earlier this year.


(click to enlarge)

Monday afternoon

Dr. Grumpy: "Okay, let me get an MRI form... Are you claustrophobic?"

Mr. Bakpayn: "I don't think so. Can I take a blood test to find out?"

Mary's Desk, March 22, 2010

Mary: "Dr. Grumpy's office, this is Mary."

Miss GPS: "Yeah, where are you? I'm here for my appointment, in building 1."

Mary: "We're in suite 605."

Miss GPS: "Okay, I'll be right up" (click).


1 minute later


Mary: "Dr. Grumpy's office, this is Mary."

Miss GPS: "Yeah, your door is locked, and there's no sign on it?"

Mary: "Are you at suite 605? The door is open."

Miss GPS: "Crap, I'm at 505, sorry, hang on" (click).


1 minute later


Mary: "Dr. Grumpy's office, this is Mary."

Miss GPS: "There is no 605 in building 1!"

Mary: "Ma'am I promise you there is."

Miss GPS: "There's only a plastic surgeon and a huge cardiology office up here".

Mary: "You must be in building 4."

Miss GPS: "I AM? How do you know? Are you tracking me on Google or something?"

Mary: "That's where the cardiology practice is. We're in building 1."

Miss: GPS: "When did you move there?".

Mary: "We've been here since 1998."

Miss: GPS: "That can't be! Downstairs it says this building was built in 2005".

Mary: "You're in building 4! It was! We are in 1! Look, you need to get here soon, or the doctor won't have time to see you!"

Miss: GPS: "I'm coming! What building did you say you're in?".

Mary: "Building 1. Go out the front entrance of building 4, turn left and go..."

Miss: GPS: "You don't need to lecture me! I have my own GPS unit, so I won't get lost!"

(click).

Sunday night, 7:45 p.m.

Dr. Grumpy: "This is Dr. Grumpy, returning a page."

Mr. Phone: "Yeah, I see you for epilepsy, and I take Tegretol. Anyway, I'm in Outofstate City, and I left all my pills back in Grumpytown."

Dr. Grumpy: "Okay, how long has it been since your last dose?"

Mr. Phone: "Um... I've been here since last Sunday, so I guess it's been a week."

Dr. Grumpy: "A WEEK?!!! Have you had any seizures?"

Mr. Phone: "No."

Dr. Grumpy: "Okay, is there a pharmacy I can call some Tegretol into for you?"

Mr. Phone: "No, I don't know any here. I'm at the airport, at the gate, so I really can't leave, either."

Dr. Grumpy: "Where are you heading now?"

Mr. Phone: "I'm flying back to Grumpytown tonight. My flight leaves in about 40 minutes."

(long pause)

Dr. Grumpy: "Okay. Let me get this straight. You've been without Tegretol for a week. In Outofstate City. And you didn't call me until now, 3 hours before you get back to your home pill supply. And you did this knowing that there is really no way for me to easily call in a refill for you."

Mr. Phone: "Er, yeah, that's about it. There was a magazine lying here, and to kill time I began reading it, and there was an article about how important it was to take your medications as prescribed."

This is Mrs. Grumpy

Due to my husband pretending to be sick, so I had to cancel the babysitter tonight, posting has been temporarily suspended.

He is pretending to be barfing, pretending to be achy, and pretending to have a fever (I think he had the thermometer in Snowball's ass before putting it in his own mouth to fake that one).

Okay, so he's not really faking (it sure sounded better, though). But anyway, I'm not allowing him anywhere near the computer until he's unlikely to puke on it.

I need him healthy and back to work so he can continue to support my lavish school-nurse lifestyle. And because Mary pulls her hair out if she has to reschedule a whole day of patients. And we don't want her to be bald.

Don't call us, we'll call you

She showed up 30 minutes late for her 10:00 appointment.

Normally I wouldn't have seen her, but since the 10:30 had canceled at the last minute, I did.

She apologized for being late, because her pain medications made her so confused she got lost finding my office.

She spent most of the visit telling me how her chronic pain kept making her late for work, on the days when she was able to go to work at all.

She talked about how she didn't think she'd be able to work much longer, and was looking into applying for disability.

And when I asked her if she had any further questions, she whipped out a copy of her resume and asked me if I was interested in replacing any of my current staff.

Dear Drug Company,

Thank you for running an ad campaign that helps dispel the myth that neurologists are eccentric and have no sense of modern fashion. We REALLY appreciate it.

Lying kid? Thermodynamic fail? All of the above?

Dinner is cooking. It will be ready in 20 minutes.

I walk into the kitchen, and startle Craig. He's standing at the toaster, and I've caught him putting Pop-Tarts in it.

"Craig! What are you doing?!!!"

"I'm, uh, making Pop-Tarts."

"I can see that. Dinner is in 20 minutes. Why are you making a snack?"

"Because..."

"Craig, you know better then to have a snack this close to dinner."

"I'm not! It's, um, for my breakfast tomorrow. I'm toasting them now, so they'll be warm when I get out of bed in the morning."

What the hell?

Dr. Grumpy: "So we'll see how the medication change works. Any other questions?"

Mr. Baker: "Have you tried the Local Grocery cinnamon coffeecake?"

Dr. Grumpy: "Um, I, uh..."

Mr. Baker: "They're HUGE! How do you think they can afford to sell them for only $3.99?"

Dear Fleet Enema Company,

Thank you for your recent press release about a new product. Marketing people are truly an amazing group.

I have absolutely no idea how humanity managed to survive so far without it, but now that it's here, the planet can keep rotating safely. We can all be secure in the knowledge that there's finally an enema available for "elective cleansing", "before or after anal intimacy."

(click to enlarge)





Thank you to my reader Amy for submitting this.

Skool Nerse Time

This is Mrs. Grumpy.

Attention Miss Hogtie, the 3rd grade teacher:

I don't mind treating grown-ups for minor injuries, either.

But when you come to me looking for something you can put on rope burns, that are ONLY around your wrists and ankles, AND which we all know occurred during your recent trip to Vegas with your boyfriend, DON'T try to make up some crap about how you had an accident weeding your backyard. We both know what you REALLY did.

Just take the aloe lotion, and spare me the details.

March Madness starts tomorrow! Lets get snipped!

I'd like to thank my reader Joey for submitting this ad. For my non-American readers, March Madness is the college basketball championship tournament. It's played out over 3 long weekends, and the first weekend, in particular, is non-stop games on TV from Thursday morning to Sunday night.

(clip, I mean click, to enlarge)

Let me count

Doing another fun-filled online survey this morning.


Screen #1: "Are you in solo or group practice?"

So I clicked on solo practice, and it moved to screen #2:

"Besides yourself, how many other doctors are in your solo practice group?"

Not hereditary

Dr. Grumpy: "Any major illnesses run in your family?"

Mrs. Olde: "Yes, my Dad was killed by a land mine."

It's covered by the HMO, I guess

She wasn't joking, either.


Mrs. Pain: "When I have the headache on the right side, I have my husband knock me, hard, on the left side of my head."

Dr. Grumpy: "Does that help?"

Mrs. Pain: "Kind of, because when both sides are hurting, I don't notice the right side as much."

Who needs specifics?

Reading another doctor's notes this morning, and I found this gem:

"Impression: High blood pressure. Verapamil isn't helping. I told her to stop it and take something else."

Hmmmm

Like most neurologists, I read EEG's (brainwave tests). Usually the study is accompanied by a note from the tech, listing the reason for the test, the patient's other medical issues, and their medications.

So one of the studies I read tonight had this note attached:

"Has history of seizures. EEG ordered to see if patient is safe to drive. She has diabetes, high blood pressure, and is blind."

I'm not following this

"It's a new problem, but sort of old. I mean, not new-new, but kind of an oldish new-old. I wouldn't say it's old-new, more new-old than anything else."

When dictation goes bad

This has to be one of the most bizarre dictation/transcription errors I've ever seen. It was in another physician's note. I have no idea what the original phrase could have been.

For my non-medical readers- a C-arm fluoroscopy is a large piece of metal equipment used for radiology procedures.

(click to enlarge)

Sunday morning, 10:17 a.m.

Dr. Grumpy: "This is Dr. Grumpy, returning a page."

Mr. Time: "Yeah, I have an appointment tomorrow, and I need to move it to Friday."

Dr. Grumpy: "Hang on..." (turns on iPod) "uh, you're appointment is on Friday, March 19th"

Mr. Time: "Oh. So is that the next Friday, or the following Friday?"

Dr. Grumpy: "It's Friday, March, 19th, 2010. I'll tell you the specific date to keep it clear."

Mr. Time: So when did you move it to Friday? How did you know I'd need to do that?"

Dr. Grumpy: "You must have. We don't do that."

Mr. Time: "Friday is good for me. Would Monday work better for you?"

Dr. Grumpy: "Friday is fine. See you then. Have a nice day."

Saturday afternoon

"Frank!!! What is this MESS?!!!"

I'm surveying our kitchen table. At 1:00 it was clean, having been wiped down after lunch.

When I wandered into the kitchen at 2:00, it was covered with a bizarre mixture of crayons, ink markers, scissors, tape, and green colored papers, all heavily smeared with pancake syrup.

"Dad, we were busy."

"Doing what?"

"Making St. Patrick's day cards for our friends."

"Why is there pancake syrup everywhere?"

"Because I forgot where the glue was, and thought we could use that instead."

He's mad I tell you! Mad!

Since Alice in Wonderland is in the news right now, I'm putting up 2 history posts in one day.

The Mad Hatter is well known in English literature. He was created by Lewis Carroll (real name Charles Lutwidge Dodgson) for the story Alice's Adventures in Wonderland. An interesting side note is that the character was most likely based on a furniture dealer, and not a hatter.

The phrase "mad as a hatter" actually predated the story, and has an interesting neurological history.

Mercury is a metal with multiple human toxicities. It can affect many organ systems, and in sufficient amounts can cause brain damage. When this occurs common symptoms are memory loss, confusion, and behavioral changes.

Mercury poisoning is uncommon in modern medicine, but before it had been identified as a toxin it was commonly used in the cloth industry, in the manufacture of felt.

A hatter, obviously, is someone who makes hats. And in 18th & 19th century England, felt was commonly used in hats. So hatters had a fairly high level of exposure to mercury, and after several years of plying their trade they sometimes developed brain damage, and went "mad". And that's where the phrase came from.




Alice in Wonderland has other neurological trivia. As many of my migraine patients will tell you, their headaches can be preceded by all kinds of visual changes. Typically these are flashing or sparking lights, dark spots, colors, or squiggly or zigzag lines. But some patients will see visual distortions, where things suddenly seem to grow or shrink in front of them. This perception change is now called Alice in Wonderland Syndrome.

It's known from his personal diaries that Lewis Carroll suffered from migraines with visual changes. It's unknown if he had the perception changes of things growing and shrinking, but who knows? Maybe one of the most famous books ever written was partially inspired by a migraine.

It's something to think about.

March 13, 1918

On this day in 1918, a U.S. Navy ship failed to arrive in Baltimore as scheduled.

No trace of the ship has ever been found. To this day, it remains a complete mystery, and the largest unexplained loss of life in U.S. Naval history (306 passengers and crew)

The ship was the collier U.S.S. Cyclops. A collier was a ship designed specifically to carry coal (the 1918 equivalent of an oil tanker), though on the last trip she had a cargo of manganese ore. The Cyclops was a reasonably large ship, 542 feet long (165m) and just under 20,000 tons. And she vanished without a trace.

The ship was en route from Brazil to Baltimore when she disappeared. Much has been made over the captain's (George Worley) health & temperament, and his possible pro-German leanings (this was during World War I) but nothing has ever been substantiated. An extensive check of German archives after the war turned up no evidence of the ship having been sunk or captured by hostile action.

Realistically, the ship likely sank in a storm, or due to major structural failure. I'm not a believer in the Bermuda Triangle or more exotic theories of things that vanish. Lawrence Kusche, in his excellent 1975 book "The Bermuda Triangle Mystery Solved" postulated a storm sinking the ship, which already had known mechanical problems.

In 1968 diver Dean Hawes reported finding wreckage of a ship that matched the Cyclops description off Norfolk. Subsequent attempts to locate this wreck have been unsuccessful. And there have been several.

There are a handful of mysteries I'd love to see solved in my lifetime. This is one of them.

More from the Department of Contradiction

I'd like to thank my reader Glen for submitting this screenshot.

He was trying to show a patient why she shouldn't be using quinine for her leg cramps, only to be betrayed by an ad in the lower right corner.

(click to enlarge)

BUSTED!!!

Mr. Seizure: "Sorry I'm late, I was driving around looking for a parking space."

Dr. Grumpy: "I thought I told you that you're not allowed to drive until April?"

Mr. Seizure: "Um, yeah, I mean, I was, uh, riding and, um, looking for an empty bike rack."

I finally did it

Okay, for all of you who have written in asking me to do Twitter, I finally have. I may be the last person on Earth to have signed up for it. I'd like to thank (or blame) ERP for inspiring me.

I'm going to use it for those moments that are too brief to warrant a full blog post. I promise not to use it to update anyone on my lunch choice, sock color, are other pointless trivia. I likely won't use it more than a few times a week, but who knows.

I am @docgrumpy. You can also, I think, look me up by my email address pagingdrgrumpy [at] gmail [dot] com

(for those of you rushing to add me to twitter, don't forget to check the previous post below- it's another patient gem).

Thursday night, 8:47 p.m.

Dr. Grumpy: "This is Dr. Grumpy, returning a page."

Mr. Flick (loud music in background): "Yeah, I'm gonna run out of medication tomorrow, and I need you to call some in."

Dr. Grumpy: "Which medication?"

Mr. Flick: "I don't know it's name. The bottle is at home. It's the one I take twice a day."

(someone screams in the background)

Dr. Grumpy: "What's all that noise?"

Mr. Flick: "I'm at a movie."

Dr. Grumpy: "Why are you calling me for refills from a movie?"

Mr. Flick: "It's boring, and I wanted to call you while I was thinking about it."

Dear U.S. Census Department,

Thank you for your letter reminding me that my census forms are coming, and asking me to fill them out when they arrive.

Government waste is a universal phenomenon, and certainly this country is no exception.

But I have to wonder, how much money did it cost to send "your census is coming, please fill it out" forms to EVERY FREAKING HOUSEHOLD IN AMERICA?!!!

You guys have been running TV and radio commercials, magazine ads, newspapers, and billboards about this for months already. Not including the many news features about the census coming. You'd have to be living under a rock NOT to know the census is this year (every 10 years, for my non-U.S. readers).

Wouldn't it have saved money, and made a hell of a lot more sense, to include this letter WITH the census, saying "here is your census, please fill it out"? Do you really think sending an advance letter will make a difference? Do you really think anyone is going to remember the first letter by the time the REAL census forms show up? Do I really think that me writing this will make a difference?

Your's truly,

Ibee Grumpy, M.D.

Unpredictable

You guys may remember this post, from a month ago. Basically, one of my readers (Bob) had his truck blocked into a parking space by an overzealous pot hole repair crew.

Bob died, quite unexpectedly, yesterday. His wife, Cheryl (also a reader) sent me an email last night. She wanted me to know how much he enjoyed seeing his truck nightmare up on my blog.

While I'm not planning on making online condolences a regular feature of my blog, I do want to send mine to Cheryl. I didn't know Bob at all (beyond the comment he posted that day), but anyone who can look at his truck trapped in a parking space by a malfunctioning maintenance drone, and have a good laugh (instead of, say, a shit fit or heart attack) is my kind of guy.

We all talk about the company we work for, who our boss is, etc. Always keep in mind who it is that you REALLY work for, and what is truly important.

IG


Tell me not, in mournful numbers,
Life is but an empty dream!
For the soul is dead that slumbers,
And things are not what they seem.

Life is real! Life is earnest!
And the grave is not its goal ;
Dust thou art, to dust returnest,
Was not spoken of the soul.

Not enjoyment, and not sorrow,
Is our destined end or way;
But to act, that each tomorrow
Find us farther than today.

In the world's broad field of battle,
In the bivouac of life,
Be not like dumb, driven cattle !
Be a hero in the strife !

Lives of great men all remind us
We can make our lives sublime,
And, departing, leave behind us
Footprints on the sands of time.


- A Psalm of Life, by Henry Longfellow

Leave me out of it

A young couple were in today.

Dr. Grumpy: "Any other issues you wanted to discuss?"

Mrs. Young: "No, I think you covered it."

Mr. Young: "Yeah. If we were to die, who do you think should raise our kids? My sister or hers?"

Mrs. Young: "Why the HELL are you asking him?! He doesn't know either of them!"

Mr. Young: "He's a doctor, so he knows about this kind of stuff."

Dr. Grumpy: "No, sir, I really don't..."

Mrs. Young: "Let's go. You're an idiot." (drags Mr. Young out).

Things that make me grumpy

Gad (short for gadolinium) is an element. In my field it's used in certain MRI studies as a contrast agent. Not all MRI's need to be done with gad, but for some things it's very helpful.

Gad is also expensive, roughly $200-$500 a dose, on top of the already pricey MRI. So I only order it when I need it.

A few MRI places (not most, just a few) try to push giving gad, even in cases where it's not needed, just to pad the bill. Annie and I know which ones do that, and generally don't use them. But yesterday, for various reasons, we ended up scheduling a patient at one to have a study there.

So I faxed over an order that said "Brain MRI". That's all.

Annie had to run an errand, so I was covering her calls while she was gone. At one point Mary grabbed me between patients, and said I needed to talk to the staff at the MRI place, who had questions. So I picked up the phone.

Dr. Grumpy: "This is Dr. Grumpy."

Ms. Gouge: "Hi, I'm looking at your order here, and it doesn't specify if you want gad on the study."

Dr. Grumpy: "I didn't write "gad", so therefore, no gad."

Ms. Gouge: "But shouldn't we do it with gad?"

Dr. Grumpy: "Do you have my patient info form in front of you?"

Ms. Gouge: "Of course."

Dr. Grumpy: "What indication for gad do you see on there? She doesn't have any."

Ms. Gouge: "Yeah, but it's still helpful. So just give me an order for gad, and I'll take care of it."

Dr. Grumpy: "You and I both know that she has no indication for gad, and so her insurance won't pay for it."

Ms. Gouge: "Yeah, but we can bill the patient for it."


I hung up on her. I immediately called the patient myself, and moved the study to another MRI place.

Cookie reruns

We've now survived that most difficult part of the year, Girl Scout Cookie season. Fortunately, this year went off without a hitch, as Marie has gotten better at the art of sidewalk sales.

For those of you who weren't following along last year, I present this rerun from the 2009 Girl Scout cookie sales.



Yesterday was my daughter's turn to hawk $4 boxes of cookies in front of Local Grocery. So your hero accompanied her, as Marie assaulted innocent, but cookie-less, people on their way into the place.

Some nice guy came over and said he didn't want any cookies, but gave us $20 and told us to give a box to the next 5 senior citizens who came out of the store. It was a kind thing to do. So I called Marie over, and explained it to her.

A minute later an elderly lady came out, and Marie attacked. She handed the woman a box of Thin Mints, and loudly said "Here! You win these cookies free, because you're really old!"

I tried to pretend I didn't know her, and wasn't successful.

20 Questions

Dr. Grumpy: "Any medication changes since you were last here?"

Mr. Brite: "Yeah, my internist started me on 2 new pills last week."

Dr. Grumpy: "What are their names?"

Mr. Brite: "Ummm... One starts with 'M', and the other with 'S'. Do you know those?"

Dr. Grumpy: "No. What do you take them for?"

Mr. Brite: "Not sure. But they're both round. Does that help?"

Kids today!

One of the staff's sons was in the office yesterday. He's 9, and was sent home from school with a cold.

So they set him up with some books and a Nintendo DS, and he was pretty good. When he got bored they put him to work, and at one point he was sent to the storage closet next to my office to get copy machine paper and post-it notes.

At that time I was seeing an older gentleman for memory loss, and was going through the usual questions to check his functioning. Typical stuff. What's today's date, who's the President, how many quarters are in a dollar, etc.

A few minutes later the kid walked up front, and asked his mother, "Mom, why does the doctor ask people such easy questions? Even I know those answers."

More hairs fall out

Dr. Grumpy: "Is the new medication helping? Any side effects?"

Mrs. Dimwit: "No, the headaches are the same, but I haven't noticed any side effects."

Dr. Grumpy: "And let me check... You should be up to 2 pills, three times a day?"

Mrs. Dimwit: "No, I take 1 pill, once a day."

Dr. Grumpy: "Why didn't you increase the dose? I wrote out a schedule for you to do that."

Mrs. Dimwit: "I didn't think it would help, so I didn't bother."

Sunday night, 7:45 p.m.

Dr. Grumpy: "This is Dr. Grumpy, returning a page."

Mr. Skin: "Yeah, you started me on Halitosum last week, and it gave me a rash. And I think it's getting worse."

Dr. Grumpy: "Didn't you talk to Annie about this on Friday? I thought she told you to stop it?"

Mr. Skin: "Yeah, she did, and I didn't take it, just like she said."

Dr. Grumpy: "When was your last dose? Friday morning?"

Mr. Skin: "No, this morning."

Dr. Grumpy:"Whaaa... I thought you said you stopped it on Friday?"

Mr. Skin: "Well, she said not to take it. I assumed she meant just that night. So I took it again Saturday morning, and last night, and this morning."

Sunday weirdness

I have one hospital patient to round on. So I drove in.

It's pretty damn cold out today.

I'm in the suburbs of a large, modern, American city. Generic suburbia.

And I had to slam on my breaks to avoid a llama running across the street, being chased by a man on a horse.

WTF?

No, I don't live anywhere near a zoo, or movie set.

Incongruity

As part of our hot date on Saturday night, Mrs. Grumpy and I stopped at Target (yes, I know, we're a wild pair).

In one aisle they had this sign:

"Your choice, 4 for $9.
Ziploc plastic bags OR Pepperidge Farm goldfish crackers
Mix and match for variety"

Saturday morning, 8:27 a.m.

"Hey, someone told me to call and make an appointment? My friend Sandy said I should see Dr. Grumpy for the problem I'm having. Also, when you call back, could you please let me know what kind of doctor you are? Because if you're a psychiatrist I'm gonna beat the crap out of Sandy."

An opposing viewpoint

"Flaming Lisa" gave a dissenting opinion on my post about death, "Checking out". While I disagree with her, I do believe in fairness. I'm therefore putting up her entire comment verbatim, as an opposing viewpoint.



Hmmmm. It's too bad that the original post had to be all balled up with Killer Kevorkian and Terri Schiavo (2 very different cases).

As a Catholic, food and water are considered ordinary (required) care even if medically assisted--so Terri Schiavo would be alive and her murder would never have happened and perhaps her parents would have been able to care for her as they wished. Wow! How awful is that????

Kevorkian is a murderer and has served jail time for such a crime.

This woman in the original post, however, was trying to die but was subject to her husband's wishes. As much as you "healthcare workers" keep harping that this happens all the time, I have a hard time believing it. I don't see hospitals crammed with people being given every possible test under the sun in these circumstances. It is an exaggeration on your part.

MDKauffman: is it really so hard to administer antibiotics to a woman with a UTI? Where's your compassion you idiot? UTI's don't have to be a dying persons disease--you just don't like old people. Get a new profession.

You've all lost your heart! How cold and hard have you gotten???? I am convinced now that NO ONE should be making these decisions (and especially not you people) for a family except the family. Thank you for clearing that up for me and making me thoroughly distrust the medical establishment.


--Flaming Lisa

Mary, bring me a sword

Dr. Grumpy: "So did the Painbegone help your migraine?"

Mr. Unsure: "I don't know."

Dr. Grumpy: "Did it make the headache better?"

Mr. Unsure: "Ummm... Maybe?"

Dr. Grumpy: "That doesn't sound very convincing."

Mr. Unsure: "I don't remember."

Dr. Grumpy: "Didn't you just take it yesterday?"

Mr. Unsure: "I think so, umm, yeah."

Dr. Grumpy: "So, after taking Painbegone, did the headache get better? Yes or no?"

Mr. Unsure: "A little of both."

Dr. Grumpy: "What does that mean?"

Mr. Unsure: "It got better eventually."

Dr. Grumpy: "Define eventually."

Mr. Unsure: "At some point I didn't have a headache."

Dr. Grumpy: "How long is 'at some point'?"

Mr. Unsure: "One hour, maybe several more. I didn't pay attention."

Dr. Grumpy: "Was it faster than it normally takes your headaches to get better when you don't take medication?"

Mr. Unsure: "What medication are you talking about? The white pill? Or the tan one?"

Dear Dr. Staff,

Thank you for referring Miss Carpaltunnel for "an abnormal MRI" (at least that's what it said on your referral form). Unfortunately, your office didn't send a copy of the MRI report in advance.

Earlier today I called your staff, asking that you fax over her MRI results before the appointment. Your secretary said she'd do it immediately.

One hour later, we faxed over a release, and Mary called again. Your helpful staff said we'd have it soon.

90 minutes later I called again, and someone said she'd "get right on it."

So I was glad when a fax from your office finally showed up.

Unfortunately, it wasn't her MRI report.

It was her chlamydia test. And it was positive. But I didn't have that kind of interaction with her, I swear.




So, if you guys can find the brain MRI report, please send it over.

Thank you.

I am humbled

I'm absolutely overwhelmed with your positive responses to my previous post, "Checkout time". Thank you. It's my most commented-on post, ever.

I didn't expect so many would see it from my side.

I'm just one doctor. I can't change the world.

But maybe sending a link to the post to others who DON'T see this side of dying will help more people understand. So if any of you want to, go ahead.

Death touches all of us. Thinking about it in advance won't stop that. But it can help us deal with it better when the time comes.

I was so surprised by your responses that I didn't put up any of my usual stories from the medical trenches. We will return to our regular program format of sarcasm and medical practice idiocy tomorrow.

Checkout time

I'm sure I'll get flamed by somebody over this post, but I've been stewing over this for a few weeks, and just want to say it.

I haven't ever saved a life. No doctor has. We may prolong the inevitable, but we don't save anyone.

We aren't immortal, and weren't meant to be. We die. All things do. Plants, animals, even stars.

Death is as much a part of life as birth.

And yet, at times people chase medical science as if we have immortality in all our gadgets and pills.

Why am I writing this?

A few weeks ago I had a hospital consult on a horrible, awful, sad case. Lady in her 60's with advanced cancer. It had spread through every organ of her body. Brain, lungs, bones, liver, intestines. You name it.

She'd had surgery. And radiation. And chemotherapy. Established treatments. Experimental treatments. Alternative treatments. Her husband had taken her to every major cancer center in the U.S. (using YOUR insurance premiums, of course). And every single one told them there was no hope. So he fired them and moved to the next center.

She landed at my hospital, somehow. Sick as shit. Ended up a ventilator. Tubes in every orifice. Comatose from every body system failing. Suffered a bleed into the brain. Seizures. You name it.

We health care people have seen this stuff a million times before. But my readers who aren't in the field may not have. And trust me, this situation happens A LOT. More than you'd ever believe. The media leaps onto cases like Terri Schiavo as if they were rarities, but in reality cases like this are frighteningly frequent, every day, in every hospital in the country. Really.

And of course, her husband is beyond denial. He's not a bad person, just hears only what he wants to. He has the room covered in family pictures and religious symbols. He tells me his family is hoping for a miracle, and knows it will come.

So who is he REALLY doing this for? Not for her. To the sad shell of what was once a beautiful, vibrant woman what he's doing is more likely some form of torture. She's gone, sir. Elvis has left the building. But he won't hear that, no matter how many doctors, in innumerable ways, and many times, tell him.

Ask yourself: How do you want your life to close down?

How many of you said you want to die incapacitated in a hospital bed, with plastic tubes in your urethra and butt, and down your throat? And another one in your nose? And maybe a 5th one in your abdomen, going directly into your stomach? With IV lines going into veins in both arms, the few veins that haven't already collapsed from repeated IV lines in them. And the tube in your throat keeps forcing air in and out. Does that sound like a comfortable way to end your days?

I'm not, by any means, arguing against critical care. Some people end up like the above, with a realistic plan of recovery. And many do. I'm talking about people where this is done with absolutely no goal other than to drag life out for as many seconds as possible.

And so back to my lady. Me and 4 other docs (neurology, cardiology, pulmonary, renal, and oncology) had a 1 hour meeting with husband and his grown kids. We told them this was futile. That what we were doing to her was prolonging her suffering. They all listened. They accused us of being "too negative". The next day they transferred her to another hospital. So I have no idea what happened after that.

Beyond human suffering and reason, let's look at this in the cold hard facts of money. Yeah, I'm sure you Sarah Palin fans will accuse me of putting a price on human life. But hell, your insurance company already does, whether you want to believe that or not.

This woman's care has cost at least a million dollars here, likely a hell of a lot more. I'm pretty sure this family's premiums don't cover that, and I know they aren't wealthy. So the money is coming from their insurance company, which is YOUR premiums.

So let's say futile care for this woman cost $1.5 million dollars. Would that money be better on helping treat people who had a more reasonable chance at recovery and significant quality of life? Maybe several?

Yeah, this is a slippery slope, and there's no easy answer as to where you draw the line. The military deals with this in battlefield or disaster area conditions, where you put your resources to those who are salvageable, and letting those who aren't die. But you can't say that in the polite world of modern medicine.

But for all the controversy over the phrase "death panels", ask yourself this- are they so unreasonable? In a case like this, should, say, a panel of 3-5 certified doctors in oncology, with no ties to the patient or the insurance, objectively review the the data and say "Stop this madness"? Or maybe determine further treatment would be beneficial?.

If they decide it's futile, I'm not saying that treatment should stop, but at that point the insurance company can end it's involvement and the entire financial burden falls on the family. I suspect that when they realize realistically how much futility costs to torture a loved one, they'll let her go.

Money, unfortunately, is a finite resource. You have to pay hospital staff, and drug costs, and facility electric bills, and supply bills. In a perfect world I could support my family and care for patients for free. But I have a mortgage and kids and bills, too. As do the nurses and other hospital staff.

Balanced against this finite resource is human suffering. Which is infinite. And you can't keep paying unlimited need with limited resources. In any situation.

Annie's Desk, March 3, 2010

Annie often gets sales pitches. When that happens, she has carte blanche from me to do or say whatever she wants. And she does.


Annie: "Dr. Grumpy's office, this is Annie."

Donny Dingo: "Hi! This is Donny Dingo! From FubarMED medical software! Can I speak to your office manager?"

Annie: "You got her. How can I help you?"

Donny Dingo: "No, I'd like to help YOU! With our all-purpose electronic medical records system!"

Annie: "No thanks, but can you help me with your screwed up online prescription service? It's a piece of crap."

Donny Dingo: "Yes, I can direct you to someone who knows about that sort of thing. But first, let me send you a link to try our electronic medical record keeping system FOR FREE! ABSOLUTELY FREE!"

Annie: "We don't need one. Dr. Grumpy wrote his own. But we do use your online e-prescribing service, and I'd like to discuss problems with it because..."

Donny Dingo: "That's great! I'm looking forward to working with you guys! What is your office phone number and fax and email, and I'll send you the link!"

Annie: " You already have our phone number, because you called me. You have no clue about the e-prescribing issues, do you?"

Donny Dingo: "I'll get you this info right away! Thank you! Have a nice day!"

Annie: "Can you at least give me a number for the e-prescribing complaint department? Hello?"

(click)

Okay

Mr. Talk: "My speech was fine when this happened, in all the languages I know."

Dr. Grumpy: "How many languages do you speak?"

Mr. Talk: "Just one."

So there!

I'd like to thank the anonymous reader who sent this to me.

I'll get you, my pretties! HAHAHAHAHAHAHA!!!

Mary: "Dr. Grumpy's office, this is Mary."

Ms. West: "Yes, I need to make an appointment."

Mary: "Okay, we can see you tomorrow afternoon... What's your insurance?"

Ms. West: "I have Medicare."

Mary: "I'm sorry, we aren't currently taking any new Medicare patients."

Ms. West: "What? Why not?"

Mary: "The new Medicare cuts went into effect this week and..."

Ms. West: "My internist cut me because of this, too. This is ridiculous. I can't find anyone who takes Medicare!

Mary: "I'm sorry, but..."

Ms. West: "I'm putting a hex on your office."

Mary: "Excuse me?"

Ms. West: "I'm serious. I'm a modern witch, and am putting a hex on your office and..."

Mary: "Good bye." (hangs up)


No, I'm not making this up. This was a first for my practice. And that says a lot.

Tuesday morning whatever

Ms. Ictal: "So I had a seizure 2 weeks ago, and you did the episiotomy last week. What were the results?"

Dr. Grumpy: "You mean the EEG?"

Ms. Ictal: "Whatever, the test that started with an "E". What did it show?"

Monday night, 7:05 p.m.

"Hi, this is Mrs. Ramble calling. I need to make an appointment with Dr. Grumpy, who I think I saw once. It's not for the problem he saw me for then, it's for a new problem, but it's been going on for a while, so it's sort of old. Maybe it is the same problem, I'm not sure. But whatever it is, I think I need to see Dr. Grumpy for it, unless it's the problem I had before, in which case he needs to have a new look at it. So can someone please call me back tomorrow?"

Beating my head on the desk

Dr. Grumpy: "How's the tremor doing with the new medication?"

Mr. Shake: "Pretty good. I mean, some days the tremor is still bad, but on most it's okay."

Dr. Grumpy: "Any connection you've noticed on the days when it's worse? Are you more tired those days? Or drink more coffee? Or..."

Mr. Shake: "Mmm... I guess it's worse on the days when I forget to take the pills."

Yes, I'm juvenile

This invitation to a CME (Continuing Medical Education) course showed up in the weekend mail (I have no idea why there is a gray box instead of a picture. I didn't do that).

(click to enlarge)




For other great MD names, please see this post, and the comments that followed.