Dear Mr. Winkie,

I try to be prompt, and run my schedule on time. I really do. Most of my patients are used to that, but you're new to my practice.

So I understand you bringing something to read. People often do, as the assortment of People, Newsweek, Home & Garden, and other lobby magazines can be boring. So I see people with books, newspapers, knitting stuff, Nintendos, laptops, and such to pass the time.

But if you're going to bring something to your next visit, please DON'T make it another issue of Penthouse.

I've got nothing against porn specifically. If that floats your boat, more power to you. But reading it in my lobby, where one of my patients had her kids, didn't make for the calm and tranquil environment Dr. Pissy and I try to cultivate.

So next time, just stick with the Newsweek or Glamour* issues in my lobby.

Thank you.

(*we Seinfeld fans know who we are, huh?)

Yes, that's a very common disease

I was doing an online medical survey this morning, and encountered this question:

(click to enlarge)

Important safety measures

Mrs. Klumsy: "I used to fall when going down stairs, but I was able to stop that."

Dr. Grumpy: "How did you stop it?"

Mrs. Klumsy" "Now I only walk down them with my eyes open."

Detective work

Dr. Grumpy: "So what kind of symptoms are you having?"

Mr. Papyrus: "Didn't Dr. Imed send you a note?"

Dr. Grumpy: "No. Are you hurting somewhere?"

Mr. Papyrus: "Yes."

Dr. Grumpy: "Where are you hurting?"

Mr. Papyrus: "It said in his note."

Dr. Grumpy: "Okay, but where do YOU remember the pain being?"

Mr. Papyrus: "Wherever Dr. Imed told you it is."

Dr. Grumpy: "How long has it been hurting?"

Mr. Papyrus: "How long has what been hurting?"

(long pause)

Dr. Grumpy: "By any chance did Dr. Imed think you were having memory problems?"

Mr. Papyrus: "Maybe. That sounds familiar. Why? Did you find the note?"

Welcome to Grand Rounds, year 7!

As you're all aware, I was asked to host online Grand Rounds this week. So thank you all for coming! I'll be returning to my regularly scheduled whining tomorrow.

Coffee and bagels are in back. Sign in on the sheet. Medical students, please remember that you're allowed to sit ONLY if there are chairs left after the attendings, fellows, residents, and homeless people (here for the bagels) have been seated.

Food was provided by our drug rep Rikki, on behalf of Wirfliss Pharmaceuticals. She asks that when writing a prescription, please keep their many Wirfliss products in mind.

Before beginning, I'd like to thank Dr. Fizzy for her suggestions on doing grand rounds, and (as always) her totally awesome collection of medical cartoons. If you don't already read her, then (after this) click here and get started.

A big thank you to everyone who sent stuff in. I received A LOT of submissions, and unfortunately couldn't use them all. So if you didn't make it, I'm sorry. Everything I got was good. Some of you sent great anecdotes and stories, but in keeping with tradition, I limited it to links for blogs.

And we're off! The topic was: THINGS THAT MAKE ME GRUMPY!


To start, I present: THE PHARMACISTS!




The king of pissed-off pharmacists, The Angry Pharmacist, submitted this post about an issue that drives him (and many docs) nuts- the prevalence of meds ending in -XR, -XL, -CR, etc.

My esteemed colleague Pharmacy Chick sent her list of pet peeves from the other side of counter. And I have to agree with her.

Next up in the center ring: THE NURSES!





From the Florida keys, we have Mojito Girl. She brings us stories from the ER "spa" there. Mojito, dear, although your email promised "truckloads of money sent to a Swiss bank account" for putting this up, I still haven't received it. Perhaps this is because I don't have a Swiss account. Or simply the logistics of you driving trucks from Florida to Switzerland.

Nurse Running Princess (like many of us) finds herself stymied by some of the asinine ideas that drift down from hospital management.


Here they are: THE MEDICAL RECEPTIONISTS!





My idol, Dr. Oscar London, once wrote that "The doctor is your humble servant. The secretary is Her Majesty, the Queen", and I quite agree. You all know my boss secretary, Queen Mary, but she's far from alone in the combat of front desk medicine.

Queen Kate sent 4 totally awesome examples of the insanity that goes on in the trenches, and I couldn't pick one over the others (I tried). So here, in no particular order, they are:

Crayzee 1, Crayzee 2, Crayzee 3, and Crayzee 4.

I think if Mary and Kate start a blog together, they'll drive me off the web.


Next up: THE PARAMEDICS!





Medic999 had a lot to say about the insanity of an answering service that doesn't quite grasp what "the patient is dead!" means.


Now taking the stage: THE DOCTORS!





Dr. Orion, from the wild world of psychiatry, writes about misadventures on a book tour.

On the topic of false advertising, pathologist Gizabeth writes in about being promised a lab specimen of gangrenous hemorrhoids (doesn't that sound horrible?), and her disappointment when they weren't.

Doctor D gets peeved over patients who want a doctor to have superpowers to diagnose and treat without ever seeing them.

Jill-of-all-Trades, M.D. wanted to stress ways to avoid being grumpy (no, I don't understand that, either), and sent in tips to properly conduct the circus of medical practice.

Master Surgeon RLBates wrote in concerning a trend that makes her (and me, too) grumpy: A TV show that's promoting plastic surgery as a prize package for brides!

Manixter, an anesthesiologist who specializes in passing gas, writes in to tell us what it's like when you have to use bedside manner with a relative. She also had a Jeff Foxworthyesque piece on you may be an anesthesiologist if...

Dr. Kirsch, while not necessarily grumpy, sent in a poignant post on faith and medicine.

Glass Hospital sent in his secrets about working at a university student health center.

Dr. Dalai, a radiologist who specializes in the "I'm tearing my hairs out by the roots" field of IT, sends in his grumpiness over trying to set up a PACS system.


Entering the spotlight: THE RESIDENTS!





MD Resident, who's surviving the hazing ritual of call, wrote about annoying aspects of residency.


And now... THE MEDICAL STUDENTS!





Action Potential wanted to gripe about schools promoting "new curriculum" ideas that do nothing but make you look socially inept.

Mack wanted to grump about the serious medical condition Facebookalgia.


And last, but certainly not least,... THE PATIENTS!





The Banshee, who recently had a baby without any freakin' pain meds, sent in this story of a whiny family member.

Pink Tee Shirt sent in her peeves from the patient side of the medical world.

Copewithpain wanted to discuss problems encountered at the doctor's office.

Joseph Morris wanted to discuss disgusting things about public bathrooms.

While I, personally, revel in my grumpiness, the folks over at Bedside Manner wanted to suggest ways to avoid being Grumpy. Here are their suggestions, though they forgot to list "don't run out of Diet Coke."





It looks like we're running out of both time and bagels, so I'll wrap up. In closing, I'm going to post my own pick, something entirely unrelated, and one of the best pieces of blog writing EVER. Nurse Maha's awesome take on Edgar Allan Poe's classic poem, The Raven.

And that's all! Thanks for joining us for Grand Rounds. Let's have a round of applause for Nick Genes (no relation to Splice) and Val Jones for asking me to do this (I'm still waiting for my Diet Coke, by the way). Next week Grand Rounds will be held over at Sharp Brains, so tune in then.

Medical students, please don't put the leftover bagels in your white coats until the residents have picked them over.

Homework

Tonight Marie asked me to look over her math homework. It featured this:

Question: "Write a word subtraction problem using the numbers 18 and 10."

Under it Marie had written: "Frank had 18 words and gave 10 of them to Craig. Frank had 8 words left."

More Medical Research

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

I think we've all played beer pong. I mean, what would college be without it?

And most of us, especially shitty players like me, can attest that you can get pretty damn drunk playing it. Definitely more so than other drinking activities, such as watching football or flying a commercial plane.

So you can ask pretty much any college student "Hey! Do you get really drunk when playing beer pong?" And the answer will be "Yes!".

Of course, walking around a college campus and asking such questions, or simply hanging out in a bar and taking notes, are way too simple for your average researcher. So instead the folks at one university had to create a simulated model of beer pong using computer software. Really.

What did they learn?

That playing beer pong leads to increased alcohol consumption. Shocker, huh?

Here's the article.

September 27, 1854

After the war of 1812 , the United States and Great Britain resumed commercial trade.

On both sides of the Atlantic, businessmen competed for their share of this increasingly lucrative business. Faster ships made more money, even if it meant going full speed into bad weather and poor visibility. Many ships vanished, forever listed as overdue, and presumed lost to bad weather and icebergs.

On the Eastern side, the driving force was Samuel Cunard. In the 1840's he came to dominate the Atlantic market, with the line that to this day bears his name. The British government backed him financially, so the ships could, in the event of conflict, be requisitioned by the navy (which they often were).

On the Western side, a number of American lines tried, with varying degrees of success. The U.S. government was less inclined to become involved in these matters, and so capital was harder to raise for building ships.

As sail gave way to steam, this changed. The Americans were concerned that Cunard's steamers could be converted to warships. Faced with both real economic and feared military competition, the government began backing various companies to try and win trade back from Cunard.

The man to lead this was Edward Collins. With government subsidies he built 4 large steamships (Arctic, Pacific, Baltic, and Atlantic), bigger, faster, and more luxurious than Cunard's ships, to challenge his rival. The plan was to run a tight schedule across the Atlantic.

The Collins Line ships, with their combination of sails and paddle wheels, were some of the fastest in the world at the time. They showed the Atlantic could be crossed in the remarkable time of 10 days, and in a few cases, 9.

Backed by their respective governments, Collins' and Cunard's lines competed intensely to dominate the 3000 miles of north Atlantic. Until 12:15 p.m. on this day.

As the Arctic steamed west, through a heavy Newfoundland fog, she collided with a small French ship, the S.S. Vesta. The Vesta, although much smaller, had a hull reinforced with iron.

In the first few minutes after the collision, many of the Vesta's crew assumed their damage was fatal, and abandoned ship (against orders) to try and reach the larger Arctic. They were wrong. The crew of the Vesta worked miracles and overcame the damage.

Captain James Luce of the Arctic was a veteran of the sea. Believing his own damage to be minimal, he turned the Arctic around to aid the Vesta, and launched 2 lifeboats to help evacuate it's passengers to the Arctic.

These orders were quickly canceled when one of the lifeboats reported the severity of the damage to him. The ship was badly damaged. Like the Titanic 58 years later, he had the legally required number of lifeboats. And they weren't nearly enough to hold everyone on board.

Cape Race was 4 hours away. With his duty to his own ship clear, Luce abandoned the Vesta, heading for land. His hope was to beach the ship before she could sink.

The wreck of the Arctic over the next few hours quickly turned into a nightmarish struggle for survival, very different from the civility seen in the Titanic. Captain Luce accepted that he and his 11 year old son (who was traveling with him) were going to die, and did his best to save passengers. He was betrayed by his crew and most of his officers.

His crew disobeyed orders, commandeered the lifeboats, and fled. A trusted officer and handpicked team of seamen were placed in a lifeboat so that passengers could be lowered down to them. As soon as they reached the water they rowed away, with plenty of space in their boat.

Without lifeboats, Luce and his few remaining crew did their best. They tore the wooden deck to pieces, frantically trying to build rafts. Doors were torn from hinges to be used for flotation. All furniture made of wood was assembled on deck in hopes of saving more lives.

Of 408 who sailed, there were 86 survivors (64 crew, and 22 passengers). Not a single woman or child lived. They're remembered by a monument in Brooklyn's Green-Wood Cemetery.

Captain Luce, surprisingly, survived. He and his son went down with the ship, but were ejected from the vortex as it sank. As they swam away, a large wooden paddle wheel cover broke loose from below the sea. It launched into the air like a rocket, then came down, killing his son. And yet, at the same time, it became a makeshift lifeboat for Luce and a handful of swimmers. They were picked up after a few days by a passing ship.

The loss was a disaster, both personally and financially, for the Collins Line. Besides Luce's son, the deaths included Collins' wife and 2 of their children.

Although mostly forgotten today, the disaster dominated headlines on both sides of the Atlantic for a month, until replaced by the Crimean War. It had the same effect then as the Titanic would in 1912. Safety specialists recommended specific East-West shipping lanes. Slower speeds and loud whistles in fog. Lifeboats for everyone. The majority of the recommendations were ignored until the aftermath of the Titanic.

2 years later, in 1856, the Arctic's sister, the S.S. Pacific, vanished en route from Liverpool to New York.

It was another blow for the Collins line. There was an economic recession, and the U.S. government was now willing to let Cunard have the Atlantic. Collins' subsidies were cut, and in 1858 his line folded. The surviving ships were auctioned off.

The wreck of the Arctic hasn't been found (to my knowledge no one has looked).

The Pacific was thought to have been lost to storms or icebergs in the north Atlantic. To the surprise of everyone, she was accidentally found in 1991 in the Irish Sea, only 60 miles from where she left Liverpool. Why she sank remains a mystery.

Cunard survives to this day, though is now owned by Carnival Lines.

Government subsidies for shipping, with the ships to be used in time of war, continued into this century in all the major powers.

The last American attempt to share the Atlantic trade lies, mostly forgotten, in Philadelphia. She is the liner S.S. United States, built with subsidies after World War II. The government paid for her huge size and (even to this day) remarkable speed, with the plan of using her as a fast troop transport in future conflicts. Her commercial career, like all liners, was doomed by the passenger jet. Multiple attempts continue to be made today to save her from the scrapyard.

Attention crooks!

Look, if you're trying to smuggle cocaine on an airplane, you take your chances. I think all of us have had our luggage lost at some point. So I suppose a bag with illegal drugs is as likely to go missing as one with my dirty laundry.

BUT, in the event that happens, you should probably take it as a loss. It is NOT going to help you to file a "lost luggage claim" on your case of contraband.

Like these guys.

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

No means no

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

Mr. McPayne: "Yeah, are you covering for Dr. Cortex this weekend?"

Dr. Grumpy: "Yes."

Mr. McPayne: "Okay, I need more Vicodin for my pain."

Dr. Grumpy: "What kind of pain are you having, sir?"

Mr. McPayne: "You know, stuff that hurts. I need Vicodin for it. I get it from Dr. Cortex."

Dr. Grumpy: "Is this a new problem?"

Mr. McPayne: "Nope. If I can get some Vicodin I'll be fine."

Dr. Grumpy: "I can't call in narcotics for other doctor's patients on the weekend."

Mr. McPayne: "Why not? It sounds like your phone is working?"

Dr. Grumpy: "I don't know your case at all. You can call on Monday when Dr. Cortex will be back, or go to an ER if you feel this is urgent."

Mr. McPayne: "I ain't going to ER. I just want some Vicodin. Can I come to your office today so you can see me, and I can prove I have pain?"

Dr. Grumpy: "No, sir. My office is closed on Sundays."

Mr. McPayne: "Then can we meet at a McDonald's or something?"

Dr. Grumpy: "Goodbye." (click)

Sunday morning, 2:25 a.m.

"Hi! I'm a patient of yours and I'm 8 months pregnant and my water broke and I've started having regular contractions and I think I need to go to the hospital and can the doctor please call me back ASAP because OH SHIT! I THINK I CALLED THE WRONG DOCTOR PLEASE IGNORE THIS MESSAGE!"

(click)

I still can't stand it.

This is a repeat of a post I ran last September. And since the same issue STILL drives me nuts, I'm putting it up again.


Dear Mr. President,

I don't want this to be a political blog. There are plenty of other sites for that. But we now face a national crisis of such serious proportions that it dwarfs other issues, such as global warming, health care, and middle-east peace. It now threatens the very fabric of our society, and directly affects every citizen. And I can remain silent no longer.

It's still September, and every store near me ALREADY HAS THEIR CHRISTMAS DECORATIONS UP!

I have nothing against the holidays, Mr. President. Peace on Earth and all that stuff. But moving them up as if they were being held in another time-zone or alternate universe is getting out-of-hand. As far as I know, Christmas hasn't budged in my lifetime. And treating every day like it was Christmas (like the stores seem to want me to do) is not helping.

The well-respected Nick documentary program, The Fairly Oddparents, has carefully researched what would happen if Christmas were held every day (Episode 107, air date 12-12-01 I have kids, OKAY!). Their conclusion? It would be catastrophic.

There also seems to be a degree of unintentional discrimination. For example, Hanukkah starts more than 3 weeks before Christmas this year, but I didn't see Hanukkah decorations going up 3 weeks before the Christmas ones. In fact, I haven't seen any at all yet. Or Kwanzaa stuff. Or Festivus. Or New Year's.

This seasonal perversion extends to other holidays, too. I mean, by January 2nd most stores are decked out with Easter junk, and on July 5th the Halloween crap is up.

So, Mr. President, I propose the following, federally mandated solutions (please note: I'm only including those holidays that retailers love. Let's face it, not many of us are out there buying gifts for Groundhog day or cards for Columbus day. I'm also leaving out local holidays like Delaware Statehood Day, the Montana Huckleberry Harvest Celebration, and the Byron, Illinois, Turkey Testicle Festival).

Valentine's Day Decorations will NOT be put up until the 3rd week of January.

St. Patrick's Day Decorations will NOT be put up until after March 1st.

Passover/Easter decorations will NOT be put up until after St. Patrick's day.

Independance day decorations (July 4th) will NOT be put up until the 3rd week of June.

Halloween stuff will NOT be put up before October 1st

Thanksgiving Stuff will NOT be put up before November 1st.

Christmas/New Year/Hanukkah/Kwanzaa/Festivus stuff will NOT be put up until the day after Thanksgiving.

(Please note: there should be some flexibility here, as Hanukkah and Easter/Passover may vary, but decorations should NOT be hung more then 3 weeks prior to holiday onset).


An alternative plan would be to have a single annual holiday combining all of the above, called St. Christmukahpasseastkwanpatfourthnewfestgivingween. Decorations for the combined holidays may be hung for 30 days prior to this event, and MUST be removed the day after.


Punishment for business owners who violate these laws would be on a 3-step basis:

1st offense: Business license revoked for one month.

2nd offense: Tarred, feathered, and forced to eat fruitcake.

3rd offense: Drawn and quartered, then served with fava beans and a nice chianti.


Yours truly,

Ibee Grumpy, M.D.

Tough case

I'm reading a hospital discharge summary, and discovered this quote from a neurosurgery resident:


"The patient was given Valium 10mg and Haldol 10mg. He then become lethargic, with decreasing oxygen saturations. The cause of his sudden lethargy was unclear. A head CT was unremarkable, and a STAT neurology consult was called."

Doctors for Gooder English

Doing an online survey this afternoon, and encountered this question.

Gosh, I wonder what happened?

Yesterday afternoon I went to the hospital's EEG reading room to look at the day's studies.

Unfortunately, only one had gotten done all day, and there was a note on the monitor that said "Doctors, sorry we couldn't do all the studies today. We had to send the EEG machine to Bio-Med to have it thoroughly cleaned".

Lucky for me, it was one of my studies that did get done. It was on a confused ICU patient, so I started reading it.

The study ended abruptly at 8 minutes (normally they go for 20), with the following commentary in the tech notes:

0745: Pt yawning.
0748: Pt moving around, agitated.
0750: Pt pulled poop tube out of butt and is playing with it. Nurse running to bedside.
0751: Ending study.

Mary's Desk, September 22, 2010

(Lady comes in, signs in, then continues to stand at counter)

Mary: "Hi, Mrs. Patty. We'll get you back in a sec. Do you need something?"

Mrs. Patty: "Um, yeah, do you guys have a hamburger I can have?"

Mary: "Excuse me?"

Mrs. Patty: "Do you have a hamburger? I just dropped my mom off at the airport, and I'm really hungry."

There's a lot of that going around

For the original post on this topic, click here.


Dr. Grumpy: "Did you have an X-ray for the neck pain?"

Mrs. Daypro: "Yes. A friend said the carpal tunnel there is causing my neck problems."

Now THAT'S ambitious!

I'd like to thank my reader Miriam for submitting this. She noticed it in a hospital patient's (admitted for a knee problem) paperwork .

(click to enlarge)

And now for something completely different

Okay, people. Yours truly, Dr. Grumpy, has been asked to host (drum roll please) ONLINE GRAND ROUNDS next Tuesday. As many of you know, this is a weekly collection of blog posts of a certain theme.

Next week starts the 7th year of this, and they wanted someone talented, popular, and successful to host it. Unfortunately, that person wasn't available, and so they asked me instead. I've been assured that their decision to pick me was based on stringent criteria, such as having a pulse and a website. I tried to negotiate for a case of Diet Coke, without success.

So the topic for next week's Grand Rounds will be "Things that make me grumpy". I whine enough, so I'm opening up the floor to you guys. Please submit links to blog posts following this theme, but try to keep them (roughly) in some limits:

1. They should have at least SOME medical background to them. I don't want to hear about the guy who cut you off in traffic (unless it was a neurologist wired on Diet Coke), the crappy service you got at Denny's, or the high cost of flour.

2. Try to have some element of humor in it.

3. This is NOT a political blog, so I'm NOT going to put up rants from either side about health care, elections, or whatever.

How to submit: Please send your entries to pagingdrgrumpy [at] gmail [dot] com. Put "Grand Rounds" in the subject line, and include the URL of the post in the message, with a sentence or two about it. Sending huge amounts of money to my Paypal account is also recommended, but not necessary (nudge nudge wink wink).

The deadline will be Saturday, September 25, at 6:00 p.m. U.S. Eastern time. So submit early. Or else.

Urgent matters

Dr. Grumpy: "Have a seat. I'm Dr. Grumpy."

Mrs. Arowana: "Thank you. Pleased to meet you."

Dr. Grumpy: "What can I do for you?"

Mrs. Arowana: "Well, for the last 7 years I've had... Oh! I need to leave. I'm sorry!"

Dr. Grumpy: "Is something wrong?"

Mrs. Arowana: "I forgot to turn on the light in my fish tank after I cleaned it this morning!"

Dr. Grumpy: "But..."

Mrs. Arowana: "No, I have to go deal with this. The fish are my babies, and I don't want them to get angry at me."

(patient walks out)

Dear Ambien-CR,

Thank you for recently sending patient information packets to my office (I've already safely recycled them, don't worry).

I know your logo is a rooster. I still don't understand this, since the drug is supposed to make you fall asleep, NOT wake you up. But whatever.

Anyway, considering another term for rooster is "cock", and we all know what that's slang for, perhaps you should think of a better package design than this. Or maybe license the logo to Viagra, instead.

Because somehow I can just see this ending up in a novelty store next to a mistletoe belt buckle.

Dead men tell no tales...

Yo ho, yo ho, a pirate's life for me!

We pillage, we plunder, we rifle, and loot,
Drink up, me hearties, yo ho.
We kidnap and ravage and don't give a hoot,
Drink up me hearties, yo ho.

Yo ho, yo ho, a pirate's life for me!

We extort, we pilfer, we filch, and we sack,
Drink up, me hearties, yo ho.
Maraud and embezzle, and even hijack,
Drink up, me hearties, yo ho.

Yo ho, yo ho, a pirate's life for me!

We kindle and char, inflame and ignite,
Drink up, me hearties, yo ho.
We burn up the city, we're really a fright,
Drink up, me hearties, yo ho.

We're rascals, scoundrels, villains, and knaves,
Drink up, me hearties, yo ho.
We're devils and black sheep, really bad eggs,
Drink up, me hearties, yo ho.

Yo ho, yo ho, a pirate's life for me!

We're beggars and blighters, ne'er-do-well cads,
Drink up, me hearties, yo ho.
Aye, but we're loved by our mommies and dads,
Drink up, me hearties, yo ho

Yo ho, yo ho, a pirate's life for me!

Aaargh! Happy Talk Like a Pirate day, mateys!

Rolling on the River

It was the American Civil War.

In February, 1862, the city of Nashville, Tennessee, was captured by Union forces. This began one of the strangest episodes in North American military history.

Overnight Nashville was converted into a supply depot for the Union's southward moving forces. The amount of locomotive and riverboat traffic increased dramatically, as did the population of Union soldiers. Some were stationed there, others were passing through on their way to different fronts.

And prostitutes, the eternal ancillary business to military campaigns, became prevalent. An area of town called Smokey Row (named after the opium dens) featured over 70 brothels. Aside from thousands of soldiers, rumored clientele included Lincoln's future assassin John Wilkes Booth, and Lincoln's successor to the Presidency, Andrew Johnson (no link aside from coincidence has ever been uncovered).

Syphilis and gonorrhea were rampant. Soldiers and prostitutes equally became ill from diseases spread in Smokey Row.

Pvt. Franklin Bailey wrote his mother that he'd need a dictionary "to find words enough, and then I could not find them bad enough, to express my hatred of those beings calling themselves women" in Smokey Row. Later in the same letter, however, he tried his best (perhaps he borrowed a thesaurus) and wrote that they were "abominable, low, vile, mean, lewd, wanton, dissolute, licentious, vicious, immoral, and wicked."

Pvt. Bailey, however, was an exception. The general feeling of most troops was that "No man can be a soldier unless he has gone through Smokey Row"

The Union commanders were less concerned with morals than they were with military capabilities. With many of their troops hospitalized from sexually transmitted diseases, the ability to launch further military campaigns was impaired.

Punishing soldiers didn't help. Nor did medical lectures. And antibiotics were in their infancy.

Something had to be done. Since the soldiers were needed to fight the war, they couldn't leave.

And so, on July 6, 1863, General James Morgan issued "Special Order No. 29".

This order basically said that prostitutes in Nashville were to be rounded up and sent somewhere else. How and where weren't specified.

And so into the picture entered a plain 3-month-old steamboat named Idahoe and her captain/owner, John Newcomb.

Idahoe was one of many steamboats at the waterfront under charter to the army. History has not recorded why she was chosen out of the many available.

Union forces rounded up hundreds of women from Smokey Row, storming buildings and catching women who tried to jump out of windows to escape. Non-prostitutes were also inadvertently nabbed in the confusion, just from being too close to that part of town during the operation, and required family to free them.

On the morning of July 8, Capt. Newcomb was finishing his breakfast coffee on board the Idahoe, when he was assaulted by noise. As he walked to the gangplank he was met by Colonel George Spalding, who handed him an order that read, "You are hereby directed to Louisville, Kentucky with 100 passengers put on board your steamer today, allowing none to leave your boat before reaching Louisville."

Even as Newcomb read this, the ladies were being driven on board. He was given no money to buy food for them, nor guards to enforce discipline.

How many women were put on board the Idahoe is unknown. The ship was built for 100 passengers. No reliable count was taken, and the best estimate is 150-200.

The journey to Louisville was a nightmare for Newcomb. His unwanted passengers destroyed the boat's once luxurious furnishings. He had to buy ice (for fevers) and food, at his own expense. Places where he stopped for supplies put guards at the dock to keep the women from disembarking.

The prostitutes continued to ply their trade, waving at men as they went upriver, and raising their dresses to advertise. Customers rowed themselves on board for brief stays as the Idahoe chugged slowly along.

By the time he got to Louisville on July 14, word of his unusual cargo had preceded him, and local authorities refused to allow him to disembark the ladies. Instead, he was ordered to proceed to Cincinnati. Kentucky's military governor assigned several soldiers to the Idahoe to serve as guards to help enforce discipline. This quickly failed, as the men given this coveted assignment received free services from the passengers.

By the time he got to Cincinnati, of course, the local government also refused to let him unload his passengers. Newport, Kentucky, on the other side of the river, didn't want the "frail sisterhood" (as the local newspaper called them), either.

So with nowhere to go, the Idahoe anchored off Cincinnati for several days, and turned a brisk business as a floating brothel while Captain Newcomb aged rapidly. Somehow he managed to persuade the army to telegraph Washington D.C. for a decision, and the question went all the way to U.S. Secretary of War (now called Secretary of Defense) Edwin Stanton.

Stanton was managing the complex issues of a war covering half a continent and an ocean, and was likely stunned by the unusual decision that showed up on his desk that day. He came up with a direct solution: Take them back to Nashville, and deal with it.

So on August 3rd the Idahoe returned to Nashville, and it's passengers resumed their usual lifestyle. This gave the headache back to the Union commander (now General Robert Granger) who spent a few days trying to find a solution, and finally came to a very pragmatic one: he legalized prostitution.

Under the new rules, each "public woman" had to have a license ($5) but needed to pass a medical examination first. She was then required to have another exam every 10 days in order to keep her license.

The solution was a success. Suddenly the "wayward women" had a legal profession. Disease control (by the standards of the time) improved. The prostitutes now had access to medical care that they didn't have previously. The Union doctors assigned to the "Hospital for the Reception of Valetudinarian Females from the Unhealthy Purlieus of Smokey" (yes, that really is what they called it) began taking notes, and wrote some of the first detailed reports on the sociology of prostitution.

The program was such a success that physicians from other cities came to study it.

Captain Newcomb spent the next 2 years trying to get reimbursed, meeting with military officials and eventually pleading his case in Washington. Finally, on October 19, 1865, he received payment of $5316.04. This was the amount he'd been asking for from the beginning for damages, new furniture, fuel, food and medicines purchased, etc.

He had a long career on the river, but never shook off the reputation as the "captain of the floating whorehouse".

He sold the Idahoe a few years later. In 1869 she was lost in the Washita River, cause unknown.

Skool Nerse Time

This is Mrs. Grumpy. Yes, another exciting school year has begun, and I'd like to share a short play with you.


Kid walks into my office today, doing some sort of weird I-can't-hold-still dance move.

Nurse Grumpy: "What's up?"

Little kid: "My butt itches!"

Nurse Grumpy: "Have you tried scratching it?"

Kid scratches ass for 10 seconds.

Little kid: "Thanks nurse, that feels much better." (leaves my office)

Thursday evening, 6:18 p.m.

Dr. Grumpy: "This is Dr. Grumpy. You called earlier?"

Mr. Husband: "Hi, doc. Hey, sorry my wife couldn't come to her appointment today. She's had such a bad migraine it's unbelievable. She's been so dizzy with it she can't drive or ride in a car. She can't even get out of bed."

Dr. Grumpy: "I'm sorry. Has it gotten any better this afternoon?"

Mr. Husband: "No, if anything it's worse. She's barely able to move."

Dr. Grumpy: "Can I talk to her?"

Mr. Husband: "Not right now. She's out in the yard climbing a tree, trying to get the cat down. Can she call you back when she's done?"

Anatomy 101

Yesterday I saw a guy who repeatedly mentioned that he's a nurse.

When he called he said he was having "carpal tunnel problems". That's fine, I can handle that.

But when he came in, all he wanted to talk about was his neck pain.

I can handle that, too. But I asked him why he'd said he was having carpal tunnel problems when he called.

He said "because the carpal tunnel is in the neck".

When I tried to correct him, he argued with me, then walked out. Said he was going to "find a doctor who knows his damn anatomy."

Who lives in a pineapple under the sea?

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

There are some things you never want to be stuck with.

Like finding out that you've been a habitat for SpongeBob Squarepants.

Or worse, that you're the one who left him there.

E-prescribing idiocy

I bitch about it. The Angry Pharmacist bitches about it. This is nothing new.


But yesterday afternoon I discovered a whole new reason to hate e-prescribing.


I have a lady who takes Fukitol 3mg, four times a day.

Fukitol only comes in 1mg pills. So she takes 3 pills, four times a day.

So 12 pills each day. OR 360 pills in 30 days.

HOWEVER, her insurance requires her to use Lostinthe Mail-Order pharmacy.

Like most mail-order pharmacies, this one only sends out 90 day pill supplies at a time.

So Mrs. Patient asked me to send it by e-script to Lostinthe Mail pharmacy.

12 pills x 90 days is 1080 pills. So I just transmit a script for 1080 pills.

Sounds easy, huh?

The online thing rejected the script, on the grounds that it won't allow pill supplies of more than 999 pills at a time.

I tried submitting it for 2 scripts of 540 pills each. It wouldn't allow 2 scripts of the exact same thing.

So I submitted it for 999 pills for 90 days, and figured Annie would just tell the patient the reason for this, and we could make up the difference with samples.

Of course, the online e-script program rejected this, too, and pointed out that a 90 supply for the patient is 1080 pills. It even asked me to resubmit it for that amount.

Which I did. And it was promptly rejected for being > 999 pills.

Catch-22.

I mailed a written script for 1080 pills to the patient and told her to send it to them. And scream.

Let's hope you aren't

Dr. Grumpy: "Does the hand pain wake you from sleeping?"

Mr. Carpal: "Sometimes."

Dr. Grumpy: "Does it bother you when you're driving?"

Mr. Carpal: "Why would I be driving while I'm sleeping?"

The joys of search engines

A doctor in my area died last week. Dr. Pissy and I were wondering what happened, so I typed his name into a search engine.

These were the first 3 links that came up:

1. Read the obituary for Dr. Unusualname.

2. Sign the online memorial book for Dr. Unusualname.

3. Make an appointment to see Dr. Unusualname.

Afternoon patient at Dr. Grumpy's

Mrs. Cuticle: "Harold! Stop chewing your fingernails! We're at the doctors!"

Mr. Cuticle: "Shut up! I'm hungry!"

Hmmm...

While I was at the hospital yesterday, I stopped in to read some EEG's. The studies always have a cover sheet attached, giving me a brief patient history. One had this on it's paperwork:

"Indication: Patient has spells of "tripping out" when he drinks heavily and smokes marijuana. Dr. Local ordered the study to make sure they aren't seizures."

Boob job

I got dragged in to the hospital today to see a patient, and was walking by the cafeteria.

The sign in front listed today's special as:

"Italian style roasted breasts, with rice."

Hygienic Horrors

It is a really scary, when catching up on the laundry, to realize that in the last 8 days your son has worn only 2 pairs of underwear.

How about a cheeseburger for stroke awareness?

15% off nfl scrubs with checkout code "nfl_jrl"

For various reasons this has been a CRAZY week at my office, and I'm still trying to catch up. So while I'm attacking the giant Pileofdictations Monster, I'm putting up this gripe sent in by Stacey, who's a radiology tech. At least that's what she says. For all I know she's another yak herder in the next valley over from me.

I was walking over to the fitness center on campus today when I was accosted by 3 women at a little sidewalk booth.

They were having a bake sale to raise money and awareness for heart disease. One women piped up as I walked by...she asked me if I would buy something to support their cause.

They were selling cupcakes, BIG cookies, thick slices of chocolate cake, and pastries. To raise money to fight heart disease. And they wanted me to support this fight by contributing to my own vascular risk.

I lost it. I said "Are you kidding me? Obesity is a major cause of heart disease! Don't you think that maybe, just maybe, you should be selling something healthy? Maybe you should try selling something healthy to promote heart health, awareness and raise money at the same time".

They all looked at me like I'd just bitten the head off a puppy and spit it on the sidewalk.

Finally one of them said "Well, we have oatmeal raisin cookies... they're kinda healthy..."

This could mean a lot...

From a patient intake form yesterday afternoon.

(click to enlarge)

Delay in game

I went up front to get a patient from the lobby.


Dr. Grumpy: "Mrs. Fourdown? Come on back to my office."

Mrs. Fourdown: "Oh dear. Can you take someone else ahead of me?"

Dr. Grumpy: "No, you're the only one here right now, and it's time for your appointment. Is something wrong?"

Mrs. Fourdown: "No, but I just started a crossword puzzle."

Annie's desk, September 8, 2010

Mr. Jade: "So what's my sed rate?"

Annie: "5".

Mr. Jade: "Is that good?"

Annie: "Yes".

Mr. Jade: "Did you ask the doctor?"

Annie: "Yes. He said 5 is fine."

Mr. Jade: "Was that today that you asked him?"

Annie: "This morning."

Mr. Jade: "Is 5 in the normal range?"

Annie: "Yes."

Mr. Jade: "What is the normal range?"

Annie: "Less than 20."

Mr. Jade: "So that's less than 20?"

Annie: "Yes."

Mr. Jade: "Which is normal, right?"

Things that make me grumpy

B12

Sounds simple, huh?

1 letter, 2 numbers. One of the B vitamins. It's important in a number of body functions, particularly the nervous system and blood cell production. It's in pretty much all meats and vegetables, and multivitamins you can buy.

To me, it's also a good example of what's wrong in health care.

Let's take Mrs. Olde.

She goes to her internist, and is complaining of feeling weak and tired. So he checks a B12 level, thyroid labs, and other stuff.

A week later, she's out with some friends, and trips in a movie theater. She breaks her leg, and lands in ER. She gets admitted to the hospital.

There she mentions that she feels weak and tired to the admitting hospitalist. So, with the usual pre-surgical labs, she checks a B12 level, thyroid labs, and other stuff.

She does fine in surgery, but afterwards has a mild anemia, which doesn't improve. So after she gets out of the hospital she goes to a hematologist. This doctor doesn't have any of the previous tests, and so orders another B12 as part of the work-up.

While she's recovering, she's taking Percocet for her broken leg. She mentions to her daughter that her memory is foggy, and so the daughter takes her to see a neurologist.

The patient comes to the neurologist. He thinks the problem is due to Percocet, but to cover himself he orders a head CT. Since he doesn't have access to her hospital records, and she doesn't have any of her previous labs with her, he orders a bunch of blood work, including a B12, thyroid labs, and other stuff.

Story over.

Now, a B12 level, according to Local Lab, costs $198. So this lady has had 4 done, for a total of $792, in less than a month. B12 levels generally don't change that dramatically in a month, so only 1 was really needed (yes, I know some of you are thinking a methylmalonic acid level is more useful than a B12, and I agree with you. But that's not the point here. And try getting Medicare to pay for an outpatient methylmalonic acid).

$198 isn't that much, is it? But multiply it by thousands of patients a month with similar stories. That's a HUGE amount of money wasted. And then extrapolate it to many other redundants tests: CBC's, TSH, chest X-rays. And then add pricier items (though not as commonly reduplicated) like CT's and MRI's.

I generally don't order labs if I know a patient has recently had them. I try to get the old records, then order anything I need that hasn't already been done. But many docs don't do that. And sometimes the patients are less than helpful. They forgot they had stuff done 2 weeks ago. Or don't remember the name of the doctor/hospital who did them, making it impossible for me to track them down (you'd be amazed how many times people have no idea what hospital they were in recently, or what doctor ordered their tests).

I'm guilty of this myself. Yesterday I admitted a guy to the hospital, who told me his outpatient work-up hadn't included any labs. So I ordered a bunch. This morning I came into my office to find everything I had done last night was also done 3 days ago, and was sitting on my fax machine. According to the hospital labs, the total cost on these duplicated labs was $1278.

I don't think the patent did this intentionally. He'd either forgotten, or (and this is common, believe it or not) thought that the labs his internist ordered wouldn't be ones a neurologist would want, and therefore didn't count.

Redundant tests, I think, are a huge waste of money. I'm not sure what the answer is here.

Some would say we need to have ALL these records in a humungous database, searchable from anywhere, and protected by elaborate security checks. This would likely be the best answer, but I think all of us have huge concerns about the security and privacy issues involved.

Better communication between doctors would help. You have no idea how much I appreciate it when a referring doctor sends labs and test results in advance, or even with the patient. That way we all save time, money, and blood on further tests.

Another option is to put the patient in charge of their records. Some are good at this, bringing copies of labs going back to their childhood. But most don't. Giving them a memory stick or CD with past tests sounds good, but those things can be forgotten. Or lost. Or not work on a different type of computer.

I don't have an answer for this. I wish I did. A good solution on a large scale would likely save a huge amount of time, money, and aggravation for all of us.

Yes, I have kids

I have a patient who always starts his sentences with a long "Ohhhhhh..."

Like this:

Dr. Grumpy: "How many physical therapy sessions have you had?"

Mr. Star: "Ohhhhh... maybe 5 or 6."


And I have to say, when he does the "Ohhhhhhh..." thing, it's REALLY hard not to yell "Who lives in a pineapple under the sea?"

Tuesday morning, 1:55 a.m.

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

Mrs. Wokeme: "Yes, I see you for migraines, and I have one. What should I do?"

Dr. Grumpy: "Didn't I give you a prescription for Painbegone? Have you tried one?"

Mrs. Wokeme: "No, but I have the package right here. It says to take as needed for migraine."

Dr. Grumpy: "So take one, if you have a migraine."

Mrs. Wokeme: "Okay. I just wanted to be sure. I thought I once read that 'take as needed' was some sort of medical code meaning I should call the doctor first."

Tips from Dr. Grumpy

I'm spending this holiday weekend being abused by my kids AND evil archenemy (the Wii Fit trainer). So to keep you guys entertained until I return to my desk, I'm providing awareness of important news stories (this and the previous post).

Obviously, if you're a veteran of huffing paint/glue/whatever, I don't expect you to still have all brain cells working.

BUT here's a tip: walking around with the lower half of your face spray-painted a lovely shade of metallic gold, like this guy, WILL NOT help you blend in with a crowd (at least most crowds).


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

NEW! Treats pain AND fatigue!

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

(click to enlarge)

Excuses

Dear Patients:

Apparently this 3 day weekend snuck up on many of you, to the extent that you frantically canceled yesterday's appointments at the last minute. I assume this was so you could leave town/start drinking/both early (Americans love a reason to drink. I think we're the only country that steals holidays from other countries, like St. Patrick's Day or Cinco De Mayo, just to have an excuse to drink).

Anyway, the day started with a typically full office schedule, but by the time you guys were done canceling, I'd worked a total of 2 1/2 hours, and we gave up and closed down at 1:25.

I appreciate those of you who were considerate enough to call. This is actually preferable to the ones who simply don't show up, leaving me in suspense. At least by calling you let us know we can shut down early.

I'm sure some of you had legitimate reasons not to come in. But it's hard for me to tell. So here, in no particular order, are some of the excuses we received.

1. I broke my arm.

2. My kid broke his arm.

3. My car died on the freeway, and I'm up here on the off-ramp waiting for a tow-truck (the message on this one featured loud music and a guy ordering beer in the background).

4. My hemorrhoids are killing me.

5. I don't remember why I see you anyway (possibly legitimate given the nature of my practice).

6. My ex-husband is in town.

7. My kid lost my car keys.

8. I have to go to Costco.

9. My cat threw-up.

10. I'm in the middle of my pap smear, and my GYN just called out for an emergency, and I'm up in the stirrups and don't know when she'll be back.


THE WINNER, however, has to go to Mr. Bowman. He's been a reliable patient of mine for a long time, and knows I'll forgive him. He also knows my sense of humor. And he left this message (Mary didn't get it, but I did).

"Hi, this is Mr. Bowman. I need to cancel my 2:15 appointment today because OH MY GOD! IT'S FULL OF STARS!" (click).

Have a good weekend everyone.

Good answer

Dr. Grumpy: "Is that mark on your eye a lifelong thing?"

Mrs. Literal: "Well, it's been there since I was born. Before that I'm not sure."

Geography FAIL!

Okay, I'm doing a research survey this morning, and screen #1 asked me which country I resided in. So I checked "USA".

The next screen came up, and asked me what state I lived in. It featured a drop-down menu with all the states. And the "A's" went like this:

Alabama
Alaska
Alberta
Arizona
Arkansas...


I REALLY hope they did that to see if I was paying attention.

Another one bites the dust

I don't do that much teaching anymore. I like it, but the constraints of time with a family and solo practice make it damn near impossible.

But I still do it, albeit rarely, on special requests from friends, nurses or docs I know, etc. And yesterday was one of those days.

I got my start in a college program where I shadowed docs to see if I wanted to be one, and so I have a tender spot for those kids. Last week one of the hospital nurses called me. Her son is in his 2nd year of college, and is thinking about medicine. She was calling around to see if anyone would let him watch for a day. And since I'm a softy, I said sure.

He shows up, neatly dressed, trying to look young, eager, and professional. My first patient was in for an EMG (electrical test of the nerves and muscles), and she didn't have a problem with the student watching.

I fired up the machine, and made some notes. Joe College leaned over my shoulder to see what I was doing. I stuck a needle in the patient's deltoid, and turned to the machine to look at the results.

There was a loud "thunk" behind me. The patient and I both turned to see Joe College sprawled unconscious on my exam room floor.

The patient began laughing. I pulled the needle out of her arm and called Mary for help. We got Joe out to the break room as he woke up, and got him some water.

By the time I was done with the EMG he was gone. He'd told Mary he was thinking about becoming a pharmacist or accountant. He also asked for her phone number.

History FAIL!

"I had my kids way back, in the 1970's. They were complicated births, because they hadn't invented the C-section yet."