Tuesday guest post

Today I'm honored to have a contribution from everyone's favorite man-on-the-beat, Officer Cynical!


Today I tried to stop a woman with a revoked license. We went 10 blocks with my lights and siren going, and she acted like I wasn't there.

She finally pulled into her driveway, and rolled down her window. The alcohol fumes rolling out of the passenger compartment were almost visible. She said she'd taken "some pain pills and a few muscle relaxants and maybe some other stuff" on top of it.

I arrested her and headed downtown. On the way to jail, she said she had to go to the hospital because "the left half of my brain is numb." So, to be safe, I took her to ER.

I told the ER doc what she said, and he responded (with a straight face), "Well, that doesn't sound right". He agreed with me that it was more likely the whole brain - not just the left half - that was numb.

He went out to my squad car in the ambulance port and told her, "When whatever you're on clears, if your brain is still numb you can come back." Then he signed off on the jail clearance and we left.

Outstanding.

Memories...

Years ago, Freebase Pharmaceuticals assigned a pretty blond sales rep to my office. Like most reps, she scheduled lunches with us here and there.

One lunch, in spite of the fact that Pissy and I, and our staffs, were there, she decided to try to increase sales by aggressively coming on to me. Asking questions like:


"Does your wife ever travel and leave you alone?"

"I live on the north side. Let me give you my number,  in case you're ever in that area."

"I have a meeting near here this Saturday. Any chance you'll be at your office that day?"


The highlight, however, was what she didn't know.

This was at a time when Mary was out on maternity leave. And filling in for her was Mrs. Grumpy.

Who was sitting directly behind Miss Hooters (who she figured was just the secretary).

So, while Miss Hooters was discussing her pharmaceutical wares and underwares, my wife didn't say a word. She just made faces at me over Miss Hooter's shoulder, occasionally holding up bunny ears behind the rep's head, or the finger, or her sandwich, or whatever office supplies were within reach.

Pissy, who had the same view of the show as I did, pretended to have a coughing fit to keep from laughing, and ran out.

"Dude, does this mean I have to roll my own?"

Actual CNN headline from April 26, 2013:

Dear OBG Management,

A colleague recently sent me a cover shot of this recent issue:

It looks pretty generic on the surface. Just another medical journal. But then you look closer.

A story on surgical robots? Fine. A story about vibrators? Okay. BUT DID YOU REALLY HAVE TO JUXTAPOSE THEM LIKE THIS?

Better living through machinery

I mean, in this sense it looks like an ad for a 1950's horror flick about giant vibrators from outer space, that arrive on Earth pretending to be friendly.

 

Of course, while we're on the topic of juvenile humor, I also noticed this headline in the top right corner:

Thank you, ER's Mom!

I'm stumped

Okay, people, time to see how good you are at being armchair neurologists.

This is an unusually challenging case I saw yesterday, involving a 54 year-old lady. Her internist had referred her to me because of  some recent changes in her vision. The following is quoted verbatim from my chart note:


"She has 2 glasses prescriptions, one for near and another for distance. 1 month ago she had an annual optometry check-up, and was told she needed a new near-vision prescription. She ordered the new glasses, and picked them up last week.

Since then she finds that when she puts on the new glasses things look “funny and unclear.” This resolves with taking them off, and doesn’t occur with the distance-glasses on, or using her previous prescription."


This case really has me stumped. So if any you are able to figure out what the problem is, please write in.

Mary's desk, April 23, 2013

Guy walks in, stands at counter.

Mary: "Hi, can I help you?"

Guy: "Yeah, I want to know if I need an MRI?"

Mary: "Let me look up your chart. When did you see Dr. Grumpy?"

Guy: "I've never seen him. I just want to know if I need an MRI?"

Mary: "I really can't say, sir. I'm not a doctor, but..."

Guy: "I have this neck pain, and my right hand feels numb. So does that need an MRI?"

Mary: "...but I can set you up with an appointment to see the doctor to discuss this. We have an opening Thursday afternoon at 2:30."

Guy: "I don't want to come in. I just want to know if I need an MRI, and if so, to get one."

Mary: "I can't answer that, sir, and the doctor would need to evaluate you before deciding what's needed."

Guy: "You people are just in it for the money."

Leaves and slams door.

Sleep deprivation

I couldn't sleep, so finally gave up and went to the hospital to see a consult that had come in during the night.

I sat at the nurses station and called up the CT scan on a computer. It looked like a stroke, but the dictation wasn't transcribed yet. So I dialed the radiologist covering nights.

Dr. Radar: "This is Dr. Radar."

Dr. Grumpy: "Hi, Mike. Can you look at the scan on Mrs. Platelet? It looks like she has a right frontal stroke."

Dr. Radar: "Hang on... No, that's not a stroke. That's volume averaging artifact."

Dr. Grumpy: "Really? It looks like a stroke."

Dr. Radar: "No, definitely volume averaging."

Dr. Grumpy: "Okay, thanks."

I hung up and was a bit surprised. I began writing a note, when a nurse came over to tell me Dr. Radar had just called back looking for me.

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

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

Dr. Grumpy: "Right."

Dr. Radar: "Oh, sorry. The left is artifact. On the right, that's a stroke. Big one, too."

Prize giveaway!

Congratulations, sir! You've won a free clipboard!

Now, we at the Grumpy Neurological Emporium are pretty protective of our office supplies. It's been 4 years since drug reps were allowed to give us bountiful gifts of pens and post-it notes. But, in some cases, an exception should be made, and you, sir, are the lucky recipient of our benevolence.

Even in this digital age, every practice has paperwork. Usually it involves an info sheet with your contact information. You fill it out on a first visit, and maybe once a year after that. Mary hands you the clipboard and form when you come in.

Most people sit in the waiting room and fill them out while she copies their insurance card.

Why you decided to take it in the bathroom with you, I have no idea. But it was blank when you went in, and completely filled out when you exited 10 minutes later.

You can keep the pen, too.

Sunday reruns

One of my favorite patient quotes:

"I was on my way to my girlfriend's place and did some meth in the car because if I waited till I got there she and her roommate might use it all. But there was something wrong with it and I began shaking, and got real dizzy, and then began puking all over the steering wheel. Then my vision got blurry and I couldn't see the road very well, and I was afraid to pull over cause then a cop might come try to help me, and I'd be in deep shit, so to be safe I started driving as fast as I could to get to the nearest emergency room."

Theater

Mrs. Drama: "I apologize for being late. It's been an awful day. I lost my son this morning."

Dr. Grumpy: "Oh, that's terrible. I'm so sorry."

Mrs. Drama: "It's okay. We eventually found him playing games at the arcade."

Games and players

Recently, some of you may have seen ads for "Fresh & Sexy," a new product on the market with somewhat provocative ads. Basically, they're "intimate wipes," to be used for frantically wiping off your naughty bits in situations where you're filthy, and desperately need to clean up before getting laid.

Now, I personally have to question the need for this product, at least in civilized societies. The majority of us bathe regularly, and hopefully don't need such items. A friend of mine commented that if she were "in a situation where I was that disgustingly filthy, like a long camping trip away from water, I'm pretty sure I wouldn't have the wipes with me. Or be near a store where I could buy them." By the same token, societies where regular bathing is rare are unlikely to carry "Fresh & Sexy" in local stores.

There's also the point that people have been banging each other for roughly 2 million years, of which only the last 100 or so have seen regular washing. So filth, and the absence of "intimate wipes," has never stopped them for >99.9% of human history.

But this is modern marketing. Necessity is no longer the mother of invention. Nowadays, instead of making a product that people actually need, it's easier to make a product, then convince people they need it. It's how P. T. Barnum got rich.

The same trend is in pharmaceuticals. There are a lot of drugs that are legitimately useful, but some companies try to create drugs we don't need, then hope to convince us we do.

Let's take the fictitious drug Ophelicia, which is an overpriced knock-off of a cheap generic, polonicoxib.
 
R&G pharmaceuticals (the original manufacturer of both) knows their aging drug has been used off-label* for a boatload of stuff, and its profitable patent life is running out. So they're sinking research dollars into getting more indications for it, rather than, say, a new drug that might benefit people.
 
Sometimes you get a REALLY painful hangnail. It hurts more if you accidentally bang your finger on something, you can't pick your nose with it, and start screaming if Purell or salsa get on it.

There are MANY dirt-cheap generic drugs, such as polonicoxib, that can be used for a hangnail, all reasonably effective.

R&G, smelling a market opening, sinks a few hundred million bucks into getting Ophelicia OFFICIALLY FDA APPROVED for hangnail pain. Granted, their data didn't show it was any more effective than the 20 cheap generics out there, but now their sales reps can proudly say "We are the ONLY drug with an FDA approval for this debilitating condition."

Unfortunately, there aren't enough people with painful hangnails to make this indication financially worthwhile. Besides, any insurance company will force you to try 5 cheap generics before they'll let you think about prescribing Ophelicia and it's $20/day price tag (I agree with them).

BUT it adds to the razzle-dazzle. Your average doctor will figure it has so many indications for pain, it must be good for anything, and grab it off the shelf without trying a generic. It's much easier to hand someone a bottle of samples than it is to write a script (R&G knows this. Why do you think the companies give away all those samples?). If the patient is hooked, maybe they'll pay for it. Or the doctor will find it easier to have her staff fill out a pre-authorization form than call in for some cheap polonicoxib. After all, it's not her problem.

This gets back to the need for intimate wipes: Is it really there in modern societies? Probably not. But there isn't a need for a drug that's specifically indicated for hangnail pain, either. It's the game, and R&G and their competitors are simply players looking for an edge.

The key to selling is marketing, and the gold standard of marketing is making people think they need something that they don't.


*Prescribing it for something other than what the official FDA rules say you should use it for. This is very common. Odds are that you've taken something off-label.

Dear Kids,

As the weather warms up, I think it's great the 3 of you want to walk home together after school. It's about 2 miles, certainly nothing awful, and gets you home sooner than riding the bus, or waiting for me to finish at work, would.

I also think it's good you guys want to get some exercise now that the snow has gone.

BUT

Stopping about 1/3 of the way home at Kwik-E-Mart to get "snacks" of chili-dogs, candy, and slushees, then hanging out with friends there and calling me to come get you, is sort of defeating the whole idea.

I bet the Powerpoint can cure insomnia

A friend of mine does consulting work for the FDA. Recently she was invited to this meeting:

"I can't wait to go! The excitement is killing me!"

I couldn't do it. I am SO not the meeting type.

Memories...

One of the other residents in my neurology program was a nurse in her previous life. As a result, she moonlighted with a nursing registry at different hospitals, and made far more money than the rest of us starving residents combined.

So one night, when I was on call, I was woken at around 2:00 a.m. by a page from the ICU.


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

Dr. Violet: "Hi, Ibee. I need an order for Tylenol on Mr. Stroke. He spiked a fever."

Dr. Grumpy: "Peggy, is this you? What's going on?"

Dr. Violet: "He has a fever. The resident taking care of him didn't write a Tylenol order before they left."

Dr. Grumpy: "His resident is... HEY! He's your patient! You signed him out to me before you left."

Dr. Violet: "Uh... yeah."

Dr. Grumpy: "Why are you calling me, anyway? Why don't you order it?"

Dr. Violet: "I'm his nurse tonight, not his doctor. I have to page the resident on call, which is you."

Dr. Grumpy: "Am I on Candid Camera?"

Letting it all out

WHY? WHY? WHY?

Dr. Grumpy: "Are you right or left handed?"

Mr. Whack: "I write with my left, but masturbate with my right."

Phone calls

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

Mrs. Coordinate: "I'm calling to update my address, you have the wrong one."

Mary: "Okay, let me look this up... I show you as living at 42 N. Fred Gwynne Drive."

Mrs. Coordinate: "Yes, that's correct."

Mary: "All right, so it looks like we do have the right one."

Mrs. Coordinate: "NO, you DO NOT have the right one. Otherwise I wouldn't have gotten this bill with the wrong address on it!"

Mary: "But how did you get the bill if it had the wrong address on it?"

(pause)

Mrs. Coordinate: "I guess you do have the right address. Never mind."

(click)

Great moments in research

For whatever reason, Dr. Brian Mautz of Canberra decided to research penis size in the homo sapiens male, and how it relates to other body features.

I suppose there are a lot of oddball studies out there. Competition to get published is stiff, so you need eye-catching hard data to penetrate journals.

But this upstanding one just gave me the giggles.

It was published in the Proceedings of the National Academy of Sciences, better known by the acronym PNAS.

Dr. Mautz's co-authors included Drs. Wong and Peters, of Melbourne.

And, inevitably, Dr. Peters' first name is........ Richard.

Thank you, SMOD!

DANGER! DANGER, WILL ROBINSON!

EVERYTHING in medicine comes with a little packet of paper that tells you what it is, what it's for, how dangerous it is, and how to handle emergencies it might cause.

Bizarrely enough, this includes the most common liquid on planet Earth: water.

Yes water.

And this is the actual warning label that comes with water:

 

So, as per the last paragraphs, let's keep these important points in mind:

1.  If you accidentally get water in your eyes, IMMEDIATELY flush them with more water for 15 minutes.

2. If you accidentally drink water, induce vomiting.

3. If you get water on your skin, wash it off with soap and water.

4. If the water catches fire, extinguish it immediately with something "appropriate."

5. And always call poison control if you drink water! It says so!

Thank you, Webhill!

Whatever

Mrs. Adenoca: "I want you to know, right now, that I won't take any medications. I don't believe in your pills. I'm an intelligent woman, and I do a lot of research on my own. Every drug you use has the potential to cause cancer, and I know you doctors lie and say they don't. I'm smarter than that, and refuse to take anything that could do that to me."

Dr. Grumpy: "Didn't you tell me earlier that you smoke?"

Mrs. Adenoca: "Yes, 2 packs a day."

Dr. Grumpy: "And you don't think that causes cancer?"

Mrs. Adenoca: "You guys lie about that, too."

Neurology made ridiculously simple

Uh, where you fix a Prius?

Thank you, Jennifer!

Wednesday

Dr. Grumpy: "Have a seat, Mr. Needsglasses. Boy, I haven't seen you in about 10 years."

Mr. Needsglasses: "Wow. That long? I can't believe it."

Dr. Grumpy: "Yeah, it looks like you were last here in 2003."

Mr. Needsglasses: "Had no idea. 10 years. Boy, doc, you haven't aged well. You look awful."

Today's contest

A marketing rep dropped off a booklet today, featuring better living through a company's various gadgets. Normally it wouldn't get my attention, but with this picture it was hard not to stare.

So, let's all try to think of some creative captions. Here's a few to get started:

"Yes, nothing makes you smile like matching his & hers pelvic floor stimulators."

"Crank it up and we'll REALLY start swinging."

"These go to eleven."

It's fun to stay at the A.N.Z.C.A!

Next month, for those of you who don't follow meetings outside your own hemisphere, is the annual Australian & New Zealand College of Anaesthetists convention. This year it's being held in Melbourne.

Normally I don't pay attention to ANY meetings. Not even the ones in my own specialty, let alone someone elses' on the other side of the International Date Line. But my reader Rebecca (thank you, Rebecca!) brought this one to my attention.

All these meetings are composed of various lectures and workshops you sign up for, and this one is no different. Here's a sampling of the exciting courses available:

  

If anything sounds more stimulating than a course on coagulation management, I don't know what it is. Oh wait, I do. A can of Diet Coke.

But if you scroll farther down the list, there IS a stimulating course:

Of course, caffeine isn't the only thing you can learn about at the meeting. If your anaesthesia machine (the one that goes "ping!") is all tuned up, why not work on...

After that course, a few cups of coffee, and a bathroom break you'll be ready to move on to...

After a long day of such interesting meetings you've done all sorts of things, but on the way out of the building you discover the elevator has no windows and no doors, which offers you this chilling challenge: to find a way out!

Of course, there's always my way...

Annie's Desk

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

Mr. Lombardi: "Hi, I see Dr. Grumpy for my seizures, and he increased my Nomoshakin dose last week."

Annie: "Okay, let me look up your note."

Mr. Lombardi: "Anyway, yesterday I was playing football with my buddies, and one of them stepped on my left hand, really hard. Today that wrist hurts and is all swollen."

Annie: "Did you have a seizure?"

Mr. Lombardi: "No, but do you think the wrist problem is from the medication increase? Because I didn't have it on lower doses."