Sunday night, 11:23 p.m.

The following message was left on my office voice mail last night:

"Hello, I'm a patient of Dr. Grumpy's. It's Sunday night, about twenty minutes after 11:00, and I'd like someone to call me back. Thank you."

That's all. Never called back with anything more helpful, like a name or phone number.

Random weekend pictures

All right, time to hit the e-mail bag of stuff you guys have sent in.


First, this was taken at an art museum in Budapest (it's actually the name of the artist being featured).

"On your right is the Sheriff Jim Clark display, and in the next hall are Ernst Zündel's works"

Next, we have this. Apparently telling someone to "go pick up paper towels" at the store is no longer enough. I had no idea the world needed this many varieties. I mean, IT'S A FUCKING PAPER TOWEL!!!

7 varieties of paper towels. For this we evolved from microbes.

Then there's this massage company, who probably should have thought out their logo a bit more carefully:

"The pun sucks, too."

Speaking of interesting signs, I have no idea what this means:

"The counter lady yelled at me. Maybe they mean bitches."

The box makes it sound like they sing, dance, and perform theater:

"I'm trying to eat, and my fork keeps doing the Macarena."

Next is an ad for a group that does bio-identical hormones. The name sounds like they're all clones.

"Did you want to see Dr. Grumpy, Dr. Grumpy, or Dr. Grumpy?"

And last, I have no idea why this company couldn't come up with a better way to say "non-allergic pet food"

"Which end of Fluffy do we put it in?"

Great Public Service Announcements

Whirrrrrrrrrrrrrrrrrrrr

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

Mrs. Sikorski: "You saw my daughter yesterday? I was at the appointment if you recall, and you started her on Migrazap?"

Dr. Grumpy: "Yes, I remember. Is there a problem with the medication?"

Mrs. Sikorski: "No. I'm calling because she drove back to college today, and I don't think she's getting enough sleep."

Dr. Grumpy: "Well, the medication won't affect sleep, so it..."

Mrs. Sikorski: "That's not the issue. I need you to call her and discuss how important sleep is, because it's going to affect her grades. She also needs to study more."

Dr. Grumpy: "Well, that's not really my place. I mean, she's 21 years old, and away at college, and..."

Mrs. Sikorski: "Could you at least bring it up at her appointment next month? Also, can you say a few words about her current boyfriend? I don't think he's good for her."

Annie's desk

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

Mr. Valproate: "I want to know why the doctor won't refill my seizure meds!"

Annie: "Let me see... I don't show that we have a request for that. Did you call your pharmacy?"

Mr. Valproate: "Yes! They told me they've sent it to Dr. Intern 3 times, and all she does is say that she doesn't prescribe my seizure meds. So why won't Dr. Grumpy refill it?"

Annie: "Why are they sending it to Dr. Intern? Did you ask them to fax it to Dr. Grumpy?"

Mr. Valproate: "No. Am I supposed to?"

Memories...

As readers know, my roommate for all 4 years of medical school was a guy named Enzyme.

Enzyme was about 6'3" and maybe 190 lbs. He was calm, cool, and confident, the perfect model of the U.S. Navy officer that he is today. Handsome and a ladies man. He knew how splendid he looked in his uniform. He loved the military, and didn't let anything alarm him.

Until one night.

It was, maybe, around 2:00 a.m. I'd gone to bed at midnight after giving up on studying for the day, and was in a deep sleep.

While I slumbered, deeply napping, suddenly there came a tapping, as of someone gently rapping, rapping at my bedroom door.

Med student Grumpy: "Hello?"

Enzyme: "Ibee, are you awake?"

Grumpy: "I am NOW. What's up?"

(silence)

Grumpy: "Are you okay?"

Enzyme: "I... Need your help."

Grumpy: "It's 2:00 a.m. What's going on?"

(silence)

Grumpy: "Enzyme?"

Enzyme: "There's a spider in my room."

Grumpy: "What?!!!"

Enzyme: "I said there's a spider in my room."

Grumpy: "What the hell? So squash it and let me sleep."

(silence)

Grumpy: "Hello?"

Enzyme: "I'm scared of spiders."

It wasn't even that big, FFS.

"Are you shitting me?"

Awesomeness

For those of you who don't follow Twitter, I'm going to have to put this up.

My random observation was good. But WhiteCoat's response made it great:

Senior citizens behaving badly

A "Neurology Update" sent out recently by MDlinx. Hazards of leaving the "T" out...

Thank you, Gene!

Postage stamps

While waiting in line at the post office yesterday, I saw this stamp in a machine:

I had a brief thought about trying trying to ask for one at the counter:

"I need a great sparkled fraternity. I mean, a freight spanked fickle lilly. No, wait, a crate mangled fritterfrilly. No? A great teutonic titterwilly? Trait-specific hereditary? Um... fate frazzled hillbilly? Razzle-dazzled pickled lorrie?

"Fuck it. I need a 70-cent stamp."

How not to get an appointment

Mary: "Okay, Mr. Suidae. Now, let me give you some forms... here's a clipboard, and a pen... I'll need to get a copy of your insurance card. Any questions?"

Mr. Suidae: "Yeah, will you go down on me?"


And no, folks, he had no neurological reason to act like that.

Beware of the Dragon

Seen in a vascular ultrasound:

"We're gonna need a really big ultrasound machine."

For non-medical readers: It should have said "left lower extremity."

Thank you, Homebru!

12:07 a.m.

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

Miss Myelin: "Hi, I'm a Multiple Sclerosis patient of yours, and I wanted you to know I'm in the emergency room. The doctor here is probably going to call you."

Dr. Grumpy: "Okay... Why did you go to ER?"

Miss Myelin: "I lost vision in my left eye. I didn't want to bother you, so I came right in. I was worried that I should get it checked out."

Dr. Grumpy: "Sounds like you did the right thing. Has the doctor seen you yet?"

Miss Myelin: "No, but they just got me back here."

Dr. Grumpy: "When did you lose vision in your eye?"

Miss Myelin: "About a month ago."

Dr. Grumpy: "A MONTH AGO? Why didn't you call me?!!!"

Miss Myelin: "Like I said, I didn't want to bother you."

Dr. Grumpy: "Did you start the MS medication, the Tyglatfiderexa, that I prescribed 2 months ago?"

Miss Myelin: "No. I don't know why you gave me that. I informed you at the first visit that I won't take narcotics."

Dr. Grumpy: "It's not a narcotic! I told you that. It's for your immune system. Who said it was a narcotic?"

Miss Myelin: "This lady I met."

Dr. Grumpy: "Is she a doctor?"

Miss Myelin: "No, she's the cashier at Qwik-Mart. But I think her boyfriend's dad is."

Back from the trenches

Frank and Craig returned yesterday from 10 days at Camp Befouled, where they did outdoors type stuff with other guys in the forests of northstate.

To the horror of all (except the boys) we discovered they were wearing the same clothes they'd left our home in 10 days earlier. And, on looking through their bags, we discovered no dirty clothes at all. Just neatly folded shirts, underwear, socks, etc. So they'd been wearing the same outfits, day and night, for 10 days.

They didn't seem to have a problem with this, but on the drive home Mrs. Grumpy and I sure did. In the high humidity of a hot day we had no choice but to keep the windows down so we wouldn't die. If I'd thought to bring some twine I might have just put them on the roof rack for the ride.

Upon getting home, even the dogs didn't want to get close to them. When you smell so awful your dog isn't interested... That's really bad.

We immediately directed them to the shower closest to the garage.

Weekend reruns

Dr. Unka is in my office building. When he refers a patient to me, he often walks them upstairs to my office and waits with them up front (while his own waiting room backs up) until Mary has scheduled the patient. He often asks that I drop everything I'm doing to come meet his new referral, instead of just, say, having them call us to make an appointment.

So today Mary grabbed me to say Dr. Unka was up front, and wanted me to come meet a new patient. So I excused myself from my current patient and went up front, to see him standing there with a familiar, somewhat irritated-looking, older lady.


Dr. Unka: "Ibee, I'd like you to meet Mrs. Ancient. I'm referring her for memory loss."

Dr. Grumpy: "Uh, I saw Mrs. Ancient 3 weeks ago for that."

Mrs. Ancient (glaring at Dr. Unka): "I told you! Why didn't you listen to me?"

Dr. Unka: "She did?"

Mrs. Ancient: "Yes!"

Dr. Grumpy: "Yes, I sent you a note."

Dr. Unka: "You did?"

Mrs. Ancient: "Yes! He did! It was even in my chart at your office! I pointed it out to you!"

Dr. Unka: "You did? Um, I mean, then have her make a follow-up." (leaves my office).


So, in this situation, who REALLY needs to be seeing the neurologist?

Thursday afternoon

Dr. Grumpy: "Hello, sir, I'm Dr. Grumpy. Have a seat... so what can I do for you?"

Mr. Thebaine: "My life is a never-ending orgy of pain and misery."

Ma-Ma-Ma Bell

 Mrs. Dementia lives with her daughter. She's on the ball enough to remember that she doesn't like me because I took away her driver's license, but that's about it. Anyway...


Mrs. Dementia: "Hello?"

Mary: "Hi, Mrs. Dementia. This is Mary, from Dr. Grumpy's office."

Mrs. Dementia: "Hi, Mary. You have the wrong number. I don't live here anymore."

Mary: "Okay, well, I'm calling to remind you about your appointment tomorrow."

Mrs. Dementia: "I won't be able to go. My daughter's car isn't working, and can't be fixed. I can't go to doctor appointments anymore."

Mary: "Is your daughter there?"

Mrs Dementia: "No, she drove to the grocery store because we're out of bread."

Mary: "Can you have her call me when she gets home?"

Mrs. Dementia: "She doesn't live here anymore, either. I don't know when she'll be home."

Mary: "Okay, I'll just call back later, thank you."

Mrs. Dementia: "You can't. Our phone is broken, and no one has been able to reach us for days."

Mary: "Does your daughter have her cell phone with her?"

Mrs. Dementia: "That's broken, too. I think you have a wrong number."

Mary: "Okay. Thank you. I'll try..."

Mrs. Dementia: "Our phone is broken, so don't try to call back. The grocery man told us it can't be fixed."

Daughter (picks up extension): "Hello? This is Sue. Mom, who are you talking to?"

Mrs. Dementia: "I'm sorry Sue, I think you also have a wrong number."

Mary: "This is Mary, at Dr. Grumpy's office."

Mrs. Dementia: "Our phone is broken, and we can't hear you."

Sue: "Hi, Mary. Is this about tomorrow?"

Mary: "Yes, at 2:45.

Sue: "We'll be there."

Mrs. Dementia: "You both have a wrong number because the phone is broken. I didn't hear it ring."

Mary: "Thank you. See you then."

Decimal points. Use 'em.

Seen in a hospital chart:

Thank you, Kim!

Stop!... Shovel time!

 While catching up on reading last weekend I came across this in a medical journal:


"The goal of the project is to supply an interactive system that translates vast amounts of data and scientific literature into insights that professionals can consult to inform their treatment decisions.

"A database, in this case big data, provides the foundation for the potential to use state-of-the-art analytics to generate truly actionable insights."


WTF does that mean?

This is the problem with modern buzzword bullshit. It is, like Macbeth said, "full of sound and fury, signifying nothing." Yet, medical journals are full of similar crap that tells you zilch.

EHR today is the same way. 5-page notes that automatically fill in what medications someone is on, what their allergies are, what their blood pressure is... yet only rarely do you find anything comprehensible telling you what the physician's impression and plan are- WHICH IS THE MOST IMPORTANT PART OF THE NOTE. Usually it's hidden in the ICD numeric codes, and oftentimes the "plan" says something like "see orders database." Which doesn't help me at all.

Quantity has replaced quality in medical writing, and the problem shows no sign of getting better.

The above collection of horseshit, BTW, was from an article about epilepsy treatment.

Rorschach

This is a neuron. It's the basic nerve cell that runs your brain, my brain, pretty much everything's brain:

Sometimes it's hard to leave my job at the office. Work is always on my mind.

One night, when I got home, I found my kids had spilled something in the kitchen. And it reminded me of...

Sigh.

June 6, 1944

"There have only been a handful of days since the beginning of time on which the direction the world was taking has been changed in one 24-hour period by an act of man. June 6, 1944, was one of them.

"No one can tell the whole story of D-Day. Each of the 60,000 men who waded ashore that day knew a little part of the story too well. To them the landing looked like a catastrophe. Each knew a friend shot through the throat, shot through the knee. Each knew the first names of five hanging dead on the barbed wire offshore, three who lay unattended on the beach as the blood drained from the holes in their bodies. They knew whole tank crews who drowned when their tanks were unloaded in 20 feet of water.

"There were heroes here no one will ever know because they're dead. The heroism of others is known only to themselves.

"What the Americans and the British and the Canadians were trying to do was get back a whole continent that had been taken from its rightful owners. It was one of the most monumentally unselfish things one group of people ever did for another.

"It's hard for anyone who's been in a war to describe the terror of it to anyone who hasn't. How would anyone know that John Lacey died in that clump of weeds by the wagon path as he looked to his left towards Simpson and caught a bullet behind the ear? And if there had been a picture of it - and there weren't any - it would've shown that Lacey was the only one who carried apples for the guys in his raincoat pocket.

"If you think the world is rotten, go to the cemetery at Saint-Laurent-sur-Mer on the hill overlooking the beach. See what one group of men did for another, D-Day, June 6, 1944."

- Andrew Rooney (1919-2011)

Medicine by committee

I'm with a new patient.


Dr. Grumpy: "What did the MRI show?"

Mr. Triad: "I'm not sure, my other neurologist said..."

Dr. Grumpy: "Wait, you have another neurologist?"

Mr. Triad: "Actually, I have 2 others. I saw both of them earlier this week."

Dr. Grumpy: "Why are you seeing 3 different neurologists?"

Mr. Triad: "Well, it seems like a good idea. I mean, this way if I disagree with something one does I can call the other two, and see what the majority opinion is."

Dr. Grumpy: "Who are the other 2 neurologists?"

Mr. Triad: "I don't want any of you to know who the others are. I think that will help keep all of you impartial."

Long pause.

Dr. Grumpy: "Honestly, I'm really not comfortable with this situation. I can understand someone wanting a 2nd opinion, or even a 3rd, but to have 3 different neurologists trying to manage the same condition, ordering tests, and prescribing medications at the same time... I'm going to have to end this appointment. I won't charge you for it, but I just don't think this is a good idea, and don't want to be a part of it."

Mr. Triad: "You know, that's funny. My 5th cardiologist said the same thing yesterday."

Great deals on prions! This week only!

Dear Major Chrysler, Jeep, & Dodge,

A reader sent me your flyer about the recent Memorial Day car & truck sale.

I can only assume you don't have a lot of customers who are neurologists...

Methinks I smell a rat

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

Mr. Gad: "Hi, I saw Dr. Grumpy a few years ago, and am worried about my records there."

Annie: "What's the problem?"

Mr. Gad: "Well, I'm concerned they might affect a legal action I'm in, and would like to change them."

Annie: "We can't change records, sir. If you feel something is incorrect you can send us a letter and we'll note it in your chart, or you can make an appointment to discuss it further with the doctor."

Mr. Gad: "That won't do. I need you to change my diagnosis."

Annie: "We can't do that."

Mr. Gad: "Okay... How about if you shred my chart and destroy any scheduling records, bills, and whatever that says I was there? I'll pay you, in cash, for your time."

Annie: "I'm sorry, sir, but that's illegal, and we can't do that."

Mr. Gad: "Don't you believe in 'the customer is always right'?"

Annie: "That's not the issue here."

Mr. Gad: "Thanks for nothing." (hangs up)

Numbers

How much did your employer give to charity last year?

Contrary to popular belief, American doctors and hospitals give away free care quite often, to the tune of $74.9 billion for 2013. That, in case you don't understand numbers, is a fuck-ton of money. Let's look at the zeros: $74,900,000,000.

Of course, most of it isn't voluntary. There are a lot of uninsured people in America, and, whether you like it or not, you're still paying for them (and always have been, long before the current health policies). Even though they don't have insurance, that doesn't mean they won't get sick or injured and land in the hospital. There they'll likely need labs, tests, medications, supplies, and (of course) doctors and nurses. Since the amount of money charged for medical services are realistically beyond what most can pay, the doctors and hospitals have no choice but to write them off as losses. So you pay for them by higher insurance rates (I've addressed this before).

But the office is a different matter. Most doctors, including me, collect payment up front. Maybe not the full amount, but we copy your insurance card and charge your $50 co-pay (or whatever) before seeing you. The rest we'll bill to your insurance company. For the record, I don't like billing people before their appointment, but it's amazing how many people have "forgotten" their wallet if you try to collect after the visit. Me and my staff have families to support, too.

My point here is that office care generally isn't free, unless previously arranged. To make an appointment you have to have insurance (or agree with our cash prices). Before you even get seen we copy your insurance card and charge you for your share.

Like most doctors, though, I still see the occasional uninsured patient for free. Sometimes as a courtesy to someone else, sometimes because I genuinely feel bad for someone and am trying to help. Most doctors do.

So how much free office care are U.S. doctors voluntarily giving up? Well, for 2013 it was $10.5 billion. $10,500,000,000. I'd still call that a shitload of money (shitload < fuck-ton).

For comparison, let's look at America's biggest retail company: Walmart. According to their own website, last year they gave away roughly $1 billion in cash and merchandise to various charities.

That's a lot, but it's not even 10% of the amount that doctors like me provided. Sam, you're a cheap-wad compared to us (but I love the way your shoppers dress).

Keep that in mind next time you hear some politician or "patient activist" talking about how doctors are all greedy bastards who don't really care about people. Maybe you should ask that person what they gave up to help others.

Odds are they don't have a 6-figure educational loan hanging over their fat heads, either.