Gee, That's a Tough Case

Okay, fans, I had a neurology consult (granted, I don't get many other kinds) at the hospital this morning, on a 16 year old guy who began acting weird around 1:00 a.m. last night.

The following is, I swear, what the admitting hospitalist's note said:

"Impression: Patient who took LSD around midnight, and is now brought in for bizarre behavior and hallucinations. We will consult neurology to determine cause of altered mentation, check MRI, EEG, and labs. May need spinal tap to rule-out meningitis."

Checked Out, but Signing In

Like every other doctor's office, I have a sign-in sheet up front. At the top it says my name (Ibee Grumpy, M.D., Neurology), today's date, and asks people to write their names and the time of arrival.

So some lady showed up this morning, wrote her name on it (Ima Bimbo) and the time.

THEN she actually wrote next to that "I am not here to see Dr. Grumpy!!! I am here to see Dr. Harry Mole, a dermatologist in suite #405, but this is the only sign-in sheet I could find!"

Excuse me, Ms. Bimbo, but if I walked through an office door that said "Ibee Grumpy, M.D., Neurology, Suite #600" AND saw the same thing on a sign-in sheet, I (and likely the vast majority of the mammal population) might consider that maybe I was the one in the wrong office.

In fact it would never occur to me (or any of my office staff in a just-held unscientific poll) to write on the sign-in sheet that I was here to see another doc (in another suite, no less!) then have a seat in the lobby!

There's nothing wrong with asking us for directions to Dr. Mole's office.

But signing in and writing that you're here to see a doc who obviously ain't here???????.

Eating Healthy After a Stroke

This is from last September, I meant to put it up before, but somehow misplaced it on the computer.

Anyway, I had a stroke survivor in the office, who asked me for information she could take home. I did a quick internet search, and found the Mayo Clinic website about stroke.

The information was good. Like many websites (including mine), Mayo sells ad space.

Unfortunately, the ad displayed on the stroke-prevention page was for Jack-in-the-Box tacos!

I just LOVE where it says "Tools for healthier lives" above and to the left of the taco ad.

Bon appetit, Mrs. Strokesurvivor. I'll see you back, soon.........

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It's the Thought That Counts

One of my lovely office ladies got married 3 weeks ago, and this was one of her gifts.

She was trying to find some adjectives to describe it, or even figure out a way to write a decent thank you note for this clay edifice.

The staff, however, were concerned that perhaps their opinions of this offering were, uh, not those of the majority.

So let's hear it, Grumpyites: What are your candid opinions of this?

Please note: it is lifesize (i.e. the size of a real fruit bowl and fruits).

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Got Sarcasm?

My cell phone rings at 11:58 p.m. on a Sunday. It's the hospital on the ID.

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

Miss Idiotclerk: "Hello? Is this Dr. Grumpy?"

Dr. Grumpy: "Yes."

Miss Idiotclerk: "You were here this afternoon and wrote an order for a head CT scan on Mrs. Stroke."

Dr. Grumpy: "Yes?"

Miss Idiotclerk: "So did you want that scan on her head?"


For those of you who are wondering, all I said was yes. Lord knows I'd LOVE to be sarcastic with this imbecile, especially when she's just woken me up for such an insanely stupid question. But, as I've learned from experience, doing so will get me written up to the hospital's board, and then I'll have to appear at some meeting to apologize for my actions, and write this bozo an apology, and agree on a 12 step plan to manage my anger. At the same time, though, there is nobody at the hospital for ME to complain to about criminally stupid employees.

I need some of this (I have no idea who did it)

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E-prescribing Crap

I had started writing this a while back, and hadn't planned on putting it up today, but since my esteemed colleague over at the The Angry Pharmacist decided to talk about it today, I will too.

Regardless of what your government or insurance company tells you, e-prescribing is a pain in the ass. It is free for me to do it, but your unfortunate pharmacy is paying around 30 cents a script each time your doctor sends this crap over the internet.

It takes me, literally, 3-5 minutes PER DRUG to send this over the internet, with a decent high-speed DSL internet connection. As opposed to the 1 minute or less for me to neatly write it out, call in, or fax in.

The U.S. government is so enamored with this way to reduce efficiency and waste time that, starting 2 years ago, they began pressuring us to do this. In fact, Medicare pays us a small bonus to use it for Medicare patients. As a result, I am doing it too, because I can use the money. But that doesn't mean I like the system. I think the whole program should be cancelled and e-prescribing ditched.

But MOST frustrating to me is what happens when I have to do a controlled substance refill online. Yes, this group of drugs includes things like Methadone and Percocet, but also includes more pissy drugs like Lyrica and Ambien.

Here it is:

For refills on regular drugs: I have to click on "approve" or "disapprove". Simple enough.

For controlled drugs: I also have to click on "approve" or "disapprove".

BUT if I click on "approve" it says "This is prohibited by law. Click on the 'contact me' button to send a message to the requesting pharmacy that they need to request this from you by either means, i.e. fax or phone"

So I click on "contact me". Sounds benign, huh? But wait...

What then happens is that the pharmacy gets a message that ONLY says "Prescription denied by physician" (and they pay 30 cents for that). It doesn't say ANYTHING about actually trying to reach me by another method. I've personally verified this with 3 local pharmacies.

So the pharmacy tells my patient that I am the one at fault, because, after all, I refused to fill it (even though that isn't what I did). And so Mr. Patient gets angry, and calls my office pissed to yell at my staff and me.

What I don't understand is:

1. Why doesn't it actually tell them to contact me by another method (like it says it will)

2. WTF does it let them submit controlled requests online, WHEN IT ALREADY KNOWS I CAN'T REFILL THEM THAT WAY ANYWAY!!!

I'm now stepping down, putting my soapbox away, and shutting up, since my complaining won't matter at all to the bureaucrats who actually can change this.

Thank you, TAP, for bringing this up.

That's Lieutenant Hurwitz, he thinks he's Ethel Merman

(for those of you who recognized the source of this post's title, congratulations!)

As anyone in this field will tell you, the alcohol withdrawal (or "DT's" as we say in the medical biz) patients can be a nightmare or entertaining.

So while on call today, I got consulted to see a 60-something lady in DT's.

Unlike Mr. Pizza Guy DT, this lady was belting out Ethel Merman's greatest show tunes, at the top of her lungs! Thought she was in a show (which, technically, I guess she was. Me and a nurse as the audience, though when the room was empty she sang to the TV).

"THERE'S NO BUSINESS LIKE SHOW BUSINESS LIKE NO BUSINESS I KNOW!"

And finishing that one, she gave herself a round of applause, and went on to "Everything's Coming Up Roses", then "The Lullaby of Broadway". This has continued, as I wander on and off the floor doing consults. Later in the afternoon she switched to Barry Manilow, doing a surprisingly on-key rendition of "Copacabana".

They tried closing her door. It didn't do a thing. Her voice was in the gigadecibel range, and the use of duct tape is (unfortunately) forbidden.

At one point a security guard with the hospital's patrol K-9 wandered by. The dog stopped outside the door and began howling along.

On Call, Pissed Off, and Pissing

I'm on call again today. In fact, I'm on next weekend, too. For those of you who don't remember how much I LOVE being on call, click here.

Anyway, many wonder where we medical people get our stamina from. Is it an IV Red Bull drip? Is it our nerves of steel? Is it metal clamps applied to sensitive regions of our bodies?

Nope. It's caffeinated beverages and the need to eliminate them.

We all have our poisons. Mine are tea in the winter and Diet Coke in the summer. Many choose coffee. They keep us alert so that we may provide better service to you, our loyal customers. Equally important, however, is the tension that their consumption puts on our bladders. I mean, let's face it. It's hard NOT to be alert when you have to pee a lot, or desperately have to go. It's not like we can just run behind the nearest tree.

In medical school this became such a pre-test phenonemon that my roommate, Enzyme, actually made up a sign that said "PissFest-1989" after the first 2 tests in our M-1 year, and we left it there for the next 4 years. We thought about getting PissFest T-shirts made up, but since they were unlikely to get us girls we decided the effort wasn't worth it.

Wherever you are, Enzyme, I'm still thinking of your sign when I'm on call.

And now, back to the neurology floor. The victims (uh, I mean patients) await.

You, YES YOU, are an Idiot

Thank you for coming in on this lovely Friday afternoon, ma'am. I guess you called around 1:30 today, and since we didn't have a 4:00, which is my last slot of the day, my secretary Mary put you in. Let me just open another Diet Coke, and we'll get started.

So you've had headaches for the past 20 years? And never seen a doctor before for them? What made you come in today, of all days, for this? Oh, you did a Google search.

Thank you for this printout of all the horrible types of brain tumors and aneurysms that can cause headaches and kill people. I appreciate it, because as a board certified neurologist with over 10 years of experience I really have no idea what sorts of things can cause headaches.

If you'd read it you might have noticed that the average survival from these awful things is 1-2 years, not 20. But I'm sure you're busy and didn't have time to actually read the articles you were printing up. After all, you had your hands full calling every neurologist on your insurance plan trying to find one who still had openings on this lovely Friday afternoon.

Of course we can get an MRI. I understand it would make you feel better, and allows me to cover my own legal butt, too.

Oh, you're claustrophobic? No, an MRI is really the best test we have right now for evaluating this sort of thing. I'm sorry that Reader's Digest somehow gave you the impression that I had a gadget in my office I could wave over you to make sure everything is okay, but I don't. Dr. McCoy borrowed my tricorder a while back and hasn't returned it yet. But we can do the MRI with Valium to relax you, if such a thing is possible.

I'll have my staff schedule the test for next week. No, I'm sorry. It's now 4:00 on a lovely Friday afternoon. Your insurance company requires an MRI request to be approved by a panel of dart-throwing chimpanzees before agreeing to pay for one. All of their offices are in another time zone, and have closed by now on this lovely Friday afternoon.

You really feel you need it immediately? Then the only thing I could suggest would be to go to an ER, and tell them you need an MRI right now. I'm sure, that after hearing your story and realizing how urgent this is, as opposed to a guy with chest pain, the ER doc will be happy to waste (uh, I mean spend) time and money on your case. Just don't tell him that I'm your doctor.

Oh, I had no idea your ER co-pay was so high. $50 does seem a bit extravagant for a lady with diamond rings on every finger and Porsche keys hanging out of your LV purse. I certainly can understand your refusal to go there.

Then it will have to be next week. My staff will call your insurance first thing Monday morning to get this authorized and scheduled.

Your insurance coverage runs out at the end of this month? My calender shows that today, May 29, is a Friday (which is a lovely afternoon by the way) and the last workday of the month. So Monday will be June, and we won't be able to get the MRI from your current insurance then, since it will have run out.

What insurance will you have on Monday? I'm sorry, I'm not contracted with that plan. I can send your internist a letter asking him to order the MRI. Oh, he's not contracted with it either. I see.

Yes ma'am, I agree it was entirely unreasonable of Mary to not have foreseen that you'd be changing to an insurance I don't take next week. You didn't mention that to her when you called for this appointment a few hours ago, but she really should have known, anyway. I'll discuss her suboptimal psychic powers with her at her next job evaluation in 2018.

I'm sorry you have to go already. Well, try to take it easy over the weekend, and I'll send my records to a neurologist on your next insurance, so they can help you out.

Going to a hockey game tonight sounds like fun, and it's great that you have such good seats. That looks like a nice air horn in your purse. I'm sure that sort of quiet, relaxed environment will help improve your headaches in the meantime. Thank you for sharing this lovely Friday afternoon with me.

Drug Rep From Hell

I like most of my drug reps. I'm sure many medical people will be horrified at me saying that, but it's true. Most of them are decent people, working hard to support their families, just like I work hard to support mine. They have their job and I have mine. No, I'm not getting TV's, trips to Tahiti, or even a cheap pen to say that. It's just true in my experience.

HOWEVER it only takes a few bad ones to give them all a horrible name. I've had my share of bad ones. My current nightmare is Rikki Phoneysmile, who works for Giant Pharma, Inc. This company is known for teaching it's reps to be aggressive and obnoxious, and quickly eliminates reps who actually try to be friendly and well-mannered.

Rikki is a serious pain in the ass. My staff knows to not even ask me if I need anything from her. They just tell her I need none of her samples, and to go away. I keep hoping that if she goes long enough without my signature Giant Pharma, Inc. will demote her to their farm team at the used car lot.

Anyway, today Mrs. Grumpy e-mailed me to get some tomatoes on the way home (off the subject, I have no idea where all these tomatoes are going. She has me pick up tomatoes all the damn time, and I've never seen one on the dinner table in any form). So I stopped at the grocery store.

I'm standing in produce, fondling the tomatoes, when I'm suddenly assaulted by Rikki Phoneysmile! Out of the blue, she's suddenly in my face, between me and my tomato, extolling the virtues, mechanism of action, and low incidence of adverse effects seen with Flatulata, the latest unneeded product from Giant Pharma, Inc.

Rikki has actually, I shit you not, left a shopping cart with 2 small children (oh crap, she's breeding) and her purse in it, about 25 feet away, so she could come capitalize on her chance encounter with your's truly. She even whips out a signature pad, asks me to sign, and says she'll be happy to get me some Flatulata samples out of her trunk.

I frantically looked around for a cop, or someone having a stroke I could run to help, or a judge who could issue me a restraining order on the spot. No such luck. Just a lot of people staring at me and Rikki.

So I said "can you hold this for me?" and handed her the tomato. She automatically reached for it. And I ran out of the store.

Mrs. Grumpy isn't happy about the lack of tomatoes for her arcane purposes. But I consider that the lesser of the two evils.

Dumb and Dumber

I have a nice young lady in my practice who, as far as I can tell, has only made one major mistake in life. She fell in love with, married, and had kids with Mr. Dumb. He later decided he'd rather be a crackhead, and dumped his family in favor of the excitement of living on the street and smoking crack.

So Miss Nicelady heroically soldiers on, dealing with single Mom stuff. She was awarded child support from Mr. Dumb. Unfortunately, this only gets withheld from his paycheck on the rare occasion he's actually working. So it amounts to $20-$30 once every few months, when he finds temporary work as a dishwasher.

So at her appointment today I asked her how things were going. She paused, and then began laughing.

2 months ago she suddenly began getting steady money from his child support withholding- $100 or so every 2 weeks. She was thrilled, and didn't want to look a gift horse in the mouth.

Until one night, some guy she'd never heard of called to see why she was stealing HIS money!

And so the story played out. Get this, Grumpyites:

Mr. Dumb, trying to get crack money, sold his identity (Social Security Card, Driver's License, etc) to Mr. Dumber for $50.

Mr. Dumber, now hiding under Mr. Dumb's ID, went off and got a job.

And so, when Mr. Dumber began getting paychecks, his salary was withheld and sent to my patient!

Basically, Mr. Dumber paid $50 in order to have $200 a month withheld from his paychecks. How inconsiderate of Mr. Dumb not to have mentioned these minor details to his purchaser.

In addition, Mr. Dumber was also angry at my patient (like it's her fault) because he got pulled over one day, and discovered Mr. Dumb's license was suspended 2 years ago.

Miss Nicelady told me the best part of the whole thing was when Mr. Dumber told her he was going to call the police on her.

Great Job Titles

Alright folks, I'm seeing a Workers Comp case here. Her documents from the state list her occupation as a "data and document extractor".

This is a job I've never heard of, so I asked her what she does. And she said:

"I work in the mail room. My job is to open up all the envelopes, and give the letters to the sorting people."

So that's what a "data and document extractor" does. Now you know.

It's 3:28 a.m. Do You Know Where Your Neurologist Is?

He's at the 24-hour Wall-to-Wall-Mart, buying a boatload of decongestants for the stuffy nose that's kept him up all night.

And the cashier is a girl with a shaved head, different colored eyes, and a surgically forked tongue.

She's wearing a T-shirt that says "Eat Corpses Now!"

Attached to the T-shirt is a big blue Wall-to-Wall-Mart "How can I help you?" button.

He has an Appointment in..... the Twilight Zone

A guy comes in today, signs in, and sits down in the waiting room. Mary, my secretary, checks the sheet and comes back to me. He doesn't have an appointment today. How do I want her to handle this?

So she starts talking to him. He insists he has an appointment today, and to prove it he pulls out an appointment card. On a crumpled card, in Mary's handwriting, it says "Next appointment: May 27, 2008"

So Mary checks the schedule. Sure enough, he had an appointment on that day. Which, of course, he no-showed. And hasn't been here since.

So we tell him he's a year late for his appointment (which is a record for my practice), and offer to reschedule him (we're swamped today).

So what does he do? He gets pissed off (in front of my full waiting room) that we won't see him today.