Signs of a Bad Economy

This gives new meaning to chips & dip.

Basically, a lady who traded oral sex for Fritos. For the news story, Click here.

TPA Commentary

When I put up the TPA post (see below) the last thing that ever occurred to me was that it would spark discussions in families about advance directives and TPA.

But, from reading your comments, obviously it has done so.

I consider this a good thing. Hopefully you'll never be in the situation below, but I think it's good to have talked about it in advance, so those who may have to make decisions for you know what you would want.

Dr. Grumpy.

TPA- A Play

Before telling this story, I’m going to have to lay some background for my non-medical readers.

The most obscene word in English, in my opinion, has 3 letters and is an acronym. It’s TPA (stands for Tissue Plasminogen Activator).

This drug gets a lot of press as a clotbuster. It has the potential to break down clots and reverse a stroke. That potential, though, has a dark side. By breaking down clots it can also cause catastrophic bleeding into the brain.

So as a result I'm not a fan of this drug. I use it very judiciously, and with a solid understanding by the family and patient of what they are getting into. It can lead to great rewards- and serious complications.

Compounding this is the fact that the drug MUST be given within 3 hours of a defined stroke onset, or the risk of bleeding really goes up. So if I'm told that the symptoms started at 1:45, then a clock immediately starts running, and if the drug isn’t given by 4:45, then it ain’t gonna be. So in that 3 hour window I need to get to ER, confer with the ER doc, assess the patient, get a CT scan and labs, explain the situation and drug (and it’s dangers) to the family/patient, and get their understanding and approval (or refusal) to give it.

So those 3 hours become a very frantic, fast-paced blur. It’s even worse if the patient gets to ER 1 hour after this started, so then I only have 2 hours to work with.

And with that background, I now present “TPA- A Play”, which was performed this weekend at Local Hospital.


Our play opens in ER, where our hero, Dr. Grumpy, has just arrived. The patient is an elderly gentleman with abrupt onset of speech difficulties and right-sided weakness at noon. He got to ER at 1:30, our hero was called at 1:45, and arrived in ER at 2:00. He’s hurriedly examined the patient and met with the wife, and discussed the risks & benefits of TPA.

(Curtain rises)

2:15 p.m. Dr. Grumpy: "What are your thoughts about this treatment, or any other questions?"

Mrs. Smith: "Let me call our children."

Mrs. Smith then whips out a cell phone, frantically calling people all over the country, leaving messages on their voice mail, then calling back to see if they've picked up their voice mail yet. Dr. Grumpy wanders back to nurses' station to review labs.

2:22 p.m. Nurse says wife wants Dr. Grumpy to come discuss this with the patient again. Because of the stroke Mr. Smith is unable to speak or understand speech, but Dr. Grumpy attempts to do so anyway. He reminds Mrs. Smith of the urgency of the situation. She continues to make phone calls. Dr. Grumpy goes back to nurses' station.

2:28 p.m. Mrs. Smith reaches a daughter, and tries to explain situation to her. Then gives cell phone to Dr. Grumpy to explain to daughter.

2:29 p.m. Daughter becomes hysterical and asks to talk to her mother again.

2:31 p.m. Mrs. Smith hands phone to Mr. Smith, and tells him to explain his symptoms to the daughter. The unfortunate stroke patient can’t speak, just stares at phone, saying nothing. Dr. Grumpy leaves the room to keep from breaking down, again reminds wife of urgency.

2:35 p.m. 4 minute attempt to get Mr. Smith to talk to daughter on cell phone ends, with no decision. Highlight was when Mrs. Smith turned up the volume on the cell phone, figuring that might help patient understand daughter better. The look on Mr. Smith's face makes it apparent he's suddenly regretting his choice of spouse.

2:38 p.m. ER volunteer says wife wants Dr. Grumpy to come back and explain to patient for 2nd time what is going on. He good-naturedly attempts to do so. Mrs. Smith repeats everything Dr. Grumpy says, screaming loudly into patients ear, hoping that will help. Dr. Grumpy has a fleeting image of Garrett Morris doing "News for the Deaf" on SNL in 1975. Again reminds wife of urgency.

2:41 p.m. Parents of screaming child in room next door ask Mrs. Smith to stop yelling at Mr. Smith, as it's upsetting their child. She goes into their room to argue with them.

2:43 p.m. Mrs. Smith starts making more phone calls. Dr. Grumpy reminds her of urgency.

2:44 p.m. Dr. Grumpy goes back to nurses' station, asks staff to play the “Jeopardy!” theme over the loudspeaker.

2:46 p.m. Mrs. Smith somehow decides that the reason she can only reach voice mails is because the cell phone reception inside the hospital is poor.

2:47 p.m. Dr. Grumpy goes back to see if Mrs. Smith has made a decision. Discovers she’s absent from room.

2:49 p.m. Dr. Grumpy and nurses stand at window, incredulously watching Mrs. Smith walk across the street and get in line at a Starbucks, still frantically dialing phone numbers.

2:55 p.m. Mrs. Smith gets a coffee and starts coming back to ER. She walks in front of an oncoming ambulance, which slams on it's brakes and swerves to avoid flattening her. Mrs. Smith goes over and pounds on the driver's side window to cuss out the driver, arguing with him in the middle of the street.

2:58 p.m. Mrs. Smith attempts to enter ER again through ambulance entrance, which only opens for a paramedic or hospital ID. She frantically knocks and waves at the paramedic who she just finished cussing out. They get into another argument about which of them needs to pay better attention.

3:01 p.m. Mrs. Smith finally finds way back to patient room, asks nurses to call Dr. Grumpy.

3:03 p.m. Mrs. Smith says she's made a decision. She wants to do whatever Dr. Grumpy thinks she should do. Dr. Grumpy informs her that he is not going to do anything, as the TPA window has closed. Mrs. Smith asks Dr. Grumpy where she can get some sugar for her coffee.


(Curtain falls).

Public Service Announcement

Dear owners of the Fuk-Yu Dragon,

Mrs. Grumpy and I enjoyed our meal there tonight, as always. I'm glad we got to meet for dinner while I was on call.

Generally speaking, however, if you want to attract loyal customers (as opposed to sending them screaming down the street to dine at the Jade Wong instead) you should NOT repeatedly play certain background music. I'm referring, of course, to tonight's choice of "Air Supply's Greatest Hits of the 80's", played again and again and again overhead.

Thank you.

(For those of you who are now thinking "Hey! I remember Air Supply! I wonder where they are now?" the answer is that they've been playing hotels in Macao, China for years. Click here if you don't believe me).

I'll Just Use the Sink, Thanks

I'm on call this weekend (for those of you who don't know how much I just LOVE being on call, click here).

Since I was last on call, the hospital has installed these signs in the bathrooms (sorry for the bad picture, it's a cheap cell phone camera).




Given the IQ's of some of the folks I deal with, and how they tend to take everything quite literally. I would NOT want to be on the hospital janitorial staff these days.

WTF? Friday Patient Freakshow

Dr. Grumpy: "Did you have any other questions, Mrs. Brown?"

Mrs. Brown: "Yes, Doctor, just one. Is it normal for me to be able to stick a Q-tip this far up my nose?" (whips out a Q-tip, shoves it up nose until it disappears)

Dr. Grumpy: AAAAAAAAAAAAAAUUUUUUUUGGGGGGHHHHHHHHH!!!!!!!!!!!!!!!!!

Patient Quote of the Day

"My last Doctor was from India. Or maybe it was Indiana. Anyway, it was one of those foreign places."

Expect the Unexpected

I'm a veteran of the neurology wars. I've done front-line service in ER. I've done trench warfare in hospitals and even at my office desk. After 10 years of this I feel like I can handle most situations in my field, or at least know where to transfer the patient if I can't.

But there are some things you are never prepared for. Like showering buck naked in the pitch dark at 4:00 a.m. (so you don't wake up the family). And suddenly having a zillion megawatt flashlight shined in your eyes. And an 8 year old girl in Little Mermaid pajamas, Spongebob slippers, and a fireman's hat suddenly yell "DADDY! YOU UNDER ARREST!"

Nothing prepares you for that. Ever.

Tell it Like it Is

I've got a junkie over in the ICU, who overdosed on a bunch of stuff yesterday. She was on a ventilator (a breathing machine) this morning, but they were going to see if she improved enough today to get her off it.

So I called over there a minute ago to talk to her nurse:

Dr. Grumpy: "How'd she do this morning?"

Nurse Icu: "She's more awake, and we got her off the ventilator, but may have to put her back on again."

Dr. Grumpy: "Why? Is she still having trouble breathing?"

Nurse Icu: "No, she's just a bitch."

WOW! That is SO Useful!

Okay, Grumpyites. My friendly neighborhood Lidoderm (a skin patch for pain after shingles) drug rep was by last week.

Drug reps aren't allowed to take us to ball games anymore (I'm okay with that). In fact, this year they've actually been banned from bringing us even cheap pens and post-it notes.

BUT they are still allowed to bring us oddball stuff which falls under "patient education". Like this thing:




What is it? An art deco cactus garden? A model of Bikini Bottom (the home of Spongebob Squarepants)?


Nope. It's a model of the nerve endings of your skin, showing how painful post-shingles pain can be. When you turn it on, notice how the nerves glow red (it's pain, get it)?





And HERE! When you push down on the Lidoderm patch (get it? you're applying it to the skin?) they now glow soothingly blue (ah, that feels better). Thank you, Craig, for the hand cameo.



Isn't this useful! Isn't this revolutionary! Isn't this a great use of your medication money!

The kids and I have now taken out the batteries, and this weekend will study the feasibility of turning it into a new home for Ed, my office fish.

Marketing Errors

Avinza is a once-daily form of Morphine. A few years ago they ran this ad, to show a typical patient who may need once-daily narcotics.

I hope she's supposed to be a waitress. Because I'd hate to think they're encouraging a typical patient on sedating and addictive pain medication to start downing daiquiris, and a whole tray of them at that.

They pulled this ad rather quickly. I can't imagine why.

(Click to enlarge)

Unforgettable Weddings

I have a lady with Trigeminal Neuralgia. This causes episodes of sudden, severe, facial pain, which can be quite disabling when they occur.

Her daughter's wedding was this past weekend, and the patient had been asked to stand up front as the couple wed. She's been anxious about it for months, terrified that if she has an attack of pain during the ceremony she'll start crying, and make a scene.

So to prevent pain she decided to a take a handful of Percocet just before the ceremony. About halfway through the wedding she suddenly began vomiting uncontrollably, then passed out on the alter.

I'm glad she didn't make a scene.

One Good Stroke Deserves Another...

There's an irregular heart rhythm called V-tach (short for ventricular tachycardia). Sometimes it's harmless and transient, but at other times can lead to more life-threatening heart rhythms. Therefore, when it shows up on the cardiac-telemetry monitor, it needs to be checked out FAST.

So this morning, around 5:00 a.m., I was on hospital rounds, reviewing a chart on the cardiac floor. I'd been asked to see the gentleman in room 31 (Reverend Jones, of Local Church), for a small stroke he'd had.

Suddenly the monitor tech paged overhead: "Room 31 is in V-tach! Check patient STAT!!!".

About 5 nearby nurses jumped up and ran into the room, throwing the door open, flipping the lights on, racing to the bed.

Reverend Jones was, uh, playing with certain things. Without sheets over him, either.

He explained that he "just wanted to see if my man-parts still work after the stroke".

I decided to just see him this afternoon, after his MRI is done. He's had enough embarrassment for the morning.

In Memoriam

This week marked the passing of a dear friend and associate.





This is my Panasonic electronic pencil sharpener. I have no idea what the model number was, if it had one.

I don't know when it was bought. I first remember seeing it in my Dad's law firm when I worked there in the summer of 1982 (I ran the copy machine for $2/hour).

At some point it got relocated to our house, and I took it with me to college, then medical school. It's since sat patiently on my desk, heroically and faithfully performing it's services when called to do so. It's been with me for at least 20 years, and likely more.

This week, it passed into the great machine heaven, done in by having to sharpen 6 dozen pencils in preparation for the new school year. It tried valiantly, but just couldn't handle it.

Besides the Grumpy family, it leaves behind many friends, including a stapler, tape dispenser, and desk lamp.

Services will be held in the next few weeks, as Frank requested an autopsy be performed to see what's inside an electric pencil sharpener.