Skool Nerse Time

Mrs. Grumpy is a veteran school nurse. This year, she's starting at a new (to her) elementary school.

So she spent this morning sorting through all the medical cards parents have turned in.

Under allergies, some listed for kids at her school include:

"unwashed lettuse"
"sugar, fake sugar, and artificial sugar sweets"
"byprodukts"
"rubber bands or glue and/or whatever stuff like that"
"no Aspirin, but Aspirin is okay"
"that drug that killed Michael Jackson" (hell, this district doesn't even supply Tylenol)
"band-aids"
"metal cans"
"ear thermometers"
"that bad kind of paper I read about"


On the line marked "Other medical concerns you'd like us made aware of":

"Don't let him eat Legos again this year, PLEASE!"

"Can I get a copy of the district's swine floo plan?"

"I don't like her getting junk food. Can you make sure she doesn't bring any for lunch" (who's packing her lunches? Not the nurse, you bozo)

"He doesn't like beer or coffee" (on a 2nd grader)

"Please don't make him swallow goldfish. I saw that on TV once."

If he faints in PE, no blood transfusions"

Sunday Morning, 5:51 a.m.

I suddenly sit bolt upright in bed. My 3rd year of medical school starts the Tuesday after Labor day, and I'm not even ready. A horrible feeling of dread comes over me.

It's a 2 day drive from my parents' house to my medical school. My roommate Enzyme is likely already back there, and wants to kill me (I've got the stereo with me). After I get there I have to buy one of those short white coats that the medical students are required to wear on rounds, and a boatload of clinical textbooks. The school bookstore isn't open on Sundays and holidays. So I'll have to leave here by Thursday at the latest.

I'm not even packed with all the clothes and crap I need for my 3rd year. I don't even own a tie. My car needs an oil change before the 1500 mile drive. I have no idea where the stethoscope I bought last month is.

I jump out of bed in a panic and cold sweat, and call to my Mom if she knows where my suitcase is. Mrs. Grumpy yells "What the hell are you doing?!?"

Suddenly I'm wide awake. The only drive I have to face is the 2 miles to my office on Monday. This isn't my parents' house. I've been an attending physician for 11 years. I've just woken up the dogs. Snowball starts barking his stupid head off, waking up the kids.

No more deep fried ice cream before bedtime for me.

Early Saturday Morning, 12:47 a.m.

I'm deep asleep. My cell phone chimes. A voice message has been left.

Loud music and people talking in background.

"Hello? This is Suzy Kyoo. I see Dr. Grumpy for migraines and I'm out with my girlfriends and some asshole stepped on my foot and the nail polish came off my big toe and the nail is really brown and gross when I looked at it and I showed it to the bartender and he said he thinks it's like some sort of fungus or something nasty like that and I'm not sure if it's safe to paint over it again and I once saw this TV ad for pills or a spray or lotion or something like that to treat toenail fungus and I've got a date on Saturday night and I don't want to scare the guy off with this disgusting toenail and I was wondering if Dr. Grumpy could call in some of the toenail stuff I saw advertised on TV for me and hey Cindy can you get me another daiquiri I'll pay you back Monday at work oh I love this song I'm gonna go dance to it hang on let me get off the phone."

More Forms

I love crap like this, and I get a lot of it.

Here's a form that I need to sign, then fax back to a drug company to get medication samples.

Notice how, in the same paragraph that says I'm supposed to sign and fax, it also says that a signature stamp isn't allowed.

It's a freakin' fax! How would they know?

(click to enlarge)

Screw You, Dr. Rude

Whenever another doc calls and tells Mary to interrupt me, I take the call. I do this because I assume there's an urgent patient matter they need to discuss with me.

Likewise, I'll usually take a few minutes between patients to talk to new docs who call looking for business. When I started in 1998 I went to every medical plaza I could find to hand out cards and ask for work, and still appreciate those docs who were willing to meet with me.

So today I'm with a new patient and Mary comes back to flag me down. She says Dr. Rude is on the phone (I've never heard of him) and told her he urgently needs to talk to me about a case.

So I apologize to the patient sitting in my office and pick up the phone. "This is Dr. Grumpy."

Dr. Rude: "Hi, I'm Dr. Rude. I'm a new specialist in your area, and have just opened my office. I wanted to make you aware that my practice is accepting new patients, and I'd appreciate any referrals you might send my way".

I thanked him and hung up. With a patient across the desk from me, I'm not going to start yelling at another doc.

Piss on you, Dr. Rude. I'm not sending you any damn patients. Having me interrupted by lying to Mary about the reason for your sales call is just wrong. You may be a good doc, but manners mean a lot, too.

I Hope He Didn't Have Anything Serious

Timely communication between doctors is (at least in my opinion) important for good patient care.

So yesterday, this letter from a local kidney specialist showed up on my fax machine. I can't put the whole thing up, but this is the key paragraph.

Besides what it says below, the letter itself was marked as having been dictated on July 4, 2009 (which was both a holiday and a Saturday) and was promptly transcribed on August 18, 2009, then quickly faxed to me on August 27, 2009.





I guess it's also notable that it doesn't mention which January is being referred to.

Medical Resources

Sir, I certainly understand you wanting to find out more about your Parkinson's disease and it's treatments. In fact, I encourage it.

I am, I swear, a board-certified neurologist with over 10 years of combat experience at this desk. While you are welcome to get information from whatever sources you choose, I'm concerned that you're basing your decisions on opinions rendered from non-medical people who may not even have neurological illness. Specifically:

1. The stockboy at Local Grocery who thinks his aunt in Buffalo has Parkinson's disease.

2. The lady you met in line at the movie theater who's hands were shaking a little and told you medications were the work of the devil.

3. The retiree handing out ravioli samples at Costco who told you her last customer had a tremor like yours.

4. bigdavesparkinsonsdiseaseandroofingmaterialsinformation.com

5. The guy who flipped you off in traffic and yelled that you should stop whatever medications you're taking.


These are just suggestions, though. You can do whatever the hell you want.

No Thanks, I'm Trying to Cut Down

Mrs. Oldbird, I'm truly sorry that the medication trial for your husband's Alzheimer's disease caused him to have diarrhea. That is, unfortunately, a known side effect of the drug. I'm glad he got better after we stopped it.

I really do take your word that it gave him the runs. You didn't need to bring in a pickle jar full of his week-old liquid shit to show me. And I really don't want to know what you did to collect it. And I don't need to keep it here to run tests on it. And, if you even THINK about loosening the lid, so help me I'm going to leap over my desk and throw you out the window.

We All Live in a Yellow CME...

I get ads in the mail for CME (Continuing Medical Education) courses. They're generally boring-looking brochures, listing courses like "Stroke Update- 2009" or "Epilepsy Review". They're held at places like "Headupyourbutt University Medical Center" or "Insanely Expensive Resort & Spa". So I toss them in the paper recycling bin.

Yesterday, however, a remarkable one came in the mail for a music themed neurology CME! Featuring hits of the 60's, 70's, 80's and 90's!

I'm still not going to the meeting, but you guys at Case Western get a big Dr. Grumpy "A+" for creativity.

Check it out! Test your classic rock trivia!

(click images to enlarge)

Time to Start Aricept Myself

Look, lady, maybe your husband is demented. Maybe he's had a stroke, and forgotten how to do this particular household activity. Maybe he's just being a guy (I have some experience in that field).

BUT, when I ask you why you brought the old fellow to see me, a neurologist, you're gonna have to give me more information than a note saying "He doesn't know how to make the bed".

Using only that as a criteria, the majority of guys, myself included, will need to start seeing a neurologist. So will most of the pediatric population.

And there ain't enough female neurologists to see us all.

Any Other Bright Ideas, Doc?

Alzheimer's is never fun, but sometimes you have to see the humor in it.

Because patients forget to do routine things, family members often try to compensate by leaving large signs around the house as cues: "remember to brush your teeth", "remember to take your pills", "remember to drink a glass of water", etc.

So today I was asking a family how this method was going with Grandpa. He lives in a condo by himself, near his son, and the family checks on him frequently.

Grandpa saw the signs all over, and for unclear reasons (there are never clear reasons with these people) assumed they were meant for his dog.

And, since his dog obviously wasn't obeying the signs, he had to do something about it.

So one day the son wandered over to find Grandpa vigorously brushing the dog's teeth.

Upon further investigation, he found that, in the week since he'd put up the signs, the dog had been receiving Alzheimer's pills (no, I don't think they helped at all), and sleeping pills (no wonder he was so easy to catch). He'd also moved the "drink water" sign from the refrigerator door to the floor next to the dog's bowl.

This also explained why the dog was wearing a pair of clean underwear, since they'd put up a note reminding Grandpa to change those daily, too.

The signs have come down, and the family is looking into care homes.

The dog has been adopted by the son's family, and is much happier (though his breath isn't as minty-fresh).

The underwear has been washed, with bleach.

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).