Sunday Reading

Sitting in the hot tub this afternoon, trying to catch up on my neurology reading. I learned that:

1. People with lots of stress tend to have problems sleeping (paper presented at the 23rd annual meeting of Associated Professional Sleep Societies, source- Neurology Reviews, September, 2009, page 15).

2. Pilots who fly routes of more than 16 hours in length who take naps during the flights (these flights are mandated to carry 4 pilots) have a lower incidence of fatigue than pilots who don't take naps during similarly long flights (paper presented at the 23rd annual meeting of Associated Professional Sleep Societies, source- Neurology Reviews, August, 2009, page 5).

Since both of these papers were presented at the same meeting, I have to wonder if the audience slept through the results. And it was held in Seattle, the coffee capital of North America, too.

Death and Money

Since we seem to be in an ethics mood following that last post, let me put up this one up. It's a case that's bothered me for over 15 years. I know this is a change from my usual bitchy humor, but what the hell.

Let's take the Way-Back machine to the early 1990's. Dr. Grumpy is a 3rd year medical student, doing a 6-week surgical rotation at a VA Hospital in the heartland. Please remember, I am at the level of a peon (or lower) and therefore have no input in the case.

Patient is a 75 year old man, who, to use a medical term, is sick as shit. Multiorgan disease. Metastatic cancer. Sepsis. On dialysis. He has gigantic bedsores down to muscle and bone on his back and butt (this is why surgery was involved, to debride these horrifying things). He's suffering terribly. He's had a stroke, and can't talk or understand speech.

He has a wife, 20 years younger than him, who he married 2 months earlier, when he was still ambulatory. She is the POA. I know nothing about how long she'd known him previously. If he had kids, I don't remember, and I never saw any.

This poor man needs to die. That is blunt, but true. He will never have a meaningful quality of life, ever. He is suffering, and we can do nothing to really comfort him. We can't give him Morphine for his pain, because that might shut down his breathing and make him die because...

He has a large life insurance policy, the details of which I don't remember. BUT I do remember one thing very clearly, because it was a big topic of discussion. The wife ONLY gets the money IF the patient dies after June 1. If he dies before, she gets nothing. Maybe his unknown kids would get it before then, I just don't know. Please remember this was over 15 years ago, and I don't remember a lot of the details.

So it's now February 24. Over 3 months left until the wife can collect money. And the patient is a full code. He codes at least once every 2-3 weeks. Each time the medicine team runs in, shocks him, forces him to stay alive. Forces us to continue cleaning these horrible gaping wounds down to the bone. And, from a financial viewpoint, his care is likely costing $5,000 to $10,000 of your tax dollars per day.

And the wife won't let him go. She maintains that she loves him and can't live without him, and can't bear to let him die. Maybe that's true. Or maybe not...

I don't know how the story ends. I went off rotation, and to another hospital, at the beginning of April.

Sorry to be a downer, but I thought it would be interesting to toss out an ethics case after the responses to last night's post.

I Ain't Coming

I can always use money. Regardless of what the public seems to think, doctors are generally not phenomenally wealthy.

So I hate turning business away. But tonight I refused a hospital consult. Why would I do that?

Because.

The consult was for an 88 year old lady with advanced Alzheimer's Disease. Her sad life was reduced to lying in bed staring at the ceiling.

The patient had been seen by 2 other neurologists during this admission, and 3 others in the year previously. All had told the family the same sad facts of the case.

Yet, the family called me last night for a 6th opinion. A granddaughter poured out this sad story to me, and begged me to come see Grandma.

I asked her exactly why she wanted me to come in, since it didn't sound like I had much to add. Grandma has already had every test in the book.

So granddaughter said "Because the other neurologists just keep giving us bad news, and tell us to call hospice. We're looking for someone who will tell us this can be reversed, and who can fix her."

And that's why I turned down the consult. Because I'm not going to be a party to this insanity just to collect $100 from Medicare. It's not fair to anyone, especially Grandma. I bet she'd be horrified if she knew what was being done.

This is sad. But I won't be part of this family's denial issues. Me telling them the bad news for a 6th time obviously isn't going to change their actions. They'll just keep looking for someone who is either incompetent or willing to lie.

And that's why I turned it down. Because I respect Grandma. I'll never know who she was, but I doubt she'd want more docs being a part of her family's inability to let her life go with dignity.

Random Saturday Moments

Random moment #1

We took the kids to a sporting event today. After a while Mrs. Grumpy sent me to get drinks and nachos.

So I'm standing in line at the counter, with one guy ahead of me, buying a hot dog. I overheard this:

Mr. Hotdogbuyer: "It's $5.95 for THAT dinky hot dog! Geez, my dick is bigger than that!"

Counter girl: "I certainly hope so, sir."



Random moment #2

We stopped at Target to get assorted junk. Up in front they had various holiday gift sets. One of them was a "sampler set" in a green and red box with snowflakes on it.

What was it a bunch of samples of? Beer? Chocolates? Coffee?

Nope. Deodorant. Had 5-7 things of deodorant, different brands and scents. I swear.

If someone gave that to you, what would you think?

We're Not There Yet

Mrs. Technophobe, I understand that this "internet" and "email" thing look kind of magical, as you only sent your first email last week, with your granddaughter's help.

And I appreciate you telling me that you can look up movie show times online. I tried my best to look impressed. I didn't have the heart to tell you that you may be the last person in a G8 country to find this out.

And you're clearly fascinated by the fact that I can send your prescriptions in by email. Obviously, being a net newbie, you haven't read posts by myself or The Angry Pharmacist bitching about how much we HATE e-Scripts.

But, as much as you apparently think this is going to happen (because in your mind what else could "e-prescription" mean), your pills ARE NOT going to come to you by email. I swear. The matter-to-energy-to-matter conversion technology isn't there yet. And arguing with me and Annie about this is not going to make it happen.

Keep an eye on your mailbox. The metal one, yes, that thing, in the front yard, and your Plavix will magically appear there in about a week.

You Idiot

Dr. Grumpy: "At your last visit I started you on Neurontin for the pain. How's it working?"

Mr. Idiot: "It works fine, but I don't like the side effects."

Dr. Grumpy: "What kind of side effects are you having?"

Mr. Idiot: "If I stop taking it, the pain comes back."

Progress Note Addendum

William, a medical student, has submitted the following, more detailed, chart for your perusal.

I still think we neurologists should have a special "Freaks and Greeks" heading for our field, though.

Thank you, William!

(click to enlarge)

Why Did You Decide To Become a Neurologist?

I get that question a lot, people wondering why I'm a doctor, how I got into neurology, if this is my real hair or just a cheap rug, and... but I digress.

Anyway, I'd like to present this flow chart which explains the complex process by which a medical student (sort of like a stem cell) eventually transforms into their specific field. It was sent to me by an anonymous reader, so thank you whoever you are.

You'll notice neurology isn't listed here, likely due to space constraints. I'd put it somewhere under internal medicine, with a special "Freaks and Geeks" section leading to my field.

(click to enlarge)

Turkee and Grayvie! Yum!

Alright, my kids school district sent a flyer home with them tonight.

They're having a Thanksgiving lunch next week, and are inviting parents to join their kids at it. The flyer included the following:


"Please join you child during they're regular lunch schedule"

"Includes choice of desert" (Sonoran? Sahara? Gobi?)

"Sliced turkey brest"

Holy Electric Boner Batman!

The Science Marches on Department has brought the following medical research breakthrough to my attention:


Penile Shockwave Therapy Shows Promise For Erectile Dysfunction

Thursday Morning 2:48 a.m.

Today's Quiz

I (and most of my neighborhood) were blasted out of bed this morning.

I was woken by:

A. Phone call from a deranged patient.

B. Phone call from a frantic ER doc.

C. Phone call from a bored nurse.

D. My 8-year-old son Craig, who for whatever reason thought it would be funny to turn on his CD player in the middle of the night, playing "YMCA" at full volume.

(If you guessed "D", congratulations! And I had no idea Mrs. Grumpy and the neighbors even read this).

It's fun to stay at the...

That's The Way It Is

My esteemed colleague ERP put this up today, and I thought it was worth sharing.

Family Math Issues

Mrs. Hyper: "I have 3 kids."

Dr. Grumpy: "That's nice. Boys? Girls?"

Mrs. Hyper: "One of each."

Dear Mr. Attorney,

I appreciate you sending payment for Mrs. Jones' medical records.

As you know, her chart was quite large, so printing it up took quite a bit of time and paper. You also wanted me to have it notarized, so I had to drag it down to Local Bank and wait in line.

Then postage was a fortune, since you wanted it sent certified.

Anyway, because it took some time and effort, I enclosed a cover letter asking for $50 payment. Your office manager was kind enough to send me a check for $50 last month to cover this, on the same day she received the packet.

So it was quite a surprise to get a personal note from you yesterday, saying that you felt the $50 was excessive. You did some calculations in your letter, and said that (based on state law) you only owed me $27.45, instead of the $50 I'd previously asked for (and received).

But it was still nice of you to send a check for $27.45 attached to your letter, paying me what you thought was "reasonable, and more than fair" for Mrs. Jones' records.

I've deposited both checks, and thank you and your law firm for having paid me a total of $77.45 for a chart I'd only asked $50 for in the first place. Extra money around the holidays is always nice.

Yours truly,

Ibee Grumpy, M.D.