Anatomical Variant

From a history form a patient handed me today:

"I've had both right shoulders replaced twice."

Thank You For Sharing

Dr. Grumpy: "Do you take anything for the neck pain?"

Mr. Kreepy: "Viagra."

Dr. Grumpy: "Viagra isn't a pain medication."

Mr. Kreepy: "Yeah, but when I'm jacking off I don't notice the pain as much."

I need to learn not to ask. Sometimes I don't want to know. And the mental images are never pretty.

Medical Guidelines

Okay, medicine is full of guidelines and acronyms. Phrases like SOAP, BRAT, TURP, CAPRIE, HIT, CABG, CHOP, etc. all have meaning to different specialties.

So (and thank you to reader Kaitlin for bringing this to my attention) there's a scale used to help assess vomiting during pregnancy, called the Pregnancy-Unique Quantification of Emesis index, aka PUQE.

Really. PUQE.

I'm not making this up- Journal of Midwifery and Womens Health. 2009;54(6):430-444.

I can just see something like this:


Frantic husband: "Doctor, my wife is still throwing up!"

Doctor: "What's her PUQE index?"

Frantic husband: "Um, looks like pizza she ate last night, and maybe a cookie. Could be some pickles, too. Hard to tell."

Tuesday Evening, During Desert

Dr. Grumpy: "Dr. Grumpy, returning a call."

Mr. Duh: "Yeah, I was there this afternoon, and you told me to stop taking my Lipitor?"

Dr. Grumpy: "Yes, I did."

Mr. Duh: "And you wrote me a note, I have it here, it says 'Stop taking Lipitor'."

Dr. Grumpy: "Correct."

Mr. Duh: "So, does that mean I should stop taking it? Or just cut the dose in half?"

Dr. Grumpy: "It means you should stop it."

Mr. Duh: "Should I stop just the Lipitor, or should I stop stuff you didn't write down?"

Dr. Grumpy: "Just the Lipitor."

Mr. Duh: "Completely stop the Lipitor, you mean?"

Dr. Grumpy: "Yes."

Mr. Duh: "Okay, thanks for clearing that up, your note was kind of vague."

Averages Aren't Always Helpful

Dr. Grumpy: "At your last visit you were averaging 2 migraines a week, how has that been since starting the new medication?"

Mrs. Analytical: "Better" (whips out PDA) "The first week on it I went to 1.94 migraines, the second week I had 1.89 migraines, and the 3rd week I had 1.85 migraines. Last week, though was worse, and I had 1.91 migraines."

Dr. Grumpy: "How do you figure out these numbers?"

Mrs. Analytical: "I use accounting software."

Dr. Grumpy: "But how is 1.91 migraines different from 2 migraines?"

Mrs. Analytical: "The software says it is."

Not a Good Sign

On today's schedule, my first patient of the day is listed as "Mrs. Ancient, referred for memory loss".

I look in the lobby. She's out there, holding a magazine upside down. And she has her bra on outside her shirt.

Bartender, Gimme a Light

And a big Dr. Grumpy thank you to alert reader Allison, who sent me this.

Mary's Desk, November 23, 2009

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

Ms. Bright: "Yes, I need to make an appointment to see Dr. Grumpy."

Mary: "Okay, let me look... We can see you tomorrow afternoon at 4:00?"

Ms. Bright: "Oh, that won't work. How about at 5:00?"

Mary: "Sorry, that's when we close. Would earlier in the day be better?"

Ms. Bright: "No, I can only come in at 5:00 in the afternoon on any weekday."

Mary: "I'm sorry, our last slot of the day starts at 4:00."

Ms. Bright: "Okay, but if someone who has a 5:00 appointment cancels, can you call me?"

Sunday Night, 11:25 p.m.

Snowball is a mutt with a lot of curly white fur. Our vet thinks he's a LhasaPoo.

In the last few months the fur has overgrown his eyes, so that we can't see them. This doesn't appear to be a problem for him, as watching him navigate the house it's obvious that he sees quite well.

Marie, however, has serious issues with this. She's convinced he's now blind, in spite of all evidence to the contrary.

So last night we were woken by wild howling and barking. The hall bathroom light was on, so I ran in there.

Marie apparently was unable to sleep, and was up worrying about Snowball's vision. She REALLY felt something had to be done, so she'd cornered him in the bathroom, and was using all sorts of her own hair things to pull the hair out of his eyes. She had his bangs tied up in ponytails over each eye. She also had plastic hair clips placed above and below both eyes to hold more hair out of the way.

It was so sad. He looked like the guy in "A Clockwork Orange" where they wired his eyes open to force him to watch movies.




I sent Marie to bed and freed Snowball. He spent the rest of the night in bed with me to show his appreciation.

Between my kids and my cell phone I'm getting pretty damn sleep deprived. Maybe my dementia patients today won't notice if I nap in front of them.

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.