More things that make me grumpy

When Dr. Cortex is out of town, I cover his patients.

I try to work within my patient's means as much as possible. If they have crappy (or no) insurance, I try to use the cheapest generic medication possible.

Dr. Cortex, however, uses a lot of brand-new, pricey Wonderdrugs, mainly because he has samples to give out. The problem here is that he also sees A LOT of Medicaid-subplan indigent patients, and once the patient runs out of samples there is NO FREAKING WAY the plan will pay for the prescription.

Normally, this is a problem between he and his patients. Except when he's out of town. Like now.

So Mr. Ictal runs out of expensive Wonderdrug samples for his epilepsy. Dr. Cortex's nurse calls in a script to Local Pharmacy. Local Pharmacy finds out Wonderdrug isn't covered by his Medicaid plan, and tells Mr. Ictal it'll be $400.

So Mr. Ictal calls Dr. Cortex's office. And his staff closed the office to take a 4-day New Year's weekend (which they weren't supposed to, but figured the boss was in Brazil, so who cares?). And so the answering service routes him to me (my office is closed for the 4-day weekend, too).

Wonderdrug won't be covered without a doctor begging, pleading, and filling out a 30 page form. I call the Medicaid subplan to at least beg. But I'm not contracted with that subplan myself, so they won't even talk to me.

The pharmacy (understandably) can't afford to take the loss on a $400/month pill that they know won't get reimbursed. And Mr. Ictal can't afford this at all. And he has 1 sample pill left, and it's pretty damn dangerous for epilepsy patients to stop their meds cold turkey. And he has no idea what he's taken in the past. And I really hate to change meds on a patient I know nothing about. And his chart is locked up in Dr. Cortex's office until next week.

I feel bad for Mr. Ictal. This insanity (mostly) isn't his fault.

What did I do?

Fortunately, I live close to my (closed) office. So I drove down there this morning to meet Mr. Cortex, and gave him enough samples of Wonderdrug so he won't run out before Dr. Cortex can get back and decide what to do. But this is me (and at least I had samples). In all honesty, most other docs wouldn't care, and say they can't help him. Or would tell him to put the pills on a credit card. Or say it's the pharmacy's issue and to call them. Or to go to an ER (I have no idea why he should go to ER for this, but it's amazing how many docs send patients there for stupid shit like this).

The bottom line here is that you should try to work within your patients' means as best you can. It prevents crap like this from happening, and your call partners will be grateful.

Stupid questions

Dr. Grumpy: "Here are the names of 3 hand surgeons I recommend."

Mr. Carpal: "Are they good docs? I don't want to see a bad one."

My inner voice: "No, you dipshit. They're all dangerously incompetent. WTF would I knowingly refer you to a bad one?"

You VILL do ze physical therapy!!!

This note is from Local Physical Therapy, and hot off the fax just now.

With therapists like this, who need enemies?

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Is she a cephalopod?

Getting ready for the day, and reading another doctor's note on a patient coming in this morning:

"Her pain can involve 1 to 4 limbs at a time, but never more than that."

Mary's Desk, December 29, 2009

Mary: "Okay, I have you down for a follow-up appointment in 3 months, on March 22nd at 9:30."

Mr. Organizer: "Let me write that in my daily planner, hang on... wait, is that a weekend? I can't find it on my calender."

Mary: "Um, no, it's a Monday, like you asked for."

Mr. Organizer: "You must be wrong, that date isn't in my planner."

Mary: "March 22?"

Mr. Organizer: "Oh, I thought you said March 72nd."

Somebody put something in my drink

Sometimes finding the humor is the best we can do.

This morning I saw a new dementia patient, Mr. Bukubux.

He's an older gentleman, who hasn't quite been himself for a while, but his family couldn't put a finger on what was different... Until recently.

He and his wife are members of Headupthebutt Country Club, and have an annual holiday party for their friends. At these shindigs he's always the bartender, which he enjoys doing and is good at.

At this year's party, however, several guests complained to Mrs. Bukubux about their drinks. He'd forgotten various people's favorites, though that was a minor issue.

More concerning was that he was mixing them incorrectly, combining ingredients at random, depending on which bottles happened to be near him at the time.

One lady ordered a scotch & soda. Mr. Bukubox handed her a coffee mug containing milk and red wine, with a lemon floating in it.

Another man asked for a martini. He was handed apple juice with a Ritz cracker bobbing in it.

More things that make my grumpy

A December phenomenon that drives me nuts.

I'm sorry that your regular neurologist is closed/on vacation/dead until after New Years, and that you don't like the doctor covering for them.

But I'm not some sort of neurological urgent care. Showing up at my office without any old records because of some acute issue you need addressed, and planning to return to your previous doc as soon as they get back, doesn't fly here.

I mean, I have my own patients to take care of, and it's not like you're planning to stay with my practice. You make it pretty clear that you're just coming for me to patch things up until Dr. Wondrous returns/detoxes/is resurrected next week. There's a doctor on call for him. SO CALL THEM, NOT ME!

And I'm really pissed off at your internist for participating in this. He tells you to come see me until Dr. Wondrous comes back, because he doesn't know what to do, and he doesn't know Dr. On-Call, and so he sends me a note that says something like "please manage meds until regular doc returns" or "patient has had neck pain since 1972, please do something about it in Dr. Wondrous absence". These notes are especially grating when written by an internist who never refers to me anyway.

Of course, I have none of your past records, and Dr. Wondrous staff is gone, too, and you have no freaking idea what you've tried before, or if it worked, or what tests you've had done.

This is why we have call groups people. I'm sorry if you don't like the person who covers for your regular neurologist. Tell them when they come back. But I am not providing temporary coverage for them.

Job Counseling

In the early 80's, when I was in high school, we had to take these career guidance tests. You answered a bunch of questions, and a computer (like a TRS-80: anyone else out there have one? I had the top-of-the-line model, with a whopping 16K of RAM) would tell you what career was best suited to your personality.

My test results suggested a career in farming and agriculture was best for me. (Oddly, so did my Dad's tests in the 1950's. And he's a lawyer now).

In October I put a resume up on a medical site, looking for research work in addition to my regular practice.

Today I got an email from the site's "job assistant", saying that I'm qualified for an exciting career as a Certified Nursing Assistant, and should register for classes NOW.

Memo to Patients

LOOK! Just because you people waited until the END OF THE FREAKING YEAR to see if you met your insurance deductible, does NOT make it an emergency here for Annie and I.

I don't care that you now need the test (which I ordered 6 months ago) urgently because your insurance is changing, or because you finally met your deductible, or you just looked at a calender for the first time in 6 months and had forgotten December is the last month of the year, OR WHATEVER.

These are not tests you can generally get Bozo Insurance, Inc. to authorize and schedule in under a week, let alone a few days.

And the auth department at Bozo Insurance, Inc. is running half-staffed right now so their people can go on vacation, or get their tests done, or whatever. So auths are slow right now.

A lack of preparation on your part does not constitute an emergency on ours.

And don't give me the line about how you had no idea the end of the year was coming, either.

Yours truly,

Dr. Grumpy.

Dear Mrs. Thoughtthatcounts,

I just wanted to write and thank you for the tray of homemade chocolate brownies that you brought my office last week.

I'm well aware of your fondness for improvising new recipes, and the staff and I appreciate you telling us which brownies had jalapeños in them, which had bacon, and which had both.

As always, you've outdone yourself. Many of us here thought you'd never be able to top your 2007 tray of chili-pepper-and-white-chocolate-cookies, but we underestimated you and your fondness for spicy foods.

As you can imagine, your unique brownies didn't last long in our breakroom, and quickly disappeared.

You work so hard in the kitchen around the holidays, perhaps next year you should take a break and just rest. You've earned it.

Yours truly,

Ibee Grumpy, M.D.

My readers write

I'd like to thank my reader Brian, who submitted this story. For my non-medical readers, NPO is medspeak meaning "no food, water, or pills orally". Advair is a drug that's INHALED.


Hi Dr. Grumpy! I'm a pharmacist at an academic medical center. Tonight I received a phone call from a surgical resident.

Dr. Surgistud: "My patient is NPO for surgery and is on Synthroid. Is there an IV formulation and what is the conversion?"

Brian, RPh: "Yes, it's 50% of the oral dose."

Dr. Surgistud: "OK, great. And also - the patient is on Advair. I need to change him to Levalbuterol and Atrovent, right?"

Brian, RPh: "Um... no. Those are different drugs. Why do you want to change the Advair?"

Resident: "Because the patient is NPO."

Hope you got a good laugh out of that... all of my colleagues did!

Loose playlists sink ships... or something like that

Ya know, given the ease with which a guy was apparently able to walk on a plane with a bunch of explosives last week, some of the other measures seem somewhat out of place.

For example, when I was accused of contributing to terrorism a few months back.

So this morning I'm updating my iTunes software. A friend had told me about this a while back, but I'd never looked for it before today (hell, who actually reads the consents that come with software updates?). But, there it was.

I direct you to item #10 of the iTunes update agreement.

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I really love the last line. "You also agree that you will not use these products for any purposes prohibited by United States law, including, without limitation, the development, design, manufacture, or productions of missiles, or nuclear, chemical, or biological weapons."

I freely admit that my taste in music doesn't suit everyone (Mrs. Grumpy hates it), but I think the most that could be said is that my iPod constitutes a weapon of mass good taste destruction.

December 26, 2009

Dr. Grumpy: "FRANK, CRAIG, MARIE GET IN HERE NOW!!!!!!!!!!!!!!"

(shifting feet, poor eye contact)

Dr. Grumpy: "Why on Earth are you all jumping on the trampoline, in cold weather, NAKED????"

"I told you we'd get in trouble!" "Well, it was your idea!" "Wuz not."

Dr. Grumpy: "ANSWER ME."

(quick glances back and forth)

"Um, they all fell off."

Dr. Grumpy: "I'm not stupid."

"No, really, we were jumping hard and the bouncing made them..."

Dr. Grumpy: "I said I'm not stupid."

"We were out on the trampoline and wanted to play dodge ball."

Dr. Grumpy: "So why were you all naked?"

"Because we didn't want to go find a ball, so we used our clothes to throw at each other."

Dr. Grumpy: "Do you have any idea how cold it is outside?"

"Yeah, um, but not until we were naked. Then it seemed pretty cold."

Dr. Grumpy: "Frank, where are your clothes?"

"Because Marie is a bad loser. After she lost, she threw my clothes over the fence."

Traditions of Christmas

The morning after Christmas I got dragged in to the hospital to see a guy for headaches.

He kept referring to he and his wife as having "a traditional Christmas", which apparently landed him in the hospital. "Traditional" obviously varies from person to person. Here is how Mr. Traditional and his wife spent their traditional Christmas (and it took A LOT of coaxing to get the whole story out).

They woke up on Christmas morning. Then:

They had a traditional cup of coffee. Then:

They had a traditional exchange of gifts. Then:

They had several traditional shots of scotch. Then:

They smoked a few traditional joints. Then:

They did a few traditional lines of cocaine. Then:

She gave him a traditional under-the-mistletoe blowjob. Then:

When he blew his traditional load he had sudden onset of the-worst-headache-of-his-life (not a tradition).

He was taken to ER, where he had a traditional head CT, MRI, and MRA (having to drag in an MRI tech on Christmas).

So then he had a traditional spinal tap. Which was equivocal, because he wouldn't hold still.

So then the angiogram team got called in on Christmas.

So then he had a traditional 4-vessel cerebral angiogram, complicated by bleeding and a BIG hematoma at the groin puncture site (yeah, your wife's gonna love that thing next to your yule log, dude).

The admitting doc then felt a second traditional spinal tap was needed.

And that's how Mr. Traditional spent his Christmas.

When I met him (and his charming wife) this morning he asked me if I'd ever seen a case like this before.

I gave him my traditional answer. You guys can guess.