Annie's desk, August 6, 2010

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

Ms. Daughter: "Hi, my Dad has Parkinson's disease, and I was wondering if you had any birthday gift ideas specifically for Parkinson's patients?"

Annie: "Hmm. Well, there's a really good physical therapy program for them over at Local Rehab."

Ms. Daughter: "No, I'd have to drive him to that, and don't have the time. He already has a cane, otherwise I'd get him one. Can you write a script under my name for his meds? That way I can have my insurance pay for them, and save him money?"

Annie: "No, we really can't do that. What about just a regular gift? Like baseball tickets, or a book?"

Ms. Daughter: "No... He likes movies. Do you know of any movies that are out now about Parkinson's disease? He's already seen 'Awakenings'."

Annie: "Why don't you take him out for a nice brunch, or dinner?"

Ms. Daughter: "You people aren't any help at all." (click)

A noiseless flash...

65 years ago today.

My copy is 118 pages, of regular size print. You can read it in an afternoon.

It's just a story about 6 people, all ordinary people, and strangers to each other.

It's just a collection of interviews, first published by "The New Yorker" magazine in 1946, and later put together as a book.

It's never, to my knowledge, gone entirely out of print. You can buy it, used and new, on Amazon for a few bucks (no, I'm not selling my copy. It's a 1946 original, and I stumbled across it in 1996 for $12.85 at a used book store).

It's called, simply, "Hiroshima", and it was written by John Hersey.

It has no science in it. No history of the development of the bomb. No history of World War II (aside from the immediate content). No political commentary on the right or wrong of war. Minimal, if any, emotion. If anything, it's rather dry and simply factual about what the people interviewed said.

It's the collected experiences of 6 people, who at 8:15 a.m. were all 1/2 to 2 miles from the center of the Hiroshima nuclear bomb explosion, and their experiences in the minutes to a few days after.

None of them (like most of us) were politicians. They were:

A Catholic priest
A clerical worker
An internist
A Methodist minister
A widowed seamstress with young children
and a surgeon.

4 men, 2 women.

If you haven't read it, I'm telling you to invest a few bucks and an afternoon in it. It's as powerful today as it was then.

What does she know? She's just the patient

From another neurologist's note:

"Impression: Patient referred here for carpal tunnel syndrome. She clearly has significant headaches, though denies having headaches at all. She also obviously has trouble sleeping, though tells me she sleeps fine. She keeps asking me to address her carpal tunnel syndrome, but that's not the main issue here."



15% off tall scrubs with code "tall_savings"

Wednesday afternoon punting

Mrs. Migraine: "I need to go off Topamax, because my husband and I want to have another child."

Dr. Grumpy: "Okay. We'll see how the headaches do as I lower the dose. Are you on any other medications?"

Mrs. Migraine: "I'm on birth control pills. Will I have to stop those, too, before we try to get pregnant?"

(long pause)

Dr. Grumpy: "Why don't you ask your OB/GYN about that one."

Things that make me grumpy

Dave showed up at my office last week with neck pain, worsening weakness in his arms and legs, and changes in his bladder control. All signs pointed to something gone bad in his neck.

His internist had already thought of this, because he'd ordered the appropriate MRI's. And they'd all been read as normal, leaving me without a cause.

Here is where the problem began. EVERYTHING about Dave's exam and story pointed to something serious in his neck. But the tests were normal...

There are A LOT of MRI places out there. Some of them have good quality machines, while others haven't updated their machines, or software, in a long time. In addition to this, some places use specially trained neuro-radiologists to read MRI's, while others use general radiologists. So there's a different quality of reader, too.

This isn't meant as a slap against general radiologists. As a general neurologist, I don't claim to be exceptionally good at various subdivisions of my field, either. No one is good at everything, and recognizing our limitations is part of the job.

As a result, Annie and I have a short list of MRI places I use, where I trust both the equipment and radiologists.

But your average internist doesn't usually know the difference, as they're too busy with the insanity of a general medical practice. Most of the time the decision is made by a scheduling person, based on the patient's insurance, when the next available opening is, and maybe even what place brought them lunch. And, Dave, unfortunately, had his studies done at Shitty MRI, Inc.

So I called Shitty MRI, Inc., and asked for the films, which came the next day. The image quality was terrible, and Dave moved during the study. From what I could see, the films were unreadable.

But I'm not much of a radiologist, let alone a neuro-radiologist. So I dragged the films to someone I trust. She agreed. They were unreadable and worthless.

Now, it might have been a tolerable situation if the reading doctor had dictated something about the films being useless, and recommended they be repeated with sedation, or on a different machine, or whatever. But instead he dictated them as normal.

So I needed another MRI, done on a decent machine, with sedation, and read by a neuro-radiologist. Easier said than done.

I ordered the study. His insurance denied it, on the grounds that he just had an MRI last week, and so they wouldn't pay for another.

I appealed it, and personally called their physician-reviewer. I told him the patient had something serious going wrong in his neck. I told him the previous films were worthless. I even offered to send him the films to look at himself.

He told me that I'd have to live with them, and it wasn't his fault that the ordering doctor had chosen that facility.

(For those of you who believe there aren't bureaucrats between you and your doctor, the above is how it's been in the U.S. for the last 15 years).

So I was stuck. And Dave was getting worse. What could I do?

I had only one option.

I admitted Dave to the hospital. It was a gamble. Once I had him in I could do whatever tests I wanted, but if I were wrong, it would be a nightmare to justify the admit to his insurance.

While I was working at my desk, Dave was rolling into the hospital's MRI. Within an hour the neuro-radiologist called me. Dave had a HUGE herniated disk in his neck, crushing his spinal cord. I called a neurosurgeon immediately, and 2 hours later Dave was having the disk, and it's threat of landing him in a wheelchair, taken out.

Dave did fine.

But the case is still pretty damn scary when you think about what might have been.

Why? Why? Why?

Dr. Grumpy: "Did you have any side effects?"

Mr. Bozo: "Nope."

Dr. Grumpy: "Did the medication help?"

Mr. Bozo: "No, it didn't do anything. Well, I shouldn't say that. I mean, I never got it filled, so I haven't tried it yet."

Blatant Plagiarism

In my continuing attempts to bring you awesome writing that deserves wide recognition, I'd like to present this comedy piece. It was recently written by my esteemed colleague Phathead. I take no credit for it at all, except to say I laughed quite hard.



Introducing Lipitor-HD

It seems as if you can get almost anything in 'HD' today. Oh no, HD is not just for televisions anymore. There are HD Sunglasses, HD paint, and I even saw a sticker on a mirror claiming it was HD quality.

Naturally, it would make sense for Big Pharma to jump in on this. And why not? They prey on the lack of knowledge the public has on drugs, so might as well kick it up a notch.

I'm sure it would go something like this:


NEW YORK CITY, NY - Today Pfizer CEO Jeff Kindler announced their newest product to be offered to consumers, Lipitor-HD."Everyone knows that Lipitor will soon be going off patent. As a company that's been unable to produce an innovative drug in years, it's imperative that we find some way to continue making money while doing as little work as possible", he said.

"One of the most popular terms signifying quality and wealth is the phrase 'High-Definition' or simply 'HD'. We decided that we needed to be the first company to produce a HD drug, and thus Lipitor-HD was born."

Kindler said Pfizer will explain to consumers that Lipitor-HD is Lipitor, but at a much higher resolution. This makes it more effective because a higher resolution automatically means it works better.

"Then we decided to market it in a 10,000 µg, 20,000 µg, 40,000 µg and 80,000 µg (instead of the previous 10mg, 20mg, 40mg, and 80mg) because bigger numbers mean that Lipitor-HD is more powerful than non-HD Lipitor."

It is expected that Pfizer will price Lipitor-HD at a 50% markup from the current price of Lipitor.

"The increase in price is representative of the fact that we'll continue to make sure the public believes our product to be vastly superior to any generic counterpart."

Lipitor-HD is expected to hit pharmacies nationwide in Q3 2011.

Note: Lipitor-HD is a fictional product.

I'm quaking in my boots

Dr. Grumpy: "Look, I'm not going to give you any more narcotics."

Mr. Druggee: "This is very stressful, and you're not helping me. I'll just have to start smoking again, because of you. And when I die of lung cancer someday it'll all be your fault, and I hope my family comes after you and sues your ass to the poorhouse."

Mail call

So let's see. While I was gone I received:

27 job offers, all of them offering a huge salary, incredible benefits, and infrequent call in places with low crime rates, wonderful year-round climates, great activities, and excellent schools. None of them actually tell you where these places are, of course (they want you to call to find out). Perhaps on the banks of the beautiful river Wah-Hoo?

16 ads for medical education conferences on such topics as "The neurological manifestations of toenail fungus" and "Halitosis- Can you bill extra for putting up with it?"

1 letter to join the U.S. Army reserves, saying the army needs doctors with my skills (yet showing a picture of a guy doing surgery, which definitely ain't my skill).

7 offers to buy "exciting real estate opportunities" in medical office plazas.

8 letters inviting me to seminars on medical billing and coding.

24 ads from drug companies touting the virtues of their now once-a-day drug, which is otherwise identical to their previous twice-a-day drug (now available as a generic, of course) but costs 478% more per pill.

10 ads from financial services people holding "free" seminars at overpriced restaurants to help me manage my money.

5 ads for me to subscribe to journals I've never heard of.

3 ads to buy textbooks, such as "More about chronic back pain than you'll ever want to know, 34th edition."

1 ad from the Grumpyville Ballhogs wanting me to buy season tickets.

And a letter from a patient saying she was firing me for being out of town when she needed to see me.

The importance of using "at"

Reading the news tonight, and saw this headline:





Wow. I thought she'd just married ONE guy.

Returning to the trenches

Today I am flying home, while Mrs. Grumpy finishes her family visits. So while I travel, I leave you with one of my favorite poems.


The Cremation of Sam McGee

by Robert Service

There are strange things done in the midnight sun
By the men who moil for gold;
The Arctic trails have their secret tales
That would make your blood run cold;
The Northern Lights have seen queer sights,
But the queerest they ever did see
Was that night on the marge of Lake Lebarge
I cremated Sam McGee.

Now Sam McGee was from Tennessee, where the cotton blooms and blows.
Why he left his home in the South to roam 'round the Pole, God only knows.
He was always cold, but the land of gold seemed to hold him like a spell;
Though he'd often say in his homely way that "he'd sooner live in hell."

On a Christmas Day we were mushing our way over the Dawson trail.
Talk of your cold! through the parka's fold it stabbed like a driven nail.
If our eyes we'd close, then the lashes froze till sometimes we couldn't see;
It wasn't much fun, but the only one to whimper was Sam McGee.

And that very night, as we lay packed tight in our robes beneath the snow,
And the dogs were fed, and the stars o'erhead were dancing heel and toe,
He turned to me, and "Cap," says he, "I'll cash in this trip, I guess;
And if I do, I'm asking that you won't refuse my last request."

Well, he seemed so low that I couldn't say no; then he says with a sort of moan:
"It's the cursed cold, and it's got right hold, till I'm chilled clean through to the bone.
Yet 'tain't being dead — it's my awful dread of the icy grave that pains;
So I want you to swear that, foul or fair, you'll cremate my last remains."

A pal's last need is a thing to heed, so I swore I would not fail;
And we started on at the streak of dawn; but God! he looked ghastly pale.
He crouched on the sleigh, and he raved all day of his home in Tennessee;
And before nightfall a corpse was all that was left of Sam McGee.

There wasn't a breath in that land of death, and I hurried, horror-driven,
With a corpse half hid that I couldn't get rid, because of a promise given;
It was lashed to the sleigh, and it seemed to say: "You may tax your brawn and brains,
But you promised true, and it's up to you, to cremate these last remains."

Now a promise made is a debt unpaid, and the trail has its own stern code.
In the days to come, though my lips were dumb, in my heart how I cursed that load.
In the long, long night, by the lone firelight, while the huskies, round in a ring,
Howled out their woes to the homeless snows — Oh God! how I loathed the thing.

And every day that quiet clay seemed to heavy and heavier grow;
And on I went, though the dogs were spent and the grub was getting low;
The trail was bad, and I felt half mad, but I swore I would not give in;
And I'd often sing to the hateful thing, and it hearkened with a grin.

Till I came to the marge of Lake Lebarge, and a derelict there lay;
It was jammed in the ice, but I saw in a trice it was called the "Alice May."
And I looked at it, and I thought a bit, and I looked at my frozen chum;
Then "Here," said I, with a sudden cry, "is my cre-ma-tor-eum."

Some planks I tore from the cabin floor, and I lit the boiler fire;
Some coal I found that was lying around, and I heaped the fuel higher;
The flames just soared, and the furnace roared — such a blaze you seldom see;
And I burrowed a hole in the glowing coal, and I stuffed in Sam McGee.

Then I made a hike, for I didn't like to hear him sizzle so;
And the heavens scowled, and the huskies howled, and the wind began to blow.
It was icy cold, but the hot sweat rolled down my cheeks, and I don't know why;
And the greasy smoke in an inky cloak went streaking down the sky.

I do not know how long in the snow I wrestled with grisly fear;
But the stars came out and they danced about ere again I ventured near;
I was sick with dread, but I bravely said: "I'll just take a peep inside.
I guess he's cooked, and it's time I looked"; ... then the door I opened wide.

And there sat Sam, looking cool and calm, in the heart of the furnace roar;
And he wore a smile you could see a mile, and said: "Please close that door.
It's fine in here, but I greatly fear, you'll let in the cold and storm —
Since I left Plumtree, down in Tennessee, it's the first time I've been warm."

There are strange things done in the midnight sun
By the men who moil for gold;
The Arctic trails have their secret tales
That would make your blood run cold;
The Northern Lights have seen queer sights,
But the queerest they ever did see
Was that night on the marge of Lake Lebarge
I cremated Sam McGee.

Grumpy Summer Vacation, Day 17

This morning started when someone (I can’t imagine who) put the mannequin outside my MIL’s window.

Today we went whitewater rafting. Our guide, I swear, was a guy named Stoner.

Craig, of course, was horrified at the idea he might get wet, and so insisted on sitting in the middle of the raft. Frank and Marie loved the idea of getting soaked, and even wanted to help row. So Stoner gave them each a paddle.

For a while they were somewhat helpful, and it kept them busy. Until we hit a stretch of non-rowing quiet water.

Somehow a shouting match broke out, and I turned around just in time to see them beating each other WITH THE PADDLES while Craig tried to hide in the bottom of the raft. Before I could yell at them to stop, Frank sent Marie’s paddle into the river. Craig, trying to avenge his sister, stood up and knocked Frank’s into the river.

And now we were heading into white water, with half our paddles gone. Stoner was clearly horrified to be watching his company’s property floating behind us, and began frantically steering the boat to try to get them, while Mrs. Grumpy and I paddled away. The next few seconds sent some big waves crashing over the raft, drenching everyone (including Craig). He began hitting Marie on the grounds that it was her fault he was wet, since she’d lost her paddle.

Fortunately, we were able to collect the paddles at the other end of the rapid run. But we spent the rest of the day hearing from Craig about how this was “the worst day ever” because he got wet. All the kids, when we got back to shore, agreed that they liked the river rides at amusement parks better. Wimps.

On the way home we stopped for burgers.

In most of the U.S. condiments are fairly simple: ketchup (yes, I know the Filipino’s like ketchup made from bananas, but I’m talking about the tomato kind), mustard, mayo, BBQ sauce, sometimes 1000 Island dressing. Preferences vary by person and region, but those are the basics

EXCEPT in Utah (and southern Idaho). In this area the main condiment is a concoction called Fry Sauce.

What is Fry Sauce you ask? Nobody really knows, because it’s wildly variable depending on where you eat. Each restaurant/roadstand/house has their own peculiar recipe for it.

But here’s the basic idea: imagine a bunch of typical condiments (ketchup, mayo, mustard, BBQ sauce, 1000 Island, relish, chopped onions, chopped pickles, Russian dressing, Ranch dressing, etc.), all on a shelf. Basically, Fry Sauce is a random combination of any number of these, and it’s usually a pink-red color. To make it I think they take a guy, blindfold him, spin him around 3 times, then send him into the pantry. The first 3 bottles he picks up are what's go into that day’s Fry Sauce. As a result, when you get Fry Sauce, you have no idea what it’s going to taste like.

This evening the planned dinner was turkey & spinach burgers. This didn’t sound good to me to begin with. Then we discovered that the turkey meat had been forgotten. And by the time this was noticed, the town’s grocery store was closed.

So my SIL tried to improvise. She chopped up the spinach, and tried to get it to form patties by mixing it with egg whites, then grilling them.

This was a remarkable unsuccessful endeavor. Frank was convinced that we were either going to starve to death or be forced to eat bugs to survive. I was trying to convince them that they'd love to have hamburger buns with leftover Fry Sauce on them.

Then Mrs. Grumpy saved the day. She went out to the car, and brought in the Costco bag of pancake mix. This was a MUCH more popular item, and we had syrup and butter leftover from breakfast. After a dinner of pancakes everyone was happy, and thanked her for saving our lives. Except for the SIL left with a tray of untouched grilled spinach patties. Who was pissed. She forced her husband and kids to eat her horrible offering (though didn't touch them herself), and ignored the rest of the family who was eating pancakes.

We caught her trying to sneak out of the kitchen later, with a leftover pancake in her purse.

Attention kids

I overheard you playing with your cousins on the trampoline this morning, pretending you were all skydiving.

While this may work fine in an imaginary situation, for future reference:

If you jump out of a plane and forget your parachute, it is NOT good form to ask another falling skydiver if you can borrow theirs for a few minutes, and then give it back to them after you've landed, so then they can land with it, too. Gravity doesn't work that way.

Thank you.

Grumpy Summer Vacation, Day 16

Today we drove to Middleofnowhere, Utah, where my MIL has rented a large house for us to meet up with her, Mrs. Grumpy’s brothers, and their families for a few days.

Family reunions with this branch have always been interesting. In the past they’ve involved trips to the lake, which have ended with someone accidentally sinking a boat in shallow water. So this year they picked a place nowhere near a lake.

As we drove through Utah we had to stop for highway construction. A young guy holding one of those Stop/Slow signs brought our column of cars to halt. He motioned for us to roll down the window.

Mrs. Grumpy: “Hi.”

Mr. RM: “Sorry, folks. Road work going on. Gonna be about 5 minutes before the guide vehicle comes back.”

Mrs. Grumpy: “Okay.”

Mr. RM: “While you’re waiting, would you like a copy of the Book of Mormon?”

When we finally got to high-altitude Middleofnowhere, it was colder than we thought it would be. Unfortunately, we’d sent our jackets back home with my parents after the cruise.

All of us were fine except Craig, who was convinced he was going to die of hypothermia. So I set off to find a cheap sweatshirt.

This wasn't as easy as it sounds. We’re in the middle of nowhere, and couldn’t find a Wal-Mart (those of you who know how much I hate Wal-Mart will understand how desperate I must have been to be looking for one).

After driving through town (which took < 1 minute) I located the local store, which had some cheap sweatshirts. When I was checking out the guy at the cash register asked me “do you need any ammo or kerosene?”

My MIL has rented this HUGE house for the family reunion, so that each family can have their own bedroom. Whoever designed this place was remarkably fond of mirrors, and has them on, quite literally, every wall (and a few ceilings) in all the rooms & hallways. It makes me wonder if we’re being videotaped for some sort of “family reunities in the boondocks and kills each other” reality show.

Another oddity of the house is an old headless mannequin, wearing a white dress.




Exactly why anyone thought this would enhance the beauty of the place is beyond me. All it needs was some blood on the gown and ghost stories to scare the little kids.

Since getting here the thing has made the rounds, randomly showing up in various showers, closets, and beds.

One of my SIL's brought some gifts for the kids, leftover headbands from the movie "Kung-Fu Panda". Their are 5 types, each one listing a character's martial arts style from the flick. So they say things like "Monkey Style" or "Tiger Style". In retrospect, I guess it's a good thing there wasn't a doggie in the film.

When dinner finally rolled around, my MIL called a local place to order food, and my BIL Rob and I were designated to go pick it up.

Rob is an interesting guy. His job requires him to drive long distances between rural areas. To pass the time he installed a DVD player in his truck so he can watch movies while driving (I swear!). Ever since I married his sister he’s been after me to leave my job and open a lawn mowing service with him.

As we were driving along I noticed that the the DVD player had broken, and asked him what happened. He replied “Oh, I loaned the truck to this stupid kid who lives in town. While he was driving he accidentally spilled a milkshake into it. People are so fucked up these days. I mean, what kind of idiot would trust a kid like that?”

I didn’t bother to answer the question.

The sign in front of Local Dump said: “Take-Out Service: Pull up on east side of building, and we will bring it out to you.”

So Rob pulled up on the west side of the building, and stopped.

I wanted to be polite, so I didn’t say anything. I watched as someone drove up to the other side of the building, got their order, and headed off. Rob just sat there.

Finally he said: “I wonder where our order is?”

Dr. Grumpy: “Um, I think we’re supposed to be on the east side of the building. That’s what the sign says.”

BIL Rob: “I know, but we are on the east side.”

Dr. Grumpy: “We’re on the west side. See, look at the sun.”

BIL: “No, the sign meant east side as you look at the building from the road. We’re turned around now, and so the sides are reversed”.

Dr. Grumpy: “East and west don’t change. We need to be on that side of the building”

BIL Rob: “We’re on the east side. Trust me.”

It wasn’t worth arguing. So we continued waiting. After a few more minutes Rob went into the restaurant and came back with the food. He told me he hadn’t tipped the waitress, because she was an idiot who didn’t know the difference between east and west.