Attention staff!

This morning I dragged in early because I couldn't sleep. To keep it quiet at home I decided to brush my teeth and shave at the office. I keep stuff here for the occasional times this happens.

You guys know that I'm usually half asleep when I come in on these days.

If I figure out which of you filled my little toothpaste tube with K-Y jelly while I was gone, you're fired.

Mary's Desk, August 10, 2010

Man comes in, signs in, stands at counter. Mary looks at his name and checks the schedule.

Mary: "Sir, we don't have you listed for an appointment. In fact, it doesn't look like you've ever seen Dr. Grumpy."

Mr. Lost: "You're wrong! I have an appointment right now!" (whips out appointment card, hands to Mary).

Mary: "Um, your appointment is with Dr. Darth, the neurologist across the street. You're at the wrong doctor's office."

Mr. Lost: "So you people screwed up my appointment? Dammit!"

Mary: "Sir, your appointment isn't at this office. I'll call over to Dr. Darth's and let them know you're on your way. Do you know how to get there?"

Mr. Lost: "Of course I do! Where is it, anyway?"

Mary: "You go back to the street and make a left turn, go 1 block down, make a right, and it's the 3rd building on the left. Here's the address."

Mr. Lost: "I don't want to pay a co-pay, since this is you people's fault."

Mary: "Well, you can discuss that with his staff when you get there. I'll call now and tell them you're coming."

Mr. Lost: "My car is low on gas. Can you drive me to his office?"

Smells like left brain

A key epilepsy question (at least to a neurologist) is "Where in the brain is the seizure coming from?"

As a result of this, we neuro docs look for clues as to which side of the brain is the seizure trigger, so to speak (we call it "lateralization"). Sometimes the answer is obvious on MRI or EEG, sometimes it's more subtle. In those cases we have to look for details in the patient's history or exam that lead us to the answer. Different findings have what we call "lateralizing value", meaning how useful it is.

Now, I'm all for further research into this. But, I have to say, some researchers looking for new lateralizing features have gone a bit too far. Or at least shown a determination to notice things that I don't want to.

(Neurology word: "Ictal" means "seizure-related")

Click to enlarge





I'd like to thank the Science Marches On Department for bringing this important research to my attention.

Patient quote of the day

"Doc, you should have seen the way the blood was pouring out of my nose. It was, like, like, um, like really horrible diarrhea. Except it was red. And it was coming out of my nose."

Come on over, Mom, we're having a party!

I was doing some medical education credits online this morning, and came across this question. I just LOVE the 4th answer.


(click to enlarge)

Date night

Waitress: "Hi! I'm Lacey! I'll be taking care of you tonight. How are you folks doing?"

Mrs. Grumpy: "We're fine. How about yourself?"

Waitress: "So-so. My daughter spent most of the afternoon in ER!" (starts crying).

Mrs. Grumpy: "Oh... I'm sorry. Is she okay?"

Waitress: "She shoved a Lego up her nose!"

Dr. Grumpy: "Usually they can get those out."

Waitress: "The doctor there tried for, like 2, hours, and couldn't. So on Monday we have to take her to a pediatric ENT."

Mrs. Grumpy: "I'm sure she'll be okay."

Waitress: "Our specials tonight are meatballs fornicato..."

Memories...

It was the early 80's, and Big State University was under a reign of terror (okay, more of a reign of creepiness) about an evil criminal mastermind.

I don't remember his name, if I ever knew it at all. One of my co-workers dubbed him "The Mad Whacker". It was as good a title as any.

He had a fetish for buildings. Really. He was sighted in front of various places on and around campus, staring at buildings, and, uh, madly whacking.

But he had a preference for religious places. The Mormon center. The Campus Crusade for Christ office. The Jewish Hillel center. He didn't discriminate. He'd stand in front of them at night, and, if he didn't see anyone immediately around him, do his thing.

Enter into the picture young BSU student Ibee Grumpy.

He was thinking about becoming a doctor someday, so was looking for anything to pad his resumé. More importantly, he was interested in meeting girls. Or at least trying to figure out how to talk to one without barfing from anxiety.

So he joined the campus safety patrol. This group of dedicated (and similarly lonely, resumé padding geeks) carried radios and were tasked with walking girls to different locations around campus at night to help deter crime.

So one night, Student Grumpy was on his way back from walking a girl out to her car, and took a shortcut near the Catholic center.

And there he was.

I don't remember who was working dispatch that night. I think it was a guy named Rob. I picked up my radio, trying not to be too loud.

"Come in, Rob"

(for those of you who remember the scene in Ghostbusters, I felt like Bill Murray, mumbling into the radio "Come in, Ray. It's looking right at me, Ray." And like Bill Murray's character, I was hoping not to get slimed).

Rob: "Dispatch, what's up?"

Student Grumpy: "It's the Mad Whacker, Rob . He's in front of the Catholic Newman Center."

Rob: "Are you shitting me?"

Student Grumpy: "No! Why don't you call someone to come get him? I've only got a radio with me."

Rob: "Okay. Is he almost done?"

Student Grumpy: "How the fuck should I know? You want me to ask him?"

Rob: "Tell him to drop it and put his hands up."

Student Grumpy: "Will you send somebody?"

Rob: "I did, a campus cop is near you and is running over."

At this point the Mad Whacker heard us, and started to run away. Fortunately, the campus cop was already there, and the Whacker couldn't run very fast with his pants around his ankles.

I have no idea where Rob is today.

I never did date any of the girls I met working there, but you all know what happened to Student Grumpy.

I don't know what happened to the Whacker. He's probably teaching kindergarten somewhere today.

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.