Thursday

Mr. Vegas: "My wife is a nurse, and wanted me to see you. She says she knows you."

Dr. Grumpy: "Oh, where does she work?"

Mr. Vegas: "I have no idea. We just met last weekend."

Secrets of the Jedi Masters

Today I am going to reveal one of the deep, dark secrets of neurology. A secret so carefully hidden that this post could result in my excommunication from the neurobrotherhood.

Most doctors, in some way, are snobs. Some are money snobs (a malady not limited to medicine), others about where they went to med school, still others about their clientele, others about research.

And what are neurologists snobs about?

We are snobs about...

(looks around furtively and whispers)

Reflex hammers.

Yes, reflex hammers. The little rubber triangular thing your internist uses to tap on your knees.

But we're NEUROLOGISTS, damnit! We did 3 years of training to learn how to properly use a reflex hammer! Plus, while your internist will only tap on your knees, we have a bunch of other reflexes we check.

I mean, we have to do SOMETHING to make it worth your higher co-pay to see a specialist. Would Harry Potter carry around just any old wand? No! Reflex hammers are to neurologists as lightsabers are to Jedi.

This is what your internist likely uses:





It's called a Taylor hammer. Or Tomahawk. They give you one in med school. No self-respecting neurologist would EVER be seen holding one. It's like a toy to us, and we are specially trained to look down our noses at them with a "you call THAT a reflex hammer!" look.

Someone once pointed out to me that this was one of the very first types of reflex hammer specially designed for this purpose. My answer to that is that the Wright brother's plane was the first one built, but I don't see anyone catching one to Chicago these days, either.

The only thing (in the eyes of a neurologist) lower than a Taylor hammer is this bizarre contraption:




Yes, it's a sad attempt to combine a Taylor hammer and a tuning fork (another item commonly used by neurologists). In the Bible they called things like this "abominations unto the Lord" (or, in our case, abominations unto Charcot).

It's like a sofa-bed: when you combine 2 things, you often get something that isn't quite as good as either one alone. When I was in med school I thought these things looked cool and practical (it took up less pocket space in that stupid looking short white coat). Now that I'm a neurologist, I realize how worthless they are. If you ever have a neurologist use one on you, ask them how many box tops they had to exchange for their medical degree.

The only thing worse than either of the above is using the head of your stethoscope to check reflexes. Might as well put on a shirt that says "Beware! Greenhorn on rounds!"

Next up, and maybe a notch or 2 above the Taylor hammer:

This is a Buck hammer.



The Buck is a few notches above the Taylor. It means that you're somewhat serious about checking reflexes. It's often carried by neurologists on hospital rounds, because it's convenient to toss in your bag.

A word of warning- the top piece on most Buck's unscrews to reveal a sharp pin. This is a throwback to the pre-AIDS era when you could freely jab multiple patients with the same sharp object and not worry about spreading disease. If your doctor pulls one out of his hammer and tries to jab you with it, RUN AWAY. You don't know where it's been.

A few rungs up, and we get the Trömner hammer (or Troemner, depending on where you trained).



Now THIS is a good hammer. It's what I carry in my hospital bag. The picture alone can't convey what it feels like to hold one. Although it looks somewhat like a Buck hammer, in reality it's larger and heavier. It has a solid, reassuring, feel to it, like if the patient suddenly lunges, you can beat the crap out of him with it. No other reflex hammer gives you that sense of security.

For my pharmacy readers, my faithful Trömner actually was a gift from a Naprosyn rep. Which says more about me than I want to admit.

This is a Berliner hammer. I've never used this type.



It looks, somewhat reassuringly, like an axe (to keep the Haldol deprived at bay until the orderlies arrive).

Now we come to the royalty of reflex testing, the Queen Square hammer.



As simple as it looks, this is THE HAMMER for the serious neurologist. It's what I (and most) keep in our offices. It's nicely weighted and allows you to swing it easily from several directions to test reflexes in different limbs, without having to reposition yourself or the patient too much. It's not as solid as the Trömner, but if the patient attacks you can stun them with it (it breaks after 1 solid hit, don't ask how I know this) as you draw your other hammer.

But neurologists sometimes have to round at the hospital, and the Queen Square, with it's long stalk, doesn't conveniently fit in a black bag. So, if you don't like the Trömner or Buck, there's the Babinski hammer.



This is basically the smaller handle of a Buck hammer with the Queen Square head. The head usually tilts to the side and the handle telescopes to a smaller size so you can put it in your bag.

It has the bizarre history of having been introduced to the U.S. by neurologist Abraham Rabiner, who received his personally from the great Dr. Babinski himself. This was as a peace offering after the 2 of them had physically beaten the shit out of each other (REALLY!) during a debate over a neurophysiology question at a Vienna black-tie dinner (Hey, we neuro Jedi take this shit seriously).

There are a handful of other hammer types out there (Krauss, Wintrich, Ebstein, and Wintle to name a few), mostly variants of the above. Some of them, like Ebstein and Wintrich, are of mostly historical interest and no longer used.

That's reflex hammers in a nutshell. Now you have something to talk about when you want to see a neurologist, or pretend to be a neurologist, or want to score points on your neurology rotation, or end up on Jeopardy saying "I'll take 'Reflex Hammers' for $500, Alex."

And know, ye of lesser hammers, why those of us who wield a Trömner or Queen Square look down on you as unwashed heathens. And appropriately so.

Entomological Neurology, Inc.

Dr. Grumpy: "Any seizures since your last visit?"

Mrs. Thorax: "No, that issue is fine. But my big toe is killing me. A spider bit it this morning."

Dr. Grumpy: "What kind?"

Mrs. Thorax: "I don't know. What do you think?" (whips out tupperware with big ugly spider crawling around in it).

Tips for bank robbers

Okay. If you're planning on robbing a bank, please keep the following in mind:

If the teller asks you to show an ID so you can complete the robbery, you SHOULD NOT do it.

Take this guy, for example.

That's helpful

Mr. Vague: "My dad had Alzheimer's disease. Or maybe it was Parkinson's disease. It was some kind of disease. Do you know which one I'm talking about?"

Miracles of modern technology

Dear Dr. Hitech,

I think it's great that you recently felt the need to shell out a fortune for FUBARMED, the new computerized chart system that runs your office.

Apparently FUBARMED has a feature that lets you list me, or any other doctor, as a "consultant" in a patient's chart. I assume the idea here is to improve physician communication.

It seems like an absolutely great idea. You order an MRI, or labs, and your computer automatically faxes the results to my office, too.

In theory, that sounds nice.

But FUBARMED has no fucking clue what different doctors care about.

So it faxes me EVERY DAMN THING. Mrs. Patient (who I'm seeing for migraines) gets a pap smear? I get the results. She calls you with a runny nose? The phone note shows up on my fax machine (along with your delightful response "what color is her mucus?"). She needs a refill on her cholesterol medication? FUBARMED faxes me a notification, then a copy of your approval.

As far as I can tell, this great program of yours is functioning primarily to waste my time, paper, and fax machine toner.

Hoping to see one come over soon that says "Patient doesn't like Dr. Grumpy, wants you to take him off the consultant list."

Yours truly,

Ibee Grumpy, M.D.

Sunday Funday

Dr. Grumpy: "This is Dr. Grumpy, returning a page."

Mrs. Frantic: "Help! You see my mom for Alzheimer's disease, and she's completely out of control. She's walking around the house all day and night, and yelling constantly!"

Dr. Grumpy: "At her visit last week I gave you a script for Calmherdown for this problem."

Mrs. Frantic: "Yeah! It's in the medicine cabinet!"

Dr. Grumpy: "Did it help?"

Mrs. Frantic: "Oh, was I supposed to give it to her? I thought it was for me, to sleep through this!"

Weekend reading

While catching up on journals yesterday I learned that:

Some people's headaches will get better with Ibuprofen. Others won't. (Neurology Reviews, November, 2010, page 4).

Alzheimer's patients who are unable to care for their own needs are more likely to be placed in a nursing home than those who are still able to do so. (Neurology Reviews, November, 2010, page 10).

Parkinson's patients who are OLDER at time of disease onset won't live as long as people who are younger (Neurology Reviews, October, 2010, page 5).

March 12, 1944

It happened during World War II. But it isn't a war story.

It's about a basketball game. But it's not a sports story.

It involved medical students. But it's not a medical story.

It was 1944.

The Duke University Blue Devils had won the Southern Conference basketball championship. Surprisingly, though, the official university team wasn't even the best one on campus.

The military had set up wartime training programs at Duke, and brought in young men from all over the country. Many were good college players in their own right, but their schools had closed down athletic programs due to the war. So when they came to Duke they formed intramural teams.

The medical school team was considered, by far, the best (possibly the last time in human history that will be said). The players had all been stars at their previous schools. Although they never played each other, it was generally thought that the medical school team was better than the Blue Devils themselves.

It had also been a good year for another local basketball team, the Eagles of the North Carolina College for Negroes. Their coach ran an aggressive high-speed game, and they'd only lost once all season. But that was how it ended. Neither of the basketball tournaments (NCAA and NIT) allowed black colleges to participate.

The details on how it started are lost to history, but somewhere, somehow, the idea came to have the invincible Duke medical students meet the NCCN team on the basketball court.

In 1944 North Carolina this was unthinkable. It was actually a crime, and color lines were enforced. A few months earlier a black American soldier had been killed by a white bus driver for not moving to the back of a city bus fast enough (the driver was found not guilty).

Coach John McLendon of the Eagles liked the idea, and contacted his counterpart at the medical school. The white team was shocked. Such a thing was unheard of, illegal, and seemed to be just asking for trouble. But eventually their pride won, and they agreed to the game. As medical student player David Hubbell said, "We thought we could whup 'em."

The game would have to be played at the NCCN gym, because there was no way to get black students onto the Duke campus without drawing attention. They'd have a referee, but no spectators would be allowed. They'd play on a Sunday morning, when most of the town (and hopefully police) would be in bed or church. The doors to the gym would be locked as soon as all the players were inside, to keep anyone from seeing what was happening. Neither school administration was aware.

The medical students drove to NCCN with a winding route, to keep from being followed. They wore hats, and had their jackets pulled up partly over their heads to keep their skin color hidden.

Inside, the Eagles were very nervous. Aubrey Stanley (who was 16 years old at the time) later said "I had never played against a white person before, and I was a little shaky."

The game got off to a nervous start, with both sides making mistakes and missing easy shots. But they soon got into their routine. Duke went to their strong half-court game, and the Eagles played their speed attack. Stanley recalled "About midway through the first half, I suddenly realized, 'Hey we can beat these guys. They aren't supermen, they're just like us.' "

The second half was a blow-out, with the Eagles scoring almost every time they had the ball. Duke wasn't accustomed to their aggressive, high-speed, full-court game, the likes of which wouldn't be seen in the NBA for another 20-30 years.

The final score was NCCN 88, Duke Medical 44. Not even close.

And then, after the 2 teams had rested, the unthinkable happened: They played again, this time a mixed game, shirts vs. skins. Black and white on the same teams. A serious violation of state law.

A few NCCN students walking by the gym heard noise inside, looked in the windows, and saw this unthinkable match-up. Nobody called the police. It was amazing to watch.

Neither game ever happened by official records. There was no scorecard. Only the player's memories.

Jack Burgess was a Duke player. He was from Montana, and a few days after the game wrote to his family "we played basketball against a Negro college team... and we sure had fun and I especially had a good time, for most of the fellows playing with me were Southerners. When the evening was over, most of them had changed their views quite a lot."

In being able to tell this remarkable story, I (and all of us) owe a great deal of thanks to writer Scott Ellsworth. Without his determined research in chasing it down, it would have been lost to history.

Skool Nerse Time

This is Mrs. Grumpy.

Dear Principal Skinner,

I think it's an interesting project idea to have each 4th grade class develop their own identity. Like flags, secret codes, and secret claps. I understand this is a 2 week project, this week with students developing their own "countries" and next week sharing their ideas with other classes.

But I think you could have ended your talk better than with the line "Next week you'll visit other classrooms to share your clap with them."

And you wondered why the teachers in back began snickering.

Mary, bring me a Diet Coke. With rum.

Dr. Grumpy: "Anything going on at home?"

Mrs. Bright: "Just a lot of stress. My husband told me this morning he has a computer virus. I hope my daughter doesn't get it, because she's already missed 5 school days out sick this quarter."

Insurance Company Follies

I'd like to thank Kalie, who sent in this letter she saw from an insurance company.


(click to enlarge)

Mary's Desk, March 9, 2011

Guy walks in, stands at counter.

Mr. Tardy: "I have an appointment today with Dr. Grumpy."

Mary: "Sir, your appointment was at 10:00, over an hour ago. We have you listed as a no-show."

Mr. Tardy: "I spoke to you this morning, and you said to be here by 10:00, and I told you I'd try."

Mary: "Yes, but you're here at 11:15. I can reschedule you for later this week..."

Mr. Tardy: "Why can't you see me today? Traffic was bad."

Mary: "I understand that, but we're booked solid, and..."

Mr. Tardy: "When I called earlier you didn't even mention that traffic would be a mess today."

Mary: "Sir, I didn't know, but I did tell you to allow extra time."

Mr. Tardy: "This is bullshit. You don't have the courtesy to warn me about traffic conditions, and now you tell me it's MY fault that I'm late. I'm going elsewhere."

Today's fashion tip

If you're getting a haircut, and suddenly find yourself in need of a weapon, I can understand that the scissors being used by the stylist may be the closest thing at hand.

HOWEVER, after you're done stabbing someone with them, it's always important to complete your haircut.

Otherwise you run the risk of having a seriously bad hair day when the police take your mug shot.

Like this guy.

Thank you, Kathryn!