Jupiter is lovely this time of year

Dr. Grumpy: "Are you allergic to anything?"

Mrs. Flake: "Oxygen. I can't be anywhere near the stuff. I can't breathe it at all. Just being around it makes me horribly sick. I can only go places where there isn't any, so I don't accidentally inhale it."

Things that make me grumpy

All right, this just pisses me off. Here's a doctor who's been suspended for re-using prostate biopsy supplies on patients. NOT re-sterilized. Just using the damn things until they get "too bloody" to keep using. And we all know how clean that area is.

Wanna get angry, too? Here's the link. (Thank you, Andrew, for sending this in).

Stories like this aren't new. Since we invented money some people have always tried to find ways to rip others off.

But in health care it somehow seems worse. Nurses have done it, too. And pharmacists.

Why the hell would anyone do this? Especially after all the damn training we go through?

I'd like to think they're just stupid. It doesn't make it better, but it's somehow easier to accept than the more likely option: greed.

If the doctor keeps re-using the biopsy equipment, it's good for his overhead. He has to buy fewer supplies to do the same number of billable procedures. He may even be charging the insurance for a new kit each time he uses the old one.

The pharmacist knew what he was doing. Just greedy.

The nurse is a little less clear. Maybe she's just lazy. But who knows? Maybe she took the fall for a greedy hospital that secretly condoned such a practice. Maybe they were paying under-the-table bonuses to staff who found illicit ways to save money.

Regardless, ANY doctor, nurse, pharmacist, or other health care person, who does ANYTHING for personal gain at the expense of a patient, should never be allowed to do this job again. These people come to us for care, and screwing them over for your profit line is absolutely unforgivable.

To me, this is worse than fraudulant billing (example: charging for taking off a mole when you really didn't). They're both wrong, but when you intentionally put it a patient in harm's way just to make a buck, you should be banned from medicine forever (provided you haven't already been locked up).

In medicine the prime directive is "do no harm". This is a balanced statement, because obviously we DO harm: Surgeons cut people open. Chemotherapy can make you horribly ill. I do procedures with needles. The issue is that in these cases we're doing harm with the overall end result being (hopefully) for the better.

But when you cross to the dark side, and knowingly hurt a person to make some extra dollars, you should be hung out to dry.

And if you're in this field, and disagree with that, then get out of it now.

Medical students: I'm a PGY-18. And some fires never go out. And I hope they never do.

The Time-Traveler's Neurologist

This message was left on Mary's voice mail at 10:35 this morning:

"Hi! This is Mrs. Clock. I need someone to call me back at home. I'll be at the house until 10:15 this morning, and it's 10:30 now, so if you can call me back before I leave 15 minutes ago that would be great."

Ibee Idiot, M.D.

I'd finished an appointment yesterday afternoon, and was walking the patient up front.


Mrs. Crotchety: "You seem like a nice doctor, and smart too. I've seen 2 different neurologists before, both times when I was in Local Hospital. They were both incompetent idiots."

Dr. Grumpy: "Thank you. I'll get those records to review, and Mary will help set up this test."


I walked back to my office, and logged into the hospital computer system. The patient had seen neurologists there in 2005 and 2007.

And both times it was me.

Adventures with the Boy Scouts

Craig spent Saturday at a Scouts' activity, trying to earn his Craftsman badge. They were doing woodworking, clay, and other assorted stuff.

One of the projects was to make a roughly 4" tall ring-holder out of clay.

Without further comment, I'm now posting front & side views of the ring-holder my son made with the Boy Scouts.

Breaking news! Stop the presses!

When Dr. Grumpy was a teenager he had...

(head down, whispers)

zits.

Yes, that horrible scourge of adolescence. I had zits.

The pimples, as always, popped up at the worst time. Like the big honker on my nose just before a date. Or asking Suzy Weintraub out. Or other (by teenage standards) major-league events.

And yes, it was depressing. It made me feel ugly. And so (like many other teenagers) I invested my hard earned money in whatever product promised results. Because what girl would want to go out with a guy with a zit the size of Sheboygan on his forehead?

And, although you were ashamed to talk to other kids about zits, EVERY teenager obviously felt the same way. Hence, the enormous success of Zitzaway! and other skin care products aimed at adolescents. Hell, zits even had their own page in the unofficial puberty bible "What's Happening to Me?"

So, obviously, zits are a longstanding, well-known, part of adolescence, impacting emotions and confidence. Right?

Of course, actually having gone through puberty, or having kids doing so, just isn't good enough. Someone actually had to STUDY THIS!

And they found that (SURPRISE!) having zits in adolescence can effect the way you feel about yourself!

Really. Here's the article.

Weekend reruns

Due to the usual crazy amount of kid stuff, I'm re-running this from about 2 years ago.


Being a neurologist means sometimes being LOUD. In residency, no matter how quiet and soft-spoken you may be, you learn how to SHOUT, yet still be polite.

Is this because we deal with little old deaf people? A little. But the main reason is because we are frequently consulted to wake the dead (or at least try) and evaluate the comatose. In order to do so you need to make sure that this person definitely isn't responding. So you learn to be able to shout into their ears in the gigadecibel range, to see if they can actually hear you.

And you yell simple commands, trying to break through a wall of brain damage, drugs, and loud ICU machines to see if there's anyone in there. "MR. JONES! CAN YOU WIGGLE YOUR TOES FOR ME?" or "MRS. SMITH! CAN YOU SHOW ME TWO FINGERS?"

If you don't believe me, just ask any ICU nurse. They often carry their own earplugs for when they see a neurologist going into a patient's room.

This morning I got called in to evaluate a guy with brain damage named Mr. Dick.

So I did my usual shouting routine to try to wake him.

"MR. DICK! CAN YOU HEAR ME? CAN YOU HOLD UP TWO FINGERS?"

No response.

"MR. TOES! CAN YOU WIGGLE YOUR DICK FOR ME?"

Mercifully, the patient didn't respond. The nurses' station, however, broke down in hysterical laughing. So did the patient 2 doors down. I'm sure I turned bright red when I realized what I'd said.

Leave me alone. It's 5:00 a.m., and I haven't had a Diet Coke yet.

Kids

Mary told me a drug rep I like was up front, so I went to sign for samples and say hi.

Mrs. Rep: "Sign here... How have you been?"

Dr. Grumpy: "Fine. I thought your kids were on Spring Break this week?"

Mrs. Rep: "They are."

Dr. Grumpy: "Oh, I thought you'd said you were taking this week off to spend time with them."

Mrs. Rep: "I did, but they drove me nuts. This morning I couldn't take it anymore. I called in sick for my husband, and told him I was going to work. He can deal with them."

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.