Neurology, 2011

Dr. Grumpy has lost his neurology mojo over time.

Actually, I shouldn't say I've lost it, as much as it's been worn down by red tape.

Yesterday I turned away a good hospital case, and told them to find someone else.

The patient was insured. The patient was interesting. Not some run of the mill chronic back pain case.

28 year old guy admitted for abdominal pain and weight loss. Large mass found (possibly lymphoma). Within 2 days of admission he developed 2 separate cranial nerve palsies, on opposite sides.

Now, I know you residents and medical students are out there, holding up your hands and yelling "Oooh! Oooh! Mr. Kotter! He could have meningeal lymphomatosis with cranial nerve palsies! He needs an MRI and spinal tap."

Hell, you think I didn't know that? Like I said, these are the interesting cases that make the job fun.

So why did I tell them to find another neurologist?

Here's why:

The patient had seen another neurologist (who didn't come to my hospital) about a week before. He'd had an MRI done as an outpatient. He'd had a spinal tap done as an outpatient.

And yet, no one, including the patient and his family, had ANY FREAKIN' IDEA about which neurologist he saw (beyond "his office was on the west side"), or where the MRI was done, or where the spinal fluid had been sent for tests.

I don't care that someone else had already done the key parts of the work-up. I'm not looking to stand up as the great Grumpy, solver of the unsolvable. Any competent neurologist would know what to do.

And getting results is reasonably easy IF you know where to fax a release.

But in order to get the answer here I'd have had to try to track down a neurologist, an MRI facility, and a laboratory. And there are no shortage of any in Grumpyville.

And from personal experience (particularly involving tracking down labs) I knew it could easily take an hour or more of phone time to do this. I've found that when you want something specific, delegating it to an order in a chart ("please get outside labs from Planet Phlebotomy") will often get you nowhere, or some results you didn't want. So I'd likely be doing the calling, and getting transferred between departments, and then cut off, and having to call back... you get the idea.

When you have a full-time office practice, and a family of 5, adding an extra hour or two to the day isn't something you want to do. Especially when you're going to get paid the same amount for the consult no matter how much work you put into trying to track the results down.

And so I quietly told them to call another neurologist.

I still like what I do. But the realities of time, money, and frustration can dull the scientific curiosity of anyone. Even me.

Do not try this at home

No matter how easy surgery looks on your favorite TV show, it should only be done by trained professionals.

Also, it is not recommended that you try to staunch blood loss with a lit cigarette.

Like this guy.

Thank you, Lee!

Helpful

Dr. Grumpy: "Do have your MRI report here?"

Mr. Lumbar: "No, but it said I have disks in my back."

Dr. Grumpy: "Everyone does. Did it say anything more specific?"

Mr. Lumbar: "Um, it mentioned bones, too."

Fun with drugs

Wild times with hallucinogens.

Sunday night. 11:35 p.m.

"I know the waiters there spit in my food, because they don't like people who just eat salads. I told the waiter that I had special powder I'd sprinkle in my salad to show traces of saliva, so he better not try it. But now I'm afraid to go anywhere else, because the food servers throughout the country are conspiring against me. They've hired a chemist to find ways to make it so that their spit doesn't show up with my special powder, and my powder doesn't work now. I know they're still secretly spitting in all my food, so I need to hire someone to make me a new powder that will detect their invisible saliva. Does Dr. Grumpy do this sort of thing? Please call me back in the morning."

Memories...

The brain that would not die...

In 2005 I took care of a patient with Jakob-Creutzfeld disease (or Creutzfeld-Jakob, depending on where you trained). This an uncommon, rapidly progressive, neurological disease.

My patient's family got in touch with a research program at the NIH, where they were collecting brains from these patients for further studies. So after he died later that year, his brain was sent off to their research center.

To this day, once a year, around the time he died, I get a letter from the NIH, asking how the patient is doing.

I used to write back pointing out that THEY had his brain, and to ask him. Now I just toss them.

Today, on the Travel Channel

One of my friends was recently on a trip to China, and sent back a few pics.

This one shows the location of a party school. I suspect there's a big difference between the American and Chinese definitions of "party school".

(click to enlarge)





In his hotel room, among the usual amenities, was a box of condoms. Obviously, these people take their birth control seriously.

(click to enlarge)





This last one, which I'm not going to comment on (that's your job) he says was taken in a generic shopping mall, in a store that featured local crafts.

(maybe you shouldn't click to enlarge)

The joy of Wikipedia

It was pointed out to me that the entry for IRNA, the Iranian government's news agency, lists their website as having started in 1981.



This is very impressive. In 1981 I was in high school. My computer at the time was a TRS-80 (top-of-the-line model, with 16K of RAM!) and in spite of all that technical saavy I'd never heard of webpages. I didn't learn about such things until the mid-90's, during my residency.

Friday afternoon whatever

Dr. Grumpy: "What kind of exercise are you doing?"

Miss Fit: "Yogurt."

Dr. Grumpy: "You're on a yogurt diet?"

Miss Fit: "No, yogurt. The exercise thing, where you hold different positions and stretch."

Dr. Grumpy: "You mean yoga."

Miss Fit: "Whatever."

Urgent matters

Last night I saw a hospital consult, with the following admission note:

"On Saturday, while packing his car, he suddenly felt lightheaded, followed by right-sided weakness and slurred speech. He didn't seek medical attention at the time. In fact, he and his wife drove to Connecticut that day for a short vacation. All symptoms have since persisted, and upon returning to Grumpyville this afternoon they went home, unpacked, and then came to ER for evaluation."

Balancing act

Medicine is never an easy field. People accuse doctors of not doing enough, or doing too much.

There are no easy answers. We're caught between doing what's best, without putting the patient through too much, and doing what's needed to protect ourselves from legal action.

Let's take Mrs. Summer. She's a nice 78 year-old lady I saw in the office last week.

Earlier this month she hurt her back. So she saw her internist, who correctly diagnosed her with a muscle strain. He gave her a muscle relaxant and Tylenol #3.

A few hours after she took the medications she became confused and sleepy. Her family called Dr. Internist, who said to stop them immediately.

She was absolutely fine the next morning, but her daughter is a nurse at the hospital, and wanted me to have a look at her for the episode. So she called Mary, and they came in last week.

The odds are that all she had was confusion due to Tylenol #3. So do nothing. It's most likely and least expensive.

BUT maybe she had a TIA. If I don't correctly diagnose that, and she has a big stroke, than they could sue me. So let's order a brain MRI, head & neck MRA, and echocardiogram. That's a few thousand dollars in tests.

Or maybe she had a seizure, and needs to be started on seizure medications. So lets order an EEG, too. Another $500.

Perhaps it was a metabolic event, with her blood sugar getting too low. So I'll order some labs. That'll be another $500-$1000 depending on how much I order.

This is the dilemma your doctor faces each day, many times over. None of us come to work saying "Oh boy! I can't wait to drive up the cost of health care today!" But we're faced with finding an (at times) impossible balance.

We don't get a 2nd chance, either. If we guess wrong we run the risk of getting sued. Another doctor is always willing to make a living as an expert witness and testify that we are incompetent.

And yet, with this sword of Damocles hanging over our heads, I and thousands of other doctors do this every day. And try to do the best we can, within the limits of human fallibility.

High speed chase

Look, people. If you're planning on being a crook, you need a decent getaway vehicle to outrun the cops.

You should NOT pick something that they can catch on foot.

Thank you, Jok!

Guess again

Dr. Grumpy: "Have you ever had surgery?"

Mr. Hollow: "Yeah, they took out my internal organs."

Dr. Grumpy: "Which ones?"

Mr. Hollow: "Um, I don't know. All of them?"

Maybe I should dress better

Yesterday a drug company hired me to do a lunchtime talk at an office down the street. It wasn't one I'd ever been to before.

I showed up at the appointed time, and politely waited at the front desk. After a few minutes a lady noticed me, and before I could speak, she said "Oh, glad you're here. Go through the door, and down the hall. It's the 3rd room on the right."

So I obligingly headed that way. I found myself in a room with a few business machines, and no people. An odd place to do a lunch talk, but some offices have very limited space. So I got out my speaker's notes and quietly glanced them over while I waited.

A few people walked by and looked at me, but didn't say anything. Finally the lady who sent me in came back.

Office Lady: "Uh, you can start whenever."

Dr. Grumpy: "But there's no one here yet to give my talk to."

Office Lady: "Talk? What do you mean?"

Dr. Grumpy: "I'm Dr. Grumpy, here to give a talk on Fukitol..."

Office Lady: "Oh, I thought you came to fix the copier."