The teenage mind

I'm sitting at my desk, about an hour before my first victim patient. My wife is at a meeting out of town, but fortunately the kids are old enough to drive themselves to school.

Then the text came in.

Craig: Dad. I'm locked out of the car. I need help.


What the hell? School started 20 minutes ago!


Dr. Grumpy: Ask Marie for her keys.

Craig: I can't. She's at school.


WHAT?!!! Okay, this isn't making sense.


Dr. Grumpy: Then where are you?

Craig: I'm at 7-Eleven.

Dr. Grumpy: Why are you at 7-Eleven twenty minutes after school started?

 Craig: It was an emergency! I had to get something for class! Do you have keys to the 4Runner?


Sigh.


Dr. Grumpy: Yes. Which 7-Eleven are you at?

Craig: The one at South Street and Central.


So I tell Mary I'm going to rescue Craig and will be back in a few. Fortunately, South & Central isn't too far from my office.

I get to South & Central, and Craig is nowhere to be seen.


Dr. Grumpy: Craig, I'm at the 7-Eleven at South & Central, and you're not here.

Craig: Well, I'm at a 7-Eleven. Maybe it's not that one.


I roll my eyes, take out my iPhone, and look up his location.


Dr. Grumpy: Craig, you're almost 3 miles away, at the 7-Eleven at 12th St. and Elm.

Craig: How was I supposed to know that? Please hurry, I'm going to get in trouble at school!


So I head over and find him there, standing outside the car. As I unlocked it he picked up two Slurpee's in a cardboard carrier and set them on the floor.


Craig: "Thanks, Dad. I'm sorry."

Dr. Grumpy: "It happens. What did you need for school, anyway?"

Craig: "The Slurpees."

Dr. Grumpy: "You left school to get 2 Slurpees? This whole thing was over a Slurpee?"

Craig: "Slurpees. I mean, yeah, Marie wanted one, too."

Dr. Grumpy: "Why didn't you get them at the 7-11 by the school?"

Craig: "I went there first, but they don't start making them until 10:00. But I remembered there was another 7-11 down here."

And he drove off.

Random pictures

Okay, time to hit the mailbag for stuff you guys have sent in:


First we have this picture, taken at an airport, where bicycles using the bathroom is, apparently, an issue:

Then there's this place's answer to "what should we get grandma for Christmas?"

"Wow! Verapamil, metformin, morphine... this place has the best gifts!"

While we're on the subject of places to get gifts, who can forget...

Then there's this product so you can "keep balling all night."

And, finally, there's this happy-go-lucky coloring book about everyone's favorite viral-disease-of-cheerfulness, RABIES.

Holidays are coming!

So if you'd like to send in a horrifically tasteless submission for this year's Dr. Grumpy gift guide, please do so! My email is in the right sidebar.

Thank you!

IG

Frail

Like most neurologists, I do EMG/NCV's. This is a test that involves needles and electrical shocks.

It's nobody's idea of a fun test, but we do get a lot of information from it, and for many disorders it's the best test there is for sorting things out.

As a result, it's not uncommon for me to get a fax from another physician's office asking me to do one on a patient. They send over the insurance info and all, and Mary calls the patient to schedule it.

About a week ago I received a fax from Dr. Livingston. It was an order sheet that said "Please do EMG/NCV on Mrs. Geri, possible hand pain." Mary called her number, reached her daughter, and set up the appointment.

Mrs. Geri came in a few days later. She was in a wheelchair, pushed by her daughter. Advanced Alzheimer's disease and incapable of doing anything other than mumbling gibberish. Frail, maybe 90 pounds. Occasionally she'd randomly wave one or the other hand back and forth.

I asked her daughter why Dr. Livingston wanted the test, and her daughter told me it was because of the intermittent hand waving. She hadn't complained of pain (or pretty much anything else).

And... I couldn't do it.

Sorry, Dr. Livingston. The $250 I'd get for putting this poor old lady through an unpleasant test that she couldn't understand seemed more like an exercise in greed and torture than a diagnostic medical procedure.

Not that I really blame Dr. Livingston. I'm sure he was just trying to find out why she'd occasionally wave her hands, but to me it was immaterial. Even if I found something, after putting this sad lady through unneeded discomfort, what would really be done with that knowledge?

I explained this to the daughter and sent them on their way. The billing sheet and her insurance info went into the shredder. I took a loss on the hour and sent Dr. Livingston a polite letter explaining why I hadn't done the test.

I'm sure he can find another doctor to do it. Maybe someone hungrier than I, or less willing to ask questions.

But I just couldn't do it.

Mary's desk

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

Ms. Caller: "Hi, I'd like to make an appointment with Dr. Grumpy."

Mary: "Okay, and what will you be coming in for?"

Ms. Caller: "I have Spritzgong-Fleagle Syndrome, and need to have an MRI done annually to check for new damage."

Mary: "Okay, let's see... This week is pretty busy, but I can get you in next Thursday, at 10:15."

Ms. Caller: "That won't work. I was hoping to get in this week so I can get the MRI done soon."

Mary: "Are you having new problems?"

Ms. Caller: "No, my regular neurologist will be back from vacation next week, anyway."

Mary: "Wait... you already have a neurologist?"

Ms. Caller: "Yes, I see Dr. Stevens, at Huge University Hospital. She specializes in Spritzgong-Fleagle Syndrome, but she's on vacation until next week."

Mary: "Then... why are you calling to see Dr. Grumpy?"

Ms. Caller: "I thought he could order an MRI, then I'd have it when I see Dr. Stevens next week."

Mary: "I'm sorry, but he doesn't cover for Dr. Stevens. You'd have to call her office to get the test done, or wait until she comes back."

Ms. Caller: "Thanks for wasting my time."

Click.

Parenthood

Dr. Grumpy: "How's she doing with the new medication?"

Mrs. Daughter: "Calmer, but she still treats me like a child."

Mrs. Dementia: "Are we at the doctor's yet?"

Mrs. Daughter: "Mom, this is the doctor."

Mrs. Dementia: "How do you do? This is my daughter."

Mrs. Daughter: "He's met us before, mom."

Dr. Grumpy: "How are you feeling, Barbara?"

Mrs. Dementia: "Don't talk back to me, young man!"

Mrs. Daughter: "Mom, he's the..."

Mrs. Dementia: "You don't talk back to me, either! Go to your room, right now!"

Dr. Grumpy: "Barbara, it's okay."

Mrs. Dementia: "And you're grounded, young man!"

September

Reminding all the guys out there that it's Prostate Cancer Awareness month. So be sure to get checked. And here's some special guests to say more.

Wednesday afternoon

I'm in line at the bank, and hear this conversation in front of me:



Teller: "Ma'am, I'm sorry, but we can't give you a cash withdrawal without any identification."

Ms. Deceit: "How about I just get the money today? I can come back tomorrow with ID."

Teller: "No, we need a form of identification before giving you the money."

Ms. Deceit: "Like I said, I left my purse at work, or I wouldn't be here in the first place."

Teller: "Well, you can certainly get it and return later."

Ms. Deceit: "Don't be silly. For that kind of trouble I might as well go to different bank. How about if I give you my cell phone number? You can call it right now, and I'll put my phone on the counter. When it rings that will prove it's me."

Teller: "We can't accept that. What we need is a photo ID and..."

Ms. Deceit: "A photo ID is easy. Don't you have a computer back there? I'll show you my Facebook page, so then you can see my picture and know I'm telling the truth."

Teller: "Ma'am, Facebook isn't an acceptable form of identification, and we'd also need to see..."

Ms. Deceit: "This is why I prefer online banking. Places with people in them, like this, just aren't customer-friendly."

(she leaves)

Phone calls

I'm with a patient. Mary interrupts me to say there's another doctor on hold, who needs to talk to me.


Dr. Grumpy: "This is Dr. Grumpy."

Dr. Call: "Hi, we have a mutual patient, Mrs. Memory."

Dr. Grumpy: "Hang on, let me pull up her chart... Okay. It looks like I haven't seen her since 2014."

Dr. Call: "Okay, you need to pull her driver's license. I don't think she's safe to drive."

Dr. Grumpy: "I really can't do that after 4 years without seeing her. Why don't you have her family call Mary to bring her in? I can see her tomorrow morning at..."

Dr. Call: "That's ridiculous. She needs to have her license cancelled today. Immediately."

Dr. Grumpy: "Why don't you call the state DMV? You can do it, too."

Dr. Call: "I'm very busy! I don't have time to do things like that! This is your problem!"

Dr. Grumpy: "I..."

Dr. Call: "Okay, since you don't seem to be able to, I'll take care of it. What is the DMV phone number?"

Dr. Grumpy: "I don't know it off the top of my head, but you can..."

Dr. Call: "I'll just have my staff do it. You're not very helpful."

She hung up.

"Stand back!"

Seen in a bladder-flow report:

All I need is a miracle

Aimovig is the first FDA-approved drug specifically developed to prevent migraines.

It’s getting a lot of press. Some articles talk about it as a breakthrough, some on how it shows the pharmaceutical industry is now focusing on migraine as a real disease, some on how it represents a new era in diseases that affect predominantly women, and many other spins.

Of course, it isn’t alone. There are 2-3 similar agents on the launch pads to join it in the next year.

From my daily office view, the phone calls (and drug reps) come in, and inevitably I hear it referred to as “the miracle drug.”

“I want to try the miracle drug.”

“I saw an ad for that miracle drug.”

“Someone at work told me about this miracle drug.”

Amgen, to their credit (not that the FDA would allow it, anyway), has NOT claimed it’s a miracle drug. The information they provide doctors is the usual glossy graphics surrounding dry statistics and obligatory legal wording. (Note - neither Amgen, nor their competitors, or anyone else, has paid me to write this post. These are my own thoughts).

People seem to need to think a drug is a miracle, in spite of all evidence to the contrary. This isn’t a slight against Aimovig - it’s human nature. Just as people thought of the Titanic as unsinkable (a claim never in reality made by her builders, owners, or officers) there’s a desire to believe human intelligence has somehow overcome a problem and cured it.

It’s not like Aimovig is the first drug to get that label, either. Botox is a miracle drug. So was Imitrex in 1992. Interleukin-2 in the 1980’s. Penicillin in the 1940’s. Willow bark in 500 B.C. (that's where Aspirin came from, people). And too many others to list.

Are these bad drugs? Far from it. But, like every other drug ever discovered, they have a lot of limitations. They work for some conditions, but not others. They ALL have side effects (if someone tries to tell you a drug or supplement doesn’t have any side effects, they’re lying). And, most importantly, humans are not a biologically identical group. No medication will work for everyone. If you read the stats on any med you’ll see that approval is based on a percentage of people who respond to it - and it’s never 100%.

There is absolutely no way to predict with 100% certainty who will - or won’t - respond to any given drug. For that matter, there’s no way to know who will - or -won’t - have side effects, or even which ones.

This is a trial-and-error crapshoot, people. We make decisions based on facts, but an educated guess is still just that - a guess.

There is no such thing as a “miracle drug. " And there never will be.

You won’t hear me, or hopefully any other reputable physician, ever tell you that a drug or surgery or whatever is guaranteed to cure you, or has no chance of harming you. Medicine is about as imperfect a science as there is.

If someone is making such a claim to you, run away. They just want your money, and don’t care about helping you.

I’m not knocking Aimovig. For some people it will be life changing. For others it won’t do a damn thing. Still others will have an unpleasant side-effect. The jury on it and its cousins is still out, and will be for at least 2-3 more years.

But don’t go into any treatment plan, for anything, thinking it’s going to be a miracle. There’s nothing wrong with being hopeful, but you can still do that and keep reality in mind. Because in this field, there are no guarantees.

Memories...

 

In the mid-80's I had a medical school interview in Chicago. It ran over and finished about 45 minutes before my flight home. And the drive to the airport was around 45-60 minutes.

I went out and hailed a cab. The driver was a dude with a scruffy beard. I climbed in and asked him if he’d be able to get me there on time.

He looked at me in the rear-view mirror and said “do you mind if I smoke?”

I said no.

He lit a cigarette, mumbled “fuck” then yelled “HANG ON!” and slammed on the pedal.

I discovered my seatbelt didn’t work, but just kept my mouth shut.

I made my flight.

I gave him a good tip.

Annie's desk

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

Mr. Consultant: "Hi, I saw Dr. Grumpy last week, and he told me to increase my dose of Flookadook from once a day to twice a day, and it hasn't helped my symptoms at all."

Annie: "Okay, did the increase cause any side effects?"

Mr. Consultant: "No. Why would it cause side effects? I'm still taking it once a day, and haven't had any problems with it."

Annie: "But you said you increased the dose to twice a day?"

Mr. Consultant: "No, I said Dr. Grumpy told me to do that. I didn't say I had."

Annie: "So..."

Mr. Consultant: "Anyway, my symptoms aren't any better. Can you please ask Dr. Grumpy what I should do?"

Bueller? Bueller?

Seen in a chart: