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:

Sympathy for the devil

Please allow me to introduce myself. I’m Dr. Grumpy’s evil arch-enemy, neurological disease.

I’ve been around for a long, long year, stole many a man’s (and woman’s) soul to waste.

In the last year I’ve been in the headlines for my trifecta of stars with Parkinson’s disease: Neil Diamond, Alan Alda, and Linda Ronstadt.

The funny thing is that you people often believe life decisions or habits or activities can change your risk of meeting me. That may work for my friend heart disease, or for certain types of cancers, but me? Don’t kid yourself. Plenty of the things I do don’t have a known cause or risk factors, regardless of what some guy on the internet or TV tell you (and I bet he's trying to sell you something, too, claiming to cure it).

Others believe that a virtuous life will keep me away, or that I’m a punishment from God for being evil. You want good and evil? How about Pope John Paul II and Adolf Hitler (both Parkinson’s disease)?  You American evangelicals think you’re immune? How about Billy Graham (Normal Pressure Hydrocephalus). You think I care?

I especially love it when you try to attach political significance to me, like I’m here to punish someone on the side you disagree with. Let’s talk about Glioblastoma Multiforme, probably the most dreaded form of cancer there is. Here are 2 names from across the aisle, Ted Kennedy and John McCain. Here's another pair: Lee Atwater and Beau Biden. Political affiliations and age don't matter to me. The last pair were 40 and 46 respectively.

Before I forget, let’s talk about Alzheimer's disease: Ronald Reagan. Rita Hayworth. Charlton Heston. Glen Campbell. James Stewart. Perry Como. Jackie Fisher. Charles Bronson. Peter Falk. E.B. White. Rosa Parks. Burgess Meredith. Norman Rockwell. James Doohan. Fred Trump (yeah, his dad).

How about entertainers (besides those I mentioned above)? Slim Pickens. Gene Siskel, Ethel Merman, and George Gershwin (all Glioblastoma). Michael J. Fox, George H. W. Bush, Muhammad Ali (all Parkinson’s Disease). Terry Garr, Annette Funicello, Ann Romney, Richard Pryor, Montel Williams (all Multiple Sclerosis). Sir Laurence Olivier (dermatomyositis). Robin Williams (Lewy-Body disease). Dudley Moore (Progressive Supranuclear Palsy).

Let’s move to Amyotrophic Lateral Sclerosis, AKA Lou Gehrig’s disease or Motor Neuron Disease. This is probably the most dreaded disease in all of medicine. Obviously, Lou Gehrig and Stephen Hawking are the most well-known, but here are some other names: Mao Zedong. Catfish Hunter. David Niven. Stephen Hillenburg (creator of SpongeBob).

Epilepsy, while not usually fatal, can still have an impact on one’s life. Believed to be something to ashamed of for years, many places used to have laws on the books forbidding people with seizures from marrying or having kids. Here goes: Hugo Weaving. SCOTUS Chief Justice John Roberts. Bud Abbott. Vladimir Lenin. Neil Young. Lindsey Buckingham. Lil Wayne. Former U.S congressman Tony Coelho. Prince. Florence Griffith Joyner. Fyodor Dostoevsky. POTUS James Madison.

This list, of course, only covers famous people I’ve affected. There are far more who aren’t famous, but who are just as important. Somebody’s parent, grandparent, child, spouse, aunt, uncle, cousin, friend, co-worker, and many others. If I’ve touched them, then I’ve touched you. And you probably still remember both of us.

Years ago, I first met Dr. Grumpy when he switched from internal medicine to neurology, and I remember him telling me that it was a real shock. Back in medicine he saw mostly old people sick and dying, but in neurology it had shifted to younger folks. That discrepancy still bothers him after more than 20 years of doing this job. And it always will. He has me to thank for that.

So don’t go around making me a political, religious, age, cultural, racial, national, or whatever issue. I don’t give a crap about any of those things. I’m a human issue. If you think you’re special, and have done something that will guarantee I leave you alone, you’re wrong.

Seriously bad things, like me, can happen to you. Or anyone. Sometimes it’s just shit luck.

You don’t like that? There’s only one thing you can do. If you have some cash you don’t know what to do with, donate it to a reputable organization working to eradicate one of the diseases I’ve mentioned. Because research leads to knowledge, which leads to treatment. That’s the only way you may be able to get ahead of me.

'Cause I'm in need of some restraint.

Monday night, 11:18 p.m.

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

Mr. Vasculopath: "Hi, you were my neurologist at the hospital last week, when I had a stroke."

Dr. Grumpy: "Yes, what's up?"

Mr. Vasculopath: "Well, I'm really worried. You prescribed Otquoobo to keep me from having another stroke, and I read about it on AllDrugsArePoison.com. It says it's really dangerous, and so I haven't started it, and now I'm worried I'm going to have another stroke, and I got all upset."

Dr. Grumpy: "Okay, let's talk about it. Are you okay right now?"

Mr. Vasculopath: "Yeah, I'm better. I just smoked a pack of cigs to calm down."

"Hey, what's that smell?"

Seen in a chart:

Mary's desk

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

Lady: "Hi, I need to make an appointment with Dr. Grumpy."

Mary: "Sure. What will you be coming in for?"

Lady: "I've been falling a lot - I fell today, actually - and want to get my balance checked out."

Mary: "Okay. Our next opening is Tuesday, at 3:45, then Thursday at 9:00. We also..."

Lady: "Oh, I'll need farther out then that."

Mary: "Any idea when? Like a week, or..."

Lady: "Not sure. I mean, I broke my leg when I fell today. I'm in ER, being admitted to the hospital right now. I'm supposed to have surgery tomorrow morning, so I'll be here for a few days, and then they say I'll need to go to rehab for a couple weeks."

Mary: "Why don't you just call back when you know when you'll be able to come in?"

Lady: "Am I allowed to do that?"

Mary: "Of course."

Lady: "That's a better idea. I'll do that, then."

Weekend on call

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

Nurse: "Hi, this is Susan. I'm a nurse on the 7th floor, calling in a consult on room 7147."

Dr. Grumpy: "Sure. What's the story?"

Nurse: "He's a 22 year old who took LSD a few hours ago, in the park next to the hospital, and has since been really confused. His friends brought him to ER. Dr. Newgrad wanted neurology to see him for the confusion."

Pause

Dr. Grumpy: "Are you shitting me?"

Nurse (laughing): "I wish. I tried to talk Dr. Newgrad out of the consult, and suggested we just put on some Grateful Dead in there until it wore off."

It's a guy thing

Seen in a chart:

Birthday gifts

One of Dr. Pissy's staff has a delightful 2 1/2 year old girl named Rachel.

This summer, due to her babysitter being on a family vacation, Rachel is at the office most days. I'm sure this irritates some people, but at our little dumpster fire of an office, we don't care. She's fun and adorable, and is a pleasant distraction from the everyday routine of medicine.

Currently Rachel is in a phase where EVERYTHING is related to her birthday, even things that are not. For example:

Dr. Pissy: "Those are nice shoes, Rachel."
Rachel: "I got them for my birthday."
 
Dr. Grumpy: "Is that a good corn dog, Rachel?"
Rachel: "Yes. I got it for my birthday."

Random Patient: "Is that a horse you're drawing a picture of, Rachel?"
Rachel: "It's for my birthday."

(for the record, Rachel's birthday is somewhere around Christmas)

Yesterday, I was getting ready to leave and went to get my briefcase. For some reason Rachel followed me down the hall, and I didn't hear her behind me.

I picked up my briefcase, turned around, and WHACK! my briefcase hit Rachel on the side of her forehead. It wasn't too hard, but enough to surprise and hurt her.

"WAAAAAAAAAAAAAHHHHHH!"

Her mother (and most of the front office) came charging back to see what happened. I was trying to comfort Rachel (without much success) and as soon as she saw her Mom, she ran to her.

Mom: "Rachel, did you get hurt? What happened?"
Rachel: "DR. GRUMPY HIT ME IN THE HEAD FOR MY BIRTHDAY!"

Helpful

Actual fax received at my office:

Annie's desk

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

Mr. Tush: "I'm really not happy about this whole situation."

Annie: "Okay, what is..."

Mr. Tush: "Now they're telling me that my insurance may not cover the colonoscopy at all, and I can't afford this, so really don't want to go ahead with it."

Annie: "I think..."

Mr. Tush: "LISTEN TO ME! I'm not done yet. This is stupid. I'd never have agreed to go ahead with the colonoscopy except the doctor told me it was needed. I'm not going to pay for this and I want to cancel the whole thing. It's crazy that you people..."

Annie: "Sir..."

Mr. Tush: "NO! YOU LISTEN FOR A CHANGE. I didn't really want the colonoscopy, and now I find out it may not be covered, and..."

Annie: "LISTEN!"

Mr. Tush: "WHAT?"

Annie: "This is Dr. Grumpy's office. He doesn't do colonoscopies. You've called the wrong office."


Pause


Mr. Tush: "Well, shit. Sorry about that."

Click

Cue the "Jeopardy" theme

Dr. Grumpy: "Do you have a medication list?"

Mr. Time: "Nope, I know everything I'm taking."

Dr. Grumpy: "Okay, what are you on?"

Mr. Time: "The first one begins with 'T' and has a lot of letters."

July 4, 1939

"Fans, for the past two weeks you have been reading about the bad break I got. Yet today I consider myself the luckiest man on the face of the earth. I have been in ballparks for seventeen years and have never received anything but kindness and encouragement from you fans.

Look at these grand men. Which of you wouldn’t consider it the highlight of his career just to associate with them for even one day? Sure, I’m lucky. Who wouldn’t consider it an honor to have known Jacob Ruppert? Also, the builder of baseball’s greatest empire, Ed Barrow? To have spent six years with that wonderful little fellow, Miller Huggins? Then to have spent the next nine years with that outstanding leader, that smart student of psychology, the best manager in baseball today, Joe McCarthy? Sure, I'm lucky.

When the New York Giants, a team you would give your right arm to beat, and vice versa, sends you a gift — that’s something. When everybody down to the groundskeepers and those boys in white coats remember you with trophies — that’s something. When you have a wonderful mother-in-law who takes sides with you in squabbles with her own daughter — that's something. When you have a father and a mother who work all their lives so that you can have an education and build your body — it's a blessing. When you have a wife who has been a tower of strength and shown more courage than you dreamed existed — that's the finest I know.

So I close in saying that I might have been given a bad break, but I've got an awful lot to live for. Thank you."



-Lou Gehrig, terminally ill at age 36 with ALS (aka Motor Neuron Disease), in his retirement speech. He died less than 2 years later.

This is likely the worst disease in neurology, if not all of medicine. It's been 200 years since the first published report on it, and effective treatment remains a mystery.

If you're looking for a cause to give money to, consider the ALS Association.

Random pictures

All right, time to hit the mailbag for stuff you guys have sent in.


First we have this delightful hand lotion:

Then we have this playground equipment, apparently designed prior to Copernicus, or the discovery of the sun for that matter:

Here's a "trending" news item, apparently created by a random word generator in Wisconsin:

Here's a mystery question that a reader says was part of her on-line medical license renewal:

Then there was this guide to grilling that could have used an extra word:

Seen in a chart

The Master

In the 1980's Mojo Nixon claimed "Elvis is Everywhere." While anyone who visits Vegas might concur, I have to disagree.

Here, at Grumpy Neurology, Yoda is everywhere.

Sure, he may be in many disguises, but even a Jedi Master can't hide that characteristic language pattern from a trained DoC* like me.

The following are quotes I've encountered:

From patients:

"Twenty-one headaches I had in May. Many migraines that is."

"Make the seizures stop, can you?"

"I tried to talk, but speech-wise, I could not." 

"Much pain my back does have."

"Forgot you also this, Topamax, work it did not."


In an MRI report:

"Nothing abnormal does the MRI show."


From a nurse:

"Ativan received at 8:00, she did."


From a drug rep:

"Reduction in pain they will have, yes."


From my secretary:

"3:15 tomorrow his appointment is."


And (my favorite) was this patient interaction:

Dr. Grumpy: "You really need to stop overusing Excedrin."

Lady Rebound: "It's hard, but I'll try."

Mr. Rebound: "No! Do... or do not. There is no try."


*Disciple of Charcot

Blood pressure and other things

Mrs. Methodical: "My blood pressures have been good, too."

Dr. Grumpy: "I'm glad. What have they been running?"

Mrs. Methodical: "I have a list in my purse. Would you like to see it?"

Dr. Grumpy: "Certainly."

She rummaged in her purse for a minute, then handed me this:

GAAAAAHHHHH!!!

Dr. Grumpy: "Any side effects with the new pill?"

Mr. P: "Only one, it makes my urine smell like something terrible."

Dr. Grumpy: "Okay and what about..."

Mr. P: "I brought some, in case you want to smell it."

Pulls Tupperware container out of bag.