Patient quote of the day

Mr. Eosinophil: "I'm allergic to all man-made chemicals, including MSG, nitrates, glucose, oxygen, all proteins, and hemoglobin."

Negotiations

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

Ms. Oxy: "Hi, I need to make an appointment to see Dr. Grumpy."

Mary: "I can help with that. Our next opening is..."

Ms. Oxy: "Wait, before you get to that, I need to know how many Percocets Dr. Grumpy will allow me per month."

Mary: "Did you just ask me..."

Ms. Oxy: "Because my current doc only gives me 150 a month. I'm not going to switch unless you guys make this worth my while. I'm thinking 180 Percocet per month would be enough."

Mary: "Okay, we don't work that way."

Ms. Oxy: "Of course you do. Patients are money to you people, and you need the money. All right, let's say 170 Percocet. I'll settle for that."

Mary: "I think you should stay with your current doctor. It doesn't sound like you're a good match for this practice."

Ms. Oxy: "Okay! 160 Percs a month, and I'll do co-pays in cash, will..."

Mary hung up.

50 Shades of Blue

A few months back I poked fun at Fycompa, a new epilepsy drug with an interesting side effect profile. Little did I realize I'd have the chance to do it again (different drug this time) so soon.


Like neurologists everywhere, I was surprised to hear the news Monday about a newly reported side-effect concerning the epilepsy drug Potiga.

Namely, that it makes people blue.

I'm not talking depression here, either.

Let's look at the official FDA announcement:


"FDA is warning the public that the anti-seizure medication Potiga (Ezogabine) can cause blue skin discoloration... (and) does not currently know if these changes are reversible.

The skin discoloration in the reported cases appeared as blue pigmentation, predominantly on or around the lips or in the nail beds of the fingers or toes, but more widespread involvement of the face and legs has also been reported. Scleral and conjunctival discoloration, on the white of the eye and inside eyelids, has been observed as well."


Now, with that said, I want to remind you that if you look at the side effects of ANY drug, you'll find scary shit on all of them. I'm sure I'll put patients on Potiga, and most will likely do fine. But that doesn't mean we can't have some fun with it.

For one thing, they don't even tell you what shade of blue. There are 45 of them. Some people if given the choice, would like a nice turquoise, while others would prefer royal blue. Hopefully further research will shed light on this important topic.

The interesting part is this: Let's say a patient had a choice between this drug and one with a "YOU COULD DIE FROM THIS!!!" black box warning. Felbatol, for example, while very effective for seizures, has the potential to cause TWO (not one, but TWO) great ways to die: severe liver failure and/or destruction of your bone marrow.

Yet, human nature is such that most people would prefer Felbatol, figuring the risk of death is preferable to that of turning blue. After all, death generally isn't socially embarrassing. We ALL die. But blue skin? That's just not fashionable.

Unfortunately, GSK (the drug's manufacturer) is likely going to see this as a drawback to Potiga. They'll tell their sales reps to minimize it and move on to something else. Or mumble "and they might turn blue" hurriedly under their breath.

The truth is they should turn it around, and make it a strength of their spiel. The best way to do this, as I see it, would be to go after some commercial tie-ins.

I've compiled a few modest examples:


Live theater:

Potiga is a proud sponsor of tonight's appearance by:

Blue Man Group

1960's psychedelic movies:

United Artists

To treat seizures, All You Need is Love. And Potiga.

1970's psychedelic movies:

Paramount Pictures

"Violet Beauregarde has been seizure free on Potiga. Next month she'll be endorsing juicers, too."

2000's movies:

Twentieth Century Fox

Potiga for epilepsy: It's out of this world!

2000's remakes of 1970's psychedelic movies:

Warner Brothers

Potiga is now available as chewing gum for your patients who won't swallow pills. Violet Beauregarde set a world record with it!

Music acts:

Atlantic Records

"We're both proud to be on Potiga. Otherwise we wouldn't be able to drive as safely as we do."

Historical tie-ins:

Bunker Hill: Would history be different if British officers had given their men Potiga beforehand?

Using it as an excuse...

ABC television

"No, officer, he wasn't into that sort of thing. He's that color from taking Potiga."

Currently Potiga is only approved for ages 18 and up. But maybe it will work in kids. If that happens, GSK is fortunate to have a wide range of endorsers to choose from!

Dupuis Cartoons

Shaky Smurf, Seizey Smurf, Ictal Smurf, and Aurette are all doing great on Potiga! If it's right for Papa Smurf, isn't it right for your child?

And, of course, who could forget

Sesame Street

New Potiga powder! You can sprinkle it on all your child's favorite foods! EVEN COOKIES!!!

Thank you, SMOD, for bringing this to my attention!

Tuesday guest post

Today I'm honored to have a contribution from everyone's favorite man-on-the-beat, Officer Cynical!


Today I tried to stop a woman with a revoked license. We went 10 blocks with my lights and siren going, and she acted like I wasn't there.

She finally pulled into her driveway, and rolled down her window. The alcohol fumes rolling out of the passenger compartment were almost visible. She said she'd taken "some pain pills and a few muscle relaxants and maybe some other stuff" on top of it.

I arrested her and headed downtown. On the way to jail, she said she had to go to the hospital because "the left half of my brain is numb." So, to be safe, I took her to ER.

I told the ER doc what she said, and he responded (with a straight face), "Well, that doesn't sound right". He agreed with me that it was more likely the whole brain - not just the left half - that was numb.

He went out to my squad car in the ambulance port and told her, "When whatever you're on clears, if your brain is still numb you can come back." Then he signed off on the jail clearance and we left.

Outstanding.

Memories...

Years ago, Freebase Pharmaceuticals assigned a pretty blond sales rep to my office. Like most reps, she scheduled lunches with us here and there.

One lunch, in spite of the fact that Pissy and I, and our staffs, were there, she decided to try to increase sales by aggressively coming on to me. Asking questions like:


"Does your wife ever travel and leave you alone?"

"I live on the north side. Let me give you my number,  in case you're ever in that area."

"I have a meeting near here this Saturday. Any chance you'll be at your office that day?"


The highlight, however, was what she didn't know.

This was at a time when Mary was out on maternity leave. And filling in for her was Mrs. Grumpy.

Who was sitting directly behind Miss Hooters (who she figured was just the secretary).

So, while Miss Hooters was discussing her pharmaceutical wares and underwares, my wife didn't say a word. She just made faces at me over Miss Hooter's shoulder, occasionally holding up bunny ears behind the rep's head, or the finger, or her sandwich, or whatever office supplies were within reach.

Pissy, who had the same view of the show as I did, pretended to have a coughing fit to keep from laughing, and ran out.

"Dude, does this mean I have to roll my own?"

Actual CNN headline from April 26, 2013:

Dear OBG Management,

A colleague recently sent me a cover shot of this recent issue:

It looks pretty generic on the surface. Just another medical journal. But then you look closer.

A story on surgical robots? Fine. A story about vibrators? Okay. BUT DID YOU REALLY HAVE TO JUXTAPOSE THEM LIKE THIS?

Better living through machinery

I mean, in this sense it looks like an ad for a 1950's horror flick about giant vibrators from outer space, that arrive on Earth pretending to be friendly.

 

Of course, while we're on the topic of juvenile humor, I also noticed this headline in the top right corner:

Thank you, ER's Mom!

I'm stumped

Okay, people, time to see how good you are at being armchair neurologists.

This is an unusually challenging case I saw yesterday, involving a 54 year-old lady. Her internist had referred her to me because of  some recent changes in her vision. The following is quoted verbatim from my chart note:


"She has 2 glasses prescriptions, one for near and another for distance. 1 month ago she had an annual optometry check-up, and was told she needed a new near-vision prescription. She ordered the new glasses, and picked them up last week.

Since then she finds that when she puts on the new glasses things look “funny and unclear.” This resolves with taking them off, and doesn’t occur with the distance-glasses on, or using her previous prescription."


This case really has me stumped. So if any you are able to figure out what the problem is, please write in.

Mary's desk, April 23, 2013

Guy walks in, stands at counter.

Mary: "Hi, can I help you?"

Guy: "Yeah, I want to know if I need an MRI?"

Mary: "Let me look up your chart. When did you see Dr. Grumpy?"

Guy: "I've never seen him. I just want to know if I need an MRI?"

Mary: "I really can't say, sir. I'm not a doctor, but..."

Guy: "I have this neck pain, and my right hand feels numb. So does that need an MRI?"

Mary: "...but I can set you up with an appointment to see the doctor to discuss this. We have an opening Thursday afternoon at 2:30."

Guy: "I don't want to come in. I just want to know if I need an MRI, and if so, to get one."

Mary: "I can't answer that, sir, and the doctor would need to evaluate you before deciding what's needed."

Guy: "You people are just in it for the money."

Leaves and slams door.

Sleep deprivation

I couldn't sleep, so finally gave up and went to the hospital to see a consult that had come in during the night.

I sat at the nurses station and called up the CT scan on a computer. It looked like a stroke, but the dictation wasn't transcribed yet. So I dialed the radiologist covering nights.

Dr. Radar: "This is Dr. Radar."

Dr. Grumpy: "Hi, Mike. Can you look at the scan on Mrs. Platelet? It looks like she has a right frontal stroke."

Dr. Radar: "Hang on... No, that's not a stroke. That's volume averaging artifact."

Dr. Grumpy: "Really? It looks like a stroke."

Dr. Radar: "No, definitely volume averaging."

Dr. Grumpy: "Okay, thanks."

I hung up and was a bit surprised. I began writing a note, when a nurse came over to tell me Dr. Radar had just called back looking for me.

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

Dr. Radar: "Yeah, it's me again. Did you say right or left?"

Dr. Grumpy: "Right."

Dr. Radar: "Oh, sorry. The left is artifact. On the right, that's a stroke. Big one, too."

Prize giveaway!

Congratulations, sir! You've won a free clipboard!

Now, we at the Grumpy Neurological Emporium are pretty protective of our office supplies. It's been 4 years since drug reps were allowed to give us bountiful gifts of pens and post-it notes. But, in some cases, an exception should be made, and you, sir, are the lucky recipient of our benevolence.

Even in this digital age, every practice has paperwork. Usually it involves an info sheet with your contact information. You fill it out on a first visit, and maybe once a year after that. Mary hands you the clipboard and form when you come in.

Most people sit in the waiting room and fill them out while she copies their insurance card.

Why you decided to take it in the bathroom with you, I have no idea. But it was blank when you went in, and completely filled out when you exited 10 minutes later.

You can keep the pen, too.

Sunday reruns

One of my favorite patient quotes:

"I was on my way to my girlfriend's place and did some meth in the car because if I waited till I got there she and her roommate might use it all. But there was something wrong with it and I began shaking, and got real dizzy, and then began puking all over the steering wheel. Then my vision got blurry and I couldn't see the road very well, and I was afraid to pull over cause then a cop might come try to help me, and I'd be in deep shit, so to be safe I started driving as fast as I could to get to the nearest emergency room."

Theater

Mrs. Drama: "I apologize for being late. It's been an awful day. I lost my son this morning."

Dr. Grumpy: "Oh, that's terrible. I'm so sorry."

Mrs. Drama: "It's okay. We eventually found him playing games at the arcade."

Games and players

Recently, some of you may have seen ads for "Fresh & Sexy," a new product on the market with somewhat provocative ads. Basically, they're "intimate wipes," to be used for frantically wiping off your naughty bits in situations where you're filthy, and desperately need to clean up before getting laid.

Now, I personally have to question the need for this product, at least in civilized societies. The majority of us bathe regularly, and hopefully don't need such items. A friend of mine commented that if she were "in a situation where I was that disgustingly filthy, like a long camping trip away from water, I'm pretty sure I wouldn't have the wipes with me. Or be near a store where I could buy them." By the same token, societies where regular bathing is rare are unlikely to carry "Fresh & Sexy" in local stores.

There's also the point that people have been banging each other for roughly 2 million years, of which only the last 100 or so have seen regular washing. So filth, and the absence of "intimate wipes," has never stopped them for >99.9% of human history.

But this is modern marketing. Necessity is no longer the mother of invention. Nowadays, instead of making a product that people actually need, it's easier to make a product, then convince people they need it. It's how P. T. Barnum got rich.

The same trend is in pharmaceuticals. There are a lot of drugs that are legitimately useful, but some companies try to create drugs we don't need, then hope to convince us we do.

Let's take the fictitious drug Ophelicia, which is an overpriced knock-off of a cheap generic, polonicoxib.
 
R&G pharmaceuticals (the original manufacturer of both) knows their aging drug has been used off-label* for a boatload of stuff, and its profitable patent life is running out. So they're sinking research dollars into getting more indications for it, rather than, say, a new drug that might benefit people.
 
Sometimes you get a REALLY painful hangnail. It hurts more if you accidentally bang your finger on something, you can't pick your nose with it, and start screaming if Purell or salsa get on it.

There are MANY dirt-cheap generic drugs, such as polonicoxib, that can be used for a hangnail, all reasonably effective.

R&G, smelling a market opening, sinks a few hundred million bucks into getting Ophelicia OFFICIALLY FDA APPROVED for hangnail pain. Granted, their data didn't show it was any more effective than the 20 cheap generics out there, but now their sales reps can proudly say "We are the ONLY drug with an FDA approval for this debilitating condition."

Unfortunately, there aren't enough people with painful hangnails to make this indication financially worthwhile. Besides, any insurance company will force you to try 5 cheap generics before they'll let you think about prescribing Ophelicia and it's $20/day price tag (I agree with them).

BUT it adds to the razzle-dazzle. Your average doctor will figure it has so many indications for pain, it must be good for anything, and grab it off the shelf without trying a generic. It's much easier to hand someone a bottle of samples than it is to write a script (R&G knows this. Why do you think the companies give away all those samples?). If the patient is hooked, maybe they'll pay for it. Or the doctor will find it easier to have her staff fill out a pre-authorization form than call in for some cheap polonicoxib. After all, it's not her problem.

This gets back to the need for intimate wipes: Is it really there in modern societies? Probably not. But there isn't a need for a drug that's specifically indicated for hangnail pain, either. It's the game, and R&G and their competitors are simply players looking for an edge.

The key to selling is marketing, and the gold standard of marketing is making people think they need something that they don't.


*Prescribing it for something other than what the official FDA rules say you should use it for. This is very common. Odds are that you've taken something off-label.

Dear Kids,

As the weather warms up, I think it's great the 3 of you want to walk home together after school. It's about 2 miles, certainly nothing awful, and gets you home sooner than riding the bus, or waiting for me to finish at work, would.

I also think it's good you guys want to get some exercise now that the snow has gone.

BUT

Stopping about 1/3 of the way home at Kwik-E-Mart to get "snacks" of chili-dogs, candy, and slushees, then hanging out with friends there and calling me to come get you, is sort of defeating the whole idea.

I bet the Powerpoint can cure insomnia

A friend of mine does consulting work for the FDA. Recently she was invited to this meeting:

"I can't wait to go! The excitement is killing me!"

I couldn't do it. I am SO not the meeting type.

Memories...

One of the other residents in my neurology program was a nurse in her previous life. As a result, she moonlighted with a nursing registry at different hospitals, and made far more money than the rest of us starving residents combined.

So one night, when I was on call, I was woken at around 2:00 a.m. by a page from the ICU.


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

Dr. Violet: "Hi, Ibee. I need an order for Tylenol on Mr. Stroke. He spiked a fever."

Dr. Grumpy: "Peggy, is this you? What's going on?"

Dr. Violet: "He has a fever. The resident taking care of him didn't write a Tylenol order before they left."

Dr. Grumpy: "His resident is... HEY! He's your patient! You signed him out to me before you left."

Dr. Violet: "Uh... yeah."

Dr. Grumpy: "Why are you calling me, anyway? Why don't you order it?"

Dr. Violet: "I'm his nurse tonight, not his doctor. I have to page the resident on call, which is you."

Dr. Grumpy: "Am I on Candid Camera?"

Letting it all out

WHY? WHY? WHY?

Dr. Grumpy: "Are you right or left handed?"

Mr. Whack: "I write with my left, but masturbate with my right."

Phone calls

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

Mrs. Coordinate: "I'm calling to update my address, you have the wrong one."

Mary: "Okay, let me look this up... I show you as living at 42 N. Fred Gwynne Drive."

Mrs. Coordinate: "Yes, that's correct."

Mary: "All right, so it looks like we do have the right one."

Mrs. Coordinate: "NO, you DO NOT have the right one. Otherwise I wouldn't have gotten this bill with the wrong address on it!"

Mary: "But how did you get the bill if it had the wrong address on it?"

(pause)

Mrs. Coordinate: "I guess you do have the right address. Never mind."

(click)

Great moments in research

For whatever reason, Dr. Brian Mautz of Canberra decided to research penis size in the homo sapiens male, and how it relates to other body features.

I suppose there are a lot of oddball studies out there. Competition to get published is stiff, so you need eye-catching hard data to penetrate journals.

But this upstanding one just gave me the giggles.

It was published in the Proceedings of the National Academy of Sciences, better known by the acronym PNAS.

Dr. Mautz's co-authors included Drs. Wong and Peters, of Melbourne.

And, inevitably, Dr. Peters' first name is........ Richard.

Thank you, SMOD!

DANGER! DANGER, WILL ROBINSON!

EVERYTHING in medicine comes with a little packet of paper that tells you what it is, what it's for, how dangerous it is, and how to handle emergencies it might cause.

Bizarrely enough, this includes the most common liquid on planet Earth: water.

Yes water.

And this is the actual warning label that comes with water:

 

So, as per the last paragraphs, let's keep these important points in mind:

1.  If you accidentally get water in your eyes, IMMEDIATELY flush them with more water for 15 minutes.

2. If you accidentally drink water, induce vomiting.

3. If you get water on your skin, wash it off with soap and water.

4. If the water catches fire, extinguish it immediately with something "appropriate."

5. And always call poison control if you drink water! It says so!

Thank you, Webhill!

Whatever

Mrs. Adenoca: "I want you to know, right now, that I won't take any medications. I don't believe in your pills. I'm an intelligent woman, and I do a lot of research on my own. Every drug you use has the potential to cause cancer, and I know you doctors lie and say they don't. I'm smarter than that, and refuse to take anything that could do that to me."

Dr. Grumpy: "Didn't you tell me earlier that you smoke?"

Mrs. Adenoca: "Yes, 2 packs a day."

Dr. Grumpy: "And you don't think that causes cancer?"

Mrs. Adenoca: "You guys lie about that, too."

Neurology made ridiculously simple

Uh, where you fix a Prius?

Thank you, Jennifer!

Wednesday

Dr. Grumpy: "Have a seat, Mr. Needsglasses. Boy, I haven't seen you in about 10 years."

Mr. Needsglasses: "Wow. That long? I can't believe it."

Dr. Grumpy: "Yeah, it looks like you were last here in 2003."

Mr. Needsglasses: "Had no idea. 10 years. Boy, doc, you haven't aged well. You look awful."

Today's contest

A marketing rep dropped off a booklet today, featuring better living through a company's various gadgets. Normally it wouldn't get my attention, but with this picture it was hard not to stare.

So, let's all try to think of some creative captions. Here's a few to get started:

"Yes, nothing makes you smile like matching his & hers pelvic floor stimulators."

"Crank it up and we'll REALLY start swinging."

"These go to eleven."

It's fun to stay at the A.N.Z.C.A!

Next month, for those of you who don't follow meetings outside your own hemisphere, is the annual Australian & New Zealand College of Anaesthetists convention. This year it's being held in Melbourne.

Normally I don't pay attention to ANY meetings. Not even the ones in my own specialty, let alone someone elses' on the other side of the International Date Line. But my reader Rebecca (thank you, Rebecca!) brought this one to my attention.

All these meetings are composed of various lectures and workshops you sign up for, and this one is no different. Here's a sampling of the exciting courses available:

  

If anything sounds more stimulating than a course on coagulation management, I don't know what it is. Oh wait, I do. A can of Diet Coke.

But if you scroll farther down the list, there IS a stimulating course:

Of course, caffeine isn't the only thing you can learn about at the meeting. If your anaesthesia machine (the one that goes "ping!") is all tuned up, why not work on...

After that course, a few cups of coffee, and a bathroom break you'll be ready to move on to...

After a long day of such interesting meetings you've done all sorts of things, but on the way out of the building you discover the elevator has no windows and no doors, which offers you this chilling challenge: to find a way out!

Of course, there's always my way...

Annie's Desk

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

Mr. Lombardi: "Hi, I see Dr. Grumpy for my seizures, and he increased my Nomoshakin dose last week."

Annie: "Okay, let me look up your note."

Mr. Lombardi: "Anyway, yesterday I was playing football with my buddies, and one of them stepped on my left hand, really hard. Today that wrist hurts and is all swollen."

Annie: "Did you have a seizure?"

Mr. Lombardi: "No, but do you think the wrist problem is from the medication increase? Because I didn't have it on lower doses."

Patient quote of the day

"I understand, but I don't understand. Do you understand?"

Mary's desk, March 27, 2013

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

Mrs. Khwarizmi: "Yeah, I'm driving all over, and can't find your office."

Mary: "Okay, we're in Medical Office Tower 6."

Mrs. Khwarizmi: "Yes! That's where I am! But there isn't one marked 6!"

Mary: "We're the building farthest to the east. There's a sign in front that says 'MOT 6'."

Mrs. Khwarizmi: "I must be in the wrong place. The only sign I see just says 'motvi'."

Mary: "Motvi? Wait... Okay, you ARE in the right place. The 'MOT' sign uses Roman numerals."

Mrs. Khwarizmi: "Roman numerals? Damnit, doesn't anyone speak English anymore?"

WTF?

Doing a survey last night, one allegedly for neurologists, and this question came up:

Beyond shingles I really had no comment.

Memories...

My former call partner, Dr. Darth, had an office manager (Suzee). He eventually fired her and promoted his secretary (Floozee, who he was banging on the side) to office manager.

So when Suzee needed to see a neurologist a few months later, she made an appointment with me.

Unfortunately, she came in on a week when Dr. Darth was out of town, and I was covering for him.

So as Suzee sat in my lobby, leafing through "So You're Trapped in a Doctor's Waiting Room" magazine, Floozee came in with a bunch of MRI reports for me to review in Dr. Darth's absence.

The magazine and MRI reports were quickly forgotten.

They both had pepper spray. Mary had to call hospital security to get them out before anyone got hurt.

Perseveration

Mrs. Map: "Sorry I'm late, I had trouble finding your office. My iPhone gave me weird directions."

Dr. Grumpy: "That's okay. What bring you in to see me?"

Mrs. Map: "Well I..."

Siri: "Please turn right on 24th street, then continue west."

Dr. Grumpy: "Was that your phone?"

Mrs. Map: "Um, yeah, I guess she's still trying to get me to your office."

Siri: "Please turn right on 24th street, then continue west."

Dr. Grumpy: "Siri! She found it!"

Mrs. Map: "I don't know how to turn it off."

Siri: "Please turn right on 24th street, then continue west."

I reached over and turned off the phone.

Mrs. Map: "Wow! That bitch drives me nuts!"

Weekend reruns

It's been 3 years since I ran this post. And I still believe every word.


Nurses...

Are AWESOME.

I'm a doctor. We get all the glory. And credit. And guess what? We only deserve part of it.

I started out in medicine in the mid-80's, volunteering at an ER. And the biggest shock to me was learning how much of what happens in a hospital is nurse territory. Us doctors will see you from 5-30 minutes a day (30 is A LOT), depending on how sick you are. And the rest is the nurses.

They come in all shapes, colors, and sexes. Yes, there are a few idiots out there, that I take shots at in this blog. And there are idiot doctors, too. Idiots are in all fields, but the majority of nurses are damn good.

They're the ones making sure you get your pills, checking that your vital signs aren't dropping (and doing what they can to save your ass initially if they are, of which calling a doctor is only one part). They make sure you don't fall down and break something. If you start barfing, us doctors will run out of the room and the nurses will rush in. They change your wound dressings and start your IV line. They'll bring you a warm blanket. And clean disgusting things off you. Even if you're drunk. Or delerious. Or mean. And through all of this they try be friendly and positive. Even though you aren't their only sick patient.

I respect nurses A LOT. I learned early on that they're key to being a good doctor. You piss off the nursing staff, and you'll have a miserable career at that hospital. Respect and treat them well, and you'll never regret it. They're as important to being a good doctor as your medical degree. Maybe more.

If you come out of medical school with a chip on your shoulder against nurses, you better lose it fast. Because they will make or break your training, and often know more than you do. Be nice and they'll teach you. A good neuro nurse is often a better inpatient neurologist than some doctors I've met.

I remember a guy named Steve, who was an intern with me a long time ago. He had his head up his ass about being a doctor, and saw nurses as lesser scum. We were only a few months out of med school, and as we were writing chart notes one morning a nurse came over and asked if he'd go listen to his patient's heart. With icy contempt, and not even looking up from the chart, he said "I don't have to listen to his heart, because I looked at his EKG." They ain't the same thing, dude. If he'd listened he might have noticed that the patient had developed a loud murmer in the last 24 hours. When the attending caught it a few hours later, Steve got his ass chewed out. If he'd taken the nurse's advice, and listened, he wouldn't have gotten reprimanded by the residency board.

I talk about my Bible a great deal in this blog. Here's a quote from it: "Working with a good nurse is one of the great joys of being a doctor. I cannot understand physicians who adopt an adversarial relationship with nurses. They are depriving themselves of an education in hospital wisdom."

Those doctors are also depriving themselves of friends. On a shitty day on call, sometimes all it takes is a sympathetic nurse to temporarily add you to her patient list, steal you a Diet Coke from the fridge, and let you cry on her shoulder for 5 minutes. It doesn't make the day any less busy, but helps you absorb the punishment better.

What got me started on this?

While I was rounding this weekend, a grateful patient's family brought the ICU nurses a box of donuts, and so the staff was picking through them. One said "Oh, this kind is my favorite, it has cream filling."

And some pig in one of the rooms yelled "Hey, babe, I got my own kind of cream-filled dessert in here! Come have a taste!"

You say that to a waitress, and you'd likely get your ass kicked out of the restaurant.

You say that to a co-worker, and you'd be fired and/or sued for harassment.

You say that to a lady in a bar, and you'll likely get a black eye.

And what did the nurse do? In spite of the fact that the guy was obviously a detestable jackass, she went in his room, turned off his beeping IV pump, and calmly told him that he would not talk to her that way.

And I admire the hell out of that.

Nursing is a damn tough job. And the people who do it are tougher. And somehow still remain saints.

While this post isn't about them, there are a lot of other unsung heroes who are part of the hospital team- pharmacists, social workers, nursing assistants, EMT's, respiratory therapists, X-ray techs, lab techs, physical/occupational/speech therapists, housekeeping staff. And many more.

Hospital rounds, Thursday night, 7:10 p.m.

Dr. Grumpy: "What were you doing just before you blacked out?"

Mrs. Climax: "Having a MAJOR orgasm."

Reasons Mary drinks

Lady walks into office, signs in

Mary: "Hi... ma'am, your appointment was yesterday. We have you marked down as a no-show."

Mrs. Hansen: "I'm sorry, I had a family emergency. Can't you just see me today?"

Mary: "No, we're completely booked up."

Mrs. Hansen: "But I had an emergency!"

Mary: "I understand, that can happen. We can see you this Friday at 1:00 or..."

Mrs. Hansen: "Why are you doing this to me?"

Mary: "Excuse me?"

Mrs. Hansen: "I don't appreciate that you're treating me like a leper."

Mary: "Ma'am, I'm not..."

Mrs. Hansen: "This is so unfair! I had an emergency that wasn't my fault, and for that you're punishing me."

(pause)

Mary: "Do you want the appointment on Friday afternoon or not?"

Mrs. Hansen (scrolls through phone): "No, I'm meeting a friend at the casino."

Advice for grads (new and old)

A few years ago I signed up for an account with one of those "suggest-a-doctor" sites as a way to get business.

Shortly afterwards I began getting emails that "a patient has sent you an appointment request." Figuring it was a prospective patient, I checked them. My plan was that I'd forward the info to Mary to call and schedule them.

To my horror (I guess I'm naive) people who used the site had absolutely no interest in actually coming to the office. They just wanted medical questions answered online. For free (of course).

Examples of typical questions I received included:


"I've been dizzy on and off for years. I've had lots of tests and seen many doctors, but none of them can find the cause. Can you tell me what's wrong?"

"I can't afford my medications. Can you please put samples with my name on them out in your front office? 3 months worth would be good."

"I don't have time to go to a surgeon, so can you tell me if I need back surgery? MRI images attached."

"I live in Farfaraway, but am willing to travel to Grumpyville if you can cure me. I'll do this only if you offer a money-back guarantee, and cover my plane fare."

"I think my husband is more sick from taking his pills than he is without them, but he will only stop if a doctor tells him too. Can you call him and tell him to stop?"


NONE of these people were established patients of mine. As best I can tell, of the 200+ messages I received over time, fewer than 5% were within 100 miles of my office. Some were from overseas.

Besides the obvious money issues here (I have a family to support. I am not free.) is the legal one. This basically amounts to treating a patient without actually seeing or examining them. I worry enough about getting sued by patients that I do see, and don't want to add ones I don't to the list.

I finally deleted the account last year.

So here's today's advice from Dr. Grumpy: Don't even bother with these sites. Unless the idea of practicing free, legally dangerous, medicine appeals to you.

Ouch

My 2:00 patient had a large, straight, red mark on her forehead.

Mrs. Amana: "Sorry I'm a little late. I burned my forehead."

Dr. Grumpy: "I see that. What happened?"

Mrs. Amana: "Well, I was ironing some shirts, and needed to do my hair. So to save time I put my head on the ironing board, and started doing my hair, too. Then my phone rang, and I turned my head to answer it and..."

Why do I bother?

Dr. Test is down the street from me. He sends me infrequent referrals.

I consistently send him notes about visits, listing what, if any, tests I'm ordering. Within an hour of one being faxed I always get a return fax from his office, listing the tests that I just said I'm ordering, and asking me to send the results to him when they become available.

I don't know why, but I find this thoroughly irritating. I'm actually quite obsessive about sending letters and tests to referring physicians, and after years of doing so it annoys me that this one still asks. Of course, there's also the (likely) possibility that the letters go to a trained chimpanzee who reads the last paragraph, fills out the results-request form, and faxes it back without the doctor ever seeing it.

Last week, on a quiet morning due to some last-minute cancellations, I sent his office a fax on a non-existent patient saying I was ordering a "serum profactor 7-CoA." To the best of my knowledge there is no such test.

Within 15 minutes we got a note back saying "Mr. Non Existent isn't a patient in our practice. Please send us a copy of his serum profactor 7-CoA result as soon as it becomes available."

I amuse myself.

Patient quote of the day

"I'm looking through a fishbowl, but without fish. This is because my left toenails are all pale, which explains my neck problems."

(no, folks, the patient doesn't have a left cortical lesion. Or dementia)

Mary's Desk, March, 2013

Guy comes in, stands at counter, obviously angry.

Mary: "Can I help you, sir?"

Angry Guy: "Yes! I demand to speak to the doctor!"

Mary: "Okay, he's with a patient right now. What is this about?"

Angry Guy: "My wife saw him yesterday, and she says he told her she was fat!"

Mary: "WHAT? Sir, I've worked for Dr. Grumpy for 10 years, and he's never said anything like that to a patient."

Angry Guy: "Are you calling my wife a liar?"

Mary: "No, but I know Dr. Grumpy, and he isn't like that!"

Angry Guy: "Well, you're wrong! She even brought his card home!" (waves card in air)

Mary: "Uh, that card is for Dr. Frazzle. He's the neurologist down on the 2nd floor."

Long pause

Mr. Angry: "Well, all you neurologists are the same, and your doctor should still know better!"

(storms out, slams door)

Deja Vu

Filling out an insurance company's drug authorization form yesterday, I discovered this:

History rerun

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.

Sunday afternoon

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

Dr. Hospital: "Yeah, I need you to re-consult on Joe deMentia, who you saw last week."

Dr. Grumpy: "The guy with Alzheimer's disease? What's up?"

Dr. Hospital: "He has memory problems."

Dr. Grumpy: "Correct. I diagnosed him with Alzheimer's disease."

Dr. Hospital: "Well, he still has it. Can you come back and do something about it?"

"I've been through my MacBook on a drive with..."

Great radiology reports

From a thoracic spine MRI:

"Degenerative changes are seen at T3, T4, and TSH."

Mary's desk

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

Mrs. Crabby: "I need to make an appointment to see the doctor."

Mary: "Have you been here before?"

Mrs. Crabby: "No."

Mary: "Okay, so you'll be a new patient. We can see you on Thursday at..."

Mrs. Crabby: "No, I'm not a new patient."

Mary: "But you just said..."

Mrs. Crabby: "I've already seen another neurologist, and didn't like her. I just want someone else to tell me what they think."

Mary: "Yes, but if you've never seen Dr. Grumpy before, he'll need to take a history, and review tests you've had, and examine you."

Mrs. Crabby: "The other neurologist did all that. He can just read her notes, and decide. It won't take him more than 5 minutes."

Mary: "Ma'am, if you've never been here before he needs to take his own history and all."

Mrs. Crabby: "That's ridiculous. He can have 10 minutes of my time, no more. I'm very busy."

Mary: "I can ask him, but I'm pretty sure he'll say no."

Mrs. Crabby: "Don't bother. I'll find someone who can accommodate me."

Click

And I feel fine

Unless you lived under a rock, you were probably aware the world was supposed to end twice in 2011 (May 21, then October 21, per Harold Camping) and once in 2012 (December 21, per Mayan "scholars"). Exactly why they're so fond of the 21st remains one of those mysteries (I'm assuming because it's 1/2 of 42).

This is nothing new. Since the beginning of time, people have predicted the end of the world, thus far without success. The number of failed predictions is huge, and too long to list. People hoping for an apocalypse make Cubs fans look pessimistic.

William Miller (1782-1849) was another unsuccessful doomsday seer at 0-3. An American preacher, he initially predicted the world would end between March 21, 1843 and March 21, 1844 (again with the 21st!).

When the second date passed without incident he re-scheduled the apocalypse to April 18, 1844. Then, after nothing happened, postponed it to October 22, 1844. The last failed prediction so rocked his church that it became known as "The Great Disappointment" (why they were disappointed is beyond me).

Miller himself felt the errors were from incorrect translation of the Bible's chronology. He believed the end of the world was imminent, and continued to do so until it ended for him in December, 1849 at age 67.

There have been, and will continue to be, many others.

Now I, Dr. Grumpy, will tell you how, and roughly when, the world will end.

As the sun converts hydrogen to helium, it's luminosity will slowly increase over time. The rise in solar radiation will reach a critical point somewhere between 500 and 900 million years from now, reducing the carbon dioxide in Earth's atmosphere below the level at which plants can survive. As the plants die out, the amount of oxygen in the atmosphere will decrease, and all animals will be lost, too.

About 1 billion years after all life is gone, the surface temperature will increase to where liquid water can no longer exist, and the oceans will gradually vaporize into the atmosphere. Some will also collapse into the planet's mantle, due to venting of the mid-ocean geologic ridges.

What's left of the Earth, which will likely be similar to our neighbor Venus, will continue to orbit for another 3-4 billion years. At that point the Sun will reach the red giant stage of its life, and start to expand. Its increased size will take it beyond the orbits of Mercury and Venus, incinerating them.

The now widely-expanded solar atmosphere will gradually pull the Earth's orbit inward, until it too becomes ashes scattered through the outer layers of an aging star.

Eventually the Sun will throw off the outer layers, becoming a planetary nebula with a white dwarf star at the center.

The ejected layers will travel through space for another few billion years, eventually being taken up by a cloud of dust that's slowly condensing into a new solar system - just as ours formed 5 billion years ago - and again become part of a new star and its planets. Just as we're made of the base parts of a long dead solar system, so we will become another.

And that's how the world will end. And begin, again

My dogs couldn't care less about the end of the world. And I will take that cue from them.

The heat is on

You've just driven your Pontiac through the side of somebody's trailer home.

Now, the cops are after you.

To make matters worse, you aren't wearing shoes or (for unclear reasons) pants.

You also have a suspended driver's license.

And (of course) you're drunk.

There's only one thing to do: Steal the nearest vehicle from its owner and try to escape.