Epilogue

None of us really had any warnings about my Dad's death. I mean, in retrospect there were a few things, but nothing that any rational person would have paid attention to. And you can beat yourself up all you want about "I should haves" and they won't change a thing. He was obviously depressed, but none of us ever suspected he'd go that far.

Death is inevitable for all. We grow up knowing that, in all likelihood, our parents will go before us and we'll go before our own kids. That's the natural order of life on Earth. There are exceptions, but, for most people, we know way in advance that the day will come when our parents aren't there. My parents watched their parents pass on, now it's my turn to watch mine do the same, and someday my kids will do the same with me. The physicists can argue all kinds of cool things about the nature of time, but here on Earth it pretty much has the same affect on all of us.

But nothing can really prepare you for the actuality of it really happening. Suddenly finding you can't email or call your Dad, like you just did the day before. I still see articles and think "I'll forward this to Dad, he'll love it..." and then stop.

Nor can it prepare you for the shock of what mine did. The phone call from my mom that fortunately came in the few minutes between patients. The tone of her voice and exact words. The frantic conversation with Mary about rescheduling the rest of the day. Seared memories that I'll carry with me to the end.

Dad was successful in life. He had health, family, and money to enjoy. All the reasons we think of for someone to kill themselves... he had none of them. But depression. And it can kill.

One thing I come back to repeatedly is the "why?" If he'd died of a heart attack... that would be so much easier to handle. The fact that a loved one would intentionally do something like this, to themselves and their family, is just devastating. You understand that they're not themselves or thinking clearly, but that doesn't make it any easier.

Of course, the gun didn't kill him immediately. Mom, my sister, and I stood at the bedside in ICU that afternoon, with various friends and other relatives who arrived. How word spread I still have no idea. I reviewed his CT scan myself. I kicked around moving him to a hospital with a neurosurgeon I trusted, but was stopped by the realization that this is what Dad wanted. Even though a good neurosurgeon would have been able to save his life, I've seen enough of this stuff to know he'd never be my Dad again. To this day that decision still haunts me, even though I know I did the right thing. It always will.

So, we let him go. Even with the tube out, and a shitload of Morphine and Ativan, his body wouldn't give up. So we all finally decided to say goodbye and leave forever. School was getting out, and I had to pick up my kids and figure out how to tell them.

Months before my wife had found an old alarm clock in the attic, and set it up in her home office to have a clock there. The alarm had never been set.

At 8:39 that night, we were all startled by a loud noise we'd never heard before. A search through the house found it was the clock's alarm going off, for no clear reason. The kids denied having touched it, and when I checked it was set for the default alarm of 12:00.

After staring at it for a few minutes, I called the ICU. "This is Ibee Grumpy. Has my Dad died yet?" "Why, yes, we were just about to call you. He died at 8:39."

We have an old musical wind-up cable car in the front hall that my wife picked-up on a trip to San Francisco 20 years ago. Nobody ever touches it. But for the next several nights it would randomly play a few notes after midnight and wake me up.

I'm a scientist. I don't believe in these things. But, on the other hand, I admit there are more things in heaven and earth than are dreamt of in our philosophies. Who knows?

The next day, while at my parent's house, I read through Dad's internet browser records. A lot of sites on how to beat depression, what to expect from your depression medications... not a single page about suicide or guns going back over a year. Oddly, the last internet site he'd visited was the day before he died... and it was this one.

I'd spoken to him a day or two before, and exchanged emails with him the day before. I sit and wonder why he didn't call me in his last minutes to ask for help. My wife's answer nailed it: "Because he didn't want to be stopped."

I still talk to him a lot. I probably always will. I'm not angry at him. But the one thought I'm left with more than any other will be with me for the rest of my life:

"Dad, it wasn't supposed to end this way."

Him

It was an old gun.

The man had bought the gun in 1967. He was a young lawyer, with a toddler and another on the way.

His wife was a schoolteacher, supporting their small family while he started a law practice. His father had been a cloth-cutter at a factory in Chicago, and worked long hours to support his family and pay for his son to go to law school. The older man had always believed in "give a man a fish, he'll eat for a day... teach a man to fish he'll eat for a lifetime" and wanted to do that for his son.

After graduating from law school the young man and his wife (they'd known each other since they were 15 & 14) felt like their future was elsewhere, and moved west. They left behind the only family they had and only place they'd ever lived. Most would follow them in a few years.

The man was 25 when his only son was born. A month later the man's father died at 66. It devastated him, and took him a year to recover. He was an only child and returned to Chicago to close things out, and his mother decided to move West to join the young family.

One day, after he'd won a divorce case, the lady's ex-husband threatened to kill him. Since the ex had a history of violence, the lawyer bought a small handgun and some ammo. He hoped to never use it, but also wanted to be able to protect his family. It wasn't even much of a gun. Just a .22 pistol, the closest thing to a pop gun among actual firearms.

The threat never materialized. The ex moved away, and the lawyer hid the gun in an old suitcase in his closet and forgot about it.

The man's law practice grew, and he became a successful attorney. He found his niche in life, and was good at it. He loved his work, but was also devoted to his family. As his kids grew he took time off whenever he could to do things with them. One day he and his wife called them in sick to school, so they could take them to the zoo instead. The family traveled to Hawaii. Up and down throughout western America. Europe. Mexico. Canada. Disneyland. The beach. River trips. National parks. Hawaii. Alaska. Nothing incredibly exotic, but fun. While not wealthy, they were comfortable. He worked very hard.

On a 1979 trip to Mexico City, his son remembers watching an old beggar shuffling down the street holding a bucket in one hand and shaking maracas in the other. He had no teeth, and both eye sockets were empty. The man watched the beggar, then walked over and put a handful of coins in the bucket. The beggar silently made the sign of the cross.

In a city full of people asking for money, this was the only time the man ever did that, and he told his son that some people truly needed help, and that was one of them. The boy never forgot that.

The boy grew up remembering hearing his dad get up early, like 4-5 in the morning. He'd listen to him get dressed, then the loud clumping of dress shoes going down the tiled hall to the garage, then the door lock, and his car drive away. Sometimes, if his son was awake during the summer, the man took him to work with him. He put his son in charge of making photocopies for his office when he was there. The boy loved this. Made him feel important. Sometimes, if he heard the man getting ready, the boy would cough loudly to show that he was up, hoping to get taken to the office on a school day... but it didn't work that way.

On rare occasions the kids got to go see their Dad in court. It was cool, watching him examine and cross-examine people. They could see why he was so highly regarded in local circles.

Life, as it will, goes on. The kids grew. One year, while poking around, the son as a teenager found the old gun. He quietly left it alone, locked in the suitcase. Once, during a teenage depression, he thought about it again, but never went back to see it. It was soon forgotten again.

As his kids grew the man took them on special trips. His son to Washington D.C., the girl to watch her favorite football team play in Los Angeles. He took them both Las Vegas, where he played (and won) tournament blackjack, and taught both kids to play, too. His son became a car geek for a few years. One morning, just to let the teenage boy look up close at a Lamborghini Countach that was on display, the man pretended to be interested in buying a Mercedes at a dealership.

The man and his wife aged well. He made it through a heart attack and his wife survived breast cancer. Together they traveled to Australia, Japan, Europe, Israel, Hong Kong... Places that when they were young they'd only dreamed of someday being able to see. Hard work and life had been good to this family.

Like kids do, they left the nest. The boy had always dreamed of being a doctor, and the man helped him get there. Tuition in the 1980's wasn't what it is today, but it wasn't cheap. The man, like his father, believed that you should do your best to support your kids' education so they could support themselves. His son came out of medical school with far less debt than he normally would have, and was able to start a practice and his own family. The man's daughter, to her surprise, discovered that being a mom was all she'd ever wanted, and so did that full time with her own kids.

The man and his wife saw time go by. Age brings both the good and bad, but for them it was still good. Love, 5 grandchildren, and their 50th anniversary. They celebrated the last in the company of family and many friends, most of whom had been at their 25th anniversary, too. We all have to get old, but doing so in the presence of good friends helps. Life has tragedy, comedy, and love, and it's good to have others to share them with.

A few months later the man became depressed, and it gradually worsened. There was no real reason for him to be depressed - he had everything anyone could possibly want -  but he did. He went to his regular doctor, then to a psychiatrist, and they both tried hard to help him.

Depression is REAL. And it hurts. The world is full of people who don't believe in it and deny that it's an illness. I encounter them in my practice and on trips to visit in-laws. One loves to use the phrase "people just need to put on their big-boy pants," as if her simplistic insight would magically solve everything.

I see politicians and insurance executives on the news claiming mental health doesn't need to be covered because it's not a "real" disease. In a world where fortunes are spent on breakthroughs for rare diseases a more common one - depression - takes a back seat because it's not a "real" disease. The most common treatment given is to tell people to suck it up and deal with it. And, speaking from personal experience, that only makes it worse.

The attitude of many toward mental illness today is not better than 200-300 years ago, when its victims were chained up in dungeons and forgotten.

But the man, fortunately, had good insurance. He was able to see a psychiatrist, and afford medications. And he tried hard. He really wanted to get better. He took them as directed, trying one after another, living with side effects. His family tried hard to support him. Calling him often, visiting when he was willing to see them, and telling him how much they loved him. But none of it seemed to help.

Then, one day when his wife had gone out to the store to get some things, he remembered the old gun.

Dad, I miss you so much.

Patient quote of the day

"When I wake up every morning I have blood pressure."

Statistics

Saw this in a report:

The way it reads, I can't help but to interpret it (albeit erroneously) to mean that 99% of people taking aspirin for secondary prevention of CV (cardiovascular events) did experience a life-threatening GI bleed.

Stages of weekend call

Food

Stage 1: I'll get something healthy, maybe a salad, in the cafeteria.

Stage 2: Are there any bagels left in the doctors lounge?

Stage 3: There are Graham Crackers in the nurses station galley.

Stage 4: I see old Cheetos under the ICU fridge.



Transportation

Stage 1: I'll take the stairs up to 5. I need the exercise.

Stage 2: I'll only use the elevator if it's more than 2 floors up.

Stage 3: I'm taking the elevator to go down 1 floor.



Tests

Stage 1: Ordering an MRI and a few carefully selected labs to narrow the problem down.

Stage 2: Ordering an MRI, MRA, labs, and an echocardiogram to start by covering the bases

Stage 3: Ordering an MRI, MRA, CTA, echocardiogram, EEG, VNG, EMG/NCV, CT-myelo, pneumoencephalogram, and every lab in the book... figuring your call partner will sort it out on Monday.



New consults

Stage 1: I'll be right in to have a look at her.

Stage 2: Can I see her in the morning?

Stage 3: Call Dr. Brain after 7:00 a.m. tomorrow.




Signature line

Stage 1: Thank you for this interesting consult.

Stage 2: Thanks for this consult.

Stage 3: Scribbled name.



Handwritten chart note

Stage 1: A neatly written paragraph summarizing the key history, pertinent exam findings, and your impression and orders.

Stage 2: A brief note listing your impression and orders.

Stage 3: "Patient seen, note dictated."

Modern medicine

I was seeing Mrs. Hufnagel recently, and trying to get a hand on what medicine changes and labs she's had since her last visit (she's not the most precise historian).

After tearing some hair (actually, a lot of hair), out, I finally called her internist's office, and asked them to fax over her most recent chart note.

They sent this over:


Better yet, when I called them again, they verified that it's the entirety of her most recent note. After all, the Medicare quality measures are the only things of value anymore.

Thought for the day

"We have all these jokers running for President and the biggest news story any given day is whose ass looked better in a bikini. Then we have these heroes spend months in space for the greater good and hurtle back to Earth in a tin can and no one gives a shit. We don't need to make America great again. We need to make being intelligent great again."

- Geri

Great physical exams

Seen in a chart:

Thank you, H!

The buzz

Mary: "Hi, this is Mary, from Dr. Grumpy's office. I'm calling to remind you about your 2:45 appointment tomorrow."

Mr. Apoidea: "I'm not sure I'll be able to make it. I'm being stalked by bees."

Mary: "Excuse me?"

Mr. Apoidea: "There are bees following me, whenever I leave my house. I've been stung a few times this week. You'd think I'd bathed in honey or something."

Mary: "Okay, so would..."

Mr. Apoidea: "I'm hiding in my basement now, and they haven't found me yet. I'm going to stay here for a few days to see if they leave, and will call you when I'm ready to come in."

(click)

Skool nerse time

This is Mrs. Grumpy,

Dear Kids,

There are a lot of innovative ways to cut class and/or get sent home, and I think it's commendable that you guys work together so well.

Sometimes even I get fooled.

Last Thursday, for example.

Getting a bunch of kids in with stomach aches isn't that unusual, especially since I can't test for them. But when a second crop began showing up with skin irritations and rashes on their hands, faces, and mouths... it certainly got my attention. I even called the state and poison control to see if there were reports coming from other schools along those lines (there weren't).

Until someone came in with bad eye pain, which I had to flush out with water... and they spilled the beans. Before that I really had no clue what you were all up to.

Apparently one of you cute tykes smuggled in several Carolina Reapers with your lunch. Some bravely tried to show off by eating them, while others just vigorously rubbed pieces on their skin to induce redness and swelling. And a few accidentally ended up getting it in their eyes, nasal tissues, and (in one horrifying case) rear end. ("It was an accident, Nurse Grumpy!" Uh-huh, sure.)

Fortunately, no students were permanently harmed in this debacle, though many parents were quite inconvenienced by me having to call them about what was going on. And the majority of them began laughing hysterically.

To recap:

1. Mrs. Decimal says you still have to make up the math test.

2. Your parents think you are idiots.

3. Scoville units are not to be taken lightly.

Have a nice day.

Why don't you just ask?

Seen in a hospital chart:

Random pictures

Okay, time to hit the mail bag for stuff you guys have sent in.


First is this Engrish sign:

Next up is this school job opening for, um, not sure:

Then there's a fortune cookie...

"Confucious say, when alone, use the self-service pumps."

Then there's this sign. "Lobster Happy Hour" apparently doesn't apply to the lobster:

Here's a vintage drug company promo piece. You'd think Viagra would have been a better choice:

Speaking of Viagra, here's a great pharmacy sign. Love the stick figure.

 

And, lastly, is this page from a telephone directory:

One of these things is not like the others

Source: Alaska Airlines

Thank you, Laurie!

Max and Min

A bit of background explanation for my non-medical readers is required.

In pharmacology, the points at which a drug reaches the highest and lowest concentrations in the body are called Cmax and Cmin, respectively.


Last week I was at a meeting where the speaker kept pointing to graphs and saying things like "we obtained Cmin from testing healthy volunteers," "Cmin samples were analyzed by Whatzefukk chromatography," and "Overall, we were surprised by the Cmin values that were obtained."

And through it all... She didn't seem to realize what Cmin sounded like phonetically.

Immature as I am, it was hard not to snicker.

My readers write

Dear Dr. Grumpy,

I teach psychology courses at a community college.

I was teaching Intro Psych one quarter, and we were at the neuroscience portion of the course. One student spent every class either snapping her gum, texting, or staring off vacantly with ear buds in.

On exam day students were required to list the 4 lobes of the cerebral cortex and to write just one function of each lobe.  It's an easy section of the test for most students. This one, however, could only come up with 1 lobe and its function.

Her answer:   "Ear lobe - hearing."


Thank you, J!

The front line

Me and Pissy's office building has been remodeling the public bathrooms on each floor. This involves closing one and making the other a unisex john for a few days, then switching them off, then moving to the next floor.

This week they got to our floor and taped up their little "Unisex Restroom" and "Under construction" signs while they tore out old tile and fixtures. Honestly, I don't understand this. As long as a public bathroom is reasonably clean, most people don't care about the tiles or paintings. This is a medical office building, not the Waldorf-Astoria. Besides, each one just has a toilet and a sink, and the door locks. They're freakin' identical.

Anyway. Cut to day 3 of our floor's construction project:


Guy walks in, stands at counter.

Mary: "Can I help you sir? Do you have an appointment?"

Guy: "What is wrong with you people?"

Mary: "Uh, is there a problem?"

Guy: "YES! I'm tired of people like you, trying to make me think men and women are the same!"

Mary: "What are you talking about? This is a doctor's office."

Guy: "Instead of having separate men's and women's restroom's, you liberal PC types are trying to cram unisex bathrooms down my throat. I'm sick of this trend."

Mary: "Okay, that's not even our bathroom out there. And the sign is just temporary, while they're remodeling them."

Guy: "Oh... "

Mary: "Do you have an appointment with Dr. Grumpy or Dr. Pissy?"

Guy: "No, I just need to use the bathroom."

Leaves

Seen in a chart

Thank you, B!

Monday humor

Advanced calculus

Mrs. Math: "How many kids do you have?"

Dr. Grumpy: "Three."

Mrs. Math: "Oh... I mean, that's more than two."

Dr. Grumpy: "Yeah."

Seen in a chart

Another fine example of the crap you see in today's worthless electronic charting systems:

Follies

Mary: "Can I get a copy of your insurance card?"

Mr. Card: "Sure... here you go."

Mary: "Um, you told me on the phone that you were with Medicare, but this insurance is Major Illness HMO."

Mr. Card: "Sorry, I must have been confused. Can you still see me?"

Mary: "We need a referral authorization from your internist."

Mr. Card: "They said they'd fax one. It's Dr. Wayoverthere. You didn't get it?"

Mary: "No, let me call them." (dials phone) "Hi, this is Mary, at Dr. Grumpy's. He's a neurologist on the west side? One of Dr. Wayoverthere's patients, Mr. Card, is here, and says you were going to fax a referral?"

Dr. Wayoverthere's staff: "He's lying. He's involved in a legal case, and trying to find a neurologist to say he has problems since he was hit by a kid on a tricycle. We've sent him to 2 neurologists on this side already, who say there's nothing wrong with him."

Mary: "Okay, thank you." (hangs up phone)

Mr. Card: "Is it coming now? Can you see me?"

Mary: "They said they didn't refer you here."

Mr. Card: "Maybe they didn't. I remember now, my attorney sent me. Can you get an authorization from him?"

Mary: "No, your insurance won't accept that. If you or your attorney wants to pay for the visit we can see you, but without an auth from Dr. Wayoverthere we can't see you under your insurance."

Mr. Card: "I'm not going to pay for this. I'm out of here. You guys are trying to pull a fast one on me."

WWMJD?

Last week I was reviewing a research protocol which included the Beck Depression Inventory.

While looking through the questions I came across this one, and all I could think of was "How would Mick Jagger answer this?"

The Benjamins

Contrary to popular belief, even if you don't have a co-pay up-front, you still may end up paying a chunk of your bill. So we get calls all the time from people who don't understand the concept of a deductible or percentage of cost, angry that we had the audacity to charge them for their visit (maybe I should be angry at my landlord for charging me office rent, huh?).

Blood work is also an issue. Several insurances, especially Medicare, have a whole list of diagnoses you need to have in order for them to pay for your labs. This list is hysterically obsolete and unrealistic.

Yeah. Like those.

I'm in the middle here. If I order too many labs, Medicare will claim they weren't necessary for the condition (in spite of a crapload of medical literature saying otherwise) and the patient will get cranky because OMG THEY HAD TO PAY FOR SOME OF THEM. But if I don't order all the labs I run the risk of missing something and getting sued over it. The defense of "the insurance won't pay for the test" is legally worthless in court.

So I order what I think is appropriate. I'd rather get yelled at by patients over their bill then roasted by a lawyer for malpractice. By ordering it, I put the ball in the patient's court. If they don't want to have the test, that's their decision. But at least I tried.

So what happens when you go to the lab? Before they draw blood, you sign a form saying that you agree to pay any charges your insurance doesn't cover (for the record, you do that at my office, too. And probably every doc's office. If you didn't know that you just haven't read the fine print).

Then, if you sign it, they'll do the labs and bill your insurance. It there's any left over, they'll bill that to you.

This is where things get iffy, especially with Medicare and their outdated list of tests that will only be paid for IF you have a certain condition.

Let's say, for example, that a Medicare patient is having a neuropathy work-up, and needs a vitamin B12 level done. Most docs order a B12 level. I  do, too sometimes, but generally prefer checking methylmalonic acid (MMA). Due to its role in B12's metabolic pathway, it's actually more sensitive for B12 deficiency than B12 itself. You can see a normal serum B12 in people who are metabolically deficient in it, but the MMA nails it.

I order the MMA level. Of course, Medicare, with guidelines written during the Nixon administration, doesn't recognize it as a valid part of a neuropathy work-up. Yeah, craploads of medical research since the late 80's say otherwise, but who am I to argue with the Medicare rule book?

"Damnit, Jim, I'm a doctor, not a Medicare desk jockey."

So I order the methylmalonic acid anyway. Why? Because my job is to correctly diagnose the patient.

The bill for the MMA level gets sent to insurance, where it's screened by some of the last functioning TRS-80's left on Earth. Their programming sees "MMA level ordered for neuropathy. Test not needed per our guidelines. REJECT!"

The lab doesn't get paid for the MMA. They'll now send me a note asking for any more diagnoses that might get it covered.

So, in my 15 seconds of free time each day, I crack open the chart and fill out the form with EVERYTHING the patient has (hypertension, migraines, halitosis, genital herpes, 1948 exposure to mumps) hoping one of them will somehow get it to pass through the TRS-80's scanning on the 2nd try.

Sometimes it does, and we all live happily ever after. Other times it doesn't, the patient gets a bill, and calls my office.

Now Annie will usually take a crack at it, calling the lab and consulting a Ouija Board to see if we can find anything else going on with the patient that might get it paid for. I sign off on it, and we submit it for the 3rd go-round. I'd say this works maybe half the time. The rest of them... the patient gets another bill.

Some people recognize that healthcare isn't free, and that I'm doing my best to care for them. They pay their bill. Others, however, go apeshit and call to scream at us.

They demand I find a way to make their insurance pay it, even if it means fraudulently changing the ICD codes (nope). Or that I pay it myself (nope). Some of them even threaten me:


"Get this paid for, OR ELSE!"

"If this isn't paid, I'm complaining to the state medical board."

 "This needs to be covered, or you'll hear from my lawyer."



Because now it's MY fault that I'm trying to provide decent care.

What's really irritating is that these same people screaming about me ordering a test they now don't want to pay for... would also be the first ones in line to sue me if I didn't order it and missed the correct diagnosis. I try to be thorough, and want to figure out what's wrong with you. Plus, in the sad calculus of modern medicine, my fear of being sued trumps your wallet every time.


My office's best attempts failed. Now what happens?

The patient, like everyone else out there with bills, has to either pay them or go to collections. I did my best to help. I'm not going to practice second-rate medicine and risk missing something. They don't have to get the tests, but once they've signed off on the lab form and had them drawn, it's their responsibility. Some of these labs are hundreds to even a few thousand dollars, and they're being asked to pay for, say, $89.46 on labs that totaled $1015.58 (yeah, that's from a recent one that crossed my desk). I'm going to point out that's less than 10% of the total charge.

If you go to Target for a ginormous $900 TV, and they sold it to you for $80, you'd be thrilled. But in medicine? You go bananas that it isn't free.

"$79.99, and it wasn't even Black Friday."

Once my two appeals to get it covered have failed, I'm done. I did my best. I also remind myself that, even if I do find a way to get you out of paying for them... it means everyone else (including me) is.

My sympathy on this issue has run out. I'm tired of people demanding I care for them, then not wanting to pay their fair share of the costs. If I DIDN'T order these tests, and missed something, they'd come back and sue me. But if I do order them they whine.

My view has become it's their decision to have them or not. It's a tax deduction if they want to see it that way, but healthcare is NOT FREE. Someone is paying for it, even if it's not the patient. Everything that gets covered by insurance is passed on to the rest of us in the form of higher co-pays and premiums.

Providing competent medical care is not something you can sometimes do well and other times do a half-assed job on. You either go big or go home, so I choose to go big. The same applies to the patient. If you want an incomplete work-up, that's fine, but don't go wailing when something was missed because you refused testing. By the same token don't expect quality care to be free.

You get what you pay for.

Mary's desk

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

Mrs. Grate: "I need to make an appointment with Dr. Darth."

Mary: "I'm sorry, you've got the wrong office. This is Dr. Grumpy's."

Mrs. Grate: "Okay, but I'd like to see Dr. Darth. Does he have anything open on Thursday?"

Mary: "Dr. Darth is across the street, you'll have to call his office. Let me give you their number."

Mrs. Grate: "If you have the number, can you please call them? I'd like something for Thursday, preferably in the afternoon."

Mary: "Ma'am, I can't make an appointment for you at another neurologist's office. I don't know what their schedule is, or what insurances they take, or their hours..."

Mrs. Grate: "You young people have never heard of customer service."

click

Seen in a chart

Thank you, K!

Google

Yesterday morning Craig was up early and trying to cook pearl barley for breakfast (no, I have no idea why, considering we have a pantry full of instant oatmeal). So, in the enterprising nature of modern life, he grabbed an iPad to ask Google how to cook pearl barley. As he typed some suggestions came up:

He woke me up (it was my day off, thanks Craig) laughing at this screen.

Drug addicts: I'm not sure microwaving urine will destroy whatever's in it, but it will give it that toasty "fresh from the bladder" warmth. Don't put it in for too long, or your parole officer will wonder why your urinary tract operates on the Kelvin scale. It will also make your kitchen and microwave stink (attention readers: do not try this at home).

For the record, when Craig discovered it took > 1 minute to microwave barley he decided on instant oatmeal.

I didn't even try to go back to bed.

Starry Starry Night

Last night Snowball somehow managed to knock over his allegedly spill-proof dog chow bowl (he's good at that sort of thing).

Anyway, while I was cleaning it up, I noticed how some had landed:

For those who don't recognize it :

Memories...

Back when I was interviewing for medical school in the mid-80's, I had one interview that was just an in & out same-day trip, with a 1 hour flight each way. So I wore my suit and went to the airport with just my wallet, plane ticket, and keys.

My dad, working in his unofficial capacity as the family travel agent, had found me a cheap ticket on Etohair. This airline (now long defunct) had the interesting approach of unlimited alcohol for all. So, being a Diet Coke and rum aficionado, and a poor college student, and hosting a party that weekend, I pretty much kept asking for another rum & DC at 5 minute intervals and pocketing the little bottles. The flight attendant knew what I was doing, but it's not like anyone else was different. No wonder they folded.

Anyway, after landing I caught a cab to the med school and stopped off in their lobby bathroom.

Looking in the mirror there, I suddenly noticed that my suit pockets were all bulging with little bottles that made it look like I'd been shoplifting. Having a fuck-ton of rum stuffed in your pockets, I realized, was not going to be conducive to a good impression for a guy hoping to become a future doctor.

I stood there, in a public bathroom in the medical school lobby, frantically trying to think. I had no bag to put it in. I didn't want to throw it away, either.

The janitor came in, wondered why I was taking so long to wash my hands, grabbed some toilet paper rolls out of a supply closet, and left.

And suddenly, I had an idea. Hoping no one else came in, I frantically yanked 20 rolls of toilet paper off the closet shelf, piled all the rum in the back, and put the TP in front of it.

I went on with my interview, wondering if the janitor was going to have a wild party at his place that night with my bottles.

After the last interview I ran in there, hoping not to miss my flight.

To my horror, the supply closet door was locked.

Using a credit card and my car key I managed to get it open. As I dug through toilet paper rolls for the rum, the school's dean (who I'd just interviewed with) wandered in, looked at me, and asked if I needed anything.

I mumbled "the stall was out of paper," grabbed a roll, and shut myself in the toilet area. I waited with bated breath while he peed and left (didn't wash his hands, either). Quickly grabbing my precious rum, I was still stuffing it in my pockets as I ran out to hail a cab.

I made my flight. Barely.

My roommate and I had a great party that weekend. We didn't run out of rum.

I was accepted at that school.

Annie's desk

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

Mr. Call: "Hi, I just got a letter that my Snotziva-XR pills won't be covered starting next week, on the first."

Annie: "Yeah, we got the same fax. I already sent in the form requesting an override for your case."

Mr. Call: "But how long will that take to get reviewed?"

Annie: "Well, it says 10 days, and last year it took... let me see... exactly 10 days for the same thing. So I'll guess 10 days until we have the override."

Mr. Call: "But the 1st is five days away!"

Annie: "But you just called for a refill last week, looks like we approved it."

Mr. Call: "You did, I picked it up. It was for 30 pills."

Annie: "Okay, so you've got enough for a month. We'll have it cleared before then."

Mr. Call: "But what do I do on the 1st?!!! If it's not covered, don't I have to stop taking it?"

Annie: "No, take the ones you just refilled."

Mr. Call: "Am I allowed to do that? I won't get in trouble?"

Annie: "Um, no. You'll be fine."

Mr. Call: "But it says they're not covered after the 1st. They don't send a repo-man to take the pills back?"

Annie: "No, I promise."

Mr. Call: "Oh, good. I was really worried they'd come for the bottle."

Ockham must be horrified

Seen in a chart, from the "throw stuff at the wall and see what sticks" school of differential diagnosis:

Dragon gone bad

On rounds yesterday I encountered a urologist in the doctor's lounge, laughing hysterically as he proofed his dictations (done by the hospital's Dragon system).

His sentence “due to ejaculatory problems he runs into issues during intercourse.”

Had been changed to  “due to ejaculatory problems he runs into her shoes during intercourse.”

I cracked up, too.

Another round for my staff

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

Mrs. Lost: "Hi, I'm here at the pharmacy, and my prescription isn't ready."

Annie: "Really? I called it in last night. You're at the Walgreen's, at 5th & Hamilton?"

Mrs. Lost: "I think so."


In background:

Mrs. Lost: "Hey, is this the Walgreen's on 5th and Hamilton?"

Male voice: "No, this is the CVS at 5th & Hamilton. The Walgreen's is across the street."


Mrs. Lost: "No, it's not here."

Annie: "Well, didn't I just hear someone tell you it's at the store across the street? You're in the wrong drugstore."

Mrs. Lost: "I guess so. Can you call and tell them to have someone carry it over here?"

Annie: "No. You'll need to go get it. You're in the wrong store."

Mrs. Lost: "But it might start snowing any minute now. I saw that on the weather."

Annie: "You can drive across the street."

Mrs. Lost: "But then I have to walk to my car."

Annie: "How far away is your car?"

Mrs. Lost: "It's at the Walgreen's across the street. The CVS didn't have any open parking spaces."

"Wadda ya want, I'm tired."

Seen in a hospital room:

"It's not like anyone actually reads them."

Thank you, W!

Monday reruns

I've always liked the Muppets. One of my favorite songs is "Rainbow Connection," as performed by Kermit at the beginning of their first movie.

For those of you who don't know it:





Anyway, it may be corny, but the song got me through some shitty times. After I failed the first anatomy test in medical school (big time, too- I was the class low out of 120 people) I went to a used record store and bought the Muppet Movie soundtrack just to listen to that song. In a sappy sort of way it reminded me of why I was there in the first place, and I pulled my shit together, didn't drop out of school, and forged ahead.

Life goes on. Medicine is still fun. I mean, I like what I do. I have to earn a living, so I might as well be doing something I like.

And then, one day a few years back, I was having an ordinary day at the office. And toward the end of it was served with my first malpractice suit.

Nothing will kick the shit out of you faster than that moment. Yes medical students and residents, you WILL get sued. Get used to it. Someone on Sermo recently wrote "I have believed for a long time that unless you are practicing grossly negligent medicine your probability of getting sued is small." This is a remarkably ignorant statement.

Getting sued is like cancer- something that happens to other people. I think all doctors, on a superficial level, know it will likely happen. But you're still blindsided when it happens to you.

Obviously, I'm not going to go into legal details of the case, or who won, or even if it was dismissed. Because none of those are relevant to this post.

And I'm sure there are plenty of patients out there who can write how horrible Dr. Butcher maimed you. I'm sure some of you have legitimate claims. But I'm not writing about you.

Malpractice isn't black or white. It's really mostly shades of gray. I'm not biased against lawyers, in fact- my Dad is one, and sued several doctors for malpractice. But I'm not going to get involved in arguments about lawyers vs. doctors, either.

My point is just my own experience.

People portray doctors as being arrogant or uncaring. And I'm sure some are. But anytime a case goes bad, it's personally devastating for most of us. Even if you did nothing wrong. Sometimes shit happens despite your best efforts.

It hurts. A lot. You do your best day in and day out, and feel awful when things go wrong. And now someone is accusing you of having committed malpractice in your efforts. They tell you not to take it personally, but how can you not? Hell, they even name your spouse in the suit (really, they do).

You may be absolutely right. The literature may back you up completely. But that often doesn't matter.

You see, there is always another doctor out there willing to testify in court (for a nice fee, of course) that what you did wasn't appropriate. He's Dr. Jukebox. You put in money and he'll play whatever tune they want him to (it pays a lot better than seeing patients). The statements from these whores will make you feel like shit, and the legal language used makes you sound on a par with Dr. Mengele.

No amount of medical competence can prevent someone from filing a lawsuit against you. Even if you did nothing wrong, there's always a hungry lawyer willing to take the case. After all, it only costs about $100 to file a suit, the potential payoff is 1/3 of the winnings, and he knows a Dr. Jukebox who will gladly testify that you're incompetent.

Your medical school teachers won't tell you what it's like to be sued, but I will.

It's devastating.

It kicks the shit out of you. You lie awake at night wondering if you're going to lose everything you ever worked for. You cry. You think about suicide, but have to go on for your family. With this sword of Damocles hanging over your head, you still have to go to work every day, and do your best for the patients who still depend on you. Some days it's pretty damn hard NOT to start drinking.

And, deep down, you wonder: Am I really incompetent? You question your own judgment. Suddenly every headache patient needs a brain MRI. Every person you see is a time bomb. You start to view them as the enemy.

People use the phrase "defensive medicine" in a derogatory fashion, meaning unnecessary testing doctors order to prevent themselves from being sued. But after it's happened to you, hell, you don't give a fuck how much money the "unnecessary" tests cost. You'll order anything to cover your ass.

And no matter what you did, Dr. Jukebox will testify that it wasn't the right thing. And no amount of literature in your favor will change his "expert" (i.e. well-paid) opinion. The people on the jury deciding your fate aren't medical people.

Even if you win, it still doesn't take away the living hell you and your family are put through for the 3-5 years (yes, years) it takes the case to play out. The sleepless nights, the gray hairs, the stress eating that shortens your time on Earth, and the spouse and kids who worry about you.

And, regardless of the case's outcome, it will forever destroy your Rainbow Connection, and the beliefs that once drove you to dream of being a doctor.

It's complicated

Dr. Grumpy: "How are you doing? It's been about a year since your last appointment."

Mr. Optimist: "Going okay. I've met a great girl, and this could be the one. I mean, she threw me and my stuff out of her apartment and called the police on me last week, and I had to live in my car for a few days until I could find a new place, but I think this is part of the road to a stronger relationship."

Huh?

My iPhone rings. It's a hospital extension, so I pick it up. It turns out it's one of my call partners.



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

Dr. Nerve: "Hi, Ibee. I'm over at the hospital."

Dr. Grumpy: "What's up?"

Dr. Nerve: "Will you have time in the next week or two to talk about something on the phone?"

Dr. Grumpy: "I have time now. What's up?"

Dr. Nerve: "I'm busy. I'll call you back when I have time. Thanks."


He hung up.

Tinea

Dear Mr. Floccosum,

There is a time a place for everything. When I am ready to examine you, believe me, I will.

I sent you back to my office so we can start just by talking.

I did not ask you to, right off the bat, remove your shoes and socks. Nor did I know that you hadn't trimmed your toenails or washed your feet since the Ford administration.

And for the love of all that is good and holy, you did not need to prop them both up on my desk.

Thank you.

Goodbye, David Bowie

You were awesome. Good luck out there on your way home.

"If you're ever sad, just remember the world is 4.543 billion years old, and you somehow managed to exist at the same time as David Bowie."

- Another Bowie fan.

 

 Picture from APOD.

Patient quote of the day

"I think the real issue causing the stress is that she thinks that I think that she thinks that I think that she's under stress. And I'm not under stress. And neither is she. So I don't understand why she thinks I'd think she'd think that I'm under stress, or why I'd think that she'd think that I'd think that she's under stress. I mean, the whole thing is really stressful."

Goodbyes

Mike is a great guy. Doing remarkably well even into his late 80's. He's had epilepsy since childhood, which is controlled very well with medications. I've been seeing him since he moved here 15 years ago. He comes in once a year for me to refill his medication. Because he's so stable it's really more of a social visit. We talk about families, baseball, and (his favorite topic) horse racing.

He came in for his annual visit yesterday, and looked awful. He's been diagnosed with metastatic esophageal cancer, way too extensive to operate, so he's just getting palliative treatment.

There was really nothing, from a neurological view, for me to do. We talked about the usual things, especially his excitement at 2015 having brought the first Triple-Crown winner since 1978. I refilled his medication and sent him out with a handshake, like I always do.

I know I won't see him again. He probably does, too. On the "next appointment" line I just scribbled "will call" because it seemed cruel to write the usual "1 year."

Even the easy patients aren't always easy. It's part of the job, but that doesn't mean I like it.

Thursday afternoon

Lady comes in, walks up to counter.


Mary: "Hi, can I help you?"

Mrs. Dayoff: "Hi, I'm Ada Dayoff. I'm here for my 3:00 appointment."

Mary: "I'm sorry... Actually your appointment was for yesterday, Wednesday, at 3:00. But I can reschedule you for..."

Mrs. Dayoff: "But you're the one who told me it was for Thursday!"

Mary: "I called you on Tuesday afternoon, with the rest of my reminders. The notes say I spoke to you directly."

Mrs. Dayoff: "EXACTLY! You said "your appointment is tomorrow!' I remember quite clearly."

Mary: "Yes... And since it was on Tuesday, that would have been for your Wednesday appointment."

Mrs. Dayoff: "But you called me at 4:18 p.m. See? Here's the call time on my phone!"

Mary: "Okay, that's my call, but it says 4:18 p.m. on Tuesday. Your appointment was Wednesday.  Today is Thursday."

Mrs: Dayoff: "Look! Everyone knows that if you say tomorrow BEFORE 4:00 p.m. you mean the next day, and if you say tomorrow AFTER 4:00 p.m. you mean the day after tomorrow."

Mary: "Uh..."

Pause.

Mrs. Dayoff: "Anyway, I'll reschedule. Do you have anything for tomorrow?"

That clears things up

Seen in a chart:

Crustaceans

I'm in line at the meat & seafood counter at Local Grocery, waiting to buy something other than tomatoes. Ahead of me is a couple in their late-20's, who are fascinated with the live lobster tank next to the counter.

Counter Guy in his white apron wanders over.


Counter Guy: "Hi, can I help you?"

Mr. Clueless: "Um, we have some questions about the lobsters."

Counter Guy: "Sure. What's up?"

Mrs. Clueless: "How long do they live?"

Counter Guy: "Well, until you're ready to..."

Mr. Clueless: "What do you feed them?"

Counter Guy: "Uh, not sure. The night shift handles that."

Mrs. Clueless: "Can you keep them in a regular tank? We have Tetras already, is that okay?"

Counter Guy: "Um... Not sure. Most people don't keep them alive..."


Pause.

Mr. & Mrs. Clueless are staring at Counter Guy like he's balancing a Buick on his winkie.


Mr. Clueless: "Why... would you keep a dead pet?"*

Counter Guy: "They're to eat... not for pets."


Pause.

After 10 seconds or so of silence Mr. & Mrs. Clueless walk away.


Counter Guy: "Uh..."

Dr. Grumpy: "Yeah... I know... I'd like a 1/2 pound of roast beef and a large container of cole slaw."


*How many others out there imagined John Cleese asking that question?

Perspective