Differential

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

Dr. Hack: "Yeah, this is Mike Hack, I'm an internist on the east side, and I'm not happy about what you told my patient."

Dr. Grumpy: "The guy with Myasthenia Gravis?"

Dr. Hack: "Yeah. I'd told him he had a stroke, and you have the balls to tell him something else?"

Dr. Grumpy: "But... he didn't have a stroke. His MRI was normal."

Dr. Hack: "Look, he had slurred speech. Any idiot can look up slurred speech and find out that it can be caused be a stroke. Except, apparently, a neurologist."

Dr. Grumpy: "A lot of things besides stroke can cause slurred speech. His brain MRI was normal, his Myasthenia antibodies were elevated, and he responded to Mestinon."

Dr. Hack: "Yeah, whatever fancy bullshit testing you people use nowadays. I've never referred to you before, and I sure won't do it again."

Click

Gifts

On Friday a grateful patient brought in a little basket of goodies for the office.

Which included this tea bag:

Too tired to write

Why don't you guys post comments about insanity at your jobs?

Memories...

 

It was a cheap chicken pot pie. The frozen kind, that your mom makes you eat when you're growing up.

I was a college student, living in a small condo near BSU with 3 other guys, in the mid-1980's

The place was old, and (like most college-based condos) not in the best repair.

One night, I made the fateful decision to have a chicken pot pie for dinner (this is college, man, you eat what you can afford).

I put it in the oven (a real oven, we didn't have a microwave), turned it on, set the timer, and went back to my room to read. As I left the kitchen I heard a loud mechanical "clunk," though didn't think anything of it at the time. The dump was full of weird noises.

When I wandered back 30 minutes later, I discovered the oven had somehow activated its self-cleaning mode - meaning it locks the oven door and heats itself up to something on the Kelvin scale to incinerate anything inside. Including my dinner.

The whole condo at this point began smelling like a chicken pot pie. I turned off the oven, only to discover that it had broken. Even with the cleaning cycle stopped. The door was locked and couldn't be opened.

I walked over to McD's that night for dinner.

The chicken pie was now a fixture of the condo. There was no way to get the oven door open without tearing it apart. The landlord didn't really care about fixing it since the place was falling apart, and the 3 of us didn't have the money to fix it ourselves. So we left it there.

As the semester progressed the kitchen would occasionally develop a weird smell from the culture medium residing in the oven. When this happened (every few weeks) we'd turn the oven on for a while to bake the culture into oblivion for another month or so. We'd turn it off again when it began to smell like chicken & mold pot pie. For all I know the oven had become a primordial soup experiment, and some new life form was evolving.

When I moved out 6 months later the pie was still in there. For all I know it still is.

So, if you're a college student living in a run-down condo with a locked oven that smells like a chicken pot pie when turned on... I'm sorry.

Seen in a chart

- Thank you, B!

Friday reruns

Last week

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

Mrs. Freek: "Yeah, this is Ima Freek, I need to make a follow-up appointment with you. I saw Dr. Grumpy 8 years ago, and need to come back."

Mary: "Okay, hang on... You're not in our system. Are you sure you were here?"

Mrs. Freek: "Of course. I remember your lobby, with all the golf posters, and the golf clubs on the walls."

Mary: "Oh, that's not us. That's Dr. Darth down the street. Let me give you his number."

Mrs. Freek: "No, that's okay, I'm fine seeing a different doc. Can I come in next week?"

Mary: "Sure. Tuesday at 3:00. See you then."



This week


Mrs. Freek: "Hi, I'm here for my appointment. What happened to your lobby?"

Mary: "Nothing. It's been this way for years."

Mrs. Freek: "What did you guys do with all the golf stuff?"

Mary: "We never had that. I told you, that's Dr. Darth down the street."

Mrs. Freek: "Wait a minute... You mean the golf-club doctor isn't here?"

Mary: "No. I told you that on the phone. You said you wanted to come in, anyway."

Mrs. Freek: "I can't believe you misrepresent yourself as part of another office!"

Mary: "Ma'am, I explained that..."

Mrs. Freek: "I'm leaving! This is criminal!"

(storms out, comes back a minute later)

Mrs. Freek: "Hey, I left my cell phone at home. Can you call Dr. Darth to see if he has an opening this afternoon?"

Pinocchio

One of my patients was at the lab to have her blood drawn, and the lab called me to say that she could barely walk and kept falling. I had them send her to ER, and then went to see her.


Dr. Grumpy: "Your head CT was okay, but the seizure medication blood level was WAY too high. Have you been taking it correctly?"

Mrs. Ataxia: "Um... Well, this morning I took a triple dose."

Dr. Grumpy: "Why on Earth did you do that?"

Mrs. Ataxia: "Because I was going to get my blood level drawn, and didn't want you to think I hadn't been taking it."

Dr. Grumpy: "Had you been taking it?"

Mrs. Ataxia: "Yes."

Dr. Grumpy: "Really?"

Mrs. Ataxia: "Uh... maybe... here and there."

Dr. Grumpy: "Overdoing it just before you get the labs drawn won't make up for that."

Mrs. Ataxia: "Sometimes it works at the dentist's."

Skool Nerse Time

Another exciting school year will be starting soon, and somehow I got sucked into becoming a band booster. This thrilling job involves me handling questions from other parents about band, upcoming band camp, musical instrument rentals, over-the-counter medications, do you know a good plumber, next week's weather forecast, and why are you calling me because the judge said it's my ex who has to pay for this stuff.

In a week of calls, this one was my favorite:


My iPhone rings.

Nurse Grumpy: "Hello, this is band booster Grumpy."

Mrs. Clueless: "I just found out my daughter, Marsha, has to bring her musical instrument to band camp?"

Nurse Grumpy: "Uh, that's correct."

Mrs. Clueless: "Why didn't anyone tell me this? You need to make these things clear!"

Nurse Grumpy: "Well, it is band camp."

Mrs. Clueless: "On that whole list of things to bring to camp, no where did it say 'musical instrument.' "

Nurse Grumpy: "She does need to bring it."

Mrs. Clueless: "What kind of instrument should she bring, anyway?"

Nurse Grumpy: "Um, whatever she plays. What does she play?"

Mrs. Clueless: "YOU'RE THE BAND BOOSTER! Isn't it your job to know that?"

Nurse Grumpy: "Okay... so you don't know what Marsha plays?"

Mrs. Clueless: "It's something she blows in. Where can I get one of those?"

Nurse Grumpy: "That covers a lot... What does it look like?"

Mrs. Clueless: "I don't know. It makes a lot of noise, so she has to practice with her door closed. I've never seen it. Can I rent one?"

Nurse Grumpy: "You don't have one?"

Mrs. Clueless: "Well, she has the screechy thing in her room. You mean I have get another one for her to take to band camp?"

Nurse Grumpy: "No. She can take the one she already has."

Mrs. Clueless: "Doesn't make that clear, either. This info sheet is useless."

Nurse Grumpy: "Just have her bring the instrument, whatever it is, that she has at home, to band camp."

Mrs. Clueless: "You people are really disorganized and unhelpful."

Fone Fun

The home phone rings.


Dr. Grumpy: “Hello?”

Accent Guy: “Hello, I am calling from Bank of Grumpyville technical support, and I need some information about…”

Dr. Grumpy: “I didn’t call technical support.”

Accent Guy: “Well, I am returning a call about a trouble ticket. I need your BofG…”

Dr. Grumpy: “Nurse Grumpy, did you call BofG technical support?”

Nurse Grumpy: “No.”

Dr. Grumpy: “Sorry, you must have a wrong number.”

Accent Guy: “Well, what we do is Windows technical support, so I guess there’s an issue with your Windows log-in for BofG. Can I have your computer…”

Dr. Grumpy: “No one here uses Windows.”

Accent Guy: “I’m sorry, did I say Windows? I meant it’s a Mac issue and I need your…”

 
As much as I felt like stringing him on for fun, I hung up.

Seen in a chart

"Are you shitting me?"

Thank you, ERM!

Another fun weekend

With all respect to Bob Seger.


On the long and lonesome highway
To the hospital
You can listen to your iPhone
Ringing with another call
You think about the differential
Of the case you saw the night before

But your thoughts will soon be wandering
The way they always do
When you've been awake for 27 hours
With consults still left to do
And you're sick of swilling coffee
You just wish the call was through

Here I am
Out on call again
There I am
On a rounding rampage
Here I go
Playin' doc again
There I go
Return the page

When you walk into the doctor's lounge
Strung out from Diet Coke
And the only food that's left in there
Is just a friggin' joke
So you take a half-eaten, stale, bagel
And try hard not to choke

They call to check the orders
"Hi, doctor this is Jan
In your note on Mr. Stroke
Did you want an MRI or CT scan?"
And at 2:00 a.m. you're there
Eating popcorn from a bedpan

Here I am
Out on call again
There I am
On a rounding rampage
Here I go
Playin' doc again
There I go
Return the page

Racing through the ER
The CT is 2 more halls away
And you've only got an hour left
To start the tPA
As the sweat pours out your body
"Please don't hemorrhage," you pray.

Later in the evening
As you lie awake in bed
With your cell phone like a live grenade
Lyin' near your head
You take another ER call
About a guy whose brain has bled

Here I am
Out on call again
There I am
Trapped in its cage
Here I go
Playin' doc again
There I go
Return the page.

Seen in a chart

Ashes to ashes, funk to funky

This summer we visited my in-laws, and one night they had a potluck in our honor.

Unfortunately, great aunt Frieda left a casserole at home, so I got volunteered to drive her down the block to get it. Craig came, too, as he was trying to avoid his cousins.

We walked into this small musty-smelling condo and were standing there while she rummaged in her fridge. Craig, trying to make conversation, asked “do you have any pets?”

Great aunt Frieda: “Yes, I have a cat, Marty.”

Craig: “Where is he?”

Great aunt Frieda: “Over there.”

And she pointed to a shelf above the stove. With a ceramic urn that said “Marty."

Theft

Mr. Ford came in for memory loss.

He drove himself to the first appointment with a friend's car, because his was in the shop. After the appointment he didn't remember that he had someone elses car, and walked all over the parking lot looking for his. He finally gave up, assumed his car had been stolen, and came back to my building for help.

He went to the cardiologist down the hall and told the receptionist his story. She called the police to report a stolen car. After interviewing Mr. Ford, the officer had him call a friend to come get him, but the one he called couldn't do so because Mr. Ford had his car, and couldn't make Mr. Ford understand that.

So the friend came in a cab to get my patient (who'd by now wandered back to my office). As they walked out to the friend's car, Mr. Ford said, "You know, I saw your car out there when I was looking for mine. I didn't know you had a doctor's appointment today, too.”

On Wednesday he called Mary to cancel an appointment for that day (which he didn’t have). He said he couldn’t come in because someone had stolen his car while he was at the doctor's 2 days ago. He later called in to see if he could get the appointment back, because the car had been “found” at a local repair shop (whose owner couldn’t figure out why it hadn’t been picked up for 5 days).

For the next 2 weeks we continued to get calls from Mr. Ford, asking if he could make an appointment now that he had his car back. He was politely reassured each time that he’d already been here.

I called and discussed things with his adult son, who took the car away while I notified the state about revoking his license. This only led to further (continuing to date) calls that someone has stolen his car. The local police aren't happy about this, either, and are now telling him to call me when he calls about the stolen car.

I can't say I blame them, either.

Random pictures

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


First is this book:

Mike writes in:

1. Is the guy at the top whacking off?

2. Isn't this sort-of racist?



Then we have this unusually comfortable looking external hard drive:

Another bad day for the photo-caption editor:

The name does not inspire confidence in this place's cleanliness:

This sign at Home Depot, which makes it sound like they're afraid of psychiatrists:

This car:

Jay says this sign is outside the orthopedic ward at her hospital:

"It's a total joint center, dude... totally."

Hospital rounds

Dr. Grumpy: "How are you doing?"

Ms. Dyspnea: "I don't like this oxygen mask. It hurts."

Dr. Grumpy: "Well, you need it to breathe. The other only other option would be to intubate you and have a machine do the breathing."

Ms. Dyspnea: "That's what the idiot nurse told me!"

Dr. Grumpy: "It's the truth. You need oxygen to keep going."

Ms. Dyspnea: "Bullshit. I asked the nurse if I could just get the oxygen in my IV, and she said she couldn't do that. We all know she could just take off this stupid mask and plug it into my IV instead."

1:47 a.m.

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

Ms. Phone: "Hi, this is Cindy Dingdong."

Dr. Grumpy: "Are you one of my patients?"

Ms. Phone: "No, I found your name on Google. I just moved here and have a sore throat. Can you call in some antibiotics?"

Winning bid

Dr. Grumpy: "How's the diet going?"

Mrs. Atkins: "It's on hold. I ordered that diet book you suggested, but the person I bought it from on eBay screwed up."

Dr. Grumpy: "What happened?"

Mrs. Atkins: "They sent me this instead. I'm actually going to the post office to mail it back later."


She reached into her bag, took out a book, and held it up. It was called "Working with a Transsexual: A Guide for Coworkers."


Dr. Grumpy: "That's definitely not the diet book I recommended."

Mrs. Atkins: "No. And you just know someone out there was hoping to get this book to help them at work, and is instead staring at my diet book."

Sunday night check-out

Dr. Grumpy: "In room 734 is a guy with arm weakness since a shoulder injury. I've ordered an MRI of his brachial plexus."

Dr. Nerve: "Where do you think the problem is?"

Dr. Grumpy: "Uh, in the brachial plexus."

Dr. Nerve: "You should have made that clear."

When dogs fly

Me: "What kind of dog is she?"

Mrs. Owner: "She's a Morkie. It's a cross between a Yorkie and a, um, Maltese Falcon."

Follies

I saw a guy for headaches recently. Nothing unusual in his story, but, since he'd never had them before, I ordered a brain MRI. I figured, like most of them do, it would come back normal.

I wasn't even close. It came back, not just abnormal, but weird. All kinds of odd changes. Nothing easy to point a finger at, like a stroke or brain tumor. But definitely not normal.

Like I always do in these cases, I called the neuroradiologist who read it, and discussed the case. He was pretty certain of the strange findings. We reviewed all the different causes, and none of them fit with his history.

Because of the unusual nature of the findings, I got a copy of the MRI and took it to another neuroradiologist for a 2nd opinion. She absolutely agreed with the first guy.

So, I was stuck with something weird, not easily explainable for his case. After hospital rounds the next night I went to the hospital library, and spent some time looking up the findings, what can cause them, how you work them up, etc. I had Mary bring him in, working him in over lunch to give me extra time to discuss the news with him and answer his questions.

He came in, and I took some time. I explained the findings, and what they might mean. I went over the steps to work them up further, including a spinal tap and labs. He and his wife sat in silence as I went over everything. Finally, I opened up the floor for questions.

Mr. Sternberg: "These abnormal findings, could they be caused by lymphoma?"

Dr. Grumpy: "You have lymphoma?"

Mr. Sternberg: "Had. About 10 years ago."

Dr. Grumpy: "How did they treat it?"

Mr. Sternberg: "I had chemotherapy, and they did radiation treatment on my whole body and head."

(Pause. I pick up the phone and call the neuroradiologist, who says that, yes, absolutely, the changes are typical for someone who's had radiation).

Dr. Grumpy: "Yes, they're likely from radiation. Why didn't you tell me you had lymphoma?"

Mr. Sternberg: "I didn't think it was important. By the way, my headaches are gone."

Today's lesson people: When the neurologist asks about your past medical history, lymphoma and brain radiation are things you want to mention.

Seen in a chart

Nothing can make a doctor look stupider than an EHR (computerized charting) system.

Smoking is, to me, a good example. We all ask "Do you smoke?" There are 3 basic answers: "Yes," "No," and "I used to."

That isn't so hard. I mean, yeah, occasionally you'll get someone who uses snuff or has some other answer, but in 98% of cases the answer is one of those three. My somewhat primitive human brain can handle them pretty well.

Of course, when you turn this simple question over to an EHR, you get crap like this:

What the HELL does that bizarre combination of phrases mean? In a few lines the patient has gone from being a smoker, to a chain smoker, to a non-smoker, and back to a smoker. And what's an "aggressive non-smoker" anyway? Someone who whips out a fire extinguisher and sprays people who light up?

They tell us these kinds of programs make medicine easier and safer for all involved. I think they're smoking something.