Free treatment for bleeding and glucose monitor

September 8, 2016

The patient, a he or a she,

At a party came up to me

Whilst I was feeding

I was stopping the bleeding

Performing a treatment for free.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska. Getting my wife’s (benign) brain tumor treated took a large part of the summer, then a week each in urban Alaska, Pittsburgh with family, and western Nebraska.  Any identifiable patient information has been included with permission. 

I was seated at a catered social event enjoying a turkey sandwich when one of the staff approached me, saying, “I need you to be a doctor in the kitchen.”

Without hesitation I left my lunch.

Firmly entrenched in Sioux City Society, I have friends and patients amongst employers and employees wherever I go.

Most kitchen cuts happen to the non-dominant hand, and the patient (who gave me permission to write this) had cut the left ring fingertip half-an-hour before. The bleeding hadn’t stopped. In similar situations I have used Superglue with good effect, but in this case the knife had completely detached a couple millimeters of skin, leaving nothing to glue together.

I applied pressure to the fingertip with my thumb and forefinger and a generous helping of paper towel, holding the patient’s arm extended straight overhead. I made small talk and cracked few jokes.  The internal blood pressure at the wound, weakened by gravity, could not exceed the external pressure applied by my pinch.  After 10 minutes, I brought the hand down and, sure enough, the bleeding had stopped.  I applied a Band-Aid tightly, held it in place with aging, weak adhesive tape, and had the patient put on a plastic food service glove.

Then I went back to my sandwich, sitting between a board-certified hand surgeon and my wife. Of course we discussed the case, talking about therapeutic use of superglue, the generic version of the much more costly Dermabond.

I won’t send a bill, I didn’t even get the patient’s name. I’m pretty sure Good Samaritan rules apply.

At another event, I fixed someone’s home glucose monitor, and four days later, I attended a sick child at my house.

I explained that in the absence of fever or severe pain, use of antibiotics for a one sided ear infection (in a patient over 18 months age) wouldn’t change the course of the disease, and wouldn’t increase or decrease the chance of complications. Acetaminophen and ibuprofen would do just as good a job.  We discussed alarm signs along with the importance of fluticasone (brand name, Flonase) and a Neti pot for allergies.

I won’t send a bill for that patient, either. With no prescription to write, I didn’t generate a note.

While in private practice, a parent would frequently ask me to check the ears of a patient’s sibling. I would smile, and to establish boundaries, I would say, “A normal ear exam is free.”

In the era of evidence-based medicine, sometimes an abnormal ear exam is free. I love the work and good Samaritan rules apply.  I couldn’t send a bill if I wanted to.

Leaving Nebraska. For now.

September 6, 2016

On the plains I worked for a week

The enjoyment was close to my peak

A lot of folks I befriended

But then the need ended

And new work I’ll now have to seek.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska. Getting my wife’s (benign) brain tumor treated took a large part of the summer, then a week each in urban Alaska, Pittsburgh with family, and western Nebraska.  Any identifiable patient information has been included with permission. 

 

A week passed quickly on the plains of Western Nebraska.

A respiratory virus, looking for all the world like influenza, with fever, cough, and ache, but also with runny nose, and lasting the better part of a week, provided 1/6th of my clinical material.  I really didn’t do anything for those patients except recommend Tylenol, fluids and rest.

Seasonal respiratory allergies accounted for an equal number. My two favorite drugs in that regard, Zyrtec and Flonase, now available without a prescription, have high quality evidence to support their use.  Still I gave instruction on how to use Flonase based on personal experience.

I took care of a patient with an agricultural injury, and, in the process, learned about Stewart’s Wilt, an important corn disease, which originated not far from where I worked.

I sent two patients to the new MRI, and, surprisingly, both scans picked up significant pathology.

I didn’t get a chance to take care of any hospitalized patients, but I did get the chance to talk to a couple of new doctors with a passion for rural medicine.

I had a wonderful conversation with an Army linguist, and found Arabic has 3 Hs. I got to talk about how Navajo has the only click outside of Africa (the initial consonant in string and goat, the middle consonant in blue).  We had a marvelous time tossing jargon back and forth and singing praises of Rosetta Stone.

I used my massage skills to make one of my patients better before leaving the clinic.

I started a complicated endocrine investigation, and will probably not know the results.

I kept at least one patient out of the hospital with Gatorade.

One twelfth of the patients came in with dermatologic problems. I recounted the remarkable experience my son-in-law, my daughter and I had at a Continuing Medical Education event in Pittsburgh, where the lecturer announced that we can now treat pityriasis rosea (with the same antivirals we use on herpes viruses).  He went over his daughter’s experience with a red rash in a “Christmas tree” distribution just before her wedding, with no time to change her backless, strapless wedding gown.  He told her nothing could be done; twenty smart phone minutes later she showed him his error.

All in all, I took care of 36 patients, the same number I used to consider optimal for a day’s work in private practice. In those days clinic hours went 9 to noon and 1:00 to 4:30, with two hours dictation after supper.

I had a great time. I bonded well with staff and patients, but, towards the end, though the installation might invite me back when one of their docs takes a vacation, I realized they don’t need my full-time services now.  My experience exemplified the success of the locum tenens concept.

I even got out a couple of hours early. On a Friday afternoon.

 

 

 

 

Chain Hotels: tasteful, but no local flavor

September 4, 2016

I came, I worked, and got paid

I left as twilight did fade

I did well to cheat

My exposure to heat

And in a nice hotel I stayed.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska. Getting my wife’s (benign) brain tumor treated took a large part of the summer. I worked a week in urban Alaska before heading to Pennsylvania to our married daughters and our grandson.  Any identifiable patient information has been included with permission. 

 

I stayed in a very nice hotel in Alaska, with a hot breakfast every day and tasteful décor.  I walked to the clinic in the mornings, lunched in the Doctors’ Lounge, walked back in the evenings, and watched first-run movies on the TV.  After a week, I checked out of the hotel, and met up with a longtime friend in Anchorage.  We spent a morning scouting for moose.  About sunset, I headed back to the airport where you can spot the fisherman by the coolers and the cylindrical fishing rod cases. With day faded into the subarctic’s midnight twilight, I boarded the jet and sleep poorly all the way to Chicago O’Hare.

I left Alaska under clear skies with ideal temperature and deplaned in Chicago in stifling humidity and heat. My flight from Chicago to Pittsburgh got cancelled, due to “air traffic congestion.”

I had never heard of such a thing.

I approached the ticket agent with cheery patience. Actually, I was determined to be so sweet she’d get diabetes from talking to me.  While she tapped furiously at her keyboard, I said, “Look, it’s rare in my life that this happens, but today I’m just about as flexible as can be, and these folks behind me, they just want to get onto the plane.  So go ahead and take care of them, and after they take off, you can see if you can help me.”

Jet-lagged and sleep-deprived, I slouched into a deliberately uncomfortable chair and snoozed. When the crowd cleared out I approached the podium.  The agent booked me to Pittsburgh the next day with a flight through Charlotte, NC.

I very politely asked for a hotel voucher. She looked at me for a moment, and then said that she almost never gets anyone nearly so calm as me and she would see what she could do.  I watched her take her case to her boss at the next gate, and she came back with a voucher.

I stepped outside the air conditioned airport into the heat and waited for the shuttle. I went directly into the cool of the hotel and checked in.  The clerk, finding I had no food voucher, comped me a bag of snack mix from the in-house mart.

I haven’t always gone out of my way to avoid the heat. In the summer of 1972 a college buddy and I rode our bicycles from Connecticut to Denver.  One hundred-mile day in Ohio we each drank 3 gallons of fluids and urinated not a drop.  By the end of the trip, entry into normal climate-controlled businesses felt uncomfortably cold.  Till two summers ago I wouldn’t use the car AC in town.  As time has gone on, though, I find the cold easier to tolerate than the heat.

The next day I flew into Pittsburgh. My oldest daughter picked me up.  I didn’t discourage use of the Honda’s air conditioner.

I checked into a hotel of the same chain I had in Alaska. It had the same hot breakfast and tasteful décor.  Nice, but no local flavor.

 

 

Underworked and overpaid

August 30, 2016

The setting in Alaska was pretty

Near eagles and bear’s there’s a city

With specialists plural

You can’t call it rural.

And it paid really well. What a pity.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

I worked a week in a city in Alaska.

Alaska doesn’t have many cities, but it has more than one.

They put me up in a very nice hotel, walking distance from the workplace.

Medicare pays doctors very poorly in rural areas, so badly that a doctor cannot cover overhead if the practice includes too large a percentage of elderly. So a lot of private practitioners refuse to see new Medicare patients, and some will terminate care on the patient’s 65th birthday.

Massachusetts attacked the problem by making Medicare participation mandatory for licensure. The doctors responded by moving away.

(Canada’s system pays a premium to rural practices, but they still don’t have enough rural doctors.)

So in this particular city one of the larger institutions put together a clinic for the elderly to take the burden off the Emergency Rooms. Salaried physicians see Medicare patients; the clinic depends on grant monies to continue operation.  The model lacks sustainability.

But the docs still need vacations.

I confess I said yes to the job because of ego; I liked the idea that they would fly me to Alaska, and put me up, for a week’s work.  I had hoped to work for a week a month and get in some fishing before my return, and I would have, if paperwork hadn’t moved at a glacial pace and my wife hadn’t come down with a benign brain tumor.

So on a beautiful Monday morning, I got two interviews, a name tag, and a couple of pamphlets by way of orientation, and started to work in a large hospital complex.

My previous experience with their electronic medical record (EMR) system came in handy despite the major differences between versions.

With not much on the schedule, I sat down with the first patient and said, “Tell me about your problem.” I listened without interrupting till the word flow stopped, and said, “Tell me more.”  At the next long pause I asked, “What else?”

With never more than 7 patients on a days’ schedule, I could take a lot of time with each patient. I enjoyed listening to the Alaska pioneer stories.  One 72-year-old male patient gave me permission to write that he had biceps a 16-year-old would envy.

Most of the patients of both genders have hunted, many still hunt, and I enjoyed discussion of moose and caribou weapons.

I could access specialty services, including ER, quickly, but, as easy as it made my job, it didn’t fit with my conception of Alaska as the ultimate in rural experience.

And, for me, rural makes the adventure.

My wife had stereotactic radiosurgery

August 29, 2016

The computer would focus the beam,

And I would doze, perchance I would dream.

And turn after turn

The tumor would burn

Ramsay Hunt wasn’t part of the scheme. 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

Bethany had her stereotactic radio surgery on schedule. Even though the tumor involved no malignancy, the procedure took place at the June Nylen Cancer Center and involved a radiation oncologist.  The festivities started off with the neurosurgeon using 4 screws to affix a frame to her head.  Then followed a CT scan of the head, and three hours wait.  When all was ready I walked Bethany to the linear accelerator, which didn’t make much of a visual impact.   The frame screwed to my wife’s head got bolted to the table under the linear accelerator.  I made a small contribution by suggesting a couple of rolled towels under her shoulders would favorably change the angle of her neck.

Then I walked back to wait. They said it would be an hour, and I thought about going out for lunch, but I stayed around, and twenty minutes later we walked out into the heat.

The next twenty-four hours went well but then the full impact of the radiation hit with nausea and vomiting. A couple of quick calls brought a prescription for Zofran which helped a lot.

Bethany seemed to have bounced back well, and she drove me to Omaha on a Saturday to catch a plane to Alaska very early the next day.

I brought a cooler full of 50 pounds of sweet corn to friends who live in Anchorage, before I started work on Monday.

By the time I’d landed, blisters had broken out on the left side of Bethany’s hard and soft palate; her description brought shingles to mind.

A while ago, leafing through a free medical journal called a “throw away” for good reason, I came across a photo quiz which showed zoster inside the mouth. I flipped the page to find the diagnosis of Ramsay Hunt Type 2.  I scoffed, figuring if I hadn’t seen something like that in 30 years I probably wouldn’t ever.  But three weeks later I looked in the mouth of a patient complaining of a “sore throat” and found exactly that.

I posted a poll on my favorite doctor’s social media site, and found that 80% of physicians haven’t heard of Ramsay Hunt Type 2, but 10% have seen it.

But it was the weekend. I told Bethany to schedule with her physician, and by the time she got an appointment she’d broken out with the worst cold sores she’d ever had, on the left side of her nose.

The viral culture eventually showed Herpes 1 (cold sores), not its cousin, the varicella zoster virus, or shingles.

Valcyclovir will treat both, but shingles requires a much higher dose.

And I can’t say I’ve seen two cases of Ramsay Hunt Type 2.

Mud pit volleyball

August 3, 2016

After rounds, we went to the fair.

Who knew what we’d find there!

But a volleyball flood

Made a pit full of mud

There was plenty of fun to spare.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

 

I made Saturday hospital rounds on three patients, discharging one, getting another ready for discharge, and continuing treatment for rather serious illness in a third.

We went over to the Farmer’s Market. We arrived too late to get the tomatoes that we crave, and our current cooking facilities (a microwave oven) wouldn’t let us take advantage of the good ranch chickens on sale, but we bought a cantaloupe driven in from Rocky Ford in Colorado.

Afterwards, Bethany and I headed out to a nearby (a relative term in western Nebraska) county fair.

A county with a small population holds a small county fair, one which we can circumnavigate on foot with no problem. We saw prize-winning cattle, sheep, goats, pigs, and rabbits.  We took in the exhibit hall and learned about elk and the importance of solitary bees.

Despite seeing a lot of mounted people and we arrived too early for rodeo.

But we found a couple of volley ball games in full swing.

As near as I can tell, there are three kinds of volleyball: indoor, beach, and mud pit. And I hadn’t known about mud pit volleyball before today.

Imagine a beach volleyball court excavated to a depth of 5 feet and filled knee deep with water. Participants might wear sneakers or they might go barefoot.  As the event progresses, the water gets muddier and the bottom gets more slippery and uneven.  Those inherent difficulties of trying to move radically change the character of the game, and Newton’s Laws bring a comic flavor.  Diving doesn’t work, and only the foolhardy jump.  If the ball comes to you, great, and if it doesn’t you don’t have a lot of choices.  I saw a lot of unintended slapstick comedy, including an all-out pratfall with both feet off the ground, a short-lived full water clearance, and a high-splash back-flop (like a belly flop but on the other side).  Eventually, those at the sides of the pits started to slide towards the middle.  The wind, always a factor on the Great Plains, gave a distinct advantage to one side. 

They say that the more seriously you take something, the less fun you have doing it. And I think those teams who lost had just as much fun as those who won.

 

Sports physicals and good horses

July 30, 2016

Out here they have nothing to hide

They think it’s important to ride

The unified force

Comes down to a horse

They’re cowboys and cowgirls, bona fide.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

Thursday the construction noise had become intolerable. I put on my shooting muffs, and stepped out the side door.  The worker operated an electric jackhammer, not a drill, detaching a concrete lip from the foundation.  I waited till he had hacked off a chunk, stopped his machine, and repositioned.

“Excuse me,” I said, “Um, any idea how much longer you’re going to be?”

“Almost done, probably by lunch,” he said.

“Do you have hearing protection?”

“Yeah, “he said, “In the truck.”

“Take it from me,” I said, “If you want to be able to hear the voice of your grandchildren, protect your ears.”

I had a productive day, between outpatient and inpatient I attended 14 people.

Sports physicals, required by school districts, don’t save lives and don’t prevent injuries. On average, less than once every two years I detect a problem during a pre-participation exam that I can do something about.  Still, the visit goes quickly, and I get to educate the kids.  As the athlete sits on the exam table I ask what sports.

Here in western Nebraska a lot of the students start their list with rodeo. Ranching and wheat dominate the agricultural sector.  People rely on horses for work and for play.  Ranch work goes much easier with a good horse and good roping skills.  People favor quarter horses for their intelligence and speed.  So when the kid says rodeo, I ask, “Do you have a good horse?”

Sometimes the face lights up and the grin follows, and I infer, that, indeed the horse is a quality animal. And sometimes the answer comes back, “Pretty good.”

Patient flow slowed to a negligible trickle on Friday; I attended three times more people in the hospital than in the clinic, where I only saw one.

I greatly enjoyed that patient, who gave me permission to write that I diagnosed piriformis syndrome (see my post from 2010), one of my favorite problems because I can fix it before the person leaves.

The insurance credentialing process has cleared me for 4 insurances but not for the majority. I do not understand why, because I had full credentials when I worked here in January.

So I had a slow week, and I would have preferred more patients. All in all, I saw entirely too much drama and irony in for form of patients paying the ultimate piper for their dance with tobacco.

 

A single digit error explains low patient flow

July 27, 2016

I said to the front office clerk

I hope I’m not being a jerk

Someone who works in hive

Wrote  seven, not five.

Now will you please just send me more work?

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

After two months of no patient care I returned to work three days ago. Patient flow crept in the single digits daily.

Still I had bloggable moments.

We dealt with a cardiac arrest the first day. Doing CPR constitutes a valid workout, and people fatigue so quickly that the guidelines call for a change of personnel every 2 minutes.  My turn came, and the hospital CEO followed me.

For different people with different problems that day I advised drastic alcohol reduction, complete tobacco elimination, good hydration, sleep prioritization, regular exercise, and a return to counseling. I pointed out that marijuana aggravates anxiety, deepens depression, brings on paranoia, and sabotages life goals.

Yesterday we watched through my office window as the crane lowered a new installation, really a prefabricated building with very expensive equipment, into place. The machine, worth dozens of millions of dollars, came down slowly, guided by men in hard hats with ropes.  I recalled my days in construction, when I swept the concrete footing furiously just before the crane lowered the form.  I looked at the odd clods of dirt on the footing and shook my head.  The stucco wall now sits three feet outside my office window, completely obstructing the view, and reflecting the heat from the sun.  I’ve quipped it’s a monochrome mural by a noted abstract artist titled Beige Wall, and offered to forge a Salvador Dali signature on it.

I performed my version of a complete neurologic exam on 4 different patients yesterday; all completely normal. I deal with a lot of patients with headaches, migraines and others.

But I also took care of a very sick patient. At the end of the day, I ordered a lot of lab work, all of which got sent to a reference lab an hour away.  I left my phone number with the techs, telling them that they could text me results without violating HIPAA as long as they didn’t attach a patient name.  And I could do so safely because I only had one patient hospitalized.

Today the low patient flow continued. The new installation required lots of drilling through my office wall.  I fled the intolerable noise to chat with a colleague.  But I also passed a front office staffer at a critical time.  She asked me my UPIN.

Various entities have assigned me various unique identifying numbers, starting with my 9 digit Social Security number. The longest one, with 14 digits, comes from Canada. I gave her the 10 digit number, flippantly, ending with 365.  She frowned.  The one she had on file ended with 367.

That one digit error resulted in no insurance credentialing for 5 companies. The clinic administration worked hard much of the afternoon to try to set things right.

While the drilling in the wall continued.

I thought about the Bob Dylan song, Lily, Rosemary and the Jack of Hearts.

An Abnormal MRI, too close to home

July 13, 2016

We’re doing the best that we can

To follow an abnormal scan

The rumor was tumor

But the answer was no cancer

And the treatment’s a flash in the pan.

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. All our plans have been put on hold pending resolution of my wife’s brain tumor.  Any identifiable patient information has been included with permission. 

Three weeks ago on Tuesday my wife, Bethany, awakened with severe vertigo. She couldn’t get out of bed without vomiting.  Over-the-counter meclizine helped but little.  I posted the case on a physician’s chat site the next day, and got the recommendation for the Transderm Scop patch (she had one left over from a recent trip).  It helped but the problem persisted.

I don’t like to be my family’s doctor, so that Friday morning we went to the Clinic Formerly Known As Mine. Bethany’s doctor found horizontal nystagmus (a twitching gaze), when looking to the right, and ordered an MRI with contrast.

Chaos dominates Friday afternoons, thus Friday’s MRI happened without contrast.

I have the training and education to imagine a large collection of really bad things, and by now I’ve learned that the awful moments in life come to us unanticipated. So I went through my catastrophic catalog and felt better for having done so.  My phone went off while I was gardening.

In general, you don’t want your doctor to have bad news, especially not on Friday afternoon.

The MRI showed a 2.2 centimeter something behind the left eye. The original report mentioned possible glioma with the strong recommendation for a contrast study.  The thing’s location didn’t account for the dizziness.

With advances in imaging, we have had to come up with a term that means an abnormal finding found by coincidence; we call it an incidentaloma.

I called my locum tenens recruiter to say I had put all plans on hold; she relayed the information to those facilities expecting me in Nebraska and Alaska. Bethany phoned our daughter to say she wouldn’t be coming to help with the new grandson.

That night I read Bethany the Wikpedia article on glioma: 1/3 benign, 2/3 cancer.

Bethany’s cousin’s first wife died three weeks after getting her glioma diagnosed; she only had time to pick out her husband’s next wife, and say a loving goodbye to her family. In the ‘80’s I had a patient with a glioma who lived for less than 100 days after diagnosis.

We didn’t talk about those things.

Bethany took the information in stride, with understated courage. I focused on the moment with the joy of uncertainty that gives hope.  I embraced not knowing and did my best to focus on the moment: stripping the last tart cherry tree of its fruit, bringing in the first green chiles from the garden. I clung to things precious for their normality.

We suffered through the next four days, our plans shredded, as Bethany’s dizziness faded and her balance improved.

With her vertigo improved and her calm unruffled, Bethany went in for the contrast MRI the Tuesday morning before July 4. In the afternoon our fax brought the new diagnosis of meningioma, a well-behaved tumor with little if any malignant potential.

Relief of a magnitude that brings tears defies description.

I relied on my status as a physician and on friendship to get us an appointment with a neurosurgeon the next morning.

He explained the choices: leave it alone, open surgery, or radiation. He said if it were his tumor, he’d prefer the radiation.  He also showed us the MRI image, with a bright cylinder an inch long and half-inch wide growing up from the floor of the skull just behind the left eye.

He doesn’t do that procedure, but his partner does. And that partner wouldn’t be back in the office till Tuesday the following week.

Basking in the light of a better diagnosis while marinating in the darkness of an upcoming brain procedure, we went about our business. We had ice cream with our neighbors, and friends over for dinner on Friday.

Yesterday we met with the neurosurgeon, who explained stereotactic radiosurgery. And today we met with the radiation oncologist.

The actual treatment consists of focusing a radiation beam on the tumor, zapping the same way sunlight, focused with a lens, burns one point.

The next step, the 3D MRI, remains unscheduled.

 

 

Colleagues, vitamin D, and statin myopathy

June 20, 2016

There once was a doc from Manhattan

One day we just fell to chattin’

I asked, “What would it take

Besides a muscular ache

To get someone off of a statin?”

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter found me working in western Nebraska and, later, in coastal Alaska.  After the birth of our first grandchild, I have returned to Nebraska. Any identifiable patient information has been included with permission.

 

Merkin’s Law states that any patient given a high enough dose of a statin for a long enough time will eventually hurt so badly exercise becomes impossible.

We call the drugs statins now because the generic names all end with those two syllables, but when they first came out we called them HMG coA reductase inhibitors. We used those drugs for years to lower cholesterol, in the hopes of decreasing risk of heart attack and stroke.

More than 20 years ago, though, a cynical doctor at the back of a lecture hall questioned the utility of that class of drugs if we got no net benefit in all-cause mortality. It seems, he said, that for every life saved from heart attack or stroke, one was lost to homicide, suicide, car accidents or respiratory infections.  The crowd laughed at the litany of diseases.  A year later, at the same Continuing Medical Education event, we chuckled when the same scene played, and a year after that, nobody laughed.  Aggressive drug company marketing fueled the cholesterol hysteria but I never developed a passion for treating cholesterol numbers.

My wife, after 3 years of statin therapy, over the course of 5 days developed such severe aches that her Tae Kwon Do class missed her black belt till she quit the med and recovered. Such circumstances did not endear that bunch of drugs to my heart.

Still, in context, I have the obligation to give my patients standard of care. I tell them about diet and exercise almost to the point of nagging, then I start the statin, and I warn them about side effects.

In the last two years, we have gotten convincing evidence that high-dose statins, regardless of cholesterol numbers, improve the outlook for those at high risk of heart attack and stroke.

Still if a statin patient hurts for no good reason, I tell them to stop the med, but I also test the blood for creatine phosphokinase (abbreviated to CPK or CK).

I outlined my personal algorithm to my colleague, and described my strategy of stop and rechallenge, and, if need be, use of coenzyme Q10.

He told me, gently, that coQ10 does no good, but switching to a lipid soluble statin does.

I found the discussion so constructive I went online, and found, to my chagrin, that he was right, and my past experience with coQ10 relied on the placebo effect.

I stuck my head in his office, and told him he was right. But I also told him I learned to check the thyroid and the vitamin D in those cases.  He looked at me with the same amazement I felt when I’d read about lipid-soluble statins.

We both emerged from the experience better doctors.