Archive for March, 2010

Divestiture: a family game to get rid of clutter.

March 31, 2010

Through my stuff I’m having a look

It’s hard to  throw out a book

            It could be a blast

            For an iconoclast

You won’t believe the time that it took

 

I’ve started clearing stuff out of my office.

First, I moved out three of my four dictionaries.  Print dictionaries are rapidly becoming an anachronism in the information age.  Even if I don’t use one very often I couldn’t bear to not have one on the bookshelf.

I disposed of two PDR’s, one from 2008 and one from 2009.  I remember when the publication ran much smaller and much thinner.  Our current fabulous medicinal agents just keep getting better.  Are they worth the cost?  You can have 1982 medicines at 1982 prices, they haven’t gone up with inflation.  If you want the improvements, you’ll have to pay for the updates.

I try not to put so much into the trashcan that the janitor will hurt his or her back trying to lift it.  I throw away about one trashcan full a day.

Our oldest, Jesse, started us playing the game Divestiture about three years ago.  The rules: each round specifies an end date.  You get one point for getting rid of something the size of a box or a bag, and two points for getting rid of something the size of a pony.  You can only get rid of your own stuff.  No points for stuff brought in just to be gotten rid of.  Forming the intent to take stuff away or sell doesn’t count, you only get points when things leave.  You can sell, donate or throw possessions away; consuming the consumables doesn’t count.  In the beginning we had a separate point system for things in the fridge, but we’re past that. 

You can make your own rules.

It took two years of steady streams of things going away by the literal van load till we could see a difference in how much clutter we possessed. 

Divestiture has put a new spin on what we buy, or rather, what we don’t buy.  I look at the fabulous prices at Harbor Freight, then I think of all the things I dumped off at Goodwill that I hadn’t used for years.  Then I think that I don’t want more things to stumble over.

The process is working for us as a household, and now I’m applying it to the space I’ve worked in for close to a quarter century.

Back when I started private practice, I opened my Physician’s Desk Reference several times a day.  Even back then it was so unwieldy that I memorized dosages.  I kept it on my desk because pulling it off the shelf would have given me tendonitis. In 1990 I got my first Franklin Electronic Book, put the PDR module in it, and stuck it in my pocket.  Ten years ago I got my Palm and downloaded Epocrates, an electronic pharmaceutical data base.  Most years now I get my paper PDR and I don’t even open it.

Getting rid of books, whether at home or at work, comes hard for me emotionally.  Throwing books away, even books I couldn’t stand to read, goes against my grain.  So I take some of the books home and trying to give others away.  I tell myself that in this year of going walkabout I will read some of them, because I’ll have time.

I have no trouble putting trashing the dangerously out-of-date books.  In 1987, a seven-year-old book retained usefulness.  Now a three-year old book is suspect, because it was a year old when it was printed. 

However much I might bemoan the passage of print materials, internet based data sources trump paper almost every time.  I’m sure there’s an exception, but I can’t think of one.

Mysterious abdominal pain

March 29, 2010

We don’t have to come to a truce.

Sure, I’ll write the excuse.

            But the frequent refrain        

            Of abdominal pain

Shows a survivor of kiddy abuse.

The patient’s left-sided abdominal pain radiated into the suprapubic area and sometimes into the back. I did the basic history, and I went to enter the diagnosis in the Electronic Medical Record.  I found the same diagnosis five times. 

Worry played the patient’s face during the request for a work excuse. I found all the info I needed about previous work- up.

A couple of CT scans, showed a cyst that progressed to resolution.  The patient had seen a surgeon, the right inguinal hernia had been fixed, but the pain essentially hadn’t gotten better.  Colonoscopy and EGD had been inconclusive.  Persistent hematuria had been investigated by the urologist.  Other specialists had been involved.  Everything abnormal had gone away or couldn’t explain the situation.

Today I found blood in the urine.  Again.  I made arrangements for a non-contrast CT scan to rule out a kidney stone.

Then I looked away from the screen and made eye contact with the patient.  I shut the laptop as a statement: now we are talking, your problem is important to me. 

In Spanish I reviewed the work up and I said, “Sometimes, when someone has a pain in the stomach that doesn’t go away it’s a sign that they survived sexual abuse during childhood.”

The expression fell from the patient’s face like infrastructure falls in a building implosion.  I offered Kleenex and one was taken.  Many such survivors clutch the tissue and don’t cry.  This patient was no exception. 

And the patient didn’t speak.

I said, “We must discuss this in depth.  But first we must make sure you don’t have a kidney stone.  Can you come back next week?  We’ll schedule a half-hour visit.  There’s a lot we have to talk about.”

In a perfect world I would arrange for counseling, but in Sioux City we don’t have enough people who speak Spanish who do counseling.  Actually, it’s mostly me.  Most patients need more counseling services than I can provide.  I still have to work on the patients with abdominal pain.

I attended two other patients with abdominal pain this morning, both with blood in the urine.

Pharoah’s law: nothing happens on schedule or to budget.

March 24, 2010

The bills are coming in stacks

And always make a new tax.

            What will it bring?

            I can’t read the thing.

But history gives us some facts.

People have asked me what I think about the new health care bill.  I haven’t read it, and neither has anybody in government who voted for it.  Few human beings could read it in less than a summer, and fewer can understand it. 

So, my opinion is that I don’t understand it. 

Here are some things I know for sure:

The government has never overestimated the cost of anything.  The Democrats say it will cost something, and the Republicans say it will cost something else.  The ones who want it to pass low ball their estimate, the opponents high ball it.  The worst high ball underestimates the final cost.  Any time you deal with a contractor you will get bait-and-switch and mission creep. In this case the monopoly wants to monopolize health care.  I hope this isn’t your first rodeo. 

There will always be unintended consequences.  A basic first principle; nothing ever goes completely according to plan.  The more complicated the scheme, the more pieces  end up where they shouldn’t.  Think of your own experiences, now think of your experiences with the government.

When the unintended consequences happen, fingers will point in Washington.  The more finger-pointing, the less energy expended to solve the problem, and the problem gets bigger.  Then, of course, we need more laws.

When Washington does anything, the bureaucracy swells.  It never shrinks.  Agencies long since rendered useless persist.  Inefficient machinery has the advantage of flexibility.  Look at DC now.  While fighting a couple of wars we didn’t notice that we added anybody to the payroll.  Find an example to prove me wrong and let me know.

When Washington does anything, taxes go up.  The people who estimate that the deficit will go down are either lying or stupid.  When has our government done anything that lowered its costs?

 When Washington does anything, paperwork gets worse.  About twenty years ago there was a Paperwork Reduction Act, and from time to time you’ll see verbiage on a form that gives you a fictional estimate of how long it will take to fill it out.  No one has filled those things out in the time allotted.  The act just made things worse.  Look at HIPAA, you know, the form you fill out every time you see a doctor.

When Washington pours money on a problem, they usually miss.  When the government appropriates funds for a project, most of the time some of it gets siphoned off to places it shouldn’t go.  Lots of times most of the moneys don’t go where they’re supposed to.  Look at Acorn.

When paperwork gets worse, retirement looks better.  Most people actually enjoy their work but they dislike their jobs because of the side issues, which for most people means paperwork.  Medicine is no different.  The more educated the profession, the worse the paperwork gets.  A lot of people who get out of bed in the morning and look forward to helping people.  Few look forward to filling out forms.  There has to be at least one.

 If doctors are spend time on paperwork they can’t spend time on patients.  A day has only 24 hours. 

If you want truth, don’t take a partisan stance.  Demonizing the opposition doesn’t get you anything but votes.

The vast majority of doctors oppose the plan presented to the public through the media. 

What, you want us to read it?  We wouldn’t be able to see patients for months!

Death and bourbon

March 23, 2010

My patient is right on the brink.

Of what, I try not to think.

            Money goes up in smoke       

            With whiskey and Coke.

The problem’s made worse with the drink.

 

The patient had a pain in the wrist.

Me:  How did it happen?

Patient: I’m not sure.  I was drinking pretty hard, and when I woke up, there was blood on the floor and my wrist started hurting a day or two later.  I guess I blacked out.

Me:  What do you like to drink?

Patient:  Whiskey and Coke.

Me:  When was the last time you had a whiskey and Coke?

Patient:  Yesterday.

Me:  How many did you have?

Patient:  Well, I drink most nights.  I have five or six whiskey and Cokes, and three straight shots.

Me:

Patient: That’s five nights a week, probably double on my two nights off.

Me:  Do you think that this amount of alcohol is a problem?

Patient: No.

Me:  Then we will agree that we disagree about that.  I think you have a problem and you don’t think you do.  We’re not going to agree.  Here’s what can’t you can’t disagree with:  this amount of alcohol presents a risk of death and disability, it is the reason that you’re here today.  And I recommend you quit drinking completely.

Patient:  Ain’t gonna happen.

Me:  If you ever think you have a problem with alcohol, the door’s open.  We can help you.  But for right now, let’s get an x-ray.  I’ll be back in a couple of minutes.

Years ago I would have tried to be right about the alcohol.  I attempted to make the patients see the errors of their ways.  Such an approach doesn’t work, it alienates patients, and it frustrates me.  These days I can perform my moral obligation without incurring the wrath of the patient.  Then it struck me there was an additional moral obligation.

 Me:  Your x-ray is fine.  Do you drink in or drink out?

Patient:  Out.

Me: Who drives home?”

Patient: I walk.

Me:  Good move.

The patient reveals the circumstances that started his heavy drinking: the sudden, unexpected violent demise of a friend.  The patient watched it happen and was helpless to stop the tragedy. 

We sit in a pool of silence and the patient looks at the floor.  I wait for the patient to talk. I listen to the same information rehashed till the need to talk finishes.

I diagnose post traumatic stress disorder, and I talk the diagnosis over with him.  I prescribe propranolol, to damp the effects of adrenaline overload.  We discuss the problem of main effect versus side effect and how he’ll need to come in frequently to titrate the dose. 

Then I bring out the calculator.

Me:  How much is a whiskey and Coke?

Patient: $2.50.  I know.

Me: You did the math?

Patient:  Yeah.

Me:  How much a year?

Patient:  I don’t know.

Me:  So you didn’t do the math. And how much for the straight shots?

Patient:  I know, I know.

Me:  How much?

Patient:  Three dollars.

Me:  OK, six times that and three times that, times five nights per week times fifty-two weeks per year.

Patient:  I know.

Me:  (I show the patient the calculator).

Patient:  Wow. That’s a lot of money.

Me:  And we didn’t figure in your nights off.

I didn’t forget about the wrist, nor about the three other complicated problems the patient had. 

I hope he’ll be back.

The immediate gratification of ear wax

March 22, 2010

Well, what have we here?

A curable problem, no fear!

            While I work we will talk

            Then you can get up and walk

The problem’s the stuff in your ear.

The patient’s complained of a problem with balance.  With no steadiness to the gait, and the nurse had to use a wheelchair for transport to the exam room.

I really couldn’t get much out of the history, but I know the patient doesn’t cry wolf. 

First, I checked eye movements.  The gaze following my flashlight, with no jerking movements when looking off to either side.

Next I checked the ears, not easy when the patient can’t get out of the wheelchair and doesn’t have much neck mobility.  But I maneuvered the wheelchair, took off my glasses, and positioned myself.

Sure enough, wax plugged the right canal.

I have taken a lot of ear wax out over the years.  I don’t count wax as trophy grade unless the plug is as big as the end of the patient’s little finger.  My personal record is three trophies from one ear.

I’ve taken other things out of ears.  To remove a tick from an ear you need mineral oil, a goose neck lamp, a nurse, and a tweezers.  You put the patient on the exam table with the infested ear up, fill the canal with mineral oil, turn the goose neck lamp on a foot or so directly over the ear, hand the nurse the forceps, and say, “Come get me when you have the tick.”  Then you walk out of the exam room and turn out the lights so that the only light is the gooseneck.  The approach has never failed. 

I pulled the end of a click ball point pen out of an ear canal.  The patient had lost it in sixth grade.

I took a beautiful blue object, possibly a sapphire, out of an ear canal and no one in the family could identity it.

On four occasions sprouting grass seeds have brought the patient in.

Three times the patient’s high blood pressure has permanently resolved with removal of dense wax.  Much more often than that I’ve cured a patient’s mysterious cough by taking something out of an ear canal.

Once a patient with an earache had a soy bean in the ear.  For those inquiring minds that want to know, the hull had just barely cracked.

Getting stuff out of ears requires a certain amount of training, experience, and equipment.  I actually learned in the beginning to do it with no visualization, fishing into a dark canal on the basis of forming a mental image.  Then one day I completely misused lights meant for surgery, which spoiled me forever.  In the last quarter century I’ve gotten used to using a head lamp, a disposable soft blue ear curette, and an alligator forceps.

Alligators look like a bent hemostat, and are incredibly useful things to have around the house.  In the Indian Health Service I carried my own and wore one out about every year.

Since October I’ve used a fiber optic device called a lighted ear curette.  It has a battery in the non disposable handle, and brings the light right to the tip of the plastic removal device.  It’s portable and readily accessible (the alligators in our office live three minutes away), and if I take off my glasses I don’t need a magnifier.

The wax plug came out of the patient’s ear easily, the hearing immediately improved, and the patient stood up and walked out of the exam room without the wheelchair.  I held the patient’s hand all the way to the check out desk.

Family practice doesn’t give a lot of immediate gratification.  Most of the time when an FP helps a patient, the actual improvement takes place hours, days or weeks after the visit.  Taking wax and other things out of a patient’s ear comes as a very right now kind of thing.  Curing patients is an extremely enjoyable experience.

I don’t plan to give it up.  I just want more time to savor it.

Healing with shots in the dark

March 21, 2010

If your tree seems to have the wrong bark

And the treatments haven’t made the right mark

            By dribs and by drabs,

            If you got normal labs

It’s time to shoot in the dark

During residency in Casper, Wyoming in the spring of 1981, I went to Denver Children’s Hospital to learn bread-and-butter inpatient pediatric care.  Casper just didn’t have enough sick children to properly learn how to take care of the most common problems requiring hospitalization.

Since then many of those problems have ceased to exist, primarily because of improved immunizations.

On the second day of that month at Denver Children’s, a nurse led me into a ward, a cavernous room with a nurses’ station at the center and twelve bays around the periphery.

The ward contained children, all under the age of six, with diarrhea.  They had failed to improve with three levels of care: the family doctor, the pediatrician, and the pediatric gastroenterologist.  The world-renowned authority, A. J. Silverman, wouldn’t return back for a week.  It was up to me to cure them.

I delved into the charts one by one, found exhaustive medical work-ups, and did thorough histories and physicals.   Each patient had something not found in textbooks.

The toddler I remember the best had 15-18 watery, coffee-ground like stools a day, and also had an identical twin.  The twin with the diarrhea was growing a lot faster. 

With nothing to lose, I managed to make three of the twelve better by the time I moved on. 

(If you must know, one of them stopped having symptoms with an aspirin a day.  Two others got better on cromalyn, a medication so incredibly safe that pregnant rats injected with 1000 times the normal human dose show no adverse consequences.  At the time it didn’t exist as an oral formulation. But that’s a much longer story.)

It was my first experience shooting in the dark.  It wasn’t my last.

I remember a young adult who came in the spring with signs and symptoms of rheumatoid arthritis.  The lab work came up and symptoms showed no response to anti-inflammatories.  The seventh time it happened I recommended an antihistamine.  Four hours later my nurse handed me a message saying the symptoms had promptly disappeared.  I haven’t seen the patient since.

Mayo Clinic does a very good job, but once in a while a patient will point to a stack of papers the thickness of a Fortune 500 Annual Report and say, “I just spent $18,000 and my problem isn’t any better.”  Then I shoot in the dark.

I use these rules for shooting in the dark:  1) At least two levels of care higher than me.  2) No lawyers on the case. 3) All the lab tests have to have been done.  4)  At least two reasonable pharmacologic alternatives attempted.  5)  At least two reasonable life style modifications implemented. 6) I only try low-risk treatments.

On Wednesday this last week I got a call from a friend, a man in his forties, who has given me permission to write about him.  For more than a decade he’s had disabling joint pain.  He has access to really good neurologists, internists and rheumatologists, and the lab evaluation has been complete.  He doesn’t fit into any good diagnostic models. 

He’s had round after round of antibiotics.  He’s failed on every medication that’s ever tried for fibromyalgia.  If anything, as time has gone on, he’s gotten worse.

I listened over the phone, I asked more questions, but before I could come to a conclusion I had to deliver a baby.

I’ve been thinking outside the box since.  My reasoning goes something like this:  the diagnosis doesn’t show up in the books.  Antibiotics and membrane stabilizers have done nothing.  Let’s try something different.

I called him back yesterday, and I had three suggestions: a beta blocker, an alpha blocker, and a calcium channel blocker.  He has a doctor flexible enough to work with him in his home state. 

Since I started to write this, I thought of my good friend, cromalyn, and a new comer, acamprosate.

With about a dozen beta blockers on the market, and six in common use, I recommended the oldest, propranolol.  Cheap and safe, it gets into the brain and spinal cord better than any of its cousins. I told him to start at 10 mg a day for at least three weeks.  If it made things better or worse it would tell us the next step. 

The alpha blocker I advised was clonidine.  Originally approved by the FDA for high blood pressure, its current uses mostly exist off-label things from ADHD to drug withdrawal.  Again, if it makes him either better or worse, it tells us the next step.

I had a patient once who had, struck by lightning, hurt for forty miserable years before I met him.  I prescribed Prozac and the pain stopped.  I readily admitted then, as I do now, that I didn’t know exactly how I’d helped, but I did.

I helped another lightning strike survivor with intractable pain by prescribing propranolol.  I have no idea why it helped.

Almost dead on a Friday afternoon

March 20, 2010

When a fictional patient had died

I worried, I paced, and I sighed.

     The little white spheroids

     Were pills that were steroids

The adrenals had shriveled inside.

Flash back to 1979, when, fresh out of medical school, I was studying for the Boards.

Back then there were no computer based learning programs; an “interactive” program involved using a disclosing highlighter on pulp paper. The name of the book was Clinical Simulations; it gave a clinical scenario, and a series of decision choices. At each decision point I would use the supplied highlighter and printed information would appear where blank space had been, directing me to turn to a new page.

The hypothetical patient, a fifty-four year white female with rheumatoid arthritis, took some “white pills” she got in Mexico for her joint pains, but she came in with right lower quadrant pain suggestive of appendicitis. I asked for more information and found out she smoked, she drank, and worked as a highly paid executive. Labs came through that looked OK, and I continued leafing through the book. I picked the page that let me order IV fluids and send the patient to surgery. As I ran the felt tip yellow marker across the page I read Your patient dies on the operating table. I dropped the marker and the book in shock.

At the time I had little clinical experience and no clinical confidence. A week later I discussed the case with my father, a cardiologist. He didn’t seem at all surprised. He talked about steroid dependency and the need for steroid support when people get sick.

Fast forward to yesterday.

Friday afternoons are always chaotic in doctors’ offices. People getting sick try to get in before the weekend, and I don’t blame them. But people who work in the office also would like to have a long weekend, and frequently the place runs short-staffed. For a long time I have tried to maintain a policy of not scheduling any appointments for Friday afternoon before the switchboard opens on Friday morning. Especially with a crowded schedule, I’ve tried to keep slots open for established patients, and not take new patients on Fridays. As a short timer, with weeks left in my tenure, I shouldn’t get any of the new patients.

Especially not on Friday afternoon.

Yesterday I walked cheerfully into the exam room to greet a new patient, and a relative, for the first time. The two together were a family fragment, a piece away from the context. The problem was cough.

In short order I’d found out about the colon cancer and the ileostomy as well. The patient confirmed status as ex-smoker, and I ordered a chest x-ray. The films showed the battlefield where lung tissue had fought a losing battle against smoke for a very long time.

“Your chest x-ray looks very bad,” I said. “Have you ever been told you have emphysema?”

The patient said yes. I started writing orders for antibiotics and steroids, at the same time I reviewed the medication list. I stopped in mid-prescription. “Why do you take Florinef?” I asked.

One adrenal gland wasn’t functioning when the other one was removed because of a benign tumor.

I clicked on the Vital Signs section and found a blood pressure of 60/40. “Are you feeling OK?” I asked.

The patient felt light-headed and dizzy.

I vividly remembered the yellow highlighter on the grey paper and the words Your patient dies on the operating table. I opened the door and asked my nurse to call the ambulance, and I turned back to the patient and relative. “Your adrenal glands,” I said, “Make steroids like cortisone.” They already knew that. “When you get sick,” I continued, “you have to have more steroids to keep your blood pressure up. If you don’t have adrenal glands to make more steroids your blood pressure can go so low you can die. And right now your blood pressure is dangerously low.”

(President Kennedy had Addison’s disease, where the adrenal glands fail slowly, and by the time he died he had no cortisone of his own manufacture. Back then treatment included injections of testosterone, which puts the Cuban Missile Crisis into a different perspective.)

The nurse came in to ask about what to tell the ambulance. I asked, “What injectable steroids do we have here?”

“Depomedrol and Kenalog,” she said.

“As soon as you can, give forty of Kenalog IM,” I said. “Please.”

I took out my cell phone and called Mercy’s ER to connect to a doctor I’ve known for a decade. I explained the situation, essentially an Addisonian crisis. I apologized that the best steroid I could lay my hands on, on a right now basis, was Kenalog, not the best choice but would hopefully keep the patient alive till the ambulance could get her across town. The doc accepted the transfer.

I’ve never had a patient in an Addisonian crisis before.

The patient and relative asked about continuing care after the hospitalization.  I told them the briefest version of my upcoming departure.  They expressed disappointment.

When the ambulance pulled away I apologized to other patients for my lateness.  I was too busy to breathe a sigh of relief.

From Hospice to OB: contrast is the essence of meaning

March 18, 2010

With Hospice to start out my morning,

I didn’t get any warning

            The things I would see

            When up on OB.                     

I caught the baby a-borning

I took the position of Medical Director of Care Initiatives Hospice last fall because I wanted to broaden my horizons and learn about terminal care.  I hesitated at first because  a colleague whom I wholeheartedly admire headed Hospice of Siouxland during his semi-retirement years.  I made it clear from the beginning that I didn’t want to take business away from the other program.  Usually competition results in a bigger pie and more business for everyone.

They offered the position to eight other docs before me.  The other docs declined for a variety of reasons.

But I wouldn’t have taken the job if it weren’t walking distance.  Yesterday I walked down the hill from my office, past the melting piles of snow, with moraines of river rock and debris on the sidewalk.  It was good to feel the gentle cold of March on my face, and hear the birds singing.  I make that walk once a week.

The large and sparsely furnished meeting room showed an organization recently moved into larger quarters.  A dozen people sat around a square of tables, and we talked about the seven patients on the roster.  The first one was the triumph.  With so much improvement since we started paring down the medication list, Hospice services might not be justifiable for much longer.

We have discharged three patients alive from Hospice. 

Most of the elderly who come to my attention come badly over medicated.  I try to follow the rule of never making more than one medication change per visit, but I figure that if a medication doesn’t do its job it needs to get axed.  For some of the aged, the process can go on for the better part of a year.  I take particular delight in stopping the Alzheimer’s medications and watching the patient’s “dementia” evaporate.   

Palliative care stands in stark contrast to my usual approach.  Hospice intends not to extend life so much as to relieve suffering.  This approach has changed my point of view and enlightened me.

I don’t deal directly with the patients.  I listen to reports from nurse, aid, chaplain, and music therapist, and I make suggestions to pass along to the patient’s attending physician.  Some of those physicians accept those suggestions better than others.

While I was at the Hospice meeting I got a call from Labor and Delivery about my patient who had come in for induction of labor. 

With that patient at the back of my mind all morning, I left the clinic at noon to rupture the membranes.  Of course her water broke spontaneously just before I arrived, and I stayed around till I had to go back to the office.  When I left her cervix had dilated to 7 cm, 3 cm short of the requisite ten.

That patient occupied my background thoughts all afternoon through my clinic duties and through my visit with the plastic surgeon who observed my forehead scar was coming along nicely.  Then I could finally go to Labor and Delivery and not think about trying to do anything else at the same time.

Things went well till the baby’s head stopped descending and the heart rate dropped from the 120’s to the mid 80’s.  The consultant I requested from Group A was doing a surgery downstairs.

Minutes count in those situations.  The consultant from Group B came in seconds later.

That obstetrician was able to place a vacuum extraction device on the baby’s head much higher than I would have. Pulling at just the right angle, the baby’s head rotated like a corkscrew, and when the really scary stuff finished, I took over the rest of the delivery.  All is well that ends well; the baby was large and healthy and cried immediately.  I thanked the consultant profusely.

Four hours later the postpartum nurses called me to tell me the patient had suddenly bled a liter for no apparent reason.  I ordered the right drugs by phone and the bleeding stopped, but I called every half hour till midnight to make sure the patient did OK.  All in all, I didn’t sleep well.

I rode the rollercoaster again with no grab bar.  Attending the birth of a child still brings a sense of wonder to me.  I will enjoy the last delivery I do, and then I will thoroughly enjoy doing no more deliveries

Side Effects of the Best Medicine, and Sutton’s Law

March 17, 2010

I had to apply Sutton’s law

I couldn’t believe what I saw

            The effect of the laughter

            The pain which came after

Was sharp, not a stab, not a gnaw.

 

The teenage patient, accompanied by the parent came back for the second time in three days with abdominal pain worsening.

The ultrasound done on Monday came out OK; normal blood count and good appetite in the face of increasing pain, worse with activity.

The belly itself had no masses or lumps.  Symmetric tenderness, along the sides of the abdomen, worse when the patient raises the head off the pillow.d

A puzzling picture, one that I’ve never seen before, led me to bring out Sutton’s Law.

Willy Sutton, the a great bank robber, robbed more than two hundred banks.  Supposedly, a newspaper reporter asked him why he robbed banks, and he said, “Because that’s where the money is.”

In his book, Where The Money Was, he denied ever having had the conversation, but gave an excellent history of how Sutton’s Law became a legitimate medical principle.

Sutton’s Law states: Go where the money is. It means two different things: 1) think geographically and 2) think in terms of the most likely diagnosis.

(Sutton’s Law has a lot of applications in and out of medicine.  In my case, it meant that if I wanted to find a Jewish woman willing to live in a rural area, the place to look was the synagogue in Casper, Wyoming.  Which is where I met Bethany.)

In the presence of local tenderness, I tend to think geographically, which means I have to consider the anatomic structures close to the pain.  In this case, the line of the pain followed the edge of the main muscle of the abdomen (the rectus abdominis), the one that forms into a six-pack after 10,000 sit ups and 5,000 crunches. 

Yet the patient denies new exercise programs or trauma.

The parent recently took to heart my advice on diet and exercise, dropped dozens of pounds, and started sleeping better.  The parent and the patient showed healthy interchange of ideas and jokes.  I watched their body language, showing appropriate, functional communication.  All in all they looked like they got along well.

Then the patient asks if the pain could be from laughing.

Yes, I said, it could, especially if the laughter has been extra hard in the last three weeks.

Which it has.  As the parent has gotten healthier.

I nod.  I don’t tell the patient to stop laughing but I advise cutting down on athletics for the next two weeks, and icing the painful areas 15 minutes three times a day

It’s the first time I’ve seen a side effect from laughter, the best medicine. 

Sooner or later, it was bound to happen.

Scarlet fever, saying goodbye, and taking a one month gig

March 16, 2010

Frequently the eyes are not dry

When I announce I’m saying goodbye

            With a bad case of strep

            I took the next step

Explaining the rationale why.

I’m saying goodbye to families and to individuals.

Two members of a family I’ve taken care of for years came in, a parent and a fifteen month old.  We played our way through the well-child check, the patient and I remained friends after I got a good look at the throat.  At the end of the visit, I said, “Next well child check is in three months.  I won’t be here at that time, my last day here is the 22nd of May.”

I’ve started reaching for the box of Kleenex right after that.  Most of the patients will ask who will take my place (we still have hopes of recruiting a new doctor), or they’ll ask which doctor they should see.  I give an honest appraisal of my partners’ individual strengths.  Mostly, the patients have met the other doctors in the office, and it comes down to how well personalities mesh.  The parent announced the intention to take the patient to the pediatricians’ office.

“I take that as quite the compliment,” I said.

Our pediatricians are very good doctors, every one of them patient, knowledgeable, up-to-date, and very good at what they do. 

I will miss the family.  They are easy to get along with, good parents who lovingly raise well-socialized, respectful children, and who treat each other with tenderness and joy.  I have attended them through several pregnancies and deliveries. 

One patient announced the intention of seeing me every week till I leave, and following me promptly when I take my new position in 2011.

Sometimes I don’t tell the patient that I’m leaving, especially if the follow-up would be before my departure date, or if the patient has another doctor in the office.

A sick-looking pediatric patient came in with a parent and a complaint of a “rash,” pretty dramatic, red and bumpy with the texture of sand paper, heavier in the midline than towards the sides.  As I looked in the throat, I asked if the patient had complained of sore throat, the parent said no, then I asked the parent to look at the bright red throat.  Sure enough the kid had big lymph nodes in the neck, and the parent volunteered the information (right before I could ask) that there had been a pretty strong tummy ache.  “Scarlet fever,” I diagnosed, explained that it was an extreme strep infection, and prescribed penicillin.  The parent leaned forward and asked if the family could transfer to my practice. 

Of course I had to tell them no.

Our practice has always operated on the principle that everyone wins when the patient sees the doctor they want to see, and in-office transfers have been the norm. 

I’m quite comfortable when patients with whom I did not get along transferred to other doctors.  Not everyone gets along with everyone.  I have a sense of humor, and the patients who don’t have a sense of humor generally don’t like me.  They find other doctors with whom they get along better. 

Over the noon hour I spoke with a recruiter offering me a one month position in the Mountain Time zone.  Eight to five, Monday through Friday, weekends off, no call.  I took the offer.  It’s the first time I’ll have had a new job in more than 22 years.

It will mean meeting new patients, moving away from the familiar, dealing with strangers.  I’ll have to settle in with a whole new group of people again.

I’m looking forward to it.