Archive for December, 2010

Passing eagles on roadkill

December 31, 2010

I said, “Now that I’m back,

I suppose I’ll have to unpack

     Those papers of mine

     I will have to sign

Of paperwork there is no lack.”

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  While my one-year non-compete agreement ticks away, I’m having adventures working and visiting family and friends.  I just finished a one-month assignment in Van Buren County, in southeast Iowa, which has neither stop lights nor fast food.

I cleaned the apartment and packed up the car in the morning while day crept into Keosauqua from the other side of the river.

Any time a doctor leaves an assignment, a backlog of paperwork faces an uncertain future.  Who will do follow-up on the abnormal lab and x-ray?  Who will sign the papers that need to be signed, though the signature does not contribute to patient care?  What about the dictations?

I stopped down in medical records and gave my email address as well as my home address.  “Call me before you send anything,” I said, “as I might be in Barrow, Alaska, when the mail arrives.”

I left town in light rain.  I had given Sweetheart, my mostly reliable GPS, to Bethany for her trip back to Sioux City, and I navigated by memory.  The dashboard thermometer crept from 38 to 54, and light rain fell.

As I left Van Buren County, I spotted a flock of birds feeding on a road-kill deer, and when I passed, the largest flapped slowly up, a bald eagle with bright white head and tail.

Two other eagles, eight hawks, and seven more road-kill deer graced the rest of the six-hour trip.

I met Bethany in the south part of town for lunch at a Chinese buffet.  When we left the restaurant the temp had fallen to 28 degrees.

I enjoyed the feeling of being back in Sioux City after an absence of eight weeks.  The nicest motel never is home.

Exhausted, Bethany and I went to bed before 9:00PM, and I woke at five.  The temperature had fallen to 12 degrees, and snow lay on the ground.

I went to St. Luke’s Regional Medical Center to sign documents that hadn’t been signed since I started going walkabout; everyone at medical records seems to have been out on vacation but I hung out in the doctor’s lounge.

All the docs I ran into love what they do.  I saw the accumulated sleep deprivation on their faces.  The conversation kept returning to the theme of decreasing reimbursement in an era of increasing work; complying with regulation takes more and more time but does little or nothing for patient care.  Several docs talked about wanting to cut back, but they’ve said such things for a long time.  I heard about one who wants to either work shorter weeks or retire.

One doctor, a good businessman, gushed about how much better care he gives because of improvements in pharmaceuticals.

Two used the phrase, “since my bypass.”

All complained about their beepers, a few said they’ve learned to sleep soundly even when they’re on call.

I left the hospital in single-digit temperatures.

After thirty years, a case of Reiter’s syndrome, and my last Keosauqua patient shatters my complacence.

December 30, 2010

When I stopped to check out the heart,

The rhythm gave me a start.

     It was going too fast,

     And that patient, the last,

Went out on the ambulance cart.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  While my one-year non-compete clause ticks off, I’m having adventures, working, and visiting friends and relatives.  I’ve been on assignment in Keosauqua, in southeast Iowa.

Today I finished my last clinical day in Keosauqua.  The first patient of the day and the last patient of the day each gave their permission to write the information below.

Reiter’s Syndrome includes the triad of conjunctivitis (inflammation of the eye membranes), urethritis (inflammation of the lower urinary tract), and synovitis (joint inflammation).  Such a constellation signals the body’s abrupt inappropriate reaction to an infection; while attacking germs, the defense mechanisms start to attack the person’s own tissues. 

Separately, each of these three items comes as common as rain, and for the last thirty years I’ve asked each patient with one of them about the other two.  I also ask about fever and rash.  The interview sequence qualified long ago as low-yield, but I persisted for sake of thoroughness, and, later, from habit. 

Over the years, my interview technique has evolved.  In the beginning I listen, later on I ask focused questions.  Today, when I said to the patient, “Tell me more,” three sentences in quick succession revealed knee pain, discharge from the eye, and discharge from the penis.

For the first time, ever, today I made the diagnosis of Reiter’s Syndrome.  I started the proper lab investigation and turned the case over to a colleague.

For those interested in medical history, Christopher Columbus suffered from Reiter’s Syndrome on his last voyage.

The last patient of the day came in with a routine complaint of cough, also a frequent problem in temperate climates in the winter.  Such symptoms have been going around Van Buren County during my short stay here, and I anticipated ending my tenure routinely.

The human condition tends towards complacence.  We tend to “know” we’ll find a normal cardiac exam singing “lub-dub, lub-dub.”  If those sounds don’t come through the stethoscope, the brain tends to want to make the perceived sound fit into the expected sound.

Today it didn’t.  “Breathe normally,” I told the patient, and tried to hear the heart sounds over the abnormal breath sounds.  Unsuccessful, I said, “Hold your breath.”  The first and second heart sounds refused to distinguish themselves; the first kept shifting in timing and character.  And the rate came way too fast.

I took my stethoscope off and checked the pulse, which came through nice and regular.  I listened to the heart again.  The chaotic rhythm pounded irregularly irregular. 

The reassurance I sought from the electrocardiogram fled before my eyes.  Yet the patient had no heart symptoms at all; no chest pain or sensation of his heart racing.

I grabbed one of my colleagues and showed him the strip.  In short order we had sent the patient off in an ambulance.

We agreed that the weird stuff is out there.

Muzzleloading for deer. Caution: hunting content longer than usual.

December 29, 2010

Before Christmas, I said with good cheer,

I’d like to go hunting some deer.

    It’s not a trifle

    With a front-stuffer rifle,

 It’s kinder than a car or a spear.

I am sitting in a deer blind with Jason, a man who knows the county and knows deer, and above all, knows the farm we’re hunting, across the Des Moines River from Keosauqua.

This afternoon we watch from a blind inside the tree line, a hundred yards from the river.  In front of us stretch oats and soybeans, four acres of buffet for deer.  Two hundred yards to our left a creek runs into the river; during the floods of spring a fifth of the soybeans got flooded out.

The blind itself has a six-year tenure in this location.  Stays have parted company with hubs; locally grown wood verticals and cross-braces keep the structure upright and useable.   It maintains a footprint five feet by five feet, the roof doesn’t quite permit me to stand.  The door zipper works well, the window zippers run a spectrum of functionality.

We slipped in silently before two in the afternoon, whispering.  The deer will probably come, he said, through the timber on our left, to the fence right in front of us.  Or they will come up from the timber between us and the river. You watch left, and I’ll watch right.

Through the afternoon we listened to six dozen geese on the far bank and watched eagles cruise glide over the water.  A light breeze blew from the river.

A piliated woodpecker caused a frightful racket in back of the blind, then perched two feet in front of us, peering through the window till I smiled.

From behind us I heard feet moving in leaves and my heart raced till I discerned, not the measured four steps of a deer but the chaotic hop-hop of a squirrel. 

Shortly after four Jason nudges me and whispers that he sees two, maybe one deer on the right, come up from the river just as he’d predicted.  I strain my eyes in the cloudy pre-dusk, then I can see her back about the level of the oats; her head down while she eats. 

Too far to shoot, we agree.  He tells me to watch as the deer make their way to our left, the shot will be easy. 

I resist the urge to stare, but my pulse quickens and my senses waken.

After ten minutes he nudges me to tell me I could have a shot.  I slowly ease my Savage .50 caliber, loaded with a 295 grain solid copper Power Belt over 47 grains of 5744 from the corner and poke the barrel out the window. 

In the scope the scene sixty yards away jumps to life.  The deer in front has two small dark circles on his forehead.  “He’s a button buck, should I take him?” I whisper.

“No, let him be, he’ll keep coming back,” he says.

Later, “That second one there, you’ve got a good shot.”

But in the scope I can see the ears of another deer behind the doe in front.

“Not a shot,” I say, “I could wound one on the off side.”

A few minutes more, then I say, “OK, she’s stepped forward.  I’ve got a clear shot.  The one in front.”

“Go ahead and take her,” he whispers.

I slip the safety off.  My heart pounds so loud I am sure the deer will hear me. I steady my left elbow on my left knee and I slow my breathing.  I go through my litany of questions:  Is this a good shot?  Can I make this shot?  What is on the other side of the target?

Breathe, relax, aim, stop, squeeze; the rifle kicks in my hands.  “I don’t see her,” I said.

“You got her,” he says, slaps my shoulder and laughs,“She’s down,” as the dozen suddenly obvious deer flee towards the cover on our right.

“Should I reload?” I ask. 

“No, man, you got her, she’s down.  Where were you aiming?”

“Right where the neck meets the spine,” I say, as he zips the door to the blind open.

We slap high fives.

We walk through the gate into the oats.  I shiver with intensity. 

The doe lies on her left side in the soybeans, the bloodless bullet wound showing on the front of her shoulder.  We slap unrestrained high-fives again.

And she is a very large doe.  I slip off my blaze orange coat and I don latex gloves, breaking out my field dressing hardware while Jason calls his dad, Doug, to bring a four-wheeler.

With my doe in the soybeans. Note muzzleloader across my lap.

I use a good but imperfect tool called a Buck Buster.  I have ideas for improvements: change the angle of the handle, put in a groove here and a curve there, shorten and lighten the whole assemblage, but for the time being I have the best tool for the job in my hand. 

Jason watches me work.  “You look like you might have done this before.”

“Yeah, a couple dozen times.  If it looks like I’m going too slow you just say, ‘No lawyers,’ and I’ll speed up.”  While I work I tell the story of painstakingly gutting one of my first antelope, and after forty-five minutes one of the observers said, “You know doc, I don’t think he’s going to recover, and if he does you’re going to have a bigger problem on your hands than you got now.”

The deer’s chest cavity, full of blood, shows the course of the bullet.  Hitting the spine, it exploded and fragments severed the aorta.  She died instantaneously, and probably never heard the shot that killed her.
Doug comes up on his four-wheeler.  By the time the field dressing is done, the day has passed from dusk to overcast night.  Jason and I haul the doe up and pour the blood out of her body cavity.

Then they are gone to pick up Jason’s four-wheeler with its trailer, and I am alone with the deer.  I talk to her, and I thank her for coming to feed me and my family. I peel off the latex gloves to find that both sides have leaked deer blood onto my hands.  I wipe my hands on weeds as best I can, and I put my coat back on after the blood dries.  I call my brother to tell him the news, and hang up as the two sets of headlights approach.

When Jason and I lift her into the trailer, I realize how much bigger this deer is than 80% of the bucks I’ve shot.  Even without her thirty pounds of innards she weighs close to two hundred pounds.

Jason goes ahead and I ride behind Doug.

While the exhilaration of a good shot and clean kill runs through me, I remember other hunts; Cuba, Arkansas, and Louisiana; doves, ducks, quail, geese, pheasants; elk in New Mexico; warm weather, cold weather, wind, snow, rain and glorious sunsets.

Two miles up the hill, Doug, Jason and I prepare the doe for skinning by making certain cuts before elevating her on the hoist.  We work in Doug’s machine shed.  He built it with an eighteen-foot ceiling instead of fourteen-foot, and reinforced key places so that raising deer on his hoist would not be a problem.  With the vigor of youth, Jason helps me skin and between the two of us, the job finishes in minutes. 

With the hide gone I look for the exit wound and I do not find it.  I can clearly see where the projectile shattered the spine, but my probing finger doesn’t find a bullet.

I have never shot a deer before and not found an exit wound.

Jason takes off down the hill and I start working on the deer, in a process called quartering.  I remove the forequarters, tenderloins, then the backstraps, then I trim meat from the carcass and the neck. 

I find two and a half inches of fat covering her rump.

Doug complements me on how clean my work looks.  I remark that it used to be a lot better but it used to take me all night.  Doug shows me how to use pruning loppers to detach the bony hocks, and I file the tip away for future use.  The cleanest meat, which doesn’t need further editing or washing, goes into a cooler with freezer packs.  The hind quarters, which always carry a taint of blood, go into garbage sacks.  Miscellaneous trim goes in with the back straps.  I point out to Doug the four ounces of meat along the sacrum, and I highly recommend it and I think about cooking it up tonight.

Before six-thirty the useable meat has been detached from the axial skeleton.  As I put the two coolers into the car I estimate one weighs sixty-five pounds and the other weighs fifty-five pounds. 

Driving the five minutes back to the duplex, two does try to wreak suicidal revenge on me by running right in front of the car. 

No one can deny that the country has too many whitetail deer.  This county shelters more deer than any other county in Iowa, and the population continues to grow yearly despite liberal hunting season and limits.  My permit allowed me to take antlerless deer only.

At the duplex I shake flour into a plastic container, add the only spice I have at hand, Mrs. Dash’s, and heat a generous amount of oil in a fry pan.  I dredge the thumb-sized chunks in the spiced flour, shaking off the surplus, and sear the meat till brown on each side.  I sit down with a piece of bread and I eat and I relive the eperience.

I change out of my clothes and drive to the hospital to make late rounds on a mother with a new baby.  Contrast is still the essence of meaning.

Back at the duplex I start the process of removing flesh from bone and sealing the meat into cryovac bags.  I decide to name the deer Sally.

I come across a bullet fragment in the backstrap; had this been a beef animal, the piece of metal would have been in the ribeye.

Muzzleloader bullet fragment extracted from the backstrap of my deer; paperclip shown for size comparison

 

I rarely find bullet fragments in the animals I’ve shot.

Hollywood misrepresents firearms; whole rifle bullets do not lodge in anything weighing less than a ton, and can never be used for ballistics testing.

I cut, package and freeze meat till midnight, and I start the clean-up process. 

Packages I have had cooling on the back porch come in to beds of foil in the refrigerator.  Knives get washed and sharpened.  I realize I will work with a paucity of cutlery.

Buzzed from the hunt, I can sleep no more than three hours before I waken to cut some more.   In a rhythm learned through years, over the next four days I place cryovac bags in the freezer labeled chuck, backstrap, tenderloin, best trim, trim for stew, top round, sliced round for jerky, and chunked shank for stew. 

I work in two hour segments, washing the setup thoroughly and sharpening knives before moving on to the next anatomic area.  Every two hours I take the best looking small pieces at hand, dredge them in spiced flour, and fry them.  Names of muscle groups, like supraspinatus or tibialis anterior, come to my mind as I work and as I eat.  I relive the moment over and over, from the time I first saw her to the time I pulled the trigger.

Call takes up all of Friday night and Saturday.

Monday afternoon the last package goes into the freezer before I go to work.  I clean the counters and I start rinsing the refrigerator shelves. 

The euphoria of a good shot well made courses through my veins while I work.

In a small town, word gets around.  People drop into my office and ask me how I like the deer hunting here.  (I like it a lot.)

In retrospect, I shouldn’t have bought two anterless tags; I had plenty of work from one deer.

Hepatitis, joint pain, and missing the solution to the mystery

December 28, 2010

To what disease do the symptoms belong,

When dark urine lacks odor so strong?

     I made a few points

     When I asked about joints

But the truth is I’d rather be wrong.

Synopsis: I’m a family practitioner from Sioux City, Iowa.  While my one-year non-compete clause ticks away, I’m having adventures working in new places and visiting friends and relatives.  Right now I’m staffing a clinic in Keosauqua in southeast Iowa.

My month in Keosauqua draws to a close tomorrow.

A patient (who gave me permission to write this information) came in today with a puzzling constellation of symptoms for two weeks: fatigue, malaise, chills and sweats, joint pain, morning stiffness, abdominal pain, vomiting and diarrhea.   The fingers on the right hand were swollen, visibly larger than those of the left hand, and index and middle fingers had swelling of the knuckle joint close to the hand.  I found other abnormal items on the physical exam, my fingers gliding over tiny, painful lymph nodes at the inside of the upper arm, just above the elbow.

On the basis of an impulse whose source I do not know, I asked the patientiof the color of stools had lightened and that of the urine had darkened.  They had.

At the end of the visit I said, “You want me to be wrong about everything I’m thinking of because the best diagnosis we can hope for is infectious mononucleosis.  That’s the best one.  You don’t want rheumatoid arthritis, Lyme disease, or hepatitis, or any of the worst things that I can think of.  And I suppose it’s possible that it’s work related.  We’ll have to see.”

Not widely known, but the rheumatologists make the diagnosis of hepatitis B more often than the gastroenterologists. Early in the course of the disease, any hepatitis can look like rheumatoid arthritis.  Patients can, and do, have severe joint pains without any abnormality of the liver function tests. 

Hepatitis B should be prevented by immunizations administered in infancy.  However, some parents choose against immunization (which I find foolish) and a very few people will not make antibodies in response to the vaccine.

Hepatitis C can cause similar joint pains, but usually doesn’t.  Mostly it causes an overall sensation of fatigue, less often the classic signs of hepatitis, with jaundice and swollen liver.

In medical school, hepatitis came in the classifications of infectious and serum.  By the time I finished residency, infectious hepatitis bore the name A and serum hepatitis was called B.  The third one, called non-A non-B hepatitis, eventually found the name C.  Ten years ago, hepatitis C mostly smoldered along and every once in a while resulted in liver cancer.   Five years ago we had a cure rate of 10% and now we have a cure rate better than 50%, and improving.

In the end, the patient’s diagnosis will come from lab work, but by the time the results come back I will have moved on.  I will not witness the denouement, the answer to the mystery.

At the end of the afternoon, I introduced the patient to one of the other docs here and made arrangements for follow-up.

The patient lives in a world, a social context with relatives, friends, and a job or two.  I will miss out on seeing how the disease affects the person and the world around them.

I will wonder.

After a bad Christmas on call.

December 27, 2010

While the snow outside piled deep,

Inside sometimes I’d sleep.

      But through the thin and the thick

     The people came sick,

To laugh, perchance, then, to weep. 

If you want to make a psychotic rat, you put EEG (brain wave) electrodes on it, wait till it gets to rapid eye movement (REM, or dream) sleep, and wake it up by ringing a bell. 

Christmas call did not go well.  I felt like a rat in the psycho experiment.

With reasonable volume and intensity the pace stayed steady through the night, and every time I got to REM sleep the phone went off.  Ripped from very pleasant dreams, time after time, I drove through the bracing cold the half mile to the hospital.  With one exception, the patients were sick human beings who just wanted to get better, and who had come at the right time.  I can look for no one to complain or whine to; my job snatched me from sleep’s warm and healing embrace so many times that I gave up and slept in the call room at the hospital.

Most hospitals have one place for doctors to sleep, and another for doctors waiting for a baby to deliver.  Van Buren County Hospital has both; the better room, called the ‘Doctors’ dictation room,’ near the inpatient nurses’ station, has a refrigerator, sink, and shower.  Nicer by a  long shot than the studio apartment I lived in my senior year of medical school, the mattress there provides the foundation for a good night’s sleep.  I just didn’t spend enough time on it.

My fellow human beings in distress kept seeking my training and experience so that they could feel better.  I can write about things in general without writing about people in particular.

For two of the pediatric patients I worried more about the parents than about the kid.  For another patient, inherent stubbornness provided more of a challenge than the diagnosis.

I had to dialogue with the sheriff about another patient.  After I certified neither a danger to self nor others, the sheriff made sure the person got to the other side of the county line and notified the next agency.

Three quarters of the work came from the destructive influence tobacco smoke has on human tissue. 

One quarter of the time apparent alcoholism served as smokescreen for the real problem. 

Our CT machine stopped working, won’t be functional till tomorrow, and I had to send a patient up the road to Fairfield. 

When a person comes in with press of speech (talking fast), flight of ideas (giving voice to racing thoughts), and tangential associations (can’t keep track of what they’re talking about), only four diagnoses come to mind: hyperthyroid, cocaine use, meth use, and mania.  But that person hadn’t come to see me, rather to accompany the patient.  I made the recommendation to check with their habitual doctor and ask for a thyroid test.

Putting pressure on a wound stops the bleeding almost always; elevating the bleeding part above the level of the heart speeds the process.

Shortly after a human being turns into a man, stupidity takes over and only slowly releases its grasp, if ever.    

The accumulated sleep deficit has piled up since Thursday.  My appetite control has evaporated; carbohydrates lurk near me at their own risk.  (See my post entitled Rage, Hunger, Lust, and Sleep.)

I’ve fallen asleep twice at the keyboard since I started this post.  Good-night.

Piriformis syndrome: a curable pain in the buttock

December 24, 2010

For a pain that starts in the butt

I don’t think of reasons to cut

     If a spasm is found

     To relax it I’m bound

And I can change your limp to a strut.

Most of the time if a person comes in with pain going into the buttock, radiating down the back of the leg, accompanied by numbness and tingling, or even weakness, I think about a bad disc pressing on the spinal cord, but I always ask the patient to take one finger and point to where the pain starts.

Every once in a while the patient will point to the buttock and deny any pain in the midline.

On those occasions, I sometimes find a hard triangular lump at the seat of the pain. I mash on that lump and ask if the patient’s pain going down the leg got worse, and, usually, the answer comes back “Yes.”

I diagnose piriformis syndrome this way.

The piriformis muscle runs across the buttock from the sacrum to the outside hip bone at the top of the thigh. The sciatic nerve runs under, or sometimes through the pirirformis, and spasm here can give a person sciatica, the pain and numbness running down the back of the leg. In such a case we say the sciatica comes from the piriformis syndrome, and by the thinnest of coincidences I learned a simple maneuver to relieve it.

During med school I went to the home of a physician to meet a friend giving piano lessons there. While I waited, the doctor, waxing loquacious from whiskey, told me how to apply my shoulder to the flexed knee in an osteopathic manipulative technique I would later learn to call “muscle energy.”

Over the years this tool has given me immense professional satisfaction. Starting with a limping patient in pain, performing a maneuver, and watching the patient sit up and walk without pain is an experience that leaves me grinning for the rest of the day. 

It doesn’t happen very often.

Last week, I diagnosed piriformis syndrom three times, and I manipulated one patient.  I taught one patient how to self manipulate, and for the third I prescribed a muscle relaxant.

As with anything else in medicine, success depends on proper patient selection.  Penicillin works well for strep throat and syphilis but for little else; sciatica from a ruptured disc does not respond to muscle energy manipulation.  

Sometimes a person might be too big or too fragile for me to manipulate.  In those cases I turn to the more commonly used mode of treatment: muscle relaxants.

My favorite, generic metaxolone, costs more, hence the insurance companies rarely pay for it.  All the others bring sedation to the point of sleep so often that, on the rare occasions when I prescribe them, I tell the patient not to operate anything more hazardous than a salad fork. 

I know.  Because of my back problems, I’ve tried them all.

The difference between what I dictated and what they typed.

December 22, 2010

 

Sometimes I find a mistake

In the reports that get typed on a break

    They’re good for a laugh

    A smile and a half,

And I hope the typist’s awake.

The penmanship of doctors lacks legibility.  My profession has dictated into machines in order to have readable reports for as long as the machines have existed.  Of course the transcriptionists didn’t go to medical school.  Most of them took medical terminology courses and own dictionaries. 

Sometimes a transcriptionist didn’t get a chance to get used to how the doctor talks.  Sometimes the doctor didn’t speak clearly.  Sometimes, well, sometimes I find differences between what I said and what they typed. 

I chuckle, I make a correction, and, if I got a good chuckle, I save it on my PDA.

I got these from my collection.

Someday, human transcription will give way to computer voice recognition.  I don’t know what will be funnier.

I dictated:  Much worse with use.

They typed:  Much worse with Hughes.

I dictated:  Decreased vibratory sense.

They typed:  Decreased laboratory sense.

I dictated:   Ear problems for three years.

They typed:  Air problems for three years.

I dictated:  Endogenous urticaria.

They typed:  Indigenous urticaria.

I dictated:   He had a looser cough last week

They typed:  He had a loser cough last week.

I dictated: Piriformis syndrome.

They typed:  Performance syndrome.

I dictated:  When he ran into a post.

They typed:  When he ramped through the post office.

I dictated:  Bronchitis and strep throat.

They typed:  Brown kitis and strip throat.

I dictated:  No blood clots run in the family.

They typed:  No blood clots ruin in the family.

I dictated:  Had a heart attack.

They typed:  Had a hear attack.

I dictated: decent amount.

They typed: recent amount.

I dictated:  Urine output is down.

They typed: Amputate is down.

I dictated: Marginally oriented.

They typed:  Markedly oriented.

I dictated: we can probably get her trained to use insulin pens.

They typed: we can probably get her trained to use Depends.

I dictated: labor proceeded in a desultory fashion.

They typed: Labor proceeded in a sultry fashion.

I dictated: he was also a truck driver.

They typed: He was also a drunk driver.

I dictated:  Vocal cord cancer

They typed: Focal cord cancer.

I dictated:  Bronze diabetes.

They typed: Braun’s diabetes

I dictated:  Sleep deprivation.

They typed: Sleep depravation.

I dictated:  After he spent five hours in a hotel pool.

They typed: After he spent five hours in a hotel pickle.

I dictated:  Conservative measures

They typed: Concerns of measures.

I dictated:  Drinks a bottle and a half of tequila at a time.

They typed: Drinks a bottle up to cumulative time.

I dictated:  He is a retired hospital administrator

They typed: He is a tired hospital administrator.

I dictated:  Urosepsis

They typed: Eurosepsis.

Application of medical first principles on a Tuesday in Keosauqua

December 21, 2010

Why do doctors go gray?

Is it all work and no play?

     Life can be a ball,

     Though you’re working on call,

Just don’t give in to dismay.

When I’m on call, nights or weekends, I get a lot of calls from people who have self-diagnosed an antibiotic deficiency and want a prescription called in.  Pain with urination, sore throat, and cough comprise the most frequent complaints.

I would like to say I don’t ever yield to the request, but on rare occasions I do.  I weigh the risk to the patient of treatment with an exam versus the risk of treatment without an exam.  Most of the time I’m pretty rigid, but flexibility sets in during extreme weather.  Last year a blizzard descended on Sioux City when I had Christmas weekend on call.  On a day when it took three hours to get from my garage to the street, I said “Yes” a lot.

Most sore throats do not benefit from penicillin.  Most pain with urination is not urinary tract infection.  Most earaches do not come from ear infections.

Today I saw four patients with painful urination, abrupt onset, accompanied by blood in the urine.  One had a urine infection.

I work very little to write out a prescription for three days of antibiotics; I work a great deal more explaining why the patient shouldn’t take antibiotics.

Of the last nine patients with pain in the ear, one had an actual ear infection.

Three other patients, all smokers with emphysema, came in short of breath today; they all left with prescriptions for antibiotics and inhalers.  One got a prescription for prednisone (a steroid).

On six occasions today I added up the costs of peoples’ bad habits.  “OK,” I’d say, “How much are you paying a pack for Marlboros/a bottle for Mountain Dew/a cup of coffee/a pack of generics/a case of beer?”  I got out my calculator and said, “Dang!  Eight hundred dollars/twelve hundred dollars/nine thousand dollars a year!  They must pay you well!  I’m a doctor and I couldn’t afford that.”

People who work with livestock in general and horses in particular don’t complain much, and if they do, I’d better listen.  I applied that principle twice today.

Three folks with mental health histories were in today; their complex medical problems took time.  I considered the principle that craziness doesn’t protect from physical illness.  I have a lot of lab results pending.

Four patients let drop the fact that a close relative had died in the last six months.  I listened and I sympathized.  I remembered the ten months after my mother died, when penicillin injections kept me going during a succession of eleven culture-proven strep throats.

Depressed patients get sick, and sick patients get depressed.

Appendicitis on the front lines; drama and irony close to home

December 20, 2010

For the patient who hurts low and right,

And suffers from lost appetite

    Search high and low

    The appendix must go

Would a CAT scan help? Well, it might.

Appendicitis has afflicted so many patients since my arrival that I can write about the disease without identifying anyone in particular.

The classic appendicitis patient will complain of abdominal pain starting near the umbilicus (navel), increasing over the course of three days, and moving to the right lower quadrant, aggravated by jarring, and accompanied by loss of appetite.

I always ask the patient what they had for lunch, and whether they enjoyed it.

People with appendicitis come with a back story and a social context.  Some had serious medical problems before their appendix went bad.  They may use illegal or legal things to excess.  They may have good or bad relationships with their family members; they may have no family members at all.  They may not possess the ability to speak for themselves. 

The physician must rely on the information available.

Eighty percent of appendices live near a spot two-thirds of the way along a line from the belly button to the front point of the hip bone, called McBurney’s point; a patient who points there brings immediate suspicion for appendicitis.

If I call a surgeon, he or she will want to know about rebound (increased pain on sudden release of pressure on the abdomen), psoas sign (pain on pulling the right leg back when the patient lies on his or her left side), bunny hop (pain on jumping on the right foot), bowel sounds (presence or absence of normal gurgling in the abdomen), and guarding (tenseness of the abdominal wall muscles).

None of these signs or symptoms makes the diagnosis by itself.  I have had appendicitis patients come with pain low on the right, low on the left, high on the right, and high on the left.  Some had pain in the leg or the back, and a few had no pain at all.

Not one enjoyed their lunch.

When I worked in Navajoland, my appendicitis patients complained of not being able to eat rather than pain.

CT scans help if the history and physical don’t paint a clear picture but characteristic history and physical trump a normal CT scan.  “I operate on patients,” I heard a surgeon say, “Not images.”

Six years ago, while Bethany and I got ready to go out, I told her about the twinge I’d just had at McBurney’s point.  She asked me if I’d enjoyed lunch, which I had, and if I had pain when I hopped on my right foot, which I didn’t.  I ignored the mild zing which came and went over the next six months while my gallbladder went from bad to worse.  I set a convenient date for its removal, and as I walked to the OR with the surgeon, I said, “Listen, Mike, while you’re in there, take out my appendix.  I really don’t want to get back on this table.”

Ten days later, to my unpleasant surprise, the pathology report showed carcinoid, a low-grade cancer.

More things can go wrong with the appendix than just appendicitis.

Art and Architecture in rural Iowa: Bethany and I do American Gothic

December 19, 2010

There once was an artist, Grant Wood,

Who did that best that he could

    A house he did paint,

    With a couple so quaint

And the parodies all turn out good.

Bethany drove six hours from Sioux City this weekend, and yesterday I took her for a walk around town.  We heard a skittering cry from a large bird gliding above the Des Moines River.  We stood still to watch, it circled and wheeled and leisurely came to us, twenty feet up, a bald eagle, with snow-white head and tail.

Then we heard the helicopter. 

The sound of a helicopter in a small town usually bodes ill as the harbinger of significant injury or illness.  We strode up the hill to the hospital.

My colleague had the situation well under control.

We walked past the Manning Hotel, an historic structure dating to the era when goods moved by riverboat and horse. 

The Manning Hotel, Keosauqua, Iowa, on the banks of Des Moines River

The bridge over the Des Moines River here carries partitions for three types of traffic: the east lane for pedestrians, the center lanes for cars, and the west lane for horse-and-buggy (the Amish regularly cross the bridge).

This part of Iowa has wonderful architecture, with colonnaded porticoes and functional verandas on many houses.  Victorian-style gingerbread sits next to single- and double-wide trailers.  In Birmingham we found a trailer with a colonnaded portico.

Trailer with collonaded portico

On the way there we saw the sign proclaiming AMERICAN GOTHIC HOUSE 18 MILES.  Today, we made the drive.

Grant Wood’s painting, American Gothic, ranks second only to the Mona Lisa for number of parodies.  The house, I have been told, is the second most recognizable house in the country, after the White House.

That house still stands at the edge of Eldon, Iowa, less than a half hour from Keosauqua. 

The town itself looks like many other small towns but for the beautiful architecture.

The American Gothic House reminded us of the size of our first house in Casper, Wyoming, with less than nine hundred square feet.  The American Gothic House Center, on the other hand, stood large in the neighborhood, with a CLOSED sign in the front door.

Bethany at the American Gothic House Center. Eldon, Iowa. December 2010

Of course we had to make our own parody of Grant Wood’s famous painting, which rendered difficult the task of trying to look dour.  I had not a pitchfork nor a shovel to hold, Bethany observed, as she shivered and tried not to crack a smile. 

Steve and Bethany in front of the American Gothic house, Eldon, Iowa, December 19 2010

With the camera screwed onto the tripod, the self-timer did its job as hypothermia started to set in.

The famous house now shares the corner with a single-wide trailer; functioning agricultural buildings stand between it and the corn fields.  A trendy compact car nestles in back.

The American Gothic House and Mini-Cooper, Eldon, Iowa, Dec 19 2010

The recognizable icon stands but the times, as always, change.