Archive for July, 2012

On finding the right quest

July 31, 2012

Of this I have been impressed

Some people ended up stressed

Life might be breeze

They might do what they please

But they need to follow a quest

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week.

I work late Mondays.  I start at the hospital between 6:00AM and 7:00AM, leaving in time so that I can start clinic at noon.  I may or may not get a breather to eat, and I care for patients till 8:00 PM. 

Tonight I got a break when my last patient of the evening, who had never been seen at the clinic before, failed to show for the appointment.  I’d guess that a substance abuse disorder lies at the base of the person’s problems, but, having never met them, I can’t say for sure.  I used the extra time to catch up on documentation, but left before 8:00PM to go to the gym. 

Yet Mondays do not rank as my usual heavy day; that distinction belongs to Tuesdays, when I usually take call.  I generally roll up to the clinic before 7:00AM, and take advantage of the quiet to sort through arriving lab results and other paperwork.  Patients start at 8:00AM, scheduled till noon, and the afternoon session starts at 1:00PM and runs till 4:30.  I continue to document at my desk till the ER calls me for an admission.  On occasion I’ve left my desk at 6:00PM when my efficiency fails.

Today I found a census of twenty-two waiting for me at the hospital.  I rounded on eleven of them, discharged four, and then I headed to the clinic.  I turned the others over to our full-time hospitalist.

In twenty-first century Iowa, most people need to lose weight, but our patient population has such a grand mix of pathology that today I took care of two who needed to gain.  

To put on weight I advise three scoops of expensive ice cream at bedtime.  (If you need to lose weight, you’re never going to do it if your bedtime snack continues.)  All the folks I take care who have lost too much weight have an identifiable illness, though sometimes it doesn’t account for all the person’s symptoms. 

I sat and philosophized with a young person I had coaxed back up across the 100-pound line.  I had correctly identified the pathology and, working with the patient, had come a long way towards correcting it.  Yet a problem in the grander scheme of things remained. 

Sometimes I talk to high school health classes, I told the patient, and if I walk into a classroom of 35 students I can usually be sure at least one has set him or herself on a quest for wisdom.  Others are born musicians or artists, photographers or historians.  Whatever that person might do for a living, if they can’t also follow their quest, something inside of them dies.

The patient nodded and said, “That’s my problem.  I haven’t found my quest.”

I said, “But not everyone has one or needs one.”

 And in fact, most people don’t.

On reporting battered children, women, and dependent adults

July 29, 2012

A wound without an excuse

In a child or dependent recluse

A red flag will wave

And I have to be brave

To report suspected abuse

 

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week.

Most states have mandatory reporter laws.  Certain professions have the legal obligation to report possible or proven abuse of children and dependent adults. 

We don’t have to report domestic partner abuse. 

Over the course of thirty years I asked every pregnant patient I cared for if she were being battered, and in all that time only one said yes.  I’m sure at least one of the others lied to me.

I am tempted to use gender specific language to say she won’t leave him until she’s ready, but the worst physical battering I ever saw happened to a man beaten by a woman with a baseball bat.  I asked why he didn’t flee, because no barriers impeded him just walking away.  Through swollen, bruised lips he said, “Because I love her.”

In the eyes of the law, battered adults can live with their abusers until they want to leave; the police will not intervene unless someone wants to press charges.  If the abused qualify as dependent, such as the frail elderly, handicapped adults, or children, then the state takes an interest in their protection.  If I even suspect abuse, I have the statutory obligation to report it.

In theory I just have to make a quick phone call to the abuse hotline.  In fact the call rarely takes less than 10 minutes.  If I want to, after I’ve given all the information, I can request to remain anonymous, and my name doesn’t appear on the report.  In practice, the suspected perpetrator has a suspicion and I can count on a minimum 10 minute tongue lashing. 

In the case of children, I can count on losing the family as patients.

Still the red flags demand my attention.  For children, an observed injury incompatible with described mechanism and time requires a report.  For example,  cigarette burns on soles and backs of a three-year-old’s feet cannot be consistent with stepping on lit cigarette butts in the yard. 

And report I must.  Thirty years ago investigations rarely followed reports, and never led to interventions even in cases involving multiple fractures.

For dependent adults, I have to look not only for injury incompatible with described time and mechanism, but also for injury without explanation.  I worry when caretakers won’t let the patient be interviewed alone. 

Now all reports get followed up.  Interventions follow, the state protects the children, and only terminates parental rights in the worst cases. 

Never trained as an investigator, I leave the determination to those who were.

 

Rounds from Dawn to the Newborn Nursery.

July 26, 2012

 

Sunrise in the ICU

I started the day making rounds

Checking the lungs and heart sounds 

 

It started with dawn,

Where has the day gone?

Beauty is where beauty is found.

 

 

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week.

I started so early that when I saw my first hospital patient, a perfect sunrise broke as I entered the room on the top floor of the hospital.  The water content of the atmosphere blocks the view of the sun most days till the red disc has ascended well above the horizon, but with the hot dry weather we’ve had, there was the sun, just peeking up.  And the ICU offered a spectacular view of the city in the morning.

The patient couldn’t speak and could barely respond.  Even if the patient can’t talk, I speak to him or her, tell them who I am, the date, where they are and why they’re there, and I try to give a few headlines from the news.  In this case I called attention to the phenomenal sunrise, but the patient didn’t look. 

From the ICU on 6th floor I went to see a new admission on 5 Medical, and discharged a patient who had recovered enough to go home.  Striding down the corridor to the opposite end of the hospital I came to 5 Behavior Health, the psychiatric service.  I did medical consultations on two patients admitted during the previous 24 hours.

The psychiatric portion of the service consists mostly of people who didn’t ask for their problem but got it anyway.  A surprising number of schizophrenics also qualify as bipolar.  More than 90% smoke, and a lot of them come down with type I diabetes as their pancreas withers away.  They lose years of life.  A majority of schizophrenics also have drug and alcohol problems, and they can’t learn from their mistakes.

Our society has failed our schizophrenics.  At one time institutionalized, they were turned onto the streets when the institutions closed, and went right into the criminal justice system.  The ones who stay out of incarceration use a lot of health care.

Fourth floor holds the oncology (cancer) and surgery nursing units on the south.  Contrast being the essence of meaning, I talked to those who know they have no cure and to those with a reasonable expectation of cure.

The pediatrics wing sits on the north end of the fourth floor, and I had no patients there.  Fewer and fewer children need admission to the hospital as the years wear on.  Vaccinations have prevented most measles, mumps, chickenpox, polio, rotavirus, pneumococcal, and meningococcal disease.  We see a tenth of the croup that we used to.

On the third floor orthopedics unit I did two consultations for people after total joint replacement, and on the second floor I took care of two newborns.

Death, the ultimate drama and the ultimate irony, came to three of my patients during the day.  One in middle age died surrounded by grieving family.  One went unexpectedly and alone.  A third died so old and full of years that few remained to note the death, though many, on reading the obituary, will sigh and reflect on how the passing impoverished the world. 

 

 

At last, the geographic cure worked once.

July 18, 2012

We wonder where the time went

And thinks of the hours we spent

I always guess wrong

About just how long.

Nothing’s a hundred percent.

 

I tell my smoking patients not to try to quit by cutting down, first because it doesn’t work and second because it constitutes a slow torture.  Physiologically, a gradual nicotine dose reduction prolongs the agony of withdrawal while it makes the smoking habit stronger.  And people who want to ‘cut down’ haven’t made an emotional commitment to quit.

Observation confirms theory; in the 30 years since I finished residency I have met 3 people who quit smoking and stayed quit by cutting down, but I’ve met tens of thousands who failed. 

Thus I can’t say categorically that cutting down doesn’t work, I can say that other methods offer a much higher chance of success.

Recovering alcoholics and addicts will speak derisively of the geographic cure.  Active substance abusers will, sooner or later, try to blame their addictive behaviors on their surroundings and companions.  Thinking that the problem resides externally, they try moving to another place to make a fresh start.  On arrival at the new destination they find new connections and bars, and their abstinence collapses less than three months later.  No more than a year passes and they return, generally with their dependency having moving forward a notch or two.

Those people in recovery say the first person you need to fix is yourself.

Yesterday for the first time I met a person for whom the geographic cure had worked.  For reasons of confidentiality I can’t give details, but later that evening I mentioned the case to a nurse, declaring that every day I see patients I find at least one thing I’ve never seen before.  The nurse blinked and, deadpan, told about caring for a patient who survived a fall after a parachute failed to open.

Every known malignancy has at least one miraculous survivor; people who go decades with metastatic lung cancer are common compared to those who exit airplanes without a parachute and live.  Yet we now have dozens if not hundreds of cases of people who survived falls of hundreds or thousands of feet.

Over the weekend a family member asked how much time a patient had; I refused to give a number because I guess so poorly.  I recall one patient I looked at and thought, “Just hours now”’; yet another patient I firmly believed had months died in less than two days.

We never know how much time we have in this world, and in the last 8 days (including 5 twenty-four hour shifts) I have repeatedly run into the fallout of people with terminal diagnoses deciding to tell or not to tell their families.  I advise the patients that if their loved ones would spend more time with them, knowing that the end was near, that they should by all means spread the knowledge. 

Most listen.

Life, death, Facebook, drama, and irony

July 12, 2012

Time becomes wisdoms fount,

We’re given an unknown amount

But for family and friend,

When we’re close to the end,

We try to make each minute count.

 

I won’t say when and where these events happened.

On a Monday I attended a hospital patient with a very bad malignancy.  A gratuitous cancer with a notoriously bad reputation had flung metastases to the bone, liver, lung, and brain.  Yet doctor after doctor hadn’t penetrated a wall of denial.  My job description has never included taking away a patient’s hope.  After my usual questions, exam and update, I sat and listened and didn’t contradict.

In the subsequent week, a drama played out over Facebook.  A young couple (not my patients) had found out at the 18 week ultrasound their baby had a problem incompatible with life and decided to carry to term.  The child survived a few hours.  (Not the first time nor only time such irony has appeared on Facebook, I hope that such regrettable circumstances bring learning and insight to the readers.)

The next time I talked with my hospital patient, acceptance had swallowed denial, and Hospice arrangements occupied most of the visit.

At visit’s end, the patient revealed the importance to her of a close family relationship to two teenaged grandchildren.  They had not yet received news of the poor prognosis, and the patient didn’t know whether to tell them or not.

I related the story of the people on Facebook.

In the final analysis, I said, none of us know how much time we have with our loved ones.  Though we tend to squander precious hours, when we know the time has a definite limit, we make the minutes a priority.  If those who cherish you know that the end is approaching inexorably, they will prioritize spending time with you, and they’ll treasure the moments.  Thus they need to know.

And without telling the patient, I remembered the last three days I spent with my mother after she had decided to die.

Medical Advice at Parties.

July 8, 2012

At parties I’m asked for advice

It’s happened way more than twice

Wouldn’t you know

Sometimes I say ‘no’

But I usually try to be nice.

 

Bethany and I received a surprising number of last-minute invitations to parties today. 

People ask me for medical advice in social situations.  On one occasion, shortly after my mother’s death, I snapped and yielded to the urge to sarcasm and immediately regretted it.  Yes, the request arrived at an inappropriate time and place; no, the patient had never seen me on a formal professional basis; yes, I had every right to turn the request down.  But I did so with finesse and eloquence, a misapplication of good verbal skills.

Today I recommended the book, Love, Medicine, and Miracles in the buffet line, and a trial of over-the-counter meclizine while eating spanokopita.  I listened intently to an alcoholic’s relative, and agreed counseling would be a good idea.  I nodded while a person detailed a coworker’s headaches.

In med school and residency and even later, the docs who mentored me would say, “It comes with the territory.”  I suspect the phrase comes from traveling salesmen who would use it to describe the positive and negative things about working in a particular area.  The advantages of working in Montana differ from those of New York.

I would worry more about seeing a patient as a collection of diseases rather than as a whole human being if I didn’t talk about so many other things with the same set of people.  Today I had discussions about archery, firearms, ballistics, gardening, stone fruit, bicycles, New Zealand, and Alaska.

Yesterday I had a good talk with a friend, just back from 8 weeks of locum tenens (substitute doctoring) in Barrow.  The Inuit filled their quota of 21 bowhead whales; on one day they brought in three.   Weather socked the place in more than once, preventing critically ill patients from reaching services on a timely basis.  We agreed that Barrow ranks as a place on the fringe of the 21st century, that theft was nonexistent, and that the North Slope people smile more than any population we’ve seen.

Bethany and I spent two weeks in June in southern Alaska.  Four days of fishing, four days with friends, and four days of Continuing Medical Education with the Alaska Academy of Family Practice’s 27th Annual Scientific Conference in Kenai.  The sun set about 11:30 and rose a couple of hours later.  Which gave us a lot of time to fish but played havoc with our sleep.  Not nearly as bad as the 8 weeks of unremitting day without a single sunset the first time I went to Barrow. 

I might go back to work in Alaska, eventually, but Barrow remains outside my zone of comfort, like working in Sioux City and having the nearest referral hospital in Dallas.

Blog reopened after a year on the job.

July 5, 2012

I find my job a delight

Even when working at night

On this I won’t budge,

I’m a doc, not a judge,

And there’s always something to write.

I have decided to reopen my blog after a year’s absence.  I miss writing, and I miss the immediacy that comes to my life when I go through my day thinking about my post.  I’ve been at my new job a year now.

My workplace runs on teamwork; I’ve never been any place where people seek out so many opportunities to help their coworkers. 

Our patients have few resources; 50% have no insurance, 35% have Medicare or Medicaid, and 15% have commercial health insurance.

I see a lot of schizophrenics, people whom our society has failed badly.   I’m sure if they could push a button and come to a closer contact with reality, they would.  As it is, they hear voices when they don’t take their meds and sometimes even when they do.  An extraordinary number also carry a diagnosis of bipolar.  Almost all smoke, and, given enough time, almost all develop insulin dependent diabetes. 

I find it easy to avoid judging the schizophrenics; they did not ask for their problems.  The less I judge my patients, the more energy I have at the end of the day.

We have so many patients from Ethiopia and Somalia that we have Oromo, Amharic, and Somali translators, and I’ve learned to say Hello, How are you, and Thank you.  Mostly hardworking, family oriented people, they came here after unspeakable horrors.

Many of the people who come to my clinic have been behind bars.  I don’t ask them why.  After all, I did not train as a judge.  Those folks have done their time and my job, as I see it, demands that I focus on what can be done in the future, not what has already passed. 

I start Mondays with hospital rounds till noon, then clinic till 8:00PM.  I’m on call 35 Tuesdays per year.  Most call nights I work straight through till after 9:00 PM.  I start Wednesdays at 7:00AM and finish around 6:00PM. 

I have Thursday off, along with Friday, Saturday and Sunday if I don’t have call.  I still put in 48 hours weekly.

Yet I worked no more than two days a week in the last six weeks, which I found unfulfilling.  I arrive at work Monday mornings cheerful and happy to be back, and I go home on Wednesdays ready for the weekend.

Saturday/Sunday call a year ago ran to fewer than 10 patients between two hospitals, but practice growth led to mission creep, and now a hospital census can run upwards of three dozen.  At any one time, we usually have three patients in liver failure, and three in active alcohol withdrawal.  A surprising number of non-alcoholics end up with cirrhosis.  About half our hospital patients also show up on the dialysis service.  Mental health census averages 5. 

Our patients get sicker younger than any patient population I’ve seen before, which surprisingly, gives me more hope.