Archive for September, 2012

Newton’s laws and flesh and blood

September 27, 2012

I went one night in the fall

To the ER because I had call.

Think of the drama

From significant trauma,

From a fall from a wall or brawl at the mall.

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.

When I lived and worked in northern New Mexico, in a hospital serving 3 Indian reservations, my context had a very low population density.  If I saw a strange face, I would talk about it for the rest of the week.  If I heard a siren, whether I was on call or not, I would go to my front porch to look for the incoming ambulance.  In an area with little news, an ambulance run always warranted a conversation with the doc on call the next day.

A helicopter meant only one thing, because helicopters never came our way except to pick up a patient in extreme distress.  The hospital sat walking distance from Interstate 40, and whirlybird making a round trip only beat our ambulance drivers making the straight shot by ten minutes.

I rode the ambulance a few times, and the drivers knew where they could safely go 90 and where they had to slow down to 60.

Nine times out of ten, a chopper call meant a trauma call. 

I didn’t get enough trauma experience in residency, and during my tenure in the Land of Enchantment, I got myself sent to University of New Mexico Medical Center for a trauma mini-residency.

People obey the laws of physics whether they want to or not.  Two bodies cannot occupy the same place at the same time.  Flesh, bone and blood lose when they go up against moving vehicles.

I have seen trauma related to guns, knives, buffalo, deer, horses, cattle, sheep, whales, bicycles, fishing, chain saws, rattlesnakes, boats, skis, snow machines, arrows, logs, bulls, dogs, cats, rocks, and seashells.  I took care of four people when a driverless Cadillac totaled their sedan. 

Trauma can come from a lot of causes, but cars trump when it comes to sheer numbers, and alcohol trumps when it comes to cause.

Tonight I attended a trauma patient, who came reluctantly under the rule of Newton’s Laws.  I suppose the vehicle in question sustained some damage, but dents in bumpers don’t mean nearly as much as broken bones.  Lives change forever in violence lasting less than a second.   People speak of their lives before the accident and after the accident, a defining, unplanned moment.   Sometimes it puts things into perspective or frightens someone from a destructive course, always unintended consequences follow, rippling through peoples’ lives across the years, sometimes across generations. 

I walked out of the hospital Emergency Room and into the parking lot and noted the arrival of drama and irony in two ambulances from different counties on my way out.  I wondered, as I did every time I heard a siren or helicopter in New Mexico, what happened?  Who did what?  How will the lives change, and how will the implications alter the people who weren’t even there?

Thinking in silence, on the way home in the dark, I pulled over to let another ambulance past, and I started to wonder all over again.

Advertisements

Alcohol: truth and fantasy

September 20, 2012

It seems to me this is bunk,

The uncomplicated life of a drunk

With a true loving wife

And a well-ordered life

And insight that comes by the chunk.

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 read over the information about the male patient, age 42.  The main reason given for the visit came down to concern with alcohol use.

He drinks 6 Jack and Cokes a night, 4 nights out of 7, more on the weekend.  Doesn’t smoke.  Married.  Employed.  Wife concerned he’s drinking more than he used to, and he confirms that over the last 4 years his alcohol use has accelerated.  He doesn’t have problems at work.

He maintains a normal blood pressure and pulse.  His blood work came back as normal with the exception of the liver functions, which, unsurprisingly, run high though not dramatic.  I asked for and received an acute hepatitis profile which came back normal, and I couldn’t order an ultrasound.

He has tried to cut down, he gets complaints from his wife about his drinking, those complaints annoy him.  But he has never had to have an eye opener, a drink to get going first thing in the morning.

I find no family history of alcoholism; he has no symptoms of depression, no tremor, no headache, and absolutely no sleep disturbance.  Sure that he is not an alcoholic, he notes that most of his friends drink more than he does and that most of his socializing has to do with alcohol.

And so the motivational interviewing starts.  No judgmental statements, just questions, like What is important to you?  How does your drinking fit in with that?  Visit after visit, he makes more and more progress whittling away at his tippling and then he starts going months without any alcohol at all. He changes friends, and he gets closer with his patient and loving wife.

The patient didn’t give me permission to write these details because the patient does not exist.  The information came to me in a case scenario, a clinical simulation, during my preparation for Family Practice recertification, in the module called Health Behavior.

The case presentation doesn’t match with the reality of my alcoholic patients.  As a group, none sleep well, all have family histories of alcoholism, all live in a continuous state of household chaos, going from one crisis to another, sabotaging success and intimacy.  A few have normal bowel habits, fewer live without headaches.   Most of my alcoholic patients have scintillating, quirky personalities and great senses of humor; yet prone to fits of unreasoning anger, occasional rages, and unrealistic demands on the people around them.  Despite tremendous generosity, they betray friends, lovers, spouses and children.  Embarrassing others in public leads to progressive isolation.  All but the homeless drunks have an enabler, who will sabotage progress towards sobriety.  They rarely stay dry without a 12 step program.

Even when sober, they generate chaos, though if they get religion (AA is a religion) they generate less chaos as time goes by.

With all their problems, they’re still fun and exciting to be around. Unlike patient case scenarios.

 

Periodic testing and planned obsolescence

September 16, 2012

Of course I’m doing my best,

Learning by taking a test,

If properly scored

I’ll pass the board

And post my comments in jest.

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 carry a Board Certification in Family Practice, which means that I finished a residency, I take continuing medical education (CME) at the minimum rate of 50 hours per year, and I keep passing tests.  Being Board Certified in my specialty brings me flexibility, status, and money. 

The Boards in 1982, my first year of certification, lasted, as near as I can recall, forever.  I have been recertifying every six years ever since, because I prefer to have a one-year cushion in case I don’t pass the test.

Doing the math, over my career I’ll have to sit for the Boards once more than those who chose the seven-year option.

But the Board now offers a ten-year cycle, reasoning that making a doctor study more frequently but less intensively improves the chances of staying current.  The process has become much more complicated; one doesn’t just sit in front of a computer screen for six hours, clicking on proper answer after proper answer.  Nowadays one picks three Self-Assessment Modules (SAMs) from Part II, one from Part IV, and another two from Part II.  I don’t know what happened to Part III.  If everything has been completed, then one can take the exam.

The process is more complicated than that.  For example, because 50% of my current situation entails inpatient work, and I only work 3 days a week, I wouldn’t have been able to distribute the patient surveys required for the standard Part IV, so I completed the alternate Part IV, Information Management.

As much as I dislike testing, the current run qualifies as the most enlightened examination I’ve been involved with.  Prompt feedback, fair questions, and a chance to learn at every turn; the process ranks as educational rather than punitive.

The docs get the chance to comment on every test question, and now six modules into the process, I find I learn almost as much from the comments as from reading the references.  Some of my colleagues impress me with their erudition, others with concerns for intellectual honesty.  The Board, in my view, doesn’t check the comments often enough.

I phrase my comments in limerick form.

I still find questions that come down to “Guess what I’m thinking.”

I just finished a module on diabetes.  If I would have taken it in a month, I would have gotten more questions wrong, because cutting edge information, just released in the last few days, has questioned the value of fish oil supplements.    The Board validates questions, based on best clinical information at the time, and, with all the nuance and complexity available, avoids controversial areas, where large amounts of data exist on both sides of a clinical debate.

True today does not mean true tomorrow.   Making the right decision for a particular patient involves moving targets on dancing landscapes, and the Board has to revise the examination more often than I have to take it.

Thus my certification carries inherent obsolescence, even if not planned.

Memory, sourdough, and blackouts.

September 13, 2012

A kindness that stuck in my head

No more than two loaves of bread,

But still I remember,

Five years now September

For the graciousness of having been fed.

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 run into a lot of patients from my former practice who remember the good deeds of mine that I’ve usually forgotten.  This last week I met a person who did me a kindness that stuck in my memory.

When a person averages 84 hours of work per week, little time remains to do the necessary things in life.  One summer, five years ago, while my wife Bethany visited her aging father, I found myself on call on a weekend, sprinting from the time I awakened at 530AM till I dropped into bed at unpredictable hours.  A key part of my survival strategy at the time involved bread from Panera, but I arrived on a Sunday at five minutes past closing.  An employee, who didn’t have to, very graciously opened the doors, and I left with not one but two loaves of sourdough. 

Half a decade later, I cared for a critically ill patient while on call this week, who casually mentioned that a family member had been that employee, and did I remember the incident?

Heck, yes, I remembered it.  It might have seemed a small kindness to the person who performed it, but it mattered an awful lot to me.

High emotions, whether positive or negative, make for high memory.   Learning comes easier if a hungry person eats and then studies.

We don’t understand memory.  We know that our minds consolidate memory on several different time scales: less than a minute, less than five minutes, less than a day, and long-term; in order to make it into long-term storage, the memory has to get through the first stages. 

I took care of a patient once whose B12 deficiency destroyed long-term memory.  The patient could carry on conversation but couldn’t remember being married and having children.  Yet most dementia patients, including those with Alzheimer’s, remember events from their childhood.

Too much alcohol disrupts the consolidation of short-term memory.  The experience of awakening one morning and not being able to remember what happened the night before should frighten the gin out of a person.  Yet most people who get to that point continue to drink, and will tell you, eventually, that if they didn’t black out they didn’t have enough.

I cared for a patient during a prolonged hospitalization for problems related to alcohol consumption to the point of malnutrition.  When the dust settled and the failed organ systems which could be restored had been, the person could talk intelligibly but couldn’t remember the date for a minute.  Able to remember a few names and faces but stuck forever on September 25 of an unknown year, the person achieved the lifelong goal of a cancelled memory.  Yet that prize left confusion and the confusion left fright.

Consider the irony.

 

Discharge summaries

September 8, 2012

The patient’s in-hospital chart,

I’ll finish right now, if I’m smart

The time I can ration

To complete the dictation,

To describe the finish and start.

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.

Completion of a hospital medical record demands a discharge summary.  Nobody ever showed us what a good discharge summary looked like in med school.  We learned from examples, mostly bad.

Med student discharge summaries didn’t count.  In residency I went for thorough at the expense of brevity.  I regurgitated the history and physical, admitting lab and x-ray results, admitting diagnosis, hospital course, and discharge planning in excruciating and unnecessary detail, going through the layers of paper chart day by day. Sometimes the discharge summary went to three pages, single spaced. 

In the Indian Health Service I had to cut back on my words.  However intelligent and hardworking a transcriptionist might be, lack of training in medical terminology made for a lot of errors to correct to finish the product.  Just as well; when I took to typing out my own discharge summaries I pared down the turgid phraseology and left out a lot of irrelevant numbers.  The documents became more useful.

Medical chart completion ranked low on my priorities for most of the time I spent in private practice.  I found motivation only in the periodic letters I got from Medical Records telling me I’d be suspended from the staff if I didn’t finish my charts.

Through my career the grace period, from the day of discharge to the date of suspension, has shrunk from a year in the 70’s to six months in the 80’s, and has now remained at a well-enforced 90 days for the last 15 years. 

But the pace of medicine keeps accelerating.  We strive to follow the patient less than a week after discharge, and the follow-up doc usually didn’t see the patient in the hospital.  The discharge summary becomes less of a formality and more of a necessary and useful document.  I usually dictate the summary at the time of discharge, standing in the hallway.

My format has changed.  A line or two for the story of why the patient came to the hospital, a paragraph each for relevant past medical/personal/family/social history and abnormal physical findings.  A paragraph for lab and x-ray, followed by a paragraph for hospital course, discharge medications plans, and final diagnosis. 

Even at that, a long, a complicated hospitalization (one recently lasted 29 days)can give rise to a two-page discharge summary, but most take a page or less.

In that short space, the necessary confines for a useful document, I can give the facts but not the meaning.  I don’t get to use phrases like self-defeating behavior or inadequate reality testing or stinkin’ thinkin’ or self-imposed social isolation.  If I dictate patient refused counseling, I don’t get to go into the nitty-gritty of why.

The hardest discharge summaries end with “The patient continued to deteriorate and died on…”  Such a stock phrase gives a hollow echo of the drama and irony playing out the final act on the hospital stage, but such phrases I use on a regular basis.  And every time, I can’t help but pause.  The patient gets a moment of silence from me, whether I intend to or not. 

The transcriptionist, I am sure, hears in my voice how my world diminishes with every patient’s death.

Short call on Labor Day weekend

September 3, 2012

Labor day spent making rounds.

You wouldn’t believe the diagnoses I found!

It wasn’t quite call,

I avoided a brawl,

And sent four to their homes out-of-bounds.

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

Our hospital service has grown to the point where two docs get assigned every weekend, one each for a long call and a short call.  I drew the short call this holiday weekend, not the same as the short straw.   I requested, and received, assignment to my preferred hospital, where I’ve done morning rounds now for four days. 

My natural tendencies wake me early, but today I ate a leisurely breakfast before Bethany dropped me in the deserted doctor’s parking lot.  I printed my patient list in the doctor’s lounge at 6:58 AM and took the elevator to the 5th floor. 

I returned to the doctor’s lounge, emotionally tired, at 11:30.  I had rounded on 13 patients, each one a unique human being whose illness brings drama and irony to their lives and the lives of the people around them.  Each has a marvelous story, rich with details, triumphs and tragedies enough for a series of novels.

While I can’t discuss patients in particular, I can talk about the patient population in aggregate.

Four patients carry the diagnosis of schizophrenia.  Eight qualify as hard-core alcoholics requiring treatment for alcohol withdrawal.  Bipolar disorder (previously called manic-depression)afflicts three.

Eleven of the thirteen didn’t quit smoking soon enough, such that they required treatment for nicotine addiction or emphysema or both. 

More than one has chronic kidney failure necessitating dialysis. 

Others had cancer, HIV, depression, gallbladder disease, broken bones, dementia, urinary infections, lupus, and coronary artery disease.

The nurses on the psych floor warned me about a violent patient after a near confrontation.

I didn’t even bother to count the number of patients with the garden variety problems of diabetes, high blood pressure, and high cholesterol.

I had to deal with two patients with adverse drug reactions, their hospitalizations complicated by the very medications their doctors ordered.

I discharged four patients and dictated their discharge summaries while leaning my back against the wall; I wrote prescriptions for three of them.

One of those represents a triumph of medical care; we cured the problem and sent the patient home in less than 72 hours.  Such satisfaction comes rarely and I relish it when it does.

The doctors’ lounge stood deserted at noon on Labor Day, and I power napped ten minutes before the next task, reviewing transcriptions.  I had 37 in my queue.  After that I dictated six discharge summaries.

I left the hospital at 12:40PM, the rest of a fine summer day right in front of me, and headed home for lunch.