Archive for April, 2013

One night stand as a nocturnalist; eavesdropping drama and irony

April 26, 2013

At five I had plenty of rest

I was happy, well-fed and dressed

But my attitude sours

With the wrong kind of hours

Before I got back to my nest.

 

Synopsis:  I’m a family doctor in Sioux City, Iowa.  In 2010, I left my position of 22 years to dance back from the brink of burnout.  While my one-year non-compete clause ticked off, I travelled and worked from Alaska to New Zealand, and now I’m back working part-time (54 hours a week) at a Community Health Center.

As a favor to a colleague I agreed to take call the evening of one of my days off.

I enjoyed my leisure before I started to work at 5:00 PM.  I took a friend to an outpatient procedure, did some regulatory tasks and some grocery shopping.  I slept in the afternoon.

I power nap better than anyone I know.  Given 18 minutes, I can go through a complete sleep cycle and awaken feeling rested if not euphoric; given 45 seconds I can recharge my batteries. 

But this time my post-lunch siesta went for hours. 

The beeper started to chirp at 5:03PM.  I handled calls from the inpatient units at two hospitals.

About 7:00PM I got my first ER page for an admission.  I briefly considered bolting a snack before I left, but then I thought about my large lunch and my desire to reduce my waistline.

I admitted the patient in the hospital closest to home, and stopped in the Newborn Nursery on my way downstairs to admit the newest addition to the practice. 

The beeper sounded as I walked in from the garage.  Not really hungry, I took the call and went to the other hospital, feeling chipper and well rested.

I could get used to duties as a nocturnalist (the sort of doc whose main function consists of admitting patients and caring for problems that go wrong in the middle of the night), I thought. 

That hospital grew across a street, and I had to cross a bridge from the old section to the new.  A man stood in the bridge, looking out over the city, talking on his cell phone, the sun setting as the last snow melted.

Confidentiality doesn’t apply to information spoken in a public place by a person not my patient; the words directed to a cell phone registered as I walked past.

“Yeah, his blood counts all messed up now and it looks like he’s got leukemia, and he’s just about had it, he doesn’t want to fight it.”

The drama and irony hit me in four strides of involuntary eavesdropping.  I didn’t look up.

I arrived in the ER still energetic and smiling.  I got as far as introducing myself to the patient, when the beeper started into an unbroken orgy of interruption lasting half an hour. 

I left that ER and got halfway home when another page brought me back.  I had to admit two more patients over the course of the next two hours while another at the other hospital deteriorated.

Midnight found me in the ICU with that patient, talking in hushed tones to the family and shaking my head in unison with the pulmonologist, my nerves jangled, my optimism crushed, and not very much in favor of the idea of being a nocturnalist.

Protecting the patient from medical care

April 24, 2013

Be careful the diagnosis you make,

Could it be that the patient’s a fake?

If they take too much caring,

And just leave you swearing

That this one sure takes the cake. 

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 54 hours a week.

In another century, in another state, I cared for a patient who feigned seizures.  She knew enough neurology to easily fool me and almost enough to fool a very good neurologist.  Before HIPAA, fax machines and the Internet, we did the best we could for the young woman coming in off the highway in the middle of the night, not realizing that her “epileptic” activity came under her complete conscious control.

On her third hospital day, we started getting information in from hospitals and clinics in other states.  I spoke with her parents but she had burnt bridges years before; they stated without rancor that they wanted nothing to do with her. 

The patient was the first I would care for with Munchhausen’s syndrome, a disease where the patient makes the doctors believe illness exists when it doesn’t.

I cared for such a patient today; because of confidentiality I will reveal no details.

Munchhausen patients constitute a no-win situation for the doctor.  If not confronted, they continue the drama, and the illness never resolves.   If confronted, they deny, dissemble, and project, and move on to another facility.

Some but not most work.  Most but not all lead geographically unstable lives.  Occasionally parents use their children to create medical chaos, giving rise to the syndrome of Munchhausen by Proxy.

Some patients have physiologic abnormalities, such as a blood test or an electrocardiogram that never normalizes.  Some have horrendous scars.  A subset of patients uses words and physical findings to obtain narcotics either for their own use or for resale.

They play a dangerous game; I have seen limbs amputated and surgeries performed.  Mostly Munchhausen patients die from medical misadventure.

Once the patient has the diagnosis established, there exists no effective treatment.  At best, a doc hopes to not personally making the patient worse.

Sometimes, the patient seeks nothing other than attention, and I have set up thrice weekly appointments for months to try to protect them from medical care.  But others thrive on manipulating the medical establishment, and find no satisfaction outside of misdirected heroics or anger.

Still, they are human beings, and I wish I had a good treatment for the person I saw I today.

Brief conversation with a widower

April 13, 2013

Time is the ultimate thief

Our allotment is always too brief.

I learned while in line

This wisdom now mine:

When we leave, we always leave grief.

Synopsis:  I’m a family doctor in Sioux City, Iowa.  In 2010, I left my position of 22 years to dance back from the brink of burnout.  While my one-year non-compete clause ticked off, I travelled and worked from Alaska to New Zealand, and now I’m back working part-time (54 hours a week) at a Community Health Center.

In theory, working part-time, I get two days off per week, except when I have call.

My natural body clock wakes me between 5:00AM and 5:30AM, and I can get a lot done before normal businesses open.  Today, I had to renew my driver’s license.

Most people hate the Driver’s License authorities in their states; I get along with a grudging coexistence.  This time I made sure I arrived early, and I parked in the cold and the rain at 8:20AM, listening to an educational CD on breast cancer.  At 8:27 a man walked up and stood by the door; I switched off the disc and went and stood beside him. 

He looked a decade older than me.  He complained about the office not opening on time right until the key turned in the lock precisely at 8:30.  I stood behind him in line and watched him dealing with the clerk to have his picture taken.  When it came to my turn, I gave up my old license, looked at the bottom lens, and received a ticket with the number 201 on it.  I took my seat beside the retiree at the front.

“I forgot and let my license expire,” he said, and announced he’d be moving to San Diego to live with his son, his only child.

We sat together and didn’t speak.  “I forgot to renew my license when my wife died,” he said.  “We were married for 60 years and I loved her.”

A moment of silence passed while the drama of the ultimate drama irony’s echoes washed through the drudgery of the routine.  I considered contrast as the essence of meaning.

“I bet you miss her,” I said.

He was about to answer when the PA announced his number, 200, for service at counter 8.

I waited and contemplated the enormity of what he’d told me.  I hadn’t told him not to pile too many stressors on at the same time.  Usually I’d tell a patient to wait for a year to move after such an emotional shock.  But he wasn’t my patient, and he hadn’t asked for advice, and I couldn’t say, for sure, that my advice, while qualifying as common sense, had good clinical evidence in large studies.  And it was a public place.

The automated voice on the Public Address called my name to counter 10.  I confirmed my address, height and weight and did the vision test.  My banter with the clerk lacked my usual verve.  I walked out of the office with my temporary license in my wallet, looking around at the mob of people who had gathered in the previous 10 minutes, congratulating myself on arriving early and finishing early and not getting stuck in the line.

As I exited I saw the widower walking slowly to his car, looking lost, and I thought about the meaning of time.

Mission creep: a census grows and genomics comes now comes retail

April 10, 2013

Does a thousand seem likes it’s cheap?

Beware the assumptions you keep.

Don’t think that it’s strange,

There will always be change,

And ever the mission will creep. 

Synopsis:  I’m a family doctor in Sioux City, Iowa.  In 2010, I left my position of 22 years to dance back from the brink of burnout.  While my one-year non-compete clause ticked off, I travelled and worked from Alaska to New Zealand, and now I’m back working part-time (54 hours a week) at a Community Health Center.

Last night I took the handoff for a hospital census of 4, a record low since I started with this clinic.  Even though I arrived for rounds before 7:00AM, that number had grown by 3.  I whizzed through two admissions, three patients with kidney failure, one each with alcohol withdrawal and complex pneumonia, five diabetics, a newborn, and two coronary patients.  (Do the math, you’ll figure out that a patient rarely enters the hospital with one problem.)

The longer a person lives, the richer their life story; and in the course of half an hour I had the treat of listening to a wonderful family history unfolding over the course of three generations.  I left them hope that the specialist would be able to cure the problem. 

But I squandered 15 minutes trying to educate a nurse, who overhearing me speak Spanish, made disparaging remarks about immigrants. 

Still I finished at the one hospital before ten.  At the second hospital, still in the throes of transition from paper charts to a new Electronic Medical Record (EMR) system, I only had to round on the pediatric floor, and I held onto hope of getting to the office early. 

I discovered an EMR quirk: one now needs 9 keystrokes, not 1, to edit a dictation.

I got to the office early, but not nearly as early as I’d hoped.

After half an hour of buffing documentation and messages, I attended what had been billed as a provider meeting.

The man who brought the lunch didn’t pitch a drug but a lab test.  Using material on a cotton swab from the inside of the mouth, for a mere thousand dollars, his company can provide us with genomic information about how fast or slow a person might metabolize a range of medications. 

For example, a single standard 30mg dose of codeine provides good pain relief for 80% of the population.   But 20% of population lacks the enzyme to convert codeine to morphine; for those people, codeine might suppress a cough but won’t relieve pain.  The super enzyme found in 1 in 3 Somalis converts 100% of the codeine to morphine on the first pass through the liver, enough to kill half of those who try it.    

Our clinic prescribes almost no codeine.  For whom will the test bring a thousand dollars with of benefit when it comes to choosing an antidepressant, antipsychotic, or ADHD medication?  We requested more information.

I didn’t ask the larger question: how long will it be till an entire genomic sequencing becomes available for that price? 

Mission creep remains a permanent fixture on the constantly shifting medical landscape.  Whether a doctor deals with a growing census, or a company sells technologic improvements, we all know that the world, at the end of the day, will not be the world we had at the beginning.