Archive for September, 2013

Scenes from a weekend on call

September 29, 2013

The weekend covers days three

And guess who’s on call?  It is me!

With period and comma

I document drama

You wouldn’t believe the stuff that I see.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  I’m just back from a working vacation in Petersburg, Alaska.

Scenes from a weekend on call

Saturday Morning

I sit in a hospital room with a new admit and I take a history.  Sunlight streams through the window, the first day of fall gleams outside with perfect temperature.  When I get to my 84-question Review of Systems, where I ask about every conceivable symptom, violence from the next room shatters the mood.  A domestic disturbance has broken out in the adjacent room and spilled into the hallway along with items of furniture and things that can be thrown.  A mother hurries away with an 8-year-old in tow.  I read the child’s face and the look of wonder and awe, and I see he has been handed a script loaded with dysfunction.  Overcoming what he accepts as normal will take intelligence, persistence, insight, determination, optimism, and, probably, help.

Saturday Morning

I sit beside the patient’s bed.  “What do you think the CT showed?” I ask.

“I don’t know.”

“Do you want to guess?”

“I don’t know.”

The patient knows, and I know it.  I make small talk and then start the trip around the track again.  “What do you think the CT showed?”

After four laps I get the patient to say “cancer.”

Saturday Afternoon

“Yeah, I know I got cirrhosis and I know I should quit drinking but hey, you know, I was about oh I don’t know probably about 3 or 4 weeks and I hadn’t had a drink then, oh I  don’t know, I got pretty hammered.  But I didn’t do it that much and I only did it a couple of times.  And sometimes, geez since July I blow up and then I’ll pee off like about 25 pounds and it comes and goes and now my belly hurts up here on the right.”

 

Saturday Afternoon

“I think she has decided to die.”  The patient’s children look at each other and their faces carry nuance beyond description.

“We kinda thought that since we read that book.”  They refer to Love, Medicine, and Miracles.

 

Sunday Morning

“I gotta be outta here tomorrow for a court appearance.”

I nod.  I have a patient with a heart attack waiting for me in the ER across town and I need to move.  “So how are things going for you?”

“MM?”

“You know, life in general.”

“Real good.”

“Do you really believe that?  When you just told me you girlfriend left with your kid and you have a court appearance?”

“Yeah.  (pause) Well, no.  No.  I got a country and western song in my head.  It’s my life.”

Sunday Evening

It’s past midnight and I’m talking to a judge by phone.  I explain that the patient’s brain function, loosely connected by an accident of genetics, has not improved with a major electrolyte imbalance occasioned by and coincident with severe hypothyroidism and failure to take meds as prescribed by a psychiatrist and endocrinologist.  After non-stop clinical work starting 19 hours previous I can remember the patient’s name and age but not birthdate.  I can, however, relate details about the request for hospitalization, docility in the ER and a quiet hour on the medical floor followed by increasingly loud, bizarre, and violent behavior over the subsequent 2 hours (which responded temporarily to 1 mg of Haldol, but which will necessitate a 48 hour court hold).  The call takes twenty minutes and ends at 1:30.  Vigilance robs my sleep for the next 3 1/2 hours and then I get up, shower, eat, and start rounds again.

Sixty-four cups of coffee a day

September 15, 2013

It comes to excess caffeine,

The insomnia, tachycardia scene.

For with cups sixty-four,                                                      

Not less and not more,

We see the toxic side of the bean.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  I’m just back from a working vacation in Petersburg, Alaska.

I went to breakfast with a couple of other docs.  All three have worked locums and enjoyed it.

Over coffee we discussed caffeine’s medical effects.

One doc told about a patient with a racing heart (tachycardia) and diabetes.  Eventually he stopped the family from bringing in 7 caffeinated sodas a day, and then the patient’s sugars normalized and the heart rate slowed.

The other doctor asked if headache had followed.

I made the observation that I can give anyone a migraine if I give them a high enough dose of coffee for a long enough time and then stop it suddenly.  Then had to tell about the worst caffeine addict I ever took care of.

For the sake of this blog and the patient’s identity, I won’t say where or when I met a fellow in his early sixties with insomnia and a racing heart.  On the first visit he revealed his 64-cup a day caffeine problem.

“Sixty-four cups a day?”  My colleagues asked.

“Yep,” I said.  “I had him taper down a dose a day, stay at a dose for two days if he got a headache.  It took all summer but I got him down to zero, had him stay at zero for two weeks, then rechallenge.  Two days later he was back to 64 cups a day.  He just felt lousy without it.  Clearly, he wasn’t wired like you and me.”

“What was his blood pressure?” one asked.

“Normal to low,” I answered, my memory making a successful leap over a long chasm of years.

“Did he have Addison’s?”

I came to a screeching halt.

Addison’s disease comes from inadequate cortisone production, a failure of the adrenal glands to produce a hormone necessary to maintain blood pressure and salt retention.  The most famous Addisonian patient was JFK, and owed his signature deep tan to the disease.  In the course of the last 30 years I have managed a handful of cases (one found by a really sharp psychiatrist) but diagnosed none.

I had to admit I hadn’t considered the diagnosis at the time but I should have.

Then I had to recall lessons learned from managing blood pressure in a suspect pheochromocytoma (docs shorten it to “pheo”) patient.

This disease involves a tumor of the outer adrenal gland, the part that puts out adrenaline.  We spent lecture after lecture in med school on the subject.  With a case rate of 3 per million, though, primary care doctors can tell when they arrived by the time it takes them to see a case.  It took me 30 years.

We talked about alpha and beta blockade, and a drug only used for this vanishingly rare disease.

But we also talked about negotiating, game theory, decision making with imperfect information, the origin of the Syrian nerve gas, Sarin (probably Iraq), Israel’s precarious position, hospital politics, our respective future plans, and problems with Obamacare.

We didn’t always agree, but when we finished we were better doctors for the colloquium.

I won. It felt like losing.

September 11, 2013

I suppose I got mad for a spell

On the issue of testosterone gel

For more lab the rep asked it,

And I blew a gasket

I won, I’m not proud to tell. 

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  I’m just back from a working vacation in Petersburg, Alaska.

Technically, I don’t work the afternoon after night call, but I rounded on 17, discharge 4, had a leisurely lunch and went to the office.

The tide of mail and email doesn’t stop when you go on vacation.  I sat at my desk behind a closed door, and steadily worked my way down the stack of paper.

Near the bottom I came across a note from an insurance company dated 8/30, demanding information within 5 working days, or my patient would be past any appeal of a denial of coverage for testosterone gel.

(I have a lot of patients with testosterone deficiency.  Insurance companies notoriously drag their feet about paying for high-priced meds.  I have revealed no unique information about anyone.)

This particular insurance denial of coverage for this particular medication goes back 10 months.  I appealed at the time.  They thought for 90 days and wanted me to get more lab work, which I suppose seemed reasonable in a far-fetched way.  They thought about it for another 60 days and sent a letter telling me I had to have appealed on a different form before the deadline which had now passed.  I called and spoke with a representative who told me to get more lab, which I did.  With new numbers in hand I called again and got put on hold for a quarter-hour.  I fired off a well-worded, articulate, calm letter to the company, which never got acknowledged.  I called again a few months later and talked to a different rep, who said, another imaginary deadline having passed, that the patient would have to make his own appeal.  I sent the patient a letter recapping the events, telling him the company’s dealings lacked good faith, but urging him to call the company; I sent the company a copy.  And there the matter stood when I went off to Alaska.

I struggled to keep my voice calm when I spoke with the rep.  Such a deadline could never be considered reasonable, I asserted, I had been gone and it was only under the thinnest of coincidences that I happened upon the letter in September at all.

She told me she’d gotten a call from my office and that on the basis of only one lab result the medication could not be approved.

I blew a gasket.

“I’m telling the patient to get a lawyer,” I said.  “I suggest you talk to corporate counsel today to figure out how he’s going to defend this thing because I have copies of letters that I’ve been sending and you’ve been shredding and it’s going to look very bad in court.”  I didn’t raise my voice.

Silence reigned at the other end.  I ended the call courteously.

I had my nurse give the patient the info.  For the first time in thirty years, I suggested the patient retain legal counsel.  And asked him to come in for one more round of lab tests.

The rep called me back a few minutes later to tell me that she’d spoken with the committee and the denial had been rescinded.

I had my nurse phone the patient.

I felt good about getting the patient the medication he rightfully deserved, bad about blowing a gasket, and worse that blowing a gasket had worked.

It’s not a technique I want to use frequently.

The patient decided to drop his insurance, feeling, rightfully, that the cost was certain but the benefit doubtful.

 

 

A tour, follow up on drama and irony, and a very bad pun

September 8, 2013

The eggs of the salmon, the roe

Brings in plenty of dough.

But as the workers grew fewer,

We took a fine tour,

And filled in a tale of woe.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  I’m taking a working vacation now in Petersburg, Alaska.

Bethany and I had the chance to tour the salmon cannery the day before we departed Petersburg.  Even at the end of the season we left impressed.

This year’s run of pink (or chum) salmon broke records, as did the number of pounds of salmon packed (56 million and counting, when we left).  Each fish, sorted on the tender before arrival at the cannery, runs through another sort before it enters the processing line. The outside of the cannery, that interfaces with the fishing boats and tenders via enormous vacuum cleaners, gets the name Beach Crew.

It doesn’t look like a beach but the people get to work outside.  A good part of that job consists of sorting fish, and they reject a fair number on the basis of species or advanced maturity.

Technology has improved the problem of by-catch, the taking of fish unintentionally.  King salmon, for example, having suffered in numbers, can’t be sold but can be kept and returned to the captain of the crew that caught it.

Workers can tell from inspection which fish have come too close to spawning and had the palatability of their flesh deteriorate, and we saw a fair number of fish rejected thereby.

In the Egg Room, we watched the processing of salmon roe, and learned that some years the roe brings more money than the fish.  The best of the best goes to Japan; the next two grades down get shipped to Russia.  Off-shore Japanese and Russian interests pay their own workers in sorting, and, to a limited extent, in packing.  The eggs take an enormous amount of salt.  A very large ship brings the refrigerated, not frozen, ikura across the Pacific.  I made the observation, that no matter how big such a vessel, if it functions thus we must call it a roe boat.

Five pressure cookers, each five feet in diameter and thirty yards long, cook the fish.  The hand trucks that enter the cookers each carry five layers of 96 cans.  Moving the cans on those carts requires an enormous expenditure of energy.

The facility freezes fish all year long, but freezes more when the cannery work finishes.  As we walked through chilling rooms at 40 degrees below zero I got a chance to talk about the process for chilling hog carcasses back home.

As the tour progressed, different people mentioned the young man I saw terminated in the street two days before (see previous post).  As the 16 hour work days exacted their toll, his behavior became more and more bizarre.  This person had seen him near the Laundromat, that person had seen him angrily gesticulating en route to the bar, extending his middle finger at inanimate objects.  Another heard he’d been in a fight and the police became involved.

All hoped he’d avail himself of his plane ticket that afternoon.

In the end I figured the 16 hour days had pushed him past his limit.  I had seen sleep deprivation induce major psychopathology before, in the aftermath of the New Zealand earthquake.

And I worried about myself and my workload at home.