Archive for November, 2013

An inpatient care program drawing to a close

November 24, 2013

As I walk down a hospital hall

I think of the burden of call

What helps me to cope

Is a heart full of hope

That this month is the end of it all.

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.  Since August I’ve done a working vacation in Petersburg, Alaska, Continuing Medical Education (CME) in San Diego and Denver, and a trip to Mexico for our daughter’s wedding.

Our clinic’s inpatient program draws to a close in ten days.

The US remains the only industrialized country where primary care doctors attend hospitalized patients on a regular basis; for most of the world primary care ends at the hospital doors.

Community Health Centers, in particular, rarely send their docs to the hospitals.

I like making rounds, and talking to the specialists.  I have established a rapport over the years with physicians who know more than I do about their fields, and I enjoy the learning process.  On a usual basis I will leave the lunch table in the lounge a better doctor.  A tremendous amount of learning goes on in the peer-to-peer environment.   Once in a while I’m the teacher.

Today I saw 10 patients, ranging in age from 1 day to 77 years in one of the hospitals.  The problems included renal failure (both acute and chronic) abdominal aortic aneurysm, thoracic aortic aneurysm, COPD, cellulitis (face and leg), pelvic inflammatory disease, bipolar type I, alcohol abuse, tobacco abuse, hepatitis C, cirrhosis, chronic pain, narcotics abuse, amphetamine abuse, rectal bleeding, and pneumonia.  I greeted patients in Somali, English, and Spanish.   I got consultations, both curbside and formal, in cardiology, surgery, nephrology, and pulmonology.

Every patient came with a unique and fascinating back story.

I arrived at the hospital at 7:00AM and I left at noon.  Mostly I take the elevator to the 6th floor and work my way down, but today I took the stairs up to the nursery on the second floor, and worked my way up from there.

I discharged two patients.  In an irony of specialist vs. generalist, I did a consultation on a patient with a problem outside the expertise and field of the admitting doc.

I uncovered a few surprises, mostly to do with vitamin D and underactive thyroids.

I walked the hospital corridors and dictated into my hand-held recorder suffused with an existential awareness, which I can compare to the edginess of a high school senior in late May.

However much I find meaning and pleasure in the rounds of inpatient work, the afterhours call burden has become unsustainable.  I won’t miss the phone calls ripping me from sleep through the early morning hours and recovering from a bad night on call; it now takes me three days of a zombie fog in the wake of such a night.

After December 3, we’ll take hospital call only for pediatrics and newborns.  I’ll be able to exercise and sleep on the nights when I have call.

I hope.

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Fake drugs, acidosis, and antifreeze

November 19, 2013

The patient would sweat and then shake

Every time the fever would break

What was expected was not

What was got in the shot.

The drug turned out to be fake

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.  Since August I’ve done a working vacation in Petersburg, Alaska, Continuing Medical Education (CME) in San Diego and Denver, and a trip to Mexico for our daughter’s wedding.

I couldn’t interview the patient the first time I came to the bedside in the ICU because of the ventilator.  Nor did the physical exam get me very far.

Talking with the family helped, as did, to a lesser extent, looking at the lab work.

The original problem started out as a viral infection.  Untreatable 10 years ago, treatment 5 years ago never got better than 10%, now a long and expensive series of injections and pills can bring about a 60% cure rate.

This patient started the treatment on a Friday.  Beset by sweats and tremors over the weekend, two ER visits brought no improvement.  Seriously ill by the third visit, respiratory arrest followed shortly on the decision to admit.

The human body normal operates on the alkaline side of the acid-base continuum with a pH of 7.4, and very small disturbances in that number signify severe disease; this patient’s pH bottomed out at 7.24: just low enough to be deadly.

In short order I had three opinions from different specialists: a combination of antidepressants had caused a serotonin syndrome with fever and high blood pressure.  The doctor who had prescribed the sophisticated new drugs blamed the new drugs (and took that blame, I thought, unjustly).

But the third doc pointed to one particularly expensive drug on the list, declaring, “In my country, it gets counterfeited and there’s been a big scandal lately.”

Despite the differences, all three opinions boiled down to ABCD: Always Blame the Cottonpickin’ Drug.

More consultants came to the ICU and the patient received vigorous supportive care: we kept her alive while she healed herself and we pushed the investigation.

Three days later the toxicology report showed propylene glycol, antifreeze, in the blood.

The doc who thought to look for antifreeze notified the CDC.  An interview with them would come as no surprise.

Each dose of that drug costs 4 figures, thus counterfeiting also comes as no surprise.  The fact that the counterfeiters used toxic adulterants instead of, say, sugar water perplexes me.  Inactive fakes can stay on the market a lot longer than poisons that come in an identical box.

I wonder how many other people the phony meds have damaged, and whether or not they got the proper diagnosis.

Notes from a smaller conference

November 14, 2013

The conference seemed rather small

A hundred and sixty was all

I picked through the fluff

And brought back some stuff

And we’re all taking way too much call.

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.  Since August I’ve done a working vacation in Petersburg, Alaska, Continuing Medical Education (CME) in San Diego, and a trip to Mexico for our daughter’s wedding.  I’m in Denver now picking up more CME.

As the older, balding male white-haired docs, my generation, lecture about transformation of the American Health Care System, the younger docs, mostly female, no gray hair, file in with their coffees.  The young primarily work for someone else, these lecturers work private practice, fee for service. Except for one who just started working for the govt.  But the guys at the podium attack the problem from a logical, systemic approach.

The whole conference amounts to 160 people and the intellectual intimacy makes up for the lack of world-famous speakers.

When interest lags, the subtle sounds of electronic devices accumulate.  From the back of the room I see screens showing recreational, non-topic displays.

In the hallways and the lounges the practicing docs pass the students.  It’s not that they seem so young or naive, it’s that they seem energetic and passionate.  The phrase dilapidated, meaning literally to have polish removed, comes to mind when I look at the older physicians.

In a lecture on sinusitis, the doctor next to me falls asleep.  His face shows the stress of too many life-and-death decisions made in the middle of the night, the slings and arrows of healing without the healing balm of sleep for the healer.  I want to fall asleep, too.

In the evening I find my right rear tire low and I inflate it at a service station, but in the morning the tire gauge reveals pressure loss.  I pass a leisurely hour in the tire center and avoid horrendous traffic to arrive two hours late.  I have missed two lectures but neither topic interests me.  The first lecturer I listen to goes long because the next lecturer arrives late. He got stuck rounding by difficult cases.

The speech speed of two lecturers trumps intelligibility; twenty minutes into each talk the attendees start to whisper to each other about it, and the recreational screens light up again.  I suspect inappropriate pharmacologic use but I don’t say so.

I quit OB as my 60th birthday present to myself, in 2010, and I have no intention of making a comeback.  So I skip the day’s last lecture on prenatal care.  But I stop to chat with an ER doc and an OB/GYN next to the depleted snack table.  Conversation soon turns to Colorado’s legalization of recreational marijuana, and we start volleying data back and forth.  Children who show up in ER after getting into the now legal brownies and cookies never go to ICU and never die from the toxicity.  Too much marijuana causes terrible vomiting in the cannabis hyperemesis syndrome.  Those who toke before driving having more car accidents and fatalities than those who drink.  We fired facts back and forth like this in undergrad and med school instead of coming to blows, now we try to inform rather than convince.

Between lectures, consistent themes from the docs revolve around the amount of time that the EMR demands; we’re all spending more hours with the computer and less with the patient.

A professor emeritus lectures on William Osler, the premier physician of the last century.  The speaker’s voice is high and doesn’t project well.  He shuffles when he walks on the stage, his arms don’t swing, and the diagnosis of Parkinson’s shows painfully obvious.  But the talk goes well.  The startling news that Gertrude Stein went to med school and washed out in her 4th year brings the proper gasp of amazement, as does the fact that the founding 4 female philanthropists of Johns Hopkins Medical School demanded admission of women.

At the end of a week of lectures, we all agree we work better than we sit.

Taking call as an addictive process

November 10, 2013

Let me talk about my predilection,

Which looks a lot like addiction

I keep taking call

After I’ve hit the wall

But improvement is my prediction.

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.  Since August I’ve done a working vacation in Petersburg, Alaska, Continuing Medical Education (CME) in San Diego and Denver, and 4 days In Mexico for our daughter’s wedding.

In 2001 a government Task Force declared pain the 5th Vital Sign that needed to be assessed at every visit along with temperature, pulse, blood pressure, and respiratory rate.  In the aftermath, pain management did not improve.   But the unintended consequences marched forward, with non-suicidal lethal overdoses of prescription opiates quadrupling in the course of ten years, until last year those drugs killed more than traffic accidents did.

Since September I’ve logged more than 70 hours of CME; about one-fourth of those hours have concerned addictions, pain management, and narcotics.

All addiction processes share certain characteristics.  The behavior continues despite adverse consequences, and occupies time to the detriment of other important activities.  Loss of control strongly indicates a pathologic behavior, where, for example, a person might say at the beginning of the night, “I’ll only have two drinks,” but loses count.  Or the runner who, intending to just do a quick 5 miles, ends up doing 14.  Loss of control counts even if it happens rarely.

The part about the addictive behavior robbing time from family hit home when I thought about my years taking call.  When I have call, my family knows they can’t depend on me.  I need increasing amounts of time to recover afterwards, both because I am aging and because the call burden has grown.

I have had adverse consequences.   About a year ago I started having palpitations corresponding to runs of atrial tachycardia from the stress of staying up too many nights in a row.

And I have lost control.  In residency, one can understand the naïve young doctor volunteering to help another resident out, but I failed to learn.  Recently I found myself working at 2:00PM though my call had ended at noon.

Yes, my employment depends on my taking call.  But I also have a friend in the wine and spirits business, who drinks for a living.  That he does it professionally does not negate his alcoholism.

To the best of my knowledge no one has examined taking call as an addictive process, but it sure looks that way to me.

I have only two bad nights of call until my clinic hands over our hospital business (with the exception of patients under the age of 18) to the hospitalists.

I wonder if I’ll backslide when I can’t find (or start) a Calloholics Anonymous meeting.

At a wedding in Mexico

November 4, 2013

In my elevated social position

As a respected family physician

My patients I serve

But there are those who have nerve

To be mean to those of lower condition.

:  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, an educational trip to San Diego, and a wedding in Cancun.

Bethany and I went to our oldest daughter’s wedding in the tourist district of Mexico, on the Yucatan Peninsula.  The staff treated us royally.  At mealtimes someone would pull out the chair for me to sit and push it in as I did; another someone would unfold the napkin and to place it in my lap.  On the trails that meandered through the jungle from villa to villa, hotel staff would step off the concrete to let us pass.  They learned our names the first day, and on the second morning knew how I take my coffee/tea/chocolate.

Not only do I not expect such service but it made me feel a little creepy.  I tried to ameliorate the sociologic disparity by speaking to the staff in their own language, but it didn’t help, and it took me a couple of days to figure out why.

In any service industry, an inherent power inequality permeates the relationship between the service and the client.  Even a physician, with a high social rank, has to face this inequality with every patient, and I have worked in that position for so long I have grown comfortable with it.  Speaking the language of the client makes me a better service provider, but I still maintain my position as a service provider.
The position of client brought me out of my zone of comfort.

The resort staff, for the most part, spoke English passably or well, and I suspect that gaining employment there depended on a demonstration of language proficiency.  I still spoke Spanish with them because I find it soothing, and because it felt like I ameliorated the disparity between us.

Back home, when I go out to eat, I go out of my way to bring respect to the client-service relationship.  I shudder when I see restaurant wait staff treated like furniture; I make eye contact and I use peoples’ names.  I say please and thank you.  If the server is having a bad day, I do my best not to add to the problem.  And ordering food came easily in Mexico.

I still felt bad for the people who stepped off the path at my approach, even when I figured out that, at the very least, it gave them a small break in their work.

In the end, I came back realizing that the patients who treat me like furniture and who bring no respect to the service-client relationship are the worst patients.  They demand time to get advice they won’t take with no consideration for the patients who come afterwards.

I suspect they’re mean to restaurant wait staff as well.

 

Pathognomonic names the disease: swearing to the truth means admitting to a lie

November 3, 2013

You swear to no drugs, me o my.

If it’s the truth, can you tell me why

My belief you demand

As you raise your right hand

When you know perfectly well that you lie

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 back from a working vacation in Petersburg, Alaska, and an educational trip to San Diego.

Pathognomonic comes from the words pathos meaning disease and gnomon, meaning name; roughly speaking, it names the disease.  Koplik’s spots, for example, a particular sort of lesion on the gums, occur only in measles.  If I would see Keiser-Fleischer rings in the irises I would know instantly that the patient had Wilson’s disease.  A bull’s-eye rash happens only in Lyme disease.

When I was a med student an intern told me that palpable lymph nodes just above the elbow, on the inside of the arm were “almost” pathognomonic of infectious mononucleosis (they aren’t).

Imagine a patient fixing his or her eyes on yours, raising a right hand and saying emphatically, “Doctor, I swear to God…”  (It doesn’t matter what comes after that.)  Such a vocalization and gesture rate as pathognomonic for patient lying about drugs.

Bill Clinton used the same facial expression when he said, “I did not have sexual relations with that woman.”

Really, a person telling the truth doesn’t need to swear or use righteous indignation.

I let the patient finish prevaricating.  I nodded.  “I live in the real world,” I said.  “You’re sick.  You need to be in the hospital.  Just like I’m ordering a patch for your tobacco addiction and an ultrasound because your tummy hurts,  I’ll put you on the detox protocol.”

The righteous indignation had faded after I said I lived in the real world.  “For what?”

“For the drugs we found in your urine.”

The urine drug screen has never rated 100% for accuracy.  It has false positives and false negatives, and I know it.  I suspected drug use, and the patient admitted to marijuana.  But as soon as the patient fixed my gaze, and raised the right hand, I knew that I needed to start detoxification procedures for those amphetamines and opiates, and to test for hepatitis C and HIV.

I walked away from the interaction proud that I had dealt with the problems without backing the patient into a corner.  I had communicated my concern about the patient’s well-being, I didn’t try to be right, and I finished the admission with more energy than if I’d tried to get to the patient to admit wrongdoing.