Archive for May, 2015

Neuropathy, lead, mercury, and a breakfast colloquium

May 27, 2015

We like to eat breakfast out

So we know what we’re talking about

The information we share

The learning, the care,

Helps to alleviate doubt.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. In the meantime, I’ve done a couple of assignments in rural Iowa, and one in western Alaska.

I breakfasted early with a friend and colleague. We worked together for a while. We kept up occasional morning meals for quite a time afterwards.

Our colloquia touch on economics, game theory, reality testing, clinical medicine, puzzling patients, family, medical politics and religion. (For why I don’t write about a couple of those topics, see my post https://walkaboutdoc.wordpress.com/2010/09/13/why-i-dont-write-about-religion-politics-or-sex/.) Much of our clinical discussion centered on neurology.

Syphilis remains the great imitator; but HIV runs a close second. Anytime a doc does a blood test on anyone, he or she has to keep in mind the chances of a false positive or a false negative test, and what can happen from either. The usual test for syphilis, the RPR or VDRL, reaches maximum usefulness 6 months after infection when the accuracy hits 95%. The false negative percentage mounts with time until 20 years later when it bottoms out at 50% (the accuracy of a coin flip). Thus I always get the confirmatory test, the TPPA (treponema palladium plasma antigen) which replaced the FTA (free treponemal antigen) early this century.

I only have that information because of a series of cases that happened before the growth of the internet.

My work up for any neuropathy (disease of the nervous system) includes B12, folate, lead, CBC, a Lyme panel, and VDRL/TPPA.

“Lead?” my friend asked, “Why lead?”

I had to admit I had never seen a case of lead poisoning, and I talked about a patient I’d attended last century (I won’t say where) who should have had lead poisoning. He’d worked with lead paint for fifty years and had all the symptoms. Every test we did to show lead poisoning, including bone biopsy, came out negative, but we didn’t get the diagnosis till he’d been in the hospital a few days and his urine turned the color of port wine.

“Porphyria?” my friend asked, and I nodded. Supposedly rare, I’ve seen three dozen cases in that family of hereditary disorders of hemoglobin synthesis.

“And no symptoms till age 73.”

I got to brag about finding several cases of B12 deficiency, each in a unique individual whose diagnosis brought drama and irony to a personal narrative and social context.

I forgot to mention a conversation I had years ago with a doc who found mercury poisoning in a patient who ate too much northern pike; the presentation had looked like dementia but included too many neuropathy symptoms.

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What do do about very bad moments.

May 25, 2015

A note for those who’d be wise

If it comes as a surprise

It’s most likely bad.

The good times you’ve had

You could probably already surmise.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, and finished a couple of assignments in rural Iowa.

Time comes to us, not as a series of days or years, but as an unbroken chain of moments.  Each moment lasts a second or three.  As human beings, when we awaken in the morning we all know we’ll have good moments and bad moments.  Most moments come and go as neutral.

I enjoy saying that if we let the bad moments contaminate the neutral moments we’re giving them too much power, and if we let them sully the good moments we’re missing the point.

Time spent thinking of bad moments that haven’t happened constitutes a misuse of imagination.  The psychiatric community calls it catastrophizing, thinking of sequences that follow from a bad “what if.”

Most of our good moments come to us announced.  Yes, once I really did find a diamond in a stairwell, and the gift of a soprano saxophone in fact rendered me literally speechless.  But my marriage, my children, my graduations, all arrived more or less on time after much anticipation.

In contrast, with few exceptions, the really bad moments come to us as complete surprises, unannounced and unexpected.   Bad medical news, such as my diagnosis of appendiceal carcinoid, and news of our daughter’s climbing accident, for example, came with no warning.   When I think of my lifetime’s 10 worst moments, I have to admit that they ambushed me, every time.

Both Bethany and I had very bad moments yesterday, the kind of moments that, despite all efforts to the contrary, ruin the rest of the day.  We commiserated, we supported each other, and we hugged.  And later, taking my own advice, I put a rubber band on my wrist for self-administered aversion therapy.  When a negative, useless thought intrudes, I pull the rubber band back about 9 inches and let it go; bad thoughts creep in with less frequency as long as I keep the rubber band on my wrist.

In the late part of the day we attended a social gathering, which celebrated Bethany’s last day on her job.  She has done a lot of good work for the last couple of years, and we’re looking forward to spending more time together.

At that gathering, a former patient I hadn’t seen for years, talked to me about a very bad diagnosis.  I listened, sympathized, and told her about my personal experience with carcinoid of the appendix.  But we also discussed our music community, and the person congratulated me on taking saxophone lessons.

The root that Mayo missed: whittling down the med list

May 18, 2015

Give bad news sitting down

May 15, 2015

The scientific method applied to a long, failing med list

May 14, 2015

Some of the things I told my patients

May 13, 2015

Canada, rainbow’s end, and pheasant glass

May 12, 2015

In the evening I dove east in the rain
With a rainbow out over the plain
No matter what you’ve been told
At the end, there’s no gold,
But in fall, we just might have grain.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Just back from Nome, Alaska, I’m now in Grundy Center, Iowa.
I drove with the sun at my back, eastwards, from Sioux City towards Grundy Center, across flat farmland dotted with wind turbines. The dramatic clouds in front of me contrasted with the sunshine behind me, clarity against darkness. Bit by bit, a rainbow emerged against the backdrop, first at the north end, then at the south, and finally arched right across the sky.

I could not help but remember our train trip south across New Zealand, between assignments. Seven rainbows graced the skies that rainy day.

I picked New Zealand over Ireland in 2011 because of the medical licensure application. Ireland’s 84-page form brimmed with dense prose, indefinite antecedents and esoteric usage despite nominal English, after a week spent on the first 10 pages I gave it up as a bad bit of work, added it to recycling, and picked up New Zealand’s four-pager, which I completed in an under an hour.

Right now I’m working on a Canadian license. The paperwork so far has been reasonable to the point of unbelievability. In fact, I don’t believe it and I’m waiting for the full weight of bureaucracy to fall across my electronic desktop.

Trish, my recruiter, has guided me with patience and kindness. We mostly talk on her days working at home. In the US, recruiters work for agencies to place physicians where needed; the doc works as an independent contractor. The agency guarantees transportation, professional liability insurance, and housing. I can’t generalize for all Canada, but my recruiter puts doctors together with institutions in need. The professional then negotiates with the employer about rate, insurance, lodging, and transportation. In the end, the Canadian recruiter takes a much smaller piece of the pie. And doctors do their own negotiations.

In the beginning, I had no particular geographic aspirations. I even considered working in Quebec because I speak French (acquired, with Rosetta Stone, last year). Later I realized that the French spelling system with its archaic silent letters would threaten sanity maintenance in a medical environment.

Alberta, Manitoba, and Ontario slipped out of consideration, one by one, for different reasons.
So over the course of the last two months, my recruiter has helped narrow my focus from all of Canada to British Columbia, and I have entered the weird world of international licensure. Each province has its own license authority, just as every state in the Union does, but they have a degree of reciprocity.
Why Canada? Not chasing rainbows. I want to work in the Canadian system, which American doctors love to revile without understanding it. I don’t understand it either; I want to experience it first hand, and write about it. In all fairness, I’ve worked the American system for 33 years and I don’t understand it.

And I have all the rainbows I want, anywhere I go. I came over the crest of a hill, and the north end of the rainbow, always retreating at a fixed distance, shone against the brown and green of the Iowa fields germinating corn in the spring. No pot of gold, no leprechauns, just gleaming yellow, and a moment later, for a thrilling second, the south end of the rainbow popped up out of a gulley.

Then, WHAM, a hen pheasant died on my windshield.

Short lines of communication, unusual prescriptions, and vitamin B12 deficiency

May 6, 2015

First day on the job in Grundy Center

May 6, 2015