Archive for January, 2016

Discharge summaries

January 30, 2016

I can’t believe how the time flies

We’ve already said our goodbyes

I got into the groove

And now we must move

And drive east into the sunrise.

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 (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. I just finished two months in western Nebraska. Any patient information has been included with permission.

 

Friday dawned clear, cool and bright. We got up early for the finishing touches on moving out.

The townhome the agency rented for us surpassed all expectations with cathedral ceilings, hardwood floors, good construction, comfortable mattress, serviceable equipment, and a killer view. I moved stuff out the front door to the walk by the car while Bethany packed. We left notes for the landlord and the neighbor.

We stopped at the hospital. I had forgotten one bit of documentation when I discharged a hospital patient on Wednesday.

The discharge summary recounts what happened during a patient’s hospital stay. When I finished residency, I would go through the whole chart from the first day, giving lab values, reading x-ray and consultation reports, and recounting vital signs in detail.  Later I learned to dictate my hospital notes so I could do the discharge summary from them.  Later still, I changed my model to answer the question: What does the next doctor need to know?

In the 80’s I deliberately waited two weeks after discharge to do the summary, because vitamin B12 levels and thyroid functions could take that long to come back. Paper charts in those days dominated the doctors’ lounge; you couldn’t get your coffee without being reminded you needed to clean up your paperwork.  And you could see everybody else’s backlogs.  I’d clean things out once or twice a month.

By the last half of the first decade of this century I had started to dictate the discharge summary at time of discharge, so I could have a copy when the patient came to see me a week later.

Some attending physicians pay residents, Physician Assistants, or Nurse Practitioners to do the discharge summaries.

Now the hospital’s Electronic Medical Record puts in all the lab values, discharge medications, and x-ray reports. I summarized 11 days of hospital care with 4 sentences typed into the middle of the document under the heading Hospital Course.  The next doc will have to scan through pages of note bloat to get to the part that he or she will need to know.

With all the documentation done, we drove the loaded car through town to a chain diner.

Over a luxury breakfast out, we talked about how fast the time had gone. It hardly seems two months since we arrived.

I found 4 new cases of Parkinson’s disease, 2 new cases of hypothyroidism, and 1 case of vitamin B12 deficiency. I referred people with, variously, a hernia, a hot gallbladder, and a bad appendix to the surgeon.

When major trauma cases came in I kept things moving in the outpatient clinic.

On the weekends when we didn’t go to Denver, visit a niece in Wyoming, or go shopping at Cabela’s, I made rounds in the hospital.

We went to the movies three times; the tickets cost less than half of what we usually pay.

We ate at every Chinese restaurant in town at least once. We saw eagles, deer, jackrabbits, migrating ducks and geese.

After breakfast, we started east down the highway, under clear blue skies with the wind at our back.

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Winding down in Nebraska

January 28, 2016

I started out making rounds

As my current assignment winds down

Right now it’s Nebraska

Next week, it’s Alaska

On Friday I’ll be homeward bound 

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 (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

At the end of Monday inpatient rounds I found one patient on my afternoon schedule, and when I finished I had seen 11. The age range falls heavily on the extremes: most patients either of preschool or Social Security age.  Despite the fact that the US has the lowest rate of smokers in the industrialized world, tobacco related illness accounted for more than half of those patients.

I discharged one of my two hospitalized patients. I try my best to be a good hospitalist, and I tried to call the attending physician at an office a half-hour away, instead I reached the nurse.  The patient would follow-up there for monitoring lab values.  I passed on a consultant’s recommendations.

Here, as everywhere, the geographic imperative impacts my approach to patient care.  Back home  I don’t even consider risk when asking a consultant to stop by a patient’s room, but here I have to think about the hazards of putting the patient on an ambulance for an hour, or going three hours for testing to a major medical center.

Sometimes the people who live here talk about “Radio Free Nebraska,” where the search function on the car radio may fail to find anything for the rest of the trip. Still, each village or town has its unique specialty; a tree nursery and sawmill here, a bridal boutique there.

Before I tell a patient to make a follow up appointment, I ask how far away they live, and I have to take time, winter highway danger, and the cost of travel into account. For anyone who lives outside of town, I say, “Don’t come if it’s snowing, call.”

In the afternoon on Tuesday I picked up another hospital patient. The Emergency doc had done the admission and put in the original orders.

At the end of the day I faced a room full of patients, some of whom had appointments and some of whom didn’t. As I went through each person’s history, the family’s background emerged, shards of tragedy, accident, desertion and betrayal against a backdrop of economic trends, population shifts and changing social expectations. People’s bodies can be impacted by germs, as well as laws of physics, or history.

I have limited ability in such cases to fix the basic problem. But I can only do four things: medicate, operate, manipulate, or educate.  Sometimes the human capacity to love leaves me thrilled, and sometimes people’s capacities for perfidy astounds.

Today, Wednesday, I discharged both of my hospital patients. I called the attending physicians.  I dealt with an EMR system that sometimes turns orders into vapor.  Getting a patient out of the hospital generates a flurry of activity, proof that all change generates chaos.

My first and last outpatients of the day required surgical consultation. I walked three steps across the hall, presented the case, and got things ready for both.

I had plenty of time to clear up my documentation and to clean my desk. The staff held a potluck in honor of my next-to-last day.

 

 

 

 

 

 

Shingling me out

January 24, 2016

It has to do with our skins

And it started with needles and pins

After six weeks of tingles,

I came down with the shingles

But it hasn’t cut down on my grins.

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 (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

This case concerns a 65 year old male with shingles.

I’ve seen two other patients with shingles here in western Nebraska so far. I started both on Valtrex during the first visit.  Easy diagnosis, any rash that follows the path of a skin nerve (dermatomal distribution) names the process.  Therapy of the immediate, acute phase of this problem is straightforward.

With this disease, I worry the most about post-herpetic neuralgia, which can happen after shingles. It happens mostly in the elderly, and sometimes they hurt till they die.  During my training, we had no good treatment.  Narcotics work for no more than a few weeks.  We didn’t know at the time that capsaicin cream and seizure medications work, and work well; although we had the tools available we didn’t know how and when to use them.  Generalists who tried to treat a patient with hopeless, severe pain would either burn out and retire or move, or send the patient to the neurologist, who would either burn out, retire, or move.  Now I only refer the patient out if I fail under my “3 strikes and I’m out” policy or if the patient requests.

If a patient, after shingles, shows up with pain where they had the rash, despite rash improvement, I will lightly stroke the area involved, and ask if it hurts. A positive finding, allodynia, pretty much cinches the diagnosis.  I like to start with capsaicin cream; available without a prescription, it depletes the structures of a particular part of the nervous system called the dorsal root ganglion of the chemical needed to transmit chronic pain signals.  If that doesn’t work,  I skip on to the anti-epilepsy drugs Depakote or gabapentin.

I can write publicly about this patient because I’m writing about me. Over the last six weeks I’ve had a tingling sensation, paresthesias, on the right side of the back of my neck.  Always worse under stress or time pressure, it came and went, and I ignored it.  I’d had something similar over the summer.  I consulted by phone with my doctor, who agreed that it could have been the prodrome, or warning signs, of shingles.  I took Valtrex and the rash never appeared.

This time, I decided to test the hypothesis, by ignoring the pins-and-needles that would crop up for no reason from time to time, last a minute or so, then disappear for no reason.

Last night, we were coming home from the movies when I noticed two sore spots on my neck, just the size of chickenpox. This morning, on rounds, I pulled my colleague into a room and showed him my rash.  He looked where I pointed at the front of my neck, followed  around to the back of my neck, confirmed my suspicion, and advised Valtrex.

Of course, a few milligrams of prevention is worth kilos of treatment, and the shingles vaccine, Zostavax, is a really good idea for anyone on Medicare. I plan to get mine when I visit the VA next week.

 

It’s harder to keep the patients alive after they’re dead

January 20, 2016

The question came up to me

About patients, who number three.

Should we try to restart

A non-beating heart?

Or perhaps just them be?

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 (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

Today I wrote Do Not Resuscitate orders for 3 hospital patients.

Television and movies thrive on the tension of cardiopulmonary resuscitation (CPR): doctors shout, orders fly through the air, the seconds tick while a life hangs in the balance, and in the end the dead come back to life. In Hollywood, CPR always works.

In real life, CPR patients rarely make it out of the hospital. The ones who have the best chance are the ones who didn’t have much wrong to start with: the young, the athletic.  Those with a tenuous hold on life, the ones most likely to have their hearts stop, do not do well.  Perhaps a third of those with cardiac arrest survive what the doctors call the code.  Most live long enough to generate six- or seven-figure medical bills, but die before they leave the hospital.  And lack of oxygen leaves many survivors with permanent brain damage.

New Zealand’s national policy, when I worked there in 2010, held that age greater than 75 constituted an absolute contraindication to CPR.

Now when I have an end-of-life conversation with a patient or a medical Power of Attorney (POA), I ask, “If your heart stops beating, do you want us to try to restart it?” always prepared for a long answer. Nobody gets to the end without a really great backstory; those who love the frail unambivalently need much less time than those with mixed emotions, and the human condition results in contradictory feelings.

A negative answer comes rolled in with long justification.

For a positive answer I have to explain what CPR and shocks do.

The act of pressing on the chest to keep the blood circulating breaks ribs in everyone over the age of 30, and almost everyone over the age of 20. Electric shocks hurt, and the shock of the defibrillator hurts worse than any shock the average American has ever felt.

Then I get to the question of the tube in the windpipe, which requires unconscious ness and eventually a ventilator.

Few of those born before WWII who retain all their faculties choose resuscitation after my discussion.

None of the patients during today’s discussions wanted CPR. Each conference took a long time.  But trying to rush such a talk is rude and disrespectful, and hurrying it can obscure patients’ real wishes.

So I gave my complete attention, easy when listening to wonderful tales, stuff I couldn’t make up.

 

A movie, an owl, and patient getting worse.

January 19, 2016

 

Last night we went out to a flick

It got prizes for being so slick

But a hoot from an owl

Who was out on the prowl

Warned of patients, who got desperately sick

 

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 (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

Last night Bethany and I went to the two-screen theater in town and saw The Revenant, an Academy Award winning movie.

On the way out of the theater, I got a call from the hospital; one of my inpatients requested a sleeping pill. Hospitals thwart the sleep that healing requires, and I gave the order over the phone

We talked about the film on the way back. It featured a lot of action, it got some bits of woodcraft and history right, and a lot wrong.  I enjoyed the Shawnee and Arikara dialogue.  We agreed that we could have done without so much gratuitous violence.  Bethany asked some medical questions, and we tried to figure out at what point the French traders stole Powaqa.

On the net, researching the real story of Hugh Glass that served as the basis for the film, I heard an owl hoot 4 times outside the north part of our townhouse. I glanced out the sliding doors to the deck, but saw nothing.

In my years with the Indian Health Service, I learned that most Native Americans regard owls as terrible omens, bringers of bad luck and death, and the sound chilled me. The film had brought memories of working in a tribal context, bringing that milieu back into my consciousness.

But I slept soundly, because call here means nothing. The doc covering the ER handles problems in the hospital as they arise.  Thus finding a “missed call” message from the hospital from 1:00AM brought alarm.  The voice mail asked me to call back immediately.

When I got to the hospital, I found that my patient, the one who had requested the sleeper, had just been transferred out. After the ironic decision to change after decades of bad health decisions, the dramatic payment to the piper came, and the patient’s fast glissade downhill started about the time I heard the owl.  His medical needs exceeded our capabilities.

And despite all the right decisions and all the right medications, just like Humpty Dumpty, some things can’t be repaired.

But the clinic patients started well and got better. One of the follow-up patients looked and felt dramatically improved on a scheduled dose reduction.  Two people had ear infections.  Nobody quit smiling when I wouldn’t give antibiotics for colds.  I had time to do some online research about testing for cystic fibrosis, and I caught a power nap over the lunch break.

The pace picked up in the afternoon. I got to speak Spanish, and I used the osteopathic part of my training to make a person well before departure.

Without the gloom of the first part of the morning, the rest of the day wouldn’t have gone so sweetly. Contrast is the essence of meaning.

 

Coming back from New Year’s Day

January 16, 2016

When it comes to the question of pot

And all the supporters it’s got

It just doesn’t makes sense

Because now evidence

Shows that good for depression it’s not

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 (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

I’ve listened to Audio Digest Family practice for 37 years. In the beginning, my aging Karmann Ghia had no place for the tape cassettes. I wore out a tape machine about every 7 years.  Last century I upgraded my vehicles and started listening over the car stereo system.  Now that cars don’t have tape cassette decks, I get the programs on CD.

Yesterday we drove east through the flat Colorado wheat country after spending the holiday with family and friends, listening to an educational CD about medical marijuana on the car stereo.

The lecturer talked slowly, leading me to wonder about his firsthand experience with the drug.

Good evidence supports the use of medical marijuana for AIDS wasting syndrome (hardly ever seen anymore) and the nausea from cancer chemotherapy. After that the quality of research falls off with small studies and poor design.

I know a doc from Colorado who supports use of medical marijuana, and points out that the sativa variety has more THC, the stuff that gets people high, whereas indica plants have more cannabidiol. He asserts that the cannabidiol has the medicinal properties.

Even the pro-pot lecturer said that all the commercial products come from hybrids.

I put marijuana’s long tenure as an herbal remedy at the same level as Teddy Roosevelt’s touting the unique properties of champagne for dysentery and brandy for everything else. Alcohol turns out to be alcohol and while it may have a number of physiologic properties, it comes in last place as a pharmacologic agent because it doesn’t make anything better.

Marijuana does not relieve anxiety; quite the contrary, it brings paranoia. Nor does it relieve pain though it interferes with the ability to reason through questions about the 10-point pain scale.  It predictably drives down the level of testosterone for both genders which leads to terrible sexual dysfunction.  Eventually, it makes people depressed.  It might help some sleep, but they don’t rest.

Yet I would agree that the FDA needs to take it off Schedule 1 so that we can start doing decent research on it.   The plant makes hundreds of compounds that can stimulate receptors throughout our bodies, and its potential remains basically untapped.

I ask everyone past the age of puberty about use of tobacco, alcohol, marijuana, and other drugs. While most people at my current assignment avoid excesses, those who don’t account for a disproportionate share of the ones who need medical help.  If someone uses marijuana, I ask how much, and whether they’re using legal stuff from across the border or the illegal weed purchased locally.  I hope that the Colorado product has fewer adulterants, but it remains largely unregulated.

Today I attended a patient with chronic pain (and a number of other problems); two weeks ago we decided gradually decreasing the morphine dose would be a good first step towards returning functionality. You could see the improvement from across the room, and we talked about the increasing exercise tolerance.  I let the patient decide on the pace of treatment, and two weeks from now we will look for more progress after another dosage reduction.

As always, I heavily recommended exercise.