Archive for February, 2016

And the CT scan shows…

February 23, 2016

The patient came in feeling sick

With sputum so bloody and thick

That I ordered CT

And pneumonia I did see

And new drugs I then had to pick

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. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

Last week I saw a patient with the chief complaint of hemoptysis (bloody sputum).

Blood from the nose might be normal, and frequently people confuse bloody post-nasal drip with blood from the lungs. In this case last Thursday I viewed with alarm the large amount of blood in the paper towel the person carried.  Despite a normal chest x-ray from a few days before, I ordered another.

A large part of my job consists of thinking of the worst thing possible; in this case, a blood clot in the lung. I also had to consider cancer, pneumonia, and tuberculosis.

The repeat chest radiograph came back as no change from the first: nothing worth writing about and certainly nothing to explain the hemoptysis. I thought things through.  Back in Iowa I would call the pulmonologist and ask whether or not he wanted a CT before the consult.  Here I had to consider the risk of flying to Anchorage.

I hesitated about the CT for a lot of reasons. As a profession we use too much technology, too much radiation, and not enough thought.  But the more I thought, the more I knew I had to make sure the patient didn’t have a blood clot in the lung.

Despite a normal plain x-ray, the chest CT showed a dense pneumonia. In short order, I consulted an on-line data base and several docs who work here and know which antibiotics will likely succeed.  The first antibiotic, obviously, hadn’t worked, and I eliminated it from the list of options.  I ordered a series of 5 daily injections, started testing for TB, and added in doxycycline, an antibiotic that dates back to the 1950’s, but, strangely, has kept good activity.

I found it hard to recognize the patient at the first appointment of the day, feeling and looking much better, pain free, and breathing easily. I asked for, and received, permission to write about the case, and the intense personal satisfaction I get from seeing a patient improve.

Tuberculosis remains a problem in this area, despite very good drugs to treat it.  On morning rounds before clinic I received the benefit of my colleagues extensive experience with a problem rarely encountered back home.

But then I presented the group with information about acamprosate (trade name, Campral), a medication to cut the cravings for alcohol. As with any treatment for any addictive disorder, it has limited success.  One can treat the physical side but trying to address the enormous complications of dysfunctional sociology can be problematic.  I felt grateful to be able to add to the group’s knowledge, rather than just taking away.

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Power outages and head lamps.

February 18, 2016

 Sometimes, when down falls the snow,

Out the power will go

But what I use instead

Is the light on my head

Which in my pocket I stow.

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. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

This winter, till now, has brought little snow to the area. Temperatures have consistently topped those at home in Iowa.

But today I trudged through fat, wet flakes the 250 yards to the hospital. Yesterday’s rounds lasted close to an hour, reviewing the significant cases that happened over the long weekend.  Today the presenting doc announced the expected death of an elder, and all action stopped for a moment.  The person’s passing will leave a void in everyone’s life.

Patient flow slowed to a trickle with enough snow to ruin driving but not nearly enough to make roads passable to snow machines.

At 10:00AM the lights flickered and went out. The laptops, running on batteries, glowed in the dark.  Then the emergency generator kicked in, and the fluorescent fixtures lit up again.  Business went on as usual.

With heavy, wet snow straining the electric wires, power went off and on the rest of the day. We kept working.

One patient gave a long, complicated, difficult to follow history, and if I’d had to hurry I would have gotten annoyed. But I didn’t, so I listened, and, after a while, I took notes.  The power flickered again, and I ordered some tests, the results of which showed serious pathology, bad enough I referred the patient to the ER and wondered whether or not the Medevac plane could fly in such snowy weather.

I took away a lesson I already knew: people get sick whether or not they can tell their story well.

A patient whom I’ve followed for more than a week came in after lunch. I asked one of the younger docs, with more surgical training, for help.  In the middle of the minor procedure, during the stitching, the lights went out and stayed out.

I carry a head lamp in the pocket of my white coat. When I first started private practice, LEDs had yet to revolutionize the flashlight industry, and head lamps stayed anchored to the wall.  A medical grade head lamp cost upwards of $200.  The one I have in my pocket cost $30 at Cabela’s, feels cheap to the touch, and provides better illumination than anything available in 1990.  I use it to examine mouths and other places where the sun doesn’t shine, to help during minor surgery, and to remove ear wax.  Today it helped finish the surgery.  Just as I cut the last suture, the lights came back on.

Then not much happened for the rest of the afternoon. I left outpatients early, and Bethany and I braved the roads to drive to the library.  I borrowed a couple of books.  If the power goes out, I’ll stay entertained.

Till my headlamp batteries go out.

Botulism, Napoleon, and a miracle

February 17, 2016

Towards death you might go to the brink

From eating the foods they call stink

Fermenting such fare

In glass with no air

And such poisoned eyes cannot blink

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. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

We discuss significant cases in the medical staff offices every working morning; the collegiality makes us all better doctors.

We started out with a spirited discussion of Native foods and botulism.

A lot of Alaska Natives prefer fermenting foods to cooking them. The non-Natives refer to those foods as what they are, preceded by stink.  Thus fermented salmon roe are stink eggs, fermented salmon heads are stink heads, the choice parts of seals are stink flipper.  Usually fermentation lasts six weeks, and traditionally takes place in a hole in the ground lined with grass and covered over with dirt.

Bacteriologically, fully rotten foods carry much less danger than those partly decayed; bacterial toxins break down with time and the germs themselves die off. Problems arise when fermentation takes place without oxygen, permitting the formation of botulinum toxin, giving rise to botulism.  Thus the hole in the ground produces less risky delicacies than Tupperware, Mason jars, or Ziploc bags.

I learned today to ask about the 4 D’s: Dry mouth, Double vision, Dysgeusia (trouble swallowing) and Dyspnea (shortness of breath), in the context of vomiting or other gut disturbance after eating native foods, especially those prepared in modern vessels.

Few Gussicks (the Native word for non-Natives) realize that Americans eat a lot of fermented foods. Most everyone, for example, knows about stink cabbage (sauerkraut), but few think about stink milk (sour cream, buttermilk, yogurt, and cheese), and stink juice (wine, cider, beer).  The English love their hung pheasants.  And traditionally eggnog was allowed to sit at room temperature for 6 weeks.

Napoleon could wage his wars because a Frenchman patented a process of fermenting ground meat with lactobacillus to kill the pathogens, and in the process made botulism-free salami and other sausages.

And later in the day, I twice gave out my never-fail recipe for constipation, the prune water protocol. Put a prune in a glass of water, I said, leave it by the side of the sink, when you go to bed drink the water, eat the prune, and brush your teeth.  Repeat morning and evening.

Rounds ended with a discussion of a medical miracle. I cannot give details about a death sentence and a reprieve, but I can talk about the ripples of hope that spread through the family, the village and the medical community.

Misnomers, eponyms, and radio traffic

February 12, 2016

We started out doing rounds

Exploring our intellectual bounds

It’s not a misnomer

To call a vomer a vomer,

No matter how silly it sounds.

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. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

Yesterday before 10:00 AM I had to research two diseases I’d never heard of before, and I didn’t attend a patient with either.

Medicine uses its own language. Some nouns, like vomer (the midline bone in the nose) have no other synonym.  Ideally one could discern the nature of a disease by its name; viral hepatitis, for example, means liver inflammation caused by a virus.  But if we call a malady by someone’s name, such as Parkinson’s disease or Lou Gehrig’s disease, we say that we use an eponym.  And we call it a misnomer if the disease isn’t what we call it, for example, a pyogenic granuloma is neither pyogenic nor a granuloma.

Another provider held up an x-ray report and pointed to a term, asking if I’d ever heard of it. I chuckled and asserted that surely the transcriptionist meant either fracture or infarction instead of what appeared in black and white, infraction.  So I looked up the eponym, only to find that the transcriptionist had typed correctly.

The other term, including an Alaskan place name, got thrown around during rounds. I had heard of the body of water, but not the syndrome.

The medical staff gets together every morning, much as we did in Barrow and each meeting makes me a better doctor. We talk about admissions, births, deaths, and interesting cases.

For the second time this week, we threw the term Wernicke-Korsakoff around without making that diagnosis.

When we talk about what might be wrong with a person, we use the term “differential diagnosis,” meaning the things that could give rise to a particular clinical picture. In conversation, we shorten it to “differential.”  In the process of dialogue, we draw on each other’s experiences and knowledge at the same time we go through our reasoning process.

After rounds I nipped out to the airport to pick up Bethany, then I came back to find that I had drawn the position of second call: help out the first call doc if overwhelmed, and take care of radio traffic.

The term radio traffic qualifies as a misnomer because we use telephones where previously radios had done the job. Dozens of villages look to the town as their hub for business, health, and air travel. Every village has a clinic staffed by a Community Health Aid or a midlevel practitioner. Each permanent doc serves as consultant for more than one village, but the second call physician converses with the clinic when the assigned doctor goes on vacation.  And right now the hospital finds itself short-handed.

I sat in the medical staff office. I cleared up documentation and read through the scores of emails that had arrived before I did.  I looked at the corporate website, and checked weather reports.  I read through some informative threads on Sermo.com, a doctors-only website.  At noon I went to a Continuing Medical Education lecture on diabetes and the new class of drugs, incretin analogs.

At one I had a few phone calls, and I phoned around to a dozen clinics.

And I drew on my experience with game theory to make decisions based on incomplete and imperfect information.

I did a necessary job, but I prefer face-to-face human contact.

 

 

Back in Alaska

February 8, 2016

On a flight I was lucky to get

I left Omaha on a jet

And then I flew far

To learn a new EMR

America’s most sensible yet

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. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

Leaving Omaha last week on Alaska Airlines included more difficulties than anticipated, mostly at the gate.  The bar code scanner flashed red three times and made an ominous noise with 20 minutes to take off.  At 16 minutes to take off the gate agent phoned for help.  Four minutes later the third, Millennial gate agent, despite obvious computer expertise, said, “I’ve been working here two and a half years and I’ve never seen this error message before.”  Four minutes before the doors closed a couple caught the plane because my computer glitch prevented an early departure.  I told the fourth gate agent I had a credit card, I knew how to use it, and sick natives awaited me where cars cannot go.  With a minute to spare I got on the plane; the airline staff resorted to hand writing my name on the manifest.  I didn’t say anything about what happens in medicine when we lose the paper option and can’t free text.

Alaska is a very big place, with roads going to only a few population centers.  A nice overnight motel in Anchorage brought little sleep.

The airport I came into has no jet way or luggage carousel, but unloading baggage involved little chaos.

The nice lady from Medical Staff who picked me up started my orientation on the drive from the airport, explaining the road system in 3 minutes.  You can’t get lost, she said, just keep walking and you’ll get there.

Few Americans can name any of the 7 states that border Iowa, but most people here can, and a surprising number have been through Sioux City.

I went through a compressed, simplified orientation.  Maybe because it’s simple and not geared towards billing, and maybe because I’ve learned 8 new ones in the last 14 months, but the electronic medical record (EMR) system didn’t need much introduction.

With no internet connection or TV at my apartment, in desperation for something to do I turned to reading the orientation materials.

Then I had to brush up on botulism, paralytic shellfish poisoning, amnestic shellfish (domoic acid) intoxication, scombroid fish poisoning, glanders, and  melioidosis.