Archive for June, 2016

Colleagues, vitamin D, and statin myopathy

June 20, 2016

There once was a doc from Manhattan

One day we just fell to chattin’

I asked, “What would it take

Besides a muscular ache

To get someone off of a statin?”

 

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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter found me working in western Nebraska and, later, in coastal Alaska.  After the birth of our first grandchild, I have returned to Nebraska. Any identifiable patient information has been included with permission.

 

Merkin’s Law states that any patient given a high enough dose of a statin for a long enough time will eventually hurt so badly exercise becomes impossible.

We call the drugs statins now because the generic names all end with those two syllables, but when they first came out we called them HMG coA reductase inhibitors. We used those drugs for years to lower cholesterol, in the hopes of decreasing risk of heart attack and stroke.

More than 20 years ago, though, a cynical doctor at the back of a lecture hall questioned the utility of that class of drugs if we got no net benefit in all-cause mortality. It seems, he said, that for every life saved from heart attack or stroke, one was lost to homicide, suicide, car accidents or respiratory infections.  The crowd laughed at the litany of diseases.  A year later, at the same Continuing Medical Education event, we chuckled when the same scene played, and a year after that, nobody laughed.  Aggressive drug company marketing fueled the cholesterol hysteria but I never developed a passion for treating cholesterol numbers.

My wife, after 3 years of statin therapy, over the course of 5 days developed such severe aches that her Tae Kwon Do class missed her black belt till she quit the med and recovered. Such circumstances did not endear that bunch of drugs to my heart.

Still, in context, I have the obligation to give my patients standard of care. I tell them about diet and exercise almost to the point of nagging, then I start the statin, and I warn them about side effects.

In the last two years, we have gotten convincing evidence that high-dose statins, regardless of cholesterol numbers, improve the outlook for those at high risk of heart attack and stroke.

Still if a statin patient hurts for no good reason, I tell them to stop the med, but I also test the blood for creatine phosphokinase (abbreviated to CPK or CK).

I outlined my personal algorithm to my colleague, and described my strategy of stop and rechallenge, and, if need be, use of coenzyme Q10.

He told me, gently, that coQ10 does no good, but switching to a lipid soluble statin does.

I found the discussion so constructive I went online, and found, to my chagrin, that he was right, and my past experience with coQ10 relied on the placebo effect.

I stuck my head in his office, and told him he was right. But I also told him I learned to check the thyroid and the vitamin D in those cases.  He looked at me with the same amazement I felt when I’d read about lipid-soluble statins.

We both emerged from the experience better doctors.

Transferring a complicated patient 3 hours away

June 6, 2016

I handled the case presentation

With the addition of great complication

Planned down to the comma

This tale of drama

Ran a full minute’s narration.

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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter found me working in western Nebraska and, later, in coastal Alaska.  After the birth of our first grandchild, I have returned to Nebraska. Any identifiable patient information has been included with permission.

On Friday a patient and I walked down the hallway. I said, “I write a blog.  Now I won’t write your gender, age, race or diagnosis, but I’d like to write that I took care of a very complicated, sick patient requiring lots of lab and x-ray and referral to a higher level of care than we can give you here.”

“Yeah, OK,” the patient said, and looked sideways at me.

I called the referral hospital, 3 hours away, and presented the case to the ER physician.

I do case presentations the way I used to do radio commercials in the early 70’s, during my college radio years at WYBC. If I can’t say it in less than 60 seconds, I need to reorganize.  This subgenre of the short story, when done well, presents human drama condensed down to the density of gold.  The very fact of doctor talking to doctor about a patient means that something important happened.  In a sense, it’s short play to a small audience.

I presented the story according to the conventional order: age, gender, race, presenting complaint, history of presenting illness, past medical history, social history, physical exam, lab, x-ray, EKG, and my working diagnosis, followed by the request, “Will you accept the transfer?”

“Yes,” the other doc said, “Of course. This is a very sick patient, but, I don’t quite understand, are you in the ER?”

No, I replied, I’m a locums. They send me the walk-ins.  Essentially, I’m doing Urgent Care, with benefits.

“You mean you did all THAT in Urgent Care?” she asked, flabbergasted.

I cared for 8 patients that day, the youngest 15, the oldest 95; 2 inpatients, 6 outpatients. I only wrote 3 new prescriptions but I stopped two others.

Though I used to look at a clinic day of 32 patients as nerve-wracking light, and 36 per day as perfect, I felt good when I left at 5:30. Learning a new EMR system takes weeks.

And towards the end of the day my ability to send prescriptions electronically directly to pharmacies suddenly stopped. While I saw the last patient, of course more complicated than anticipated, a team of 4 figured out that restoring that ability couldn’t happen, and set up my machinery to print prescriptions to be faxed.

But Bethany and I left the hospital behind, and drove to Denver, arriving after sunset, for a family gathering.

 

An afternoon with 3 patients

June 2, 2016

This afternoon, I was happy to see

Patients, but really just three

I couldn’t send the prescription

Without a description

Of where the button happened to 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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter found me working in western Nebraska and, later, in coastal Alaska.  After the birth of our first grandchild, I have returned to Nebraska. Any identifiable patient information has been included with permission.

No work for me on this last Monday because of the holiday; I spent Tuesday getting trained for the new EMR. The Basic Life Support (BLS) class took up most of Wednesday, and I left without seeing a single patient.

This morning I looked in on two hospitalized patients that I’ll care for on Friday.

Then I listened to jackhammers outside my office window for the rest of the morning while I did more BLS instruction on line. After all, hospitals only finish up their construction when they die.

My afternoon included 3 patients, scheduled at the rate of one per hour to allow me to figure out the new system. Two came from my generation, one from my parents’ generation.  The first I treated by taking away a medication.  The second, with a very complicated history and a long med list, I treated with gravity.  The EMR guru, sent by the vendor to help the transition, and living away from home for months, gently and patiently talked me through the documentation.  Then, after hours, he needed to leave for family business.

I had to prescribe a medication for the last patient, something I’d not done so far. My nurse, a stranger my end of the EMR, couldn’t help me with a very confusing task.  At that point, late in the afternoon, all the other providers had gone home.  One other remaining nurse stood over my shoulder, and told me what to do.

She had me click on an ellipsis, and then clicked her tongue and said, “Well, I’ve never seen that before.”  Fifteen minutes later, we resorted to calling the prescription in.

It reminded me of the time when the airline scanner wouldn’t take my boarding pass and my name ended up hand-written on the passenger manifest.

At the end of the day, Bethany picked me up. We stepped into an afternoon with a light breeze and a perfect temperature.  Atypical rains have left the sky clear blue and the countryside lush green.

I regretted keeping her waiting when all I’d done was take care of three patients.