Archive for July, 2016

Sports physicals and good horses

July 30, 2016

Out here they have nothing to hide

They think it’s important to ride

The unified force

Comes down to a horse

They’re cowboys and cowgirls, bona fide.

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 I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

Thursday the construction noise had become intolerable. I put on my shooting muffs, and stepped out the side door.  The worker operated an electric jackhammer, not a drill, detaching a concrete lip from the foundation.  I waited till he had hacked off a chunk, stopped his machine, and repositioned.

“Excuse me,” I said, “Um, any idea how much longer you’re going to be?”

“Almost done, probably by lunch,” he said.

“Do you have hearing protection?”

“Yeah, “he said, “In the truck.”

“Take it from me,” I said, “If you want to be able to hear the voice of your grandchildren, protect your ears.”

I had a productive day, between outpatient and inpatient I attended 14 people.

Sports physicals, required by school districts, don’t save lives and don’t prevent injuries. On average, less than once every two years I detect a problem during a pre-participation exam that I can do something about.  Still, the visit goes quickly, and I get to educate the kids.  As the athlete sits on the exam table I ask what sports.

Here in western Nebraska a lot of the students start their list with rodeo. Ranching and wheat dominate the agricultural sector.  People rely on horses for work and for play.  Ranch work goes much easier with a good horse and good roping skills.  People favor quarter horses for their intelligence and speed.  So when the kid says rodeo, I ask, “Do you have a good horse?”

Sometimes the face lights up and the grin follows, and I infer, that, indeed the horse is a quality animal. And sometimes the answer comes back, “Pretty good.”

Patient flow slowed to a negligible trickle on Friday; I attended three times more people in the hospital than in the clinic, where I only saw one.

I greatly enjoyed that patient, who gave me permission to write that I diagnosed piriformis syndrome (see my post from 2010), one of my favorite problems because I can fix it before the person leaves.

The insurance credentialing process has cleared me for 4 insurances but not for the majority. I do not understand why, because I had full credentials when I worked here in January.

So I had a slow week, and I would have preferred more patients. All in all, I saw entirely too much drama and irony in for form of patients paying the ultimate piper for their dance with tobacco.

 

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A single digit error explains low patient flow

July 27, 2016

I said to the front office clerk

I hope I’m not being a jerk

Someone who works in hive

Wrote  seven, not five.

Now will you please just send me more work?

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 I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

After two months of no patient care I returned to work three days ago. Patient flow crept in the single digits daily.

Still I had bloggable moments.

We dealt with a cardiac arrest the first day. Doing CPR constitutes a valid workout, and people fatigue so quickly that the guidelines call for a change of personnel every 2 minutes.  My turn came, and the hospital CEO followed me.

For different people with different problems that day I advised drastic alcohol reduction, complete tobacco elimination, good hydration, sleep prioritization, regular exercise, and a return to counseling. I pointed out that marijuana aggravates anxiety, deepens depression, brings on paranoia, and sabotages life goals.

Yesterday we watched through my office window as the crane lowered a new installation, really a prefabricated building with very expensive equipment, into place. The machine, worth dozens of millions of dollars, came down slowly, guided by men in hard hats with ropes.  I recalled my days in construction, when I swept the concrete footing furiously just before the crane lowered the form.  I looked at the odd clods of dirt on the footing and shook my head.  The stucco wall now sits three feet outside my office window, completely obstructing the view, and reflecting the heat from the sun.  I’ve quipped it’s a monochrome mural by a noted abstract artist titled Beige Wall, and offered to forge a Salvador Dali signature on it.

I performed my version of a complete neurologic exam on 4 different patients yesterday; all completely normal. I deal with a lot of patients with headaches, migraines and others.

But I also took care of a very sick patient. At the end of the day, I ordered a lot of lab work, all of which got sent to a reference lab an hour away.  I left my phone number with the techs, telling them that they could text me results without violating HIPAA as long as they didn’t attach a patient name.  And I could do so safely because I only had one patient hospitalized.

Today the low patient flow continued. The new installation required lots of drilling through my office wall.  I fled the intolerable noise to chat with a colleague.  But I also passed a front office staffer at a critical time.  She asked me my UPIN.

Various entities have assigned me various unique identifying numbers, starting with my 9 digit Social Security number. The longest one, with 14 digits, comes from Canada. I gave her the 10 digit number, flippantly, ending with 365.  She frowned.  The one she had on file ended with 367.

That one digit error resulted in no insurance credentialing for 5 companies. The clinic administration worked hard much of the afternoon to try to set things right.

While the drilling in the wall continued.

I thought about the Bob Dylan song, Lily, Rosemary and the Jack of Hearts.

An Abnormal MRI, too close to home

July 13, 2016

We’re doing the best that we can

To follow an abnormal scan

The rumor was tumor

But the answer was no cancer

And the treatment’s a flash in the pan.

 

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 I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. All our plans have been put on hold pending resolution of my wife’s brain tumor.  Any identifiable patient information has been included with permission. 

Three weeks ago on Tuesday my wife, Bethany, awakened with severe vertigo. She couldn’t get out of bed without vomiting.  Over-the-counter meclizine helped but little.  I posted the case on a physician’s chat site the next day, and got the recommendation for the Transderm Scop patch (she had one left over from a recent trip).  It helped but the problem persisted.

I don’t like to be my family’s doctor, so that Friday morning we went to the Clinic Formerly Known As Mine. Bethany’s doctor found horizontal nystagmus (a twitching gaze), when looking to the right, and ordered an MRI with contrast.

Chaos dominates Friday afternoons, thus Friday’s MRI happened without contrast.

I have the training and education to imagine a large collection of really bad things, and by now I’ve learned that the awful moments in life come to us unanticipated. So I went through my catastrophic catalog and felt better for having done so.  My phone went off while I was gardening.

In general, you don’t want your doctor to have bad news, especially not on Friday afternoon.

The MRI showed a 2.2 centimeter something behind the left eye. The original report mentioned possible glioma with the strong recommendation for a contrast study.  The thing’s location didn’t account for the dizziness.

With advances in imaging, we have had to come up with a term that means an abnormal finding found by coincidence; we call it an incidentaloma.

I called my locum tenens recruiter to say I had put all plans on hold; she relayed the information to those facilities expecting me in Nebraska and Alaska. Bethany phoned our daughter to say she wouldn’t be coming to help with the new grandson.

That night I read Bethany the Wikpedia article on glioma: 1/3 benign, 2/3 cancer.

Bethany’s cousin’s first wife died three weeks after getting her glioma diagnosed; she only had time to pick out her husband’s next wife, and say a loving goodbye to her family. In the ‘80’s I had a patient with a glioma who lived for less than 100 days after diagnosis.

We didn’t talk about those things.

Bethany took the information in stride, with understated courage. I focused on the moment with the joy of uncertainty that gives hope.  I embraced not knowing and did my best to focus on the moment: stripping the last tart cherry tree of its fruit, bringing in the first green chiles from the garden. I clung to things precious for their normality.

We suffered through the next four days, our plans shredded, as Bethany’s dizziness faded and her balance improved.

With her vertigo improved and her calm unruffled, Bethany went in for the contrast MRI the Tuesday morning before July 4. In the afternoon our fax brought the new diagnosis of meningioma, a well-behaved tumor with little if any malignant potential.

Relief of a magnitude that brings tears defies description.

I relied on my status as a physician and on friendship to get us an appointment with a neurosurgeon the next morning.

He explained the choices: leave it alone, open surgery, or radiation. He said if it were his tumor, he’d prefer the radiation.  He also showed us the MRI image, with a bright cylinder an inch long and half-inch wide growing up from the floor of the skull just behind the left eye.

He doesn’t do that procedure, but his partner does. And that partner wouldn’t be back in the office till Tuesday the following week.

Basking in the light of a better diagnosis while marinating in the darkness of an upcoming brain procedure, we went about our business. We had ice cream with our neighbors, and friends over for dinner on Friday.

Yesterday we met with the neurosurgeon, who explained stereotactic radiosurgery. And today we met with the radiation oncologist.

The actual treatment consists of focusing a radiation beam on the tumor, zapping the same way sunlight, focused with a lens, burns one point.

The next step, the 3D MRI, remains unscheduled.