Folic acid levels and unicorn sightings


My schedule was a basic mistake

The day off I just didn’t take

But abnormals times three?

It just couldn’t be

What kind of sense does that make?

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, traveled 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. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

 

I had a speaking engagement in Sioux City, when it got rescheduled to January I forgot to change my calendar. Thus I came in at 8:00AM to an empty schedule.  It didn’t stay empty long.

Most of my patients had respiratory problems, and most had coughs with runny noses and a tobacco problem. I enjoyed making the children smile with my yoyo tricks, but finding a toddler with not one but two infected ears made my morning.

Despite a leisurely start, morning patients didn’t finish till after the noon hour.

The cafeteria here does a good job. Reasonable prices, reasonably sized portions, and very decent cooking put it in the top 10% of hospital food services.

I don’t know that I helped the last patient of the afternoon, but as I wrapped up, I asked about her work. Though she gave me permission to write more, I will say I learned about secondary distance learning in Iowa, and may have found Bethany some work. In the long run, I suspect the networking will bring more value to our interaction than the medical care.

I sat down to my lab results queue. I found a case of a vaccine-preventable illness, and we’ll soon have an epidemic here, but the notification came in after the Health Department had closed for the day.  I’ll end up taking medication for a few days because of the exposure.  It goes with the territory, but as a self-employed physician, turning it into Worker’s Compensation makes no sense.

The next lab number just about knocked my socks off, a low folic acid level. Folic acid and Vitamin B12 work together to repair DNA, keep the marrow producing blood, and the nervous system from deteriorating.  They work together; an excess of one can hide a deficiency of the other; thus you can’t buy a folic acid pill more than 400 micrograms without a prescription.  But 15 years ago the FDA mandated folic acid supplementation in our flour supply.  The deficiency of that vitamin, never common to start with, just about evaporated.  Up to now I’ve not seen more than a half-dozen cases.

So finding one really put the music into the end of the day. I called the patient, discussed the problem, fiddled with the computer, sent the prescription, and opened the next set of lab results.

My jaw dropped. Could it be?  Two folic acid deficiencies in a row?  And there it was.  Lower limit of normal 7.1.  Patient’s level 3.9.  Yep.  What a rush!

Another enthusiastic call to a patient, another prescription sent at the speed of light to the pharmacy. And on to another lab result.

Wait a minute.

Three folic acid deficiencies in a row defy credibility.

If you see a unicorn, you get bragging rights, and if you see two in an afternoon, you get big bragging rights. But if you see three, you need to get your eyes checked.  Tomorrow I’ll have a talk with the lab.

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