Archive for February, 2017

It’s not pernicious if the patient live

February 28, 2017

To test, I wouldn’t think twice

The abnormal I find ever so nice

And if that’s what they’ve got

I just treat with a shot

Still cheap at thirty times the price.

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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. 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, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

 

About twenty years ago I stopped a neurologist in the hospital parking lot for a “curbside consult,” a long-standing tradition. These brief interactions transmit a lot of information.  In the days before the Internet, I realized I needed to know more about vitamin B12 deficiency than I could get from books or journals.

In medical school they taught us not to check B12 levels on anyone under 40. The characteristic findings on the blood smear, they said, with enlarged red cells, anemia, and white cells with too many nuclei, would show before anything neurologic; thus we shouldn’t run the expensive test if the person had a normal blood count.

Time has a way of slaughtering such dogma. I found myself in the middle of a diagnostic series of B12 deficiencies, the most recent at that time a 36-year-old with the classic blood findings. I modified my age criteria and, sure enough, found a very low B12 level, helping to account for symptoms of what otherwise looked like depression with clumsiness.

Before I collared the neurologist, I’d sat down to talk with the hematologist. In the course of 5 minutes I realized he didn’t know much more about the topic than I did.  Approaching the neurologist turned out well.

He said that anything under the lower limit of normal (has gone back and forth between 199 and 287 and has now held steady at 211) clearly shows a problem. Any B12 level over 400 can’t take the blame for a problem.  But the gray zone between 211 and 400 demands judgment.  Anyone with symptoms at or past age 65, he told me, should be treated.  At 35 cents a dose, you can’t justify the expense of further testing.

Since I started this blog in 2010, the price of vitamin B12 has gone from $.35 to $9.00 per dose, justifying further testing in the borderline area. Now when I have suspicions, I check levels of methylmalonic acid and homocysteine, two toxic byproducts that build up in the blood in the absence of adequate vitamin B12 and/or folic acid.

Just about anything neurologic, whether subjective or objective, prompts me to investigate. If someone complains of fatigue, numbness, weakness, depression, erectile dysfunction or trouble concentrating, I go looking.  And the same if the blood smear shows enlarged red cells (an increased MCV or mean corpuscular volume), or even a broadened range of red cell sizes (RDW, or red cell distribution width).

Last week I found 4 new cases of vitamin B12 deficiency on one morning, making me ecstatic to the point of silly. The next day I got elevated homocysteine levels  back on two other patients with borderline B12 levels.

We used to call vitamin B12 deficiency pernicious anemia because the patient always died, and I grew to love the diagnosis because as a frontline doctor I could save the patient’s life for 2 cents a day. Now it costs 30 cents a day.  It still makes me happy.

 

Giving bad news: it’s part of my job

February 27, 2017

I don’t wait till the end of the day

When there’s nought but bad words to say

I think that it’s best

To give one more night’s rest

Then suggest that it’s time to pray.

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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. 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, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

Part of my job is to think of the worst things I can think of, and a couple of times a day I will tell a patient that what they really want to do is to walk away from the hospital shaking their head and muttering that I’m nothing but a darned alarmist. I run a lot of tests.  Mostly I look for things I can do something about.  Sometimes I run studies so as to hand the specialist a patient with a clear-cut diagnosis, or, at the very least, the first level of testing completed.  But sometimes I’m looking for bad stuff, mostly to reassure patients.  I’d rather be happy than right.

Rarely, the battery of lab and x-ray comes back normal. Most of the abnormalities, however, come as no surprise.  People know the dangers of drugs, tobacco, alcohol and promiscuity.

Every once in a while, I have to give bad news. And, after all the labs and CAT scans and MRIs I’ve ordered in the last few days, I’m going to have to give some Very Bad News tomorrow.

The report came in at the end of the day. I don’t like to give bad news on a Friday or of an evening, when we have nothing to do but wait.  And I don’t let the nurse give the bad news, that’s my job.  I prefer to give the worst news face to face, but once in a while, for the expeditious good of the patient, I have to do so by phone.  .

People have suspicions when I start the testing, and for the most part when I sit down with them they already know the problem. So I ask, “What do you think the (blood test, CAT scan, biopsy, MRI) showed?”  Almost always they’ll say they don’t know, and I change the subject for about 5 minutes, and ask again.  The third or fourth time they come up with the diagnosis, and I confirm it, and I tell them as much as I can about what to expect.

I emphasize uncertainty when I find it, but I don’t hold out false hope. And if bad news involves a child, I come prepared for verbal abuse when the parents blame the messenger.

It’s part of my job.

 

 

 

Great hospital food and a chili cook off

February 25, 2017

In some places, the chili has meat

In others watch out for the heat!

I might cause a scene

But I won’t use a bean

And the cocoa I might have to delete

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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. 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, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

I find money. Mostly I find small change, a nickel here and a dime there, on a handful of occasions I’ve found enough to actually buy something with.  Finding a dime when McDonald’s had 15 cent hamburgers meant a lot more than finding a quarter now.  For the most part I use credit cards for business transactions, reserving cash for small vendors, and before Clarinda I had gone out of my way to avoid carrying coins.

But the cafeteria here serves very good food. I carry change now because I can buy a great lunch with it.

Working locum tenens has given me an appreciation for the wide variety of hospital food. In Barrow they cooked with love and imagination, and if I had had a party I would have tried to get them to cater.  I ate for free there, but Bethany paid $10 per meal, reasonable for a place where airplanes bring groceries.

At another place in coastal Alaska they either overcooked or undercooked everything but the soup, and charged way too much. In a couple of places I didn’t get an employee discount.

And in one hospital the cafeteria consisted of nothing but a bank of noisy vending machines. Bethany packed my lunches during that assignment.

Last Thursday Human Resources sponsored a chili cook-off.

Chili in Texas means tomatoes, beans, and burger; chili in New Mexico always has chiles, sometimes has meat, occasionally has tomatoes, and never has beans. Like a number of other things in human experience, different people can use the same word and mean different things.

Employees paid nothing for the chili that the contestants brought in, but the dietitians made cinnamon rolls available for $1. The cafeteria even made a very decent house chili, and served it for free.

Of course I entered my mole (pronounced moe-lay; it relies on a balance between chocolate and tomato). Too spicy for the mild category and too mild for the spicy category, it didn’t win any prizes.  Or maybe because I used chunked turkey instead of beef, and didn’t put any beans in it at all, thus it probably didn’t look like chili as people in Iowa understand the word.  I may have to change my recipe.

 

Flu and less than fluent Mandarin

February 24, 2017

There was an old lady who contracted the flu

She went to the doctor who knew what to do.

He said, “What is best,

Are fluids and rest

And perhaps a drug that is new.”

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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. 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, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

The havoc that influenza wreaks each year impacts the entire medical system. Predictably, the epidemic starts in the north and works its way south, spending about 3 weeks in a population center.  If multiple strains circulate, each one follows the pattern.

The CDC follows the annual flu disease activity by watching the death rate; when it spikes to 150% of yearly average, we know that the influenza has arrived. It represents the peak demand on the medical infrastructure.

Some of those excess deaths come directly from the flu, but we also see spikes in the rate of mortality from heart attacks, strokes, and just about everything else. If a person has been clinging to life, hanging on by a thread, the influenza is the knife in the hand of the Grim Reaper that cuts that thread.

At 745 on Tuesday, I discovered I had 6 inpatients including three new ones who would need a complete history and physical. Still pretty green with the hospital computer system at that point, I wandered electronically till I popped up a patient list of 10 names.

The worst flu I ever saw came in 1993. I had responsibility for 45 nursing home patients in 3 different institutions at that time.  One morning I received a call at 930 saying that a patient of mine had, that morning, developed a dry cough, fever, and muscle aches.   I ordered a flu test and amantadine (a good flu drug for more than 30 years, but it had a lot of side effects and about 8 years ago it completely lost its effectiveness).  At 1000 the nurse called back to tell me the patient was dead.

I visited that nursing home for regular rounds a week after that. I could read the shock and loss on the faces of the staffers, the grave stones in their eyes.  The had lost, on average, a patient a day for the last week and a half.

Twenty-four years later I faced a hospital census in the middle of flu season.  I don’t wager, but if I did, I would have bet that most of those who had sickened to the point of needing hospitalization did so directly or indirectly from the influenza.

But I still had a clinic schedule. I got a lot of exercise between my clinic office and the inpatient nurses’ station. At the end of the day I left the hospital with sore ankles and a backlog of documentation.

Bethany and I and a med student (who has been staying in the hospital guest house) walked a mile and a quarter (2 km) to a Chinese buffet. But I strolled for the sake of conversation instead of racewalking. We had some really excellent food, and I got the chance to show how badly I speak Mandarin.

 

 

Tagalog, flu, and a staff meeting

February 14, 2017

The patients still suffer the flu,

And I know just what I can do

Though to prevent what they’ve got

We’ve a pretty good shot

But I’m hoping for some drugs that are new.

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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. 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, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

Most sick people want to get well, and even more don’t want to be around strangers. I’m filling in for a doc whose patients love her.   They won’t come in until they feel sick or worried enough, and I haven’t had time to build a reputation in the community.

I attended one patient every half-hour from 9:00 till 11:00. I ran 5 lab tests, and ordered one x-ray.  Half the patients got prescriptions, half of them got advice because pharmacologic management would have been a good deal more dangerous than helpful.  With the unseasonably warm weather, I advised two to get over the counter Flonase for allergies. Another patient got a simple 5-day prescription that may very well save a life.  One patient has me puzzled and awaiting labs.

I exhausted my very meager Tagalog vocabulary on one person (who gave me permission to write this), prompting my patient to ask me if I’d lived in the Philippines. I explained that the most educated immigrant minority in this country are the Philippino, with a disproportionate number of doctors, nurses, and pharmacists.  Of course I’ve had colleagues from that country.  And, inexplicably, on the North Slope of Alaska, the Tagalog speakers dominate the taxicab business..

Three patients smoked; for each one I held my forefingers 18 inches apart and said, “On a scale of 1 to 10, how ready are you to quit smoking?” No matter what number they came up with, I asked, “Why not 2?” but had to explain that the doctors had already told them the bad things about tobacco, and I wanted the patient to tell the doctor something good about it.  One patient shook her head and said, “You’re good.”  I had to admit that I’d gotten the technique from an educational CD.

We had our monthly med staff meeting from 12:30 to 2:00. They announced my successful vetting (in the trade, we call it credentialing).   We went over changes in the Emergency Medical System (EMS), and talked about criteria for blood transfusions.

The flu came up briefly; the annual epidemic started about 3 weeks ago. It’s weakening but it’s still going.

I had no patients on the schedule after 2:00, and I started reading the handbook that HR gave me. I had two patients after 430, finishing at 6:00 sharp.  I walked out with all my work done.

First day working in Clarinda

February 13, 2017

My plans sure had a great bump

With an executive order from Trump

Now I’ve got me a scribe,

Which is close to a bribe

And gave my orientation a jump.

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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. 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, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

A facility has a doc out temporarily for unplanned health reasons. They do not expect the planned replacement to recover from injuries sustained in an accident in time to help out.

The Executive Order freezing federal hiring used such vague wording that a VA facility couldn’t give me a start date. Thus, at the end of 2 weeks planned vacation, I started looking for work.  One of my favorite agencies found me a spot in southwest Iowa, hard by the Missouri border.

This placement represents a success of the concept of locum tenens, temporary doctor placement.

Yesterday the clinic manager gave us a tour of town. We learned that all the patient lifts in the country come from Lyle manufacturing.  The other big plant here makes ball bearings.  Glenn Miller grew up here, the town sports a museum in his honor and has well-attended band competitions every year.  Clarinda Academy, a last-chance facility for troubled youth, sits close to a minimum security prison and a mothballed state mental health hospital.

At orientation today I toured the hospital, got my ID badge, met dozens of friendly people whose names I promptly forgot, and got trained on the Electronic Medical Record, CPSI.

Perhaps I’ve learned so many (14 in 27 months) that they all look the same, but in less than an hour, it started to make sense.

The patients love the internist I’m filling in for, and don’t particularly want to see a stranger. After a 4 hour orientation and a 1 hour lunch, I saw 3 patients.

None of them smoked, none sought prescription drugs for recreational uses. All employed, all motivated to get better.   Each got at least one prescription, all got advice on lifestyle changes, mostly about the caloric content of beverages: at 140 calories each, one serving of milk, juice, soda, or beer per day comes to 14 pounds per year.

A hundred years ago a junior doctor working under a more experienced physician kept the medical records and in return received teaching. To this day, a medical student or resident rotating through a specialty service refers to the experience as a clerkship.

With legal and financial pressures pushing doctors’ notes longer and longer, many physicians have turned to scribes: people who make notes during the face-to-face visit. The doctor gets out on time, sees more patients, and pays more attention to the patient.  Today, I had my first taste of working with a scribe, and I liked it.

 

Knowing when to stay and when to go

February 4, 2017

You know what happened? A lot!

I missed that government spot

At least for right now

But time might allow

Me to get the position I sought.

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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. 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, and short jobs in western Iowa and Alaska, the fallout of certain Presidential Executive Orders has me cooling my heels at home. Any identifiable patient information has been included with permission.

At one time I asserted that if I woke up Monday morning with nothing planned I could have work by Wednesday. In fact I’ve found a 2 week lag time between decision and employment.

Last week I gave up on taking a government position in Alaska for the winter; too much uncertainty followed the Presidential hiring freeze. I talked to my agent (more accurate than the title Recruiter that she gives herself).

A lot happened in 48 hours. I found out at least 3 places where I worked and had a good time had recruited permanent docs and didn’t need my help.  My agent opened up a discussion with an installation south of here that will offer me both inpatient and outpatient work.  I talked to them, we hit it off, I said ‘yes’ to the job.  Shortly after that I got an Alaska job offer, but I’d already committed to Iowa.

I asked for and received a 4-day work week, probably close to 40 hours, and the chance to come home on the weekends. Bethany will come with me for most of the trip.

In the meantime I miss the strong cold of the northern clime. The temps here drop into the teens at night, but days have been sunny and while long underwear has become a routine part of my wardrobe I haven’t even thought about bringing my parka out.

The last couple winters I spent in Alaska, and somehow being away from home made the cold easier.

Last week I talked with an agency seeking a permanent placement in a spot 35 miles from here; MapQuest more accurately put the distance at 75 minutes, too far for me. I have thought about telling my agent the name of the facility to see if they want a locums, but I’m concerned about the ethics.

I started correspondence with a firm who wants to place me in a hospitalist job in New Mexico. The position looked reasonable, it would give me a chance to visit the places I knew and loved during my Indian Health Service days, as well as speak a lot of Spanish and maybe renew my Navajo language.

And, with all this going on, I seem to be making progress on my planned Canadian employment.

No matter where I go, I’ll have an adventure.