Archive for April, 2017

The thrills of cerumen and B12 deficiency

April 23, 2017

Real flu has cough, fever, and ache

And I know just the pill you can take

And then there’s the test,

It’s good but not best

But a decision it sure helps me 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. 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 had a good week in Clarinda.

Orientation on the new job went well; I found it well-organized and well-planned.

The facility not only assigned me a scribe but also a cracker-jack Electronic Medical Record superuser to train me on the 14th new EMR I’ve learned in the last 28 months.

Recognizing the problems of learning a new system, my patients have come no more often than every ½ hour.

Thursday morning went well; I had the immediate gratification of curing the first patient by removing ear wax and the second with osteopathic manipulation.   Close to noon I received lab results on tests ordered earlier in the week, including three vitamin B12 levels.  Two borderline numbers (between 211 and 400) require further testing, and one came in frankly low, less than half the lower limit of normal.  That bit of information made my day; I can save the patient’s life with a simple injection once a week for 12 weeks, then once a month.

Bethany met me for lunch in the hospital cafeteria: well-prepared, healthy food at insanely low prices. I told about how I found my morning not only gratifying but satisfying.

Influenza dominated the afternoon. We have the clinical experience to predict that the annual flu epidemic starts in the north and works its way south, with 90% of the cases in any one location occurring in the course of 3 weeks.  I enjoy taking care of influenza; we have a clear-cut, good but not perfect, lab test and two effective drugs.  The older the patient, the more likely my prescription will prevent death.  Most of my patients here are over the age of 70 with several in their 90s.

The problem with taking care of old people is that I don’t get enough time to talk to them. I could easily spend a morning or afternoon just listening to one patient.  A person can’t get to advanced age without acquiring a large stock of really great stories.

Thanks to a light patient load and a scribe, I finished at 6:00PM. I walked out of the hospital at sunset, ten minutes across dry winter grass and quiet back streets.  We decided to drive back to Sioux City and our own wonderful bed.  We packed the car in less than 20 minutes.  The sky darkened as we traversed two-lane county roads through the rolling hills and farm country. We detoured to Trader Joe’s in Omaha, but missed a turnoff, adding an hour to the trip.

 

 

 

I take call and end up a patient.

April 23, 2017

At the end, it wasn’t a stroke

It was gone when I awoke

The symptoms were brief

Avoiding much grief

And I got to tell a crude joke.

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.

 

Tuesday evening while on call, I got up to play Scrabble and I couldn’t make my right leg work. It didn’t feel heavy, numb or weak; it felt too light so that any effort to move it got exaggerated.   I sat down to do a neurologic exam on myself.  I found nothing other than my right leg ataxia.  I called Bethany from the next room, and told her the situation.  She helped me dress, and drove me to the ER.

The ARNP covering the ER did the same neuro exam I did, which wasn’t impressive until I demonstrated my gait.

She did all the right tests. The first EKG showed an old heart attack, which disappeared with proper lead placement.

She also found a heart murmur.  It hadn’t been present 5 years ago, but the PA at the VA found it a couple of months ago, and I called her attention to it.

My blood work had no surprises. She offered me the choice of staying in Clarinda or going into Council Bluffs, and I chose to go.  In terms of game theory, if something happened in the middle of the night, I wanted to be close enough for timely intervention.

In the process I had to make arrangements for someone else to take call.

I napped off and on for the ambulance ride, which almost got derailed twice by herds of deer. I bypassed the ER at Jennie Edmundson Hospital.  At 2:00 AM I had gotten settled, my IV had given me a couple of quarts, the second set of labs had come back and I’d had a good visit with the hospitalist ARNP.  Just before being tucked in, I offered the nurses a choice between a clean joke, a clean joke with a bad word, or a dirty joke.  They chose the last option, and I gave them the funniest crude joke in my large arsenal.

I don’t get to tell that joke as a physician, no matter how funny it is. But, as a patient, I can get away with it.  The punch line drew gales of laughter.

By then, motor control of my right leg was functioning at about 90%.

I slept for a couple of hours and had breakfast.

The neurologist arrived, and with economy of motion, did a thorough exam. He advised an aspirin a day and starting a low dose migraine medication.

The morning parade of tests started. By the time Bethany arrived I had done the basic neurologic exam six times and the symptoms had resolved except for the funny feeling inside my head.

I had an ultrasound of my neck, a consultation with the dietician (whom I amazed with my six pieces of fruit a day and my two ounces of salmon at breakfast), a consultation with the Occupational Therapist, and then the Piece de Resistance, the MRI. In between, I napped because I’d slept so lousy.

The hospital feeds its patients on the room service system; I ordered a lunch of soup, sandwich, and fruit, and within a half hour a young Guatemalan arrived with the food. We had a brief conversation in Spanish, I introduced my wife.

And we waited. The hospitalist came back, and went over the results.  Ultrasound demonstrated clean carotids (neck arteries).   The MRI didn’t show anything conclusive.  He also recommended an aspirin a day.

We waited for echocardiogram results. The hospital public address system announced a severe thunderstorm warning, and then a tornado watch in effect till 10PM.  The internet and the TV weather agreed that severe weather approached from the west.  At 4:45PM we decided to leave before the storm arrived, without the echocardiogram results.  We didn’t want to spend the night in the hospital, nor did we want to risk hitting deer on the way back to Clarinda.

Bethany drove. We enjoyed dramatic skies and listened to a Continuing Medical Education CD.  We ate at Clarinda’s premiere restaurant, J Bruner’s, ordering off the appetizer menu.

I returned to work the next day, the episode completely resolved, making it a transient ischemic attack (TIA), also call a reversible ischemic neurologic event (RIND).  Except I noticed my handwriting was much clearer.

I don’t think anyone else noticed.

Have imagination, will catastrophize. Professionally.

April 16, 2017

Here’s a subject in which I’m well-versed,

And for 40 years I’ve been immersed

When it comes to the best

I’ll just keep it in jest.

I’m paid to think of the worst.

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.

Some people have a thought process that involves using their imagination to the worst possible effect. They think of all the things that can go wrong, and, sooner or later, they run into health consequences from dwelling on negative things that haven’t happened.  The medical profession has a term for this phenomenon; we call it catastrophizing.   As time goes on, the catastrophizer dreams up more horrible scenarios; they come to my attention when they develop insomnia, depression, and other problems.

I try to point out to the person in question that they couldn’t have anticipated the 10 worst moments of their lives, and that none of last 10,000 terrible “what ifs” they imagined came to pass. Therefore, it follows, that just by dreaming up negative scenarios, they prevented them.  Mostly, they don’t listen.

In the daily course of my work I think about the worst things I can imagine. I’m good at it, I’m a pro.  I have talent, training, and experience.  I can think of really terrible things.

Of course, like the experience of any catastrophizer, most of the really bad things I think of never come to pass. The thought doesn’t quite cancel out the possibility; I run the diagnostic tests.  At the end of the visit I frequently say, “You want me to be wrong.  You want to walk away from the tests shaking your head and complaining about what an alarmist your doctor is.”

A patient (who gave me permission to write this) came in with terrible pain in her hands. I thought of Lyme disease and rheumatoid arthritis, and ordered appropriate tests, but I also examined her med list and decided to at least temporarily remove the most likely candidate, her statin.  A week later, the pain is gone, and she feels better.

I also did not diagnose cancer, Lyme disease, syphilis, B12 deficiency, lead poisoning, measles, sepsis, and meningitis. Despite of string of previous successes, I also failed to find folic acid deficiency and polymyalgia rheumatic.

But I went looking for them. In my case, imagining the scenario doesn’t prevent it.  But, then again, I’m a pro.

 

 

Measles, a word the 7-year-olds haven’t heard

April 9, 2017

Here’s a contagious word to the wise

If there’s rash and runny eyes

With a cough, I suppose

Look! How runny the nose!

And it’s MEASLES! The CDC cries!

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 3 weeks ago I received an email from the Iowa Department of Public Health about a case of measles. The person (age and gender not given) had been in the Omaha airport on March 12.  Diagnosis of measles had come on March 15, after visiting 3 different healthcare facilities.

So I was on the lookout for a disease I hadn’t seen for 30 years.

Finishing my Indian Health Service contract in 1987 at the Tuba City, Arizona Indian Health Service Hospital, I saw hundreds of cases, and I had to learn about the disease. Measles discussions center on the 3 c’s: cough, conjunctivitis (runny eyes), and coryza (runny nose); the patient looks sick, and has a fever.  The rash starts on the face, and in the next three days works down the body, concentrating in the midline, armpits, and groin.  The 3-day or German measles has a similar looking rash that also starts on the face and spreads down, but people don’t get nearly as sick.

At the time, that reservation had an immunization rate close to 100%, but when the dust settled, the case count came very close to a 5% vaccine failure rate. Since then, the MMR has gone to a two-dose immunization schedule.

With the alert fresh in my mind, I had reason to think of the things I learned and saw so many decades ago. Working a game of incomplete and imperfect information, I called the state Department of Health.  Connecting eventually with an expert who had never seen the disease, but knew what to order, I heard for the first time of a viral transport medium called M4.  And I learned to use a culturette or a Dacron swan, not cotton and certainly not wood.

We still have no treatment for the disease. And with the illness almost extinct, we probably won’t invent one.  Yet measles still runs into complications in almost 10% of those who have it.

Exposure confers lifelong immunity, and only humans can get measles. Thus as an undergrad in anthropology, in one class we did calculations based on 2 week contagion, 3 week incubation, and generation length of 20 years to figure out how what size population can support the disease.  We decided, eventually, that measles couldn’t be more than 50,000 years old.

Measles remains contagious in the air for 2 hours after a person with an active infection leaves a closed room. Thus the case that triggered the alert, arriving on an airplane, exposed a lot of people.

I want to know about that case. What irony or drama surrounds the circumstances of inadequate vaccination?  Who did the exposing, and how sick did that patient get?  Where was the exposure, and was it linked to the Disneyland outbreak?

I never had measles as a child. The son of a physician, I served as a test patient when I was 14 for the first measles vaccine that only served to deplete what my meager natural immunity.  I had to wait till middle age to get an effective vaccine.

Later that day I asked a 7 year old if he’d ever heard the word, measles. “No,” he said, “What are they?”

The antivax movement makes no sense. Mercury has been removed from the vaccine, and all the evidence linking MMR to autism was fabricated by one researcher who has since owned up to his deception, yet that myth persists.

I fear that the antivaxxers may get enough traction to let the genie back out of the bottle, and that the word, measles, may once again become part of the language.