Archive for June, 2017

Learning about the timber industry

June 28, 2017

The market for trees comes and goes,

A boom and a bust, I suppose

At the end of the caper

Logs get turned into paper

And you can watch as the baby tree grows.

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 traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

My education in the tree industry proceeds.

When the US economy tanked in 2008, this town felt the impact. The housing bubble burst, the demand for new houses dropped and with it the demand for lumber.  At the same time, electronic publishing cut into newspapers and other print media, so that the demand for wood pulp went down, and the local jobs evaporated.  Some people stayed, but more than half left.

The market for tree products has gradually improved since. Logs get chipped, the chips get bleached and cleaned and cooked to make pulp, which gets spread into sheets, dried, and sent to China.  Rumor has it that China turns it into toilet paper and sends it back, but undoubtedly it has more uses.

The trees around here suffered from the mountain pine beetle a few years ago. Normally that insect just takes out trees about 80 years old, but fire suppression and lack of logging shifted the ratio of old trees to total trees.  Then the area had a succession of warm winters with a resultant improvement in larva survival.  The warm winters went with dry summers which weakened all the trees, which then succumbed to the beetles.

Some trees stay green for a few years after they’ve effectively died, and get used for lumber. Dead trees retain lumber value for several years, and after that they become fodder for the pulp mills.  But those who log must, by law, replant.

The only tree planter I’ve met so far has been doing other work this century, but replanting involves a shovel and remains unmechanized.

Once cut and trimmed, logs may be trucked directly to the mill, or otherwise moved to a body of water. Secured with cables into rafts or contained with booms, they might move more than 200 miles before meeting the saw or the chipper.

Lake Williston, the largest reservoir in British Columbia and the 7th largest in the world, transports a lot of floating timber, even in the winter, when an icebreaker moves the logs.

And everywhere that logs move, people move with them. I see the consequences when humans face the tyranny of Newtonian physics:  a body in motion tends to remain in motion, a body at rest tends to remain at rest, and two bodies cannot occupy the same place at the same time.

June 25, 2017

They come in, right off the street

The problem it seems, is the feet

And then when the pain

Makes them complain

Orthotics just can’t be beat.

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 traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

I have really bad ankles. I started with flat feet as a child, and things haven’t gotten better in the last 60 years.  Now I wear stiff hiking boots with orthotics you can, literally, drive nails with.  They keep me going.

A fair number of my patients, no matter where I go, come in with foot problems.

Most “ingrown” toenails result from people cutting a corner of the big toenail too short, temporarily relieving the pain but setting themselves up for worse problem when the nail grows out, cutting into the flesh. More than half the time the original problem stems from shoes functionally too small.  I tell people to keep their nails trimmed.  With a flair of showmanship I predict I’ll find a hole worn in their shoe lining from the big toenail, then I tell them to file a bevel into the end of the nail, making it both more flexible and easier to trim when it grows out.

Those with plantar fasciitis start the first step of the day OK, then the pain hits. But it gets better as the day wears on.  At the end of the day, they might sit and relax for 20 minutes but when they stand up they face excruciating pain.  I teach them stretching exercises, encourage them to lose weight, and advise new footwear.

Most WalMarts have a Dr. Scholl’s display; those orthotics (shoe inserts) can be the first step away from the pain. But if they don’t work, I recommend the podiatrist, or, sometimes, the orthotist, a person who does nothing but make orthotics.

The patient gave me permission to say that when I told her to take off her shoes and stand up, her arches sagged to the floor. They looked just like mine.

Then I talked about how I felt the first day I put my feet into the solid inserts. I walked away with a gait 30 years younger, my back straighter.

 

Dislocated thumbs and warmth in the ER

June 24, 2017

To the ER the injuries come,

So I just took hold of the thumb

Yes, dislocated

But a technique underrated

Includes no drugs to make the hand numb

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 traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

Over the years I’ve learned at least 8 different ways to put a dislocated shoulder back into place (medicalese: reduce the subluxation).   My favorite remains the one I learned in the parking lot of the hospital on my last day of residency.  I met one of the emergency docs coming in as I was going out for the last time.  He told me he’d learned the technique that involved no drugs, bandages, tape, buckets of sand, or force, and he showed it to me.  I use it to this day.

It failed only once, when in another clinic in another city a very muscular young man suffered a dislocated shoulder in the course of an electrical injury.

Last night, on call, for the first time in my career I faced a patient with a dislocated thumb (the patient gave permission to include a good deal more information than I have). I looked at the x-ray, I reviewed the anatomy, and put together a plan.  But I’d never done one before so I felt I should at least speak with someone with more experience before I tried it.  I put out a call to a consultant orthopedist and I waited.

And I waited.

One of my colleagues who had done several of the procedures, just back from an ambulance run came striding through. I told him the plan, and he gave me the nod.

I had the patient give me the thumbs up sign. I grasped the digit, and we started to chat.  As the patient relaxed, I took the weight of the hand, and, eventually, the arm.  After 5 minutes, supporting the forearm with my other hand, I let go.  Using patience and gravity, the thumb had slid back into place, with no drugs, no violence, and no clunk.

Just the way I like it.

_*_*_*

Injured people rarely come into the ER alone. Some of my patients have problems so difficult to look at that you wouldn’t see them in a horror movie.   The visual impact can jar friends and relatives into free displays of affection.  But during a recent night on call, I witnessed a kiss so astounding that the warmth flooded the ER and so memorable I had to comment on it.  I kept doing what I had to do, thinking all the while that so much love must make a difference in the healing process.

 

An ambulance ride to town and back

June 22, 2017

The patient gave us a scare
We did as much as we dare
A long ways we did ride
While it was raining outside
And I spotted a young dead black bear.

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 traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed. I finished my most recent assignment in Clarinda on May 18. Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

I ride in the back of the ambulance with the patient, a nurse, and an EMT.
I can’t talk about the patient or the patient’s problem, except to say its seriousness demanded the presence of a doctor and a nurse on the ambulance.
Sending both of us put a significant crimp on the healthcare manpower of the town, as well as leaving the municipality without ambulance coverage.
I have ridden in ambulances before, but during the last century. Common IV pumps remained a dream then, and I adjusted the IV drip rate using my wrist watch. Ambulances ran a lower profile at the time, and I couldn’t stand up while we rode; nor did I have a seat belt.
I got little precious sleep in the wind-up to this transfer, and we left in the rain while the beginnings of daylight brought color to the world.
Between the bumps in the road, the need for speed, and my position sitting sideways, after 40 minutes I begin to fear meditation failure ending in vomit, and I request a basin. The nurse, a woman of immense and invaluable experience, knows exactly where to reach for it.
I see nothing of the beautiful landscape as we proceed. Mostly I keep my eyes closed and my breathing deep and slow while I imagine worst-case scenarios, and how I would proceed if they happened.
Three times the nurse asks for permission to medicate the patient, and I consent. We keep our eyes on the instrument that measures blood oxygenation, blood pressure, pulse, and breathing rate.
A few miles out of the city the road acquires more lanes and divides, and the traffic picks up. The change in siren pattern tells me when we blast through intersections.
Ten minutes from the University hospital I look at the patient and the word “deterioration” springs to mind. But when we wheel into the brightly-lit, well-staffed, fully-equipped Emergency Room I know that we’ve done our job.
Just before we depart, one of the EMTs gets a call to transport a patient from the city back to their outlying hospital. In the time it takes to ready the next patient, we decide to go to breakfast, and the choice is easy: Tim Horton’s.
“Timmy’s,” as the Canadians call it, with higher quality than McDonald’s, not quite as fancy as Perkins, has outlets across Canada. I’d think they’d want to invade the US.
We drive a few blocks in traffic denser than anything I’ve seen for weeks. We park in a position of dubious legality, knowing ambulances never get parking tickets. The four of us stand in line, a little too polite to walk up to order. But at the end we walk out with our food, past a rapidly growing line. I carry a cookie and a yogurt parfait, hoping the way back will go smoother.
We pick up the new patient, the transport does not justify lights and sirens. I get to ride in the front.
On the way back I learn about the pulp industry, how ambulance services get billed, how EMT shifts get arranged, and some of the history of the town. I comment that although I see signs cautioning wildlife corridor I don’t see dead animals on the side of the road.
The EMT explains that Animal Control removes the carcasses quickly, so that local predators don’t hang out on the pavement and cause more problems.
And, just like that, we pass a road-kill bear.

Trying to figure out what “call” means

June 21, 2017

When my weekend came to an end

A patient off we did send

With findings so rare

It gave us a scare

And help we needed to mend. 

 

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 traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

 

People can use the same word and mean different things, different words to mean the same thing, or even the same word in different contexts to mean different things.

Doctors use the term “call” when talking about coverage after hours and on weekends, but what does that word “call” really mean?

In Utgqiavik, the town formerly known as Barrow, it never meant anything other than 12 hours. I have been places where holiday call meant ten times that.  Depending on the location, weekend call might start on Friday or Saturday morning.  Or it could include staffing a Saturday clinic.  Sometimes it meant ER coverage only.  For a couple of decades I had to field calls from nursing homes, patients, ERs and hospital inpatient units as well as obstetrical duties.  For one former employer, if I drew the duty, I could count on sprinting between hospitals to admit patients till midnight, and a minimum of one phone call every 45 minutes requiring critical decision-making.

In New Zealand, when I worked for a North Island outfit, “call” meant staying overnight in the clinic.

On one particularly memorable assignment, it meant nothing other than having my name on a calendar slot. I had protested the marginal cell coverage at my dwelling.  Administration told me not to worry, in the event of a disaster the Sheriff knew where he could find me.

I write this while on weekend call. Sunday morning dawned very early and very clear.

During my 23 years in private practice, the docs wouldn’t talk about how the weekend went until afterwards. The same superstitious factors leading to that custom led to the many Emergency Rooms that banned the “Q word” (quiet).

What does weekend call mean here? Starts at 8:00AM Friday, ends at 8:00AM Monday, followed by a day off.

Now post call, I can say I cared for 3 people who, for one reason or another, didn’t have a chart in the local electronic Medical Record. I never cared for more than 12 people in one 24 hour period.  Several times, on the verge of leaving for the apartment, I asked people on the way in if they had come for emergency services.

At the end, a patient arrived with an extremely rare problem, so serious I called a colleague for help, and ended up riding in the ambulance to the medical center.

Power failure in the hospital

June 18, 2017

Right now we don’t really know
What caused the transformer to blow
But it wasn’t a squirrel
That put the grid in a whirl
Our best suspect now is a crow.

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 traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed. I finished my most recent assignment in Clarinda on May 18. Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

Quite some time ago I worked with the Canoncito Band of Navajo; the place is now called by its proper Dine name, Toohaajilehi. At that time, most people lived in traditional hogans, round or 8-sided structures with a smoke hole in the middle of the roof. Eighty-five percent had no running water; a few of those households accessed electricity through their truck battery. With notoriously unreliable electricity, we had an average of 6 outages a day, and no way to sustain the new-fangled computers then slowly invading medicine.
We knew how to handle electric failure; every exam room had a window that we could open in the summer, and all of us knew how to layer up in the winter. If I needed the microscope I used the battery-powered otoscope for light. We kept our records on paper.
Two summers ago I worked in suburban Pennsylvania. In a thickly settled, industrialized area, one would expect reliable electricity. Nonetheless the Urgent Care outfit I worked for kept its clinics supplied with back-up generators, wired only to the computer system. On average, once a week the power outage lasted longer than the half-hour’s worth of diesel in the generator’s tank.
Last winter I worked in a coastal Alaska town with a modern grid and a hydroelectric plant. But in that relatively dry spell while I was there, the lake level dropped, the hydroelectric failed. The hospital’s emergency generator kicked in, but it also supplied juice for the town. Unfortunately the noise of the power plant invaded my office and exam rooms.
Friday the power flickered once as I came on call, then failed completely. The hospital’s back-up power system kicked in, supplying critical parts of the ER, but, strangely, only two computers at the inpatient nurses’ station. Notification came that full restoration would take 6 hours. Staffers called scheduled patients to rebook.
Different outfits react differently to power outages, but almost all look manic and giggly for the first half hour. Here the grins lasted a good deal longer, and no one got grumpy. But they did tell me such occurrences come rarely these days.
In the early afternoon I got the Emergency doctor’s computer hooked into the active portion of the back-up grid. I did the documentation from the few patients I’d seen thus far, and generated a couple of discharge summaries.
The power came back on in the late afternoon, and I attended patients, one by one, who came to the ER.
When I got home in the evening, Bethany told me that the best guess so far blamed a curious crow in a transformer. I haven’t been able to confirm the story, but, knowing how squirrels can knock out power in the US, it wouldn’t surprise me.

Spinal manipulation and other tools

June 17, 2017

When it helps, it’s ever so nice

And for me, it’s not about price

For the old spinal crunch

Can sure help a bunch

I’ll manipulate, but not more than twice.

 

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 traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

For the most part I approach medicine in a go-by-the-book fashion. But I keep an open mind, and I try to keep more than a passing acquaintance with what has been called “fringe medicine.”

I took a month’s course in acupuncture as a senior in medical school, but it would take decades and much research it to gain anything like acceptance. We now have more evidence to support the treatment of chronic pain with acupuncture than with opioids (also known as narcotics), yet many more docs use the opioids than the needles.

Honey as a cough suppressant has become a mainstream recommendation.

I went to Michigan State, which has an MD school right next to an Osteopathic school. We shared most of the basic science classes in the first two years, and twelve members of my class demanded teaching in osteopathy.  We met for an hour twice a week in a basement, and we practiced on each other.

In fact, I learned spinal manipulation even before I finished premed. You could call the crowd I ran with “nerds” or you could note that we shared information whenever we could.  But I learned how to feel where other people hurt, and I learned how to crunch backs.

At Michigan State they taught me when to and when not to use the technique. I also learned what they called “muscle energy” manipulation; the technique is also known as “push-pull” or “strain-counterstrain.” You can improve range of motion if you move the affected part to the barrier, then have the patient do an isometric contraction away from the barrier.  I use the technique, for example, after prolonged immobilization in a cast renders a limb stiff.  But it also works when spasm limits mobility.

(Properly done the technique is more complicated than I have described. Please do not try it at home.)

When our oldest daughter contemplated medical school, I steered her towards the DO track; those tools come in handy in primary care. And so far this week I have used them several times, making the patients better before they got out the door, and teaching them how to use the tool in the future.

But the power of manipulation must be used with respect.

In another clinic in another town in another country, a while ago a patient came to me with classical back pain. His chiropractor twice had helped a lot but only for a couple of days.  I crunched him twice, with good relief.  But when he came back the third time, I stuck to my guns, and, rather than manipulating his spine, I sent him for a CT scan.  I could not have imagined beforehand the very grim diagnosis.

 

A small town is a complex system

June 15, 2017

There are stories, and then there are tales

There are successes, then there are fails

I can say how it went

After the event

But I cannot disclose the details.

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 traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

 

I don’t like big cities, I never have. I grew up in Denver, and I can remember thinking at age 8 that city held too many people for my comfort.  After I left home I kept moving to smaller and smaller towns until Bethany and I found ourselves on the Acoma Reservation in New Mexico, in a settlement of about 75, attached to the hospital.  Seeing a stranger would come up as a topic of conversation for a week.

When we moved to Sioux City we found ourselves inside a city limits holding 5 small towns with pockets of wilderness that contained deer, turkey, and mountain lions. The nearest buffalo herd roamed a river bottom 30 miles away, and once a wayward moose wandered through the county.

So I really enjoy this small town. It has a good grocery store and a wonderful recreation center.  Everyone knows everyone.  The first graders walk themselves to school.  Drivers on the highway, like most Canadian drivers, stop to let pedestrians cross.

Wilderness lives hard by civilization here. Enough black bear try to sort through garbage that dumpsters lock, and have signs proclaiming A FED BEAR IS A DEAD BEAR.  I believe the story (though I haven’t verified it) that when the fence around the dump got electrified, 50 grizzlies came into town and had to be relocated.

This town qualifies as a complex system in the mathematical sense of the word: the diverse components connect, interact, and can adapt.  A person could spend an academic career studying complex systems, or even one complex system, but, in brief, everything is connected to everything.  Changing one element changes every other element in a non-linear fashion.

I can’t talk about details of the case, but at the end it involved neighbors, friends, colleagues, and my wife. In many ways a test, with drama and irony it introduced Bethany and me to the community.

The aftereffects still ripple through the social fabric here. People recognize Bethany through a friend of a friend.  People introduce themselves as friends or relatives of those with close involvement.

But the real health impact on the community will come 21 days after the event itself. For some it will bring healing, for others, illness.

Learning about forestry

June 12, 2017

Out here we’ve got poplars and pines,

And recently we’ve got a few mines

But who pays the fees

To cut down the trees

Where too many beetles have dined.

 

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 traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

Western Canada in general, and this area of British Columbia in particular, has a lot of trees; many of them currently dead, killed by the mountain pine beetle.

In the normal course of events, those pine beetles attack the mature trees in a stand. With a decreased ability to fight the invader and the fungus it carries, those trees quickly die and fall, and make room for the new generation.

A century of fire suppression increased the proportion of old trees. Because smoke kills pine beetle larvae, the number of reproducing insects increased.  All this at a time when warmer winters led to improved insect survival, and drier summers to impair sap production, further lowering the trees’ resistance.

The dead trees still have commercial value.

So a lot of standing timber, living or dead, with a conscientious government, can mean a lot of potential revenue, which, in turn, means a lot of work for foresters. And, indeed, I’m taking care of a lot of patients in the industry.

Some work on the supply side, mostly from the side of the government. They do what they can to maintain the health of the forest.

Forestry techs are the ones who go out on foot to find the harvestable trees. I have just begun to find out what their work involves.

On the private side, a lot of contractors operate in this area. One person estimated 25 outfits logging around here, but the number would depend on how one defined “around here.”  A logging camp will have between 25 and 100 employees, living 2 to 15 hours from town.  They operate year round.

I have found out about another genre of forestry worker, the person who, interfacing with the government, negotiates the complex of regulations so that the contractor can extract the resources.

I’ve talked with some of them. Their expertise has become vital to the industry.  One said, “Forestry isn’t rocket science.  It’s way more complicated than that.”

I have yet to meet up with another group of workers, the tree planters. Vital to the continuation of the timber product industry, they only work in the summer.

I want to know more about their work; forestry is an immense, complicated industry. I’ve lived surrounded by wood and wood products all my life.  I’m just beginning to find out how they happen.

 

 

When good algorithms fail

June 7, 2017

The thyroid’s a wonderful gland

And if everything goes just as planned

When we get the right number

With good conscience we slumber

But there’s another approach to be scanned.

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 traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

I do a lot of lab tests and x-rays, and I interpret results in the human context. Every result pertains to a person in a psycho-social environment, a factor in a complex system where everything is related to everything, and you can’t change one thing without having an effect on everything else.  Thus the popular medical saying, “We don’t treat lab tests, we treat people.”

Hypothyroidism, where the disease stems from an underactive thyroid, a very important H-shaped gland that sits at the base of the front of the neck, stands as an exception to that truism. We treat numbers.  If we get a high thyroid stimulating hormone (TSH) value, we give a small dose of levothyroxine, T4, the same as thyroid hormone, escalating the dose by six week intervals until reaching a normal value two tests in a row.

(The higher the TSH, the more the patient needs thyroid replacement; it represents the brain’s plea to the thyroid gland for more hormone.)

The approach works well for more than 95% of the people with hypothyroidism.

The problem arises in that small segment of the population that doesn’t convert levothyroxine (a core with 4 iodines attached) to its more active degradation product, triidothyronine or T3 (the same core but with only 3 iodines). Because each T3 is worth 6 T4s.

I explained all this to a patient two days ago, who gave me permission to write what I have.

Most people with lazy thyroid glands have symptoms that can include fatigue, depression, constipation, aching muscles, cold intolerance, mental slowing, and difficulty losing weight. And the vast majority feel normal when the TSH creeps under 3.5.

But a very few patients still don’t feel right, and microscopic doses of Cytomel (the trade name for T3) can make some, not all, feel much better.

I wouldn’t know about this if my sister’s very good endocrinologist hadn’t inspired me to read further.

The problem arises that such methodology verges on what many mainstream doctors call “fringe medicine,” because of the actions of a very small number of unscrupulous doctors. I try to keep a low profile, and I ran the case by two of my colleagues.  One expressed mild surprise, the other, as it turns out, uses the same approach