Archive for January, 2019

I’m the doctor. You need the dentist.

January 15, 2019

It doesn’t take much of a sleuth

When it comes to a pain in the tooth

In the head, but not mental

Those problems are dental

They start in the mouths of the youth

 

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

 

Canada’s recognition of care as a right means that cost comes out of everyone’s taxes, and, in that sense, everyone has health insurance.

(Actually, they don’t. The Mennonites, for example, do not have to pay those taxes.  And I ran into a young man with such massive self-defeating behaviors that he procrastinated getting his insurance card for 4 years.)

The mainstream plan does not cover dental work.

The bigger employers offer dental insurance, but, like the US dental insurance, it has a high deductible and large copay. Thus people tend to ignore their teeth.

I see between two and four patients a day with dental problems; a higher percentage when I’m on call. About a quarter of those who come in with toothaches have never visited our facility before.

If people didn’t hurt a lot, if they could get in to a dentist close by, they wouldn’t come in to ER with dental pain. When they open their mouths, I see decades of procrastination and neglect.  Broken teeth, teeth rotted to the gum line, teeth worn out from the clinching that methamphetamine brings.

I can’t actually fix the problem. I can give antibiotics and pain relief.  Amoxicillin remains the standard in dental infection.   For analgesia, I have the nurse administer ketorolac (Brand name, Toradol) 30 mg as an injection, and I give the same medication as a pill for 5 days.

If time permits I show the patient ho-ku acupressure, squeezing a point in the muscle between the thumb and forefinger, which relieves head and neck pain.

But I have to urge them to get into the dentist as soon as possible. For those who can’t afford to pay, I give them information on the free dental clinic held twice monthly in Prince George.  Staffed by volunteers, they rarely have time to do anything besides pull the offending tooth.

I suppose I could learn to do dental extractions. If I did, in short order I’d be doing almost nothing else.

Some of the patients don’t have a problem till they’re about to head into the wilderness for work for a few days; I generally give them a longer prescription of Amoxicillin, but I don’t give out pain pills that would make them dangerous around machinery, or driving to Prince George.

Confronting a smoker with a heart attack

January 13, 2019

 

When it comes to attacks of the heart

Please listen, you docs who are smart

Whenever the bloke

Steps out for a smoke

Don’t yell, and keep your words smart.

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

Though the patient gave me permission to write about him, I won’t say when this incident happened.

He came in with chest pain. As per protocol, I did the electrocardiogram which strongly resembled previous tracings.  But I also asked for and obtained a blood test for troponin, which rises only when heart muscle has sustained damage.  It came back normal.

But we have learned that sometimes the damage doesn’t show up on the initial blood work, so I ordered the same tests 4 hours later.

I read the second ECG with alarm: a sag in the line connecting the wave representing the heart’s contraction, with the deflection of the heart’s electrical preparation for the next beat. I sat down with the patient and discussed the situation.  In the middle of a heart attack, I had to make arrangements for more specialized care.  He would require a cardiologist and a catheterization, perhaps stents or a cardiac bypass graft.

I started the complicated business of sending the patient to a higher level of care while the snow fell hard enough to make the task impossible. I repeated the same story on the phone, each time emphasizing that the patient remained pain-free and with normal blood pressure and pulse.

The snow eased my emotional frustration. No medevac helicopters fly in this health district.  I only ask for fixed-wing transfer when justified by the distance to the facility, and the weather throughout the province assured that the small planes involved in medical transfer could neither take off nor land.  Still, the decision-making came at day’s end.  Vancouver’s cardiologists had no beds, we would have to keep the patient.

As I finished the hospital admit process, the nurse said, “You know, don’t you, that he stepped outside for a smoke.”

No, I hadn’t known. I confess I lost my temper.  I slammed my pen on the desk and stormed out to the front entrance.

I confronted the patient.

Those who have known me the longest will confirm that when I get angry I get articulate, but I rarely raise my voice. I don’t have to.

What I said boiled down to, “You have a beautiful young wife and a son. There are a lot of people who love you, and we’re worried about you.”  But I said it, angrily, about 6 times.

I care about my patients, but I haven’t expressed that kind of fury for years. Maybe I’d worked too many hours with too much noise.  I finished more fatigued, and I felt worse for hours.

The next day the patient thanked me, as did his family. He felt better, the best he’d felt in a year.

Outside, the snow fell thick for the next five days, when, finally, we got word we could transfer.

New Year’s lacerations

January 3, 2019

I said to my very next case

With a cut so bad on his face

He got from a grinder

Do you suppose that it’s kinder

To use stitches to close up the space?

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

I approached the third laceration patient of New Year’s Day on call. Lacking a bolt cutter, the patient had been using a power tool called a grinder to cut a bolt for a friend.  Living flesh suffered in the slip that followed.  The wound gaped straight down the midline of the chin and onto the upper part of the neck.

I said, “You got two choices. The risks of the procedure include infection, bleeding, pain, and the certainty of a scar.  The risks of not doing the procedure include infection, bleeding, pain, and the certainty of a scar.  Your choice.  Shall we proceed?”  The patient agreed.   While the patient’s wife took cell phone pictures, I cleaned and numbed the area, then held the wound open for the camera.

“Is this already on Facebook?” I asked. The patient and wife both laughed.  I said, “Then if it’s already on Facebook, is it OK if I write about it on my blog?”  They both agreed.

I put on my headlamp, slipped off my glasses, slipped on my gloves, and started stitching. Suturing fell into a rhythm: sew, tie, cut.  Between the cut and placing the next stitch, I would ask a question and the patient would reply.

We talked about ice fishing and the discomfort inherent in the activity. I made the comment that I’d been out on the ice while others fished, but, aside from the Inuit, it seemed like beer constituted the main reason to bring poles and bait outside.

We all laughed, and I said, “Ten thousand comedians out of work, and you got one with a stethoscope.”

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Bad call put my senses into a time warp. This morning I awakened thinking I had call again, not realizing till almost 9:00AM that I had clinic.

My morning’s highlight, which put a bounce back in my step, came when I met with a man I’d diagnosed with Parkinson’s last month (and who gave me permission to write about him). His stiffness melted, leaving behind a more fluid gait, clearer speech, a mobile face, and better balance.

He’d had a stroke a couple of years ago, and in the aftermath he started having auditory and visual hallucinations. The rehab staff told him that, 9 times out of 10, nursing home placement follows one spouse finding out the other hears and sees things that aren’t there.  So he’d kept his hallucinations to himself.  But they’d stopped right after he started carbidopa/levodopa (trade name, Sinemet) that I prescribed for his Parkinson’s.

Even though in the last year I’ve helped dozens of similar patients, each one reminds me of why I’m a doctor.