Archive for September, 2019

My beloved’s thyroidectomy

September 22, 2019

It’s OK for preserving the life

Of your lover, your friend, your wife

We’d like to avoid

A malignant thyroid

And so she went under the knife. 

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 further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia.  Last week a colleague’s illness necessitated my return to hospital work.   Any identifiable patient information, including that of my wife’s, has been used with permission.

Yesterday I drove my wife, Bethany, to the surgical hospital.  Our family doctor, on routine exam, found a tiny thyroid lump, leading to an inconclusive thyroid needle biopsy.

Thyroid disease comes as common as rain.  With the advent of iodized salt and the food globalization, the “goiter belt” I learned about in med school disappeared 70 years ago, yet a cold climate forces thyroid glands to work harder and wear out faster.  But it doesn’t cause cancer.

Amongst ourselves, docs would choose thyroid cancer over any other.  Slow growing, if it spreads, the cancerous tissue stays so functional that it continues to hog the body’s iodine, including radioactive iodine (I 131), which turns the remaining thyroid tissue into a microwave oven.

This problem comes when I have, in the adolescent idiot’s sense of the term, fallen in love with my wife, who has been blessed till now with wonderful health. On top of deep, mature love from 40 years together, for the last couple of years I have experienced, again, the young man’s sense of wonder, seeing in every act a reason for integrity that would make my beloved proud of me.  I felt like a teenager seeing their first love go under the knife.  I know everything that could go wrong.

We arrived at noon.  At 1:30 PM she walked down the hall to the operating room.  I sat with other families awaiting their loved ones.  I used our phones to text and call our children and my sisters-in-law about start of surgery, end of surgery, and exit from the recovery room.

I spoke with the surgeon as soon as he’d finished.  Colleagues for decades, I know him and trust him.  The frozen section, what the pathologist does during surgery, came indeterminant: a follicular lesion; neither conclusively malignant nor benign.  Final result expected next Wednesday.

I worried about the parathyroids, the tiny glands sitting at the 4 corners of the thyroid’s H.  They regulate calcium; one functions as well as 4 but none lead to lifelong problems.

I longed to see her and to be near her, but getting from recovery room to settled in bed took aching hours.

I waited in the family lounge with my computer, finding writing a soothing balm for my feelings.

From behind me I heard, “Doctor Gordon?”  I turned my head to see a comely young woman.  “You delivered me,” she said.

She told me one of my former patients, a relative, had a joint replacement, and gave me the room number.  In the conversation I found a distraction from my worry, and went to visit.

I code shifted, English/Spanish, with my patient.

Yes, the patient said, “You delivered her 27 years ago. You look great.  You look younger!“  I didn’t mention that quick arithmetic showed me the delivery came the year my OB practice peaked.

Nor did I mention running into a hospital staffer who recognized me 3 minutes before I recognized her; I also delivered her babies.

Bethany looked pale and felt nauseated and high.  We dozed together without the TV.  At 10:00 PM I left for home, not wanting to be away from her at a vulnerable time.

I drove through the dark, watching the Big Sioux and Missouri Rivers threatening their banks, flooding for the 3rd time this summer.

 

 

 

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Some diagnoses considered and rejected

September 21, 2019

My colleague, it seems, came down sick

It happened, I fear, rather quick

Then I got the call

To pick up the ball

To save someone’s life is a kick.

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 further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia.  Despite intention to take some time off, I did a couple of days of hospital work this week.  I really do intend to take a couple of weeks off.   Any identifiable patient information has been used with permission.

It doesn’t take Sherlock Holmes to predict that if 8 docs work 14 hours daily two weeks running in a facility crawling with germs, that sooner or later someone will get sick.

I got a call on Monday to come back to work in the hospital, one of the other docs had taken ill abruptly.  I said yes.

I like hospital work.  I get to rub elbows with docs who know more than I do.  And I like working in one of my old hospitals, I get to see my old buddies.

Adequate restrictions on tobacco and alcohol would have robbed me of half my work.  Each person came with a back story of drama and irony, of love and regrets and unfinished business.

Sometimes I find myself the least knowledgeable person on the team.  Thus I walked into the ICU, introduced myself as the generalist.  I told the family and patient my job consisted mainly serving as an English translator of the situation, and what to expect.

But every once in a while I find myself adding substantially to the patient’s care.

Potentially my most valuable contribution this week caused me to remember my experience with Wernicke-Korsakoff, which I’ve written about before.

httpIs://walkaboutdoc.wordpress.com/2015/12/15/double-vision-remembering-wernickes-without-korsakoff/

https://walkaboutdoc.wordpress.com/2010/06/18/wernicke-without-the-korsakoff-dont-hold-the-thiamine/

I think back to those two experiences and to a third patient who didn’t get his thiamine in time and got trapped in a summer’s day in the first decade of this century.

Few lab findings make me dance, among them a low vitamin B12 level and a high TSH (thyroid stimulating hormone); in both cases I get to save the patient’s life for pennies a day.

But I came across another lab finding that required I call the hematologist (blood specialist), who, in our culture, is the oncologist (cancer specialist).

Of the 20 patients I saw each day, six had cirrhosis of the liver, but not all from alcohol.  Two had liver cancer resulting from cirrhosis.  I overlapped with the nephrologist (kidney specialist) on six more.  Four others got stuck in a holding pattern until insurance would agree to pay for rehabilitation placement.

A physician should always keep in mind the possibility of Munchausen’s syndrome: the patient purposely makes the symptoms happen.  A rare problem, to be sure, but a good deal more common than a dozen others I considered and rejected.  And the patient involved almost always knows more about the disease than the doctor does.

 

 

A dual-purpose dental visit

September 14, 2019

When I had a bad pain in my jaw

It turned out that the dentist I saw

Had sciatica pain

From an infrequent bane

A piriformis muscular flaw.

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 further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia, and now I’m taking a few weeks off.   Any identifiable patient information has been used with permission.

 

I have sleep apnea but I have so far avoided the dreaded CPAP machine by using a dental device called the TAP.  It works well enough but over the last three months, with increasing frequency the right side of my jaw will get stuck if I chew something that’s too tough.  What that happens I have trouble opening my mouth all the way.  Up till now the problem has resolved itself in a matter of hours, generally with a soft but satisfying pop as that joint slides back into place.

Yesterday it happened and all my maneuvers failed to put things back into line.

I refuse to be my own doctor, so I called the dentist who fit me with the device.

He got me in promptly, and reassured me my problem boiled down to a sprain.  He advised ibuprofen.

I had to stop all non-steroidal anti-inflammatory drugs, I said, because of kidney damage from taking indomethacin, naproxen, Vioxx, and others for a couple of decades.

He ran through an impressive list of herbal anti-inflammatories, and gave his experience with them.  He’s had terrible problems with sciatica, despite getting state-of-the-art diagnostics and therapeutics.  I listened, I nodded, and didn’t say anything till he mentioned piriformis syndrome, a problem I’ve written about before: https://walkaboutdoc.wordpress.com/2010/12/24/piriformis-syndrome-a-curable-pain-in-the-buttock/.  And then I couldn’t help myself.

He understood all the jargon having to do with isometric contraction away from the barrier to range-of-motion, including fooling the gamma efferent into providing reflex inhibition of the antagonist groups.  On the floor of his office I showed him how to relax the piriformis, a muscle that both externally rotates and extends the hip, with an osteopathic technique called muscle energy (he gave me permission to include more information than I have).

I explained that I have an MD, not a DO, but I went to Michigan State where the two schools share classes, and I learned manipulation.  I stumbled across this piriformis syndrome treatment by accident as a first-year med student.  Two or three times a year, I said, a patient will limp in and strut out.

Sometime during the last 9 years, to avoid hurting my back, I quit manipulating the patient and I started showing them how to manipulate themselves.

At the end of the visit I mentioned my plan to get acupuncture, and named the same chiropractor he goes to for that service.  He asked me to send his regards.

 

Collegial colloquium at Sam’s

September 12, 2019

 

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 further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia, and now I’m taking a few weeks off.   Any identifiable patient information has been used with permission.

My 24-hour homeward journey from Canada has acquired a familiar flavor.  I recognized the black bear on the road to Prince George by the white patch over his sternal notch. Sooner or later I may get to know the Customs and Border Protection people on a first-name basis.

The morning after my return I ran into a friend and colleague at Sam’s Club.

Less than a minute into the conversation I showed off the picture of Bethany and me with our 92-pound halibut.  I talked about our travels, which brought the conversation around to the generalized wonder that 21st century North America has become.

I missed the chance to gesture around at the Sam’s Club environment and assert that monarchs 100 years ago could not access what exists in just one store in one small city in the middle of the US.

Instead, I asked about his family

A pediatric cardiologist married to a family practitioner, the couple have 4 sons, three in medical school and one studying for the MCATs (Medical College Admission Test).

He recently spoke to his oldest son.  As a 3rd year medical student he admitted a patient in his 90s with a terminal diagnosis and a request for a Do Not Resuscitate (DNR) status.  The student and the patient bonded during the hospital course which ended with the patient’s death, leaving behind a family at peace and a grief-stricken student.  The son wept as he recounted the experience to his father.

Father to son, the older doctor gave consolation and support and the advice to never stop feeling.

I didn’t recount one of my experiences earlier this year, with a 98-year-old patient I admitted to the hospital with a list of diagnoses that included heart, kidneys, lungs, and metastases.  I followed my routine at the end of the history and physical: I explained the clinical situation, discussed treatment options, clarified the patient’s goals, and asked the last question of the interview: if your heart stops beating, do you want us to try to restart it?

She did not hesitate, and said, “I’m ready to die.”

Writing months later, I still find myself pausing like I paused when I sat down to do the admission orders.  I thought about life and death and mortality and the unique place a physician holds in the orderly circle of life. In a space away from the noise of the nurses’ station I paused before I checked the DNR box, then I burst into tears.

.

 

Labour Day Weekend Call: Real Time.

September 5, 2019

You’ll find at the end of the day

If you call the tune up to play

You can say it’s no fair

And I don’t mean to scare

But the piper you will have to pay

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 Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, South Central Alaska.  After two weeks vacation and 5 weeks as a hospitalist in my home town, I have found my way back to British Columbia. Any identifiable patient information has been used with permission.

They spell Labour Day differently here than in the US but it remains the same day: the first Monday in September, a day to not work.

I have call.

I slept in, not arising till 6:30 AM, ate a leisurely breakfast, and went back to bed.

At 9:30 AM I got a call for the first morning patient, followed quickly by the second morning patient, both on-the-job injuries from the same plant.  One injury resulted from safety features gradually disabled over the last 40 years, the other from safety features that should have been in place 40 years ago.,

The plant is in the process of closing down.  Economic downturns, a decrease in the demand for forestry products, outdated technology, and changes in the transportation network have resulted in shuttering plants processing trees all over the province.

Noon:  That piece of glass didn’t belong there.  I removed it from a person moving ahead with hopes and aspirations.

12:15 PM:  A patient with a straight forward infectious problem arrived with a family context.  The children enjoy a few yo-yo tricks.

1300:  In an over-resourced system this patient would have a CT scan regardless of age or concern for late effects of radiation.  I exercised clinical judgment involving a trip to Prince George for more sophisticated diagnostics.

1330:  I slipped out of the hospital to the convenience store to buy lunch for the crew.  Not mandatory, but certainly appreciated.  Originally intending to just get wedges and wings, I found samosas and egg rolls.  While I’ve had better samosas, I haven’t had many, and certainly not at this price.

1345: In Canada a doctor can be a locum tenens only for a specific physician for a defined time period.  The US has a much more flexible view of locum tenens, and I have worked in facilities where temporary physicians provide most of the care, with permanent docs found in administration.  My current position requires review of lab, x-ray, and consults that come in under the name of the doc I substitute for.  With the vast majority normal, the remainder bring messages of drama and irony, from gratuitous bad luck to the piper demanding a long overdue accounting.  In the last week I’ve checked off more than 1100 items.

1500: Another patient with job uncertainty because of plant closings.  Your problem is not imaginary, I explained; stressed people get sick.

1630:  If you call the tune, sooner or later you pay the piper.  This patient, like so many others, knew the diagnosis even without having an extensive medical vocabulary.  I listened, I gave choices, and we agreed on the treatment.

1715:  Another person called the tune, and had to pay the piper.

1930:  Another piper-patient payment.

2100:  Trying to warn an intoxicated patient of the inevitable piper’s payment does no good.

2200: Back in my room, I sleep poorly.