More Parkinson’s

A new Parkinson’s patient a day

And together we figured the way.

I said, “No treatment” and smiled,

“If the symptoms are mild,

“’Cause the progression it won’t delay.”

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 Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.   I did 10 months of telemedicine in my basement, followed by 5 months staffing a COVID-19 clinic in southeast Iowa.  Since autumn, I’ve relaxed, exercised, done some telemedicine, and worked on administrative stuff for the next adventures.  Since January 1, I worked a week in Iowa, attended a funeral in San Francisco, got Veterans Administration training in Pierre and Sturgis, South Dakota, and started work in 1 of 10 of the VA’s Community Based Outreach Clinics (CBOC) in South Dakota.  Any opinions expressed are mine; any resemblance to VA opinion or policy is coincidental.

Up until this now this assignment has brought one new Parkinson’s patient daily.  A few have the classic “pill-rolling” tremor, but all had lost music from their voices and animation from their faces.  None had normal arm-swinging with walking, and all shuffled when making a 180-degree turn.

I told all of them (or their caregivers) that treatment (carbidopa-levodopa, tradename Sinemet) would not slow the progression of the disease but would help the symptoms.  I emphasized that I never want the treatment to be worse than the disease; thus anyone not bothered by symptoms would probably be bothered by treatment.  And the medication for mild symptoms can’t bring anything better than mild improvement. 

This week I started hearing back from the first patients I diagnosed.  One expressed delight at being able to resume household tasks.  But one had significant side effects from the first pill and I advised against taking the second. 

I heard from a tele-neurologist last afternoon about an unrelated patient, and I used the opportunity to get teaching on how to better treat my Parkinson’s patients.  While Sinemet remains the mainstay of treatment, he gave me some pointers on how to initiate therapy.   

I mentioned my distress at the amount of Parkinson’s I see in my Viet Nam veteran patients.  The smiles of collegiality fell from our faces while we dwelt on the downstream horrors of Agent Orange.

Yet this week I didn’t see a single new Parkinson’s patient till to day in a veteran approaching 90, who had noticed no symptoms.  “Nothing moves fast at your age,” I told him, “And I don’t foresee rapid disease progression.  If you notice balance problems, stumbling, or falling, come back and we can discuss it.  If it’s a problem in, say, 20 years, just remember that I noticed it first.”

Weight loss makes me worry

Exercise, I’ll tell you that

Muscle will replace lot of fat

Good advice on a diet?

Does anyone try it?

Cause it won’t make you abdomen flat.

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 Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.   I did 10 months of telemedicine in my basement, followed by 5 months staffing a COVID-19 clinic in southeast Iowa.  Since autumn, I’ve relaxed, exercised, done some telemedicine, and worked on administrative stuff for the next adventures.  A week in Pittsburgh, 8 continuous call days, almost a day at home. I am working as a contractor for 1 of 10 South Dakota Veterans Administration clinics.  Any opinions expressed are mine; any resemblance to VA opinion or policy is coincidental.

I cared for 6 veterans today. 

5 need to lose weight, they know and I know it.  I have wonderful dietary advice that has yet to help anyone to shed pounds and I gave out small amounts but I hold no illusions.  I used more confidence and enthusiasm giving out exercise advice because more people take it.

The 6^th vet, in contrast, went from grossly obese to svelte.  I expressed my concern, and started a major work-up. 

I didn’t express the worry that I feel because I don’t want to alarm the patient.  I left it up to the patient to say the C word (cancer).

Weight loss in 21^st century United States is not normal.  Because males comprise 90% of the patients, I examine the belt, and I count the new holes.  Between two patients so far this week, I have seen 13 new belt holes.

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The patient gave me permission to write the following:  cleaning heavy equipment brought a hand-held tool at high speed into a stationary object, producing pain in the muscles between the neck and the right shoulder blade. 

As I have been doing since before med school, I felt for an interruption in the ridge-valley-ridge-valley sequence in the midline of the back, and confirmed the site of greatest tenderness.  Soft tissue massage brought relief to the tender spot in the muscle, and osteopathic manipulation (“back crunching”) did away with almost all the rest of the pain.  After which the patient said, “I would have called my chiropractor, but he’s a state senator, and his office is closed while he’s in the legislative session in Pierre.”

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Half of my patients today carry the diagnosis of prostate cancer.  Agent Orange’s proven causation of that disease explains some but not all the cases. 

So far this week I have yet to make a new Parkinson’s diagnosis, and we only have Thursday and Friday left. 

But while sweating on the elliptical at the gym I saw a man walking the track with a stiff gait and poor arm swing, and as he made more laps I watched his face for the loss of animation (medicalese=poverty of affect).  But as he walked he loosened up, and when I finished the signs that I found so florid at the beginning of his work out faded to subtle.

A Parkinsonian patient per day

Parkinson’s?  Maybe you’ll shake

So badly you can’t cut your steak

No definitive test. 

So you might think it best

A Sinemet challenge to 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. I followed 3 years Community Health Center work with further travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.   I did 10 months of telemedicine in my basement, followed by 5 months staffing a COVID-19 clinic in southeast Iowa.  Since autumn, I’ve relaxed, exercised, done some telemedicine, and worked on administrative stuff for the next adventures.  A week in Pittsburgh, 8 continuous call days, almost a day at home.  I am working as a contractor for 1 of 10 South Dakota Veterans Administration clinics.  Any opinions expressed are mine; any resemblance to VA opinion or policy is coincidental.

I haven’t seen more than 8 patients per day.  Yet up until today, I found one new Parkinson’s disease patient daily.  

Until I started with the VA I had no idea that Agent Orange caused 8 different cancers, ischemic heart disease (commonly called heart attacks), hypothyroidism, and a couple of unusual skin conditions (chloracne and porphyria cutanea tarda).

And Parkinson’s disease.

When most people think of Parkinson’s, they think of the tremor in the hands that goes 5 times a second.  Diagnosis comes easily for those patients.  But years ago I learned that a person destined for Parkinson’s will develop quivering muscles between the thumb and forefinger long before an outright tremor.  Then I started to watch for the stiff, leaning gait without arm swing, and the face losing animation, and to listen for the speech losing music.    

Over one lunch hour I tuned my computer to YouTube and watched Parkinson’s diagnosis videos.  I learned more tells of the disease, including decreased eye blink frequency, and mysterious pain that responds poorly to usual therapeutic and diagnostic measures. 

Yet we lack a single touchstone physical finding or gold-standard test for Parkinson’s.   The closest we have is the Sinemet (carbidopa-levodopa) challenge: we give the medication and see if it works.

For the first time since I started, I didn’t see a new Parkinson’s patient.  But I got calls from two of the first ones I diagnosed.  One felt much better on the medication, the other had side effects worse than the symptoms. 

I ate lunch at a nearby restaurant.  The man at the next table shook with Parkinson’s, so badly he appeared untreated, so badly he could barely keep food on a fork.  Which might mean he was misdiagnosed, or that he hadn’t sought help, or that he had side effects from Sinemet.  But he wasn’t my patient.  I had the urge to lean over, ask if he were a veteran, and whether or not, give him a diagnosis. 

Out of respect for his dignity, I didn’t approach him as a physician in public.

A real cowboy

He survived the Vietnam battle.

And now out where the diamond backs rattle

He works on a horse

With courage of course,

Supplying the country with cattle.

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 Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.   I did 10 months of telemedicine in my basement, followed by 5 months staffing a COVID-19 clinic in southeast Iowa.  Since autumn, I’ve relaxed, exercised, done some telemedicine, and worked on administrative stuff for the next adventures.  A week in Pittsburgh, 8 continuous call days, almost a day at home.  We have come to San Francisco for a funeral.  I am working as a contractor for 1 of 10 South Dakota Veterans Administration clinics.  Any opinions expressed are mine; any resemblance to VA opinion or policy is coincidental.

One of my patients (who gave permission to write more than I have) chews tobacco and doesn’t want to quit.  He drinks, in his words, “a lot” of whisky on Saturday night.  He works as a ranch hand, feeding cattle, and works on horseback. 

He politely but firmly declined the COVID-19 vaccination.  In fact, he declined all vaccinations. 

He did 18 months in the infantry in Vietnam, much of it combat.  He managed to escape the ravages of Agent Orange. 

We sat quietly for about a minute, then we talked honestly.  He never wanted his life to be ruled by fear.

He told me about his octogenarian coworker who shows up every day on time, and works hard till the sun goes down.  Except during calving season, when everybody on the ranch is up all night. 

Then he lost his reserve and described the ranch hands in their 30s who work for 3 or 4 days and then disappear. 

We both shook our heads at the decadent state of American masculinity, so much deteriorated in just 3 generations. 

“When did that start?” he asked. 

The Second World War left a generation of men with PTSD.  They loved their sons but tried to make up with material goods what they couldn’t supply emotionally.  The senseless Southeast Asia conflict killed too many who had the courage to fight, and preserved those who would question the idea of giving up their lives for their country.  That same war ended up weakening the whole notion of gender roles. 

But I didn’t think to say those things.  Instead, I asked him to compare the long underwear of 40 years ago to his Under Armour.  He grinned.  We agreed that it brings exceptional comfort.