Archive for the ‘Being a doctor’ Category

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.

How did those samples find me?

May 11, 2017

The samples can help people quit
Without the nicotine fit
Tobacco detox
In a little brown box
Came free, and it made quite a hit.

 

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 ten days ago I found a box on my desk, sturdy cardboard, about 6 inches on a side. It held Chantix samples from Glaxo, Smith, Kline.
I hadn’t asked for the samples, I’d signed no papers for them, and I have no idea how GSK knew where I am. After all, I’ve only been here since February.
And they were the right samples to treat exactly one patient: a starter pack, because abruptly starting full dose Chantix risks major side effects, and two months follow-up therapy. Chantix turns out to work better in real life than it did in the lab; it works more consistently than anything besides quitting cold turkey.
The first patient of the day came in for other things (and gave me permission to write what I’ve written). But just like I do for everyone else, I asked if he smoked.
And, indeed he does.
I used to lecture people on the evils of smoking. By now, though, everyone already knows all the bad things about tobacco. Lecturing only brings antagonism into the relationship; “educating” the patient can thinly mask judging the patient.
These days I use a script from Motivational Interviewing, a technique that capitalizes on ambivalence. I hold my two forefingers a foot apart, and I ask, “On a scale of 1 to 10, where 1 means you’re not ready to quit, and 10 means you’re ready right now, how ready are you to quit?” If they say 1 or 10, I stop. For any other number, I ask, “Why not 2?” Mostly the smokers don’t get the question, and will tell me the bad things about tobacco. I interrupt them, explain that they weren’t ready for the question, and ask them the 3 best things about tobacco. When the patient understands what I’m asking, they mostly talk about stress relief, anxiety, and habit. A few talk about taste. One said “Breakfast, lunch, and dinner.” After they tell me their favorite things about tobacco, I give them a blank stare for 3 seconds, then change the subject. The idea of Motivational Interviewing is to get the patient to think.
But this patient gave me an enthusiastic 10. I don’t get many of those, just like I don’t get many 1s. And he’d done well with Chantix in the past. In fact, he wanted me to give him a prescription for Chantix. “I’ll do better than that,” I said, “I will give you the Chantix.” And 90 second later I reappeared with the samples.
He already knew how to use them, and he already knew about side effects.
I couldn’t think of a more appropriate way to use the samples. Tobacco makes any other medical problem worse.
I enjoy helping people, but certain parts of my work bring me disproportionate pleasure. A low B12, a high TSH, or curing someone by stopping their statin makes my day.
This one came close.

Reflections on medical frauds

May 8, 2017

The system is inherently flawed

They want me to sign and to nod

They have no excuse

It’s all billing abuse

And I’ll say to their face, “You’re a fraud.”

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.

Sunday I visited a web site that promised to cure my tinnitus. It had all the marks of snake-oil fraud: heavy reliance on testimonials, repeated themes that the establishment didn’t want the product to succeed, recounting hard-to-believe medical horror stories for those that relied on established medical practice, and at the end the assertion that the narrator didn’t want to make money, he only wanted to do good for the world but mainstreamers would soon make him take down his website because of jealousy over his success.  Those tools exist because they work, and they nearly worked on me.  I wanted to believe.  But I knew if the narrator really just wanted to help people, he would have made the audio download available for nothing, and relied on contributions to keep the website up.

Towards the end of the video the phone rang. I listened to the robot,  pressed one, and told the live operator, “Your prerecorded announcement said I got the call because I’d responded to a TV back brace commercial.  Is that right?”

“Yeah.”

“How can that be? I don’t have a television.”

The line went dead.

This morning when I dove into my IN box  I found 4 faxes from a physical therapy operation in a nearby town, wanting me to sign off on very general orders for patients that I didn’t know and certainly hadn’t examined. I called the number at the bottom of the sheet, and spoke with a secretary who explained that the firm had a direct access program.  I tried to explain, in turn, that I could not in good conscience sign off on a patient with whom I had had no contact.  But as Mark Twain observed, it is difficult to get people to understand if their jobs depend on them not understanding.  I turned the papers over to our clinic manager.

Yet I also got a similar order sheet for medical supplies, and I checked with the staff; the doc whose place I’m holding indeed orders those supplies yearly, and I signed.

Our country has an enormous amount of medical fraud; vendors interested more in profit than patients buy a lot of late-night TV commercial time, and some people call in to get scooters and other durable medical goods. Over the years I had a lot of requests to sign off on knee, back, elbow and shoulder braces, none were needed.

Yet a few vendors offer diabetic supplies at greatly reduced cost. So I can’t just shred all the requests.  I have to read each one.  After all, the fraudsters only copy successful business models.

 

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.

Weekend call: nature abhors a vacuum

March 27, 2017

I took the weekend on call

I started with no patients at all

But I fixed that up quick

With the ill and the sick

The thin and the fat, the short and the tall.

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.

 Perfect people don’t come to see me. When I find a patient who has to face the music and pay the piper, I do my best not to judge.  Strangely, when I can condense my approach to, “You’ve made mistakes in the past, let’s move forward,” I find it easy to establish rapport.  I like to think that the rapport brings better chance of patient cooperation in lifestyle modification.  At the very least I have more energy at the end of the day.

In residency and in private practice, when I would take sign-out for weekend call, I would look first at the gross number. Of course we like it when no-one occupies a hospital bed.  But if the number came in really low, I’d shudder and remember the adage, “Nature abhors a vacuum.”

This weekend, I started call on Friday afternoon with a census of 0. By the time Saturday morning dawned, the census had climbed to 5.  Most, not all, had pneumonia.  Most, not all, sickened from a combination of tobacco damage and the aftermath of the influenza. I went into a rhythm of admission history and physical.

I dictate with sophisticated software. Still, sometimes I get so frustrated that I use my well-honed keyboarding skills.  For example, dictating a list gets me correct numbers except “4” which prints out as “for.”

And beneath the commonalities of fever, cough, and wheeze, each patient has a unique circumstance, a story of drama and irony that brought them to illness. And almost all have come at a time of stress in their lives.

Nothing is 100% in my business. A very few patients sickened gratuitously.  A genetic accident should not constitute a death sentence.

I enjoy talking with the patients. I ask them what they do in their spare time if they haven’t told me before I get to the question.  Over the years I’ve acquired enough vocabulary to speak meaningfully about a wide range of subjects.  Particularly in rural America, being able to talk about farming, crop yields, soil management, firearms, archery, and hunting gives me credibility.

Here in Clarinda, close to St. Joseph, Missouri, I ask people my age and older if they remember the Jerome Hotel.

It belonged to my grandfather. I drop his name.

 

 

 

What does “call” mean? Don’t look in the dictionary

March 26, 2017

Consider the places I’ve been

Then tell me, what does “call” mean?

For sometimes the word “call”

Means nothing at all

And sometimes it can make me turn green

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.

People can use the same word to mean different things, and the same person can use a word at different times to mean different things.

For example, when I worked in the Indian Health Service, “call” started at 4:30PM and lasted until 8:00AM. Weekend call started on Friday afternoon and lasted till Monday morning.

In my years of private practice, it started at 5:00PM and went till 7:00AM. The doc who took Friday evening call worked the clinic on Saturday from 9:00AM till 2:00PM.  The physician with weekend call started Saturday as early as he or she wanted, rounded on the patients in the hospital, and took care of admissions till 7:00 Monday morning.  For a long time we saw the patients who came to the ER, but that faded over the years.  The on call doctor did the obstetrics over the weekend.

Call in Barrow (now called Utqiavik) never meant anything other than 12 hours, weekend, weekday, or holiday.

In Petersburg, the physician on call also covered the emergency room.

In western Nebraska, being on weekend call meant doing a Saturday clinic till noon, rounding on patients Saturday and Sunday, and admitting patients from the ER.

In Metlakatla, where we had no hospital beds, the two main ER nurses had excellent clinical skills. I could rely on them to know when I needed to come in and when I could safely wait to see the patient in the morning.

I have call this weekend, starting at 8:00AM on Thursday and going to 8:00AM on Monday. During that time, I’ll round on the hospitalized patients.  But someone else will work the Emergency Room.  If a patient needs admission, the Emergency doc does an admit note and writes admitting orders.  If a patient needs me to come in and see them before morning, they generally need to be at a larger facility.

I have had two nights of call so far. The first one passed without my phone going off, not even once.  The second time I worked steadily till 9:00PM stabilizing a very ill patient for transport.

But what does call really mean, here, this weekend?

I can tell you on Monday.

And I can guarantee it won’t mean the same thing a month from now.

It’s not pernicious if the patient live

February 28, 2017

To test, I wouldn’t think twice

The abnormal I find ever so nice

And if that’s what they’ve got

I just treat with a shot

Still cheap at thirty times the price.

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 twenty years ago I stopped a neurologist in the hospital parking lot for a “curbside consult,” a long-standing tradition. These brief interactions transmit a lot of information.  In the days before the Internet, I realized I needed to know more about vitamin B12 deficiency than I could get from books or journals.

In medical school they taught us not to check B12 levels on anyone under 40. The characteristic findings on the blood smear, they said, with enlarged red cells, anemia, and white cells with too many nuclei, would show before anything neurologic; thus we shouldn’t run the expensive test if the person had a normal blood count.

Time has a way of slaughtering such dogma. I found myself in the middle of a diagnostic series of B12 deficiencies, the most recent at that time a 36-year-old with the classic blood findings. I modified my age criteria and, sure enough, found a very low B12 level, helping to account for symptoms of what otherwise looked like depression with clumsiness.

Before I collared the neurologist, I’d sat down to talk with the hematologist. In the course of 5 minutes I realized he didn’t know much more about the topic than I did.  Approaching the neurologist turned out well.

He said that anything under the lower limit of normal (has gone back and forth between 199 and 287 and has now held steady at 211) clearly shows a problem. Any B12 level over 400 can’t take the blame for a problem.  But the gray zone between 211 and 400 demands judgment.  Anyone with symptoms at or past age 65, he told me, should be treated.  At 35 cents a dose, you can’t justify the expense of further testing.

Since I started this blog in 2010, the price of vitamin B12 has gone from $.35 to $9.00 per dose, justifying further testing in the borderline area. Now when I have suspicions, I check levels of methylmalonic acid and homocysteine, two toxic byproducts that build up in the blood in the absence of adequate vitamin B12 and/or folic acid.

Just about anything neurologic, whether subjective or objective, prompts me to investigate. If someone complains of fatigue, numbness, weakness, depression, erectile dysfunction or trouble concentrating, I go looking.  And the same if the blood smear shows enlarged red cells (an increased MCV or mean corpuscular volume), or even a broadened range of red cell sizes (RDW, or red cell distribution width).

Last week I found 4 new cases of vitamin B12 deficiency on one morning, making me ecstatic to the point of silly. The next day I got elevated homocysteine levels  back on two other patients with borderline B12 levels.

We used to call vitamin B12 deficiency pernicious anemia because the patient always died, and I grew to love the diagnosis because as a frontline doctor I could save the patient’s life for 2 cents a day. Now it costs 30 cents a day.  It still makes me happy.

 

Giving bad news: it’s part of my job

February 27, 2017

I don’t wait till the end of the day

When there’s nought but bad words to say

I think that it’s best

To give one more night’s rest

Then suggest that it’s time to pray.

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.

Part of my job is to think of the worst things I can think of, and a couple of times a day I will tell a patient that what they really want to do is to walk away from the hospital shaking their head and muttering that I’m nothing but a darned alarmist. I run a lot of tests.  Mostly I look for things I can do something about.  Sometimes I run studies so as to hand the specialist a patient with a clear-cut diagnosis, or, at the very least, the first level of testing completed.  But sometimes I’m looking for bad stuff, mostly to reassure patients.  I’d rather be happy than right.

Rarely, the battery of lab and x-ray comes back normal. Most of the abnormalities, however, come as no surprise.  People know the dangers of drugs, tobacco, alcohol and promiscuity.

Every once in a while, I have to give bad news. And, after all the labs and CAT scans and MRIs I’ve ordered in the last few days, I’m going to have to give some Very Bad News tomorrow.

The report came in at the end of the day. I don’t like to give bad news on a Friday or of an evening, when we have nothing to do but wait.  And I don’t let the nurse give the bad news, that’s my job.  I prefer to give the worst news face to face, but once in a while, for the expeditious good of the patient, I have to do so by phone.  .

People have suspicions when I start the testing, and for the most part when I sit down with them they already know the problem. So I ask, “What do you think the (blood test, CAT scan, biopsy, MRI) showed?”  Almost always they’ll say they don’t know, and I change the subject for about 5 minutes, and ask again.  The third or fourth time they come up with the diagnosis, and I confirm it, and I tell them as much as I can about what to expect.

I emphasize uncertainty when I find it, but I don’t hold out false hope. And if bad news involves a child, I come prepared for verbal abuse when the parents blame the messenger.

It’s part of my job.