Archive for the ‘Nebraska’ Category

Leaving Nebraska. For now.

September 6, 2016

On the plains I worked for a week

The enjoyment was close to my peak

A lot of folks I befriended

But then the need ended

And new work I’ll now have to seek.

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, travelled 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. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska. Getting my wife’s (benign) brain tumor treated took a large part of the summer, then a week each in urban Alaska, Pittsburgh with family, and western Nebraska.  Any identifiable patient information has been included with permission. 

 

A week passed quickly on the plains of Western Nebraska.

A respiratory virus, looking for all the world like influenza, with fever, cough, and ache, but also with runny nose, and lasting the better part of a week, provided 1/6th of my clinical material.  I really didn’t do anything for those patients except recommend Tylenol, fluids and rest.

Seasonal respiratory allergies accounted for an equal number. My two favorite drugs in that regard, Zyrtec and Flonase, now available without a prescription, have high quality evidence to support their use.  Still I gave instruction on how to use Flonase based on personal experience.

I took care of a patient with an agricultural injury, and, in the process, learned about Stewart’s Wilt, an important corn disease, which originated not far from where I worked.

I sent two patients to the new MRI, and, surprisingly, both scans picked up significant pathology.

I didn’t get a chance to take care of any hospitalized patients, but I did get the chance to talk to a couple of new doctors with a passion for rural medicine.

I had a wonderful conversation with an Army linguist, and found Arabic has 3 Hs. I got to talk about how Navajo has the only click outside of Africa (the initial consonant in string and goat, the middle consonant in blue).  We had a marvelous time tossing jargon back and forth and singing praises of Rosetta Stone.

I used my massage skills to make one of my patients better before leaving the clinic.

I started a complicated endocrine investigation, and will probably not know the results.

I kept at least one patient out of the hospital with Gatorade.

One twelfth of the patients came in with dermatologic problems. I recounted the remarkable experience my son-in-law, my daughter and I had at a Continuing Medical Education event in Pittsburgh, where the lecturer announced that we can now treat pityriasis rosea (with the same antivirals we use on herpes viruses).  He went over his daughter’s experience with a red rash in a “Christmas tree” distribution just before her wedding, with no time to change her backless, strapless wedding gown.  He told her nothing could be done; twenty smart phone minutes later she showed him his error.

All in all, I took care of 36 patients, the same number I used to consider optimal for a day’s work in private practice. In those days clinic hours went 9 to noon and 1:00 to 4:30, with two hours dictation after supper.

I had a great time. I bonded well with staff and patients, but, towards the end, though the installation might invite me back when one of their docs takes a vacation, I realized they don’t need my full-time services now.  My experience exemplified the success of the locum tenens concept.

I even got out a couple of hours early. On a Friday afternoon.

 

 

 

 

Mud pit volleyball

August 3, 2016

After rounds, we went to the fair.

Who knew what we’d find there!

But a volleyball flood

Made a pit full of mud

There was plenty of fun to spare.

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, travelled 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. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

 

I made Saturday hospital rounds on three patients, discharging one, getting another ready for discharge, and continuing treatment for rather serious illness in a third.

We went over to the Farmer’s Market. We arrived too late to get the tomatoes that we crave, and our current cooking facilities (a microwave oven) wouldn’t let us take advantage of the good ranch chickens on sale, but we bought a cantaloupe driven in from Rocky Ford in Colorado.

Afterwards, Bethany and I headed out to a nearby (a relative term in western Nebraska) county fair.

A county with a small population holds a small county fair, one which we can circumnavigate on foot with no problem. We saw prize-winning cattle, sheep, goats, pigs, and rabbits.  We took in the exhibit hall and learned about elk and the importance of solitary bees.

Despite seeing a lot of mounted people and we arrived too early for rodeo.

But we found a couple of volley ball games in full swing.

As near as I can tell, there are three kinds of volleyball: indoor, beach, and mud pit. And I hadn’t known about mud pit volleyball before today.

Imagine a beach volleyball court excavated to a depth of 5 feet and filled knee deep with water. Participants might wear sneakers or they might go barefoot.  As the event progresses, the water gets muddier and the bottom gets more slippery and uneven.  Those inherent difficulties of trying to move radically change the character of the game, and Newton’s Laws bring a comic flavor.  Diving doesn’t work, and only the foolhardy jump.  If the ball comes to you, great, and if it doesn’t you don’t have a lot of choices.  I saw a lot of unintended slapstick comedy, including an all-out pratfall with both feet off the ground, a short-lived full water clearance, and a high-splash back-flop (like a belly flop but on the other side).  Eventually, those at the sides of the pits started to slide towards the middle.  The wind, always a factor on the Great Plains, gave a distinct advantage to one side. 

They say that the more seriously you take something, the less fun you have doing it. And I think those teams who lost had just as much fun as those who won.

 

Sports physicals and good horses

July 30, 2016

Out here they have nothing to hide

They think it’s important to ride

The unified force

Comes down to a horse

They’re cowboys and cowgirls, bona fide.

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, travelled 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. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

Thursday the construction noise had become intolerable. I put on my shooting muffs, and stepped out the side door.  The worker operated an electric jackhammer, not a drill, detaching a concrete lip from the foundation.  I waited till he had hacked off a chunk, stopped his machine, and repositioned.

“Excuse me,” I said, “Um, any idea how much longer you’re going to be?”

“Almost done, probably by lunch,” he said.

“Do you have hearing protection?”

“Yeah, “he said, “In the truck.”

“Take it from me,” I said, “If you want to be able to hear the voice of your grandchildren, protect your ears.”

I had a productive day, between outpatient and inpatient I attended 14 people.

Sports physicals, required by school districts, don’t save lives and don’t prevent injuries. On average, less than once every two years I detect a problem during a pre-participation exam that I can do something about.  Still, the visit goes quickly, and I get to educate the kids.  As the athlete sits on the exam table I ask what sports.

Here in western Nebraska a lot of the students start their list with rodeo. Ranching and wheat dominate the agricultural sector.  People rely on horses for work and for play.  Ranch work goes much easier with a good horse and good roping skills.  People favor quarter horses for their intelligence and speed.  So when the kid says rodeo, I ask, “Do you have a good horse?”

Sometimes the face lights up and the grin follows, and I infer, that, indeed the horse is a quality animal. And sometimes the answer comes back, “Pretty good.”

Patient flow slowed to a negligible trickle on Friday; I attended three times more people in the hospital than in the clinic, where I only saw one.

I greatly enjoyed that patient, who gave me permission to write that I diagnosed piriformis syndrome (see my post from 2010), one of my favorite problems because I can fix it before the person leaves.

The insurance credentialing process has cleared me for 4 insurances but not for the majority. I do not understand why, because I had full credentials when I worked here in January.

So I had a slow week, and I would have preferred more patients. All in all, I saw entirely too much drama and irony in for form of patients paying the ultimate piper for their dance with tobacco.

 

Colleagues, vitamin D, and statin myopathy

June 20, 2016

There once was a doc from Manhattan

One day we just fell to chattin’

I asked, “What would it take

Besides a muscular ache

To get someone off of a statin?”

 

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, travelled 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. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter found me working in western Nebraska and, later, in coastal Alaska.  After the birth of our first grandchild, I have returned to Nebraska. Any identifiable patient information has been included with permission.

 

Merkin’s Law states that any patient given a high enough dose of a statin for a long enough time will eventually hurt so badly exercise becomes impossible.

We call the drugs statins now because the generic names all end with those two syllables, but when they first came out we called them HMG coA reductase inhibitors. We used those drugs for years to lower cholesterol, in the hopes of decreasing risk of heart attack and stroke.

More than 20 years ago, though, a cynical doctor at the back of a lecture hall questioned the utility of that class of drugs if we got no net benefit in all-cause mortality. It seems, he said, that for every life saved from heart attack or stroke, one was lost to homicide, suicide, car accidents or respiratory infections.  The crowd laughed at the litany of diseases.  A year later, at the same Continuing Medical Education event, we chuckled when the same scene played, and a year after that, nobody laughed.  Aggressive drug company marketing fueled the cholesterol hysteria but I never developed a passion for treating cholesterol numbers.

My wife, after 3 years of statin therapy, over the course of 5 days developed such severe aches that her Tae Kwon Do class missed her black belt till she quit the med and recovered. Such circumstances did not endear that bunch of drugs to my heart.

Still, in context, I have the obligation to give my patients standard of care. I tell them about diet and exercise almost to the point of nagging, then I start the statin, and I warn them about side effects.

In the last two years, we have gotten convincing evidence that high-dose statins, regardless of cholesterol numbers, improve the outlook for those at high risk of heart attack and stroke.

Still if a statin patient hurts for no good reason, I tell them to stop the med, but I also test the blood for creatine phosphokinase (abbreviated to CPK or CK).

I outlined my personal algorithm to my colleague, and described my strategy of stop and rechallenge, and, if need be, use of coenzyme Q10.

He told me, gently, that coQ10 does no good, but switching to a lipid soluble statin does.

I found the discussion so constructive I went online, and found, to my chagrin, that he was right, and my past experience with coQ10 relied on the placebo effect.

I stuck my head in his office, and told him he was right. But I also told him I learned to check the thyroid and the vitamin D in those cases.  He looked at me with the same amazement I felt when I’d read about lipid-soluble statins.

We both emerged from the experience better doctors.

Transferring a complicated patient 3 hours away

June 6, 2016

I handled the case presentation

With the addition of great complication

Planned down to the comma

This tale of drama

Ran a full minute’s narration.

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, travelled 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. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter found me working in western Nebraska and, later, in coastal Alaska.  After the birth of our first grandchild, I have returned to Nebraska. Any identifiable patient information has been included with permission.

On Friday a patient and I walked down the hallway. I said, “I write a blog.  Now I won’t write your gender, age, race or diagnosis, but I’d like to write that I took care of a very complicated, sick patient requiring lots of lab and x-ray and referral to a higher level of care than we can give you here.”

“Yeah, OK,” the patient said, and looked sideways at me.

I called the referral hospital, 3 hours away, and presented the case to the ER physician.

I do case presentations the way I used to do radio commercials in the early 70’s, during my college radio years at WYBC. If I can’t say it in less than 60 seconds, I need to reorganize.  This subgenre of the short story, when done well, presents human drama condensed down to the density of gold.  The very fact of doctor talking to doctor about a patient means that something important happened.  In a sense, it’s short play to a small audience.

I presented the story according to the conventional order: age, gender, race, presenting complaint, history of presenting illness, past medical history, social history, physical exam, lab, x-ray, EKG, and my working diagnosis, followed by the request, “Will you accept the transfer?”

“Yes,” the other doc said, “Of course. This is a very sick patient, but, I don’t quite understand, are you in the ER?”

No, I replied, I’m a locums. They send me the walk-ins.  Essentially, I’m doing Urgent Care, with benefits.

“You mean you did all THAT in Urgent Care?” she asked, flabbergasted.

I cared for 8 patients that day, the youngest 15, the oldest 95; 2 inpatients, 6 outpatients. I only wrote 3 new prescriptions but I stopped two others.

Though I used to look at a clinic day of 32 patients as nerve-wracking light, and 36 per day as perfect, I felt good when I left at 5:30. Learning a new EMR system takes weeks.

And towards the end of the day my ability to send prescriptions electronically directly to pharmacies suddenly stopped. While I saw the last patient, of course more complicated than anticipated, a team of 4 figured out that restoring that ability couldn’t happen, and set up my machinery to print prescriptions to be faxed.

But Bethany and I left the hospital behind, and drove to Denver, arriving after sunset, for a family gathering.

 

An afternoon with 3 patients

June 2, 2016

This afternoon, I was happy to see

Patients, but really just three

I couldn’t send the prescription

Without a description

Of where the button happened to be.

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, travelled 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. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter found me working in western Nebraska and, later, in coastal Alaska.  After the birth of our first grandchild, I have returned to Nebraska. Any identifiable patient information has been included with permission.

No work for me on this last Monday because of the holiday; I spent Tuesday getting trained for the new EMR. The Basic Life Support (BLS) class took up most of Wednesday, and I left without seeing a single patient.

This morning I looked in on two hospitalized patients that I’ll care for on Friday.

Then I listened to jackhammers outside my office window for the rest of the morning while I did more BLS instruction on line. After all, hospitals only finish up their construction when they die.

My afternoon included 3 patients, scheduled at the rate of one per hour to allow me to figure out the new system. Two came from my generation, one from my parents’ generation.  The first I treated by taking away a medication.  The second, with a very complicated history and a long med list, I treated with gravity.  The EMR guru, sent by the vendor to help the transition, and living away from home for months, gently and patiently talked me through the documentation.  Then, after hours, he needed to leave for family business.

I had to prescribe a medication for the last patient, something I’d not done so far. My nurse, a stranger my end of the EMR, couldn’t help me with a very confusing task.  At that point, late in the afternoon, all the other providers had gone home.  One other remaining nurse stood over my shoulder, and told me what to do.

She had me click on an ellipsis, and then clicked her tongue and said, “Well, I’ve never seen that before.”  Fifteen minutes later, we resorted to calling the prescription in.

It reminded me of the time when the airline scanner wouldn’t take my boarding pass and my name ended up hand-written on the passenger manifest.

At the end of the day, Bethany picked me up. We stepped into an afternoon with a light breeze and a perfect temperature.  Atypical rains have left the sky clear blue and the countryside lush green.

I regretted keeping her waiting when all I’d done was take care of three patients.

Return to Nebraska

May 31, 2016

I wonder what could be cuter

Than an easy to use computer

But here is the deal

For the ones that are real,

You need a professional tutor.

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, travelled 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. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter found me working in western Nebraska and, later, in coastal Alaska.  After the birth of our first grandchild, I have returned to Nebraska. Any identifiable patient information has been included with permission.

 

Western Nebraska has greened up since I left in January. The temperatures hover near a perfect 66F.  But the same pure white clouds scud across the same clear blue sky.  I walked into the hospital where I worked last winter.

I called it the most reasonable job I’d ever had. One Saturday clinic every 4 weeks, no nights, always finished before 6:00PM and almost always before 5:30PM.

A lot of people grinned when they saw me.

I heard about two of my patients, one with a neurologic problem and one with a chemical problem, who had started to improve with my care and had done very well since.

I also heard about the transition to a new EMR, so that the outpatient and inpatient sides could talk to each other. And, indeed, my task to day consisted of learning the new system.

Superficially, it looked familiar, but I have learned 11 new EMR systems in the last 18 months. I try not to get whiney about quirks that impede work flow and make no sense; I just try to master the task at hand.  However, RPMS, the system I used in Alaska from February through April, made the most sense, and I found it the easiest to use.

I got back my old office here, but the temporary CT scanner trailer outside the window has left, giving me a very nice view of the sky.

I spent more time with Continuing Medical Education (CME) than on computer training in the last year and a half, but not by much. The worst training was from a person who wanted to get her 15 students out early and went way too fast, the best was from a gifted teacher who worked one-on-one with me for three days, combining orientation and EMR.

Today I sat in front of a computer screen and talked to a trainer in Arizona over a speaker phone. Parts of the system looked familiar, most didn’t.  Real fluency and economy of motion will take time, but I have to start somewhere.

In small towns like this, the sound of a helicopter means someone’s serious illness. I heard the unwelcome thwap thwap thwap of the rotor blades while I talked to the Arizona trainer about some of the fine points of documentation for billing purposes.

I prefer taking care of patients to dealing with computers, but here I found myself torn: my favorite patients have problems where I get to think, I don’t find them on the brink of death.

The chopper landed just outside my window. I had to ask for half a minute of quiet at the peak of the landing noise.  Then, while unspeakable drama ran rampant elsewhere in the hospital, I went back to the intricacies of an Electronic Medical Record system.

 

Discharge summaries

January 30, 2016

I can’t believe how the time flies

We’ve already said our goodbyes

I got into the groove

And now we must move

And drive east into the sunrise.

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, travelled 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 am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. I just finished two months in western Nebraska. Any patient information has been included with permission.

 

Friday dawned clear, cool and bright. We got up early for the finishing touches on moving out.

The townhome the agency rented for us surpassed all expectations with cathedral ceilings, hardwood floors, good construction, comfortable mattress, serviceable equipment, and a killer view. I moved stuff out the front door to the walk by the car while Bethany packed. We left notes for the landlord and the neighbor.

We stopped at the hospital. I had forgotten one bit of documentation when I discharged a hospital patient on Wednesday.

The discharge summary recounts what happened during a patient’s hospital stay. When I finished residency, I would go through the whole chart from the first day, giving lab values, reading x-ray and consultation reports, and recounting vital signs in detail.  Later I learned to dictate my hospital notes so I could do the discharge summary from them.  Later still, I changed my model to answer the question: What does the next doctor need to know?

In the 80’s I deliberately waited two weeks after discharge to do the summary, because vitamin B12 levels and thyroid functions could take that long to come back. Paper charts in those days dominated the doctors’ lounge; you couldn’t get your coffee without being reminded you needed to clean up your paperwork.  And you could see everybody else’s backlogs.  I’d clean things out once or twice a month.

By the last half of the first decade of this century I had started to dictate the discharge summary at time of discharge, so I could have a copy when the patient came to see me a week later.

Some attending physicians pay residents, Physician Assistants, or Nurse Practitioners to do the discharge summaries.

Now the hospital’s Electronic Medical Record puts in all the lab values, discharge medications, and x-ray reports. I summarized 11 days of hospital care with 4 sentences typed into the middle of the document under the heading Hospital Course.  The next doc will have to scan through pages of note bloat to get to the part that he or she will need to know.

With all the documentation done, we drove the loaded car through town to a chain diner.

Over a luxury breakfast out, we talked about how fast the time had gone. It hardly seems two months since we arrived.

I found 4 new cases of Parkinson’s disease, 2 new cases of hypothyroidism, and 1 case of vitamin B12 deficiency. I referred people with, variously, a hernia, a hot gallbladder, and a bad appendix to the surgeon.

When major trauma cases came in I kept things moving in the outpatient clinic.

On the weekends when we didn’t go to Denver, visit a niece in Wyoming, or go shopping at Cabela’s, I made rounds in the hospital.

We went to the movies three times; the tickets cost less than half of what we usually pay.

We ate at every Chinese restaurant in town at least once. We saw eagles, deer, jackrabbits, migrating ducks and geese.

After breakfast, we started east down the highway, under clear blue skies with the wind at our back.

Winding down in Nebraska

January 28, 2016

I started out making rounds

As my current assignment winds down

Right now it’s Nebraska

Next week, it’s Alaska

On Friday I’ll be homeward bound 

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, travelled 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 am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

At the end of Monday inpatient rounds I found one patient on my afternoon schedule, and when I finished I had seen 11. The age range falls heavily on the extremes: most patients either of preschool or Social Security age.  Despite the fact that the US has the lowest rate of smokers in the industrialized world, tobacco related illness accounted for more than half of those patients.

I discharged one of my two hospitalized patients. I try my best to be a good hospitalist, and I tried to call the attending physician at an office a half-hour away, instead I reached the nurse.  The patient would follow-up there for monitoring lab values.  I passed on a consultant’s recommendations.

Here, as everywhere, the geographic imperative impacts my approach to patient care.  Back home  I don’t even consider risk when asking a consultant to stop by a patient’s room, but here I have to think about the hazards of putting the patient on an ambulance for an hour, or going three hours for testing to a major medical center.

Sometimes the people who live here talk about “Radio Free Nebraska,” where the search function on the car radio may fail to find anything for the rest of the trip. Still, each village or town has its unique specialty; a tree nursery and sawmill here, a bridal boutique there.

Before I tell a patient to make a follow up appointment, I ask how far away they live, and I have to take time, winter highway danger, and the cost of travel into account. For anyone who lives outside of town, I say, “Don’t come if it’s snowing, call.”

In the afternoon on Tuesday I picked up another hospital patient. The Emergency doc had done the admission and put in the original orders.

At the end of the day I faced a room full of patients, some of whom had appointments and some of whom didn’t. As I went through each person’s history, the family’s background emerged, shards of tragedy, accident, desertion and betrayal against a backdrop of economic trends, population shifts and changing social expectations. People’s bodies can be impacted by germs, as well as laws of physics, or history.

I have limited ability in such cases to fix the basic problem. But I can only do four things: medicate, operate, manipulate, or educate.  Sometimes the human capacity to love leaves me thrilled, and sometimes people’s capacities for perfidy astounds.

Today, Wednesday, I discharged both of my hospital patients. I called the attending physicians.  I dealt with an EMR system that sometimes turns orders into vapor.  Getting a patient out of the hospital generates a flurry of activity, proof that all change generates chaos.

My first and last outpatients of the day required surgical consultation. I walked three steps across the hall, presented the case, and got things ready for both.

I had plenty of time to clear up my documentation and to clean my desk. The staff held a potluck in honor of my next-to-last day.

 

 

 

 

 

 

Shingling me out

January 24, 2016

It has to do with our skins

And it started with needles and pins

After six weeks of tingles,

I came down with the shingles

But it hasn’t cut down on my grins.

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, travelled 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 am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

This case concerns a 65 year old male with shingles.

I’ve seen two other patients with shingles here in western Nebraska so far. I started both on Valtrex during the first visit.  Easy diagnosis, any rash that follows the path of a skin nerve (dermatomal distribution) names the process.  Therapy of the immediate, acute phase of this problem is straightforward.

With this disease, I worry the most about post-herpetic neuralgia, which can happen after shingles. It happens mostly in the elderly, and sometimes they hurt till they die.  During my training, we had no good treatment.  Narcotics work for no more than a few weeks.  We didn’t know at the time that capsaicin cream and seizure medications work, and work well; although we had the tools available we didn’t know how and when to use them.  Generalists who tried to treat a patient with hopeless, severe pain would either burn out and retire or move, or send the patient to the neurologist, who would either burn out, retire, or move.  Now I only refer the patient out if I fail under my “3 strikes and I’m out” policy or if the patient requests.

If a patient, after shingles, shows up with pain where they had the rash, despite rash improvement, I will lightly stroke the area involved, and ask if it hurts. A positive finding, allodynia, pretty much cinches the diagnosis.  I like to start with capsaicin cream; available without a prescription, it depletes the structures of a particular part of the nervous system called the dorsal root ganglion of the chemical needed to transmit chronic pain signals.  If that doesn’t work,  I skip on to the anti-epilepsy drugs Depakote or gabapentin.

I can write publicly about this patient because I’m writing about me. Over the last six weeks I’ve had a tingling sensation, paresthesias, on the right side of the back of my neck.  Always worse under stress or time pressure, it came and went, and I ignored it.  I’d had something similar over the summer.  I consulted by phone with my doctor, who agreed that it could have been the prodrome, or warning signs, of shingles.  I took Valtrex and the rash never appeared.

This time, I decided to test the hypothesis, by ignoring the pins-and-needles that would crop up for no reason from time to time, last a minute or so, then disappear for no reason.

Last night, we were coming home from the movies when I noticed two sore spots on my neck, just the size of chickenpox. This morning, on rounds, I pulled my colleague into a room and showed him my rash.  He looked where I pointed at the front of my neck, followed  around to the back of my neck, confirmed my suspicion, and advised Valtrex.

Of course, a few milligrams of prevention is worth kilos of treatment, and the shingles vaccine, Zostavax, is a really good idea for anyone on Medicare. I plan to get mine when I visit the VA next week.