Archive for the ‘Medical Care’ Category

June 25, 2017

They come in, right off the street

The problem it seems, is the feet

And then when the pain

Makes them complain

Orthotics just can’t be beat.

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 have really bad ankles. I started with flat feet as a child, and things haven’t gotten better in the last 60 years.  Now I wear stiff hiking boots with orthotics you can, literally, drive nails with.  They keep me going.

A fair number of my patients, no matter where I go, come in with foot problems.

Most “ingrown” toenails result from people cutting a corner of the big toenail too short, temporarily relieving the pain but setting themselves up for worse problem when the nail grows out, cutting into the flesh. More than half the time the original problem stems from shoes functionally too small.  I tell people to keep their nails trimmed.  With a flair of showmanship I predict I’ll find a hole worn in their shoe lining from the big toenail, then I tell them to file a bevel into the end of the nail, making it both more flexible and easier to trim when it grows out.

Those with plantar fasciitis start the first step of the day OK, then the pain hits. But it gets better as the day wears on.  At the end of the day, they might sit and relax for 20 minutes but when they stand up they face excruciating pain.  I teach them stretching exercises, encourage them to lose weight, and advise new footwear.

Most WalMarts have a Dr. Scholl’s display; those orthotics (shoe inserts) can be the first step away from the pain. But if they don’t work, I recommend the podiatrist, or, sometimes, the orthotist, a person who does nothing but make orthotics.

The patient gave me permission to say that when I told her to take off her shoes and stand up, her arches sagged to the floor. They looked just like mine.

Then I talked about how I felt the first day I put my feet into the solid inserts. I walked away with a gait 30 years younger, my back straighter.

 

When good algorithms fail

June 7, 2017

The thyroid’s a wonderful gland

And if everything goes just as planned

When we get the right number

With good conscience we slumber

But there’s another approach to be scanned.

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 do a lot of lab tests and x-rays, and I interpret results in the human context. Every result pertains to a person in a psycho-social environment, a factor in a complex system where everything is related to everything, and you can’t change one thing without having an effect on everything else.  Thus the popular medical saying, “We don’t treat lab tests, we treat people.”

Hypothyroidism, where the disease stems from an underactive thyroid, a very important H-shaped gland that sits at the base of the front of the neck, stands as an exception to that truism. We treat numbers.  If we get a high thyroid stimulating hormone (TSH) value, we give a small dose of levothyroxine, T4, the same as thyroid hormone, escalating the dose by six week intervals until reaching a normal value two tests in a row.

(The higher the TSH, the more the patient needs thyroid replacement; it represents the brain’s plea to the thyroid gland for more hormone.)

The approach works well for more than 95% of the people with hypothyroidism.

The problem arises in that small segment of the population that doesn’t convert levothyroxine (a core with 4 iodines attached) to its more active degradation product, triidothyronine or T3 (the same core but with only 3 iodines). Because each T3 is worth 6 T4s.

I explained all this to a patient two days ago, who gave me permission to write what I have.

Most people with lazy thyroid glands have symptoms that can include fatigue, depression, constipation, aching muscles, cold intolerance, mental slowing, and difficulty losing weight. And the vast majority feel normal when the TSH creeps under 3.5.

But a very few patients still don’t feel right, and microscopic doses of Cytomel (the trade name for T3) can make some, not all, feel much better.

I wouldn’t know about this if my sister’s very good endocrinologist hadn’t inspired me to read further.

The problem arises that such methodology verges on what many mainstream doctors call “fringe medicine,” because of the actions of a very small number of unscrupulous doctors. I try to keep a low profile, and I ran the case by two of my colleagues.  One expressed mild surprise, the other, as it turns out, uses the same approach

 

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.

Have imagination, will catastrophize. Professionally.

April 16, 2017

Here’s a subject in which I’m well-versed,

And for 40 years I’ve been immersed

When it comes to the best

I’ll just keep it in jest.

I’m paid to think of the worst.

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.

Some people have a thought process that involves using their imagination to the worst possible effect. They think of all the things that can go wrong, and, sooner or later, they run into health consequences from dwelling on negative things that haven’t happened.  The medical profession has a term for this phenomenon; we call it catastrophizing.   As time goes on, the catastrophizer dreams up more horrible scenarios; they come to my attention when they develop insomnia, depression, and other problems.

I try to point out to the person in question that they couldn’t have anticipated the 10 worst moments of their lives, and that none of last 10,000 terrible “what ifs” they imagined came to pass. Therefore, it follows, that just by dreaming up negative scenarios, they prevented them.  Mostly, they don’t listen.

In the daily course of my work I think about the worst things I can imagine. I’m good at it, I’m a pro.  I have talent, training, and experience.  I can think of really terrible things.

Of course, like the experience of any catastrophizer, most of the really bad things I think of never come to pass. The thought doesn’t quite cancel out the possibility; I run the diagnostic tests.  At the end of the visit I frequently say, “You want me to be wrong.  You want to walk away from the tests shaking your head and complaining about what an alarmist your doctor is.”

A patient (who gave me permission to write this) came in with terrible pain in her hands. I thought of Lyme disease and rheumatoid arthritis, and ordered appropriate tests, but I also examined her med list and decided to at least temporarily remove the most likely candidate, her statin.  A week later, the pain is gone, and she feels better.

I also did not diagnose cancer, Lyme disease, syphilis, B12 deficiency, lead poisoning, measles, sepsis, and meningitis. Despite of string of previous successes, I also failed to find folic acid deficiency and polymyalgia rheumatic.

But I went looking for them. In my case, imagining the scenario doesn’t prevent it.  But, then again, I’m a pro.

 

 

Measles, a word the 7-year-olds haven’t heard

April 9, 2017

Here’s a contagious word to the wise

If there’s rash and runny eyes

With a cough, I suppose

Look! How runny the nose!

And it’s MEASLES! The CDC cries!

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 3 weeks ago I received an email from the Iowa Department of Public Health about a case of measles. The person (age and gender not given) had been in the Omaha airport on March 12.  Diagnosis of measles had come on March 15, after visiting 3 different healthcare facilities.

So I was on the lookout for a disease I hadn’t seen for 30 years.

Finishing my Indian Health Service contract in 1987 at the Tuba City, Arizona Indian Health Service Hospital, I saw hundreds of cases, and I had to learn about the disease. Measles discussions center on the 3 c’s: cough, conjunctivitis (runny eyes), and coryza (runny nose); the patient looks sick, and has a fever.  The rash starts on the face, and in the next three days works down the body, concentrating in the midline, armpits, and groin.  The 3-day or German measles has a similar looking rash that also starts on the face and spreads down, but people don’t get nearly as sick.

At the time, that reservation had an immunization rate close to 100%, but when the dust settled, the case count came very close to a 5% vaccine failure rate. Since then, the MMR has gone to a two-dose immunization schedule.

With the alert fresh in my mind, I had reason to think of the things I learned and saw so many decades ago. Working a game of incomplete and imperfect information, I called the state Department of Health.  Connecting eventually with an expert who had never seen the disease, but knew what to order, I heard for the first time of a viral transport medium called M4.  And I learned to use a culturette or a Dacron swan, not cotton and certainly not wood.

We still have no treatment for the disease. And with the illness almost extinct, we probably won’t invent one.  Yet measles still runs into complications in almost 10% of those who have it.

Exposure confers lifelong immunity, and only humans can get measles. Thus as an undergrad in anthropology, in one class we did calculations based on 2 week contagion, 3 week incubation, and generation length of 20 years to figure out how what size population can support the disease.  We decided, eventually, that measles couldn’t be more than 50,000 years old.

Measles remains contagious in the air for 2 hours after a person with an active infection leaves a closed room. Thus the case that triggered the alert, arriving on an airplane, exposed a lot of people.

I want to know about that case. What irony or drama surrounds the circumstances of inadequate vaccination?  Who did the exposing, and how sick did that patient get?  Where was the exposure, and was it linked to the Disneyland outbreak?

I never had measles as a child. The son of a physician, I served as a test patient when I was 14 for the first measles vaccine that only served to deplete what my meager natural immunity.  I had to wait till middle age to get an effective vaccine.

Later that day I asked a 7 year old if he’d ever heard the word, measles. “No,” he said, “What are they?”

The antivax movement makes no sense. Mercury has been removed from the vaccine, and all the evidence linking MMR to autism was fabricated by one researcher who has since owned up to his deception, yet that myth persists.

I fear that the antivaxxers may get enough traction to let the genie back out of the bottle, and that the word, measles, may once again become part of the language.

Chickenpox, and cannabis hyperemesis syndrome

January 3, 2017

The patient came down with some spots

All over, in multiple crops.

So I called up the State

To tell them this date

To watch out for chickenpox.

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 a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

I saw a patient with chickenpox today (and received permission to mention it and more in my post). Though outbreaks came a couple of times a year last century, the varicella vaccine has made the diagnosis a rarity.

The characteristic lesion starts out as a red bump. The bump grows a blister, characterized by the poetic catch-phrase “dew drop on a rose petal.”  Then follows a pimple (doctors say pustule), which collapses in on itself (medicalese=umbilication because it looks like a belly button), and scabs over.  To make the diagnosis, the patient has to have multiple crops of lesions, coming successively over the course of several days, visible in various stages of healing.

A very small proportion of those vaccinated, less than 1%, will develop the disease from the shot, sometimes a year afterwards. Among the vaccinated, 5% will get chickenpox if exposed to the wild virus, but the infection may be so light as to be unrecognizable.

Still my strong suspicion and the public health laws made me call the Alaska State Epidemiologist, and I found out that, in fact, the illness is currently circulating. In the end, I based my decision not to medicate on the number of days elapsed since onset and the desire for the treatment not to be worse than the disease.

I saw two cases of cannabis hyperemesis syndrome today; if a person smoke a large amount of weed for a long enough time, they start to vomit and very little can help them besides stopping the marijuana. I went to my favorite physician’s social media site, Sermo, to research the problem and found, to my surprise, the tendency of those so afflicted to crave hot showers and baths.

I saw two men with astonishingly similar injuries from astonishingly similar circumstances.

One patient came to me after a specialist work-up and MRI and many, many primary docs over the years failing to help. I listened without interrupting. I came to a much different conclusion, and advised that the dentist had a better chance than anyone of fixing the problem.  At which point the patient told me the diagnosis.  Not in medical terms, but in plain English.

 

An MD who acts like an osteopath

January 1, 2017

There once was a doctor named Still

Who wanted to cure more than bill

He went out on his own

For the crunching of bone

But retained the scalpel and pill

 

 

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 a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

In 1874, Andrew Taylor Still, MD founded osteopathy.

At the time, before the acceptance of the germ theory of disease, philosophical schools divided medicine. Allopaths, the dominant force, felt that illness came from outside the body.  Homeopaths felt that illness came from inside the body.

Still felt that illness resulted from a misalignment of the boney elements of the body, but embraced the scientific method and rejected dogma.

Time has marched on. Homeopathy gave rise to our discipline of immunology and our approach to allergies, but in 1954 Hahnemann University School of Medicine officially stopped being a homeopathic school.  Mainstream US medicine still calls itself allopathic, but recognizes autimmune diseases and medical problems arising from internal disregulation.

Osteopathy continues, distinguished only by teaching and use of osteopathic manipulation.

Michigan State, my medical alma mater, has programs for MDs and DOs. While I have an MD degree, my class was the first to cross the tracks to get instruction in osteopathic manipulation.

In fact, in my first undergrad career I had a roommate who had had a roommate who had been in chiropractic school, and via that long chain of learning, I acquired the skills to manipulate the spinal column. But I got those skills without the rest of medical school, so that I learned to manipulate without learning when or why or why not.  Yet, to the best of my knowledge I never hurt anyone.  I got a lot of practice on the young and the healthy.

(Daniel David Palmer, the founder of chiropractic, probably attended Still’s Osteopathic college in Kirksville, Missouri, for a short time.)

Osteopathy along the way evolved an approach to the patient that I find a good fit. The body, a complex system, functions as a unit.  Ask why the patient got sick before asking what you can do for the symptom.  Maximize the patient’s natural tendency to heal, and do your best not to interfere with it.

I still manipulate, but I recognize those who manipulate better than I do. I like to say that some chiropractors get better results than others, and if I don’t know the local talent pool I say so.

Yesterday I brought my skills into play, got the satisfying crunch so easily as to be humorous, and made the patient better before she left. (And she gave me permission to say more than I have.)

And the same day, I got praise for being thorough, digging through the layers of physiologic dysfunction to figure out the root source of the illness.

Both of those patients benefited from the osteopathic approach, more obvious for one than for the other.

In the 21st century, more and more MDs do manipulation, at a time when more and more DOs leave it behind.   And more and more of the non-subspecialist physicians, regardless of training, take a holistic and humanistic approach to the patient as a whole human being.

I saw profit motive build a bridge between the doctors and the chiropractors, when the docs own an MRI and want the business.

December 14, 2016

Is it the crud, or is it the croup?

Is there ought that beats chicken soup?

Get my advice in

Azithromycin

Will stop the cough that’s a whoop.

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. 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. 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, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

When I went to med school I had my father’s microscope cleaned and refurbished. He’d gotten it during his education, and used it in his office to run diagnostic tests on his patients.  I hoped to avoid the microscope rental fee.

I shouldn’t have bothered. By the time I started, Michigan State didn’t demand proficiency in microscope use, because little remained in the practicing physician’s purview that demanded a microscope.  Even in the 70’s, most lab work got sent to hospitals.

Forty years later, we have the slow growth of CLIA (Clinical Laboratory Improvement Act) waived Point of Care testing: we can run pregnancy tests, urinalyses, urine drug screens, strep tests, and influenza tests so quickly and accurately that we don’t need a federal inspection sticker to do so. We send the rest on to a hospital.  But the hospital relies on a reference lab for assays run infrequently or requiring more sophisticated equipment.

Yesterday I got three low folic acid levels in a row, leading me to question the accuracy of the test, so I started the day with a trip to the lab. The director agreed with my skepticism.  By the sheerest of coincidences he knew that the reference lab had just changed their methodology, and agreed to call them.

Pertussis, or whooping cough, has reared its ugly head here recently. At one time I read that the Chinese name for the disease is Cough of a Thousand Days.  It starts with a runny nose and progresses to a brassy cough that doesn’t get worse at night.  The disease doesn’t threaten adults or even older children, but it can kill infants when the airway swells shut.  I learned of my exposure this week, and I have to start treatment with an antibiotic in the macrolide class, which includes erythromycin, clarithromycin, azithromycin, the notorious Zpack, , and Biaxin.

Employers would cover the cost of the medication as part of Worker’s Compensation, but I am an independent contractor, and, as such, I carry my own WC insurance. Compared to the hours and hassles of filing, the cost of the medication seems small indeed.  When the head of Infection Control for the hospital offered to have the institution cover the cost of the antibiotic, I refused.

The most important thing you can take into or out of a bank is a clean conscience.

Folic acid levels and unicorn sightings

December 12, 2016

My schedule was a basic mistake

The day off I just didn’t take

But abnormals times three?

It just couldn’t be

What kind of sense does that 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. 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. 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, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

 

I had a speaking engagement in Sioux City, when it got rescheduled to January I forgot to change my calendar. Thus I came in at 8:00AM to an empty schedule.  It didn’t stay empty long.

Most of my patients had respiratory problems, and most had coughs with runny noses and a tobacco problem. I enjoyed making the children smile with my yoyo tricks, but finding a toddler with not one but two infected ears made my morning.

Despite a leisurely start, morning patients didn’t finish till after the noon hour.

The cafeteria here does a good job. Reasonable prices, reasonably sized portions, and very decent cooking put it in the top 10% of hospital food services.

I don’t know that I helped the last patient of the afternoon, but as I wrapped up, I asked about her work. Though she gave me permission to write more, I will say I learned about secondary distance learning in Iowa, and may have found Bethany some work. In the long run, I suspect the networking will bring more value to our interaction than the medical care.

I sat down to my lab results queue. I found a case of a vaccine-preventable illness, and we’ll soon have an epidemic here, but the notification came in after the Health Department had closed for the day.  I’ll end up taking medication for a few days because of the exposure.  It goes with the territory, but as a self-employed physician, turning it into Worker’s Compensation makes no sense.

The next lab number just about knocked my socks off, a low folic acid level. Folic acid and Vitamin B12 work together to repair DNA, keep the marrow producing blood, and the nervous system from deteriorating.  They work together; an excess of one can hide a deficiency of the other; thus you can’t buy a folic acid pill more than 400 micrograms without a prescription.  But 15 years ago the FDA mandated folic acid supplementation in our flour supply.  The deficiency of that vitamin, never common to start with, just about evaporated.  Up to now I’ve not seen more than a half-dozen cases.

So finding one really put the music into the end of the day. I called the patient, discussed the problem, fiddled with the computer, sent the prescription, and opened the next set of lab results.

My jaw dropped. Could it be?  Two folic acid deficiencies in a row?  And there it was.  Lower limit of normal 7.1.  Patient’s level 3.9.  Yep.  What a rush!

Another enthusiastic call to a patient, another prescription sent at the speed of light to the pharmacy. And on to another lab result.

Wait a minute.

Three folic acid deficiencies in a row defy credibility.

If you see a unicorn, you get bragging rights, and if you see two in an afternoon, you get big bragging rights. But if you see three, you need to get your eyes checked.  Tomorrow I’ll have a talk with the lab.