Archive for the ‘Medical Care’ Category

Surviving grizzly bear attacks, controlling drug prices, and training a Dragon.

July 13, 2017

The thought that gives me a scare

Has do to with a grizzly bear

For he’s big and he’s massive

And pretty aggressive

And, out here, not terribly rare.

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 travel and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent US 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.

Some people survive events far beyond the usual human experience.

Lightning strikes more citizens of New Mexico than any other state, and when I worked there I met several. The Natives hold such survivors in high esteem; some tribes elevate them, obligatorily, to Medicine Man status.

Alaska, with the highest percentage of licensed pilots in the country, seemed to have a disproportionately large number of people who lived to tell about plane crashes. I met survivors of gunshot wounds there and in Nebraska.

Today I spoke with a person who survived a grizzly bear encounter.

Most of the bears around here are black bears. Though they’ll eat anything, the majority of their diet comes from plants.  They climb trees, and do their best to avoid people.

Grizzlies are different. The largest land predator on the planet, they have an aggressive temperament.

The bear only bit my patient once, then retreated to keep track of her cubs (the person gave me permission to write a good deal more than I have). If you’re in bear country with the inexperienced, before you start out, make sure everyone knows to freeze if a grizzly approaches, and never to run.  Carry either bear spray or a rifle, and be prepared to use it.

I really wanted to talk to the patient about life and work in this area, but my primary job, fixing people, comes first.

-*-*-*

Price of medication exceeds the price for physician services. In the US, the prices have escalated beyond reason, making the drug company stocks some of the best.  Insurance leaves a lot of Americans without adequate medical coverage, and the cost of medication becomes an important consideration.  When I worked Community Health, all our prescriptions went through our pharmacy. The pharmacists determined the formulary (the choice of drugs), and did a good job of containing costs.  The facilities in Alaska have a similar system; in those places the people don’t pay for their prescriptions.

For most in this town, employers pay for health insurance to cover what the Province’s Medical Service Plan (MSP) doesn’t, like medications.  PharmaCare, a government program, buys the meds  for the low income segment.  Only a very few lack money for drugs, and most of those are self-employed.  The Indigenous and Metis (of mixed Native and other descent) have all their drugs paid for.

*_*_*_

Over the weekend the facility got new dictation software installed. The previous version had worked just well enough to let you think you wouldn’t have to proofread, but still made glaring errors.  Today I used the system for the first time, training my Dragon over the lunch hour.  It did pretty well, but, once, when I said Prince George it typed first gorge.

Locks on the Clothes, Keys on the Shoelace: the dress of a millwright.

July 9, 2017

The millwrights has many a key

For the mill cuts up many a tree

On the machine go the locks

Preventing visits to docs

And keeping the workplace accident-free

 

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.

Thursday I took care of 17 patients. One pediatric patient required all my patience, skill, and accumulated experience to get the job done without alienating the kid.  The oldest patients barely qualified as septuagenarians.

I wrote a lot of prescriptions for blood pressure drugs.

I used my deep-breathing techniques on three patients to bring blood pressures into the acceptable range.

Though only 15% of Canadians smoke, the nicotine addicted comprised more than half my patients.

I wrote several back-to-work slips, all employees in the timber industry.

I cared for even more millwrights and former millwrights. Changing logs into useable products involves a lot of dangerous machinery, and the people who fix the machinery come in loaded with padlocks on their clothing.  They lock a machine before they work on it, to make sure it won’t start accidentally.  Spare keys get carried where they can’t get lost, such as tied into shoe laces.  During the work day, a “whistle” signals a need for a millwright.

One of my patients in frustration said, “Can you give us a referral to see a specialist we can actually see?’ and we laughed after I asked for and received permission to use the quote in my blog. While I know my way around the human body, and most of the things that go wrong with it, I don’t know the local medical community.  Yet the permanent doctors trained near here, and know the consultants personally.

There’s also a province-wide network providing phone-in advice for docs . The consultants get paid on a fee-for-service basis; the patient has a unique identifying number, and the doc has a bunch of unique numbers (I have 8), one of which is the right one to use.  Computer algorithms coordinate compensation.

Lower blood pressure with deep breathing

July 5, 2017

It’s a technique, and I don’t mean to brag

But when the smoker lights the first fag

And breathes deep and slow

Though the smoke is the foe

They’re champs at that very first drag.

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 see a good number of people with high blood pressure, some better controlled than others. If the pressure is too high, I repeat the reading.  A second round of measurement less than 5 minutes after the first will give a falsely elevated reading.

Most of those with hypertension (a blood pressure greater than 140/90) smoke tobacco and drink more than healthy amounts of alcohol. I point out to the smokers that they have a valuable tool, that they didn’t realize they had.

I was still working for the Indian Health Service when I had a conversation with the worst nicotine addict I ever met. She had quit 4 packs per day about 10 years prior.  Half the relaxation of the cigarette, she said, is the deep breathing technique that goes to taking the first drag.  Every meditation system in the world stresses the deep breathing that all smokers have taught themselves.

Breathing can change blood pressure a lot. The FDA approved a device to teach people to slow their breathing down; the studies showed it safe and effective for blood pressure control.

So I tell the patient to pretend they’re taking the first puff of the day, to breathe slow and deep, and I breathe with them.

I repeat the blood pressure measurement after 6 deep, slow breaths, and almost always the top number drops by 30 points and the bottom by 15, good enough for most people. Whether the improvement is adequate or inadequate, I tell the patient to breathe slow and deep for 20 minutes a day, whether in one chunk or twenty.  For those current smokers, I point out that they could get half the calming effect of tobacco just by doing the breathing exercise that they already know how to do.

+=+=+=

I had call last night. With light traffic in the ER I managed to get back to the hotel early, but I got called back at 10.

As far north as we are, I walked to the hospital with the setting sun in my eyes. Forty-five minutes later, I walked back in the twilight, thinking that I should have brought the bear spray with me.  I crossed the highway with literally not a single vehicle moving.

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.