Posts Tagged ‘alcoholic’

Sleepless doctors losing caring

May 7, 2013

We deal with death and with pain

The job brings a whole lot of strain

The hours on call

Are the worst of it all

When your sleep goes right down the drain

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

Sunday afternoon in the doctors’ lounge the faces show the strain.  We have worked too many hours too intensely.  The energy and the intelligence helps but 48 hours into the weekend call the pulmonolgist, the nephrologist, the hospitalist, the cardiologist and the family practitioners have all done too many admits in the context of not enough restful sleep.

As a med student and a resident I had times on call when I made the mistake of letting myself go all the way to sleep, and then I aroused only with difficulty.  Now amusing stories at the time carried frightful embarrassment.  Most docs had similar experiences, and we learned to doze rather than sleep fully.  I’ve asked other physicians, and about 15% say they can sleep well if they’re on call.  I fall into the other group. 

The muscles in my upper back and the base of my neck grow tender knots and then cramp up. 

With the geographic layout of our town’s two hospitals, walking from car to patient to car, a round trip of hospital-patient-hospital-patient comes to a little over a mile, and with admissions piling up at the average rate of 4 to a shift, physical fatigue adds itself to the list of emotional and intellectual weariness.

Even the brilliant, overachieving docs from other countries who work insane hours without complaining (the way I did as a resident) look tired.  While no one wants to be seen as a whiner, we commiserate and we wonder why this weekend, of all weekends, should be so hard.

My near participation in the pity party ends when my beeper for the other hospital goes off.

I can tell from his use of profanity that the ER specialist has passed his emotional elastic limit.  All his rant about the alcoholic’s manipulative behavior rests solidly on truth, and I recognize in my heart my own impatience with the self-defeating behaviors that brought the person in.  But the doc on the other end of the line goes on for minutes, communicating little about the patient’s medical condition and much about his own anger. 

Across town the patient’s blood alcohol level runs 224.  From experience I know that the interview process will yield little useful information.  Drunk patients want to appear clever and they want to talk and they have problems focusing, but as a physician I just want to collect the information and go home.  I don’t try very hard when it comes to my 140 question Review of Systems, where I ask the patient about every symptom possible.  I break off questioning at the first sarcastic remark, and I don’t try to fight the scrunched-up eyelids to examine the pupils.  My dictation uses the sentence, “could not be obtained because of patient intoxication” a lot.

Overworked docs with inadequate sleep may or may not provide the same quality of care as normally, but they definitely lose out on caring.


Limits of normal

October 27, 2012

The neurologist I saw face to face.

We discussed a clinical case.

Involving depression

And a bad drinking session

And an interesting diagnostic chase.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

The lower limit of normal for Vitamin B12 has moved from 200 during my residency in the 80’s to a high of 287 in the mid ‘90s and has hovered at a more or less constant 220 ever since.  The lab report always comes with a  caveat: if the level is over 400, replacement rarely benefits the patient, but between 220 and 400, some people will benefit from B12 shots.

In the hospital parking lot a couple of decades ago, I stopped a neurologist for advice in generating an algorithm to deal with B12 deficiency.

In med school and residency, they taught us not to test anyone under 40, and not to test if the blood count (CBC) showed normal looking white cells without extra lobes in their nuclei, and normal, rather than large, red cells. 

By the time I’d been out of postgraduate training for ten years, I recognized I’d gotten a poor substitute for truth.  I’d tried pumping wisdom out of a hematologist (blood specialist) but quickly realized he didn’t know more than me. 

Then I spotted the neurologist in the parking lot while I puzzled over a patient, age 38, with numbness and a normal CBC but a B12 level less than 150.

Curbside consultation, the discussion of cases with colleagues on an informal basis, remains a vital institution even in the digital age, and comes with its own etiquette.

The neurologist smiled, and in less than 30 seconds slaughtered enough sacred cows for a Texas-sized barbecue.

Forget the CBC, concentrate on the symptoms.  In a patient over age 70 with symptoms and a level under 400, treat with injectable B12, don’t do any follow-up testing unless they deteriorate neurologically.  If you really, really want to know if B12 lies at the root of the problem, you can do further testing (methylmalonic acid and homocysteine levels) if you want, but at the rate of $3.50 per year of treatment, extra testing rarely justifies its cost.

Since then I learned that alcohol interferes with a body’s ability to utilize B12, thus most alcoholics have big red blood cells and levels of B12 over 3000.

B12 deficiency, formerly known as pernicious anemia because before B12’s discovery the patient always died, remains one of my favorite diagnoses.  I get to save the patient’s life for less than a penny a day, with an injection given once a month.

Yesterday on rounds I sat in a patient’s room and leafed through the lab work.  With very large red cells on the CBC, and some vague neurologic symptoms, I had ordered a B12 level two days before.  I suppressed a whoop of delight when I found a 188.  “We can help you,” I said.

One floor down, I talked with an alcoholic about a marginal B12 level, 244, and recommended starting B12 shots.  Your depression won’t improve, I said, if you don’t have enough B12, and it’s hard to control your drinking when you’re so depressed.

Then I walked, grinning, down the hallway.  My favorite diagnosis, twice in a morning.

Short call on Labor Day weekend

September 3, 2012

Labor day spent making rounds.

You wouldn’t believe the diagnoses I found!

It wasn’t quite call,

I avoided a brawl,

And sent four to their homes out-of-bounds.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week

Our hospital service has grown to the point where two docs get assigned every weekend, one each for a long call and a short call.  I drew the short call this holiday weekend, not the same as the short straw.   I requested, and received, assignment to my preferred hospital, where I’ve done morning rounds now for four days. 

My natural tendencies wake me early, but today I ate a leisurely breakfast before Bethany dropped me in the deserted doctor’s parking lot.  I printed my patient list in the doctor’s lounge at 6:58 AM and took the elevator to the 5th floor. 

I returned to the doctor’s lounge, emotionally tired, at 11:30.  I had rounded on 13 patients, each one a unique human being whose illness brings drama and irony to their lives and the lives of the people around them.  Each has a marvelous story, rich with details, triumphs and tragedies enough for a series of novels.

While I can’t discuss patients in particular, I can talk about the patient population in aggregate.

Four patients carry the diagnosis of schizophrenia.  Eight qualify as hard-core alcoholics requiring treatment for alcohol withdrawal.  Bipolar disorder (previously called manic-depression)afflicts three.

Eleven of the thirteen didn’t quit smoking soon enough, such that they required treatment for nicotine addiction or emphysema or both. 

More than one has chronic kidney failure necessitating dialysis. 

Others had cancer, HIV, depression, gallbladder disease, broken bones, dementia, urinary infections, lupus, and coronary artery disease.

The nurses on the psych floor warned me about a violent patient after a near confrontation.

I didn’t even bother to count the number of patients with the garden variety problems of diabetes, high blood pressure, and high cholesterol.

I had to deal with two patients with adverse drug reactions, their hospitalizations complicated by the very medications their doctors ordered.

I discharged four patients and dictated their discharge summaries while leaning my back against the wall; I wrote prescriptions for three of them.

One of those represents a triumph of medical care; we cured the problem and sent the patient home in less than 72 hours.  Such satisfaction comes rarely and I relish it when it does.

The doctors’ lounge stood deserted at noon on Labor Day, and I power napped ten minutes before the next task, reviewing transcriptions.  I had 37 in my queue.  After that I dictated six discharge summaries.

I left the hospital at 12:40PM, the rest of a fine summer day right in front of me, and headed home for lunch.

Blog reopened after a year on the job.

July 5, 2012

I find my job a delight

Even when working at night

On this I won’t budge,

I’m a doc, not a judge,

And there’s always something to write.

I have decided to reopen my blog after a year’s absence.  I miss writing, and I miss the immediacy that comes to my life when I go through my day thinking about my post.  I’ve been at my new job a year now.

My workplace runs on teamwork; I’ve never been any place where people seek out so many opportunities to help their coworkers. 

Our patients have few resources; 50% have no insurance, 35% have Medicare or Medicaid, and 15% have commercial health insurance.

I see a lot of schizophrenics, people whom our society has failed badly.   I’m sure if they could push a button and come to a closer contact with reality, they would.  As it is, they hear voices when they don’t take their meds and sometimes even when they do.  An extraordinary number also carry a diagnosis of bipolar.  Almost all smoke, and, given enough time, almost all develop insulin dependent diabetes. 

I find it easy to avoid judging the schizophrenics; they did not ask for their problems.  The less I judge my patients, the more energy I have at the end of the day.

We have so many patients from Ethiopia and Somalia that we have Oromo, Amharic, and Somali translators, and I’ve learned to say Hello, How are you, and Thank you.  Mostly hardworking, family oriented people, they came here after unspeakable horrors.

Many of the people who come to my clinic have been behind bars.  I don’t ask them why.  After all, I did not train as a judge.  Those folks have done their time and my job, as I see it, demands that I focus on what can be done in the future, not what has already passed. 

I start Mondays with hospital rounds till noon, then clinic till 8:00PM.  I’m on call 35 Tuesdays per year.  Most call nights I work straight through till after 9:00 PM.  I start Wednesdays at 7:00AM and finish around 6:00PM. 

I have Thursday off, along with Friday, Saturday and Sunday if I don’t have call.  I still put in 48 hours weekly.

Yet I worked no more than two days a week in the last six weeks, which I found unfulfilling.  I arrive at work Monday mornings cheerful and happy to be back, and I go home on Wednesdays ready for the weekend.

Saturday/Sunday call a year ago ran to fewer than 10 patients between two hospitals, but practice growth led to mission creep, and now a hospital census can run upwards of three dozen.  At any one time, we usually have three patients in liver failure, and three in active alcohol withdrawal.  A surprising number of non-alcoholics end up with cirrhosis.  About half our hospital patients also show up on the dialysis service.  Mental health census averages 5. 

Our patients get sicker younger than any patient population I’ve seen before, which surprisingly, gives me more hope.