Posts Tagged ‘amoxicillin’

I’m the doctor. You need the dentist.

January 15, 2019

It doesn’t take much of a sleuth

When it comes to a pain in the tooth

In the head, but not mental

Those problems are dental

They start in the mouths of the youth

 

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

 

Canada’s recognition of care as a right means that cost comes out of everyone’s taxes, and, in that sense, everyone has health insurance.

(Actually, they don’t. The Mennonites, for example, do not have to pay those taxes.  And I ran into a young man with such massive self-defeating behaviors that he procrastinated getting his insurance card for 4 years.)

The mainstream plan does not cover dental work.

The bigger employers offer dental insurance, but, like the US dental insurance, it has a high deductible and large copay. Thus people tend to ignore their teeth.

I see between two and four patients a day with dental problems; a higher percentage when I’m on call. About a quarter of those who come in with toothaches have never visited our facility before.

If people didn’t hurt a lot, if they could get in to a dentist close by, they wouldn’t come in to ER with dental pain. When they open their mouths, I see decades of procrastination and neglect.  Broken teeth, teeth rotted to the gum line, teeth worn out from the clinching that methamphetamine brings.

I can’t actually fix the problem. I can give antibiotics and pain relief.  Amoxicillin remains the standard in dental infection.   For analgesia, I have the nurse administer ketorolac (Brand name, Toradol) 30 mg as an injection, and I give the same medication as a pill for 5 days.

If time permits I show the patient ho-ku acupressure, squeezing a point in the muscle between the thumb and forefinger, which relieves head and neck pain.

But I have to urge them to get into the dentist as soon as possible. For those who can’t afford to pay, I give them information on the free dental clinic held twice monthly in Prince George.  Staffed by volunteers, they rarely have time to do anything besides pull the offending tooth.

I suppose I could learn to do dental extractions. If I did, in short order I’d be doing almost nothing else.

Some of the patients don’t have a problem till they’re about to head into the wilderness for work for a few days; I generally give them a longer prescription of Amoxicillin, but I don’t give out pain pills that would make them dangerous around machinery, or driving to Prince George.

Road Trip 8: Fantasy bare-bones formulary

November 18, 2014

For our tools, the meds are the core
I used to use way less than a score
Is a need demanded
Drugs that were branded?
Saying “no” is really a chore.

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center, where I worked for 3 years. I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system. I just returned from a road trip, to visit family and friends and attend a Continuing Medical Education conference.

After the Continuing Medical Education ended, two daughters and one son-in-law accompanied me to sushi lunch, followed, naturally, by dessert.

The ice cream parlor sat in a building that had previously housed a drug store. Closed in 1979, the interior stayed intact until the building sold to new owners who rehabilitated it and decorated it with stuff that had remained from the pharmacy years.

We observed the lack of variety in the drugs that graced the shelves, and soon the two physicians (my daughter and I) dominated the conversation with the question: If you were Minister of Health for an impoverished, small island nation, what drugs would you have on your formulary if you could only have twelve?

We started with pain relief, my younger colleague wanted ibuprofen and acetaminophen (Motrin and Tylenol); and for high blood pressure lisinopril and metoprolol. I agreed with acetaminophen and lisinopril, allowed as how I could live with metoprolol but would prefer carvedilol (in the same class of high blood pressure meds, but also useful in heart failure), and didn’t want ibuprofen at all. “Too many side effects,” I said, “Ulcers and kidney damage and such.”

Diabetes, I declared, should be met with metformin; she would prefer a long-acting insulin. And I could see her point. A long-acting insulin would at least keep the Type I diabetics alive.

I kept looking over her shoulder at the few shelves lined with medication bottles. I remembered, during residency, checking out the 1979 Physician’s Desk Reference and comparing it to the 1980 edition and thinking how small the earlier version looked. With more than 4,000 pages verging on folio size, the current edition dwarfs both put together.

What about antidepressants? We agreed on citalopram. Antipsychotics? Haloperidol (brand name Haldol). Sleeping pills? I voted for trazodone as a triple function drug, useful for depression, chronic pain and sleep.

For antibiotics, we agreed that if we only used amoxicillin sparingly, resistance to it would fade. I wanted another one in addition, such as doxycycline or azithromycin. And I shook my head; doxycycline has gone from $.04 per pill to $3.50 per pill. I asked, What about mupirocin (a topical antibiotic) but the question went unanswered.

If we hadn’t forgotten about thyroid disease, I would have suggested levothyroxine. But we finished our ice cream and went out into the afternoon sunshine. “You know,” I said to my daughter, “In the last three years, working at a Community Health Center, I know there are a lot of really neat new drugs out there, but I don’t prescribe many. Do you write for much in the way of branded meds?”

“No,” she replied, “About the only drug that’s on patent that I prescribe is Plavix (which helps prevent blood clots).” She recounted a conversation with a salesman representing Oxycontin; neither of us prescribe it at all. The rep had asserted the new reformulation made it less addictive. We laughed. A drug like that doesn’t need a rep.

During residency, I clearly remember the program director teaching us that most doctors use fewer than 20 drugs. Pick one from each class, he said, and get familiar with their side effects and their interactions. But he taught us those things before the Information Age and the Internet.

We got in the car. “What about asthma?” I asked.

“We’d have to have albuterol,” she said.

“And prednisone?”

“Yeah, I guess we’d have to have prednisone,” she said.

I suggested single 20 mg tablets scored with three lines on one side and four on the other.

Protected: Unemployed but not out of work

October 8, 2014

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Gravity therapy for sinusitis

October 27, 2010

When I say no it causes a scene

Because the truth is not what it’s been

     It’s a plus or a minus

     Antibiotics for sinus

Whether or not the mucus is green.

Sinusitis hit me in the winter and then spring of 1973.  At that time I lacked money for a car or for a doctor.  A bicycle carried me from point A to point B, and for weeks and then months the cold Colorado wind drove spikes of pain into my inflamed sinuses.

Poverty loves company more than even misery does.  I fixed a friend’s bike and in return I got the yoga treatment for sinusitis: hang your head upside down for five minutes.

It seemed hokey to me, but even if I had no money I had time, and per instructions I lay crossways on my bed, face down, with my mid-chest hitting the edge of the bed.  I relaxed and, sure enough, the top of my head pointed at the floor.  Four minutes later I felt a pop around my eyes and gross brown liquid drained out my nose by the teaspoon.  When I stood up my sinus headache had disappeared.

At the time I knew no anatomy nor physiology; I had no idea that the sinuses under the eyes drain uphill, and when a cold or allergies attack the outflow becomes blocked by swollen tissue. 

Medical school physical exam taught us to apply pressure on the cheekbones if we suspected sinusitis; if the patient experienced relief, they said, antibiotics would probably cure the problem.  One day in the late ‘80’s while performing that maneuver, I heard a loud squeak, gurgle, gurgle, and the patient experienced immediate relief.  Since then I’ve tried the same technique hundreds of time and never replicated the results, though about a third of the patients will experience some improvement.

Decades ago the truth about sinusitis ran something like this: antibiotics only help if the mucus is green.  Since then, we’ve found out that sinusitis gets better 85% of the time with antibiotics and 75% of the time without them.  Which means that for every one person I really help with amoxicillin, seven others took the medication for no good reason.  Oh, and color of mucus doesn’t make any difference.

In my current position I’m seeing a lot of “sinusitis” and I don’t prescribe antibiotics.  The medical profession did such a great job selling the public on the need for those drugs for this diagnosis that unselling becomes problematic. 

I can write a prescription for the latest -cillin or -mycin much faster than I can explain to a patient why they don’t need it; naturally there are those docs who find themselves behind schedule and cave in to the pressure from the patient.

Re-education for physicians and the population will take time.