Posts Tagged ‘ankylosing spondylitis’

Meeting the VA’s New Rheumatologist

January 11, 2017

I drove through the snow to Sioux Falls

The place with the old red brick walls

Where it seems it’s the norm

For the staff to be warm

To the vets who walk down those halls.

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 assignments in western Iowa and southeast Alaska, I’m back home. Any identifiable patient information has been included with permission.

I heard this joke in 1982: You walk into the patient’s room in the VA and there are three glasses of orange juice on the bedside table.  What’s the diagnosis?

The punch line goes, “Patient died 3 days ago.”

Fast forward 20 years.  Having suffered for more than 30 years with chronic back pain from ankylosing spondylitis (much like rheumatoid arthritis but affecting the spine) I had started the miracle drug Enbrel a year prior, and finally got an appointment with the Veteran’s Administration rheumatologist in Sioux Falls, South Dakota.

Please do not judge the VA on the delay of care. I separated from the Public Health Service (along with National Oceanographic and Atmospheric Administration, the two uniformed services that no one knows) with such anger that I divested myself of certain papers. After the critical regeneration, booking a first-time rheumatology appointment took the same 6 months that it would in the private sector.

I came unprepared for the warmth and caring that flowed from everyone in the institution. I certainly did not expect two secretaries on their lunch break to help a clearly disoriented vet wandering the hallway, nor to do so with such kindness.

Since then I’ve driven once or twice a year back to Sioux Falls to meet with the rheumatologist. Every month or so I get a refrigerated container in the mail worth about $2,500.

The routine includes a lab appointment; if scheduled for 9:00 I can count on being done with the blood draw by 9:02. I have watched the system acquire bits and pieces of efficiency, until it happens as fast as possible without rushing the patient.

I’ve not had a morning doctor’s appointment previously. The blood test itself takes an hour to run, and I can only imagine the clockwork precision behind the scenes.

I sat down to wait. I napped.  I read a medical journal I’d brought from home.

I chatted with another vet, one of the moral giants who regularly walk the corridors there. I saw a lot of modified heroes.  In the last 15 years I’ve seen the number of women vets steadily increase.

A nurse came out to tell me of the doctor running behind schedule. I told her I understood patient flow, especially in a raging blizzard.

The doctor apologized to me for the delay, too, before anything else. I’d not met her before.  Young, energetic, and kind, she has a quiet competence about her along with the extraordinary intelligence that  permeates the subspecialty.

We both spoke well of the rheumatologist who preceded her during his semi-retirement, and I thanked her for coming to the VA. We agreed that telemedicine might be the future in a few specialties, but not in rheumatology.

Not until I explained my ankle problem in medicalese did she ask, and I told, of my status as a physician.  After that things went much faster.

I spoke briefly of how much I liked locum tenens. But I didn’t give details, so as not to make the next patient wait longer.

Where I’d walked into the building in low visibility, I walked out in bright sunshine. A fierce north wind which ruined gas mileage on the trip up sped me on my way home.

 

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Spotting the TSA agent with abdominal pain

November 30, 2015

Whatever the time or the space

The day of the week or the place

It won’t come as a shock

I’m always a doc,

And I could read the pain or her face.

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, and working Urgent Care in suburban Pennsylvania.  Right now I’m in Virginia for the holiday.  Any patient information has been included with permission.

 

I travel with an expensive medication for my ankylosing spondylitis.   Every 5 days I take a shot, and I have to keep the stuff refrigerated.  I put a month’s supply into the smallest cooler in the house along with a gel cold pack, fully prepared to submit to TSA inspection.

With TSA Precheck, I didn’t have to take off my boots or show my computer at the airport in Omaha.  I stood in line waiting for my carry on to finish in x-ray, and I watched the TSA personnel.

The youngest member of the staff sat by the x-ray monitor, and stopped the belt when my backpack came through.  He summoned an older woman, either his supervisor or his trainer.  They conferred while I watched.  My medical training never stops, it’s who I am, and I saw pain on the face of the lightly built, blonde woman.  She might have hidden it from her coworkers, but not from me.  After a moment, I could see that her left hand spent more time hovering over her lower abdomen than anywhere else.  I couldn’t make a diagnosis without a good history and a physical exam, but I could see her abdomen swelled more than normal for a person of her build.  What could this be?  I asked myself, What’s the differential?

The two TSA officials conferred, they went back and forth.  After a minute, my backpack came down the belt, I picked it up and I walked on.

But I knew what had happened.  Pain lowered the standards of the TSA security official.  She had guessed, accurately, that I posed no threat.  But we already knew the TSA hassles constitute more placebo than real security.

***

I like to show off my talent for sharpening knives.  On arrival to Virginia, I volunteered to carve the turkey and immediately brought a shaving edge to the blade I would use.

Later that evening, one of the family members, chopping onions with that chef’s knife, cut the end of his ring finger, and the cut bled vigorously.

I have no license in this state, but, heck, anyone can apply first aid.  And I learned plenty of basics this summer working Urgent Care; I can’t remember a shift when I didn’t see at least one fingertip injury.  Mostly on the non-dominant hand (because the dominant hand holds the blade), and happened usually in a time of crisis or stress.  Dominant hand lacerations happened almost always on the job.

So we sat together, I applied local pressure, squeezing the area vigorously for 5 minutes.   The bleeding stopped, and I applied Superglue.

 

No such thing as a free breakfast

November 15, 2015

Uncle Sam sure lied to me
And paid me a much smaller fee
I didn’t know what I’d get
Because I’m a vet.
Still, free breakfast just wasn’t 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, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.
On Veteran’s Day, Bethany and I went out to a chain restaurant that offered a free breakfast to veterans. I brought my VA card.
Ankylosing spondylitis kept me out of the war in Viet Nam. Later on, when I sought to enter the Indian Health Service, I believed them when they said that I could only get in if I went as a Commissioned Officer (they lied); ankylosing spondylitis would have disqualified me, but a report from a shaky radiologist sealed the deal, saying “no evidence of sacroiliitis.”
The Department of Defense (DoD) controls 5 of our Uniformed Services (Army, Navy, Air Force, Coast Guard, Marines), but not the Public Health Service (PHS) or National Oceanographic and Atmospheric Administration. My service in the PHS qualifies me for Veterans’ benefits at the VA, and the VA has been very good to me.
In fact my IHS service units had Civil Service employees working the same job as Commissioned Officers. They got overtime past 40 hours a week and started with more than twice the base salary. All in all, my naivete cost me more than a quarter million dollars early in my career, but the value of my VA benefit is catching up. And I count my time as a Commissioned Officer as priceless.
There is no such thing as a free breakfast.

Another Road Trip 12: reminiscing in Saginaw

June 22, 2015

It was such a long time ago

O’er the bridge I would walk to and fro

But one day running late

I hopped on a freight

And survived.  But how, I don’t know.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, and I just finished an assignment in rural Iowa. In the midst of combining work with a family visit, I had to make a sudden trip to Colorado for a funeral. Right now I’m starting out on a bicycle trip with an alumni association.

We arrived in Detroit with our circadian rhythms disrupted by bad sleep and grief, got onto the highway and went north.

I came to Saginaw in the summer of 1977 for my medical school clinical training.

I had no car and barely money for food.  I lived across the street from the St. Luke’s parking lot, a block away from Saginaw General Hospital.  St. May’s, directly across the river, would have taken 20 minute bicycling in good weather.  Or I could walk across the railroad bridge, a process that took 8 minutes if I walked fast, and gave me a brief respite of outdoor exercise.

One day, running late, a slow-moving train occupied the bridge.  Remembering a technical conversation with a hobo,  I ran alongside the train, matched speeds, grasped the ladder, and jumped on.  I rode across the bridge, dismounted at a jog, and arrived at the noon lunch lecture on time.

I repeated the process a dozen times, but once, after the temperature had dropped with the seasons into the teens, the train started to accelerate while on the bridge.  I had dressed for a short walk across town, and the wind chill numbed my hands in less than a minute.  I had visions of freezing to death as the train headed out of town and picked up speed.

I made a stumbling dismount from the train at a run, in front of a waiting car. (What did that driver think, seeing me in a white coat with a stethoscope around my neck?)  I made it to the lecture, alive and on time, and never rode another freight.

And now I could ride the streets in my own car.  While the day faded, I showed Bethany what I remembered of my time in Saginaw.

Covenant took over Saginaw General and St. Luke’s and merged them into one institution.  A bronze statue and a couple of nice plaques now sit outside of St. Mary’s Hospital, on grounds much better maintained than any I ever experienced during my tenure.

A vacant lot has devoured the house where I lived my senior year, the furnished room rented for $200 per month.  The letter bearing news of my National Health Service Corps scholarship came to that address.   The grocery store and the greengrocer, walking distance from my first dwelling here, have disappeared.

Medicine has changed as well.  Laparoscopic surgery, unknown then, has become the norm.  Ibuprofen, Tagamet, Prilosec, Zyrtec, and Flonase, each a game changer, no longer require even a prescription.  Total knee replacements (I saw Saginaw’s first) are routine.

When I lived here, research hadn’t even started to elucidate the inflammatory cascade of ankylosing spondylitis, and aspirin was the best drug for its close cousin, rheumatoid arthritis.  And my back hurts less now than it did 40 years ago because of Enbrel, the miracle drug, which would not be invented till 1999.

We parked at St. Mary’s and  I led Bethany to the intersection where I alit from the train.  We walked up the tracks to the railroad bridge.  I had never seen the river that high.

reminiscing

Let’s see what happens.

July 27, 2013

A matter of prognostic projection

When it comes to a diagnostic question

My pain management skills

Involve very few pills

And no longer my Enbrel injection

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In 2010, I danced back from the brink of burnout and traveled for a year doing temporary medical assignments from Barrow, Alaska to New Zealand’s South Island.  I’m now working at a Community Health Center part-time, which has come to mean 54 hours a week.

During my senior year of medical school I arranged to get credit for an elective rotation in acupuncture in January of 1979.  I studied under a very smart non-Asian internist for a month, and learned the vocabulary and the rudiments.

Before I had passed any Boards or actually obtained a license, I did acupuncture on a friend in a time crunch.  I applied a needle in each shin, close to the knee (the name of the point is Su Zan Li, but its nickname means three villages).  He responded well, and worked with tremendous efficiency for the next 9 days, turning out top-notch work.  The bottom dropped out of his energy three days later, and he slept for the next two days.

In retrospect, I had precipitated a hypomanic episode; his bipolarity would not be diagnosed for many years.  Nor did I realize the enormity of the power of those two needles for decades.

High-quality research with acupuncture showed mixed results.  A study published in a major journal demonstrated very good results in treatment of the most severe alcoholics (regretfully, the study didn’t detail exactly where needles went nor how they were placed).  Another, published in JAMA, showed acupuncture and sham acupuncture equivalent in the treatment of migraine.  Many docs point to that study and assert acupuncture has no validity; I look at the same data and conclude that you don’t have to be much of an acupuncturist to treat migraine; put a half-dozen needles anywhere you want and not very deep, on a regular basis and at the end of a year the patient will have half the migraines he/she used to.

I went to my acupuncturist today for a session because I’ve been off Enbrel for three weeks.  My sacroiliac joints haven’t fused despite my age, leading my rheumatologist to question the diagnosis of ankylosing spondylitis.  He would like to see if my sed rate (ESR) and my C-reactive protein (CRP) go up in the absence of therapy.

I can hope for a misdiagnosis, or for news that my disease has burnt itself out, but as the days go by the pain in my spine grows.  I’m now relying on the pain management skills I developed between 1967 and 2000, when I got my first injection.

I can do a lot of things to bring down the level of pain a notch or two; I can’t do anything to make the pain go away completely.    When I walked away from the acupuncturist/chiropractor’s office the pain between my shoulder blades had faded by about two-thirds, and I could sneeze without grunting.

Now I have to work on my sleep pattern.

Pills and skills: you need a tool set to deal with chronic pain. (Caution: longer than average.)

December 9, 2012

This post is far from laconic

On a subject that’s close to demonic

I don’t think it’s wrong

To write twice as long

On pain, not acute, that is chronic.

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.

A lot of people deal with a lot of pain in this world.  I’m one of them.

Acute pain, short term in duration and a useful signal to avoid destructive situations, distinguishes itself from chronic not only in terms of duration but in neurophysiology.

My back started to hurt at age 13; my pediatrician initially attributed the problem to growing pains.  Worsening symptoms brought me to the orthopedist at age 17; he proposed surgery and I declined.  By the time I came up for my draft physical during the height of the Viet Nam war, I had a solid 7 year history of back problems well documented.  But the x-ray of my low back gets more credit for keeping me out of a stupid war and saving my life than the pain.

Normal people have five vertebrae between the last rib and the top of the pelvis.  I have four; what should be the bottommost one, the fifth, is fixed to the pelvis on one side but not the other, giving me a mechanically unsound low back. 

So I survived when 50,000 of my generation did not, and my back hasn’t stop hurting.

By the time I hit age 30 I had seen seven different doctors; in their aggregate they convinced me that the pain was in my head.  In so doing, they taught me the most important part of learning to live with the pain.  In a shared triumph of therapeutic decision making, they hadn’t started me on narcotics.

In fact I owe my life to a disease called ankylosing spondylitis, which hits the spine in much the same way that its cousin, rheumatoid arthritis, hits the joints of the arms, hands, legs, and feet.

In the intervening years I had a disc go bad.  One of my low back vertebrae has slid forward on the one below up (spondylosis and spondylolisthesis), and I have developed a worrisome curvature (scoliosis) in the same region.  All in all, I have five bad diagnoses between my ribs and my pelvis.  I’ve only met three people who have worse backs than mine.

When I finally got the right diagnosis of my main back problem, I got a prescription for indomethacin, a very powerful anti-inflammatory drug.  I took it for a decade and I paid for pain relief with loss of kidney function.

I have learned a great deal about chronic pain management on a personal basis.  As with most other problems in medicine, successful management includes both pharmacologic and non-pharmacologic approaches (pills and skills).

We currently measure pain on a ten-point scale; zero being no pain at all and 10 being the worst pain of a person’s life.  When thinking about my pain, I think about the hours after abdominal surgery when I refused narcotic pain relief; it hurt about as bad as when my disc broke open and pushed against the nerve that goes to my shin muscles. 

Life, just the ordinary course of living, includes pain, on the ten-point scale, up to level 4.  At level 6, I start to withdraw socially, and at level 8 I cannot acquire new information or learn. 

As the years went by, I put together a skill set, much like a set of tools, to deal with the pain.  None of the tools would take away all the pain, but each could take away at least a half point.  I recommend my chronic pain patients put together their own tool kit to learn to live with pain.

Indomethacin helped me by at least 3 points; its close relative, naproxen (the active ingredient in Alleve) helped by 2 points but also hurt my kidneys, and now I’m permanently off the entire class of drugs.

Acetaminophen (Tylenol) takes two points off my pain and deserves a Personal Favorite Drug designation.

A 6 level of pain turns into a 4 with a good night’s sleep and into an 8 after a night with poor sleep, and everyone knows it; much of the time and energy I put into pain management goes into sleep management. 

Skelaxin, a muscle relaxant, takes two points off pain caused by spasm.

Enbrel, a drug that costs $1500 a month, takes 4 or 5 points off my pain because it quells the root cause of my ankylosing spondylitis pain, inflammation.

Acupuncture can take two points off.

Massage or a long hot shower is each good for a point.

I can lose between a half point and a point of my pain by socializing, just getting out and talking with other people.

A good, long aerobic work-out can drop a point or two.

A person becomes completely insensitive to pain during orgasm; and relatively insensitive to pain during foreplay and afterglow; how much the activity reduces pain and how long the reduction lasts varies from person to person. 

Good footwear, including shoes, orthotics, and socks, can take off a half point each if I have been ignoring their importance.

Capsaicin cream helps me more in the winter months than in the summer months.  The active ingredient in jalapenos interferes with the dorsal root ganglion’s ability to transmit the signals of chronic pain.  I have no problem slathering it on whenever I need it.  However, most people need to start with a small area, the size of a quarter or half-dollar, apply it three times a day, and not enlarge the area for three days.  And everyone needs to wash their hands with soap and water twice after applying it.

Fish oil capsules, from 2 to 6 grams a day, can reduce inflammatory pain by up to a point (I get about half a point) if used conscientiously for six weeks, but fish oil that sat too long on the shelf (more than six months) can make things worse.

Transcutaneous electrical nerve stimulator (TENS) units bring me about a point of pain relief, but only during certain parts of the flare cycle; they are much more effective for the pain that follows shingles.

I haven’t mentioned the anti-depressants like Cymbalta, trazodone, or nortryptylline.  Good agents all, a doctor in a call rotation can’t take them regularly because of sleepiness.

Study after study has shown oral narcotics capable of reducing chronic pain by 2.7 points, placebo by 2.1 points, and lowly Tylenol by 2.4.

Relating to a patient at the end of a long day.

December 7, 2010

As I came to the end of the day,

I heard my clinic nurse say,

    It’s hard to believe,

    But it’s not time to leave,

One more patient is on the way.

I walked to work this morning. 

I reside a half mile from the hospital, along roads with no sidewalks.  I awoke rested, without an alarm.  I cooked and enjoyed my breakfast, did my morning dishes, and suited up for the cold.  On a day with no wind, a temperature of 8 F didn’t challenge me.  I watched the sunrise over the Des Moines River. 

Sunrise over the Des Moines River, viewed from Keosauqua, December 7, 2010

One of the other doctors and I have decided to discuss patients first thing in the morning.  He talked about his patient from the day before and I went over my chest pain admission from yesterday.  I discharged the patient by 9:00 AM.

The morning went well, mostly adults and children with coughs.  Pertussis, or whooping cough, appeared in the school system last week, but none of the patients showed anything like a typical case.  I told lots of people to quit smoking, and I wrote ALL SMOKE OUTSIDE as a prescription four times. 

I left the clinic area at noon for the cafeteria.   I enjoyed my lunch, I talked to the staff members and received many subtle and not-so-subtle hints that I should move to Keosauqua. 

I had finished with afternoon patients and documentation by 4:30 this afternoon.  While considering whether or not I’d leave early, the nurse told me one more patient, a very complicated one, remained, but wouldn’t arrive for a while yet.

I sat down at the computer, unfazed.  Paid by the hour with no other agenda for the evening except supper and laundry, I had no grounds for annoyance.  If such had come to pass eight months ago, I would have seethed, frustrated that the goal posts had moved, and worried about paying staff overtime.

Tonight, I focused on taking care of the patient. 

I listened to the history without interrupting, then did a thorough exam.  Enough time elapsed during the visit that a critical lab result arrived before the patient left.

Ninety percent of what we know about a patient comes from the story the patient tells, eight percent comes from the examination, and two percent comes from lab, x-ray, CT scans, and ultrasounds.

During the visit I recalled my experience with ankylosing spondylitis.  At age seventeen the back pain started, accompanied by morning stiffness.   Three years later my body temperature dropped to 94.8 F.  I dealt with relentless symptoms for the next thirty years, and in the process acquired a first-hand appreciation for chronic pain, ruthless non-restorative sleep, and fibromyalgia.

I talked to the patient as one who has “been there.” I trust my words brought hope. 

I left the hospital under black, starry skies.   After supper at the restaurant around the corner from the apartment, I returned to do laundry, and I thought about a list of diagnoses that no-one wants to have.  

Ten-hour days reasonably paced beat ten-hour days rushed.

ABCD: Always Blame the Cottonpickin’ drug

December 4, 2010

I relieved a lot of the fears

Of some folk with pain in the ears

     There was no detection

     Of otic infection

And I avoided the toddler’s tears.   

Friday’s schedule brought several patients with ears, nose, and throat problems.

Four, of varying ages, had earaches.  Not one had an ear infection. 

The ear sits so close to the jaw joint that less than the width of a dime separates the two at their closest approach.  The more sensitive structure, the ear, perceives pain before the jaw joint; people feel their jaw joint or temporal-mandibular joint pain in their ear, not their jaw. 

I removed ear wax, I prescribed antibiotics for dental infections, and I advised acetaminophen (Tylenol).

I examined four children under the age of three.  I played with them until their ears, nose, throat, heart, lungs, and neck had been examined.  Despite expectations of the caretakers to the contrary, I didn’t require the restraint of the child.  I use a number of tricks to reassure children, which vary by age; I enjoy exercising my expertise with this problem.

One of the patients, aged 76, of whom I write with his permission, has been married for more than fifty years and retired from carpentry for six.  He intended to do a lot of fishing when he retired, but now he’s as busy with carpentry as he was before he started drawing his pension.  We talked about what goes into a good retirement, and we agreed a person has to retire to, not from, and if a person stops they die. 

I received word about another patient I’d previously attended for confusion; I’d recommended cessation of Aleve.  Prompt resolution of symptoms followed.

I use the acronym ABCD as one of my guiding principles:  Always Blame the Cottonpickin’ Drug.  Naproxen, the key ingredient in Aleve, has few mental side effects.  Many people, like this patient, have taken it for years with no problem.

Twenty-seven years ago, Bethany and I went on a tandem bicycle trip, where she developed knee pain.  At the time I took indomethacin for the chronic back pain caused by ankylosing spondylitis (a disease much like rheumatoid arthritis of the spine), and I offered her one of my pills.  Half an hour later, she said, “I think I’m getting high from the indomethacin.”  I assured her she’d imagined it.  Three minutes later she started to giggle.  The road conditions abruptly went from great to perilous, and she continued to giggle, asserting that indomethacin caused her sudden good mood.  During the subsequent six hours when she didn’t giggle she laughed.   The drug wore off about the time we found a motel for the night.  She enjoyed indomethacin so much she never took it again.  Later I found the Physician’s Drug Reference (PDR) listed euphoria as the least common side effect. 

I learned from that and other experiences that any person can have any side effect from any medication. 

I have never seen a patient confused from Aleve before, and I probably won’t again.

Two doctors appointments, two views of the future; agreements about realities

November 9, 2010

Some will be choosing to flee

When Medicare starts cutting the fee

     A trend we are gauging,

    Docs and patients are aging

But no one should be working for free

I had two doctor appointments today.

Dr. Donahue, the podiatrist, confirmed my suspicions that I have posterior tibial tendonitis in my right ankle, and gave me permission to write about our conversation.

About ten years ago, I had a surgery for a similar problem in the left ankle, with mediocre results.   Neither of us  relished the idea of another surgery.  She told me to continue my current course:  rest, rigid orthotics, elevation, ice, elastic bandage, and hiking boots with a lot of ankle support; but I need to get an elaborate hinged brace made for my ankle.

I suspect that the same autoimmune tendency that gives me ankylosing spondylitis makes me prone to tendonitis; I’ve had it now in both wrists, both ankles, both elbows, and one shoulder.

We talked about slowing down.

I told her how I just finished two golden weeks in Grand Island, Nebraska, getting regular sleep, working less than forty hours a week, seeing respectful, hardworking patients.

Dr. Donahue has a three-year-old and works 30 hours a week.  We discussed the joys of rational hours.  She gets the best of both worlds; she looks forward to going to work, she looks forward to coming home and she gets regular sleep.  “So,” I said, “THAT explains your clear complexion and your shampoo commercial hair.”

Doctors’ life expectancy runs seven years behind the rest of the population because of stress and sleep deprivation.

If all the doctors do what I’ve done, I said, we won’t have enough doctors.  We can increase the number of doctors going into primary care by democratizing the first two years of medical school, and letting anyone who can pass Part I of the Boards go on to a clinical program.  We would get a lot of docs who would work fewer hours for less money.

A few hours later I talked to a doctor while he took care of a premalignant condition.  One of the few people who has read the whole health care bill, I asked him how he plans for the future.  “I’m stockpiling guns and ammunition,” he said. 

I filled him in on what I’d been doing (see my previous posts), and we talked about medical economics.  He pointed out that Congress will soon cut Medicare reimbursement by 29% and another 11% cut will follow a few months later. 

Most family practice offices run 60% overhead.  Where Medicare reimbursement falls below the cost of seeing the patient, many practices have stopped accepting Medicare.  If payment goes down, the trend will continue.

Then, we agreed, we’ll come to a situation where medical care is rationed.

One fourth of our doctors are over the age of 60; the more onerous the regulationsand the lower reimbursement, the earlier the doctors will retire.   Trying to get smart young people to give up seven years out of their ‘20’s is a tough sell now, and will only get harder.

A rheumatologic Skype call

November 4, 2010

Don’t go off on the wrong tack

Perhaps I have a knack

     It might sound inane

     But I’m dealing with pain

That comes from a very bad back.

Last night I did a long medical Skype call to another state more because of my personal experience with rheumatologic problems than my education as a physician.

Diagnosed with growing pains in the back at age twelve, things escalated when I was seventeen.  Over fourteen years seven doctors said the problem had no physical basis; I believed them.  After I started med school, I couldn’t make sense, either, of pain sometimes right, sometimes left and sometimes sharp and sometimes dull. 

In the process, I learned to live with it.

Things worsened in the aftermath of a marathon I ran in residency.  Morning stiffness lasted into the afternoon; breathing hurt.  My colleague, friend and mentor diagnosed ankylosing spondylitis, a problem like rheumatoid arthritis but affecting the spine rather than the extremities.

The previous doctors who missed the diagnosis had done me a great service; the limited treatment options at the time carried such toxicities that the manufacturers have since withdrawn them from the market.   By learning to live with the pain, I learned what my patients go through.  By 1990, I had acquired several tools, each of which would bring down the pain by a half or whole point.

By now I have tried most of the non-steroidal anti-inflammatory drugs (cousins of ibuprofen and Alleve) on the market.  Indomethacin worked well till my stomach rebelled; naproxen did OK but Vioxx did wonders. They damaged my kidneys.  A short course of prednisone worked too well; it put me into a near-manic state. 

On December 2, 2000 I had my first dose of Enbrel and thirty-three years of pain fell away abruptly.  All my fibromyalgia points melted as my body temp went from 94.8 to 98.4.  It took me six months but I learned to live without the pain.  The VA pays for this fabulously expensive drug.

I now live with the residual back pain from heavy wear of sixty years and a bad disc.  If I have to stop my injections the problem returns and I rely on the skills I’ve developed.

During the phone call last night, I detailed some of my techniques, to be used until a rheumatologist could start definitive treatment for a young patient:

Sleep management:  I write a lot about sleep in this blog because good health demands good sleep.  In rheumatoid arthritis, quality of sleep the night before predicts pain the next day better than pain the day before predicts sleep the next night.

Acetaminophen:  Lowly Tylenol relieves pain a point or two with the best safety record.

Massage:  Imagine the difficulty of running a placebo controlled trial with massage; everyone knows a massage feels good.

Heat:  Especially in rheumatic diseases, heat helps.  Moist heat beats dry heat.  Put a massage together with heat and you get a whirlpool.

Acupuncture:  This modality did the best of anything short of Enbrel; it brought my body temp up to 97.2.

Capsaicin cream:  Available over the counter, the active ingredient found in jalapenos interferes with the ability to transmit chronic pain. 

Socializing and other distractions:  When I wanted to get into bed and hurt, I really needed to be out and around people.

Fish oil capsules:  Must be taken six continuous weeks before they become effective.

Exercise:  Swimming helped a lot.

When I finished the conversation, I knew I carried credibility because I spoke from personal experience.