Posts Tagged ‘antibiotics’

A straightforward ear infection, and the work up of vasculitis

November 19, 2016

Tell me how can I choose?

The labs will come slowly as news

I won’t be so brash

As to diagnose a rash

That shows as many a bruise. 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

Friday morning arrived and the sweetness of yesterday, with 15 patients before lunch and no computer, lingered.
The first patient of the day, an adult with ear infections, gave me permission to write more than I have. Most people who come to the doc with cold symptoms expect an antibiotic, though studies show a good explanation of why an antibiotic runs more risks than no treatment satisfies the majority. Still the explanation takes more time than writing the prescription.
Current wisdom holds that a physician can justify an antibiotic in the presence of fever, more than 10 days of symptoms, or “second sickening,” where a patient started to improve and then worsens.
I see adults with ear infections so rarely, and I spend so much time gently coaxing patients away from antibiotics, that finding not one, but two bright red ear drums in a single patient gave a great start to the day.

The second patient came in with a rash.  I said, “I write a blog.  I won’t say gender, age, name or diagnosis, but I’d like to write about vasculitis and the steps a doctor has to go through,” and the patient agreed.

When I look at a rash, I want to know if it blanches, that is, loses its color under pressure.  And I want to know if I can feel it.  Tiny bruises, petechiae, that cannot be felt, herald serious disease.  I went to the Internet to find what labs to run.  In the three years since I last saw a case of vasculitis, the work-up has changed, but not much.  I printed off a page, handed it to my nurse, gave her a thousand apologies, and asked her to enter the orders into the Electronic Medical Record.

Then I settled in to read about treatment.  We always like to have a firm diagnosis before we start administering medication, and the firm diagnosis can’t happen until the lab results come back.  A lot of those probably won’t arrive before Thanksgiving.  After that, urgency of treatment depends on symptoms.

It took the nurse as long to enter the long list of lab tests into the computer as it did for me to read the monograph.  I thanked her profusely.

I read the authoritative monograph, and shook my head when it said that 72% of cases of vasculitis will not be conclusively diagnosed.

Last century, at another clinic in another city, a young man came in with a sore throat in the middle of a strep epidemic.  I love a slam-dunk diagnosis I can do something about, but as I exited the room, he asked, “What’s this rash?  I was just sitting here and I noticed it,”  and he pointed at his ankle.  With outside temps hovering in the negative double digits, he wore no socks.  Those tiny purple bruises on his lower legs prompted an investigation leading to a hospitalization, and uncovered a heartbreaking story of drama, irony, hunger, homelessness, love, betrayal, and chemical dependency.

Some things don’t show up on a lab test.





Gravity and wound healing.

October 22, 2015

When it comes to a wound and pain,

Think of gravity to help and to drain

Leave out the drugs

Prop up with some rugs

And cut out Big Pharma’s gain.

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, and two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

Sunday went slowly till the last, a patient or two an hour.  I got time to eat lunch and supper without rushing.

I saw a lot of respiratory ailments today.  Most people get a runny nose, a low-grade fever, and after about 4 days a sore throat and a cough.  So far, the strep and influenza tests keep coming back normal.  I counsel patients about Tylenol, rest, and fluids; antibiotics would have a greater chance of harming than helping.  And, indeed, recently I saw a couple of bad reactions to antibiotics.

One of the non-respiratory patients, extremely sharp and quite elderly, came accompanied by an offspring.  The therapy recommended a couple of weeks previous had failed to resolve the problem  I observed that swelling in a limb puts the skin under tension and makes wound healing impossible.  Thus to fix an ulcer on a swollen ankle, one must first fix the swelling.  In the majority of cases gravity will drain the edema.  During my 23 years of private practice, I regularly hospitalized patients for non-healing diabetic foot ulcers.  I called in a podiatrist consultant, whose therapeutic mainstay consisted of keeping the patient’s feet elevated above the level of the heart.  It always worked.  So I told the patient to stack blankets and towels on the recliner to keep the foot higher than the heart by at least 12 inches and preferably 18.  Pillows don’t work, I explained, because they compress.  And if we can just keep the part involved elevated, chances are you won’t need other therapy.  And if you don’t keep it elevated, all the antibiotics in the world won’t help.

I needn’t have worried about unselling the drugs; the offspring currently studies naturopathy.  The patient related a family member’s story, full of drama and irony and reflecting poorly on my industry, as the background for a low enthusiasm for medication.  I couldn’t argue with the conclusion.  And my approach, using a low-cost, low-hazard, readily available commodity (gravity), met with great approval.

I had barely finished the documentation when the evening rush started with six patients checking in after 7:00PM.  I still managed to get my charting done by 8:17PM, and walked out into the darkness.

Application of medical first principles on a Tuesday in Keosauqua

December 21, 2010

Why do doctors go gray?

Is it all work and no play?

     Life can be a ball,

     Though you’re working on call,

Just don’t give in to dismay.

When I’m on call, nights or weekends, I get a lot of calls from people who have self-diagnosed an antibiotic deficiency and want a prescription called in.  Pain with urination, sore throat, and cough comprise the most frequent complaints.

I would like to say I don’t ever yield to the request, but on rare occasions I do.  I weigh the risk to the patient of treatment with an exam versus the risk of treatment without an exam.  Most of the time I’m pretty rigid, but flexibility sets in during extreme weather.  Last year a blizzard descended on Sioux City when I had Christmas weekend on call.  On a day when it took three hours to get from my garage to the street, I said “Yes” a lot.

Most sore throats do not benefit from penicillin.  Most pain with urination is not urinary tract infection.  Most earaches do not come from ear infections.

Today I saw four patients with painful urination, abrupt onset, accompanied by blood in the urine.  One had a urine infection.

I work very little to write out a prescription for three days of antibiotics; I work a great deal more explaining why the patient shouldn’t take antibiotics.

Of the last nine patients with pain in the ear, one had an actual ear infection.

Three other patients, all smokers with emphysema, came in short of breath today; they all left with prescriptions for antibiotics and inhalers.  One got a prescription for prednisone (a steroid).

On six occasions today I added up the costs of peoples’ bad habits.  “OK,” I’d say, “How much are you paying a pack for Marlboros/a bottle for Mountain Dew/a cup of coffee/a pack of generics/a case of beer?”  I got out my calculator and said, “Dang!  Eight hundred dollars/twelve hundred dollars/nine thousand dollars a year!  They must pay you well!  I’m a doctor and I couldn’t afford that.”

People who work with livestock in general and horses in particular don’t complain much, and if they do, I’d better listen.  I applied that principle twice today.

Three folks with mental health histories were in today; their complex medical problems took time.  I considered the principle that craziness doesn’t protect from physical illness.  I have a lot of lab results pending.

Four patients let drop the fact that a close relative had died in the last six months.  I listened and I sympathized.  I remembered the ten months after my mother died, when penicillin injections kept me going during a succession of eleven culture-proven strep throats.

Depressed patients get sick, and sick patients get depressed.

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.