Fatal? Sometimes. Never recover? Frequent.

To humans, I say, one and all

The risks, I tell you, are small

Please get the vaccine

For COVID-19

To avoid the dreaded “long haul.”

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 further travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  Since the pandemic started I did telemedicine, got COVID-19 and then the vaccinations, and did a week of in-person medicine close to home.  I just started an assignment in Iowa.  Identifiable patient information, including that of my wife, has been used with permission.

I walked to work today, in the cool, clear spring air, with the temperature hovering just at freezing, a few patches of frost on the grass in the low spots.

I like a short commute.  The best ones don’t require a car, which builds exercise into the work day. 

My fluency with this particular electronic medical record (EMR) continues to grow but today I still needed a lot of help.  Certain design flaws and redundancies bear a strong resemblance to a system I worked with 5 years ago, but not so strongly that I could call it identical.  All EMRs evolve; every update makes each one harder to use (I’ve not heard of an exception but will accept an assertion to the contrary). 

COVID-19 and its fallout dominate our clinical thinking.  Today we had a bunch of corona-positive patients, along with a series of patients with new onset atrial fibrillation. 

I have an advanced, digital electronic stethoscope to help make up for my hearing loss, that I didn’t use once in my 10 months of telemedicine.  During that time I examined exactly two eardrums using an otoscope (the patient had the digital version).  Today those two instruments proved key to properly diagnosing more than half my patients, leaving me to wonder how much I missed without them.

COVID-19 hits a lot of body systems.  By now we all now about the cough, fever, muscle aches, and loss of sense of smell.  But a small number of people have symptoms mostly referable to the skin or the gut. 

The virus also can hit the heart.  An increased tendency to clot can lead to heart attacks and blood clots in the lungs; the virus can irritate the sac that surrounds the heart (pericarditis) and it can settle directly in the heart muscle (myocarditis).  And days to months after the infection, the heart can have problems keeping its rhythm.   

Between 10% and 30% of people who get COVID-19 will have symptoms that last for more than 3 months and earn the unofficial designation “long haulers.”  Some will never fully recover. 

But I still meet COVID-19 vaccine hesitancy.

I found out today 1) I can test patients for mycoplasma and 2) we have an inordinate amount of mycoplasma illness. For the last 40 years, anytime I diagnosed mycoplasma, I did so based on my “clinical impression,” a fancy way of saying “best guess,” not nearly as good as the serology we have here and now.

Why so much mycoplasma?  Probably because we have so much livestock so close to people. 

The script our parents give us

To the problems I can relate
My family was in a sad state
Let’s call a halt
To blame parents’ faults
We’re obliged to master our fate.

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, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, and a bicycle tour of northern Michigan, cherry picking in Sioux City, I’m back in Pennsylvania. Any patient information has been included with permission.

After a week off, I addressed the drama and irony behind the first patient’s very real physical problem from the perspective of my own experience. My mother had borderline personality disorder, my father had narcissistic personality disorder; no medication exists for either of those two problems. I observed that we don’t get to write the script that our parents hand us, but we have the obligation to edit it, and that obligation gives us freedom. Stressed people get sick, and sick people get stressed. Some of the stress that life brings us we cannot avoid and we just have to deal with it, but some of our stress we make for ourselves.
I saw a lot of people sick in the aftermath of a death in the family. For some I mentioned my brother-in-law’s untimely drowning and we had a mini support group. With others I talked about my 11 culture proven strep throats in the 10 months after my mother’s death.
Early in the day I recounted two stories to the PA I worked with. The first had to do with a different clinic in a different century, during the days of paper charts, when I caught myself over emphasizing the importance of thyroid testing to a med student. “Think thyroid!” I pontificated. “Depression? Think thyroid. Weight gain? Think thyroid. Weight loss? Think thyroid. Diabetes, hypertension, or cholesterol? Think thyroid.” We walked up to the next exam room, and I pulled down the chart so we could read the chief complaint on the routing slip.
“C’mon,” she said, “Sore throat? Think thyroid?”
And with a trifle more certainty than my experience justified, I said, “Think thyroid!” We walked into the room, I said to the patient, “Take one finger and point to where you hurt the worst.” She pointed to her thyroid, and turned out to have Hashimoto’s thyroiditis, with an anti-TPO about 100 times the upper limit of normal. I hope the med student recognized the luck that played into that impressive bit of diagnosis, but still went on to test the thyroid for the least justification.
The second story had to do with a patient in another clinic in another state, who might have come in for one thing but routine exam picked up an irregular heartbeat and EKG showed atrial fibrillation.
All in all, the day went well. The PA stayed till 2:00PM. I ordered delivery Chinese, and inhaled forkfuls of fried rice between patients.
The last patient of the day teaches high school history. We had a marvelous but all too brief conversation about that subject. While some might complain that current history curriculum includes an excess of politically correct material, I remember clearly the Cold War propaganda from my own high school days; we students recognized that material as a pack of lies. Which inspired me to study history on my own, and to find out the real story.

Thinking thyroid, learning history

Here’s something that we should note
For a diagnosis I’ll throw in my vote
When it comes to life’s stress
The immune system’s a mess
Is it really just a sore throat?

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, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral and a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m back in Pennsylvania. Any patient information has been included with permission.
After a week off, I addressed the drama and irony behind the first patient’s very real physical problem from the perspective of my own experience. My mother had borderline personality disorder, my father had narcissistic personality disorder; no medication exists for either of those two problems. I observed that we don’t get to write the script that our parents hand us, but we have the obligation to edit it, and that obligation gives us freedom. Stressed people get sick, and sick people get stressed. Some of the stress that life brings us we cannot avoid and we just have to deal with it, but some of our stress we make for ourselves.
I saw a lot of people sick in the aftermath of a death in the family. For some I mentioned my brother-in-law’s untimely drowning and we had a mini support group. With others I talked about my 11 culture proven strep throats in the 10 months after my mother’s death.
Early in the day I recounted two stories to the PA I worked with. The first had to do with a different clinic in a different century, during the days of paper charts, when I caught myself over-emphasizing the importance of thyroid testing to a med student. “Think thyroid!” I pontificated. “Depression? Think thyroid. Weight gain? Think thyroid. Weight loss? Think thyroid. Diabetes, hypertension, or cholesterol? Think thyroid.” We walked up to the next exam room, and I pulled down the chart so we could read the chief complaint on the routing slip.
“C’mon,” she said, “Sore throat? Think thyroid?”
And with a trifle more certainty than my experience justified, I said, “Think thyroid!” We walked into the room, I said to the patient, “Take one finger and point to where you hurt the worst.” She pointed to her thyroid, and turned out to have Hashimoto’s thyroiditis, with an anti-TPO about 100 times the upper limit of normal. I hope the med student recognized how much luck played into that impressive bit of diagnosis, but still went on to test the thyroid for the least justification.
The second story had to do with a patient in another clinic in another state, who might have come in for one thing but routine exam picked up an irregular heartbeat and EKG showed atrial fibrillation.
All in all, the day went well. The PA stayed till 2:00PM. I ordered delivery Chinese, and inhaled forkfuls of fried rice between patients.
The last patient of the day teaches high school history. We had a marvelous but all too brief conversation about that subject. While some might complain that current history curriculum includes an excess of politically correct material, I remember clearly the Cold War propaganda from my own high school days; we students recognized that material as a pack of lies. Which inspired me to study history on my own, and to find out the truth.