Posts Tagged ‘back pain’

Why I Came, and Can I Fix the American System When I Get Back?

August 14, 2017

My reasons? I’ve got quite a few

I didn’t want to say I withdrew

My application

But my rationalization

Got me to work with the right crew.

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 traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

The patient (who gave me permission to write a good deal more about her than I have) asked why I came to British Columbia.

A lot of people ask me that question, and I truncate the truth, too complex for brevity. In no particular order:  I have a thick stubborn streak.  I had a tiger by the tail: see the project through or have to say that I’d withdrawn an application for licensure.  I wanted to spend more of my time taking care of patients and less time at meaningless but marginally lucrative mouse clicking.  I have a sense of adventure.  I wanted to know the truth behind what US doctors vilify and US liberals champion but neither have any experience or knowledge about.

There are more.

So I just said, “I wanted to know find out about the Canadian system.”

As I opened the door she asked, “So, when you get home, are you going to fix the American system?” I said, “No, but the first step is educating the American docs. And I’m not sure they’ll believe me.”

Actually, I don’t think the liberals will believe me, either.

+=+=+=

Last night the smoke from the forest fires drifted into town. The dramatic evening sky progressed from intriguing to eerie.  Finally, darkness fell, thick and hard, two hours early.  The smell of smoke kept me from falling asleep.  This morning we watched the news for two hours to see how close the fires are.

We don’t want the fires to come this way. Too close and the town dies from lack of wood.  Much too close and the whole city goes up in flames.  I wouldn’t want to have to evacuate, and I don’t know which way we would go.

We’re seeing an increase respiratory problems from the smoke. Some people have come in from BC’s largest city, Prince George, because of air quality.

=+=+=+=

Last time I was on call, I saw 14 patients, and 3 diagnoses accounted for 13 of them: back pain, abdominal pain, and left facial pain. The only one not covered by those three complaints came in before the others, and left, cured.

 

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The diversion of patients because of forest fires

July 12, 2017

The forest, it seems, is on fire.

And the wait can sure make me tire

When our referral facility

Has maxed capability

And my patients have problems most dire.

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 traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

As I write this, 183 wildfires rampage through the wilds of British Columbia. The smell of wood smoke permeates the air and a haze hangs over the nearby mountains.

We have been lucky during this last week of fires, with 3 days of solid, soaking rain. But with complex topography comes complex weather patterns, and nearby valleys have had no precipitation at all.

Yesterday I had call. I took care of people with problems in their skins, bones, throats, lungs, hearts, eyes, abdomens, fingers, toes, brains, ears, and genitals.  Two came in close together, with problems exceeding our facility’s capability.  I ordered blood work; I like to sound prepared when I speak to a doc in a referral center.  Then I waited.

And waited. When I got results back, I called the hospital in Prince George to speak to a couple of consultants and to formulate a plan, then I had the central ambulance dispatching service called.

Theoretically, the dispatch centralization makes sense; practically, however, it means a terrible delay in getting patients into the ambulance.

I had hoped to send both patients in the same vehicle to Prince George, but in the course of making arrangements I found out that the number of injuries coming in out of the forest fire had overwhelmed the schedule for sophisticated diagnostic tools, and couldn’t I please send the second patient to Dawson Creek?

It meant a longer delay for the second patient, but I agreed, and called the ER there with a bizarre, creepy history perfect for the opening of a horror movie.

Of course, in the hours between the arrival of those two patients and their departure, other patients came in for treatment.

At six I walked to the hotel to eat supper with Bethany. I had been continuously occupied for the previous 10 hours.  I wolfed my food, napped briefly, and walked back to the ER.

I started in on documentation, typing directly into the Electronic Medical Record. I continued between the patients who kept trickling in.  I ran into a surprising number of patients with back pain who adamantly spoke against narcotics (and I agreed with them).

I finished at ten, and returned to the hotel. I had attended 21 patients.  The emotional fatigue of waiting to transport those two critical patients far exceeded the physical tiredness.

And then I had no calls for the rest of the night.

A bad bed, great Northern Lights, and a patient with “red flag” symptoms

March 25, 2015

The bed here? Let’s just call it bad
The second worst I’ve ever had
But for the sake of the night
I saw Northern Lights
‘Twas worth it. It made my heart glad

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 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) I can get along with. Right now I’m on temporary detail to Brevig Mission from the hospital in Nome, Alaska.

The bunk here came near to the worst I have slept in, second only to a very bad mattress in New Zealand. I contemplated putting the mattress on the floor, but at 3:00 AM I remade the bed head for foot. Before lying back down I watched a spectacular aurora borealis for about 5 minutes. A person, apparently a teenager with a backpack, walked through the darkness and didn’t waken the sleeping dogs.

The clinic, built to standards set by the Joint Commission on Accreditation of Hospitals and Organizations (JCAHO), has my bed thirty paces from the exam room, which in turn is 12 paces from the break room. Across the 8 feet corridor from my exam room the two-bay trauma room yawns, almost the size of the ER in Petersburg, Alaska. On my way to work I pass the 2 chair dental suite, two other exam rooms, a shower, the pharmacy/lab and two generous utility rooms.

The Community Health Aids (CHAs) staff the facility most of the time in the absence of a physician, PA, or NP. Selected on the basis of intelligence and resourcefulness rather than on degree, they handle the load most of the time, and call for help when they can’t.

Today I met a patient I’d heard about in Nome. Now doing well, one could never imagine the difficult Anchorage ICU course after Medevac complicated by a storm, an experience shared by many here.

On three occasions today I talked to patients with long-term back pain, and none of them requested narcotics. My personal experience with the problem gave me credibility when I talked about ways to approach the problem without drugs, including nicotine, caffeine, alcohol, and marijuana.

One patient near the end of the day came up with “red flag” symptoms serious enough to send to Nome but not serious enough for a Medevac. I shared the CHAs’concerns. I called the PA in Nome who will see the patient tomorrow and relayed my differential diagnosis. While doing so I could talk about the patient’s use/non-use of nicotine, alcohol, and marijuana by pantomiming to the CHA and receiving either a nose wrinkle or an eyebrow raise (Inupiaq for no and yes respectively). Before I hung up the staffers prepared paperwork, all I had to do was sign it.

With the last patient seen and the janitor finished, after another 9-hour work day, I went out into the cold. I wore my new sealskin mittens for the first time. I stood on the beach and looked north and west at the tip of the Seward Peninsula.

No illusions: lies and drugs.

December 15, 2012

This rule I won’t even bend,

I no longer even pretend

I see no excuse

For those drugs of abuse

That make up a frightening trend.

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.

Last year legally prescribed narcotics killed more Americans than the bullets or the cars.  This frightening statistic comes after a four-year near-logarithmic increase and matches the same trend in the number of narcotic pills prescribed.

Several layers of government keep track of the use of certain medications, the ones most susceptible to abuse, now referred to as controlled or scheduled drugs.  I have to have a slip of paper from any state government where I practice and the federal government to prescribe any narcotic, also addictive tranquilizers, most sleeping pills, and testosterone.

I tend to reach for those drugs as a last resort.  We have a lot of other things to treat pain and anxiety and sleeplessness; nonetheless controlled medications have their place in the work I do.

Of course a lot of patients disagree with me as to how big that place needs to be.

As required by my state licensing board, I took a two hour video course in the proper prescribing of pain medications, exhorting me to watch out for personal and family history of crime or substance abuse, past incarcerations, or frequent missed appointments.

More than half of my new patients don’t show for their first appointment, which leads me to wonder about substance abuse even before I see them.

Our practice includes a large number of people who have done significant time behind bars; I don’t want to know their crimes.  Everywhere I’ve practiced, abuse of alcohol and other substances runs rampant.

So, all in all, I keep my suspicions high, particularly when a new patient comes in with a long med list including tranquilizers and narcotics.

The number of good reasons to prescribe long-term narcotics continues to dwindle; for example, evidence-based medicine shows the opiates lose their effectiveness for back pain after 8 weeks.  I never prescribe large numbers of the two most popular short acting tranquilizers, alprazolam and lorazepam; if the person really has that much anxiety I recommend the long-acting but less marketable cousin, clonazepam.

Really, the problem comes down to diversion: someone other than the patient taking the prescribed drug.   

Thus, for those patients on long term controlled medications, we make sure they sign an agreement that says they won’t share those drugs, and that they’ll come in, when asked, for a urine drug screen and pill count.  And that they won’t seek controlled substances from more than one provider. 

I used to believe people who would tell me they used to abuse drugs but named a date when they quit.  Most can tell twelve-step stories. 

Two of my patients flunked the urine test this last week. 

I’ve asked our case manager to contact them, to see if they’ll come in to get counseling.

I don’t hold high hopes.

Piriformis syndrome: a curable pain in the buttock

December 24, 2010

For a pain that starts in the butt

I don’t think of reasons to cut

     If a spasm is found

     To relax it I’m bound

And I can change your limp to a strut.

Most of the time if a person comes in with pain going into the buttock, radiating down the back of the leg, accompanied by numbness and tingling, or even weakness, I think about a bad disc pressing on the spinal cord, but I always ask the patient to take one finger and point to where the pain starts.

Every once in a while the patient will point to the buttock and deny any pain in the midline.

On those occasions, I sometimes find a hard triangular lump at the seat of the pain. I mash on that lump and ask if the patient’s pain going down the leg got worse, and, usually, the answer comes back “Yes.”

I diagnose piriformis syndrome this way.

The piriformis muscle runs across the buttock from the sacrum to the outside hip bone at the top of the thigh. The sciatic nerve runs under, or sometimes through the pirirformis, and spasm here can give a person sciatica, the pain and numbness running down the back of the leg. In such a case we say the sciatica comes from the piriformis syndrome, and by the thinnest of coincidences I learned a simple maneuver to relieve it.

During med school I went to the home of a physician to meet a friend giving piano lessons there. While I waited, the doctor, waxing loquacious from whiskey, told me how to apply my shoulder to the flexed knee in an osteopathic manipulative technique I would later learn to call “muscle energy.”

Over the years this tool has given me immense professional satisfaction. Starting with a limping patient in pain, performing a maneuver, and watching the patient sit up and walk without pain is an experience that leaves me grinning for the rest of the day. 

It doesn’t happen very often.

Last week, I diagnosed piriformis syndrom three times, and I manipulated one patient.  I taught one patient how to self manipulate, and for the third I prescribed a muscle relaxant.

As with anything else in medicine, success depends on proper patient selection.  Penicillin works well for strep throat and syphilis but for little else; sciatica from a ruptured disc does not respond to muscle energy manipulation.  

Sometimes a person might be too big or too fragile for me to manipulate.  In those cases I turn to the more commonly used mode of treatment: muscle relaxants.

My favorite, generic metaxolone, costs more, hence the insurance companies rarely pay for it.  All the others bring sedation to the point of sleep so often that, on the rare occasions when I prescribe them, I tell the patient not to operate anything more hazardous than a salad fork. 

I know.  Because of my back problems, I’ve tried them all.