Posts Tagged ‘ear wax’

Apology and an abnormal thyroid

October 25, 2016

A veteran I might legally be

Does it feel like that?  Not to me

I sure owe a debt

To the Viet Nam vet

Without any PTSD  

 

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 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.  I just returned from a moose hunt in Canada.  Any identifiable patient information has been included with permission. 

I cleared out most of the month to take some holidays, but I accepted a couple of days’ work in a rural clinic not far from home.

I didn’t get formal training on the Electronic Medical Record. It turned out it didn’t take much to get me going.  They let me dictate my notes and they let me work with a nurse who knows her way around.  It doesn’t hurt that I’ve learned 12 new systems in the last 24 months.

I made that observation to a colleague involved in the residency, who noted that our Family Practice residents have to deal with 7 different systems.

The first day I worked in the new venue, I massaged away the headaches of two patients, and helped two others by taking out ear wax. In the evening, I saw three patients in the ER, two of whom required hospitalization and consultation the next day.

The pace of work went well that next day, and I drove home in a reasonable time frame.

Bethany came with me when I returned at the end of last week, driving past corn and soybean fields in the early stages of harvest.

Doctors can take some pretty rough verbal treatment, and an apology first thing in the morning made my day.

I did several pre-op evaluations. In one case, my findings came so markedly unexpected I had to call the surgeon to formulate a plan.

I cared for a Viet Nam combat vet with no Post Traumatic Stress Disorder. I told him how highly I regard the VA.  I see him as a Real Veteran but I don’t see myself that way.  He reassured me that anyone who has to put up with owning a uniform, and having a rank in a system with bad pay and bad management  qualifies as a Real Veteran.  We had a good discussion about emotional resilience and how it plays a big factor in PTSD.  He gave me permission to write about more than I have.

Even if I can’t write about people, I can write about medical conditions. I really like finding abnormal thyroid results.  Because a thyroid gland, either over- or under-active, can cause a lot of different symptoms.  When my thyroid went into overdrive, I could not sleep, I lost weight, I had no inner peace, and I couldn’t sit still.  I know that, sooner or later, my thyroid will quit working and I’ll need to take replacements.  And at the end of the day, the nurse handed me a slip of paper with an abnormal thyroid result, which explained a lot but not all of the patient’s symptoms.

 

 

 

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Trade offs in Urgent Care

August 11, 2015

I enjoy my Urgent Care job
The patients come by the mob
But sometimes it’s our fate
We’re not done, but it’s late,
The rush just makes the staff sob.

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, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

I enjoy my current gig for an Urgent Care facility in suburban Pennsylvania.

My nominal work hours run from 8:00AM to 8:00PM. I go late on average one night out of three. Patients generally come in with problems of short duration and intense acuity. Most have a primary care provider who can’t see them in less than 3 days. Because management has developed a patient-centered approach, I do little redundant clerical work and thus I can spend a lot more time concentrating on patient care.

So far this week slow patient flow in the morning has given way to a brisk pace in the afternoon. Staff morale stays high, the big gripe comes against the rush of patients that starts after 7:00PM (about half the time). So tension builds on quiet nights as the clock ticks out the last half hour.

Poison ivy made up half the business back in June, but is now decreasing in frequency and severity. I have sewn up a lot of finger and hand lacerations. Two or three times a day we have the joy of curing the patient before they leave, mostly by taking out ear wax; but we also drain an average of one abscess a day. A majority of the x-rays I order show fractures.

People around here like to vacation at the beach, mostly New Jersey,Virginia and the Carolinas. We get a significant number of patients with swimmer’s ear and urinary tract infections related to the travel and swimming. And also the worried well who don’t want to be sick while on vacation.

August brings in the sports physical crowd. Basically healthy, the rare surprise disqualifications justify the activity.

Then, sometimes, with such a high patient volume (I consider 30 in a 12-hour shift light), serious illness demands an ambulance or an injection. Twice so far today I’ve advised patients to go directly to ER.

Earlier this week I helped wheel a patient into her waiting vehicle. I enjoyed breathing the warm summer air and smelling growing vegetation and seeing the summer thunderheads building in the north.

Occasionally a physical finding I’ve never before seen heralds a puzzle, and I refer to a specialist.

We refer all broken bones to orthopedists.

Urgent Care has its share of joys but so much of the fun comes from the fast pace and the easy-to-solve problems that the awe and mystery of unraveling complex disease one lab result at a time gets lost. An upscale, insured population obviates the opportunity to serve the under-served. And I miss speaking Spanish.

Life always involves tradeoffs.

Another road trip 10: starting with drama and finishing with a friend.

June 17, 2015

I started the day off with drama

For me, psychological trauma

But then at the end

I made a toddler a friend

And impressed the papa or mama.

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. Right now I’m working in suburban Pennsylvania, combining work with a family visit.

Bethany and I boarded the elevator this morning, and another passenger came on.  I looked at his name tag lanyard and recognized the monogram logo.  I looked closer and saw the words “Health Care.”

“You rep for GE?” I asked him.

“Yes,” he answered, grinning.

“Centricity?”

“Yep.”  He still smiled.

I will confess to evil thoughts that I trace to my involvement with that EMR system.

I fantasized picking my laptop up, throwing it as hard as I could through the glass window and into the street, timed just right so that a speeding semi going 70 mph on a city street would smash it on the grill.

I have imagined walking up to the promotional booth at the American Academy of Family Practice, and starting a strident, offensive series of questions, accusing the rep of complicity with the Forces of Darkness, and I would be joined in a matter of minutes with hundreds of sweating, frazzle-haired doctors carrying signs and chanting louder and louder until, screaming, we dismantled the booth.

Or, better yet, getting a humbled software engineer into the clinic and showing him how badly the system worked and kicking him in the shins and saying, “Why would you bury landmines in a sandbox?”

In the time it took for a hundred things to run through my mind, I decided to say, “I left a job because of that system.”

His grin didn’t dim.  “We don’t sell it anymore.”

I had to stop my runaway emotions in their tracks.  My grim imitation of a smile broadened to genuine and I laughed.  “You absolutely can’t imagine how validated I feel.”  I shook his hand and thanked him profusely.

***

I can’t write anything specific about the first patient of the day, but I can say things started unexpectedly early with unexpected drama.

After that, the pace slowed till 11:00AM.  While I ended up caring for 39, the majority came in after 5:00 PM.  Poison ivy accounted for half the business, earache for another quarter, and eyes for 10%.

Removing ear wax, making the patient better before they leave, brings me great satisfaction across a wide age range of patients.

But the clinical highlight came with a frightened 20 month old.  I played my way through the exam, I finished with more energy than when I had started, and left the patient more trusting of doctors.  The parent, impressed with my gentleness and patience, gave me permission to write that, and a good deal more.

Protected: Unemployed but not out of work

October 8, 2014

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Chocolate, tornado, lemonade, ear wax, and a supervisory visit

May 3, 2011

Don’t even try to refute,

For this there is no dispute

     Could I get any closer?

     I tell you, No Sir!

Happiness is a shorter commute

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  After a six-week assignment in Barrow, Alaska, I’m working on the North Island of New Zealand.

I started the day at leisure with a seven-step commute to my office.  I sat down promptly at 8:00 AM and started to review lab work.

In the quiet of the morning, early, before the first patient arrived, I found an alarming erythrocyte sedimentation rate (ESR) with the highest C-reactive protein (CRP) I’ve ever seen; both markers of inflammation throughout the body, I prescribed prednisone.  I don’t prescribe that medication often, and always in the context of getting a specialist’s opinion.

I can’t talk about patients and their medical problems without permission, but I can talk about myself and about medicine.  Yet diseases don’t come to me, people come to me; none of them perfect, each with flaws, quirks, a terrific back story and a family.  Every person who seeks my advice has a unique smell, voice, accent, style of dress and body language.

If a person presents with an ear wax problem, and I take the wax out with a simple instrument called an ear curette, I’ll tell them how to keep the wax problem at bay.  I make sure they’ve never had a hole in their ear drum and I instruct them to start with body temperature water and put in enough white vinegar that it smells like vinegar but not so much it feels cooler.  Then, I say, use a bulb suction syringe to rinse the ears out about once a week.

I saw another person today with appendicitis, making three since I arrived.  At least, I hope I saw the first case of appendicitis I’ve ever seen in a person who had enjoyed their lunch.  I worry that my patient has something worse.

I saw a person with a single distended vein where I’ve never seen one before.

I made referrals the general surgeon, ophthalmologist, urologist, neurologist, and orthopedist.

At mid-morning, I took a tea break.  While the fifteen minute hiatus comes built into my schedule, most mornings I use it to catch up.  Today I walked back through the apartment, picked a lemon from the tree, came back in, made hot lemonade and sipped it while I talked with Bethany, nibbling on some exquisite dark chocolate macadamia nut bark.

When noon came round we lunched while we watched the shocking, driving rain outside.  The first thunder we’ve heard since we arrived made us stop and listen.

The rain continued for the afternoon drive to Wellsford.

In accordance with the Medical Council of New Zealand rules, any doctor new to the system requires supervision their first year.  In this case my supervisor is the clinical director, and we met in the early afternoon.

I enjoyed the interview. 

A reasonable clinical pace.  I told people on asthma medication to quit smoking.   I gave others with high cholesterol levels instructions about diet and exercise.

Driving back to Matakana in the rain, we learned that the same storm that gave our afternoon’s deluge spawned a tornado, so rare in New Zealand that rating came only with difficulty.

Left-sided trauma, skin infections, paperwork for income, and a surgical emergency at the end of the day

March 30, 2011

I will not belittle or curse

Nor whine when it comes to my purse

     I won’t cry or scream

     I work on a team

And I can delegate to the nurse.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  Just back from a six-week assignment in Barrow, Alaska, the northernmost point in the United States, right now I’m in Leigh, New Zealand and working in Wellsford, Matakana, and Snell’s Beach.

Today I attended twenty-seven patients.

Four asked me to fill out paperwork so that they would get an income from the government.  One denied any medical problem so clearly that I suspected some agency had recruited a patient to try to trap me into bad practice, and I refused.  For the others I advised lab investigation, retraining, and lifestyle modification.

Nine patients had superficial skin infections.  I heard the term “school sores” applied to a painless blister that rises, then drains pus, and starts to spread.  I prescribed a lot of mupuricin (Bactroban).  Three patients had fungal skin infections, and I prescribed clotrimazole, available back home over-the-counter as Lotrimin.

The vast majority of the trauma I saw happened to the patients’ left side, and included fracture, sprain, bruise, cut, and contusion.

I learned that cigarettes go for $12 per pack of 30, and that those smokers who protest they can’t afford medical care don’t like me getting out the calculator any more than the smokers at home do.

I calmed three children by playing with my yoyo.

Freezing off warts, a simple operation that requires about fifteen minutes of training, pays obscenely well at home because our system rewards procedures more than cognitive-based actions.  Today I had the delight of sending a patient with warts to the practice nurse, who was happy to apply liquid nitrogen.

I sent two patients to the Ear Clinic for wax removal.  I’ve written other posts about the satisfaction that comes from getting out a really nasty hunk of cerumen, but I never detailed the occasional frustration and back pain that goes along with it.  The frequency of ear wax impaction justifies dedicating a nurse three days a week.

I checked patients’ blood pressures today.  For twenty-three years I could say, “Vital signs?  That’s the nurse’s job,” but I’m in a different framework here.  The nurses have a lot more responsibility and power.  They do a good job and free me up for other things, and I don’t mind if I pay the price of collecting all the vital signs I want.

At five, as I settled down to complete my documentation for the day, a nurse asked me if I’d see a patient.  The doctor on call had stepped out.  Not a problem, I said, and saw an opportunity to demonstrate good team work. 

I can’t write any of the specifics of the case because I didn’t get the patient’s permission. But I can say that the nurse did a good workup and that I had the satisfaction of going one layer deeper to uncover a true surgical emergency.

I had seen a couple similar cases a year ago, and even in my own clinic and zone of comfort, my emotions ran high.

Currently, I have limited access to the Internet. 

A nose full of jelly bean, an ear full of wax, and parasitology vies with heart failure in the morning

February 23, 2011

A toddler will try, I suppose,

To stick jelly beans up in the nose

      With patients in stacks

     We take out ear wax,

While outside the arctic wind blows.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  Avoiding burnout, I’m taking a sabbatical while my one-year non-compete clause winds down, having adventures, visiting family and friends, and working in out-of-the-way places.  Currently I’m on assignment at the hospital in Barrow, Alaska, the northernmost point in the United States.

Long before dawn (the sun rose about ten today), with the mercury firmly at -28 F (-33 C), the physicians of Barrow sat down together in the hospital’s Commons Room.

We start clinic days with a conference, an hour discussion of patients who need to be brought to the group’s attention.  Sometimes the debate runs hot.  No two docs have the same range of skills; we all come away from the discussion better physicians.

The hour, for the last week, now features a five-minute starter from the Case Manager, giving us updates on the patients sent to Alaska Native Medical Center (ANMC) for hospitalization. 

We don’t talk about drama and irony nor contrast and meaning, though we talk about the impact of illness and injury on people’s lives. 

We focus on diabetes and smoking, emphysema (which we call COPD or chronic obstructive pulmonary disease) and steroids, heart disease and the interplay of factors that bring a person to illness.  Occasionally we’ll talk about tragedy and trauma and domestic abuse.

Narcotics seeking behavior comes up a lot, but as a group we’ve evolved a way to deal with the problem.  Part of the solution includes the doctors communicating with each other.

One doc gave an erudite rundown on congestive heart failure, renal physiology, and hypertension.  He did it as casually as giving directions to the gas station.  An in-depth round table on practical parasitology followed 

Morning appointments follow morning conference.

My last patient before noon survived burning, stabbing, shooting, being run over by a riding lawn mower, and falling from a roof and bouncing (and gave me permission to use more information than I’m including ).  After all that trauma, his lifestyle choices threaten his life more than anything else that has happened.  I called a specialist in another city, and, in the spirit of full transparency, included the patient in the conversation by leaving the speaker phone on. 

 The specialist said a lot of things he wouldn’t have if he’d known the patient were listening, like using the phrase, “stupid idiot,” but he also gave a good if emotional rundown of the physiology in the case.  I watched the patient’s face, he seemed neither offended nor surprised.  I respect him as a man of remarkable emotional and physical resilience, whose intelligence has not been ruined by schooling.  But I disagree with a lot of his choices. 

Afternoons, the clinic opens to walk-ins with no appointments necessary or available.

Ears, nose, and throat problems dominated the afternoon.  One patient left cured after ear wax removal.  Four others had ear infections.

The mother of a young girl gave her OK to post the following: the child inserted a jelly bean into the nose.  Toddlers imitate reflexively though their first response to a command is No.  I held one side of the mother’s nose shut, with a tissue guarding my hand, and had her blow through the other nostril.  Given the opportunity, the kid did the same thing, and the jelly bean, its colorful sugar coat dissolved, shot onto the paper.

I don’t often get the chance to cure patients before they leave.

Foil on windows, wax in ears, blood in the nose

June 13, 2010

The patients get sick, we know why

From the outlying village they fly

     Those on four wheelers

     Need the help of the healers

The North Slope is not really dry

Most of the twelve-hour call shift yesterday was reasonably paced.

Weekend medical staffing here covers Emergency Room and what is locally known as Walk-in Clinic.  Heart attacks and ATV accidents, for example, go to Emergency Room and colds, earache,  and allergies go to Walk-in Clinic.  Although the two things happen within steps of each other, and use the same paperwork and staffing, they are conceptually separate. 

The reality of Barrow and the bush hurt people in unique ways.  Four wheelers are a part of life on the North Slope, pavement is not.  Accidents happen and bones break.  Despite the high cost of cigarettes, $100 a carton, people smoke a lot.  They get emphysema and heart attacks.  Soft drinks are consumed by the rack (24 cans) or half rack (12); teeth rot, diabetes and its complications set in, obesity is common.  (My clientele in Sioux City also used an insane amount of soda pop.)  They cut themselves dealing with waterfowl and fish and get peculiar infections.  Alcoholism stumbles side by side with complete abstinence.  I took care of an 8-year-old who weighed twenty pounds more than a 51-year-old.

I talked to people whose relatives died in the tuberculosis and meningitis epidemics.

We sent a patient to Anchorage via Medivac; we had another fly in commercial aircraft from an outlying village.

On three occasions I spoke with Community Health Aides.  Each of the outlying villages has one.  Most are EMT’s, some are paramedics. 

I took care of a patient yesterday with a severe nosebleed, using 1% lidocaine with epinephrine rather than cocaine.  I cured a patient’s earache by taking out a piece of ear wax the size of the patient’s pinky finger.

I admitted a patient yesterday with half a dozen major diagnoses.  I’ve ordered some labs that won’t be back for a week or two.  On rounds this morning the patient is feeling better, but not well enough for discharge.

Being a non-Arctic resident, I admitted defeat in the presence of twenty-four hour daylight and took a trip to the grocery store.  I needed a roll of aluminum foil and a roll of duct tape, and as long as I’d taken the taxi there, I couldn’t pass up a bag of cherries.  And a bag of dark chocolate squares.  Fifty bucks.

I also visited the Cultural Center, a very nice facility.  Being sixty, they consider me a senior and let me in free.  I bought a T-shirt saying “I had a whale of a time.  Barrow, Alaska.”  There’s a one hour show for the tourists who come in with Top of the World Tours; I’ll go with Bethany when she comes.

A day and half in the life

May 19, 2010

A day and a half I’m on call

I know I can’t do it all 

     I take wax from the ears

     I give Kleenex for tears

And then I just hit the wall.

My long day on call grows no shorter as I write.

I get to the office most days before 7:30; I review lab results and scanned documents, and I read a medical journal.  Patients start at 8:30.

A reasonable morning opens with a sequence of 5 diabetics in several linguistic and ethnic groups.  I do a lot of tearful goodbyes.

A thank-you note and card comes from an Hispanic family;  the note verbatim reads Para: Dr. Gordon.  De familia (family name deleted) le deseamos mucha suerte en este nuevo camino que enpieza Gracias por todo lo que nos alludo en nuestra salud.  Lo vamos a extranar.

The few brief sentences carry much warmth.

A patient, whom I have known for many years, comes in with arm pain and no trauma.  I get an x-ray on a hunch; most times such studies yield little information but this time the pattern of light and dark suggests something very unusual and much deeper.  I show the films to my partners, we nod and say, “periosteal elevation.”  I arrange for a CT of the arm for the next day.

Urgent Care calls me about noon to ask if I’ll work there; illness disrupted regular coverage.  I can’t say no because of my job description.

The drug rep brings lunch and after my sandwich and chips we chat, mostly about my future.

The afternoon stars six people with earache.  Four have normal eardrums, and, speaking from personal experience, I ask them if the short, sharp, stabbing pain, severe enough to make them wince, comes at random intervals.  I explain the problem with temporal-mandibular joint dysfunction, I get to the bottom of the problem, and treat without medication. 

Two of the people with ear pain have ear wax stuck, hard, in the ear canals, and I have the satisfaction of curing the patient before they leave.

At five Bethany shows up and I let her know about my late shift.  We go across the street to the grocery store for Chinese food.

We get the Senior Two Entree Special (I’m 60 now), an enormous amount of food, and two sets of chopsticks.  We sit in the corner dining area and share the small intimacies of our days.

Back at the office, I finish my documentation from the afternoon, and at 6:00 the first of the evening patients arrives.

I move quickly while the dusk gathers outside.  I speak Spanish and English to the patients, some of them my regular clinic patients who couldn’t get in to see me on a timely basis or who can’t take time away from work.  I send a patient with puzzling abdominal pain and chest pain to the hospital for consults with specialists, and I wonder what I would do with that patient in Barrow with the nearest surgeon 800 miles away. 

Three more patients with ear pain: one with TMJ problems, one with wax packed hard enough to have turned to stone, and one with an actual ear infection. 

I face the dilemma of treating smokers for cough.

At 8:23 I go back to my office and I try to finish my afternoon’s documentation.  I answer and dispose of email.  At 8:58 I shut down my computer, hoping to  leave promptly at 9:00

But I find the fourteenth and last patient ready at 8:59.

At 9:10 I walk out of the clinic, into the deepening night, and I smell spring running riot.  My back hurts, not as bad as it did 20 years ago. My feet hurt, but they hurt worse 30 years ago because now I have rigid orthotics. I’m tired, but not like I was tired 15 years ago; within striking distance of the end and I have slept much better since I gave up OB.  I walk straighter and stand straighter than I did when I was half my age.  Even when I’m tired.

I miss my workout at the gym, the hour and a half to sweat and watch TV.

At home I take care of more ework and roll into bed at 10:30.

In the middle of the night I take a call from the nursing home about a patient with a significant change in condition since striking their head in a fall a few hours earlier; I instruct the nurse to send the patient to the ER.

At 5:55 I get an alarmed call from St. Luke’s Labor and Delivery: come for a STAT C-section.  I am dressed and brushing my teeth in the car 4 minutes later.  I exceed the speed limit.

I arrive just as the crew gets into position, and I have time to pull on booties and scrubs before the actual surgery starts. 

With a very good obstetrician at the helm, I have absolute confidence as the secondary member of the team, and the baby arrives in short order but distressed.  Stabilized in less than 10 minutes and up to the NICU, we sit down to debrief at the nurse’s station at 6:30. 

We discuss inexplicable physical findings during the labor.  “I want to know why,” the OB says.  Then, “God humbles me weekly.  If not daily.”

I talk about how every day I see something I’ve never seen before.

When I get home at 6:50 in the morning Bethany has my lunch packed and is finishing breakfast.  I shower, eat, leave the house half an hour later than usual and have to face traffic.  My commute takes 18 minutes instead of 13 and I arrive at the office sleep deprived with hoarse voice and a sense of humor even weirder than usual. 

More people with ear problems, and the nurse and I marvel at how many of those I’ve seen in the last few dozen hours.

Gridlock seizes my rooms from 10:40 to 11:25.  A patient with chest pain needs x-ray and EKG; a patient with pain on urination needs a urinalysis; and a patient on Coumadin for a blood clot needs a protime.  I feel trapped with both lab and x-ray backed up.  The people in the waiting room get angrier and angrier. I twiddle my thumbs, powerless.

The CT scan results come back for the patient with the arm pain from yesterday; non specific abnormalities can only be elucidated with MRI, which I order.

Then the lab and x-ray start to move again and by neglecting my documentation I manage to get the last morning patient out by 12:10 PM.

By that time day has gotten longer and my voice has deepened into the subwoofer range. 

Chinese food comes to the break room courtesy of a drug rep who doesn’t even stay to pitch his product.  I eat too much of it and then I eat the fabulous sandwich Bethany has sent me (green chile, avocado, artichoke heart and baked chicken on fresh chipotle baguette).  Fatigue drives my appetite runs out of control.

I power nap for 20 minutes, then I go back to my documentation.

The afternoon brings more earaches, loss of hearing, and dizziness.  I take out plugs of wax as big as the patient’s little finger. 

A patient with broken ribs contracts pneumonia.

My tongue sticks to the roof of my mouth as I feel dehydration set in, but I can’t slow down long enough to get to the water cooler.

A bipolar alcoholic patient with migraines, and a problem of just not feeling right also has chest pain, a main complaint that can’t be delayed.  The amount of clinical material exceeds any reasonable time limits for one visit.

Patients with borderline personality have limited emotional resilience and come  at a time in my day when I am pressured, fatigued and running behind.  That patient wants to get everything taken care of right now, and when I resist, threatens to leave without being seen.

Which, of course, is a ploy.  If not a short timer, I would grit my teeth, get through the visit, and send a termination letter while I still upset.  I let the patient manipulate me.  I don’t have long to go and I don’t have to fire anyone. 

Sore throat, cough, and two well-child checks. 

The Hispanic well-child checks constitute a problem; a lot of the parents don’t speak English, and none of my partners speak Spanish.  Like all my patients since February, I have to arrange for follow-up after my departure.  I send a lot of the children to a pediatrician who speaks Spanish well. 

After I finish documenting the last visit, I walk out of the back door into the sunshine and an absolutely perfect afternoon, and I drive through the spring warmth to the gym for a workout.  I lose myself on the elliptical machine and the stationary cycle, sweating out the exhaustion.

The immediate gratification of ear wax

March 22, 2010

Well, what have we here?

A curable problem, no fear!

            While I work we will talk

            Then you can get up and walk

The problem’s the stuff in your ear.

The patient’s complained of a problem with balance.  With no steadiness to the gait, and the nurse had to use a wheelchair for transport to the exam room.

I really couldn’t get much out of the history, but I know the patient doesn’t cry wolf. 

First, I checked eye movements.  The gaze following my flashlight, with no jerking movements when looking off to either side.

Next I checked the ears, not easy when the patient can’t get out of the wheelchair and doesn’t have much neck mobility.  But I maneuvered the wheelchair, took off my glasses, and positioned myself.

Sure enough, wax plugged the right canal.

I have taken a lot of ear wax out over the years.  I don’t count wax as trophy grade unless the plug is as big as the end of the patient’s little finger.  My personal record is three trophies from one ear.

I’ve taken other things out of ears.  To remove a tick from an ear you need mineral oil, a goose neck lamp, a nurse, and a tweezers.  You put the patient on the exam table with the infested ear up, fill the canal with mineral oil, turn the goose neck lamp on a foot or so directly over the ear, hand the nurse the forceps, and say, “Come get me when you have the tick.”  Then you walk out of the exam room and turn out the lights so that the only light is the gooseneck.  The approach has never failed. 

I pulled the end of a click ball point pen out of an ear canal.  The patient had lost it in sixth grade.

I took a beautiful blue object, possibly a sapphire, out of an ear canal and no one in the family could identity it.

On four occasions sprouting grass seeds have brought the patient in.

Three times the patient’s high blood pressure has permanently resolved with removal of dense wax.  Much more often than that I’ve cured a patient’s mysterious cough by taking something out of an ear canal.

Once a patient with an earache had a soy bean in the ear.  For those inquiring minds that want to know, the hull had just barely cracked.

Getting stuff out of ears requires a certain amount of training, experience, and equipment.  I actually learned in the beginning to do it with no visualization, fishing into a dark canal on the basis of forming a mental image.  Then one day I completely misused lights meant for surgery, which spoiled me forever.  In the last quarter century I’ve gotten used to using a head lamp, a disposable soft blue ear curette, and an alligator forceps.

Alligators look like a bent hemostat, and are incredibly useful things to have around the house.  In the Indian Health Service I carried my own and wore one out about every year.

Since October I’ve used a fiber optic device called a lighted ear curette.  It has a battery in the non disposable handle, and brings the light right to the tip of the plastic removal device.  It’s portable and readily accessible (the alligators in our office live three minutes away), and if I take off my glasses I don’t need a magnifier.

The wax plug came out of the patient’s ear easily, the hearing immediately improved, and the patient stood up and walked out of the exam room without the wheelchair.  I held the patient’s hand all the way to the check out desk.

Family practice doesn’t give a lot of immediate gratification.  Most of the time when an FP helps a patient, the actual improvement takes place hours, days or weeks after the visit.  Taking wax and other things out of a patient’s ear comes as a very right now kind of thing.  Curing patients is an extremely enjoyable experience.

I don’t plan to give it up.  I just want more time to savor it.