Posts Tagged ‘eczema’

Rationing medical care: in the absence of an infinite budget, it only makes sense.

May 23, 2011

Out here where they’re grazing the sheep,

They know MRIs don’t come cheap

      The skin takes a beating

   Though winter is fleeting

And the snow never gets very deep.

    

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to dance back from the verge of burnout, I’m having adventures and working in out-of-the-way places.  Right now I’m living in Amberley, and working the last half of a four-week assignment in Waikari, less than an hour from quake-stricken Christchurch, in New Zealand’s South Island. 

This part of New Zealand lies as far south of the Equator as Sioux City lies north, but has a much gentler climate.

The trees shed more leaves every day, most have bare branches.  I found frost on the windshield one morning last week.

Still patients come in wearing shorts, albeit with three or four layers up top.  With the first day of winter only twenty-eight days away, and a dusting of snow most mornings on the Southern Alp peaks, I wear my jacket in the car. 

We haven’t seen central heating in New Zealand.  Our apartment has two space heaters and good sunshine during the day; we haven’t needed more so far, and I wear my jacket inside.  My medical consultation room has a switch marked HEAT, I turn it on and the room warms up but I can’t tell where the heat comes from.

I see lots of firewood piles; smoke rose from chimneys in Waikari on my way home.

Of course my clinic load reflects the change in climate.  Cold air dries when heated, and in turn dries out skin and medical problems follow.

Thus dermatology constitutes a disproportionate part of my case mix.  I saw patients today with scabies, eczema, ringworm, psoriasis, viral rashes, and impetigo; all received straightforward treatment. 

One pediatric patient came in with fatigue, poor appetite and fever.  The physical exam gave no diagnostic clues.  My dialogue with the parent (who gave permission to use this much information) boiled to two choices: do nothing and see what happens, or draw blood work and get x-rays.

In fact, in the US, I would order CAT scans of the chest and abdomen, because fear of lawyers drives the system.  The parent laughed at the idea.  In New Zealand, generalists like me can order CAT scans and MRIs only if the patient wants to pay for those studies out-of-pocket. 

I don’t find the idea insulting, in fact I rather like it.  In Iowa I relied far too much on CYA documentation and not enough on common sense. 

In Alaska, the nearest CAT scan machine resided at a distance of eight hundred air miles, and the over-worked specialists I talked to did their best to keep my patients away.

Here, the referral hospital in Christchurch maintains a website with excellent clinical information for the front line doctor, so that calls to registrars (the equivalent of US residents) go smoothly and efficiently.

The twenty-one District Health Boards effectively ration medical care when they decide what services are subsidized.  After all, with a finite budget, they have to set priorities. 

Demented octogenarians with sputtering neurologic symptoms, for example, don’t get a full neurologic workup.  Not only wouldn’t the government pay for it, but the families wouldn’t stand for it. 

When I made my weekly rounds at the Waikari Country Hospital, five of my seven patients (not the oldest one) struggle with dementia to one degree or another, but further neurologic work-up remains out of the question.  And no one expects it.

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The physics of dry Arctic air, eczema, and hives considered as an infectious disease

February 16, 2011

The North Slope has air that’s so dry

Ice disappears on the sly

     You might grow old

     But you’ll never grow mold

And geese turn to jerky as they fly.

 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.

The air in Barrow is clean and clear and incredibly dry.

This part of North Slope of Alaska rates a classification of desert because it receives less than five inches of precipitation (including snow) per year.  As air cools it loses ability to hold water; when it cools enough the water condenses.  A cold window in the winter acquires a layer of dew, or if it gets cold enough, a coat of frost.  The cold Kool-aid pitcher becomes wet when the air next to it cools below the dew point. 

If the dry air of a desert cools below the dew point, the water it holds drops out as rain, fog or, well, dew.  That air, when warmed, becomes positively desiccating as it acquires the ability to pick up more moisture.

The air here sucks water from a person’s body.  It holds so little wetness that windows don’t fog or ice; frost doesn’t form on windshields though the mercury has dipped to twenty below.  Ice changes from solid to gas without going through a liquid stage, via a process called sublimation.

I see eczema literally ten times worse than any eczema I’ve ever seen.

Eczema at home in Iowa would have dry red patches on the hands and cheeks, bad eczema would show on the forearms and calves, perhaps the forehead or the corners of the mouth.  In Barrow those red patches flow together till the entire skin of the patient has turned bright red.  At a large gathering, like the Messenger Feast, I can look around the gym and I can pick out the bad eczema patients, they look like Martians.  The dermatologists who come to the specialty clinics make the usual recommendations for creams and moisturizer, but the patients continue to walk around with bright red faces.

Thus in Barrow I see a lot of chronic (long-term) skin problems, but few acute (short-term) rashes.  Last night I saw a couple.

Urticaria (hives) looks like a bunch of mosquito bites: hard, red, itchy lumps with a white center.  When I was in training, I was taught that it was an allergic reaction to something the patient didn’t know they’d gotten into, and the treatment consisted of antihistamines.

In the years since, I’ve noted that cases of urticaria come in clusters; I’ll see several cases over the course of six weeks, then I won’t see any for months or years.  Ninety-eight percent of the people who come in with hives have the problem exactly once in their lives; the ones who have repeat cases can point to the precipitating circumstances, such as stress, cold, or a particular food.

Thus the problem looks allergic to the patient, but infectious to the population.

Medicine is full of mysteries.

Snow machine excess, cold injury, and wolverines

January 19, 2011

Some people, they smoke and they drink,

Some trap the otter and mink

     But the story’s been told

     That Barrow’s so cold

You can’t open your eye if you wink.

Synopsis: I’m a family practitioner from Sioux City, Iowa.  To avoid burnout, I’m transitioning my career, and while my one-year non-compete clause expires, I’m working in exotic locations, traveling, having adventures, and visiting family and friends.  Currently I’m in Barrow, Alaska, the northernmost point in the United States.

I’ve been back on the job for less than twenty-four hours, here in Barrow.  I’ve seen several cases related to snow-machine use.

In Barrow, one avoids the terms sled or snowmobile in favor of snow machine.   The people here use them, not for recreation, but to do necessary work.  People hunt from snow machines, so that hunting injuries are almost synonymous with snow machine injuries.

Most, not all, caribou migrated south past the Brooks Range when the days grew too short.  Herds of up to five hundred remain, grazing on the tundra.  In temperatures so cold that alcohol freezes, in the Arctic night when the sun doesn’t rise and the moon doesn’t set, subsistence hunters go after them with firearms ranging from .22 magnum handguns to 7mm Remington Magnum rifles.

A lot of parkas here sport wolverine fur on the ruff. Unique in that breath frost won’t stick to its fur, hunters eagerly seek the “skunk bear.”  The creature has such a nasty disposition that it acts like a serial killer, slaughtering everything in its path for fun and eating for necessity. 

The government issued a wolverine fur-trimmed parka to a person I know (not a patient) during the cold war, for work done in the Arctic.  To this day, the nature of the work and the circumstances of issuance remain clouded in mystery.

Hunters also go after wolves; polar bears occur as targets of opportunity.

Most of my clinic load, whether in Iowa or Alaska, has to do with damage from alcohol and tobacco.  Respiratory infections, cough, asthma, depression, fatigue and malaise, hypertension, high cholesterol follow from those two substances.  Counseling people to quit, though a good idea, rarely works.

When the patients come in with fetal alcohol syndrome and fetal alcohol effect, it’s too late.  With irreparable damage I just make the best of the situation.

I won’t say where, but I attended a set of fraternal twins, one of whom had fetal alcohol syndrome and one of whom had much milder fetal alcohol effect.  Some people are more resistant to alcohol than others, and such resistance starts before birth.

If most of what I see in any clinic has to do with drinking and smoking, the majority of the remainder has to do with the unique factors of where the clinic stands.  Barrow’s air is so dry that eczema here runs an order of magnitude worse than any I’ve ever seen.  Yet most people know the cold so well that frostbite comes rarely.

The first case of frostbite here in Barrow came my way today, very shallow damage, but not to fingers or toes.

The sea ice broke up, the eczema responded to propranolol, the young respect the elders. And don’t use possessives when you talk about whales.

June 25, 2010

I’m learning the Inuit tongue,

Enjoying respect from the young.

     It’s a terrible loss

     To get hurt blanket tossed

These are wonderful folk I’m among

I have permission to give the following information.

A teenaged patient with eczema, severe to the point of disability, came in a couple of weeks ago.  For reasons clear to me only at the time I did a thyroid test and his TSH was slightly low, indicating an overactive thyroid (the current primary thyroid test, the TSH or thyroid stimulating hormone, measures the brain’s demand for thyroid hormone; low levels indicate excessive circulating thyroid hormone).   A week or so ago I prescribed propranolol.  The eczema is markedly better today; the patient looks happier and is sleeping better. 

Next time I have a patient with poorly controlled eczema, I hope I remember the patient who had been to multiple dermatologists for years and got better with propranolol.

The patient was happy, the relative was happy; I could see things had turned out well, and I came away with job satisfaction. 

The young people treat me with great respect.  I commented on that to a knot of early twenty somethings.  They smiled at me with grandchild-like love and talked about how reverence for elders is part of the culture.

I got to talk to two people with critically low vitamin D levels, in the single digits, today.  Both have diffuse bone pain.  I explained how calcium doesn’t get absorbed or used properly without vitamin D, and in compensation the calcium in the bones gets mobilized.  Which keeps the circulating calcium up at the expense of skeletal strength.

Alas, one of the two uses narcotics recreationally; I hold confidence that I’ll make the bones better but I harbor no illusions that the narcotics seeking behavior will stop.  I hope I’m wrong.

The sea ice broke up in the early hours today.  This morning, working on the elliptical, I watched white ice flows on blue water floating slowly south, pushed by the winds. 

We’ve seen the first Nalukataaq injuries.  I’m a person with enough sense to say that blanket tossing looks like fun for the young but not for me.  Not everyone agrees with me.

My Inupiak language acquisition program is progressing.  I’m in the stage of echolalia, where I can repeat short sentences but I don’t know what they mean.  I was able to say “Good morning.  How are you?  I’m fine.  My name is Dr. Gordon.”  But my head is not in the language and the language has not taken root in my head.  I am, however, working on it.

Seeking to get a better handle on the grammar, I asked one of my informants how possessives are handled.  I got a blank stare.  I have a limited number of nouns in my vocabulary, so I started with whale, agvik.  “How would you say my whale?” I asked.  I got another blank stare.  Finally the informant said, “You wouldn’t say that.  You never say my whale or your whale or even our whale.  You just say whale, ahagvik.