Posts Tagged ‘headache’

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.





Medical Advice at Parties.

July 8, 2012

At parties I’m asked for advice

It’s happened way more than twice

Wouldn’t you know

Sometimes I say ‘no’

But I usually try to be nice.


Bethany and I received a surprising number of last-minute invitations to parties today. 

People ask me for medical advice in social situations.  On one occasion, shortly after my mother’s death, I snapped and yielded to the urge to sarcasm and immediately regretted it.  Yes, the request arrived at an inappropriate time and place; no, the patient had never seen me on a formal professional basis; yes, I had every right to turn the request down.  But I did so with finesse and eloquence, a misapplication of good verbal skills.

Today I recommended the book, Love, Medicine, and Miracles in the buffet line, and a trial of over-the-counter meclizine while eating spanokopita.  I listened intently to an alcoholic’s relative, and agreed counseling would be a good idea.  I nodded while a person detailed a coworker’s headaches.

In med school and residency and even later, the docs who mentored me would say, “It comes with the territory.”  I suspect the phrase comes from traveling salesmen who would use it to describe the positive and negative things about working in a particular area.  The advantages of working in Montana differ from those of New York.

I would worry more about seeing a patient as a collection of diseases rather than as a whole human being if I didn’t talk about so many other things with the same set of people.  Today I had discussions about archery, firearms, ballistics, gardening, stone fruit, bicycles, New Zealand, and Alaska.

Yesterday I had a good talk with a friend, just back from 8 weeks of locum tenens (substitute doctoring) in Barrow.  The Inuit filled their quota of 21 bowhead whales; on one day they brought in three.   Weather socked the place in more than once, preventing critically ill patients from reaching services on a timely basis.  We agreed that Barrow ranks as a place on the fringe of the 21st century, that theft was nonexistent, and that the North Slope people smile more than any population we’ve seen.

Bethany and I spent two weeks in June in southern Alaska.  Four days of fishing, four days with friends, and four days of Continuing Medical Education with the Alaska Academy of Family Practice’s 27th Annual Scientific Conference in Kenai.  The sun set about 11:30 and rose a couple of hours later.  Which gave us a lot of time to fish but played havoc with our sleep.  Not nearly as bad as the 8 weeks of unremitting day without a single sunset the first time I went to Barrow. 

I might go back to work in Alaska, eventually, but Barrow remains outside my zone of comfort, like working in Sioux City and having the nearest referral hospital in Dallas.

Both more and less sympathy for migraine sufferers

April 18, 2010

If half of your head has a pain

And you’re sure that it is migraine

     It only figures

     Avoidance of triggers

Beats having the problem again

I had my first migraine when I was 26.  I’ve had three since.  I figured out the circumstances precipitating the event and I have avoided them.  

When the first one hit I thought I was having a stroke.   The beautiful flashing lights puzzled but did not displease me; I didn’t have the medical background at that time to be able to give them their proper name, scintilliating scotoma.  Most of the left half of my vision blanked out, and, as a second year medical student at the time, I thought to myself “left-sided bilateral hemianopsia.”   Then the nausea and the blinding, hammering pain started and made me sure, for about two hours, that I would end up crippled if not dead.  After the pain left and I got back to Michigan and out of a sociologically hostile environment, I figured out I’d had a migraine.

My sister had been having them for years.

I had my next migraine my first week as a third year med student in Saginaw, Michigan, during a gratuitously hostile instructional session.  We were supposed to learn how to do peripheral smears of our own blood, but mostly the lecturer convinced us of our dangerous incompetence.

I have taken care since then to bring an ally with me if I go someplace hostile, and I’ve only had one migraine since.

I still get the aura, the neurological warning shot across the bow.  The beautiful yellow and blue lights, spread slowly in shimmering bars in a semicircle across my vision.  Most of the time I have to keep working, but on two occasions I’ve been able to just kick back and shut my eyes and watch the light show.

The experience gave me sympathy for people with migraines.  It also taught me to approach the problem by teaching avoidance of triggers.

On the other hand, I don’ t have a lot of patience for people who keep doing things to get migraines and then ask me for Vicodin, Percodan, or Lortab.

Diagnosis of migraine properly would take about ten pages, and remains far from simple.

(I had a patient with a long history of migraines that experienced a change in headache pattern, and only because I listened well could I determine the necessity of an MRI, which in turn led to treatment and thus avoided  death.  Another patient with more talent for dramatics than communication needed a sequence MRIs and a really, really sharp neurologist colleague to find three aneurysms. The pathological evaluation showed giant cell arteritis inside two of them.  The patient fired me anyway.)

If I have a firm diagnosis of migraine, I divide the current frequency by four, and ask the patient if that would a “good enough” goal; most respond enthusiastically in the  affirmative, and we talk about triggers:

     Nicotine.  Of course I tell smokers to quit, but especially migraineurs.  Some express surprise on hearing that nicotine causes migraines

     Caffeine.  A distressing percentage of migraines are really caffeine withdrawal headaches.  To put it another way, caffeine relieves the headache only because the person hit the caffeine withdrawal threshold.  I tell the patient to cut the caffeine intake by one dose per day till they get to zero, and then avoid caffeine completely for 2 weeks, then rechallenge.  Most don’t rechallenge. 

     Alcohol.  Yes, strangely, hangovers include headaches.  Some people only have their migraines after drinking.

     Sleep.  Too much or too little sleep can precipitate migraine in a lot  of people

     Nutrasweet.  Just one more reason to avoid artificial sweeteners.

     Cheese.  This low-item applies to a very small minority of migraine sufferers

     Hot dogs:  This is an even lower yield item.  Most people who get the hot dog headache know it before they get to me and have stopped eating hotdogs.

     Hormonal Birth Control:  Bad migraines in the presence of prescribed hormones greatly increases the risk of disabling stroke.  Thus I ask about migraines (and other things) before I prescribe birth control pills.  Or patches.  Or shots.  Or rings.

     Pain reliever overuse.  People sometimes get into a cycle of using increasingly frequent doses of ibuprofen, acetaminophen, naproxen, or aspirin to stop the headaches, and don’t realize that so much analgesic use leads to worsening migraines.  Those cases can be very difficult to treat, and on occasion I’ve hospitalized patients to do so.

Ninety percent of my migraine patients get to goal with no medication. 

Ninety percent of the rest get to goal on 10 to 20 mg of propranolol a day.

After that it’s a toss-up between other daily medications and acupuncture.

A very few patients can tolerate no migraines at all, and they get prescriptions for triptans.

If a patient shows up with a migraine in progress, I order a 60 mg injection of ketoralac.

I NEVER prescribe narcotics for migraines.

I’m leaving: now public knowledge

February 14, 2010


Communication is never a picnic

In any medical clinic

            I sign ASL      

            And I speak Spanish well,

Oh NO! He is schizophrenic!

Our clinic’s conference room used to be our medical records storage area till we got our electronic medical record system.  Quiet and tasteful with a very nice boardroom table and comfortable executive chairs, windows along the ceiling let in the weak winter sun.

My steps bounce as I walk in, smiling, to find our two office managers, our corporate CEO, and one of my partners talking, lighthearted discussion among female executives who are good at what they do in the health care world and who enjoy being in touch with their feminine side. 

One by one, the other partners filter in. 

Bryce, like me, is a second generation physician.  Jeff is the most recently added partner, and, like me, is pushing sixty pretty hard.  Janice, like me, enjoys the behavioral aspects of the trade but wouldn’t mind slowing down.  Delna, our youngest doc, could easily be described as smokin’ hot, like me has a keen intellect and a passion for learning.  

Shanin, the CEO, notes everyone is present, does some magic things to the telephone and brings Mike, our most senior member, the only doctor who has been in our clinic longer than me, to a disembodied presence from the other side of the state.

I announce my career decision, grinning.  I dwell on the positive points: I have more resilience now than I’ll have in five years, I’ve met my lifetime financial goals, I’ve examined my original mission statement which emphasized serving the underserved.  I’m slowing down while I can still enjoy it.  I’m very positive about my career plans.  While my non-compete clause runs out I’ll be journeying around, revisiting the places where I was before I arrived and seeing how things have changed.  I’m going to be doing a lot of hunting come fall.  When my non compete is up I’ll probably work part time for the Community Health Center for a year, and after that I’ll probably open up a small office in South Sioux City.  Bethany and I have been talking about this for a long time and she’s taking classes to become a Certified Medical Assistant.

While I talk I look around the room.  Delna looks absolutely stricken. 

My delivery is very upbeat and optimistic.

I answer questions.  My partners, who have the same contract, didn’t know that the non-compete clause is for one year and 30 miles.

(My lawyer assured me that if I wanted to fight the non-compete clause I would probably prevail; they are illegal in Maryland and Colorado.  I assured her that when two doctors square off in a courtroom nobody wins.)

I talk about my time table, giving a tentative end date of the Friday before Memorial Day. 

 There will be, I say, a lot of details that will need to be hashed out, and I bring up the nursing home.

I’ve been the Medical Director at a nursing home for just over twenty years.  The relationship has been a good one, and we have made steady progress on the measurable quality parameters: falls, infections, hospitalizations, deaths, skin tears, and medication errors.  That relationship is external to my clinic duties, but the patient care I deliver there is not.  I have no intention of violating my non-compete clause by rounding on patients in the nursing home.  Does anyone want to round on them during that year?  Every two months?  There are only a half dozen or so? 

My partners all shake their heads, indicating a firm no. 

The CEO tells me I can be an independent contractor, do the billing through Corporate, and not be in violation of the contract.

My partners speak.  They all wish me well.  Bryce notes that I’m blazing a trail here because all of us will eventually retire, and we talk about Dan.

Dan is a good, solid doc.  For two decades he did medical care and documentation every bit as thorough as mine, and he did as good quality of medical care as mine, but he did it forty percent faster, and he never seemed strained.  He and I shared a love of words and etymology, and we both kept a stable of dictionaries in our offices.  He retired two years ago and disappeared.  We miss him. 

I have no plans to disappear.  I’m planning to come back and cover the December 25th holiday.  Janice says that means that the rest of them will still have to work Rosh Hashana, Yom Kippur, and Pesach.  We all laugh.

Mike’s disembodied voice comes from the speaker phone and wishes me well.

Shanin announces that there’s a young physician looking for a place in Sioux City.  The news is unexpected and very heartening.

Delna has been working on her computer off and on during the discussion and asks if we can help with a case.

She presents a patient, starting with age, gender, race, and presenting complaint, and goes into pertinent details.  Janice says that there’s now a Sjogren’s antibody panel.  I express surprise, and say that the patient’s dry mouth (in medicalese, xerostomia)  can probably be handled most economically with pilocarpine eye drops. 

I suppress the urge to the convoluted history of pilocarpine; it’s interesting to me, but for the time being I embrace just being part of the easy going interchange of ideas that has been the strength of our group for more than a quarter century.  It’s a very quick colloquium and at the end we are better doctors; it’s something we do several times a day and we’re very good at it.

The tone of the meeting has been very optimistic.  I have emphasized the good; I haven’t mentioned my ambivalence.  I emerge from the meeting euphoric.  I walk through the lunch room and grab a handful of chips.  The nurses and the PA’s notice my smile.  I don’t break the news. 

I’m in my office at 12:30 when the office manager calls for a quick meeting of all staff in the meeting room, and right afterwards my middle daughter calls.

She suffered a traumatic brain injury three years ago in a rock climbing accident and has been making slow progress since.  In the last few weeks she’s been doing hyperbaric oxygen and acupuncture and other treatments in Phoenix.  Insurance doesn’t pay. 

Her voice comes strong and clear as she asks me a medical question about her back pain, and I catch my breath.  When she done talking I ask her if she knows that the music has come back to her speech and my voice breaks.  I bask in the moment.  Yes, she has noticed, and she’s grateful that Bethany and I are paying for the treatments and enabling her to make progress.

When we hang up I sit quietly, grateful for the call and what I’ve heard. 

When I open up my email the first message that pops up promises to double or triple my income, have me seeing 10 patients a day instead of 30, for an investment of only $80,000.  I write them back that my career is taking the opposite direction, on purpose.

The first patient of the afternoon has an unusual headache.  I do the usual questions, take a quick look at the back of the eye, note the veins pulsing normally and I’m about to sit down and do my usual headache talk when I remember the dictum from the first day of med school: always touch the patient where they hurt, an eternal verity that will not change with technology.

The heat rises from the scalp to my fingers; the patient doesn’t feel at all feverish, yet the skin temp is very high.  When I sit back down I listen more carefully and I get a history of palpitations and unexplained weight change.  In the end I conclude that the problem is probably the thyroid, and I arrange for tests.

Throughout the afternoon the nurses and other staff come in, and I take hugs, one after another.  They will miss me. But I’m not gone yet.