Posts Tagged ‘heart attack’

Reversal of knowledge flow: heart attacks, beta blockers, migraines, sleep, jet lag, and premature ejaculation

November 15, 2012

A piece of wisdom, please heed.

If you want to know more, you can read.

But don’t think to balk

At the casual talk

Between docs.  It’s something we need.

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.

Quite some time ago I attended a series of patients with porphyria, a blood disease so rare that most doctors will never see a case.  When the dust settled I had successfully proven the diagnosis three dozen times.  The story of the research I never published and why I would even think to look in a particular bunch of selected patients would take pages and would only interest a small handful of people who probably would never think to look at my blog. 

I learned that if a doctor reads for four hours about a disease, he or she will know more than half of the doctors.  Eight hours of study will bring one to a state of knowledge greater than 80%, and sixteen hours will put a physician in the bottom half of the top ten percent.  But to get to the top of the top requires years of study and clinical experience.

No doctor can know everything about everything, though one of my colleagues comes close (he has good social skills, too, and if we could clone him I’d be out of a job).  Average front line docs have, on average, about the same level of knowledge.  I really, really like hospital work because it makes me talk to doctors who know more than I do.

Most of the specialists and subspecialists I deal with approach the knowledge gap gently, and every conversation brings me to a richer state of learning.  Once in a while, I get to push the knowledge flow the other way.

An excellent conversation over mediocre hospital food with a cardiologist started with discussion of the fine points of managing heart attacks, and brought us to a discussion of beta blockers, a class of blood pressure drugs that interfere with some of the actions of adrenaline.  Labetalol rates favorite status among some of the docs, he said.  I pointed out that it cost more than any other generic in the class; carvedilol, the most recently generic of the group, costs the least.  I looked at the priceless expression on his face and explained that I’d just talked with one of the Community Health Center pharmacists.

Then we talked about propranolol, the oldest beta blocker of them all.  The cardiologist mentioned that men won’t take it because of sexual dysfunction, I talked about how I prescribe very low doses to treat premature ejaculation. 

While the cardiologist listened, I held forth about propranolol’s uses having nothing to do with its original indication, hypertension.  His interested escalated when I got to migraines, which led me to sleep and thence to jet lag.

No reason, I asserted, to have jet lag in the 21st century.  A simple sequence of five drugs would multiply the effective days of vacation.

In the course of twenty minutes, I learned more cardiology, he learned a good deal about sleep management, and we both walked away better doctors.

 

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Food uncertainty: salmon and heart attack

November 14, 2012

Uncertainty comes with the call

If you’re hungry you might hit the wall

But a cardiac doc

Gave quite a talk

Then time slowed down to a crawl.

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.

As soon as I graduated med school I discovered that doctors never go hungry.   The doctors’ lounge in the hospital has pastries, fruit, and coffee in the morning and a lunch at noon.

Pharmaceutical manufacturers’ representatives, the drug detail force, line up to bring lunch and breakfast to outpatient clinics, in return asking for time to talk to the doctor.

As soon as I came to private practice, the dinner invitations started to roll in.  In 1987, the format included fine dining, a lecture, and a $100 check.  As regulations tightened, the out-and-out bribes stopped, replaced by “medically relevant” gifts; really good stuff useful for physical examination, like headlamps and otoscopes. 

Those gifts have gone, but the great meals continue in the century when I’m looking for opportunities to eat less and eat earlier.  I usually turn down the invites, especially if the lecturer comes from out-of-town.  But yesterday the chance to listen to a local cardiologist whom I trust and respect accompanied the chance to eat at one of Sioux City’s premier restaurants.  With call scheduled that night, I gave a tentative yes.

Clinic finished early with most of my documentation done.  I arrived before the appetizers. 

I enjoyed the lecture, I came to a better understanding of a beta blocker than few of my patients will be able to afford before it goes generic. 

But I paid the price of tension; call begets uncertainty and no one does their best work when hungry.  Eight PM came and went and the entrees had not arrived and my beeper went off.  The patient in the ER had classic findings of heart attack.  

A clinical summons always includes a time frame.  Flexibility ranges from drop everything to OK to wait till morning, depending on circumstances.  In this case the ER doctor had done all the right initial things, giving me a twenty-minute window.

I waited and the tension mounted.  Three minutes before I would have walked out without eating, my Scottish salmon with lotus root chip and black risotto arrived. 

I suppose it might have tasted good if I hadn’t bolted it, but bolt it I did and left, remembering how luxuriously wonderful cheese and crackers had tasted eaten at leisure on our Alaska road trip.

When I walked into the hospital I had the good sense to call ER first to find out the patient’s location.  After much dialogue I got a room number and I called the nurses’ station.  No such patient here now, they said.  I called back to the ER: nope, not here either; maybe X-ray; wait, please hold.  After a lot of hold, they told me the patient had just come back.  I went directly to ER.

Of course, I missed the patient who had been sent to an inpatient bed.  The nurses laughed, I didn’t.  When I finally got to the patient’s bedside, I had expended enough pursuit time that I could have eaten leisurely.

I had no way of knowing that beforehand.

The difference between a medicine and a poison, the difference between the life of the party and a drunk

August 9, 2012

Tell me, what do you think,

About having the occasional drink?

If it’s one, sometimes two

It’s a great thing to do,

Any more and you’re needing a shrink.

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 48 hours a week

I took premedical classes as the University of Colorado at Denver.  My biology lab partner and I stayed friends.  In the fall of my first year of med school, she wrote me that she had multiple sclerosis (MS).  In 1975, very little could be done to change the course of the disease, which usually progressed relentlessly shutting down various parts of the nervous system.  Three years later, she mentioned going to AA, and I expressed my surprise.  When pressed, she said, “Well, you’ve got your high bottom drunks and your low bottom drunks.  And thank my Higher Power I’m a high bottom drunk.”

By that she meant she had hit bottom before a lot of things had gone bad in her life.  Later clinical experience showed me that MS and alcoholism frequently, though not always, go hand in hand.

The alcoholic who hits bottom early in the course of the disease does a lot better than the ones who hit bottom late. 

Not surprisingly, alcoholics get sick more often than non alcoholics; and smokers tend to drink and drinkers tend to smoke.  Thus I see the spectrum of alcoholism from those who learn early to those who learn too late, from those who function well despite their drinking to those who don’t, from those who drink daily to those who drink once or twice a year but go all out when they do.

I’ve watched alcoholics destroyed their families, finances, bodies, and careers without figuring things out.  On the other hand I have known alcoholic professionals who did something crazy on a dance floor, heard about it the next day, and never had another drop.  They never went to meetings, but a lot of them embraced their religion.

In between I can tell you stories of hundreds who quit just before their liver or their heart or their brain gave out for good, those folks who came back from the edge of the pit and lived to tell the tale though they lived the rest of their lives with significant disabilities.

Most people know about alcohol’s tendency to damage the liver, and we all know about liquor’s brain toxicity.   Yet most alcoholics who keep drinking and don’t die of trauma tend to die from heart attacks and strokes brought on by intemperance; booze raises blood pressure, brings hardening to the arteries, and directly weakens heart muscle.

But wait, you say, isn’t a glass of wine a day good for you?

Sure, just like labetalol 100 mg twice a day is good for some people, but if you save 3 months worth for the day of the Superbowl, it’ll kill you.  Thus a medication differs from a poison by nothing other than the dose.

And women who drink a glass of wine a day double their risk of breast cancer.

In my experience, a typical alcoholic is witty, fun to be around, unique, and intellectually stimulating when sober. And when drunk he or she is just another drunk.

Why I do and I don’t do housecalls

March 6, 2011

The number of docs is deficient

Though the need would appear quite sufficient

    If you ask me why is it?

    I’ll say a home visit

In the end remains inefficient.

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.  I just got back from a six-week assignment in Barrow, Alaska, the northernmost point in the country.

My father made house calls.

He graduated from medical school sixty years ago, when women were systematically excluded from the profession.  At that time, a physician finished an internship, hung out a shingle, worked solo practice, and took call 24/7/365. He made hospital rounds in the morning, saw patients through the day, and, after supper, made evening rounds and house calls.

Our 1960 Ford Falcon had a spotlight, like the police used, so he could see house numbers at night.

He used to take me with him, to the hospital and to patients’ homes, when I was in elementary school.  I waited in the front lobby of the hospital at a time when it constituted the main ingress, but I got to go into houses with him.  I remember the time spent with him, I don’t remember the time spent waiting.  I can see his stethoscope hanging by the front door, his electrocardiogram machine in the back seat, and his doctor’s bag with the blood pressure cuff and medications like Demerol , penicillin, and digitalis.

But in an era of generalists, my father specialized first in Internal Medicine, and then in Cardiology.  ICUs and CCUs didn’t exist, and before revascularization, statins, and beta blockers, patients with heart attacks frequently received treatment at home.  Looking back, hospital care at the time differed little from a doctor making a home visit.

I have done house calls, but I probably don’t do more than twenty a year. 

When I worked for the Indian Health Service in New Mexico, the government tore down a perfectly functional clinic and paid me to do nothing until the new clinic was built.  After two weeks I realized I had started to be mean to my kids and I hijacked the Community Health Nurse to take me on hogan visits.  I learned a lot about my patients I wouldn’t have otherwise known.

Mostly, when I care for a patient in the home now, I do so more for my convenience than for the patient’s. 

Once, when a heavy, wet snow closed the city and the clinic down in the middle of the day, I got a page from a patient with bad lungs, heart, and balance just as I was about to exit the building.  In the days before common use of cell phones, I turned around, shucked off my parka, and returned the call.  After a brief conversation, I knew I lacked certain key items of information from the physical exam to make a good clinical decision, and I didn’t want to endanger the patient by making him go to the ER in bad weather.  I asked the address, and saw that the patient resided between my clinic and my home. 

I arrived fifteen minutes later on roads I could only negotiate with four-wheel drive.  Fifteen minutes after that I asked for a towel as I washed my hands at the kitchen sink, grateful for the warmth of the water and a ritualized end to the visit.

Today, I talked with a friend and patient who lamented the absence of my house calls.  We talked about how inefficient such delivery of care is, and how we don’t have enough doctors to make the service available on a regular basis.

It’s rare that I do house calls now.  Documentation suffers the longer one waits to make one’s note.  Still, I have a dedicated stethoscope and otoscope in my car.

But I don’t carry a black bag with Demerol, digitalis, or penicillin.