Posts Tagged ‘hematuria’

Application of medical first principles on a Tuesday in Keosauqua

December 21, 2010

Why do doctors go gray?

Is it all work and no play?

     Life can be a ball,

     Though you’re working on call,

Just don’t give in to dismay.

When I’m on call, nights or weekends, I get a lot of calls from people who have self-diagnosed an antibiotic deficiency and want a prescription called in.  Pain with urination, sore throat, and cough comprise the most frequent complaints.

I would like to say I don’t ever yield to the request, but on rare occasions I do.  I weigh the risk to the patient of treatment with an exam versus the risk of treatment without an exam.  Most of the time I’m pretty rigid, but flexibility sets in during extreme weather.  Last year a blizzard descended on Sioux City when I had Christmas weekend on call.  On a day when it took three hours to get from my garage to the street, I said “Yes” a lot.

Most sore throats do not benefit from penicillin.  Most pain with urination is not urinary tract infection.  Most earaches do not come from ear infections.

Today I saw four patients with painful urination, abrupt onset, accompanied by blood in the urine.  One had a urine infection.

I work very little to write out a prescription for three days of antibiotics; I work a great deal more explaining why the patient shouldn’t take antibiotics.

Of the last nine patients with pain in the ear, one had an actual ear infection.

Three other patients, all smokers with emphysema, came in short of breath today; they all left with prescriptions for antibiotics and inhalers.  One got a prescription for prednisone (a steroid).

On six occasions today I added up the costs of peoples’ bad habits.  “OK,” I’d say, “How much are you paying a pack for Marlboros/a bottle for Mountain Dew/a cup of coffee/a pack of generics/a case of beer?”  I got out my calculator and said, “Dang!  Eight hundred dollars/twelve hundred dollars/nine thousand dollars a year!  They must pay you well!  I’m a doctor and I couldn’t afford that.”

People who work with livestock in general and horses in particular don’t complain much, and if they do, I’d better listen.  I applied that principle twice today.

Three folks with mental health histories were in today; their complex medical problems took time.  I considered the principle that craziness doesn’t protect from physical illness.  I have a lot of lab results pending.

Four patients let drop the fact that a close relative had died in the last six months.  I listened and I sympathized.  I remembered the ten months after my mother died, when penicillin injections kept me going during a succession of eleven culture-proven strep throats.

Depressed patients get sick, and sick patients get depressed.

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Can a soprano beat a Naked Lady?

May 23, 2010

My spirits soar to the max

Here are a few of the facts:

     What gives me a lift

     Is the receipt of a gift,

A brand new soprano sax.

On my last afternoon of my last day of my last job my last patient, Diane, gave me permission to write about her.

We have known each other for decades.  She taught my oldest daughter trombone, my middle daughter saxophone, and my youngest daughter flute.  She has retired from her job as instrumental music teacher in the Sioux City Public School system.  To properly explain our relationship I would have to start with my music history.

When I graduated high school forty-two years ago and drove away, vowing never to return again, and sure to become a musician and composer, I could not have imagined a career besides music.

Passions die hard.  Two years later I embraced the conclusion that I had neither the talent to make my living that way nor the inclination to put up with the requirements of the job: chaos, salesmanship, and artistic compromise.

Proper attention to the craftsmanship of music, sometimes called practice, would have developed my marginal talent to the point where I could have made a marginal living. 

But I kept my saxophones.  I knew that my alto, a Selmer Mark VI, carried much more valuable than what I paid for it, but I had no idea about my tenor.

From time to time I brought my horns out when I needed to play, but I quit composing.

When my middle daughter, Chaya, entered in middle school and started instrumental music, she usurped my tenor sax.  On the first day of band, Diane heard snickering in the corner, and went to see what the fuss was about.

Chaya was showing off the engraving of a topless woman on the bell of the saxophone.  The teacher immediately recognized the instrument as a Naked Lady Conn, the jazz equivalent of a Stradivarius.

(At the risk of too many coincidences, my mother grew up in Elkhart, Indiana, where the instrument was manufactured.)

Chaya was bursting with the news over dinner.

I had no idea of the value of the horn, my grandmother purchased it for my at a pawn shop when I was 13; it took Diane’s knowledge to inform me.

I saved her life about six years ago by finding leiomyosarcoma, a malignancy so rare that it has no chemotherapy experience.  She has been teaching me a great deal about the nature of healing ever since.

When Chaya fell climbing three years ago, I discovered the value of embracing uncertainty.  Diane and I talk frequently about the things we do to live in the moment, about savoring the positive moments through the neutral moments, and not letting the negative moments last.

We speak often of the need to write her story into a screenplay; I become George Clooney, she becomes Nicole Kidman, and the surgeon at Mayo becomes Danny DaVito for comic relief.

Diane’s survival exceeds all expectations.  The quality of her life sines as a beacon to those who know her.  (Bethany and I ran into her and her husband, Lynn, at the movies the summer after her diagnosis; at age 45 she had been carded trying to get into an R-rated film.)  She and Cheryl, my office nurse for 20 years, have become close friends. 

When I made my career decision I decided to bring music back into my life and I asked Diane for saxophone lessons; she was going through a career change at the same time.  I still have the passion for the music but my expectations of being a star have faded.  I like playing scales, I don’t need fame.  But I couldn’t bring the instrument with me to the northern end of the continent.

Diane booked the last appointment of the day, to follow-up blood in the urine.

I relish the treat of finding a simple problem with a great patient at the end of a Friday afternoon, the cherry on an ice cream sundae.  When I walked into the exam room at 4:25, I found the dipstick urinalysis in the result cue of my computer.

We had chatted about the good news for a couple of minutes when Cheryl knocked on the door and entered, carrying a box with a card.

Of course it was a surprise. 

“Can I open it now?” I asked.

“The card,” they said, “Read the card now.”

ACHIEVEMENT started the platitudes on the front of the card.  I opened it and Pomp and Circumstance came out.  It was a graduation card.  We laughed.  Do great moments get better than this?

I used my key chain pocketknife to slit the tape on the blue wrapping paper.  I looked onto the top of the cardboard under the paper, and read the word Soprano.

Yes, great moments can and do get better, and sometimes they get so much better we have no imagination of it, and they become astounding moments. 

Cheryl, Diane, and Lynn had bought me a new B flat soprano sax.  Struck speechless and tearless, I stared.

I had wanted a soprano for forty-two years.  I didn’t buy one back then because I didn’t have the money, and when I had the money I didn’t have the time to play it.

Now I have time and money and an instrument small enough to put in my luggage.

I opened the case and the new brass and mother-of-pearl gleamed at me against the plush lining.

Diane walked me through the proper assemblage, how to put the reed in the mouthpiece and the mouth piece on the neck. 

I looked into the hallway.  Patients still here, rats!  No playing in the hallway. 

I shut the door and played a piece I’d written in 1970, forty years ago to the day.