Posts Tagged ‘MRI’

I take call and end up a patient.

April 23, 2017

At the end, it wasn’t a stroke

It was gone when I awoke

The symptoms were brief

Avoiding much grief

And I got to tell a crude joke.

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, traveled 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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

 

Tuesday evening while on call, I got up to play Scrabble and I couldn’t make my right leg work. It didn’t feel heavy, numb or weak; it felt too light so that any effort to move it got exaggerated.   I sat down to do a neurologic exam on myself.  I found nothing other than my right leg ataxia.  I called Bethany from the next room, and told her the situation.  She helped me dress, and drove me to the ER.

The ARNP covering the ER did the same neuro exam I did, which wasn’t impressive until I demonstrated my gait.

She did all the right tests. The first EKG showed an old heart attack, which disappeared with proper lead placement.

She also found a heart murmur.  It hadn’t been present 5 years ago, but the PA at the VA found it a couple of months ago, and I called her attention to it.

My blood work had no surprises. She offered me the choice of staying in Clarinda or going into Council Bluffs, and I chose to go.  In terms of game theory, if something happened in the middle of the night, I wanted to be close enough for timely intervention.

In the process I had to make arrangements for someone else to take call.

I napped off and on for the ambulance ride, which almost got derailed twice by herds of deer. I bypassed the ER at Jennie Edmundson Hospital.  At 2:00 AM I had gotten settled, my IV had given me a couple of quarts, the second set of labs had come back and I’d had a good visit with the hospitalist ARNP.  Just before being tucked in, I offered the nurses a choice between a clean joke, a clean joke with a bad word, or a dirty joke.  They chose the last option, and I gave them the funniest crude joke in my large arsenal.

I don’t get to tell that joke as a physician, no matter how funny it is. But, as a patient, I can get away with it.  The punch line drew gales of laughter.

By then, motor control of my right leg was functioning at about 90%.

I slept for a couple of hours and had breakfast.

The neurologist arrived, and with economy of motion, did a thorough exam. He advised an aspirin a day and starting a low dose migraine medication.

The morning parade of tests started. By the time Bethany arrived I had done the basic neurologic exam six times and the symptoms had resolved except for the funny feeling inside my head.

I had an ultrasound of my neck, a consultation with the dietician (whom I amazed with my six pieces of fruit a day and my two ounces of salmon at breakfast), a consultation with the Occupational Therapist, and then the Piece de Resistance, the MRI. In between, I napped because I’d slept so lousy.

The hospital feeds its patients on the room service system; I ordered a lunch of soup, sandwich, and fruit, and within a half hour a young Guatemalan arrived with the food. We had a brief conversation in Spanish, I introduced my wife.

And we waited. The hospitalist came back, and went over the results.  Ultrasound demonstrated clean carotids (neck arteries).   The MRI didn’t show anything conclusive.  He also recommended an aspirin a day.

We waited for echocardiogram results. The hospital public address system announced a severe thunderstorm warning, and then a tornado watch in effect till 10PM.  The internet and the TV weather agreed that severe weather approached from the west.  At 4:45PM we decided to leave before the storm arrived, without the echocardiogram results.  We didn’t want to spend the night in the hospital, nor did we want to risk hitting deer on the way back to Clarinda.

Bethany drove. We enjoyed dramatic skies and listened to a Continuing Medical Education CD.  We ate at Clarinda’s premiere restaurant, J Bruner’s, ordering off the appetizer menu.

I returned to work the next day, the episode completely resolved, making it a transient ischemic attack (TIA), also call a reversible ischemic neurologic event (RIND).  Except I noticed my handwriting was much clearer.

I don’t think anyone else noticed.

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Giving bad news: it’s part of my job

February 27, 2017

I don’t wait till the end of the day

When there’s nought but bad words to say

I think that it’s best

To give one more night’s rest

Then suggest that it’s time to pray.

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, traveled 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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

Part of my job is to think of the worst things I can think of, and a couple of times a day I will tell a patient that what they really want to do is to walk away from the hospital shaking their head and muttering that I’m nothing but a darned alarmist. I run a lot of tests.  Mostly I look for things I can do something about.  Sometimes I run studies so as to hand the specialist a patient with a clear-cut diagnosis, or, at the very least, the first level of testing completed.  But sometimes I’m looking for bad stuff, mostly to reassure patients.  I’d rather be happy than right.

Rarely, the battery of lab and x-ray comes back normal. Most of the abnormalities, however, come as no surprise.  People know the dangers of drugs, tobacco, alcohol and promiscuity.

Every once in a while, I have to give bad news. And, after all the labs and CAT scans and MRIs I’ve ordered in the last few days, I’m going to have to give some Very Bad News tomorrow.

The report came in at the end of the day. I don’t like to give bad news on a Friday or of an evening, when we have nothing to do but wait.  And I don’t let the nurse give the bad news, that’s my job.  I prefer to give the worst news face to face, but once in a while, for the expeditious good of the patient, I have to do so by phone.  .

People have suspicions when I start the testing, and for the most part when I sit down with them they already know the problem. So I ask, “What do you think the (blood test, CAT scan, biopsy, MRI) showed?”  Almost always they’ll say they don’t know, and I change the subject for about 5 minutes, and ask again.  The third or fourth time they come up with the diagnosis, and I confirm it, and I tell them as much as I can about what to expect.

I emphasize uncertainty when I find it, but I don’t hold out false hope. And if bad news involves a child, I come prepared for verbal abuse when the parents blame the messenger.

It’s part of my job.

 

 

 

Leaving Nebraska. For now.

September 6, 2016

On the plains I worked for a week

The enjoyment was close to my peak

A lot of folks I befriended

But then the need ended

And new work I’ll now have to seek.

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. Last winter I worked western Nebraska and coastal Alaska. Getting my wife’s (benign) brain tumor treated took a large part of the summer, then a week each in urban Alaska, Pittsburgh with family, and western Nebraska.  Any identifiable patient information has been included with permission. 

 

A week passed quickly on the plains of Western Nebraska.

A respiratory virus, looking for all the world like influenza, with fever, cough, and ache, but also with runny nose, and lasting the better part of a week, provided 1/6th of my clinical material.  I really didn’t do anything for those patients except recommend Tylenol, fluids and rest.

Seasonal respiratory allergies accounted for an equal number. My two favorite drugs in that regard, Zyrtec and Flonase, now available without a prescription, have high quality evidence to support their use.  Still I gave instruction on how to use Flonase based on personal experience.

I took care of a patient with an agricultural injury, and, in the process, learned about Stewart’s Wilt, an important corn disease, which originated not far from where I worked.

I sent two patients to the new MRI, and, surprisingly, both scans picked up significant pathology.

I didn’t get a chance to take care of any hospitalized patients, but I did get the chance to talk to a couple of new doctors with a passion for rural medicine.

I had a wonderful conversation with an Army linguist, and found Arabic has 3 Hs. I got to talk about how Navajo has the only click outside of Africa (the initial consonant in string and goat, the middle consonant in blue).  We had a marvelous time tossing jargon back and forth and singing praises of Rosetta Stone.

I used my massage skills to make one of my patients better before leaving the clinic.

I started a complicated endocrine investigation, and will probably not know the results.

I kept at least one patient out of the hospital with Gatorade.

One twelfth of the patients came in with dermatologic problems. I recounted the remarkable experience my son-in-law, my daughter and I had at a Continuing Medical Education event in Pittsburgh, where the lecturer announced that we can now treat pityriasis rosea (with the same antivirals we use on herpes viruses).  He went over his daughter’s experience with a red rash in a “Christmas tree” distribution just before her wedding, with no time to change her backless, strapless wedding gown.  He told her nothing could be done; twenty smart phone minutes later she showed him his error.

All in all, I took care of 36 patients, the same number I used to consider optimal for a day’s work in private practice. In those days clinic hours went 9 to noon and 1:00 to 4:30, with two hours dictation after supper.

I had a great time. I bonded well with staff and patients, but, towards the end, though the installation might invite me back when one of their docs takes a vacation, I realized they don’t need my full-time services now.  My experience exemplified the success of the locum tenens concept.

I even got out a couple of hours early. On a Friday afternoon.

 

 

 

 

An Abnormal MRI, too close to home

July 13, 2016

We’re doing the best that we can

To follow an abnormal scan

The rumor was tumor

But the answer was no cancer

And the treatment’s a flash in the pan.

 

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. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. All our plans have been put on hold pending resolution of my wife’s brain tumor.  Any identifiable patient information has been included with permission. 

Three weeks ago on Tuesday my wife, Bethany, awakened with severe vertigo. She couldn’t get out of bed without vomiting.  Over-the-counter meclizine helped but little.  I posted the case on a physician’s chat site the next day, and got the recommendation for the Transderm Scop patch (she had one left over from a recent trip).  It helped but the problem persisted.

I don’t like to be my family’s doctor, so that Friday morning we went to the Clinic Formerly Known As Mine. Bethany’s doctor found horizontal nystagmus (a twitching gaze), when looking to the right, and ordered an MRI with contrast.

Chaos dominates Friday afternoons, thus Friday’s MRI happened without contrast.

I have the training and education to imagine a large collection of really bad things, and by now I’ve learned that the awful moments in life come to us unanticipated. So I went through my catastrophic catalog and felt better for having done so.  My phone went off while I was gardening.

In general, you don’t want your doctor to have bad news, especially not on Friday afternoon.

The MRI showed a 2.2 centimeter something behind the left eye. The original report mentioned possible glioma with the strong recommendation for a contrast study.  The thing’s location didn’t account for the dizziness.

With advances in imaging, we have had to come up with a term that means an abnormal finding found by coincidence; we call it an incidentaloma.

I called my locum tenens recruiter to say I had put all plans on hold; she relayed the information to those facilities expecting me in Nebraska and Alaska. Bethany phoned our daughter to say she wouldn’t be coming to help with the new grandson.

That night I read Bethany the Wikpedia article on glioma: 1/3 benign, 2/3 cancer.

Bethany’s cousin’s first wife died three weeks after getting her glioma diagnosed; she only had time to pick out her husband’s next wife, and say a loving goodbye to her family. In the ‘80’s I had a patient with a glioma who lived for less than 100 days after diagnosis.

We didn’t talk about those things.

Bethany took the information in stride, with understated courage. I focused on the moment with the joy of uncertainty that gives hope.  I embraced not knowing and did my best to focus on the moment: stripping the last tart cherry tree of its fruit, bringing in the first green chiles from the garden. I clung to things precious for their normality.

We suffered through the next four days, our plans shredded, as Bethany’s dizziness faded and her balance improved.

With her vertigo improved and her calm unruffled, Bethany went in for the contrast MRI the Tuesday morning before July 4. In the afternoon our fax brought the new diagnosis of meningioma, a well-behaved tumor with little if any malignant potential.

Relief of a magnitude that brings tears defies description.

I relied on my status as a physician and on friendship to get us an appointment with a neurosurgeon the next morning.

He explained the choices: leave it alone, open surgery, or radiation. He said if it were his tumor, he’d prefer the radiation.  He also showed us the MRI image, with a bright cylinder an inch long and half-inch wide growing up from the floor of the skull just behind the left eye.

He doesn’t do that procedure, but his partner does. And that partner wouldn’t be back in the office till Tuesday the following week.

Basking in the light of a better diagnosis while marinating in the darkness of an upcoming brain procedure, we went about our business. We had ice cream with our neighbors, and friends over for dinner on Friday.

Yesterday we met with the neurosurgeon, who explained stereotactic radiosurgery. And today we met with the radiation oncologist.

The actual treatment consists of focusing a radiation beam on the tumor, zapping the same way sunlight, focused with a lens, burns one point.

The next step, the 3D MRI, remains unscheduled.

 

 

Give bad news sitting down

May 15, 2015

Three Community Health Clinic Doctors in an Evening Colloquium

October 5, 2012

It turns out my daughter’s a doc,

So’s her fiancee, no shock

At Community Health

You get lots, but not wealth.

Last night we sat down to talk.

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.

Our oldest daughter, Jesse, finished her Family Practice residency in July.  Bethany and I came to visit her and her fiancee, Winfred, also a family practitioner, in Tacoma.  Jesse represents the third generation in her family in medicine; Winfred the second.  Both grew up with medicine discussed at the dinner table.

All three of us currently work in Community Health Centers; my position permanent part-time, theirs full-time locum tenens.  We had a great colloquium last night.

Patient falling with urinary incontinence and memory loss?  “Normal pressure hydrocephalus,” Jesse said, even before I got to memory loss, and we talked about the handful of cases we’ve seen between the three of us.  The discussion included the human drama of the cases along with a recounting of the physical exam and the MRI.

The question of “What’s your personal best TSH?” came up.  Jesse had a patient with a 56, but once I saw a lab slip come in with “>105.”  The TSH remains the most important thyroid test; the higher the number, the more desperately the body screams for thyroid hormone.  My case dates from the last century, and I told the story, including pseudofractures, hyperparathyroidism, hypercalcemia, familial dysfunction, and bad physician communications.

All three of us serve underserved populations, which in this country means that our patients have very little money.  For a variety of reasons, poverty and diabetes go hand in hand.  Long a staple of therapy, insulin comes in a variety of strengths and costs, but none are cheap and we talked about the high cost of essential medications.  I recounted my experience bringing insulin to Cuba on a medical humanitarian aid mission.  In a small town, word spread quickly that I had brought a refrigerated package with me.  A young woman, a prostitute who worked the hotel where I stayed, approached me. Her younger brother had diabetes and couldn’t get insulin because of the inefficiencies of Castro’s system.  She made it clear she’d do whatever it took to save his life, ignoring my teenage daughter standing beside me.  It broke my heart to tell her I’d turned the insulin over to the Red Cross the day before.  Twenty years ago, $200 only bought 4 vials of an injectable medication that made the difference between life and death.

What beta blocker do you use?  Jesse knows generic propranolol rates as one of my favorite drugs, but I prescribe it mostly off label, for migraines, panic attacks, blushing, and performance anxiety.  Labetalol, which should be cheap because it’s been generic for so long, turns out to be very expensive; but the least costly one in my clinic, carvedilol, only lost its patent four years ago, and has a lots of good qualities.  All three of us use a lot metoprolol.  None of us start patients on atenolol, though we’ll keep people on it if they’re doing well.

None of us like prescribing narcotics or tranquilizers; Jesse and Winfred won’t prescribe sleeping pills at all.  Not even trazodone?  I asked, naming an antidepressant with good effects on sleep and chronic pain.  Well, they said, maybe trazodone.  How about Rozerem?  I asked.  It’s effective, minimal interactions, and no potential for abuse.  But it’s so expensive, and insurance won’t cover it.  I paused and thought and then admitted I’d given out samples but never written a prescription for it.

An afternoon off

October 3, 2012

Doctors are in short supply,

Demographics can tell you why.

Agencies try to recruit

By offering loot

But most of us come off as shy.

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.

On my afternoon off I got 11 business phone calls in an hour, as I tried to nap.

A radiologist paged me, to report a very odd set of findings. 

I’d like to tell about the patient, the drama and the irony, the impact of the illness for the person and their social context, the facts and the meaning.  I did not obtain the permission; I ordered the study more as a formality than with the expectation I’d have to launch a full-court diagnostic press. 

But I called the nurse back and ordered MRI’s and magnetic resonance angiography, on the advice of the radiologist.

That radiologist doesn’t call me for routine findings.  I wouldn’t mind if he did, I enjoy him and his conversation and we have a very good working relationship.  He has a lot to teach me, and every time we talk I become a better physician. 

After that flurry of calls, while I started to close my eyes, my phone rang, and I took the call from a physician recruiting company.

During my year of walkabout, one of the recruiters from that company rubbed me the wrong way with pushiness.  I kept my words calm, respectful, and professional, but made it clear to him that I wouldn’t work with him or his company, ever.  Which, in the 21st century means not for three years (by then it’s a different company).

I told the recruiter I’d had a lengthy call from one of her coworkers the day before.  I learned that their primary care department has 10 full-time recruiters, and the company employs more than 400.

No wonder I get so many calls; that company competes with 80 other agencies. 

Yes, I still toy with the idea of going back walkabout, and if I had enough annual leave hours built up, I’d go on a working vacation.  And I’d go for spots mostly shunned by other docs.  I’d enjoy rural, Indian reservations, even prisons or Armed Forces installations.  I like low population density and the opportunity for outdoor adventure.  Even if it means lousy weather. 

I had barely hung up when another recruiter from a different agency called.  One of the places where I worked suffered a leadership crisis, making them critically short-handed.  I had to turn him down; I have a contractual obligation here.

Yet rural America’s health care force runs chronically short, and a lot of people in Western states live hours away from the nearest health care. 

The radiologist called me back; a CT scan I ordered showed an ominous set of fractures that hadn’t shown up on plain x-ray.  I called the nursing floor back and ordered calcitonin, highly effective only in fracture pain.  I put out a page to Utilization Review; and on the strength of the findings got approval to keep the patient in the hospital another day.

I got in a short nap, and cleared up documentation at two hospitals and the office, while fielding another 8 calls.

But I never got rushed.

After all, it was my afternoon off.

Great ice cream and no spoon. I still love the 21st century

August 30, 2012

Going back doesn’t sound like a blast,

Sure, time is moving too fast.

There were things to endure

That now we can cure.

Nostalgia’s a thing of the past.

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.

Doctors tend to suffer from nostalgia.  Many of us express a longing for the good old days when having MD or DO after your name automatically brought you respect, a simpler time, before technology kept butting between the doc and the patient, when government and insurance companies didn’t interfere with clinical decisions.  Sometimes I’ll say to a colleague, “Pick a year, any year, not this one.  When would you rather live and practice?”

Don’t get me wrong.  I resent the second guessing by health care bureaucrats, whether private or public.  Clearly physicians rely too much on MRIs and not enough on physical examination, and the constant fear of a lawsuit detracts from every patient encounter. 

But I don’t want to go back. 

Immunizations have done away with more than 80% of the pediatrics problems leading to hospitalization in 1982, the year I finished residency.  I can now distinguish between a true positive TB skin test and a false positive from a BCG vaccination(given in another country) with a test called IGRA.  Testicular cancer patients now have better than a 90% chance of cure.  PET scanners, more available now than ever before, show up malignancies with incredible accuracy.  Outpatient surgery has become the norm. 

We can cure schistosomiasis and we can treat rheumatoid arthritis.  Cure rate on Hepatitis C has gone  from 10% to 60% in ten years.  We have good, solid drugs for alcoholism and nicotine addiction.  The generic $4 list includes a lot of medications that used to fetch three figures a month.

In addition to the incredible technology and the great pharmaceuticals, we have consultants of unprecedented caliber. 

I’m fond of saying that if you want 1990’s medicine you can have it at 1990’s prices or lower, but you have to pay for the updates.

Our clinic has a contract with a program for the medically indigent.  Briefly, we get $20 per visit for patients who can’t pay for medical care.  If they need services outside the range of primary care, we can send them to fine specialists 4 to 6 hours away.

The program looks great in theory but the execution leaves much to be desired.  Some of those patients have to drive 2 hours to get to me.  Scheduling referral services involves a faceless, glacial bureaucracy. 

The geographic imperative rears its ugly head; a six-hour drive represents a huge barrier to quality care, no matter how great the facilities at the other side of the state.

On the one hand, the drive deters overuse of medical care.  On the other hand, I worry that my patients may suffer lasting harm from treatment delay, that the system offers too many opportunities for the ball to drop.

Twenty-first century medical advances have made medicine an incredible profession, but economic realities present huge frustrations.  Like having the world’s best ice cream and no spoon.

I still wouldn’t want to practice in any other era.

 

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.

Mennonites and CT scans

December 14, 2010

For the patient, here is the plan

Forget the equivocal scan

     I don’t need much urgin’

     To call up the surgeon

With the results of the tests that we ran

SYNOPSIS:  I’m a Family Physician from Sioux City, Iowa, making a career transition to avoid burnout.  While my one-year non-compete clause ticks off I’m traveling, doing locum tenens, and having adventures.  Right now I’m working at Van Buren County Hospital in southeast Iowa, where there are no stop lights or fast food.

I’m on call in Keosauqua, Iowa, where the mid-level providers (Physician’s Assistants and Nurse Practitioners) take first ER call, and the MD or DO provides back-up and more definitive care. 

The day till now has run on a low stress level.  As with any other day I care for patients, I came across a physical finding I’d never seen before, a soft lump where I should find hard bone.  The MRI machine comes in a trailer tomorrow and will give me an answer.

I hesitate more about ordering MRIs now than I did when I owned a part-share in a scanner, but I seem to order the same number.  I’m likely to fill out the paperwork and jump through the insurance company hoops when back pain goes down the leg and doesn’t get better, when mysterious physical findings can’t be denied, or when the patient worsens.  I find a lot of occult fractures, that is, broken bones that didn’t show on x-ray.

I remember patients I sent for MRI when I had profit motive to do so; scans showed problems malignant and benign, and surgeons prolonged or saved lives.

Keosauqua has growing Amish and Mennonite populations.  They call us English even if we aren’t English, we call them Pennsylvania Dutch even if they don’t live in Pennsylvania and they aren’t Dutch.  Their economic basis depends on subsistence farming; their agricultural methods qualify for the trendy buzzword sustainable.  I haven’t seen horse-drawn vehicles on the roads here but I have seen traditionally dressed people at the café and in the hospital waiting room.

A call comes from the ER for me to evaluate a Mennonite patient.  I find the family straightforward, respectful, and friendly.  I’ve seen the problem at hand hundreds of times.  The CT scan, ordered before I saw the patient, comes back equivocal, but my exam makes a firm diagnosis requiring a surgeon.

Our surgeon and I have come to similar places in our careers: we want to work but we want to slow down.  His solution to the full-time-means-eighty-hours problem led him to work two weeks out of four, while I intend to go to a forty-hour week when I get back to Sioux City. 

Thus, the patient arrives while our hospital’s surgeon is en route to Florida.

I admit my surprise when the matriarch pulls a cell phone from her skirt pocket.  You should have been there.  The family requests a surgeon across the state line in Missouri.

I make the call requesting a transfer, speaking to the surgeon herself.  My presentation of the patient comes off smooth and articulate.  

The family drives into the night, subsistence farmers with hard copies of lab results and a CD copy of the CT scan.

Contrast is the essence of meaning.