Posts Tagged ‘Parkinson’s’

Sense of humor restored

January 25, 2018


Thinks of all the calls that I dial

And the round trips I make by the mile

And the hours on hold

Can leave my humor just cold

But it got restored with the sight of a smile.

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia, and now I’m living at home and working 48 hours/week in rural Iowa. Any identifiable patient information has been included with permission.

I go out of my way to keep a sense of humor. But I’m only human.

I had 8 patients on the morning clinic schedule. I cured the first patient of the morning and sent him on his way.  I returned to a clipboard with 4 sheets of redundancy inherent in a government-based workman’s compensation case.

About 11:00AM nurses told me of an arriving ambulance. By that time I had 5 undictated charts.

The hundred paces to the ER disappeared rapidly under my shoes. I took the history, ordered the CT scan and some blood work, and quick-stepped back to the clinic.  I knew I faced a serious, complicated case which would require a transfer and demanded prompt action.  I finished the last three morning patients and retreated to the break room to listen to the drug rep pitch very expensive asthma drugs and bolt Chinese food.

At 12:45PM I returned to ER just as the patient got back from CT. I finished the history and physical, and awaited the radiologist’s call.

I started with a call to the transfer operator, and the basic clinical picture. Then to the hospitalist, who accepted the transfer.  I started typing up the history and physical and was 75% finished when the hospitalist called back, clarifying some historical details.  Is the patient OK for MRI?

Trips back and forth from my work area to the ER. Calls to a specialist in Minneapolis.  Holding for 10 minutes at a time, while patients waited in the clinic and the piles of unfinished documentation fermented.

No, the specialist said, not a candidate for MRI.

On hold for another 10 minutes with the hospitalist. Do not send patient without speaking with neurosurgeon.

Twenty minutes later the neurosurgeon, dithered for 5 minutes and refused the transfer, and recommended Mayo clinic.

I considered how badly things could go during the hours necessary to get to Rochester.

The nurses recommended a competing Sioux Falls hospital. I announced that my sense of humor was weakening.

Another 5 minutes on hold. The hospitalist accepted the transfer graciously.

I gave the history and physical last-minute revisions to reflect the past two hours of clinical and clerical actions.

With the paperwork all packaged, I went back to the clinic. After 3 hours of the drama, irony, and frustration inherent in trying to be two places at once; after all the tension built into a system of inefficiencies dedicated not to patient care but to the cash flow generated thereby; after literal miles of fast walking hospital hallways, I stepped into the exam room.

The patient whom I started on Parkinson’s medication last week beamed at me when I walked in. The very small doses of a very old drug had done their job; the patient (who gave permission to write more than I have) bloomed.  Now the smile went all the way to the eyes, the speech had music, and the expressions danced on the face.

In less time than it took to shake hands, my sense of humor returned.

Yes, emergency work brings me challenging cases, but I do not want to give up the satisfaction and gratification that comes with patient follow-up.


Finishing early=playing hookey

March 22, 2017

The morning went just a bit slow

And I left with an hour to go                                              

But with the time I had freed

I got in some read

And enlarged the stuff that I know

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.

Last night Bethany and I had the chance to tell my story to a housemate. Coming up to my 60th birthday I knew if I didn’t slow down I’d burn out.  But I had a one-year, 30 mile non-compete clause.  That’s when I went to Barrow, Alaska, the northernmost place in the US.

Bethany recounted the time I called her to say that I had put in 63 hours that week, but I had time for the gym, playing my sax, participating in a jazz group, recreational reading and writing, socializing and watching TV. I initially attributed the extra time to commute reduction and other factors inherent in living in a small community, but then I applied the same criteria to what I’d been doing in private practice and came up with a conservative estimate of 84 hours a week, not counting obstetrics work.

Nowadays, any work week shorter than 60 hours feels like vacation. And when I walk into the clinic on Mondays, my steps bounce and I grin because I love the work.

I love it passionately up to about 50 hours, and after that my enjoyment starts to decay.

And I think my patients can tell when I get excited about a diagnosis. And when the patient makes my day, I tell them so.

Since I got here I’ve been able to radically help about a dozen patients with either Parkinson’s (involving tremor and stiffness) or PMR, polymyalgia rheumatic (an inflammation of the arteries).

But as influenza season wanes, so does the patient flow. This morning I had no inpatients at all.  Of my two scheduled morning patients, the first one showed on time at 9:00 and the second at 9:30.

I used the hours to read up on PMR . It overlaps with giant cell arteritis (GCA) and temporal arteritis (TA).  Because it comes in clusters, some authorities think it might be viral, and, indeed, if a biopsy of the temporal artery (which runs from right in front of the ear up into the scalp on the side of the head) shows TA, 3 times out of 4 it has the chickenpox virus in it.

Bethany met me for lunch.

In the afternoon I did some more work on my Canada license. I read up on Parkinson’s disease.  I saw 4 patients and finished their documentations.  Throughout the clinic, calm and low patient flow prevailed.  I got permission to leave at 430PM.  Bethany picked me up outside the front entrance, with a stiff March breeze blowing.  She took one look at me.  “Feel like you’re playing hookey?”  she asked.

I nodded. I had only worked 9 hours.

Six clinical triumphs and a tornado

March 17, 2017

I had me a wonderful day

I was keeping the blindness at bay

And I helped stop the shakes

Oh, the difference it makes!

To start steroids without a delay.

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.

I can’t write about particular patients but I can write about clinical trends.

Sometimes I suspect Parkinson’s in the first 60 seconds after I meet a patient. I note a shuffling gait with arms that don’t swing, a face with limited movement, and a quiet voice lacking in music.  After the patient finishes their concerns,  I ask about shrinking handwriting size and loss of sense of smell.  Then, if the patient lacks the characteristic resting tremor, I’ll hold the patient’s hand.  If I feel the muscles between the thumb and forefinger quivering, I strongly suspect the disease.

No single sign or symptom serves as a gold standard. Without a lab test for Parkinson’s, the diagnosis frequently relies on response to the medication Sinemet, (levodopa and carbidopa).

Parkinson’s always progresses, but the rate varies. No matter what stage I find the patient in, I tell them that we have no medication that will slow disease progression, but we have a whole sequence of drugs for the symptoms.  Most elect to try the meds, a few don’t.

I love seeing a person in the hour or two after their first Sinemet dose, especially if I find the family close at hand. It really deserves the term, awakening, the title of the Oliver Sachs book and Robin Williams movie about the development of the drug.

I have picked up more than one case per week here.

I’m also finding an inordinate number of people with polymyalgia rheumatica (PMR), also called giant cell arteritis or temporal arteritis. For unknown reasons, worse with advancing age, occasionally a person’s body will attack the arterial lining with very large immune cells.  As a result, people feel terrible, lose strength in their shoulders and hips, and get severe morning stiffness lasting more than an hour.  The symptoms can sneak up over the course of months, or ambush over the course of days.  I ask if their jaw gets tired while chewing.  I feel the arteries over the temples; once in a while I feel hot, ropey spots on the scalp, where the blood vessel pulses .  We use two non-specific blood tests, the C-reactive protein (CRP) and the erythrocyte sedimentation rate (sed rate or ESR), which help make the diagnosis.  The conclusive test is the temporal artery biopsy, but only if it’s positive, which it never is.

Blindness ranks as the most feared complication of the untreated PMR; the artery that supplies the retina can clot off. Thus if I have strong suspicion I start steroid therapy promptly.  A quick response helps make the diagnosis.

Last Tuesday I had the wonderful experience of seeing more than one Parkinson’s patient and more than one PMR patient in their initial positive response to therapy.   Bethany picked me up at the hospital, and in the time it took for me to walk out the front door and get into the car the sky darkened so fast that the street lights came on.  As we drove to the gym I started to recount my day full of successes, but halfway there our phones interrupted with the announcement of a tornado warning.  We continued on, but the noise of the hail drowned out my words.  Three blocks later we arrived at the gym just as the tornado sirens started.

We sat on a bench inside and watched the vacant pool while I finished recounting my 6 clinical triumphs in one day.

Another EMR, and a Parkinson’s patient improved.

December 19, 2015

A tremor after the Great Flu
Is Parkinson’s, we already knew.
There’s more! Please just wait,
There’s a shuffling gait,
And the facial movements are few.

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 am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

Towards the end of his life, my father developed Parkinson’s disease, which eventually killed him. Ever since I’ve been alert to the diagnostic clues.

When I started in training, 80% of the Parkinson’s that we saw came in the wake of the Great Influenza of 1918. By the 90’s I could tell you from across the street who had escaped that flu (the spry) and who hadn’t (the slow movers). That generation has passed.

When most people think of Parkinson’s, they think of the characteristic “pill-rolling” tremor that goes away when the person moves with intent. But I don’t often see that tremor. I look for facial expression that doesn’t change much, a stiff, shuffling gait, and very small handwriting (micrographia). I listen for monotonous, quiet speech. I inquire about loss of sense of smell (anosmia). I feel the muscles between the thumb and forefinger while I talk tot he patient, which will show the beginnings of a resting tremor long before it becomes visible.

Today a patient made my day with Parkinson’s visibly improved. I had made the diagnosis relatively early. The voice had more music, and the small, involuntary facial and hand movements had returned. Much work remains to fine-tune the medication.

I now have access to the current EMR, NextGen, the 7th EMR I’ve learned since January. I have left off dictating my records like I did in the first two weeks. The computer gets in the way of patient care, but complaining about it does no more good than honking one’s horn in a traffic jam. Nonetheless I worked three unscheduled patients in, and for each one I spent a good deal more time entering data into the computer than I did with the patient. I’ve had lots worse EMRs here in this country (New Zealand’s, MedTech32, stands as a shining ray of hope that we could have a good system), but I have had better, too. It doesn’t stick very much. When I run into a click-and-wait, it doesn’t last more than 20 seconds. Sign on takes less than 3 minutes. But it has design flaws. The button to sign off sits in the top left corner right next to the button used to clear one patient’s chart and move to another. Every drug for every patient comes with a warning, mostly frivolous, but a lot like the boy who cried wolf.

The clinic won’t have it much longer, Cerner will replace it in February.

Another road trip 8: diagnosing in public

June 15, 2015

I can write about things that I see

In public, where the viewing is free

The many, the few,

With no interview

It’s observation, that is the key.

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 am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, and I just finished an assignment in rural Iowa. Right now I’m working in suburban Pennsylvania, combining work with a family visit.

Confidentiality applies to my patient population; it doesn’t have anything to do with what I can observe in public.

In 1977, when I was junior medical student, I went out for a walk with my first-year family practice resident roommate in Saginaw, Michigan.  We walked past a man with coarse features, a very broad nose and heavy jaw, and outlandishly heavy bones over his eyes.  “Acromegaly?” I asked after we’d past him, referring to a pituitary tumor that starts in adulthood, after the growth plates have fused.  He concurred.

I never stop being a doctor; Even before I had a license, I diagnosed based on observation.

A couple of months ago I sat next to a friend, waiting to get dismissed from jury duty.  I looked down at his right hand, and saw the muscles between the thumb and the forefinger twitching; the medical term, fasciculations, don’t care the evocative quality of “bag of worms.”  I asked if he had Parkinson’s.

Today, my skills kicked in full force at a social gathering.

The bug eyes of Grave’s disease are easy to spot.  The thyroid lump that some people have in the lower part of the front of the neck, goiter, sometimes goes with it.

I saw two cases of scoliosis.  In the crowd I spotted the moon face and “buffalo hump” (enlargement of the fat pad between the top of the back and the bottom of the neck) that signals Cushing’s, from too much steroids (whether made by the body or taken for other problems.)  I could diagnose autism in the young man who rocked and didn’t make any eye contact at all.  From one woman’s rolling gait I could tell she’d had a failed hip replacement.  Several of the elderly showed early osteoporosis.  Several men showed testosterone deficiency by their prematurely narrowed shoulders.

When a person looks at the floor, moves slowly, and dresses in muted colors, I don’t have to do an interview to diagnose depression.

An extraordinarily tall young woman with very long, thin fingers showed all the signs of Marfan’s syndrome; her male relative at 6’8” probably had the same problem, but I didn’t get a chance to see his hands.

I heard the whistle at the end of the cough that tells me that person has asthma.

When another person sneezed three times in a row, I didn’t even have to turn around to diagnose allergic rhinitis.

And after one day’s unemployment…

October 26, 2014

I drove a half-hour away
I had a great clinical day
Oh, what a tonic,
I ignored the electronic
And dictated what I had to say.

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center. I did two short assignments in Petersburg, Alaska. On Sept 2, I turned in my 30 days’ notice.

On Monday this week I drove to Anthon, Iowa for a day of locum tenens work.

Over the weekend, in different social situations, two people approached me for medical advice, mostly having to do with medical care by other docs. For one I later wrote an email to the family, using physical examination buzzwords, expressing my concerns, and, hopefully, getting the patient into a neurologist in a timely fashion.

I made a phone call for the other patient, leaving a voice mail for their other doctor that I wasn’t officially on the case, I had observed certain things, and if the patient took Zoloft and Prozac, perhaps lorazepam could be discontinued?

Monday I left home early for Anthon, a quiet, prosperous but very small farm town. I’ll be working here from time to time for the next couple of months, in the complicated aftermath of a rural doctor’s personal tragedy.

The patient demographics stand in stark contrast to the Community Health Center. Most patients have insurance or jobs or are retired. No one has an accent. I did not see a single patient with major psychiatric illness all day.

Alcoholism, regretfully, stalks the clinical landscape as ruthlessly as everywhere. I applied my recently acquired Motivational Interviewing skills to the situation, and got at least a couple of people to think hard about their lifestyles. At one point, having gotten the initial three minutes of history, I asked very specific questions about the family history and got accused of being a psychic.

The ravages of past tobacco abuse permeated the day. I got the chance to interview one patient about experiences during World War II, and what it was like to grow up on a farm in the 20’s.

I said, as I have said before, “Weight loss in 21st century Iowa is NOT NORMAL and whatever else is wrong with you we have to investigate,”

I prescribed trazodone for depression, chronic pain, insomnia, and appetite loss, noting that the young doctor knows 20 drugs that will treat a disease but the old doctor knows one drug that will treat 20 diseases.

For the second time since I left the Community Health Center, the possibility of Parkinson’s came up.

I ate a leisurely lunch with the staff in the clinic’s tiny lunch room. We finished at 3:15, and I drove back to Sioux City.

I passed the whole day without getting behind in my documentation. The management spared me the learning curve of an apparently very bad Electronic Medical Record system, and I got to dictate my notes. Like in the old days when we had paper charts.

Notes from a smaller conference

November 14, 2013

The conference seemed rather small

A hundred and sixty was all

I picked through the fluff

And brought back some stuff

And we’re all taking way too much call.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  Since August I’ve done a working vacation in Petersburg, Alaska, Continuing Medical Education (CME) in San Diego, and a trip to Mexico for our daughter’s wedding.  I’m in Denver now picking up more CME.

As the older, balding male white-haired docs, my generation, lecture about transformation of the American Health Care System, the younger docs, mostly female, no gray hair, file in with their coffees.  The young primarily work for someone else, these lecturers work private practice, fee for service. Except for one who just started working for the govt.  But the guys at the podium attack the problem from a logical, systemic approach.

The whole conference amounts to 160 people and the intellectual intimacy makes up for the lack of world-famous speakers.

When interest lags, the subtle sounds of electronic devices accumulate.  From the back of the room I see screens showing recreational, non-topic displays.

In the hallways and the lounges the practicing docs pass the students.  It’s not that they seem so young or naive, it’s that they seem energetic and passionate.  The phrase dilapidated, meaning literally to have polish removed, comes to mind when I look at the older physicians.

In a lecture on sinusitis, the doctor next to me falls asleep.  His face shows the stress of too many life-and-death decisions made in the middle of the night, the slings and arrows of healing without the healing balm of sleep for the healer.  I want to fall asleep, too.

In the evening I find my right rear tire low and I inflate it at a service station, but in the morning the tire gauge reveals pressure loss.  I pass a leisurely hour in the tire center and avoid horrendous traffic to arrive two hours late.  I have missed two lectures but neither topic interests me.  The first lecturer I listen to goes long because the next lecturer arrives late. He got stuck rounding by difficult cases.

The speech speed of two lecturers trumps intelligibility; twenty minutes into each talk the attendees start to whisper to each other about it, and the recreational screens light up again.  I suspect inappropriate pharmacologic use but I don’t say so.

I quit OB as my 60th birthday present to myself, in 2010, and I have no intention of making a comeback.  So I skip the day’s last lecture on prenatal care.  But I stop to chat with an ER doc and an OB/GYN next to the depleted snack table.  Conversation soon turns to Colorado’s legalization of recreational marijuana, and we start volleying data back and forth.  Children who show up in ER after getting into the now legal brownies and cookies never go to ICU and never die from the toxicity.  Too much marijuana causes terrible vomiting in the cannabis hyperemesis syndrome.  Those who toke before driving having more car accidents and fatalities than those who drink.  We fired facts back and forth like this in undergrad and med school instead of coming to blows, now we try to inform rather than convince.

Between lectures, consistent themes from the docs revolve around the amount of time that the EMR demands; we’re all spending more hours with the computer and less with the patient.

A professor emeritus lectures on William Osler, the premier physician of the last century.  The speaker’s voice is high and doesn’t project well.  He shuffles when he walks on the stage, his arms don’t swing, and the diagnosis of Parkinson’s shows painfully obvious.  But the talk goes well.  The startling news that Gertrude Stein went to med school and washed out in her 4th year brings the proper gasp of amazement, as does the fact that the founding 4 female philanthropists of Johns Hopkins Medical School demanded admission of women.

At the end of a week of lectures, we all agree we work better than we sit.

I can’t stop being a doctor, I don’t want to try. I just want to slow down.

September 22, 2010

I can’t stop being a doc

Leave me alone and I’ll diagnose a rock

     Say what you please

     I can see a disease,

Sometimes from the end of the block.

I can’t stop being a doctor.  I have a one-year, thirty-mile non-compete clause, so I can’t give advice or write prescriptions unless I am out-of-town.  But at the same time I make a purchase at a store or talk to someone on the street I can’t stop making diagnoses.

I can tell the sleep deprived people by the fine wrinkles on their faces, the front parts of their cheeks, and the bags under their eyes.

A particular kind of hyperthyroidism, Grave’s disease, shows itself in prominent or bulging eyes; actor Marty Feldman displays this eye finding, exophthalmos, which overlaps incompletely with a visibly enlarged thyroid, or goiter.

Parkinson’s disease displays several early findings before the tremor starts.  People walk rigidly, their smile seems frozen, they start to lean. 

People with neuropathy walk with a broad-based, uncertain gait, something like Frankenstein’s monster in the original movie. 

I looked at a clerk’s hands today and noted a rash on the left hand in the web space between the little finger and ring finger; red and swollen with sharp edges.  I wanted to tell the person that a fungus was growing there, and to use over-the-counter antifungal till it cleared.

Another person had some fine red bumps on the inside of the forearms; whether insect bites or poison ivy or other contact allergy didn’t make any difference.  I had the urge to instruct on the use of over-the-counter 1% hydrocortisone cream for itch, and to ignore it if there were no itch.

I can smell the smokers by the smell, sometimes I cough from being near them.  I want to offer advice, but I don’t if I’m in town.

I miss my work but I don’t miss the sleep deprivation.  I’m looking forward to going back to medicine on a forty-hour a week schedule. 

I’m arranging my next placements.  I’m having trouble deciding where I want to go during the month of October.  Do I want to take a job for fewer hours but better rate with very short commute, or do I want to drive further?  I know I want a better adventure, but possible work availability complicates the picture.  With many variables in many unknowns, eventually I have to commit to a course of action.

This morning at the Care Initiatives Hospice meeting we talked about patients and I made more recommendations for decreasing or eliminating drugs than I did for starting new drugs. 

At the end of the meeting, I was the first one in line for the flu shot. 

Last flu season went easily probably because we immunized so well.  The H1N1 wasn’t nearly as bad as we’d thought.  The possibility of a change in virulence remains, but looks a lot less likely.

I can’t stop being a doctor.  I don’t even want to try.  I just want to slow down.

The three question interview

April 6, 2010

I make the patient’s eyes glisten,

When I just quietly listen.

            I use questions three

            And eye contact, you see,

I avoid interruptions and dissin’.


My approach to interviewing patients changed radically about 15 years ago.  I start with “Tell me about your (problem).”  I wait till the patient stops talking, then I say, “Tell me more.”  When the patient stops talking I say, “What else?”  With the electronic medical record and a good set of software abbreviations I can keyboard 80% of what the patient says word for word.  Before I start asking directed questions, the patient has given me the vast majority of the history and has gotten the impression that I’m a good listener (which I am), mostly because I don’t interrupt.

Even if the patient’s narrative wanders I keep listening while the patient tells me what is on their mind.

I make exceptions to the rule of not interrupting.  I’ll interrupt an item by item account of a meal.  If the patient has given me an account of problems in 3 different systems before I can get the first sentence down, I’ll ask the patient to try to slow down and focus. 

If the patient has ADHD, I’ll ask straight out if their problem is acting up.

Which happened today.  The patient had a child and a sibling with ADHD, and the conversation drifted off topic between a sentence’s beginning and the end.  Such circumstances make a discussion difficult but not impossible, and by consistently asking the patient to redirect we could go over lab work and discuss therapeutic alternatives.

Another of today’s patients came in a wheelchair.  Our association goes back 18 years.  I cared for the patient and spouse during that time, watching the spouse’s increasing debility and finally the terminal illness.  I also cared for the patient after a surgery gone bad with chronic, unrelenting pain in the aftermath, and decreasing mobility from Parkinson’s.  Today, probably the last time we’ll meet, we discussed the fact that we made it three years past when the patient figured to die.

A third, wondering what to do after I take off, expressed the desire to see the doctor at the VA here in town.  I encouraged the decision, naming the doctor I go to.

I saw an unusual number of young people today between the ages of 14 and 20.  For some our relationship started with their mother’s positive pregnancy test and continued through the pregnancy, delivery, well child checks, and school physicals.  Some have joined the work force; one had a work-related injury, and balked at reporting it to the employer.  One came for a sports physical.  Two were in with coughs, one had an enlarging spleen which  warrants further investigation.

I love the breadth of human experience that comes with Family Practice, the depth of understanding unique to being privy to the secrets of real lives over decades.

Ten digits tell the tale: Gordon’s sign.

March 9, 2010

If the pace is too much to stand,

Just examine the hand

            Let your eyes linger   

            While you check out the fingers

The patient will think it is grand

Next time you can speak safely with a violent person, ask to look at their hands.  If you look at several sets of hands that have been asked to solve problems inappropriately, you will see a pattern.

The knuckles of the pointer and middle finger become enlarged, and the skin over them becomes reddened.  The skin of the hand itself becomes a network of scars and marks, tracks of ineffective reactions. 

Martial artists who are not violent by nature will show the hypertrophy of the knuckles.  People who work hard with their hands will show scars.  Put those two things together and you generally find someone you do not want on your team.

Others things leave enlarged knuckles of the index and long fingers.  Rheumatoid arthritis, psoriatic arthritis, and Lyme disease will enlarge the joint where the finger joins the hand and the joint of the finger closest to the hand, and spare the last knuckle.  Any repeated small trauma, or even a one time large trauma, will leave a finger joint permanently swollen.

A patient today had the worst fractured finger I’ve ever seen; the bone had been exposed since last week.  Those two telltale knuckles on one hand were enlarged enough to give pride to a Kung Fu master, but were normal on the other hand.  The patient had never trained in martial arts, hadn’t been in a fight for decades, couldn’t remember any significant trauma, and didn’t have any morning stiffness.  No scars on the back of the hands, no enlargement of the other joints.  It was a pattern I’d never seen.

A lecturer in med school said, “If you’re stuck and you need time to think in front of a patient, if you need to stall and you want to seem caring rather than clueless, examine the hands.”  If someone takes both your hands and looks closely at them, you immediately sense caring. I generally use that trick every week or two, sometimes more.  In the moment of silence it buys me I can put my thoughts together, think things through, and figure out the next step.

In the process, over the last thirty years, I have learned a lot about people from looking at their hands.  Outdoors people who have the skin of their index fingers roughened and thickened in the middle bone on the surface that faces the thumb have problems with blisters (they tie their boots too tight).  Smokers with rigid personalities have the nicotine stains; the more flexible ones rotate their grip.

Biting nails is a nervous habit but to really get them gnawed down to the quick takes devoted obsessive compulsive disorder; those people will have other OCD characteristics in their lives. 

If I suspect Parkinson’s disease, I’ll sit and hold the patient’s hand while I talk to them and feel between the thumb and forefinger for the subtle trembling of the muscle that precedes the frank pill-rolling tremor.  I’ll use the degree of quaking to judge progress of Parkinson’s progression or treatment.  Don’t look in the textbooks for that one, it’s an observation I found on my own. 

I’d like to think that someday it will be in the medical dictionary as Gordon’s sign.