Posts Tagged ‘penicillin’

More Like Have a Nice Vacation Than Saying Goodbye

January 8, 2017

If not normal, what could it be?

I can think of a horror or three.

I don’t try very hard

And those thought I discard

But this time, I know what I see.


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 a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.


Between patients my nurse asked, “Did you see that outside?”

I looked out the window. “It’s snowing,” I said.  “In January.”

“But it never snows here!” she said. Indeed, this island in the Japan Current rarely gets so cold that the precipitation falls as a solid.

I have come to another last day of an assignment. I worked here in April, and enjoyed it.  But they only needed me this time for their holiday vacation coverage.

The upcoming Tribal Council Inauguration had shifted the clinic routine, with the last patient scheduled at noon today. But the Council postponed the ceremonies out of respect for the family of a suicide.  That tragic event got splashed across Facebook.  I know no more than the general public knows about the case, and, considering a few insiders, I know a good deal less.  I won’t write about it.

But in a community this small, where everyone knows everyone, I started to see the medical fallout within 48 hours. Two of my 9 patients today would not have gotten sick but for the stresses and chaos from that suicide.

The island has a strep epidemic going. We now have clinical criteria, the Centor Score, which takes into account age, fever, tonsillar exudate (if you prefer, pus), enlarged lymph nodes, and absence of cough.  I have asked for rapid strep tests on my sore throat patients, but, after examination, if the patient has fever, big lymph nodes near the jaw, pus on the tonsils, and no cough I prescribe penicillin (to the non-allergic) no matter what the test shows.  Our facility ran out of injectable penicillin, though, a week ago.  But as I read up on the subject last night, the main preventable complication of strep, rheumatic heart disease, dropped below less than one case in a million 20 years ago, and the CDC stopped keeping statistics on it.

Four of my 9 patients had sore throats today. More had coughs.  Towards the end, people start wishing me well, but it felt more like telling me to have a nice vacation than saying good-bye.  I’d like to come back again.

I make a living out of thinking of the worst thing possible.  It’s something I do with every patient.  Mostly I delete the catastrophic stuff from my consideration, but today I went ahead and got an x-ray which should have had a low chance of being productive.  I waited as long as I could for the radiologist’s report, but as the hum of the clinic faded to a whisper, I went ahead and ordered the MRI because I couldn’t deny I’d seen a shadow where I shouldn’t have.

I put on my jacket and slipped the cleats onto my boots. I stepped out into the driving snow.  As the fat, wet flakes melted on my face, I hoped I was wrong.


Strep: to treat or not to treat

November 15, 2016

You might have a pain in your throat

There are a lot of folks in that boat

The very next step

Might be testing for strep

But the score will help with the vote.
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. 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. After a moose hunt in Canada, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

The day after Thanksgiving 1997 I hit my personal record for patients seen in a regular clinic day, 63. In other contexts, for example taking call, I’ve attended more, but never in a 9:00AM-Noon, 1:00PM 4:30PM office day.
And not one of those 63 had an appointment when the switchboard opened at 8:30AM.
That November day came in the perfect storm context of coinciding influenza and strep epidemics.
I loved strep epidemics. A simple, curable problem where a minute of history, a minute of physical, a minute of warmth, a minute of education, a simple lab test and a shot of penicillin can relieve great suffering.
We treat strep throat to make the patient feel better, but more importantly, we tell ourselves, to prevent the complications of strep throat: rheumatic heart disease and post-streptococcal glomerulonephritis (kidney failure that follows a strep infection anywhere in the body).
When I started residency, we swabbed every sore throat and sent the culture to a program set up by the family who lost a member to rheumatic heart disease, brought on by strep throat.
In ’85 a widely read article questioned continuing strep treatment in an era of declining rheumatic heart disease.  Much discussion followed, the majority opinion holding that the strains of strep responsible for rheumatic heart disease would start to circulate again. Which, thankfully, has not come to pass.  I heard one doc assert there hadn’t been a single case in the US last year, but couldn’t quote a source.

For decades we’ve had rapid strep tests, which remain in common practice, but in the last year the Centor score, now validated statistically, threatens to make the test obsolete.  The patient gets a point for fever, enlarged nodes in the neck, pus on the tonsils, lack of cough, and/or for age between 3 and 14.  Patients who score 4 or 5 should have antibiotic treatment; under 3 should not.

Those over 44 lose a point; but run a very low risk of rheumatic heart disease.  Treatment in that age group only shortens illness by, on average, 18 hours.

And the post-strep kidney failure?  Treatment does absolutely no good.

But I saw a patient, whose parents gave me permission to write that I’d come up with a perfect score of 5.

I gave penicillin with a clean conscience.

When low scorers come in with sore throats, I discourage testing because a positive result would most likely indicate colonization, where the germs live in the throat without causing problems, rather than infection.

I still do testing if the patient requests penicillin injection, and no injection follows if the test comes up negative.  And I’ll continue the practice till further research demonstrates a reason not to.

Most of the patients with strep throat I saw last week had a sandpaper rash, and very few knew it.

Some things you only find by touching the patient.



Orientation in Wellington, New Zealand I: jellyfish stings, rheumatic fever, and electronic health records.

March 14, 2011

When it comes to a medical fee,

There’s a co-pay, there’s nothing for free.

     The discomfort that lingers

     From jelly fish stingers

Is cured with hot water or pee.

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.  Just back from a six-week assignment in Barrow, Alaska, the northernmost point in the United States, we’re in New Zealand, getting ready to go to work.

New Zealand knows its capitol city as “Windy Wellington.”  Bethany and I haven’t been able to sleep in because our bodies haven’t accommodated to the time difference yet, and we went out before dawn, in the cloudy, breezy early morning, looking for a hot breakfast place, then went to the offices of NZLocums for orientation.

The first speaker, an erudite General Practitioner with a long and distinguished career talked to us, doctors from Holland, Singapore, Oregon, and Iowa, physician to physician, about what it means to be a GP in New Zealand.    The country has twenty-one health care areas, and each one has a Community Management Board, which has a budget and sets priorities.    About 30% of the population has health insurance, and the private sector does well here.  The public sector supplies the rest, and patients have a significant co-pay at time of service.  The Community Management Board keeps pharmacy costs down by maintaining formulary control.  Most prescriptions are filled for 90 days unless they’re addictive or the practitioner puts in a limit.  Watch out for drug seekers, he warned us.  Many of them will try to get a prescription for pseudoephedrine, the key ingredient for making crystal meth. 

I regret my lack of surprise at hearing that the white plague of crank has reach here.  I have never recommended pseudoephedrine.  In the US, it remains a non-prescription item, though some states keep it “behind the counter” and limit the amount that one person can buy.  If you fear for your safety from a drug seeker, he said, prescribe a small number and notify the police. 

The average New Zealander with medical coverage sees the doctor 6.6 times per year, the average visit runs 15 minutes, and 20% of the visits consist of filling out forms.  New Zealand has a no-fault law that covers injuries from all accidents, including “therapeutic misadventure,” which would be called medical malpractice in the US.  For unknown reasons, this country has a disproportionately high rate of asthma and asthma death.  Common problems here include red tide shell-fish poisoning, a neurotoxin without antidote.  Jelly fish stings deserve treatment with warm water, with urine as a good substitute.  The red back spider, an accidental import from Australia, has a poisonous bite for which treatment exists.  The Maori’s genetic predisposition to rheumatic fever sways the treatment algorithm for sore throat towards presumptive penicillin prescription.  An epidemic of meningococcal disease is starting to abate.

When he finished speaking I could tell much remained to be said, and I could have listened to him for days.

The recruiter walked us, like a tour guide with tourists, to the bank.  We all set up accounts so that we could receive payment via direct deposit and for the first time I considered the problem of getting my hard-earned money back into the country. 

We lunched on curry with the doctor from Holland; I talked about the tradeoffs faced by working people with families.  His father, like mine, was a physician.

After lunch we spent three hours in front of computers learning to use the most common electronic health record system in the country.  New Zealand embraced the Information Age early, and a few years ago attained the world’s highest number of laptops per household.  Sunshine came in bright through the blinds, and wind gusts rattled windows as the afternoon wore on.  The system has a reasonable learning curve, and I finished with confidence.

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.

Hospital staff changes, strep and Herpes epidemics, and polar bears shot with light rifles

February 7, 2011

I’ve hunted pheasants and quail

But the hunters here are way off my scale

     They don’t find a scare

     If faced with a bear

When they’re out on the sea hunting whale.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  Avoiding burnout, I’m taking a sabbatical while my one-year non-compete clause winds down, having adventures, visiting family and friends, and working in out-of-the-way places.  Currently I’m on assignment at the hospital in Barrow, Alaska, the northernmost point in the United States.

Today the temperature bottomed out at twenty below Fahrenheit (negative twenty-five Celsius).  The morning went reasonably well, I never fell too far behind, and the patients came in an orderly fashion.  The schedule allotted plenty of time for each one.

At 11:30, the entire medical staff was called to the Commons for a meeting with the President of the Hospital’s governing body.

She told us about personnel changes, and didn’t give reasons. 

I don’t know, and I don’t want to know, why one person left or was asked to leave.  The transition will take place after my departure.  My day will run much better if I concentrate on the things I can change and influence.

No institution has attained perfection, but the hospital here made marked steps towards the better between the time I left and now.  Most notably we have developed a compassionate, effective algorithm to deal with narcotics seekers.

The afternoon brought patients in the aftermath of the influenza.  Of course several people came in with their asthma kicked into high gear.  But I also saw three cases of Herpes Simplex Virus I (HSV I, or cold sores), one of which was just in time for treatment.  Back pain and headaches worsened after the virus had gone; flu hammers the body so badly that we’ll be seeing aftershocks in the form of other diseases for six weeks.

We also have a strep throat epidemic circulating, and I prescribed a lot of penicillin.

And while those two plagues rage, there’s a subtler infectious problem at the same time: babies with aphthous stomatitis (blister-like sores inside the mouth).

Anticipation of the Qiviuk, or Messenger Feast, runs through the town like electricity.  Knowing that a patient expects fifteen or twenty patients to stay for a week colors therapeutic decisions. 

More than half my patients today are whalers.

A man I spoke with gave me permission to recount the following information.  A co-captain of a whaling crew, he killed a polar bear last year during the spring whaling season.  He used a 7.62×39 rifle, a cartridge considered by many as marginal for deer.  They had scared this particular polar bear away three times, but the fourth time the bruin approached he was not to be deterred.  At a distance of twelve paces, the man shot the bear just behind the corner of the jawbone.  The bullet did not exit, but the bear died instantaneously.  In the six hours it took to skin the first bear, three other, smaller bears approached and were easily shooed away.  He explained how he’ll use the sea to clean the hide for tanning.

Guarding the camp against bears, he said, is a very important job.  I couldn’t imagine doing it with a rifle that light.

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.