Posts Tagged ‘propranolol’

End of a Canadian month

May 7, 2018

I have to leave by the first day of May

At least that’s what the border guards say

So my bridges don’t burn

I plan to return

And next time for a 90-day stay

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. After a month of part-time in northern Iowa, a new granddaughter, and a friend’s funeral, I have returned to British Columbia.  Any identifiable patient information has been included with permission.

I wrapped up April’s assignment today with a full clinic. I attended 18 patients.

I have written before about propranolol, a remarkable drug whose new uses have vastly eclipsed the original indication, high blood pressure. I prescribe it for stage fright, social anxiety, ADHD, buck fever, overactive blushing, and migraine.  Today two of my patients received prescriptions for propranolol; one has taken it for years for stuttering, and it works well (I received permission to write a good deal more than I have).

Seven patients’ medical problems come from alcoholism. Treatment depends on willingness to change, and that trait today ran the spectrum from having quit to wanting to die drunk and soon.

Two patients suffer from bipolar illness but came in for something else.

Three needed notes approving them back to work. Two asked me to write slips containing little truth, and I declined.

Two patients have puzzling clinical pictures. I don’t have to know everything, all I need to know is how to find someone who knows more than me, and I sent both patients to specialists.

The clinic manager plans to make scheduling changes, staggering start times for the docs and the Nurse Practitioner, running clinic through the lunch hour, and perhaps starting night hours. Details have to be worked out, but, as one of my colleagues observed, and gave me permission to quote, 100% of the ideas you didn’t try will fail.

I walked back to the room at lunch, ate some very tasty leftovers, and did some last-minute packing.

Back at the clinic I tried to catch up on documentation while I cared for patients, and reviewed lab, x-rays, and consults. Outside, the fine clear day clouded over, and the snow piles continued to melt.

Patients expressed dismay when I told them that Immigration decreed that to keep a relationship good enough to return I would have to leave on May 1. Actually I said that Immigration was kicking me out, but they’d probably let me come back in October.

In the long northern afternoon, Bethany and I loaded the car and headed to Prince George. Just outside of town we saw three mule deer grazing by the side of the road, and a hundred kilometers further on, far off at the edge of a flat marshland, we saw a cow moose with her calf.

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Weekend call: propranolol, Mounties, x-rays, Dave Brubeck, and geographic confusion

April 16, 2018

Geography knowledge is rare

And even those doctors who care

Have recommendations

That get emendations

With exclamations of “WHERE??!!”

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. After a month of part-time in northern Iowa, a new granddaughter, and a friend’s funeral, I have returned to British Columbia.  Any identifiable patient information has been included with permission.

Another weekend on call has passed. The heaviest day was Saturday; I attended 13 patients.  For the most part people came in a steady stream, yet I got breaks for lunch and supper.  With no regrets, I took every opportunity to nap.

I saw 4 Workman’s Compensation cases and 3 others from a motor vehicle crash. I don’t know why, but  I stand to benefit from laws governing reimbursement these two classes of injuries.  They represent the only two Canadian system areas lacking crystal-clear transparency.

My broad background helps me connect with a wide variety of patients. I relied on my short musical career to help one patient.  In the ‘60’s the Dave Brubeck Quartet’s artistry enchanted me into relentless listening of the ground-breaking album, Time Out.  I advised the patient to check two cuts on YouTube, Take Five and Unsquare Dance, examples of drum solos in difficult, unconventional rhythms (5/4 and 7/4) taken to artistic extremes.

I used my 7 years’ experience attending Adult Children of Alcoholics meetings to help another person. I pointed out that, just as perfect people rarely come to see me, perfect people rarely choose to become doctors.

I dealt with patients with neurologic, respiratory, infectious, psychiatric, blood, eye, gut, skin, and bone problems. I ordered and interpreted 3 electrocardiograms (all normal) and two x-rays (both abnormal). Four people had viral illnesses, expected to resolve with no treatment.   I ran 2 urine drug screens, results from one but not the other had surprises.

I sent one patient by ambulance to Prince George.

I called the Mounties once.

I ordered two CT scans for the upcoming week, fairly confident that one will come back normal and concerned that one might not.

I sought consultation from a Vancouver specialist who gave me a series of recommendations. After I hung up I called back.  She hadn’t realized the geography involved.  Just as well.  The patient (rationally, I felt) refused those measures.

I prescribed propranolol twice. With the blood pressure indication eclipsed by better drugs in the same class, it still has a lot of off-label uses: migraines, ADHD, stage fright, performance anxiety, premature ejaculation, rapid heart rate, tremor, and buck fever.  It stands as the first-line treatment for over-active thyroid.

I drove rather than walked the kilometer to the hospital. Temperatures have stayed close to freezing, with daytime thaws since I arrived, and frost coated the car windows after sunset.  This car rental didn’t include a scraper so I used a movie rewards card.

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

November 15, 2012

A piece of wisdom, please heed.

If you want to know more, you can read.

But don’t think to balk

At the casual talk

Between docs.  It’s something we need.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

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

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

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

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

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

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

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

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

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

 

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.

My patient might have the same disease I did, but not the same symptoms

November 1, 2010

Last week, during a check

Of the thyroid, I said, “What the heck?”

     To me it seemed much

     On the basis of touch,

To find a lump in the neck.

The patient gave me permission to write the following information.

A nurse came to see me last week in follow-up for pneumonia.  She felt, more or less, back to normal.  I whizzed through the exam till I got to her neck.

Back in the physical exam course of medical school, they said, “If you want to learn to palpate, start with a watermelon under a blanket and work up to a dime under a phone book.” Perhaps because Saginaw, Michigan’s phone book lacked epic thickness, in short order I could, indeed, find the dime under it.  Whether from training or talent, I have sensitive fingers. 

In one case, I found a thyroid tumor the size of a Milk Dud.  Oftentimes, though, I feel things that lack reality, and I’ve gotten used to sending people for imaging studies which find nothing.

I make a habit of checking a patient’s neck by running my fingers over the entire area, finishing up with the thyroid. 

The thyroid gland sits just above the sternal notch, that finger-sized depression between the base of the throat and the top of the breastbone.  Enlargement of the thyroid is synonymous with goiter.  The thyroid gland functions much like the factory’s time clock’s mainspring, setting the pace for the whole plant.

When I ran my fingers over the patient’s thyroid, a large, woody-feeling gland stopped me abruptly. 

I asked the patient if she had symptoms of thyroid dysfunction: weight gain or loss, sleep disturbance, trouble with heat or cold.  No, she replied, she felt just about usual.

Of course I got blood tests; the results and the patient came back today.

In the normal course of events, the brain sends signals to the thyroid in the form of TSH, or thyroid stimulating hormone.  The thyroid then makes T4 with four iodine atoms, sends it into the body, where the muscles and the liver rip an iodine off to make T3, with six times the potency of T4.  Sometimes the thyroid gland makes the hormone without command from the brain.  In those cases the brain stops sending signals to the thyroid, the TSH level falls, and the T4 and T3 levels skyrocket.

I had to explain that information to the patient, along with the fact that she made an antibody aimed at thyroid destruction.  Then I thought back to the time my own thyroid went berserk and I remembered how I felt when I could, and did, walk barefoot in the snow leaving puddles.  Did the patient have heat intolerance, weight loss, tremor, an irrationally large appetite, a bounding pulse, and no inner peace?

No, she told me, none of those symptoms.  Yet her TSH came in as undetectable, with her T4 and T3 running twice the upper limit of normal. 

I prescribed propranonlol and arranged for an endocrinology referral. 

I marvel at how different two people with the same disease can feel.

Real people who lose a hundred pounds do it slowly

September 8, 2010

In this twenty-first century date

Americans are quite overweight

     It cannot be beat,

    This food that we eat

But fat is not inevitable fate.

A lot of my patients over the years have had problems with overweight.

Twenty-first century Americans have access to the cheapest, richest foods in the entirety of human existence and things just keep getting richer and cheaper.  On the one hand this overabundance of convenient calories brings political stability, as well-fed people don’t really want change.  On the other hand Americans are getting fatter and fatter.

It’s hard for me to write about weight loss because I was a fat kid.  Most people who know me might agree I could lose a couple of pounds and can’t imagine me seriously overweight, but I was.  When I graduated high school I weighed fourteen pounds less than I did when I was thirteen.  Though most people see me as slender, maintaining my weight has been a struggle eased by love of exercise. 

During the weekend we had a visit from Jeff and his wife, Lindsey.  Jeff had lost a moderate amount of weight over a couple of years the last time I saw him.  He’s kept up with his program, pounds have continued to drop off, and when he stopped by he looked great.  His eyes were clear, his skin glowed, and he looked four years younger.  He’s now lost over a hundred pounds

I’ve also been following a blog, by a friend and patient, Charlie: heavythoughts-lightliving.blogspot.com/ He’s now lost a hundred pounds.  He writes well and eloquently about how he got to be overweight, how he’s lost the weight, and what the weight loss has meant emotionally.

Many years ago I had a Jewish patient who was wandering through life.  When he came to see me for new onset diabetes he was working in a dead-end job which did not require any of his considerable intelligence.  At that time he was more than a hundred pounds overweight.   After a short hospitalization and some rudimentary education about diet and exercise, he started keeping kosher, and the weight started to come off slowly.  When he’d lost fifty pounds he realized his work would take him nowhere and he started having friction with his boss.  He began making school plans, and when he’d lost eighty-five pounds he got himself fired, commenced to collect unemployment, and left town.  I heard from him briefly a few months later, when his weight loss totaled one hundred pounds.  His diabetes had disappeared; his blood pressure was under control and he was working towards a degree.

When topiramate (brand name Topamax) came on the market for migraines and seizures, the drug rep mentioned the side effects of weight loss and appetite suppression.  At that time my first choice migraine treatment involved no medication, and my first choice medication then, as now, was generic propranolol.  After the drug had been on the market a year I met an overweight patient with seizures and migraines who, for various reasons, needed to change medications.   I wrote the prescription for a Topamax starter kit.  A month later the seizures and migraines were gone.  At six months follow-up the patient had lost 87 pounds and had remade herself with a new color scheme, clothing pattern, speech rhythm and gait.  She returned to school and got out of a bad relationship. 

Though topiramate has helped some people lose weight, I’ve never seen another patient lose that much since, but it’s a good migraine drug.

The sea ice broke up, the eczema responded to propranolol, the young respect the elders. And don’t use possessives when you talk about whales.

June 25, 2010

I’m learning the Inuit tongue,

Enjoying respect from the young.

     It’s a terrible loss

     To get hurt blanket tossed

These are wonderful folk I’m among

I have permission to give the following information.

A teenaged patient with eczema, severe to the point of disability, came in a couple of weeks ago.  For reasons clear to me only at the time I did a thyroid test and his TSH was slightly low, indicating an overactive thyroid (the current primary thyroid test, the TSH or thyroid stimulating hormone, measures the brain’s demand for thyroid hormone; low levels indicate excessive circulating thyroid hormone).   A week or so ago I prescribed propranolol.  The eczema is markedly better today; the patient looks happier and is sleeping better. 

Next time I have a patient with poorly controlled eczema, I hope I remember the patient who had been to multiple dermatologists for years and got better with propranolol.

The patient was happy, the relative was happy; I could see things had turned out well, and I came away with job satisfaction. 

The young people treat me with great respect.  I commented on that to a knot of early twenty somethings.  They smiled at me with grandchild-like love and talked about how reverence for elders is part of the culture.

I got to talk to two people with critically low vitamin D levels, in the single digits, today.  Both have diffuse bone pain.  I explained how calcium doesn’t get absorbed or used properly without vitamin D, and in compensation the calcium in the bones gets mobilized.  Which keeps the circulating calcium up at the expense of skeletal strength.

Alas, one of the two uses narcotics recreationally; I hold confidence that I’ll make the bones better but I harbor no illusions that the narcotics seeking behavior will stop.  I hope I’m wrong.

The sea ice broke up in the early hours today.  This morning, working on the elliptical, I watched white ice flows on blue water floating slowly south, pushed by the winds. 

We’ve seen the first Nalukataaq injuries.  I’m a person with enough sense to say that blanket tossing looks like fun for the young but not for me.  Not everyone agrees with me.

My Inupiak language acquisition program is progressing.  I’m in the stage of echolalia, where I can repeat short sentences but I don’t know what they mean.  I was able to say “Good morning.  How are you?  I’m fine.  My name is Dr. Gordon.”  But my head is not in the language and the language has not taken root in my head.  I am, however, working on it.

Seeking to get a better handle on the grammar, I asked one of my informants how possessives are handled.  I got a blank stare.  I have a limited number of nouns in my vocabulary, so I started with whale, agvik.  “How would you say my whale?” I asked.  I got another blank stare.  Finally the informant said, “You wouldn’t say that.  You never say my whale or your whale or even our whale.  You just say whale, ahagvik.

Death and bourbon

March 23, 2010

My patient is right on the brink.

Of what, I try not to think.

            Money goes up in smoke       

            With whiskey and Coke.

The problem’s made worse with the drink.

 

The patient had a pain in the wrist.

Me:  How did it happen?

Patient: I’m not sure.  I was drinking pretty hard, and when I woke up, there was blood on the floor and my wrist started hurting a day or two later.  I guess I blacked out.

Me:  What do you like to drink?

Patient:  Whiskey and Coke.

Me:  When was the last time you had a whiskey and Coke?

Patient:  Yesterday.

Me:  How many did you have?

Patient:  Well, I drink most nights.  I have five or six whiskey and Cokes, and three straight shots.

Me:

Patient: That’s five nights a week, probably double on my two nights off.

Me:  Do you think that this amount of alcohol is a problem?

Patient: No.

Me:  Then we will agree that we disagree about that.  I think you have a problem and you don’t think you do.  We’re not going to agree.  Here’s what can’t you can’t disagree with:  this amount of alcohol presents a risk of death and disability, it is the reason that you’re here today.  And I recommend you quit drinking completely.

Patient:  Ain’t gonna happen.

Me:  If you ever think you have a problem with alcohol, the door’s open.  We can help you.  But for right now, let’s get an x-ray.  I’ll be back in a couple of minutes.

Years ago I would have tried to be right about the alcohol.  I attempted to make the patients see the errors of their ways.  Such an approach doesn’t work, it alienates patients, and it frustrates me.  These days I can perform my moral obligation without incurring the wrath of the patient.  Then it struck me there was an additional moral obligation.

 Me:  Your x-ray is fine.  Do you drink in or drink out?

Patient:  Out.

Me: Who drives home?”

Patient: I walk.

Me:  Good move.

The patient reveals the circumstances that started his heavy drinking: the sudden, unexpected violent demise of a friend.  The patient watched it happen and was helpless to stop the tragedy. 

We sit in a pool of silence and the patient looks at the floor.  I wait for the patient to talk. I listen to the same information rehashed till the need to talk finishes.

I diagnose post traumatic stress disorder, and I talk the diagnosis over with him.  I prescribe propranolol, to damp the effects of adrenaline overload.  We discuss the problem of main effect versus side effect and how he’ll need to come in frequently to titrate the dose. 

Then I bring out the calculator.

Me:  How much is a whiskey and Coke?

Patient: $2.50.  I know.

Me: You did the math?

Patient:  Yeah.

Me:  How much a year?

Patient:  I don’t know.

Me:  So you didn’t do the math. And how much for the straight shots?

Patient:  I know, I know.

Me:  How much?

Patient:  Three dollars.

Me:  OK, six times that and three times that, times five nights per week times fifty-two weeks per year.

Patient:  I know.

Me:  (I show the patient the calculator).

Patient:  Wow. That’s a lot of money.

Me:  And we didn’t figure in your nights off.

I didn’t forget about the wrist, nor about the three other complicated problems the patient had. 

I hope he’ll be back.