Posts Tagged ‘rheumatologist’

A moral dwarf amongst real veterans

March 14, 2019

Technically, you can call me a vet

Though I never faced much of a threat

And now the VA,

Making up for bad pay,

Is paying off Uncle Sam’s debt. 

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, western Nebraska and Canada.  Any identifiable patient information has been used with permission.

Bethany and I drove up to the Sioux Falls VA hospital for my annual rheumatology appointment.

I have ankylosing spondylitis, a close cousin of rheumatoid arthritis which primarily affecting the spine.  It hurt me since before I turned 18 until my first injection of Enbrel in 2000.  It kept me out of Viet Nam, but not out of the Public Health Service.

So that I now qualify for Veterans’ Benefits, including health care.  The VA pays for an injectable medication which would retail at over $60,000 per year.  When I need a refill, I make a call and it appears on my doorstep in a Styrofoam insulated box in 2 or 3 days.

By comparison to the price, one 2-hour drive and 4 lab appointments yearly rates as a Best Buy.

Because I hurt for so many decades, by the time the pain stopped my body had gotten really good at generating and recognizing endorphins.  All in all, I feel better than I did when I was 18.

And when I sit in public places, I never stop my physician observations, even when I’m a patient.

I watched and listened to the Real Veterans in the waiting rooms today, and I made diagnoses.  The swollen knuckles of rheumatoid arthritis.  The blotchy facial redness and bags under the eyes of alcoholism.  The bug eyes of hyperthyroidism.  The slowness, shuffle and tremor of Parkinson’s.  Way too many “thousand-yard stares” of PTSD.  The scalp scars, cane, and abnormal gait of a traumatic brain injury.  Too many missing limbs to count.  Behind me, the conversation’s speed and volume (loud enough to hear, too fast to understand) of bipolar mania.  The hopeless faces of depression.   And attentive spouses steering veterans in wheelchairs.

While the lab tech (who gave me permission to write this) drew my blood, I noticed swelling in the front lower part of her neck.  I told her to get her thyroid checked, specifying thyroid stimulating hormone (TSH), and anti-thyroid peroxidase (TPO); and an ultrasound if those tests come up normal.

It doesn’t take much historical knowledge to be able to recognize the conflict that modified the hero.  Although, with two fronts ongoing for the last 25 years, I can’t tell the Iraq vets from their Afghanistan contemporaries.  Some served in both theatres.  Some Korean vets served in Viet Nam.

I don’t feel myself a veteran in the presence of the real ones, I feel a moral dwarf.  I never faced a greater danger than a drunk’s slow punch in the ER.  I put up with bad pay and bad management for 5 years.  I lost income, my fellow beneficiaries lost things that cannot be replaced.

Still, the VA treats me the same as they treat the Real Veterans.  Part of the culture of VA employees involves a lot of caring and warmth that people bring from their hearts but the Federal Government does not pay them for.

For my time in the Public Health Service I got 5 years of cross-cultural experiences that could never be purchased.  And now I get benefits equal in value to a good full-time job.




Let’s see what happens.

July 27, 2013

A matter of prognostic projection

When it comes to a diagnostic question

My pain management skills

Involve very few pills

And no longer my Enbrel injection

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In 2010, I danced back from the brink of burnout and traveled for a year doing temporary medical assignments from Barrow, Alaska to New Zealand’s South Island.  I’m now working at a Community Health Center part-time, which has come to mean 54 hours a week.

During my senior year of medical school I arranged to get credit for an elective rotation in acupuncture in January of 1979.  I studied under a very smart non-Asian internist for a month, and learned the vocabulary and the rudiments.

Before I had passed any Boards or actually obtained a license, I did acupuncture on a friend in a time crunch.  I applied a needle in each shin, close to the knee (the name of the point is Su Zan Li, but its nickname means three villages).  He responded well, and worked with tremendous efficiency for the next 9 days, turning out top-notch work.  The bottom dropped out of his energy three days later, and he slept for the next two days.

In retrospect, I had precipitated a hypomanic episode; his bipolarity would not be diagnosed for many years.  Nor did I realize the enormity of the power of those two needles for decades.

High-quality research with acupuncture showed mixed results.  A study published in a major journal demonstrated very good results in treatment of the most severe alcoholics (regretfully, the study didn’t detail exactly where needles went nor how they were placed).  Another, published in JAMA, showed acupuncture and sham acupuncture equivalent in the treatment of migraine.  Many docs point to that study and assert acupuncture has no validity; I look at the same data and conclude that you don’t have to be much of an acupuncturist to treat migraine; put a half-dozen needles anywhere you want and not very deep, on a regular basis and at the end of a year the patient will have half the migraines he/she used to.

I went to my acupuncturist today for a session because I’ve been off Enbrel for three weeks.  My sacroiliac joints haven’t fused despite my age, leading my rheumatologist to question the diagnosis of ankylosing spondylitis.  He would like to see if my sed rate (ESR) and my C-reactive protein (CRP) go up in the absence of therapy.

I can hope for a misdiagnosis, or for news that my disease has burnt itself out, but as the days go by the pain in my spine grows.  I’m now relying on the pain management skills I developed between 1967 and 2000, when I got my first injection.

I can do a lot of things to bring down the level of pain a notch or two; I can’t do anything to make the pain go away completely.    When I walked away from the acupuncturist/chiropractor’s office the pain between my shoulder blades had faded by about two-thirds, and I could sneeze without grunting.

Now I have to work on my sleep pattern.

Changing the diagnosis in the face of change: against complacency

January 23, 2011

I took a good look at the hand

I kept an expression so bland

     without honest guide,

     You can run but not hide

Just keep your head out of the sand

Synopsis: I’m a family practitioner from Sioux City, Iowa.  Transitioning my career away from the brink o f burnout, I’m taking a sabbatical while my one-year non-compete clause expires.  I’m having adventures, visiting family and friends, and working in out-of-the-way places.  Currently I’m in Barrow, Alaska, the northernmost point in the United States.

I took care of a patient who has given me permission to write the following information.

Hand pain, concentrated at the joints where the fingers meet the hands and the knuckles closest to those, and pain in the wrists, brought her in to see the docs here in the fall.  Concerned about some abnormal blood work, they requested a rheumatology consultation.  The rheumatologist diagnosed osteoarthritis and prescribed non-steroidal anti-inflammatory drugs (NSAIDs).  Osteoarthritis comes from wear and tear on the joints.  In the hands, it characteristically affects the knuckles closest to the nails.  It has nothing to do with rheumatoid arthritis, a disease which scourges the entire body.  Treatments for the two diseases differ vastly.  NSAIDs comprise the mainstay of osteoarthritis therapy, the powerful drugs which modulate the immune system in rheumatoid arthritis have no place in osteoarthritis.

The patient got steadily worse.  She now has severe morning stiffness, pain that wakes her up at night, and worse pain than ever in more joints than before, now including her shoulders and knees.

As soon as I walked in the room, I saw that the fingers of her right hand were swollen in a fashion that gives rise to the term “sausage fingers.”

While I’m checking for other diagnoses, I’m fairly confident she has rheumatoid arthritis.  Her x-rays, normal in December, confirm the joint erosion and bone thinning near the joint, typical of the disease.

Like every patient, she lives in a social, family, and community context.  Whatever her diagnosis, the course of her illness will touch everyone she knows in an unpredictable fashion.

My sensitivity to the rheumatologic diseases stems from my own ankylosing spondylitis, and my experience with the medical profession misdiagnosing me for seventeen years (which was the best thing they could have done for me at the time; the rudimentary treatments back then weren’t much better than the disease).

I know when I don’t know and when I don’t know I know what to do: call someone who knows more than I do.

Humans tend to complacency.  I had the urge to accept the diagnosis of osteoarthritis, because I regard the rheumatologist as having expertise in the area.  But in the end, I just couldn’t make the patient’s history and the physical findings fit.  Even if the patient had osteoarthritis in December, she doesn’t have it now.

  Patient conditions change, world conditions change, and without the ability to adapt, survival becomes problematic.

Hepatitis, joint pain, and missing the solution to the mystery

December 28, 2010

To what disease do the symptoms belong,

When dark urine lacks odor so strong?

     I made a few points

     When I asked about joints

But the truth is I’d rather be wrong.

Synopsis: I’m a family practitioner from Sioux City, Iowa.  While my one-year non-compete clause ticks away, I’m having adventures working in new places and visiting friends and relatives.  Right now I’m staffing a clinic in Keosauqua in southeast Iowa.

My month in Keosauqua draws to a close tomorrow.

A patient (who gave me permission to write this information) came in today with a puzzling constellation of symptoms for two weeks: fatigue, malaise, chills and sweats, joint pain, morning stiffness, abdominal pain, vomiting and diarrhea.   The fingers on the right hand were swollen, visibly larger than those of the left hand, and index and middle fingers had swelling of the knuckle joint close to the hand.  I found other abnormal items on the physical exam, my fingers gliding over tiny, painful lymph nodes at the inside of the upper arm, just above the elbow.

On the basis of an impulse whose source I do not know, I asked the patientiof the color of stools had lightened and that of the urine had darkened.  They had.

At the end of the visit I said, “You want me to be wrong about everything I’m thinking of because the best diagnosis we can hope for is infectious mononucleosis.  That’s the best one.  You don’t want rheumatoid arthritis, Lyme disease, or hepatitis, or any of the worst things that I can think of.  And I suppose it’s possible that it’s work related.  We’ll have to see.”

Not widely known, but the rheumatologists make the diagnosis of hepatitis B more often than the gastroenterologists. Early in the course of the disease, any hepatitis can look like rheumatoid arthritis.  Patients can, and do, have severe joint pains without any abnormality of the liver function tests. 

Hepatitis B should be prevented by immunizations administered in infancy.  However, some parents choose against immunization (which I find foolish) and a very few people will not make antibodies in response to the vaccine.

Hepatitis C can cause similar joint pains, but usually doesn’t.  Mostly it causes an overall sensation of fatigue, less often the classic signs of hepatitis, with jaundice and swollen liver.

In medical school, hepatitis came in the classifications of infectious and serum.  By the time I finished residency, infectious hepatitis bore the name A and serum hepatitis was called B.  The third one, called non-A non-B hepatitis, eventually found the name C.  Ten years ago, hepatitis C mostly smoldered along and every once in a while resulted in liver cancer.   Five years ago we had a cure rate of 10% and now we have a cure rate better than 50%, and improving.

In the end, the patient’s diagnosis will come from lab work, but by the time the results come back I will have moved on.  I will not witness the denouement, the answer to the mystery.

At the end of the afternoon, I introduced the patient to one of the other docs here and made arrangements for follow-up.

The patient lives in a world, a social context with relatives, friends, and a job or two.  I will miss out on seeing how the disease affects the person and the world around them.

I will wonder.