Posts Tagged ‘shingles’

My wife had stereotactic radiosurgery

August 29, 2016

The computer would focus the beam,

And I would doze, perchance I would dream.

And turn after turn

The tumor would burn

Ramsay Hunt wasn’t part of the scheme. 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

Bethany had her stereotactic radio surgery on schedule. Even though the tumor involved no malignancy, the procedure took place at the June Nylen Cancer Center and involved a radiation oncologist.  The festivities started off with the neurosurgeon using 4 screws to affix a frame to her head.  Then followed a CT scan of the head, and three hours wait.  When all was ready I walked Bethany to the linear accelerator, which didn’t make much of a visual impact.   The frame screwed to my wife’s head got bolted to the table under the linear accelerator.  I made a small contribution by suggesting a couple of rolled towels under her shoulders would favorably change the angle of her neck.

Then I walked back to wait. They said it would be an hour, and I thought about going out for lunch, but I stayed around, and twenty minutes later we walked out into the heat.

The next twenty-four hours went well but then the full impact of the radiation hit with nausea and vomiting. A couple of quick calls brought a prescription for Zofran which helped a lot.

Bethany seemed to have bounced back well, and she drove me to Omaha on a Saturday to catch a plane to Alaska very early the next day.

I brought a cooler full of 50 pounds of sweet corn to friends who live in Anchorage, before I started work on Monday.

By the time I’d landed, blisters had broken out on the left side of Bethany’s hard and soft palate; her description brought shingles to mind.

A while ago, leafing through a free medical journal called a “throw away” for good reason, I came across a photo quiz which showed zoster inside the mouth. I flipped the page to find the diagnosis of Ramsay Hunt Type 2.  I scoffed, figuring if I hadn’t seen something like that in 30 years I probably wouldn’t ever.  But three weeks later I looked in the mouth of a patient complaining of a “sore throat” and found exactly that.

I posted a poll on my favorite doctor’s social media site, and found that 80% of physicians haven’t heard of Ramsay Hunt Type 2, but 10% have seen it.

But it was the weekend. I told Bethany to schedule with her physician, and by the time she got an appointment she’d broken out with the worst cold sores she’d ever had, on the left side of her nose.

The viral culture eventually showed Herpes 1 (cold sores), not its cousin, the varicella zoster virus, or shingles.

Valcyclovir will treat both, but shingles requires a much higher dose.

And I can’t say I’ve seen two cases of Ramsay Hunt Type 2.

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First day on the job in Grundy Center

May 6, 2015

Low quality research, infectious mononucleosis, and clinical experience.

July 25, 2013

 

People and doctors think twice

For a test that’s ten times the price

When for a positive test

The treatment is rest

And the quick, easy lab seems so nice. 

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.

Eight viruses belong to the human herpesvirus family.  Herpes 1 brings cold sores or fever blisters; herpes 2 gives the recurrent STD blisters.  Herpes 3 is the Varicella-Zoster virus and gives rise to chickenpox and shingles.  The Epstein-Barr virus belongs to the same family, and causes infectious mononucleosis, or mono.

My personal experience with mono came in January of 1969, with a sore throat, nausea, loss of appetite and headache.  I dragged myself to the Department of University Health, got a blood test and went to sleep for the next week and dragged myself back.  The doctor declared I did not have mono.

I didn’t get better, and 8 weeks later dragged myself to a different doctor in the same building who announced the diagnosis of mono.  No, I replied, the other doctor told me the test came up negative.  Well, he said, look at the lab slip.

Sure enough, someone had written the word POSITIVE on the yellow 3×5 lab slip.

They used the Beef Heterophile Agglutination test back then; the updated version carries the trade name MonoSpot.

Twenty percent of the population cannot make the chemical that causes the reaction; we now have sophisticated confirmatory tests that can distinguish between mono acute, chronic, recent past, distant past, and not mono.  But it costs ten times more than the Monospot.

Chronic mono happens but not very often; those patients who get it have other problems with their immune systems.

I had to explain those things to a patient Wednesday who kept having problems with recurrent severe sore throats (and who gave me permission to include a good deal more information than I have) for years.

The standard treatment for mono boils down to six weeks of bed rest.  More common non-standard treatment includes steroids.

No one would use the word brilliant to refer to the research done last century on the use of Tagamet (cimetidine) in mono.  The patients in each arm numbered in the few dozen.  The publication did not mention the dose.

Within 5 years of reading the article I had personally treated more mono patients with cimetidine than had been in the original study.  After 10 years, I could tell my patients my clinical experience: 25% of mono patients bounce back dramatically under Tagamet in less than 24 hours, 50% bounce back but less dramatically in less than a week, and 25% do not respond.

The patient considered the costs of the lab tests and the cost of the generic cimetidine, and decided for treatment.

I’ll know the outcome next week.

Two patients in forty-eight hours with the same unusual eye problem

May 18, 2011

On the white of the eye, a small bump

Surrounded by vessels so plump

     I don’t know why

     It shows up in the eye,

When the infection is down by the rump.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my one-year non-compete clause ticks away I’m having adventures and working in out-of-the-way places.  Right now I’m living in Amberley, and seeing patients in Waikari, in New Zealand’s South Island, an hour outside of Christchurch.

Twice in the last forty-eight hours I’ve seen patients with the same unusual eye problem.

Both had irritation of the eye and a little bit of discharge, neither could tell me the color.  When I looked closely at the sclera (the white part of the eye), I saw a white lump the size of a caraway seed, surrounded by inflamed blood vessels. 

“That little lump,” I said in both cases, “Is a phlyctenule.”

I didn’t learn about phlyctenular keratoconjunctivitis(PKC) in med school or residency but in the Indian Health Service, when I took the IHS tuberculosis course.

I have not seen a good explanation of PKC, where an infection somewhere else in the body triggers an allergic reaction in the eye.  In the IHS we maintained a protocol that included a TB skin test and a chest x-ray.

I haven’t seen a case of PKC triggered by TB since I left the Indian Health Service; in the absence of respiratory symptoms or a history of probable exposure I don’t check a chest x-ray.  I ask about other infections, especially skin, and especially fungus.  Usually I don’t get anything to go on and I end up giving the patient an anti-inflammatory eye drop.

Both patients with PKC turned out to have other infections, and in the process of explaining and asking, I uncovered drama, irony and surprising facets of human love.

I don’t see all that many phlyctenules since I no longer work for the Indian Health Service and sometimes I’ll go years without seeing one.  Most docs don’t recognize the abbreviation PKC, but the charge sheet we used in New Mexico listed it on the menu of 50 most common diagnoses.

Outside of contact lenses, most non-traumatic eye problems have to do with infections.  The majority of patients with the red, runny mattering that signals pinkeye have conjunctivitis, mostly viral.  The ones with bacterial infections need antibiotics.  Viruses outside the herpes family clear without treatment; herpes I, herpes II, or the chickenpox/shingles virus in the eye constitute a true eye emergency, requiring a specialist.

Eye infections that keep coming back, I explained to one of the patients, usually respond better to baby shampoo and Q-tips than to antibiotics.  The follicles of the eyelashes become clogged with debris related to the eight-legged crustacean called the human eye mite, and detergent action cuts down on the infestation.

Chickenpox, shingles, and widows. Drama=irony, surgery=theatre

April 9, 2011

For lunch I had me a pie

I went back to work bye and bye

          I am no cheater

          If surgery’s theatre

I won’t make the audience cry.

 

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, right now I’m working on the North Island of New Zealand.

I arrived early at the clinic in Snell’s Beach and started work in the quiet of the morning.  With the doors of the clinic open to the sunny, cool air, I reviewed lab and x-ray results; four of fourteen needed follow-up.

When patients started, I refilled a lot of prescriptions, many of them for asthma.  A lot of kiwis have asthma, mostly unrelated to smoking.  The commonest combination, salbumetol and flixitide, would be called albuterol and fluticasone in the States.

In New Zealand, surgery refers to seeing outpatients.  What we would call surgery at home gets the word theatre here.  Thus whereas in the States “Have you done much theatre?” might mean anything from “What live acting credits do you have?” to “Are you gay?” the Kiwis mean “Have you done many operations?”

At lunch I stepped outside into perfect weather, with cool, breezy air and bright clear sunshine, and went to the bakery for an unhurried steak and curry meat pie.

Back at the clinic I’d started tidying up my documentation when the nurse said, “I know you’re still on your lunch break, but…” 

In fact, I’m not used to an hour lunch break; at home I got into the habit of bolting my meals.  Of course when I got the opportunity to do what the locals would call theatre to help a patient cope with the consequences of steel’s excess kinetic energy contacting flesh I said yes.

When I finished I found myself twenty minutes behind schedule.

I’d almost caught up by 4:00 when a patient asked for a letter for court.  I couldn’t contact the requesting lawyer.  I made it clear that both parties had to be comfortable with the letter, and I would only write truth but not conjecture.  I wrote, we edited, and in the end, the piece of paper left with the patient but the process took twenty-five minutes.

By 5:15 I’d seen 24 patients and written refill prescriptions for another.  One third of my patients, both male and female, mentioned their status as widows.  Half had been widowed more than once, all wanted to tell their stories, and the drama and irony of the human condition flowed raw and unrestrained.  I listened with sympathy.  At one point I mentioned the high rate of spousal death.  “Oh, yes,” the patient said, “Snell’s Beach is full of us.”

Four of the day’s patients had superficial skin infections.  One had shingles, and I remarked that if it didn’t presage a chickenpox outbreak it would constitute a unique experience in my career.

I drove the rough, narrow, winding road with dense traffic and courteous drivers to the clinic in Wellsford.  I checked in with the nurses, and a flurry of confusion followed.  With my name on the roster (as they call the schedule), and another doctor’s name on the computer template, I had the option of taking off and going home.

The thought of another forty minutes on the roads pushed my decision to take the night on call, thereby earning me a dinner break and collegial gratitude.

I walked down the street, gobbled mediocre steam-table Chinese food, and walked back in the gathering gloom.

The anticipated chicken pox outbreak had arrived, the pharmacy (in Kiwi, the “chemist’s”) had closed, but I rooted through the after-hours drug dispensary and found, to my surprise, a good supply of aciclovir.

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Hagen Dasz comes this far north.

July 8, 2010

The hunters go out after seal,

The harvest makes quite a meal

    My face doesn’t frown,

    For I have slowed down,

I got ice cream for the end of the meal.

People don’t move to the North Slope of Alaska to get lost in the crowd or to thrive on the non-stop action.  There are a lot of business opportunities but people do well finding the balance between work and other things.

I talked to a person who had a high salaried job using a professional degree but found 80 hour weeks irksome.  Now on hourly, this person is getting paid overtime after 40 hours and earning more money for less responsibility.  I talked about what a great time I’m having, slowing down and making less money.

But for all that I added up my hours and most weeks I’ve been working more than 60 hours.  Still it feels a lot freer than it did in Sioux City.

I’ve started corresponding with companies who place American docs in New Zealand and Ireland, and the opportunities sound fabulous.

The hunters here are out after seal, and at the same time gearing up for the caribou, who come to the coast for the breeze that helps protect from mosquitoes and biting flies.   Walrus should be coming north soon.  Of course I see the injuries having to do with the unique and not so unique activities of Barrow.

I have permission to give out the following information.  A patient started noticing an itch on the right side of the back and chest about two weeks ago, and a rash broke out a week ago.  Any rash that follows the skin segment innervated by one nerve (a dermatome) is shingles unless you prove it isn’t something else.  I got to talk about my shingles and how the first symptoms started three weeks to the day after I’d made my career change decision.  Promising I wasn’t a psychic, we were able to pinpoint a significant twenty one days prior to the onset of itch.

I directed two of my patients to my blog today, to the post entitled Rage, Hunger, Lust, and Sleep.  It has most of my recommendations about using sleep therapeutically.  I was flattered when I found that post pasted wholesale in other blogs.

Clinic went late tonight.  The last patient, a person with whom I would love to sit and chat for hours, said, “We might be masters of the Arctic, but the ice and the temperature still rule.”

After clinic I went for a walk.  The air temp has dropped again and the sea ice extends a good seventy meters from shore.  I found the library closed today.  I went to the Arctic Coast Trading Post down the street and was surprised and delighted to find Hagen Dasz ice cream in more flavors than we get in Sioux City.  I hesitated not because of the princely price tag (roughly ten dollars a container) but for fear of melting before I got it back to the freezer.

I walked fast enough and the weather was cool enough that the bright sun didn’t melt ice cream.