Posts Tagged ‘sinemet’

The Summer in Review

October 1, 2018

The months I spent here were 4

And I thought as I walked out the door

Of the esprit we displayed

And the tractor parade

And how I might come back later for more.

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, a friend’s funeral, a British Columbia reprise, my 50th High School reunion, I just finished a 4-month assignment in northwest Iowa.  Any identifiable patient information has been included with permission

I spent the last 4 months in Iowa farm country. Agriculture dominates the town’s economy.  The local subculture has biases against tobacco, alcohol, drugs, and infidelity, and for hard physical work with personal integrity.  Thus my patient population included a lot of very spry folk in their 70s, 80s, and 90s.

I attended several in those age groups with Workman’s Compensation injuries.

I identified Parkinson’s disease in more than a dozen patients, and over the course of the summer saw them improve as I gradually increased their doses of carbidopa/levodopa (trade name, Sinemet).

Four different patients presented with various symptoms which turned out to be hypothyroidism. Some I made better.  But I left before the mandatory six week wait for hypothyroid follow up.

I suspect vitamin B12 deficiency in anyone with neurologic problems. Five such patients had low B12 levels.  Several had borderline levels, and when I did the confirmatory tests of methylmalonic acid and homocysteine I found disease that needed treatment.

I approached several cases of heart failure with the relatively new combination of ACE inhibitor and beta blocker.

Nobody made an inappropriate request for a scheduled drug, a tribute to the tiny medical community and the doc who preceded me.

A number of patients came in with confusing, dramatic neurologic symptoms looking like stroke but resolving when treated for infection and dehydration.

The hospital CEO, a nurse by training, has great leadership skills and no fear of getting her hands dirty. She did a fantastic job with difficult IV starts. When a staffer fell ill unexpectedly, she cooked and served supper to the inpatients.

Such leadership quality echoes throughout the organization. The clinic manager keeps the staff pulling the wagon in the right direction.  People work hard here. Lab and x-ray results came back with dizzying speed.

I used the electronic medical record to retrieve data, but I dictated my hospital, clinic, and ER notes. I entered my inpatient orders on paper.  My outpatient nurses entered prescription, lab, and x-ray orders for me.  All in all, I got to concentrate on patient care and not on the computer.  In fact, policy keeps computers out of exam rooms.

Early in the summer, a nurse, the clinic manager and I went on a house call. As we left town on the country road, we pulled up in back of a slow-moving MRI semi.  Eventually, he passed a farmer on his tractor, who turned out to be part of a tractor parade that stretched as far as the eye could see down the road.

It slowed us, but we all enjoyed the experience and talked about it for the rest of the summer.


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.