Posts Tagged ‘smoking’

Weekend call: nature abhors a vacuum

March 27, 2017

I took the weekend on call

I started with no patients at all

But I fixed that up quick

With the ill and the sick

The thin and the fat, the short and the tall.

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.

 Perfect people don’t come to see me. When I find a patient who has to face the music and pay the piper, I do my best not to judge.  Strangely, when I can condense my approach to, “You’ve made mistakes in the past, let’s move forward,” I find it easy to establish rapport.  I like to think that the rapport brings better chance of patient cooperation in lifestyle modification.  At the very least I have more energy at the end of the day.

In residency and in private practice, when I would take sign-out for weekend call, I would look first at the gross number. Of course we like it when no-one occupies a hospital bed.  But if the number came in really low, I’d shudder and remember the adage, “Nature abhors a vacuum.”

This weekend, I started call on Friday afternoon with a census of 0. By the time Saturday morning dawned, the census had climbed to 5.  Most, not all, had pneumonia.  Most, not all, sickened from a combination of tobacco damage and the aftermath of the influenza. I went into a rhythm of admission history and physical.

I dictate with sophisticated software. Still, sometimes I get so frustrated that I use my well-honed keyboarding skills.  For example, dictating a list gets me correct numbers except “4” which prints out as “for.”

And beneath the commonalities of fever, cough, and wheeze, each patient has a unique circumstance, a story of drama and irony that brought them to illness. And almost all have come at a time of stress in their lives.

Nothing is 100% in my business. A very few patients sickened gratuitously.  A genetic accident should not constitute a death sentence.

I enjoy talking with the patients. I ask them what they do in their spare time if they haven’t told me before I get to the question.  Over the years I’ve acquired enough vocabulary to speak meaningfully about a wide range of subjects.  Particularly in rural America, being able to talk about farming, crop yields, soil management, firearms, archery, and hunting gives me credibility.

Here in Clarinda, close to St. Joseph, Missouri, I ask people my age and older if they remember the Jerome Hotel.

It belonged to my grandfather. I drop his name.

 

 

 

Not confronting a smoker

December 28, 2014

On the edge of a change, on the brink,

I might bring a person to think

About why they’re broke,

Or continue to smoke,

If into the cold they must slink

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center, where I worked for 3 years.  I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system.  Now I’m back from a road trip, working a bit with one of the rural docs, and getting ready for another job in Alaska.

On my way into a drug store to pick up melatonin for my upcoming trip, I saw a young, depressed-looking woman leaning against the brick wall of the adjoining building, smoking a cigarette next to the employee entrance of a health care establishment, and I faced a dilemma.

I could something or I could say nothing.

If I said something, I could say any of the things she’s already heard, but, as her continued tobacco use showed, those things hadn’t dissuaded her.  I could point out that the lungs of a smoker beat every other place on earth for radioactivity (including the hospital basement in Chernobyl where the radioactive clothes were dumped and where they remain) except a nuclear power plant; she probably hadn’t heard that.  Or I could whip out my calculator and point out how much money she burns a year.

I briefly considered saying nothing, but only briefly.  Not speaking out would go against my very identity.  Tobacco killed too many members of my family.

Whatever I would say I would have to use a minimum number of words.

I didn’t try to show her the wrongness of her actions.  I didn’t ask her, on a scale of one to ten, how ready was she to quit.

I exited the car.  “So, how’s that smoking thing working out for you?” I asked.

Her joyless face blossomed into a sardonic smile.  “It’s OK,” she said.

I said nothing more.  I can hope I made her think about the problem, I can hope I made a difference, I can hope I did the right thing.  But I cannot know.

I can regard the irony of a health care worker smoking, and I can wonder about the drama.

November 23, 2014

It’s now the start of the season
With the coughin’ and sore throat and sneezin’
And then there’s the nose
From whence mucus flows
And the smokin’ brings on the wheezin’

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center, where I worked for 3 years. I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system. Now back from a road trip to visit, and take in Continuing Medical Education, I’m helping to fill in at a clinic not far from home.

I drove east on a Friday morning, into the rising sun, listening to a Continuing Medical Education program and my GPS, Samantha, to an outlying rural clinic.
The town qualifies as small. People don’t lock their houses or cars; local funds built the library, and nobody can claim the traffic made them late. I parked in the alley behind the clinic.
A short tenure in a health facility doesn’t justify the expense and pain of setting up an Electronic Medical Record (EMR) system account when the doc just fills in for a few weeks. Thus I got away with dictating my records as I’d done for the first couple of decades of my career. I passed 15 minutes determining that neither of the ancient micro-cassette recorders could be rendered functional. And then the nurse told me my first patient awaited.
Seventy-five percent of the patients I saw had respiratory problems. I spent a lot of time explaining why I wouldn’t prescribe antibiotics and felt relief when a patient with sinusitis (who had been better and then got worse) needed amoxicillin. The pattern for almost everyone started with high fever, resolving within hours, followed by a severe sore throat lasting less than a day, and a main complaint when they arrived of cough and stuffy nose. I quoted Star Trek twice by doing my best Bones imitation of “Why, Jim, I can no more do that than I can cure the common cold.”
On three occasions, I asked the patient, “On a scale of 1 to 10, how ready are you to quit smoking, where 1 means you want to die with smoke in your lungs, and 10 means you quit an hour ago?” As always, I had to coax a numeric response, and then I asked, “Why not 2? Tell me three good things about smoking.” I listened and repeated, but I didn’t belittle or make fun of the response. After all, everyone knows the dangers of smoking, everyone has been told to quit, and shaming hasn’t worked. To capitalize on their ambivalence, I sought only to make them think about their habit.
For many, the worst symptom came down to a stuffed-up nose. Ipatroprium effectively relieves that problem, but I prescribed so much that the town’s pharmacy called before 11:00AM to say that had run out of it and couldn’t I please prescribe something else.
After being away from clinical work for weeks, I reveled in the tasks, the patient contact and the conversation. I got to talk with farmers and cattlemen. I established rapport with pediatric patients by playing with my yoyo. I successfully examined the ears of an 8 month old without using force.
I got to eat lunch, then I used a phone-in dictation line.
And I finished early.

Short call on Labor Day weekend

September 3, 2012

Labor day spent making rounds.

You wouldn’t believe the diagnoses I found!

It wasn’t quite call,

I avoided a brawl,

And sent four to their homes out-of-bounds.

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 48 hours a week

Our hospital service has grown to the point where two docs get assigned every weekend, one each for a long call and a short call.  I drew the short call this holiday weekend, not the same as the short straw.   I requested, and received, assignment to my preferred hospital, where I’ve done morning rounds now for four days. 

My natural tendencies wake me early, but today I ate a leisurely breakfast before Bethany dropped me in the deserted doctor’s parking lot.  I printed my patient list in the doctor’s lounge at 6:58 AM and took the elevator to the 5th floor. 

I returned to the doctor’s lounge, emotionally tired, at 11:30.  I had rounded on 13 patients, each one a unique human being whose illness brings drama and irony to their lives and the lives of the people around them.  Each has a marvelous story, rich with details, triumphs and tragedies enough for a series of novels.

While I can’t discuss patients in particular, I can talk about the patient population in aggregate.

Four patients carry the diagnosis of schizophrenia.  Eight qualify as hard-core alcoholics requiring treatment for alcohol withdrawal.  Bipolar disorder (previously called manic-depression)afflicts three.

Eleven of the thirteen didn’t quit smoking soon enough, such that they required treatment for nicotine addiction or emphysema or both. 

More than one has chronic kidney failure necessitating dialysis. 

Others had cancer, HIV, depression, gallbladder disease, broken bones, dementia, urinary infections, lupus, and coronary artery disease.

The nurses on the psych floor warned me about a violent patient after a near confrontation.

I didn’t even bother to count the number of patients with the garden variety problems of diabetes, high blood pressure, and high cholesterol.

I had to deal with two patients with adverse drug reactions, their hospitalizations complicated by the very medications their doctors ordered.

I discharged four patients and dictated their discharge summaries while leaning my back against the wall; I wrote prescriptions for three of them.

One of those represents a triumph of medical care; we cured the problem and sent the patient home in less than 72 hours.  Such satisfaction comes rarely and I relish it when it does.

The doctors’ lounge stood deserted at noon on Labor Day, and I power napped ten minutes before the next task, reviewing transcriptions.  I had 37 in my queue.  After that I dictated six discharge summaries.

I left the hospital at 12:40PM, the rest of a fine summer day right in front of me, and headed home for lunch.

At last, the geographic cure worked once.

July 18, 2012

We wonder where the time went

And thinks of the hours we spent

I always guess wrong

About just how long.

Nothing’s a hundred percent.

 

I tell my smoking patients not to try to quit by cutting down, first because it doesn’t work and second because it constitutes a slow torture.  Physiologically, a gradual nicotine dose reduction prolongs the agony of withdrawal while it makes the smoking habit stronger.  And people who want to ‘cut down’ haven’t made an emotional commitment to quit.

Observation confirms theory; in the 30 years since I finished residency I have met 3 people who quit smoking and stayed quit by cutting down, but I’ve met tens of thousands who failed. 

Thus I can’t say categorically that cutting down doesn’t work, I can say that other methods offer a much higher chance of success.

Recovering alcoholics and addicts will speak derisively of the geographic cure.  Active substance abusers will, sooner or later, try to blame their addictive behaviors on their surroundings and companions.  Thinking that the problem resides externally, they try moving to another place to make a fresh start.  On arrival at the new destination they find new connections and bars, and their abstinence collapses less than three months later.  No more than a year passes and they return, generally with their dependency having moving forward a notch or two.

Those people in recovery say the first person you need to fix is yourself.

Yesterday for the first time I met a person for whom the geographic cure had worked.  For reasons of confidentiality I can’t give details, but later that evening I mentioned the case to a nurse, declaring that every day I see patients I find at least one thing I’ve never seen before.  The nurse blinked and, deadpan, told about caring for a patient who survived a fall after a parachute failed to open.

Every known malignancy has at least one miraculous survivor; people who go decades with metastatic lung cancer are common compared to those who exit airplanes without a parachute and live.  Yet we now have dozens if not hundreds of cases of people who survived falls of hundreds or thousands of feet.

Over the weekend a family member asked how much time a patient had; I refused to give a number because I guess so poorly.  I recall one patient I looked at and thought, “Just hours now”’; yet another patient I firmly believed had months died in less than two days.

We never know how much time we have in this world, and in the last 8 days (including 5 twenty-four hour shifts) I have repeatedly run into the fallout of people with terminal diagnoses deciding to tell or not to tell their families.  I advise the patients that if their loved ones would spend more time with them, knowing that the end was near, that they should by all means spread the knowledge. 

Most listen.

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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Why is a tire pressure gauge like a time sheet?

December 13, 2010

Take this from the wisdom’s true fount

Or you’ll never know the amount

     Of things saved or spent

     Or where the time went

Unless you keep true account.

The day started with dropping my car at the garage.  When my gas mileage plummeted I checked my tires and found a slow leak in the right front, which I couldn’t have done without a pressure gauge.  As I walked away from the service station in the clear sunshine and bitter cold, I reflected on the damage done by estimation in the absence of accounting. 

A vague answer to a specific question means either “I don’t know,” or “I don’t want to tell you.”  Navajo has a specific word, hola, which means exactly that.  In English, we just prevaricate.

When I ask patients, “How much does your smoking cost?” frequently the answer comes back, “I know.” But when I press, I find out that they haven’t done the arithmetic. 

With alcohol, my query starts “When was your last drink?” and goes on to “How many did you have at that time?  Is that typical for you?  When was the last time you had more than five in a night?”  The vaguer the answer, the more I worry that the person really doesn’t know and doesn’t want to know.  I never ask “How much do you drink?” because the only accurate answers come from people who don’t have a problem.

The same thing happens with eating.  The greater the overweight, the less well the person knows when they’re hungry or keeps track of how much they eat.

When I worked in private practice, I did a lousy job of keeping count of my hours.  When, in Barrow, I filled out a time sheet to the tune of 63 hours in a week with a lot of leisure, I realized I hadn’t been working 56 hours a week but usually 80.  I hadn’t counted the calls at home, the time spent in medical records, the after work documentation, or the time spent doing Continuing Medical Education (CME).  Nor had I amortized the hours spent on weekend call over the course of the month. 

Though most docs receive good pay for their services, we perform many professional duties for no reimbursement.  A fifteen minute patient visit generates five minutes of dictation; one visit in two results in lab work for review; one visit in six demands a call to another doctor.  Time spent reviewing refill requests or lab data generates no income.  We don’t get paid for phone calls to worried patients.

The corporate parent of Care Initiatives Hospice asked me to start filling in a time sheet.  Why should it matter, I asked, if I’m paid straight salary?

I started keeping track of my hours.  I was surprised at how fast twelve phone calls, five minutes each, add up to another hour.

Estimation never compares to keeping count.  If we don’t have a gauge, we won’t know about our leaks.

I can’t stop being a doctor, I don’t want to try. I just want to slow down.

September 22, 2010

I can’t stop being a doc

Leave me alone and I’ll diagnose a rock

     Say what you please

     I can see a disease,

Sometimes from the end of the block.

I can’t stop being a doctor.  I have a one-year, thirty-mile non-compete clause, so I can’t give advice or write prescriptions unless I am out-of-town.  But at the same time I make a purchase at a store or talk to someone on the street I can’t stop making diagnoses.

I can tell the sleep deprived people by the fine wrinkles on their faces, the front parts of their cheeks, and the bags under their eyes.

A particular kind of hyperthyroidism, Grave’s disease, shows itself in prominent or bulging eyes; actor Marty Feldman displays this eye finding, exophthalmos, which overlaps incompletely with a visibly enlarged thyroid, or goiter.

Parkinson’s disease displays several early findings before the tremor starts.  People walk rigidly, their smile seems frozen, they start to lean. 

People with neuropathy walk with a broad-based, uncertain gait, something like Frankenstein’s monster in the original movie. 

I looked at a clerk’s hands today and noted a rash on the left hand in the web space between the little finger and ring finger; red and swollen with sharp edges.  I wanted to tell the person that a fungus was growing there, and to use over-the-counter antifungal till it cleared.

Another person had some fine red bumps on the inside of the forearms; whether insect bites or poison ivy or other contact allergy didn’t make any difference.  I had the urge to instruct on the use of over-the-counter 1% hydrocortisone cream for itch, and to ignore it if there were no itch.

I can smell the smokers by the smell, sometimes I cough from being near them.  I want to offer advice, but I don’t if I’m in town.

I miss my work but I don’t miss the sleep deprivation.  I’m looking forward to going back to medicine on a forty-hour a week schedule. 

I’m arranging my next placements.  I’m having trouble deciding where I want to go during the month of October.  Do I want to take a job for fewer hours but better rate with very short commute, or do I want to drive further?  I know I want a better adventure, but possible work availability complicates the picture.  With many variables in many unknowns, eventually I have to commit to a course of action.

This morning at the Care Initiatives Hospice meeting we talked about patients and I made more recommendations for decreasing or eliminating drugs than I did for starting new drugs. 

At the end of the meeting, I was the first one in line for the flu shot. 

Last flu season went easily probably because we immunized so well.  The H1N1 wasn’t nearly as bad as we’d thought.  The possibility of a change in virulence remains, but looks a lot less likely.

I can’t stop being a doctor.  I don’t even want to try.  I just want to slow down.