Posts Tagged ‘Van Buren County’

After thirty years, a case of Reiter’s syndrome, and my last Keosauqua patient shatters my complacence.

December 30, 2010

When I stopped to check out the heart,

The rhythm gave me a start.

     It was going too fast,

     And that patient, the last,

Went out on the ambulance cart.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  While my one-year non-compete clause ticks off, I’m having adventures, working, and visiting friends and relatives.  I’ve been on assignment in Keosauqua, in southeast Iowa.

Today I finished my last clinical day in Keosauqua.  The first patient of the day and the last patient of the day each gave their permission to write the information below.

Reiter’s Syndrome includes the triad of conjunctivitis (inflammation of the eye membranes), urethritis (inflammation of the lower urinary tract), and synovitis (joint inflammation).  Such a constellation signals the body’s abrupt inappropriate reaction to an infection; while attacking germs, the defense mechanisms start to attack the person’s own tissues. 

Separately, each of these three items comes as common as rain, and for the last thirty years I’ve asked each patient with one of them about the other two.  I also ask about fever and rash.  The interview sequence qualified long ago as low-yield, but I persisted for sake of thoroughness, and, later, from habit. 

Over the years, my interview technique has evolved.  In the beginning I listen, later on I ask focused questions.  Today, when I said to the patient, “Tell me more,” three sentences in quick succession revealed knee pain, discharge from the eye, and discharge from the penis.

For the first time, ever, today I made the diagnosis of Reiter’s Syndrome.  I started the proper lab investigation and turned the case over to a colleague.

For those interested in medical history, Christopher Columbus suffered from Reiter’s Syndrome on his last voyage.

The last patient of the day came in with a routine complaint of cough, also a frequent problem in temperate climates in the winter.  Such symptoms have been going around Van Buren County during my short stay here, and I anticipated ending my tenure routinely.

The human condition tends towards complacence.  We tend to “know” we’ll find a normal cardiac exam singing “lub-dub, lub-dub.”  If those sounds don’t come through the stethoscope, the brain tends to want to make the perceived sound fit into the expected sound.

Today it didn’t.  “Breathe normally,” I told the patient, and tried to hear the heart sounds over the abnormal breath sounds.  Unsuccessful, I said, “Hold your breath.”  The first and second heart sounds refused to distinguish themselves; the first kept shifting in timing and character.  And the rate came way too fast.

I took my stethoscope off and checked the pulse, which came through nice and regular.  I listened to the heart again.  The chaotic rhythm pounded irregularly irregular. 

The reassurance I sought from the electrocardiogram fled before my eyes.  Yet the patient had no heart symptoms at all; no chest pain or sensation of his heart racing.

I grabbed one of my colleagues and showed him the strip.  In short order we had sent the patient off in an ambulance.

We agreed that the weird stuff is out there.

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Mennonites and CT scans

December 14, 2010

For the patient, here is the plan

Forget the equivocal scan

     I don’t need much urgin’

     To call up the surgeon

With the results of the tests that we ran

SYNOPSIS:  I’m a Family Physician from Sioux City, Iowa, making a career transition to avoid burnout.  While my one-year non-compete clause ticks off I’m traveling, doing locum tenens, and having adventures.  Right now I’m working at Van Buren County Hospital in southeast Iowa, where there are no stop lights or fast food.

I’m on call in Keosauqua, Iowa, where the mid-level providers (Physician’s Assistants and Nurse Practitioners) take first ER call, and the MD or DO provides back-up and more definitive care. 

The day till now has run on a low stress level.  As with any other day I care for patients, I came across a physical finding I’d never seen before, a soft lump where I should find hard bone.  The MRI machine comes in a trailer tomorrow and will give me an answer.

I hesitate more about ordering MRIs now than I did when I owned a part-share in a scanner, but I seem to order the same number.  I’m likely to fill out the paperwork and jump through the insurance company hoops when back pain goes down the leg and doesn’t get better, when mysterious physical findings can’t be denied, or when the patient worsens.  I find a lot of occult fractures, that is, broken bones that didn’t show on x-ray.

I remember patients I sent for MRI when I had profit motive to do so; scans showed problems malignant and benign, and surgeons prolonged or saved lives.

Keosauqua has growing Amish and Mennonite populations.  They call us English even if we aren’t English, we call them Pennsylvania Dutch even if they don’t live in Pennsylvania and they aren’t Dutch.  Their economic basis depends on subsistence farming; their agricultural methods qualify for the trendy buzzword sustainable.  I haven’t seen horse-drawn vehicles on the roads here but I have seen traditionally dressed people at the café and in the hospital waiting room.

A call comes from the ER for me to evaluate a Mennonite patient.  I find the family straightforward, respectful, and friendly.  I’ve seen the problem at hand hundreds of times.  The CT scan, ordered before I saw the patient, comes back equivocal, but my exam makes a firm diagnosis requiring a surgeon.

Our surgeon and I have come to similar places in our careers: we want to work but we want to slow down.  His solution to the full-time-means-eighty-hours problem led him to work two weeks out of four, while I intend to go to a forty-hour week when I get back to Sioux City. 

Thus, the patient arrives while our hospital’s surgeon is en route to Florida.

I admit my surprise when the matriarch pulls a cell phone from her skirt pocket.  You should have been there.  The family requests a surgeon across the state line in Missouri.

I make the call requesting a transfer, speaking to the surgeon herself.  My presentation of the patient comes off smooth and articulate.  

The family drives into the night, subsistence farmers with hard copies of lab results and a CD copy of the CT scan.

Contrast is the essence of meaning.

Arrival in Keosauqua

December 1, 2010

The condo is sure a nice perk

I told the hospital clerk.

    Although I might roam

    And I’m far from my home,

It’s good to be back to work.

I drove into Keosauqua, Iowa as the sun set.  For unknown reasons, Sweetheart, my GPS, guided me right to the hospital parking lot.  She had a psychotic break on the interstate near Champagne, but responded to the standard Microsoft fix: turn off, then turn back on.  After that she did fine.

Van Buren County in southeast Iowa, population six thousand, has no fast food and no stop lights.  Keosauqua, the largest town, sits in a bend of the Des Moines River.  The business district still uses diagonal parking. 

The hospital, built at the top of the hill in 1951, has grown and kept pace with the times.  The only original parts of the institution still in use may be the longest continuously used hospital cafeteria and kitchen in the country.

The assistant administrator guided me down the hill to the duplex that will house me for the next month.  A very livable place, well furnished, it has a living room big enough for martial arts forms and a kitchen adequate for Real Cooking.

I’ll try to keep the TV off.

I went out to dinner the first night in town with another doc and his wife.  The primary care cadre has fallen from six to three (including me).  Over world-class beef we talked about the realities of medical practice, and the thrill that comes when you can fix the patient before they leave.

Orientation lasted the morning.  I’ve been introduced to three dozen people,  all of them friendly and smiling, of whose names I remember four (including my own).  The first-rate facilities represent all the necessary services. 

I talked with a surgical specialist who snow birds two weeks out of four; by his estimate he works an average of forty hours a week.  We agree that docs in private practice don’t know how to count the number of hours they put into their jobs, that in reality full-time for a doctor means an eighty hours a week, and that sustainability means forty hours.  We discussed the perennial Medicare pay cut that threatens and what would happen if it came through.

I shared observations with another surgical specialist who moved here after decades in a big city.  We shared consensus on the tradeoff between money and management on the one hand, and decreased stress on the other.

In the afternoon I saw patients ranging in age from a few weeks to almost a century.  One I educated about posterior tibial tendon dysfunction, drawing on my experience; we also discussed retirement.  With another I talked about corneal abrasions and deer hunting.  With a third we conversed about B12 deficiency, anemia, and the Great Influenza.  I took care of thumb pain, ankle pain, constipation, and confusion.  I got to refer the patient with a sebaceous cyst to the surgeon; I didn’t have to wedge the procedure into a crowded schedule. 

Throughout the afternoon I felt the profound relief of being back to work, the joy of the profession that I love.