Posts Tagged ‘x-ray’

Doing the best for a difficult patient

February 2, 2015

Sometimes it’s almost a test
The inappropriate narcotic request
If it’s bad that I judge
I just will not budge
For the patient I’ll do what is best

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 am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Right now I’m in Nome, Alaska.

Confidentiality limits what I can say about my patients, and what I write here may or may not relate to a particular patient or a composite of patients.
Our country has a major problem with prescription narcotics or opiates, painkillers with significant feel-good potential. I find them useful in terminal conditions with long term pain, like cancer, and in short term conditions like kidney stones, fractures, and burns. When I get to a new location, patients frequently flock to me to see if I’ll generously dole out the prescriptions. The word leaks into the drug-abusing community very early that those who seek from me come away disappointed.
I worked the patient in on request from an ancillary service, on short notice so as get the patient to the scheduled commercial flight in time.
Most of what a doctor knows comes from what the patient says, physical exam, lab, and x-ray account for less than 10% of medical decision making. This particular patient couldn’t come up with a straight story.
After twenty minutes of rambling, I made the Time Out signal and said, “Do you know that you interrupted me every time I tried to ask a question?”
No, the patient hadn’t realized it. And I had made clear that I would not prescribe the narcotics so stridently demanded.
After all, if the patient had asked for anything else inappropriate and dangerous, say, plutonium or a whole vial of Botox, I wouldn’t prescribe it, either.
The doctor always wants to know these things about the pain: context, quality, intensity, location, duration, modifying factors, and timing pattern. In short order, I figured out the patient really couldn’t answer the questions. So I would have to guess, and my best efforts would have to be at the veterinary level. I proposed an x-ray.
The patient emphasized the request for pain pills and needed to get to the airport. And wouldn’t I please call the airline and have them hold the plane?
I could have someone do that, I said, and I can do a lot of things for chronic pain, and I really like normalizing a restorative sleep pattern.
The patient didn’t want the sleeping pills but the pain pills, but then let slip the 23 pound weight loss, that had occurred but she couldn’t recall the time interval.
I knew right then the patient couldn’t make the plane. And I said so, noting the slack flesh and wrinkled facial skin.
I have to work harder for some patients than for others; I find those who require more intelligence or persistence. My job is always to do the best thing for the patient, no matter how difficult, demanding, or inappropriate.
I ordered the x-ray, blood count, chemistry panel, sedimentation rate, and thyroid/diabetes/B12 and folate tests. Then I started slogging through old records.

A hospital without surgery, down the road from a mobile OR

May 9, 2011

The hospital’s a hundred years old

And I watched the drama unfold

    No dark and no gloom

    In these inpatient rooms

Built during the rush for the gold.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical avoid burnout, while my one-year non-compete clause ticks away I’m having adventures and working in out-of-the-way places.  After four weeks in Wellsford, on the North Island of New Zealand, I just arrived at my new assignment.

I drove the plains east of the Southern Alps, low white clouds racing across clear blue skies, to my first morning at the Waikari clinic, where I found the mobile surgical unit parked.

People face a long wait for elective surgery in New Zealand.  To ease the burden on the hospital facilities, Christchurch has a mobile operating theater that travels the outlying areas. 

The US medical system includes a number of specialty hospitals for low risk surgical operations, but the larger hospitals complain about cherry-picking.  Here the bigger institutions send out a mobile Surgi-center.

New Zealand’s approach involves less bricks, mortar, and whining.

A tour of the interior showed a modern OR, including scrub sinks and anesthesia. 

The roster (=schedule) included patients with umbilical hernias and hemorrhoids, procedures which needed general anesthesia and an OR but not much recovery afterwards.

It seems like a good idea to me, something we could probably start up in the States, but unlikely to occur because the Joint Commission on the Accreditation of Hospitals would never approve.

The manager showed me around the clinic.  My office for the next four weeks looks much like the offices I used for the last seven weeks in Wellsford/Matakana, and I asked if the furniture came as a standard issue.

I don’t like the layout; a desk separates me from the patient. 

They asked me if I’d mind making ward rounds at the hospital.

Not at all, I said, but I hadn’t known one existed.

Walking distance up the road, the hundred-year-old Waikari Country Hospital commands a striking view. 

I don’t know when surgery stopped at WCH, but I met several people who had been born there and talked with others who had their babies there.  The midwife movement has taken over non-operative obstetrics in New Zealand, most babies deliver at home or in birthing centers. 

The hospital here has facilities for emergency childbirth, but no operating theater. 

Nor do they have lab or x-ray.  A courier collects blood work once a day, and patients needing radiologic studies get sent to Christchurch; thus the clinician relies more on physical exam and reasoning than on imaging or test results.

The hospital here cares for people who don’t need an acute hospital bed, but who cannot go home.  Some come for respite care, some for terminal care, and some for fine-tuning of chronic problems. 

The atmosphere stays quiet and restful, and the Victorian architecture lends a touch of grace, but the last earthquake cracked walls that had never been cracked before.

Charts remain thin despite long stays.  Reducing paperwork keeps nurses efficient and the staff small.

The Joint Commission would never approve.

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.