Notes from the Country Doctor

Wrapping up Gut Instinct and Too Much Information

2009-11-14T05:58:00.000-08:00

A reader recently commented on my post "Too Much Information", "So...what's the outcome? Can't help but wonder.By the way, I really enjoy your writing! Thanks for sharing your story."

First of all, I always appreciate when someone enjoys my writings and the stories I have to tell. While I obviously think they have some entertaining lessons to teach it's nice to hear others do as well.

The patient in this story, who at 36 weeks had a cord around the baby's neck incidentally picked up on ultrasound, went into L&D four days before her due date with her water broken and actively contracting. After manually reducing this pesky nuchal cord that gave me so much heartburn, I delivered a vigorous baby boy as healthy as any baby I've ever delivered.

On another note I thought I'd offer an update on "Gut Instinct". This was an elderly woman who I admitted with intractable nausea and vomiting. The residents on service were content to tank her up with fluids and send her home, but I made them order a CT scan which revealed a cholangiocarcinoma. While I think the patient had accepted her diagnosis and fate almost immediately, her daughter did not do as well. She struggled with the diagnosis and decline, but palliative therapy was all there was to offer. She past away about two months after I met her in the hospital.

The only other update is my daughter continues to improve from her pneumonia. She's already resumed playing hide and seek with her sister.

The Country Doctor

Influenza Complications Get Personal

2009-11-11T11:10:00.001-08:00

My six year old had a classic case of influenza along with every other member of the household, save me who received vaccine. She had an abrupt onset of a fever, cough, fatigue, and aches which lasted five to seven days. Her fever went away and after missing a week of school she went back to school for a day or two before the fever returned.

Then the cough returned. A normally perky and playful first grader became sluggish and tired. Of course her Dr. Daddy had gone to a CME while she had turned for the worse so her Mom took her to her family doctor her quickly referred her to the ER. Chest x-ray showed bilateral infiltrates with a clear predominance toward the left lower lobe. Not only did she have a textbook case of influenza, but now she had a textbook superinfection.

Obviously I rushed home and now sit with her in her hospital room on the pediatrics floor blogging. She's been hospitalized for two days now and thanks to some chocolate pudding therapy and a third generation cephalosporin is doing well and should go home today.

All of this for just a little flu? Influenza is not a benign disease. To this the vaccine is riskier than the disease is just irrational and foolish. As equally as irrational is why we continue to have vaccine supply issues.

The Country Doctor

Sick of Flu

2009-11-06T05:17:00.000-08:00

I made it through the week and a half or so it takes for the H1N1 influenza vaccine to take hold, but the flu has still taken quite a toll on me.

Normally I refer to this time of the year as my Hunting Season Lull, but with at least a half dozen patients with influenza-like illness in my schedule every day I'm not sure I've ever been quite so busy. Fortunately most of these folks just need to go home, rest, and drink plenty of fluids. If nothing else this year has reminded people how bad it feels to have true influenza apart from what we casually refer to as the flu. Unfortunately I've admitted two patients to the hospital with influenza as well. One was a four month old baby who was more precautionary and the other a middle age woman who stayed four nights with a nasty COPD exacerbation triggered by H1N1. Hopefully she will see this as a teachable moment and finally quit smoking.

We have been lucky at work with only one nurse out for a week with the flu. She received her vaccine only a few days before coming down with symptoms herself. If she had been able to receive her vaccine a week earlier as I did, she likely never would have become ill. The rest of our staff is hanging in there, and all but one, my stubborn nurse, received vaccine.

Our county still appears to be short supply of vaccine at least compared to one neighboring county. We received enough for our staff and pregnant patients. To date, these twenty or so doses, for which we had to beg and plead, are all we have received for our some 3,000 patients.

Where H1N1 has taken its greatest toll on me, however, has been on the home front. My wife and three kids all have come down with it and are now in various stages of recovery. While the struggle to balance one's personal and professional life is always present, trying to meet the needs of people with influenza at both home and work has been both mentally and physically draining.

It's been so tiring in fact that you would think I had the flu.

The Country Doctor

Flu, Flu, Flu

2009-10-23T11:13:00.000-07:00

It is all the buzz lately, so I thought I should probably jot down a few notes on what has been going on out here.

Like many areas, people with influenza like illness are everywhere and most of these folks probably do have true H1N1 influenza, but I tend to place then in the "like" category since tests done in clinical practice aren't the most helpful, so few are performed. At least a half dozen of these folks are on my schedule everyday and all are masked and asked to sanitize their hands before even having a seat in the waiting area. Fortunately none no one has required admission to the hospital.

Vaccine for H1N1 is in terribly short supply around here in part due to the widespread manufacturing issues and in part due to our county health department. Rumor has it they have been hoarding what little they have received in order to conduct school clinics leaving the CDC designated priority groups of pregnant patients and health care workers without access. Don't even get me started on this.

Fortunately I also practice in another county, so yesterday I crossed the county line and received my H1N1 vaccine without any problems. Given the number of exposures I have undoubtedly had over the past few weeks I'll be quite thankful if I don't come down with the illness prior to the vaccine taking effect.

The Country Doctor

Don't Try This At Home

2009-10-17T05:04:00.000-07:00

In medical school and residency we are frequently reminded to be compassionate and empathetic in our patient encounters. Be a good listener and don't rush to judgement are frequent mantras. This is a good rule for practice, but there is a patient type out there for which this approach should be completely thrown out the window.

One such patient came to see me yesterday for chronic shoulder pain. Years of wear and tear commercial fishing had left his rotator cuffs frayed and battered. He came in to discuss his MRI findings and to discuss treatment options including an injection, physical therapy, or referral to an orthopedist. He didn't like any of my ideas.

Now ordinarily the correct approach is to get a broader patient perspective at this point and see what sorts of barriers they have to these options. For example, had they had or known someone who had a bad experience with a steroid injection in the past? Could they not afford time off for surgery?

I learned long ago with this salty old guy he didn't go for any of that. Be too nice to him and he'd consider it patronizing. It would just add to his anger. What he responded better to was his doctor to being brutally blunt and borderline rude to him.

"Well, what do you expect me to do here?" I blurted out. "You know you come to see me wanting my opinion well here it is. You've waited how many years to have this looked at? I don't think this is getting better on its own. I think you should try one of these ideas. If you don't it's your choice, but you ain't gonna get any better doing what you're doing."

Upon getting off my soapbox he sat there in thought with a content look on his face feeling like his doctor really cared enough about him to tell him off. He decided to try a little therapy and if that didn't work he'd think about his other options.

This communication style must be done very carefully as it will anger offend far more than it will work for, but when you find the right patient it can become a quite satisfying patient encounter. Not only does the patient feel well cared for in the end, but I must admit, it can be a therapeutic venting for the physician at times too.

The Country Doctor

The Health Fair

2009-10-11T05:04:00.000-07:00

Spent Saturday representing our office at the area health fair held at the county fairgrounds. Forty of so "vendors" from various medical offices, health agencies, or hospitals set up booths and displays offering information, some health screening, and generally showing off their stuff.

Since we are the only physicians in our half of the county who provide maternity care, this was a natural topic for my display. I must say, for a novice booth maker I definitely impressed myself with this one. It was multi-media with looping DVD on prenatal care and hands on in the form of a series of fruits and vegetables meant to represent various ages of fetal gestation. All of this was in addition to various pieces of literature on pregnancy in English and Spanish and, of course, some candy for the kids. It was difficult to find a food item for a term baby, but I went with the largest butternut squash I could find which came in around 7 lbs.

Many of the people who came through I already knew, but I certainly meant some new folks as well and probably picked up a couple of patients. My booth was near the hospice folks, organ/tissue donation, and the dairy princesses, so we all made a little small talk throughout the day long event.

If nothing else my Saturday raised a little awareness about the importance of good prenatal care and gave our practice a little good PR. At best, however, a new booth making talent has been discovered.

The Country Doctor

The Cycle Continues Epilogue

2009-10-04T18:24:00.001-07:00

A final update on the post, "The Cycle Continues". In this sad race the baby arrived in this world four hours before the young woman left it. The baby was delivered in a room only with the mother, a two nurses, a pediatrician, a resident, and myself present. The young woman may have not felt loved in life, but she was surrounded by family and friends at the time of her death.

This morning when I rounded on the new mother I asked her if she planned to breastfeed as is my custom. Her response, "Oh, no. I smoke cigarettes and I don't want my baby to be exposed to any of the nicotine through the breast milk." How considerate.

The Country Doctor

Gut Instinct

2009-10-04T04:57:00.000-07:00

It's hard to say what we often refer to as gut instinct really is. Is it some type of paranormal sixth sense, or perhaps it's just a subconscious collection of past experiences that we apply to the situation at hand? Whatever it is, one would hardly find it in the medical literature and one can hardly consider it to be evidence based medicine.

A very nice and ever so slightly demented woman in her early 90s was admitted this weekend with some fairly nonspecific abdominal pain, nausea, loss of appetite, and dehydration. She had a somewhat similar episode three months ago, but didn't feel the two were related. What did concern her, however, was that she was dying. In fact when I admitted I asked her her thoughts on what the diagnosis was and she said, "I think I'm dying."

We did some simple blood tests and x-rays and noted she had some mild pancreatitis and a couple of gallstones which could have been at play. The IV fluids were tuning her up and she was clearly clinically improving. There just was something unsatisfying still though. My gut instinct told me there needed to be more done. She was certain she was dying and I still really didn't have a lock on what process was going on here.

The residents I was working with thought I was crazy to go to the time and expense to order a CT on the abdomen of a patient clinically improving as she was. Fortunately in this situation I'm the attending and they are not. Unfortunately for the patient she appears to have a cholangiocarcinoma--a difficult to treat cancer of the biliary system and often involving the liver and pancreas.

We have some difficult conversations ahead today, but now at least we know what is wrong. I'm glad I trusted the patient's gut instinct about her gut.

The Country Doctor

The Cycle Continues

2009-10-03T11:02:00.000-07:00

On call this weekend and find myself bouncing between the ICU and L&D today. Upstairs is a woman in her early thirties dying from the alcohol and tylenol she used to heal the physical and emotional wounds from her boyfriend's beatings. Downstairs another young woman has walked in to have her baby without any prenatal care. Best estimate she's about 36 weeks, or a month before her due date. Preterm labor and no prenatal care unfortunately is almost diagnostic of drug use during pregnancy. Her last child was taken away from her and is in foster care.

I find myself playing a sick guessing game. Which will happen first? Will the baby be born or will the woman die? The cycle continues in many ways.

The Country Doctor

Reality vs. Fantasy Update...Reality in the Lead

2009-09-30T13:53:00.000-07:00

Munching on some of my favorite freshly smoked salmon my retired office manager brought by the office today I thought I'd offer an update on a patient I recently wrote about.

The patient is a young woman who told me a horrific story of a crime she witnessed and was victim to. Each time she'd tell me a little more it seemed to take on the feel of a TV crime series more than reality of life around here. All the same, I believed she thought she was telling the truth. I quickly decided she wasn't malingering, but completely delusional was a strong possibility.

Since I last posted on this I have been slowly getting her to open up with more details about the violent acts which took place and why she is still concerned for her safety. I've tried to gently lead her to a place in which she offers me some tidbit I could verify. Yesterday she dropped a name for the first time.

I hopped on my laptop to do a little investigative work on my own and began with a simple Google search which wasn't terribly helpful. The guy was incarcerated, she said. I could try to verify that I thought. Went to the state pen site to look up inmates, and BINGO! There he was listed at a nearby prison.

On a roll now I went to the local newspaper's web site and searched back during the time when this PTSD inducing crime may have taken place, and there it was. A newspaper article from two years ago told me the story of the event just as my patient had described them. She was even referenced to in the article, but no name given. Thrilled to have discovered much of what she has told me is likely true, I was also saddened that such a thing happened to her and has destroyed her life ever since.

While this does not completely settle the debate of reality vs. fantasy for this patient, reality is clearly in the lead. At least for now I feel better sitting back and eating more of my smoked salmon.

The Reunion

2009-09-28T04:59:00.001-07:00

A couple of months back I posted on some internal struggles I had over whether or not to attend my 20 year high school reunion. Many offered helpful comments on this conflict, and in the end I decided to go. I thought it only right to jot a few notes on the experience.

The first night, a casual classmates only night at a local bar, was really why I had chosen to go in the end. I wanted to see in person and get the thirty second rundown beyond what I could tell from friending people on Facebook. Most of the egos that made high school such a miserable experience had seemingly disappeared with time. I must vainly admit it was nice to have my hair, weigh the same as the day I graduated, and be able to drop that I'm a doctor. (I tend to not do this terribly often in social situations, but if there ever seemed to be a time to do so, this was it.) There was a little reminiscing about fond experiences, but as I said before, I didn't have too many of those in high school.

The next night included spouses which, having been on both sides now, I can says always makes for an awkward set up. Half of the gathering ends up feeling like a third wheel. There were a few more people I had a chance to chat with, but for the most part I had gotten out of the experience that which I wanted too. Somewhat early I turned to my wife and said, "Okay, I'm done," and we left. That was that for at least another ten, if not twenty, years.

The Country Doctor

My Desk

2009-09-23T12:42:00.000-07:00

I found myself rummaging through my desk this morning looking for the combination to the office safe and I realized the disordered content of the desk likely reflected its owner.

There are an assortment of pens, including official practice pens, drug company pens, and highlighters. A role of paper tape and a role silk, a scalpel, 2 prescription pads, various samples to get through the day (arthotec (joints), protonix (stomach), claritin (allergies)). I have 3 staplers with one box of staples. I'm not sure why so many, I don't do a lot of stapling. There are an assortment of baby pictures from kids I've delivered over the years. I have some saline solution and a case for my contacts should I need to take them out (although no glasses if I had to). Business cards, clothes pins, file folder labels, and a can of pepper spray which fortunately I've never had to use. I have 2 tape measures to measure pregnant women's bellies, but I'm fairly certain I've never used one in my office. The final notable items are 2 shots glasses that have been sterilized and run through the autoclave.

I think perhaps it's time to clean out my desk a little.

Too Much Information?

2009-09-23T05:11:00.000-07:00

Obstetrical patient at 36 weeks and she's not measuring as much as I would expect. I think it may be because the baby is transverse instead of head down, but I'm not sure. I order an ultrasound to help sort this out and thankfully by the time this is done the baby has assumed the correct position and the baby's growth is appropriate. That's all I really wanted to know. But wait. There's more. The ultrasound is so clear, the radiologist can see the umbilical cord looped around the baby's neck.

Now what do I do with that? At delivery at least 1/3 of babies will have what's referred to as a nuchal cord, or a cord around it's neck. At times it is thought this may cause some concerning decelerations in the baby's heart rate during labor, but labor management does not change and good outcomes are still the rule.

Of women who come into labor and delivery at or near term with a fetal demise probably the most common identifiable cause is what's referred to as a cord accident (the most common cause of term fetal demises is unknown). In a cord accident blood flow to the baby is somehow completely cut off asphyxiating the fetus. Occasionally a true knot will be found in an umbilical cord for example.

So what do I do with this piece of information that I wasn't looking for anyway? The odds are so remote that this will lead to anything disastrous, most would not change their management of this pregnancy and move to early delivery which poses a greater likelihood of risks to the baby. On the other hand, am I obligated to tell her about this, so I can at least say I told her? I think the radiologist most likely included it in his report, for that reason. If anything goes wrong for whatever reason, he is absolved. He can at least say, "I told you the cord was there."

In the end I did tell my patient, though I am still obviously conflicted over it. I told her to monitor baby's movement closely and we talked about kick counts. In the back of my mind, however, I know there's little evidence these practices are effective and my patient lives far enough away from the hospital that should a cord accident take place and she does detect the lack of fetal movement the chance of intervening successfully is incredibly remote.

Have I just passed the buck and given her something to worry about which is unlikely to happen and that she has absolutely no control over anyway?

The Death of Santa Claus

2009-09-15T05:12:00.000-07:00

The ache in my tooth just having returned from the dentist was nothing compared to the pang in my stomach as I walked into my practice Monday morning. There on my desk waiting for me was the death certificate for Santa Claus.

It shouldn't have been a surprise since I knew we would soon be here when he walked into my office one month ago. At that time he still wore his plaid flannel shirt, red suspenders, and black work boots to go with his white beard, balding head, and pot belly. This time, however, his pale skin had turned into painless jaundice.

A few days later I had enough information to confirm my fear he had a tumor obstructing his bile duct and multiple smaller tumors studding his liver. Two weeks later as Santa and his family were still absorbing this diagnosis, he was admitted to the hospital for low blood sugar from his diabetic medications. "Now he decides to actually take the meds I had prescribed," I thought to myself.

This simple admission may have been for the best, however, as it forced everything to come to a head. The family uncertain if this would be the end gathered in the hospital room. They caught a glimpse of what Santa would face if they were to continue on a more "curative" pathway. I was present as was a close colleague/hospice director. I told him this was the first time I had seen him without any red suspenders. He shook my hand, thanked me for being there, and gave me his usual jolly smile. I had a feeling this would be the last I saw of him.

A week and a half later at home with the support of hospice and surrounded by family Santa Claus passed away quietly.

I'll choose to remember the man I met almost four years ago. He presented as an out of control diabetic who perpetually ran out of his medications while working in the woods. As an aside that first visit he asked me to look at a mole on his back which turned out to be a softball sized abscess which I drained for him. He was the classic small town logger.

A few years ago I had a chance to visit with the doctor who I replaced. He had been here for almost twenty years. He missed his old practice, but the one thing he didn't miss was having to watch his close patients pass away. After only five years here, I am understanding more and more what he meant.

The Country Doctor

Family Pictures

2009-09-02T12:31:00.000-07:00

If you ever have a loved one in a skilled nursing facility or nursing home make sure they have pictures in their room.

Made monthly rounds at our local care facility and noticed more of my patients had family pictures up than usual. At least I noticed them more today. There were black and whites of the patient in their youth. Plenty of photos of grand kids at birthday parties or Christmas celebrations and a few of relatives in military uniforms.

While most of my patients can offer me only so much personal information at this point in their life, the pictures told a broader and deeper story. The pictures were a blunt reminder that the person before me unable to tell me the story of their life still had one. They once had a life not too unlike the one I now enjoy. They encouraged me to treat this person as well as or better than I hope to be treated someday.

Put pictures in your loved one's rooms not for them to admire, but as a reminder to the staff caring for them.

The Country Doctor

Reality vs. Fantasy

2009-09-01T11:48:00.001-07:00

Sometimes I become incredibly aware how small the window into which I am able view my patients' lives is. How much of what I am told is true, how much is distortion, and how much is just fantasy or plain delusional? All I see is what I'm told in the four walls of the exam room.

She's a relative new patient in her early twenties who has come to see me for the last few months for Post Traumatic Stress Disorder (PTSD). She tells horrific stories of witnessing a terrible crime. She now believes these people are after her and she comes to see me terrified and with worsening anxiety symptoms.

In fact her stories are so dramatic part of me questions what is reality and whether any of this is delusional. The things could very well be out of a police TV drama. It's not I don't believe thing like this couldn't happen in our area, but there's something about the description which seems all too classic. It's not I believe she is trying to deceive me. When she tells me about her life she is clearly terrified and even breaks out in hives from the worry.

Ordinarily patients come to me with some sort of paper trial, but not her. She offers no prior health care provider and she has no insurance, but always pays cash for her visits. I've thought about trying to contact some of the people she's told me about (e.g. the police), but I might quickly find myself in the middle of HIPAA issues.

Meanwhile I wait for our next encounter to interrogate the witness again.

The Weekly Journal

2009-08-29T04:59:00.000-07:00

While a quaint and pleasant job filled with intangible rewards, being a small town doctor is also filled with moments of intensity and stress. Emotionally exhausting conversations about terrible topics no one should have to talk about, dealing with patients who are less than pleasant either because of illness or general disposition, and working in a broken health care system are just a sampling of the reasons we feel the pressure of the job and are at risk of burn out.

We all need to build stress relievers into our job to release this tension. I've found running at lunch to be one of the best ways to clear my head from the morning and prepare for the afternoon. One of my partners bakes when she feels the job taking it's toll. My other partner looks forward to reading her favorite weekly journal.

Every Friday the office receives its copy of The Journal of People. According do her while the methodology may be lacking, what some refer to as People magazine, offers unique insights into the human condition. Looking forward to this weekly indulgence and escape into some trashy reading is part of what keeps her going week after week. For the rest of us we receive the joy of watching a respected and intelligent woman, who at times is known as a real hard ass, shout out into the hallway, "Did you hear so and so got back together because so and so is pregnant?"

Whatever it takes.

The Country Doctor

Breaking Bad News to Santa

2009-08-25T05:06:00.000-07:00

In prior posts I've mentioned a patient with an uncanny resemblance to Santa Claus. From his grey beard, pot belly, big work boots, and red suspenders to his jolly disposition this logger in his mid to late sixties has always embodied why I like caring for the local patient population. While his diabetes has never been well controlled and he regularly stops his medications a few months after restarting them, his independent spirit living life on his own terms one can not help but admire.

Last week he came to see me looking quite jaundiced. Initially he said it came on overnight, but as we talked it became apparent this had been brewing for at least a few weeks. Blood tests not surprisingly demonstrated a marked increase in his liver function tests and an ultrasound revealed multiple lesions in his liver showing what in all likelihood represents a metastatic malignant process from an unknown source.

Yesterday I broke the bad news to Santa. While I didn't have a definitive diagnosis, he needed to know what I was thinking so he'd understand what the next steps would be. Cancer was what he was afraid of he said as his yellow eyes welled up with tears. Even as I gave him probably the worst news he had ever received; however, he smiled as he wiped away the tears and thanked me for taking care of him.

I've always known I might someday find myself breaking my kids heart about Santa Claus, but I never thought I'd break Santa's.

The Country Doctor

The Reunion

2009-08-21T05:38:00.000-07:00

Personal and professional boundaries are important in the life of a physician, but at times they are challenged particularly in a small town in which the doctor is often called upon to care for friends, staff, and even family. In "Notes from the Country Doctor" I generally attempt to respect these boundaries and deal with my professional life only. Here, however, I'm going to step on and blur the line just a smidge.

This summer marks the twentieth anniversary of my high school graduation and I've struggled with whether or not I'll go to the reunion. I missed the ten year since I was some two thousand miles away and on my surgery clerkship; and anyone who has done a surgery clerkship knows that just wasn't going to happen.

I've been flipping through my high school year book to try to desensitive the PTSD remnants from my high school days. I grew up in an affluent suburb a hundred miles from my current practice, but it might as well be on the other side of the world. My car was a clunker compared to what it seemed like most others drove and we never vacationed in Maui or Cabo. It's a good thing I was never too fashion conscious because my parents certainly wouldn't have bought me designer anything. Never really fitting in I was the shy, quiet, kind of nerdy kid people seem to just kind of forget about. I never went to parties and barely found a date to my senior prom. When my family moved while I was an undergrad I was grateful to leave the place behind.

The question is, why all this angst about whether to take this trip down memory lane? I think I'm fairly comfortable with my station in life. I became the doctor I wanted to be even if I'm not as financially successful as the radiation oncologist or cosmetic dermatologist in my class undoubtedly are. I have a wonderful family and have all of my hair with only a handful of greys around the temples. I must admit most who I've wondered what ever happened to I found on Facebook. Is it that I just don't care if I see any of my former classmates? Perhaps I just need to sort through this flood of bad memories and flashbacks from those days.

I think it's time to flip through the yearbook therapy again. "It wasn't really that bad. It wasn't really that bad."

The Country Doctor

Role Modeling

2009-08-20T05:17:00.000-07:00

Small town doctors play the role of more than just physician to their patients. We are counselors, social workers, and business advisers to them among other parts we play. Yesterday it was parental role model.

Everyone could hear children yelling and the sounds of things crashing down in the exam room. Occasionally there would be an adult woman's voice telling a child not to do something, but the chaos continued despite the futile warnings to the kids. One of the nurses walked by the room and commented, "That's society's future in there."

I finally couldn't avoid the room any longer, so I grabbed the four year old's chart, took a deep breath, knocked on the door, and entered. I walked in to see the four year old had cornered his 2 1/2 year old brother and was slapping him in the face alternating left and right hands while his mother sat in another corner just watching.

Instinctively, as I would with my own kids, I grabbed the four year old and in a stern, but not yelling voice said, "Johnny, we do not hit people in here," as I plopped him onto the exam table. Initially he was shocked as I don't think anyone had told him "no" before. Then it was my turn to be shocked as he looked away and spit at his brother. "Johnny, there will be no spitting here either," I said holding him by the jaw so I could turn his head back in my direction while making sure he didn't spit at me. All the while, young single mother in her early twenties just sat there.

I can't help but think in a couple of years when these kids hit school age they'll be back with the teacher and mother wanting to medicate them for ADHD. They'll be oppositional and thrive off of conflict with what should be authority figures. On Vanderbilts, Conner scales, or Acters forms they'll meet all the criteria. They'll get their medication as a form of damage control.

How much of this would be preventable for these kids?

The Country Doctor

Worse Before Better

2009-08-15T12:31:00.000-07:00

I thought this might have been the case, but as health care reform has played itself out over the last two weeks I am now convinced more than ever. Things must worsen before they will improve.

While I see the waste, inefficiencies, and injustices of the health care system everyday, I realize most don't. Most don't see the barrage of administrative and marketing excesses of private insurance corporations and the pharmaceutical industry. Most don't have to deal with unnecessary bureaucratic hoops often meant to improve efficiency, but which only come to embody it. Most are unaware of the sense of entitlement to unlimited medical resources and lack of personal responsibility many have toward their health and health care. Most people don't have to choose between denying care to a family and keeping their own business open.

Once again any meaningful attempt and reinventing our health care system is going to pass. Things must get even worse. Police officers, teachers, and nurses must find themselves among the uninsured. Lines must extend far out Emergency Room doors like a developing nation. I fear people must become sick and even die for no other reason that they did not have access to health care.

When this happens perhaps the fear of change will be outweighed by the fear of the present.

The Country Doctor

Hollywood Script

2009-08-08T15:44:00.000-07:00

For the number of television shows about doctors it may come as a surprise to many what a mundane job being a doc can be at times. Day after day I get up, get dressed, go to work, and come home just like any other job out there. Occasionally, however, the exceptional day does happen.

Driving into the community hospital at which I chair a department committee I knew it was going to be a busy day, but would start off fairly ho-hum. An ER doc from a critical access hospital some thirty miles from the one I headed to called in the middle of the night with an admission. I'd have to see this guy after my meeting and before starting to see patients in the office. As expected, the departmental meeting involved a lot of paper pushing and pontificating not worth mentioning any further.

By 9:30 I arrived at hospital number two to see my admission from the night. He was a man my age with an MRSA skin abscess over his knee. While the infection hadn't invaded his joint this was clearly the understandable concern the ER physician had. Complicating matters, he had no insurance and no doctor. He waited until he he couldn't take the pain before presenting to the ER and then he was initially discharged home after the abscess was incised. When he worsened the next day after he was unable to get the antibiotic prescribed, admission was really the only option.

I snuck into the office as the resident with me this month finished seeing the first patient. My partners are both gone this week and between covering their paperwork and patients I have been very lucky to have him around. We'd see 21 by the end of the day on a day shortened by two hours with a late start due to my meeting.

The second patient of the day was a woman in her late thirties about a week out from a C-section by an obstetrician. She called his office three times with concerns about back pain and trouble breathing. "You just had a baby. This is normal," she was told each time. We squeezed her into the schedule and she didn't look terribly sick, but she didn't look terrible well either. The resident who saw her had conerns for epidural complications or even cardiac issue given the nature of her symptoms. The one thing I wanted to rule out was a pulmonary embolus. Late thirties, recently pregnant, post op, recently quit smoking she was a set up for this.

The critical access hospital was willing to run her throught the CT scanner immediately, but her insurance company, Aetna, wouldn't authorize the scan immediately, but said they'd have an answer within four hours. "She could decompensate and die in four hours," I thought. My staff called back and I talked to some anonymous person and the best I could get was a "peer review appointment" in a half hour.

I'm concerned a patient has a PE and she wants me to wait a half hour for a "peer review" appointment? If anyone listens to the tape of the call I'm sure I sound quite agitated and even hostile when I gave her the option of getting me someone who could approve the scan immediately, or she was going to have to pay for an ER visit for this patient and the CT scan because I wasn't going to keep her in my office potentially decompensating until I could have a peer review appointment.

She held her ground so I sent the patient to the ER and notified the doc up there what I was thinking. Not too long after I received a phone call back from him. I was right. She had a single PE in the arterial system of her left lungs lower lobe. She needed to be started on blood thinners immediately. One of the leading, if not the leading, cause of perinatal maternal mortality is a pulmonary embolus. We avoided this this day.

After finishing up the morning, running my three and half miles at lunch, I tackled the afternoon and headed back to the critical access hospital to admit the patient with the PE. He room was filled with concerned friends, her husband, and her week old baby. "Thank you for listening to me," she said. "You saved my life."

Sometimes life does imitate art, or is it the other way around?

The Country Doctor

Head Lice!

2009-08-05T08:55:00.001-07:00

Back in medical school a professor once said if there are a number of treatments for one illness that means none of them work terribly well.

Yesterday a nasty case of head lice came in the form of a ten year old girl with an otherwise beautiful head of thick brown hair. There weren't just a few knits, they were everywhere. Immediately everyone in the office who had any contact began to scratch their heads. My nurse bombed the exam room with a head lice spray and Lysol. We didn't use the room for the rest of the day.

Once the girl left the office, stories of infestations flew out of everyone's mouths as well as lists of medicines and home remedy their mothers used on their siblings (because no one fessed up to having it themselves). By the time I left the office yesterday the list of treatments for head lice generated included: vinegar, mayonnaise, olive oil (which apparently is easier to get out than mayo), combs, shaving, saran wrap, permethrin/malathion, and my personal favorite--Listerine.

Based on this professor's rule of thumb, none of these work terribly well, and most parents I've talked to would agree.

The Country Doctor

Fear Mongering

2009-08-03T12:29:00.000-07:00

Had a delightful man in his late sixties come see me today complaining of shortness of breath likely related to smoking two packs of cigarettes a day for the past forty years. His history and exam indicated a chest x-ray and EKG to be reasonable diagnostic measures and a trial of a bronchodilator a reasonable treatment as well as smoking cessation.

As many patients have asked lately, he wanted to know what I thought about the rumblings of health care reform. Specifically, he wanted to know if it was true what he heard on the radio. Was the government was really trying to "pull the plug" on all seniors to save money?

Fortunately I heard much about this falsehood over the weekend and was prepared. A section of one of the health care bills in the House includes reimbursement for physicians to talk about end of life issues with their patients. As it stands now, this may only be billed for in conjunction with a known diagnosis. I cannot bill Medicare for this an asymptomatic senior who just wants to talk about advanced directives. While I don't believe Terry Schiavo was on Medicare prior to her illness, had she had this discussion with her physician prior to the event, much of the controversy surrounding her could have been avoided.

It's one thing for conservatives to be against the current legislation and against government intervention in health care in general. A rational argument can be made for this even though I do not subscribe to it. However, this is not it. Engaging in misleading rhetoric playing on the fears of seniors is reprehensible. It shows how little this segment of this end of the political spectrum has in the way of ability and/or desire to make a logical argument when scare tactics are quick and dirty. Once more it deprives the public of a reasonable debate on a critical topic.

I hope I set this patient straight. I fear, however, he went right back out to his car and turned on his talk radio again.

The Country Doctor

Wine and Cheese Fridays

2009-07-31T16:14:00.000-07:00

A couple of months ago we stumbled upon a practice tradition called "Wine and Cheese Fridays". At times we forget the cheese, but never the wine.

This all started when we moved into our new building and had a grand opening party for family and colleagues (we also had a much drier event for patients and the community). While many attended and all had a good time there were some leftovers which we made sure did not go to waste. Since then as the last patient walks out door, or even makes it to the check out window, the wine appears and starts to pour in cheap plastic drug company tumblers.

While it may seem somewhat silly or even unprofessional, it has become a way to relax every Friday with our staff. Instead of dreading those last few dictations, I am able to see the light at the end of the tunnel and know at least I can finish my paperwork with a drink in hand.

The Country Doctor