Caj Mahal

6 weeks off to complete a systematic review (a.k.a. thesis, capstone project, master's hoop, the paper, the project, the PICO, the vacation, the procrastination....)

Call it what you will, but I am thoroughly enjoying my break from khakis and business casual wear. I'm unshaven and wearing flip-flops. I can see my wife from where I am sitting.

Anyway, oh faithful readers, this blog will likely be taking a hiatus, unless I come across some really interesting paragraphs about "the off-label use of prazosin for sleep disturbances in noncombat related PTSD" and feel the urge to share.

Otherwise, check back in a few weeks for a more reader friendly topic....My trauma rotation in downtown Portland.

Recommendations, Cont.

A few more recommendations, on the lighter side:

If you lose the spacer for your 2 yo daughter’s inhaler, please call us for another one instead of spending over 1 week spraying the medicine into your own mouth then trying to blow it into your daughter’s mouth like some kind of weird backwards asthma CPR.

If your IUD mysteriously falls out, please don’t mysteriously place it in your urethra. That’s not where it goes.

Can we please get back on track after discovering that you and I went to the same high school in Ohio, albeit 20 years apart, which yes is a bit weird, but we can’t spend 15 minutes discussing it, if you also want your olecranon bursitis drained with this needle I am wielding.

When I meet you in the hospital on rounds for the first time can you please not say that you saw me in your dreams last night so we can avoid the weird creepiness of you being a 52 yo mustachioed man who lives with your mom and me just being here to listen your lungs before lunch.

4 days left of this rotation. Can I please have a 6 week break? I need it.

A Case Study of Lactic Acid Buildup.

I'm Tired.

Recommendations

I recommend tummy time to increase abdominal muscles for the 7 month old struggling to sit upright. But apparently it is hard to find space for the luxury of tummy time when you live in a 400 sq ft. mobile unit on an orchard, the floor scattered with dirt and pesticides, dragged in from the field.

I recommend taking the insulin and Metformin we prescribed to the 60 year old diabetic with an A1c of 11.7. But apparently when you cannot read, cannot afford medications and cannot figure out which medicines are which in your sac full of expensive drugs, it becomes less feasible to be compliant.

I recommend some common anxiety and depression treatments, but apparently when both your parents just died in Mexico within days of each other and you cannot afford to go there for a funeral, you cannot afford to buy caskets, and instead of getting to say goodbye, you are stuck in overcast Oregon, it’s easier said than done.

I recommend not shoplifting for your $100 per day ($3,000 month, math whiz) heroin habit. But apparently when your Dad is a meth addict, your Mom is an alcoholic and you really, really, really like the heroin in your veins, it’s tough to keep your hands off the merchandise.

It’s one thing when recommendations fall on deaf ears. If you really don’t care what I say, then fine. Sign here and bring the next one back to room 19. You like the potato chips and TV more than exercise. I get that. Say hi to your pannus for me.

But what kills me is the recommendations that the patient soaks up like a sponge. They desire change. They want the best for themselves or for their children. The ears are not deaf. The instructions flow in and register in the brain. But something stops them from being able to follow through. Enter life’s circumstances. Some would call it an excuse, and perhaps that is true in some cases. But when was the last time you lived as a migrant farm worker? When was the last time your parents died and you could not afford to bury them? When was the last time you couldn’t afford a $4 Wal-Mart medicine? When was the last time you had to steal to pay for a habit that you know is killing you? The sadness in this clinic abounds, though I realize it is not confined to this place or this population.

Trying each day to show up and put myself in the patient’s shoes has been an exercise in futility. I will never know what some of these people have been through. All I can do is show up and listen. And recommend. And then listen some more. And count my blessings: supportive family, adequate shelter, functioning pancreas, and only a very minor caffeine addiction.

Shuffle: Off

Much of medicine is like listening to an iPod on shuffle. One minute I am interviewing a talkative 73 year old about her breathing problems and long list of medication refills. The next room over, I might encounter a shy 2 year old, clinging to her mom’s leg. Shuffle in some diarrhea, some dental pain, some fancy new medicines with lots of Z’s and X’s in their names and some old school procedures like suturing up a hand. In other words a day can take you from Beethoven to Brittney and back with the knock of an exam room door. The ER is a shining example of this randomness. Things happen, hangliders crash, hearts attack, and the doors are never locked. People come and go all day. And despite the inevitable frequent flyers, most are brand new customers. Like hearing that good song on a shuffling iPod….and never hearing it again.

But some albums just require listening in the right order. Pearl Jam’s Ten or Pink Floyd’s Dark Side of The Moon, for example. Maybe they have a message, certainly they have a flow. Before the days of shuffle, the end of one song would have you humming the beginning of the next, before it started. A certain level of expectation is then satisfied when sure enough, it plays. Life is certainly more random, but sometimes in primary care medicine, while often a day is chaotically scheduled, sometimes it feels like listening to an album in the correct order.

Even as a “short-timer” student, inhabiting the clinic for a few months I have a case in point:

Seeing a pt for her last 2 or 3 prenatal visits, and then following her to the hospital for post term induction. Learning to read her “bad strips”, and then watching her c-section. Doing a newborn exam on her little baby boy, a bit banged up from delivery, with a possible broken clavicle. Seeing everybody back in the office a few days later for a weight check, then assisting with his circumcision a few days after that. I could anticipate the next song. If I hung around for a few years, I could anticipate a few colds, maybe some asthma. Lots of shots. Throw in a broken arm from snowboarding, some questions about puberty, and a weird rash. If I hung around for a few years after that I might anticipate some low back pain, a consult to an expert in Portland, and some advice as he starts his own family.

So while an individual day might have that feeling of shuffling through 20 gigabytes, the overall picture has an underlying rhythm. And while, impossible to truly anticipate the next song that will arise in a patient’s chart, just experiencing the album in order is satisfying.

Heart Medicine

Dried mud clumps start in the hallway and lead into the exam room, where I find two men sitting. The first is a heavy set Hispanic man, with bulging arms and chest likely from a life of hard work. Just south of the muscular thorax is a similarly bulging abdomen, this likely from a life of hard eating. He wears a tight generic Wrangler shirt that appears to want to pop. He is round, but strong. Saying his name, “Rolando”, I shake his calloused hand and offer, “mucho gusto.” He eyes me with distrust, but that’s OK.

I turn to the man sitting next to him, an Anglo. He is tall, with thin gray hair. His skin is tan but Anglo tan. He spends a fair amount of time outside, surely. He wears a zippered fleece and while his boots are also contributing to the trail of dirt, his jeans are new and clean. He’s el patron, the boss. “Mucho gusto, Jeff.”

Sorting through the history and the reason for the visit is the first challenge. It is generically listed as Health Maintenance Exam, but the patient immediately launches into… Chest Pain. Pressure. Aqui. When those words are spoken they seem to just float there, waiting for me to attach them to something. My heart rate rises. I scan his chart and after a few more questions, understand that he suffered a heart attack in November and presents for continued angina. Worsening. When he walks in the house. When he does dishes. Pressure in all the places you don’t want pressure. Radiating to all the places you don’t want radiating. But at least the initial Chest Pain. Pressure. Aqui. is attached to something. I can slow down.

Jeff wants to know when his employee can get back to work. I want to know when he can get back to a cardiologist.

I’ll admit my initial thought was that this orchard owner was just trying to get his “help” back in the fields as soon as possible, despite the consequences. I assumed he just wanted medical clearance for Rolando so he could enforce a return to hard work. I couldn’t have been more wrong.

It turns out these men have known each other for over 25 years. They consider each other friends. They know each other’s families. Admittedly, there is a lopsided role of power, finances, and access to healthcare. One owns thousands of acres and (like me) probably pays somebody to change the oil in his car. The other is a poor immigrant from Mexico with ill-fitting clothes and no car. But what’s not lopsided is Jeff’s evident compassion for Rolando. He wants to make sure no further damage is possible to Rolando’s heart, while at the same time helping get him out of the trailer that he is trapped in, a prisoner to his chest pain. He wants to advocate for his employee, helping him get a cardiologist appointment. He will drive him to Portland. He is helping with the cost of expensive medications and consults. While miles apart in their background, today finds them sitting next to each other in an exam room. And in the end, they both have mud on their boots.

We were able to increase some medications that will likely extend the exertional capacity of Rolando’s heart. Not in heart failure, the problem exists in the coronary arteries, not the pump itself. He has a stent in one of the offending arteries, but another one was, for lack of a better term, unstentable. We gave our blessing to try some work, as tolerated. Stay off the big tractor for now. With close follow up, we will see if the medicine change helps him.

But Rolando may eventually need a bypass, meaning open heart surgery. If he does, I suspect that in a hospital in downtown Portland there will be two sets of muddy boot tracks, where there might have only been one….or none. And that is the heart medicine that might be the most important.

Best Reason to keep a Brightly Colored somewhat Sporty Looking Jacket in your Car in One Sentence or Less.

So when you are travelling through windy* and windy* but gas-station-less Columbia River Gorge at a high rate of speed on Monday morning trying to make it to work on time and you suddenly notice that your gas-light-less car is on empty and then 3 minutes later realize that you are sputtering to a halt on Interstate 84, you can put this jacket on and represent yourself as an obviously not crazy one-toothed psycho hitchhiker and make yourself appear as a much more benign skier or PA student in distress, so that this one guy will pick you up and drive very fast to Hood River without functioning seatbelts in his car and then this couple with a rental car with Ohio plates and rental skis will pick you up and take you westward to your car, thus making it possible to still make it to your cold rental house, shower, shave and make it to work with 4 minutes to spare.

*windy as in breezy
*windy as in curvy

Self Titled

I describe to my preceptor the perfect viral pharyngitis. Not one single symptom of strep throat. No fever, no lymphadenopathy, no “painful swallowing”, not in the age range that would increase suspicion, no tonsillar swelling or exudates. There is the perfect history for post nasal drip with cough and no contacts with strep. My description of the throat rivals a text book of what Strep Throat Doesn’t Look Like. I won’t bore you with details.
“So we’ll just do a rapid strep test and send them on their way.” says my preceptor, apparently unconvinced. He is unsure of why, so I help him out. I validate the possibility of a strep test, noting this could be a “therapeutic” test. In other words, a lab test that may help assure the patient that a bacterial organism is not causing her pain. It may provide some relief to know that we did everything possible to find a reason to give her antibiotics, even if she walks home empty handed, despite the evidence that gives her a next to zero chance of having strep throat. He then needs a glass of water so we spend 10 minutes in the kitchen while he lectures me on the point that I just made for him. It is a cheap test and if everybody sleeps better tonight then so be it. But, in order for her to sleep better tonight, we have to get her out of our office before midnight. Put the water glass down and let’s do something, even if that something includes doing a test that I can guarantee will be negative.

I gag the patient with a swab and send it to our lab. Alas, it is negative. (If it had been positive for strep, I would have been devastated and probably too embarrassed to relay this story to you.) I then wait, and wait some more, for the preceptor to be ready to go see the patient. A 15 minute visit turns into 45. He’s been frustrated all morning, slow in his pace and deliberately making things like being put on hold, or logging into his computer seem overly dramatic.


We shuffle into the room and I listen to my preceptor describe viruses, post nasal drip, and the lack of need for antibiotics. The mother of the patient tells the tale of being prescribed antibiotics in the past for similar episodes. Not today, honey. We offer symptomatic relief.

After we’ve left the room and the patient was left with her salt water gargling instructions, my preceptor turns to me and in a demeaning tone says, “I certainly hope you won’t be one of those providers that prescribes antibiotics for that in the future.”

“You got it, pal,” I think as I watch the family leave, well over an hour after they should have.
Funny moment when you realize that, despite not knowing it all, or even not knowing a lot, you still develop your style of practicing medicine. Mine is different than his. Or maybe I just don’t like him.

New Guy Once Again

First week of 3 months in Hood River completed. I'm renting my own house close to downtown. It has a wood burning stove but no WiFi, so I bought a 1/4 cord of wood and will likely spend more time stoking the fire than surfing the web.

A very different feel here compared to Cheha-town Peds. There it was fast paced, 2 minute dictations, crack-the-whip, sort through the viruses medicine. My patient presentations eventually got boiled down to: "It's diarrhea. They look good." Even in Scrippsville, if they walked in the door they got a Statin. A door prize that didn't require much thought or reason.

My preceptors here expect a much deeper and wider differential diagnosis. They also expect a little more evidence based approach. We actually use things like Framingham's Cardiac Risk Score. They want my notes to say things like "...due to lack of abd pain and blood in stool, we ruled out bacterial etiology of this patient's diarrhea although if symptoms persist we may order fecal leukocytes and occult blood studies." Their ortho exams entail more than their fingers hitting keyboards to order an ortho consult.

It's refreshing. And difficult at the same time. It's easier to practice loose and fast medicine and blame everything on how busy your schedule is and how the "real world" doesn't include a legit review of systems and lengthy differential. It's easier to keep the patient's sweatshirt on and call a specialist than to actually examine their shoulder.

And at the same time 85% of my patients speak only Spanish. So my brain is doing a bit of spinning right now. I am being humbled on multiple levels. From basic communication skills (come se dice 'blister' en espanol) to detailed pimping (what are the guidelines for phototherapy in newborn hyperbilirubinemia?)

I'll keep you posted. But for now, I'll be stoking that fire with a textbook on my lap. I've still got a lot to learn.

Little Moments in a Big World

Interesting Moments in Pediatric Medicine:

Realizing that pediatric nurses, despite their teddy bear scrubs, will cuss, smoke cigarettes, and make fun of whiny kids behind their backs.

Picking up a previously undiagnosed heart murmur during a visit for vision change. And being reminded why I listen to the heart and lungs in every patient every time.

Realizing that kids actually are hoping that the X-ray will show a fracture, as it is a much cooler diagnosis than "contusion".

Being asked by a teenager to explain to him what a MILF is. And going for it, with the blessing of the parent and preceptor.

Telling a mom that her son's "Gait Disturbance" is because he is wearing shoes that are twice the size of his foot, and loosely tied. Rx: Nike Outlet down the road.

My wife "stealing" the prized quilt from the Clinic Owner in the Christmas Party Gift Exchange. And watching my evaluation go down the tubes.

Realizing that the child who cut the tail off the family dog and stabbed a teacher with scissors then repeatedly punched self in face until bleeding, and is now in handcuffs, foam helmet, 4 point harness seat and spit mask needs to have my fingers near his mouth, just as the guards tell me he likes to bite.

Referring for evaluation for medical marijuana for chronic pain.

Pneumothorax in a 6 hour old boy.

Still not understanding the whole immunization schedule. Thank God for the aforementioned pediatric nurses. Despite their sailor-like attitudes, they can certainly help me decipher the IPV,Hep,VZV,PCV,MMR,HIB,DTAP,TDAP madness.

Having the moment of clarity, which led me to utter the words, "I could do pediatrics...."