A Country Doctor Writes:

In Sweden, back when I trained, three blood tests were the “routine labs” done at most doctor visits: Hemoglobin, White Bloood Cell Count and Erythrocyte Sedimentation Rate. I’m trying to remember, but I don’t think everyone waited an hour to see the doctor, so they must have used a modified rapid sedimentation rate.

The “Sed Rate”, or “sänkan” as we call it, was invented by Robin Fåhraeus, a relative of one of my High School teachers. Fåhraeus described the phenomenon in his doctoral dissertation in 1921 and was professor of anatomy and pathology at Uppsala University around the time I was born. He was nominated for the Nobel prize several times but was never awarded it. He collaborated with another Swede, Alf Westergren, on perfecting the technology. Blood in a vertical tube will separate into liquid on top and clumped together red blood cells on the bottom. The height of the fluid pillar after one hour is the “sedimentation rate”.

Anyway, in Sweden we were often faced with what to do when the sedimentation rate was abnormally high. In addition to the usual causes like infection, autoimmune disorders and multiple myeloma, it was drilled into my head to look for kidney cancer.

I’ve never heard any of my American colleagues talk about that, although there are several articles about the connection if you Google it.

A few weeks ago I saw a man who wasn’t feeling well. I ordered some lab tests, including a sed rate. It came back at 100 mm, five times the normal limit. I ordered a CT of his abdomen to look for kidney cancer. Before he ever got the test, he ended up in the emergency room with pneumonia. That could have explained the abnormal lab result. Because of the severity of his pneumonia, the hospital did a chest CT on him, so when he got the call about his appointment for the abdominal CT I had ordered, he told them he didn’t need it because he already had one. He thought one CT covered everything.

At his followup appointment, he was back to feeling nonspecifically unwell and his sed rate was now 118. I asked him to please reschedule his abdominal CT.

Today I got the result, a “Code Yellow, Unexpected Finding” fax in my office chair.

He has a one inch tumor in his right kidney, highly suspicious for cancer.

As of July 1, pharmacies in Maine cannot honor paper or telephone prescriptions for controlled substances, from OxyContin down to Valium, Lyrica and Tylenol with Codeine.

EPCS, or electronic prescribing of controlled substances, is a double security step in the prescription process built into EMRs, electronic medical records. It involves another password entry and the use of onetime passwords from a small number generator issued to each prescriber.

It has been said that this will prevent fraudulent prescriptions via phone or on stolen prescription pads, as well as altering of legitimate prescriptions.

But there is another reason that doesn’t get much mention:

EPCS is going to prevent doctors from prescribing controlled substances for friends and relatives outside their regular office activity.

Now and then a physician is disciplined by the Board of Licensure in Medicine for writing pain medication prescriptions for friends, sometimes even getting pills back for their own use.

Not long ago a well respected older doctor gave up his license during a Board investigation of his career-long habit of prescribing a low dose tranquilizer for his wife. That was probably not an unusual thing to do for small town doctors in solo practice with no colleagues for miles around. It is not tolerated in today’s regulatory environment, where doctors are viewed as having no more integrity and judgment than anyone else.

The next step is probably what they did in Sweden many years ago: Pharmacies there were unable to submit prescription charges to the health insurer if scripts were not written on special forms, linked to each doctor’s place of employment. But in this case in tomorrow’s USA, the requirement will be electronic prescriptions linked to our EMRs.

That reminds me, I was too busy yesterday to answer a text message from Autumn, my nurse. She’s on vacation and came down with a bad cough. Should I prescribe her an antibiotic over the phone? She isn’t actually a patient in our office…

A HORSE DOSE

Each of my girls weighs less than 900 pounds (400 kg), but the amount of medicine they require when they are ill can be staggering.

My heartburn medicines, omeprazole (Prilosec/Losec) or esomeprazole (Nexium), are 20 mg pills that cost $25 for a box of 42. Humans take one or two of these per day.

When one of our girls was diagnosed with ulcers, which is something very common in horses after stressful events like trailering, she was prescribed 2000 mg per day of omeprazole at a cost of $1000 for a month’s worth of paste made especially for equine patients. While waiting for the mail order prescription, I crushed just twenty omeprazole tablets in a coffee grinder for each temporary daily dose of 400 mg. Without the protective coating, that medicine is extremely bitter. She hated it.

The paste, Gastrogard, at one hundred times the typical human dose, is truly a horse dose. It tastes sort of like cinnamon.

LONG IN THE TOOTH

I’ve heard the expression ever since I moved to America, but never truly knew its meaning. Now that I have horses, I know their teeth keep growing, and may need filing down. They even have a line in them, Galvayne’s Groove, which lengthens in a way that you can tell a horse’s age from within a five year range.

The white juvenile milk teeth stay in until a horse is five years old or so, and are then replaced with more yellow permanent teeth.

The angle between the top and bottom teeth also changes with age.

All of this contributes to the notion that you “shouldn’t look a gift horse in the mouth”, or be picky about any gifts you receive.

WHAT’S GOT YOUR GOAT?

In horse psychology, there is this thing about goats.

When we at one point had a single horse, we put three miniature goats in the empty stall for company in he barn. That worked very well, and gave some credence to the stories we’ve heard about how high strung race horses sometimes have a goat as a companion and stall mate in order to keep the horse calm. It is said that stealing the goat the night before a race can unsettle the horse and alter the outcome of the race.

So if a race horse seems edgy, the obvious question would be “What’s got your goat?”

HORSE AILMENTS

Equine medicine has its own terminology, which always makes me think of watching the Darrowby farmers speak in “All Creatures Great and Small” by James Herriot. The old English words for some diseases are strikingly graphic:

Strangles: A streptococcal infection with lymph node swelling that can cause facial swelling and suffocation.

Choke: Esophageal obstruction.

Shivers: A neurologic disease involving spasms of mostly the hind legs.

Cribbing: A compulsive wood biting behavior with neck tightening, laryngeal retraction and air sucking that is thought to release endorphins.

Founder: Also called laminitis, a hoof inflammation caused by overweight, rich diet or high blood sugar, causing the horse inability to bear weight on its feet.

Heaves: COPD in horses.

Roaring: Noisy breathing from vocal chord paralysis.

COLIC: TRIVIAL OR DEADLY?

As a father and primary care physician, I’ve always thought of (infant) colic as a harmless, even if challenging, annoyance. As caretaker of horses, I have the deepest respect for what we call colic in equine medicine. It would be as if abdominal pain in adults were to be called colic. Imagine appendicitis, pancreatitis, peritonitis, bowel obstruction or incarcerated hernia.

Horse colic is anything that looks like a bellyache. It can be anything from gas to constipation to impaction or obstruction, and as we can’t bring a downed horse anywhere for a CT scan, our diagnostic and management tools are crude and primitive to say the least. All we do in the field is treat pain, inflammation and spasm and see what happens.

I’m glad I’m just a Country Doctor and not a large animal veterinarian.

“Noncardiac Chest Pain” was Laurie Black’s discharge diagnosis. Her chest CT Angiogram didn’t show a pulmonary embolus, her troponins were negative for a heart attack and her nuclear stress test was negative for coronary ischemia.

“So what do you think it was?”, she asked while I read through her hospital discharge summary.

“I don’t know…show me where the pain was”, I answered.

“It started in my back, on the left side, and then it went up and around to the front and then down my left arm and my hand felt kind of tingly.”

“Where in your back, upper or lower?”

“Upper.”

I palpated her left trapezius and put some pressure between her spine and her scapula.

“I assume the doctors at the hospital did all kinds of poking and prodding here”, I asked.

“No, I don’t think anybody really touched me”, Laurie answered.

“Can you move your shoulders around a bit”, I asked as I pushed my fingers in a little harder.

“That’s very sore”, she said, and I could feel the tightness in her muscle.

I moved to her front and asked her to show me the range of motion in her neck. It seemed close to normal.

“Try to go a little further”, I said.

“Ouch, I just felt something, in my arm”, she startled.

“Looks like it’s all coming from your neck. How about that…”

Just a few days earlier I had another “aha” moment, this one regarding a patient with abdominal pain.

Nora Friedman had seen one of my colleagues with a one month history of a painful lump in her right lower abdomen. She ended up with both a CT scan and an ultrasound, and the only abnormality they showed was a very large cyst in the lower portion of her right kidney. The radiologists suggested this cyst could be drained in order to relieve her pain. That’s where I came into the picture and as she is on blood thinners, I ended up fussing with the management of her anticoagulants before and after the procedure.

When I saw her after it was done, she told me that her pain hadn’t changed at all.

“Show me where it hurts”, I asked her.

“Here”, she said and laid her hand across her abdomen near McBurney’s point.

I asked her to lie down. She did and I felt nothing.

“I actually feel it more when I stand up”, she offered.

As she stood in front of me and I placed my hand where she directed me, I asked her to cough. Suddenly I felt a soft, almost squishy protrusion under my fingers.

I called the interventional radiologist who had aspirated her renal cyst through a long needle in her back.

He confirmed that her cyst wasn’t likely to have reaccumulated that quickly and I told him that both she and I thought we felt a hernia when she stood up and coughed.

“I’m looking at her CT right now…”

His voice trailed and there was a long silence.

“Actually, I can see a spigelian hernia now. That would explain everything. She needs to see a surgeon.”

So, in hindsight, a more carful examination of the patient at our end, and of the images at the radiology end, could have saved Nora an invasive procedure, just like Laurie could have been spared some of her fancy hospital tests for what turned out to be a simple neck problem instead of a cardiovascular emergency.

He had been in for a physical the day before.

Like so many people, he seemed to have this need to run half a dozen minor bodily symptoms past me, while I worked my way through the agenda of screening colonoscopy, whether or not to test his PSA, calculating his ten year cardiovascular risk, talking about alcohol use, screening for depression and so on.

I remember his left leg pain. He had had it for about 48 hours. It was along the outside of the leg and seemed to be related to a climb he had made up a steep hill, lugging camping equipment.

There was a little tenderness along the center of his gastrocnemius muscle, but even more along the outside of his knee.

I remember explaining that the location of his pain would be quite atypical for a blood clot, and that a mechanical strain seemed the more likely explanation. We moved on down his list of concerns, and I didn’t put any of it in his record, because it would have made me run over his allotted appointment time even more than it did.

The very next morning, my Care Coordinator told me as I hung up my spring jacket on the back of my office door and and booted up my computer: “Jack Errold is in the ER at Cityside with chest pain this morning. They’re working him up for a pulmonary embolism.”

For the next 24 hours I couldn’t get Jack’s left leg out of my mind. Did he have a blood clot there after all? If so, how would he and his wife react to the realization that I missed it? Was he still okay?

I knew I wouldn’t see a PE protocol chest CT show up in my computer because of his compromised kidney function. They’d probably do a VQ scan, but maybe there would be a Doppler study of his left leg.

Nothing.

That night, with the house all quiet, my thoughts continued. He has always been a matter of fact guy, never bitter about losing his job or having a less than perfect outcome after his trauma surgery many years earlier. He didn’t seem likely to sue if I had missed an atypical presentation of a deep venous thrombosis.

But what if he wasn’t okay?

This morning I was met with the news that Jack’s stress test was abnormal and he was on his way to the cath lab.

A sense of relief washed over me. Not because he had a probable critical coronary stenosis, but because I had not failed him by missing a blood clot in his leg that traveled to his lung.

We face dozens of such inquiries every day in primary care, minor complaints and casual mentions of bodily symptoms that could potentially require an entire visit or more for each and every one, but we don’t have that kind of time. We are constantly triaging; we go through each day scanning for avoidable disasters, and even if we appear relaxed, congenial and reassuring, our minds are on high alert.

Failure is a constant possibility in medicine. We have to live with that and we must be willing and able to settle for probability and not certainty most of the time.