A Country Doctor Writes:

Today I met a man who wanted to interview me before transferring his records.

He was about my age and seemed polite and pleasant enough. He told me his doctor of a dozen years had started to taper him off his long term narcotics after he reported some of them missing because of theft. He used to take the equivalent of about 1,200 mg of morphine per day for his back pain. Our office classifies anything over 120 mg of morphine as a high risk dose.

He left that practice and transferred his care to a hospital run clinic across his home town. His next doctor at first prescribed him the medications, and then quickly begun tapering him off them. The story was a little vague as to exactly why.

He then landed in the hospital for something unrelated, and the report from that admission was available on our state’s medical information sharing website. He told the hospitalist that he was on the high dose that actually two doctors had already tapered him off. The hospital doctor called his new primary care doctor to clarify things and was told the patient had failed a urine drug test because it contained a pain killer he was supposed to have run out of months before. He told me he wasn’t trying to deceive the hospital, he just thought they wanted to know what he used to be on before things changed. He also told me he had kept a few of the discontinued pills on hand, and had used them when his main medicine was being tapered.

The man said he had been off his narcotic pain killers for a few weeks now. He drove himself the 25 miles to our clinic, and he walked the long way from the parking lot to my corner office. He sat in a relaxed position in the office chair across from me, but he told me that he had suffered a big loss of quality of life when he lost access to his narcotic prescription.

After he was done telling me about what it felt like to be tapered off his pain medications, and as a by-the-way, he also told me he needed to get back on the amphetamine he had been on for his attention deficit disorder.

I listened carefully and told him with my most gravelly and serious voice that I didn’t think any doctor would prescribe the kinds of doses he used to be on, and that he did seem to function without them – at least to a degree. I told him that his best bet was probably to talk with the doctor he had known for twelve years. I told him that particular practice has a committee that reviews the care of their difficult pain patients, and he could ask for their involvement. I offered to take care of his other medical needs if he wanted me to, but that there was not enough trust between us for me to just give him narcotics again because of the history he provided me with.

He thanked me politely, rose from his chair, offered a firm goodbye handshake and walked slowly down the hall back to the reception area.

“I was surprised when the emergency doctor at Cityside Hospital said he was going to call you to discuss my case”, Farmer Carr said when I saw him today. “I figured you’d be asleep at that hour.”

I smiled as I recalled the cell phone call that had come in at 9:30 the night I had sent him back to the hospital for a reassessment.

“No, I was sitting in my camping recliner in the tack room in our horse barn, writing on my iPad and listening to the barn animals chewing their hay.”

I saw his eyes soften. He no longer had a hundred head of cattle, but he was still Farmer Carr, and he loved animals.

I had been working on my post “This is America, You Don’t Have to Do Anything”, and I kept thinking about Farmer Carr. He had been hospitalized with pneumonia and when I saw him in followup he was weak, pale, short of breath and tachycardic; his resting pulse was 125 and after I had him walk down the hall, he reached 145. His EKG showed sinus tachycardia. His oxygen saturation was in the low 90’s, which wasn’t bad, but he had a little swelling and tenderness in his left calf, so a blood clot was a possibility. His white blood cell count was elevated, and his chest X-ray had some hilar fullness and some streaking in the mid right lung. I didn’t have access to his hospital X-ray, but even if I did, he looked like there was more going on than a slow-to-resolve pneumonia. He agreed to return to the hospital for reevaluation, and I called ahead and sent my records.

I remember, working on my post, hoping I would get a call from the hospital, and my mind wandered further back in time to call nights over the years when I had wished the opposite – that no one would call me.

When I started working at our clinic thirty years ago, one year out of residency, our town had a volunteer ambulance corps without Advanced EMTs, and it was the on-call doctor’s duty to meet the ambulance at the scene of car accidents, cardiac arrests and other calls that could use skilled care during transport to the hospital. It was also our duty to open the office, with no staff to help, for emergency cases that requested that we do so.

I remembered cleaning a facial road rash on a mean looking leather clad motorcyclist from Massachusetts in the middle of the night. He was twice my size, and he didn’t like the way I caused him pain picking out the pavement residue from his scraggly chin.

I remembered treating allergic reactions and asthma attacks with injectable medications, alone with the patient in the clinic.

I remembered the times I had to do CPR, in a motel room off Route One, in a trailer at the end of a dirt road and in the jalopy town ambulance with howling sirens over icy and snowy roads.

I remembered the sense of dread on call nights when anything could happen. I remembered trying to quiet my crying infant son late at night, with the little black Motorola beeper on my belt, and every cell in my body knowing that at any moment the shrill beeping might tear me away from him and out into the night to face situations I might or might not be able to handle with little equipment and little assistance.

Times have changed. We have a professional ambulance service. The hospital has full time hospitalists and we don’t open the office at night anymore. Some people miss the old days when we were available for emergencies right here in town, but most know that medical technology and the standard of care have advanced over the thirty years that have passed. A normal EKG doesn’t rule out a heart attack anymore, and no one rules out a fracture in a trauma case without X-rays anymore.

We are still available to triage and coordinate care after hours. And with remote access to our EMR I can even send a patient summary to the emergency room from my iPhone. Primary care doctors don’t try to do everything themselves anymore. But we take our job of coordinating care seriously.

Oh, I almost forgot: Farmer Carr’s CT scan didn’t show a pulmonary embolus, just an almost resolved pneumonia; his pulse was normal in the ER and when I saw him back today at the emergency doctor’s request, he did look a lot better.

“Today, you’re able to walk and talk at the same time”, I pointed out as we walked down the hall a ways together.

The clues are usually there, even in the hardest of cases. They just aren’t presented to you on a silver platter.

Gwen Stephenson had an ill-defined polyarthritis and had been on methotrexate for some time. Her rheumatologist, Norm Fahler, had tapered her off the medication while keeping an eye on her inflammatory markers and they had leveled off at just above the normal range.

Seven or eight years ago, Gwen had suffered a bad bout of sciatica, and a few weeks ago, she had told me her sciatica was bothering her a little again. “Not enough to have those injections yet, mind you”, she had said with a grimace and a gesture indicating the length of the needle her pain specialist had used to deposit the steroid in her lumbar epidural space.

The visit when she mentioned her sciatica was a diabetes visit, full of bookkeeping tasks – keeping track of her eye exam, foot exam, microalbumen, blood pressure readings, blood sugar log, lipid management and cardiovascular review of systems.

I accepted her assessment that her sciatica was not of the magnitude that it required any immediate intervention.

After Gwen left, Autumn came into my office to pick up some forms I had signed, and she said:

“Did you notice that Gwen’s temperature was 99 for the second time in a row? I wasn’t sure if I should have pointed that out to you.”

I had not noticed it. Looking back, I saw that a week earlier, when she had come in just for her B-12 shot, it had also been 99.

“I’m not sure if that means anything”, I remember saying.

Two days later, Gwen came in with a nasty cough and I thought I could hear some very faint rales in her lower left lung. Her temp was 99.4 and I put her on antibiotics for pneumonia. We didn’t have X-ray available that day, but it was obvious at that time she needed an antibiotic.

The following evening I was on call. Gwen phoned the answering service around 9 pm and asked if an axillary temperature of 103 was high enough to be alarming. She hadn’t been able to take an oral temperature because her teeth were chattering with the terrible chills she was having.

She was admitted to the hospital, where intravenous antibiotics were started for her apparent pneumonia. Her fever didn’t come down, and the radiologist disagreed with the initial emergency room reading of her chest X-ray. So she became a “fever of unknown origin”. The blood cultures that were drawn in the emergency room grew staphylococci, and, because her back pain kept getting worse as she lay in bed day after day, she had an MRI of her lumbar spine. This showed a possible discitis at L5-S1 and a psoas abscess.

They teach you in medical school that early imaging isn’t indicted with back pain or sciatica, unless there are “red flag symptoms”. Fever is one of them. But Gwen’s back pain was recurrent, and had been there for a while, and her fever was borderline when I saw her, and it developed after the back pain. Still, I was quite humbled. I wasn’t actively connecting all the dots, and I was too focused on the housekeeping tasks of her diabetes care to see the subtle manifestations of her smoldering infection.

It started with a sore thumb and ended with a lifetime of medication. In between there was an emergency room visit at one small hospital, an ambulance transfer to a big hospital, a Medevac flight to Massachusetts General Hospital, multiple invasive procedures and a diagnosis of an often lethal condition. And I was not the one who made that diagnosis.

Paul Allard had developed severe heartburn and indigestion earlier this fall, and had just recovered from a bout of wrist pain when I saw him a month ago. The pain and swelling had been there for a week or so, did not seem to be caused by any trauma or overexertion. It had cleared up after just three days of prednisone, and his rheumatology blood profile was completely negative.

This time, Paul had a pain along half of his left thumb and in the web space between his thumb and his index finger. It was sharp, burning and persistent.

As I asked all kinds of questions and checked his hand strength, skin temperature, monofilament and temperature sensation, arm strength, neck movements, axillary and supraclavicular lymph nodes, Paul clearly seemed uncomfortable. His partner, who usually seemed a little disinterested in Paul’s medical concerns, was leaning forward in his chair watching our exchange and my exam intently.

“I’m not sure what’s going on”, I said to the two men. “It could be something arthritic, like that episode of wrist pain, or maybe some type of vascular inflammation in a very small vein or even one of the four arteries that supply the thumb, but it could also be a pinched nerve, especially because it involves the space between the thumb and index finger.”

I suggested that Paul finish the course of prednisone he had been able to stop early when his wrist pain resolved. Paul and John agreed and we set up a five day followup.

That was Friday. Monday morning, my inbox had the next several installments of the story:

Late Friday night Paul suddenly developed nausea, severe abdominal and left flank pain, and went to our small hospital emergency room. They did a CT scan of his abdomen, which showed an infarction of his left kidney. When that happens, the cause is usually a blood clot, so they transferred him to Cityside Hospital for evaluation by the vascular surgeons.

A CT angiogram showed a large clot in Paul’s thoracic aorta. He was started on a heparin drip and airlifted to Boston. There, they didn’t see a clot in the thoracic aborts, but it had apparently just moved down to his abdomen. The clot was removed surgically, and while his kidney showed signs of recovery, and several specialists were working out his diagnosis, his left lung suddenly filled with blood. He had three quarts of blood drained through two chest tubes and was finally allowed to return to Maine with a diagnosis that explained what had happened and committed him to a lifetime of warfarin to prevent future blood clots.

“So, you have Lupus Antigen”, I said, rhetorically. “But they didn’t think that you have lupus?”

“Right”, Paul and John answered in unison.

“Sure, the wrist pain could have been something else. What did they think of the thumb pain, a small embolus in one of the four little arteries that supply the thumb?”

“They weren’t sure”, Paul answered.

“Who would have known…”, was all I could say.

“He could have died, they told us”, John said.

“Most people with this kind of clot do”, Paul filled in.

I half shook, half nodded my head as I punched in Paul’s warfarin dosing order in the computer. I thought, not for the first time, about how you see things on the front lines of medicine that turn out to be the first sign of a condition that other colleagues diagnose hours, days or even weeks later, as symptoms evolve and the clinical picture comes into clearer focus. It is a humbling experience.

It has been said about the Lupus Antibody Syndrome’s sister condition, “If you know lupus, you know medicine”.

Theresa arrived in a cloud of noise and commotion.

She had called after four o’clock the day before, but I hadn’t noticed the new message in my electronic inbox before I left the clinic.

Her almost brand new alprazolam bottle and her pain pills were missing, and Theresa was reeling. As she walked down the hall to the exam room, I heard her explain to Autumn how she had been to Walmart and a couple of other stores, slinging her big handbag over her shoulder, opening it to pull out her wallet, stuff receipts and her reading glasses away and fumble for her asthma inhaler.

In my exam room she repeated her story and demonstrated how she had held the bag open, pulled things out of it and then put them back in, and then realizing that her two pill bottles were missing. She proceeded to also show me how she rummaged around for the pill bottles and even emptied the large, brown bag with its purple lining.

In a loud voice and with oversized gestures, she replayed every conversation she had had about her missing pill bottles with store clerks, her girlfriend and her pharmacist in the last thirty six hours.

I sighed. Theresa had a small amount of pain pills on hand, which she could safely go without, but she was one of those patients who had seemed stable and truly helped by her long-term alprazolam. This was endorsed for selected patients at the psychopharmacology courses I had attended in Boston many years ago, but it has now fallen out of fashion.

“Well, Theresa, you know these controlled substance agreements you’ve had to sign always say that lost or stolen medications will not be replaced”, I said.

“But this has never happened to me before.” Her voice was as shaky as her large, bony hands. “I’ve been on alprazolam for years, what happens if I stop it suddenly? I took my last pill last night, one I had saved in my nightstand.”

“You’re right. Stopping alprazolam suddenly can actually be risky”, I agreed. “Here’s what I can do: I can give you half your usual dose, in weekly refills that you will have to pay for yourself, and I’ll see you back every Wednesday until your next regular prescription is due. Then we can assess how you’re doing.”

“Okay.”

I entered the new dose in the computer and clicked with my trackball on the “print” button. I doubted that Theresa was trying to scam me with diversion or addiction, but rules were rules. Obviously, I didn’t want risk withdrawal seizures.

Later that night I thought about Theresa again. I couldn’t completely ignore a slight shade of doubt. Was she becoming addicted or irresponsible with her medication? A mental black hole lay open but I resisted falling into it.

The next day, I heard Theresa’s resonant voice again, talking with Autumn somewhere down the hall. A short while later, Autumn appeared at my door. In her hand she held three pill bottles.

“Remember Theresa’s missing pill bottles?”

Without waiting for my answer, she continued:

“Well she was just here with that big handbag of hers. She lost her cell phone last night, so she emptied out her whole bag again and found a five inch hole in the lining. There, between the lining and the outer shell, was her cell phone, her two pill bottles and one of her spare pairs of reading glasses!”

The black hole was real, I thought, not in my mind, but in that big handbag of hers.