A Country Doctor Writes:

“I should be home well before nine o’clock”, I said to my wife on the phone as I steered my eight cylinder SUV quietly down the highway at 75 mph (121 km/h) with more than 100 miles left to go.

“More like eight fifty-five”, I added.

“That’s well before nine?” She sounded both weary and incredulous. I knew what she meant. I am not as obsessive about time as I used to be, but even outside the clinic, I have an awareness of time that is possibly not entirely normal or healthy.

As a physician in America today, I work within a schedule of fifteen minute blocks. Some visits, like physicals or hospital follow-ups are scheduled for thirty minutes, but the bulk of what I do has to average out to fit a fifteen minute slot, or sometimes, when we double-book, half of that.

It takes constant awareness of time to function in that manner, and I work very consciously not to relay that awareness too plainly to my patients.

Whenever I work with new scheduling staff, I have to help them learn how long things take. They don’t usually know much about medicine, but it is essential to have a sense of which things take a lot of time and which don’t.

For example, a person with acute chest pain and shortness of breath, although this may sound serious, only takes a few minutes, because it involves a triage decision – if it’s bad enough we ship them out to the hospital. If it’s not, we order a basic set of tests with relatively few possible outcomes.

On the other hand, an older person with fatigue, depression, nausea, weakness, weight loss or any kind of gynecological or bowel related problem takes a lot more time. Just getting an older person undressed and on the exam table can take half of a fifteen minute slot, let alone taking a good history from someone whose memory, conversation style or medical savvy isn’t in tune with the pace of today’s society.

In the past I remember making lists. An earache takes five minutes, severe headaches up to fifteen, and so on.

I also often say, “if you can’t figure out what they need or if you can’t get off the phone with them, I probably can’t solve their problem in a double booked, seven and a half minute slot.”

Compared to ten or fifteen years ago, I am less emotionally affected by my gains or losses in my daily race against the clock. I tend to make more automatic, subconscious corrections in my pace, depending on how my day is going. And, more importantly, I seldom get frustrated about time.

Managing time is a little like driving, more automatic after more years of practice.

I remember how I completely failed to notice two pedestrians trying to cross the street in one of my early driving lessons. I was stopped at a red light on a hill and getting ready to turn left. I was completely focused on my left foot on the clutch, the ball of my right foot on the brake pedal and my heel on the accelerator, hoping the baby blue Volvo wouldn’t stall on me.

Now, even though I don’t drive a standard very often, I can still do those kind of maneuvers without engaging my conscious mind.

In the clinic, even though I am always aware of where I am, time-wise, I almost always carefully control how I express that awareness. My years of experience often help me get to the heart of things quicker than I did in my youth, and my years of relationship building with my patients give me the credibility to sometimes declare priorities when there is more going on than I can reasonably address in one visit.

At the same time, some of the things I have seen over the years have helped me recognize those times when I have to stop everything and do what needs to be done, no matter how long it takes.

Handling time, like so many other things we do in medicine, is a necessary part of our work, but it isn’t the essence of our work. Time can be a distraction, just like our technology can be too visible.

People who don’t treat patients themselves don’t usually understand the nature of our work. Instead, they focus their attention on things they know: Is the doctor running on time, is the documentation complete, are the billing codes correct, or does the doctor have “huddle” with the scheduler and medical assistant every morning?

Focusing too consciously on any one of such housekeeping issues detracts from the real work that we do, at least when we are new in our careers. For a brand new driver, how you drive is at first more important than where you are going, because of all the components that necessarily go into driving a car safely. For a new healthcare provider, the form of our work tends to dictate the function, especially in today’s hyper-regulated corporate environment.

When we deal with patients, we need to keep the external considerations as invisible as possible. We need to inspire the confidence that we are really paying attention and we need to create an atmosphere that is conducive to healing.

When I talked to my wife from the car the other night, I should have dropped my instinctive thoughts of that five minute margin, just like I didn’t give her a blow by blow account of which way I was turning the steering wheel, whether I was using cruise control or not, or whether I had switched on my high beams.

I should have just said, “I’ll see you at nine”.

A woman in her mid thirties with a terrible limp and a past surgical history in the dozens became my patient two years ago. Her prosthetic left leg served her well, but her right leg was moving awkwardly because of advanced hip arthritis and a formerly shattered ankle.

She was on long acting morphine and short acting oxycodone. Her Social Security disability insurance didn’t cover the long acting form of oxycodone.

She told me several times how much she hated being on narcotics, but they kept her functioning. She was able to do her own housework and she was taking classes in medical coding and billing.

Her pill counts were always correct and her urine drug screens always showed morphine and oxycodone – never anything else.

A year ago, an anonymous caller told Autumn that my patient was injecting her morphine. I saw a couple of scratches on her arms, and she told me she had this nervous habit of picking at her skin. I said that habit could keep her from receiving future prescriptions for pain medications, and I never again saw any marks on her arms or legs.

Last summer, we got an emergency room report from Massachusetts that documented how my patient had presented with symptoms of opiate withdrawal. The story she had told there was that she had lost all her pain medication when her car was broken into at a highway rest area several days earlier. She was dehydrated and needed intravenous fluids.

When I saw her back, she was still shaky, and she asked me not to represcribe her long acting morphine. She said, tearfully, that she was determined to get off her narcotics. Just some oxycodone to take the edge off her pain, but she didn’t want to have these drugs in her system all the time, she told me.

Her next drug screen only showed oxycodone and its metabolite, oxymorphone, just as expected.

A few months later, she ended up missing her followup appointment because her mother fell ill and needed emergency surgery. “I stretched my oxycodones”, she said, “and I did all right”.

“Let me do another drug screen, to prove that you didn’t take anything else”, I said.

She tensed up, but didn’t say anything, except “will the results go up on the new patient portal?”

“As soon as I’ve signed off on them, yes.”

A few days later, the opiate confirmation test came in. Her oxycodone level was medium high, but there was no oxymorphone, suggesting only recent oxycodone intake, but not proving continuous use. That was reasonable as she had been taking her prescription less regularly. But, confusing at first, her morphine level was higher than the assay could measure. There was also a high level of codeine.

I had in front of me a test result that suggested probable heroin use.

I had to check my facts, but needed some extra time to do my research. Meanwhile, she called to inquire about her results. Autumn told her that they probably hadn’t come in yet, if they weren’t on the portal.

Heroin, also called diacetylmorphine, is rapidly metabolized to 6-monoacetylmorphine (6-MAM), which is six times more potent. Within a few hours, 6-MAM is transformed to morphine and no longer detectable in urine or other body fluids. Street heroin often has some acetylcodeine in it, which is metabolized into codeine.

I checked with the reference lab. They could run a test for 6-MAM, but because it is present only for a few hours, it might still be negative even if my patient was using heroin. The turnaround time for the analysis could be up to a week.

I picked up the phone.

“I’ve got your opiate confirmation test”, I started.

She was silent.

“It shows your oxycodone, but also more morphine than I’ve ever seen, and some codeine.”

She said nothing.

“That is the pattern we see with heroin use. And, in any case, you wouldn’t be expected to have that much morphine in your system when you are no longer prescribed morphine, and I never prescribed codeine for you. I have a confirmation test pending for 6-MAM, which is a breakdown product that we see in the body before heroin becomes morphine. But this disappears quickly from the system, so we don’t always see it in heroin users”, I explained, based on my recent homework.

She still said nothing, except “can you put the result up on the portal so I can look at it?”

That was it. She hung up. I never heard from her again.

A few days later, her 6-MAM report came back. It was positive. I signed off on it, and it went up on the portal.

Dustin Ouellete grew up a bit the other day.

I had known Dustin as an infant, and his mother before that. Several years ago, the Ouellete family moved away to the big city, but last summer they came back.

Dustin came in a few times with his father, and his main concern was migraines. Dustin’s father, a quiet man who seldom smiles, was concerned that the headaches were keeping his son from excelling in sports, and Dustin seemed overwhelmed with the idea of taking daily medication.

It seemed clear that physical exertion beyond a certain intensity was a trigger for Dustin’s s migraines, and at first, he thought he might be able to treat them as they came along and just be careful about learning his limits. Ibuprofen, taken early during a migraine, seemed to work three quarters of the time. The sumatriptan I had prescribed worked once and seemed ineffective another time, his father reported on the phone a few weeks after Dustin’s first visit.

I saw them in followup, and he agreed to try topiramate. During the titration period, he still had a few migraines, so I got a phone call that they were stopping it.

A short while ago. Dustin came in with his mother, an exuberant woman who used to have migraines as a teenager.

Dustin had tried out for another sport and had started to have migraines again. He had restarted the topiramate, but at 50 mg twice a day it wasn’t holding him. He was considering dropping that sport and choosing something less strenuous. His mother said “it’s up to you, Dustin”. He looked glum and overwhelmed.

I thought for a minute, then leaned back and started:

“Well, Dustin, you have a choice here. You can spend the rest of your life tiptoeing around the triggers you have for these migraines and turn away from this sport or that, or you can invest some more time and effort in finding the right dose of the medication we have started, or another one, and figure out once and for all what it’s going to take to beat this problem so you can do anything you want, maybe not this season but for the future.”

I could see his mind working.

I continued, “it’s like my right shoulder. I have dislocated it many times, but now I know exactly what I have to avoid in order for that not to happen – I can’t put my jacket on while sitting down, I can’t reach for something in the back seat while I’m driving, and so on. I decided not to have surgery, so I have to live by my limitations. That was the right decision for me, but someone with a different job might have made the opposite decision.”

Dustin sat motionless for what felt like two full minutes. Suddenly his posture changed, from a semi-slouch to bolt upright, and his eyes came alive.

“I think I’ll drop out off track this year, work my way up on the topiramate dose, see how the beginning of the summer goes just doing some informal stuff, and then be ready for soccer season.”

“You claimed it!” I made a “yes” gesture with my hand. “You stopped being a victim, you are taking charge, and not letting your migraines run your life”, I said.

Dustin almost squirmed with enthusiasm in his seat, and his mother beamed in her corner of the room.

I continued, “you can up it by 25 mg every week, I’ll send a new prescription for some 50’s, take sumatriptan if you get a migraine, and you call me when you get to 100 mg twice a day, oaky?”

“You got it!”

Dustin stood up, and his mother followed. He was taking charge.

Back in my first year of blogging, I wrote a post, titled “A Day Without a Diagnosis“, about the way we now spend most of our time “managing” chronic diseases, some of which weren’t even considered diseases when I went to medical school.

That’s not how all my days go nowadays: A week ago I had a day of some very real doctoring.

My first patient of the day was a woman in her mid thirties. She told me she had been suffering from hives almost every day for two years. She was taking a once a day antihistamine, loratadine, faithfully and sometimes also some diphenhydramine when the itching got too bad. She had seen a dermatologist and an allergist early on with no resolution.

She also had problem with chronic abdominal cramps and diarrhea. That had also started about two years ago. She had already tries lactose and gluten free diets without relief.

Her hives seemed to erupt when she felt warm, and in her work, she was often exposed to temperature variations. At home, she slept in an upstairs bedroom with poor heating, and wore flannel pajamas under a down comforter. Her hives were terrible at night, but after sleeping on the couch in the living room for a couple of nights, she thought her hives had diminished.

I explained that she has cholinergic urticaria, triggered by heat. I e-prescribed famotidine, 40 mg twice daily and advised her to continue her loratadine every morning, but to also take cetirizine at night and to avoid bundling up at night, which she had already discovered to be helpful. She listened attentively to my mini-lecture on histamine 1 and histamine 2 receptors, their blockers and the overlap between them.

When I moved on to tell her that it sounded like she had irritable bowel syndrome, she seemed to think that was interesting, but when I got to my recommendation of taking Metamucil or a similar psyllium powder to help regulate her bowels, she seemed a little skeptical. “I thought that was for old people”, she said, I explained my rationale, and she said she’d give it a try.

My second patient of the day was a young man who had come to establish care two weeks before. In that first visit it became evident that he was bothered by a high pulse rate of several years’ duration, performance anxiety, elevated blood pressure and erectile dysfunction. His thyroid test had come back normal, and his outside blood pressure readings were all elevated.

I told him I felt a beta blocker would help all four of his problems. I shared with him that in the past, when he was just a baby, we used to choose blood pressure medications according to the overall clinical appearance of each patient, but that in recent years we had been encouraged to choose the same initial medications for all hypertensive patients, based on outcomes data in large groups of patients. I shared that with today’s new DNA profiling aiding in medication selection, we seem to be right back were we were thirty years ago, and that I thought the less common first choice, metoprolol, would fit his clinical presentation better than lisinopril or hydrochlorothiazide.

The same day I saw an elderly woman with terrible pain in her shoulders and thigh pain with walking. She also had carpal tunnel syndrome in both hands. She had seen a general orthopedic surgeon twice, and had some temporary relief after a cortisone shot to her most arthritic shoulder, but her symptoms came back in full force.

I knew in my bones she had polymyalgia rheumatica. I prescribed 10 mg of prednisone twice daily and ordered lab work including a sedimentation rate. Later that day it came back at 96, almost pathognomatic for PMR.

Today I saw all three of them back in follow-up.

The young woman was beaming. “I can’t believe it. Two years of hives every day, and in two minutes you tell me what I have and what to do about it. I haven’t had a single hive in ten days!”

“Great”, I said, “and how’s your gut?”

“Like clockwork, and no cramps. I’m amazed.”

“It’s very gratifying when simple remedies work so well”, I said.

“Well, I am certainly grateful”, she proclaimed as I renewed her prescriptions for a year.

My blood pressure patient had a pulse rate well under 100 and his blood pressure was almost down in the normal range. He could feel how the medicine helped him deal with stressful situations, and, he smiled, his girlfriend sent me her thanks.

My elderly PMR patient had regained all her movement in her better shoulder and had gone shopping in the Mall over the weekend. Her son suggested she might have had a touch of mania on her steroids, but she seemed mellow enough today.

As I wrapped up my work for the day, I thought about the reasons I wanted to be a doctor ever since I was four years old. I always wanted to help sick people feel better and I have come to find great satisfaction in the teaching aspect of medicine.

But not every patient that takes a seat in my exam room is looking for me to do either of those things. Some don’t really want to be there, and some come in hopes that I will fix them without any effort on their part.

The times I can make a diagnosis that brings relief to a fellow traveler are precious, and some days I am blessed with many such opportunities.

Theodore Black woke up two weeks ago with a massive bruise from the left side of his chest to his lower abdomen. He ended up admitted to the intensive care unit and wasn’t discharged from the hospital until today.

“Cough and rash”, was his chief complaint in my clinic schedule that morning. I had an emergency room report from Lakeside Hospital, near where he had spent a week at a conference. Two days before I saw him, he had gone to Lakeside’s ER with a nasty cough and pain across his lower chest and upper abdomen, radiating all the way around his mid-back like a vice. They got a normal chest X-ray, and a normal complete blood count and chemistry profile, so they sent him out with prescriptions for pain pills and some cough medicine.

“I’ve still got this really bad cough, and the pain hasn’t let up”, he started, “and when I woke up this morning, I had this rash…”

He lifted his shirt and exposed a massive bruise running along the left side of his body from the level of his nipple to his hip.

My mind raced into action as I listened to his heart and lungs, palpated his lymph nodes, examined his abdomen by inspection, auscultation, palpation and percussion. His breath sounds were slightly diminished at the base of his left lung, the bruised area was dense and extremely tender. His abdomen wasn’t very tender, except under the bruise, but he had some flank dullness on the right. He hurt too much on the left side to let me percuss him there, and he was unable to roll over on his left side to allow me to check if the right-sided dullness to percussion shifted with a chance in position.

His blood pressure was a little lower than usual, but his pulse was low – which was to be expected with the beta blocker he takes for his blood pressure.

I couldn’t remember the eponym for what he had, but I knew he had massive internal bleeding somewhere. In the back of my mind I thought I remembered retroperitoneal bleeding from coagulopathy or cancer, necrotizing pancreatitis or possibly intraabdominal bleeding.

I ordered a fingerstick prothrombin time, which came back normal at 1.0 and a CBC and a chemistry profile which I knew would be ready in just a few minutes with our new chemisty analyzer. I told him I’d be back as soon as the labs were done.

Back in the office I googled “flank ecchymoses” and saw the eponym I had forgotten, Grey Turner’s Sign. Everything I remembered or just instinctively knew about it matched the monograph I found.

His CBC came back first, and his hematocrit had dropped from 40 at Lakeside to 27 – definitely a massive bleeding. I went back in his room and told him that I not only wanted him to go to the hospital but that I didn’t want him going all the way there in a private car, but in the ambulance. Just as Autumn was calling the emergency dispatch number, Ted’s chemistries came back, with the lowest sodium level I have ever seen, 116 mg/deciliter. It had been 140 two days earlier.

I have seldom seen symptomatic hyponatremia, and the correlation between sodium levels in the brain and in peripheral blood isn’t very predictable, but the literature suggests that people with sodium levels as low as Ted’s are likely to be obtunded or having seizures. He seemed quite normal in that regard. Still, it made me feel good about my decision to recommend that he should go to the hospital via ambulance.

Ted had a chest CT angiogram, showing a modest amount of blood in his left chest cavity, but there was no bleeding or any other abnormality in his abdomen or pelvis on those scans. His pancreas and kidneys looked just fine.

They slowly corrected his sodium deficiency and watched him carefully, but he didn’t lose any more blood and he had no seizures or any other neurological symptoms.

In the end, after his long and likely very expensive hospital stay, he was discharged for the second time on pain pills and strong cough medicine.

The final diagnosis was “Hyponatremia secondary to volume loss from left hemothorax and extensive ecchymoses from severe cough”.

I had expected to hear bad news any day from the hospital, but my first and possibly only sighting of Grey Turner’s Sign turned out to be very benign. My colleagues were aware of my initial observations and this afternoon I walked around and told them how things had turned out.

“I’m sure someone will write that case up and publish it”, Dr. Brown said, probably referring to one of the major medical journals.

“Definitely”, I answered. I never did get around to telling Dr. Brown that I am writing this blog.

So, if The New England Journal of Medicine runs a piece on hyponatremia due to severe internal hemorrhage from coughing, you read it here first.