A Country Doctor Writes:

My uncle in Sweden got hit by lightning twice. He is a stubborn farmer, who twice was a little too late getting his tractor and plow off the field in a flash thunderstorm.

Today I saw Gordon Grass, the man who had surgery for his subclavian steal that I had diagnosed recently. One of his symptoms had been dizziness and multiple falls. Gordon’s blood pressure is now equal in both arms and his brain doesn’t have to share its blood supply with his left arm anymore. But he is still dizzy and lately he has had this strange, irregular clicking in his right ear. It is definitely not his pulse. I had seen him for this a week ago and as his right eardrum looked dull and his Weber and Rinne tuning fork tests were equivocal, I prescribed a nasal steroid spray and told him that would probably clear up his symptoms.

Today he was back.

“I’ve been reading online about acoustic neuromas, and I have all the symptoms”, he said.

“Don’t you know you can only have one rare condition and you’ve already had yours”, I sad with feigned seriousness. He smiled faintly. I repeated his tuning fork tests and did a whispered voice discrimination test. His eardrum still didn’t look quite normal.

At that moment, there was a ruckus in the hallway. I excused myself and left Gordon’s room. Autumn and the receptionist were wheeling a man I’d never seen before, about my own age, down the hall in a wheelchair. He was moaning and writhing in obvious pain.

I instantly remembered Winfield Smith, a patient I had almost twenty years ago. He arrived the same way, writhing in the waiting room wheelchair, and he had an arterial embolism in his leg. We shipped him to Cityside via ambulance and he was soon on the operating table under the care of the same vascular surgeon, then new to our area, who had just taken care of Gordon Grass across the hall.

“It’s my leg, it’s a clot, just like seven years ago”, the stranger in the hall groaned.

“What happened?” I asked as we wheeled him into an empty exam room. His right shoe and sock were already off.

“I was walking to the store and this pain just grabbed me in the thigh”, he said.

“The sheriff dropped him off”, Autumn said. “He flagged the cruiser down.“

I knelt down in front of him, just like I had done when Mr. Smith rolled in the same way twenty years ago, and checked the skin temperature of his right foot. He winced at my light touch. His foot was a little dusky in color and his skin was slightly cool. I couldn’t feel any pulses.

“Let me just get my Doppler”, I said and got my little hand held device from my office.

Same result with the Doppler – no distal pulses.

“Let’s call the ambulance. I’ll alert the hospital” I began. A few minutes later the crew wheeled him down the hall to their rig and I returned to Gordon and his ticking ear.

I told Gordon that it wasn’t likely that he had an acoustic neuroma, partly because of his exam findings and also (I guessed) because the MRA’s he had before his vascular surgery probably would have picked up a tumor. I said I wanted to make a referral to Dr. Ritz, the wise old ENT specialist who bailed me out with my bacterial parotitis case a while back.

“This ticking is driving me crazy”, Gordon said.

“We sometimes prescribe low dose Valium for ear noises, because of how intolerable they can be”, I explained.

“I’ll have some then”, he quipped.

The other day I ordered a CT scan with contrast on a patient with an apparent mass on his neck. I explained about the need to get a blood test to make sure his kidneys could handle the iodine contrast. Because our lab was closed, I had to print a requisition for him to bring to the hospital lab.

Printing a requisition from our EMR is a multi step process that involves leaving the “superbill” (I don’t know what’s so superior about it, but that’s a different topic), going to “chart”, clicking on “requisitions”, highlighting the “creatinine” I just ordered, selecting “in-house lab” even though the requisition is meant to bring to the hospital, selecting “ok”, then getting transported to another screen where I must again highlight “creatinine“, clicking “print”, getting to a pop up window that says “could not find a printer…”, clicking on the name of the only printer on the network I ever use (immediately to the left of my desk back in my office), clicking “ok” and walking down the hall to get the piece of paper, signing it by hand even though it says “electronically signed” and (finally) giving it to the patient.

The next day we got a fax from the x-Ray department with their premedication protocol for iodine allergic patients. I had missed the fact that my patient had an allergy to iodine.

I simply missed the fact that my patient had this allergy, and he didn’t catch my comment about “iodine contrast”. I should have asked more specifically about iodine allergy, and I should have made the detour from “superbill” to “medications” to “allergies” before going to “chart” to go through the steps of ordering the creatinine, but this time I didn’t.

My million dollar system, which doesn’t even have a spell checker, doesn’t know that a CT with contrast requires a creatinine and is contraindicated if the patient is allergic to iodine. It makes me follow a “workflow” that reminds me of my High School introduction, in the early seventies, to the early programming languages of the day (COBOL and Fortran, if I remember correctly) and my first Atari home computer. It is far removed from the $500 iPhone I carry on my belt.

In the days before our EMR, filling out a paper requisition took only a few seconds and gave me more time and mental space to chat with the patient about the test itself while I was completing the task. With the archaic workflows of my EMR, my attention is drawn away from the clinical scenario to the not-so-smart computer in the room.

What was supposed to make the practice of medicine safer and more efficient is, to date, only a gleam in the eye of software designers, politicians and clinic administrators. For those of us in the trenches, it is at least some of the time just a bunch of extra work with very uncertain benefits.

Flossie Marks used to complain now and then about shortness of breath on exertion. She never had chest pain and, after all, she carried firewood from the basement to feed the wood stoves and fireplaces in her large Victorian house. At 81, who wouldn’t be a little short of breath doing that?

Last summer, she finally sold the house where she and Eli had raised four children and hosted nine grandchildren for holidays and summer vacations. After Eli died three years ago the large house had become a millstone around her neck and she had lowered her asking price by more than half before it finally sold. She had confided in me last spring that she didn’t think she could handle another winter there.

She had been so excited when she told me about the cute little apartment she would be moving into in September.

Then in November, I saw Flossie with a concern about nighttime coughing. She had gained some weight, but of course, she wasn’t running up and down three stories and down in the basement anymore.

She confided in me that she wasn’t thrilled with the apartment complex she had moved into. There was loud music and neighbors’ late night arguments sometimes kept her awake.

Her EKG and chest X-ray were normal, and she wasn’t anemic, but her BNP was mildly elevated. I ordered an echocardiogram. That was normal. As I contemplated my next move, Flossie ironically broke her ankle slipping on the wet bathroom floor. She never injured herself feeding the fires in her Victorian, but a wet tile floor put her in a cast boot and crutches.

I needed to proceed with my assessment of her cough and shortness of breath so I offered to do a housecall.

The first thing I noticed when I arrived at dusk for my visit was that several light fixtures outside and inside the building weren’t working. I also heard the music Flossie had told me about as I walked down the dimly lit carpeted hallway.

Entering her ground floor apartment at the back of the building, my nose instantly registered a strong smell of mold and my mucous membranes started to burn.

Flossie was sitting in a recliner with her injured foot elevated and as we spoke, her conversation was interrupted now and then by a dry cough.

“Did you see all the broken lights and did you hear the thumping rock music coming in?” Flossie asked. “I should have moved into the Leblanc Apartments instead – they have more people like me there. My best friend Norma Beck lives there, you know her. The Superintendent there has said I can have an apartment close to Norma’s that becomes available the first of next month.”

“Sounds like that could be a good change for you”, I said, and I thought to myself as my eyes watered from the mold in the air, “it might stop our breathing work-up right there”.

Friday noon, in typical fashion, I seemed to have an emergency on my hands. This time, it was an ocular one.

Philip Brown had driven 35 miles in a steady snowfall to see me. Four days earlier he had been to the Cityside Emergency Room for modest pain and a couple of small blisters on the right side of his forehead. They diagnosed him with shingles and put him on an antiviral. Now he had 48 hours of severe, burning pain in his forehead, where at first there had been only mild discomfort, as well as a new, piercing pain and profuse tearing in that eye.

“Well, we’ve got two things to take care of”, I began. “The pain can be managed with the same medication you took when you had that pinched nerve in your back last year, but we have to figure out exactly what’s going on with your eye.”

He grimaced and struggled to open his eye. With his left eye he could see 20/30 but with his right only 20/200. His squinting eye had a mixed injection – redness that extended all the way to the limbus, or corneal margin.

“Let me get some more equipment to examine your eye with”, I said and headed to the procedure room for the Wood’s light and some fluorescein strips to look for signs of zoster ophthalmicus, the dreaded dendritic fluorescence you can see when the virus attacks the cornea.

I reached for the eye tray on the top shelf in the cabinet over the large stainless steel sink. My heart sank as I fumbled around among its contents. The fluorescein strips were gone.

I knew exactly what had happened. The half full box had December of last year printed as the expiration date. I remember thinking the last time I used them that we needed to order new ones. The ordering of supplies is done by one of the younger nurses at the other end of the clinic.

“Autumn, have you seen the box of fluorescein strips?” I asked, but she hadn’t.

I returned to Philip with the bad news: “I’m going to have to refer you to an eye doctor today, because we ran out of the stuff to look for shingles in the eye. Who do you usually see?”

“Dr. Pomeroy.”

I looked at my watch.

“An hour from here, in good weather.”

“With good eyesight”, Philip added.

Just then, there was a knock and the door opened. A triumphant Autumn handed me the box of fluorescein strips.

“They were on Sally’s desk, ready to be thrown out”, Autumn said. “I left a note for her not to get rid of the old box until the new one comes in.”

Moments later, I knew that Philip didn’t have shingles of his cornea. What he had was a peripheral superficial corneal abrasion at twelve o’clock, caused by a curled eyelash. With the eyelash out of the way, his eye stopped tearing and his pain was instantly reduced by half. On his second trip to the eye chart, he scored 20/25 with his right eye.

With prescriptions and instructions taken care of, I went back to my office, opened my thermos and ate my sandwich.

Just then, Sally, back from her lunch, came in.

“What’s this about the fluorescein?”

I swiveled around and looked up at her.

“Let me tell you a story about how, with outdated equipment, I saved a man from pain and agony and a dangerous two hour round trip in a snow storm…”

Gordon Grass had fallen three times. He said he was always lightheaded.

A slender chain smoker with nicotine-stained fingertips, he didn’t go to doctors much. He was on a blood pressure pill, though, started years ago by a colleague over in Danderville.

I looked at his vital sign display in my EMR. His blood pressure had never been high in the years that I had known him. In fact, sometimes it was on the low side. His typical systolic blood pressure was 130-134, but occasionally it was in the 100-110 range.

His exam was unremarkable when I saw him a couple of weeks ago. I listened carefully for bruits in his carotid arteries, did a standard neurological and ENT exam and even took out my tuning fork to check his Weber and Rinne; everything was normal.

Sitting on my stool opposite Gordon in the drafty, north facing Room 4, its old windows rattling as a powerful nor’easter pounded on the brick walls of the former hospital, I pulled the portable blood pressure cuff stand closer and tightened it on Gordon’s right arm. Sitting, his blood pressure was 136/68, and standing, it was 122/60.

“I think we should stop your blood pressure pill and see how you do”, I said. Gordon said he was happy to get rid of them, and we agreed to check his blood pressure and his symptoms in a couple of weeks.

I knocked on the door to Room 1 and entered the sun-drenched room across the hall from where I had seen him two weeks earlier.

“Feel that solar heat”, I said as he squinted in the warm, bright yellow room. “How are you doing?”

“Better, not as lightheaded.”

I looked at his vital signs. Autumn had entered his blood pressure when she checked him in: 112/62.

“Your blood pressure is lower than last time”, I mumbled, adding “I have read that the effect of hydrochlorothiazide can last for months after you stop it.”

Instinctively, and without speaking, I pulled the wall mounted sphygmomanometer down from the concrete wall between Gordon’s chair and the exam table on his left, tightened it around his arm and pumped up the cuff. Listening carefully as I released the pressure, I, too, recorded a lower blood pressure than last time: 116/60.

“I like the cuff we used last time better, but let me check your right arm also with this cuff”, I said and stretched the tubing across to his right arm. There, his blood pressure was 132/78.

“Hmm, let me check a few things again”, I said and ran my fingers along his neck, his collarbones and in his armpits. I put my stethoscope in my ears again and listened to his carotid arteries and his lungs.

Finally, I took both his wrists and found each radial pulse with my index fingers. I took a deep breath and relaxed. Then I sat quietly as my fingertips registered his pulse, bom-boom, first in his right wrist, and, a split second later, in his left.

“This is the first time I’ve diagnosed this condition in thirty five years”, I began.

I explained Subclavian Steal Syndrome to Gordon; how a blocked artery under his left collarbone causes blood to be shunted from the right carotid artery, across the brain, and downward through the left carotid and into his circulation-deprived left arm, stealing some of the blood that was supposed to fuel his brain.

“There are two ways you can get this condition”, I said. “One is similar to any blocked artery from smoking and all the other causes of poor circulation, and the other is something constricting the artery from the outside, like a cervical rib or a tumor of the lung”.

Gordon made a silent gesture to the pack of Pall Mall cigarettes in his breast pocket.

“Yes, them, either way”, I said. “Let me order some tests…”

A few days later, the Chief of Radiology called me: Subclavian Steal, no tumor.

Next week, Gordon meets with a cardiovascular surgeon to discuss a bypass of his blocked subclavian artery, because he is still symptomatic, even without his blood pressure pill.