A Country Doctor Writes:

Henry Halvorsen was in to see me the other day. 79 years old and usually brimming with optimism and vitality, he seemed subdued and frail. His weight loss and muscle weakness were obvious.

“Good to see you, it’s been a long haul”, I greeted him.

“Three surgeons, two CT scans, two hospital stays before they found out what was wrong with me, and then rehab and everything that happened there”, he said, exasperated.

It had started when I saw him in the office at the end of February. He had been in three weeks earlier with a flare-up of his recurring back problem. That had cleared up, but Henry was having some bowel trouble, mostly constipation but then sometimes a day of loose stools. He thought it was his muscle relaxant that caused his bowels to act up, but his bowels didn’t straighten out after he stopped his cyclobenzaprine.

He wasn’t running a temperature, but his appetite was off. He was definitely a little tender deep in his right lower quadrant, but there was no involuntary muscle guarding when I let go of the pressure with my hands. I ordered bloodwork and a CT scan and told him that even though his pain and irregular bowels had been there for a whole week, he could have a subacute appendicitis.

His white blood cell count came back mildly elevated, and his sedimentation rate was elevated at 40 mm. The wait for the CT seemed long, but he was feeling better. Then, the day before his scan was scheduled, he woke up with worse pain and severe diarrhea, so he went to the emergency room. The ER physician, Jack Morton, told him right away he was suspicious of appendicitis.

His blood count was a little higher, and his sedimentation rate was 50. His abdomen was mildly tender, as it had been in my office. The CT scan showed no definite abnormalities, but the appendix was not visible.

The surgeon who saw him didn’t feel there was quite enough reason to remove his appendix, and with intravenous fluids and bowel rest, Henry started feeling better. Another surgeon did a follow-up evaluation on the weekend and Henry was discharged home on the third day.

Two days later at one o’clock in the morning, he woke up with abdominal pain, followed by a very large, soft bowel movement. He had chills and felt nauseous. He called the ambulance and arrived at the emergency room actively vomiting.

Dr. Morton was on that night, too. He ordered the same bloodwork again and another CT scan. This time there were signs of a small bowel obstruction and free fluid in the abdomen. There were nonspecific inflammatory signs in the right lower quadrant but the appendix was not clearly identified.

The surgeon on duty that morning didn’t hesitate. In short order Henry was on the operating table and had his ruptured appendix removed and two Jackson-Pratt drains placed. He received intravenous antibiotics and spent the next few days mostly sleeping with a Foley catheter draining his urine and a nasogastric tube draining his stomach.

At the rehab, where he was receiving intravenous antibiotics, he developed urinary retention shortly after his catheter was removed. The nurses were unable to reinsert a catheter due to his enlarged and inflamed prostate. Henry had to be transported back to the hospital where his urologist managed to get a Foley in. Then, back at the rehab, he developed diarrhea again and was diagnosed with Clostridium Difficile enteritis, resulting in more, but different, antibiotics.

As we went over everything that had happened to him, he sighed and said “I’m lucky to be alive”.

I nodded and mused out loud. “It’s such a common disease, but it can present in so many ways”. I thought about the first CT scan and the first surgeon’s decision not to perform an unnecessary operation.

I told him when I was a resident in Sweden, surgeons used to talk a lot about what percentage of innocent appendices you needed to operate on in order not to miss any guilty ones. Between 15 and 40 percent of emergency appendectomies have been reported to reveal a normal appendix, and yet 20 percent of appendicitis cases are initially misdiagnosed.

By the time I did my residency here, my hospital had just installed its first CT scanner, and the diagnosis of appendicitis was no longer a purely clinical one. In some centers, the diagnostic accuracy of CT scanning is said to be as high as 98 percent. But, when the tests are inconclusive or, worse, wrong, it is still a hard judgement call whether to operate or not.

Older patients tend to have less typical symptoms and are diagnosed later in the course of the disease than younger patients. While most cases of appendicitis fulminate within 48 hours, in 2 percent of cases the duration is more than two weeks.

“I’m just happy I pulled through”, Henry said as he rose from his chair with obvious effort.

I shook his hand and answered, “I am, too, and we should all be humbled that the great trickster almost did it again.”

It’s another Monday morning at the substance abuse clinic. It is my turn as the doctor in the black swivel chair in the corner office overlooking a half-vacant strip mall.

Today’s first inductee is a pregnant 22-year old with track marks on her forearms. Her obstetrician and caseworker at the Department of Human Services made her come. It is obvious she is less than thrilled.

“How long have you been doing opiates”, I ask with my fingers hovering over the keyboard. She tells her story, first in monosyllabic monotone, but as we move through the questions and she realizes I am not there to lecture her on anything, she warms up a little.

Because she is pregnant, she didn’t arrive here in withdrawal out of concern for the fetus. Her last use was the night before. I explain how to place the Subutex tablets under the tongue and avoid swallowing, so the medication is fully absorbed through the mucous membranes of her mouth. Then I fill out the prior authorization form for Medicaid. I make sure to put her due date on the form, so she will be approved until she delivers. Then I write the prescription, sign it and spell out my name and my special DEA number for opiate replacement prescriptions.

My next inductee is in a cold sweat. He is the same age as my own son. He snorted some Oxys and Ritalins Friday night. Today he has the shakes and the runs. He has no job, is in trouble with the law, and he has been here before, but was discharged because of repeated failed urine drug screens.

I document his COWS score, the degree of physical withdrawal he is in. He had been doing high doses, so I prescribe him 16 mg of Suboxone daily. I explain that since last time he was here, we have switched from tablets to strips that melt under your tongue the same way. He knows; he knows everything about opiates. Is he here again because of his circumstances, I wonder, more than from a deep desire to quit right now? His counselor’s notes in the computer record have a hint of skepticism in them.

“I hate coming here”, says my third patient for the morning. He is a foreman at a nearby factory, logging week number 178 in the program. He is on 2 mg per day. Going from 3 to 2 mg, he had a terrible time with both physical symptoms and cravings.

“I wish I didn’t have to be on this stuff. I want to be over this. I sit in the waiting room with these people who trade stories about what they have done, and I don’t want to hear it. I have a job, a family, and I hate having to come here for my lousy prescription, but I know I can’t keep my life together without it.”

Fourth up is a woman in her forties I haven’t seen before. She transferred in a week ago when Dr. Feiner sat in this chair. I recognize the woman’s name. She is a physician, who just lost her license a few months ago. She is stable on her dose. I write the prescription and she leaves quietly.

The next patient is a mother of two, who just had surgery for ovarian cancer. She is in obvious pain. We had talked last time about how Suboxone does help with pain, but it is not all that potent. She had told me then that she was more afraid of falling back into addiction than being in pain.

This time, she is tearful. Her cancer has already metastasized, and she speaks of what will happen to her two girls if she can’t be cured. She winces with pain, and I ask her again if she is sure she wants to stay in the program. Her husband already manages the Suboxone strips for her, and he could manage pain medications for her as well. But she knows that the naloxone in her Suboxone strips keeps her from feeling the same high that other opiates give.

“I am so grateful for what this program has done for me, that I don’t want to risk that, even for this”, she says and points to her abdomen. “Whatever time I have left..” She chokes, tears streaming down her cheeks, and blows her nose with tissue from the box on the corner of my desk. “Whatever time I have left, I want to be sober, and I want to be all there for my girls and for my husband. I don’t want to be strung out.”

“I hear you”, I say. But you are in pain, I can see that.” She nods.

“I’m going to increase your dose back up to our maximum. That will make some difference. But you may be helped by something like a fentanyl patch, that stays on for three days at a time…”

“Thanks, but this is fine”, she says as she takes her new prescription and strains to rise from the visitors’ chair by the window.

I rise and open the door for her. Then I close it and sit down quietly in my black swivel chair for a few minutes as I look out over the boarded-up windows of the empty storefronts across the parking lot.

I don’t hate coming here, as some of the patients do. It is sobering to think back on the ones who are forced to come here, the ones who come here when they can’t afford their drugs of choice, the ones who fight valiantly to get their lives back in order and the ones who have lost, or are about to lose, everything.

The other day Bigtown Pharmacy sent an angry fax addressed to me. It was a printout of an electronic prescription I had sent the night before. Scribbled at the bottom were the words: “Unit field can’t say unspecified. Please correct”.

I looked at the printout, which was actually a fax they had received from the prescription clearinghouse that connects doctors and pharmacies. Even though I enter prescriptions in my Electronic Medical Record, that pharmacy receives it from the clearing house via fax.

My prescription was for lancets for a 72-year old diabetic to check her blood sugar once a day. But it didn’t say “lancet”. It said “lancer”. My first thought was that my two-fingered typing had offended the Bigtown pharmacist.

The way electronic prescribing works, at least in my EMR, is by having every medication available in this country already programmed into the prescription module, so there can’t be any misspellings or ambiguities of which drug I want my patient to have. But medical supplies like glucometer strips and lancets are not in the system, so they have to be entered manually, which means my computer program doesn’t know at all what I am prescribing; it’s just a bunch of letters to it. The same thing happens when I prescribe a Canadian medication, not available in this country, for patients who cross the river for their prescriptions; the computer can’t check for allergies or interactions because the drug had to be “manually entered” instead of picked from its list.

As I hastily had entered “lancer” instead of “lancet” in the box for “unit” in my EMR, I assumed at first that the angry pharmacist didn’t tolerate any typos, but as I looked closer at the fax, I realized that there was more to this.

The layout of the form didn’t look anything like the layout of my prescription screen. There was a field titled “unit”, and it said “unspecified”. The misspelled word appeared in a free-text window a little below, so the context seemed obvious, even if the spelling was off.

I called Bigtown. The pharmacist explained that Medicare will not pay for my patient’s strips if any of the boxes, particularly the “unit” box, is not specific enough. This is apparently a new requirement. That sounded similar to the “meaningful use” criteria medical practices have to meet in order to get paid under the new health law. One of those requirements is to reach a certain percentage of prescriptions done via the computer instead of on paper prescriptions or sent via fax.

As I was talking with the pharmacist, I pulled up my patient’s prescription log and there was my misspelled “lancer” just where it belonged in the “unit” box on my screen, even though it was missing on the pharmacy’s fax.

“Lost in translation at the middleman”, I mumbled to myself. I asked the pharmacist:

“It is entered correctly, except the spelling, at my end. What can I do?”

“You can free-text ’Unit: Lancet’ anywhere, and we can accept it.”

“Will do”, I said and typed it into the comment field. Then I moved the cursor up to my own “Unit” field and corrected “lancer” to “lancet”. I couldn’t just leave it blank, because if I did that, my EMR wouldn’t send it electronically; I, too, have to fill out all my boxes, even if the receiver can’t see them. After all, I still have to meet my own “meaningful use” requirements.

A couple of weeks ago I wrote a post titled “Never Assume” about a handful of patients, whose case histories took an unexpected turn.

Well, as it happened, a few more twists and turns unfolded since then:

Peter Bartley, the man with upper abdominal pain and black stool, not just from the Pepto-Bismol he had taken, had his upper endoscopy. It only showed some mild gastritis without bleeding. Fortunately, the surgeon also did a colonoscopy, which showed an actively bleeding polyp almost the size of a clementine in his transverse colon.

Black stool is generally thought to be from the stomach or duodenum, located above the ligament of Treitz. It has been said that it takes the digestive juices 14 hours to change the color of our hemoglobin into black melena. Peter’s intestinal transit time must have been slower than most people’s for this to happen with a bleeding polyp in his colon.

Norma Daigle, who had received another patient’s trazodone and Lexapro, called the other day and told Autumn she wanted some trazodone of her own, because it had made her sleep so well.

Beatrice Nash, whose hip pain seemed to come from a mass in her left pelvis, had her CT scan. It showed a very large probable lipoma, a harmless fatty tumor. She has seen the surgeon, who wrote in his not that she described the pain as sharp and coming directly from the hip, and not at all from somewhere higher up than that. He didn’t think the lipoma had anything to do with the hip pain, and recommended she see an orthopedic surgeon.

As it happened, a few days later she had a follow up visit with her orthopedist for a cortisone shot to her arthritic knee. I eagerly read through his note to see if he thought her pain was from the hip joint or not, but there was no mention at all of her hip pain!

Diane Fehrer, who never seemed to remember to take her thyroid medication, accepted the pharmacy’s offer to put her pills in monthly calendar bubble packs. I am keeping my fingers crossed that she will remember to look at the bubble pack every day, and I keep wondering: If she does take her levothyroxine every day, will my prescribed dose be too high and cause her tremors, palpitations or even atrial fibrillation?

Finally, Matt Wikert, the physical therapist with high blood pressure and chest pains, showed up at the hospital for his stress test as planned. Earlier that morning he had a 45 minute episode of chest pain. His EKG showed some subtle changes from the one I had done, so the stress test was cancelled and he was admitted for observation. He ruled out for myocardial infarction and was discharged with plans for a rescheduled stress test. We still don’t have a date for it.

Every day, just like that day a few weeks ago, I see patients whose stories don’t quite fit the expected pattern. In the words of Sir William Osler:

“Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease.”

Peter Bartley came into the office today with a two day history of black, tarry stools. The day before this started, he had had a terrible case of indigestion and took several slugs of Pepto-Bismol to quiet it down. This had helped, and he was feeling quite well today, but the color of his stools bothered him.

“His stools are probably black because of the Pepto”, Autumn said as she filled me in. I had another patient to see before Peter, so I asked Autumn to get orthostatic vitals on him while I went in to see Norma Daigle for her regular 3 month visit.

Norma’s thyroid test was normal, and her blood pressure was stable, but she looked very concerned, and she was clutching a pill bottle between her hands.

“Bigtown Pharmacy delivered this yesterday along with my other medicines, but I don’t know what it was for, so I didn’t take it”, she said, adding “there was also a bottle of trazodone, and I took one of those because I used to take them and I knew it worked good helping me sleep”.

I looked at the bottle. It contained escitalopram, the generic form of Lexapro. Norma is on lithium and Prozac. Lexapro in addition would be redundant and could bring on a manic episode if she were to take it for any length of time. At the upper right hand corner of the label was the prescriber’s name, a psychiatrist at Cityside Hospital.

“It’s from Dr. Hirsh, did you ever see him?” I handed the bottle back to her. She frowned and said “never heard of him”.

I called Bigtown Pharmacy on my cell phone. I posed my question and was put on hold for less than a minute. The pharmacist came on and admitted they had made a mistake. The medication was for Nancy Daigle, another patient of mine.

The pharmacist asked “Can we pick the medications up at your office this afternoon?”

“Well, one bottle is here and the other one is at the patient’s house”, I explained.

“Tell her we’ll pick both up at her house”, said the embarrassed pharmacist.

“Good thing you read labels”, I said to Norma, who just sat there, shaking her head.

Peter Bartley’s standing blood pressure was the same as when he sat down. His pulse was normal. As I placed my hand in the upper center of his abdomen and pushed slowly downward, he winced a little. His black stool tested strongly positive for blood. I told him it looked like he might have a bleeding ulcer and not just black stool from Pepto-Bismol.

My next patient, Beatrice Nash, was in for pain in her left hip. She had already been to the emergency room for this, and her hip x-ray had been normal. As I listened to her symptoms, I knew this was no ordinary groin pull, as the emergency room doctor had thought.

“I hurt more after I stand for a while”, Beatrice said.

“Show me where”, I asked her, and she put her left hand over the bony pelvis, well above the hip joint. Both hips and both knees had full movement without pain, her straight leg raising test was normal, there was no pain when I resisted her hip movements, and there was no groin hernia when she stood up. After she laid down on the exam table, I palpated her abdomen and there, deep in the left lower quadrant, was a tender mass.

“Is this where you hurt when you stand up”, I asked.

“Yes, that’s where I hurt”, she answered.

“We need to get some bloodwork and a CT scan of your abdomen and pelvis”, I said, “because it doesn’t look like your hip is the problem. You might have some sort of cyst in your pelvis.” I was worried this could be a tumor, but felt pleased that I had come up with a plausible explanation for her pain.

Diane Fehrer’s TSH was even more out of range than last time, when I bumped up the dose of her thyroid medicine, and she was feeling very tired.

“Are you sure you haven’t missed any pills”, I asked her, but she said she was sure she always remembered to take them. “Let me just double check with the pharmacy that you got the right strength”, I said and pulled out my cell phone. The pharmacy technician’s answers to my questions explained her slipping thyroid status: Diane had not picked up her old dose of levothyroxine for several weeks before her previous blood test, and last months’s new prescription was still waiting for her at the drugstore.

Next up was Matt Wikert, who had run some high blood pressures at home. The other day at at the nursing home where he is working as a physical therapist, the nurse had recorded 178/98 and had wondered if I wanted to see him right away. I said to have him check it a few more times and see me today. His pressure at check-in was 148/80.

“So your blood pressure looks better today. How are you feeling”, I asked.

“Well, I still have some pressure in my chest…”, he began.

My heart sank. The nurse had not said anything about chest pain, and I had not specifically asked. I know better. Fortunately his EKG was normal, and the character of the pain was quite atypical, so it probably isn’t angina, but, still, it was a sobering reminder that you really can’t assume anything in the practice of medicine:

A chief complaint is often only the patient’s self-diagnosis, or interpretation of a symptom. A high blood pressure can seem more significant than a vague pressure in the chest, and a pain above the hip can seem easier to explain as a hip pain than something there is no word for.

A pharmacist or a physician can get their patients mixed up, and patients forget their pills more often than we’d like to believe.

Not all patients with black stool while on Pepto-Bismol have black stool because of the Pepto-Bismol. Some have a bleeding ulcer, which is why they took the Pepto-Bismol in the first place.

And, if we hurry in our work, we are more likely to assume, instead of evaluate and examine thoroughly.