A Country Doctor Writes:

“I think I’ve tried every medication there is for my OCD”, Debbie Kurbitz said as she pulled out a large notebook from her canvas bag. “I’ve had reactions to all of them.”

Her record keeping was consistent with her diagnosis of obsessive-compulsive disorder. Listed on the pages of her notebook were the doctors she had seen, all the usual medications in our armamentarium they had prescribed and the particular side effects each drug had caused.

I already knew Debbie truly needed something done. She was struggling with rituals like counting everyday objects, words and even the steps she took.

It was clear that Debbie hadn’t done well with SSRI’s, the serotonin reuptake inhibitors we typically use for OCD. She had listed all the side effects I could think of off the top of my head. I concluded she must be very sensitive to these medications

“What doses of these did you try?”

She hadn’t listed the doses she had taken, but her recall was impeccable.

I looked at her list for a few moments before I spoke again.

“I think you might be helped by any one of these drugs, but in much lower doses than you tried before.”

“How much lower?”

“Well, I think Lexapro, escitalopram, would be worth trying again, but I would prescribe the liquid form and start you off with one milligram per day instead of ten, which is what you started with and didn’t tolerate.”

She raised her red eyebrows and put her chin in her hands.

“Take one milligram per day for three or four days. Then, if you don’t feel nauseous at all, go to two milligrams. If that agrees with you, go to three milligrams, but if you are the least bit nauseous, stay with that dose until you feel OK. Work your way up to no more than five milligram per day, and I’ll see you in two weeks.”

“OK…”, she said, but her green eyes almost seemed to roll back in disbelief.

Two weeks later those same green eyes were sparkling under her bushy red hair and eyebrows.

“I feel fine. Not a speck of stomach upset, and I’m not counting anymore!”

I smiled.

“How did you know this would work, or did you just guess?”

“I’ve been around. There are serotonin receptors in the stomach and they make you nauseous the first week on an SSRI like Lexapro. If you can get beyond the first week, you generally don’t have to worry about nausea unless you increase the dose.”

“But I only needed five milligrams…”

“Well, Lexapro has what we call a flat dose-response curve. Many people have the same effect from five as from twenty milligrams, just fewer side effects.”

“So a lot of people are taking higher doses than they need?”

“Possibly. When new drugs are introduced, the drug companies often look for a dose that is effective for the largest possible number of patients. Not everybody has serotonin receptors in their stomachs and brains as sensitive as yours. I suppose if you started everybody off at a very low dose, many people would get impatient and draw the conclusion that the drug wasn’t working and the drug company would lose a sale.”

“I can’t thank you enough. Now, do I still need to see the counselor you talked about?”

“I still think it would be worth your while.”

(The concept of prescribing the minimum effective dose goes back to Greek medicine, including Hippocrates. Many have interpreted his “First, do no harm” as a warning not to be heavy handed with medications.)

Eleanor Burrill reminded me Friday that she turns 90 next month. She has been a patient here as long as I remember, even though she lives in the next town and has to drive 20 miles to get here. We see her once a month or more, because she has to get her bloodwork done to regulate her blood thinner.

She has always been an inspiration because of her vivid intellect and never-ceasing curiosity about how things work, not just her blood sugar, pulse and blood pressure, which she diligently records every day in her monthly planner. Eleanor has a hunger for knowledge and even surfs the Internet. There, she also keeps in contact with her great-grandchildren.

She has always maintained a dignity and a certain distance. I have always thought of her as quite a lady.

She looked serious this time, and after we had taken care of her prescriptions, she told me:

“You know I’ll be ninety next month. I’m afraid I might be getting too old to be driving through moose country to come and see you, especially with winter coming…”

“I can understand that.”

“So I have made an appointment to see the new doctor at Tall Pines Medical Group at the end of next month. Believe me, it was not an easy decision, but I know it’s time. I wish you were closer.”

“You know, I think that’s a wise decision. It will be so much more convenient for you.”

“I didn’t want to hurt your feelings. You have been so good to me.”

“I don’t take this personally at all. You need to be practical and do what works best for you. I hope it works out well for you.”

We both got up from our chairs and shook hands. As I opened the exam room door for her and stepped aside to let her leave the room first, she turned back towards me.

“Thank you. I have a question, though.”

“Yes?”

“If I don’t feel comfortable with Dr. Selig, would you consider taking me back?”

“Of course I would!”

She smiled, turned away and made her way down the hall.

I should have hugged her.

This morning was a whirlwind of patients, paperwork and phone calls from specialists and home health nurses. It was also one of those mornings when nothing went the way I had hoped. Mr. Fielding’s liver biopsy results were nowhere to be found, Mr. Carlson’s CT scan had been done without intravenous contrast even though we had specifically ordered it with contrast, and Ms. Grondin who is on chronic narcotics for back pain had been seen playing Frisbee and doing the limbo at the county fair last weekend. At one point near the end of the morning I was starting to think that I was treading water and not really helping anybody.

My last patient before lunch was Joe Salvino. He was in for a blood pressure check and a refill of his pain medications. He has been talking about giving up his career because of his worsening neuropathy pain. He works more hours per week than I do and admits he can’t say no when his manager asks him to do more. He has researched Social Security Disability and he knows most people don’t get it the first time they apply, and nobody gets it unless they have been unable to work for a long time.

Joe’s blood pressure was finally under control with his expensive combination pill. He didn’t smell of cigarette smoke today. He told me he smokes well under a pack per day now. He still has high cholesterol, but we haven’t tackled that yet. Joe told me a while back he wasn’t ready, but today he told me he is eating better.

I gave him refills for his medications and even though we were running late, I got philosophical with him.

“It isn’t necessarily an all or nothing situation, Joe. Instead of going for disability you could work fewer hours. You don’t always have to be a good sport and make things work for others at your own expense. If you always play the hero, why would your boss not keep piling on more for you to do? ‘Give it to Joe, he never says no.’”

“I know…”

“If this boss won’t meet your needs, there may be others who would.”

“You’re right…”

“I’m not telling you to quit. I’m telling you that you have options, and that things can change. You need to figure out what you need and ask for it where you are or look for it somewhere else.”

I ended the visit by getting up from my chair and handing him the follow-up instructions for the receptionist. Finally, I shook his hand and said:

“I’ll see you in a month.”

His hand squeezed mine back long and hard and he looked straight at me and smiled.

“I like coming to see you. You give me hope.”

Stuart Green had lost his career as a lobsterman due to his bad back. His wife divorced him and he lost his boat and his home on the water. Land-locked and lame, he walked with a cane and had been on chronic narcotics for years.

When I first met him twenty years ago, he had just started seeing a psychiatrist. Stu told me he had hit rock bottom shortly before and there was nowhere to go now but up. His disability had gone through and that gave him health insurance and a steady if modest income.

His pain was partly mechanical with bone-on-bone grinding in his lower back, but also nerve related with relentless burning and weakness in his right leg.

His psychiatrist had him on a mood stabilizer and an antidepressant. These medications seemed to help his depression and also helped take the edge of the nerve pain.

I gave him a low dose of methadone, which did wonders for his pain. His spirits were clearly improved.

Two months into our acquaintance, he told me he had decided to restore his sister’s old boat, similar to the one he had given up, but much older. It now sat behind her barn on her farm near our clinic. He hoped to use it for charter some day.

Over the next few months, Stu got more and more involved with his restoration project. He would come in for his prescription refills regularly, but would never complain about his pain, even though he worked long hours. He had a purpose and seemed to thrive on it. He almost didn’t limp anymore.

I asked about his psychiatrist appointments. Stu told me Dr. Chasse was really helping him feel better about himself.

As winter drew nearer, Stu cancelled a couple of appointments and rescheduled them for bad weather days, so he could get more work done. He was working on the boat outside and was hurrying to get as much done as possible before the first snow.

The week of our first storm, Stu called the office three or four times to rearrange his appointment, but the day he was supposed to come in came and went with no sign of him.

The next day I had a call from the Deputy Sheriff, who had found him.

Weeks later the toxicology report showed that Stu had died from an overdose of methadone and his antidepressant. There was no trace in his blood of the mood stabilizer he had been prescribed.

(Up to 50% of bipolar patients attempt suicide, and 15-20% of people with bipolar illness die from completed suicide.)

Over the years I have developed a friendship with our local small animal veterinarian. He has seen us through joys and sorrows with our cats and dogs and we have shared dinners and some family outings.

Inevitably, we have often ended up talking shop. Medicine is very much the same, whether your patients are adults, children or beagles. We have found that we do very much the same things for the same conditions, but we have a running competition about who has the toughest job.

Calvin C. Carruthers, DVM, C-3 for short, is a highly energetic and charismatic man. He insists his job is tougher than mine because pet owners in this part of the country tend to be less than forthcoming with medical history and useful information when their animals are ill. Calvin’s favorite patient complaint is “Dog Ain’t Right”. He tells me those three words are sometimes the only help he will get from an owner when diagnosing a sick dog. He doesn’t believe me when I tell him some of my patients don’t offer any more details than “I just don’t feel right, Doc”.

Calvin’s job is easier than mine in that he has developed a habit of often taking three and four day weekends and “signing out” to a vet in the next town over, about 20 miles away. He does the same thing when he goes on one or two longer vacations every year. We have accepted these inconveniences, because he is an excellent veterinary surgeon and a good friend. As of this fall, there will also be another veterinarian joining him, which will make his practice independent of call-sharing.

About two months ago our youngest beagle, thirteen-year-old Snickers, developed some swelling of her nose. We were concerned she might have a tooth abscess as Calvin had wanted to do a “dental” on her for some time. That was the week of the North American Lindy Hop festival, and Calvin and his wife were off somewhere in their spectator shoes, grooving to 1940’s music. His office answering machine directed us to the covering veterinarian, who after a fairly quick examination concluded that this seemed more allergic than infectious. We were relieved, but still wondered if this was the correct diagnosis.  

Snickers nose seemed to get better, but two weeks ago she acted a little lethargic and stopped eating. This time, Calvin was in Chicago at a veterinary convention and the young assistant veterinarian of the practice in the next town was the one on duty. He seemed baffled, and speculated Snickers might have had a stroke. He offered to do some bloodwork, but couldn’t get blood from her little legs. At that point we decided to bring the dog to the Emergency Veterinary Clinic in Capitol City.

The Emergency Clinic vet was sure she had a severe tooth infection with early sepsis, or blood poisoning. We agreed to start intravenous antibiotics and after the weekend we saw Calvin, who did the dental surgery last Tuesday morning.

Snickers’ recovery has been slow, but today we see a healthy appetite and a fair amount of tail wagging. She is still weak from her ordeal, but she is on the mend. We regret our delay in getting her teeth done in the first place and for wanting so much to believe the covering veterinarian, who thought Snickers’ swelling was harmless and would go away by itself.

Our seventeen-year-old, otherwise extremely youthful male beagle has started to act strange in recent months. He is drinking a lot of water, pants when we take him for a walk, and is showing a bit of a potbelly even though he has lost some weight. We took him to Calvin for an exam and some bloodwork. Stormy’s blood sugar and thyroid tests were normal and Calvin didn’t think there was any heart failure. Some of the liver tests were a little elevated, which could be transient or the beginning of something serious, so we didn’t have a diagnosis yet.

The other night I was reading from the book I got for my birthday, Harvey Cushing’s biography of Osler. My wife started talking about what might be the matter with Stormy. I closed my book and as we talked about the dog, my right hand came to rest as if I were pointing to the name Cushing on the cover. Suddenly she stopped talking and put her index finger near mine on the book.

“That’s it! Stormy might have Cushing’s! He’s panting, he’s got heat intolerance, increased thirst, potbelly and an elevated alkaline phosphatase. And remember he didn’t shed out this spring. Those are all symptoms of Cushing’s disease.”

My Nurse Practitioner wife may have figured it out first; I just knew the dog wasn’t right.