A Country Doctor Writes:

A couple of months ago I had a request to connect on social media from a woman named Charlotte something. The name didn’t sound familiar and I didn’t recognize her face. I ignored it, but she tried again a few weeks later. She told me what her maiden name was.

She was my first girlfriend when I was 17. We were explorer scouts and we drank tea together on weekends when I took the bus to see her in the next town over. We once visited her friend, who had an indoor swimming pool. That’s when I decided to have my own some day, which I did. Life happened but we stayed in touch until I was in medical school in Uppsala. Then we lost track of each other.

It turns out she became a social worker, another healing profession. She married and had a son a few years before I adopted my first child. Her son suffered a severe birth injury. When I told her about my books, she told me her son wrote a book with a little help from her.

She sent me two copies, one in Swedish and one in English. I was very touched, by what she told me about her son, how she and her husband have supported him and by the content of the book.

Here are the first two pages of the English version. Note that this boy’s dreams are more about connections with people than his own physical abilities.

My Swedish morning paper has an interesting story about psychiatric prescribing by “net doctors”. 20-39 year olds in Stockholm are heavy users of telemedicine and in this population, 25% of all prescriptions for the antidepressant sertraline (Zoloft) and an even greater proportion of those for escitalopram (Lexapro) are from telemedicine doctors. There is a lot of concern in the psychiatric community about where this might lead, particularly the risk for inappropriate prescribing and inadequate followup.

https://www.dn.se/vetenskap/natlakarnas-forskrivning-av-lakemedel-oroar-psykiatriker/

Leo Dufour is not a diabetic. He is in his mid 50s, a light smoker with hypertension and a known hiatal hernia. He has had occasional heartburn and has taken famotidine for a few years along with his blood pressure and cholesterol pills.

Over the past few months, he started to experience a lot more heartburn, belching and bloating. Adding pantoprazole did nothing for him. I referred him to a local surgeon who did an upper endoscopy. This did not reveal much, except some retained food in his stomach. A gastric emptying study showed severe gastroparesis.

The surgeon offered him a trial of metoclopramide. At his followup, he complained of cough, mild chest pain and shortness of breath. His oxygen saturation was only 89%.

An urgent chest CT angiogram showed bilateral pulmonary emboli and generalized hilar adenopathy, a small probable infiltrate, a small pulmonary nodule and enlargement of both adrenal glands, suspicious for metastases.

He is now on apixiban for his PE, two antibiotics for his probable pneumonia and some lorazepam for the sudden shock his diagnoses have brought him.

I ordered a pulmonary consult and tonight I was thinking to myself: “Does the vagus nerve sometimes get compromised by hilar masses or adenopathy?”

My first search hit was a 2014 article about a previously unknown association between gastroparesis and pulmonary adenocarcinoma. It has been associated with upper gastrointestinal cancers since 1983 and also with small cell lung cancers and pancreatic cancer.

So my compromised vagus theory may or may not be relevant, but the general link with malignancy was news for me.

As so often in medicine, one diagnosis leads to another.

(For some reason, Labor Day this year makes me think of my first experiences on the Labor and Delivery unit – 40 years ago this month!)

“Please call 2350 STAT” were the most dramatic pages I got during my residency. It was Labor and Delivery at Central Maine Medical Center in Lewiston. I can still feel the mixed worry and excitement that call gave me. I never felt anything positive being called to a code or other medical urgency. I don’t revel in the drama of disease, even though I, obviously, handle it. Delivering babies, with or without the drama, had its own magic.

I had a reasonable education in office gynecology in medical school. But obstetrics is more of a carve-out in Sweden, something family doctors, or allmänläkare (general physicians) don’t really come in contact with. Prenatal care and Infant care are (or were, at least back then) centralized at clinics that sometimes, but not always, were housed in a primary care office building. They are still viewed as their own specialties and mostly nurse-run under protocols with physician supervision.

Because my medical school was 5 1/2 years compared with the US 4 year curriculum, I felt better prepared, medically, than my fellow residents. I started my American residency having already had hands-on experience in the “smaller” specialties people think of as surgical sub-specialties: otolaryngology, orthopedics, ophthalmology and so on. But I had a fair amount of cultural catching up to do, learning where the Americans did things differently than the Swedes. I knew the diseases, but drug choices and general approaches were sometimes very different.

Obstetrics was an entirely new field for me. The Lewiston program was known for its strong OB experience, which is not why I picked it. I was looking for a program in Maine and liked what I saw in Bangor and Lewiston more than Augusta or the urban Portland. But Bangor seemed so far north – and here I am, practicing almost 200 miles further north of Bangor today! I also resonated with the faculty in Lewiston.

So there, wouldn’t you know it, OB was one of my first rotations. It was a trial by fire. I learned so much, so fast. And, wouldn’t you know it, the fist delivery I did on my own, with the summoned obstetrician guiding me from the delivery room doorway, still in his street clothes, was a double footling breech. Everything turned out just fine, but I decided right then and there that I would not be doing obstetrics in my own practice.

But, even though I never practiced obstetrics after I left Lewiston, some of my OB experiences have etched themselves in my mind and helped form me as a physician.

I still think about the woman in tears about her unwanted pregnancy that turned out to be a beautiful baby boy that strengthened her whole family. And I still remember the woman who thought she was too old to become pregnant and the magical moment when we listened to her fetal heart tones, both of us holding the Doppler in silence.

Knowing how to deliver a baby made me a better doctor, even though I chose not to continue doing it. It made me comfortable during snowstorms with closed roads in northern Maine. It made me comfortable doing my routine well woman care. The number is only my best estimate, but I can honestly say to a female patient, “I’ve delivered close to a hundred babies”.

Off The Record

Good, Strong Heart Beat – 140 and Regular

Especially in these strange and uncertain times, many people feel uneasy. Some of them come to us with concerns over their state of mind.

In primary care, our job is in large part to perform triage. We strive to identify patients who need referral, medication or further evaluation. We also strive, or at last should strive, to reassure those patients whose reactions are normal, considering their circumstances.

A set of emotions we consider normal during the first weeks of the loss of a loved one may constitute pathology if protracted or if there is no apparent trigger.

But what is normal in today’s reality?

People today often have a low tolerance for deviations from the mean. They measure their heart rates, sleep times, steps taken, calories eaten and many other things on their smartphones. They compare their statistics to others’ or to their own from different circumstances.

Is it normal to sleep less when the last thing you do before bed is take in the latest disaster news? Is it normal to have a higher resting heart rate when you are threatened by eviction? Is it normal to feel sadness that life as we knew it doesn’t seem to be within our reach right now?

The worst thing we can do is tell people there is something wrong with them if we see them doing and hear them expressing what many other people also do.

It’s bad enough to feel bad, but even worse if you think your reaction is a sign of psychiatric illness or psychological or constitutional inferiority.

Not everyone checks in with other people if they feel the same way, and not everyone gives themself permission to feel bad.

Just like some people expect their body metrics as measured with their devices to be “normal”, many in today’s culture don’t expect to feel the ups and downs that life brings us. And right now, the “downs” seem to be piling up, to coin an oxymoron.

Just like there are people who prefer to live where all seasons have the same weather, there are those whose tolerance for emotional winters is low.

Well, snowstorms happen in Texas and hurricanes hit New York City these days. The Bell curves for all kinds of things are shifting.

We must find ways to help people see the difference between endogenous and exogenous states of emotion, and we must help each other accept that you cannot expect to feel “normal” when the world and the times are not.

We must find ways to be supportive without medicalizing valid and appropriate emotional reactions. We should probably not pin new diagnoses of anxiety and depression lightly on people right now.

Adjustment reaction with [this or that] mood seems like the way to go under these circumstances.