A Country Doctor Writes:

I was telling Autumn in the last few minutes of my “early dismissal” Friday before the Labor Day weekend that this was so much easier than in the earlier parts of my career.

Thursday I saw a man with a strange leg pain and swelling halfway down the lower leg as well as tenderness on the inside aspect of his thigh. The knee was a little swollen but moved just fine and the tenderness there was both above and below the joint.

He had already been to the ER and their workup included an X-ray but no labs.

I did some inflammatory markers that were mildly positive, a normal CPK, suggesting no muscle damage and a normal uric acid level, speaking against but not ruling out gout.

I had also ordered a D-dimer because there was tenderness over the femoral vein but no pain with testing the nearby adductor muscles against resistance. My strongest clinical impression was that this was an inflammatory process, so I prescribed prednisone.

2 pm Friday, going through labs before the big weekend, there was the D-dimer result: Mildly elevated.

The X-ray department had no openings for an ultrasound.

In the old days the choice would have been do nothing or send him to the emergency room where they would either commandeer an emergency ultrasound before releasing him or admit him for a heparin drip until a clot could be ruled in or out. Then, if he had a DVT, he would have been on heparin until his warfarin became therapeutic.

Today, I just called him up and explained about the test not being able to rule out a clot but could be a false alarm, for example due to inflammation. He had less pain, but no decrease in swelling.

I explained today’s choices, doing nothing until we could get an ultrasound or playing it safer and take samples of apixiban over the weekend as if he did have a clot and staying on it until we could get an ultrasound.

He chose the latter. I bagged up some samples and left them at the front desk. I walked out the back door almost on time, thinking again how much easier some things have become since I started out.

UPDATE, DAY AFTER LABOR DAY: THROMBUS IN PROXIMAL GREATER SAPHENOUS. “KEEP TAKING THE ELIQUIS THE WAY WE TALKED ABOUT AND SEE ME NEXT WEEK FOR A FOLLOWUP.”

Muriel complained of cold feet but they felt warm to me. Martha’s cold feet had bluish, red blotches on most of her toes, which hurt so much she begged for pain medication. Mary’s feet were cold with steadily darkening blue toes and they hurt so much she refused to wear shoes.

In each of my clinics I have a pocket Doppler, good for recording peripheral blood pressures and listening to fetal heart tones. That little device has made it easier to triage the symptom of cold feet.

Muriel’s calf blood pressures, recorded at the posterior tibial artery with my Doppler, was 160, greater than in her arms. “Water pressure in the basement is usually higher than on the top floor”, I always explain as I do the procedure. But she had decreased monofilament sensation, so in her case it turned out to be a search for the cause of her peripheral neuropathy.

Martha’s painful, discolored toes felt only a bit cold, and the rest of her feet had normal temperature. Her calf blood pressures weren’t bad, but she had femoral bruits and a CT angiogram showed severe atherosclerosis of her aorta and iliac arteries; she was throwing emboli into her toes, causing the pain and the discoloration. The vascular surgeon explained to me on the phone “we call them trash toes”. The emboli aren’t pure blood clots, but more plaque fragments. So anticoagulation, he answered my question, doesn’t do much. What she needed was a new aorta. One vascular surgeon wanted to stent her, but she ended up with a second opinion from the one who told me about “trash toes”. He said she was too young to expect a stent would last her lifetime. He recommended a graft. She went for it and did well.

Mary had Raynaud’s disease, a manifestation of scleroderma. She eventually developed dry gangrene. This was early during the pandemic when specialty consultations were hard to come by. The rheumatologist I talked to approved of my nifedipine prescription, encouraged me to treat the pain and said, “don’t let the surgeons near her”. He ended up leaving the state and she eventually saw another rheumatologist and a vascular surgeon. The two of them decided together to amputate the affected toes.

Two men who presented with more than just cold feet are vivid memories from my career. They were screaming with pain from sudden onset of pain in only one foot. The first one happened to come in just after we purchased a Doppler at my downstate clinic. He lived very close to our clinic. His foot wasn’t all that cold, but he had no dorsal pedal pulse by Doppler due to major embolization. He did well with his surgery. The second one was up north, where I had asked for a Doppler shortly after I arrived. He had the same classic presentation. It helps to know that there is absolutely no pulse, because your fingers often can’t palpate a weak pulse accurately. In both of these cases the diagnosis was firm. We called the ambulance and the hospital was ready for action.

Today I saw a woman with foot pain, bluish toes and excellent blood pressure at her calves. She carries a diagnosis of rosacea, and when she removed her mask for me, her cheeks looked much worse than I remember them. “It’s this mask”, she said.

“Maybe, but I’d like to do a bunch of blood tests to see if you have an autoimmune disease”, I explained. Was this an innocent Raynaud’s phenomenon or Raynaud’s disease secondary to previously unrecognized lupus? We will soon know. I started her on nifedipine while we wait for the blood test results.

A common symptom we may not always pursue can be big trouble:

“Feet cold, huh, let me see…”

This is just what the title says. All doctors know that a progress note is our way of documenting the development of a diagnostic or therapeutic process. In fact, for the longest time I pictured my default post category, “progress notes”, would be the title of my first book. It will instead be the title of another book later on in my A Country Doctor Writes series.

A commenter called yesterday’s post “the best post of your career”. I won’t try to top that right away today, but will instead take that as a reason to stop and reflect on where I am.

Since I started blogging on April 28, 2008, I have published 818 posts so far before this one. Today I got the announcement from WordPress that I exceeded 500,000 lifetime page views on my blog. I also have broken my previous annual 67,021 view record from 2017. So far this year (10:30 pm 8/30/21), I have had 102,953 page views. And in the month of August 2021 I have posted 29 out of 31 days.

I have posted 19 videos, available on Vimeo and on A Country Doctor Talks (with a permanent link in the MENU), but I may not continue double-posting them on A Country Doctor Writes also.

I have also, finally, activated HOW TO BEAT DIABETES, because there is still too much confusion and misinformation about how to deal with (and cure) type 2 diabetes in overweight patients.

I have tweaked my social media buttons in the sidebar of this blog. I still have a “company page” on LinkedIn and Instagram, but I have redirected my Facebook link to my personal, public, Facebook page. I don’t need to be “friends” with everybody, because I only have that much time to keep up with other people, but if anyone wants to know what this 68 year old Swedish born family doctor working within walking distance from Canada is up to, there it is.

I am a regular contributor, featured on the masthead, of The Health Care Blog and an occasional contributor to The Deductible and KevinMD. My work is often reblogged in Australia. Today I finished an interview with Medscape News (for an article going live on 9/1/21) and I may be writing now and then for them.

I have found, a little bit to my surprise, that the more I write, the more ideas I get for what more to write about.

I’m having the time of my life, doing two of the things I enjoy the most: Doctoring and Writing.

Thanks for keeping me company of my journey.

The Enlightenment, or the Age of Reason, was that time in the 1700s, quoting Wikipedia, that “included a range of ideas centered on the pursuit of happiness, sovereignty of reason, and the evidence of the senses as the primary sources of knowledge and advanced ideals such as liberty, progress, toleration, fraternity, constitutional government, and separation of church and state”.

And here we are: Much of the world is struggling too much just to survive to worry a great deal about happiness. Sovereignty of reason has given way to “alternate truths”; the evidence of the senses no longer informs almost half of the US population; the ideals of liberty, progress, toleration and fraternity are not at all shared – not in this country, and nowhere else that I can think of. And our constitutional government was within a few feet and a couple of gunshots from crumbling just over six months ago. As far as the separation of church and state, this country has never truly done that. Their constitutional powers were certainly separated, but Protestant ideology has always influenced American politics. And now the Bible, at least briefly, has been used as a prop by a President who very successfully folded fundamentalist Christians into his antisocial, anti-science, intolerant mob campaigning against the principles this country was built on.

As we face a pandemic of a rapidly mutating virus, almost half our population is more afraid of the vaccine than the disease that has killed 637,000 Americans as of this writing. And a small, however imperfect measure, of wearing a mask in public has become a matter of pride and a symbol of individual freedom by selfish people who won’t even try not to be spreaders of disease.

The conspiracy theories suggest vaccinations and vaccination identifiers will be the actual manifestation of the biblical Sign of the beast, part of a grand scheme to annihilate scores of people.

This did not happen with smallpox, and nobody I’ve talked to harbors such grand delusions about flu shots, even if they don’t like them.

Just a few years ago we marveled at a pill, albeit an expensive one, that cures hepatitis C. Before that, we got drug cocktails that stopped HIV from killing its victims. We have, during my career, seen cancer cure rates thought impossible in the 1970s. Genetic deadly diseases like Phenylketonuria (PKU) don’t exist anymore, except in very small numbers of surviving patients born in the years before screening was introduced.

I am no friend of the drug companies’ business tactics, but I acknowledge and respect the cures they have brought us.

Indeed, here we are: We live in a country where a sizable minority is going backward, rejecting science and common sense. They drive their motorcycles to tightly packed rallies; they harass store owners who ask patrons to wear masks; they lock themselves out from the “established” sources of news – to be sure they hear only what they want to hear.

Things are looking pretty dark. Because science has become a dirty word in the minds of almost half our population. Because more people than necessary will die from this disease. And because we are more openly divided than we were just a few years ago.

There are many cultures in this country who “do their own thing”, but when we face the biggest threat to mankind in generations, half of our citizens are not finding enough common ground with the rest of us to do even the basics.

God help America, God help us all. Raised Protestant, I write these words, because we as a nation are clearly not united in helping ourselves. And that is what it would have taken to avert what I’m afraid is likely to happen in the coming months.

I am not worried about myself. I am worried about our larger community and our nation. If things go better than my worst fears, it will be in spite of the naysayers; it will be due to dumb luck or divine intervention, not because everybody did their part.

I am a 68 year old family physician in rural Maine. This morning I read yet another article about physician burnout, this time in The New York Times. (I’m not linking to it, because they have a “paywall”.)

I did not end up exactly where and how I expected to be at the end of my career, or life in general to be brutally honest. But I am the happiest I have been since the beginning of my journey in medicine.

I have a balance in my life I didn’t have, or even seek, for many years as I juggled patient care, administration, raising a family and pursuing interests that often brought me away from home.

My days in the clinic are a bit shorter than they used to be, but in the past several years I have had to do much more work from home – even more so in the last two. The “half-empty glass” way to look at this is that work has intruded more into my personal life and my home. The “half-full” view is that I can do my computer work when it suits me the best. For one of my clinic positions, I can do charting on an iPad mini in bed, coffe on my nightstand and sleeping dogs at my feet. The clumsier EMR requires a laptop (which in my view can’t be used the way its name might suggest) I sometimes work on in the barn and sometimes on a picnic table in the grass outside.

Ironically, the pandemic has brought me a peace and clarity I probably wouldn’t have achieved otherwise.

I had thought moving back to Caribou for a position with no administrative responsibilities would open up social opportunities I hadn’t allowed myself for the last few years. I expected to become involved with the Swedish community here, connecting more with neighbors and other horse owners, and so on.

But the lockdown forced me to sit more with my own thoughts, my own feelings and memories. It forced me to consider, not for the first time but again, that in this unpredictable life, the only sure thing is that I am me and I am where I am.

When I, as many other people, realized that this pandemic could wipe out countless people including myself, and completely change the living conditions for those who survived, it completely freed me from worrying about the small stuff. Or, rather, from considering the small stuff, because I’m not really a worrier. I just used to run a lot of what-if scenarios through my head. I used to be several steps ahead in my mind and have not only Plan B figured out. I would have backups to my backups.

Now I fully accept the unpredictability of life and that has freed up a lot of mental capacity and even time for me.

I have published three books and my blog has continued to grow. At this writing I have posted every single day for the last three weeks. The more I write, the more ideas I have. And my writing is inspired by my engagement with patients and the thinking about medicine they provoke in me. My clinic work informs my writing and my writing makes me a more curious clinician. I go to work thinking “what interesting things will I see today?”

How could I feel burnout when every clinic day is where I go for writing inspiration?

The pandemic has also, ironically, brought me closer to friends and family. Pre-pandemic, I felt too busy to connect, especially in person, never liked to talk on the phone, and I was not into social media. Now I text, call or chat often with my children. I FaceTime biweekly with my exchange student year brother from 50 years ago. I email and chat with cousins in Sweden and some of their children are in my Facebook feeds.

I am also more connected to my home. I take greater joy in doing the little fix-ups. In years past, my home improvements were on a grander scale. Now I do the little, low key things with just as much pride.

I only leave the property to work in my clinic (my second job is via telemedicine from my kitchen island) and to go shopping. The animals thrive on being all together and mild summer nights we all sleep in the barn with the top doors open. I love falling asleep to the sounds of summer, the snoozing of dogs and the chomping of hay.

I am so content with my life as a country doctor.

https://hansduvefeltmd.com/2021/08/28/burnout-not-even-close-video/amp/