A Country Doctor Writes:

Archive Page 150

When a Housecall is Worth a Thousand Tests

Published January 18, 2015 Progress Notes 1 Comment

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”.

Outdated Equipment

Published January 17, 2015 Progress Notes 3 Comments

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…”

All the President’s Mail

Published January 5, 2015 Reflections 4 Comments

Perhaps doctors should be more like the President.

After all, we also carry the ultimate responsibility for our constituents, even though we, too, have team members who do part of that work.

The way I understand things to work at the White House, those other team members collect, review and prioritize the information the President needs in order to manage his, and all our, business.

That is how things used to work in medicine, too, before computerization revolutionized our workflows: Nurses, medical assistants or secretaries would open the mail, gather the faxes, look over the lab and X-ray reports and put them on physicians’ desks in a certain order. Highly abnormal or time-sensitive information would be prioritized over routine “signature-needed” forms, and in my case, essentially normal reports on patients already scheduled to be seen within a few days wouldn’t even reach my eyes until the patient appointment.

Computers changed all that.

Now, most of the information goes straight to the doctors’ inboxes, unseen by other human eyes in the office. This is said to be faster. It is, to a degree, in the sense that the information leaves the laboratory or the X-ray department faster via their Internet connected computers. But in the typical medical office, we have now turned decision making doctors into frontline mail sorters and de facto bottlenecks of routine information.

The average doctor sees a different patient every fifteen minutes and the medical assistant rooms patients, takes vital signs, inputs visit information into the EMR and listens to voicemails, which are turned into physician emails. At the same time, the doctor’s electronic inbox is continually filling up with lab reports, X-ray results, consultation reports, electronic prescription refill requests, emails from case managers, and messages from counsellors and other care team members to please read and respond to their issues.

So when does the doctor check his or her inbox?

“Between patients”, is the way many people imagined this “system” to work. But, how much time do we have between all those back to back fifteen minute patient encounters? And how do we prioritize in those precious moments between the various types of new information waiting for our review?

Most EMRs color code “urgent” or abnormal reports, but when it comes to standard laboratory panels, “normal” patients statistically have 5% of their results outside the “normal range” without being sick, so the majority of Complete Blood Counts and Comprehensive Metabolic Profiles show up red, whether they contain panic values or just statistical noise. (See my post “The Red Blues“.)

Where does a doctor even begin a two minute dash through their overflowing virtual inbox?

By lunchtime, or after the last patient visit is over, we dive into the information that has been waiting all day, speedily delivered but bottle-necked for hours while we have been seeing patients.

Imagine if the White House IT Department instituted a similar workflow for the President: After a day of speeches, audiences with foreign dignitaries, ribbon cuttings and baby kissing, he has a few minutes before the State Dinner, and hastily types in his multiple passwords on the Executive Computer.

A hundred messages await. One of them contains information about hostile troup movements on our border, another a ransom demand from extremists threatening to blow up our embassy in a faraway land, but most of them are routine missives, reports and requests marked “urgent” in hopes of grabbing the President’s attention.

Is that any way to run a country? No, and any such proposal would surely be vetoed by the Commander in Chief. But that is exactly how information is managed in today’s medical office, on the frontlines of primary care.

Tick-tock, Doc! Three patients waiting, no more time for refills, emails or test results, urgent or not.

And stop reminiscing about having a secretary. Who do you think you are? The President??

The Man with the Up and Down Blood Pressure

Published December 27, 2014 Progress Notes 4 Comments

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.

The Art of Antibiotic Selection

Published December 23, 2014 The Art Of... 2 Comments

Jacques Johndreau did not look like his usual self when I saw him in the office a few weeks ago. He looked part retired bank manager and part Disney cartoon chipmunk.

He spoke with hardly any facial movements:

“Holy Boys, my wife said to me this morning, you look like you’ve got the mumps again!”

I was aware that Jacques had an atrophic testicle from catching the mumps as a teenager. This time, it was not likely the mumps, but a bacterial parotitis. He was afebrile, and could open his mouth when asked to. I could not palpate a stone in Stensen’s duct and he didn’t experience any worsening of pain when eating acidic foods, so I wasn’t so sure he had a stone.

This was an early, mild case of parotitis and I thought he had a good chance of beating the infection with oral antibiotics. The majority of these infections are caused by staphylococci, but sometimes gram-negative bacteria are the culprit. Whatever I chose, I needed to consider that Jacques takes a blood thinner, warfarin, which interacts with many antibiotics, particularly ones with gram negative coverage.

I e-prescribed a high dose of Ceftin, or cefuroxime, a second generation cephalosporin with good coverage for both staph and gram-negatives and no effect on warfarin.

“If you get worse instead of better on this”, I explained, “you’ll need intravenous antibiotics. So, by Saturday, 48 hours from now, you’ll know if you need to go to the hospital or not.”

Monday morning came. There were two ER reports with accounts of late Friday and Saturday visits with intravenous administration of ceftriaxone, a third generation cephalosporin. There was also a CT scan report with a hedged opinion that there was no frank parotid abscess. The third ER note, from late Sunday night, described how the doctor on duty had selected clindamycin and instructed Jacques to see me Monday morning for a referral to an otolaryngologist.

Monday morning Jacques definitely looked worse than the week before. His cheek was bigger and firmer, although not red. It seemed warm, but he didn’t have a fever. He had trismus; his mouth opened very little.

“Wait right here”, I said. “I’m going to call Dr. Ritz, the ENT specialist over at the hospital.”

I logged on to UpToDate and quickly looked at half a dozen treatment regimens for parotitis, and all were multi-drug intravenous protocols with oral step down alternatives.

“He’s in Danderville today, seeing patients at the Outpatient Clinic and tomorrow he’s in surgery all day”, his nurse said. She agreed to double book Jacques for Wednesday morning.

I called the Danderville clinic and asked to talk to Dr. Ritz.

After reassuring me that he never minded taking calls from a colleague, he listened to my story, and said “you’re old enough to remember Duricef, cefadroxil, right?”

“Sure”, I said. “I haven’t used it for years, though.” I remember we used to think of it as having better tissue penetration than other first generation cephalosporins.

“These are all staph. And Duricef works better than any other oral antibiotic. In thirty seven years, I’ve never had to operate on one of these.”

I thanked him and mentioned that I had scheduled Jacques to see him two days later, just to be safe.

“Oh, I’m happy to see him, but he’ll be fine”, the old otolaryngologist told me.

I related my phone conversation to Jacques and told him about his Wednesday appointment with Dr. Ritz at his office, thirty five miles away.

“If I can make it there. It’s going to storm, you know.”

Jacques’ usual drugstore didn’t have any cefadroxil in stock, but the other pharmacy in town did, so I e-prescribed it there.

“I’ll see you back here if the roads are too bad, but if you spike a fever or feel worse, go back to the hospital”, I concluded our visit.

I had a vague, uneasy feeling about just switching from one cephalosporin to another, but Ritz has a lot of experience and he’s the only ENT within a hundred miles.

Wednesday morning brought eight inches of snow with a thin layer of ice. After a slow commute in four wheel drive, I stomped the snow off my boots inside the clinic back door and hung my thick leather coat on the back of Autumn’s and my office door. I changed to my indoor shoes and booted up my desktop and tablet computers.

“Jacques Johndreau is coming in at nine”, Autumn told me, “he didn’t dare driving down to Dr. Ritz’ office.”

At nine o’clock I knocked on the door to room 2 and entered. Jacques stood up from his chair and greeted me with a handshake.

“I wanted you to confirm”, he said, and paused to show me how far he could open his mouth. “But I am definitely better.”

There was no question. His gland was half the size it had been 48 hours earlier.

“You didn’t need me to tell you that, even. This is very good news, that such an old drug worked better than two newer ones that I and the ER tried, even intravenously. I’ll call Dr. Ritz to let him know just how dramatic the difference is”, I said and patted Jacques on his broad shoulder.

The experience of an almost seventy year old solo doc beat the Boston medical Brahmins this time. I was fortunate to have my senior consultant to back me up.

And as for antibiotics, too, sometimes newer isn’t better.

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