A Country Doctor Writes:

Archive Page 192

Switching Places

Published May 19, 2010 Progress Notes , Short Stories 1 Comment

At 3 o’clock in the morning the emergency room was quiet. The aroma of fresh coffee from the staff lounge seemed welcoming and reassuring as I slowed my steps walking down the long, chilly corridor from the on-call room in the old psychiatric wing of the hospital.

One week into my psychiatry rotation, with almost two years of residency experience behind me, I was on call for psychiatry for the first time.

All I knew about the patient I was about to see was that he was a middle-aged man who was “seeing things”.

I poured myself some coffee and took a few sips. My sleepiness dissipated as the coffee warmed my chest. Walking into the nurses’ station I got sassed about working on the psych ward now instead of where the real excitement was.

I gulped a few more sips and put my cup away in a corner where I might find it again later. Grabbing the chart, I scanned the available background information on Jan-Erik Melander, a married 45-year old engineer, who was “seeing things”.

He rose politely as I entered the room. His wife sat next to him, red-eyed and quiet. She looked sad and tired.

I introduced myself and we sat down. “What’s been happening?” I asked, in Swedish.

Jan-Erik sighed and pulled his long-fingered hands through his thick, unruly hair. His eyes were dilated and he must not have shaved for several days.

“Nothing has happened”, he answered with an impatient tone in his voice. His wife looked at me, then back at her husband.

“Tell him about the TV”, she said quietly.

He gave her an irritated look.

“You don’t believe me”, he hissed.

There was silence.

“Believe what?” I asked.

“It’s not just the TV. That just confirms it”, he said emphatically.

“Tell me”, I suggested.

“OK, I’ll tell you what I know”, he said in a low, controlled voice, pulling his chair closer while fixating his eyes on mine.

“I have come to realize”, he explained calmly, “that we are not alone in our solar system.”

I made myself nod.

“Analyzing various coincidences I have realized there is a planet at the opposite point in the solar system from Earth with the exact same molecular composition. Everything there is an exact replica of everything here, even you and me!”

I nodded again and let out a “huh”.

“It cannot be seen, because its location is exactly at the opposite point of Earth’s orbit around the sun.

I found myself in no hurry to end my encounter with Jan-Erik. It was an interesting thought, perhaps the plot of a sci-fi movie, and I didn’t feel alarmed.

As if reading my mind, he looked furtively around the room, moved within inches of my ear and whispered:

“In three days our planets will switch places. They will be here and we will be there, and then we will be annihilated!”

His eyes widened again and he raked his greasy hair with his long fingers.

“I happened to intercept one of their radio signals on the UHF band on the TV in the den a few nights ago.”

He got up and started pacing.

“Jan-Erik, please stop!” his wife sobbed. “You’re not eating, you’re not sleeping. You’re driving us all crazy!”

“None of you believe me”, he accused, his pale blue eyes boring into mine.

It was my turn to speak, to do something as the resident on call for psychiatry. Nothing in my medical school training had prepared me for choosing the right words.

“Are you the only one who knows?” I asked.

“Yes. Nobody else knows. Nobody else believes what I tell them.”

I thought for a moment.

“I don’t know what to believe”, I said. “You must be exhausted, the only one with knowledge of something this huge…”

“You’ve got to help me stop this”, he said. “There isn’t much time. We need to tell the government and the military!”

“I can’t help you get through to them, and I can’t help you convince them. I’m just a small town doctor manning the fort until 8 am”, I said. Inspired, I continued:

“What you need right now is to avoid exhaustion. You are already running on empty. If you hope to get through to someone in charge and have them take you seriously, you need to be clear-headed. My suggestion is that you stay here tonight, get a couple of hours’ sleep and figure out in the morning how to proceed. Nobody in charge is going to be available at 3:30 anyway.

He seemed suspicious.

“You’re safe here”, I reassured him. “You can sleep in one of our observation beds. Then, in the morning I will introduce you to the head of our clinic and he can help us deal with the situation.”

He hesitated. My heart pounded and my mind raced. Swedish law, at least in 1980, made it impossible to commit psychiatric patients involuntarily from within a hospital that provided psychiatric services. An outside physician had to petition the legal system for this. Besides, there was no indication at this point that Jan-Erik was homicidal or suicidal. Maybe he wasn’t even dangerous to himself or anyone else – yet.

“Maybe just a couple of hours”, his words interrupted my internal dialogue.

“A wise decision”, I affirmed.

Suddenly he flew out of his chair and darted toward the exam room window that overlooked the highway between the hospital and the nearby soccer arena. Before I was even out of my chair, he had opened the window and climbed up on the marble windowsill.

“Wait!” I called out as his wife ran over and grabbed his arm. “Don’t get hurt, and don’t wear yourself out!”

“OK”, he resigned. “I’ll stay until eight.”

I called for the nurse and an orderly and we brought Jan-Erik over to the psychiatric ward, where he was checked into a room near the nurses’ station.

I slipped away to the on-call room and laid down on top of the bed with my already rumpled scrubs still on.

An hour later, my pager went off. The charge nurse wanted me to come and see Jan-Erik. When I arrived on the unit he was standing on a chair, talking loudly to a couple of patients in the TV room. Their interest seemed to be fading quickly and as they turned away from him, he caught sight of me.

He put one foot on the back of his chair and reached for the skylight molding. Heaving his lanky body up into the light well, his legs wiggled in all directions. The wooden chair fell to the floor with a loud clatter and there he hung, legs still flailing about.

“You’ve got to get some rest”, I said as calmly as I could.

“OK, just help me down”, he said.

Together, the nurse and I guided his descent and he allowed us to lead him back to his room, where he finally settled down.

After morning rounds I was no longer responsible for Jan-Erik Melander’s physical or emotional safety. The assistant chief of the psychiatric clinic took over with a slight nod of approval after I presented the case history to him.

Driving home, I thought about the twin planets at opposite ends of the solar system and how Jan-Erik’s life had taken such a drastic wrong turn out of the blue.

At home I showered and fell into bed. I must have fallen asleep instantly.

I woke up at noon to the smell of fresh coffee. The sheets were twisted around my body. My heart was pounding and I felt clammy all over. My throat was sore and my muscles ached. I remembered running, screaming desperately to warn people about the impending switch of the twin planets.

The Emperor’s New Bones

Published May 15, 2010 Progress Notes 1 Comment
Tags: osteoporosis

Mrs. Budreau has seen an endocrinologist in the Capitol City for her osteoporosis for over five years now. Her last bone density test shows that she is almost at the point where the average woman her age is.

The specialist has sent me a note outlining how Mrs. Budreau might be a candidate for yearly intravenous infusions. The specialist has pointed out that not much is known about the long-term effects of the medicine Mrs. Budreau is taking, so perhaps it is time to switch over to the newest type of injectable osteoporosis medication instead. The only problem is that I would have to be the one ordering the treatment, since the specialist doesn’t have any affiliation with our local hospital.

I was very honest with the Budreaus when this issue came up. I told them I had never before prescribed the infusions she had been recommended. I told them I needed to do some reading before agreeing to order them.

Her chart spent the next month on the far left corner of my desk. Every so often I would pick it up, read the note from the endocrinologist, and scroll down the drug information page on my computer screen. And every time I felt this was wrong.

Finally, I called Mrs. Budreau up and told her how uncomfortable I still felt with ordering the infusions for her. I told her we don’t have any proof that treatment beyond 5 years with the medication she has been taking is better than stopping and that some researchers have reported increased fracture risk with longer treatment. Thus far I gave her the same advice as the endocrinologist had. But I couldn’t find any evidence to support now giving her another drug with less of a track record. She would be a guinea pig, part of the first large group of people to try the infusions after already treating osteoporosis for five years with the older medication.

I made sure Mrs. Budreau knew that her latest bone density test was much better than her first two, and while she still had osteoporosis, this only means that her bone density is below the normal range for a 17-year old (called T-score). Compared to women her own age (her Z-score) she is in the lower 25%, but not off the chart, which is where she started out five years ago.

I made sure she was aware that with osteoporosis, unlike most other medical conditions, the line between normal and abnormal has been drawn with reference to young people in such a way that even a perfectly average woman over the age of 80 will, by definition, have osteoporosis.

I told her I would be more comfortable if she let the specialist do the infusions at her own hospital, even though this would mean an extra annual trip for the Budreau’s. I just didn’t feel that I should be the one putting my name on her infusion order.

She thanked me for the call and told me she had decided not to go ahead with her infusion anyway.

Sometimes I feel like the little boy watching the Emperor parade down the street in his new, invisible, clothes…

A Quick Listen

Published May 13, 2010 Progress Notes 1 Comment

Jack Frommer has been my patient since last fall. He has high blood pressure and high cholesterol and he had a small heart attack six years ago.

Jack hates to take pills, and that was one of our topics when I first met him. He needed some changes in his regimen, based on his history, lab work and physical exam.

We had a lot of ground to cover in that first visit, but I don’t remember feeling particularly rushed. Other than his blood pressure, his cardiovascular exam was normal. I re-read my notes the other day. His heart sounded regular without murmurs, his neck veins weren’t engorged, his carotid arteries didn’t have bruits, and the pulses at his ankles were good and strong. I remember him pointing out as I listened to his neck that nobody had done that before.

His three-month follow-up was encouraging. His cholesterol had dropped below his target level with the new medication I had prescribed, and his blood pressure was almost normal. I spent some extra time on his smoking and the importance of taking aspirin.

I didn’t do much of an exam that day because it was a brief visit with a lot of numbers to talk about.

At his six-month follow-up all the numbers looked good. We talked about the 3-4 cigarettes he was still smoking. I listened to his lungs and repeated his cardiovascular exam.

Suddenly, there it was: A loud, harsh scraping bruit in the lower portion of his right carotid artery.

An ultrasound suggested a stenosis greater than 80% and an MRA clinched the deal. Within weeks, Jack had surgery to remove the buildup in his neck artery.

In follow-up he and his wife showered me with praise for saving him from a stroke by listening and noticing the abnormal sound in his carotid artery.

I felt humble. I had not heard it the first time I listened.

Time, Money and Midlevels

Published May 9, 2010 Reflections Leave a Comment

A Primary Care resident wrote in one of the journals recently about making the limited time she has with each patient matter the most.

How refreshing, I thought when she concluded that time ultimately is an absolute and finite resource. We often feel as if we are battling time as much as we are battling disease, and we sometimes have trouble admitting when we are losing either one of those battles. Some of us find it more difficult than others to say “no” to unrealistic demands for clinical output per unit of time.

But the writer had another agenda: By teaming up with Nurse Practitioners or Physician Assistants, she envisioned having more time to spend with each patient.

This type of New Math doesn’t really work in Primary Care. A physician who performs expensive procedures can maximize his or her time in the operating room by sharing office visits with a less trained and lower-paid “midlevel” practitioner, who could never replace the physician in the operating room.

In Primary Care, however, physicians, Nurse Practitioners and Physician Assistants tend to do the same type of work, and if anything, physicians tend to have shorter appointments than “midlevel practitioners”, reflecting their higher level of training and justifying their higher salaries. Every patient deserves the best care we can give them, and there is no reason to believe that patients who see a physician are so much more complicated that they always deserve more time than patients who see a “midlevel”.

If the young writer expects to have “midlevel providers” somehow subsidize her requirements of time and money, she is not likely to find this in today’s medical environment. She may instead find herself in direct competition with them. In states where Nurse Practitioners can practice without physician supervision, she might actually be at a competitive disadvantage, should her productivity drop below that of providers making half her salary.

“But I Still Have Chest Pain!”

Published May 6, 2010 Progress Notes 1 Comment

Doris Delaney came back to see me a week after her semi-urgent cardiac catheterization. I already knew her coronary arteries were normal. The cardiologist had called from the cath lab immediately after the procedure to let me know. His words on the phone and in his discharge summary were that she had “noncardiac chest pain”.

Doris was obviously not relieved. She comes from a family with a dark cloud of cardiac history hanging over it and she had a markedly abnormal stress-EKG. She was still having crushing, squeezing chest pressure with exertion.

Could this really be esophageal spasm, nerves or chest wall pain, I wondered.

Her symptoms didn’t really fit the definition of vasospastic angina, which tends to occur more at night or with emotional stress than with physical exercise. Women do tend to develop blockages in smaller arteries than men, but in Doris’ case, the cardiologist was adamant that it was not her heart.

I have asked a couple of cardiologists what their thoughts are on patients with classic angina pectoris, positive stress-EKG’s and normal nuclear scans. Everyone has told me the nuclear scan overrides the EKG findings, and no one argues with a catheterization report.

That answer intuitively makes me uncomfortable. The electrical recording of the EKG can pick up changes in potassium levels and inflammation like pericarditis. Why might it not pick up small changes in oxygen supply to parts of the heart muscle that other technologies can’t?

But Doris had “essentially clean coronary arteries”. Why could I not leave it at that?

I prescribed a calcium channel blocker to tighten her blood pressure control, also hoping that it would help what I thought might be some coronary spasm. I made sure she was still taking her new cholesterol medication and her acid reflux pills. We agreed on a follow-up with blood work beforehand within a few weeks.

Less than a week later I saw her name in my schedule again. After her name were the words “still having chest pain”.

My heart sank. I sat down at the computer, logged on to my online database and did a quick search.

There, suddenly, was exactly what I had felt in my own heart was behind Doris Delaney’s chest pain. How many more patients had I seen with the same condition? How many patients were leaving the cath lab at Cityside Hospital without finding out that this is what they have?

I sank deeper into my chair as I kept reading.

Cardiac Syndrome X, not to be confused with the Metabolic Syndrome (previously called Syndrome X), is twice as common in women as in men. Patients have typical, exercise-induced chest pain, positive stress-EKG’s and minimal coronary artery abnormalities on catheterization. They sometimes do worse on the medications we often use for vasospastic angina, do better on beta blockers, tend to have only a moderately increased risk of myocardial infarction and sometimes get better on their own over time.

Searching elsewhere I found that even the New England Journal of Medicine has published a couple of articles on Cardiac Syndrome X in the past decade. I don’t remember seeing them before. I wish I had.

I clicked on “Print”, gathered my thoughts and papers, and knocked on Doris’ exam room door.

“I’ve been thinking a lot about your chest pain, and I’ve found some things I’d like to show you”, I began.

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