A Country Doctor Writes:

Our new Nurse Practitioner stopped in my doorway the other day to update me on a patient’s progress. It was a difficult case we had talked about before, with several complications, twists and turns in his case history.

I reflected about how similar that case was to one of my own, where she had been involved enough to know the dilemma – in both these cases, why neurosurgeons sometimes turn down patients with far-gone tissue damage and risk for poor outcomes.

“You know, in just one year here”, she said, “I have seen so much more and learned so much more than my classmates. None of them work in big cities or anything, but they’re all closer to specialists in towns that seem less remote than here.”

“I know”, I answered. “Sometimes it feels a little heroic to be the only resource a patient has or is willing or able to use. So many of my patients have major diseases and don’t want to go 20 miles down the road to Caribou or 35 to Presque Isle. And now endocrinology is gone, rheumatology almost not available, with even Bangor short staffed, and on and on.”

“People think primary care is just simple stuff”, she said. “But it isn’t at all when you practice in rural Maine.”

Thinking back over my career I certainly agree. As it happened, the very same day I saw a patient I once puzzled about and found a rare diagnosis in: a fifty-something man with undiagnosed fairly rapidly progressive shortness of breath seemed to have weaker breath sounds on the left side of his chest. His left lung looked different on X-ray, almost as if it was starting to shrivel up. His CTA showed agenesis of his left pulmonary artery. Only in rural America does the family doctor make that kind of diagnosis.

The Man With the Shrinking Lung

We use the expression “licking your wounds” as an act of defeat and it may be, but I’m thinking about the medical implications of this ancient practice of our closest companions.

I have had dogs and other pets incessantly lick their wounds and have been forced to cover them up to prevent further damage. We even have those Elizabethan collars to keep dogs from doing that.

Recently I had almost parallel experiences with an elderly male patient and a young Alabai female dog who happens to be the latest addition to my household.

The older man has venous insufficiency, chronic edema and a past history of leg ulcers. He had a new one that was treated (elsewhere) with four layers of various dressings I’m not familiar with.

The smell in the room after his dressings were removed was alarming. We (my nurse practitioner and I) cleaned his leg up. The leg ulcer wasn’t bad, but most of the area that had been covered under the thick bandaging was denuded, red and weepy. We decided on a thin layer of Silvadene cream and plain gauze wrapping.

Within a week, he was almost healed and my conclusion was, as often before, that in wound care, less is usually more.

My Alabai had a couple of puncture wounds on her front leg from play fighting with the other Alabai. The breed is nicknamed volkodav in Russian. I never learned that word, as I dropped out of the Swedish military’s interpreter school to pursue my medical training. But it means “wolf crusher”. These dogs are fearless livestock guardians and practice fight with each other.

Anyway, my young dog seemed to be licking her front leg an awful lot, so I got worried and bandaged it up with antibacterial ointment, a Telfa non-stick pad, gauze and “vet-wrap”.

When I got home from work the next few days, the Telfa pad was always on the floor and the dressing seemed intact. But there was redness and hair loss under the bandage, suggesting she had been bothering her front leg through the bandage.

In an act of faith and courage, I then left her without any bandage in her barn guarding spot and went to work.

Lo and behold, she’s licking it almost casually now and then and it is healing nicely.

Again, less is more in wound care.

(There is something about those nonstick pads and animals. Last year my horse had a leg wound. I started out, on my veterinarians recommendation, using such a pad under all the other prescribed wrapping. On three occasions I found the Telfa pad on the ground in the paddock with a completely intact bulky dressing on the horse’s leg. I don’t know how she got it out of there but clearly she didn’t want that kind of dressing material on her wound. So I simplified the dressings and she healed just fine.)

I don’t have a TV and I seldom listen to the radio. Pandora and satellite car radio don’t interest me much anymore. If I watch a movie on my iPad, it is a conscious choice.

Once in a while I play music on my Bose while I iron shirts, but more often I do that and all my other chores in silence.

It is like when I was a young boy, a quiet only child, living in a silent household with my parents or staying with my grandparents. My head was full of thoughts, dreams and reflections.

My grandmother, who was born in 1900, had no toys at her house. She gave me paper and pencil and it was up to me to do something with them. She told me about how she used to play farm with pine cones for animals when she was little. There were different kinds in the park-like woods outside her house and I, too, played with them.

I have written almost a thousand blog posts. Sometimes after a significant clinical event or encounter, I make a note to myself to write about it. But more often, my days pass and their observations fade into some recesses of my mind. They don’t come back until I find myself in silence, doing manual tasks or sitting down, in bed or in my recliner, with the blank, white screen of my iPad in front of me.

Thoughts like, “what have I learned this week”, or “what has struck me about my work or the practice of medicine lately” make me bring back those fleeting moments I almost have forgotten.

I consume less and less and create more and more. The Internet nomenclature for people who do what I do is just that: Content Creator. Sometimes I write because something I read made me reflect or react, but mostly I draw from my own experiences.

I find that the more I write, the more ideas I get for what more to write about. Nothing I think or write about is totally new or earth shattering, but it serves a purpose for me in keeping me deeply conscious of what I do and who I am.

Knowing that others read my words is a great and humbling privilege that gives me more inspiration to keep trying to capture the essence of being a 68 year old, 41 year veteran family doctor in rural America.

From the silence in my life to all these published words, I am firmly present here on this plot of land, and I am out there, all over the world. How strange.

Brett Norén is a man in his late 50s with multiple medical problems. He also has chronic pain, anxiety and ADHD. He scored high on the Prescription Monitoring Website. He came to me on opiates, a stimulant and a low dose benzodiazepine. I saw him for a while and his drug tests were always on target. Then I didn’t hear from him for a few months.

His prescriptions expired. The pharmacy sent renewal requests. I refilled everything except the controlled ones.

Then he reappeared in my schedule.

“I’d like to get back on my meds”, he said. “I’m not doing well without them. My nerves are shot, I can’t sleep because of my pain and I can’t finish anything I start.”

“Well, you’d have to start from scratch with a drug test right now”, I said.

“Oh, I tell you, Doc, it wouldn’t be good.”

“So, what would be in it?”

“Meth”, he answered without hesitation.

“That can cause anxiety and insomnia”, I said.

“Not for me. I feel no pain, I sleep at night and my nerves are doing better when I use.”

“How often?”

“Couple of times a week.”

“So you have a choice. Meth or meds.”

“Meth.”

“Your choice.”

“Even the lorazepam?”

“Yes, it’s a controlled substance.”

“All right, I hear you. I guess I’ll see you in three months for my diabetes”, he said, rose from his chair and started moving toward the door without making eye contact again.

Phil Casey ran into some bad luck recently. Like many men in their sixties, he has an enlarged prostate, which slows his urine flow. He’s on medication to ease his symptoms, and it works pretty well.

But Phil ran out of his tamsulosin last Thursday and his urologist’s office did not renew the prescription before the weekend. A minor, unfortunate hiccup, it seemed.

Tamsulosin is a GO-pill for men in his predicament. It relaxes the muscles within the prostate gland and bladder. This helps improve speed and completeness of bladder emptying and reduces delayed start and afterdrip

That interruption may not have caused much trouble if it wasn’t for another unfortunate coincidence.

Phil threw his back out over the weekend. In the back of his medicine cabinet was a bottle of cyclobenzaprine, a muscle relaxer he had taken for back spasms in 2018.

Cyclobenzaprine’s powerful anticholinergic effects can slow urine flow. It is a powerful STOP-pill for men like Phil. The fact that he took this medication when his tamsulosin had just run out was a case of double trouble, a hackneyed “perfect storm” for urinary retention.

The better his back felt, the slower his urine flow got. Monday morning, in my office, his blood pressure was high and his lower abdomen sore with a palpable bladder.

His urologist is 20 miles away. They agreed to see him as soon as he could get there. We don’t have catheters in our office like we used to in the old days. I actually also remember when we got rid of the spinal needles 35 years ago. You just don’t do spinal taps in the office anymore. That’s a very good thing. But I’m not so sure we shouldn’t have some Foley catheters, just in case.

Pharmacology:

GO-pills that improve urine flow are mostly peripheral alpha blockers like tamsulosin, doxazosin and terazosin. Finasteride and its sister drugs, which also end in -steride, don’t do much in the short run but may slow down worsening of symptoms over time. Then there is tadalafil, a cousin of sildenafil (Viagra) that can also help.

STOP-pills come from several drug classes, from those that are pure anticholinergics to those with anticholinergic side effects

Anticholinergic drugs inhibit salivation, stomach acid production, urination and bowel movements. They are used to treat intestinal cramps (dicyclomine) and frequent urination (Toviaz and many others but not Myrbetriq). The motion sickness patch scopolamine is an anticholinergic. Cogentin (benztropine), used to stop involuntary movements from antipsychotics or Parkinson’s disease is also an anticholinergic.

Other medications with anticholinergic side effects men with prostate problems need to be careful with are older antidepressants like amitriptyline (closely related to cyclobenzaprine) and older antihistamines like diphenhydramine (Benadryl).

What about inhaled anticholinergics, commonly used to treat COPD?

I don’t know how often they cause full blown urinary retention, but I have seen it at least once, in a patient whose COPD and Beningn Prostatic Hyperplasia (BPH) were equally severe.

On the other hand, I once used an anticholinergic inhaler to control severe acid reflux in a patient!

Inhaler Cures GERD?(!)