Flowing tears
Empty hearts
Sadness touches all
Nine years old
Child so bold
Never to grow tall
Tucson town,
Where sadness reigns
Child of 9/11
Taken from us
All today
With a killer's gun
Congress mourns
Parents cry
Everyone says, Why?
Did our
Christina Taylor Green
Get shot and fall and die?
Thursday, January 13, 2011
Tuesday, January 11, 2011
Personal Health: The Doctor is Ill
Muscle aches (myalgias), irritated throat, aches to swallow, sudden sneezing, feeling warm, thirst. Which patient had these symptoms? I remember one person with a common cold and another couple of patients with sore throat and cough. What are the chances that I contracted a respiratory infection from an infected patient?
So what does a physician do for early symptoms of a cold? Water, Naproxen Sodium, Echinacea and Vitamin C. Rest and watch a video (The Visitor which has some nice parts about playing Djembe drums). More water.
Headaches, neck aches. No cough yet. Maybe it's a quick virus that will ease up quickly. More water. Eyes ache and feel tired and sleepy. One cough, one yawn.
More water. Two more introductory coughs. It's heading for the lungs. Bed time. 2 teaspoons of Tussin (same as Robitussin DM) and so to bed. No thoughts, by the way, of calling a physician, needing antibiotics, or going to a health care facility. (That might be cheating, since I'm a doctor)
Awakened by phone ringing at 4:59 AM by page on cell phone to call a local Emergency Department to discuss with the emergency physician a patient I hadn't seen in ten years who had a lung infection and unusual finding on a CT scan of the chest. Two and one half hours later another phone call from an employee calling off work for having infection worse than mine.
I arise, feed the cat and take my vitamins, echinacea, vitamin C, vitamin D3, naproxen sodium, omega 3 fish oil and water. No more muscle aches or sore throat. No cough. One sneeze. I feel fine. Drink water, get dressed and off to work site.
I've had my annual flu shot and my diptheria, tetanus, and pertussis (whooping cough) booster. I wash my hands about 35 times per day. I follow infection control strategies recommended by the Henry the Hand web site.
I feel fine at work all day and the day after. I guess my immune system warded off a viral respiratory infection.
So what does a physician do for early symptoms of a cold? Water, Naproxen Sodium, Echinacea and Vitamin C. Rest and watch a video (The Visitor which has some nice parts about playing Djembe drums). More water.
Headaches, neck aches. No cough yet. Maybe it's a quick virus that will ease up quickly. More water. Eyes ache and feel tired and sleepy. One cough, one yawn.
More water. Two more introductory coughs. It's heading for the lungs. Bed time. 2 teaspoons of Tussin (same as Robitussin DM) and so to bed. No thoughts, by the way, of calling a physician, needing antibiotics, or going to a health care facility. (That might be cheating, since I'm a doctor)
Awakened by phone ringing at 4:59 AM by page on cell phone to call a local Emergency Department to discuss with the emergency physician a patient I hadn't seen in ten years who had a lung infection and unusual finding on a CT scan of the chest. Two and one half hours later another phone call from an employee calling off work for having infection worse than mine.
I arise, feed the cat and take my vitamins, echinacea, vitamin C, vitamin D3, naproxen sodium, omega 3 fish oil and water. No more muscle aches or sore throat. No cough. One sneeze. I feel fine. Drink water, get dressed and off to work site.
I've had my annual flu shot and my diptheria, tetanus, and pertussis (whooping cough) booster. I wash my hands about 35 times per day. I follow infection control strategies recommended by the Henry the Hand web site.
I feel fine at work all day and the day after. I guess my immune system warded off a viral respiratory infection.
Sunday, January 9, 2011
Family Medicine: Patient Parts and Patient Pain- Hair and Scalp
Patients tell us a lot about their parts and their pain. We have to get the general situation and context to do our best thinking about parts and pain, then they fit better with therapeutic strategies. We family physicians have a lot of training and experience dealing with parts and pain. We share the patients desire to have less pain in fewer parts, or no pain in no parts.
If we start from the top, the hair roots may hurt if infected or the hair is pulled. The scalp may hurt if traumatized or overused or overly sensitive to neck muscle spasms which can radiate pain to the scalp muscles (until it feels like your eyeballs are going to pop out). Drug withdrawal can cause pain in the whole body, including the scalp. The scalp may have excruciating pain such that you can't brush your hair without wincing in patients with temporal arteritis, which can lead to sudden blindness if not treated with steroids for a prolonged period of time (guaranteed to get steroid side effects like facial swelling, thinning bones, weight gain and elevated blood glucose). Unusual viral infections may generate scalp pain also, sometimes with intense burning on only one side of the scalp similar to nerve pain in diabetic feet .
Then there's the shingles, herpes zoster, a delayed effect of childhood chicken pox that hides in the spinal cord until the most in-opportune time when it burns like fire for 7-12 days before breaking out in a rash. Not just any rash, but one that is on only one side of the body (scalp in this case) in a narrow band, aligning with a dermatome (area served by one nerve) in blisters with a red base. Every grandma and great-grandma in America can tell when a rash is the chicken pox (trunk first then it goes elsewhere) so most can carry over that wisdom to recognize the shingles rash.
Bad news on the shingles is that the pain may persist, after the rash is gone, intermittently forever. This is called post herpetic neuralgia (PHN) happening about 6% of the time if you read the studies conservatively and possibly 30% if you own shares in a company that manufactures the "shingles" shot, which is available for people 60 and over for $250 (not covered by medical insurance). The shot is only effective 14% of the time for 80 year olds, so the $250 may not be such a good investment for many. It also may cause you to break out with the shingles. In families that all get the shingles and the PHN, they are anxious to get the shot.
Also in shingles of the scalp it may move down across an eye onto the face, threatening vision loss and requiring evaluation by an ophthalmologist. Bummer of a pain.
I've also seen scalp pain from staphyloccal infection of the hairline (sometimes methicillin resistent staph aureus: the famous MRSA) sometimes resulting from a haircut. Burns of the scalp from accidents in hair salons also hurt and can make your hair fall out.
Unusual scalp pain might be caused by insect infestation, stings, bites or burrowing under the skin.
Wow, we haven't got to the sinuses and face yet and I'm low on blog space. I'll split parts and pain up and dole it out in bits over the next year or two. Pain is a big deal in family medicine practice. And it hurts. And we care.
If we start from the top, the hair roots may hurt if infected or the hair is pulled. The scalp may hurt if traumatized or overused or overly sensitive to neck muscle spasms which can radiate pain to the scalp muscles (until it feels like your eyeballs are going to pop out). Drug withdrawal can cause pain in the whole body, including the scalp. The scalp may have excruciating pain such that you can't brush your hair without wincing in patients with temporal arteritis, which can lead to sudden blindness if not treated with steroids for a prolonged period of time (guaranteed to get steroid side effects like facial swelling, thinning bones, weight gain and elevated blood glucose). Unusual viral infections may generate scalp pain also, sometimes with intense burning on only one side of the scalp similar to nerve pain in diabetic feet .
Then there's the shingles, herpes zoster, a delayed effect of childhood chicken pox that hides in the spinal cord until the most in-opportune time when it burns like fire for 7-12 days before breaking out in a rash. Not just any rash, but one that is on only one side of the body (scalp in this case) in a narrow band, aligning with a dermatome (area served by one nerve) in blisters with a red base. Every grandma and great-grandma in America can tell when a rash is the chicken pox (trunk first then it goes elsewhere) so most can carry over that wisdom to recognize the shingles rash.
Bad news on the shingles is that the pain may persist, after the rash is gone, intermittently forever. This is called post herpetic neuralgia (PHN) happening about 6% of the time if you read the studies conservatively and possibly 30% if you own shares in a company that manufactures the "shingles" shot, which is available for people 60 and over for $250 (not covered by medical insurance). The shot is only effective 14% of the time for 80 year olds, so the $250 may not be such a good investment for many. It also may cause you to break out with the shingles. In families that all get the shingles and the PHN, they are anxious to get the shot.
Also in shingles of the scalp it may move down across an eye onto the face, threatening vision loss and requiring evaluation by an ophthalmologist. Bummer of a pain.
I've also seen scalp pain from staphyloccal infection of the hairline (sometimes methicillin resistent staph aureus: the famous MRSA) sometimes resulting from a haircut. Burns of the scalp from accidents in hair salons also hurt and can make your hair fall out.
Unusual scalp pain might be caused by insect infestation, stings, bites or burrowing under the skin.
Wow, we haven't got to the sinuses and face yet and I'm low on blog space. I'll split parts and pain up and dole it out in bits over the next year or two. Pain is a big deal in family medicine practice. And it hurts. And we care.
Friday, January 7, 2011
Family Medicine: Another Thursday in the Office
Four messages from or about patients on my "hot pile" greet me right away.
1. Someone over 80 died in a hospice situation in a nursing home where she was placed after terminal metastatic cancer piled on to her deteriorating general health. I reflected on she and her husband, also terminal from various chronic problems plus acute events. We've dealt with rheumatoid arthritis, hypothyroidism, stroke, cancer, depression, hypertension, foot problems, back pain, skin cancer, hospitalizations, arrhythmia, alcohol, nicotine, dog's death, housing changes, discussions of heritage, dying, family issues and aging. A long, rich and meaningful relationship. Amen.
2. Fat chart with note on front saying the mobility device (e.g., scooter or powered chair) sales company wants the form changed that we submitted after our nurse practitioner spent 45 minutes with patient carefully answering each question on the multi-page questionnaire. Looks dishonest to me. My comment: "No, we won't change the answers on the form, even if it means that the patient doesn't get the chair." I've seen this before, where a vendor says that the form has to be filled out a certain way, even though it's lying, or the payor won't approve payment for the product. That's not how professionals function. Lying isn't our strength.
3. The"back pain is unbearable" in a patient, "someone has to do something. It's worse than ever." She doesn't want to come in because she was just here. I look at the note and remember that the recent visit wasn't about the back. It was hypertension and urinary problems. I ask the MA to get the medical record for this patient. Sure enough, the reason for the appointment, the chart note and prescriptions written had nothing to do with the back. These type patient comments are confusing and troubling. We're not connecting somehow with this patient. I feel disappointed that we're not on the same page. And the time/money isn't available to facilitate my direct calling of patients instead of seeing those who make appointments. And a back in severe pain needs a history and physical exam if a physician is expected to relate to its owner as a physician. It's the minimal expectation of our profession, inside and outside of it, we see, listen, think, touch, speak and act. Less is less quality and maybe not real medical practice. I write a note at the bottom of the patient call note. Call pt. "I'd have to see her to help with the severe back pain, we didn't relate about it at the recent visit."
4. A subspecialist discerned that the weird pain in one of our patients was a rare side effect of one of his diabetic medications. Patient would like to stop that medication and get a replacement. I know offending drug is a $4 drug and replacement is about $130, tier 3 on most prescriptions benefit programs. It may even be disapproved by his plan until he uses one or two other drugs. OK, I write a note to stop the first drug and call in the new one #30, one daily with one refill. And to schedule a follow-up visit with lab test in four weeks regarding the pain, chronic disease and the new drug for the chronic disease. Also, I ask the MA to call patient and let him know the new drug is costly, just as a heads up.
5. I look at my schedule for the day again, noting that two acute illness slots are still available at the end of the day. While looking, one of the MA's informs me of a cancellation at 2 PM by someone recently found to have another physician, also prescribing anxiety and pain medication. An MA from that office called to let us know about the duplication, which is an illegal act by the patient. I already called the patient personally to inform him of this situation. He knew he was about to be caught. I just don't know if he's addicted and abusing the drugs, or selling drugs. Anyway, it's a felony in Ohio to lie to a physician to procure controlled substances. If the patient comes in and I find that he's lying to me to procure these medications, I call the county Sheriff and a deputy shows up with a simple form the next day. The patient is arrested one or two days later. I feel professionally obligated to report the violation instead of ignoring it. The patient may need an addiction program and get their life back. Or, they may get jail time and save lives by terminating their sales of controlled substances. We'll see, unless the patient never comes in.
6. Now it's time to see my first patient of the day. A typical day in family medicine.
PS. The patients here are assemblages of multiple persons over the years and not just one specific person.
1. Someone over 80 died in a hospice situation in a nursing home where she was placed after terminal metastatic cancer piled on to her deteriorating general health. I reflected on she and her husband, also terminal from various chronic problems plus acute events. We've dealt with rheumatoid arthritis, hypothyroidism, stroke, cancer, depression, hypertension, foot problems, back pain, skin cancer, hospitalizations, arrhythmia, alcohol, nicotine, dog's death, housing changes, discussions of heritage, dying, family issues and aging. A long, rich and meaningful relationship. Amen.
2. Fat chart with note on front saying the mobility device (e.g., scooter or powered chair) sales company wants the form changed that we submitted after our nurse practitioner spent 45 minutes with patient carefully answering each question on the multi-page questionnaire. Looks dishonest to me. My comment: "No, we won't change the answers on the form, even if it means that the patient doesn't get the chair." I've seen this before, where a vendor says that the form has to be filled out a certain way, even though it's lying, or the payor won't approve payment for the product. That's not how professionals function. Lying isn't our strength.
3. The"back pain is unbearable" in a patient, "someone has to do something. It's worse than ever." She doesn't want to come in because she was just here. I look at the note and remember that the recent visit wasn't about the back. It was hypertension and urinary problems. I ask the MA to get the medical record for this patient. Sure enough, the reason for the appointment, the chart note and prescriptions written had nothing to do with the back. These type patient comments are confusing and troubling. We're not connecting somehow with this patient. I feel disappointed that we're not on the same page. And the time/money isn't available to facilitate my direct calling of patients instead of seeing those who make appointments. And a back in severe pain needs a history and physical exam if a physician is expected to relate to its owner as a physician. It's the minimal expectation of our profession, inside and outside of it, we see, listen, think, touch, speak and act. Less is less quality and maybe not real medical practice. I write a note at the bottom of the patient call note. Call pt. "I'd have to see her to help with the severe back pain, we didn't relate about it at the recent visit."
4. A subspecialist discerned that the weird pain in one of our patients was a rare side effect of one of his diabetic medications. Patient would like to stop that medication and get a replacement. I know offending drug is a $4 drug and replacement is about $130, tier 3 on most prescriptions benefit programs. It may even be disapproved by his plan until he uses one or two other drugs. OK, I write a note to stop the first drug and call in the new one #30, one daily with one refill. And to schedule a follow-up visit with lab test in four weeks regarding the pain, chronic disease and the new drug for the chronic disease. Also, I ask the MA to call patient and let him know the new drug is costly, just as a heads up.
5. I look at my schedule for the day again, noting that two acute illness slots are still available at the end of the day. While looking, one of the MA's informs me of a cancellation at 2 PM by someone recently found to have another physician, also prescribing anxiety and pain medication. An MA from that office called to let us know about the duplication, which is an illegal act by the patient. I already called the patient personally to inform him of this situation. He knew he was about to be caught. I just don't know if he's addicted and abusing the drugs, or selling drugs. Anyway, it's a felony in Ohio to lie to a physician to procure controlled substances. If the patient comes in and I find that he's lying to me to procure these medications, I call the county Sheriff and a deputy shows up with a simple form the next day. The patient is arrested one or two days later. I feel professionally obligated to report the violation instead of ignoring it. The patient may need an addiction program and get their life back. Or, they may get jail time and save lives by terminating their sales of controlled substances. We'll see, unless the patient never comes in.
6. Now it's time to see my first patient of the day. A typical day in family medicine.
PS. The patients here are assemblages of multiple persons over the years and not just one specific person.
Tuesday, January 4, 2011
Family Medicine: Hospice Nurses Lead with Love
Over the 31 years in family medicine, I've had many patients reach the end of their life, one way or another. Those with a terminal diagnosis were often fortunate enough to get enrolled in a hospice program and meet some special nurses. Some of them are like angels who connect with the patient and allow nature to take its course with minimal distraction. They may befriend patients in a unique professional way. They may give back rubs or scalp massages. They may be the honest mirror that the patient needs to relate to their own struggles with the end of life. They may be the prayer connection to allow the patient to refresh their spiritual self.
The hospice team includes a chaplain, social worker and nurses. They care deeply about people at the end of life and develop special insights about their circumstances and their family members. They have to relate to family physicians and other primary care practitioners who are involved in a more distant sense with their dying patients. I'm a bit more involved than most, I'm told, since I want to be the attending physician for my patients who are "referred" to hospice. I've made house calls on most of my hospice patients. Hospice has pre-printed orders to facilitate understanding by all involved about medications and specific orders for medical issues at the end of life.
Caring for the patients at the end of life has always been meaningful to me since I care for most family members of my patients. I've had a "Families Only" new patient policy for 30 years so generations of people relate to my practice. Giving their care over to another physician at the end of life would be a violation of my commitment to our patient-physician relationship. If I've treated their life and their hearts, lungs, brains and pains over the years, the dying process shouldn't and doesn't separate us. The individual and family life cycles make more sense in the context of family care in family medicine.
For family physicians, the contact with hospice nurses is critical, but sometimes challenging since we usually don't get to meet each other face to face. We have to talk on the phone a few times to get to know each other before anything medically intense happens. We need to hear their philosophy of care and share ours. We need to share our perspective on what's medical and what's nursing and what's both. We need to know how we perceive this terminal patient and their family and their situation. Context matters. I see death as a natural process that may have some medical components and the care of the dying as having many nursing and even more family components. How do we best relate our beliefs to each other? How do we allow dying and death to be as natural as possible? How do we allow the family to follow their own beliefs and processes with the dying?
Not with "efficiency". Not with overly rigid protocols. Dying isn't smooth and predictable. At the end of life, "Love" is the treatment of choice and generally the hospice nurse is the leader with the most love. Hospice Nurses: Thank you for all you do.
What's next (should be already widely used)? Now we need the web cams and two way real time and asynchronous communication to the patient's home/bedside. We need to use social media and whatever it takes to get our best connections between hospice nurses and family physicians. The audio-visual contact will tighten the relationships in the primary care end of life team and allow more connection between patients, families, hospice nurses and family physicians. Sometimes even angels need technology to get the most heavenly results.
The hospice team includes a chaplain, social worker and nurses. They care deeply about people at the end of life and develop special insights about their circumstances and their family members. They have to relate to family physicians and other primary care practitioners who are involved in a more distant sense with their dying patients. I'm a bit more involved than most, I'm told, since I want to be the attending physician for my patients who are "referred" to hospice. I've made house calls on most of my hospice patients. Hospice has pre-printed orders to facilitate understanding by all involved about medications and specific orders for medical issues at the end of life.
Caring for the patients at the end of life has always been meaningful to me since I care for most family members of my patients. I've had a "Families Only" new patient policy for 30 years so generations of people relate to my practice. Giving their care over to another physician at the end of life would be a violation of my commitment to our patient-physician relationship. If I've treated their life and their hearts, lungs, brains and pains over the years, the dying process shouldn't and doesn't separate us. The individual and family life cycles make more sense in the context of family care in family medicine.
For family physicians, the contact with hospice nurses is critical, but sometimes challenging since we usually don't get to meet each other face to face. We have to talk on the phone a few times to get to know each other before anything medically intense happens. We need to hear their philosophy of care and share ours. We need to share our perspective on what's medical and what's nursing and what's both. We need to know how we perceive this terminal patient and their family and their situation. Context matters. I see death as a natural process that may have some medical components and the care of the dying as having many nursing and even more family components. How do we best relate our beliefs to each other? How do we allow dying and death to be as natural as possible? How do we allow the family to follow their own beliefs and processes with the dying?
Not with "efficiency". Not with overly rigid protocols. Dying isn't smooth and predictable. At the end of life, "Love" is the treatment of choice and generally the hospice nurse is the leader with the most love. Hospice Nurses: Thank you for all you do.
What's next (should be already widely used)? Now we need the web cams and two way real time and asynchronous communication to the patient's home/bedside. We need to use social media and whatever it takes to get our best connections between hospice nurses and family physicians. The audio-visual contact will tighten the relationships in the primary care end of life team and allow more connection between patients, families, hospice nurses and family physicians. Sometimes even angels need technology to get the most heavenly results.
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