Anger Issues

I am angry with the ER. I don’t remember which person in the ER so I’m just upset with the whole department.

Budd Chiari’s baby saw me today. She’s 8 days old and about as beautiful as a baby can get. Her mama hasn’t breast fed her for 24 hours, though, since the ER told her not to.

What. The. F

Oh. Of course it is because she has a urinary tract infection.

What?

Oh. Well, they gave her ciprofloxacin.

WHAT????

I mean, it’s not like we don’t have at LEAST 4 other medications that could work for this, in a patient with no allergies, most of which are completely safe for breastfeeding.

Also, ciprofloxacin is less worrisome than previously thought so she could PROBABLY also breastfeed with it (took me 25 seconds to find that out) IF THAT WAS YOUR ONLY OPTION. Which it is not.

I tried not to look as horrified as I felt.

“You know, I’ll prescribe you something right now that is totally safe with breastfeeding. And then you can start again, right away. Probably also pump a bit to get the supply back up.”

Mom was pretty excited to hear this.

Saving lives. It’s just what I do.

Take that, ER.

The Big One

???

Lately I can’t even finish a thought. That is because everyone who walks in the door has splenomegaly or a giant pelvic mass or a blood pressure of 194/105 or a hematocrit of 20%.

Sometimes I try to redirect them into familiar territory.

“Yes I know you have a giant spleen, but do you also have diabetes?”

“Your blood pressure is quite high. When was your last pap?”

But, really, those things don’t matter when you’re staring the Big Question Mark in the face.

My job is full of little question marks. “Should I check labs now or in 3 months?” “What’s the best antidepressant for this patient?” “Does this patient need a follow-up DEXA scan?”

But time stands still when I have to ask “What the hell is happening here?”

And it’s not such a great week when the Big Question Mark happens 5 times.

Put aside for a moment the technical difficulties in actually obtaining diagnostic tests in such very sick patients without insurance or any money for food. It’s hard enough to even know where to begin the work-up.

Monday started with a patient with itchy hands and feet, worse at night. No rash. Oh, and she’s also 37 weeks pregnant. I ordered some bile acids and LFT’s, and started her on ursodiol for presumed cholestasis. Then I called the Dragon, who happens to be an expert in the field. I interrupted him during tai chi. Yes, he is 85. And Chinese.

“So if this turns up positive, should I induce? She’s a VBAC.”

Then on to the next several patients. Soon I met a man with a rash all over his body for 8 years with a large, firm spleen. To be honest, I’ve never felt anything like it before. I’ve tried and failed in Africa, and confirmed its absence in kids with mono. This one was hard to miss. I percussed it too. I texted a photo of the rash to Dr. DDX. Then I got out my Washington Manual and read the section on splenomegaly. HIV. TB, mycobacterium avium. EBV. Portal hypertension. Tumor. Hemolysis. Awesome.

Then I put in 2 IUD’s.

Tuesday a lovely lady came to see me after a several year absence in which she developed worsening pelvic pain. She is 49. She has a gigantic pelvic mass.

Forgot to mention the 47 y/o cocktail waitress who presented with restless legs and turned out to have a hemoglobin of 5.7. I ended up sending her to the ER to get transfused so we can potentially get her a colonoscopy.

None of these people have insurance.

I soon found myself between patients texting my dad about splenomegaly, emailing Dr. DDX, and browsing through 3 derm atlases and a stack of charts, with 5 AAFP articles open on my desktop.

It was a bad week. I read a lot and didn’t come up with many answers. I was just busy enough not to dwell on the ridiculous inadequacy of our medical care delivery system. Not too busy to feel completely inadequate, myself, though.

But the good news is there’s time. All except for the pregnant lady, who’s been in and out of labor and delivery three times this week at my behest.  Everyone else has time. Time for me to think, and study. Time for studies to be done. Time to work on funding.

Everything seems urgent, because these are major medical unknowns. But the truth is these people have been living with these problems for a lot longer than I have. All of them for months, at least. And if all I can offer them is questions, at least I’m asking them. At least they’re here. It’s not my fault they couldn’t see a medical provider sooner. It’s not my fault they don’t have any money. It’s not really theirs either. It is what it is.

I can’t fix very much about this system. And I'm not going to know all the answers tonight. So probably I should go home before it’s time to come back again.

I added 5 stickers to my S.L.

Budd Gets Better

Remember Budd-Chiari? Here’s what I love about family medicine: I get to be part of the story.

Here’s what I hate about family medicine: the hospitalist thinks I’m stupid.

A couple of months ago Budd-Chiari was sick, no doubt about it. After I called several specialists and read everything I could on Up-to-Date, I ordered some tests.  And the tests showed he was marginally sicker. His sedimentation rate, a marker of inflammation, was climbing to 100. His white blood cell count, while not outlandish, was high. Higher than before. And he was still having fevers, with hallucinations.

This is not normal in a 35 year old.

And I had it on good authority that it wasn’t explained by the clot in his liver, either. And by good authority I mean the jovial gastroenterologist I managed to reach by phone. I don’t know what the hell I’m doing.

So I sent him that evening to the emergency room, for further work-up on his spiking fevers to 103, with delirium and worsening lab values.

The dictation for his admission goes something like this:  “35 year old male sent over by primary care doctor for abnormal lab values, including elevated sedimentation rate. There is really nothing wrong with him and so I don’t know what the big deal is and why I had to waste my time on this admission. Obviously he has a clot in his liver and that is why he feels sick. Stupid family doctors who freak out about the Erythrocyte Sedimentation Rate. Temp 101.5. Whatever, dude. I’m going back to bed.”

I may be paraphrasing a bit. Not much.

Sure enough, they sent him home the next day. No antibiotics. Still spiking fevers. Still delirious.

I was disheartened to say the least. Now the enigma was back in my lap, and I had even less confidence than before.

A week later the blood cultures from his overnight admission came back growing gram-negative rods. At the same time the blood cultures I had drawn with the ESR and CBC came up positive as well.

It was my day off. They called the residents, for reasons I don’t understand. The residents called me. I called the family. They weren’t keen on going back to the hospital, understandably. We talked about options. They felt he was better and might be able to take oral antibiotics.

Then he spiked a fever again and they called the answering service, who connected them to Leafy.

Leafy is just like me, fresh out, 6 months younger than I am if that’s possible. She told him to go to the ER. Leafy has an asset I don’t: her husband is an ER doctor who may also be a Linebacker. He took the case.

She called me. “Yeah, I read that history and physical from his earlier admission. A little passive-aggressive, I thought.”

“Me too! I knew something was wrong with that guy. And they totally didn’t take me seriously.”

“And they implied as much in their dictation. But you were right – he was sick. Not cool, hospitalist.”

I was right. –ish. I mean, I didn’t know what was wrong with him, just that he was SICK. And none of us could ever have guessed, nor spelled, the cause of his illness:

Erysipelothrix rhusiopathiae.

He got lots of attention in the hospital. IV antibiotics, ID consult, the works.

And then he got better. I saw him 2 weeks out, smiling, laughing, a quick wit. He told me about his heavy metal band, and the impending birth of his daughter.

What a difference a few antibiotics make. 

It’s pretty great to see the end of the story, to see him get better. I kind of want to call that first hospitalist to let him know. But I don’t think I’ll allow him that gratification.

Panel Management

They say, and “they” are some study I never read but heard about from Dr. DDX, so that’s pretty much as good as gospel, that it takes 14 hours a day to manage chronic disease. As in, 14 hours a day for just your patients with diagnoses like high blood pressure and diabetes, just for panel management. Ensuring they get tests done, follow-up labs, check their blood pressure, learn to eat better, stop smoking, see specialists, etc. etc. etc.  This is called panel management.

14 hours a day for those guys. Not counting prevention of disease in healthy persons. Not counting managing folks who are acutely ill or have an extensive work-up going on.

Not counting, you know, actually seeing patients and the like.

This is how much time it takes to do our patients justice. And how much is allotted providers for this in reality? 35 minutes? Nothing at all?

When I think about this I have a panic attack and 5 more of my hairs turn grey.

Thus I have created a simple, elegant and entirely inadequate Panel Management Device.  I have limited it to the patients whom, when I think about them, I have a panic attack and 5 more of my hairs turn grey. That is my selection criteria. I call it the Shit List.

Now, do not misunderstand me. The patients on this list are wonderful people. The list is not named for them. Nor is it named because they are on my bad side, or because I am angry with them. It is so named because it is the first and only thing I could think of naming it. Also because it is what I might do in my pants if I can’t track these people down for follow-up. Another selection criteria.

No one else knows what it is called. I have labeled it simply S.L. and have drawn attractive and distracting designs on the back side.

Now what I do is occasionally look it over and review outstanding items. I make sure folks got to see specialists. If an imaging study hasn’t been done I have someone remind the patient to do it. Everyone on the list has a follow-up with me in the next month, and a working phone number listed. Hopefully. There’s a revolving list of specialists to curbside, cases to talk through with colleagues, and topics to read about.

Then I have a panic attack and give 17 sticky notes to my MA.

I’m pretty sure this is how panel management works.

Imaginary Conversations with Absent Police Officers

Haven’t written much for a while. Sometimes that means there’s nothing going on. Sometimes it means there’s too much going on. First it was the first one. Mostly now it’s the second. But I have a feeling there’s a lot of writing to come.

One great/terrible thing about being a family doctor is that there’s very little in terms of routine. When you think you’re settling in is when the fun begins. Which is also known as all hell breaking loose.

In times like these I take comfort in truly predictable things.

Like how every time I’m on call my husband receives a speeding ticket in the mail two weeks later.

We have those awesome photo enforcement cars parked around town, generally directly between me and the hospital at the exact moment a baby wants to be born. The speedometer, as previously mentioned, works roughly 10% of the time so I pretend I’m in Montana circa 1999 and drive as fast as “reasonable and prudent.” Also it’s a lot safer to drive while looking at the road rather than the speedometer, so I’m a better driver than most folks out there. And then the automaton snaps a photo of me.

I wish an officer would just pull me over instead.

I often think of what I would say to them when they ask “Do you have any idea how fast you were going, young lady?”

“Yes. Roughly just fast enough to deliver excellent health care.”

“Truly, speed is relative, sir. The earth was going just as fast in the opposite direction.”

“Which units of measure do you mean?”

“No, dude. This meter is broken. And a baby just fell onto a bed because of you.”

But I have no opportunity to use the above excellent defenses.

Instead the robots think that GB has been speeding again because I drive his car every day. And they send him a ticket. And I call them to tell them to send it to me instead but it falls on deaf ears. And then I forget about it for a month and GB gets a default notice.

It’s nice to know you can count on such a reliable system of nonsense.  It’s almost as good as our health-care system.