What I learned from my first doctor job

When I started my first job, I had a nurse and a receptionist within a bigger clinic, all primary care. Fresh out of residency. One month in I asked to meet with my nurse and the receptionist.

The receptionist brought the office manager. I was surprised, but ok.

I started the meeting. “I am having trouble keeping up with 18-20 patients with fat charts that I have never seen before, but I think I am getting a little better at it. What sort of complaints are you hearing and how can we make it smoother?”

The office manager and the receptionist exchanged a look. Then the office manager excused herself.

Weird, I thought.

The three of us talked about the patients and the flow and me trying to keep up. About one third were Spanish speaking only and I needed my nurse to translate. That tended to gum things up a bit, because she could not be rooming another patient or giving a child vaccinations.

I thanked them both and the meeting broke up.

Later I found that the office manager had been brought in because another doctor tended to manage by yelling and throwing things. And another doctor had tantrums. So the receptionist was afraid of me and had asked the office manager to stay. The moment they realized that it was collaborative and I was asking for feedback and help, the receptionist was fine without the office manager.

That was an interesting lesson on working with people. I had been very collaborative with the nurses and unit secretaries in residency. As a chief resident, I told my Family Practice residents to treat the nurses and unit secretaries and in fact everyone, like gold. “They know more than you do and if you take care of them, they will save your ass!” The unit secretaries would go out of their way to call me in residency. “Mr. Smith is not getting that ultrasound today.”

“Shit. Why not? What the hell?” I would go roaring off to radiology to see what the hold up was.

The unit secretaries did not help the arrogant residents who treated them like dirt.

I thought it takes a team. I can’t do my work without the nurse, the pharmacist, the unit secretary, the laundry, the cafeteria workers, the administration. It takes the whole team. I value all of them.

writhe

You are sick as shit.

You go to the ER.

You finally feel safe, on a bed, they will save me, you think.

The nurse is on autopilot. He does not seem concerned. You are shaking a little as he arranges you on the bed. He puts the heart monitor stickers on and hooks you up. Blood pressure cuff, pulse ox. Blood pressure is fine, pulse is a bit fast, at 110.

You notice he is not making eye contact.

“I’m cold.” you whisper.

He doesn’t reply. He keeps messing with the wires. He puts the call button next to your hand. He leaves and returns with a warm blanket. It feels wonderful. He doesn’t say a word.

You feel better under the warmth.

The respiratory therapist wheels in the ECG machine. You smile at her but again, no eye contact. She puts more stickers on you. “Hold a deep breath.” The ECG spits out. She takes it and leaves.

The radiology tech wheels the portable xray machine in. You watch his face but don’t bother to smile. He looks everywhere but at you. It’s a bit creepy. Are they all robots? It’s 3 pm, not 3 am. “Lean forward,” says the tech, putting the radiology cartridge behind you. “Take a deep breath and hold it.” He takes the cartridge and leaves.

The nurse is back. Puts in the iv and draws 5 tubes of blood. You are shivering a little. He doesn’t seem to notice. You think about another warm blanket. The iv fluid starts and you can feel it running cold into your arm.

There is a child crying in the ER, in some other room. You start noticing the noises. Machines beeping. People typing on computer keyboards. No one is talking. The kid gives a howl of protest, rising and then is abruptly quiet.

Your hands and feet are tingling and burning. You writhe a little under the blanket. Sensation is returning to your hands and feet. It hurts but it is also good. You were at the point where all your feeling had shrunk to a tiny spark in the center of your chest. As the iv fluid runs, feeling slowly spreads out from that.

The doctor comes in. Grumpy, clearly. “Lean forward.” Listens to your chest. “Sounds clear.”

“It’s been hurting for 5 days. It hurts to breathe. Burns.” You are anxious as hell. BELIEVE ME.

The ER doc gives a little shrug. “Oxygen sats are fine.” He does a half-assed exam. He leaves.

You look at your feet, taking your socks off. Because he didn’t. There are two black spots, a couple millimeters across, old blood. Those are new.

You press the call button.

Time goes by. The nurse floats back in.

“Look. Tell the doctor to look. These are petechiae.” You point to the black spots.

If the nurse had laser vision, your feet would be burned. The nurse glares at your feet. He goes out.

The doc comes in and looks at your feet.

“They are petichiae. I have an infection.”

He gives a tiny shrug. “Your chest xray looks clear. Your labs are normal. You are not running a fever.”

“I am on azithromycin for walking pneumonia. I suddenly felt like all the fluid was running out of my arms and legs. I am worried that I am septic.”

“Blood pressure is fine. You are really really anxious.”

You are furious. It probably shows on your face. You are terrified.

“Could it be an antibiotic reaction?”

Shrug. “No rash.”

“Except the petechiae.” A sign of sepsis.

“I will change the antibiotics. Clindamycin.” He leaves.

You lie back, terrified. He doesn’t believe you. He is sending you home, septic. You will probably die.

The nurse comes in. Removes the iv and unhooks the monitor and the blood pressure cuff. You get dressed, numb and frightened and cold. The nurse goes out and returns. He recites the patient instructions in a bored voice and gives you the first dose of clindamycin.

You walk shakily to the door of the emergency room. To go home. While you are septic and they don’t believe you. You know what happens with sepsis: your blood pressure will drop and then organ damage and then IF you survive you could have heart damage or lung damage or brain damage and you might not anyhow.

You go home.

Covid-19: working in healthcare

So, should healthcare workers be required to have Covid-19 vaccines?

Yes.

What is the precedent?

Take tuberculosis, for example. Airborne, very contagious. I was born in a Knoxville, Tennessee tuberculosis sanatorium, because my mother coughed blood a month before she was due and got quarantined for active tuberculosis. Yes, the state could quarantine my mother. I was removed immediately at birth because tuberculosis doesn’t cross the placenta. The antibodies do, but the infection doesn’t. However, newborns usually catch it and die very quickly. I was lucky. My father and grandparents took care of me for 5 months. Then my mother was allowed out (after 6 months total) but was not strong enough to take care of me. So I was taken to my maternal grandparents for the next four months, and did not touch my mother until I was 9 months old.

My mother was taking 36 pills a day at home, because you have to use multiple drugs to kill tuberculosis. It develops drug resistance very very quickly.

Well, so what, you say?

Healthcare workers in the United States are routinely checked with a ppd for tuberculosis. If it is positive, you cannot work until further testing. If you have latent tuberculosis, you are treated. If you have active tuberculosis, the treatment is longer and more complicated, here: https://www.cdc.gov/tb/topic/infectioncontrol/default.htm

My cousin then said, “Well, you don’t have to show the tuberculosis test to go in a restaurant!”

Well, not right NOW, because currently tuberculosis is under more or less reasonable control in the US. Remember that guy who came in to the US with active multi drug resistant tuberculosis and knowingly exposed everyone on that airplane? Great. I remember reading about that and thinking what a selfish jerk he was. And then the group of unimmunized people who went to India and all got measles. The US at that time did not bar anyone from returning, but asked them to finish a 3 week quarentine before returning to the US. One person did not do that. There was a measles outbreak in the midwest which cost the CDC (and therefore you and me because those is tax dollars) millions to trace, quarantine and clean up. So there was discussion at that time about whether the policy should be changed and we should not allow US citizens with known infectious diseases to come in on airplanes. We DON’T allow immigrants in with infectious diseases: they are tested for tuberculosis if coming from countries where it is endemic.

So, if we had a huge outbreak of tuberculosis, we WOULD have quarantines and shut downs.

I have tested a patient for tuberculosis, about two years ago. Her son had been diagnosed with active tuberculosis. We tested her with a blood test and then repeated it in three months. Negative, hooray. In residency I also saw a case of miliary tuberculosis. That is where the tuberculosis is growing so well in the lungs that it looks like little grains of rice in the lungs on imaging. Not a good thing.

My cousin: “You shouldn’t have to put something in your body to work.”

If you have tuberculosis, you do not get to work in healthcare, because you can kill your patients. I think that this is a good thing, to not kill our patients.

I am submitting this to the Ragtag Daily Prompt: starspangled. Keep America Healthy, how about that?

Covid-19: in flew Enza

Survey shows 6 in 10 Americans will delay or skip flu shots this year.

Oh, dear. Not going to get your influenza shot? I am. Well, you say, YOU are on oxygen and have tricky lungs and keep yammering about imaginary Pandas.

Yes, and you should get your vaccine anyhow, even if you are healthy as a hoss.

If not for yourself, for everyone else. Because usually influenza kills 12,000 to 61,000 US citizens a year and gosh, guess what it will do to post-Covid long haulers. Um, kill, I would expect. And with a very low influenza winter last winter, because covid and masks and social distancing, immunity is down and the infectious disease folks are anticipating that it could be a worse than usual influenza year. How many people have long covid? This just in: More than half of covid survivors experience post acute sequelae to covid 19 (PASC) at 6 months after. ““The most common PASC involved functional mobility impairments, pulmonary abnormalities, and mental health disorders,” wrote Destin Groff, Penn State College of Medicine and Milton S Hershey Medical Center, Hershey, Pennsylvania, and colleagues. ”These long-term PASC effects occur on a scale that could overwhelm existing health care capacity, particularly in low- and middle-income countries.”

AND not only that, even if you or your friend or mother or grandmother don’t die of influenza, far more people clog up emergency rooms and doctor’s offices. The “CDC estimates that influenza has resulted in between 9 million – 45 million illnesses, between 140,000 – 810,000 hospitalizations and between 12,000 – 61,000 deaths annually since 2010.”* And the doctors and nurses and emergency people and nursing home employees and first responders are already short staffed and tired. So if you won’t get your flu vaccine for the general public, get it for the first responders.

AND before you tell me that “the vaccine gave me flu”, hello, it takes up to two weeks for the flu vaccine to confer immunity, and so if you got influenza two days later, you didn’t get it from the vaccine, you got it because you got the vaccine too late. Vaccine complications, well, I have seen one complication in my 30 years of Family Medicine, and it was someone I knew, not a patient. And half the people who tell me that “the vaccine gave me flu”, stomach flu with diarrhea and barfing is not influenza. It’s more likely to be a hangover than anything else. I see a lot more post alcohol “stomach flus” than true food poisoning. Quit drinking so much alcohol, ok?

And while you are at it, you’d better get the Covid-19 vaccine while it is still available free. And before you get on an airplane for Thanksgiving or go Trick or Treating with all those little germ spreaders or fly off to see family at Christmas/Kwanza/Winter break/whatever. Two weeks before, at least. Like, NOW. Or don’t, whatever, just don’t whine to ME about more deaths.

This public service message has been brought to you by a beneficent alien lizard. Feel free to send money.

*https://www.cdc.gov/flu/about/burden/index.html

Admitting diagnosis: old guy, don’t know

I wrote this in 2010, after I worked for three months at Madigan Army Hospital. I really enjoyed working there. It was the first time since residency that I had worked in a big hospital — 450 beds — and in a not rural setting. I kept asking to work with residents and eventually the Captain and I worked it out to both our satisfactions.

______________________________________

During my three months temp job at a nearby Army Hospital, I am asked to help the Family Medicine Inpatient Team (FMIT) whenever a faculty member is sick or out or deployed, which turns out to be fairly often. I enjoy this because I want to work with residents, Family Practice doctors in training. It is very interesting to be at a training program, watch the other faculty and work at a 400 bed hospital instead of my usual 25 bed one.

Two patients need to be admitted at the same time on our call day, so the second year resident takes one and I take the other. The report on mine is an 82 year old male veteran, coughing for three weeks, emergency room diagnosis is pneumonia.

The resident soon catches up with me because her person is too sick and gets diverted to the ICU. Mr. T, our gentleman, is a vague historian. He says that he has always coughed since he quit smoking 15 years ago and he can’t really describe his problem. He’d gotten up at 4:30 to walk around the assisted living; that is normal for him because he still does some o the maintenance. He had either felt bad then or after going back to sleep in a chair and waking at 10. “I didn’t feel good. I knew I shouldn’t drive.”

He’s had a heart attack in the past and heart bypass surgery. Records are vague. The radiologist reads the chest xrays essentially as, “Looks just like the one 3 months ago but we can’t guarantee that there isn’t a pneumonia or something in there.” He has a slightly elevated white blood cell count, no fever, and by then I do a Mini-mental status exam. He scores 22 out of 30. That could mean right on the edge of moderate dementia, or it could be delirium. I get his permission to call his wife.

“Oh, his memory has been bad since he spent a year in a chair telling them not to amputate his toes. And he was on antibiotics the whole time. He wasn’t the same after that. This morning he just said he didn’t feel right and that he shouldn’t drive.” So his wife called an ambulance.

The third year chief resident comes by and wants to know the admitting diagnosis. “Old guy, don’t know.” is my reply. “Either pneumonia or a urinary tract infection or a heart attack maybe with delirium or dementia or both.

The second year is helping me put in the computer orders, because I am terrible at it still. She could put them in upside down and asleep. “Why are we admitting him, anyhow? We can’t really find anything wrong, why not just send him home?”

“We can’t send him home because he can’t tell us what’s wrong. He might have an infection but he might not, and he has a really bad heart. If we send him home and he has a heart attack tonight, we would feel really bad. And he might die.”

I was getting a cold. I had planned to ask to work a half day but half the team was out sick so I just worked. But by morning I had no voice and felt awful. I call in sick.

At noon the phone rings. It is the second year. “You know Mr. T, who we admitted last night?”

“Yes,” I say.

“He had that heart attack during the night. Got taken to the cath lab. You made me look really good.” We had worked on the assumption that it could be early in a heart attack though the first labs and the ECG were negative. I had insisted on cardiac monitoring and repeating the enzymes. The resident had finished the note after I left and the night team had gotten the second and abnormal set of enzymes.

82 year olds are tricky. With some memory loss he couldn’t tell us much except that “I don’t feel right.” He was right not to drive and we were right to keep him in the hospital. And if it had all been normal in the morning, I still would not have felt bad about it. The residents are looking for a definitive diagnosis, but sometimes it’s “Old guy, don’t know,” until you do know.

Graced

Poem: Graced

I touched base with the psychologist

not one I know

just one who was around

asked if I could talk
for 15 minutes

indeed, he said
a difficult situation

you know that the person won’t change

echo
won’t change won’t change

I believed this
for two days

then I remembered
why I am a doctor
my secret weapon
my healing talent

I always have faith in change

everyone
has choices

“I can’t stop smoking.”
says the man

“My father quit three years ago.
55 years of two packs a day,
unfiltered Camels.”

“Camels!” says the man
“Those are bad!”

“You can quit too.
It might take more than one try.”

Why would I go to work
to talk about hypertension
exercise, birth control
obesity, heart attacks

unless at my core

I believe each person has choices?

Sometimes the choices
are between miserable
and horrible

life and death

still
whether a person is 9 or 90

they are graced
by choice

The photograph is from May 2012, at the memorial for my sister. My father is on the left, sitting, wearing oxygen.

No pandas

Today is PANS/PANDAS awareness day. I wrote this a couple weeks ago.

PANDAS PHYSICIANS NETWORK: PANS/PANDAS AWARENESS DAY

___________________________________

No pandas

I don’t have PANDAS because in the United States we barely believe in it in children and we don’t at all in adults.

I don’t have PANDAS because even though one psychiatrist said I did, he retired, and the next one says I don’t. Then not sure then no. They don’t agree.

I don’t have PANDAS because my primary care doctor won’t read the guidelines even after I have been her patient for seven years.

I don’t have PANDAS because my pulmonologist has never heard of it.

I don’t have PANDAS because it would be a lot easier to put me on a mood stabilizer to shut me up than listen to me.

I don’t have PANDAS because I am labelled difficult because I am afraid to take a mood stabilizer because I do not get a fever or a white count so my main symptom of infection is that other doctors think that I am manic though I am hypoxic and short of breath. They want to fix my mood while I want to not die of pneumonia, so our goals are at odds.

I don’t have PANDAS because I am a doctor and if I had PANDAS my fellow local doctors would feel guilty that they have told each other that I am bipolar and manic for the last 18 years and have shunned me at the county medical meetings and won’t even send me the invitations, except for the one that forwards them. He says he has given them my email and he doesn’t understand why they don’t send me the invitations.

I don’t have PANDAS because Seattle Children’s doesn’t allow the Cunningham Panel to be drawn and they say there is not enough evidence yet.

I don’t have PANDAS because I can’t afford to pay $925 on my own for the Cunningham Panel and anyhow my antibody level is back to whatever is my new baseline, higher than before no doubt.

I don’t have PANDAS because the other doctors are frightened: if I have PANDAS then who else does and if I have chronic fatigue caused by hypoxia and fibromyalgia and it’s related to PANDAS then who else would they have to test and neuropsychiatric is a whole different thing from psychiatric and we swear that we don’t know what causes chronic fatigue and fibromyalgia.

I don’t have PANDAS because I am an adult who lives in the US though if I was in Canada or Europe I could in fact have PANDAS.

I don’t have PANDAS because in the United States we barely believe in it in children and we don’t at all in adults.

Covid-19: Emotional weather

I do not think of emotions as bad or good. None of them are bad or good. They are information, controlled by electrical impulses and hormones, evolved over millions of years (or endowed by our creator, for those who swing that way).

I don’t dismiss emotions. I listen to them.

I think of myself as an ocean. There is all sorts of stuff happening in the depths that I don’t understand. Probiotics, for example. I don’t take them. If not for penicillin, I’d be dead many times over, from strep A pneumonia twice and other infections. I don’t think we understand probiotics yet. We don’t understand the brain, either.

The emotions are the weather in my life. I don’t really control them but they don’t control my ocean, either. Some days are sunny and gorgeous and then a storm may blow up. I am afraid of hurricanes, one destroyed my grandparents’ house in North Carolina, on the outer banks. I think all the cousins still mourn that house. And I miss my grandparents too, all of them. And my parents and my one sister.

See? The weather got “bad” there for a moment, but it isn’t bad. Storms have their own beauty though we hope to batten the hatches and that not too much damage is done. Maybe there is rain, scattered showers, sun breaks, a lenticular cloud. In the Pacific Northwest on the coast, the weather can change very quickly and we have microclimates. My father lived 17 miles away, but inland from me and in a valley. It was warmer in the summer and colder in the winter.

My goal with my weather emotions is to pay attention to them, let the storms blow in and out, and try not to harm anyone else because of my weather. When my sister was in hospice, we had a sign up in my small clinic. It said that my sister was in hospice with cancer and that clinic would be cancelled at some point with little warning. Patients were kind and gentle with me. And then it was cancelled, when she died. I got cards from people. They were so kind, thank you, thank you, and I could barely take it in. My maternal family then dealt with grief by having lawsuits. I don’t think that is a good way to deal with grief, but we just see things differently. Maybe it’s the right way for them. I don’t know.

Whenever I was having internal emotional weather that stirred me up, I would tell my nurse or office manager. Because they will sense my weather and need to know what is up. I had enormous support from them during a divorce, while my partners treated me horribly. My nurses and office manager knew me and my partners didn’t. My partners distanced me as if a divorce were catching. Whatever. Their loss.

Sometimes patients sensed that I was upset. I could tell by their faces. If they didn’t ask, I would. Bring the emotions out. Reassure them that I AM grumpy but not at them. Stuff in my own life. No worries.

Sometimes clinic is about a patient’s weather. They ask if they can tell me something. Often it is prefaced by “Maybe I need an antidepressant.” or “I feel really bad.” When they tell the story, usually I would say, “I think it is perfectly reasonable and normal that you feel angry/hurt/shocked/horrified/grieved/upset.” And then I would ask about an antidepressant or a counselor and most of the time, the person would say, “Well, I don’t think I need it right now.” What they needed was to know that their weather was NORMAL and REASONABLE.

I am seeing things on Facebutt and on media saying that mental health problems and behavioral health problems are on the rise. Maybe we should reframe that. Maybe we could say, “The weather is really bad right now for everyone and it’s very frightening and it is NORMAL and REASONABLE to feel frightened/appalled/angry/in denial/horrified/confused/agitated/anxious or WHATEVER you feel.” This weather is unprecedented in my lifetime, but as a physician who had very bad influenza pneumonia in 2003 and then read about the 1918-19 influenza, I have been expecting this. Expecting a pandemic. Expecting bad weather. This will pass eventually, we will learn to cope, be gentle with yourself and be gentle with others. Everyone is frightened, grieving, angry, in denial or in acceptance. The stages of grief are normal.

Hugs and prayers for all of us to endure this rough weather and help each other and ourselves..

I took the photograph in color. My program made a black and white version. It looks like the back of a stegosaurus to me, a dinosaur now living as a mountain.

For the Ragtag Daily Prompt: rainbow. Because sometimes the rain and sun combine to make a rainbow.

send the remaining vaccine to another country

I know that it sucks for US nurses and doctors and hospitals to say this. You are having to intubate and take care of and watch people die, who have refused vaccination. You are really really tired and discouraged and sick of death and sick of working way too many hours without a break.

However, I think it’s time to give up on the oppositional defiant section of the United States, say “ok, boomer” or twenty two year old or seventy old and send the rest of the vaccines to people who want it and who would be happy and grateful and glad. If we don’t help vaccinate the rest of the world, we’ll see more strains. They might morph to something milder than Delta. They might turn into something worse and more lethal.

Send the vaccine to people who want it.