Category Archives: worry

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Quota

Quota

honestly
I feel despair
when I try
to think about the new schedule

Twenty four slots
Of 20 minutes
See three people
For 40 minutes
Twenty on the schedule

Unanswered questions
Wake me on Sunday morning
If I am called to a labor patient
Must I make up that clinic face time?
What of holidays?
The clinic is closed.
Night call is nowhere addressed
Will they hire more and more
Who don’t take call
Until I am the last woman standing
Red rimmed eyes staring
Numb with fatigue

What of my nearly deaf patient
Who reads lips
May we take forty minutes?
All the fairly deaf elderly?
New parents, anxious
Questions pour out like
Coins from a jackpot win
What of the tearful brokenhearted
And anxious?
I shrink at the thought
Of crushing their hearts
Into twenty minutes

And what if I’m sick?
(sick leave & vacation all one)
It’s not a holiday if I’m on call
No make-up day off
If I cancel clinic
For illness
Do I make up those days
A quota of patient face days

I am in the factory
The mines
People are the shirts I must sew
The tons of coal I must load
I must meet a quota

Doctors die younger
Our life is measured out
In patients
I won’t let the quota
Kill my love

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Influenza: check your pulse!

This year influenza is bad. My key test in influenza is not a chest x-ray. It is taking a resting pulse and a walking pulse.

Why? Influenza can cause a walking pneumonia. Walking pneumonia is where the lungs are infected throughout and there is tissue swelling. It is different from a lobar pneumonia. In lobar pneumonia people run a higher fever, look sicker, and on the chest x-ray, that part of the lung is white: infection, not air.

In walking pneumonia, the chest x-ray may be read as normal. This is because all the lung tissue is equally swollen. The swelling means that there is less air space. The person may feel ok at rest. They feel exhausted when they walk because the heart must take up the slack for the missing air space, the swollen lungs. At rest this week one person’s heart rate is 84. After walking it is 124. Normal is 60-100, so 124 is like running a marathon: exhausting and hard on your heart and body.

I have patients saying “I was sick two weeks ago and I am still exhausted.” If their pulse is much over 100 after they walk, they cannot work until it comes down. If they work and wear themselves out, the lungs can’t heal. The treatment is rest. If they are at work with a pulse of 114 or 124, then they risk getting a secondary infection in already damaged lungs. They could die.

Check your pulse at home. Count the number of heartbeats in 60 seconds. That is your pulse. Walk around, sit down, and check again. That is the walking pulse. Over 100 is not normal.

This is a bad influenza. The tamiflu (oseltamivir) helps but works best in the first three days of flu. Check your pulse, be seen, rest and get well.

http://www.peninsuladailynews.com/news/three-die-of-flu-on-peninsula-public-helath-officals-say-a-fourth-death-said-to-have-been-in-seattle/

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cat worries

My cat is turning 17 soon. She and I visited a friend yesterday. The friend and I went off to the farmer’s market and returned. I called and the cat didn’t come. I looked under the bed, where she usually hides but she wasn’t there. I search the house and stand staring at the bed…. She couldn’t have gotten out, could she?

Unfathomable….

For the Ragtag Daily Prompt: fathom.

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forest fires and your lungs

Our air quality is still bad today. I got my first alarm on my cell phone for bad air quality yesterday: the first time in 18 years.

Here are some links regarding forest fire smoke and your lungs:

Forest fires and Respiratory Health Fact Sheet: here. This pdf has other links at the bottom.

Breathe: the lung association: here. A Canadian site. Good, short and clear.

American Lung Association: How wildfires affect our health.

Fire fighter health: US Forest Service. Effects of Smoke Exposure on Firefighter Health

The photograph is not a fire: it’s a sunset in Hawaii.

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My clinic and the state of medicine

January has been the busiest month in clinic since I returned to work in April of 2015 after the ten month systemic strep A hiatus. It took another ten months for my fast twitch muscles to start working again. I was working “half time” for the first ten months after I returned.

Right now, though, my receptionist and I are about maxed out. We saw 4-8 people a day in January, averaging 6.5, and with Martin Luther King’s birthday off. I see patients five days a week, try to stop by 2 pm and then do paperwork until 4 or 5. Lately I have been going in at 7 am, because I am feeling behind. Three very sick patients, one who has been sick and hospitalized nearly weekly since October, are each taking 1-2 hours a week and I can’t get to the routine paperwork. Labs, referral letters that need to go out, reading referral letters that come back and updating the med list, xrays, pathology reports….

Yes, we could hire someone to scan it all faster, but scanning it does not mean it has been read. And it is me that has to read it. One of the complex patients has five specialists and four different electronic medical records are involved. I had to call the rheumatologist, because the doc was not responding to the patient’s calls. I had sent the rheumatologist letters and updates: turned out the doc didn’t read any of them until the patient missed a visit because their car broke down. And another of the specialists said they “didn’t have the notes” from the other hospital. I wrote a letter to ALL of the specialists and said, the notes are in there because I faxed them to our hospital myself. Unfortunately scanned notes are difficult to find in the EPIC electronic medical record. Ironically both hospitals use EPIC but the two versions do not share their information. This is REALLY REALLY BAD. It is bad for patient care and bad for this specific patient. Not only that, but when one of the specialists orders something, the report doesn’t get sent to me as well as them. I tracked down labs and I tracked down an xray report and sent him back to the hospital at that visit. I do not know if the hospitalization could have been averted, but….I’ve told the patient and spouse that if ANYONE orders a test, call me. So I can track down the results.

So it looks like five clinic days a week, seeing up to eight patients a day, will take forty hours or more. This is a rural family practice clinic. I cannot see any way to see more and actually keep up with the information coming in with my patient population, half of whom are over 65. And an additional one is in hospice and another on palliative care.

A fellow doc has retired from medicine, in her 50s. She is “med-peds”: internal medicine-pediatrics, which is sort of like family practice except they don’t do obstetrics, less gynecology and less orthopedics. I hear that she is retiring because every 20 minute clinic visit generates an hour of paperwork. The hospital considers 4 days a week, 18 patients a day, full time. Ok, that is 72 patients a week, seen in four 8 hour shifts. 32 hours plus 72 hours of paperwork. One hundred and four hours. Can’t be done.

I dropped to 3.5 days in 2009 when the hospital said we had to see 18 a day. So 28 hours, 63 patients. 28 hours plus 63 hours. That is 91 hours a week. I still could not keep up with the information coming back from specialists, labs, xrays, pathology reports, medicine refill requests, requests for those evil ride on carts, spurious nonsense from insurance companies, and families calling about their loved ones. All ten fingers in holes in the dyke and 90 other holes spouting water.

Something has to give and something IS giving. Care is falling through the cracks and providers are quitting. I am not quitting, I just am not making anything anywhere near to the “average family practice salary” in the US. And we hear that burnout is now at 54% of primary care doctors. Hello, US. If we don’t go to single payer, you might have to ask your naturopath to take out your appendix. And good luck with that.

If I see 7 per day, five days a week: that is 35 patients. I do longer visits and more paperwork in the room, so call it 45 minutes of paperwork per patient. I see patients from 8:30 to 12 and 1 to 2. 4.5 hours five days = 22.5 hours plus (35 patients x 45 minutes)= 26 hours and now I am at 48.5 hours a week. And then if I have three really sick ones: more.

If we hire help, they have to be paid. Then I need to see more patients in order to generate that pay. Then there is more paperwork that I can’t keep up with. An infinite loop.

Let’s look at my clinic population verses county and state.
Clinic: 2.4% under age 18
20.7% age 19-50
28% age 50 to 64
48.9% over 65
Jefferson county (2014): 16.7% under age 19
51.5 age 19-65
31.8% over age 65
Washington state (2014): 29% under age 19
56.9% age 19-65
14.1% over age 65

We have an older county and nearly half my patients are over 65, and 77.9% of my clinic patients are over age 50.

And I should be reading all the new guidelines as they come out. The newest hypertension guidelines say that the blood pressure should be taken standing in all patients over age 60. Those guidelines are now a couple of years old. My patients tell me that I am the ONLY doctor that they have taking their blood pressure standing. The cardiologists aren’t doing it either. Just this week there are articles in the AAFP journal explaining the blood pressure guidelines. But the doctors need time to READ the articles. The guidelines themselves tend to be 400 pages of recommendations and explanations and a list of hundreds of studies reviewed since the last guidelines. And ok, there are also hundreds of guidelines. On blood pressure, who should be on aspirin, what to do for heart pump failure, urinary incontinence, osteoporosis, toenail fungus.

https://www.uspreventiveservicestaskforce.org/
guidelines: https://www.uspreventiveservicestaskforce.org/BrowseRec/Index
Ok, that is a list of 96 guidelines, which doesn’t even include the hypertension ones. The hypertension guidelines are called JNC 8, for the eighth version:
http://jamanetwork.com/journals/jama/fullarticle/1791497
Here is the two page hypertension JNC 8 algorithm: http://www.nmhs.net/documents/27JNC8HTNGuidelinesBookBooklet.pdf. Memorize it and the other guidelines, ok?
And here is the Guideline Clearing House: https://www.guideline.gov/

This week another clinic suddenly closed and we have gotten walk in patients and calls. About eight so far. We are booked for new patients out to April…..

I took this photograph from the beach as the sun set, camera zoomed. Different mountains were lit up while others were in shadow as the sun went down. This is Mount Baker and friends….

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Cold homes

For the Daily Prompt: float.

Float… but some of my patients are not floating. They are sinking.

It has been clear and below freezing for a few days now. I have more than one patient who is not exercising or not taking care of their blood sugar or not eating adequately…. because they don’t have heat. They are staying in bed with an electric blanket or staying in one room because they have an electric heater plugged in. My house has 1930s wiring and I am told that it is a fire hazard to plug one of those heaters in.

I went home yesterday and my house felt cold. I checked the monitor: 49 degrees. I had cleaned the heat pump filters two days before and then had forgotten to restart the heat pump. It was up to 57 degrees by this morning and will be warm tonight.

Prayers and donations for the people in all our areas who do not have adequate heat….

 

 

 

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At what age should we talk to our kids about drugs?

I am a rural family physician and my recommendation: before age 9. Before third grade.

WHY? Your eyes are popping out of your head in horror, but my recommendation comes from surveying my patients. For years.

The biggest drug killer is tobacco. However, it takes 30 years to kill people. It is very effective at taking twenty years off someone’s life, destroying their lungs, causing lung cancer, heart disease, mouth cancer, breast cancer, uterine cancer, stomach cancer, emphysema, heart disease….

I ask older smokers what age they started smoking. This is informal. This is not scientific. But most of my male older smokers say that they first tried cigarettes at age 9. I think parents need to be talking to their children about cigarettes by age 9.

And then start talking about alcohol and illegal drugs and the terrible dangers of pills.

“My innocent child would never….” Unfortunately my daughter said that as a senior in high school in our small town, there were 4-5 kids out of the 120+ that were not trying alcohol and marijuana. But there are kids trying far worse substances. We have methamphetamines here, and heroin, and pain pills sold on the street.

The perception that pills are safe is wrong too. Heroin is made from the opium poppy and it’s rather an expensive process, not to mention illegal and has to be imported from dangerous places. But teens take oxycodone and hydrocodone, bought on the street, to get high. And now drug sellers are making FAKE oxycodone and hydrocodone and selling that on the street. It contains fentanyl, which is much much stronger. If the dealer gets the mix wrong, the buyer can overdose and die.

Talk to your children young! NEVER take a pill from a friend, never take someone else’s medicine, never take a pill to party! YOU COULD DIE! And if you have a friend that is not making sense, that you can’t wake up, DON’T LEAVE THEM! Call an ambulance. Your friend may have used something illegal, and may not want you to call an ambulance. But if you think they are too sleepy….. don’t take a chance. People can get so sleepy, so sedated, that they stop breathing.

And parents, you are the ones that have to set a good example. Don’t drink alcohol every night. Don’t use pot every night. Take as few pills as possible. Pills aren’t necessarily safe because they are “supplements” or “natural” — hey, opium and heroin are plant based! Stop using tobacco and if you have a hard time doing it, tell your children you are struggling. It takes an average of eight tries to quit smoking. Get help.

Lastly, we talk about childhood innocence, but we let kids babysit at age 11. That is the Red Cross youngest age. My daughter took a babysitting course at age 11 and babysat. If we think they are responsible enough to do CPR, call 911 and do the heimlich maneuver, shouldn’t we also be talking to them about addictive substances by that age?

Talk to your children about addiction young… so that they can avoid it.

I am submitting this to the Daily Post Prompt: calm. I am not calm about this topic, but the photograph is calm…. and if we can help more children and families…..