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.

Top ten causes of death: US 2020

Top ten causes of death US 2020, according to JAMA, here.

Total deaths: 3,358.814
Contrast total deaths in 2019, at 2,854,838. That number had been on a very slow rise since 2015 (2,712,630) to 2019 (2,854,838). That increase over four years is 142,208 people. Then the death rate suddenly jumps 503,976 people in one year. Ouch. I cannot say that I understand vaccine refusal.

1. Coronary artery disease: 690,882
Heart disease still wins. And it went up 4.8%. It is suspected that people were afraid to go to doctors and hospitals. I saw one man early on in the pandemic for “constipation”. He had acute appendicitis. I sent him to the ER and his appendix was removed that day. He thanked me for seeing him in person. Might have missed that one over zoom.

2. Cancer deaths: 598,932
This is cancer deaths, not all of the cancers.

3. Covid-19: 345,342
I have had various people complain that covid-19 is listed as the cause of death when the person has a lot of other problems: heart disease, cancer, heart failure. The death certificate allows for more than one cause but we are supposed to list the final straw first. I cannot list old age, for example. I have to list: renal failure (kidneys stopped working) due to anorexia (stopped eating) due to dementia. That patient was 104 and had had dementia for years. But dementia is not listed as the final cause. So if the person is 92, in a nursing home for dementia and congestive heart failure, gets covid-19 and dies, covid-19 is listed first, and then the others.

4. Unintentional injuries: 192,176
Accidents went up, not down, which is interesting since lots of people were not in their cars. However, remember that the top of the list for unintentional injuries is overdose death, more by legal than illicit drugs. If there is no note, it’s considered unintentional. Well, unless there is a really high blood level of opioids and benzos and alcohol. Then it becomes intentional. They do not always check, especially if the person is elderly. The number rose 11.1%, which seems like a lot of people.

5. Stroke: 159,050
This rose too.

6. Chronic lower respiratory diseases: 151,637
This went down a little. This is mostly COPD and emphysema. So why would it go down? Well, I think bad lung disease people were dying of covid-19, right?

7. Alzheimer’s: 133,182
This seems to belie me putting renal failure due to anorexia due to Alzheimer’s. I think they actually read the forms and would put that as Alzheimer’s rather than renal failure, because it is not chronic renal disease.

8. Diabetes: 101,106
This rose too. 15.4%, again, probably partly because people avoided going to clinic visits. Also perhaps some stress eating. Carbohydrate comfort.

9. Influenza and pneumonia: 53,495
So this went up too in spite of a lot less influenza. Other pneumonias, presumably.

10. Kidney disease: 52,260
This went up.

And what fell out of the top ten, to be replaced by covid-19?

11. Suicide: 44,834
This actually went down a little. What will it do in 2021?

So what will 2021 look like? I don’t know. It depends what the variants of covid-19 do, depends on what sort of influenza year we have, depends on whether we are open or closed, depends if we bloody well help the rest of the world get vaccinated so that there is not a huge continuing wave of variants.

Today the Johns Hopkins covid-19 map says that deaths in the US stand at 608,818 from covid-19. If we subtract the 2020 covid-19 deaths, we stand at 263,495 deaths from covid-19 so far this year. Will we have more deaths in the US from covid-19 than in 2020? It is looking like yes, unless more people get immunized fast.

Take care.

beach walk

My daughter is home and we went on a beach walk yesterday! The stupid oxygen keeps me from going fast. She went for a bike ride afterwards. Hooray!

Yesterday evening she brought up social distancing and how careful she should be. She has about 5 friends who are home that she is going to walk with. I am still wearing a mask over my oxygen tubing most places. She will unmask if they are vaccinated and they don’t have a cold or anything else. Even a cold would make me worse at this point. It makes me grumpy to be vulnerable, but I appreciate the discussion.

Liars and the lying lies they tell

This blog post: hanging from a telephone wire intrigues me.

Why do the liars lie?

I disagree with Ms. Kennedy.

The liars lie for the same reason that addicts lie. They are not lying to you or to me. They are lying to themselves FIRST. They want to believe what they say.

“My marriage is perfect.”

“I love all my children the same.”

“I never make an error.”

“I talk to my mother every Sunday morning because we are so close and love each other so much.”

“I can see right in to your head.”

“I don’t care about anything.”

“I am happy all the time.”

Whew. A totally easy list to come up with and I could go on and on and on…. and so could you. When someone says something like this… I am always (fill in blank) or I never (fill in blank)… stop. Think. They want to believe it. They might like you to believe it too. They might even kind of know that it’s a lie and very convincing one but the best liars have convinced themselves.

I saw it in clinic all the time. Over and over and over.

It’s the glitter that gives it away. When they come in all glittery and sparkly and their eyes shine and they are too beautiful for words and they charm your socks right off…. check your wallet. They are an addict or a manipulator or they WANT SOMETHING FROM YOU. And there are people who just do it automatically. They lie all the time.

Whatever. When someone reminds me of my mother or my sister… or the other extremely well trained enablers on the maternal side of my stupid family…. ooooooo. The person has my full focused attention. Which thing is the lie? What do they want? What are they going to try to get out of me?

When I trained in buprenorphine treatment, the guy (enabler) that I was dating was horrified. “You can’t treat addicts!” he said.

“Why not?” I asked.

“They LIE.”

I laughed. “ALL patients lie. There are studies. They lie about whether they are taking their blood pressure medicine. They lie about how much salt they are eating. They lie about exercising. The first question I ask if someone’s blood pressure is too high, is “Are you taking the medicine?” More than half the time I get a sheepish, “Yeah, well, no, I ran out of it two weeks ago.” “Yeah, well, then I can’t tell if it’s working or not, can I? And you’ll have to redo the stupid labs once you have taken it for two weeks and come back for another check.” “Ok, ok, I get it.” If you lie to your doctor, well, you might get hurt. Tell them about the pills your friend gave you, tell them about the supplements, and that infected toe? Might help if you tell the truth about it. Even though it was when you um inserted well we were just, like he has an infected um. That is important information and changes which antibiotics I use plus now I want to check for chlamydia and gonorrhea and same sex male so we gotter talk about HIV prophylaxis and this is a 15 minute clinic visit? I am now running late and annoyed. You need another visit in 1-2 days or else I gonna hospitalize yo dumb self.

And WHY do people, and especially people in addiction, lie to themselves?

Damage. ACE scores. Adverse Childhood Experience Scores. They wish that they were that close to their mother. They long for a perfect marriage. They were beaten in secret by the perfect father. The famous man, their grandfather, sexually abused them. The list is endless.

And how do we help? The person I just stopped dating told me that his children said to him “My picker’s broke.” Our pickers are not really broken. We are attracted to the people who can teach us.

In the book Passionate Marriage, the author writes about how we are attracted to the people who have what we lack. What we want to learn. What we are afraid of. What we need to learn. I needed to learn how to really look at anyone I date with my full on intuition right away and also that it is seriously Not Nice of me to get curious, activate my inner scientist and stick around. I recognize the projection on me at some point and then the scientist in me is intrigued. Really? The most recent one said that inside me there is a sweet innocent joyous tiny girl.

Well, I thought. No, not really. There certainly is a baby. But it’s a baby honey badger or a baby Iron Bitch Alien Lizard. Don’t care what you call it. But it is about as sweet as a pissed off porcupine or skunk. Polecat. Octopoggles done got us! Squirting ink and sliding into an impossibly small space and escaping from the acquarium over and over until the captors let me go…..

And that was actually the moment I should have spoken up. Calmly. Kindly. “Um, no. I was never a sweet innocent joyous tiny girl. I was bathed in antibodies to tuberculosis in the womb and no doubt alcohol and my parents were newly married and I came out saying, “What is happening now? Some new torture? Augh! Bright lights! Is there food? I am really really hungry. Feed me or I will eat YOU.” And then I lost my mother for nine months so that I would not catch tuberculosis from her and die. I didn’t really understand it. I thought people kept giving me away and that you couldn’t trust those evil adults.

In the end this is all actually necessary, says the Passionate Marriage author. WHAT? WHAT? Well, in a truly loving relationship, both people will withdraw the projection. The projection is the “falling in love” where the person is golden, perfect, your true love. No, they aren’t. But you love that aspect of them that you want/need/can’t do. True love is when you withdraw the projection and you see the real person and you love them.

It isn’t easy. But people do it. Birds do it, squirrels do it, trees do it, even elementary bees do it… let’s do it… let’s fall in love.