Tag Archives: call

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Busy clinic

Clinic has been hopping. I have been at the present site now for six weeks, so I am starting to know a few of the patients. That is, the ones that are sick and I am worrying about. It is best if your doctor’s pupils don’t dilate when they hear your name.

I have been getting helpful calls back from specialists. I have a person who has high liver tests where hepatitis and overweight and alcohol don’t seem to be the cause, so I needed an updated list of what labs to send for some of the less common liver problems. Thyroid disease, hemochromatosis, alpha one antitrypsin deficiency, smooth muscle antibodies, various other antibody disorders. The list is quite a bit longer than in the past. I warn my patient that some will come back right away and some may take a week or two. The patient is anxious and wanted to go right to the emergency room, but I ask them to wait: I get a call back from gastroenterology within 24 hours to set up the current laboratory order list.

For liver tests, we ask about alcohol intake first. Then look at weight: a high body mass index can cause fatty liver disease. Unfortunately, that can lead to cirrhosis and liver failure, so it is not trivial. We check for hepatitis A, B and C. Then we start looking for the less common causes. My person is relatively young, but that is with me taking care of age 18 and up. I tell my person not to take any supplements, I look at any prescribed medicines. No alcohol for now.

The list of tests changes quickly. If I have not worked this up recently, it’s good to check in with the specialist. The gastroenterologist may not be up to date on ankle sprains, but they are tracking the changes in their specialty. My specialty is everything, so sometimes I need a current update. Most of the specialists are just fine with this phone call.

Occasionally I do this by message. I have a new diabetic who has a cardiologist already. Diabetics are usually put on either an ace inhibitor or an angiotensin receptor blocker to protect kidney function. I message the cardiologist and get a fast answer. Start an angiotensin receptor blocker and the suggested dose. Also very helpful.

A patient tells me on the phone that I get an “A” for the day. I called them to check on them two days after changing a medicine dose and to say that the other specialist wants even MORE laboratory tests. The patient says she has not gotten a call from a doctor before. The “A” made me laugh, but it did feel good.

I am learning the local medical pathways and how to get things done in this particular medical system. The functional bits, the dysfunctional bits, and how to work around them.

For the Ragtag Daily Prompt: functional.

Sol Duc really likes staying in her pillow fort. Sometimes I want to hide in a pillow fort too. So much for being “grown up”.

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Conserving energy

I was out of clinic for two years and then very part time for a year and now not quite full time as a temp. I bargained to not quite be full time.

The electronic medical record is having a consequence, along with the pressure to see more people faster. The primary care doctors, at least the younger ones, do not seem to call their peer specialists any more. (Family Medicine is a specialty, just as Internal Medicine and Obstetrics/Gynecology are.) I called a gastroenterologist and left a message last week about a difficult and complex patient. The patient had cried three times during our visit. The gastroenterologist was very pleased I had called, was helpful, agreed with my plan of using the side effects of an antidepressant to try to help our patient, and thanked me three times for calling her. Wow. I am used to calling because during my first decade in Washington State, our rural hospital had Family Practice, General Surgery, a Urologist, Orthopedics and a Neurologist. For anything else, we called. I knew specialists on the phone for a one hundred mile radius and some knew me well enough that they’d say a cheery hi.

Now communication is by electronic medical record and email on the medical record and by (HORRORS) TEXT. Ugh. I think that there is quite a lot of handing the patient off by referring them to the Rheumatologist or Cardiologist or whatever, but the local Rheumatologist is booked out until February for new patients. That leaves the patient in a sort of despair if we don’t keep checking in on the problem. If I am worried, I call the Rheumatologist and say, “What can I do now?” I’ve had two people dropping into kidney failure and both times a call to the Nephrologist was very very helpful. I ordered the next tests that they wanted and got things rolling. One patient just got the renal ultrasound about three months after it was ordered. Sigh.

I have one patient who is booked in February for a specialist. I called that specialist too, they did not want any further tests. I told the patient, “You aren’t that sick so you won’t be seen for a while. It isn’t first come first serve: it is sickest first. We all have to save room for the emergencies and sometimes those are overwhelming.” The specialist agreed and the patient is fine with that and I think pleased to know that we do not think she’s that sick. She feels better. If things get worse, she is to come see me and might get moved up. Neither I nor the specialist think that will happen.

Is this conservation of energy, to communicate by email and text? I don’t think so. I think sometimes a phone call is much more helpful, because the other physician knows exactly what I am worrying about and they can tell me their thoughts swiftly. Sometimes they want me to start or change a medicine. Things can get lost in the overwhelming piles of data and the emails and labs and xrays and specialist notes all flowing in.

My Uncle Jim (known as AHU for Ancient Honorable Uncle Jim) used to sing part of this:

Yeah, that’s just how I call my fellow specialists.

For the Ragtag Daily Prompt: conservation. Don’t cats win at conservation of energy?

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fawn call

This starts with my ornithology teaching assistant in college, at the University of Wisconsin, Madison.

I LOVE ornithology. A generalist class: bird wings, ecology, biology, zoology, physics of flight and they SING! Also we walk around in the woods with the teaching assistants trying to see and hear birds. We memorize their songs and markings.

We go out at night. Our teaching assistant hears a barn owl. He replies. He is an expert at that call. The barn owl answers. After a few back and forths, the barn owl swoops over us, coming to check out the caller! The barn owl is unnerving and gorgeous, passing just over our heads.

We all talk to the birds. We make pshhh, pshhh, pshhh noises and lbbs (little brown birds) will sometimes hop out on a branch, curious about us. Hooray! It’s a warbler!

We practice our bird songs.

Fast forward to the present. I walk with my friend and he is messing with his enormous zoom lens. We see crows harrying something in the top of a tree. A hawk, who calls. I start answering. The hawk is young and calling its parents. It’s the time when the parents say, you have to go hunt. My friend gets an amazing picture of the hawk looking right at us, mouth open, crying. I dig around on my cell phone, and think it’s a Swainson’s hawk. I play the Swainson’s song and then the young hawk REALLY cries: I feel terrible, as if I have teased the young one. Yes, it’s a Swainson.

We run in to two young bucks. I sing to deer. The deer are always alert and ready to run when I appear, but when I sing they just stand and look at me. My friend takes a photograph of the buck, just watching and listening to me.

My friend finds a fawn in his yard. The mother leaves the fawn for 8-24 hours. My friend has a low fence around most but not all of the yard.

The doe returns for the fawn one day. My friend is outside. The mother hops the fence. The fawn tries to, but it can’t hop high enough. It hits the fence and cries. It tries over and over. My friend goes up slowly and opens the gate. The fawn goes out the gate after he backs off. Both fawn and doe look at my friend.

I stop by his house to pick up a package for him. I park and hop out of my car. A fawn behind the fence startles and goes around the side of the house! It’s late afternoon and two fawns and a doe were lying in the shade in the front yard. The second fawn gets up and mom stands. I hold still and sing to them a little. Then I go in through the gate, get the package and slowly get back in my car.

Word gets around. The other day my friend has six fawns in his yard. He’s charmed and a bit shocked. He is outside. A doe comes and calls her fawn. It’s a bit of a meh or ma sound. My friend tries to make the same sound. Three of the fawns eating grass stop. They turn their ears towards him, alert. One fawn walks up to him….

….so now he’s a fawn caller.

 

For the Daily Prompt: gate.

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Pair

Hiking last Saturday, we both heard and alerted to a bird call. Here: song.

However, there were two, and not an alarm call.

We spotted both and then on the hike back, here they are, perched in the snag. A pair of adult bald eagles. I think it was flirting calls that we heard, or a pair talking about this year’s nest.

I am so glad that bald eagles are back in numbers…. and that we are protecting them.

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stomach flu

On call for my patients, I get a call about flu.

The spouse sounds worried. I speak to the sick person.

“Do you have a fever?”

“Yes, 100.6. I am throwing up and I don’t want to eat.”

“Do you have muscle aches?”

“Not really. I know I need to drink water.”

“Are you coughing?”

“Not really. Not much.”

“Not very congested. Do you have diarrhea?”

“Yes, lots. And my stomach hurts when I eat.”

People often say “flu” meaning “stomach flu” which is not influenza. “Stomach flu” is gastroenteritis, another set of viruses entirely. It could be a bacterial food poisoning, but in 17 years in my rural town, I have seen a total of two food poisoning bacterial infections. Most here are viral.

“Is there blood in the diarrhea?”

“No.”

Viral, then. Blood in the stool is more likely to be bacterial.

The important thing is to stay hydrated. If the person gets too dehydrated, they tend to just keep throwing up and may need iv fluids. To keep them out of the emergency room, I give the following recipe:

One quart of water
one teaspoon sugar
A pinch of salt
(with or without a pinch of baking soda)

If the person is quite nauseated, try drinking just a tablespoon every 15 minutes, with a timer. The electrolytes and sugar help the fluids absorb. Small amounts are easier to absorb and less likely to come up. If they keep throwing that up, go to the emergency room.

“I’m not eating.”

That’s ok. A day without eating won’t hurt you unless you are starting very underweight. Get the fluids in first and then you can go on to chicken soup and try some crackers.

Gatorade or flat ginger ale or pedialyte contain electrolytes too, but the home recipe is fine. And for small children, regular or pedialyte popsicles, because they can’t really drink them quickly.

Most people will recover on their own, especially if they stay hydrated. We don’t tend to try to stop the diarrhea, it’s better just to hydrate people to keep up. If someone is immunosupressed, on chemotherapy or with HIV or after a transplant, they may need hospitalization.

Does the picture look upside down? A bit nauseating or disorienting? I took it in Portland, and yes, it’s upside down.