Tag Archives: email

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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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The isolated working

I ran my own small clinic from 2010 to 2022, working somewhere else, got Covid, was on oxygen for a year and a half, did some healing and then came back to work.

There has been a culture change in medicine that feels very strange to me. I did not notice it because I was in a solo clinic and not “part of the system”.

All the doctors, providers, are more isolated. I got a compliment yesterday when I was doing a “warm hand off” of the most sick or complicated patients, three new diabetics, a person with cancer, a person with a genetic heart problem. The doctor who I was handing off to is in the same clinic but we have barely talked since May. I don’t know her at all. She complimented me on excellent care “and calling specialists”.

I thought, huh. But I think that is a dinosaur doctor thing. I think mostly people communicate through the electronic medical record email, send messages about patients. For the decade that I was solo, I had to call other specialists because I was on a different electronic medical record. The email didn’t connect. The hospital reluctantly gave me a “link” to their system, but it was only a link to look. I could not write or send anything.

About two months ago I got an echocardiogram result. I read it and thought, ok, it’s not normal but what does it mean? Outflow obstruction by the thickened heart wall. Hmm. I called cardiology and spoke to the cardiologist who read it. He sounded surprised and said, “Idiopathic hypertrophic cardiomyopathy, most likely. It’s a classic echo.” “So, what do I do?” “Send him to me.” “Anything that I should change meanwhile?” “Yes,” says the cardiologist. He had me stop one medicine and start another. “No vasodilators and the beta blocker slowing the heart rate should help decrease the outflow obstruction.” “Got it.” I said. He also gave me two more tests to order.

I referred the patient to cardiology but it was a month before he got in. The two tests were done and they ordered more. If the diagnosis is correct, he’ll be sent to a special clinic in Denver. I called my patient while we were waiting for the cardiology visit. The medicine change had not made much difference as far as he could tell.

I was also told when I got here that I would never get a local nephrologist to see a patient, they were two busy. However, I have called two nephrologists about two patients and both took the patient and again, gave me instructions.

Two specialties have been very difficult to contact: orthopedics and gastroenterology. I have no idea why they are so difficult.

I can see that email feels faster. But there is no human contact, asking follow up questions is difficult, I don’t get that bit of further helpful education: this is what you do next. I have learned so much over the years by touching base with specialists. Once I fussed at a patient to go to hematology oncology about their high platelet count. The patient didn’t want to. He came back and said, “Apparently I have this newly found genetic problem. They put me on two medicines, not expensive. And I feel better than I have in 20 years.” I asked the oncologist about it the next time I called. He lit up, excited, and told me about the JAK-2 mutation. It is so exciting to learn about new areas in medicine and my patient says, “I have to thank you for pushing me to see the oncologist. I feel so much better.” Wow and cool.

Clinic feels like I am mostly isolated, a silo, an island, rarely talk to the other physicians unless I go to find them. I think hospital administrations like this, keeping the physicians in line by having their schedule be so packed that they almost never talk to each other. What a good way to keep physicians from interfering in the money making production! Ugh, I think it is quite horrible and unhealthy for the providers and for our countries medical system in the long run. I was seriously less lonely in a solo clinic.

The prognosis for our current medical system is very poor. The patients say to me, “Why do my doctors keep leaving?” They aren’t attached, they are isolated, I don’t think the physicians know what they are missing. Colleagues. Not silos.

For the Ragtag Daily Prompt: prognosis.

The photograph is from the Fruita Fall Festival.

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Spam hater: Covid test email spam

The latest spam email I have gotten is “to order Covid-19 tests”. WATCH OUT FOR THAT ONE! I am sending hate thoughts to whoever sent that one out, predators trying to get information or lock up the computers of vulnerable people.

The clue for me is the email address of the sender. If I hover over the address and get a string of weird things, it is spam. I am fast at deleting it now.

Old fashioned and very strong curses against the people sending out this spam.

Here is the correct link for ordering tests: https://special.usps.com/testkits

Or if you would prefer, search (or google) USPS covid test kits. Make sure you do not click on advertisements but go to the real site!

Blessings all.

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Email quack spam: try CBD oil for free!

Lovely email QUACK spam. TRY CBD OIL FOR FREE!

“The Miracle Molecule! Everything You Need To Know About the Health Benefits of CBD Oil“. The link implies that the article was in Reuters. I ain’t pressing no spam link. Internet search on Reuters Everything You Need to Know About the Health Benefits of CBD Oil does not bring up a Reuters article.

“All natural formula. All CBD products use proven, organic all natural ingredients that are toxin-free.”

Ok, now WAIT a minute. Proven? By what the hell method? We dropped some and got high so it’s good? And don’t get me started on toxin-free. Sure, and they’ll sell you a bridge too.

Let’s discuss all natural.

Is CBD oil “all natural”? Um. Well, it could be organically grown, I will give them that. There have been pesticide poisonings from illegal pot and the laws for growers vary state by state. Check your state laws re whether they have specified what the growers can use on the marijuana plants. Paraquat is very strongly implicated in Parkinson’s (https://pubmed.ncbi.nlm.nih.gov/20094060/) and you don’t want that, do you?

How do you define “all natural”? Innocent virgin farmer girls and boys, skipping through the pot plans and milking the oil out gently? Oh, ye innocent and foolish peoples. Here is a nice article about fires in CBD processing plants: https://www.sandiego.gov/sites/default/files/dsdfire-38-1.pdf. They burn real good, it turns out.

The National Fire Protection Agency (NFPA) has guidelines: https://www.firefighternation.com/prevention/nfpa-approves-420-standard-on-fire-protection-of-cannabis-growing-and-processing-facilities/. You do keep up with the NFPA, don’t you?

An older article illustrating the problem: https://www.politico.com/story/2019/02/18/marijuana-factories-explosions-safety-issues-1155850.

And the title of this seems pretty self explanatory: https://extraxx.com/the-top-five-safety-concerns-in-a-cannabis-extraction-facility/. “Let’s begin with the obvious. When dealing with flammable gasses or liquids in extract production, there is a risk of fire or explosion during the handling process. The easiest way to understand the risk of fire or explosion is to consider the fire triangle. Essentially, a fire needs three things to start: a fuel source, oxygen, and an ignition source. The basic philosophy here is that by removing legs from the fire triangle, we can make the process safer; by removing two legs, an operator can make their extraction process significantly less incident-prone.” Later in the article: “there are two tools that should be kept on site to make known the presence of unnoticed flammable vapors: a permanent LEL, or Lower Explosive Limit, monitor should be installed in the extraction room; and a handheld two or four gas portable monitor should be on site as well.”

I don’t have much experience with LFL monitors. Now I want to buy some of the gummies and try lighting them on fire. Does the smoke make one high? Well, I think it depends what it is suspended in. I thought vaping was insane when I read that some of the nicotine vapes suspended the product in antifreeze. Um, your dog may die if they drink it. Absorption in the lungs just does not seem wise. Also, some of the vapes get so hot that heavy metals get in the lungs. You know, lead and stuff. When I researched it last, China was turning out 500 different kinds of vape machines. Uh, ick, don’t do that. Sugar burns so the gummies might. I have some “Annie’s organic fruit gummies” so I can check whether they burn. Though they shouldn’t contain CBD oil. Now you know what I am doing while disabled. Home chemistry and on line research.