Practicing Conflict II

Practicing conflict II

In Practicing conflict, I wrote about practicing conflict by arguing different sides of a topic inside my head. I wrote that I don’t fear conflict and have learned to enjoy arguing with myself. I am a physician and physicians argue all the time.

What? No they don’t. Well, the doctor persona does not argue with the patient much. Some doctors give orders to patients, others try to negotiate, some try to convince. But behind the scenes, doctors are more like the Whacky Racer Car with the Cave Guys, running with their feet and hitting each other with clubs.

In residency in Family Practice at OHSU in Portland, Oregon, I start on General Surgery during internship. This is in the early 1990s and there was not much in the way of “disruptive physician” rules. I have to cover Trauma and Plastic Surgery and General Surgery at night on call. The resident is present but I get paged first for patients on the floor. I learn that I should go to all Trauma pages in the emergency room. If I know what is happening with the new Trauma patient, it’s a lot easier to handle the phone calls for more drugs and so forth. Also, the resident is less mean to me.

We attend the Trauma “Grand Rounds”. These are unreassuring to a new intern. A resident presents a trauma patient, giving the history in the accepted formal order. The Faculty Trauma Surgeons interrupt, disagree with management of the patient and yell. They yell at the resident and at each other. The upper level residents yell too, being well trained. The Trauma Surgeons do not agree with each other. They are inflammatory and rude. I am shocked initially: medicine is not a cookbook, is not simple and it appears that it is a controversial mess. It turns out that medicine IS a controversial mess.

There is not as much yelling on the next rotation. At that time Trauma Surgeons yelled more than any other set of doctors that I ran across. They yelled in the ER, at each other, at the staff, at the nurses, at the residents. The culture has changed, I suspect, but that’s how it was then.

I take Advanced Trauma Life Support as a third year resident. The Trauma Surgeons at OHSU helped write the course. They don’t agree with it. On some questions the teaching Surgeon says, “The answer to this question is (c), “ followed by muttering loudly, “though I totally don’t agree with that and I would do (b).” Another Trauma resident or surgeon then might start arguing with him, but they moved on pretty quickly, to teach the current agreed best practices in the book. Which change every few years. Great.

Years later (2009) I join the Mad as Hell Doctors, to go across the US talking about single payer. They are a group from Oregon. Physicians for a National Healthcare Program are a bit cautious with us the first year: we might be whackos. We have an RV with our logo and we have a small fleet of cars and what do you think we do in the cars? We argue. Or discuss. Or whatever you want to call it. We spend the driving dissecting issues and how to present things best and tearing apart the last presentation and rebuilding our ideas. The group does 36 presentations in 24 days. Each presentation takes an hour to set up, two hours to do and another hour to break down and debrief. We get more and more exhausted and cranky and um, well, argumentative, as the trip proceeds. Even though I think of the Whacky Racer Cave Guys running with their feet and bonking each other with clubs, this is the most wonderful group of doctors I have ever been with. A common goal that we all want to get to, discussing and disagreeing on strategy all the way! I feel closer to those physicians in a week then I feel to any of the physicians that I’ve worked with for the last 9 years in my small town. Conflict with a common goal.

Doctors are TRAINED to argue, even with themselves, to document every decision in the chart with reasons why they have reached that decision. And that they have thought about all of the reasons for say, a low potassium, thought of every possible cause and worked their way through testing. The testing always has two strands. One strand is rule out the things that could kill the person NOW, even if rare. The other strand is what is common? You have to think about both at the same time, always. And argue with yourself about which tests should be done, in what order, what is most important, how do you treat the person while awaiting results, and have I missed anything? And if we aren’t sure, we call another doctor, run it by them, wait for them to shoot holes in our logic or to say, no, I can’t think of anything else.

We can deal with conflict. We must deal with conflict. The world is too small not to deal with conflict, with disagreements, with different viewpoints and positions and ideas. If doctors can do it every single day at work, then everyone else can too. Trying to see all the positions and possible diagnoses saves lives in medicine. We need to extrapolate that to everything else. Try to see other positions, try to understand them, to respect them. We can and we must.

Blessings.

Here are the Whacky Racers:

And Madashell Doctors blog: http://madashelldoctors.com/category/uncategorized/page/3/

For the Ragtag Daily Prompt: discuss.

The photograph is from my clinic once we had stopped seeing patients and were selling everything. Mordechai was our clinic skeleton, made of plastic, from China. This was in January 2021.

Care bare? No, Care Barrier.

My cardiologist told me to go to the Mayo Clinic six months ago.

I saw him last week and he wanted an update.

I said, “I filled out a request for a visit and my primary care referred me, but Mayo Clinic never called.”

He replies: “I will refer you.”

A week later I get a call from Mayo Clinic. But I do not have an appointment yet because

  1. They are booked out until November 18th. I am advised to “call daily” to get my appointment. They open up a week at a time, but don’t say when. A new meaning to “maybe you’ll get lucky”.
  2. They do not take my insurance and want a $5000 deposit prior to seeing me. I can fill out paperwork to ask for patient assistance. This would be the fifth hospital system in which I have filled out that paperwork. I have had to do it for four other places. The paperwork is different for each one and some even want a copy of my taxes. Do you think it’s secure? Of course it isn’t.
  3. I have to go in person to Minnesota, so add a round trip plane ticket to that $5000. They may do tests while I am there, so I don’t know how much of the $5000 I would get back. If any.

At the moment this seems insurmountable, but I will keep chipping away at all the insane barriers and paperwork. What a stupid medical system the US has, right?

We still need single payer and medicare for all. There would be one set of patient assistance papers, not five.

foxglove

The source of digoxin and digitalis. I am interested when people tell me they don’t take prescription medicines and that they only take “natural” medicines. Meaning pills. Pills do not grow on trees or bushes and are made by human beings. How exactly is the person defining “natural”?

My father said that anything a human could think up was “natural”. “Though that does not mean safe.” Think wingsuits and basejumping.

Digoxin and digitalis are used less than in the past, because there are many other medicines to choose from to control heart rate. However, they are still used because digoxin is one of the very few rate controlling medicines that does NOT lower blood pressure. Most of the others do lower blood pressure. When nothing else works or is tolerated, the cardiologist may sigh and say, ok, start digoxin. It is a tricky medicine because levels that get too high are toxic and the dose is different for each person and the dose must be lowered as kidney function changes with age. We still use it, though.

About one third of prescription medicines originate from a plant source like this, where the plant actually makes the active substance. Plants and animals and humans evolved together. We have deer all over town and they do not eat the foxglove. They love roses but stay away from foxglove.

I am seeing advertisements for a book to make your own medicines at home. I have not bought it. I would stay away from any recipe with foxglove: I want a lab to test to get the dose exactly right.

For Cee’s Flower of the Day. Heh, it turned into an essay of the day too. Wordy, wordy, wordy.

Is this a tree?

Is this a tree?

I would not call this a tree. I would call it a cone. It contains seeds. It is not a tree.

A pregnancy is called an embryo until 8 weeks after conception and then a fetus until birth. It is not a baby, any more than a seed is a tree. Here is a link to a picture of the embryo developing:

https://en.wikipedia.org/wiki/Human_embryonic_development#/media/File:HumanEmbryogenesis.svg

It’s a bit difficult to call the embryo a baby.

After 8 weeks (10 weeks from the last menstrual period) the developing pregnancy is called a fetus. It cannot survive outside the womb. A term pregnancy is 37 weeks, and the due date is at 40 weeks. The earliest survival, certainly not natural, is around 24 weeks. This takes heavy intervention and technology, a premature infant on a ventilator for months. There is risk of damage to the eyes from high oxygen and risk of spontaneous brain bleed and cerebral palsy, because the newborn can weigh half a pound. Once born, the fetus is termed a baby.

This is important from a medical standpoint and pounded into us as physicians. WHY? Because in a trauma situation, the life of the mother comes first. In Obstetrics and Family Medicine, the life of the mother comes first. In Oncology, the life of the mother comes first. My sister was diagnosed with stage IIIB ductal breast cancer at age 41. She was engaged and it turned out that she was pregnant. She wrote this essay on her blog, Butterfly Soup:

The hardest loss of breast cancer.

She had an abortion and chose chemotherapy, because it was her or the fetus. If she had chemotherapy pregnant, at that time she was told that it would probably kill the fetus or cause terrible birth defects. If she held off on chemotherapy for seven months, her oncologist thought she would die. She had a very very aggressive cancer and she already had a daughter who needed her.

She lived until age 49, with multiple rounds of chemotherapy, radiation, gamma knife radiation, whole brain radiation. And she lived until her daughter was 13. Without the abortion, her physicians thought she would have died when her daughter was 7.

My ethics in medicine are that patients have autonomy. I would NOT have wanted my sister to choose to refuse chemo and try to bring a baby to term while dying of breast cancer. However, it was HER CHOICE, not mine. It was private and no one else’s business and how dare people make moral judgements about another person’s medical choices. I give my patients CHOICES. They can choose not to treat cancer and go into hospice. They can choose surgery or refuse it. They can choose to treat opioid addiction or refuse. They may die of a heroin overdose and I grieve. I try to convince them to go to treatment and I give them nalaxone to try to reverse overdoses. I refuse a medication or treatment that I think will harm my patients, but my patients have autonomy and choices. That extends to women and pregnancy as well.

It is NOT a baby in the womb, however emotionally attached people are to this image. It is an embryo first and then a fetus. And in a car wreck, the woman comes first and the fetus second.

For the Ragtag Daily Prompt: explain.

Robust healthful manhood

The photograph of “a healthy man” to go with my Ragtag Daily Prompt conflate post.

I LOVE the caption. “Robust healthful manhood is the source of mental and physical power.” How differently the author portrays health womanhood, as shown in the conflate post. The book is Macfadden’s Encyclopedia of Physical Culture, in three volumes, 1911. Volume I is 500 pages. It is easy to read but it’s a different style from now. Here:

As a rule, if you will simply retain the idea that food should be swallowed at all times without effort, that is, that never, by any means, wash it down with water, milk, tea or any other liquid, that you should masticate it until it seems to disappear without swallowing, you can rest assured that you are masticating sufficiently. p. 97, volume I.

I plan to read the entire set. I think I will find lots of wonderful words for the Ragtag Daily Prompt (hey, I don’t think we’ve used masticate yet!) and material to write about.

Are there still interesting medical ideas out there? Oh, yes. LOTS. Only now they use the internet. I have subscribed to some of the series of videos, telling people how bad and wrong minded allopathic doctors are. Sigh. We do our best. The scam is that they let folks watch one a day for a week, or let them watch one, and then want you to buy the series. “Only $349.99!” Nice scam that is proliferating rapidly. I have now gotten emails saying “Health coaches should make as much or more than physicians and we can teach you how to market and target people and make that money.” Ugh and ick. Really?

I have patients in clinic who present by saying, “I don’t usually go to MD doctors, I go to a naturopath, but I am here because I need an antibiotic.”

I learn to respond gently. “Oh. If you need an antibiotic, maybe you have signs of infection? What are your symptoms?” I have to get past their dislike of allopathic medicine and find out what the symptoms are. Usually if I can diffuse them by getting the story, we can work together. Once in a while it doesn’t work: I have people come in and give me orders. “Do these labs.”

“Uh. Where did this list come from?”

The answer could be a video (by a naturopath, a biochemist, a biologist, whatever. I have watched some of these series. They start by saying that doctors are wrong/stupid/stubborn/misguided/etc.) or a “cash only” doctor or a magazine.

“Why are you coming to me?”

“I want medicare/my insurance to pay for it. I have done my research.”

“Well, medicare does not work that way. I have to list a symptom or diagnosis code for every lab ordered.”

“WHAT?”

I try to be patient. “Every lab has to have an attached appropriate diagnosis code or medicare will not cover it. There is a place in town where you can order your own, but it does not take medicare. You pay for it.”

“Just order it!”

“No. I am a medicare/insurance provider, which means I have a contract with them. It would be fraud and illegal to make up codes. Does your cash only provider use diagnosis codes? Can your bring their clinic note to me?”

One person replies, “My provider doesn’t take notes.” Oh, how nice. That provider does a very expensive panel of labs three times a year that the person is paying for out of pocket. “My provider checks EVERYTHING.” Um, and makes a boatload of money off you too, I think. That patient is very angry that I won’t take her orders and switches clinics. Oddly enough, this does not break my heart.

Some days I hate Dr. Google. There are lots of websites and people on line swearing that they can improve your health. There are scientific looking papers that swear something has been tested, but read the fine print: if the sample is 8 people, how does that stack up against the Women’s Health Initiative, where one arm of the study had 27,000 people? The evidence is weighted. We get multiple articles in medical school and subsequently about how to read a paper, how to weigh the evidence, how to recognize fraud or a poorly designed study.

I do not object to people looking on the internet and I have had people who came in and said, “Is it possible that I have THIS?” and who are correct. However, I see more fraud, always.


rural doctoring

I read Grampa’s Solo Visits this am and it makes me laugh.

Since I have been a family doctor in my town of 9000 for 22 years, the grocery store and coffee shops can be interesting. When I moved here, my daughter was two and my son was seven. We have three grocery stores. I usually go to the one 7 blocks from my house. I would see patients. My diabetics would sometimes look guilty and scurry away when they saw me. Another patient comes to peer in my cart.

“I want to know if YOU are eating healthy food.” he says.

I laugh.

“I don’t see any vegetables.” he says.

“I am in a CSA,” I say. “I get a box from the farm once a week.”

He frowns. “Do you get to choose?”

“No,” I say. “But since I hate throwing vegetables out, we eat more vegetables. Also, we eat ones that are unfamiliar. The first time I got celery root, I had to look it up. I didn’t know what it was.”

He nods. “Hmmm. Ok. We want to be sure you practice what you preach.”

I laugh again. “I sneak in to get the ice cream at midnight, ok? And where is YOUR cart?”

“My wife has it,” he says. “You don’t get to see it.”

“Ok, then. Have a great day.”

When we were first in town, occasionally someone would come start talking about their health in a store.

“I can’t discuss your health in front of my children. HIPAA.”

“Oh,” they’d say, “Uh, yeah. I should call the clinic Monday?”

“Yes, please.”

We had a coffee shop that made the best pastries that I’ve had since I was an exchange student in Denmark. I wished they’d make tiny pastries, bite size, for the diabetic folks. Those folks would slide a newspaper over their plate when I walked in with my family. They looked terribly guilty. I might nod, but I wouldn’t say anything. Sometimes they would confess at the next visit.

There are lots of jobs in small towns where people are very much public figures. Not just doctors, but the people who work for the city and the county, the ones who redo the taxes for homes, the realtors, all sorts.

After I was divorced, another doc at the hospital asks, “Dating someone new?”

I frown, “How do you know?”

She grins, “He lives on my street. I saw you.”

Dang it. The rumor mill is very very efficient and can often be fabulously wrong. That time it was correct, though I don’t think she passed it around. Other people live on the street.

A few days ago someone that looked familiar walks by me. “What are you doing with so-and-so?”

I laugh. “Rumors abound.” I say. “You would not believe the rumors!”

I took the photograph of the coyote yesterday, driving home. Stopped dead in my lane, no one else on the road. People will be stopped in the road here, talking to each other in two cars going opposite directions, or talking to a friend on foot.

behavioral health, cancer, and the immune system

There are more and more articles about immune causes of “behavioral health” diagnoses.

The latest I’ve read is about schizophrenia:

https://www.nature.com/articles/s41598-020-63776-0

Auto-antibodies are antibodies that we make against something else that then attack a part of ourselves. The most well know version of an auto-antibody is Rheumatic Fever, where an antibody to streptococcus A attacks the joints or skin or heart. I had a patient in Colorado who needed a new heart valve at age 10 or 11 because of Rheumatic Fever.

I have written a lot about PANDAS and PANS (respectively Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep A and Pediatric Acute Neuropsychiatric Syndrome) because an older psychiatrist was suspicious that I have PANS. I have had pneumonia four times and it is accompanied by anxiety and fear, part of which turns out to be hypoxia and tachycardia. I think a heart rate of 135 makes just about ANYONE feel anxious. It feels awful.

But what about other Behavioral Health Diagnoses? Remember, we are on the DSM V, the fifth manual of psychiatric diagnoses. We have not had markers or a clear cause. That is, we are aware that serotonin is low in the intracellular spaces in the brain with depression but we don’t know what the mechanism is, what the cause is and what exactly is happening in the neuron or brain cells. A paper on a particular rat neuron said that there were 300 different types of serotonin receptors on that neuron. Blocking one type caused rats to act in an obsessive compulsive manner. But there are 299 others and then combinations. Whew, there is a lot to be learned about the brain.

Fibromyalgia can be caused by autoantibodies, at least some of the cases: https://www.sciencedaily.com/releases/2021/07/210701120703.htm

Chronic fatigue: https://pubmed.ncbi.nlm.nih.gov/34441971/

Lupus and fibromyalgia overlap: https://pubmed.ncbi.nlm.nih.gov/9207710/

Autoimmune disorders are more common in women. We think this is because of pregnancy. The woman’s immune system has to tolerate a pregnancy where half the genetic material is from the father. Yet the immune system also has to recognize “not me, infection” and be able to distinguish that from the pregnancy. This is tricky. The most common autoimmune disorder currently is believed to be Hashimoto’s Thyroiditis, where there are self antibodies to the thyroid. Post covid could potentially beat this out.

Chronic fatigue and fibromyalgia have been orphan diseases in that we do not have an inflammation marker that defines them. The ESR (erythrocyte sedimentation rate) and CRP (um) are usually normal. These are often elevated in rheumatological disorders. Not having a marker doesn’t mean that the muscles are not painful and doesn’t mean that the fatigue is not real.

I am hopeful that we are on the cusp of a true revolution in medicine, with more understanding of the immune system and behavioral health disorders, as well as post covid, fibromyalgia and chronic fatigue. I worked at the National Cancer Institute in the 1980s before medical school, with Steve Rosenberg, MD. He was trying to get the immune system to fight cancer.

Now there has been a cancer treatment with 100% success: an immune treatment for people with rectal cancer with a particular immune profile. This is AMAZING! https://www.zmescience.com/science/experimental-trial-cancer-complete-remission-02725735/

Only 18 patients, but 100% success! No surgery.

The patch for the National Cancer Institute shows a man fighting a crab: Cancer, the crab. Dr. Rosenberg talked about Sysiphus, who was rolling a stone up a mountain eternally while it rolled back on him. From here: Later legend related that when Death came to fetch him, Sisyphus chained Death up so that no one died. Finally, Ares came to aid Death, and Sisyphus had to submit. In the meantime, Sisyphus had told his wife, Merope, not to perform the usual sacrifices and to leave his body unburied. Thus, when he reached the underworld, he was permitted to return to punish her for the omission. Once back at home, Sisyphus continued to live to a ripe old age before dying a second time.

Maybe the stone has reached a resting place. Blessings and peace you. Please peace me.

failure of the medical non-system

One thing that makes me gloomy, as a Family Practice Physician: the only person who has read my medical notes from the multiple specialists is ME.

Since March 2021, I have seen Family Practice, Cardiology, Pulmonology, Infectious Disease, Immunology and Psychiatry. I am in a rural area, so this involves three different hospital systems. They all use the EPIC electronic medical record, but they won’t release information to each other. I have gotten two of them hooked together under ONE of my names and passwords but guess what: my primary care physicain can’t see the notes from the other sites. Only I can. “Proprietary infromation.” Hey, you stupid medical non-systems, this is MY healthcare, MY notes, and YOU SUCK.

My primary care physician COULD request the notes from my pulmonologist but she hasn’t. I find this incomprehensible. I have been on oxygen for over a year. I guess my doctor frankly doesn’t care. Has she farmed my lungs out to pulmonology and doesn’t have to pay attention any more? My goal in practice was to have all of the specialists’ notes. If that was five different specialists, I requested them. Ok, it is next to impossible to get psychiatry notes. I keep wondering if psychiatrists really write notes. The patients never seem to know what diagnosis the psychiatrist is using. One hundred percent of the people that I have seen put on an (addictive) benzodiazepine say that it is for sleep. Meanwhile, at the conferences, the psychiatrists say that primary care should not give the patients benzodiazepines for sleep. I raise my hand: “Even when you psychiatrists have started them? The patients all say it’s for sleep. We don’t know WHAT you have them on it for.” When I try to stop the benzo, the patient has a fit and says that psychiatry said they have to have it. And the psychiatrist has retired or left or changed the phone number and there are no notes ever.

Anyhow, I am counting up specialists. I had really bad strep A pneumonia in 2012 and 2014. Since 2012 I have seen 20 specialists. That is counting the three Family Practitioners, because Family Practice is a specialty too. I thought it was about taking care of the whole person, which to me means reading all the specialists notes, but not one of the ones I have been to has done that.

So the medical system is an abject failure. I blame the US citizens. We choose the system with our votes. We need medicare for all, single payer healthcare, and one electronic medical record for all of the United States. Right now, there is a push to privatize medicare and turn it over to For Profit. We need to fight this and we need to demand better healthcare. Hospital organizations should not be refusing to send my clinic note to my primary care doctor. It is stupid and bad care.

https://pnhp.org/ Physicians for a National Healthcare Program for more information.


how doctors think, a dual pathway

A friend calls today and says that another person is bleeding and yet they have been set up to be seen Monday. Why isn’t this an emergency?

Based on the limited information the friend tells me, I agree with the doctors. It is NOT an emergency and I explain why. It is uncomfortable for the person because it may be cancer. Why is that not an emergency?

Let’s use chest pain in the emergency room as an example. Doctors have two brain tracks that are triggered simultaneously by every patient. The first one is “What could kill this person in the next five minutes?” The second is “What is common?” Common things are common and more likely. In medical school the really rare things are nicknamed zebras. You know there are a lot of horses but you can’t miss the zebra. I suppose that in Africa the common things are zebras and the rare ones are orcas or something like that.

Anyhow, the killers for chest pain are heart attacks, sudden death. But there could also be a dissecting aortic aneurysm, where the largest artery in the body is tearing. That person can bleed to death really really fast and that is a surgical emergency. No doctor wants to miss it. There could be a pulmonary embolism, a clot blocking the lung. Chest pain could be from a cancer. A very rare chest pain is from the valve leaflets in the heart tearing so that the person goes in to flash pulmonary edema. And there is Takayasu’s Arteritis, “broken heart syndrome”, where the heart suddenly balloons in size and again, heart failure ensues. Heart failure is actually pump failure, so fluid backs up in the lungs or the legs or both. It is usually slow but rarely very fast and dramatic. A collapsed lung can also cause a lot of pain. And my list is still not complete, I haven’t mentioned pericarditis or myocarditis or a compression fracture.

The common things do include heart attacks, but also anxiety, musculoskeletal problems, inflamed cartilage of the chest wall, fibromyalgia flares, broken ribs, trauma and other things. I was very puzzled in clinic by a woman with pain on both sides of her lower chest wall. In front but cutting through her chest. I ruled out many things. I thought that it was her diaphragm. I sent her to a rehab doctor for help. The rehab doctor sent her to radiology. She had a compression fracture of her spine and the nerves were sending pain messages on both sides. That was not even on my “differential diagnosis” list, because she had no back pain at all. My list changed that day.

Physicians and nurse practitioners and physicians assistants and registered nurses and licensed practical nurses and medical assistants are all trained to think of this differential diagnosis. We are alerted by the history and have to think down both pathways. Last year working as a temporary doctor, the medical assistant came to me saying, “This patient’s blood pressure is 80/60.” “Is he conscious?” I asked, as I went straight for the room. “Yes, he’s talking.” He WAS talking, which means that he’s gotten to 80/60 slowly or is used to it. His heart rate was fast, up near 120. I immediately had him drink water and keep drinking, as soon as he denied chest pain. The problem was dehydration: he was developmentally delayed and had only had one cup of fluid that day and it was now midafternoon. I spent time explaining that he needed 8 cups each day. Not more than that, because if he had too much fluid, it would lower his sodium and make his muscles weak. Most days he drank 3-4 cups. His chart graphed the problem: some days he had normal blood pressure and a normal heart rate. Other days his blood pressure was below normal and his heart rate was fast, his heart trying to make up for the low level of fluid. Cars don’t do so well when there is almost no oil, do they? His kidneys were affected as well. I asked him to drink the 8 cups a day, discussed the size of the cup (not 8 gallons, please) and then recheck labs in 2 weeks. If his kidneys did not improve, he would need a kidney specialist. It turned out that he had nearly fainted that morning in the waiting room. His group home person admitted that no one had noticed that he really was not drinking fluid. I thought that the patient understood and would try to drink a better amount of fluid.

So back to the person I was called about. Infection has been ruled out. This is blood in the urine. A kidney stone has been ruled out, but there is something in the kidney. This is urgent, but if the person is not bleeding hard, it is not emergent. When there is blood in the urine it does not take very much to turn it red. If there is a lot of blood, that can be an emergency, but from the story I got third person, it’s not very much. The emergency things are ruled out but there is still not a clear diagnosis. Yes, cancer is one of the possibilities but it could also be benign. Now a specialist is needed to figure out the next step and the differential diagnosis, the list of things it could be. They will order tests in the same dual order: what could kill this person quickly and what do we need to rule out as common? People often can be very anxious during this period, which is normal. The person says, “I don’t care what it ISN’T, I want to know what it IS.” But sometimes it is a zebra and it takes a while to get to that specific test.

Another example is a woman that I sent to the eye doctor. The optometrist thought it was something rare and bad. He sent her to the opthamologist, who ruled out the first thing, but thought it was something else rare and bad. He sent her to a retinal specialist. The retinal specialist ruled out the second rare and bad thing and said, “No, you have something very rare that is benign.” My patient said, “I have three diagnoses. Who do I believe?” I replied, “No, you have one. The optometrist knew it was unusual and sent you to an eye doctor. The eye doctor know it was unusual and sent you to an even more specialized eye doctor (a “sub specialist”. We keep them in basements.) Now you have a diagnosis. It was a scary process, but I think you should focus on the third opinion because hey, she said it’s benign and it won’t hurt you! That is the best outcome!” She thought about it and agreed. The process was frightening but the conclusion could not have been better.

For the Ragtag Daily Prompt: disquieting.

sciatica

Gnomes have dermatomes
call me on their cell phones
inflammed neurons fire moans
after lifting heavy stones

gnomes with grumpy dermatomes
stop riding on your spotted roans
ice your backs, lie down at home
gnomes complain and curse and moan

gnomes with calming dermatomes
glad they iced them there at home
families help, they’re not alone
healing gnomes pained dermatomes


For the Ragtag Daily Prompt: dermatome.