share the road!

Here is some food for thought about folks who might be sharing the road with you. A early 60's year old overweight, chain-smoking long-haul trucker with onset of chest pain while loading his 18 wheeler in Texas, took a nitro sl. and hit the road in a convoy with two other 18 wheelers, all headed to ABQ. Continued to have chest pain on the road, got to ABQ, took several more nitro and decided to try sleeping. Woke up, still having chest pain, more nitro and on the road again headed to Gasandoilington where, upon reaching home, still with chest pain, went to the ER and was found to be having.....you'll never guess.....an MI! Ended up with a stent. Next time you see an 18 wheeler coming at you at 70 mph on a 2-lane highway, consider the typical long-haul trucker lifestyle and give them wide berth!

WTF (what the frac?)

Interesting reading at http:// www.durangoherald.com/asp-bin/article_generation.asp?article_type=news&article_path=/news/08/news080717_2.htm (7/17, 7/20 and 7/23/08) articles on ER nurse with chemical exposure from a gas drilling worker and the difficulty her doctors had in determining what chemical she was actually exposed to after she became quite ill. This incident raises serious questions about the safety rights of healthcare workers vs the rights of the gas and oil industry to protect their "secret chemical formulas" from being disclosed in an accident situation. It is also an eyeopener on the profits that these companies are making and how poorly they are regulated in terms of health and environmental effects of the "fracing" process. The current fuel crisis is a HUGE opportunity for these companies to significantly increase their profits which are already astronomical and at what price to the health of the people and the environment in areas where the numbers of gas and oil drilling sites are increasing exponentially? When I first moved here I was shocked at the numbers of patients with gliomas. I did a little research on risk factors associated with gliomas and found the only known correlation is exposure to petroleum products. At our very small regional medical center, there have been, in the past 6 months, 3 cases of bile duct cancer. I also know of another case in this area in the same period treated at another medical center. I would appreciate hearing comments from readers in oncology or gastroenterology re: the risk factors associated with this kind of cancer. I do not believe that the answer to the current fuel crisis is to escalate the destruction of our environment by pumping more toxic substances into the earth to extract fuels to make yet even more profit for megabillion dollar corporations like Weatherford and Halliburton whose arrogant policies of protection of their "secret formulas" for profit put the almighty dollar above the value of human life. Where are our elected leaders in this mess? Is it their job to protect these corporations or to protect the citizens they have been elected to represent?

Outpatient followup

This is a followup to my most recent blog on the patient with cad, malignant htn, probable sociopath, depressed, tsh of 66. He actually kept his clinic appt with me. He came with his daughter and 2 year old grand-daughter. He was d/c'd over the holiday weekend on 8 meds for which he paid over $700 cash. 4 of the meds were bp meds, he took them all yesterday morning and felt bad midday and checked his bp, it was 70/40 and his cuff measures 10pts higher than our office cuff. He was afraid to take any meds this morning. This guy was d/c'd on Lisinopril 20 mgs, diovan 80 mgs, hctz 12.5 mgs and norvasc 10 mgs. Also Plavix 75 mgs, Synthroid 50 mcg, Crestor 80 mgs and Advair. I believe his discharge meds are setting him up for another failure for several reasons: too many pills, he's likely to (and has already had) adverse effects from his meds (hypotension), there is no way this man is going to continue to pay over $700 per month for meds. Is the best management of his htn to send him home on small doses of 4 different bp meds? Could he have been treated with only the ace and the hctz at higher doses and see how he does? This would certainly have been much less expensive and probably less likely to cause side effects. Could the Crestor (another big ticket item) have waited a bit for the thyroid function to normalize with synthroid (another inexpensive drug) and is the Plavix (yet another big ticket item) absolutely necessary at this point as he did not sustain an MI this admission, doesn't have stents and no hx of cva's. Isn't it wiser to attempt to treat the most urgent issues as first priority while working on developing a sense of trust in medical care with this man by not throwing a whole bunch of expensive medications at him all at once creating a high liklihood of side effects resulting in his rejecting everything? I found myself very frustrated at what I felt was a discharge treatment plan not well thought out and tailored to this man's individual situation and thus not likely to succeed in treating his problems. At any rate, I ultimately took away the diovan and I'm hoping he will call in a few days to tell me his bp is still too low so I can knock off more pills. Problem is, the d/c'd pills were a huge waste of his money. I think part of the problem is that both the hospitalist and the cardiologist were ordering meds and not coordinating care and discussing the psychological and financial issues also impacting on this patient's ability to care for himself. This is an example of the importance of the role of a primary care physician, which this man does not have.

don't like to go to the doctor's?

Short of breath? Go to the local welding shop and get a tank of oxygen, take it home and treat yourself! As I sat and talked to this guy, it just got worse and worse.....56 with cad, 2 mi's, came in with a bp of 220/115 and chest pain, had taken two of his brother's bp pills "they dropped the lower number by about 20 points but the chest pain kept getting worse". Hyperlipidemia......"I went to ____Clinic and they gave me some pills, took 'em for a week, turned jaundiced, that chic was crazy, she told me to just keep takin them, she near killed me". (He repeated this story every time I talked to him. He had periorbital edema and was bradycardic and seemed a little slow, neither the hospitalist nor the cardiologist thought to check a TSH, so I did.....78, repeated to rule out a lab error.....66. "Yeah, I have a thyroid problem, Dr.___ gave me some pills, I took 'em but I ran out. Then I did some studyin on it and I started takin kelp and selenium but I stopped. I ran into some bad times with the wife, started havin nightmares about killin people, woke up and didn't know whether I really did it or not. "I done some bad things and sometimes they come back to me... I cut this dude up real bad one time......... I was takin LSD......". " Yeah, I been depressed, a doctor one time put me on a pill and I got to where I felt like I wanted to kill someone, not myself, I ain't never been suicidal". "I left home when I was 15, I backed out the door at the trigger end of a Colt, my daddy was gettin ready to kick my ass for no reason, just cuz he was mad and wanted to kick someone's ass". " I been workin since I was 5, my daddy was an alcoholic, I started smokin and drinkin when I was about 7, my daddy said I worked like a man so I can drink and smoke like a man too so he gave me beer and cigarettes". He says he now smokes pot "every day, all day". He asks if we can give him "some of 'em pills my brother has, they worked good". He apparently doesn't know that the hospitalist started him on Lipitor. I guess the hospitalist didn't read my note describing the patient's repetitive angry references to his experience with Lipitor in the past. He doesn't have a doctor so Dr. Drugrepschmoozer reads the guy the rules: "We'll take care of you but you have to take the medicines we prescribe and follow the treatments we recommend and if you miss two appointments, you will be fired". Thanks Dr. Drugrepschmoozer for writing a discharge order that he be scheduled for an appointment with me post-discharge! What to do with a homicidal, probably bipolar, angry sociopath? Book him in the NP's schedule and see what happens. You are a brave man!

another immaculate conception

36 year old morbidly obese woman presents to the er with sob, edema, chest pain, bp 200/113. Chest ct neg. for p.e., cxr shows pulmonary edema, admitted by hospitalist. echo mod mitral regurg, mild lae, trops neg. started on multiple meds including lasix, aceI, nitro gtt. LMP a month ago, last partner a year ago. Something missing from initial labs......a beta sub! Done the next day.....positive. Surprise! Immaculate conception! OB consulted, ultrasound shows approx 23 week fetus. Fortunately (or not) there aren't many lawyers here in Gasandoilington. If there were, maybe a beta sub would then be on the A list for initial labs on females of childbearing age. The patient ended up being shipped out.....low level of amniotic fluid in the sac and she began to bleed.

give me a break

Running into your patients in the community can be pretty awkward sometimes. I've lived in and practiced in both a big city and a small community and had some interesting, unexpected encounters with patients outside of work. One incident stands out in particular. A patient caught me at K-Mart one Saturday morning, I was in a hurry, buying a diaper genie for a friend for a baby shower gift. The patient spots me, comes right over and proceeds to tell me how she's been having diarrhea and an upset stomach (I'm thinking, get out of my face, it's my day off, the kaopectate is in aisle 3). I listened patiently for a few minutes then gave her brief advice on what she might do then asked her to call for an appointment if she wasn't feeling better. She left probably feeling taken care of, I left feeling "aren't there any boundaries?" Small community encounters don't feel as much like a violation of personal space, they feel more like "this is my patient and my neighbor". Office hours are more fluid in a small community. One place where I think it's a good thing to run into patients is at the gym (unless the patient is a highly competitive egomaniac who has to outdo you on the treadmill and every other piece of equipment there). When patients see you at the gym, you become a true role model for the healthy behaviours you preach in the office. Your presence there may drive home the point that exercise really is important if you take the time to do it too.

DRIVING WHILE NATIVE AMERICAN

Sad story: Native American guy ran a red light early one recent morning and t-boned another driver. He was badly hurt, ended up in the ICU. The local "pathetic excuse for a newspaper" printed the story and quoted a fireman who pulled him from the wreck as saying "his eyes were red and he smelled of alcohol". The newspaper noted that "charges will likely be filed for DWI".
At the hospital where the guy was admitted, Dr. Drugrepschmoozer was involved because of chest injuries and every time he mentioned the patient, he referred to him as "the guy who was drunk and t-boned somebody" . A week later, the newspaper printed a front page headline saying that the man was not drunk, his blood alcohol level was the equivalent of recent use of mouthwash and that his eyes were bloodshot because he was tired and on his way home from work. At least they had the decency to make it a big prominent headline but a few days later, the editor got on his high horse and printed an editorial about how public servants like police and fireman need to be particularly vigilant about making misleading statements at accident scenes or other such public interest "events". Of course the editor of the newspaper took no responsibility for printing the unsubstantiated accusations for the titillation of the good citizens of Gasandoilington, who could then be satisfied that their first thought when reading the last name of the victim was correct, he was probably drunk. Sadly, the man died this week of his injuries and his family, in his obituary, took the time, despite their grief, to express their gratitude to the doctors and nurses who cared for him. As for the fireman, the newspaper editor and Dr. Drugrepschmoozer, I sincerely hope that they have learned and will be better at what they do because of their experience wth this gentleman and his family.