lizardinlaw's New Writeups

The Calorie Count (idea)

2010-02-07T15:00:16Z

In my residency for Family Practice some patients stand out in my memory. They are the ones that I struggled with: what was the right thing to do?

A woman in her 60s was admitted to the service. She was very disabled by a long-standing disease call scleroderma. She lived in a group home for disabled elders. I had never met her before.

She was admitted for a DVT, a deep venous thrombosis. This is a blood clot in the deep veins of one's legs, though it can occasionally be in the arms. If the clot extends above the knee, there is a risk that pieces will break off and go to the lungs. That is called a pulmonary embolus and can cause severe damage to the lungs or death.

We treat DVTs with heparin initially and then coumadin. At that time, we only had intravenous heparin. It had to run continuously. The heparin does not break down the clot; rather, it keeps it from extending. The coumadin is a tablet. Usually we keep someone on coumadin for 6 months after a DVT. Risks for a DVT…

The Bounceback (idea)

2010-02-07T13:17:20Z

In my third year of residency training in Family Practice, the county health clinic doctors had a disagreement with the Internal Medicine Service; overnight they switched their patients to us. Not only did our number of inpatients double, but the county health doctors took care of 2/3 of the HIV and AIDS patients in the city. This was before the current cocktail of drugs. It was slowly lethal and in our area it was mostly young men that were dying.

The county health doctors took care of their patients on a shoestring budget and with a very limited formulary of inexpensive drugs. They were incredibly good at keeping their people out of the hospital.

When one of their patients came in, they were sick as snot. Really, really sick. We felt like we were running to keep up with the county doctors' comprehensive knowledge of AIDS.

One man was in his 30s, with AIDS and a falling CD4 count, almost to nothing. He had fevers and facial pain. The dentists thought it was his sinuses.…

Living with Cancer (idea)

2010-02-03T12:54:51Z

I'm not living with cancer, so I shouldn't be writing this.
"Maybe you are," says the cool heartless medical intuitive part of my brain.
"No I'm not," I say.
"Maybe we all have cancer cells all the time, it's just that in the vast majority of cases they die and don't take over." It starts listing evidence.
"Shut the fuck up," I say.

My sister Grundoon was diagnosed with breast cancer nearly 5 years ago. I lived around cancer before that because my mother died of ovarian cancer in 2000, and I'm a family physician. I always have some patients with cancer. I can name them. And their families.

Cancer used to be a death sentence. If you got cancer, you died. Our culture used to be a lot more familiar with death. The Louisa May Alcott book "Jack and Jill" describes a 19 year old in a community getting a fever and cough. It gets worse. He dies. Probably pneumonia. The book is quite matter of fact about the loss and the grieving and the wondering at God's plan.…

January 29, 2010 (log)

2010-01-30T15:39:04Z

Grundoon called me at 2. I was trying to find the hematology oncology clinic at Madigan to ask about an inpatient. I answered the phone and said, "I can talk for two minutes."
"I have a two centimeter mass on the MRI in my left frontal lobe."
I was at a desk in Internal Medicine so I couldn't swear aloud. "Ok, I can talk for longer. Crap."

I felt derailed as I went to track down heme-onc. The Family Practice team had drafted me because they were so swamped. I was helping a medical student with three complex patients. This one had a negative MRI of her head, but we suspect a breast cancer recurrence because she came in with a calcium twice normal and has a normal parathyroid hormone.

I found the oncologist. I said, "I'm not going to quite be coherent because my sister just called and has a brain metastasis recurrence of breast cancer." We discussed the inpatient and my question was answered. No formal consult needed, a "curbside".

Then the oncologist said, "Don't give up…

January 23, 2010 (log)

2010-01-25T12:10:12Z

Well, I'm feeling rather cheerful.

I've been working at MAMC, Madigan Army Medical Center, with an 1.6 to 2 hour commute each way for 3 weeks. So far I have seen exactly one patient alone and then the computer note took me about 3 hours, what with meeting with the computer geek, I mean, tech guy who told me everything that I was doing that was wrong. The electronic medical record has four different intersecting programs and is rather challenging. They've already asked me to stay for longer than three months, mostly I think because I am entirely cheerful about the computer training and because they keep moving me around to plug different holes and I don't mind. Also I'm being a self-starter and have gone off to the "Help" desk where the eye-bagged cynical computer guys say, "Yeah, the passwords they give you only work 50% of the time at best." And I am cheerful there and hurry up and wait.

I have a bumper sticker that says "Honor veterans and fight for peace." That's a…

January 15, 2010 (log)

2010-01-15T12:57:24Z

I've been commuting to my locum tenens job for three weeks.

It is a long commute. About 87 miles, and a slow down where 16 meets I5. This is the worst time of year to commute, it rains, rains, rains. But I like the rain better than the first week, when it was frozen. We get black ice on the Peninsula and it's bad.

I am driving my partner's Subaru down and back. I have a 1986 Honda Civic, which is great for milage, but would not be fun in a wreck with an SUV. The 1995 Thunderbird totally sucks on ice. The Subaru is a 2005. It has front and side airbags. I feel wrapped in caring. Ten years ago I would have never accepted a loan like this, but my porcupine independent suspicious prickles have quieted down a lot. And the commute takes anywhere from an hour and 40 minutes to two hours.

Two days ago I was driving down and warning lights lit up on the dash.…