A Negative Workup

Jonathan Blake is a hardworking 62-year-old janitor, who seldom complains. A few weeks ago I got several hospital reports about him.

He had gone to the emergency room with pain in the upper left portion of his chest, radiating down his left arm. He is a diabetic, who takes blood pressure and cholesterol medications, and he smoked cigarettes until five years ago. Needless to say, the hospital kept him overnight because he seemed such a high-risk patient for coronary artery disease, and put him through a stress test the next morning.

His nuclear stress test was normal, so he was discharged with a diagnosis of “non-cardiac chest pain”.

Almost two weeks later I happened to see his name on the computer screen at my workstation. Jonathan was in to see my colleague, Dr. Wilford Brown, who often sees patients the full-time doctors at our clinic cannot fit into their schedules. I always have full confidence in Dr. Brown’s ability to handle any situation, which also turned out to be the case this time.

I forgot about the whole incident until a few days later, when I, as Jonathan’s PCP (Primary Care Provider) had to sign an insurance authorization for a shoulder MRI. A few days later the MRI report arrived. Jonathan had torn a large portion of the rotator cuff of his left shoulder and he had also torn the long head of his biceps tendon.

Last week I saw him for his regular diabetes follow-up. By that time, he had already seen the orthopedic surgeon who will be repairing his rotator cuff. Jonathan showed me the telltale bulge in his upper arm, where the useless biceps muscle had contracted. At his age, that particular injury isn’t usually repaired, but the rotator cuff is essential.

“I can’t believe they didn’t pick this up at the hospital”, he said. “They didn’t listen to me. I told them all along my arm hurt, and all they worried about was my heart.”

Instant Feedback

My pager went off just after supper. The caller was Cindy Spofford, who works in a local real estate office, the patient was her four-year-old daughter Amanda, and the number was a cell phone. Their regular physician is Dr. Wilford Brown.

“Hi Doctor, thanks for calling me back. We’re down in the Capital City visiting my parents for Christmas. Amanda has had this terrible cough for two days and we just took her to the emergency room. They diagnosed her with bronchitis but didn’t give her an antibiotic. We wanted to check with you if that makes any sense.”

I inquired about her general condition. She didn’t have a high fever, had no trouble breathing, was eating and drinking fine, didn’t have any history of asthma, and her cough was dry and almost barking; I could hear her in the background, coughing in the back seat.

“Well, bronchitis is usually viral”, I explained. “Doctors have been quick to prescribe antibiotics for bronchitis for many years, but most of the time, they’re not necessary. Even ear infections are often caused by viruses, and can go away without antibiotics. You probably know how much trouble we’re having now with drug-resistant staph infections, right? They are such a problem because of all the antibiotics we have used unnecessarily over the years.”

I made sure that Amanda had had a decent physical exam and reviewed the warning signs that would warrant a return trip to the emergency room down in the Capital City.

Cindy thanked me. I wished her family a Merry Christmas and mused over how a reassuring voice on a cell phone from your hometown sometimes rates higher than an in-person opinion from a big city emergency room doctor.

Our Last Visit

Mary and Joseph Washburn are moving back to Massachusetts tomorrow after a dozen years in our little town. They were active retirees from the big city, involved in the community in several ways. Joe was a baseball coach, Mary was on the board of more than one charitable organization, and their home was a beacon on the local cocktail circuit; Joe was the best amateur bartender our community had ever seen.

Over the past few years, Joe’s faculties failed him rapidly, and Mary came down with rheumatoid arthritis. For a while, between his strong body and her sharp mind, they were able to hold things together, but as his dementia worsened, Mary’s ability to reign in his confusion lessened and a few weeks ago she told me the time had come for them to leave their adopted home town and move back to Massachusetts in order to be closer to family.

Today I saw Mary for her last visit and it was a profound ten-minute encounter.

As I entered the exam room, Mary was writing out a deposit slip for ten thousand dollars.

“I sold Joe’s truck,” she explained, “but he doesn’t know yet. He thinks it’s in the shop. He is so much worse just since you saw him last. He doesn’t even know who I am. Sometimes he thinks I’m a friend and sometimes his sister.”

“I can’t do this paperwork in front of him, so I had to do it now”, she continued. “We bought this little row house so I can continue to take care of him because we promised each other a long time ago that we’d never put each other in a nursing home, although we have long term insurance.”

I found myself counseling a woman about the same age as my mother.

“We sometimes make promises without ever imagining what circumstances we might end up in,” I began. “Don’t be hard on yourself. Do the best you can, but if you find that the situation isn’t safe for one or both of you, do what is best at that time. If he is restless or agitated and you can’t keep him safe with just the power of your wit and your love for him, you will need to find another way.”

She nodded and sighed.

“It’s gone so fast.”

Shrugging, she added: “Do you know we got a thirty year mortgage on our new home – at our age. Who knows how long we have together.”