Archive for the 'Progress Notes' Category

The Real Reason Behind EPCS?

As of July 1, pharmacies in Maine cannot honor paper or telephone prescriptions for controlled substances, from OxyContin down to Valium, Lyrica and Tylenol with Codeine.

EPCS, or electronic prescribing of controlled substances, is a double security step in the prescription process built into EMRs, electronic medical records. It involves another password entry and the use of onetime passwords from a small number generator issued to each prescriber.

It has been said that this will prevent fraudulent prescriptions via phone or on stolen prescription pads, as well as altering of legitimate prescriptions.

But there is another reason that doesn’t get much mention:

EPCS is going to prevent doctors from prescribing controlled substances for friends and relatives outside their regular office activity.

Now and then a physician is disciplined by the Board of Licensure in Medicine for writing pain medication prescriptions for friends, sometimes even getting pills back for their own use.

Not long ago a well respected older doctor gave up his license during a Board investigation of his career-long habit of prescribing a low dose tranquilizer for his wife. That was probably not an unusual thing to do for small town doctors in solo practice with no colleagues for miles around. It is not tolerated in today’s regulatory environment, where doctors are viewed as having no more integrity and judgment than anyone else.

The next step is probably what they did in Sweden many years ago: Pharmacies there were unable to submit prescription charges to the health insurer if scripts were not written on special forms, linked to each doctor’s place of employment. But in this case in tomorrow’s USA, the requirement will be electronic prescriptions linked to our EMRs.

That reminds me, I was too busy yesterday to answer a text message from Autumn, my nurse. She’s on vacation and came down with a bad cough. Should I prescribe her an antibiotic over the phone? She isn’t actually a patient in our office…

Horse Medicine

A HORSE DOSE

Each of my girls weighs less than 900 pounds (400 kg), but the amount of medicine they require when they are ill can be staggering.

My heartburn medicines, omeprazole (Prilosec/Losec) or esomeprazole (Nexium), are 20 mg pills that cost $25 for a box of 42. Humans take one or two of these per day.

When one of our girls was diagnosed with ulcers, which is something very common in horses after stressful events like trailering, she was prescribed 2000 mg per day of omeprazole at a cost of $1000 for a month’s worth of paste made especially for equine patients. While waiting for the mail order prescription, I crushed just twenty omeprazole tablets in a coffee grinder for each temporary daily dose of 400 mg. Without the protective coating, that medicine is extremely bitter. She hated it.

The paste, Gastrogard, at one hundred times the typical human dose, is truly a horse dose. It tastes sort of like cinnamon.

LONG IN THE TOOTH

I’ve heard the expression ever since I moved to America, but never truly knew its meaning. Now that I have horses, I know their teeth keep growing, and may need filing down. They even have a line in them, Galvayne’s Groove, which lengthens in a way that you can tell a horse’s age from within a five year range.

The white juvenile milk teeth stay in until a horse is five years old or so, and are then replaced with more yellow permanent teeth.

The angle between the top and bottom teeth also changes with age.

All of this contributes to the notion that you “shouldn’t look a gift horse in the mouth”, or be picky about any gifts you receive.

WHAT’S GOT YOUR GOAT?

In horse psychology, there is this thing about goats.

When we at one point had a single horse, we put three miniature goats in the empty stall for company in he barn. That worked very well, and gave some credence to the stories we’ve heard about how high strung race horses sometimes have a goat as a companion and stall mate in order to keep the horse calm. It is said that stealing the goat the night before a race can unsettle the horse and alter the outcome of the race.

So if a race horse seems edgy, the obvious question would be “What’s got your goat?”

HORSE AILMENTS

Equine medicine has its own terminology, which always makes me think of watching the Darrowby farmers speak in “All Creatures Great and Small” by James Herriot. The old English words for some diseases are strikingly graphic:

Strangles: A streptococcal infection with lymph node swelling that can cause facial swelling and suffocation.

Choke: Esophageal obstruction.

Shivers: A neurologic disease involving spasms of mostly the hind legs.

Cribbing: A compulsive wood biting behavior with neck tightening, laryngeal retraction and air sucking that is thought to release endorphins.

Founder: Also called laminitis, a hoof inflammation caused by overweight, rich diet or high blood sugar, causing the horse inability to bear weight on its feet.

Heaves: COPD in horses.

Roaring: Noisy breathing from vocal chord paralysis.

COLIC: TRIVIAL OR DEADLY?

As a father and primary care physician, I’ve always thought of (infant) colic as a harmless, even if challenging, annoyance. As caretaker of horses, I have the deepest respect for what we call colic in equine medicine. It would be as if abdominal pain in adults were to be called colic. Imagine appendicitis, pancreatitis, peritonitis, bowel obstruction or incarcerated hernia.

Horse colic is anything that looks like a bellyache. It can be anything from gas to constipation to impaction or obstruction, and as we can’t bring a downed horse anywhere for a CT scan, our diagnostic and management tools are crude and primitive to say the least. All we do in the field is treat pain, inflammation and spasm and see what happens.

I’m glad I’m just a Country Doctor and not a large animal veterinarian.

Where Does it Hurt?

“Noncardiac Chest Pain” was Laurie Black’s discharge diagnosis. Her chest CT Angiogram didn’t show a pulmonary embolus, her troponins were negative for a heart attack and her nuclear stress test was negative for coronary ischemia.

“So what do you think it was?”, she asked while I read through her hospital discharge summary.

“I don’t know…show me where the pain was”, I answered.

“It started in my back, on the left side, and then it went up and around to the front and then down my left arm and my hand felt kind of tingly.”

“Where in your back, upper or lower?”

“Upper.”

I palpated her left trapezius and put some pressure between her spine and her scapula.

“I assume the doctors at the hospital did all kinds of poking and prodding here”, I asked.

“No, I don’t think anybody really touched me”, Laurie answered.

“Can you move your shoulders around a bit”, I asked as I pushed my fingers in a little harder.

“That’s very sore”, she said, and I could feel the tightness in her muscle.

I moved to her front and asked her to show me the range of motion in her neck. It seemed close to normal.

“Try to go a little further”, I said.

“Ouch, I just felt something, in my arm”, she startled.

“Looks like it’s all coming from your neck. How about that…”

Just a few days earlier I had another “aha” moment, this one regarding a patient with abdominal pain.

Nora Friedman had seen one of my colleagues with a one month history of a painful lump in her right lower abdomen. She ended up with both a CT scan and an ultrasound, and the only abnormality they showed was a very large cyst in the lower portion of her right kidney. The radiologists suggested this cyst could be drained in order to relieve her pain. That’s where I came into the picture and as she is on blood thinners, I ended up fussing with the management of her anticoagulants before and after the procedure.

When I saw her after it was done, she told me that her pain hadn’t changed at all.

“Show me where it hurts”, I asked her.

“Here”, she said and laid her hand across her abdomen near McBurney’s point.

I asked her to lie down. She did and I felt nothing.

“I actually feel it more when I stand up”, she offered.

As she stood in front of me and I placed my hand where she directed me, I asked her to cough. Suddenly I felt a soft, almost squishy protrusion under my fingers.

I called the interventional radiologist who had aspirated her renal cyst through a long needle in her back.

He confirmed that her cyst wasn’t likely to have reaccumulated that quickly and I told him that both she and I thought we felt a hernia when she stood up and coughed.

“I’m looking at her CT right now…”

His voice trailed and there was a long silence.

“Actually, I can see a spigelian hernia now. That would explain everything. She needs to see a surgeon.”

So, in hindsight, a more carful examination of the patient at our end, and of the images at the radiology end, could have saved Nora an invasive procedure, just like Laurie could have been spared some of her fancy hospital tests for what turned out to be a simple neck problem instead of a cardiovascular emergency.

There but for the Grace

He had been in for a physical the day before.

Like so many people, he seemed to have this need to run half a dozen minor bodily symptoms past me, while I worked my way through the agenda of screening colonoscopy, whether or not to test his PSA, calculating his ten year cardiovascular risk, talking about alcohol use, screening for depression and so on.

I remember his left leg pain. He had had it for about 48 hours. It was along the outside of the leg and seemed to be related to a climb he had made up a steep hill, lugging camping equipment.

There was a little tenderness along the center of his gastrocnemius muscle, but even more along the outside of his knee.

I remember explaining that the location of his pain would be quite atypical for a blood clot, and that a mechanical strain seemed the more likely explanation. We moved on down his list of concerns, and I didn’t put any of it in his record, because it would have made me run over his allotted appointment time even more than it did.

The very next morning, my Care Coordinator told me as I hung up my spring jacket on the back of my office door and and booted up my computer: “Jack Errold is in the ER at Cityside with chest pain this morning. They’re working him up for a pulmonary embolism.”

For the next 24 hours I couldn’t get Jack’s left leg out of my mind. Did he have a blood clot there after all? If so, how would he and his wife react to the realization that I missed it? Was he still okay?

I knew I wouldn’t see a PE protocol chest CT show up in my computer because of his compromised kidney function. They’d probably do a VQ scan, but maybe there would be a Doppler study of his left leg.

Nothing.

That night, with the house all quiet, my thoughts continued. He has always been a matter of fact guy, never bitter about losing his job or having a less than perfect outcome after his trauma surgery many years earlier. He didn’t seem likely to sue if I had missed an atypical presentation of a deep venous thrombosis.

But what if he wasn’t okay?

This morning I was met with the news that Jack’s stress test was abnormal and he was on his way to the cath lab.

A sense of relief washed over me. Not because he had a probable critical coronary stenosis, but because I had not failed him by missing a blood clot in his leg that traveled to his lung.

We face dozens of such inquiries every day in primary care, minor complaints and casual mentions of bodily symptoms that could potentially require an entire visit or more for each and every one, but we don’t have that kind of time. We are constantly triaging; we go through each day scanning for avoidable disasters, and even if we appear relaxed, congenial and reassuring, our minds are on high alert.

Failure is a constant possibility in medicine. We have to live with that and we must be willing and able to settle for probability and not certainty most of the time.

Everybody is Special

I was scheduled to attend a Medical Director’s Retreat the other day, but because of a horse emergency the day before, I had to stay home, so I offered to skip the retreat and see patients instead.

It would have been almost an entire day hearing about “Trauma Informed Care” and the lifelong impact of Adverse Childhood Events. As a primer, the conveners of the seminar emailed a “Dear Doctor” letter from a woman with a horrific childhood trauma history. One of the many vignettes in that letter was about her heart murmur, which disappeared when she started understanding and dealing with her trauma history.

I remember how, many years ago, a patient leaned forward in the exam room and blurted out at me “You don’t know me!” I think many of my patients could say that, but hopefully most see me at least honestly trying.

Over my career, I have seen many diagnoses and many minorities grab public attention for a limited time, demand special treatment and claiming to be severely misunderstood by the medical establishment and by individual practitioners. Every few years there is another medical condition and one more misunderstood minority to attend webinars, conferences and collaboratives about. Just when you feel you’ve integrated that one in your practice, another one comes along.

We have already, and I’m dating myself here, dealt with codependency, adult children of alcoholics, recovered memory, fibromyalgia and bipolar illness, brushed by narcissistic mothers and alexithymia, struggled with bulimia and anorexia, not to mention cultural and religious minorities. We are right now scrambling to become politically correct with every form of transgenderism there is.

What’ll be next? I don’t know, but I do know this: These are not issues we can tackle one by one. There will always be new ones that never managed to get their fifteen minutes of fame. So, maybe some more of the airtime needs to be devoted to the fundamental fact that every patient we see comes to us with their own story, their own journey, their own wounds, dreams, hopes, fears and demons.

We will never know everything there is to know about any fellow human being, and we need to be very careful when we see a general pattern in any one of our patients, not to pigeon hole them as being a classic example of whatever category they seem to fit into. Stereotyping is bad when we do it, and we should not steer our patients into stereotyping themselves.

We need to meet every fellow human being with an open mind, on their own terms, their own turf and in their own reality.

Sir William Osler said it a century ago: “The good physician treats the disease; the great physician treats the patient who has the disease.”

A Bug in His Ear

It was a small deer tick, hidden by the Crus Helix, embedded in the Cymba Conchae, the crevice just above the ear canal of my seven year old patient halfway through my Saturday clinic.

He was worried that it would hurt. His parents hadn’t wanted to try removing it on their own. I had a hard time even seeing the small tick as it was sitting at an angle where I saw it from straight behind.

“Let me get some stuff”, I said.

I drew up a couple of milliliters of Xylocaine with epinephrine and discarded the needle, grabbed some 2″ by 2″ gauze pads and rummaged among my autoclaved instruments for the finest foreign body forceps we have.

Back in the exam room, I explained my strategy:

“This syringe doesn’t have a needle on it. I’m just going to pour some Novocain over the tick, then we’ll wait a few minutes before I gently pull him out with this instrument.”

The boy looked worried.

“Piece of cake”, I said, “it won’t hurt a bit”.

I asked the boy to lie on his side with his tick-ear facing upward. Holding his head at just the right angle, I expressed enough Xylocaine from the syringe to completely fill the cone shaped crevice in his ear where the tick was submerged . I then held his head firmly but gently to make sure the tick stayed under the surface of the anesthetic.

“I’ve seen a lot of tick bites already the last two weeks”, I said as we waited. “I haven’t seen any new cases of Lyme disease yet, though.”

“You know the rash of Lyme disease was actually first described in Sweden, way back in 1909, by a doctor named Arvid Afzelius. And it was discovered a long time ago that penicillin could be used to stop it. I remember hearing that was routine when I started medical school in 1974. But it wasn’t until the early 1980’s that doctors in Lyme, Connecticut saw the connection with all the other symptoms we now call Lyme disease.”

As I prepared to finally remove the tick, I added:

“We vaccinate dogs for Lyme disease here, but not people, but in Sweden, all my relatives have been vaccinated.”

I grabbed the handles of the forceps, pointed the tip away from me, reached into the Cymba Conchae while still holding the boy’s head in place. Then I closed the tip of the forceps gently, without locking the instrument, and pulled. The tick offered no resistance. It was intact.

“See, here he is, legs, jaw and all, out of where he doesn’t belong.”

The boy and his parents squinted as they looked at the tiny deer tick.

“And he didn’t feel a thing”, I added. The boy finally smiled.

“People use all kinds of different oils and things to suffocate the tick”, I said. “I prefer Xylocaine, which by the way was in developed in Sweden in 1943.”

To myself, I reflected that I don’t even remember when I first decided to try Xylocaine. I know people have had good luck with oils, but we don’t keep any of them in the office. But we always have Xylocaine. And that does add more of an air of medical magic than just plain olive oil.

The Power of ACT

She didn’t seem obviously depressed as I entered the room.

“So, we have you taking a good dose of both antidepressants now”, I said. “How are you doing?”

“I feel about the same.”

“Have you done anything lately that could have made you feel a little better?”

“I’m not sure…”

“I’ll give you some examples. They can be different things for different people. It could be reaching out to a friend, helping a neighbor, watching the sunrise…”

“I listen to music. John can tell what kind of mood I’m in depending on what I’m playing. And I watch my shows on cable TV. I feel better when I do those things.”

“Are there things in your life that are more important than music and TV?”

“Our grandkids. Our youngest daughter lives here in town and her kids really light up my life.”

“And you see them quite often, right?”

“Yes, we babysit them every weekend. You should see John with them. He’s such an awesome grandfather. It warms my heart…”

“You’ve started seeing Betty now, right? Did you notice over in the Behavioral Health wing that there is a white board that’s divided in four rectangles with a little circle in the middle?”

IMG_0284.JPG

“Yeah, I think I’ve seen that…”

Has Betty talked with you about that yet?”

“No…”

“She probably will. It’s a great way to organize your thoughts and your feelings. It’s called ACT. Let me tell you about one aspect of it. It’s the difference between away moves and toward moves.”

She shifted a little forward in her chair.

“The bottom right is what’s really, really important to you, like your grandkids. And the bottom left is all the stuff inside your mind that keeps you away from what’s important. The top left is all the moves you make that take you away from your sadness, anxiety, pain and so on, but that don’t actually bring you closer to what’s important. We call that Away Moves, almost like escapes. That’s where music and TV might belong, unless they are in the box on the lower right. But those things don’t bring you any closer to your grandkids and the happiness they give you, right?”

“I see what you mean…”

“The horizontal line has arrows at each end. By the arrow to the left it says Away and to the right it says Toward. And in the top right rectangle are little things, steps you can take, that bring you closer to what’s important.”

“I see the difference…”

“So, other than your grandchildren, who or what else is important to you?”

“My daughters in Lewiston and Bar Harbor.”

“Anything else?”

“I don’t know…”

“You have a cross on that chain. What’s your faith?”

“I was raised Baptist. My daughter in Lewiston sings in the church choir there and I used to do that many years ago…”

“How often do yo see these two daughters? How often do you go to church?”

“Not often enough…”

“Could you do more of that?”

“I don’t think John would want to go.”

“He might, or he might want to take care of the grandkids while you do those things, right?”

“I never thought of that…”

“It sounds like you have a lot of love inside you that hasn’t been expressed often enough, and it sounds like your faith hasn’t had enough space in your life lately.”

She nodded.

“I know you as a very caring and soulful person and I think of you as someone who thrives on connecting with others. Maybe your bond with your other daughters could be a lot stronger, and maybe that would help you feel happier and less depressed. You and Betty could talk more about that in your next session…”

“I really hope we can.”

“Because there is more to treating depression than picking the right medicine”, I said.

She smiled and locked her gaze straight at me. Her eyes were moist and she smiled faintly.

[”Acceptance and Commitment Training/Therapy (ACT) is an an evidenced-based way of helping people let go of struggling and get moving toward valued living. “Traditional” ACT is complicated and hard to learn. The ACT Matrix is easy.” Dr. Kevin Polk]
https://www.theactmatrixacademy.com/


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