Kinda puts it all into perspective, doesn’t it? July 15, 2008

I’ve been seeing a new patient for a complaint of “body pain.”  She’s a tiny lady from Guatemala who had never been to a doctor before her son was born here 2 years ago.  Her 2 adolescent girls live with her family in Guatemala.  I already knew that she couldn’t read or write in Spanish, and when she showed up for an appt 2 hours late, I got an inkling that she may not be able to read numbers, either.  At our last visit, I wanted her to keep a log of her pain symptoms.  The problem is that she doesn’t have a calendar in her home, and she wasn’t sure that she could read a calender that I offered to give her.  She was reflecting on her lack of schooling, which led us to a discussion of how she came to the U.S.  “Well,” she said, “I want my girls to go to school so they can be smarter than me.  I don’t want them to be a country girl like me.  I need to make money for them”  That’s how I heard about how she walked from Guatemala, through Mexico and up to the Northeast.  I heard about how she used to be a sheep herder, and her job as a dishwasher seems cushy now.  She’s happy in her apartment, even though the landlord turned off the hot water without an explanation.  She’s afraid of getting deported, because her son is a U.S citizen and she thinks he might be taken away from her.  But overall, she feels lucky.

A tale of two anemias July 15, 2008

In the past week, I have seen two different and fascinating (for a health care dork like me) cases of anemia.

Case #1: A woman in her 20’s, with a complaint of several months of nausea, unintentional weight loss of 30lbs in a year, diarrhea and stomach upset. Hx of hypothyroid. Came in complaining of increased fatigue. Lab results: Hgb 9.0, WBC 4.0, MCV 105, HIV negative, TSH wnl. Ok, what’s the differential? Cancer, hemolytic anemia, B12 deficiency. I repeated the labs 1 week after they were initially done, and she had Hgb 8.4, WBC 3.9, MCV 104, B12 100 (normal is >150). After nervously viewing the declining Hgb, I extra-checked for hemolytic anemia by adding a Coomb’s test (negative), blood smear (schistocytes), haptoglobin (30–normal) and LDH (wnl). Lest I sound like a hematological genius, you should know that I went running straight for the attending when the first set of labs came in, and I spent about 20 minutes poring over the “anemia” sections on UpToDate (god bless you, UTD!). Once hemolytic anemia was ruled out, we settled on B12 deficiency-induced anemia (the giveaway? the macrocytosis). But why? She’s not a vegan or vegetarian and denies a hx of alcohol abuse. How do the stomach problems fit in? Hmmm, maybe pernicious anemia? And if she has a wicked case of celiac’s, that would explain the lack of intrinsic factor in her stomach. I found out that the lab for pernicious anemia is the anti-IF antibody. And anti-gliadin antibody is soooo 1990’s for celiac–now we’re supposed to check for anti-tTG antibodies (and one other lab, but I already forgot what it was…dammit!). We’re waiting for the fancy labs to come back in from Quest, but the patient has already started her daily B12 injections this week.

Case #2: Woman in her 30’s, with a hx of iron-deficiency anemia. Used to take iron pills, but stopped a few years ago. Has really heavy periods, but never went to GYN for the check-up recommended 2 yrs ago by her PCP. Feeling fatigued and weak for about 6 months. A little short of breath. Looked a little pale in the clinic. Hgb was–get ready for it–5.1. She had a hematocrit of 16! No wonder you’re feeling a little tired, lady. This lucky lady was sent asap to the ER for a transfusion of packed red cells and was admitted for 2 days. I saw her today for a hospital follow-up visit. There are 2 morals to her story: Please, pretty please take your iron. And please, please follow up with a pelvic U/S and GYN consult!

Lesbonurse puts her foot down July 9, 2008

Yesterday I was paid a visit by my special friend, the Ron Jeremy lookalike.  Apparently he insisted upon an appointment with me, rejecting other, earlier appointments with different providers.  His chief complaint: “body rash.”  His mental health issues were on full display as he begged me to admit him to the hospital for what appeared to be a bad case of contact dermatitis.  Even worse, he tried to drop his pants and show me his penis the second I came into the room.  “NO!” I barked at him, “I need to get a chaperone first!”  After I roped an innocent new male intern (who happened to be standing in the hall) into being my chaperone, I went back in to face my creepy, creepy friend.  He not only lifted up his clothes to show me his rash (as most people do), he actually stripped down to his boxers to show me every inch of his unsexy flesh.  As he exposed his penis to me and the poor intern, I said, “Ok, so the rash isn’t really on the penis itself, just around it.”  “No,” said the patient, “You have to touch it to feel the rash.”  Um…no thanks, dude.  During the exam, he disclosed that he recently had sex with “a stripper at a club” when he got his disability check on July 1.  “And,” he added, “I didn’t use a condom.”  Normally I might be tempted to explore why someone would make this poor decision about their sexual health.  Instead, I threw up a little in my mouth and chose to file this away in the “follow up at next visit for STD testing” section of the note.  As I was leaving the room to check my Fitzgerald derm book, I instructed him to put his clothes back on while I was gone.  “That’s ok,” he said, “I”ll keep them off in case you need to see the rash again.”  This time I pointed my finger at him and said “PUT YOUR CLOTHES BACK ON.”  He reluctantly obliged.  When I came back into the room to give him his rx’s for prednisone, benadryl and hydrocortisone cream, he asked “When will I see you again?”  I informed him firmly that I am not his PCP and would not be providing his care on a regular basis.  “But I like YOU,” he whined.  “I want you to be MY nurse practitioner.”  After sending him away (which involved me saying repeatedly “I have to go now.  I have patients waiting.  I’m going now.  Goodbye.”), I asked the front desk to put a banner notification in his file that he should see male providers only.  No more free penis fondling for this fine gentleman!  I also informed his team nurse that she should not, under any circumstances, schedule him with me.  Ha–take that, Ron Jeremy!  Good luck showing me your wiener again.

Another installment of ‘The Totally Innappropriate Comment’ July 7, 2008

Last week my job provided more opportunities to practice my therapeutic responses:

• 32-year old male patient with schizophrenia and a substance abuse problem: “My new fiancee and I are trying to have a baby and I want you to check my sperm to make sure it’s ok.” Me: “Last time I saw you, you were single. When did you and your fiancee meet and how long have you been trying to get pregnant?” Patient: “We’ve been trying for 2 months. We met 2 months ago. We’re getting married this month!” Actual comment: “Wow, sounds like a whirlwind romance!” TIC: “This is the WORST decision that you could possible make! Please don’t do this.”
• 56-year old schizophrenic patient with complaint of “pain in my big toe” for the past few months. When I asked him to take off his shoes and socks, he revealed feet that had grizzly-bear-worthy toenails that had clearly not been cut for years. Actual comment: “Ok…[big pause]…I think part of your pain is because your toenails are cutting into your feet. We’re going to refer you to a foot specialist so they can help you get this taken care of.” TIC: “Oh my god! Your toenails look just like Mr. Burn’s on that episode of The Simpsons where he spoofs Howard Hughes! How could you let this happen to your feet?”
• Patient with a history of a heart transplant, presenting with sinus symptoms and a phlegmy cough that have not been cured by a course of Amoxicillin (rx’d by his transplant team). Actual comment: “Hmm, I don’t have a lot of transplant patients, so I’m just going to step out and ask one of our senior doctors about your case.” TIC: “I don’t know what the hell is going on. I’ve never even met a heart transplant patient before.”
• 70-year old woman with complaint of vaginal discharge who is cleaning her vagina with rubbing alcohol(!). Actual comment: “Well, I can see why you might try rubbing alcohol if you think you have an infection, but the truth is that rubbing alcohol is very irritating and it’s probably actually making things worse.” TIC: “Doesn’t that burn like fucking FIRE?!?”

Do not have sex with this man! July 3, 2008

Today I saw a 45-year old woman for her pap.  After a long visit in which we talked about her efforts to lose weight, her pending divorce, her history of depression and her inconsistent medication use, I could see her muster up her courage to ask me a final question at the end of her exam.  Her question was, “Is it normal to have pain every time you have sex?”  I answered, “It’s not normal, but it’s very common.”  I then asked her a bunch of questions about position changes, lubricant use, foreplay and previous sexual trauma.  After a few therapeutic prompts from me (ex: “Many women tell me that if their partner doesn’t spend enough time making sure they’re aroused, sex is uncomfortable for them.”) we finally got to the reason for her pain:  “My husband never touches me down there, and he told me I was sick because I wanted him to do stuff.  He just gets on top of me and we have sex, and that’s it.  He told me there was something wrong with me because it hurts all the time.”  I felt that I had developed a friendly rapport with the patient, so I only had to censor myself a little bit.  Instead of my first response (”Honey, your husband is an asshole!”) I went with the second (”Listen, he’s totally wrong about that!  You’re perfectly normal!”).  I also couldn’t hold back from a little dating advice: “If you start dating again and you find another guy that thinks like that, dump him right away, alright?”  That’s right, I’m a primary care provider, a spiritual advisor and now a dating guru!

More healthcare haiku July 1, 2008

Patient wants to change

to “English-speaking doctor.”

Racist or ok?

Asthma follow-up–

Never got controller med.

Surprise!  Still can’t breathe

First day of July:

Flock of fresh-faced residents

wandering the halls.

Woman has seizure–

Doctor yells “Get the crash cart!”

We have a crash cart??

Take off your shirt, please June 27, 2008

This week I saw 2 butch lesbians for their complete physicals, including paps. I have another genderqueer patient scheduled for a pap next week. This makes me pleased, because I feel like I can do a much better job than my colleagues (hey, just bein’ honest). However, I’m still working on the best way to do a sensitive but competent exam. I had one patient this week that was in her 20’s, had never had any sexual contact with a man and had never had penetrative sex. She was so nervous about the exam that she was shaking and terrified. To make her feel less exposed, I told her she could leave her sports bra and tank top on during the breast exam, and I just lifted up her clothes one side at a time to do it. This seemed to make her feel better, so I told my next butch patient that she could also leave her bra on under her gown. But I have a question for any of you blog readers that have experience with clinical breast exams: do you think this compromises the exam? I understand that having a bra on does reduce the ability to visualize the entire breast area, but do you think it reduce the efficacy of the palpation? And if it does make the exam less reliable, do you think that the decrease in reliability is significant enough that I should make all patients take off their clothes, regardless of how uncomfortable it makes them?

When one head injury just isn’t enough June 25, 2008

Devoted readers of this blog may remember an early post where I described an incident in which a man was mistakenly told that he had cancer, only to forget this devastating news due to a combination of alcohol abuse, mild mental retardation and a brain injury.  Today I saw this gentleman again for a medication follow-up visit.  He’s had a few misadventures in the past year.  About 6 months ago, he drunkenly fell down a flight of stairs and ended up with a subdural hematoma.  After a little time in the hospital, he was released, blessedly free of any obvious long-term effects from his traumatic brain injury.  Today I walked into the room, said hello and asked how he was doing.  “Oh, not so good,” he said.  “I think I broke my ribs.”  How did that happen?, I asked.  As it turns out, he had locked himself out of his 3rd floor apartment and thought it would be a good idea to crawl across the roof and break in through his window.  Unfortunately–but not surprisingly–he fell from the roof into a crumpled heap on the driveway below.  He never went to the emergency room, choosing instead to wait a week for his appointment with me.  No, he said, no headache.  No vision changes either–just this nagging rib pain.  What has he been taking for the pain?  That’s right…aspirin.  (”They told me not to take it after I left the hospital, but it hurts a lot and I don’t know what else to take”). 

*For readers who aren’t health care providers, aspirin is the worst over-the-counter choice you can make if you have a brain injury, since it can contribute to bleeding in the brain.

The return of Ron Jeremy June 24, 2008

I was walking down the hall with a urine sample in one hand and a chart in the other, when I saw my new friend Creepy Crazy Guy.  He was beckoning wildly to me to come over and talk to him.  I walked over, thanking the universe that he wasn’t on my schedule today.  I was even more thankful when I got to my new friend and he muttered urgently to me “I have to see you!  I have a rash on my…you know where…I think maybe I have to go to the hospital.”  I informed him that my schedule was full and that he would be seeing someone else.  “NO NO!  I want to see you!”  he bellowed.  “When will I see you again?”  Like a prize fighter, I ducked and wove out of the exam room, reassuring him that the resident would take good care of him and tell him when to follow up.  Buh-bye!

Nurse vs. nurse June 24, 2008

I hate to be one of those “Boo hoo, my underlings don’t respect me” jerkoffs, but the nurses at my clinic have a really bad attitude!  I got an inkling of this in my first week on the job, when one of the nurses gave me a skeptical look and said, “So if you haven’t been a nurse for very long, what makes you think that you can be a nurse practitioner?” (Ouch!  It’s the ol’ “Hospital nurse vs. fast-track NP” rivalry).  Things improved slowly over time, and I seemed to have risen in esteem from “Stupid New Girl Who Can’t Do Anything Right” to “Somewhat Competent But Not Entirely Trustworthy.”

Today, however, set the process back a few months.  I had a patient with a fairly straigthforward case of otitis externa, except for the fact that her ear was totally impacted with wax and I couldn’t see her tympanic membrane at all.  I was concerned that she might also have a otitis media that I couldn’t see, and would need oral antibiotics instead of just drops.  I tried to curette the wax out, but it was too packed and hard to break up with the wimpy plastic loop (note to readers: using q-tips really does jam the wax back into your ear).  I checked UpToDate, which informed me that proper cleaning of the ear (”aural toilet”) is key to treating otitis externa.  It also told me to avoid irrigating the ear, but I couldn’t figure out how else to get that crap out.  I went to the nurses and asked if they could do an ear irrigation for me.  I explained that the patient had an external ear infection, and that I wanted to be able to visualize her TM before I was comfortable in letting her leave.  The nurses balked, saying that they weren’t allowed to irrigate anyone’s ear if they have ear pain, or might have an ear infection.  I responded by saying that I already knew that the patient had an ear infection, and that I planned to treat her as soon as I could see the rest of her ear.  One nurse finally, begrudgingly said she would do it.  She went into the room, set up all her supplies, and then thought better of it.  But instead of finding me to tell me that she wasn’t comfortable with the task, she went to the attending MD instead!  I was wandering around the clinic looking for the missing nurse when I found her discussing the situation with the attending.  He wisely took the high road by suggesting that I call an ENT for a phone consult.  This seemed like a good idea to me, since by this point I was doubting my own decision and wondering if I was the worst NP on the planet.  I called ENT and got my consult.  The verdict: it’s fine to do an irrigation on someone with otitis externa and impacted wax.  Apparently the ENT office does their irrigations with a 50:50 mix of vinegar and rubbing alcohol.  I went back to the nurses and relayed this message.  This brought up a new issue:  apparently the nurses felt that they were bound by protocol to only use a mixture of hydrogen peroxide and water for irrigations.  I asked to see the protocol, but it turned out to be vague on the subject of irrigation ingredients.  I was pushing for 50:50 alcohol and water, since we don’t carry vinegar in the clinic.  The original nurse was boycotting the entire process, despite the reassurance of the ENT consult.  Another nurse decided to help me, but she was freaked out by the alcohol-instead-of-hydrogen-peroxide issue.  I went back to my office to gather a few papers, and when I walked out of my office the nurse was running the situation by our clinic Medical Director!   I thought it was unprofessional of them to take it to the attending MD without discussing it with me, but then to take it to the Medical Director…you would have thought that I was performing a kidney transplant in the back room.  I guess you could say the conflict ended in a draw: the Medical Director ended up supporting my decision, but after one squirt with the irrigation syringe the patient had too much discomfort to continue the process.  I sent her away with a rx for Cipro otic drops, an appointment to come back in 3 days for a repeat exam and a decidedly pissy feeling for the rest of the day.  The nurses felt smug because the irrigation hadn’t worked out, which made them feel that they were right to oppose it.  I guess everybody–and nobody–won.  poo.