Posts filed under ‘How things work’

Learning from the young

I just had my second root canal in two weeks. The first one was an endurance event with four roots. The significance was the skill of the endodontist at administering the lidocaine nerve block. He used a very small needle, made a gentle initial insertion with tiny bits of novocaine, then waited for that to take effect before giving the rest. Nearly painless.

From the start I worked hard at accomplishing what he does and indeed I generally am able to succeed, however… it became obvious to me that I have slacked off and have relapsed into a habit of being quick. But the experience these last two appointments was so pleasant that I will once again start over to see if I can reach the level of skill this young dentist has accomplished.

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03/11/2015 at 12:47 PM Leave a comment

Timing, like in life, it is also the only thing about blood tests and medication dosages

12/15/2014 at 10:31 PM Leave a comment

Not fast enough?

I received a call from a radiologist yesterday. Not usually a good thing for the patient. I braced myself to hear the bad news, a tumor ( or as schartzenager would say Tumah) and recommendations for further imaging. However this time I was in for a surprise, apparently the MRI machine which had been used in the first evaluation was not fast enough.

Not fast enough? I did not even know we were in a race. Fast enough compared to what? A turtle? After all, those MRI’s are heavy and can’t move very fast. Once past the surprise I learned that to image the part of the liver we were interested in, they needed to catch the contrast dye in the various parts of the circulation: as it enters the arteries, then the veins and finally out of the liver and these things happen fast. With the MRI (open because of claustrophobia) being made with a weaker magnet it could not attain the images quickly enough to differentiate the various phases of the dye. Old dog, new lesson.

Apparently the patient now had a choice, allow us to sedate her to be able to use a regular ‘donut’ shaped magnet or get a Cat Scan with its significant radiation and less detail. She chose the sedation.

Now I have a new concept regarding MRI, speed, not over ground as typically expressed but in processing power.

Personally, it is hard to understand the claustrophobic issue. It is not that you are in a tiny box, there is open space on either side; how do you get into a car without problems? Into bed with the covers tightly around you? In stores on black friday? In crowded movie theaters? I know, I am being insensitive, still….as my daughter would say, “just saying”.

 

12/01/2014 at 9:53 AM 1 comment

answer the phone message

I have a rule that I try to follow. Whenever I receive a phone message that I do not want to answer, my rule is to answer that one first and get it done. The reasons I may not want to answer could be that the person does not know how get to the point and even after a long monologue I am left in a quandary as to why they called, or that I have no new answers to their persistent and recently answered questions , or that they will be telling a very sad story hoping to wheedle an increase in their narcotic prescription. They are difficult phone calls. But there is one more type; that of a patient recently seen that may not be improving as quickly as expected ( or more commonly as quickly as they expect) and they need more time but don’t want to hear that, or worse that their situation has worsened, or that I missed something.

However my experience is that usually the calls tend to go far better than I feared and the other day I had such an occasion. This patient had sliced her thumb and index finger on one of Walmart’s latest and greatest slicers. Man those things are sharp. It happened on a Sunday and it was sutured at an Emergency Department. Ten days later, I was removing the sutures.

Her finger had healed completely but the thumb was going to take a while. I removed the sutures, placed steri strips and bandaged it well. I told her it would heal just fine, not to worry, she did not need any more antibiotics.

Then two days later the phone call. Apparently her fingers were not doing fine. Did I miss something? Could an infection have started 10 days after the initial event? I bucked up and called her, fearing the worst.

It turns out that she had slammed those same two fingers in a drawer and now the flap of skin that was healing had torn off. She wanted to know how to take care of it–piece of pie.

Like my rule says: don’t fret about it, just call the patient.  And in reality it generally is not as problematic as my brain makes it out to be.

 

11/27/2014 at 5:48 PM Leave a comment

The value of the skipped question

From time to time it is not at all clear what is wrong with the patient or perhaps even why they are in the office in the first place. At these times when I am not sure what to do next, one of my tools is the skipped question. The question I don’t ask is:

Why are you here?

Do you know how this started?

What do you think this is?

What I do ask is “Tell me what is causing this.” Assuming they know, not giving them the ‘out’ to say ‘I don’t know.”

Of course i get the answer, “that is why am here, so you can tell me.” But not as often as you would think. For the most part there is more information I have not been able to elicit. So I will get a variety of answers, from “this started when my daughter ran away, or got married” or ” Its all my husband’s (wife’s) fault.” or “I am not really bothered by this Pain/dyspepsia/fill-in-the-symptom but I am afraid it is cancer because my mother died of it.

Another example, particularly effective with young people, You can ask if they smoke, but they are ready for that, rather you can ask how much they smoke or even better “have you quit yet.”  If they do smoke, the surprise of the question inevitably gives it away.

Now, i have a thread to pull on. I can either look for a cancer or reassure them that the symptoms they have are not consistent with such things. Or I can delve into how their kid’s actions caused the problem or why they are so angry at their spouse. Sometimes the emotional issues have triggered a physical problem that won’t go away until they deal with the underlying issue but can nevertheless be treated, sometimes just venting helps them feel better. Sometimes they do indeed have something bad and had an intuition but were afraid to bias me in that direction.

When i leave a patient visit more confused than when I started I usually feel that I just could not get enough of the right information. Many times it is beyond the patient’s ability to relate a sufficiently coherent history, sometimes I wasn’t good enough to get it out of them. But fortunately in Family Practice we almost always get another chance, we prescribe a little tincture of time, perhaps give something for particularly bothersome symptoms and have them come back. It is amazing what the human body and spirit can do when we don’t get in the way.

10/22/2014 at 7:24 PM Leave a comment

You need the details

One of the hardest things to learn in primary care medicine and perhaps in any mature sciency field is that details matter. I will go further that details are the only things that matter.

Many times a new grad will be trying to come up with the answer to a clinical problem with only the bare outlines of the problem; what the patient offers. My advice is that “we are professionals now and we don’t do guessing.”

Our job is to probe deeper, sort the problem out, get more information from the patient than even she/he knew he had. Only then do we have a good idea of what is going wrong in this super complex, self- adjusting, self healing machine we call our bodies.

We start with the complaint of “I am having headaches more often. They are also lasting longer.” At this point all we have is enough to ask more questions. You can’t get to downtown Portland with a map of the United States. The number of questions seem daunting to both new providers and certainly to patients, but there are numerous body systems that could be responsible and these systems interact with each other. Our bodies are orders of magnitude more complex than the most frustrating car and you know how hard it can be to diagnose a subtle problem in those.

A sample of questions:

When did the headaches become worse? Was there anything new going on in your life? What time of day do they occur? is there any pattern to them–such as before stressful events? What helps a headache–either OTC meds or laying down or exercise… What makes them worse? How long do they last in general. How long do the worse ones last? Is there a pattern of headaches in the family. Are there accompanying symptoms? Any new medicines you take, OTC or prescription, How about your alcohol consumption, cigarettes, other drugs? and many more.

And from the answers to these an more a subset of questions ensues and then we are in the position to not guess but make a tentative diagnosis.

This came to mind to me the other day when I missed a question. A lady was having intestinal distress and the symptoms were vague and a bit unusual. All my questions yielded little that was helpful and we began the process of trying various changes in diet plus some medicines. At the end of a few weeks, she had not improved one iota and I was totally out of ideas. I was about to admit this to her, when she said that she thought she knew what was causing this.  As a rule if a patient tells me they know, I shut up and give them the stage. Sometimes they are wrong, much of the time they are wrong, for they are positing what they are afraid of. However, IMHO, most of the time their idea will give me another clue that can be invaluable and lead me to the real issue.

This time she said that it was the diet soda that she drank. I was not impressed and dismissed it, her symptoms were too predictable and intense for that to be the cause. Then she said: I drink 23 cans a day! Yup, that would do it. In my mind the possibility of someone drinking two gallons of soda a day was nil, so I had not considered it. She was taking in so much carbon dioxide in the bubbles that it was causing all kinds of mayhem in her bowels. Things improved markedly when she reduced her intake.

In retrospect I had asked her about her soda consumption but neglected to ask about the volume. Another question added to my repertoire.

10/15/2014 at 6:42 AM Leave a comment

What is a professional?

For What Its Worth

 

One of the best definitions I have heard, was from a football color commentator. An dedicated amateur works on something until he gets it right, a professional works on it until he can’t get it wrong.

I have thought about this as it applies to the technical aspects of my work, in particular, suturing, draining wounds, removing nails, moles, etc. And I can see what he was talking about. I find myself continuous working on how to do it better, simpler, less painful, faster (if appropriate), I am never satisfied and every time it doesn’t go as planned I re-evaluate. I don’t have to work at it, that’s just the way I do things. The routine of the procedure is so automatic that several things happen: I don’t have to think about the nuts and bolts, I recognize immediately if something is not right, I know what to do about it. The lack of brain power required for the process is then freed up for other things, getting ready for the next two steps, considering other issues that might complicate the procedure, anticipating what I might need next, distracting the patient with funny stories. Many times I have finished suturing someone without remembering each step–just cruising on autopilot.

This became clear to me this morning while working on my car, something I am clearly an amateur (although perhaps an dedicated talented one?) . I was working on the exhaust manifold  and the oxygen sensor. Nothing hard except they are very hard to reach and it is very dark under the car. It generally requires a variety of tools that have to switched. I realized that as I took a socket extension off, I did not pay attention where I placed it and when I needed it I could not find it and had to crawl out from under the car to locate it. I began paying more attention and consciously placed the tools in a specific easy to locate and reach spot. That is when it hit me that I do that as a matter of course at work.

The car however is not as familiar to me as patients and a much larger part of my thought is on the immediate issue at hand. And there is the difference.

 

 

11/01/2010 at 12:41 PM Leave a comment

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