Archive for September, 2019

COULD WE FINALLY GET A DOCTOR TO SEE THIS PATIENT?

September 8, 2019

A physician-friend of mine consulted me the other day about an unusual symptom.  I don’t get consulted much these days—I’m old, out of date, and nowadays just about everybody seems to be a medical expert either through being or knowing a first responder, nurse, PA, or some of the people I know in the hiking club.

Anyway, my friend had flexed his neck and felt a shock go down his body for a few seconds. He wondered if he were crazy.  Few things are as clear to a neurologist as this Lhermitte’s sign, named for the Frenchman who first wrote about it.  This means there is a problem in the cervical spinal cord, either due to MS, if the person is young; or arthritic changes or cervical spondylosis if older, with a spinal cord tumor,  foramen magnum meningioma, or Arnold-Chiari malformation, where part of the cerebellum, called the tonsils, tries to join the cervical spinal cord rather than staying in the skull. I did a brief exam, which showed no weakness, and told him he needed an MRI of his neck. 

He saw a nurse practitioner and convinced her that he needed an MRI.  That was done, and the radiologist wrote a report and sent it to the office.  The nurse in the office, not the NP, and certainly not a physician, read the report to my friend over the phone, which showed “moderate changes at C3-4,” mild changes elsewhere.  Nothing else. No future care was offered.  

In my practice, I not only saw the report but felt I should look at the films, often with a radiologist, and then call the patient and discuss what was next. The radiologists loved it when a clinician showed up by the alternator where the films were stored, and I learned a lot, too. I called my patients with the results and returned their calls. I wasn’t paid to do this and I never expected to be.  It was part of the office visit, in my opinion. It was not a fun part of the job, but it was part of the job.  I can’t remember any time in the past six years a treating physician—or a midlevel, for that matter—called me.  Even with email queries, only once has a physician has ever responded to me.  Something has been lost.

I told my friend he had to get a diagnosis.  Lhermitte’s is not some minor ache and pain associated with growing old.  It isn’t mild deafness or an early cataract.  This is a potential problem when mid-levels take over a lot of care and physicians don’t closely oversee it. Midlevels are excellent physician extenders but should not be considered complete physician replacers, either. I told the physician to get the CD of the images and I would look at it with him.

When I looked at the images, spinal cord compression at C3-4 jumped right out at me.  There was a 2 mm offset in a person with a small spinal canal to begin with, meaning that there wasn’t ever a lot of room for the spinal cord, and the slight change in alignment had removed 2 additional mm.  This was severe.  It explained the Lhermitte’s sign, and the question was how it should be dealt with.  He then called his primary physician, who made a referral to the spine clinic.  

My friend got an appointment six weeks out—-with a PA.  

This is discouraging.  This problem is a major cervical cord issue that explains a classic symptom that needs to be addressed sooner rather than later, and it shouldn’t have to be screened again six weeks later by another mid-level.  It’s frankly insulting. It’s time for a doctor to see this patient.  The referring physician dropped the ball, too.  At least it’s real pathology. This isn’t a person with a little osteoarthritis.  When I saw “headache, emergency, rule out bleed,” the headaches were almost always tension.

My friend has to wait, and it is a grim reminder that Oregon is not physician friendly and has a hard time attracting and keeping doctors.  I still haven’t a new internist a year after my other one left, although I’ve seen a physician assistant twice.  

The more recent appointment was for my injured hand which I got losing an argument with a rock on a river crossing on a backpack of the Timberline Trail around Mt. Hood.  I had a second metacarpal fracture, closed and non-displaced, and the diagnosis made, after which I elected to go to the local orthopedic institute to make sure my hand was going to be properly treated.  It is, after all, a broken hand. I did a lot of reading about broken hands, just like I do with other conditions I have.  

I went to the orthopedic center and saw…a NP.  She put me into a splint, which made sense, but again, I have to wonder, why aren’t doctors seeing routine real pathology?

Don’t get me wrong. For years, I spoke to first responders in Benson, Arizona, about head injury.  I had a video made at one hospital showing my dissection of a human brain, one of many I did, a crowd of nurses around me, so they and others could see the structures.  I did this, because I like to teach and I wanted ancillary personnel  who saw patients to increase their knowledge.

I now feel I need to direct my care a lot more than I thought I ever would. I’m on my own, the way I was on Mt. Hood, deciding to keep hiking another 30 miles with an injured hand rather than bail out at Top Spur Trailhead.

I worry, however, how I will deal with something serious in the future, and given the opiate issue, I worry greatly should my wife or I develop a painful condition— like metastatic cancer.  There are too many barriers between us—both retired physicians—and a treating physician. They are physical as well: I go into a medical office these days, and I need a GPS to find my way back out.  It didn’t used to be that way. 

I find it odd that when I was in medicine, I treated all sort of things that my training never touched upon and didn’t treat many things—carotid artery disease, and MS, to name two—that I had the training for. Internists would treat those conditions and send me people with obvious tension headaches.  Now that I am away from medicine, I am subject to non-physicians as gatekeepers and wonder what will happen if I am not mentally sharp enough to check what is happening. I am starting to be far more assertive about what I think needs to happen.

I also wonder what my friend would have done, if he were not medically trained and hadn’t contacted me. He would have eventually become diagnosed, but he might have had deficits from a myelopathy (spinal cord damage) assuming he didn’t have a fall first and become paralyzed. How many people are out there who are not getting full evaluations because physicians have delegated much of front line care and it isn’t clear to me who might be falling through the cracks? 

At the minimum, when I am given an appointment with a medical practitioner, I want to know before I go who it is. This does not always happen, unless I specifically ask.  Second, if I have seen a midlevel, I want to know whether a physician has signed off on my medical record. Third, I can afford my care, but why is the cost the same with a midlevel as with a board certified specialist, or in one recent case, $100 more for less workup?

Finally, if the electronic health record is too burdensome, some day we are going to have a new health care system. If you are a practitioner and don’t like the time spent on an EHR, assert yourself and design something better. Take back control, like I’m trying to.

QUIET HEROISM

September 5, 2019

There are only three fires burning in Oregon in early September, and none is anywhere near the west Cascades.  It’s been a great summer with near normal temperatures and even some rain, for the first time in six summers I have been here. Few have heard of the Eureka Ridge fire, and for good reason: no fire was called that this year.  But, had it not been for a few amateur astronomers, we would have had a nasty conflagration not far south of us.  

In late August, several from the local astronomy club were observing the night sky from a dark site, and science fiction writer-amateur astronomer-has done just about everything Jerry Oltion writes “Some rocket scientists were shooting guns down on the knob below our observing site …which has happened before, so we didn’t think much of it until we noticed they had a fire going. They seemed to be shooting into the fire, and every now and then there would be a big flare of flame, as if they were shooting explosive rounds.”

Reminded me of Arizona in April 2017, where an off duty Border Patrol person was firing explosive rounds in the desert during one of the windiest, driest months of the year, and started the 45,000 acre Sawmill Fire in eastern Pima County.  

“We saw three people milling around…so we figured they were putting it out. The first one [fire] never quite went all the way out, though. The sky got darker, and we figured these fine specimens of human intelligence were camping out…until we watched their car leave. With the fire still burning. 

We were so incredulous that we thought they must have left somebody there, and maybe one of them had driven off to get more beer or something, but the fire began to grow and eventually we saw a small tree catch fire and whoosh into flame like a torch.”

They tried to create a firebreak—with their feet—and called 911 with a GPS reading of the location.  It took two hours for a fire team to appear on the scene. In the meantime, they discovered the shooters had been firing at propane canisters. “We found  a number of them, each with a bullet hole all the way through. They had started a fire and set up propane tanks in front of it and when they burst a propane tank they would get a huge fireball. Spectacular, I must admit. And what could possibly go wrong?”

“When they did…arrive, they put out the fire in short order. They sprayed down the flames with water, then ripped apart the log pile with axes and Pulaskis (probably the single most effective firefighting tool made) and sprayed water on the smoking remains until they had a mud pit.”

This was an easy fire to extinguish.  An hour later, it would have been off to the races. By morning, there would have been a smoke plume, and a few million dollars and weeks later there would be another ugly scar on the land. 

All because of the gun culture.

Yes, the gun culture.  I know this isn’t fair to the majority of gun owners who lock their guns up when not using them, are knowledgeable in gun safety, want background checks to be universal, and obey the law.  But the few ruin it for the many, and frankly it’s time the gun culture got punished for the bad apples just the way I have for my whole life.  Just like I got sworn at or things thrown at me when I rode the bike, because of a few bad apples who ran lights, flipped off cars, and hogged the road, those who shoot up road signs, shoot early on the weekend, leave messy campsites with beer bottles, shell casings, and other trash left behind ruin it for the good guys.  Rich doctors who play golf and don’t take care of their patients? I was harangued once when I got to a consult late on a weekend day, because I had seen half a dozen others, and was greeted by, “Did we pull you off the golf course?”  A few blab about patient records and we have HIPAA.  Patient dumping occurred by some, and we got EMTALA.  Sloppy labs in offices, and we got CLIA.  Jerks in the wilderness, and I have to get a permit.  Life can be hard.  When the gun and the logging culture intersect, a lot of logging leaves slash piles that may well have been what these people used as a backdrop for propane canister shooting.  

I had to obey traffic laws on the bike or risk a ticket.  Fair enough. I had to make sure our ED did a medical evaluation on every patient or we could be sanctioned.  Fortunately, I had good professionals who did it, much as it was a big inconvenience at times. Gun owners need to obey gun laws or risk the same.  I didn’t start a 45,000 acre fire in Arizona or leave a burning fire in the Umpqua drainage in Oregon. 

I doubt these people will be caught, and if so, they aren’t likely to be punished.  They are men in the outdoors, not outdoorsmen. To me, they have just forfeited their right to own firearms.  They have the mental illness called terminal stupidity, and even the president thinks that mentally ill should not be in possession of guns.  At least today. If push came to shove, he’d cave on that, too.

Amateur astronomers were heroes.  Jerry recommended bringing more than a telescope to Eureka Ridge next time—five gallons of water, a shovel, and a Pulaski.