Harpers Ferry: 1

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medical            *

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TUE: I had a sleep that lasted 5 hours, the longest continuous stretch that I can recall in the past few weeks. I used a combination of low dose doxepin, a rapidly acting barbiturate, and a percodan with additional tylenol. Because doxepin can cause urinary retention, I added an alpha blocker--prazosin 1 mg which is what I had on hand. THIS IS NOT MY RECOMMENDATION FOR ANYONE ELSE.

It has been almost a week since I have had any tooth or jaw pain. This was a symptom that had me probing my gum line with a dental pick looking for a painful spot back in July and August. I have attributed it to some kind of vagal nerve irritation brought about by tumor growth.

However, I am having some voice changes but less prominent than a month ago. A diagram illustrates the nerve that is particularly vulnerable.

The vocal cords are innervated by the right and left recurrent laryngeal nerves. During the embryonic period the two nerves become trapped beneath arteries. As the length between the larynx and the Arch of the Aorta expands during fetal growth, the two recurrent nerves are pulled away from their targets, the vocal cords. The diagram above does not show all of the great vessels and the tracheal-bronchal tree that are coming together in proximity to the recurrent laryngeal nerves. That picture reveals that this is a very busy place.

Courtesy: anatomy topics at wordpress.com

There are numerous lymph nodes not shown in the above picture. Swelling of these can cause pressure on the nerve as well.

WED: No Significant Change since Yesterday.

THU: Have developed some mild pain in left lower ribs in front, probably from coughing. Awoke after 2 1/2 hours and decided to get up and write.

Harpers Ferry: 1

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In my last post I mentioned important sources of information about medical practice that I used in setting up. I forgot the most important source: "Problem Oriented Practice" by Cross and Bjorn. These were GPs in Maine who decided to implement the Problem Oriented Medical Record in a rural medical practice. These were innovative clinicians who also developed a number of "encounter forms" for various  kinds of medical problems, e.g. Gyn Pap Smear, Minor Surgery, Arthritis, Hypertension, etc. They managed their chronic medical problems almost entirely with a spread-sheet like matrix that made it easy to see at a quick glance the degree of success that a patient was experiencing.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1119525/

The struggle for managing the volume of information in the medical record is a complex and ongoing problem. In the 1960s Lawrence Weed, M.D. of Cleveland published an article in an Irish Medical Journal that advocated the use of a "Problem Oriented Medical Record." He promoted the development of a list of all known medical problems for a patient and then fleshing out the list by a note that incorporated 4 sections, Subjective--the patient's report, Objective--signs, symptoms, labs, images, Assessment, Plan.
We know the sections today as the SOAP note in the medical record.

Weeds article was an inspiration to thousands. I had visited Weed in his laboratory at the University of Vermont in the fall of 1970 and it was he who put me in touch with Bruce Waxman. In 1973 Peter Walton, M.D. of the Technology Branch was made the project officer (government public health official) to oversee Weed's grant. Walton became a very strong advocate for all things Weed and later joined that  interesting and committed group of researchers.

Weed also advocated the development of a real-time marriage between the medical record and current medical knowledge. Some of that is spelled out here:
http://xnet.kp.org/permanentejournal/sum09/Lawrence_Weed.html

In my first practice, I used the Cross-Bjorn, Problem-Oriented approach.
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Molly and I had moved to Harpers Ferry in 1973 to live in a community known as Keyes Ferry Acres, a several hundred acre parcel of mountainside sloping down to the Shenandoah River. The parcel had been divided up into a number of  2 acre building lots. Most were unbuilt but there were 50 or more, primarily pre-fabricated "kit" types of houses placed on foundations throughout the community which was connected over a number of dirt roads.

We lived in an A-frame that had been placed on a basement that was partially dug into the hillside. There was no stairway to the very rough basement area that contained the laundry room and my workshop. The northern exposure of the A-frame was an entire wall of glass with a view of a lake 60 or 80' below and the river (at least in winter) about a quarter of a mile beyond the lake.

Community residents were very friendly and consisted of retirees, a number of lesbian couples, and a growing number of younger couples for whom the property was a starter home.

The community was within 60 miles of Washington, D.C. which supplied both government and building trade opportunities for work. There was also a commuter B&O train to D.C. a couple of times a day.

If memory serves me, Harpers Ferry is the lowest point in West Virginia. It is situated at the junction where the Shenandoah flows into the Potomac.

Potomac Foreground. Shenandoah extending West at top left.

 Courtesy of Blogger: http://blog.mrpetermore.com/2007/06/19407-harpers-ferry-west-virginia.html

The town is smack in the middle of Civil War History. It is very close to Antietam. The original federal arsenal was there. Charles Town is a few miles west and contains the Court House where John Brown was hanged.

Charles Town and Ranson WV


Charles Town is the county seat of Jefferson County WV. Ranson abuts Charles Town. It is impossible to logically determine where one begins and the other ends. The hospital for the county is located in Ranson. Charles Town is in the Eastern Panhandle of West Virginia and is sometimes mistaken for Charleston, the state capital which is in the far west of the state.

In the summer of 1974 I approached the hospital about their interest in having another family physician on their staff. The administrator, Don Bagwell, was very receptive and he offered me a line of credit of $15,000 which I believe was interest free.

One of the responsibilities of a staff physician was providing coverage to the emergency room on a rotating basis, approximately 3 or 4 days of the month.

The age of the staff fell into two general tiers. There were 4 physicians over the age of 50 who were well established in the community. Two of them were primarily surgeons. There were was a young surgeon who had come to the community two years prior and a recently arrived internist.

I rented office space across the street from the Charles Town Hospital, an aging structure of about 30 beds. Work had already begun on a new facility that was scheduled to be opened in 1975.

I was very busy getting in equipment, setting up a couple of examining rooms and a little laboratory while doing the paperwork necessary to obtain the West Virginia license and privileges for practice at the hospital. I flew to Charleston for the necessary appearance before the board in November 1974. I asked to purchase a copy of the rules and regulations for medical practice in the state. The Director of the State Board said that no one had ever requested that before and he gave me his copy.

Our Neighbor Sue
My staff privileges were due to start on Monday, December 2, 1974. However, on December 1 I received a call from a local licensed nurse, Sue, whose son, Eric, had fallen from the cellar staircase from a distance of about 5 feet and banged his head against the concrete floor. The child was initially limp, then exhibited some clonic movements, and had begun to cry normally. He was a very large toddler. Sue took him to the emergency room. By that time, Eric was behaving normally. His examination was normal. There was a knot over the back of his head and not much else in the way of physical findings. An x-ray was considered not necessary at that moment and Eric was sent home with standard instructions for observation after a head injury.


A few hours later, Sue called and said that Eric wasn't quite right. He was irritable and whiny. I went over to their place and examined him and didn't see any focal neurological signs, but there was the irritability and he was getting fussier. A return to the emergency room resulted in an x-ray which showed a large skull fracture that extended through the foramen magnum. So, Eric was admitted to the hospital to Dr. Z who was perhaps the busiest GP in the area. I gave Dr. Z a call and told him that the family were personal friends and that I would probably be around during the afternoon to check in from time to time. Dr. Z expressed no problem with that.


About 8 hours later, Sue called me from the hospital and said that Dr. Z had never shown up to look at Eric. I said, I would call him. I did call and asked Dr. Z if he were going to see the child that day.


"What business is that of yours?" he asked. There was quite a bit of irritability in his voice. I told him that I was passing on the mother's concern, that the child had incurred a nasty injury and that the family was looking to him for comfort and guidance. After the call, he did go to the hospital and met with the family.


Eric's irritability cleared rapidly. Some specialist follow-up occurred within the next week or so and there was a complete recovery.

Sometime in the first week or so, I was scheduled for a three day rotation in the emergency room. This meant that I was on call for 72 continuous hours. I was expected to be able to show up to see cases in the emergency room within some time-limit--I believe 45 minutes or so.

Being available in the emergency room is one of the quickest ways of generating new patients for a practice. The patient and the patient's family have an opportunity to see the doctor working under the gun of the emergency and they are often particularly appreciative for good services at that time. The physician may gain both the emergency patient and the patient's family for a long-term relationship.

However, in communities that are struggling economically (and Charles Town was certainly in that category) the emergency room becomes the treatment of last resort. Poverty drives people to seek more routine kinds of medical care from this source.  The physician on call is obliged to see the patient and in this way establishes a relationship that may have legal ramifications that require ongoing treatment of the patient's problem, at least for some period of time. The bottom line was that in Charles Town, steady exposure at the emergency room guaranteed that the bulk of my new patients would be economically disadvantaged. That was just the way things were. But hey! I was young and we didn't have much in the way of material needs.

A Warning: Some Bad Behavior Ahead...fill in on marriage

If you choose to continue reading this, you will find out some things about me that are pretty ugly--probably makes you want to read more--right? You will see that I will have to own the destruction of my marriage to Molly through infidelity, even brazen infidelity and the inability to comprehend the suffering that I was causing in another.

That said, there were some dynamics in our relationship that made it more difficult for us to grow a healthy nest. Some of the issues for us were childhood traumas of a reasonably severe degree as we both witnessed the destruction of our fathers to alcohol and demoralization stacked on top of a dangerous combat history. Neither of us had the opportunity to observe loving, practiced intimacy in our parents--so we had no role models. Both of us had mood disorders and we suffered from depression. We were probably using more alcohol than what was good (certainly was true for me).

There was also a discrepancy in education at the time of our coupling. I had been on a straight track that led me through graduate school. I had enough support at home to live there while going to college and received a scholarship that made medical school more manageable. Molly had to balance school with the need to make a living. When we got together, she was able to spend the first couple of years completing her degree in English. Although I may have appeared to be floundering through until 1974, I was practicing a profession that had become my "false god" if you will. This was put to good use by my narcissism but it placed her vocational aspirations into the second tier.

However, in 1973 she had begun to work full-time in a survey research firm where her talents pushed her toward the fast track for promotions. She was incredibly bright and could write well. She had an analytical mind. She was hard working. She has a rapier wit, some of which I'll relate while bleeding in other posts.

From the outset, our notion of family was never written in stone. She sometimes talked about a dream of having boys but on a couple of occasions she warned me that she wasn't really sure that she wanted to have children. So, contraception was a very important issue in the first few years of the relationship.

I think we made a mistake in 1974 by deciding that we should do the practice together. That automatically cut her off from a position where she was making a professional advancement and made her work status subservient to mine. It may have appeared to make economic sense at the time--elimination of two hours commuting and commuting expense, elimination of the need to hire someone to do the front office, one car instead of two, do shopping errands locally during the day, etc.

However, it was a professional death for her, although it was not obvious at the time.

The Charles Town Hospital Emergency Room:


Without patients, your appointment book will be empty. If your office is across from the hospital and you have some patients admitted to the hospital, you are likely to find yourself spending time at the hospital, particularly on those days when you are on duty for the emergency room. This is how I got introduced to the wonderful nursing staff at the hospital and, believe me, it was a wonderful nursing staff.

The emergency room was very antiquated. I upset the chief nurse immediately, when I refused to use any instruments that were cold sterilized, i.e. scrubbed up with soap and water and then placed in germicidal solution for storage. It is not a safe practice. After all, I had been reading a lot about public health the previous few years. The following is interesting for some of us:
http://www.emro.who.int/publications/emhj/0101/09.htm

By the early 70's it was well known that cold sterilization was not effective against Hepatitis B. My refusal to use such instruments required that the Emergency Room nurses arrange suture and wound trays that were autoclaved for my use. This did not go over well.

The emergency room could get quite lively and generally 25 -- 30 patients were seen during the course of a day. However, the call was for 72 hours straight and there were always calls at night. To save the back and forth commute, I generally slept in the office during call days. Many nights, Molly slept in the office as well.

The emergency room call was a source for inpatient work, too. If hospital admission was necessary, the on-call physician was responsible for the hospitalization.

During the first year of practice, I devoured knowledge like never before, particularly in the area of differential diagnosis.  The first few paragraphs of this wikipedia article describe some of the process and then the material becomes very complex.

  http://en.wikipedia.org/wiki/Differential_diagnosis

The process of differential diagnosis begins with a consideration of major types of disease, such as inflammatory, vascular, toxic, neoplasm, endocrine, trauma, etc. Each of these broad categories are associated with a time course. For example, vascular diseases like heart attacks and strokes are likely to have a sudden onset, whereas neoplasms or cancers are more likely to begin gradually. Given the symptom complex, the goal is to generate a list that contains the correct diagnosis as one of the possibilities. An old adage is that you can't make the diagnosis if you don't consider it in the first place.

So the differential diagnosis begins as a list of possible disease entities that may be producing the illness you are seeing in the patient. The next step is the elimination of as many of the candidates as possible. How? You gather information about the candidate disease and discover why it does not fully match what you are seeing in the patient.

This process was nothing new to me--it is a standard procedure in the evaluation of any patient. What was new to me was a new "mental stickiness." Although I was eliminating candidate illnesses, my brain was retaining much more information about the diseases that I was rejecting in a particular case. The absorption of medical information was never so easy, before or since.

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Example: Differential Diagnosis Mr. Beri


During my days of traveling from one drug abuse treatment center to another, I worked on a ward at the VA hospital in Baltimore attending to returning GIs from Viet Nam who had managed to get themselves hooked on opiates while in the field. There was a mental health program and screening facility for them in downtown Baltimore. Mr. Beri had been found to have a psychosis and he was sent to the hospital for admission.  I was responsible for doing the admission hospital work and for following him for his drug related problems while he was in the hospital. He was noted to have a heart murmur and to have a blood pressure of something like 130/70.


Mr. Beri was a very reclusive individual who hoarded carbohydrates. He had been started on an antipsychotic medication at the downtown clinic and this was continued during his hospitalization. Despite the medication, his thinking was off at times. Looking back, Mr. Beri was experiencing what is known as a delirium. Delirium is not a psychiatric disorder but the effect of another disease state upon the functioning of the brain. Delirium remains a very much underdiagnosed illness today, particularly in the elderly in hospitals.


Mr. Beri began to develop leg swelling, called 'edema,' and the internists were asked to see him and follow along. They did the usual evaluations but found no explanation for the condition. A little bit of swelling became a lot of swelling and Mr. Beri began to complain of chest pain. EKG and heart enzymes were negative for any acute heart damage.


Mr. Beri's edema was now 4 plus and he had become bedridden. His murmur was worse and his blood pressure was now 150/60. The internists were coming regularly but they had no diagnosis. I was worried that Mr. Beri was going to die.


I remember working that case for several hours. There are so many causes for edema, so it was time to pick another aspect of his illness that might narrow things down. Well, what had been changing was his blood pressure. The difference between the systolic and diastolic blood pressure is something called the 'pulse pressure.' It was elevated. I was home and I had a copy of Willis Hurst's Cardiology Book and began reading about pulse pressure. Here is a wiki link about pulse pressure.
http://en.wikipedia.org/wiki/Pulse_pressure


In the wiki link there is a list of conditions associated with a wide pulse pressure:

Examples: (these are examples of WIDENING pulse pressure causes)

• Atherosclerosis
• Arteriovenous fistula
• Chronic aortic regurgitation
• Thyrotoxicosis
• Fever
• Anaemia
• Pregnancy
• Anxiety
• Heart block
• Aortic dissection
• Endocarditis
• Raised intracranial pressure

So this list would be a differential diagnosis list for a wide-pulse pressure.

The Willis Hurst Textbook, devoted as it was to cardiology, would suggested that Vitamin B1 deficiency be included on your list as an example of a high output failure.

Given the list, you begin to eliminate diseases. He wasn't anemic, he was past anxious, he had no heart block, he wasn't febrile, he was a little young for atherosclerosis, etc.

And then you read about B1 deficiency. One of its forms is BeriBeri. There is a dry beriberi, associated with mental confusion, and a wet beriberi associated with edema. Because of the high output of the heart, a murmur is frequent. 

This was probably my eureka moment as a physician, about 38 years ago. It was a Sunday night. I drove 40 miles to the hospital. Mr. Beri was not doing so great. If he had BeriBeri, an infusion of Vitamin B1 should lead to fluid loss. It was amazing to see the urine flow.

So, Mr. Beri who was hoarding his carbohydrates and not eating his salads had presented downtown with Vitamin B1 deficiency that so affected his thinking that he was considered psychotic and sent to us for hospitalization. Our primary concern was his thinking but under our care and his continued hoarding of carbohydrates, his B1 deficiency worsened and he developed another stage of the disease, the"wet" type.

Within a few days of using Vitamin B1 he was released to the community.

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Medical Staff Appointment

One of the things about hospitals is that there is a lot of committee work required to maintain accreditation. One of those committees is generally a "therapeutics" committee. I was assigned to that during my first medical staff meeting. What was interesting about it was that it made it possible to audit any chart in the hospital to look at what the other doctors were doing. Also, my first dying patient was someone who experienced a "Disease of Medical Progress."

Alma

If she had been born in the 19th century I'll bet she would have lived longer. At the age of about 23 she developed tuberculosis. However, the disease burnt out at an early stage in the 1930s, before the availability of any antimicrobial agent for the disease. In other words, Alma's own immune system had figured out a way to bottle up the TB germ.

Now we know that the human immune system is generally not capable of totally destroying the tubercle bacillus. The immune system walls off the organism in various ways. A link of interest may be

http://en.wikipedia.org/wiki/Ghon's_complex

So, this is what happened to Alma in her 20s. Even 100 years earlier, it is almost certain that this particular human being would have had the biological tools to fight the illness to the standoff. But, she was born in the 20th century. Cortisone was introduced into medicine in about 1950. Alma began using it for arthritis in the 1950s. Cortisone weakens the immune system. In Alma it allowed the tuberculosis to re-emerge and it did so with a vengeance. She was hospitalized and given antibiotics, but she lost a substantial amount of lung tissue. As she continued to age, she developed right-sided heart failure and this is when I met her.

She was in severe heart failure, quite swollen and debilitated. Hospitalizations, oxygen, and medications provided a marginal life for about six months. Then she decided that life was not worth living in this fashion.

I stopped by the house once a week for a month or so. Then one night her son called me to say that she was worse. 

I went to see her about nine-thirty. She was in a small back bedroom. There wasn't more to do medically and I just sat there with her for a while. Some of the family was off in the living room watching television. It  was a sitcom. I could see the flickering of light from the TV screen and hear the canned laughter.

Hers was the first death of a patient in my own practice and it wasn't the way I had pictured it. The loving family was not gathered around her. Instead they were gathered around an escape from reality. I wondered if she had taken too long with her dying.

Antibiotic Shots in the Emergency Room

Shortly after being assigned to the Therapeutics Committee, two emergency room nurses came to me with a complaint. Several doctors were routinely ordering penicillin shots for patients who presented in the emergency room with apparent infectious illnesses. The physician never actually saw the patient but made a diagnosis based upon the nurse's report and then ordered an injection. The nurses said that they were concerned about their liability in these cases.

At the next staff meeting I brought up the nurse's concerns and asked for a discussion. No one spoke. I then made the motion that a doctor's examination of a unkown patient was an expectation before using an injectable antibiotic. The language of "unknown" patient was to permit the doctor to handle his own private patients in whatever fashion he chose, but for other patients in the community an examination was in order.

The motion was not seconded and could not stand for a vote. After the meeting I asked the hospital administrator what he would do if the nurses balked and said they wouldn't give shots under such circumstances. "I'd have to fire them, I guess."

Sohr's Explanation for the Growth of Medical Narcissism

As I continued on in practice, my assessment of the skills of other physicians declined while an assessment of my own increased. How might that happen?

Well, it is very simple. If you are new in town, patients often come to you with stories of how bad all the doctors are. They also tell you how much better you are than the previous guy. You get to believe this.

In the meanwhile, all those people who think you are a terrible physician have already moved on to another doctor where they no doubt told the tale on you.

I'll Make It My Business, Dr. Z

In my second month of practice I was working in the hospital and a nurse held up a newborn for me to see. The skin was peeling off. I looked at the chart and then went to the pediatric textbook to read about Ritter's Syndrome. It was Dr. Z's patient. He had done the delivery. However, Dr. Z was treating the child with tetracycline. 

It was well known that Tetracycline was contraindicated in children under 8. In my generation its use was associated with thousands of cases of permanently discolored teeth. So I gave Dr. Z a call.

I got the same line that I heard when I called him about the skull fracture, "What business is that of yours?"  I told him that I was on the therapeutics committee and I was just giving him a friendly call about one of his patients and that I would leave a note in the chart outlining our conversation. I also told him that if there was a bad outcome with this child, I would make it my business.

Within an hour, the child was on the way to the regional center at Winchester and I had a permanent enemy.

And so I was slogging through the first few months of medical practice, when an old friend called and asked if I wanted help in practice! I was so excited.