Billings, MT 2

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medical      *
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It's Sunday Dec 4 at 2AM. I'm a little discouraged. In addition to the chest pain, there is midback pain consistent with problems at Lumbar 2. One of the hopes of chemotherapy was a cessation of tumor spread in that vertebra. Since I was having minimal pain before and more significant pain now, I am naturally disappointed. I'm also having headaches fairly frequently but these generally respond to analgesics. However, I've had one for five hours at this point that has not responded to anything. I have started to log my use of pain relieving drugs in a more formal way.

Monday 3 PM.. Yesterday was odd. Quite a bit of pain in the A.M.--then a really good day until about 5 PM, then draggy and sick until about 9 then a good response to medication and up until 2 A.M.

I calculated my analgesic consumption yesterday and it was equivalent to 30 mg of parenteral morphine or 90 mg of oral morphine.

My shortness of breath has been better the past few days. I have no explanation for it. I'm starting to notice some constipation from the opiates.

Tuesday 3 A.M. I am scheduled for a PET-CT of the chest and abdomen today at Stanford in Redwood City. Jasmine and I will drive up, leave Archie in Paso Robles for the day and return later this evening. This scan should give me information about tumor progression.

My friend, Jamie Kopper left yesterday. We went to the same high school, college and medical school. He was a year behind me but we ended up taking several of the same courses in college at the same time and frequently studied together. He is still working as a pediatrician in Baltimore. Like almost all pediatricians, he is underpaid and overworked. It was a wonderful weekend--three physicians in the same house who would practice medicine until the day of death if given a chance--all practicing the same religion so to speak.

Billings MT  2

The Arrival of the Home Computer
In 1979 I bought the Commodore Pet computer for about $1300 and the floppy disc drives for another $1200. Fifteen years prior I had worked on a Honeywell 1200 computer that had 32K of six bit memory and used tape drives for data storage.That machine was worth about $250,000 in 1965 dollars. The Commodore Pet had 32 K of 8 bit memory (byte) and floppy disks for storage. It was just as powerful computing wise and cost only 1% of the Honeywell 1200.

Almost all of my previous programming experience had used punched cards to enter programming instructions. The cards were read by another program called a compiler that actually created a program that could be read and understood by the machine. The Pet came with a BASIC programming language that eliminated the punch cards. One could directly type a program onto the computer screen in an interactive fashion. I think this increased programming productivity by a factor of 10.

I noticed the names of two programmers who had written the BASIC language for the 6502 Microprocessor--Bill Gates and Paul Allen--what wonderful work.

Over the next few years I became more heavily involved in attempting to write computer software with commercial value. The Commodore Pet used the same microprocessor as the APPLE II. The most ambitious project was the development of a keyword data base for tracking collections, such as medical literature or recipes. The APPLE had become the best selling computer and therefore the largest market for software. Once I had developed a proof of concept with the Commodore Pet, I went to an APPLE users meeting in Billings, where I met Ed Puckett.

Ed Puckett--the Computer Man
I attended an APPLE users meeting in Billings in 1981. I was looking for an expert who would be capable of helping me export a concept from the Commodore Pet to the APPLE II. While there I met a 19 year-old kid who was demonstrating some type-face software. His name was Ed Puckett. As we talked, I was surprised to find that he was married to the daughter and granddaughter of two of my patients and that he was actually living near my clinic in Worden.


I also realized that Ed was a mathematician although he had quit college in his first year. (I'm certainly not a mathematician but I've had enough coursework and interaction with them to recognize the species) Ed was working in his father-in-law's cleaning business and he was very unhappy. He agreed to take a look at my stuff and did some initial work that was very impressive. We had started talking about royalty sharing, but after a few weeks there was no more production from him. I called a couple of times. Eventually he was able to tell me that he was too depressed to work either at his job or for our project. Things were so bad that his computer had been repossessed.


I had recently purchased an old Mercedes with an accompanying "parts car"--so I  had another project that could consume all of my available time. I offered Ed the use of my APPLE. He needed money. Instead of royalties, he asked if I could pay him minimum wage for his time. We agreed on that.


There are many smart computer programmers. I had worked in a large shop in the summer of 1965 at a place called Vitro Laboratories in Silver Spring, Md. The project was an air-to-surface missile presumably to take out SAM sites in Viet Nam. I had also seen programmers developing materials for the Third National Cancer Survey at NIH in 1968. I believe that I had worked with more than a hundred programmers.


But I had never seen anything like Ed Puckett. 


I had learned to flowchart everything--it was almost my religion. Ed did not.


When writing a program, names are assigned to variables. Once done, the computer will not tolerate any misspelling of that name. When working on code that took up more than a page of monitor screen, I found that I spent a lot of time going back to pick up the exact spelling of a variable name. Ed never seemed to have to do that. Once he had assigned a variable name, it seemed to stick with him forever.


Ed's code was beautiful. In the movie Amadeus, Salieri finally gets to see a first draft of Mozart's musical scores. He can't believe that the transfer from brain to paper occurred in the absence of cross-outs or scratch outs. There were several areas where Ed went back over some of my code and simplified it and made it better.


I was fascinated by Ed's patience when he ran across something unexpected. For me, I would have been satisfied with trial and error approaches to get something working. Ed needed to know, first of all, why something wasn't working. I have seen Ed spend a couple of weeks of his free time looking at the disk boot up code for the APPLE II floppy disk system. There were some instructions in the code that didn't seem to belong--it was hard to see that they were doing anything. Eventually Ed discovered and was able to prove that these "dead" instructions were actually a timing device, allowing the disk reading armature time to get to the beginning of the disk.


This is a quality that sets Ed Puckett apart from most others. The force that guides his life is really 
quest for knowledge . When he comes across something that he doesn't understand, he has reached the limit of his knowledge about a particular entity. Instead of being frustrated at this event, he actually views it as an opportunity for learning. Instead of looking for a work-around (which is what I often do), he begins to work the problem itself. At those moments, he is really at the cutting edge of his personal understanding. He is the weight-lifter who is exercising the muscle to the point of exhaustion--in this case his mental muscle. 


The propensity to direct energy to an area not well-understood guarantees that he is always on a path of self-improvement. This is what I most admire about him.


Ed and I made a decision to write the entire project in Assembly Language (there is a one-to-one correspondence between Assembly Language instructions and Machine Language instructions.) As far as our commercial project was concerned it was a resounding failure with respect to making money. However, my brother Dana wrote a manual for our software. People weren't much interested in our software product, but people did like Dana's work. This started him down a very successful career path. Ed's life was made a little easier by an infusion of cash for doing something that he loved.


In 1982 Ed went back to college at Bozeman where his skills were quickly recognized. I believe that he had a single B in his four years there. He then went on to MIT for post-graduate work in Artificial Intelligence. I've been told that fewer than 1% of applicants to the program are accepted.  After MIT, Ed happened to be in a small company that was working on an internet browser in 1995. When the company was bought by AOL and Ed did very well.


The Worden Clinic Practice
I worked at the clinic in Worden for five years, most of that time as a solo family physician. One couldn't have asked for more considerate or appreciative patients. I continued to do some obstetrics, perhaps 2 or 3 deliveries a month. It was much easier to do this in Billings where there were several obstetricians and almost always someone around if there were problems.

In Glendive, immediately after delivery, one had to look to the child and resuscitate if necessary. When the fetus is in distress, it may have a bowel movement into the fluid environment, the amniotic fluid in which it is bathed. This discolors the fluid and it is called "meconium-stained," meconium being the name of the first bowel movement of the child. Meconium is not the result of food or milk being ingested, but the remnants of what the fetus has swallowed in utero.

The standard practice in 1978 for meconium staining was to attempt to clear the child's airway as much as possible to reduce the amount of meconium that might be inhaled in the child's first breath. This was done by immediately intubating the child before the first breath and passing a tube that permitted the doctor to clean out the upper airways with mouth pressure.

In Billings, there were well-trained Neonatal nurses who took the baby as soon as it was out and did the resuscitation. This included a very vigorous rubbing of the skin and removal of a great deal of the vernix. Although it was was nice to not have to worry about the child, I thought the nurses were overly aggressive for most newborns. The vernix is the remnants of skin cells that have been shed and contains quite a bit of fat. (Cell membranes are predominantly fat.) If the child is just wrapped and kept warm, the vernix melts and provides protection against excessive drying of the skin. The vernix also appears to have antibacterial properties as well as indicated in the following article.

Pediatr Res. 2006 Oct;60(4):430-4. Epub 2006 Aug 28.

Proteome analysis of vernix caseosa.

Tollin M, Jägerbrink T, Haraldsson A, Agerberth B, Jörnvall H.

Source

Department of Medical Biochemistry and Biophysics, Karolinska Institutet, SE-17177 Stockholm, Sweden.

Abstract

Vernix caseosa (vernix) is a white creamy substance covering the skin of the fetus during the last trimester of pregnancy. The function of vernix has long been debated but no consensus has been reached. We here report a proteome analysis of vernix using two-dimensional gel electrophoresis, matrix-assisted laser desorption/ionization mass spectrometry and liquid chromatography coupled to tandem mass spectrometry. We have identified 41 proteins, of which 25 are novel to vernix. Notably, 39% of the identified vernix proteins are components of innate immunity, and 29% have direct antimicrobial properties. These results form a substantial contribution to the knowledge of vernix composition and demonstrate that antimicrobial protection of the fetus and the newborn child is a major and important function of vernix.

PMID:

  
16940245
[PubMed - indexed for MEDLINE]

Obstetrics is associated with high malpractice insurance rates. When I went to Glendive in 1977 we charged our patients $250 for prenatal care, delivery, and care of the newborn--this was the entire cost to the patient unless a C-section was required. (Circumcision was also extra and I did my best to talk every parent out of doing it. I considered it a mutilation. If a parent insisted, I waited until the child had been discharged from the hospital and had spent a few days at home.) By the time I left Montana in 1983, I was paying about $400 in malpractice insurance alone for each individual delivery.

The Worden practice gave me a great deal of flexibility over the medical records. I utilized the E Book and managed chronic illnesses using flowsheets that permitted me to see sugar or blood pressure control over multiple office visits on the same page--a spreadsheet kind of arrangement.

We tracked all of our ear infections in children. One of the charitable foundations provided free audiometric screening for children. Twice a year, they would come to our clinic for a morning and test all of the children with recent infections and follow up any children with chronic problems.

As a rule, teen-agers are generally healthy. Most of my contact with them would be centered around a need for a physical examination related to playing a sport or participating in vigorous field trips, such as hikes or camping trips. I asked every teen if they were smoking tobacco, if they were using alcohol or other drugs, and  if they were sexually active.

If they said they were sexually active, we had a much longer discussion about birth control methods and phone numbers for Planned Parenthood. If they said they weren't sexually active, I told them that the clinic was available to assist them should they begin having sex. They were given information about planned parenthood as well.

Most parents were grateful that we were addressing the issue. A few parents became concerned or angry. Generally these were folks who had a more fundamentalist approach to their religious beliefs. I would just tell these parents that unwanted pregnancies among teens were common and that as a physician, I had a moral obligation to inquire. I would point out to the parent that there was no way I could tell about someone's sexual practices without asking.

At least 3 or 4 times a year a girl would come to tell me she was pregnant and didn't know what to do. I tried to encourage the involvement of a parent without putting pressure on the child to do so. Generally the girl was agreeable and the mother was the most likely to be told first. Usually the teen was grateful if I agreed to be the one to break the unwelcome news. We would schedule the appointment last thing in the morning or at the end of the day to allow sufficient time to process and discuss the situation. I was surprised at the number of times that mothers decided to keep this information from fathers.

In the routine of primary care, there were sometimes terrible events.

Gerry B.
One summer I got a call while on a vacation about the death of a patient who was a teen-age boy. I don't recall his first name--I'm going to call him by another name, Gerry. He had recently acquired his driver's license and was driving with a friend to Billings. He was fiddling with his radio and in this distracted state he slammed  the vehicle into a bridge abutment. Gerry died from his injuries within a few hours. His friend broke his leg. 


I had been caring for his family--his parents, his sister, and his paternal grandparents. A few weeks after the death, Gerry's mother came to see me about a medical problem and mentioned that she had received the strangest bill from the hospital--a charge from a plastic surgeon, Dr. P., for work done on Gerry in the couple of hours from the time of arrival at the hospital until his death. It was a considerable amount of money and it was done by a physician who did not participate in the family's insurance plan. The family had never met the surgeon.


I told the Mom that I would call Dr. P and try to find out some more. I did call him and he explained that he had been on call for the trauma team on the day of Gerry's accident. Gerry had suffered severe facial injuries in addition to chest and abdominal injuries and that the team of trauma surgeons worked simultaneously on several problems at the same time. Dr. P told me that this was the standard treatment for these kinds of injuries.


I told Dr. P that the family was hard working and that their insurance wasn't going to be much help to them. I asked him if he would consider renegotiating his fee with the family in light of their economic situation. Absolutely not! 


Looking back from my current vantage point, I wonder if Dr. P was offended that another physician was privy to his charges and nervy enough to suggest that he reduce them. It certainly changed my opinion of Dr. P. I would never send him a patient after this experience.


Gabriella and Gary
Gary was a rancher interested in real-estate. He had shown me some properties that were more than twenty miles off of paved roads in 1979. He had been married in his twenties but had no children and his wife had decided that she couldn't live in such an isolated place and had divorced him and moved on.


In his early 40's he had begun a correspondence with Gabriella, a woman in her early thirties from the Philippines. He went to the Philippines and met her family and decided to marry her. She was lovely and he adored her. I really enjoyed taking care of them.


Two years after marriage she became pregnant. In her eighth month she presented with what appeared to be an infection in the right breast. I referred her to a gynecologist who made the diagnosis of inflammatory breast cancer, a particularly aggressive cancer.  There was already evidence of metastases. Gabriella died  within 6 months leaving Gary with a beautiful baby girl and a large hole in his heart.


Much of the practice was geriatric and the patients were generally appreciative of having local medical services and avoiding a trip to Billings.For the most part, I would say that it was not high pressure. However, it was a solo practice. No one else in the St. Vincent group did pediatrics or obstetrics. I generally got 5 or 6 calls a night, most of them before 10 o'clock. I might have to go back to the office once or twice a week after hours on weekdays. I expected to go to the office at least once on Saturday and Sunday. Once I received a call on a weekend that would require an evaluation, I tried to push it off as far as I safely could. For example, if I received a call at 9 A.M.from the parent of a teen-ager who had a sore throat but was mobile, I would try to schedule the office visit for the mid afternoon. In that way, if there were other calls, I might be able to group them and see more than one person on the trip back to the office.

Acquiring a Partner and Re-evaluating Myself
In 1981, St Vincent hired another family physician, John Malloy. He was an excellent physician and the son of a physician. He had just completed three years of a family practice residency in Minnesota. He did Obstetrics and Pediatrics as well. So, we could cover for one another and have some time off.

The arrival of John was one of the primary factors in my decision to leave Billings when I did. I couldn't have asked for a better partner but I was forced to look at myself with a much brighter light, to see where I was in my career, to re-examine core values, and most importantly, to determine where I was going.

Training: 
In the first place, I had only a year of formal training after medical school. At the time of my internship, I think that there were only 1 or 2 family practice residencies in the United States. The usual pathway for family doctors was to do the year of internship and, occasionally, another year of surgery or internal medicine. In 1978 I had been "grandfathered" as board certified in Family Practice. Anyone certified after 1978 had to have completed three post-graduate years of training. So I had gotten in just under the wire. John had two more years of training.

Taking on Newborns:
I was acutely aware of my limitations as a physician. I only accepted low risk obstetrical patients. I only accepted newborn patients whom I had delivered. This meant that I had an established relationship with the parents of the child. John was willing to take on all newborn patients. When you are building a practice, this makes sense. If you get the child as a patient, you are likely to end up with all of the family as patients.

When I cared for the newborns from my obstetrical patients, it meant that I was already at the hospital for the delivery and I could see the child before I went home. A lot of bad things can happen to newborns very quickly. When those things happen to families that you know, it is one thing. When they happen to a family that you barely know, there is a much greater chance of legal consequences and the involvement of malpractice lawyers.

So I was very uncomfortable with John's decision to see any newborns he had not delivered.

Qualifications of Family Physicians:
One of the risks of being a family doctor is that when things go wrong with the patient, there is often the presumption that a physician with more qualifications in the particular area of concern could have done a better job. When bad things happen to the specialist's patients, the specialist's qualifications will not be an issue. If  I were to be sued for malpractice as a family physician, the plaintiff lawyer would blast away at my grandfathered status for Board Certification and create a doubt about my core competence. It would be hard to rebut this.

Use of Phone for Triage:
When on call for my own patients, I had a relationship and a history. When receiving a call from a patient, the physician needs to make a decision about the probable risk to the patient of delaying the evaluation. With your own patients, you have some data about the patient's or parent's problem-solving and observational skills. You also have knowledge about the patient's ability to tolerate uncertainty. Will the patient call back if things are getting worse? Is this mother an airhead? If so, you need to see the kid.

While Jamie Kopper was here this weekend, we talked a lot of medicine, particularly about very sick children. Our experiences were similar. In the majority of cases of super sick kids with pneumonia or meningitis,  parental delay in seeking help was a primary factor in the severity of illness. The case that I recall most vividly was a toddler who was near death when her 16 year-old mother brought her to the clinic. The child had been sick for several days with a pneumonia. The pneumonia resulted in fluid in the pleural space which then became infected. The infection deposits protein materials on the surface of the lung that organizes into something approaching "leather."  This material is called the "peel." The lung can no longer expand.

This child almost died. I assisted the surgeon for this case. The protein material needs to be peeled off of the lung by the surgeon.
http://www.chest-surgery.com/disease-info/empyema_decortication.html

When you don't know the patient, it is hard to treat any non-trivial problem over the phone. When I was on call for John, I needed to see a much higher percentage of phone calls from his patients.

I Had Become Too Accepting:
There were two cases that made me rethink my approach to medicine and my relationships with consultants.

Temporal Arteritis:
Temporal arteritis is an inflammatory disease medium size arteries--generally of the head and neck.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001484/
Louise was a patient who had chronic headaches. Knowing that temporal arteritis is a cause of blindness in folks over 50, I had ordered a sedimentation rate that was high. I had sent her off to the neurologist who sent her back saying that she did not have temporal arteritis. Two years later, John was on call and saw Louise on a Saturday. He strongly suspected temporal arteritis, hospitalized Louise, started her on steroids, and scheduled the biopsy for Monday, the day that I returned to work. It was temporal arteritis.

Maybe you can imagine how I felt. I was glad that the diagnosis was made for Louise. Naturally I felt embarrassed about having missed it.

Cervical Osteoarthritis:
I was caring for a woman who had chronic back pain. Her husband, Paul, had come several times with her and was always wearing a neck brace. He scheduled an appointment and described long-standing neck pain. He claimed that the brace helped quite a bit by immobilizing the neck and reducing his pain. I did several lab studies and ordered C-spine x-rays which were read as consistent with osteoarthritis. I gave him a prescription for pain but can't recall the details at this time. Paul also had a generalized skin rash and he was frequently rubbing and scratching at his forearms during the evaluation.

He wasn't happy with this outcome and he went to see John who ordered tomography of the neck and discovered that the patient had osteomyelitis, an infection of the bone of the neck. The probable mechanism was the continued scratching of the skin that had provided a portal for bacterial invasion. The bacteria found a home in the neck and began growing, eating away at normal bone and causing pain,which is generally severe in such a case.

Implications:
Clearly I had given up on these two cases. Louise still had her headache pain but armed with the neurologist's opinion I had gone no further with her evaluation and I had not gotten a second specialist opinion. John Malloy had enough confidence in himself and concern about the patient to push ahead and do what needed to be done for her. I had failed to do that for two years.

When I thought about Paul, I realized that I had not formed a relationship with him. He probably sensed rightly that I didn't care enough about him and went elsewhere. Even when people don't get better, if you have done your job as a physician, the door should be open and they should feel that you will welcome them back whether they have improved or not. I certainly hadn't done that.

The Marriage
When I look back at the five years in Billings, it is clear that I was never truly committed to our marriage. As a consultant in 1978 or 1979 I had visited a a large family practice in Baltimore where a medical record system was being installed. While there I met an interesting, married woman who was in her mid-twenties. We hit it off and had dinner together. We both had children that were born on Christmas Eve with very similar names but different sexes. When I returned to Montana, I got a post office box and began a correspondence with her. I kept the letters at work to minimize the chance that Molly would run across them. Although there was no sex and no discussion between us of the ongoing intimacies with our spouses, it was an affair by correspondence.

So, why did I stay married? I had already failed in a previous marriage and I couldn't imagine taking the first step out of the marriage. Maybe I wanted Molly to leave me--that this would have been easier and I had certainly given her enough cause. The correspondence also undermined my marriage by splitting off intimacy that one would normally reserve for marriage and placing it elsewhere.

I just wasn't trustworthy.

Molly and Eric: Billings about 1979

Molly and I had the opportunity to talk about this period on our life a few weeks ago. She hasn't given me a pass for all the pain that I caused her in the course of our marriage but her life since the end of our marriage has brought her peace and joy in her current marriage and the opportunity for a satisfying career.   The way that I have looked at our time in Billings was as a five year separation and divorce.  Granted this appears to be self-serving given my "cheating heart."