Rural Provider Cases

Stop Your Whining

2010-08-25T11:13:00.000-07:00

I have two patients in their mid 60s who put all of us to shame. Not only are they tough, but they both have inextinguishable optimism.

The first, "Bob," suffered an electrical accident back in the seventies. He was working for the power company on some downed lines. Somehow in the midst of untangling the wires power was restored too early and Bob had thousands of volts traveling through his body. The electricity entered through his left arm, and roasted it from the inside out. The arm was amputated at the hospital that same day. But the electricity that entered his arm had to find an exit, so it arced out of his abdomen and right thigh like water bursting through a dam. The exit wounds left behind massive tissue damage, required several surgeries including skin grafts to repair severe burns on his torso. The accident also left most of his right hand paralyzed, so in rehab they set his fingers to be permanently curled into a sort of hook, with only his thumb still working. He has a prosthetic left arm with a pincer hook that is activated by moving his shoulder blade. His left foot drags due to nerve damage, and Bob only this year decided it had gotten bad enough to seek treatment (he was tripping over his foot several times a day).

After recovering from the accident, Bob chose not to go on disability. He wanted to keep working, but not with electricity. He's done farming and ranching ever since, and the last time I saw him he had just finished running a combine to collect up bales of hay. Bob's always cheerful, full of energy, and in the middle of lots of projects around the farm. He also sings in his church choir.

My other sixty-something patient, is "Paul." I saw Paul for the first time last year. He smoked three packs a day, has a paralyzed right arm with the same claw hand as Bob has, and is blind in one eye. Paul was the victim of two hunting accidents. The first one from getting sprayed in the face by a shotgun, which took his left eye. He now has a prosthetic eye, and quick to show off its fine craftsmanship. The second accident occurred while deer hunting. He and a friend were hiking, his friend slipped, dropped his rifle and Paul was shot in his right shoulder, causing severe muscle and nerve damage. Paul has worked construction his whole life, mostly building structural rebar for bridges and buildings.

When I met Paul, I suggested that the best way to preserve his health was to quit smoking. In a period of four months he cut down from three packs a day to one, then went on Chantix (a smoking cessation med) to quit completely. He hasn't smoked in over a year.

Paul came into the clinic a couple of months ago complaining of abdominal pain for several days. He had chills and fever, was sweating, and groaned periodically from the spasms. He figured it was gas, but his wife wanted him to get checked. On exam his belly was firm, and he couldn't relax. Knowing that Paul was tough, I figured that if the pain was enough for him to complain, it was serious. He drove himself, with his wife, to the ER and it turned out he had a ruptured diverticula in his colon, which was spilling infection into his abdomen. He had part of his colon removed that day, and a temporary colostomy was opened in his belly so his the infection could clear enough to reattach the cut ends of his colon. Paul showed up in the clinic to go over everything that had happened and was proud to show me his colostomy. With only one good hand, he meticulously removed his colostomy bag, cleaned the opening, and reattached a clean bag better than I've seen nurses do it. Plus, he thought it was cool, but was looking forward to having it reversed.

So the next time you start complaining, think about Bob or Paul or the miners in Chile stuck in a hole in the ground for 4 months, and shut the hell up. I know I do.

Laments from the Grave

2010-08-11T13:50:00.000-07:00

An 83 year old woman complains that her right ear has felt plugged for the past six months. She denies any pain, any runny or stuffy nose, and has not had a cough. The ear pops open from time to time, but mostly feels plugged. Her hearing is muffled in the right ear, but normal in the left. She denies having had a cold and has not had trouble with her ears before. She says the ear has been bothering her since her husband died. She adds that her husband has been visiting her nightly since his death.

"Your husband visits you?" I ask.

"Yes," she said, "every night between 2 and 3am. At first it terrified me, but I'm getting used to it."

"What does he say?"

"Mostly he apologizes for the mess he left me. His family is fighting over his property and are trying to take it from me. They really want his car, but he says not to give it to them. It's mine now."

"And this happens every night?"

"Yes, and to be honest, I wish he'd come at another time. He wakes me up and I can't get back to sleep. But what can I do?"

"I guess you could ask him to come by later, but I don't really know how that works," I offer.

"I tried that but he just goes on and on like he can't hear me. Just like when he was alive."

I prescribed her some nasal steroid spray to open her ear, and told her check back in a couple of weeks.

Less is More

2009-12-15T15:53:00.000-08:00

41 year old man complains of severe right-sided back and flank pain for the past five days. For the first two days the pain was 10/10 and constant. He had difficulty breathing because of the severity of the pain, but is not short of breath currently. He now rates the pain as 7/10, but it occasionally spasms back up to 10/10. He has been sweating profusely since the pain started; the worse the pain the more he sweats. Sitting in the exam room, he has some sweat beads on his forehead, upper lip and the neck of his t-shirt is damp. Over the last couple of years he's had two other episodes of similar pain. Once on his left side, and once on his right side. He works as a framer, but has been out of work for the past six months. He had a previous related injury when a wall he was framing fell on him, with one of the main boards hitting him across the middle of his back. Nothing was broken, and after the initial injury the pain resolved. His current episode came on gradually over a few hours, just as they have before. He first noticed the pain this time while he was standing in the kitchen.

He denies any heartburn, has had no nausea, no vomiting, no abdominal pain, no diarrhea, and has continued to have a good appetite. Food doesn't make the pain better or worse. He hasn't seen blood in his urine, his urine isn't smelly or dark, and he hasn't been urinating any more or less than usual. He denies any chest pain, palpitations, dizziness, changes in his vision or cognition. He hasn't had any swelling anywhere, he denies any fever or chills and says that his sweating isn't due to feeling overheated but seems to be due to the pain. Other than currently, he denies any heavy sweating, denies weight loss or gain, and has been sleeping well. His back doesn't hurt anywhere other than the area described, his left flank feels fine. He's tried taking ibuprofen and Tylenol, without effect. He doesn't smoke, doesn't drink, isn't overweight and rarely goes to the doctor.

On exam, he's a very healthy 41 year old, sweaty, periodically grimacing in pain. He has only a tiny bit of tenderness on the front edge of his right ribcage, but not under it where the liver and gallbladder are. It's the rib itself that's tender, but only slightly. The rest of the abdominal exam is completely normal, his back is weirdly not tender even in the spot where he has the most pain, which he can point to. His mouth, neck and lymph nodes are all normal, his heart and lungs are fine and his urine tests normal without any sign of infection or blood.

So this is where the healthcare rubber hits the road. What do I do now? The patient's pain is slowly resolving, just like it has twice before. In between episodes he's fine, no pain whatsoever. He has no insurance, so any tests I order he has to pay for out of his own pocket. I explain some of the tests we could perform, an x-ray to look for kidney stones or bone lesions, a CT or MRI to look for masses or other lesions, blood work to look for clues as to what is causing his pain. Or we can treat the pain, let it resolve and recheck things in a week or two, or not at all. Everybody wants to know the why of their illness, but it often escapes us.

Last year I saw a patient in the emergency room with similar pain, although more severe. This guy had uncontrolled diabetes and was writhing in agony. Nothing I did controlled his pain and his blood sugars ere climbing to dangerous levels so I had him flown by helicopter to a larger city. After several days in the hospital, and innumerable tests, nothing was found and the pain resolved. He now owes the hospital over $40,000 but still doesn't know why her hurt.

My 41 year old patient decided that some anti-inflammatories, muscle relaxers and a few vicodin to help him sleep was the better way to go. His pain resolved as before, and he looks and feels great. He decided not to get any additional tests. Until next time.

Not to Worry

2009-12-11T11:46:00.000-08:00

Sometimes I get tired. Listening to problems all day is my job, and I like being able to help, but if I'm punchy I may actually say what I'm thinking. Which isn't such a good thing.

A 37 year old woman complains of weight gain, a darkening mustache and chin hairs (none were visible to me) secondary to her polycystic ovary syndrome (PCOS). This is a hormonal condition that's fairly common and can cause obesity, diabetes, and hirsutism. This lady had a long list of concerns, including smoking cessation, depression, really bad PMS, and warts on her thumb. So we had a lot to talk about, and as much as patients want me to solve every problem in one 45 minute visit, it's rarely that easy. She said her primary issues were the smoking, the warts, and the depression. I worked all of these up, came up with a plan, and was wrapping things up but then she wanted to revisit the PCOS.

"What can I do about the facial hair?" she asked. As far as I could tell, she had normal facial hair. But she was probably fixating on it, and so it seemed much worse to her.

"As we discussed, birth control pills are the first line treatment for that," I reminded her, " but until you quit smoking, hormone therapy is a bad idea for you due to the risk of getting a blood clot."

"And my weight, what about that?" she asked.

"Again, as we discussed, it's part of the symptoms related to the PCOS. When you quit smoking, we can try some hormone therapy and work on the weight." At this point my fatigue began to show, "You really shouldn't worry. I have some patients with PCOS who weigh 400 pounds and a full beard. You're fine."

She stared at me for a second and then asked, "what do you do for them?"

"I tell them to shave."

Fortunately, she laughed.

Hospitality by Any Other Name

2009-11-10T16:54:00.000-08:00

47 year old man complains of nausea, diarrhea and occasional vomiting for the past several days. He's weak, pale and has mild body aches. He has no upper respiratory symptoms and no pain in his stomach nor anywhere else. He has been staying with some friends since he lost his job and his apartment. He has no prior history of gastrointestinal problems, denies any intolerance of fatty or spicy foods and denies any heartburn. He hasn't had any new foods, doesn't take any medications and rarely drinks alcohol. He has no fever, but has had the chills off and on and looks sick. He's taken some Pepto Bismol, but he's having trouble keeping it down. He has been drinking lots water, aware that he is at risk for becoming dehydrated.

The exam doesn't reveal anything except some mild abdominal tenderness.

It looks like the stomach flu, so I give a prescription for an anti-nausea med, advise him to eat bland foods and keep drinking lots of water. I asked him to come back in a week if the nausea and diarrhea persist.

He returns a week later, feeling much better. He said he figured out what had caused his problem, and wanted to find out if there might be any serious side-effects from it.

"What happened?" I asked.

"Well, it was the pot roast that Shelley made."

Shelley was the wife of the friend he was staying with.

"What about the pot roast?" I asked.

"Shelley cooked the pot roast about two weeks ago. Sort of in honor of me staying with them. Then we had left-overs every day after, which is when I started getting sick. After I saw you, and took the nausea medicine, I felt better and was even hungry so I went to the kitchen and saw Shelley cuttin' on the pot roast, and then put it back in the oven. I didn't say nuthin' because they're lettin' me stay there but it turns out that when Shelly cooks meat in the oven, she keeps the leftovers there. That pot roast had been sittin' out for days, makin' me sicker and sicker. Turns out the whole family has diarrhea most of the time, and they blame the water. When I figured that out, I found another place to live, and ain't gonna eat at Shelley's no more."

"Good idea," I offered.

"But now I'm wonderin' if I hurt myself by eating there. I mean, am I gonna be ok or am I gonna get cancer or somethin'?"

"You'll be fine," I told him. "But you might want to warn your friend. Her cooking is going to kill somebody."

"Naw," he replied, "I can't do that. He's my best friend."

Doomed as Doomed Can Be, Ya Know

2009-11-06T14:36:00.000-08:00

A woman recently brought in her eight year-old son for his annual exam. It turns out that the boy was actually her foster child, and she noted that he was physically healthy, but had some difficult behaviors. He was very jealous of any attention from his foster parents and would become upset or hit the other kids if they shared their time. He would also hoard food, but didn't eat very much. The mom would find stashes of food in his room, even though there was plenty of food in the house. On exam, the kid was normal and healthy but never took his eyes off his mom, wouldn't make eye contact with me, and seemed to be a little "lost in space" like his mind was elsewhere all the time. I set up a referral to a counselor, but didn't hear any more about it.

A few weeks after that exam, I was given a report from a psychiatrist at the state mental hospital. The kid was now a resident at the hospital. The boy had continued with his hoarding and jealous behaviors, and the parents continued to try and manage him. A friend of one of his foster-siblings had been to the house one day, they were all playing video games and all was well. Later that day, the boy wanted to play one of the games but couldn't find the cartridge, nor could anyone else. Nobody thought much about it until that evening at about 11pm when the police called the foster parents. The boy had gone to the house where his foster-sibling's friend lived, went through a window and up to the room where friend was sleeping. The kid then jumped on the friend's bed and started punching him in the face while demanding that he turn over the video game. The kid was taken to the state hospital for observation and was being treated with various drugs. Sadly, the foster parents felt they couldn't take him back so the kid is stuck at the institution, probably for the rest of his life.

The report also described the kid's early years. He was born in a large city, his mother was homeless, worked as a prostitute and was a crack-head. The boy was taken from her when at the age of three he was found panhandling in front of a building while his mother was upstairs buying meth.

Doomed with no hope of escape.

Bad Patient, Good Escape

2009-10-05T16:05:00.000-07:00

Sometimes I help out in the local emergency room. I was there seeing a patient with abdominal pain, and in the next bed was a 31 year old man who had been found unconscious in a ditch. He wasn't wearing a shirt, but did have "gang-banger" jeans and a variety of homemade/jail tattoos. According to the paramedics that picked him up, he also had a fresh surgical scar on his low back which still had the metal staples in place. The story was that he'd gotten a spinal disk repaired a few days before.

He was attended by his girlfriend and her sister, both attractive in a meth-head/stripper sort of way. The girlfriend held her baby (the patient was the father) in her lap. The baby was sleeping soundly, despite the man's screaming tirade of profanity. As he yelled, the two women tried to soothe him. He was angry because he was strapped to a back-board, and he wanted to be released. A back-board is a stiff plastic board to which someone is secured to protect their spine from injury. The paramedics also put him in a neck brace and taped his head to the board to keep him still. When he came to, he immediately started threatening anyone in sight and even spit on a nurse; a very unwise move.

"This is fucking bullshit!" he hollared, "Let me fucking up! I'm gonna sue you motherfuckers!"

"Be quiet, honey," his girlfriend begged.

"Fuck you! Let me up, you fuckin' cunt!" he replied.

It seems that he took more of his post-surgical pain medicine than he was prescribed, and combined it with several 40 ounce malt beverages. This resulted in him somehow winding up in a ditch, passed out and topless.

"My back fucking hurts! You fuckers! Let me up!" he screamed.

So here's an important lesson about going to the ER. Everyone is given the benefit of the doubt when they arrive. But because about fifty percent of the people who show up in the ER are drug seekers and scumbags, patients are rapidly designated as a good or bad. Good patients have a valid reason for being in the ER, and bad behavior is forgiven if you are truly scared, in pain, or having a serious problem. The staff will be compassionate and take good care of you. However, if you are a bad patient, you will be left to suffer. The 31 year old described above is a bad patient. Bad patients will be left in cold rooms without any clothes, they will wait hours for pain medication and then be given Tylenol, they won't get lidocaine gel as their catheter is inserted, needles will be gouged around in their flesh during blood draws, they won't be brought food, and they won't be allowed to go to the bathroom. In general, bad patients will have their misery enhanced as much as possible by the staff without actual malpractice being committed.

So the guy on the back-board continues to complain, yell, curse, threaten his girlfriend and her sister, and struggles fruitlessly against the straps to get himself free. A doctor finally shows up to examine him and decided to free him from the board, primarily to shut him up.

Once he was free, the cursing and threats continued, with his girlfriend and her sister continuing to beg him to be quiet.

"Fuck you!" he yelled at them, now perched on the bed, "Fucking doctors! I'm gonna sue all you fuckers! Then all of a sudden, he ran out of the room, down the hall, and out the back door. A few of us followed him, and watched as he ran to the parking lot, got in a truck and drove away. When we came back, the women and the baby were gone. And that was the last that anyone heard from any of them.

Human Foie Gras

2009-09-30T12:36:00.001-07:00

A morbidly obese woman complains that her one-year old daughter has been vomiting repeatedly over the past week. The woman was easily 300 pounds, with dried food dribblings down the front of her sweatshirt.

She said that the baby was eating alright, but was throwing up some of what she ate several times a day. It had no fever, no cough or runny nose, was alert and happy, and was producing plenty of wet diapers. Other than the vomiting, the only thing wrong with the baby was that it weighed 32 pounds. The normal weight for a one-year old is 9.5 pounds.

In order to create a baby like this they must have been feeding it doughnut batter.

"Has your baby ever had problems with vomiting before?" I ask.

"Once in a while, but now she's doing it all the time," replied mom between labored breaths.

"How often do you feed her?"

"Whenever she's hungry."

"How often is that?"

"I don't know. When she's hungry."

"Does she only vomit after meals?" I ask.

"Mostly. And it's the worst at night," she adds.

"You mean while she's sleeping?"

"No. I mean when her daddy comes homes. He loves to feed her. He does it for hours."

"Hours? Really?" I ask.

"Yeah, and that's when she's urping up the most. But it don't bother her."

"So is your plan to create a circus freak, or just a two-year old diabetic?" I ask.

"What did you say?" she demands, her lolling girth begin to stir.

"Ma'am," I offer, "you need to stop over-feeding your baby, today. Right now. Give her two small feedings a day and water the rest of the time. We need to see you back every month to track her weight and hope that we can correct it or she'll be the world's only first grader to have bariatric surgery."

"But her daddy loves to feed her," she protests.

"Get him a pig."

Eat Your Heart Out

2009-09-16T10:46:00.000-07:00

16 year old boy accompanied by his father has been suffering from sinus congestion and a cough for a few days. The dad wants him checked for West Nile Virus. I suggest to the dad that rather than do expensive blood tests to check for an unlikely infection, I should first find out what else could possibly be causing the symptoms. I've seen the father and son a few times, and they are both memorable.

The son is memorable because at the age of 14 he weighed 430 pounds. A year ago, he had a gastric bypass and managed to lose 100 pounds, but has been steadily gaining it back. Turns out he has an eating addiction. He can't and won't stop eating. He never speaks, he never shows any emotion, he is just an inert mountain of flesh who only mumbles responses.

The father is a creep. He always sits in a wheelchair, but it's not certain that he even needs it. He's 70 years old, so it's unusual for him to have a son that is 16. The boy's mother ran off long ago. The father also has a reputation for grabbing and fondling nurses whenever he gets the chance. He like to park his wheelchair such that nurses have to step over or around him, and he gives them a poke or brushes his hand against them as they pass. He is also a right-wing zealot, lover of the NRA, and gives off a similar vibe as Ted Kaczynski (the Unibomber).

My personal theory is that the father is and has been sexually abusing the son, which is the cause of his eating disorder. The two of them just don't seem right together; their relationship is weird and strained and there is much lying just under the surface but the kid isn't talking.

I ask the boy, "Do you have any history of seasonal allergies?"

The father answers, "He does!"

He then asks the boy, "Have you been taking your allergy medicine?"

The boy replies quietly, "No."

The father sighs dramatically, the boy does not react in any way. A few more questions and a simple exam reveal that allergies are indeed the cause of the problem. At least the runny nose.

Creepy Little Dude

2009-08-12T03:18:00.000-07:00

39 year old man with a history of bipolar depression complains that he wants to be put on medication for attention deficit disorder (ADD). He is on Zoloft and Lithium, which has stabilized his moods. He's a chubby little guy, with thinning hair, a pronounced pug nose and is apparently quite far-sighted because his glasses magnify his eyes to the size of a Manga character. He speaks with a lisp and has slightly feminine mannerisms. He wants to be put on ADD meds because he has developed a habit of staring at women in public and his girlfriend is upset.

Welcome to the club, I think to myself.

He goes on to explain that he's worried because he doesn't even realize he's doing it, and as a result he's unable to stop.

"Are you staring at anything else, besides women?" I ask.

"No, I don't think so," he offers.

"How do these staring episodes begin?"

"Well, you know, I just stare." He then demonstrates his creepy little leer, and he keeps on demonstrating for longer than I'm comfortable. I fear he may be getting aroused, so I start talking.

"Yeah, I don't think that's ADD," I tell him. "ADD is when you can't pay attention, and you don't seem to have that problem. If that's really the way your staring at women, your going to end up slapped or having the life beaten out of you by an angry boyfriend."

"That's what my girlfriend said. That's why I'm here," he said.

I think for a moment.

"Do you ever find yourself, or has your girlfriend ever noticed you staring at anything else? Like a dog or a car or anything like that?"

"No, just women," he pauses, "and girls," and then smirks.

"Do you like your girlfriend?" I ask, trying to redirect his greasy little brain.

"I love her doc. We've been together for two years, and were supposed to be getting married this year, but our counselors thought it would be a good idea for us to wait. She didn't like that I treated her like a piece of ass, rather than a girlfriend. She's had a lot of abuse in her past: foster parents molesting her, being tied to beds, y'know, stuff like that, so she was feeling like I wasn't respecting her. She's beautiful, she has this amazing ass that ..."

"I get the picture," I interrupt. "It sounds like the problem you have is more of a bad habit, than a medical issue. What you need to do is really think about why you're staring at women (you little pervert) and how that affects your girlfriend. If the staring seems more important than her feelings, they you should break off the relationship. However, if you're free to stare as much as you like, you're going to wind up beaten to death. So rather than having her catch you in the act of staring, ask her to help you to notice when you're doing it so you can stop. Change the way you're thinking about it and make it something you can work on together."

"Thanks doc, I'll give it a try," he chirps.

Hopefully, I've reduced the creepy pervert population by one.

The Good Old Days

2009-07-21T16:05:00.001-07:00

73 year old woman comes to clinic to have some blood drawn before her appointment. I overhear her and the nurse are chatting about family and the nurse asks, "how many children do you have?"

"I have eight children," the old lady replies.

"Eight!" the nurse exclaims. "You must really like children."

"My husband made me have them. I didn't want that many. I went to three different doctors asking for birth control and each time they called my husband, and he told them not to give it to me. Being pregnant was misery for me."

"Oh. I'm sorry," the nurse answers.

"Well, he didn't live all that long," she adds. "He died about twenty-five years ago and I've been a happy widow since then. I like the kids now."

A Better Habit

2009-07-16T09:59:00.001-07:00

67 year old man returns happy that he has been able to quit smoking. Three months before I put him on Chantix, an excellent med for smoking cessation. He was now completely smoke free, but continued to drink a twelve-pack or more daily.

As he told me about his success, I noticed that he had developed an odd tic. He used "air quotes" with almost every other word he uttered. Most of the time he would use only one hand, his smoking hand, but would occasionally use both hands. He would air quote words like "the" and "or" and at one point I almost stopped him to ask if he knew what using air quotes meant.

But then I figured it was better than smoking, so what the hell.

Some Days You're the Dog, Some Days Your the Hydrant

2009-06-06T18:10:00.001-07:00

Being the only health care choice for many in my community, I see it all. Sometimes all in the same day. Here's a sampler of a recent busy day:

81 year old man fell on his fireplace shelf and has a massive hematoma on his right arm. No kidding, it was the the size of a grapefruit bulging from his forearm. It had been there about a week and was gradually getting a little bigger. He went to the ER right after it happened, they wrapped it with an ace bandage and sent him home. I tried to drain the lump with a needle, but nothing came out. I then cut a slit, and squeezed out about a liter of clotted blood (looked just like blackberry jam).

52 year old man taking high doses of methadone for chronic pain was changing a tire on his truck when the jack slipped out of position, and the bar that turned the crank flew into his face. I sent him to the hospital to get a CT of his head, but he was adamant he did not want to go to the ER (no money). The CT showed he had a fracture of his right maxillary sinus and the orbit of his right eye. I advised him to at least see an Ear, Nose and Throat specialist to make sure his eye and/or brain weren't seriously injured. He declined. Since he was on a high dose of methadone, the only thing I could do for his pain was suggest ibuprofen, rest and ice.

A 16 year old boy stopped by because he had been kicked in the groin by a cow. He wasn't worried, but his mother made him come. The kick mostly hit his thigh, but his scrotum had a nice little bruise from being vigorously pinched.

Another 16 year old boy who fell from his bike and now had a deformed shoulder. He had a painless lump at the far end of his collarbone about the size of a peach. His dad had him x-rayed and brought it to me. Nothing was broken, but the bones were a little bit out of alignment. Nothing more to be done.

71 year old woman with atrial fibrillation whose heart had been racing for the past week (heart rate of 126) and wildly irregular heartbeat. She couldn't catch her breath and couldn't sleep. I called her cardiologist, and we decided to add some medications. She came back three days later and was fixed.

48 year old morbidly obese man with massively swollen right testicle, along with nausea and chills. It was the size of a pomegranate, but stated that for the past year had only been as big as an orange. He weight 435 lbs, and had a mighty pannis (belly that hangs down below the crotch). As a result, his penis was long gone in folds of fat and his scrotum dangled beneath his body like some flesh-colored hammock. His right testicle was indeed swollen, and as firm as a bowling ball. He forgot to mention that the left one was also swollen, but only to size of an apple. I sent him to the ER before they blew.

71 year old diabetic with urinary incontinence and abdominal pain who was much better since I suggested not eating wheat. She in the interim had decided to go on a jello diet. Also wants to discuss hypertension, arthritis, coronary artery disease, acid reflux, gallstones, elevated cholesterol and her transient ischemic attacks. It took about 45 minutes, but we managed to cover it all.

17 year old boy with back pain, accompanied by his non-English speaking family (mom and two sisters). He had mild pain after playing soccer. He wasn't too worried, but his family was concerned it might be cancer. Turned out to be a mild back sprain, which I tried to communicate to them but I don't think they believed me.

52 year old woman who was in a car accident two days ago who has pain in her right foot. On exam, it looks like a fracture. On x-ray it is a fracture through the distal joint of her third toe; broke the joint right through the middle. She'll be off her feet for at least two months, and may have to get it surgically pinned back together. She tells me she can't afford to do that, so could she just have some pain medication instead. I tell her no, and send her to an orthopedist who is willing to work out payment plans.

Drama queen with mild vertigo. Convinced that she is dying, but it looks like allergies to me. She's 57 and should know better, but thinks she's a saint for the suffering she has endured. After about ten minutes I notice her teeth. They look like broken Chiclets, and poke out from her gums at weird angles. I realize that I've been working her long enough that her teeth look normal to me. All the while she goes on and on about her petty problems. I cut her off and tell her to get some Claritin at the store.

26 year old woman whose sister is a nurse, wants all the moles removed from her back. Her sister thinks they look suspicious. There are about twenty of them. They all look fine, but there is one on her foot that looks bad. I show her the punch I use to remove moles (looks like a little cookie cutter) and tell her each one will leave a scar worse than the mole, which all look normal, by the way. I convince her to remove the one on her foot, which turned out to be benign.

Also saw a 13 year old boy with ADD, bipolar disorder, Asperger's and bed wetting. His mom is a recovering prescription meth addict who had a hysterectomy at at 23. I go through his medications, which appear to be working okay. I then talk to mom in private, and she tells me about her drug history, that she is having a hard time and is thinking about using again. I find a local AA group and get her to promise me that she'll go. Don't know if she did.

Pride Goeth Before a Fall

2009-06-04T06:24:00.000-07:00

81 year old man with a past history of Type II diabetes, renal artery stenosis, coronary heart disease, hypertension and dizziness returns to the clinic for follow-up. It's the first time I've met him.

He talks awhile about his various medical complaints in a vague way; no specific complaints. After a few minutes of this, I interrupt him.

"Yes, but what brings you in today?"

"I'm still dizzy." he says.

From his chart I see that he has been complaining about dizziness off and on for about two years. He's been worked up by a cardiologist; his heart disease is stable and his blood pressure is well controlled. His diabetes had been a suspected cause (low blood sugar can cause dizziness) but that too has been stable for the past year. So despite these evaluations, his dizziness remained.

I asked him to describe in detail what he is feeling.

"If I stand, or sit up, I feel like I'm being pulled backward or to the side. Also, if I turn my head just right, I'll feel dizzy."

"Once you're up on your feet, do you ever feel unstable?" I ask.

"If I can get myself going, I'm fine. But I don't want to get up because I'm afraid I'll fall down. I've been doing less and less around the house, and my property is going to waste because I can't keep up with it."

His symptoms fit best with a diagnosis of vertigo, a problem with the inner ear. I talk with him about this, and suggest that he go to a nearby specialty clinic (in a larger city about an hour away) to be evaluated. He hems and haws at this suggestion, and wonders again if his diabetes and heart might be the cause of his dizziness.

I go over once again that we already ruled those out as causes. He then suggests that maybe his cataract surgery is to blame. I tell him that problems with his eyes can't cause the symptoms he describes. He doesn't seem convinced.

I then ask him to lay the exam table, and move his head rapidly side-to-side, and then look at the ceiling. "Do you feel the spinning?"

"Yeah," he answers.

I have him sit up and ask, "what about now?"

"I feel like I'm being pulled backwards," he offers.

"That's vertigo," I tell him. "The only thing that can cause it is a problem with the inner ear. This has been a problem for two years and you're becoming debilitated. You need to be evaluated for it."

Even after this, he was still reluctant to go.

"Why don't you want to get this solved?" I ask. "What's the problem?"

He then admitted that he could no longer drive, due to the vertigo. He also told me that since his wife died two years ago, he was reliant on his daughter for help. He had spent his whole life taking care of his family, and now he felt useless and helpless and he hated it. He complained that he could barely take care of his chickens, let alone anything else (turns out he raises four different breeds of chicken). His daughter was good to him, but he hated being so helpless.

I tried to point out that his daughter loved him, and was probably happy to help. He had taken good care of his family, but now it was their turn to take care of him. Plus, if he didn't like being so dependent on them, he really needed to get the vertigo fixed or he'd become more and more debilitated.

He finally agreed to be seen. The Golden Years can suck.

Good Deeds Done Dirt Cheap

2009-05-24T09:57:00.000-07:00

A 16 year old girl is accompanied by her older sister. I've never seen either of them before, but they look a little nervous as I enter the room.

"So, what's the story?" I ask, my usual patient opener.

The younger sister nervously replies, "I need a doctor's note so I can keep my dog. I moved her a few months ago to live with my dad, and all my friends are back home. I used to never leave the house and was really sad, but now, with my dog, I'm much happier."

"So why do you need a note from me?"

"If you write a note that says I need to have the dog at home to treat my depression, then we can keep him. Otherwise my dad has to pay a $300 deposit, and he doesn't have the money." Her eyebrows furrow as she says this, and she tears up a little bit, but quickly stifles them.

"No problem," I say. "What do you want the note to say?" Her face brightened, as she told me what she needed.

I write the note, and tell her to let me know if she needs a letter or anything else that will help her to keep the dog.

Good Thinking

2009-05-14T10:32:00.000-07:00

22 year old woman with bipolar disorder and morbid obesity complains of a red bump on the inside of her eyelid. She has a past history of alcohol and cocaine abuse, but has been stablized on medication.

The bump has been there for about a week, and she tried to treat it on her own a few days ago.

"What did you do?" I asked.

"I popped it," she answered.

"How did you do that?"

"I turned the eyelid inside-out, and popped it with a pin. Nothing came out. I sterilized the pin though."

On exam, she had a chalazion (small cyst on the underside of the eyelid). I told her to use a hot compress for a few day, to see if the cyst would resolve. I also advised that she not jam pins into her eye anymore.

Please Stop Talking

2009-03-25T06:38:00.000-07:00

48 year old man complains of bleeding from his rectum for three days. He suffers from liver failure secondary to alcoholic cirrhosis and end-stage kidney failure. Because of the liver failure, he has been drinking lactulose three times daily. Lactulose is a powerful laxative with the side effect of preventing his burnt-up liver from poisoning his bloodstream. His hair has some stray twigs in it, he reeks of woodsmoke and has grubby, soot-stained hands. He lives in a trailer park in town and all the plumbing works but he prefers to be filthy.

One of the most common causes of rectal bleeding is hemorrhoids. The most common cause of hemorrhoids is constipation. Because of the laxative he takes, I know that constipation is not his problem. After some questioning, I tell him that I'll need to take a look to see if I can find the source of the bleeding.

As he unbuckles his belt, bits of dirt and grass fall to the floor, freed from the folds of his clothing. The sour funk of the unwashed fills the exam room as his pants drop to the floor. As he bends over the exam table, he says,"Don't be stickin' nothin' up my ass Doc. The only thing goin' up there is a woman's tongue!"

My gut tightens at the image he plants in my brain. A quick look reveals that his butt raw and bleeding slightly. To his credit, he's been using toilet paper, if a bit too aggressively.

I tell him to apply some ointment and send him on is way, still haunted by the mouth-to-ass scenario he described.

Good Luck With That

2009-03-08T18:18:00.000-07:00

22 year old complains that he is losing muscle mass and his wounds won't heal due to the "anti-seizure" medication he is taking. He appears to be a normal, healthy 22 year old with numerous small cuts and scratches on his hands and arms. He also has a far-way look in his eyes. By that, I mean that I can see gears turning in his mind that have nothing to do with the conversation we're having. Also, he has a very flat affect; speaks in a monotone and doesn't show any emotion. It's the first time he's ever been to our clinic.

"So what medication are you taking?" I ask. He hands me a prescription bottle that is half-filled with pills.

"Lamictal," I read from the label. "And this was prescribed by Joan Durr? Is that who's treating you?" I hand the bottle back. [Lamictal is used for bi-polar disorder as well as an anti-seizure medication. It has many, many side-effects but not the two he has mentioned.]

"Not anymore," he replies. "I didn't like her. Now I'm seeing somebody else."

"Who's that?"

"John Franken," he answers.

"Why aren't you talking to him about the medication?" I ask.

"I haven't seen him yet," he says, "but I have an appointment. They work at the same place."

Normally at this point, I'd tell the patient that he needs to follow-up with his provider, because it's bad practice for me step in the middle of someone else's treatment plan. But now I'm curious to see what's going on.

"So you say that you're losing muscle mass. How's that?" I ask.

"I used to be a lot bigger than I am now, but since I started on that medication I can't put on any muscle. I work out a lot, but I keep getting smaller."

He's wearing a t-shirt and jeans, so I can see that he is a fit, modestly muscular young man. He doesn't look at all skinny or malnourished in any way.

"Since I haven't seen you before, it's hard for me to say whether you are or aren't losing muscle. But I can say that right now you look perfectly normal."

"I'm a lot smaller than I used to be. And my wounds won't heal. Look." He holds his hands out for me to examine. From the elbow down he has numerous small scratches and cuts, in various stages of healing. Again, they look perfectly normal.

"How did you get those?" I ask.

"Playing with my cat."

"It looks like they're healing pretty well." I point out several cuts that have scabs, others that are only pink marks and the fact that none of them have remained open or oozing. Some of the scratches look much to big to have been made by a cat, and I wonder how he really got them.

"Yeah, but they've been here a really long time."

After a moment I ask, "are you taking the lamictal for bi-polar disorder?"

"I told you I take it for seizures."

"Are you being treated for anything else?"

"Just seizures."

"Have you been diagnosed with any other problems? Something that your not being treated for?" I ask.

"My wounds won't heal."

"How long is it before you see John Franken, for your appointment?"

"Couple of hours," he replies.

"Your seeing him today?" I ask.

"Yes."

"That's good." I say. After a moment I ask, "What kind of cat do you have?"

"I don't have a cat,"he says.

"But you said your cat scratched your arms."

"It did. But it's dead now. It wouldn't stop jumping on the TV."

I get up from my stool and move toward the door. "Sorry I can't help you, but I'm sure John will get this figured out. Make sure you keep that appointment. Okay?" I'm out the door and in the hall. I hand him his billing slip.

"Good luck!" I say, and stand in the hall until he is out of sight so he won't be able to follow me to my office and eat my heart.

The Joy of Alcohol

2009-02-17T08:51:00.000-08:00

49 year old man tells me he recently quit drinking. He estimates he drank a case of beer daily since he was twelve. He received a DUI about a month ago, was ordered by the court to stop drinking and enroll in AA. He has been dry for twelve days. He wants me to help him with his anxiety. He feels jumpy, on edge, and has no patience. He is a stocky guy, well-muscled with a line-backer's neck.

He also tells me he's been out of work for two weeks. He was fired because his wrist began to hurt while he was roofing, and complained to his boss. His boss told him he'd have to work anyway, and according to the patient he was fired for complaining. He has numerous prison tattoos on his face, neck and hands (two tear drops, a spider web, and some half-finished cartoons. He also has F-U-C-K spelled out on his left fingers). He says he got through his DTs okay, but now can't settle his mind.

I start to explain to him part of why he feels so edgy, "When you've been an alcoholic for a long time, your body ..."

"I'm not an alcoholic," he protests.

I ponder this for a moment. "Why don't you think you're an alcoholic?"

"I just drank because I liked it. I still like it, but I know I can't drink anymore so I stopped. But I never lost my job or anything," he offers.

"You just got fired," I remind him.

"But that's because of my wrist. It had nothing to do with my drinking."

"What about your time in prison? Did alcohol have anything to do with that?" I ask.

"That was because of my fucking ex-wife. I never hit her. She fell. Fucking cops are always out to get me," he replies.

After a short pause, I ask "prior to these past twelve days, what's the longest you've gone without alcohol?"

"Couple of days, but I like it, so I drink," he clarifies.

"So you've been drinking a case of beer, or more, every day for the past 37 years. You've been to prison, you just lost your job and got a DUI. You've stopped drinking for twelve days only because the court ordered you to and you're going to AA so you can get your license back. Do I have all of that correct?" I ask.

"Yeah. so," he replies.

"Do you think your alcohol consumption contributed to any of those problems?"

He stares at me and tightens into a slight crouch and I can tell he's getting upset. Not weepy upset, but snap my little neck upset.

"Are you here to help me or what?" he demands.

"What does your sponsor in AA think about your drinking? Does he think you're an alcoholic?" I ask.

He straightens and says, "I know I have to give myself over to a higher power, and with His help I'll be okay."

"Yeah," I say, "that's not really an answer. I'd suggest that you really try to be honest about what's going on at AA because it could save your life. You're an alcoholic, looking at it any other way is kidding yourself. You're agitated because for the first time in 37 years you don't have alcohol to use as a crutch and you're having to deal with things on your own. You don't have the skills for that yet. So in the meantime I'll give you a prescription for something that will help you with your anxiety."

I gave him a prescription for Paxil, an antidepressant that also helps with anxiety. He's supposed to come back in three weeks for a re-check, but I doubt that I'll ever see him again. Unless he decides to beat the crap out of me in the parking lot.

The Dangers of Small Business

2009-02-03T16:32:00.001-08:00

50 year old man comes to the clinic for the first time. He is accompanied by his mother and sister who do most of the talking. He is in a wheelchair, and mostly stares at my shoes. He has just been released from the hospital, where he spent the last month recovering from brain surgery. He developed a large tumor and gradually become more and more impaired. He lives with his mother on the family's compound where his other brothers and sisters also live. The family decided to take him to the hospital when they noticed that over the course of a week he had lost the ability to feed himself. At the ER he was incoherent, had soiled himself, and could not walk without assistance. He also complained of a severe headache.

His surgery was a lobectomy, in which they removed a chunk of his temporal lobe. He also has a glioblastoma which is inoperable, but stable. They did several scans and found no metastases, so the cancer seems to be restricted to his remaining brain.

As I speak with him, he is mostly mute. His mother answers for him, until I tell her to stop.

I ask him if he is able to understand me and if he is able to speak. He nods his head.

I tell him that it is important for him to start talking to show that he can. He shrugs his shoulders.

I ask him what day it is. He shrugs.

I ask him what month it is. He shrugs.

I remind him that I need to hear him speak if he is able. He finally begins to respond and is able to identify the month, year, the name of the president, and what city he is in. He seems to be mentally intact, but does not want to speak.

I have them wait while I request medical records from the hospital, since they arrived without any information.

In the meantime, I get the family's back story from one of the nurses. The guy in the wheelchair and his brothers used to be the busiest meth cookers in the county. His brothers have all died off from various forms of cancer; he is the only survivor. The family owns a bunch of land and keep building houses and buildings on it to give shelter to their expanding clan. Other people in town avoid the road on which the family lives, for fear they will be robbed, shot, kidnapped or worse.

The brothers used to operate a chroming shop (applying chrome to car parts and such) and used the business to to smuggle drugs. They would seal and chrome an exhaust pipe or similar item, and ship it off to various parts of the country. They were successful, until the brothers started to die off.

This patient's past history in the meth trade partially explains his reluctance to talk. When you operate a meth factory, you don't talk outsiders. It's the same reason the family waited a week before they brought him to the ER.

I get the records from the hospital, and despite his seeming ability to respond to my questions, he is no longer able, or at the very least willing, to take care of himself. His family will have to help him eat, bathe, go to the toilet and dress himself for the rest of his life. He is scheduled to have chemo and radiation therapy for the remaining cancer in his brain.

Did I mention that he doesn't have any insurance? Although now that he's essentially had a lobotomy, he'll probably qualify for Medicare.

Sole Mate (See Also: Heel)

2009-01-28T08:17:00.000-08:00

26 year old woman with bipolar disorder and schizophrenia complains that she is having a breakdown. She is dishevelled, reeks from cigarette smoke, has numerous tattoos on her hands, neck, and chest. A tongue stud clacks against her teeth as she talks. She is accompanied by her fiance; a large, round-shouldered, wall-eyed co-dependant in a Members Only jacket.

"What do you mean by breakdown?" I ask.

"I'm losing it. I'm crying all the time, I feel totally overwhelmed ... I can't take it!" she cries.

"What triggered this?" I ask.

"I don't know," she sobs, "Nothing, everything, the same old shit. And look!" she rolls up her sleeves to reveal several dime-sized lesions on both her arms. "I'm doing it again!"

She shows me her wrist, which has two neatly spaced lesions of white skin, the result of two popped blisters. She had taken a cigarette butt and burned her wrist. The marks on her arms are older burn sites. In all she's burned herself about twenty times.

I ask if she's taking her medications. She claims that she is. I then tell her that if she's harming herself, then she needs to go to a hospital immediately.

"That's what the cops said, but I don't want to go to Smith Valley Hospital. That place is for scumbags and the staff is terrible." she complains. "I'm waiting for a bed at Jones Regional Hospital. It's much nicer."

"When did you talk to the police?" I ask.

"They came to the house. I think my neighbor called them," she replies.

I tell her that she should take the bed that's available, and if she's unwilling to do so then she's putting herself at risk.

"The cops said if Tony stays with me, I can wait," she points to her fiance. Tony suddenly sits up straight and nods.

"You're going to stay with her all the time? Twenty-four hours a day? She can never be alone. You're willing to be responsible for her safety?" I ask.

"Yes." Tony replies, through half-open eyes.

"Okay. I'll note it in the chart that you're responsible for her, and if you feel you can't handle it you'll call the police or take her to the ER. Right?"

"Right." Tony replies.

I was tempted to ask Tony if this woman is really what he wants in a life partner, but thought better of it.

Everybody Needs a Hobby

2009-01-26T15:35:00.000-08:00

58 year old woman with neurotic dermatitis (chronic face picking caused by craziness) returns to the clinic. She is in tears and very anxious as I enter the room. I see a large scab on her cheek just under her right eye that is about the size of a silver dollar. Around the scab, the skin is swollen and red, obvious signs of infection.

"It's going for my eye! It's going for my eye!" she sobs. Months earlier, she had been referred to a dermatologist for this skin condition. She quit going when she was told that she was crazy and that she needed to stop picking at her skin with dirty needles.

She took offense.

Now she is back to see me, because I was able to help her last time, or so she says. In a long breathless monologue she tells me how she's been fighting this skin disease for the past twenty years and that even the best specialists in the country have not been able to figure it out.

I stop her and say, "So what do you think I can do? I just do general medicine; I've got no special talent for skin problems."

"I love that you said that," she offers, "I like your honesty!"

My hope was to get her to leave, but no such luck. She continued to tell me how the rash had started to mutate based on the treatments she was on. How the medications would work for awhile, but then the rash would change and start up again and she'd have to once again pick the disease out of her skin.

"Now when I pull things out, they turn to dust as soon as they hit the air! What causes that?" she asks.

I shrugged. But then a little ray of hope appeared.

"Maybe it's my anxiety," she mused. "My daughter is handicapped and I have to care for her and it's very stressful. I think the rash is worse when I'm stressed."

Seeing an opening I said, "What have you done for stress in the past?"

"I take Lexapro." [an anti-depressant]

I then tell her how stress can certainly cause skin conditions to worsen. Hives, psoriasis, eczema are all worse when people are stressed.

"It could even depress your immune system," I tell her. "You might want to consider going back on the Lexapro."

I sell her a little more on the idea, and she agrees to a six-month trial. I also gave her a long course of antibiotics to help the infection on her face and reminded her to not pick at the scab no matter what. She agrees to this.

She comes back in three weeks, the lesion much better but still there.

"What happened?" I ask.

"The medicine was working," she offers, "but then I wondered if I had been on the antibiotics too long. I mean, how long can somebody be on antibiotics? So I thought I better stop taking them. But up until then, it was getting much better. But then it got worse, so I had to pick it out again."

"So because it was working, you stopped taking the antibiotics. Is that right?" I ask.

"No," she protests, "I quit because I was worried about taking the medication. But it was definitely helping!" she said, conveying how happy she was with my care.

"Okay," I say, "Let's try this again. This time for a whole month. No stopping early, no changes to the medications -- keep taking all of them. No matter what."

"Oh yes, I will. I promise," she says.

I write the prescription once again, remind her to keep taking the Lexapro, and send her on her way, certain that next time she'll have another excuse for why she had to pick at her face yet again.

The Upside of Crime

2009-01-18T10:07:00.000-08:00

51 year old man complains that the other night after he got out of his easy chair and walked to the kitchen, he felt that he was going to faint. He eased himself onto the floor, sat there for awhile and finally recovered. He is worried because he has a history of coronary artery disease and high blood pressure. I glance at his chart and see that his blood pressure is 278/140 (the high end of normal is 140/90). He's thin, with a lot of broken blood vessels in his cheeks, which often denotes lots of alcohol consumption. I ask him about his coronary artery disease.

"I had open heart surgery awhile back. Triple bypass."

"How old were you?" I ask.

"Thirty-eight."

"When's the last time you were seen by a doctor?"

"Just after the surgery," he replies. I can smell tobacco smoke on his clothes.

"How much do you smoke?" I ask.

"Two packs a day," he answers.

I've learned that when I ask patients about drinking and smoking, I get a much more honest response if I ask "how much do you drink/smoke" rather than "do you drink/smoke?" If they think I don't know if they smoke and/or drink, they are much more likely to lie about how much of either they consume.

"How much do you drink?" I ask.

"Four or five a night," he replies.

"So, more like a six-pack every night, right? And more on the weekends?"

"Yeah," he offers.

Obviously this guy is a time bomb with a short fuse. I get an EKG on him, mainly so I have a baseline to work from as treatment progresses. I examine him and other than being able to see his chest vibrate from the force of his heart beat, he looks pretty good. I suggest that we should get some blood to check his cholesterol, cardiac enzymes and liver function. I also get him started on a handful of blood pressure medications from our sample bin, and tell him to come back in one week for a recheck.

"Is it okay for me to go elk hunting this weekend?" he asks.

I tell him that no, I don't recommend that somebody who is in imminent danger of having a heart attack or stroke should be hiking around in the mountains.

He looked at me a moment and then said, "what about my chest pain?"

"What chest pain?" I ask.

"I've been getting chest pains like I did before I had the surgery. Feels like a heavy weight. It gets worse if I go up stairs or go hiking."

I give him a prescription for nitroglycerin tablets and explain when and how he should use them. I remind him to come back in a week, or to go to the ER if his symptoms worsen.

I don't hear anything from him for two months. Then we get a request from the jail, asking what medications he's on for his hypertension. He had been arrested for public intoxication and a few other charges, and was going to be locked up for a few months.

Once he's released, he returns to the office. While he was in jail, he had the nurse check his blood pressure six times a day and he hands me the record he kept of it, along with what medications he was or was not taking. It was extremely helpful. With that record I was able to narrow in the exact medications and the proper doses he needed to control his blood pressure.

I wish I could do it with all my patients.

He continues to drink and smoke, unabated.

Good Breeding is Essential

2009-01-06T06:46:00.000-08:00

57 year old woman complains of head pain on the right side of her head for a number of years.

"A headache?" I ask.

"No. (long pause) My head hurts on that side," she answers.

This is a patient I've seen occasionally and is, I'm sorry to say, one of the dumbest patients I've met. I'm sorry because she's as harmless as a tranquilized puppy. She has the mental capacity of an eleven-year-old, yet has never been diagnosed as developmentally disabled. She has a job, is married and lives some kind of a life but really puts the "more" in moron.

Her "head pain" problem started a few years ago when she run over by her own car . She had parked on a slightly inclined driveway and was was unloading groceries from the passenger side. As she removed the bags, the car began to drift backward. She dropped the groceries, ran around the back of the car and was knocked to the ground. Laying on the ground, screaming for help, the car slowly rolled over her right side. She suffered a few broken ribs and abrasions, but otherwise tolerated the experience well. Except, of course, for the head pain. She's had MRIs, and been to a variety of specialists but to no avail. Part of the problem is that trying to get her history is like talking to a good-natured but terribly drunk sorority girl; she keeps repeating the same information over and over, and you have to redirect her back on topic constantly.

So she still has head pain and wants some help. She tells me that if she got head pain when she was a little girl her grandfather would blow pipe smoke in her ear and it would get better. I told her that I didn't smoke. But it made me wonder.

"Have you always had headaches?" I ask.

"No, not like this. This is different. It's been different since my accident," she answers.

I decide to try some physical therapy, which sometimes work with recalcitrant head pain. As I filled out the referral form, one of the nurses noticed. This particular nurse has lived in the area most of her life.

"Is that for Lulu?" she asked.

"Yeah. Thought we'd try a little PT," I reply.

"Poor thing," she offers, "Run over by her own car. Her family's terribly inbred. She's a little bit slow." She raised her hand in front of her face, fingers spread wide.

"She has webbed toes, you know."

So Pleased to Meet You

2008-12-04T19:00:00.000-08:00

Charles Manson-looking guy (really skinny, long grey hair, white beard, beady eyes) with 25 plus year history of drinking one to two fifths of vodka per day arrives in the clinic to establish care. He was sent here by a gastroenterologist who has been seeing him since he started vomiting blood four months ago. He used to work as a logger but hasn't worked in the last year. He was vomiting blood because of his cirrhosis, which caused portal hypertension which in turn cause varices in his esophagus, which finally burst causing him to vomit large amounts of blood. He also has terrible ascites (fluid in his abdomen) and his legs swell up like tree trunks. So they have been working to put rubber bands (literally) around the varices and high doses of diuretics to keep his fluids under control. He is in my office because he has terrible abdominal pain and hasn't ever seen a doctor prior to becoming a blood fountain.

On the up side, he has quit drinking. I question this because after 25 years, it seems like it would be a difficult habit to break. He insists that he has stopped. He does smoke, and has used cocaine and some IV drugs in the past, but nothing in the recent past. I ask if he has ever been tested for hepatitis, almost guaranteed among the needle sharing. He has not. He reminds me that his primary complaint is his abdominal pain.

Because his liver is shot, I have to be careful about any pain meds I give him. Many, if not most, medications are cleared through the liver, and if you have liver damage the meds can cause more injury or fail to be cleared properly and keep building up to lethal levels. I ended up giving him Dilaudid, which does go through the liver but doesn't have any Tylenol combined with it, as do most pain killers. I also had some blood drawn to check for hepatitis and HIV.

He came back a couple of weeks later, and looked a little better. He didn't like the pain meds because they made his head too fuzzy, so he's decided to just live with the pain. He also turned out to have Hepatitis C. Whether it was the hepatitis or the drinking that caused the liver damage it's unclear, but he seemed like he was stable. If he kept away from alcohol, and kept taking all his meds there was actually a chance that he would live.

Life in the Hills

2008-12-02T13:56:00.000-08:00

44 year old woman with long, greasy hair and smelling of woodsmoke complains that she may have hookworm. She is one of the "hill people," as I like to call them. They live up in the mountains, in rotting cabins, mobile homes or campers at the far end of bumpy dirt roads that are overgrown with brush and trees. Needless to say, they don't get out much. She says that her feet and arms have been itching for the past year. She has intermittent diarrhea and constipation and feels certain she has worms. She wears an over-sized red plaid shirt, jeans, heavy boots and swings a plastic bag from Wal-Mart between her legs. I can see the top of a plastic container in the bag, but it's opaque so I can't see what it holds.

"So what makes you think you have hookworm?" I ask.

"My cousin had 'em, and he thought I might too. So I wanted to get it checked. I got some right here." She dropped the bag to the floor with a heavy thud. I suddenly realized that the odor I had assumed was due to poor hygiene was in fact far more ominous. She lifted the container out of the bag and I suddenly realized that she had brought a football-sized sample of poo.

"The sample has to be fresh!" I exclaimed, before she could pry off the lid. "You can hang onto that for now."

I examined her arms and legs, which were perfectly normal.

As I checked her feet, without any prompting she said, "My dog licks them. He was weaned too early." The feet were also normal.

Remembering my Hippocratic oath, I performed a rectal exam. Mystery solved. She had a hemorrhoid. I told her she needed more fiber.

Despite my finding, she still wanted her poo tested. I gave her a take-home kit, and told her to bring it back to the lab once she had three good samples.

We Should All Be So Lucky

2008-11-26T11:49:00.000-08:00

69 year old woman complains that she's feeling anxious and overwhelmed. She's dressed neatly, but looks a little worried. She seems like a woman who likely raised a bunch of kids very successfully on a ranch and kept everything and everyone fed, clothed, clean and happy. One week ago her husband was diagnosed with rectal cancer, and it is deemed terminal. An MRI scan showed that the cancer had spread to his lymph nodes and liver. He had been treated for prostate cancer years earlier, and all indications were that the cancer was in complete remission. He woke in the night one day last week, unable to urinate and in extreme pain because he could not empty his bladder. He had no other indication he was ill.

Years before, when this woman's father died, she was put on Paxil for six months and found it helped her get through the funeral and cope with the grief. She wants to resume the Paxil.

"I just can't think straight," she tells me. "There's too much information and too much to do. All of a sudden we're seeing doctors every day and running around all over for tests. I just need some distance from all this. I have to keep my wits. I have to. He's depending on me."

She explained that she and her husband had been together since she was fifteen. They celebrated their 54th wedding anniversary one month ago. Tears welled in her eyes; as she dug through her purse for a tissue, I handed her one.

"We were supposed to grow old together!" she raised her voice slightly, "Now they tell me he might only have three months left! What am I going to do? We've never been apart!"

She made two fists and tightened her face, "I can't be like this now." She sniffed and her eyes cleared. "I can't fall apart. I have to keep track of the appointments and he's going to be starting radiation and chemotherapy. I can't fall apart."

She took a deep breath and asked what she should do. She warned that she had been put on Ambien to help her sleep a few months ago, after developing a nagging cough.

"I slept too well," she said, "last week when my husband had his trouble I didn't hear him, and I didn't help him. He finally had to wake me up on his own. That can't happen again."

I told her it was okay for her to fall apart, at least a little bit. I told her she could restart on the Paxil, and that I'd give a prescription for some Valium to help her feel a little less anxious.

I also told her to call me any time if there was anything else I could do to help.

Woman on Fire

2008-11-20T09:50:00.000-08:00

A 40 year old woman with Type II diabetes, hypertension, congestive heart failure and severe asthma is in for a re-check visit to discuss her medications and illnesses. I've never met her before, but she is a long-time patient at our clinic.

She is morbidly obese and has large patches of fiery red skin on her face and arms. The patches have a thickened scale on the surface over a base of what looks like severe road-rash. Some of the lesions seep a small amount of clear fluid. We discuss her various issues and the management of them, and she is pleasant and relaxed. After we talk about the diabetes, high blood pressure, heart failure and asthma I ask her about the rash.

"I've got it all over," she says as shows me the patches cover her chest, back, belly, butt and legs. "

"Does it itch or burn?" I ask.

"Hell yes. But it's been that way for years," she reassures me, "don't worry about it."

I offer some treatment ideas, but she declines.

It Only Hurts When I Breathe

2008-11-13T12:03:00.001-08:00

25 year old man complains that he has had a "click" in his chest for the past six months. He hears and feels it about every second or third breath and it seems to be getting worse. He says it's driving him crazy partly because nobody else seems to be able to hear it. It's especially bad when he's falling asleep at night. He was seen at clinic a few months ago by someone else and was given some medication for gastric reflux, which makes no sense at all. He tried it, but of course nothing changed. I ask him where the click seems to be coming from but he can't tell.

At first I think maybe he is crazy because the symptoms are strange. I see plenty of crazy all day long. I ask him what he does for work and it turns out he's a waiter. He often carries heavy trays and has done so for many years. He is also right handed.

Strangely enough, when I listen to his lungs, I can hear the click. I can also just barely feel the vibration from it when I put my hand on his chest as he takes deep breaths. Listening with my stethoscope I'm able to follow the click as it radiates up to his right shoulder. I examine his right shoulder and in the groove where the biciptal tendon travels from the arm to the clavicle, he's very tender. I have him take a deep breath as I press on the tendon, and he says it hurts but the click is gone. He has tendinitis.

I told him to take two Aleve twice a day for two weeks . After he did his click disappeared completely.

Welcome to the "Duh" Zone

2008-11-05T12:57:00.000-08:00

47 year old woman who is obese, suffers from bi-polar disorder and has chronic low back pain complains that she has had nausea, vomiting, chills and has felt like her skin is crawling. She takes methadone for her pain, ten milligrams three times daily. She has terrible hygiene, is wearing filthy, sour-smelling sweat pants and a floral blouse with food spattered on the front. I flipped through her chart and noticed that she had similar symptoms a few months ago, which resolved on their own.

"Did the symptoms come on suddenly or gradually?" I ask.

"Gradually. And my back has been hurting, but I think that's from throwing up so much," she replied.

"Any fever?"

"I'm sweaty, but cold," she answered.

"Is anyone else at home sick?"

"Nope, just me."

"Any diarrhea?"

"Well no," she begins, "but I've been shitting a lot. Not diarrhea, though."

I tentatively ask, "what do you mean by 'a lot?'"

"I'm going several times a day, and lots comes out. But it's not runny."

It then occurred to me to ask, "When was the last time you took your pain medication?"

She replied, "I ran out four days ago. I can't get any more until tomorrow."

I tell that she is having withdrawal symptoms from her narcotics. Methadone causes constipation, which explains the sudden avalanche of stool. The last time she had the symptoms it was at the end of the month, and she confirmed that she had run out of her pain medication that time as well. I also told her that her back pain had returned because she stopped her meds. I refilled her pain medication one day early, and her symptoms resolved completely.

I'll Take Mine Rare

2008-11-04T11:26:00.000-08:00

A 19 year old cowboy complains that he can't gain any weight no matter how much he eats. His lack of weight gain has led him to believe that he may have a tapeworm. He is about six feet tall and thin; made up mostly of muscle and sinew. He works long days building barb-wire fences, tending to livestock, and other labor-intensive farm activities. He volunteers that he chews tobacco and swallows the "tobacco juice" to keep the tapeworms under control. He learned to do this because whenever his hounds get worms, he shoves some Skoal down their throat "and the worms come out the back end." He also adds that an uncle of his once had a tapeworm, which is why he thought he better get checked.

To me, his world seemed to be rife with worm infestation. And although he could get a tapeworm by handling contaminated feces (pig, dog or cow) or by eating undercooked fish, it rarely happens in the United States. I didn't take him for a sushi type of guy, but just in case I asked him if he eats any raw meat.

"Oh yeah," he replied, "I eat tons of venison and elk that way. I like it bloody."

Although humans can't contract worms from elk or deer meat, it was possible that he picked up some parasites somewhere. Also, he was worried so to put his mind at ease I decided to give him an ovum and parasite test kit. He took three samples of his stool (at home, happily), and brought it back to the lab.

He did not have a tapeworm.

All his other lab work was normal so I advised that he try a high calorie diet. He never came back.

What If There Hadn't Been a Kitten?

2008-10-30T13:54:00.001-07:00

A 33 year old woman brings her 5 year old son to the clinic for evaluation. She is well known to the clinic, and crazy as a loon. She says that she wants me to check the scratches on her son's arms and legs.

"How did he get the scratches?" I ask.

"From a kitten."

"A kitten," I repeat, somewhat confused, "so why do you want them checked?"

"Some of the scratches are pretty deep." she said.

At this point I'm wondering what's going on. The kid got scratched by a kitten? How can that possibly merit a trip to the doctor.

"Was the kitten scared?" I ask.

"It was fighting," she replies. "Our dog, he's an Akita, grabbed the kitten out of my son's lap and the kitten clawed him while it was trying to get away. It's a huge mess. The Akita bit and shook the kitten so hard that there's guts and cat shit all over the walls."

"I see." I pause for a moment, not quite sure how to respond. "But the dog didn't bite your son, right?"

"No, just the kitten." She answers.

I examine the kid, who is either somewhat autistic or possibly normal for his house. The scratches are mild, but I advise some topical antibiotic and a return to the clinic if any them start to get red or swollen.

Nice doggy.

My Fine Hispanic Patients

2008-10-30T08:08:00.001-07:00

One of the nice things about my job, is that I've had the opportunity to grow a bit culturally. Many of my patients are Hispanic, and nearly all of them are a pleasure to treat. I've picked up a few Spanish medical terms but still rely very heavily on our interpreters. Unlike the bulk of my Caucasian patients, my Hispanic patients rarely come to their appointment alone. Grandmothers come with granddaughters, husbands with wives, brothers with sisters and on an on. The family is both aware and seemingly interested in one another's welfare. Also, the kids are much better behaved than with most of my Caucasian patients. Poverty is almost a universal experience with my patients, and the Hispanic patients seem to handle it more easily by having lots of family support. From what I've observed, when you're poor and don't have any help, the stress of everyday living wrings you out and your kids are neglected. These kids are generally wild, aggressive, don't respond to direction and fight during the entire exam. The Hispanic kids are almost universally sweet and cooperative, despite their poverty.

The other thing I've observed is that my Hispanic patients refer to the act of taking medication as "drinking" rather than "swallowing" a pill. At first I was confused when patients would say, "Yes, I drank all the medicine" when what I gave them was pills. Eventually, I got it.

They also very commonly expect that once they take a pill for something, the problem is solved. This is the case with something like an infection, but not with high blood pressure or diabetes. I've had to learn to explain up front that a patient will have to stay on a medication for a long time, or their problem will return. This often takes several explanations because their expectation is that when the doctor treats you, you're fixed.

No freaky horror stories this time, just some observations.

A Banana Walks Into a Clinic ...

2008-10-23T13:46:00.000-07:00

59 year old woman comes to the clinic because a friend noticed that she turned yellow. She is accompanied by her morbidly obese and ruddy-faced husband. The “whites” of her eyes are a light, canary yellow and her skin has soft glow like she had highlighter ink in her veins. She is thin and a little over five feet tall. I ask about alcohol consumption and she admits that she is an alcoholic, drinking a twelve-pack per day for the last ten years. She has no pain and other than a little fatigue, feels fine. She has no nausea and no diarrhea but explains that she doesn’t really eat. Her husband agrees telling me that usually has a piece of bread every day but mostly just drinks beer. She has been through Alcoholics Anonymous before with intermittent success. She also has diabetes but takes no medication for it. She doesn’t smoke, has not gained or lost weight, has no fever or night sweats, has not felt dizzy and has not had any dark or tarry stool.

I examine her and find that along with her eyes and skin, the roof of her mouth and fingernails are yellow and that her liver extends three finger-widths beyond her ribcage. Normally, your liver is neatly tucked under the ribs. An enlarged liver is normal with alcoholism but this is the biggest one I’ve seen. The rest of her exam was normal.

I tell her the first thing she has to do is stop drinking immediately.

To my surprise she says, “No problem.” She then adds, “I’ve done it before.” Her husband nods his head in agreement.

“Good,” I say. “We’ll get some lab work done and see what we can find out.”

The thing I had to figure out was whether she had an inflamed liver or if her liver was dying. She could also have some internal bleeding somewhere but that didn’t seem too likely.

The tests came back and showed that her liver was indeed inflamed (elevated liver enzymes) and she had record high levels of biliruben (which made her yellow). She was also anemic and had low platelets (common in alcoholism). The surprising part of her lab results was she was otherwise in good health. I expected to see signs of starvation, but things looked normal. The other odd thing was that her diabetes seemed to have regressed. Normally this would be good, but in her case it meant her liver was shutting down.

I spoke to her husband and told him the lab results. The next step was to get a CT of her abdomen to get a better look at her liver and see what sort of damage there might be. The CT showed that she had a massive liver that was littered with scars and fatty infiltration (that’s bad). She also had portal hypertension which is blockage of the flow of blood from the intestines to the liver. The blood from the gut goes to the liver to be filtered, but because her liver was so messed up the blood was backed up. You can read about I saw with a similar problem at http://ruralprovider.blogspot.com/2008/08/long-and-winding-patient.html.

At this point I called a gastroenterologist to discuss the findings and set up a referral. His first question was, “is she still alive?” Once that was confirmed, we set up the appointment with the husband, who told us that his wife had stopped drinking and was doing well.

As you might guess, she never made it to the appointment. Instead she showed up in our lobby three days later, very confused and demanding crackers. That's right, crackers. I was out at the time, so she was told to wait. She sat in a chair for a moment, and then laid down across some other chairs for a nap. I’m told that she was so yellow that she seemed to be glowing. Before the receptionist could find someone to sort it all out, the woman roused herself and staggered out the door.

The next day we called her husband. When told what had happened he said, “Yeah, well, she stole my car. If you see her again, have her call me.”

Apparently after a few days on the wagon, our heroine decided she needed a road trip and a nice little drinking binge. We tried over the next week to reach her husband but the calls went unanswered.

About a month after I saw her, someone read about her in the paper. She had died in a nearby hospital.

Does This Parasite Make Me Look Fat?

2008-10-08T09:06:00.000-07:00

A 58 year old woman who can't stop picking at her face returned to the clinic. She was concerned that she might have worms. She explained that she had noticed something irregular after a recent wiping of her ass. Upon inspection, she was convinced that the unidentified object was a tapeworm. It was then I noticed the plastic baggy on her lap, which contained some toilet tissue. She insisted that I see it and despite my revulsion, curiosity won out.

I know that as a medical provider these things should not phase me, and usually they don't. I've investigated all manner of foul, oozing, rotten, puss-covered, fecally-infused problems that people might legitimately have. But when crazy people bring in their shit for me to inspect, I tend to draw the line.

So I told her, "Fine. show me." As she began to unwrap her precious treasure she also moved toward me with great speed.

"Stay where you are!" I ordered, "I can see it from here."

Again, the sadness of this lady's life is difficult to imagine. She's been picking imaginary things from her face for the past fourteen years and has the scars to prove it. Now her parasite delusions have gone internal and she's picking through her poo.

She opens the tissue and I see a tiny piece of something translucent which looks like a piece of onion skin. In fact, it looks exactly like a cooked onion ring, with the batter removed. I tell her what I think, and she demands that she wants the object tested. I instead offer her a home testin kit with which she can collect samples of her poo and tested in the lab for parasites and eggs. She agrees. After all, what could be more fun than poo collecting?

She then pulls a bottle from her purse and explains that it contains the things that she has been picking out of her face over the past several months. She handed it to me for assessment. The bottle looked like a former pickle jar, half filled with cloudy water. The objects inside included some hairs, yellow bits of tissue that looked like chicken fat (human fat looks the same) and a tiny thread-like object that was white and squiggly. I was pretty sure the thread was actually a nerve. She explained that when she removed it, "it hurt like crazy."

As I marvelled at her collection she mentioned that the current sore on her face was very painful. I told her that pulling nerves out of your skin will tend to do that. She was not amused.

I had the nurse get her the poo collection kit and hoped she would not return for at least a few months.

Sofa-Phobia

2008-10-07T15:59:00.000-07:00

A 47 year old man complains that he is suffering from bug bites, specifically spider bites. He is morbidly obese (400 plus pounds), breathes heavily, and is festooned in a jogging suit that is greasy from wear. He also speaks with a terrible slur because his teeth are mostly missing and those that remain reek from rot and with gums that look like jerky. He says the lesions are very itchy.

He shows me his arms and legs, which are covered with linear lesions that are slightly red and scabbed. None of them look like "bites." They look more like marks from scratching an itch.

"Why do you think this is due to bug bites?" I ask.

"I think I have a couch spider," he answers, looking at me like I should understand what he means.

After thinking quietly to myself for a moment ask, "what is a couch spider?

"He rolls his eyes and responds, "a spider that lives in the couch. They love it in there!"

"Have you seen it?" I query.

"No, but when I'm sitting on the couch, under a blanket, I can feel it bite me. Like right here, " he points to one of the marks on his leg. "I was watching TV, I felt something bite me on the leg, pulled off the blanket and there was a mark but the spider had run off."

"Have you tried taking off the cushions to find the spider?" I asked.

"Hell yeah," he responded, "I tore that thing apart a couple of times. Didn't find the spider, but I know it's in there."

He looks at me, air gurgling through his open mouth, as I ponder what to say next. Finally I come up with, "have you ever had scabies?"

"Yeah."

"Do these marks remind you of when you had that?"

"Sort of," he paused, "but how do you explain the spider?"

Again I keep my thoughts to myself and ask, "do you have any of the medication left from the last time you had scabies?"

"Yeah." he replied.

"It will work for spiders as well. Give it a try."

I've Got You Under My Skin

2008-10-07T08:51:00.000-07:00

58 year old woman complains that she has had a cough for a week but that's not why she wants to see me. She wants me to hear about the skin problem she has had for the past fourteen years. Her face has numerous healed scars scattered over the forehead, cheeks and chin. She has a scabby lesion on the right side of her chin that is about the size of a quarter. It looks like an abrasion that is healing well. She says that over the past fourteen years the lesion has travelled all over her face, and has never totally healed. She examines the lesion several times a day and uses a needle to remove, "things that don't belong there." The items removed include, "hairs that extend beneath hairs." She also removes "long strings, both black and white." Recently, she pulled a string from the wound and saved it in a bottle of water, but did not bring it to the appointment.

"The string used to look sort of yellow and very thin, but now it's puffed up and looks like a vein maybe. Or maybe a nerve. Either way it hurt like crazy when I pulled it out. " She offered. "There are also little black things in there and cheese-looking things. I pulled them all out and saved them for someone to see."

Sadly, this lady suffers from neurotic excoriation. Simply put, she can't stop picking at her skin. The common areas for this are the face, the upper back, and the forearms; all places that are easy to reach. Strangely, skin below the waist is rarely involved. These patients often report that they feel something under their skin and are compelled to remove it. Sometimes they think it's due to a parasite, sometimes due to infection, sometimes as a cyst or blister that has to be removed. They are almost impossible to treat because no matter what you tell them, they won't believe that the cause of their lesions is the constant skin picking and scratching. You have to wrap them up in bandages for a couple of weeks and let the wounds heal before they will get better. And then, as was the case with this woman, at the first sign of a pimple or bump or wrinkle, they're start digging again. The best way to treat is with psych meds, but they usually won't take them because "I'm not crazy."

The photo above is a Guinea Worm being removed, which is real.

I asked her about her cough, and she told me it was just a cold and left.

Small Town Values

2008-09-24T08:30:00.000-07:00

A meth-mom brings in her 12 year old daughter and tells me she has had a swollen throat for the past five days. The mom has given the kid a single tablet of Aleve to ease the symptoms and nothing else. The daughter looks pale, and miserable. I can easily see that the right side of her face is swollen from the cheek to below the jawline. I take a peek in her mouth and I see an abscessed tooth with the gumline sporting a plum-sized lump that is draining pus. I also see that her tonsils are so swollen that they are touching, are as red as fresh hamburger and are dripping with pus. She also has a quarter-sized cold sore on the corner of her mouth and cold sores on her uvula, which is also swollen. The kid didn't complain once during the exam.

She tested positive to strep throat, so I gave her some penicillin for that and the abscessed tooth. I also gave her a prescription for naproxen (Aleve) for the pain and inflammation, and referred her to a program for kids under 18 with no money for dental care. Her mom chimed in at this point and said that her daughter would need some narcotics for the pain.

"Oh really? Which one?" I asked.

"Percocet. Or Norco Ten also works," she offered.

I told the mom I don't prescribe narcotics for dental pain, and contemplated if I had enough information to alert child services about the situation. I decided I didn't, and sent them on their way.

Something Must be in the Water

2008-09-18T14:23:00.000-07:00

34 year old woman complains that when she brushes her teeth she gags herself to the point that she vomits. She has a past history of IV drug use, is covered with elaborate tattoos and normally sports a tongue stud which she was not wearing today.

"How hard do you brush your teeth?" I ask.

"Pretty hard." she says.

"Have you tried brushing more gently?"

"Sort of, but it didn't seem to help." she answered.

(Sort of? What the hell does that mean? I continue.)

"Do you have any problems when you eat? Do you gag on food? Any nausea?" I ask.

"No. I can eat just fine," she says. "No nausea and no problems with swallowing."

At this point I'm wondering if this is a joke. But she's serious, so I continue further.

"Do you brush your tongue?" I ask, grasping at straws.

"Yes."

"Is that when you gag?" I ask.

"Yes."

"Have you tried not brushing your tongue?"

"No."

"Why not?" I ask.

"I thought you were supposed to brush you tongue because there are lots of bacteria there. Also, I don't want to have bad breath." I decided to not point out that having a gaping whole in her tongue where the stud should be which can fill with half-chewed food might have more to do with her bad breath than any lack of tongue brushing.

"Why don't you try rinsing with mouthwash, and stop brushing your tongue for awhile. If that doesn't work, them come back and we'll see what else might be going on."

She agreed to try the mouthwash, and did not return.

Solo Electrocution, Almost

2008-09-17T12:15:00.000-07:00

25 year old cowboy complains of right hand and shoulder pain for the past several days. When I ask if he has had any new activities or trauma, he describes a recent experience he had working on a remote electrical box. It seems that he works for a heavy equipment company that services farms in the area. For some reason, he was doing electrical work in the middle of some ranch land miles from anywhere. He thought the power to box was turned off, but discovered to his surprise that the box was indeed hot. He managed to to touch two hot wires, completing a circuit and causing his hand to grip the box so firmly that he cannot remove it. This a 6 foot 4 inch cowboy with hands like pie plates and shoulders that nearly fill the door frame. After struggling for a minute or so to free his hand, he noticed the odor of a freshly branded calf begin to waft from his hand.

He was all alone, his hand and arm began to ache from the involuntary squeezing, and all the while he kept jerking on his arm trying to free himself. He tried kicking his hand, but couldn't get the proper angle to knock it free. He finally jumped up and slammed his leg down onto his forearm, at last knocking it free of the box. Once free, he looked at his still curled hand, and saw a blackend stripe along the inside of his middle finger and palm, the result of a nasty electrical burn.

He hadn't taken anything for his hand and shoulder pain, but did notice as he was flinging 100 pound sacks of grain in order to get to a generator, that his shoulder seemed to hurt.

On exam, he was fine. When I tested his grip strength, he nearly crushed my fingers into pulp. He had full range of motion, and just a slight twinge in his right shoulder when he lifted his arm over his head. I suggested that he take Aleve and put ice on his shoulder, which he declined.

"Hell doc," he offered, "I just want to make sure I hadn't broke nothin'." And off he went.

License to Drive (not)

2008-09-16T12:52:00.000-07:00

33 year old patient complains that she wants her driver's license back. I explain that I wasn't aware that she had lost it, so she would have to fill me in. About six months prior the patient was seen in a nearby emergency room for unknown reasons. This particular patient was well known to me and memorable because I suspected she had a mild case of Munchausen syndrome wherein she fakes diseases by inventing symptoms, injuring herself or ignoring simple illnesses in the hope that they will develop into something more serious. In her case, refusing to treat bronchitis because it might turn into pneumonia and refusing to treat a cat bite on her hand (actually quite serious) in the hope that it would develop into an invasive infection of the soft tissue.

So she comes in demanding that I fill out a form that indicates she is fit to drive. On her chart, I notice that she has a past history of seizure. She says she is not currently on any medication for the seizures because they don't help.

"When was your last seizure?" I ask.

"Three and a half months ago," she repies, "my neurologist said that if I go three months without a seizure then I'm okay to drive."

"Why aren't you talking to him right now?" I query.

"He's too expensive. I can't afford to see him anymore," she answers.

"What's his name? I'll give him a call right now." I offer. To my surprise she gives me his name and I call to find out her story. Turns out he is very familiar with her. She suffers from "conversion disorder with non-epileptic events." This means that she had seizures, but they are triggered by psychological stress. Sort of like when someone passes out when they see blood, but instead they have a seizure. His assessment of her ability to drive was the same as mine: she is not safe to drive.

I told the patient this, and she became red-faced and started cursing the neurologist. I told her I was sorry, that not being able to drive was indeed a major set-back, but reminded her that her disability should allow for some public assistance. She hissed at me that she had already tried to get on disability and was told she was able to work. She stormed out warning that she was going to give the neurologist a piece of her mind.

Mysteriously Powerful Period

2008-09-15T15:32:00.000-07:00

51 year old woman complains of a heavy period and abdominal pain for the past day. She said that yesterday in the shower, she noticed some mild abdominal pain and that she started her period "with a gush of blood." She notes that her periods are always heavy and would go on for at least seven days if not longer, but they have never erupted before. I asked if she had done anything different in the past few days, and indeed she had. The night before, prior to having sex with her boyfriend, she had used a contraceptive film that she had never used before. She denied any pain or itching or swelling when she applied the film and denied any pain during or after sex. She denied any urinary frequency, urgency, pain with urination, vaginal discharge, and did not have a fever nor any nausea. She did note that the abdominal pain felt deep inside, and not around the vaginal opening. Her past medical history was significant for uterine fibroid tumors which had been diagnosed many years ago as well as a mother with cervical cancer. She denied hot flashes and irregular periods. Her urinalysis was negative for any infection.

On exam, everything appeared normal. She had no abdominal tenderness. There was no swelling on the vaginal walls, no bruising, no redness, no lesions of any kind. The cervix also looked totally normal. With the manual exam, I didn't notice any masses but there was quite a bit of tenderness when I pressed the posterior wall of the vagina against the pelvis on both sides. I had the patient get dressed and then did a musculoskeletal exam of her hips, which were fine.

After discussing the options with her, she decided she wanted to get a CT of her abdomen. She was worried about the fibroid tumors and overall freaked out about the sudden appearance of her period. I also did some blood to look for anything out of the ordinary.

The CT came back essentially normal. She still had the fibroid tumors, which were of moderate size, but there were no other unusual findings. Her blood work was also normal.

So what happened? Turns out she had an allergic reaction to the contraceptive film, which caused some mild-to-moderate swelling of the vaginal mucosa. Her fibroid tumors were the cause of her long-standing longer than normal periods (menstrual blood and tissue get caught up in the irregular lumps and bumps in the uterus and don't flow out normally). The swelling blocked up her vagina such that she couldn't menstruate properly until she was standing up in the shower and washing herself the next day. The tenderness she had during the exam was due to the residual swelling from the allergic reaction.

A Long and Winding Patient

2008-08-27T08:11:00.000-07:00

52 year old man is brought to the hospital by ambulance. He has been camping in the mountains for three days and his family noticed that he had been getting progressively more confused. The day before he had tried to put his pants on his arms, put dishes in the dryer and tried to use the telephone to change channels on the TV. His family called the ambulance the next day when he wouldn't wake up. His past medical history was significant for chronic renal insufficiency (kidney failure), cirrhosis, Hepatitis C and hypertension. He was also a recovering alcoholic and claimed (in his previous medical records) he had been on the wagon for several years.

On exam he appeared to be sleeping quietly. Noxious stimuli (pressing a pen firmly across his fingernail) did not cause him to stir. His breathing was steady, his EKG was good, but his fingernails looked pale (a sign of anemia). He had no signs of trauma, and his family told the paramedics they weren't aware of any recent drug or alcohol use. His abdomen was distended and moderately firm. He would occasionally stir and groan, shifting his arms and legs. His pupils were dilated, but would react sluggishly to light. Because all of his limbs were moving and his pupils reacted, it was unlikely that he had suffered a stroke. he had shit himself at some point, and his poop smelled foul. The particular odor produced indicated blood in his poop. When I checked him (put finger up his butt to check for fresh blood/hemorrhoids/fissures -- none found) I also tested his poop which was indeed positive for blood. That finding, coupled with his apparent anemia meant that he was probably bleeding somewhere in his gastroinstestinal tract. I had the lab tech draw blood, I ordered labs, and did what I usually do in the ER: sit and wait. The ER nurses almost immediately began to badger me about what to do next. They felt that I should be doing more to bring him out of his unconscious state. I asked them for suggestions.

"It looks like an overdose. We should give him Narcan (naloxone)." Narcan is used to reverse narcotic overdose. I reminded them that with narcotics, the pupils get small, not large.

"We should give him IV fluids; he looks dehydrated." I reminded them that he had kidney failure, and if we overload him on fluids, his lungs would fill with water and he'd drown.

"We should give him insulin, it's probably his diabetes." His blood sugar was mildly elevated at 210 and we had nothing to indicate that he was diabetic. You don't go into a diabetic coma until your sugars get up around 500. Giving insulin to someone who is not diabetic can have unpredictable results like dropping their sugars so low that their brain stops working.

The nurses continued to fret, but stopped pestering me to "just do something." I continued to wait, and wait some more. The lab as the hospital is infamously slow. I've worked in lots of ERs and most labs will come back in about ten to fifteen minutes if the techs hurry. In this hospital, best case scenario is thirty minutes, but it can take much, much longer. I've been told that there is an old cranky tech that is nearing retirement that is the cause; I suspect that it's due to the lab equipment that was purchased from the Soviets in the 1940s.

On the up side, because the labwork was taking so long, the guy began to come around a little. He only said two words, "God Damn!" Over and over and over, and he was screaming. He drifted back to sleep for awhile, then opened his eyes a little, tried to focus, and would yell, "God Damn!" This was a good sign in that he was able to speak, sort of.

The labs finally came back and this guy is fucked. His liver and kidney function is all screwed up, and he is terribly anemic. On the bright side he had no infection. The reason for his stuporous state seemed to be his ammonia level which was more than double what is considered high (normal is 10 - 30, his was 70). His brain is pickled in ammonia, which is why he was unconscious. Now I knew what he had. It's called hepatic encephalopathy. Here's a little excerpt from Wikipedia that explains in nicely.

Although the onset of hepatic encephalopathy may simply reflect worsening of underlying liver disease, it may also be due to a number of independent factors, each treatable in its own right. In fact, studies have shown that the majority of cases are due to one (or more) of such precipitation factors. It is critical, then, that a search for possible precipitants be conducted in patients with new-onset hepatic encephalopathy, and specific treatment initiated if such a precipitant is discovered.

Virtually any metabolic disturbance may precipitate hepatic encephalopathy. Common culprits are hyponatremia (often arising as a result of diuretic treatment or simply as a complication of the edema typically found in advanced cirrhosis), hypokalemia (again, often as a result of diuretic use), alkalosis, dehydration, hypoglycemia (a condition to which people with cirrhosis are susceptible), and renal failureof even mild degree.

Likewise, there are several medications the use of which may bring on hepatic encephalopathy. These include benzodiazepines (e.g., diazepam, lorazepam), narcotics, and diuretics. Alcohol ingestion, whether or not it was the cause of the patient's liver disease, may also precipitate hepatic encephalopathy.

Infection is an important precipitant of hepatic encephalopathy. In some cases, the only clinical manifestation of the infection is the development of the encephalopathy. In fact, this is a frequent phenomenon in patients whose ascites has become infected (i.e., spontaneous bacterial peritonitis).

Sometimes, hepatic encephalopathy arises as a result of patient non-compliance with dietary protein restriction. Indeed, given the general lack of palatability of low-protein diets, non-compliance is common and, hence, so is its effect to precipitate encephalopathy.

Bleeding into the stomach or small intestine (both of which occur with increased frequency in people with liver disease and/or portal hypertension) may also lead to hepatic encephalopathy. Blood contains large quantities of protein in the form of plasma proteins and hemoglobin. Hence, the presence of blood in the stomach or small intestine represents a protein load which, as a result of bacterial metabolism in the lumen of the gut, is converted to potentially toxic products such as ammonia.

Certain surgical procedures employed to treat portal hypertension commonly lead to the development of hepatic encephalopathy. For example, operations to relieve pressure in the portal vein by connecting it to the splenic vein or other systemic venous vessels, have the effect of diverting incoming intestinal venous blood away from the liver. This means that such ammonia-carrying blood will not be able to be "purified" by the liver. Encephalopathy can result. In a similar manner, the more-recently-developed "TIPS" procedure (transjugular intrahepatic portosystemic shunt) often precipitates hepatic encephalopathy (~30 percent of patients undergoing it).

Once I saw the lab work, I tried to find somebody who might know the patient so I can get more history. I tracked down his sister, who told me that he had not been taking his medications. The main medication that was important for this guy to take was Lactulose, which is an osmotic laxative. It helps by moving protein out of the gut before bacteria can produce ammonia from it, and change the acidity of the intestines which helps to convert ammonia into ammonium which is less easily absorbed by the bloodstream. It also turned out that despite the initial story I had heard, he was indeed drinking again. This is a no-no for someone with cirrhosis (not to mention Hepatitis C) because it further inflames the liver, which further impairs its function.

So I had a few things to figure out:

1. how to reverse the elevated ammonia levels

2. how to reverse his anemia

3. how to do one and two without further inflaming his liver

4. how to do one and two without worsening his kidney failure

5. figure out exactly why he was anemic, and how to fix it

Luckily, by the time I get all the lab work back, the guy had had come around enough that he could drink fluids without choking to death. If asked him his name, he could answer correctly. He still has no idea where he was or how he got here, he can't tell me his last name, doesn't know what city he's in but he is able to ask for one thing, "I need a beer! Get me a beer!" Priorities.

I get him started on drinking some Lactulose, 45 ml every hour until his ammonia level starts to improve toward normal. This means lots of urgent bowel movements will be coming soon. His lab work also showed that he had been anemic for some time. His hemoglobin was 8.7, and at 8.5 you start giving somebody packed red blood cells. His oxygen saturation was still very good at 97%. Because he was still getting oxygen to his body (and brain) I could wait to correct the anemia. His most serious problem was his pickled brain. However, it was important to figure out from where he was bleeding. It was clear he had a gastrointestinal bleed somewhere, which interestingly, was feeding his encephalopathy. As mentioned above, blood is a source of protein that the gut digests, which in turn increases the ammonia levels. The most likely place for this guy to be bleeding is from his esophagus. I knew this because when you have cirrhosis bad enough it causes a backflow of the blood coming from the gut, that reverse pressure often causes varices in the esophagus. A varice is like a varicose vein, swollen and saggy and chock full of blood. Lucky for him veins are on the low pressure side of our vascular system, so he's slowly leaking as opposed to gushing. But in order to find out, we would have to shove an endoscope down his neck.

While we were working on getting the Lactulose into him, his hemoglobin level dropped below 8.5, and he was given 2 units of packed red blood cells. Unfortunately, this did not raise his hemoglobin. That means he's bleeding out faster than we can replace his blood. That's bad. He was then sent to a larger hospital because his problems were becoming more than our little rural hospital could handle.

It turned out that he did indeed have varices in his esophagus, and he was bleeding from them. It was a nice, steady leak. Think back to those educational films you saw in grade school about how a leaky faucet and can lose gallons of water per day and you'll understand why this guy's little leak was a serious problem. They gave him some medication that would lower the portal hypertension (back flow of blood from the liver) and continued to feed him Lactulose. Last I heard, he was having lots of diarrhea and bugged everyone at the hospital to bring him a beer. A lifetime of bad habits, which he is doomed to continue, are going to lead to a very ugly end.

Knocking on Death's Door, but No Answer

2008-08-19T10:24:00.000-07:00

This past winter a 67 year old morbidly obese (400 plus pounds) diabetic arrived at the clinic sweating profusely. He was pale, and was having difficulty walking because he was weak and short of breath. Once in the exam room, he continued to drip with sweat and looked like he could pass out at any moment. He had a temperature of 103, his oxygen saturation on room air was 75% (very bad; means he isn't getting enough oxygen to his tissues) and he continued to breath like he had just finished a marathon. When I asked him what's going on he said he caught a cold and it went to to his lungs. He complained that he had been without heat for most of the winter, but had gotten by bundling himself under blankets and quilts and occasionally turning on the oven for heat. He had recently gotten a space heater which he would turn on until he couldn't see his breath indoors anymore, and unplug it until his breath reappeared. But he was worried about his lungs because he kept running out of air, and was afraid he might stop breathing in the night. He was also adamant that he did not have any money for medications. Although he was diabetic, he did not take any insulin nor any medications to control his blood sugar, again due to cost.

When I examined him his skin was clammy and wet, and his lungs sounded like they were filled with cottage cheese. We checked his blood sugars, which came back at 357 (normal is 80 to 125). I told him he needed to be admitted to the hospital, which he refused. I told him he had pneumonia and because of his unchecked diabetes he had an impaired ability to fight off the infection. He told me that he had no money to go to the hospital, or for medications and asked what else he could do. I hooked him up to some oxygen, and went to search our drug samples. I managed to ferret out some Avelox (moxifloxacin), an excellent antibiotic for pneumonia. I let him breath in the oxygen for another hour or so until he began to look a little more pink. I then gave him the antibiotics with instructions to take one a day for 14 days and to come back to the clinic in 5 days so we can see how he's doing. I again tried to get him to understand that he was gravely ill and that he could very well die from his infection, which is worse than a hospital bill. He removed the oxygen tube, thanked me for the antibiotics, hefted his body from the chair and staggered to the door.

Months went by and there was no word from him. I figured he had gradually drowned in his own lung secretions and frozen into a giant, fatty popcicle. But then one day there he was, ambling into the clinic, easily ambulating his girth down the hall for a checkup. All that fat must have kept him warm enough to survive.

Teen Killer Loses Footing

2008-08-11T06:47:00.000-07:00

16 year old girl complains of a painful left ankle, and is accompanied by her father. Over the weekend she and her dad went bear hunting with their pack of bear hunting dogs. This girl is smug and obese and it was hard to imagine that she had the ability to hike across a parking lot let alone up a mountain. The smug part came from how cool she thought she was hunting bears and assumed I would be impressed. I wasn't. Her form of "hunting" was to release a pack of dogs out the back of a truck, and then follow along behind on a four-wheeler (ATV) until the dogs had treed a bear.

In this case she told me that the dogs had treed a mother and two cubs, all of which were trying to scramble ever higher up the tree as she approached. She and her dad eventually maneuvered their four-wheelers to where the dogs were barking and whelping madly while the bears ticked off the last minutes of their lives. As my teen princess patient dislodged herself off her vehicle, she stepped on a tree limb, twisting her ankle under her enourmous girth. She fell to the ground and tumbled a short way down a hill. Her tubby father wobbled after her through the din of yelping dogs, bear fear and ATV exhaust, pulled her up and discovered she was in too much pain to walk. Due to her injury, he called off the hunt.

I was reminded of how in England the royalty used to hunt foxes in a similar manner. For centuries it was considered classy to do so, until it was outlawed a few years ago. I've got nothing against hunting, so long as it's mostly a fair fight, the hunter's have to have some level of skill, and the animal has a 50/50 chance of getting away. But this type of bear hunting where some fat slobs never break a sweat and unfairly terrorize and kill an animal makes me sick. I was delighted she has twisted her chubby ankle, and was only sorry it wasn't broken. I kept it to myself of course, and treated her ankle as I would anyone else's.

Drug Abuse and Dirty Deeds

2008-08-08T16:24:00.000-07:00

47 year old woman well-known to our clinic (frequent flyer) complains of a low back injury. The story she tells is that she was helping a friend move and they were carrying a hide-a-bed down some stairs. The friend lost her hold and my patient was pinned against the wall as the bed pushed up against her. As she told the story to me, she was grimacing in pain and sitting in a wheelchair that we keep in our lobby. She was able to drive to the clinic, and walk through the parking lot, but grabbed the wheelchair for the 20 foot walk to the exam room. I have seen this patient at least once a month for similar sorts of injuries: one time she fell off a ladder and hurt her leg, another time she tripped on a hose while on a roof, another time she crashed on her four-wheeler. Each time she comes in complaining of severe pain, and each time x-rays show nothing but on exam she winces and jumps and moans. She is always friendly and cooperative, but is careful to note that ibuprofen, naproxen (Aleve), aspirin and Tylenol don't work for her. This means that the only thing that works for her pain is narcotic drugs. I asked her to step up on the exam table, which despite her grunting and moaning she was able to do. Part of my exam for back injuries and muscle stains is whether or not patients are in too much pain to get up out of a chair and on the exam table. Because she could do so with little difficulty, I knew she wasn't seriously hurt and that she wasn't in as much pain as she claimed. Of course, during the exam she winced and moaned appropriately.

An important detail about this woman is that she has a husband, 48, who also frequents the clinic with various hard-to-disprove injuries.

The Board of Pharmacy in my state offers the ability to track any patient's pharmaceutical history. When I checked this woman's history I found that her drug history went back about six years and showed she had been filling prescriptions for narcotics (pain pills as well as cough syrup) from a wide variety of providers several times a month. Often she would have multiple prescriptions filled on the same day. She was either a junkie or she was selling the drugs. Either way, I decided to ask her about it.

With the report in hand, I told the woman that I was concerned about her narcotic drug use. I laid out the history and she cheerfully thanked me for my concern but assured me that she did not have a problem and that she didn't get prescriptions filled very often. I showed her the report, detailing her drug seeking activity over the past several months. I told her that is was not uncommon for someone to suffer an initial injury, get treated for the pain and then to become physically addicted to the medication. I told her that I was worried that this had happened to her and that I would be happy to help if she thought she had a problem. She became very quiet and finally asked, "what are you going to do about my back?" I told her that I would give her a prescription for an anti-inflammatory and some muscle relaxants, recommended physical therapy but would not give her any more narcotics. She took the prescriptions and left, quietly rolling herself to the lobby.

I had seen the woman on a Wednesday, and the following Monday her chart was sitting in my "to do" pile with a note attached. It read, "Patient died in her sleep Saturday." The woman's husband called our clinic to let us know the woman had died. He described how he had woken up next to her, and she was unresponsive. Her lips were blue, and he tried to resuscitate her, but she was gone. This is one of those "oh shit" moments in medicine everyone dreads. In confronting her, had I sent her into a tailspin that caused her to overdose? Was she scared that her meds were about to be cut off and she couldn't cope without them? Was she selling the drugs and worried that the cops were about to close in on her? No way to know.

As I thought about it, and talked about it with my wife, it was my job to call attention to her drug use. I made it clear that I was going to keep keep treating her and that I would help her withdraw off the narcotics. My wife pointed out that junkies rely on co-dependent people in their lives, and in her case, health care providers that never step up to ask the hard questions. Also, because she's a junkie she doesn't have any coping skills beyond taking her meds, even if they are offered. So I guess I'm off the hook, but the plot thickens still.

On Tuesday I was handed a note from one of the nurses that the woman's husband was calling because he was having trouble with his wife's death. He hadn't slept, was crying uncontrollably and could barely get through his wife's memorial service. The service had been that same day, and the woman was to be buried tomorrow. He was asking for something to calm his nerves. I asked, "she's being buried tomorrow? Aren't they going to do an autopsy?" The nurse shrugged he shoulders and handed me the husband's chart. I flipped through the chart, was once again reminded of the husband's narcotic abuse, but wrote a prescription for ten valium anyway. His request was reasonable and may actually be grieving. But then, I thought about it a little more.

Normally when a 47 year old woman with no history of heart disease or serious illness suddenly dies in her sleep, people want to know why. This woman died on a Saturday and was going to be in the ground on Wednesday. That's really fast, and the only way the local authorities would skip the autopsy, even in my little community, is if the husband told them not to bother. Granted, the Coroner was probably relieved to put the whole matter to bed because these two were not model citizens, to say the least. But given the speed of her burial, what was the husband trying to hide? Had he given his wife some tablets out of his stash, and accidently caused the overdose? Or had he done it on purpose? We don't even know if she had any drugs in her system when she died, so we'll never know. It will be interesting to see if the husband comes back to me for more meds in the future or if he'll simply disappear into the ether.

May or May Not Be True

2008-08-06T08:59:00.000-07:00

At the very least, this is a funny site, if a little long. It lists medical acronyms and terms that we in the profession supposedly use to describe patients. I have heard a few of them, but this list goes way beyond anything I've ever heard. The terms I have actually witnessed include:

Acute lead poisoning
AQR
baby catcher
banana
BFH
Gorillacillin

FLK

I fell on it
lipstick sign
LOL
Rule of Five

http://www.messybeast.com/dragonqueen/medical-acronyms.htm

Angry Cowboy

2008-08-05T08:50:00.000-07:00

22 year old cowboy complaining of personal problems. When I call this fellow a cowboy, I mean that he is wearing a wide-brimmed hat, speaks with a drawl, wears skin-tight Wranglers that gather near his ankles over his boots and has a plaid shirt with metal snaps. When I enter the room, he apologies for wearing a hat and removes it. He normally works breaking horses, but because of the economy work has been slow the last six months and he's been working any odd job he can find. Lately he's been bucking hay (loading, unloading and stacking 85 to 150 pound bundles of hay) for anyone who needs it.

He says he's been having problems with rage. He has a past history of rage issues since the age of six and has been to counseling many times. Despite using the various calming techniques he has learned, he has been "blowing up at people over nothin'." He has problems with rage when he's driving, if he argues with his fiance (who he says just put the marriage on hold because of his anger problem) or anytime anyone crosses him. I decided not to pursue the question of why people seem to be crossing him so often, lest I bring out his inner Hulk. He's a smoker and the last time he was in the clinic reported smoking about a pack per day. Over the course of two months his tobacco intake had gone up to two and half to three packs per day. I did not ask where he was getting the money to pay for the cigarettes, but I did ask what other stressors he had in his life.

"Doc, it's coming at me from all sides." He explained that his ex-wife was holding up his divorce papers because she wanted him to sign away custody of his two kids, such that he would have no contact with them until they turned 18; something he does not want to do. However, if he were to sign the papers he would free of any child support payments, which he can't afford anyway. Because he's broke, he can't afford to pay for gas to drive around to look for work, so he's stuck asking friends and family for odd jobs or handouts, which he hates to do because it's humiliating. He's had to move back in with his parents and has credit card companies on his tail because he can't pay his bills. He can only get a few hours of sleep per night even though when he bucks hay he wears himself out to the point that he's "wrung out like a damp rag."

I decide my best option is to treat him for depression. Lots of men manifest depression as anger, and it turned out that most of his family is currently on anti-depressants. I look over the $4 medication list at Wal-Mart (month's worth of meds for just four bucks -- Wal-Mart is good for something) and select one I think will help. I have yet to hear back from him.

Grandmother Battles Cow, and Loses

2008-08-05T08:23:00.000-07:00

83 year old woman rancher comes to clinic for follow-up regarding a recent accident. It seems this grandmother was loading a cow she had raised since it was a calf into a trailer. As she was leading the cow up chute it freaked out, and suddenly rammed her up against the back of the trailer. The woman was pinned there for a moment, as the cow repeated pummeled her until finally flipped her into the air, landing in the dirt at the bottom of the chute. At the ER it turned out this nice lady's injuries included a fractured cervical vertebrae, two fractured lumbar vertebrae, four fractured ribs, and a fractured sternum. The next day, because of all the trauma, she developed a blood clot that lodged in her lungs, a bilateral pulmonary embolism. She was in the hospital for about a week and was finally sent home.

When I saw her in the clinic for follow-up, she was wearing a brace to support her back and a second brace to support her chest. The two braces wrapped around her neck at slightly different angles causing them to pinch her when she moved or took a breath. She had been put on Warfarin, a blood thinner, to prevent any further blood clots and would remain on it for at least six months. Her only other medication was occasional Tylenol for her pain. After reading her chart I sat down and asked what I could do for her.

"Get someone to clean my house. It's a pigsty." She explained that because of the back and chest braces she was unable to clean her house and it was driving her crazy. I told her I'd check with her family to see if something could be arranged.

How Cool is the WWF?

2008-07-31T13:37:00.000-07:00

18 year old girl comes to the ER complainign of back pain after her sister's roommate jumped on her. It seems the girl was trying to get into her sister's apartment to retrieve some clothing, but was not welcome to do so. The sister and the roommate blocked her entry to the apartment, eventually pushing her to the ground. The roommate then executed a WWF move, jumping into the air and landing with her full weight on the girl's shoulders as she sat on the ground. The girl heard a "pop" and immediately had 10/10 pain in her low back. She was able to move but in too much pain to do so. She called her mother, who then called 911 and paramedics strapped her to a board and brought her to the ER.

On exam, the girl was without numbness or tingling, had good pulses in her legs and feet, and was able to feel and move her toes. She was in a great deal of pain, which was calmed with 6mg of morphine. She was sent to x-ray for a spinal series which revealed a compression fracture of her T12 vertebrae; it was crushed like a beer can. Needless to say, she and her family were upset. She was sent to metro hospital for assessment by a neurosurgeon.

Gallstone Collecting

2008-07-31T09:20:00.000-07:00

37 year old Hispanic woman complains of right upper quadrant abdominal pain that appears after she eats fatty foods. This has gone on for a few years and she has previously been diagnosed with gall stones. It has been suggested that she have her gallbladder removed, but she has not wanted to have the operation. She is in the clinic today because the pain has gotten a little worse over the last month. She would like to try her gallstone diet again, but wanted to be sure it is safe to do so.

"Gallstone diet?" I ask.

She describes a liquid diet that includes olive oil, lemon juice, peppermint oil, and pineapple juice. When she does the diet, she then passes her gallstones (she checks the toilet bowl for them) and her abdominal pain subsides for a month or so. I told her that I hadn't heard of the diet, but it shouldn't do any harm. If her pain gets worse or she has other symptoms she should come back for a recheck.

I was curious and after a little search, I found the diet. I don't endorse it, but here it is. I especially like the details about gallstone capture as well as the phrase, "you may want to show your stones to some people."

THE GALLSTONE CLEANSING DIET

Pick a day when you have nothing much to do the next day, and preferably even the day after. Friday is best for most people who have the weekend off. Don't make any plans to go out!
DO NOT EAT ANY SOLID FOOD after noon on the cleanse day. You may drink water or fresh juices, as much as you like.
DO NOT HAVE ANY FLUIDS after 6.30 pm (or 30 minutes before the start of your treatment) on the day of cleanse. Give your stomach time to evacuate all the fluids. Then the olive oil won't float up on top of the fluid and your chances of nausea will be greatly reduced.
YOU WILL NEED:
One pint of virgin olive oil
One half-pint of freshly squeezed lemon juice
Peppermint oil (from your health food store)
Pineapple or V8 juice
Measuring cup or tablespoon size measuring spoon
Pitcher of water
Paint stirring stick
Jar with screw-on lid
Index cards
Net to drape under the toilet seat, to catch your stones. (Place the net under you toilet seat so it will be ready when you need it. Lift the seat and place the net across the porcelain stool, then replace the seat so it will hold the net in place. Place the pitcher of water and the paint stirring stick next to the toilet ready for when you need them. Also have handy the screw-on lid for storing your gall stones and the index card.)

If you should experience extreme nausea or vomiting, try chasing it with a small amount of V8 juice or pineapple juice. Or you might try adding a few drops of peppermint oil to the olive oil. Use one of these mixtures for a couple of doses and then go back to the olive oil and lemon juice without adding anything.

THE PROCEDURE
12 Noon -- Stop eating all solid food
6.30 pm -- Stop drinking all fluids
7.00 pm -- Using a measuring device, pour ¼ cup (four tablespoonfuls) of olive oil and drink it.
Follow immediately with one or two tablespoonfuls of lemon juice.
Lie down and relax.
Repeat this every 15 minutes. Sit up, swallow it and lie down again. If possible, have someone else bring them to you. Relax, read or watch television. Keep as still as possible. It is best to lie on your right side.
Repeat the exact dosage every 15 minutes until you have swallowed all of the pint of olive oil. If there is any lemon juice left, drink it all.
It is now probably 10.00 or 10.30 pm. Remember, if you have terrible nausea or vomiting sensations, use the peppermint oil in the olive oil, or chase the olive oil with a small amount of V8 or pineapple juice, until you can resume taking the plain olive oil and lemon juice.While you are taking the olive oil and lemon juice, if it gets hard to swallow, take a little more time between doses. Try 20 minutes between doses, or 25 minutes. Try to swallow all of the oil and lemon juice. If you are too nauseated to get it all down, take as much as you possibly can.

You have finished the olive oil and lemon juice. Now go to bed and do your best to go to sleep. Lie on your right side. This position speeds up the process of the olive oil entering the gall bladder to act as a lubricant. This, along with the softening action of the lemon juice, will help to free the stones more easily and readily from the gall bladder. Stay in bed and forget everything until the urge to go the toilet comes.

That was really quite simple, wasn't it?About 2:00 or 3:00 am you'll probably wake up with the unmistakable urge to go to the toilet. It may not happen. For some, it doesn't happen until 11am the next day. If your first bowel movement is at 2:00 or 3:00 am you will probably have no stones in it, but you'll want to check to be sure.When you have the first bowel movement after the cleanse, you'll use the pitcher of water and the paint stirring stick to wash the fecal material through the net. Pour water gently and use the stick to separate the stones from the fecal material. The fecal material will be runny and wash through the net.You can use the index card, folded in half, as a makeshift shovel. Place the stones in the jar and screw the lid on. You may want to show your stones to some people. Many will be amazed, but some will still be unbelievers. You certainly want to keep your stones for a while to remind yourself that it was all worth while. After a few days they will dissolve (because of the lemon juice and oil). If you want to keep them for an indefinite period, store them in your freezer with a label - GALL STONES. DON'T' EAT!!!!You may notice green objects and maybe greenish liquid excrement in the toilet bowl. Those are small gall stones. Some gall stones may be dissolved by the treatment. Dr Lewis found that 1% of people failed to pass gall stones. If you are one of these 1%, don't be disappointed. In some individuals, the powerful action of the lemon juice causes the stones to dissolve before they are passed out of the body. IF you have only greenish liquid bowel movements, the cleanse has been effective.Notice any increase in vitality that usually follows the cleanse.Remember, optimum efficiency in the human body can only occur if all our God-given parts are working properly.Some people (including doctors) will say that your gall stones are not gall stones but fecal matter. To quote from Dr Lewis:
"To clarify the situation and eliminate such questions, I sent a sample of gall stones to a medical analysis lab run by a Ph.D. who heads up the Science Department at Texas Woman's University in Denton. He ran the necessary tests…
His analysis of the stone sample I sent was 91% cholesterol and the rest was bile salts, water and inert ingredients. In other words, the sample had the chemical contents of gall stones. And the report clearly states it was gall stones".

Grandma Runs Amok

2008-07-31T08:21:00.000-07:00

67 year old woman is brought to the ED by her family. For the past few weeks she has not been herself. Normally a quiet, reserved, sweet grandmother she has been making odd statements such as, "Castro is coming for dinner, so watch the silverware," and "I think the cat is reading my mind." She was seen by her physician, she appeared well and was told to drink more fluids and try to rest. Her confusion progressed and finally culminated in her running through the neighborhood looking for her kidnapped grandchild. The child was safe at home at the time. She tried to recruit several confused but sympathetic neighbors in the search, but was frustrated by their lack of initiative. She then tried to recruit one of the neighbors dogs, but the dog also seemed confused by her request. She then ran about the neighborhood finally approaching a local steakhouse, kicking in the back door and accusing them of holding the child. By this time her family was trying to track her down, finally finding her and taking her to the ED.

When I saw her she was on a bed, sucking on her lips, her eyes rolling around and around not focusing on anything. She would occasionally yell out, "Fuck!" or "Motherfucker!" "Goddamn Bastards!" to no one in particular. She was also convulsing, holding her arms tightly to her chest, lifting both legs up in the air or kicking them at the bed rails. She would look at her family without recognition and then start moaning or cursing again. She was drenched in sweat due to the effort of her convulsions. Her exam was essentially normal except for the behaviors noted above. Her lab work was also normal. She had no past history of seizure, epilepsy or stroke and was not know to have a meth habit. A drug screen came back negative. She was currently taking medications for high blood pressure, high cholesterol, and depression. Her depression medication was Prozac, which her husband thought had recently been increased. In checking the adverse reactions to Prozac I found mania and seizures listed. The Prozac seemed like the most likely cause, so we gave her some Valium to relax her, admitted her for observation and hoped that once the Prozac was out of her system, she would be back to normal.

The next day when I went to check on her, she was quietly eating her lunch, looking a bit tired and sheepish but well. She said she had no memory of the past day, but had been told the details by her family. She was taken off Prozac, and has been well ever since.