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Doc's Progress Notes

Week of November 15, 1999

Last Updated: 11/21/1999 at 7:29 PM PST

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Monday November 15, 1999

It's Monday again and this month is officially half over already. We only have a month and a half more to hear all the Y2K hype and hysteria! Delanae told me this morning before I left to watch out for Nikki. I say "Who's Nikki?" She says that Nikki is who was trying to take me away from her in her dreams last night. Today is therefore officially "Watch out for Nikki Day". By the way, I don't know anyone named Nikki. If your name is Nikki and you are meeting someone new today, have her introduce herself first. If her name is Delanae, change your name quickly. Delanae e-mails me to say that warning should probably also include you if your name is Nichole.

I played around with my web site statistics a little this weekend. I have been averaging about 25 hits a day for this page according to the software. Unfortunately the software used by my server doesn't tell me where everyone is from just what their URL is and browser used and other information. That per day average after only two weeks is about five times higher than what I had hoped for in my wildest dreams when I started this site. Thanks to everyone who has dropped by and especially to those who keep coming back. If you get a chance, drop me a line just so I know who you are and please give me any feedback you care to, good or bad. After all, I can delete feedback I don't like very quickly and save the positive feedback.

Two patients this morning to comment about. The first is a lady in her mid 70's who came in for a routine check of her diabetes. I knew she went to Europe about two weeks ago and so asked her how the trip was. She went with her granddaughter and her granddaughter's new husband and while there her daughter flew over to spend another week with her touring France. While there, they went to my patient's brother's grave in Holland and the place where he was killed near a small town in Germany in November 1944. He had just turned twenty the month before. My patient 55 years later now finally felt closure regarding his death. She was still emotional about it today and now wanted to see" Saving Private Ryan" to achieve further closure.

The other patient was a seventeen year old female who came in with her boyfriend (fiancée in two years she said) who wanted to discuss contraception. After doing her physical exam and first Pap smear, we sat down and discussed methods of contraception, use of condoms to prevent transmission of sexually transmitted diseases, and most important (to me) the value of abstinence until marriage. Predictably, abstinence was not their choice for contraception; Depo-Provera was but they did agree to use condoms. A small moral victory perhaps as they were not using condoms before; if they use them that will lessen the chance that she will become another victim of the STD epidemic. Meanwhile, when I get home I plan to hug my eleven year old daughter again and tell her I love her and NO dating until you are thirty!!!

This afternoon I saw a patient who I have seen several times over the last almost two years. He has a history of ulcer disease and has had part of his stomach removed due to a bleeding ulcer also in the past. He is schizophrenic and is normally on antipsychotic medication. He is chronically anemic (low in iron and therefore his blood counts are low) and comes in periodically when someone suggests he doesn't look too good. I have checked his blood counts over and over and they are always low, I place him on iron and tell him he needs to have his stomach examined either endoscopically or with an x-ray but he never shows up for the procedure. I do this to see why he is chronically anemic, is he bleeding chronically, does he have an ulcer, or does he have stomach cancer. Today he is back with the same complaint but he has stopped his medications on his own and is now an untreated schizophrenic. How can this man understand his medical condition if he is not on medication but how can he be made to take his medication if he is unable to understand his medical condition? The classic dilemma for society; what do we do for the mentally ill who can not live independently without medication but refuse to take their medication. How do I force him to take his medication or have his studies when he is given the same rights as someone who can understand their medical condition and therefore is felt to be competent to refuse treatment? He refuses medication and studies but can he really understand the consequences of his decision given his schizophrenia? I don't know the answer to this question so I recheck his blood counts, ask him to come back tomorrow for those results and hope he shows up and that I can talk him into having his stomach studied.

Have you ever wondered what happens when a physician gets sick? Well, chaos. In our group, one physician per week covers the hospital exclusively so the nurses in the hospital know who to call and he or she can check on the patients all day rather than have to worry about their patients in the office too. Today that system breaks down because the physician on hospital duty this week is home vomiting. We will survive it but it has taken some scrambling by the rest of the group.

I have, I think, answered all the phone calls, refilled all the prescriptions, and reviewed all the lab that piled up over the weekend. I have refused to see the chronically late person who is late again today (by one hour) and cannot understand why I will not see him and inconvenience everyone else who was here on time (he will reschedule and be late again but maybe not as late next time and we will see him). I am ready to leave for the day when I realize that we have a Nikole who works here. I must remember to warn her tomorrow or the next day she is scheduled to work, otherwise she may not live through her next meeting with Delanae. (imagine the largest smiley face you can and put it here)

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Tuesday November 16, 1999

Late update last night due to the great report card discussion. My son's report card, actually a computer printout, came in the mail last night and it looked like it was for two different people. Four classes, great attitude and behavior, one class, behavior a problem, and one class, excessively tardy. Needless to say, lowest grades in the last two classes. We set him down and discussed this report, got his input which was those teachers don't like him, so now will contact the teachers and discuss it with them. Not that his grades are bad, his average is above B, but in the past we have been concerned about his attitude and want him to learn better self-discipline before he starts driving. No sanctions yet as long as he can prove that grades and behavior will improve in those two classes.

The patient I mentioned yesterday with the chronic anemia and schizophrenia did come back today. He admitted to me that he has been taking a whole bottle of ephedrine, used in decongestants, daily for 8-10 years. No wonder he has chronic stomach pain. He says he is ready to get off them which I think will require a formal drug treatment program so will try to arrange that over the next 48 hours. Ephedrine is a cousin to amphetamines and therefore he will undergo physical withdrawal by quitting "cold turkey".

We had a team meeting at noon today open to all the physicians in the team plus staff. Everyone is free to bring up anything. We had a good discussion; surprisingly there were no real problems that we needed to solve. The hardest was deciding what to do for Christmas gifts for each other. We eventually decided to contribute money and purchase gifts for a needy family. Then we had our monthly birthday cake (for everyone that month with a birthday), I had a second piece because it was chocolate, and then back to work.

This afternoon was very busy, made busier by one of our employees who had an unscheduled asthma attack. I ended up treating her for more than two hours but she still had to be admitted late in the afternoon because she was not clearing sufficiently that I felt it was safe for her to go home. This attack was precipitated by a part-time employee coming in wearing way too much cologne. We tell the staff to not wear any scents because some patients are very sensitive to them; he forgot I guess. She should be fine but asthma attacks still scare both the patient and physician. We all have our stories about an asthma patient having to go on a respirator or dying on the way to the hospital. My worst personal story is the one year old girl who I had to put on a respirator in the early morning hours then wait until it was light to fly her to the nearest Children's hospital by helicopter. It was a night spent on the telephone with the pediatric lung specialists. She did well however and eventually was able to get off all of her asthma medications.

Men's group was good as usual tonight then our worship team practice was awesome as always. I didn't get home until almost 10 PM which is why this update is this late being posted. Tuesday night will be like this.

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Wednesday November 17, 1999

Could not drag myself out of bed to run this morning. I'm now dragging at the office. I know the problem, some rhinovirus is trying to get a foothold in me. I don't plan on allowing it to do that. I am willing myself not to get sick and will start Echinacea, no certain proof that it helps but it is used in Europe against viral illnesses. A little more sleep at night would probably help too but then I could not get everything done that I don't get done anyway.

The patient admitted late yesterday afternoon because of the asthma attack is doing much better and can probably go home tomorrow. Removing her from the environment that triggered the attack was an important part of her recovering. Meanwhile, the employee whose cologne choice caused the attack is feeling very bad about what happened. It turns out he had been warned about the cologne in the past. Don't know what will happen to him.

Nothing remarkable about the patients this morning. I did two annual physical exams, cleaned out one man's earwax (he couldn't hear it was so packed in), and treated two cases of depression, one better in follow-up and one new case of depression among the usual colds. We are still having to deal with the drug seeking patient from an earlier update. He keeps calling suggesting we call in something else for his pain, these suggestions are always narcotics. We keep suggesting he find another physician but so far he hasn't taken the hint.

This afternoon was also fairly uneventful. My medical assistant is becoming hoarse, running fever, and doesn't feel good. Looks like she is getting this viral URI which is going around here locally. She is very stubborn and will probably in tomorrow even though she doesn't feel well. I understand her motivation; we see too many people here who aren't really sick and we don't want to be known as wimps. Therefore we come in and work even when we feel terrible, we are very careful about spreading germs though, washing our hands extra well between patients. Tomorrow looks fairly light today so I'm hoping she will stay home tomorrow. Me, I feel better this afternoon so I will be in tomorrow unless I have a severe setback tonight.

Feeling even better tonight so I don't expect any severe setback tonight. A family looked at our present house tonight and are very interested in it. They're coming back tomorrow and we'll see how serious they are I guess. I don't look forward to moving but we want to get in a different place, either closer to the hospital or out where we can have some land for our dogs to run on. They don't get enough exercise and our youngest one is really getting fat. We'll see what happens. Must look at some figures tonight so will see you tomorrow.

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Thursday November 18, 1999

Thursday has arrived. I'm feeling better today and my medical assistant is here today. I asked her why she came in and she said she feels great just has no voice. She croaks when she talks. One of this morning's patients heard her coughing and remarked about coming in when he was sick and the nurse sounding worse than him. We have seen a lot of this upper respiratory virus "stuff" over the past two weeks. People come in with aching all over, nasal congestion, sore throat, and dry cough. I can listen to their complaints, empathize with them but cannot give them the magic pill to make them well right away. Most understand; a few get upset with me when I tell them they don't need an antibiotic and stomp out upset because they did not get their antibiotic they felt they needed to get over their cold.

In a medical office it seems things come in spurts. We will go weeks without seeing anyone with a kidney stone for instance then one day, like this afternoon, we have two or three people with one. They are both home now with pain medication and urine strainers trying to catch their stones when they pass them. If they get worse over the next 24 hours we will probably have to admit them for pain control and see if the urologist can bring their stone out. Stones from the kidney have to travel down this tiny tube called a ureter and hurt and cause bleeding all the way down. Once they drop into the bladder they no longer hurt, then the trick is to try and catch the stone and test it to see what it is made of. One complication is the narrowest part of the ureter is right where it empties into the bladder so some stones get hung up there and have to be pulled on into the bladder by the urologist. If they hang higher up in the ureter then they can be blasted apart by shock wave lithotripsy. Hopefully both of these patients will have passed their stones by tomorrow and we won't have to worry about doing either.

After finishing up at the office I went by a local Italian restaurant and picked up dinner for my family. Then home just in time to meet the couple who had liked our house yesterday. They made an offer on the house which is way too low. We will counter back with our lowest offer we will accept and see if they take it. If not, the house will be listed with a real estate agent Monday, the same one who showed us the house last week that we liked so much. That pretty much shot the night which is why this update is so late. Tomorrow's may be late also because I plan to take my wife and daughter out to eat tomorrow night since our son will be at a friend's house for the night. So, short update tonight and probably more tomorrow night.

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Friday November 19, 1999

We've reached Friday again. I thought I would start out with a portion of an e-mail I received a couple of days ago that is both a fan mail and an explanation for what I was talking about here Monday.

-----Original Message-----
From: Cynthia Anning []
Sent: Thursday, November 18, 1999 12:31 AM
Subject: Re: New Website


I went right to the site to check it out. COOL! I'm going to look into that book, the one that inspired you. Seems like it would probably be interesting. Reading your journal was REALLY interesting. Tell Delanae not to worry about Nikki.. that is the name of one of my Yorkshire terriers that I had to find a home for before moving here. I dream about her and the other one, Petey, a lot. So, Delanae and I probably got some crossed psychic signals as we were sleeping and Nikki got mixed up in it somehow.. ha ha ha

Well I guess I pretty much just wrote a journal for YOU. =0) Sorry about that. Anyway the idea to do a web site is great, and simpler is better in almost all cases when it comes to a web site. You're off to a wonderful start. I love the pick for the domain name Very fitting! I've got it bookmarked and will continue to visit. Thanks so much for sharing it with me!

Take care,

Independent Scrapbooking Consultant,
Home Business Owner & Web Site Administrator
Inspiration, Information and Imagination for Scrapbooking Enthusiasts

Cindy is an online friend of Delanae's whom we have never met. She, her husband, and their cute little boy (I have the pictures to prove it) live in Iceland where he is a Navy officer assigned to the NATO base there. They met online because of a mutual interest in scrapbooking. Delanae is a Creative Memories consultant and Cindy would like to be but cannot at the present time because she lives in Iceland. We're hoping they will locate to this area of the country when her husband gets out of the Navy in another year or so, right Cindy?

Anyway, I left out some of the message because I felt it might be too personal for Cindy to want shared with everyone but she did give me permission to use the parts I used. Anyone who writes to me please mark your message if you do not want it possibly shared on this page or if you want your return address left out.

By the way, Cindy did write back later to say she knew Daynotes was a web site not a book. I knew she did because Cindy not only is a web site administrator, wife , and mother but also builds computers as does her husband. (Whose is fastest now Cindy?) When she moves close enough to us I plan to ask her to help me build one of my own.


More about Nikki now. The patient I told you about earlier this week who has schizophrenia and anemia and is off his anti-psychotic medicine came back this morning. My nurse told me he was acting "strange" which I told her was not unusual for him. I took about five minutes to call and set up an admission to an inpatient drug treatment program for him if he would agree to come in. Before I could go into the exam room he was in, my nurse came into my office to tell me he had walked out the back door and headed up the stairs. I told her to call hospital security to see if they could find him and bring him back so I could talk to him about being admitted.

We heard no more about him until after lunch, which (in best Dr. Keyboard imitation) consisted of a lovely roast turkey covered with gravy accompanied by dressing and mashed potatoes also smothered in gravy. This was served on plastic plates with a side of cranberry sauce. This meal was topped off by industrial grade cheesecake with a light topping of chocolate sauce. This Thanksgiving meal was compliments of the hospital where I work and was shared by all its employees with a makeshift choir(5 people) singing Christmas carols in the background. You had to be there to appreciate it believe me.

Anyway, about mid afternoon, my nurse came up and said "you have to come listen to this, you won't believe it". On the voice mail on her phone was this patient, identifying himself by name, and leaving several messages telling us he was going to bomb the place and we would be dead. We called hospital security and the local police who came right out. Just after they arrived, one of our front office people came back and told us all they thought this patient was now sitting in our waiting room again. We went and looked and sure enough there he was. He had changed clothes and was almost asleep sitting in a chair. We called all the patients sitting in the waiting room back and stuck them in every empty room there was and he continued to just sit there. The police were able to walk out to his chair and subdue him fairly easily. There were no bombs found but I am sure this will make the local news and maybe the Portland news as well.

Hopefully, this man will now be admitted to an inpatient program where he can be stabilized back on his anti-psychotic medication and treated for his drug addiction(s). But then once he is back on the street, what will motivate him to continue taking his medication? Should he be allowed to live independently or, as I believe, be forced to live in some sort of monitored environment where he would be forced to take his medication and would no longer be a possible menace to his fellow man.

So, I can hear all of you saying, what does all of this have to do with Nikki. The nurse who I worked with all day today was the previously mentioned Nichole (Nikki). This was the first day I had worked with her in a long time. A very surreal day; I think I will close on that note.

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Saturday November 20, 1999

Saturday morning is Delanae's typical day to sleep in as long as possible but this morning she was up before 7 AM. I asked why and she said she was going down to stand in line to get in and buy a Beanie Baby or two since one of the stores here just got in a new shipment. They opened at 8AM and she had to get there early to get in line to be sure of a good chance to get what Stacey wants. Stacey was supposed to go with her but would not get out of bed to go. Delanae was successful she told me after she got home. I don't understand the Beanie Baby craze but I guess I am not alone in that regard.

Last night, we took a counter offer to the couple who was looking at our house; we expect them to come over this afternoon with an acceptance or rejection. We are not going any lower so we will find out today. I then took my wife and daughter out to eat at a new Italian restaurant here in town. They both enjoyed it, even Stacey was able to find something she liked. She is a very picky eater right now at eleven but they made her a cheese pizza which she liked. Our son is coming home for a few hours this afternoon then off to a dance tonight, what a social life at age fifteen.

It's the Hogs vs the "Dogs tonight on ESPN2 (translation: The Arkansas Razorbacks play the Mississippi State Bulldogs in college football). I am awaiting word from my friend who gets ESPN2 whether he is going to tape the game for me or he is going to invite me over to watch the game live. He is also our pastor and is coming back from a retreat this afternoon or tonight so I guess a lot will depend on when he gets back. I will tell you more later when I do another update. Until then GO HOGS!!!!!!!


The couple has accepted our counter offer and given us a check for the earnest money so, assuming they fulfill the terms of the contract, we have to have a new house to live in within the next 4-6 months. Hopefully it will be the house we both like so much, but if that does not work out we will need to find a nice house to rent. We now know some realtors who have some nice houses to rent so hopefully that won't be a problem.

I'm still at home so I hope the game is being taped like it is supposed to be. I guess I will find out tomorrow at church if I have a tape or not. I'm going to finish doing some bill paying tonight so I don't have to tomorrow, look at some web statistics for this site, then go to bed not knowing the outcome of the game (maybe I will peek later at the news however).

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Sunday November 21, 1999

This has been a good weekend for my football teams. I found out on the Internet yesterday that the high school team from the town in Arkansas we moved from two years ago won their playoff game Friday night and will play for the state championship next weekend. They are undefeated this year and beat the team ranked ahead of them the whole year.

Last night, the Hogs beat the 'Dogs and today my pastor came through with the tape of the game. I watched it after church today and it was still exciting even though I knew the final score already. The Hogs will be in a January 1 bowl game after they defeat LSU Friday afternoon in still another televised game that I won't be able to watch. That game is on CBS in the afternoon and I will be working then but I will tape it if the local CBS affiliate carries it. The Jan 1 bowl game I will be able to see. Hopefully that will be the Cotton Bowl who will then match them with an old rival like Texas.

Then today the Seattle Seahawks won their game. I'm becoming a Seahawks fan but still follow the Dallas Cowboys. Mike Holmgren is teaching the Seahawks how to win; they have always had talent but did not know how to win. Hopefully we can get up to Seattle to see one of their games in the near future.

After church Delanae took family portraits to send with our Christmas cards. She has decided (notice I was not asked about this) to paste three cropped pictures in the cards since they are trifold cards. Obviously she is the creative one in the family which is why she is the Creative Memories consultant. Me, I would have just stuck one picture in each card and mailed it that way. That is probably why I was not consulted about this decision. It is quite a spectacle believe me when she and Stacey get to cropping pictures. This must be done fairly soon in order to get them in the mail early enough for everyone to get them before Christmas.

I have been doing some thinking this weekend and especially while running this afternoon. I am planning immediate computer upgrades and a home network. In our present home Delanae and I have separate offices, one upstairs and one downstairs. Wherever we end up moving, chances are we will only have one office and therefore I could buy one of the home networking kits with the shorter Cat 5 cables and NIC's in it and set up the network easily using Windows 98 SE. I will probably use the D-Link DFE-910 kit which Jerry Pournelle has highly recommended in the past. I also want to add memory to Delanae's computer since she only has 32MB, and a larger hard disk to each of our computers. I may also upgrade one modem if we are going to do internet connection sharing. Longer term, I want to build or buy a computer with a faster processor than a Pentium II 200 so I can give one of the present computers to our kids to use for their Internet surfing and ICQing and so I can use Windows 2000 when it is a stable OS or Linux or both. These plans are, of course, subject to change as funds and a different house permit.

I just received a call from our group's medical director, my boss, informing me officially that I have been elected to our group's Leadership Council. This Council decides policy for the group, decides about potential new partners, and approves all new contracts. My term starts immediately and the first meeting is tomorrow morning but, unfortunately, I will not be able to attend. I am one of the members of another committee going to Eugene Oregon tomorrow to attend the meeting of a similar committee there. We are going to learn about some of their procedures for reviewing the appropriateness of referrals in our never ending quest to learn to deal with managed care. We have to leave at 6 AM tomorrow, drive three hours to Eugene, spend 5-6 hours there, then drive three hours back if we don't get caught in a traffic jam in Portland. It will be a long day but then we have worship team practice tomorrow night which always is a great way to start off a new week. So, I will talk to you again late tomorrow night.

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