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Doc's Progress Notes

Week of January 3, 2000

Last Updated: 1/9/2000 at 6:33 PM PST

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Monday January 3, 2000

Made it through the first work day of the new year. It was a 12 hour day for me, beginning about 6:30 AM when I left the house for the office and ending about 6:15 PM when I left the office to run and then come home. Well, almost 12 hours.

The day began with our monthly group meeting at 7 AM. The breakfast that was supposed to be served was not in evidence when we got to the meeting room. Our medical director had to call the cafeteria to remind them about us so we did not get a hot breakfast as advertised but had muffins and rolls at the last minute. Other than this snafu, the meeting went well. We mostly talked about how we could change the format of the meeting to make it more valuable for everyone. I think the new format will work better. We also had a good presentation on osteoporosis by our group's rheumatologist (arthritis specialist). He presented some new information about that disease and the treatment as well as screening for it. Hopefully, all us clinicians will do a better job screening for it and preventing it now; also we'll do a better job of treating it.

After the meeting, it was time to see patients. Predictably, the first real work day of the new year brought more requests for refills and patients with complications from influenza. I did see one couple who is going to Papua New Guinea to teach at a bible college there for two years. We had a nice talk about their adventures in Nairobi and South Africa where they have previously taught. I did not realize that Nairobi was so temperate, the temperature rarely gets below 60 or above 85 the entire year. New Guinea looks to be the same, according to them since the area where they are going is at the same elevation as Nairobi, approximately 5000 feet, and around the same latitude. They loved their time in Africa and were looking forward to going back but are now all set for a new adventure on New Guinea. This is all the more interesting for me since one of my visitors to this page is from Papua New Guinea, according to my web page logs. If you are still reading this page, please send me an e-mail and tell me a little more about your country. I must admit, I have always had a fantasy about moving to an island in the Pacific, who knows, maybe someday.

One funny thing did happen this morning. If you remember from an earlier post, we have an intranet at work and I keep Outlook 98 minimized as long as I am in the office and have it configured to signal when a new message is received. I had just finished dictating when I caught the new e-mail message out of the corner of my eye. I then clicked on it to read the e-mail which turned out to be from our medical director. It was a notice about a meeting in April about physician use of the Internet and was sent to the members of our group's Leadership Council to see how many of us could go. Having a few seconds, I clicked on the calendar in Outlook, saw I was free on that day, and immediately sent back a short message that I would attend and it sounded like something I might be interested in. Our medical director sent back a reply something to the effect, "Gosh, that was quick." So I sent him back a reply explaining what I had just done and he replied that it sounded like this conference would be perfect for me. He is accustomed to other physicians taking days to reply to e-mail because they may only check theirs once a day and don't take advantage of all the features of a PIM like Outlook. I've come to like it but get frustrated at its idiosyncrasies at times just like Tom Syroid, right Tom? Almost forgot, then I entered the date in my Palm III calendar and now I will hot sync it with my home system so it is now recorded at the office, home, and the little computer in my pocket all the time. Some days I just love computers!

This afternoon was pretty uneventful, but long and busy. I saw a broad variety of patients, from people with back pain to someone needing a wart removed (I froze it with liquid nitrogen). Finally I was finished, as I said above, about 6:15 and went out to run in the rain. Unfortunately the wind is blowing out of the east also right now which made it windy and wet as well as cold. I was OK when running with my back to the wind but when it was in my face it felt much colder than 44 degrees(F). Nights like this, I really want to cut my run short but I managed to make it the full distance I had planned.

Finally I arrived home before Delanae who was trying out an aerobic kick boxing class at a local racquet club. This meant I had to fill and light the two kerosene stoves so the house would be warmer when she got home. This was accomplished with very little spilling of kerosene. Unfortunately, we got a message on the answering machine that our furnace would not be fixed until Wednesday since the part they had ordered would be in a day later than they thought this weekend. That means we have to get more kerosene tomorrow to use tomorrow night and Wednesday morning.

Now, I must go make myself some lunch for tomorrow and practice my bass for tomorrow night's worship team rehearsal. Hope you are warm and cozy where you are and I don't have to get up to a cold bathroom and house for more than another 36 hours.

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Tuesday January 4, 2000

Hurry up and wait! That pretty much sums up my morning so far. I get up and get ready to leave for the office and have to wait for Stephen to be ready to leave for school. Then we stop at the neighbors to give their son a ride to the same school and have to wait for him. Finally, I get to the office early to go and see a new nursing home patient and call to find out that he has not been admitted yet. Since I now have to wait again I decide to NOT waste time and immediately go and visit the other Daynoters sites. I feel refreshed now and can go on with my day. Try it, you might like it.

Things heated up this morning. After the above tentative start, I was running from room to room. It seems like everyone who did not get a flu shot this year is sick right now with the flu or a complication of the flu. I'm seeing bronchitis in smokers and sinus infections in people with a history of sinus trouble. Usually right after the first of the year, I see several people who are trying to quit smoking as a New Year's resolution but not this year. I imagine it is because so many of the aids to quit are now over the counter.

I also saw one of my Hepatitis C patients today who is doing very well. His liver function tests remain normal which means his disease is not very active at the present time. He is pretty paranoid that the Hepatitis C is going to become more active at any time so I spend a lot of time each appointment reassuring him that at least for the present it is not very active. We have seen the Hepatitis C epidemic slow down somewhat, at least here locally, and that has been reported around the country. Hopefully people are getting the message that sharing needles is a good way to acquire AIDS and Hepatitis C.

One patient I saw this afternoon illustrates a growing problem here. He moved here from Mexico and works in a local chicken processing factory which is fairly new in town. He speaks very little English and lives with another person who also speaks very little English. When he comes in we bring in a interpreter for him but he needed a referral to a surgeon after his last visit. We made the appointment for him but the surgeon's office called him directly instead of using an interpreter. They left him a message which neither he nor his roommate could understand so my patient missed the appointment. I found out about it today so rescheduled the appointment while he was in my office with the interpreter so he would understand. I know we told the surgeon's office before that he would need an interpreter but somehow that piece of information did not get to the person who called him and left the message the first time in English.

We have a lot of different nationalities who live here since we are on the West Coast and are a port city for ocean going ships. Caring for them can be a problem, especially with the language barrier. We have a good interpreter service here but things don't always go as smoothly as we would like. I find it interesting that there are a large number of Russians here, enough that there is a Russian speaking church that meets here. A lot of this area was settled by Swedes so there has been a large Swedish population here for more than 100 years both on this side of the Columbia River and on the Oregon side. Some of the town names on the Oregon side are Swedish and hard to pronounce for this person from the South and I still see people who speak mostly Swedish and heavily accented English.

Home tonight after 9:30 PM which gives me just enough time to compose this update then get things ready for tomorrow before going to bed. Hopefully, tomorrow my new nursing home patient will actually be admitted so I can meet him. I also need to visit some of my long time nursing home patients this week so I will be busy before and after office hours. As well there are the usual errands that need to be run to keep the household functioning as normally as possible. See you tomorrow....

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Wednesday January 5, 2000

Another long day which means short update. I am finally home to stay tonight and running out of time to do this and sleep sometime. Today was another more than twelve hour day if I count church services too, which I do. No drummer for our worship band tonight, we have to find a drummer we can depend on to show up for rehearsal and services. The rest of us are very faithful.

I did get to see the nursing home patient today that I was waiting to come in yesterday. As it turns out, he did arrive yesterday afternoon but I did not get the message until early this afternoon. The nursing home says they called my office and left a message yesterday afternoon but I never got the message. Anyway, he is a very pleasant 91 year old man who says he is in the nursing home only because he is constipated. The nursing home staff has already taken care of that {don't ask how} so he doesn't know if he needs to stay. He has the highest praise for the staff, says they really care and answer whenever he calls. He is upset at his former doctor who he says fired him for no reason. I suspect I will get the entire story in time but this gentleman is too weak and shaky to care for himself at home and his wife is too frail to care for him. For the foreseeable future he needs therapy to hopefully build up his strength and endurance so he can go back home.

Today was the day that one of my most frustrating diabetics came in for his three month checkup. I enjoy taking care of diabetics partly because the treatment of diabetes is very straight forward and lends itself to flowsheets and databases that can be created and used on a computer. Each diabetic patient is an individual, but the things you track are the same on each diabetic and the meds are pretty much the same for everyone with minor exceptions. Part of our electronic medical record being introduced in our group is a diabetes tracking project that will give us data on how well we do against published guidelines for diabetes care. I also find diabetes to be a fascinating disease, especially Type II or adult onset diabetes in contrast to Type I which has been called juvenile onset diabetes or insulin dependent diabetes. Type II is a more complex disease with several possible causes which may all be present in one patient. It is also on the increase and it is estimated that by the year 2010 one third of all patients 65 or older will have this type of disease. This is an astounding number especially when you consider that this type of diabetes is a major cause for heart attacks and the number one cause for kidney failure.

Anyway, this diabetic today is very overweight but refuses to follow a diabetic diet. He is on three different diabetic medications that do not have his diabetes in good control simply because he will not follow a diet or exercise, both of which are so important in treating diabetes. He told me today that he knows two or three people who have had amputations due to diabetic complication and he does not want to end up like that. I tell him that he needs to be in better control which we can only do if dietary control and exercise is added to his treatment regimen. If we can get him in better control, he stands less chance of needing an amputation in the future. He is still not willing to exercise any control over his dietary intake, says he is old enough he should not have to watch what he eats. I tell him he has three choices: 1) He can do what he is doing now and risk amputation in the future, 2) He can follow my suggestions and get his diabetes in better control without insulin, or 3) He can do what he is doing now, we can add insulin which will help his diabetes for some time but eventually fail and he may need amputation further in the future. He will mull on this until his next appointment in three months. My guess is he will not change his diet and we will have this discussion again at that time.

I had the opportunity to hear some Russian spoken today. One of my patients this afternoon spoke only Russian so a Russian interpreter drove up from Portland to interpret for him while he was in our office. The interpreter was about thirty minutes late because he go lost. He was very apologetic and embarrassed, saying that he was a perfectionist and he hated to not be somewhere at the time he was supposed to. I told him it was OK, no harm was done. The patient turned out to be a recent immigrant from the Ukraine and has rheumatoid arthritis. His wife works at the same chicken processing plant that my Spanish speaking patient yesterday works. There were no major language barriers after the interpreter arrived, but I realized I do not know any Russian words. I know a few Spanish words but was completely lost today when the interpreter and patient were speaking.

Tomorrow promises to be just as busy. I have to help interview a candidate for a nurse practitioner position in our group at noon tomorrow. Interviews are always a lot of work because we are trying to see if the candidate will be a fit for our group and the candidate is trying to see if our group will be a fit for him or her. There are always equal numbers of questions flying back and forth from interviewer(s) and interviewee. Our group uses several so called mid-level providers {physican assistants and nurse practitioners} to cover urgent care visits. This seems to be very popular on the West Coast but was not done near as much in the Midwest where I came from. I very much enjoy working with them and they take some of the load off, especially during cold and flu season, so the physicians can see the more complicated patients.

Time to publish this update to my website, then I will read a little bit in Dave Farquhar's book "Optimizing Windows for Games, Graphics & Multimedia" which just came today. Don't let the title fool you, if you run Windows and want to make Windows run as efficiently as it possibly can, even if you don't play games, you need this book. Run to your favorite online book store and order a copy NOW. Just tell them Doc Jim sent you <grin>. If you don't like it, ask Dave for your money back <bigger grin>.

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Thursday January 6, 2000

Today's update will be short, unlike last night's which got longer and longer. We are in the middle of an emergency pack and move things from the basement so the carpet can be replaced. This happened on the spur of the moment and has to be done by morning. It will be a long night. I promise details in tomorrow's post. Today was also very interesting at the office but you will have to wait until tomorrow to learn the details. See you later and hope YOU get some sleep tonight....

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Friday January 7, 2000

Now for a more normal post! Where shall I start? Personal stuff first, then office stuff, if you don't like that then scroll down to the office stuff, read it, then come back to here.

I had told you about the septic system backing up a few weeks ago and how that was fixed. Last week with all the rain we had, our basement took on some water through the foundation and soaked part of the carpet. This happened because the sump pump was not able to handle all the ground water and evidently has happened in this house before. We had called our homeowners insurance company when the septic backed up and they had promised to send out an adjuster to look at. Somewhere, the ball got dropped by the insurance company so we had to call them again and finally they sent out a "disaster recovery specialist" yesterday. He says the carpet is ruined and has to be replaced but could have been salvaged if someone, an adjuster, had come out earlier and found this out. He then told us he wanted to start at 7 AM tomorrow(today) and we needed to move all of the loose things off desks and light furniture items last night. He is taking up all the ruined carpet and ruined linoleum as well as scrubbing the walls, then will replace the carpet and linoleum with brand new, all paid for by the insurance company {minus our deductible which is $250(US)}. This will cost the insurance company several thousand dollars and could have been partly avoided if the ball had not been dropped by them but we are going to profit from this. We will now have new carpet in the basement which the people buying the house wanted us to replace anyway.

Back to last night though, moving all the "loose items" meant moving things like Delanae's computer and the other contents of her office. We spent until after midnight doing that without the help of our fifteen year old son who has come down with a sore throat and fever which looks to be viral in origin but not influenza. Delanae wanted her computer set up in the dining area rather than sharing my desk so I did that last night. The advantage of that is now she can use one phone line and I can use the other for Internet access. Stacey's bedroom and the upstairs are very crowded with things that are usually downstairs and will be that way for a couple of weeks until the new carpet is in. Our whole house looks like how I imagine Jerry's Chaos Manor looks, only worse.

Also today, our furnace is finally being repaired for good. They are having to replace the thermostat also since it shorted out when the furnace shorted out. All this repair work on the furnace is being covered by our home warranty which we purchased when we bought this house two years ago. Hopefully, now all the problems are fixed or will be fixed within the next couple of weeks and we don't have to smell kerosene fumes again for many years.

Today I also found out that my hospital privileges had been approved so my two year sabbatical is about to be over. Now I will go back to being on call and working some weekends but will have the opportunity to take a permanent day off every week. It should be either Friday or Wednesday, I'm voting for Friday if I get a choice. I will be gone from home more and may miss some updates if I am stuck at the hospital very late at night or all night. Still, all in all, I am excited about going back but will miss having fairly predictable hours, now I will have to work around a call schedule again. I really don't look forward to those middle-of-the-night phone calls which, by the way, Delanae says never woke her up. I can vouch for that, she used to wake up in the morning and ask me if I had gotten any calls after I had been answering the phone in our bedroom all night long. She can just sleep through many things that wake me right up.

Yes, we have heat without kerosene fumes!!!

Now for news from the office. The influenza bug continues unabated. Today and yesterday, I saw many people with complications of influenza like bronchitis, sinusitis, and pneumonia. The hospital is also very full according to my associates and there is some difficulty finding beds for all who need to be admitted. We are treating some nursing home residents at the nursing homes rather than in the hospital where they would normally be simply because of the bed shortage. Predictably, this is always the busiest time of the year for hospitals due to the influenza bug and its complications, especially in the elderly and chronically ill.

I am getting more and more opportunities to interact with the other physicians in town and will especially now with taking care of hospitalized patients again. I'm learning their particular personality quirks, especially the emergency department physicians. This is important since when on call we are victim to when and if they decide to call us about our patients they see. They can make your life miserable all night long if they want to get back at you simply by calling on EVERY patient they see, rather than just calling on the ones who need to be admitted or followed up on the next day. Yesterday, I got a chance to interact with a couple on the phone who I had not talked to much before. They were nice and I think we will get along well. I also met a new urologist who was very helpful so I will try to use him as much as possible. I still need to get to know the radiologists better so I can feel comfortable calling one in in the middle of the night if necessary. Unlike on "ER", we don't try to interpret all CT scans and MRI's without the help of a radiologist. I do go over all my x-rays after the radiologist has read them so I can keep my x-ray interpretation skills finely honed <g>.

Today I got to tell someone they do not have Alzheimer's Disease. She lost her husband at 77 years of age last year and has been more forgetful according to her daughter-in-law. The patient was also very concerned about having Alzheimer's because she recognizes that her memory is getting worse and she has also developed a tremor when she tries to do things with her hands. After some mental status testing and other specific neuro screening tests for Alzheimer's, I was able to tell her she had no sign of that disease. She was very relieved that it was only age related memory loss and age related tremor. I will be giving her a medication to help control her tremor since she is having some problems writing because of it.

I guess now I can tell two people they do not have Alzheimer's today. Hey Tom, you don't have Alzheimer's at the tender young age of 41. It sounds like stress related memory loss to me which is only temporary. If you are wondering what I am talking about, check out Tom Syroid's update for yesterday here.

Must go now. We need to move a couple of things before the "disaster recovery specialist" comes back in the morning to finish up. Tomorrow I need to enter a bunch of phone numbers into my Palm III for use when I am on call and I also hope to sit down in front of this computer with Dave Farquhar's book (see here) and use some of his tips to start optimizing it. Fair warning, be in front of your computer ready to start working when you pick up his book to read it because he has tips on literally every page beginning with page one and you will want to start taking advantage of these tips immediately. Until tomorrow......

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Saturday January 8, 2000

Late update again tonight. Spent the day first going over things with the cleanup crew here then talking about carpet replacement with the carpet installer. We are going to end up with one new room of carpet since the flooring in Stephen's bedroom downstairs will need to come up. The insurance company will replace it with carpet since the rest of the basement is already being redone. They will also pay to have the upstairs carpet cleaned since septic material was tracked on it by the repairmen. We will get a settlement amount then be able to pick out the carpet to replace what has been torn up already. This whole process will take two weeks or so, meanwhile we have barely room to walk with all the stuff from downstairs now upstairs.

While all this was going on, spent the day helping to do laundry and going through the first two chapters of Dave's book "Optimizing Windows for Games, Graphics & Multimedia". I have made changes to my system based on these two chapters and it has helped my system's performance. I did have to change my virtual memory settings back to the default however. After changing them according to Dave's method, several applications including Outlook would not run saying there was not enough memory and DLL's were corrupted. I changed back to the default virtual memory settings for Windows 98 except kept the swap file on the new partition I created for it and everything works fine now. I plan to ask him what I did wrong. Otherwise, everything worked great, I am sure I missed something and set the wrong virtual memory settings. This geekfest, or so Dan Bowman calls it is going to take quite some time as I have only gotten through most of three chapters. I till have to optimize my root directories on each of my partitions and my Windows directory before I can move on in the book. After I get my system humming along then I will tackle my wife's system, she is complaining about how slow it has gotten. It wouldn't be the wallpaper she uses or the screensavers she has to have now would it?

Tomorrow will be another busy day after church. I still have some more phone numbers to enter into my Palm III, I have to do the optimization as outlined above, there is more laundry to be done since the flooring in the laundry room has to be cleaned Monday, and I need to get ready for a busy Monday at the office starting with a Leadership Council meeting at 7 AM. See you tomorrow........

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Sunday January 9, 2000

Still haven't gotten back to the book, but most of the rest of the things on the list have been done. All the laundry is finished so the cleanup crew can now do the laundry room floor tomorrow which should finish what they have to do until it is time to install the new carpet. We will be picking that out, hopefully next week, and then it will be installed. After that, they have to clean the carpets upstairs and the house cleanup is then finished.

My virtual memory settings on this computer are now appropriate and the system is working great. Dave Farquhar helped me with the settings which I had wrong. You can ask him questions about optimizing Windows here which is an expert roundtable on If you need to enter the number of the roundtable it is 47803. Tell Dave that I sent you and he will treat you real nice <G>. I have much more to do, still haven't gotten to optimizing my Windows directory or the root directories on each drive. Maybe I will have more time to do that after supper.

Not much medical to report today since it is Sunday and I am not on call. I should say the only thing to report medically is about my family. Stephen is getting over his bout with this upper respiratory virus and will go back to school tomorrow although he missed church today. Stacey and Delanae still have shown no signs of coming down with it. I talked to my mother tonight who says she has walking pneumonia, according to her doctor. Walking pneumonia simply means that she is well enough to not need hospitalization, that she is doing well enough that can "walk" around with it although she is supposed to be resting most of the time. This is more difficult for her since she is a widow and lives by herself back in Arkansas. My brother and his wife live about 120 miles away and will be able to keep an eye on her.

Tomorrow I should find out when I will be taking call again after two years of no call. I am NOT looking forward to that part of returning to hospital practice. It is necessary, however, as it comes with hospital responsibilities. I know there will be some happy associates of mine now that there is one more person who will be taking call, especially since one physician is leaving in March to move closer to their family in British Columbia. We may recruit one or possibly two physicians to replace him but that decision will be made by those of us on the Leadership Council beginning tomorrow morning.

Optimization and supper are calling, so until tomorrow.....

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