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Doc's Progress Notes

Week of January 10, 2000

Last Updated: 1/16/2000 at 9:41 PM PST

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Monday January 10, 2000

Mondays seem so long, especially when they are. I had a meeting at 7 AM so I left home at 6:30 and just got home now at 9 PM. The meeting was fairly non controversial with no big decisions to be made. We mostly talked about expectations of clinicians in our group as far as being up-to-date on their clinic and hospital records. This seems like a reasonable expectation but human nature being the way it is, some people will try to get away with not being on time with their record completion. If they continue "living on the edge" too long, they will find their compensation cut in the future.

We also heard an update on negotiations with the union allegedly representing the nurses and medical assistants in the hospital and our offices. The reason I say allegedly is because the general membership just rejected an offer that their bargaining team had urged them to accept since they had gotten concessions from the hospital administration on the issues they thought were important. Less than 60% of the members voted however, so I wonder how representative that group was. The bargaining team gave the general membership no time to review the agreement before voting on it. Is the bargaining team really representing the general membership? This could get real ugly, informational pickets are next. This is a union part of the country but this union is really making some unreasonable compensation demands or the general membership is because the bargaining team says something different. Stay tuned for more on this situation.

After the meeting, it was on to the office. Today's theme in the office seemed to be acute pain. Everyone who came in seemed to be in acute pain. This is draining on me emotionally because it is hard to stay positive all day with everyone when they are bitterly complaining about pain and want something done to cure it RIGHT NOW! In many of these people today, I could not CURE the pain today but I could help relieve it with medication until it could be cured. Some people's body language said they didn't believe me, that I must be holding out on them when I said there was no cure right now. Sometimes the cause is a mystery and requires time and several people to unravel that mystery. Understandably, those people want relief right now and relief that will last so I spend a lot of time explaining what we need to do to find out the answer.

Other than the patients with acute pain, two patients stand out in my memory. The first was a 27 year old female who had been injured late last week when her boyfriend/significant other threw her against a wall injuring her neck. I had seen her previously and found out she was being emotionally abused by him and had advised her to leave at that time before it became physical abuse. Predictably, she went back to him and luckily has no permanent injuries as a result of this attack. She has gone back to live with her mother for the time being and I hope she doesn't give him a second chance to seriously injure her. I have known women who have been injured like this by their significant others then got back to them and married them. All of them have been abused again after marriage by their husbands and have ended up divorcing them, most of the time after having children with them. Am I down on spousal abuse? Yes!! I am usually in favor of giving people a second chance, but I have a hard time with men who abuse their wives/significant others. I just want them to suffer more physically than their targets did. I know this attitude is not politically correct but politically correct methods to deal with spousal abuse are not working all that well. I see too many repeat offenders.

The other patient was a six year old boy who his mother had brought in because of enuresis or night time bed wetting. Predictably, he was not doing it during the day and was a very heavy sleeper. There was nothing wrong with his urinary tract or nervous system, he simply does not wake up yet when his bladder is full. I explained to the mother that he would eventually grow out of this but if he was not staying over with friends because of embarrassment then we could treat this one of two ways. One was to place him on a medication delivered by nasal spray at bedtime that would help prevent him from being able to empty his bladder while asleep. The other was so called behavioral therapy which involves an alarm to wake him up when he begins to urinate in the bed. By waking him up each time, his brain learns to arouse itself quicker when it feels the sensation of a full bladder and he will eventually wake himself up before he urinates in the bed. This method takes several weeks to become successful. After talking with both the mother and the boy, they elected to go with method number one but will try to take him off it every three months to see if his natural development has eliminated the need for the medication. We don't even discuss treatment of this problem if the child is under six and after that only if the child is very embarrassed by their enuresis problem.

Tomorrow I meet with out medical director to iron out the details of my call schedule and other issues now that I am back on hospital staff. I will start seeing patients in the hospital again this coming Thursday. We will also work out what my day off during the week will be. I am hoping we can decide on Friday, probably the other alternative will be Wednesday. I would be very happy with Friday but could live with Wednesday. It will be nice to have at least part of a weekday again to run normal errands and do things like get a haircut without having to leave the office early. Wish me luck on getting Friday. I will let you know tomorrow, hopefully.

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Tuesday January 11, 2000

A little excitement coming home tonight! Thought I would start with the most exciting thing that happened today then tell you about the more mundane. We've had rain mixed with snow here since last night but today has been mostly rain. Driving home tonight after our mens meeting and running, it was raining and 37 degrees(F) until I started up the hill we live. Our house is just a little more than 500 feet above sea level while the area I was coming from is at sea level. As I began to climb, the rain started turning to snow which was coming down fairly heavily. I am driving a rear-wheel drive car and my wife is driving the 4-wheel drive vehicle at her request but the road is clear and not slick. However, as I turned to go up the final 40 yard hill to our house I realize that this section of street is covered with snow as very few vehicles have been on it. I decide to press ahead but cannot get up a lot of momentum because I have to turn a fairly sharp corner to go up the street to the house.

About halfway up the hill the car stops going forward and tries to slide down backwards. The brakes work to stop it, luckily but it begins to slide sideways. I manage to slide down a little way at a time almost sideways but before it gets to the bottom of the hill I get it turned 180 degrees around, without going into the ditch on either side of the street. {I have managed to put a 4 wheel drive vehicle in the ditch before} I am now going forward again and can stop at the cross street I had turned off of to try and go up that last section of hill to our house. I park the car in a neighbor's driveway after asking him permission to do so and then walk up that hill to our house. Tomorrow morning, Delanae and I will have to drive down the hill in our 4-wheel drive vehicle and then she can drop me off at the office since I don't really need a car during the day. Hopefully, the snow will melt off tomorrow in the rain and I can get the car back up to the house tomorrow night.

Compared to the above adventure,the rest of the day was pretty mundane. We still have influenza here, so I am still seeing a lot of acute influenza as well as complications from influenza. I did find out today that a 40 year old female patient of mine had a heart attack over the weekend. She came into the hospital after having chest pain for almost 24 hours thinking it was only the flu. Imagine her surprise and the emergency physician's surprise when tests revealed that she indeed was having a heart attack. She is now in Portland having an angioplasty done and a stent placed in her one blocked artery. Angioplasty is a procedure where a balloon is inflated inside her blocked coronary artery to open it up again and a stent is like a spring that is inserted into the dilated part of the artery to hold it open afterward. This is an unusual case because it is a woman before memopause, made more unusual by the fact that she has a cholesterol of 180 which is normal and has no history of high blood pressure, diabetes, or any family history of early heart disease.

Before someone asks, her LDL was 83 as I recall; this is well below the level we want it to be for someone who is at high risk for heart disease or has a history of heart disease. LDL stands for low density lipoprotein and is one part of what we call the total cholesterol which is what is normally measured during cholesterol screening. The LDL molecule is actually what deposits in the walls of the coronary arteries and leads to the blockage that causes a heart attack.

I did get to congratulate a patient on a job well done today. He is a diabetic who has managed to bring his diabetes into great control through a combination of exercise, dietary changes, and one medication. He is an example of what I always preach to diabetics, that they can control their disease if they will make some fundamental lifestyle changes. With those changes, they may not even need medication. He has managed to bring his glycohemoglobin (a blood test that measures diabetic control) down from 8.8 to 6.5 which is exactly what the American Diabetes Association recommends as a target for the control of diabetes (actually they only recommend that the glycohemoglobin be less that 7.0). Notice that I said he brought it down, I cannot do it with medication unless the diabetic patient is willing to change his or her diet and start exercising. I don't get to congratulate diabetics like this often enough.

I still don't know for sure what day I will have off weekly. Our medical director still has to look at the office schedule and decide later this week. It will be either Wednesday or Friday with Friday as my preference. I will start rounding in the hospital Thursday morning but still don't know when my first call night will be. The call schedule is set through at least three months but I imagine that I will be included in it long before three months from now. Tomorrow I go through the orientation that all new physicians at the hospital go through so we know where things are, like medical records and the doctors lounge. I will also get the ID badge that allows me entrance to the intensive care unit and surgery. More on this tomorrow night.

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Wednesday January 12, 2000

The roads are clear tonight, so I was able to drive my car back to the house and put it in the garage. I should be able to get it down the hill tomorrow, even if we have the snow tonight and in the morning that is predicted; 4 wheel drive is not needed to get DOWN a hill. By Friday, we will have just rain which will melt off any left over snow on the roads. No snow yet tonight, should come in after midnight.

Wednesday will be my day off according to our medical director. That will provide better coverage for the clinic and allow people to take a three day weekend on occasion. I already have next Wednesday off to go to Portland to have my car serviced so my regular Wednesday off will probably start the week after. My medical assistant has Friday off now and wants to keep it so I will be working with a different medical assistant on Fridays every week. We helped train her when she was first hired so she knows how I like to do things. In most medical offices, the medical assistant's day off is the clinician's day off. Not this group however, something to do with what they negotiated with the union representing the medical assistants. I can live with the arrangement, though.

I am now official, having gone through the short orientation that all new members of the medical staff at the hospital here go through. I now know the code to get into the physicians lounge, I have been given the talk by medical records about how to dictate on the dictating system (which is digital by the way), and I now know where the charts that need my signature will be kept in medical records just waiting for me. I also have a new pager now; it is a display pager that can accept e-mail messages as well as silence itself during the hours that you program in as "private". The instruction book warns, however, that if you try to program in more "private hours" than "on hours" it will automatically reject the number of private hours. It can't prevent me from turning it off though.

Tomorrow morning, I will round with one of my associates so I can learn my way around the hospital a little better. She also makes up the call schedule and will be putting me in a few nights over the next two months but will not have a weekend until April probably since the weekends are already scheduled until then.

Things were much less hectic in the office today. I had several new patients who wanted physicals but did not have a lot wrong with them. I confirmed that a lady had diabetes today and referred her for dietary instructions and instructions on how to check her own fingerstick blood sugars so she can learn to monitor her own disease. We will treat her with diet and exercise for 3-6 months to see if she can control her disease with those simple lifestyle changes and not require medication.

I also saw a 92 year old lady with end-stage emphysema who is not eating due to loss of appetite and is just tired of being sick. She is ready to die she told me, she just wants me to keep her as comfortable as possible until that day comes. I promise to do my best to keep her comfortable. She's not sure she will come back to the office to see me, doesn't know if she will be strong enough again to come. I will offer her a liquid supplement such as Ensure to increase her calorie and protein intake but will not force her to take it.

My success story of the day was the patient who I had sent to the hospital back in September with congestive heart failure that I feared would leave her unable to live at home again. She was back in the office today after undergoing rehabilitation in a nursing home and is now able to go home again and live by herself. She is even able to start walking for 30 minutes again without a lot of shortness of breath. She is very happy to be going back to her own home and I am very happy for her. She will require monitoring monthly for the near future but looks so much better than the last time I saw her.

I will close tonight with a letter about my comments regarding the union negotiations in Monday's post. My answer is after the letter.


There are many variables when negotiating a Union contract. The first thing the committee must do is find out what the membership wants. This is usually the earth and the heavens. Then the committee must ask "What do you REALLY want?" And so on and so forth. Meanwhile, the committee must move forward with management. Look at it this way. You have no work stoppage yet. They just read their membership wrong or there is a "Rebel" group among them. I have been on negotiation contuse for the past six years -- and I am proud of the accomplishments we have made.

The simple fact is the "workers" have desires, just as the "Bosses" do.

John D. Vogt

Points well taken. I did not go into a lot of detail about the negotiations since I am not involved in them. I spoke only as an outsider looking in. I do not believe that the negotiating team for the union really knew or knows what the membership truly wants. Of course they are asking for the "stars", I am just not sure that they know what to settle for.

A work stoppage by nurses scares me to death. Nurses are the most important people in a hospital but have to also understand that the hospital cannot possibly pay them all they think they are worth anymore than I can be paid all that I think I am worth. The union will have to compromise on their demands, so far the negotiating team for the union does not know what they will compromise for.

Thanks for writing, I may publish this discussion tomorrow if it is OK with you. {It was.}

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Thursday January 13, 2000

Being back in the hospital was fun. I had hoped that would be true and found out today that it was. The two year sabbatical was good for me, my batteries are recharged and look forward to taking care of patients in the hospital again. I know I will be a little "rusty" at first but I found out today that the knowledge is still there and comes back quickly when I need it. Admittedly, I have not had to answer the phone in the middle of the night and give orders yet but I am encouraged.

My associate took me around the hospital this morning and showed me where the important things like bathrooms are. We can't use the patients' bathrooms so need to know where the more private bathrooms are on each floor. I also got to meet a lot of nurses who knew my name but did not have a face to go with it; some of them I had seen as patients in the office and were happy to see me in the hospital. Others had heard my name from patients or family members and were looking forward to meeting me. I still have to meet a lot of the radiologists and emergency physicians who I will be working closely with.

Finally, I went to see my first hospitalized patient after office hours tonight. It really felt good to be able to go back into a room, sit down beside his bed in a chair and talk to him about his hospital course and how good the nurses were treating him. This particular man just had part of his large intestine taken out because of colon cancer and is still recovering from the surgery. He is doing very well for two days post surgery and is to the point where he is hungry again. He jokingly tried to trade some of his pain medication for some toast from his roommate. His roommate knew better than to give him anything to eat this soon after surgery but they were still laughing about it when I was talking to him. We will see tomorrow, probably, if his cancer has spread outside his colon, if it has microscopically then his chances of cure are much lower than if it has not. This will also determine if he needs chemotherapy or not.

My first call night is not until next month. This will give me a chance to get better acquainted with the hospital layout so I don't get lost in there late at night (or anytime, for that matter). Then, I have one call night in March. I won't have a weekend on call until April at least, which is fine with me. Weekends are much more exhausting than weekday nights, usually. Our group does have two people in the hospital during the day on weekends which helps reduce the load some for the person on call.

Today was fairly busy at the office. This morning was more busy, every room it seemed I was not going to be able to get out of in a reasonable time. Then, I had someone with back pain come in and demand to see me and proceed to try and stand over me in the hall. I took him into a room and forcefully explained to him that I did not appreciate anyone looking over my shoulder or following me around without my permission and he was violating the confidentiality of the other patients in the office which I would not tolerate. Obviously, he is accustomed to getting what he wants by being very pushy but after my speech apologized for his behavior. I did take care of him and explained to him that if he had simply done what my medical assistant asked him to do (wait in a room until I could talk to him) we would not have had to have any confrontation.

This afternoon I got to see my almost five year old triplets for their regular annual well child exams. I first met them and their mother right after I moved here two years ago. She is a nurse in the hospital and we got along great right from the start. Her husband has since installed a garage door at our house as part of his business and has become a patient of mine also. The triplets are growing normally and are developing their own unique personalities but the parents still have their hands full with them. It will be interesting to see how they interact with each other as they get older, especially when they hit adolescence. I kiddingly told their mother that I already had her tranquilizers ready for when they became adolescents.

I did leave three disability physical forms on my desk to fill out tomorrow. Those forms may be the worst we have to fill out. Each company or government agency seems to have their own unique version and ask different questions. Essentially they want me to find a reason that they don't have to pay the patient his disability check so I can be blamed for their refusal to pay. Since most of these patients were disabled before I saw them, I have to try and find out all the information that is needed again and fill out the forms. I will try and finish those forms tomorrow during my spare moments throughout the day.

Now, must go eat something, read the other Daynotes pages that I have not gotten to yet today, and watch ER as well as make my lunch for tomorrow. This weekend, I have plans to change the format of this page to perhaps make it easier to read. I am going to put my most recent update at the top of the page rather than the bottom. I have found that I like that format better than what I have been doing as it makes it easier for the reader to quickly get to the most current update. See you later....

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Friday January 14, 2000

Short update again tonight. Today was consumed by various and sundry things so not much time to write. Busy at the office again and my patient continues to recover well from his colon surgery. I did most of the disability forms I told you I had left on my desk to fill out today, but left one to do Monday.

I got finished about 6:15 tonight, then went out and ran. No rain for a change although it did start raining soon after as I started driving home. Then, we had a realtor come by to have us sign an agreement with her to list the house if our present offer falls through, which it looks like it will. The couple who made the offer have had no one looking at their house which has to sell before they can close on this one. They will still have the right of first refusal on this house until their offer runs out in 90 days. This way we have a backup plan if they don't go ahead and close the deal.

Now I am going to sit down with Delanae and watch a movie she rented. Tomorrow I will write more about today at the office and more about changing the format of this page. I may decide not to change it, after all and I will share with you why tomorrow. Have a good night.

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Saturday January 15, 2000

I slept in this morning until almost 10 AM, which isn't that bad considering we went to bed about 1 after finishing the movie. I needed to catch up on a little sleep anyway and had no appointments until 12:30 when I get my hair cut. In a couple of weeks I can start scheduling routine tasks like that for Wednesdays again, except I don't think the person who cuts my hair works on Wednesdays. Some tasks I guess I won't be able to change.

The flu seems to have really hit the Daynotes Gang hard. Several are not publishing right now due to being sick. I can sympathize with them from having seen so many with the flu in the office and how bad they have felt. Maybe I need to advise them to get a flu shot next fall since being one of the Gang seems to make one more susceptible to the flu. Maybe it is all the visitors from around the world who visit their sites daily; one may have the flu and pass the virus to that site. </joking mode> By getting an influenza shot next year, like me, they will protect themselves from the flu.

I just heard, from my family, who are watching the news, that David Letterman had a quintuple bypass last night as an emergency procedure. That means he had at least five separate blockages in his arteries around his heart (coronary arteries) and needed all five of them bypassed to restore blood to his heart muscle. With that many blocked areas you can't dilate them all open with a balloon, they have to be bypassed. I would guess he began having chest pain then had an emergency angiogram which revealed the blockages and immediately was operated on. That probably saved a lot of heart muscle from being permanently damaged if he went on to have a heart attack. I am guessing here you understand because I haven't seen or heard any news report yet. If this is a hoax then consider it a possible scenario. A similar thing happened to my father about twelve years ago now and he ended up having five bypasses as well. Only, he had a small heart attack before he got to the hospital so lost some heart muscle before he could be bypassed

Must go now and run some errands. I will post some more this afternoon or evening sometime.


I'm back, later than I had planned but here I am. Spent most of the afternoon optimizing my root directory and Windows directory per Dave Farquhar's book "Optimizing Windows for Games, Graphics & Multimedia". Time consuming but very effective I am sure. So far, everything is running fine and perceptibly faster. This is only chapter 3 by the way, so much more to go. I still need to optimize the root directory of my data partition and when I am done with my system start on Delanae's. Hers has less memory than mine so really needs to be optimized even more. The book continues to be highly recommended.

Friday at the office was memorablebecause of one patient. He is a patient, actually, of my associate with whom I share an office in our building. He came in one day after being seen in the Emergency Department because he was coughing up a little blood and had been diagnosed with bronchitis because his chest x-ray was negative for pneumonia or tumor. When I saw him the next day he had had a nosebleed earlier in the day and was coughing up blood again afterward. This is normal and sure enough he stopped doing that for a few days, but began coughing up a little blood again. He came in and saw my associate this time who talked to me about what to do. We decided, since he is a smoker, to send him for a bronchoscopy which is when a flexible scope is inserted into a person's windpipe then down the breathing tubes into each lung. It has fiberoptics in it which allow us to see the inside of the bronchial tubes either by direct vision or on a monitor. This bronchoscopy showed that he had a tumor mass in one bronchial tube which had not been seen on the chest x-ray. I don't know yet why the tumor was not seen on the chest x-ray but will be talking to the radiologist and pulmonologist involved with the case. The take home lesson from this patient is always be suspicious when a patient doesn't respond like you think they should. My associate and I went over the case again and agreed there was not anything either one of us would have done differently.

Finally, I have not decided how I am going to change this page yet. As you may recall, earlier in the week I had mentioned that I was going to change to a format with the most recent update at the top. Well, Svenson sent me the following message wit his usual concise analysis of the pros and cons of doing that.

-----Original Message-----
From: Jan Swijsen []
Sent: Friday, January 14, 2000 5:09 AM
To: Doc Jim
Subject: most recent at top

>I am going to put my most recent update at the top of the page rather than the bottom. I have found that I like that format better than what I have been doing as it makes it easier for the reader to quickly get to the most current update.

If you visit each day putting the most recent at the top is in deed easiest. If you don't read each day it becomes bothersome. Either you read from the top of the page downward, which is not chronologically. Or you go down to the first day you missed, read it (rolling down) than you must go back up to the next day, rolling down while you read that, going up for the next day, etc. Putting the daylinks (now at the top only) at the bottom of each day alleviates the problem somewhat (well greatly).

(Brian did that the first few weeks, Marcia ( ) does it now).


And here I thought that everyone read my page daily.<g>

Good points, as usual. I knew that having experienced it myself. If I do change to having the most recent at the top, I will put the daylinks at the end of each day as you suggest. I may change my mind again, however, and just leave well enough alone. I'm just in the mood to do something different right now. I've even thought of doing it the way you do but I don't think I am ready to learn how yet.

I think I will just sleep on it tonight. Tomorrow is another day and I may have a decision on it by then. I need to do some more optimizing on this system tomorrow (WARNING: Dave's book is very hard to put down!) and start on my wife's computer. My eleven year old daughter now has her own e-mail address and is making noises about wanting her own webpage. We need more computers and a home network before we drive each other crazy!

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Sunday January 16, 2000

Not a good day for computing. We had a windstorm here today with gusts to 60-65 mph in town and up to 90 mph at the coast. We were without power at my house for several hours this afternoon which of course meant no computer. I know some Daynoters have leftover generators from Y2K preparation, but I was not one of them so we had no power and therefore no computer. Delanae and I took the dogs and went for a long walk around the area, enjoying the feel of the wind and feeling the excitement of a storm in the air. We both miss that electricity (not lightning) in the air when a storm was about to hit in the Midwest. We just don't have that here most of the time. One of these days we hope to go to the coast and get a room there to spend a day or two when a big storm is coming in, just to see the ocean and its power stirred up by a storm.

I'm still catching up on things that did not get done earlier today when the power was out, as well as resetting all the clocks in the house. Just finished my twice weekly Quicken update and still have to get everything ready to take to work in the morning. The kids don't have school tomorrow (Martin Luther King's birthday is a holiday for them) so I don't have to worry about taking one of them to school before I get to the hospital. I do have to take Stacey to the orthodontist office tomorrow at 1 PM and have them give her the very stern lecture about brushing her teeth better, somehow when it comes from her parents she is not as impressed as when it comes from the orthodontist.

I just realized that due to the power outage, I do not know who won the NFL playoffs today. Excuse me for a minute while I go check out and find out who won. There, now I'm back and surprised to see that Tennessee managed to beat the Colts and St. Louis handled the Vikings. I thought the Vikings were on a roll now and might be hot enough to beat St. Louis. Next week's games should be very good and, barring another power outage, I will be watching them.

Also, I have not done anything about changing the format of this page. I still have not decided what to change to and did not have any time today to play with different formats. So, next week expect to see the same format as I have been using since I started this journal. Svenson is sending me the code he uses to do his one day at a time journal but it uses frames which I do not know if I am ready to tackle yet.

One other problem has emerged today. The ISP we use has had e-mail problems for the past few days, mine has been getting in and out OK but others e-mail has been having problems it seems. Anyway, somehow the mailing list address that the ISP uses for all its customers got included as the reply to address in a message to someone and since then there have been e-mails bouncing around to all their customers. Every time someone simply replies to the multiple e-mails they have gotten by mistake, more messages bounce. I had close to sixty in my inbox today, some of them very irate, asking what was happening. One person besides me had already surmised what had happened and had sent messages to everyone telling them to just "cool it" and quit replying to all the bounced messages since they were just producing more messages to every customer. Don't know yet how a supposedly "blind" address got included in the header of a message. The ISP has some very mad customers to soothe over the next few days. I just want to get a connection faster than 26.4k some day from them or someone else.

I have now used up my allotted time for journal update tonight. Therefore, I will say good night and see you LATE tomorrow.....

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