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Doc's Progress Notes

Week of January 17, 2000

Last Updated: 1/23/2000 at 8:14 PM PST

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Monday January 17, 2000

It's a new week again. I began this Monday by going into the office early to make hospital rounds. I did not have to take my son to school since he was out of school, so I did not have to wait for him to get ready. As it turned out, the only patient I had in the hospital was the man from last week who had part of his colon removed because of colon cancer. He is doing very well postoperatively and will probably go home tomorrow. I was able to do some more exploring in the hospital to find some more back ways to get places. This is the only Monday of the month that I do not have a meeting at either 7 or 7:30.

After that, it was on to the office to catch up on phone messages and e-mail before I started seeing patients at 8:30. Everyone showed up this morning; most seemed to have complications of the influenza still going around. I did see two people who I think have new Influenza infections which began over the weekend so I put them on anti-influenza medication. The rest had varying complications ranging from sinusitis to bronchitis.

Unfortunately, two of my pain patients seem to be having problems. One is going to be operated on for a ruptured disc in her upper back either this week or next week. She is having increased pain and needing more medication. She is the patient whose sister had called in before pretending to be her and asking for more pain pills so we naturally get a little suspicious when she calls needing more pain medication.

The other patient is more of a problem. He has already changed a prescription that I wrote him for pain medication and now is wanting more and calling other physicians in town trying to get more. He never tells the other offices that he is getting pain medication from us, just that he needs more pain pills. That is a direct violation of our contract to give him medication so tomorrow I will have to tell him that I can no longer prescribe him any pain medication. He had agreed in writing to only get pain medication from our office and in exchange we had agreed to provide prescriptions for the medication he needs. Evidently he has decided that we cannot give him enough or is selling it and making extra money on the side. Either way, he will have to find someone else to get the prescriptions from. I don't enjoy refusing people but he is not leaving me any choice this time.

At noon today, I took my daughter to the orthodontist where they gave her a scolding for not brushing her teeth well enough with her braces on. We can't seem to get through to her the importance of thorough brushing, but hopefully the orthodontist was able to. I ended up being almost thirty minutes late getting back to the office so I was late seeing my first patient of the afternoon. My nurse had already warned her that I might be late (I had asked her to do this) and thankfully the lady was not upset about how late I was. I explained to her exactly why I was late and that was good enough for her. When the orthodontist appointment was scheduled I thought I would have enough time to get back to the office and not be late. But, things don't always work out the way you plan.

Later this afternoon, I got the schedule for weekend call through September. Once again, my life is being scheduled for me by someone else but at least it is not as often as when we lived in Arkansas. I am not on call July 4th, Labor Day, or Memorial Day although I have the weekend before Labor Day. I cannot complain too much, having had no call for two years. There is one weekend I would like to trade for another weekend already so I will be working on that over the next few days.

That's about all for today. Not a lot going on today but that is subject to change at any moment. Before I go let me correct something I said yesterday. I had mentioned that the coast here was expecting winds of up to 90 mph yesterday, one town on the coast recorded a gust of 115 mph yesterday. Thankfully, all the downed power lines have now been repaired and everyone affected by the storm now has power again. Until tomorrow.....

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Tuesday January 18, 2000

Long day, short post. Today was consumed by giant locusts, or some such animal, again. Don't know where the time went. I just got home after worship team practice and a long day at the office. I'm having a hard time remembering who I saw today which means I am tired. I am off tomorrow and will be in Portland to get my car serviced. I should be able to write something more meaningful tomorrow after I have had some rest. Good night.

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Wednesday January 19, 2000

Sorry about yesterday, just too much going on to write much. As it turned out, I did not get much rest last night, after all. Delanae and I stayed up until 1 AM talking then I was up at 5:30 this morning.

I got up to go in and check at the hospital to see if I had any patients in who had been admitted overnight. I did not, so then I headed to Portland to have my car serviced and get the CD changer repaired so it would work again. Traffic was moving very slowly between Longview and Portland due to the freezing fog and some slick patches on the interstate. What should be a 45 minute trip took just over 1 1/2 hours but I got to the dealer in time for my appointment.

Once there, I got right in and asked them to do the routine oil change and see if they could repair the CD player and changer. They got the oil changed and washed the car as a bonus but told me the CD changer would have to be replaced again (this would make the third one for this car in six months). I said I did not think I should have to pay for it since it was less than six months old and they said I would have to go to the other dealer where I bought the car and talk to them about that part. I said fine and proceeded to get into the car to find that the radio was displaying an error message, actually it displayed CODE. This means that I have to enter a code to unlock the radio to get it to play. I asked how that got there and they said maybe the power to the radio got interrupted when they were checking the CD changer, which is in the trunk, by the way. They also said it could be the battery but I have had no problems with the car turning over quickly when the ignition key was turned so I though that was an odd worry.

I ended up taking it to the other dealer who said the reason for the CODE message was because the first dealer had removed the faceplate of the radio and in order to render it unable to be used if stolen, the radio will not play until the code is entered after this happens. To make the radio play again so the CD player could be checked the ignition has to be in the ON position for one hour and then the code entered. That meant I had to wait for an hour before they could even find the problem. They finally gave me a loaner car to drive around Portland so I went and got something to eat and then browsed around Powell's Books to see if they had all the O'Reilly books so I could add some more to my collection. Well, I went to the main store which occupies an entire city block but their technical books are in another location and my map of Portland was in my car back in the shop. I spent my time instead just browsing shelves seeing some very obscure books. I will have to find the technical book store another time.

Anyway, I go back to the dealer three hours later and they have indeed replaced the CD changer with a reconditioned model which they swear checks out perfectly. I do not have to pay for the CD changer or labor and they tell me to call them right away if this one malfunctions. You can be sure I will do just that if this one begins to give me disk error messages which is what the last one did, then would not read the discs at all. That sounds just like a computer, doesn't it?

I get home in time to pick up Stephen after school and bring him home then I just have time to run before going to church. Now, here I am doing this update while trying to keep my eyes open and concentrate long enough to finish. I did get an e-mail from a friend who used to live in Harrison and moved to Omaha before I left Harrison to come here. His mother-in-law was a patient of mine there and developed Alzheimer's Disease several years ago and has been in a nursing home now for at least 4 years, I think. Anyway, he just sent me a message saying she is not eating or drinking any and is not expected to live much longer. The family is at peace with her impending death but they are never fully prepared for the emotions that come when it finally happens. He thanked me for taking care of her and I will e-mail him back my condolence. This is one of those times that I wish I could be there to help comfort the family especially since I know them so well. That is not to be, however, and my prayers go out to them.

Now, I really must go to bed. Tomorrow promises to be a long day starting very early in the morning. We also need to have a family meeting tomorrow night and discuss some things which I may tell you about in my post tomorrow night.

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Thursday January 20, 2000

"Whose Line Is It Anyway?" That's the name of a very funny TV show which I just watched with my family. Basically, four comedians are given skits to act in on the spur of the moment and have to come up with their lines as they go. This leads to some very funny lines and lots of physical comedy. This is the first time I had seen it or heard about it. It was on the ABC television network at 8 PM PST if you are interested in catching it in the future and if you like slapstick comedy I highly recommend it. I wonder if this is old hat to a lot of you out there because I don't watch TV so I don't know much about what is popular anymore except for ER.

Our house is now officially listed by a realtor. Before, we had it listed as for sale by owner but a realtor has convinced us that we can get just as much out of it by listing with her. We have told her that we will not sell it for less than a certain amount and she says she understands and can live with that amount. We will see if this helps us move it or not. We do have an agreement with another couple to buy this house but that agreement runs out Feb 20 and is contingent on them selling their current house. This contract looks like it will expire since they have had no interest whatsoever in their house. We will have to repay them their earnest money and they can still come back and buy this house without going through the realtor if they can sell their house before we accept an offer from another family.

So far, so good. The new CD changer in my car is working perfectly and it is great to have CD quality sound back when I am driving. Svenson sent me a message suggesting that my problem with the CD changers may be that vibrations from the car are causing the alignment mechanism to fail. This happened to someone he knew and by moving the changer the problem was cured. My CD changer is in the trunk and mounted under the rear window but German engineers designed the rest of the car with few mistakes so I hope this isn't a mistake by them. If this changer goes bad I will suggest that the location be moved and see if that solves the problem.

The nurses at our hospital are now doing informational picketing. They are carrying signs and marching outside the hospital but there is no work stoppage and they are not trying to stop anyone from crossing their lines. They have to give the hospital 10 days notice before commencing a work stoppage (a strike) as I understand. So far, we have had no announcement that they have given ten days notice. They were supposed to vote on another proposed contract offer today but I have heard no news about it yet. They do not want to have any "mandatory overtime", or so they say. This is a term describing what happens if an incoming shift doesn't have enough nurses to cover all the patients and some are asked to stay and help out the incoming shift. Since one cannot perfectly predict exactly how many patients a unit will have before every shift, there will always be emergency needs for more nurses to work a shift just like sometimes there are too many and some get sent home. That is the nature of the healthcare business and the hospital has agreed to overstaff each shift then send the overflow home. This is not enough for them, they want the guarantee that they will NEVER have to work overtime, even if there is no one else to work. If somehow they win this concession, maybe we physicians should demand no mandatory overtime which would mean no call and no telephone calls answered after certain hours.

The nurses are also demanding that random drug testing not be a part of their contract. This is now a part of the contract that we sign and all the other hospital workers have signed. I used to be against random drug testing but I have now come to the realization that I do not want someone working in a position that demands complex decision making or fine manual dexterity if they are under the influence of a mind altering substance. There is no way to guarantee that does not happen unless there is the threat of random drug screening while the employee is on the job. One can argue that the level of that drug in their body is important in determining whether or not they are impaired but I don't think medical science has really hard data on exactly what level of what drug is impairing to every single person or does not cause impairment. This demand has the real potential to backfire on the union when it becomes public knowledge, which it will if there is a strike. You can be sure there will be a lot of newspaper coverage if there is a strike and some reporter will be looking for all the dirt he/she can dig up.

I hope a strike can be averted but I am afraid the nurses and the hospital are too far apart to come to an agreement anytime soon. I really have questions whether the union really knows what its members want, especially after talking to some of the nurses I know personally. They support their union but don't feel that their opinions are really being heard by their bargaining team. A federal mediator is a part of the negotiations so maybe a strike can be averted.

Computer problems tonight. My daughter received an e-mail message from a friend of hers in Arkansas tonight and when I went to print it for her, Outlook said there was no printer on my system. I went to Control Panel and our laser printer was there and checked as the default printer. I then closed Outlook, restarted it and tried to print again and still no printer. I then pasted the message to Microsoft Word and tried to print it but Word told me there was no printer also.

I then proceeded to reboot the computer thinking that maybe that would work. It didn't. I finally had to reinstall the printer and then Outlook printed the page just fine. I still don't know what happened since it was printing just fine yesterday and I have made no changes to any system files since yesterday. Another weird Windows behavior I guess.

That's about it for tonight. Must go watch ER now so I can heckle the show when something is done by the ER doctors that would not be done in real life. My wife just loves it when I watch that show but I have to get my fun where I can find it. See you tomorrow.

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Friday January 21, 2000

Telephone problems today, actually both too many and not enough. Most of today at the office seemed to be consumed with answering phone calls or attempting to find people at home to answer telephone calls. I try to never leave a phone call unanswered before I go home in the evening since that is common courtesy. Either me or my medical assistant will answer or attempt to answer all the calls. I stayed until after 6 PM tonight trying to catch everyone at home to talk with them. There was one person I was not able to catch, however, so I will have to call them back Monday. It is about a lab result, nothing critical just a little surprising. I thought her thyroid test would be abnormal so I would have to change her thyroid replacement hormone dose but it was normal so she will not need to have it changed. That is why we do testing, to be certain we are right rather than guess and maybe cause a patient some harm.

On the other hand, I waited for a telephone call today that never came. I was supposed to talk to an attorney about a workers' compensation case today at 12:45; he had called to set up the appointment and mailed me a letter to confirm the time. I had reviewed the chart again before that time but the call never came. About two hours later I got a message that he had called to apologize, saying he had forgotten about the appointment for the telephone discussion. I am tempted to forget about the message and his wanting me to give a deposition or testify in the case. You say that to err is human which is true but how do I know he is telling the truth about forgetting the appointment. I don't and I will probably end up giving him the benefit of the doubt, but first I will let him stew some more.

Yesterday's note about the informational picketing generated some mail.


I would like to comment further on the subject of the contract negotiations at the hospital where you work. The informational picketing is a positive sign. It means that the Negotiation Committee want to bargain. It's a normal tactic for this type of situation.

Next; the overtime issue. The situation you explain could result in certain employees ALWAYS working overtime, and others ALWAYS being short hours depending how the contract language is written. You are correct in looking at the demand in the worst possible light, from your side of the fence. When negotiating, one must always look at the worst possible interpretation of the language.

Now, let's consider drug testing. There are many Unions that have random drug testing in their contracts. Most of them, like you, have to do with public health and safety (i.e., Transit workers, Railroad employees, et al). The thing with random drug testing is to insure that it is truly random (not a simple task) and that the results are repeatable, accurate, and reasonable. The random part is not a trivial task. What is the random number generator? If the generator has no random inputs, there is no random outputs. Or worse, is it up to the Shift supervisor? By the numbers? where does the randomness come from?

Next is NOT as you say <<exactly what level of what drug is impairing to every single person>> . There are TESTING limits of accuracy. If the testing language does not state these cutoff points then employees can be fired for a "false positive".

Then there is the issue of collecting the sample. Are there one or two blood samples taken? Or is it a urine test? (Ask your wife how she would like to give a urine sample while someone watches her closely. BTW - Be prepared to duck quick. Blame it on me. I asked that question and nearly got divorced.) That's right; the act of urination has to be observed. "So that there are no switches." And lab handling, and spare samples, and lab accuracy, and...
See how that gets complicated quickly?
And the Union goes the easy way with publicity.
And the administrators go with the easy publicity.
And the Public doesn't know.
And Rights are taken/given away

John Vogt

PS Jim, you can edit this as long as you don't change the meaning. I don't mind random testing as long as it is "Random" and allows for "Testing Errors."

Thanks for writing. I don't edit the e-mail I receive and publish; I may and do reformat them so they fit into the format of this page, but I do not edit them. I publish them because they bring up good points for discussion or educate both me and my readers about something that interests me and presumably my readers.

Your points are well taken. Of course there are testing limits of accuracy and the possibility of "false positives", these are addressed in the policy which we are all under (except for the nurses). I have been doing drug testing in my office for years and know all the problems with it, including sample collection, lab handling, lab accuracy, etc..... Do these nurses know something that I don't about the randomness of the drug testing? If there was a real problem with the method being used to ensure randomness would I have accepted this policy? I think not.

Finally, what rights are more important? The public's right to expect that the health care workers caring for them are not under the "influence" and therefore more likely to make a potentially fatal mistake or the individual's right to privacy. If many of the unions representing workers in public health and safety occupations accept random drug testing because of this right for the public to be certain that they are protected, why would this union's management risk public embarrassment by refusing to agree to it? Again, I don't think the union management and the union members are on the same page. If they are, then we have a real problem here and will end up with the worst possible outcome, a strike. That has the real potential to endanger patients' lives.

More on this story next week, I'm sure. Hopefully, I can report a nice ending to this story; the two sides agree to a contract that neither likes much but averts a strike. Otherwise, things have a real chance to get quite ugly here.

That's it for tonight because I can't think of anything more to say. Some sleep will help my brain work better so until tomorrow.....

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Saturday January 22, 2000

Actually, my brain is not working much better than last night. I now know it is because I am trying to come down with one of the viruses that are going around right now. I feel weak and a little feverish but I KNOW I will be better tomorrow because I have the right attitude. Yeah, and I hope my immune system picks up on this positive attitude. That's where taking some Echinacea hopefully will help. I don't think it is influenza both because I had an influenza shot back in November which means it should still be effective and what has been around has mostly been Influenza A which is in the shot and because I am not having any muscle aches which are a part of influenza.

I did run this morning before I started feeling so bad but even on my run I knew something was not right. I did complete it but I felt too drained afterward. We then went and looked at a house which turned out to be nice but way over priced. It is on twenty acres but needs a new well and new heating system. This is only a five year old house and neither of the original two heated water systems the owner installed works correctly or the utilities are way too much per month. It has a beautiful view of this area but so do some of the other houses near it which are complete with functional heating systems and water and are larger but the same price. They're going to have to come down a lot to sell that house unless someone is independently wealthy (not me) and wants to sink quite a bit of money into it to make it right just as a hobby, perhaps.

This afternoon I just became a couch potato and watched two NBA games. In the second one, Portland beat LA in an exciting game which ended the way I wanted. In the first game, Utah beat Sacramento in an exciting finish also that did not end the way I wanted it to. I will get to see Portland play at the Rose Garden twice next week, Thursday against the Utah Jazz and Saturday against the San Antonio Spurs. Both should be great games. Thursday night I am taking my daughter and then Saturday Delanae and I are going without the kids.

I did fix spaghetti for the family tonight. We are trying to put together a menu for a week in advance so we can eat some as a family and have it planned ahead of time so we don't have to try and decide at the end of a hard day. Plus, we can share some of the responsibility of fixing meals. My spaghetti was compliments of Prego, I am not a cook in the same league as Dr. Keyboard. Stacey did complain about the black things in the sauce; we tried a new olives and garlic sauce that was really good. I can tell it was good because there was not much left over after Stephen had his two plates' worth.

Tomorrow, after church, I will become a couch potato again to watch the NFC championship game, the AFC game will be on while we are in church (we are on Pacific Standard Time, remember). That, hopefully, will allow me to recover sufficiently from this virus before Monday morning. I think I will end this now and go to bed very early and get some extra sleep. Knowing me though, I will probably get involved optimizing my browser which I had planned to do this weekend anyway.

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Sunday January 23, 2000

Couch potato I was after church today. Actually I sat in Delanae's recliner, with her permission, and watched all the NFC Championship game. I was pleased that St. Louis won but was really surprised that Tennessee won the AFC game, especially by the final margin. It should be an interesting Super Bowl with two teams that were not expected to be anywhere close to the Super Bowl this year. Thankfully, we don't have to go through the pregame hype for two weeks this year.

My viral infection has kept me feeling very tired again today. I barely made it through the sermon today without falling asleep and I was manning the sound board. I know that is because of the infection and the fact that I didn't sleep very well last night. I don't sleep well when I am sick, this afternoon I couldn't even nap very well. I will go in to work tomorrow and must be there before 7 AM since I have a Leadership Council meeting then.

I did get my browser and ISP connection optimized last night using Dave Farquhar's book as my guide. If you haven't bought the book yet run and get it, it is that good. Sorry if you are tired of hearing me praise the book, if you are just skip this paragraph.

That's about it for tonight. Must try and get to bed early again and get some sleep so I will be as strong as I can be tomorrow. It will be a long day with me feeling bad. I also miss running when I am sick, the exercise really makes me feel better. See you tomorrow.

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