Doc's Progress Notes
Week of January 24, 2000
Last Updated: 1/30/2000 at 8:38 PM PST
I made it through Monday, but got very tired about the middle of the afternoon. My stamina is still affected by this virus I have but I am not running a fever or having other manifestations other than the fatigue and some headache. I think this a very mild case of influenza, made mild because I already had antibodies built up against the virus or a very similar virus thanks to the flu shot I had earlier. No running today and probably not tomorrow then I should be able to resume my normal routine Wednesday.
Today began with a meeting of the Leadership Council at 7 AM. One of the items we discussed was whether or not to change the meeting day of the week or time of the day. The consensus, after discussion, was to not change anything so this meeting will continue to be two Mondays a month at 7 AM.
Another topic was how the negotiations with the nurses was going. The administrator felt that the union was not wanting to negotiate anymore and was going to use an intent to strike as a negotiating tool. Sure enough, later in the day the union sent a notice of intent to strike beginning Feb. 4. If this strike happens, it will affect most of the nurses in the hospital and a few nurses in the clinics. In our own clinic, it will affect only two nurses who answer patient calls and does things like blood pressure checks and gives shots. That means the remaining registered nurse in the office will be very busy all day, every day. Our medical assistants are union but their contract forbids them to honor a strike by another union. At this time, there are no plans by the administrative team to declare a lockout but that is an option. We tried to make clear to them that from our point of view that is not a very good option. Hopefully, this will be settled without a strike but it doesn't look promising at the moment. The Leadership Council will meet again next Wednesday in special session to discuss emergency plans if the strike is still scheduled to take place.
One patient in the office stands out today. She is a lady in her early seventies who has a husband at home with Alzheimers's Disease that she has to take care of by herself. She was diagnosed about six months ago with lung cancer that had already spread to her bone by the time of diagnosis. Since it had already spread (metastisized), instead of doing surgery to remove the main tumor which would have been done if it had been found before it had spread outside the lung, the only thing we could offer her was chemotherapy which had very small odds for success. To everyone's surprise, the cancer seems to be in remission; still present but not growing and spreading like it was before chemotherapy. She has had a lot of side effects from the chemotherapy including hair loss, weight loss, and generalized fatigue. She has now been off chemotherapy for a little over a month and is feeling better. Her question now is what to do? Stay off the chemotherapy for some period of months or continue? Neither her oncologist or myself know THE answer to this question. She is in not well charted waters now, by all odds she should have died from her cancer by now. Since there are very few patients who respond to chemotherapy with the advanced cancer she has as well as she has, no one, including oncologists at world famous cancer centers, know what the best thing for her to do at this point is. My best advice to her today was to say let's just meet again in one month and discuss this again and see how you are doing. This was after I spent about 30 minutes discussing all this with her and telling her she was a minor miracle but not a complete miracle since she still has cancer. She tells me she would have been happy to give up and refuse chemotherapy so she could die when first diagnosed but she had no one to take care of her husband after she was gone. I think the reason she has lived this long and is doing as well as she is is because she HAD to live to care for her husband.
Tonight, I am going to close with a joke. I don't usually do this, but I thought this one was especially good. Good night and have a great tomorrow!
Top Ten Things Men Understand about Women
It must be a full moon right now. Otherwise, how do you explain a day like today? It began on the way to the office when I was listening to the local news on the radio station that Delanae works for. They were reading an item about someone who had barricaded themself in his parents garage with several guns and threatened to kill anyone who came near and kill himself. The police were able to talk him into surrendering without hurting anyone but only after he had shot up the garage. Upon hearing his name I realized he was my patient who had an appointment with me this morning. According to the report, he had been taken to the hospital and found to not be suicidal or homicidal so was then taken off to jail.
Later in the morning, I received a call from his mother who said she was amazed that whoever had evaluated him at the hospital Emergency Department did not feel he was either homicidal or suicidal. She told me he had threatened to kill her and to kill himself and she was afraid of him. She was refusing to try and bail him out of jail for her and his own protection. She is also leaving for California for two weeks to get away from this area and hopes none of his friends will agree to bail him out. Later in the day, the police did take him to a local mental health clinic who will hopefully admit him for observation; otherwise I fear he is a threat to himself and others. He has been very despondent about his father's recent death from cancer and somehow is now blaming his mother partly for his father's death.
Next, we get a call from another mental health clinic about a patient who had called us in November saying he had left a bomb in our office. You may remember that he then came into our waiting room where he was arrested by the police and no bomb was found. Well now this clinic is calling to tell us that he still has some "medical problems" and would we see him again. Our office manager grabbed the phone from the receptionist and told them emphatically NO. This man has schizophrenia and is still free so no one is monitoring whether he is taking his medication or not; when he called in the bomb threat, he had stopped his medication.
This afternoon, I saw a diabetic who has had diabetes for almost nine years and has not really been very concerned with keeping it in control. Despite dietary teaching and diabetic education, she has chosen to not try and control her diet, to not exercise, and to haphazardly take her medication and check her blood sugars. All of a sudden, she is having a change of heart, wants her diabetes controlled and is now worried that her blood sugars are up to five times what they should be. Unfortunately, she is already showing some complications of uncontrolled diabetes including nerve damage and problems with her eyes. I was forced to tell her that it may be too late to begin worrying about her control but hopefully by getting her into good control we can slow the progression of her complications. I expect her to next develop heart disease and probably kidney failure. She is an example of why I start out with each new diabetic by explaining to them that they have to control their own disease, I cannot control it for them with just medication. I am here to advise them but they are the ones who have to control their disease.
Also today was the woman who lives about 300 miles southeast of here in Oregon who wanted me to evaluate and treat her breast lumps by telephone, the woman with panic attacks who was curled up into the fetal position earlier in the day unable to cope despite medication but did not want me to send her to a psychiatrist for a consultation, the 61 year old woman who works here in the hospital and was finishing up a nine day stretch of working 12 hours a day and was feeling tired and lightheaded and wanted me to tell her over the telephone that it was not exhaustion, and several of my chronic pain patients who wanted me to call in refills for them although the contracts they had signed clearly stated that I would not call in refills, I would only write them after seeing them. These are true stories and all were telephone calls today that I had to answer. See why I just know there is a full moon although with the cloud cover I can't see the moon. Hopefully tomorrow will be better but I don't hold out much hope.
Finally, I am going to close with a joke again. This is two days in a row that I have received a very good joke (in my opinion). I told this one to our medical director who really enjoyed it and is going to tell it to his 80ish year old mother so she can tell it to her Sunday School class. She depends on him for fresh jokes to tell them. Anyway, have a good night everyone and I will see you tomorrow.
Subject: Poor Old Couple...
No jokes today I promise, just a short update. Very busy at the office today and now I have three patients to round on in the hospital tomorrow, two in the intensive care unit. Plus I have a meeting with a family to discuss the immediate future of their 92 year old aunt and an interview with an applicant for an open position in our group. All this to be done before 8:30 AM tomorrow morning when I start seeing patients in the office. Looks like a busy morning for sure.
The two ICU patients are actually my associate's who will be off for the next two days and needs someone to look in on them. Since they are in the ICU, most of their management will be by a critical care consultant but I still need to look in on them the next two mornings. My other patient is the one who I am meeting with the family and her, a spiritual care consultant, and a discharge planner. We will be working out details of a plan to keep her out of the hospital but also keep her comfortable during her last weeks of life. She has endstage emphysema and all we can do is support her and make sure she does not suffer. She does not want to return to the hospital, she just wants her death to be dignified and without suffering which is exactly what I want to guarantee also.
Tomorrow night, I am taking my daughter Stacey to Portland to watch the Blazers mop up on the Utah Jazz. We are both looking forward to it. I am especially looking forward to watching the Blazers run circles around Karl Malone who I know has a lot of talent but I am tired of watching him whine and fake fouls so he can get to the free throw line. He spends more time flopping to the court than he does staying upright. It should be a good game and a large crowd.
I may or may not have an update tomorrow night. No promises at this time. You'll have to check back late tomorrow night to know for sure. I've got a lot more work to do before I can call it a night tonight so good bye for now.
My daughter and I are watching the Blazers mop up on the Utah Jazz.
Seeing as how I missed posting yesterday, I should put up something today. A very long last two days, more details in a moment, first a report on the basketball game last night for all of you who have been awaiting my report.
You probably already know that the Blazers did mop up on the Jazz 85-75 with the game not as close as the final score would indicate, at least not the fourth quarter. Karl Malone was a non-factor, scoring only about 15 points and missing a lot of the game with foul trouble caused by him trying to keep up with the younger, more athletic Blazers. He tried some of his classic flops and was ignored for the most part by the referees. The crowd in the Rose Garden booed him everytime he touched the ball and he seemed to get very frustrated with the crowd. The Jazz coach, Jerry Sloan, was not around to see the end, having been tossed out of the game for a profanity laden tirade at the referees.
The Blazers, already very deep, found another star last night. Jermaine O'Neal played a lot of minutes and was the high scorer for them. He had a couple of very athletic alley-oop dunks which really fired up the crowd and generally played the best he has played since he has been in Portland. His presence allowed Mike Dunleavy to really rest the other big men for the Blazers and they all had much fresher legs than the Jazz big men all night.
Stacey seemed to really enjoy going, especially the cotton candy she bought and the noise makers that were given away to the people, like us, sitting behind the backboards. I got up this morning to find a note on my keyboard thanking me for taking her. All in all, a very fun time last night.
Yesterday during the day was a different story, however. I went in to round expecting to find two patients to see and be done with them early so I could get to my interview with the physician candidate early. Well, I found that there was another patient admitted to me in the ICU with diabetic ketoacidosis. She was comatose, with her diabetes completely out of control due to a large abscess on her leg as it turned out. Anyway, by the time I got things arranged and saw the other two patients I had planned on seeing, I was 15 minutes late to the interview. She turned out to be an excellent candidate and had a lot of questions so by the time I got finished there I was now 35 minutes late to the office.
I finally got caught up by noon, but then the afternoon fell apart. We had planned on leaving at 4 PM so Delanae had Stacey there right on time, but I still had two patients to see and several charts to dictate. My carefully arranged afternoon schedule had somehow exploded, as they are want to do when I am trying to get out on time. Somehow, I managed to finish all but two of the charts, see the patients, and check on another in the hospital and we still got away at 5:05. No traffic problems on the way so we got to the Rose Garden in time to eat and get to our seats 15 minutes before tipoff. Whew!
This morning, I transferred care of the ICU patient to her primary doctor, saw my one remaining hospital patient (who I sent home late this afternoon), and then got the last two charts from last evening finished as well as the messages that had not been answered yesterday. Thus caught up finally, we embarked on another busy day which ended at 7 PM tonight after I discharged the patient from the hospital.
Today's highlight for me was the new patient I saw this morning. She had her four year old daughter with her and, after discussing her low thyroid state, I found out she and her husband were natives of India and had been here for about three years now. They had just moved here from Milwaukee after having been in Boston and Seattle before that compliments of the company he works for. She wants to go back and finish up her college degree in computer science once they settle in one place long enough for her to do just that. The marriage to her husband had been arranged by her family but, luckily, they fell in love before the wedding. Prior to the wedding, they were only allowed to hold hands, no other sign of affection was considered proper in their culture. They are very happy here in the US and their daughter speaks three languages already, his Indian dialect, her Indian dialect, and English. While in the office, she slipped in and out of each language with ease.
Stacey has four little girls spending the night with her and they are running in and out of here while I am typing this. I am also catching up on my e-mail which has gone unanswered for two days now as well as catching up on the sites of the other Daynoters. Lots of interesting things there, my home coordinates for those of you interested are 46.17665 N and 122.96766 W. Tomorrow afternoon, Delanae and I are going to the Blazers-Spurs games then Sunday we are hosting a Super Bowl watch gathering for some people from our church. All this is going to keep us busy this weekend but I will try to find time to update this site some. Good night everyone.
The Blazers won again for Stacey and I. Why did Stacey rather than Delanae go with me, you ask; details on that in a moment. First, the Blazers did indeed beat the defending NBA champion San Antonio Spurs while we watched. Our seats were just two rows above the ones Thursday night but I thought I could see the court better. The Blazers controlled this game from the second quarter on and had very balanced scoring. Jermaine O'Neal again had the highlight of the game, an over-the-head dunk off an alley oop pass from close to mid-court. He was not the high scorer again but he definitely had the highlight play of the game. The Blazers got a lot of dunks, I did not expect them to get so many against the Twin Towers of the Spurs. Stacey had more cotton candy than she could eat so she was a very happy girl after the game.
Now, the reason Delanae did not go. Last night, Stephen was spending the night with a friend while Stacey had her friends spending the night here. About 2:30 this morning Stephen comes into the house. It seems, he and his two friends decided that they should sneak out of the house and walk around the neighborhood where he was spending the night. According to him, they were bored and did nothing more than walk around and throw some rocks into some water in a large ditch. They got caught outside the house by the father who proceeded to bring both Stephen and the other friend back to their respective homes and drop them off. Stephen is now grounded for the foreseeable future and we don't feel we can trust him here by himself anymore. Therefore, Delanae decided to be the one to babysit him today rather than going to the Blazer game and Stacey went in her place. By the way, he will also be apologizing in person to the parents of the two boys for his role in their "escape" and will have various other punishments which have not been decided on yet.
Tonight, I had to do some updating of some of my employment history and CV for yet another credentialing document. In medicine, we are forever filling out credentialing information for various insurance companies, each of whom have their own slightly different documents and different expiration dates. It is so bad, that our group has to employ two people to just keep up with these documents so no physician misses out on sending in an application or reapplication after its due date. Now I am finished until next week probably when yet another one will turn up wanting slightly different information.
Tomorrow, we are hosting a Super Bowl watch party for some friends from church. They will just have to contend with the stuff from downstairs piled upstairs while we wait for the new carpet to be put in. We have the TV with the biggest screen, 60 inches, so we have been elected to have the party. Here on the West Coast, the game will kick off at 3:15 which means we will just barely have time to eat lunch before the gang will be arriving. Everyone is supposed to bring their own drinks and snacks but we will see.
As far as the game itself, I could really care less who wins. It should be entertaining with two first time teams playing; that means they will be equally nervous. Actually, I guess I sentimentally favor Tennessee; I have cheered for the Houston Oilers in the past. I know the game itself plays second fiddle to the pageantry surrounding it, but it is, after all, first and foremost a football game, not just an excuse to watch new commercials.
The Super Bowl was a REAL football game. I was cheering for the Tennessee Titans who showed a lot of heart to keep coming back. They never gave up and ended up just a yard short. Both teams are to be congratulated for playing one of the best football games in Super Bowl history. Kurt Warner deserved the MVP trophy and I was happy to see Dick Vermeil finally win the big one. Everyone who came to our house to watch the game really enjoyed it, even the wives who at first weren't very interested in the game ended up getting into the excitement of the second half.
There were some excellent commercials and some real duds. Everyone was tired of dot com commercials before the end of the game. We wondered how many of those companies will still be in business for the Super Bowl next year. My personal guess is less than 50% given what is happening with Amazon.com and other of the dot com companies. I do not have any hard figures or inside information, I just go by what I read and hear. Too many of these dot com companies are on paper only and have spent way too much money with no product yet.
This week will be my first week in a long time with a day off. I will start taking Wednesdays off now but my first day off and all the others will just mean I am not scheduled in the office. I will still have things I need to do like round on any of my patients at the hospital in the morning. This Wednesday I have a Leadership Council meeting at 8 AM to discuss contingency plans in case the nurses in the hospital actually do go out on strike. They had a vote on another contract Friday and I have not heard the results of that vote yet. After the meeting, I need to make nursing home rounds to see my patients in the various nursing homes. I don't seem to find time otherwise to make routine rounds so I will start using one Wednesday a month to make the routine rounds. That should take me most of the morning since I have to travel to three or four of the nursing homes at present.
That's about it from here tonight. I must go get things ready for tomorrow. Like most Mondays, it should be long. I have another noon interview with a candidate for a position in our group, by the way, the one last Thursday was excellent. Tomorrow's candidate is a physician who does internal medicine and pediatrics and is just finishing up a year as a chief resident in Philadelphia, if I remember correctly. We need another person in our group who can cover pediatrics for us when our lone pediatrician wants to be gone or wants a night off. Until tomorrow then....
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