Last Week



Doc's Progress Notes

Week of January 31, 2000

Last Updated: 2/6/2000 at 6:42 PM PST

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Monday January 31, 2000

The big news from the office today is that the nurses accepted the contract offer last Friday so there will be no strike. I do not know any details about the contract yet but I am sure both sides do not like it which means it is the best that could be worked out. I heard no grumbling at the hospital today so people are not too upset. When I get more information I will let you know what the compromises by both sides were.

We will still have our special meeting of the Leadership Council Wednesday but now the topic for discussion will be recruitment of new physicians for the group. Do we need more physicians and if so what specialties? My personal opinion is that we have enough primary care physicians but need some other specialties like otolaryngology (ear, nose, and throat) and dermatology. Both of those specialties are lacking in our area, there is one of each and the dermatologist is very difficult to work with and doesn't send back good notes at all. Our patients who need to see an otolaryngologist will have to wait longer if we don't get another one here or go to the Portland area. We are trying to prevent some of the outmigration of patients from here to the Portland metropolitan area by providing the physicians they want to see here. Our primary care patient base is now well covered by the current primary care physicians here so until we have a broader patient base or lose one or two more physicians, I think we need to stay the size we are, build up our practices some more, and get our group on more solid financial ground.

I heard today that one of my patients died this weekend. She was in her middle seventies and had a history of heart disease but continued to smoke. She had been bothered by recurrent chest pain for a couple of months and I had sent her to a cardiologist who, after doing some tests, felt her chest pain was not coming from her heart. I was therefore trying to find the cause, be it gastrointestinal or lung. She was scheduled for a CT scan of her lungs this week because of a possible mass on her chest x-ray and if that was OK then I was going to get a gastroenterologist to see her. She was seen in our urgent care clinic Saturday with chest pain again then supposedly died Sunday. I don't yet know if it happened at home or at the hospital. I hope I find out what happened.

The lady with the out of control diabetes and the abscess on her leg is getting better. I understand she is out of the intensive care unit and is fully awake and talking to people. She still faces a long road ahead. Hopefully her primary physician can help her change her lifestyle so she will be more healthy.

It seemed, today, that all my chronic pain patients were calling and had run out of pain medications early. My medical assistant, Kathy, and I were keeping a list of who had called and betting if so and so was going to be next. By the end of the day most of the people we had put on the list had either called or stopped by the office needing more medication. Two I had seen late last week and we had carefully discussed exactly how much pain medication they would need until their next visit and, with their agreement, had written prescriptions for that number. Today they called, out of their medication. Since they both had been written enough to last more than the three days that had elapsed, I refused to refill their medication early. The others wanted me to call in refills when they run out instead of seeing them, I refused since that is against my policy which I had explained to them in great detail before and they had signed statements saying they understood this policy. I expect more of the same tomorrow, for some reason this looks like a full moon week even though there is no full moon at the present time.

My day at the office ended on a frustrating note also. I had called our new cardiologist about a patient who I felt needed a stress test to rule out heart disease. He had agreed and his office was going to schedule it. Today her insurance company informed us that I would have to find her another cardiologist to do the test since our new cardiologist had not been officially added to their panel of physicians yet. There were no problems with his credentials, just the official vote of their board had not been taken yet. So now I have to talk to another cardiologist to get the same test that the first one was going to do. Delays like this are supposed to be good for the patients according to the insurance companies.

I decided it was my turn to cook dinner tonight, so, after stopping for some garlic bread and a few other things on the way home, I cooked spaghetti again. When I got home, the local Portland station had live coverage on about the Alaska Airlines crash off the coast of California. Alaska Airlines is based in Seattle and has a lot of flights into and out of Portland also, so this is very big news here in the Northwest. My prayers are with the family and friends of the victims. I'm sure the media will put pressure on the airline and the NTSB for answers into what caused the crash in the next few days. They will also speculate endlessly on possible causes and find any number of "experts" who are willing to give their theories on what happened. The news here will keep the crash in their headlines for several days you can be sure.

Enough for tonight, I still have to fix my lunch for tomorrow and get to bed on time. Tomorrow promises to be a very full day with my mens meeting and worship team rehearsal tomorrow night. Until late tomorrow night then....

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Tuesday February 1, 2000

The bug has now affected me. I have developed a laryngitis and am sounding like Barry White, according to my wife. She had me call her several times today just so she could hear my voice. What is it about women that they like a man with a deep voice. Several women at the office told me this today also. All I know is it hurts to talk this way so I don't want to continue talking like this much longer. I know I have the potential to sound very deep because I sang second bass in a mens choir in college (we sang the lowest notes in the choir) but I sound like this only when I have laryngitis. I left the office a couple of hours early this afternoon because I was afraid my voice would not hold out all day. We'll see about tomorrow in the morning although tomorrow is my day off. I have a meeting at 8 AM tomorrow morning and I have one patient in the hospital again so I need to see her also. I was going to make nursing home rounds also but now I will skip those since I don't want to expose those elderly patients to my virus when they don't have to be exposed.

I called the husband of the woman who died over the weekend today to offer my condolences and to try and find out what happened. He said she began having chest pain again then told him he needed to call an ambulance and proceeded to stop breathing. The paramedics and the ED staff were unable to resuscitate her so she was pronounced dead at the Emergency Department. Today, I had to sign a death certificate certifying what caused her death. Without an autopsy, which was not requested by her husband, I am simply guessing what happened. I cannot just say that she went into cardiopulmonary arrest and died from that, the government demands a cause which many times is impossible to say for sure. For instance, one cannot put the cause of death as old age or the patient's heart just stopped, there must be some diagnosis to cause the heart to stop. In this case, I put cardiac dysrhythmia (irregular heart rhythm) caused by coronary artery disease as the cause of death but we will never know for sure.

I will cut this short now so I can go to bed and get some rest. Hopefully I can write more tomorrow afternoon since I will probably be home and will have the extra time.

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Wednesday February 2, 2000

I'm not cured yet. I did go to bed early last night, but did not sleep very well. I usually don't sleep well when I am sick so I tossed and turned all night. This morning the alarm went off too early, it seemed like I had just gotten to sleep. My voice today has been fairly nonexistent, not deep like yesterday. This afternoon I did not get to take a nap, too many other things to do at home including catching up on Daynoters mail and web sites. I also went ahead and did my middle of the week Quicken updating rather than wait and do it tonight. My plan is to again get to bed early tonight but this time I have fresh reading material to hopefully help me fall asleep earlier.

I began this morning by attending the special meeting of the Leadership Council. We talked about recruiting and everyone accepted my recommendation that we not recruit any more primary care physicians at this time. Everyone agreed that we need to let the demand catch up with the supply then begin recruiting again. There will be some minor restructuring of the teams to make job sharing easier but no major restructuring will be needed.

We then had a confidential discussion about some present physicians who may be asked to leave our group or offered an easy exit if they so desire. We have two or three physicians who just are not team players, they refuse to come to meetings most of the time and when they do they do not participate. We have one whom none of the other physicians wants to work with because that person is too critical of everything that the other physician does. That does not leave anyone to cover for this person if no one wants to work with them. This person has also tried to get out of taking call which was a condition of their being hired. All of these physicians are good physicians, they just need to be in solo practice so they can run their own office the way they want to and not have to be subject to any requirements other than the ones for hospital staff membership and medical licensure. They will be offered an easy exit if they choose to not change their habits; if they really want to change their attitudes and habits then we will help them as much as we can. Personally, I like them all with the exception of the one who has had problems getting along with everyone including me. I hope they can change and stay in the group and if not that they find a practice more suited to their tastes.

After this meeting, I went and checked on my patient in the hospital. She is 91 years old and having abdominal pain and vomiting. This may be from a urinary tract infection and also some diverticulitis which is an infection in the colon or large intestine. She has a history of colon infections and about ten years ago had to have a portion of her colon removed due to a blockage caused by scar tissue from past infections. I am getting a surgeon to check her too but I don't think she will need surgery this time. More than likely, a couple of days of IV fluids, bowel rest, and antibiotic and she will be much better and wanting to go home. With my hoarseness and reduction in volume of my voice, I had to get right next to her ear in order for her to hear me.

Now it is time to begin getting ready to go to church tonight. I've enjoyed having a day "off" again; I have gotten a lot of errands run that I don't ordinarily get done. I also ordered a new NiMH battery for Delanae's cell phone, the old battery is a victim of the "memory effect" and will not hold a charge for very long (it was not a NiMH). She was given this one by the radio station so was not responsible for it not holding a charge. It should be in in about seven days and if it is significantly smaller than the one she had before as it is supposed to be, I may order me one for my phone. See you tomorrow......

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Thursday February 3, 2000

I'm slowly getting better but it was hard to tell this morning. I was coughing every time I tried to talk during most of the morning but this afternoon I noticed I was doing much less coughing and could actually carry on a complete conversation with a patient without having to pause to have a coughing spasm. I had several patients and my medical assistant suggest their home remedies which all involved liquor of some type. I don't think I will need a cough remedy now but later tonight who knows.

My hospitalized patient continues to improve. She has been able to drink today without problems and is starting to get up and get around some now. If she can eat some tomorrow and walk around the halls I will probably let her go home tomorrow afternoon. She is missing her cat and her home now which means she really is improving. It looks like her main problem was her bladder infection, in patients who are her age (>90) an infection like this can cause a temporary slowing of her intestinal function, called an ileus which can cause vomiting and abdominal pain. Her white blood cell count is going down which is a good sign that the infection is responding to her antibiotic treatment. I have now changed her to an oral antibiotic since she has improved so much.

My first patient in the office this morning turned out to be a sixteen year old girl who came in for her first PAP smear and to discuss contraception. She was with her mother who she asked to leave the room so we could discuss whether or not she was sexually active. You can guess the answer so I talked to her about the benefits of abstinence as the preferred way to prevent sexually transmitted diseases and pregnancy. Since that did not go over well with her, I also discussed using condoms with other contraceptive methods to prevent sexually transmitted diseases. She and her mother finally settled on DepoProvera which involves a shot every three months since she was afraid she would forget to take a pill every day. The first pelvic and PAP smear went well from my standpoint with no tears being shed by the patient. I always show and tell women what I am going to do and with what before I do it. I also warm the speculum first.

The rest of the day was fairly routine. Influenza and complications from it are still here. I am seeing patients who are having relapses after thinking they were well, me included. This has been a bad winter so far for viral infections. The hospital, particularly pediatrics, is pretty full and some of the patients are really sick. Tomorrow morning, I will be rounding for one of my associates on a patient who is a non-smoker and developed a lung abscess that had to be drained surgically. She was otherwise healthy before this infection. Most people who develop abscesses like this have some chronic illness or are smokers. Like I said, this has been a bad winter for viral infections and their complications.

Finally, here is an e-mail that has really helped Delanae and I a lot, followed by my commentary.

Thought this might be of interest:

"New Scientist" magazine of January 22 2000 had an article entitled "Rebels with a cause", and starting: '

"Stop sulking Kevin."
"But it's not fair."

"Stop treating me like a kid."
"Only if you stop acting like one."

Does this conversation sound familiar? '

It then goes on to show that in fact (probably) teenagers' brains haven't stopped maturing, and don't until their early twenties. "The frontal and parietal lobes, responsible for such things as planning and self-control, continue maturing through the teenage years."

Unfortunately, it's not part of the one third of their content that made it to their web-site. However, you could follow up through and get a reprint, or get someone to get a copy from a library. I'll even mail you a photocopy, if you like. It is suprising how much of each week's news starts in "New Scientist". It's the one magazine I would subscribe to, now that dead-tree "Byte" is no more.

In this particular case, it's comforting to know that there is (probably) a real physical reason for the behaviour of adolescent boys - at least one of mine, and maybe yours. Of course, you can't let it be an excuse - they've got to come to terms with the way they are, and learn to act in a mature manner - i.e. thinking of consequences. The one of mine I'm thinking of was a very slow developer - not stupid, but physically and in terms of outlook and attitude about three or four years slow, although the end result turned out to be something to be proud of (he's 23 now, and his mental outlook and maturity worried me until last year). I agree with your and Delanae's attitude: you can't let a young man with fast reflexes, a testoserone overdose (that's a physical fact of being a young man, not a criticism), and no ability to think of consequences drive a motor vehicle without supervision. Those are the ones who kill people - possibly including their passengers and themselves.

However, it occurs to me that it might even be useful to be able to say "See - in writing - read and understand - people mature at different rates for different facets - physical, emotional, sexual, ability to reason, attitude and forethought which lets them apply that reasoning". If you could get him to recognise that, he might also accept that he could be physically skilled enough to drive, but his judgement not trustworthy enough to drive unsupervised - in other words, you get a chauffeur.

As a doctor, you might even be able to tap some resources to show a young man why driving while only reacting, not thinking, is not a good idea. Dan Bowman might be able to give you some advice on this one as well. There are certainly legally mandated courses for dangerous (particularly drunk) drivers - I am not thinking of the whole schmeer, but some of the content as a little prevention might be preferable to the alternative.

Best wishes,
Don Armstrong

Thanks Don for reminding me of something I had read and learned about in the past but in the "heat of battle" had forgotten or had not thought about like I should. It helps for someone not directly involved to take an objective view of a conflict. I realize that we should not expect Stephen to be perfect because he is not mature enough yet to do all we ask, but we do have high expectations for him and want to trust him. We will try to get a copy of this article to help remind him and us that he still has some physical maturing to do.

In the meantime, he is still grounded for an undetermined time which will probably be about a month. He did bring home his report card today and he has improved all his grades; I still think they could be higher but his personality is to just get by and not overachieve like his sister who brought home straight A's. Hopefully, he will wake up one day and realize that the grades he is making today may have some effect on his future plans. I sound like he is failing, he is not, his GPA is 3.2 on a 4 point scale. I know he can do better though if he will just apply himself more. He obviously has some more maturing to do or stop being so much like his mother <grin>.

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Friday February 4, 2000

No update today.

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Saturday February 5, 2000

No update yesterday. Just thought I would take the night off. I went to a citywide worship service last night then Delanae and I watched a movie and by the end of it I was too sleepy to write anything. I therefore thought that was reason enough to take the night off. I slept in late this morning trying to shake this virus that still has me feeling tired, no such luck in shaking it yet. I am doing this update while waiting for a couple to come see our house. They know it is all torn up still waiting for the new carpet to be installed and still want to look at it. We have cleaned it up as much as possible.

Yesterday at the office was fairly uneventful. I did get to discuss the newest information about using hormone replacement therapy postmenopausally with one of my patients. Essentially, there is a new large study involving thousands of women that is suggesting that women on estrogen and progesterone replacement after menopause have a higher risk for breast cancer. This risk seems to rise after five years on the hormones and this study will probably change the way we use the hormones, I know it is changing the way I do already.

We now know there are at least two types of estrogen receptors present in the body. The alpha receptors are in breast and uterine tissue, the beta receptors are in brain, cardiovascular, and bone. By stimulating the beta receptors estrogen helps prevent Alzheimer's Disease and mood swings, helps prevent heart disease and hot flashes, and helps prevent osteoporosis. By stimulating the alpha receptors it can increase the risk of uterine cancer (endometrial) and breast cancer. We have used progesterone for many years for women with an intact uterus to prevent the endometrial cancer but now it appears that the progesterone somehow also increases the risk of breast cancer. So is the risk of breast cancer increased by use of estrogen alone? Probably, so I am changing the way I prescribe postmenopausal hormones.

I am now going to be using SERM's much more. SERM stands for Selective Estrogen Receptor Modulators, these drugs will stimulate only the beta estrogen receptors which remember are in brain, heart, and bone. Therefore, these medications help prevent osteoporosis, heart disease, and Alzheimer's Disease without increasing the risk of breast or endometrial cancer. As a matter of fact, they are now indicated for prevention of breast cancer in women with a strong family history of breast cancer and for the prevention of osteoporosis in women who no longer have periods and have had a history of breast cancer. There is only one on the market at the present but more will be out soon I am sure. The one out now is called Raloxifen or Evista is the trade name. What I will start doing is treating women who are menopausal and having all the symptoms (hot flashes, mood swings, etc) with estrogen (and progesterone if they still have a uterus) for five years which will take them through the time when they would have the menopausal symptoms. Then I will change them to a SERM so they will still have the benefit of the beta estrogen receptor stimulation without the increased risk of alpha estrogen receptor stimulation. By waiting five years before starting the SERM, they should not have the hot flashes they would if only the SERM was used when they became menopausal. Premenopausally, we will probably use birth control pills to prevent the symptoms of menopause. There is some evidence that women need estrogen replacement once they get to thirty since their natural levels of estrogen begin to fall then making them potentially more at risk for osteoporosis. When to begin estrogen replacement premenopausally is still a huge question without a clear answer.

Just got a telephone call saying that the family that wanted to see the house is running late and needs to reschedule. The realtor will now call us next week to reschedule showing our house. Well, the house will be picked up for one more day anyway.

That's about if for today. See you tomorrow.......

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Sunday February 6, 2000

I'm working on my website today. I'm planning to add my CV as well as my official picture taken when I joined this group two years ago. No links yet but they should be up later tonight. When they are you will see them. I will also be adding a permanent link to Delanae's page.

This week looks busy, at least with meetings. I have a meeting at 7 or 7:30 AM every morning this week and most days I have a lunch time meeting also. I have my first night on call Thursday night after having had a two year vacation from taking call. I am not exactly looking forward to being awakened by telephone calls from the hospital or from patients in the wee hours of the morning but it comes with the territory. Then, Saturday morning I have a meeting to attend in Seattle. I am a member of the Information Services Committee for the Washington Academy of Family Physicians and it is meeting at 9:30 AM that morning so I will be getting up early Saturday morning also to drive up there, about two hours from here. All in all, a busy week when you add in all the usual weekly stuff like Worship Team practices Monday and Tuesday nights, Mens meeting Tuesday night, and Wednesday night church. Updates may be very short this week.

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