Last Week



Doc's Progress Notes

Week of July 24, 2000

Last Updated: 7/30/2000 at 9:01 PM PDT

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Monday July 24, 2000

I did warn you about the possibility of no updates over the weekend. Sure enough, it was very busy. Let's see, Friday night I got home at 11:30 PM after leaving that morning before 7. 11:30 was also when I got to eat for the first time since about 12:30. I would have been home a little earlier except as I was literally driving away from the hospital I got a page that one of my patients was in the Emergency Department and they were doing CPR on him. I called as I was turning the car around and found out who it was. There was a major problem now, this patient did not want any attempts at restarting his heart done if it stopped since he had end stage heart failure and had been suffering for months. I told them to stop all their efforts and that I would be there in two to three minutes. Somehow, none of his family had communicated to the paramedics that he did not want this done even though he, I, and them had talked earlier in the week about this very subject and he made his wishes abundantly clear to them and they echoed them. When I went to talk to them, after stopping the resuscitation efforts, they agreed that he had wanted nothing done except to be allowed to die in peace and dignity. I guess they could not bring themselves to tell the paramedics to stop but were glad that I had.

Also Friday night, I admitted a three month old child who was having problems breathing. Thankfully, she stabilized quickly but that is one type of patient that still scares me. A very small child like that who is having problems breathing is a patient type that makes me very nervous. About ten years ago now, I took care of a 9-10 month old child in the hospital in rural Arkansas where we lived. This child came in with an asthma attack that was not going to break. I ended up having to put her on a ventilator and we were still having problems moving air into her lungs because her brochial tubes were shut down so. I ended up having to put her on an IV drip of a medication that I had never used before while I talked to a pulmonologist at Arkansas Children's Hospital in Little Rock 150 miles away. This finally opened her airways enough that I felt a little less scared. Unfortunately, the weather was too bad that night for their helicopter to fly up and get her so I had to wait the three hours for their ambulance to get there and bring a pediatric intensive care specialist to stabilize her for transport. She ended up doing well and once she recovered from this asthma attack, was never hospitalized again for asthma and was able to get off her asthma meds as she got older.

Saturday, in the clinic, was fairly busy. By the time I got home Saturday night, I was too tired to write any words here so Delanae and I watched a movie instead. We watched The Green Mile which I highly recommend. If you have not seen it, rent it and watch it; if you have then you know what I mean. It is fairly intense and there is some very adult language but it is a good movie for adults and has a good story.

So, I caught up on my missed sleep some Saturday night but had to be back at the hospital early Sunday morning to help out making rounds. I managed to get away long enough to make it to church to hear Delanae's special duet but had to leave again right after to finish rounds. Then, it was urgent care clinic Sunday afternoon and call again last night. I had the usual calls all night long but got home around 10 PM and did not have to go back in this time. I was not able to run any of the three days which I missed as it is a stress reliever for me. Tonight I did get to run which is making me feel better. Also, Stephen and I tossed a football around for almost an hour this afternoon which probably means I will have a very sore arm tomorrow. We will try it again Wednesday afternoon since I am off again then for my regular day off. Today I was off to recover from the weekend duty. I am also starting Stephen on a running program to get him a little prepared for football preseason practice which starts in about a month from now. Stacey is making noises about playing volleyball this year but so far has not been interested in starting to work out.

Enough for today. Tomorrow will come early in the morning so I must get to bed. See you later.

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Tuesday July 25, 2000

No update.

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Wednesday July 26, 2000

I may have to start calling this the occasional updates. In medicine we need to write daily progress notes on hospitalized patients but I have not been able lately to write something here on a daily basis. Last night we did not get home until after 10 PM and I never did get down to this computer. I am getting this update written however.

Yesterday was fairly busy but I tried doing something different. Normally I will work on refills and make phone calls at certain times during the day. Yesterday I tried doing a refill or phone call between each patient or each two patients and got done a little earlier than normal, at least with the phone calls and refills. I am going to try and continue with this method. One other thing that will help speed things up was demonstrated today. It is the prescription writing and refill software in the electronic medical record package that we are going to. Now the date is November 1 which at this time is firm. If you remember before we did not have a date for implementation. The hardware has been ordered for each patient room in our clinics and we can begin using it as soon as it is installed. It will probably be Dell desktops with Celeron processors and 128MB of memory if past purchases are any guide. They are good enough for what we use them for.

I am also going to be on the cross-regional team to standardize the forms and templates that will be used with the system. I don't know any more details at the moment but will update you as I know more. I am really looking forward to being able to refill and write and fax new prescriptions electronically thus saving a lot of writing, time, and being more accurate. No more misinterpretation of something written by a physician who may have poor handwriting. Also, the usual doses will be there on the screen to simply choose from so no mistakes will be made there. I just hate having to wait for it until November 1, I want it now and have been saying that for two years now.

Our other house did close. Our house in Arkansas finally was officially sold on July 17 and we received the balance due us yesterday. After three years we finally only have one house with a mortgage, insurance, taxes, etc. Now, we are looking for a small truck for Stephen. We want one without a lot of power (prevent speeding tickets) but which will haul things for us occasionally (things like dirt, etc). We will be getting one with great gas mileage and one that is more than 10 years old. It will not have a fancy stereo in it, unless it already has it installed. We just want to get him some basic transportation that he will be safe in and the extras he will have to provide himself. They will probably be things like gasoline and insurance and add on equipment like a cool sound system. We will probably have to provide the gasoline and insurance while he is playing football unless he finds a weekend job which will pay those expenses. We are "gently" pushing him in that direction. He needs to begin to take some responsibility for acquiring the things he wants rather than depend on us giving him everything.

Computer time is up. I have things to do to get ready for tomorrow. I have one hospitalized patient to see tomorrow and no noon meetings tomorrow. That will be something new, a day without meetings. We are having dinner tomorrow night at our former house guest's new apartment. Hopefully I will be able to update these notes tomorrow night.

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Thursday July 27, 2000

Two days in a row! How about that! I can do a daily post for at least two days in a row. I'm easing back into it because I am out of shape. I should fairly quickly get back into shape however.

No meetings today. What a concept! I only had one patient to see this morning and that was for one of my partners who is on vacation for a few days. This man was ready to be discharged today so I did that. He came in with anemia and blood in his stool which turned out to be from a very slow bleed from some ulcers in his stomach and last part of his esophagus. He is 89 but should be fine as far as the bleeding is concerned. He also has a pneumonia which is resolving very slowly. One of the complications of smoking and the resultant emphysema.

I am getting patients referred to me by my own group for treatment of their chronic pain. It is not something I have particularly wanted to specialize in, especially since there are so many drug abusers in this area, but I seem to have developed quite a few chronic patients and somewhat of a reputation for treating chronic pain in my group. I find myself using pain medications I would never have thought about using a few years ago. But, there is considerably more literature about treating chronic pain now than there used to be. A lot of these patients are Medicaid patients and there is no pain management center in this part of Washington and they cannot go across the river into Oregon where there are pain management centers. That means we primary care physicians have to do a lot of the pain management work without a good place to send them for a second opinion. I spend a lot of time documenting what I am going to do and a lot of time telling the patients what I expect of them. I am now even using Methadone to treat chronic pain in people with noncancer pain. If you had told me five years ago that I would be prescribing Methadone for anyone I would have laughed in your face since I had been taught that it was used only in heroin treatment centers. The times they are a changin'.

I am beginning to think I may have to limit the number of chronic pain patients that I take however. They take up a lot of visits which limits my ability to see other new patients and patients who are current patients and need to be seen. I am not to that point but I am keeping a close watch on my wait times for a routine appointment.

Dinner was excellent tonight. There were a lot of people in that apartment. Counting children there were fifteen people there eating. There were three families who had helped Wendi out either with moving into her apartment or giving her and her children a place to live (us). We are completely stuffed and I am getting sleepy so I think I will call it a night and hopefully will update this page again tomorrow night.

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Friday July 28, 2000

I'll bet you wish you knew your dentist this well. I saw a new patient today who turns out to be the mother of the dentist we use. She said he and his wife's sister recommended me to her. She did not realize that he was our dentist just thought he knew me through some local civic organization. She says that he is her dentist and takes her out to lunch after her appointments with him. I found out some "inside" information about him which I could use on him next time I am there but probably won't. Don't want to make your dentist upset with you while he has his hands in your mouth <g>.

Tomorrow we go to an auction still looking for a small truck for Stephen. We drove one tonight that is the leading contender so far but no final decision has been made yet. Stephen called me today to tell me that he had passed his written exam so he has his learning permit now. He got to drive a little way on a back street late this afternoon and I suppose more driving lessons are on the horizon very soon now. The pickup we are looking at now has a manual transmission and he is very hesitant to try and drive a manual transmission. I keep telling him that I learned to drive on a pickup with manual transmission and everyone should learn how to drive using a clutch. He is not excited about the prospect.

Short post tonight. I did get something written however. I will try and do more tomorrow but it is the weekend. Have a great weekend everyone.

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Saturday July 29, 2000

The auction today was a waste of time. The only cars that went as cheaply as we wanted to pay would not run. On the others were reserve bids so they would not sell for less than what the dealer needed to get out of them. I was afraid that was going to happen. We still need to get Stephen driving lessons since he cannot get his license without having completed a driver training course or he will have to wait until he is eighteen to get his license. Although I agree with this plan to hopefully make teenagers safer drivers, it means Stephen will have to wait longer for his license now. With football starting in the next three weeks it will be hard to find the time for him to take the course before school starts and then it will be even harder to find time during school. He was not able to get into the course at school this year so we will have to go to a private school.

After the auction we basically came home and "vegged out" this afternoon. I did not try and go outside and do any gardening until late this afternoon due to the heat. Then I ran and barbecued chicken on the grill for dinner Stacey was very surprised that I did not fix pasta as she said that is what I always fixed for dinner when I was cooking or that I got take out food. She actually ate some food tonight which was a refreshing change for her. She has always been a very picky eater and it seems to have gotten worse since she reached twelve years of age. The things she likes she will eat in mass quantity but will just try and skip a meal if there is nothing being served that she thinks she likes. She also refuses to try anything new, claiming that she knows she won't like it.

Tomorrow after church and mowing the yard, Stephen and I are going mountain biking on some logging trails near our house. Delanae and I have explored them a little while walking but have not gone to the end of them. Stephen and I will try to find the ends of the trails. He said he has already been on some of them so we will find out tomorrow. He is driving his mother and sister to the video store to return videos as I am writing this. We will see how frazzled Delanae looks when she gets back. See you tomorrow.

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Sunday July 30, 2000

Delanae survived Stephen driving last night. She says he tends to drive too far to the right but I guess that is just because he feels that oncoming traffic is going to run into him. I remember feeling that way when I first started driving and the only thing that will get him over that feeling is to drive more.

Today did not turn out the way I thought it would. After church, we ended up working in the yard all afternoon tearing out flower beds and weeds rather than mowing the yard and going mountain biking. I did run late this afternoon after it cooled off a little. It probably got into the low nineties today but tomorrow is supposed to be about ten degrees cooler and the rest of the week that way. Traditionally, this is the hottest two weeks of the summer in this area. We have had a dry summer so far with temperatures a little below normal but I have really enjoyed it so far.

Tomorrow is Monday again. This is our "slow" time of the year, just before school starts again. People are going on last minute vacations, etc. We do get sports physicals however at this time of the year. I need to get both Stephen and Stacey in for their physicals in the next couple of weeks. Stacey is all worried about hers while Stephen knows now what is going to happen and it is no big deal to him. I must remember to schedule them with one of my partners. I don't do their physicals for the same reason that I try to not treat my mother although I will answer questions that she has. I am too emotionally attached to treat my family.

Finally, let me close tonight with a letter from a reader about something I talked about here. I have edited out the parts he did not want me posting here, the rest is posted with his permission.

Hello Doc Jim,

I started reading the Daynotes Gang last summer while living in suburban Washington DC. Last October my wife and I moved across the country to Tacoma, about 100 miles north of you.

You mention that you are gaining a following as a pain-medicine prescriber; when I saw that, alarm bells went off in my head. There came to mind a case of a doctor who was, it seems, framed by the DEA over his prescriptions of pain medication.

A little searching turned up an account of his case, on the website of Families Against Mandatory Minimums, an organization dedicated to getting harsh mandatory minimum prison sentences repealed. In thinking about your pain patients, I urge you to take a look at the case of Dr. William Polan, given a 12-year sentence after one of his patients enlisted others to con the doctor into generously prescribing oxycodone (spelling corrected from original).

The URL is:

Best regards,
M. Praeger

First of all, thanks for writing. Always good to hear from a reader.

As far as the case you mentioned, I did read the description at the URL you sent. That is one of the things that prevents physicians from treating pain adequately, the fear of prosecution for something like that when you are not aware that the medication is being diverted. I follow, to the letter, the guidelines published by our state medical board for the treatment of chronic pain as well as guidelines published by national societies. In addition, I get a consult from either another physician or preferably a pain management center if possible with their insurance coverage. This hopefully will protect me from any problems with the DEA or state medical board. The climate today is less restrictive for managing chronic pain with narcotics which in a lot of cases are the only medications likely to return the chronic pain sufferer to some level of activity where they can be a productive citizen again. And, unlike the physician mentioned in the case, I would not allow myself to get 50 new pain patients in one year, I would stop at half that amount or less.

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