Doc's Progress Notes
Week of November 27, 2000
Last Updated: 12/3/2000 at 10:15 PM PST
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Most Recent Update
Not too bad a day today. It was actually a little slow and I hate to say that knowing that tomorrow could be an entirely different kind of day. I started out the day with a Leadership Council meeting at 7 AM. After that, I made rounds in the hospital on about 18 patients. I was only primarily managing about five of them, however, so most of the visits did not take very long. One of them is my personal patient and has a colon obstruction due to colon cancer in the first part of his colon. He has cancer that had spread to his liver prior to diagnosis but that part has shrunk some with chemotherapy. Unfortunately, the original cancer in his colon is probably now obstructing it. He will probably have to go to surgery to relieve the obstruction and will have a rough postoperative course since he is not in good nutritional shape due to loss of appetite from his cancer. He is very uncomfortable from pain and nausea so something has to be done. We have tried nonsurgical methods and nothing has worked up to this point.
I did discharge a couple of patients today but did not admit anyone, which is unusual for me. Tomorrow, I may pay for that, we shall see. Another one of the patients I saw today was a young lady who is almost a monthly visitor to the hospital. This time she took a couple bottles of pills while talking to the 911 operator on the phone and then again when the paramedics arrived. She will survive this stunt but will spend a day or two in the intensive care unit with a breathing tube down her throat which will cause her to have a very sore throat. Her psychiatrist will obviously have to change her medications because her psychiatric medications were what she overdosed on. She has also bought herself some serious time on the psychiatric ward.
The patient I admitted last Thursday night and kept me up most of the night is still hospitalized. He is still running a fast and irregular heart rhythm. He is in atrial fibrillation with a ventricular response around 130-140 which is less than the 180-220 he was running when he came in. This is despite being on high doses of two medications to slow his rhythm. This is further complicated by the fact that he has a clot sitting in the upper right chamber, the atrial appendage, of his heart necessitating that he be on a blood thinner to prevent it from breaking off and going to the brain thereby causing a stroke. He will need to have his blood thinned for awhile before he can be sent to Portland to try and ablate the irregular pathway in his heart muscle's conduction system causing the abnormal rhythm. Think of this as a short on the motherboard of a computer causing the processor to run crazy. Cardiologists can now isolate where the short is and destroy it with a heated catheter tip from the inside of the heart without the necessity of open heart surgery. Ten years ago this was just being talked about, now it is reality.
That's about it for my day. Tomorrow may be something different entirely. No decision yet on which handheld device to buy. I have set December 1 as my deadline to decide and will let you know what I decide. Have a great day tomorrow.
A different day entirely. This morning was rather slow but I paid for that this afternoon. I had several admissions with the last two between five and six PM. I was trying to leave at 6 PM but was unable to. I did finally get to leave about 6:45, however. I went to a medical education program which turned out to be a good roundtable discussion about chronic pain treatment with a physician from a pain management program in Portland. He had done a fellowship in the subject and had years of experience in the field. He just reinforced for me that what I am doing is becoming more and more accepted as standard treatment despite some negative opinions from some of my partners. They are still afraid of people becoming addicted to pain medication even though the research is showing the risk is almost negligible for the overwhelming number of people with chronic pain. Despite our group's mission statement that says we want to help ease suffering there are several of my partners who are not willing to accept that the ideas about treating chronic pain have changed in the past few years. Some of these clinicians are very recent residency graduates too. We also have office staff that need to be educated about treating chronic pain so they will stop labeling people as "druggies" just because they have pain that is not controlled on insufficient doses of pain medication and want higher doses (/end of rant).
My new patients today either had strokes or chest pain. Two had chest pain but my gut feeling is that only one of them will have heart disease, the other one I think will be noncardiac chest pain. One person had a stroke that began last night but she only came in this morning, too late to stop the stroke. Luckily, the stroke was very small and she should recover fully and very quickly. Her regular physician is in Federal Way which is almost two hours north of here. We will send her home, hopefully tomorrow, and she will follow up with him to discuss ways to help prevent a second stroke. My second patient had had a stroke back in February and it was very large leaving him with a very left side of his body. Today he had a seizure that began in that affected side and then spread to both sides. This seizure was caused by an irritable portion of the brain that had been affected by the stroke. He was started on medication in the Emergency Department and that medication will help prevent him from having seizures in the future. We will watch him overnight to be sure he is stable and, hopefully, he will be able to go home tomorrow.
Tomorrow will be interesting in one way. I will be helping to interview a specialist in our community who wants to join our group. He has just finished two years as chief of the medical staff at our hospital and has been in solo practice for twenty years or more. It will be interesting to see how he reacts to being interviewed as a candidate for a position and if he is willing to give up a lot of the day-to-day control of his practice and to having to accept the decisions of others. We will help recruit another specialist in his field that he can share call and consults with which will help him slow his practice down some which he wants to do. Like I said, it should be interesting tomorrow.
I said it would be interesting didn't I? Perhaps intense would be a better word. I started at 7 AM this morning and did not slow down until after 6 PM tonight. I was admitting, discharging, and consulting like crazy. I was asked to consult on two patients in the locked part of the psychiatric unit upstairs, one of who has, at times, been a little violent toward others. He was not today but has a pneumonia which is making him short of breath. I started him on an antibiotic and breathing treatments to help open up his bronchial tubes after years of smoking multiple packs of cigarettes a day. The other patient there was much mellower and the question was whether or not he has high blood pressure; he does not. He did think he was in Los Angeles and is a Los Angeles police officer. We may be on the West Coast but we are definitely not in southern California.
The interview today went well. I think the local neurologist would fit into our group without a major problem after talking to him. He seems to be at a stage in his career where he is seeking the security that a group would offer him. He has been in solo practice for more than 25 years and is tired of worrying about the overhead of the practice as well as all the personnel issues. I think he will be asked to join our group within the next week.
Tomorrow is my last day as inpatient physician. I always have ambivalent feelings on the last day. One part of me is glad it is over; another part will miss interacting with other physicians in the community throughout the day in the hospital. When I am in the office seeing patients the majority of the day I don't get to have hallway conversations with physicians who are not in my team of five. Today, for example, one of my partners who is an oncologist and I walked down to radiology together to look at a couple of x-rays. I learned some things from this physician plus we built more of a relationship doing this. I also build a relationship with the radiologists rather than just read their reports. That is the part of being the inpatient physician that I miss when I am not doing that duty. In no way would I ever want to be just a hospitalist but it is rewarding to do it once in awhile. Remember to ask me tomorrow night if I still feel the same.
A rather slow day today. Tomorrow promises to be different, however. No good stories from today. I spent most of the day discharging people and taking care of phone messages and refill requests at my office. Tomorrow I have four people to see, two of whom to discharge before I have a meeting of the committee I chair at 7 AM. I then start office hours at 8:30 and I already have patients double booked for some slots. I am supposed to interview a physician assistant candidate for our urgent care clinic at noon tomorrow but I wonder how I am going to have time to do that, much less eat. I also wonder what time I will be getting home tomorrow night.
Tonight, I set up Delanae's new printer. It is a HP PhotoSmart 1215 and it prints beautiful photos on the glossy paper. It is also very quiet and amazingly fast. It is part of Delanae's Christmas present (don't worry, we have talked about this). The rest will be a new computer, probably with a Celeron or Duron processor, a huge hard drive and 128MB memory so she can do her photo work much faster than she is able to now. Our house really looks good now, a computer, printer, and scanner all in the dining room/den area.<grin>
I am going to start acquiring the components to build myself a computer following the directions from RBT's book, PC Hardware In A Nutshell. In the meantime, I am going to put a second hard drive in this system so I can make it last until the new computer is built. I have also decided to buy a Pocket PC rather than a Palm with more memory. I am still trying to decide between an HP 548 and a Compaq iPAQ. Frank McPherson has recommended the HP model but the Compaq is lighter, more similar to the Palm III in size, and the display is clearer in daylight conditions. I must order the one I want Monday so I have to come to a decision by that time.
Have a good Friday everyone.
Hope everyone had a good Friday. I started rounds at 6 AM this morning and managed to see four patients before 7 AM. I then went to my committee meeting, finishing that meeting at 8:30. I saw all my patients in the office this morning and had thirty minutes to spend with the physician's assistant candidate for the urgent care slot in our group. I then came back to the office and finished dictating all this morning's charts. Most of the afternoon was spent with several stacks of charts on my desk, one of undictated charts, one of refills that needed authorizations, and one for phone calls that needed to be answered. I finally managed to get to the bottom of all four stacks (there were actually two stacks of undictated charts) and get home about 8 PM. We had pizza then watched "The Perfect Storm" on DVD.
Now, I need to pick up Stephen from the basketball game and dance afterward that he went to. He is having a friend stay the night and then tomorrow they are supposed to work on a project for a class that they have together. I need to take my daughter to her symphony orchestra rehearsal tomorrow and to get her bent glasses fixed. Her concert is Sunday afternoon. Hopefully, tomorrow I will have time to come to a decision about which Pocket PC I am going to order Monday. Maybe I can run down to Portland and actually put my hands on one rather than just read about them in catalogs and on websites. Anyway, I must run and pick up Stephen, have a great day tomorrow.
No update.
Sorry about yesterday. I don't know where the day went. Actually, I spent a lot of the day transporting my daughter to and from dress rehearsal for her concert today. The concert was excellent. I was blown away by this youth orchestra and choir doing parts of Handel's Messiah as well as some of the other arrangements they did. Their teachers and conductors have done a great job with them.
I made my decision. Tonight, I ordered a Compaq iPaq H3630. I decided to purchase a Pocket PC with an eye toward the future. I can use my present Palm for the applications that are on it which I now use and until they are written for the iPaq. I really want to be able to synchronize my schedule on all systems which I presently cannot do and the Palm doesn't really allow me to do it. I can do a much better job with the Pocket PC and it will do so much more than the Palm. The iPaq is about the size of my present Palm III which is a size I can carry easily. I believe that Compaq will solve the quality problems they have had with the iPaq and it will be the superior product in this class once those problems are resolved. I am ordering both a serial cradle and a USB cradle for it so I can use the serial cradle at the office and the USB here at home. It is on back order everywhere so I don't know how many weeks it will be until I get it. It really doesn't matter to me right now, I just needed to get it ordered and a check cut for it before the end of the year when I would have lost that professional reimbursement from my group. I will let you know when it does come in; I already have Frank McPherson's book "How To Do Everything With Your Pocket PC and Handheld PC" so I will be ready to use it when it does come.
Tomorrow looks busy again. I have another two hour meeting beginning at 7 AM in the morning and then I am booked solid with patients all day. This week should be interesting as Delanae and I will be going to a Portland Trailblazers basketball game Wednesday night, compliments of her radio station. They are playing the Toronto Raptors so we should get to see Vince Carter in action. We are looking forward to it, especially Delanae who has never seen an NBA game before. See you tomorrow.
