Last Week



Doc's Progress Notes

Week of December 11, 2000

Last Updated: 12/15/2000 at 10:13 PM PST

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Monday December 11, 2000

Where did the weekend go? It was not spent writing updates here, that's for sure. I have not written one in three days, now what did I do those three days. Friday I was the inpatient physician and was kept busy doing that and trying to keep my desk cleaned off and finishing up the RPI project as well. I was feeling pulled in several different directions that day.

Friday night, I just came home and crashed. Stephen and I watched "US Marshals" on DVD and I never made it downstairs to even check e-mail, I don't think. Stacey and Delanae were on a school field trip to a Portland area mall where her school orchestra was playing Christmas music then they had time for some mall walking. Stacey ended up getting Stephen's Christmas present there but I'm not supposed to tell what it is.

Saturday, I was the inpatient physician again. The emergency department got busy as the day wore on and I admitted several people with chest pain, none of which had a heart attack and most of which probably don't have heart disease. We probably are overly cautious about admitting people with chest pain but we don't want to miss that heart attack in someone having chest pain which is not entirely classical and the screening tests do not show. By keeping people twelve hours while checking for enzymes known to be liberated by heart muscle damage three times in those twelve hours we cut down on the chance of missing a heart attack.

Saturday night was the big holiday gala hosted by the hospital's administration for all the healthcare providers in the area. I was on call but Delanae and I went for about two hours. There were a lot more people there than I had expected. The food was good but I got called away to admit a patient after two hours so Delanae left too. The rest of Saturday night was fairly quiet, not typical of a night on call.

Sunday was again spent in the hospital. I did take a break and met Delanae and the kids at a tree stand to pick out a tree. Of course, during the thirty minutes I spent there, the emergency department wanted to admit three patients to me. We found the perfect tree, a flocked one this year for the first time, then I went back to the hospital. I got those patients admitted then spent the rest of the afternoon trying to get hold of my partners to tell them who I had admitted for them this weekend. I finally gave up on that last night about 10 PM after spending about four hours helping put lights on the Christmas tree, ornaments on the tree, and putting the lights up around our front window. It looks really nice now but I was exhausted after finishing that so went to bed so I could get up at the usual time this morning.

Today was spent catching up on the mail and messages on my desk, as well as seeing a schedule full of patients. I am finally caught up, I think. I may have my first pregnant patient with Hepatitis C. We are doing the appropriate blood tests now and her pregnancy is being managed by an obstretrician but I will need to learn more about Hepatitis C in pregnancy. I have a good resource in our group who I will be talking to. Also, my young man from last week with the tender lump in his groin had the lump biopsied today and it is lymphoma. I do not know the cell type yet and won't know his prognosis until that is back and we have looked for signs of it in other parts of his body. He is less than 21 years of age and now has to face a diagnosis of cancer. Hopefully it will be confined to just the area on his upper thigh and he will then have a good prognosis.

Tomorrow will be another long day. I have two people to round on at the hospital in the morning then an early patient appointment. My schedule is already full tomorrow plus I have a noon meeting with some officials from a new insurance company that is moving into the area and wants to discuss contracting with our group. Tomorrow night is our quarterly medical staff meeting at the hospital which should probably keep me there until 8 PM as it is the last meeting for our current chief of staff. We have a lot of business to attend to, it appears. See you tomorrow.

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Tuesday December 12, 2000

Some days I hate computers! I had written almost an entire update for today and this program crashed before I could save it. The error message was for an illegal page fault. I do not have time to reconstruct the entire update so will only do this short one and maybe I can recreate it tomorrow when I have more time.

Tomorrow, I will be going to Portland to have some routine maintenance done on my car. While I am there, I will try and find an ADS Technologies PCI USB Port Card to add USB ports to my now ancient system that I continue to use. This is the card recommended by RBT in his book PC Hardware In A Nutshell. It is supposed to be in the CompUSA chain of stores and there is one that I can get to easily as I am leaving Portland to come back home. I will try and write more tomorrow. Bye for now.

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Wednesday December 13, 2000

Let's see if I can get this one written before this program crashes. I know it will probably not happen two nights in a row but I will be saving much more often. I did go to Portland today and encountered some winter weather. The cold air, sleet, freezing rain, and snow was mostly south of here along the Columbia River Gorge. Downtown Portland got quite a bit of snow while I was there and there was ice along the Gorge. What normally takes about 15 minutes from North Vancouver, WA to downtown Portland for me took an hour this morning due to the traffic backed up on Interstate 5 southbound.

I did make it to the dealer on time however and got the oil changed. I then drove to the CompUSA store in North Portland where I found a PCI USB 2 port card to put in my computer. It was not the one I was looking for but they did not have that board in stock. I could have gone to Fry's but that is south of Portland and would have meant driving back into the worst of the roads. Besides, it would have taken another 30 minutes on a good day to get there. Instead, I bought the card and headed home.

Now, back to what I wrote yesterday but lost. One of the patients I mentioned last week was a lady who I felt probably had lung cancer based on her x-ray. I sent her for bronchoscopy to a pulmonoligist who did some further workup before the bronchoscopy. She has metastatic disease already to her liver. We will know for sure about the cell type when the bronchoscopy is done and a biopsy taken but the cancer in her liver makes her chance of cure almost zero. She probably won't live more than a year, if that long. She is a very nice lady who, unfortunately, did not quit smoking soon enough.

I did find that the pregnant patient who may have Hepatitis C doesn't have to worry much about passing the virus to her baby before or during birth. The baby will have antibodies against the virus from the mother but actual transmission of the virus from mother to baby through the placental blood flow is very rare. We will need to test the baby after one year when the mother's antibodies should be gone to be sure he is negative for the antibodies at that time. When we do a test to screen for Hepatitis C we test for antibodies against the virus. If they are positive then we test for the actual presence of the virus which causes the disease and the number of copies present. Somewhere less than 20% of people who are infected with the virus will recover from it and are actually cured without any treatment. They will always test positive for the virus. I have one of those people in my practice. The majority of people, however, will have active Hepatitis C and need to be treated.

I am trying to wait patiently for my Compaq iPaq Pocket PC to arrive. I picked up one and played with it in the CompUSA store today and I am certain that I made the right decision. I also saw one of the new Sony Clie machines which, if I wanted a new Palm machine, would be a great choice. It seemed even smaller than a Palm Vx and would fit very nicely into a pocket. I am pleased to report that the iPaq also will fit nicely into a pocket, without an expansion pack on it, and seemed to be as fast as any of the machines with the Palm Operating System. Now, if mine will just come before the end of the month!

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Thursday December 14, 2000

Another concert for Stacey tonight. We spent time at the local mall tonight where Stacey's middle school orchestra was performing in front of the Sears store in the center of the mall. Delanae and I were joking that we knew the music as well as the kids did, we have heard the program about five times now and two of those times have been this week alone. I think today was the last time to hear it however. Stacey and I did manage to get one of Delanae's presents tonight before the program; I won't give it away here because Delanae is probably listening in.

Some good news on the office front today. The young man who had the enlarged node in his groin and had it biopsied with the initial diagnosis of possible lymphoma turns out to have a very uncommon infection instead. It looks like an infection from the bacteria that causes cat scratch disease. The medical world has known for years that some people come down with lymph node swelling and pain after a cat scratch but only recently has the bacteria that causes this been isolated. It turns out that this was found in the node that was biopsied but there was another organism there also, one which causes opportunistic infections in AIDS patients. My patient denies any risk factors for AIDS but we will test him for HIV anyway since he has this uncommon presentation. We will also do other tests on his immune system to see if we can find any evidence that his immune system is not functioning properly.

This is much better news than lymphoma. I have started him on antibiotics for cat scratch disease and with time he should recover completely. He may need the lymph nodes removed still to get well, sometimes this has to be done as they remain enlarged and tender even after antibiotic treatment. At least I have not found another cancer.

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Friday December 15, 2000

There are some days when life rears up and bites you in the butt! Today was one of those. Specifically, God decided to put me in my place today by reminding me I did not know everything. I had treated a woman for a sprained ankle back in August. She had had most of the pain go away but still had an ache in it when she walked farther than two or three blocks. This did not stop her but she came in wondering why she still had pain. This was in the middle of November and I had given her an anti-inflammatory medication and told her to come back in 3-4 weeks so I could recheck her. She did come back today a little better but still having the ache. I told her I couldn't explain why she still had it and sent her for an x-ray with plans to send her to an orthopedist for a second opinion. Guess what was on the x-ray; a healing fracture of the end of the fibula which is the bone on the outside of the leg and the outside of the ankle.

I did not x-ray her back in August because I felt she had very little evidence of a fracture. Most physicians who practice sports medicine or emergency medicine use a set of rules called the Ottawa Rules to decide what ankle injuries should be x-rayed. These rules are based on research done it Ottawa and are highly predictive in the setting of an ankle injury who is likely to have a fracture. Doing x-rays of everyone with an ankle sprain is very wasteful of money and x-ray exposure since very few have a fracture. Now, in this case I did not feel she met the criteria for needing an x-ray. On reviewing the note from August, I still feel that way but hindsight has much clearer vision.

When she came back, I apologized to her and told her I was sorry for not diagnosing the fracture in August. I would have put her in a walking cast(actually a cast boot) and had her wear it for 6-8 weeks if I had diagnosed it then. She would have been painfree by now in all probability. She has done no damage to the joint and the fracture is healing, it is just taking longer than it would have if she had been immobilized back in August. Immobilizing it now is a waste of time, she will just have the ache for an indeterminate time but it will heal completely. I explained all this to her and she was not angry, especially since there is no permanent damage and the fracture is healing. She is not the first this has happened to and will not be the last.

I am feeling bad that I let my patient down but realize that I am human and will make mistakes. I retraced what I must have been thinking in August and, based on what I knew then, I would have done the same thing. Now, blessed with hindsight, I wish I would have done things differently. It is difficult for me to accept my failing in this case because I, like most physicians, want to be perfect for our patients. Intellectually we know we can't be perfect but we are perfectionists who are driven to be perfect since mistakes can hurt people. Some might think this is malpractice, that we should be perfect and if we are not we need to pay for the mistake. That kind of thinking makes us very hesitant to admit our mistakes and impedes us from learning from those mistakes. It has led to the deterioration of the doctor-patient relationship as now every patient is viewed as a potential litigation threat. With that threat, unnecessary tests are done every day just to protect ourselves. This has driven the cost of medical care higher and higher. We need to return to a more sane time with less litigation threat and really share our mistakes with each other and learn how to avoid making the same ones in the future. Instead, we are very defensive and feel uncomfortable sharing our mistakes with others in this profession since anyone could be called to testify if there is a suit filed and the plaintiff's attorney finds out we confided in our partners or acquaintances.

Anyway, thanks for listening, I needed to get some more off my chest. Stephen and I are headed to Seattle in the morning to catch the Seahawks against the Oakland Raiders at Husky Stadium tomorrow afternoon. If you happen to catch any of the game, wave at us. It is supposed to be raining so we will probably look like wet rats.

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Saturday December 16, 2000

No update.

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Sunday December 17, 2000

No update.

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