Last Week



Doc's Progress Notes

Week of January 8, 2001

Last Updated: 1/14/2001 at 9:14 PM PST

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Monday January 8, 2001

No update, on call.

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Tuesday January 9, 2001

Last week's file name had such symmetry to it. It was simply Weekof010101.html in case you hadn't noticed. I use the convention that other Daynoters use and used before me which is to name our files the date of the first day of that week, namely Monday in my case. That of course only works for those who do theirs one week at a time. Some do one day at a time so their names are different. I like this format, one week at a time, as it is more like the way progress notes are written in a hospital chart. They are sequential but have the most recently written note on top. Maybe I will change this one day as I would like to do some tweaking of the layout whenever I get a spare moment or two around here.

Last night I was on call and did not get a chance to do an update. I was busy at the hospital until after 11 then had phone calls off and on all night. I squeezed in a little sleep between the calls but this morning came very early.

One of my partners and I were talking about the phone calls and we both feel that we are getting more and more calls from patients in the middle of the night about things that are no where near emergencies. It seems like that is just the most convenient time for some people to call for information about their illness or a family member's chronic problem. They aren't sleeping so they call the doctor to have their questions asked that could have been asked during daytime hours. None of us mind the true emergencies or what could be an emergency but getting calls asking if someone's baby's formula should be changed because he or she has been constipated for several days does not in any way qualify as an emergency. At 3:30 AM it is no joking matter and very hard to be civil to that person. We have nurses who work until 8 PM to answer those very questions. Why don't we have nurses who work 24 hours a day to answer those questions? We are working toward that.

Luckily, I did not have to go back to the hospital to admit a patient after I got home. The patients we have in the hospital right now are all fairly sick. The severity of their various illnesses seems to be getting greater and greater as time goes by. Across the country physicians are noticing that their hospitalized patients are more severely ill. This is most likely a result of so many patients being treated as outpatients that only the very sick are admitted any more so all the patients in the hospital seem sicker. Luckily, our group has excellent specialists and subspecialists to help us.

Today my partner, whom I share an office with, announced that he is retiring in 90 days. This was not unexpected but the timing of it was not known until now. He will be 73 in April and has been practicing here for more than 30 years. He remembers when there were less than 30 physicians here and they would get together for dinner and an educational program once a month or once a quarter. There was only one or two surgeons and a lot of the family physicians did their own surgery and all did OB. He has been a wonderful fount of information about local physicians and former local physicians not to mention patients and their families he has helped take care of over the years. He had not taken call for three years but still rounded on his hospital patients although he had turned most of their care over to our inpatient physician or me. He has been a school physician for 30 years, traveling with football teams every year and has been honored by the Washington scholastic sports association for his years of volunteer work to the athletic teams. He was telling me this afternoon that it is getting time to give that up also. I hope he will continue to volunteer his time to local high school football teams and hopefully he can help out at the local hospice who has another retired physician as their medical director. In three months it will be strange to not have him in the office anymore.

So, now we will be absorbing a large amount of his patients while still being short two physicians. Luckily, one new physician is starting in March but she was filling another open slot. We will still be down two physicians but we will be able to handle it. This is the time of the year when patients are switching insurances and therefore some have to switch doctors. It will take some time to see if our total enrollment goes up or down, we should know by March or April what has shaken out. Last year, the other large group in town, Kaiser Permanente, was down in their total number of patients while we were up. It will be interesting to see if that holds true this year.

Now for some nonmedical news. I got an e-mail today saying that the hard drive that I ordered last week is on back order and they do not know when it will be shipped. I had planned to install it this weekend but it looks like plans have changed unless I want to drive down to Portland tomorrow or Saturday and pick one up at one of the CompUSA stores there. I had planned to spend my day off tomorrow getting this hard drive ready to transfer partitions to the new hard drive after it is installed. I am tentatively planning to leave this 3.66 GB drive as one large C: drive for the operating system and one smaller partition for the swap file, then partition the new 20 GB drive into separate partitions for programs, data, and temporary files. I have PartitionMagic 6.0 ready to do just that when I get the new drive installed. At that time, I also plan to reinstall Windows 98SE as a fresh install and, using 98lite make it a slimmer, faster operating system. That should give this PentiumII 200MMX some new life. Watch this space for further updates on this project.

Finally, we have a new ISP. I noticed over the weekend how much we were being charged for our long distance service so went surfing on the Net to find a better deal. We finally decided to go with Sprint since they would bundle long distance service with internet access through Earthlink at a discount rate that included multiple e-mail boxes. Our long distance rates will now be $0.07 a minute, twenty-four hours a day with no minimum monthly fee and no long term contract for either long distance service or Earthlink. Our internet access will now cost less than it does now and our long distance service much less. We will see if our connectivity speed improves. No change in e-mail addresses on this website will be necessary when we do officially change over to Earthlink later this week.

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Wednesday January 10, 2001

Finally, a real day off. I only spent one hour at the office this morning and did that only because I had a previously scheduled meeting at 7:30 AM. We were discussing training for implementing more of the modules of our electronic medical record software package. We decided to train the clinicians in small groups of two or three since these modules will be used primarily by the medical assistants, not the clinicians.

Next on the agenda was a trip to the dentist. I have to go every three months at present since I did not always take good care of my gums and did not floss in years past. The dentist tells me that everything looks good now and he is thinking about going longer between cleanings after the next three month recheck. Just a couple of days with my gums sore then everything should be back to normal.

I am in the process of catching up on my e-mail. None of it was a week old yet but almost. I think I have now answered all the messages and if I have not and anyone is waiting for an answer when they read this please let me know.

I am also going through my software CD's and throwing away all but the latest version of some software programs so I will not be confused when I reinstall the program after the new hard disk is installed and I reinstall Windows98. Then, I have to catalog my downloaded software better on my data partition so I can find it easily to reinstall it. It would be simpler if I had a CD burner on this system but only Delanae's system has one and we are not networked yet. That is a plan for this year as well as building me a new system. I talked to a patient yesterday who is buying a system from Dell that will have the Pentium IV processor with 512 MB RAM so he can produce music CD's that sound very professional as mentioned by Jerry Pournelle in his column Monday. He is a member of a local Christian music group that is recording a CD. They now have an 8 track digital mixer which they will interface with the PC to produce their CD without having to pay the fees for recording time at a studio. He has been burning CD copies of their previous CD on his home system but that has been much slower than what he will be able to do with his new system. Can you imagine how fast that system will be compared to what I was planning to build. Maybe I will have to plan for more RAM. I do not plan to do any recording with it though so I don't plan on going to the Pentium IV unless the price is really down by the time I am ready to purchase the processor for the system.

That's all for today. I have some more work to do here, then run, and then it is my time to fix dinner tonight so must decide on something.

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Thursday January 11, 2001

Whether to update or exercise? Exercise won out so no update tonight. Details on a very busy day tomorrow night or Saturday, depending on how tomorrow goes. Tomorrow morning comes early. Good night.

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Friday January 12, 2001

Details from yesterday now. I drove into the hospital yesterday morning expecting to have to see three patients in the hospital and when I got there I found there were five patients to see including two new admits during the night. That meant I would have to miss the meeting scheduled at 7:30 that I had also missed the previous month for the same reason. Thursdays are just a bad day for me to make any early morning meeting since I am seeing my own hospitalized patients as well as my office mate's who is off on that day. He is also the one retiring in 90 days time so I stand to inherit a lot of his patients. He and I talked about some of that this morning and it looks like I will probably get somewhere around 500 or more of his patients which would put me at over 2000 patients on my panel. That would make my panel either the second or third largest in the group and I have been here the shortest time of the top five. Our group will probably lose some of his patients but should retain 90% or so.

I made it to the office yesterday morning only a little late. From there it went downhill quickly. It seemed that everyone had multiple problems to discuss and all took longer than expected. Add on the stacks of messages, refills, and forms to be filled out for people and I did not get completely finished last night until 9 PM. My medical assistant left a little after 6 but I had not even started dictating the afternoon charts at that time. Usually I can keep up and only have two or three to dictate at one time but not yesterday afternoon. It was either dictate and be 45 minutes late to see a patient or not dictate and only be 30 minutes late. I decided to limit how late I was instead of dictating the charts as I normally would. I made notes in the progress notes to help me reconstruct all my thoughts when I went back to dictate. I make it a point to never leave a clinic chart undictated overnight after a patient visit. That is not true of hospital charts, especially yesterday. I sent two people home from the hospital yesterday and have not dictate either one yet and probably won't for another week. Those can be reconstructed easily however as there are written progress notes detailing their care every day while they were hospitalized. All I will dictate is a summary of those days.

My last patient of the day yesterday was also my last patient today. She had come in yesterday with a two day history of right sided abdominal pain accompanied by nausea and vomiting. After her exam, I was thinking more gall bladder pain than appendicitis especially with only a mildly elevated white blood count so had her come back today for an ultrasound of her abdomen to see if we could find gallstones. Her ultrasound was negative for stones or fluid collections but her white blood cell count had risen, she had begun to have fever, and she was more tender in the right lower part of the abdomen now which led me to believe that she has appendicitis. I therefore admitted her and talked to a surgeon who was going to see her and most likely do an exploratory surgery on her later this evening.

I hear people talking all the time about someone having had an emergency appendectomy. All appendectomies are emergencies in that they are done to try and prevent the appendix from rupturing, spilling pus into the abdomen which can cause temporary paralysis of the intestines or an overwhelming infection caused peritonitis which people used to die of routinely back in the days before antibiotics were widely available. No appendectomies, other than incidental appendectomies done while doing a hysterectomy for instance, are scheduled operations but rather are done as soon as possible after the possible diagnosis of appendicitis is made. That makes them all emergencies by definition. There are still a significant number of people who have ruptured their appendix before the appendectomy is done just due to the fact that there is no blood test or imaging study which can always diagnose appendicitis. It is still a diagnosis made on clinical suspicion by the clinician and confirmed or disproved at time of surgery. There will be normal appendixes taken out and ruptured appendixes at time of surgery until and if a 100% reliable test can be found for this disorder. In today's world, a ruptured appendix usually only means two or three more days in the hospital after surgery for IV antibiotics and an open incision which is left to heal by scarring in rather than being sutured all the way closed. Peritonitis is not the almost uniformly fatal disease it was fifty or sixty years ago.

Today was a much more normal day. I was able to keep up on my dictation throughout the day and finish up in time to come home, pick up Delanae and Stacey, and make it to the church for a dinner by 7 PM. Stephen was going to a basketball game pitting his high school against the other high school in town, then to a dance and afterward to a friend's house where he is spending the night. Sixteen year olds don't want to spend any more time with their parents and younger sister than they absolutely have to. For some reason, they want to spend as much time as possible with others of their own age, especially those of the opposite sex. It is much quieter around here when he is gone.

No hard drive yet, so I will not be installing it or the PCI card to add USB ports to this computer tomorrow. I am ready to install it as soon as it arrives but have not received any notice of it shipping yet. If we go to Portland tomorrow or Sunday I will try and pick one of them up at CompUSA there but don't plan to make a special trip just to get a new drive. I will wait to install the PCI card until the drive comes. I don't need the USB ports until my iPaq arrives, anyway. None of the peripherals currently attached to this system are USB devices and I have no idea when the iPaq will come. I try and not think about it but am reminded of it every time I visit Frank McPherson's website which I try and do every day to keep up with the Pocket PC world. One of these days the iPaq will arrive, however.

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Saturday January 13, 2001

Cool, gray day here. We awoke to big snowflakes coming down but the temperature was above 32F(0C) so there was no accumulation. Later this became rain and has stayed that way the rest of the day. The perfect day to be lazy and cruise all the websites I do not ordinarily get to visit that often. I was able to read all the Daynoters pages earlier and just finished with my run then thirty minutes on the NordicTrack for good measure. I had needed a good long workout for a long time. Now I will be able to relax and watch a movie or two tonight and know I have had a good workout today.

I just answered an e-mail from one of my friends back in Arkansas. He was a physician in the town on Harrison which is where we moved out here from. Just after we left, he took a job as an attending physician in the Otolaryngology Department (ear, nose, and throat) at the University of Arkansas for Medical Sciences where I went to medical school. He still has a home in Harrison and spends his holidays there. He told me that he had to get a full sized bulldozer to push the eight inches of solid ice off his driveway before he could get into it. It took the bulldozer two hours. I am really glad I was not in Harrison for Christmas this year.

Now I must go. The Blazers are playing the Knicks on national TV in about an hour and I have to take a shower before the game starts. See you later.

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Sunday January 14, 2001

Strange football day today. I never would have thought the Giants and Ravens would be the two teams to make it to the Super Bowl. That's why they play the game, because anyone could win. Now the hype will begin for the Super Bowl and last for two weeks. It won't affect me much as I really don't care which of those two teams win. Of course, I may not get to watch much of it anyway as I am on call that day. The church youth group is renting a building at the fairgrounds to have a Super Bowl party for the youth of this area, they will have big screen tv's and video games for those not interested in the football game to play. As Stacey says, now she won't have to watch football.

The Blazers lost yesterday as any of you who watched the game knows. I was wrong about the starting time so I only managed to catch the last of the third quarter and the entire fourth quarter. I didn't miss much as the Knicks really took them out of their game and won handily. We will see how the Blazers do once they are back home again and get rested. Hopefully, they will continue playing well and really come together so they can challenge the Lakers again in the playoffs.

Tomorrow night I am on call again. This is my second Monday on call and my last weekday on call this month. I still have a weekend to do but only Sunday night of that weekend on call since I traded a Friday earlier this month. Still, that is Super Bowl weekend and I have a 7 AM meeting both tomorrow morning and the Monday morning after being on call Sunday night. This must be another one of Murphy's laws, namely that you will have an early meeting after being on call the night before and, as a corollary, it will occur on a day that you would ordinarily be off. Such is life, see you Tuesday probably.

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