I stopped at a nursing home this morning, after dropping my son off at school, to see one of my elderly patients who has dementia. Luckily, her daughter-in-law works there and was present while I was there so we got to talk about her and her condition. The family realizes her condition is irreversible and they want her kept comfortable only. They don't see any difference from my last visit and neither do I; she is very confused and has to have a very low bed (actually no more than a mattress on the floor) and padding on the floor around the bed because she tends to try to get out of bed at night and falls.

When I did get to the office I found out that the course I had been on the waiting list for had a cancellation so on Friday and Saturday of this week I get to go back to class for eight hours a day. This course is Advanced Cardiac Life Support (see here ). It is an intensive review about heart attacks and other heart problems geared for physicians, paramedics, and nurses who take care of patients with acute heart problems. This is the course that teaches paramedics what to do in the field for a patient whose heart has stopped or is fibrillating. Testing is involved with the course so I will have to study this week. I just got the updated manual today which is different from the last time I was certified several years ago. It will be a good review complete with a little stress but I need to do this before going back to taking care of patients in the intensive care unit.

******

This afternoon I had two perplexing patients. The first was a man one year younger than me who has convinced himself that he is disabled and wanted to know from me how to be certified disabled. This is a man with psoriasis who was told by a physician twenty-five years ago that he would one day be disabled by it because he would be itching constantly. He is now itching all the time he says and feels that the doctor's prediction has come true. This man continues to work daily and his psoriasis is actually mild compared to a lot that I have seen. He now believes that he should be certified disabled by me. I have explained that, first of all, the Social Security Administration certifies disability not me and, second, he doesn't meet the criteria to be certified disabled. I have seen many people much worse than him who would never even consider applying for disability and here he is wanting to be certified disabled although he is perfectly capable of working in his current occupation and many others.

The second patient is a lady who has severe upper back pain probably due to a disc problem in her upper spine (not a computer disk problem). She is seeing a neurosurgeon in consultation with me to try and resolve her pain without surgery. She has been on narcotic pain medication for a number of months which I have monitored always asking her if any other physician was prescribing medication for her. Her answer was always no. Today she was in saying that her brother-in-law who lives in Texas was killed yesterday in a pedestrian versus motor vehicle accident and she was flying there to be with her sister and help her move back to this area. She would be gone beyond her normal two week recheck so I gave her enough medication to last for three weeks. Later in the day, we got a call from the neurosurgeon whom she had called with a slightly different story, asking if we had prescribed her pain medication and informing us that they also had been prescribing her narcotic pain medication for these past months. By calling around further, we found out that there was still a third physician who had been refilling narcotic pain medication for her, not knowing about the two of us. When something like this happens it makes us feel betrayed and used. We try to trust people and not put up too many barriers to proper pain management but experiences like this make me understand why pain is under treated and some physicians refuse to write any narcotic pain medication for their patients. Narcotics are great drugs for pain management but the abuse potential, at least in this area of the country, is significant. Short of going to a patient's home and searching it for prescription bottles routinely, I know of no way to prevent this from happening in every case. She obviously has problems and needs treatment but my experience has been that once she has been confronted about this she will simply find someone in another town and repeat this pattern again.

Delanae and I did get all the Christmas cards to our friends and family addressed last night. This is the first year she has wanted to do them but this is also the first year she has had sales clients who she felt she needed to send cards to. We included three family pictures with the cards as well as a newsletter discussing the highlights of our year as a family. Now we will wait to see who sends us a card but we forgot to send them one. We've already thought of one person but all the cards are gone so will have to get some different ones to be ready in the coming weeks.

Now for something much lighter to end this day. From the experiences of the other Daynoters I expected increased criticism but did not really expect it to begin with my lovely wife. Following is a message I received from her early this morning.

So, do you realize that you just made it abundantly clear to the WORLD that you have little knowledge as to what chores branch off the title of PLUMBER and what branches off the category of Mr. Fix-it??? You crack me up! You see, just because you are working on a toilet, basically without contact to ANY water unless your hand slips and falls in, you can't technically call it plumbing. You must ethically be working on parts of the toilet that carry water or "other" substances which will remain nameless from one place to the other. Now, unless there is someone with a small enough bum that they could physically be moved from this toilet seat you are working on to... oh let's say... Star Trek... then NO... Mr. Fix-it... you may NOT earn the title of PLUMBER!

HAHAHA!

Delanae...

I DARE you to add this to your site!

I sent her this reply today.

I was attempting to use a technique known as literary license. I was poking fun at myself by calling myself a PLUMBER. Obviously I did not do a good job of using that technique as it went over like a lead balloon. But I never said I was a good writer, I just put my thoughts down and hope that they make sense to someone who reads them. I must remind you though that I have done work around this house that does qualify me to be called a PLUMBER (remember the kitchen faucet?). Thanks for your feedback though, good or bad. I'm glad to know you continue to read this journal, that I have not bored you to tears.

After running Tidy on the template the code was changed to the following, which changed the size of the font used for the heading (the font face stayed the same):

<font face="Arial" size="6">Week of November 29, 1999</font>

Now, I can understand changing the HTML code to make it run on any browser which is the goal of TidyHTML but when that change changes the appearance of the page then something is wrong with the program. Be aware that if you use Tidy it may very well change the way your page looks. AAARRRGGGHHH! I just realized that the spacing on the page is different also. Must correct some more code changed by Tidy. I will not use Tidy again on these pages until the developer can assure me that it will not change the way my page looks in Internet Explorer which is the browser that the majority of my readers use. Please let me know if the browser you use will not render this page correctly from now on. Be careful with TidyHTML, it doesn't just clean up your code to make it readable by all browsers, it will sometimes change the appearance of your page. I will get off my soapbox now.

I have been following the debate among the rest of the Daynoters about whether to redirect to the current week's page automatically or not. Redirecting would allow someone to bookmark a portion of this page and that link would remain valid from now on. As it is, since this page is named current.html only until the start of next week, if you bookmarked this portion of text today, next week that bookmark would send you to that week's page. If current.html redirects you to the current week's page but that page has one name and stays that way then the link is always valid. All the issues aren't resolved yet but will be and you will see our pages going to a more standard naming practice I suspect.

I have been creating a new current.html file every Monday from a template. The next Monday I rename current.html lastweek.html and create the new current.html. If current.html was used to simply redirect to the current week's file I could simply name that file using the convention I have chosen, which is Weekofmmddyy.html, and just change the link in the redirect (current.html) every week. I could also make the Last Week link in the upper left column of this page point to one file without having to change it as I do now when I rename the lastweek.html file. If I have confused you I am sorry, sometimes I just need to think on paper and things come together better. I now have a plan once we get all the issues about the redirect file worked out. I have now stolen (plagiarized, borrowed, you pick the word) the HTML code to do the redirect from Bob Thompson so watch for it. Late news, Bob has now shared the code with the other Daynoters so forget the above confession.

Today at the office has been fairly uneventful. We did get some more documentation about the lady yesterday who has been getting narcotic pain medication from other physicians. This came from one pharmacy so I have the evidence to confront her and inform her that she has a problem and we will not contribute to it but she does need professional help which I can refer her for.

Today was consumed with physical exams, anxiety attacks, and patients with high cholesterol. Anxiety attacks because of the extra stress of the holidays and physical exams because everyone is trying to get last minute exams done before their new deductible kicks in 1/01/2000. This happens every year at this time, as a matter of fact it usually gets very slow the week before Christmas then gets crazy the week after Christmas as the people who have really put things off until the last minute pour in. I also saw two more nursing home patients today before office hours began and will see two more tomorrow.

In other medical news, interesting item on Jerry's site today about all the supplements and vitamins he takes on a daily basis. Not to start a flame war here, but I would like to see exactly what is in the supplements he takes and go over some of the literature with him about their effectiveness or lack of. Don't get me wrong, I take supplements and believe in them but there are some very dubious claims about some of them. I'm not an expert in the field but do try to keep up and recommend what has solid evidence for efficacy either here or in Europe where supplements have been better studied and are used more routinely.

After writing this throughout my day, I send this home through Microsof Exchange E-mail, then copy it to 1stPage 2000 from Outlook 98 at home and do any reformatting that needs to be done since I can preview what it will look like as a HTML document in 1stPage. I will then publish the final version to the web sometime later tonight. Before that, I have to study some more ACLS, go to my mens group meeting, and practice some with the Wednesday night worship team. Somewhere in there I will squeeze in some food. Until tomorrow.........

What begins as a routine visit sometimes leads off in directions not anticipated. This morning, an eighteen year old girl came in for a routine PAP smear and pelvic exam. While doing a history on her (highly recommended for all office visits), I found out that she was having low back pain and pain on intercourse for several months. Further, she was taking Depo-Provera shots for contraception and had been sexually active for at least three years and was now a senior in high school, still single and living in her parents' home (we won't get into the moral questions here). After her exam I suggested this could be endometriosis as well as several other possible diagnoses. I scheduled her for a pelvic ultrasound and consultation with an gynecologist since endometriosis can not be positively diagnosed or ruled out without laparoscopy. While explaining to her what endometriosis is, she asked me if that could cause her to have problems getting pregnant. I answered yes, but it would depend on how extensive it was and cautioned her I was not saying she had endometriosis, just that we needed to find out what was causing her discomfort. Later, her mother called, frantic that I had told her daughter she could not ever get pregnant. I called the mother back and carefully explained to her what I had told her daughter about possible causes of pelvic pain and that we had no diagnosis yet. She felt better after that, but now her father has called wanting pain medication for their daughter who is now having "severe" pelvic pain. Now, I know that she has no infection which is the only thing that could make her pelvic pain of several months duration more severe after I talked to her about it. She obviously feels mature enough to handle a sexual relationship but is not mature enough to handle an adult discussion of the possible causes of her pelvic pain. However, given her very emotional reaction to this, I know there are some other issues in her life which have not been resolved and which I suspect her parents do not have a clue about. Hopefully this will stimulate some real communication with her parents.

Later today I had a more pleasant experience with a patient who has schizophrenia; see this link for an unpleasant experience. The patient today was taking his medications and, without knowing his medical history, it would have been hard for someone to know he has a mental illness. He is living independently, although not employed, and we were able to have a "normal" patient-physician interaction. Medication does allow schizophrenics to function independently but they have to continue taking the medication and be aware of what could happen if they decide they no longer need it.

More times than not it seems that the last patient of the day is there just to suck you into quicksand, such was the case today. She was a new patient and very pleasant but with every question I felt the quicksand grabbing first my ankles, then going ever higher. Her history was very long and complicated and every question elicited more detailed answers and more problems. I realized I could spend three hours in the room and she would still not be finished even though she talked at a speed approaching the speed of sound. We had started this conversation about 4:30 and it was now past 5:30 and I was running out of hope of getting home anytime tonight. Finally, I managed to gain some control of the visit and we made plans to do some tests then I would see her again in one week when I can be more prepared for the quicksand. Her multiple problems can be helped but it will take several visits to sort them all out and get a plan to deal with them all.

I am finally finished with everything now after 10PM tonight. My e-mail is full of running commentaries between the other Daynoters, all of which are very funny. Sigh, I must find some way to redirect these messages during the day to my computer at work so I can join in the fun in real time. Come to think of it, do I have any real time during the day? I have patient time, administrative time, refill time, alleged lunch time, and "catch-up time", whatever that is, but do I have any real time? Maybe I will have a "real" answer tomorrow.

Now, I get to the office already twenty minutes late (thank you very much Miss Dental Hygienist for telling me it would take thirty minutes less than it took) and all the patients during the morning are complicated. There are no simple colds or bladder infections to catch up on. A simple sounding fever turned out to be a chronic recurring fever for three months in a patient who had been living in Kenya. This necessitated a lot of questions and tests, which I will not bore you with here, but which take a lot more time than was allotted. I am looking for malaria for any one out there who wants to know (Dan and Dan did you hear?).

I struggle through lunch getting caught up but now my gums are telling me that they were worked on earlier. My turkey sandwich is not as enjoyable when you can't find a non tender spot to chew. Again, no more gory details but I am not a happy camper for the afternoon. The afternoon actually goes fairly smoothly except that my last patient is again not back so I can talk to her after a test until 5:30. I finish with her then go to a meeting that was supposedly going to last 20 minutes. Wrong! Try more like 45 minutes. It involved a RPI which stands for Rapid Process Improvement project which is a corporate term for a committee to look at something we are doing to make it more efficient. This particular one was looking at paperwork generated to bill for an office visit. Some of us physicians had been saying for months that the present system needs to be changed to make it more efficient and we need to do this and that. A committee spent three days going over this process and, believe it or not, came up with a lot of the same suggestions we had made. Hopefully we can now get on to making it more efficient

I finally make it home only about 12 hours after I left this morning, not too bad. E-mail is pretty light tonight so I can get to studying ACLS before that class starts in the morning. Updates may be short like this until Saturday night due to this class and don't expect a picture on this page or a redirect page until after Saturday. I'm still debating the picture although Brian Bilbrey says I look like Leonard Nimoy (I hope he meant without the ears).

Sorry about the brevity of this update but must go back to studying. I've got some interesting E-mail to answer and I will tomorrow I promise. Wish me luck tomorrow.

I forgot to tell you last night that I am typing with nine fingers only since yesterday morning. I was helping move a room divider into place before my 7 AM meeting yesterday when I got the tip of my left index finger smashed between two sections of the divider. Very painful and because of the pain from the crush injury, I am unable to type with the index finger at this time. This makes typing this more difficult and I make a lot more mistakes which I have to go back and correct which slows me down more. It should be back to normal by the end of this coming week and typing will be easier then.

I promised E-mail tonight so here goes. This message is actually two messages which I have combined into one.

Dear Doc Jim,

As now Bob Thompson has chimed in with his once-a-day multi-vitamin versus the multitude that makes up what Jerry takes, it would be interesting to hear what an MD thinks is sufficient on a daily basis in terms of supplements.

What is your opinion of the "light boxes" that you can sit in front of during the winter months to supposedly replace the lack of sufficent sunlight.

Alan Donders
alan_donders at hotmail dot com

I personally take mostly antioxidant supplements as I am most concerned about heart disease and aging, the heart disease because there is a strong family history and aging for obvious reasons. I believe that some of the consequences of aging can be delayed by keeping active and supplementing with antioxidants. I make sure I get 1000-2000 mg of Vitamin C per day, 400 I.U. of Vitamin E, 1000 mg of garlic (not an antioxidant but to lower cholesterol), and 10000 IU of Vitamin A. In addition I take a B complex and a multivitamin with iron and folic acid which are important even in men. It is my understanding that our intestinal wall cells will limit the amount of iron absorption to only what we need. There is a rare disease called hemochromatosis where you can absorb and deposit toxic levels of iron but I am not worried about it in most people.

As far as light boxes go, there is some scientific evidence and a lot of anecdotal evidence that they work in seasonal affective disorder. We all have our stories about people who have gotten much better by putting some "Daylight" and similar blue spectrum fluorescent bulbs in their homes or offices or used a light box for a period of time every day during the winter.

Delanae and Stacey are in Portland shopping and having a girls' day out. Stephen and I are eating leftovers tonight while I try and unwind from ACLS and catch up on this update. Tomorrow or later tonight, I plan to work on a redirector page and I need to get a picture from Delanae that I can upload to link to so I will have a picture like the other Daynoters. She has the digital pictures on her computer so I will get her to copy the one I want to a floppy when she gets home. Maybe more later tonight.

******

The girls are back. I have found the picture I wanted. You can see it here. Maybe I will put it somewhere different on this page later. And I have one up on the other Daynoters now, I have a beautiful woman with me in my picture. <HUGE GRIN>

We then went to lunch at Izzy's which is a local pizza restaurant with a buffet where we can stuff ourselves which we proceeded to do. Then it was time to pick out a Christmas tree. We went to a local yard where Stacey and I consulted with each other and picked out the perfect tree. Then tie it on top the Jeep and bring it home, trim the bottom, and voila, it stands up straight in the stand.

This year we remember to put the lights around the window before we put up the tree in the living room. Putting up the lights in the window is always so much fun, those suction cup holders have to be wet before they will stick so here Delanae and I are either licking out fingers then wetting the suction cup or licking the cup directly. Either way, we manage to get them up then string the lights which is also a challenge since the channels in the holders which hold the lights cords have to be stretched first in order for the cords to fit into them. We finally get the window lights up and they all work.

Next, Stephen and I carry in the tree and manage to put it in the PERFECT spot the first time (notice the puffed out chest). Christmas CD's are then loaded into the CD changer and with various contemporary artists doing their arrangements of traditional Christmas carols as background music (occasionally there is some dancing going on too), we proceed to get all the lights and ornaments placed on the tree. Strategically, we try and keep the lower ornaments just out of easy reach of the feline animals that live with us. Here is the end result (I was going to take the picture from outside through the window to show the window lights but it is raining so maybe another night). I was going to put a small image here to link to the larger image like the other Daynoters do but I failed miserably in my attempts up to this point. More to learn obviously.

Now I must fire up Quicken and pay some bills as well as eat something at some time tonight. Hope you like the redirector page and it works correctly. If not, I copied the code from Brian Bilbrey so blame it on him. <Grin> See you tomorrow.