Tuesday, January 25, 2011

Guest Post: When it snows, it pours

*All names and potentially identifying information (including some physical descriptions and case details) have been altered to comply with HIPAA regulations, as well as to be nice and ethical.

It was snowing one recent morning when I got up to drive to work. It was supposed to rain. I’m a primary care doctor in Boston, and my commute can be 12 minutes or 60 minutes, depending on the traffic. I was lucky I left early, because the unexpected snow on frozen asphalt created a slippery mess, many accidents, and much traffic. It was pretty bad. I wouldn’t say half my morning session cancelled; rather, I was surprised that half was still on the schedule. Tough New Englanders! I took off my soaking wet boots and pulled on my white coat and waited to see who would show up in the snowstorm.

Part of me was hoping that I’d have the rest of the day off, and I could go home to cuddle with my 6-month-old. Of course, then I would have to make up the day later on… I was here and decided to make the best of it. With oodles of extra time to lavish on my patients, I looked at the schedule. My first patient, Brenda Z., was a 22-year old for a physical. Usually, I only have 20 minutes for these, but today, we would have a whole 45 minutes!

Brenda is only 5 feet tall, but she weighs 244 pounds, putting her Body Mass Index (BMI)(1) at 48. Unfortunately, she is not only one of the 34% of Americans who are obese, but one of the 5.7% who are extremely (morbidly) obese.(2,3) Predictably, she has many obesity-associated problems: asthma, sleep apnea, polycystic ovarian syndrome, and almost-high blood pressure. For the past year, I’ve had her come in every 3 months for weight and blood pressure checks. She comes from a middle-class home, works at a supermarket checkout, and goes to school part-time. She’s a hard worker and a good kid. But best of all, she had lost 11 pounds, by eating mostly fruits and vegetables and Slimfast shakes. I wasn’t at all sure this would stick, but hey, it’s a start.

As Brenda left, I noticed that the medical assistant and one of the nurse practitioners were steering a fairly off-balance woman into my other exam room.

“Um, if you don’t want to see her, I guess we can ask one of the other docs to see her, but this was the closest room…” said the NP.

The M.A. was more blunt: “This one’s drunk. Falling-over drunk.”

It’s not at all common for patients to show up at our office drunk, but this lady, Alexa J., had just wandered in looking for her usual primary care physician, who was out. She was in a bad state, so the staff had taken it upon themselves to make her safe. They checked her in and took vitals, as she promptly passed out face-down on my exam table.

“Hello? Hello, can you hear me?” I rubbed her shoulder, more than a little alarmed. She was dressed well, but absolutely reeked of Vodka. Fumes. I felt dizzy just standing over her.

“I need help, I need to stop,” she garbled.

“Stop what? Are you alright, are you hurt?”

“Alright… I want to stop this, stop drinking.” That much was clearer.

I stood and thought for a moment and then just picked up the phone and called our ER. The triage nurse took the information with aplomb, simply adding “Passed out, eh? Good luck getting her down here.” But the M.A. and I wrestled her into a wheelchair, and with two escorts, off she went to be evaluated and possibly admitted for detox.

I then got a call from a psychiatric hospital. A patient of mine, a middle-aged mom named Jane L., had been admitted with suicidal thoughts, in a background of Bipolar Disorder. I was surprised and pleased to get a callback from the treating psychiatrist, who filled me in: that she was stable, but would need residential placement after acute treatment. I offered some of my take on the situation, but the psychiatrist did not seem all that interested… That’s OK, I’m in over my head with someone who is a danger to herself; she’s in the right place. But I remembered that just a few months ago, after she had come in to see me and had expressed that she wanted to overdose on her pills or crash her car, I had walked her down to the emergency room myself. Just a few years ago, she was working and supporting herself and doing well. Now, she was on disability, in and out of the hospital, her finances in ruins. I so wanted to see her better.

My next patient was new to me, a healthy mom with a cold and a cough, and some mild wheezing. She asked me about Boston Med, the 8-hour ABC-TV documentary series that aired last summer.(4) I was on maternity leave when it aired, but my husband and I watched every episode. It was touching, yet also stereotypical: lots of trauma drama.

She asked, “Are they going to film another series like that? I hope so!”

I didn’t know. But I pointed out that the fact that only surgeons and ER staff were profiled, and that very disappointing to us primary care docs! “Primary care is exciting too,” I said.

She had some mild bronchospasm, so I gave had given her an inhaler. She seemed so reluctant to accept the inhaler, that I had to ask her why. She told me about her son who had been a micro-premie and survived, but with bad lungs. He was 9 years old now and doing well except for asthma. He had been in and out of the hospital with many infections, pneumonias, and was better now but didn’t react well to the Albuterol and they had to keep trying new meds- Pirbuterol, Levalbuterol.

“Will this happen to me?” she asked, really worried. She had equated his long battle, the sequelae of premature lungs, with her new diagnosis of reactive airways, which means mildly “twitchy” lungs that respond well to occasional puff of Albuterol. I couldn’t dismiss her fear, borne of a painful experience… and I couldn’t alleviate her fear with any quick explanation. And so we had a long discussion about it.

“Thanks for spending so much time with me today,” she said.

My next patient probably had the flu. Then I said Hi to my diabetic patient whose sugars are all over the place, and I’m following her along with our diabetes nurse.  Thank God for our diabetes nurse, who can take a good diet history and offer good solid recommendations on eating.

My last patient was Nanette M., a 32-year old African-American woman with a new breast lump. She had no breast cancer risk factors at all, and the lump was round, but it was deep and immobile. We decided to do an ultrasound and a mammogram.  Statistically speaking it’s probably a benign breast cyst. Still, breast cancer is the most common cancer in women (besides skin cancers). Also, breast cancer rates are higher in African-American women than white women before age 45. (5) I wanted to be careful. Though I have seen many women with breast changes that turned out to be benign, one time I examined a patient with breast thickening, and it was breast cancer, invasive but not metastatic. Surgeries and chemotherapy took a whole year from her. Her treatments left her a changed woman. Thankful to be alive, but changed, older. So any breast changes, basically, scare me.

And that was that. I ate a snack, tried to do some paperwork, but then I called home. I spoke to my mom (our nanny) and heard my baby squawking in the background. Then I spoke to my Hubby, who urged me to get home soon before rush hour. Baby just sounded so cute, and Hubby was worried, so I packed it up and made for home, leaving behind some paperwork and a snowy morning at the primary care office.


-MA MD

1. Centers for Disease Control and prevention: Vital Signs: Obesity. http://www.cdc.gov/nchs/fastats/overwt.htm accessed 1/18/11

2. Statistics related to overweight and obesity. National Institute of Diabetes and Digestive ad Kidney Diseases. US Dept of Health and Human Services. http://win.niddk.nih.gov/statistics/ accessed 1/18/11

3. National Heart Lung and Blood Institute BMI Calculator http://www.nhlbisupport.com/bmi/

4. Boston Med, ABC medical documentary Summer 2010: http://abc.go.com/shows/boston-med

5. Breast Cancer Facts and Figures 2009-2010, American Cancer Society





6 comments:

  1. Primary care is a great field when you have the luxury of a little bit of extra time with patients!

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  2. If I could just have 5 more minutes with each patient I'd be a happier (and better) pediatrician. Sigh....Great post!

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  3. I'm a FM doc and LOVE my job. Your descriptions sound a lot like my days..add in some baby delivering and lots of family planing.. Thanks for posting!

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  4. Primary care absolutely can be rewarding, and I'm glad to have a post about it! Thank you!!

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  5. Great post. Thanks for sharing your patient encounters and experiences in primary care!

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  6. The fantastic post. thanks for details.

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