127. Tears

A nurse came to my office in tears the other day asking me to see a patient also in tears.  No, she repeatedly said, her tears had nothing to do with the patient, this was just a "very emotional day."

22 yr old Lacey presented because a much respected previous doctor told her she needed to be seen after an abnormal Pap smear and with concerns about not being pregnant after 4 months of unprotected intercourse.  My partner couldn't make sense of the patient's explanations and since records were not available, told the patient that she couldn't be helped that day. Regrettable words were said on both sides.  The perceived infertility never came up.

My goal was to provide a blanket apology and to see if I could piece together explanations and plans for both issues.  It's a tricky ground because my partner may have simply been ambushed by someone on edge, unhappy over having to abandon her other doctor, unwilling to consider that the latter might have been wrong, or unhappy that the Pap smear overrode the more important infertility issue. Overtreatment is common with abnormal Pap smears and I assume that my partner didn't want to pursue a previously recommended but inappropriate treatment.

Well, I failed on both counts, the patient unsatisfied with my words, leaving in tears and insisting that she would simply go back to the other doctor.  As for the nurse, her 20-something daughter had experienced a similar encounter with an urgent care doctor a few months ago, an open wound it appears.

Fact or factoid:  a healthy couple requires an average of 7 months of unprotected intercourse prior to conception?  Perhaps a factoid, but helpful in encouraging patience, especially for a 22 year old.

126. Anxiety Dreams

According to Forbes (my top source for workplace issues, yours too I'm sure) lists the top ten work-related anxiety dreams, which include various tech frustrations or being late/chased/naked at work.

Here's mine:  for unclear reasons, I leave the operating room in the middle of surgery. Then I can't find my way back.  I wander inside and out, through rooms and corridors, up and down stairs, and just can't find the OR.  I know it's not good for the patient to be under anesthesia for a prolonged period of time, especially with an open abdomen, so I keep on looking, my sense of unease and distress ever increasing until I wake up.

125. INS, Another Happy Ending

Remember Inez? She wanted her husband to be present for her delivery, which required INS approval since he is a citizen of Mexico.  At her request I wrote two letters, the first making the request, the second advising against air travel since the INS had suggested that she go there instead of him coming here.

I saw her last week for a postpartum check.  He didn't make it for the delivery, but is with her now, the INS demonstrating some unexpected compassion.

124. Happy Endng

Did I mention that Jeannette is hypertensive and diabetic?

Four days after finding out about her pregnancy, Jeannette developed severe preeclampsia, probably triggered by her hypertension, and requiring induction since severe preeclampsia can be life threatening (to mom and baby) and has no cure other than delivery.

She did well during a protracted induction and just one week after she found out she was pregnant, she held in her arms a healthy newborn 6 lb, 6 oz baby girl.

123. How Could She Not Know?

A couple of months ago Jeannette visited her family practice doctor.  She was constipated and having abdominal pain.  The doctor thought there might be a pelvic mass and ordered an ultrasound, requiring a month or so to be scheduled.

You've guessed by now: she's in her 8th month of pregnancy and will deliver this month or next.
So of course we wonder about her apparent cluelessness.

But think about it.  Many years of attempted conception; pretty much given up on it.  Too many months with periods a day or a week late and thinking, "maybe this is the month, maybe I'm really pregnant this time."  And then the tests return negative, the period begins.  Disappointment, tears, the self-promise to never allow expectations to rise again only to be inevitably broken.

So of course she's not going to allow herself to think that her weight gain, the abdominal expansion, the lack of periods, the intra-abdominal turmoil, could all be signs of pregnancy.

122. I'm Going to Bring Him Back

Marissa received two units of blood (about a quart) in the ER a few weeks ago; one year of heavy menstrual bleeding had left her severely anemic.  We discussed less invasive options, but decided to proceed with a hysterectomy.

Then she explained why she needs to be as strong as she can.  Her 19 yr old son tried to hang himself last year.  Found in a closet, revived, but paraplegic with severe brain damage.

"I'm going to bring him back," she says.  Irrational? Sure, and she would probably be first to admit it, but how else can she keep going every day, day after da?

121. Penny Saved, Penny Earned

So how can my group contribute to the trillion dollars that some of my favorite experts claim can be cut from American healthcare expenses without cutting quality?

Starting this month, the trash cans in the doctor's offices will not be emptied nightly; twice a week if we're lucky.

Don't worry, though, the exam room waste will stil be cleared daily.

120: INS

Round One
At 30 weeks Ines asked me to write a letter to the INS asking that her husband be given a visa so that he could travel from Mexico to be with her for the delivery.  I have no problem with that, so letter composed and sent. I don't know her immigration status, but since she is openly petitioning the INS, I would assume she is a citizen, or has a green card.

Round Two
A few weeks later she tells me that the INS denied her request, observing that she could simply return to Mexico. So she asks me to write a second letter recommending against air travel. I agree, though I'm on shaky grounds; there is no generalized recommendation against air travel for pregnant women at any gestational age. Some airlines require a doctors note if past 36 weeks, and of course there can always be case by case exceptions, for example, a pregnancy at risk for preterm labor.

Round Three: stay tuned.

119. Scratch-Itch Cycle

Joanna presents with severe itching and pain in the "groin"--the crease or junction between the thigh and the torso (or more specifically, the vulva).  The area is a bright red patch with superficial excoriations--she has scratched herself so much that there are tiny breaks in the skin, which causes further irritation and more scratching. The goal is not so much to determine the original cause of the irritation as it is to stop the scratch-itch cycle.

But she is fixated on that original cause, certain that it started in a "conversation" tub at a nudist resort in Florida. She wants me to know that she simply accepted the invitation of some friends, not knowing it was "that kind of place."

It looks and sounds fungal but fearing a secondary bacterial invasion I provide both anti-fungal and anti-bacterial meds.  A subsequent culture confirms a bacterial infection.  And most important, I give her the strongest topical steroid that I have, whose anti-inflammatory actions should stop the scratch-itch cycle.

A week later she is doing great, the skin healed and no longer red and tender.  I've already been back in the water, she says, apparently having learned little from the episode.

118. Obamacare

Tubal "ligation" really means "transection"

Last year, at 34, 10 years after the birth of her second child and tired of taking birth control pills, Janet decided it was time too do something permanent.  But when she inquired about an operative tubal ligation, she found it wasn't covered under her insurance; she'd have to pay $6000.

This year she asked again and was told that effective August 1st, the Affordable Care Act requires that eight health care prevention services for women be offered at no cost, including contraception. She's scheduled for Aug 31st.  And that's that.

117. Do Something

36 year old Ashley recently ran a marathon.  She is 5-5 and weighs 130.  Her first words to me are, "people say I look pregnant. I need you to do something about it" 


Internal scarring from her two cesarean deliveries cause a retraction of subcutaneous tissue at the site of the incision, with a subsequent small bulge above the incision.  I acknowledge that scar tissue has resulted in unwanted anatomic changes.


But I don't tell her that she looks pregnant.  And I can't how imagine friends or co-workers could come to that conclusion.  Are they feeding into a serious self-image problem?  Or is she making it all up to stir me to action, thinking, I guess, that I can perform or approve some type of corrective surgery?


My options:
1.  Reassure her: "No, you look fine; your friends are just jealous."
2.  Pass the buck: "We don't have cosmetic surgery here, you need a cosmetic surgeon."
3.  Tell it like it is: "You have a body-image distortion."
4.  Or, a Rogerian:  "I see what you mean; sounds like you are really frustrated to have worked so hard but still short of your goal."

116. Memory

Talk with 88 yr old Rose for five minutes, about the weather or the goings on at her retirement home or her current medical problems (bladder, it appears), and you think, that's how I want to be like when I'm 88. Her eyes sparkle and maintain contact with whoever is speaking.  Hair in place, rosy cheeks, a straight back.

Then you ask about some bleeding that she apparently experienced recently, and she just shrugs her shoulders and says, "You know I have early Alzheimer's, and my memory isn't worth anything."

Sometimes Alzheimer's wears the face of depression, confusion, a wordless inward withdrawal; or sometimes anger and frustration and stubbornness.  But there can also be an engaging and seemingly engaged senior who just can't seem to remember anything that happened yesterday or the day or the week before that.

Memories.

115. Independence Day

Seems only reasonable for a themed post.  We are all into patient independence these days. Forget "paternalism," where the doctor made all the decisions not only about the course of treatment but also whether or not the patient should even know the diagnosis.  Forget "informed consent," where the doctor still made the decisions but at least informed the patient who then gave consent.  Welcome "shared decision-making," where all the options, risks, benefits are laid on the table with a full discussion and then a consensus decision.  I suppose the next stage in this progression is, "you've googled it, tell me what you want me (the doctor) to do."

So, a 26 year old walks in and says she wants a hysterectomy because of painful menses.  She's already had a tubal ligation, so she's made it clear that she doesn't want/need her uterus for it's natural function.

Removing the uterus doesn't guarantee absence of pain.  "I know that."  And there are potentially life-threatening risks to major surgery.  "I know that too."  Can we keep the ovaries intact?  "No."

Okay, how does July 25th sound?

114. Three to Ten

Andrea came in for day surgery last week, a simple procedure to remove an asymptomatic ovarian cyst.  She had been adamant about its removal even though at 32 her risk for ovarian cancer is low. Most of us would recommend a follow-up ultrasound in 3-6 months, rather than surgery, but because it did not have the characteristics of a simple, benign cyst, it was, in the parlance of modern medicine, a "shared decision-making" decision.

Before surgery, I asked her for permission to have her father present for the routine immediate postop talk (though she might appear alert, her short-term memory will be impaired and her father could serve as a back-up memory).  She explained, however, that he probably wouldn't be in the waiting room, since he might be with her mother in the car.  Her mother, she further explained, had Alzheimer's and would be disruptive in public.

Several times a year I talk with patients who want to hold off on necessary but not urgent surgery because they are the primary caregiver for a spouse with Alzheimer's Disease.  Unspoken is the shared knowledge that such deferment may not be long.  The interval between diagnosis and death can be just 3-4 years for patients older than 80 at diagnosis, up to ten years for younger patients; I would assume that Andrea's mother fits in the latter category.

I wonder if there is any association between Andrea's insistence on surgery, and the burden that she and her father carry.

113. from the Latin

The computer screen that displays my schedule tries to stuff in a lot of information, including name, number, time, age, reason for the appointment, plus a few other details. Abbreviations are part of the deal.

So when I saw "cerv mass" on the schedule the other day, I should have thought about a growth on the lower part of the uterus, right?

But no, I thought, "why would someone wanting a neck massage make an appointment with me?"

112. Stop!

Vulvodynia:  the medical term for chronic pain involving the the outer (i.e. visible) female organs.  Acute (transient) vulvar pain can be caused by fungal or bacterial or viral (e.g. herpes) infections, or mild trauma (pants too tight).  Chronic vulvodynia is much more difficult to understand and manage.

Yesterday I met Tabitha, an 18 year old who ostensibly came in to talk about abnormal bleeding patterns, but her real issue was vulvar pain, centering around the introitus--the opening to the vagina.  There is no visible sign of infection or trauma, but even the light touch of a q-tip elicits pain.  She can't use a tampon let alone tolerate sex.  

Tabitha denies past or current sexual abuse, but one possibility is aggressive intercourse (not rape per se but an unknowing or insensitive partner who has watched too much porn and an inability--for whatever reason--on her part to say, "it hurts, let's stop.") that if repeated leads to a reflexive tightening of adjacent muscles, making entry even more painful, and so a vicious cycle and chronic pain.  

My recommendation is simple: stop.  No penetrative intercourse; instead, a slow and progressive self-touching starting at the inner thighs and working in, to unlearn that reflex.  Any contact that causes pain means a return to the level of touch that did not cause pain. And the warning that this may take months.  

111. Throw the Bum Out

Commenting on her current status, 78 yr old Mildred noted that she was "not sexually active, got rid of him 7 years ago, no need for men, especially cheating ones."

110. Community Call

I think I've posted before about community call: the rotating system used to provide care for ER patients with no established doctor (they may or may not have insurance).  ER docs provide immediate care to stabilize patients but do not perform surgery or provide ongoing in-hospital care; patients that need either of these services are referred to the appropriate specialist on call.

Recently I overheard a colleague make the following comment:

"Makes me even less willing to do community call."

And what prompted this statement?   ... the several week delay in receiving reimbursement.

Dr. Zorba would not approve (or for that matter, Hippocrates either).

109. Glass of Wine?

Question from antepartum clinic:  "Can I have a glass of wine with Easter dinner?"

I'm supposed to say, "no, never."  One of my partners defers the question by noting that "there is no evidence that it is safe to do so."

My answer: It's probably okay (for first trimester patients I would say no).

But I'd probably be more scientifically (and politically) correct if I copied my partner.

108: "I Don't Like Needles"

Pertussis (whooping cough) is now an epidemic in this part of the world.  Too many parents have not vaccinated their children, allowing the virus to take hold.

Meanwhile my organization of several thousand employees has decided that employees who have direct contact with patients must either receive the flu vaccine or wear a face mask.  One of our receptionists has selected the latter.  After a few days of stuffy breathing and difficulty making herself understand, she has allowed the mask to slip; it now just covers her chin. Her rebellion stands unchallenged.

Sure, I understand true needle phobia, and initial parental concerns about the many vaccines kids are subjected to.  But shouldn't rational decision-making also play a role?

107. Pelvic Relaxation

Think of a hammock that's been outside for a number of years and subject to a lot of kids jumping in and out.  The hammock and the ropes that hold it up will stretch with time and sag.

Now take that image to the pelvic opening.  The connective tissue across that opening keep the bladder and the uterus where they are supposed to be, despite lots of kids and lots of jumping (the jumping can be lifting, chronic cough, constipation; you get the idea).  We call the subsequent sagging pelvic relaxation.

Last night a woman presented to the ER worried that everything was going to "fall out, just like a baby."
No question but that it feels that way.  Too bad that the urologist that she had seen the day hadn't spent a few minutes explaining that though very uncomfortable, this conditioning is not life threatening.

We complain about patients filling up the ER with non-urgent problems, but a proactive minute of teaching would prevent a lot of it.

106. Law and Order

A patient recounts her 90-yr old mother's exchange with her cardiologist who was proposing to place a cardiac stent.  "I know I have to be careful," he told her, "since your daughter is a cardiologist."
Not missing a beat, she replied, "She's not the one you should be worried about, it's my three daughters who are lawyers."

This story was told while I was preparing this patient (one of the lawyer daughters) for major surgery.

Yes,  I got the message.

105. San Lucas: Resolution

Locked out of the OR, I instead went to the regional government hospital in Solola, about 1- 2 hours from San Lucas (depending on public or private transportation).  Talked to the second in command and to the head of Gyn, who confirmed their reluctance (even refusal?) to care for postop complications from surgery done at San Lucas.  But then the gyn guy went on to tell me I could bring patients from San Lucas and operate at Solola, provided that I bring my own supplies, and anesthesiologist as well.  Transfusion availability and back-up would be part of the deal.

I figure day one: unpack, visit Solola, lay of the land.
day two: general ob/gyn clinic; interview pre-screened patients
day three and four: gyn surgery at Solola
day five: postop care and minor surgery at San Lucas
day six. final post op care.

I need a sponsoring organization from U.S., help from the San Lucas parish (have already started on this), final go-ahead from Solola once dates are settled on, maybe March 2013?

104. San Lucas: Anesthesia

No problem with having anesthesia able to cancel any surgery any time.  Surgeons, with their "chance to cut, chance to cure" mind-set may schedule surgery for someone with a concurrent illness (upper respiratory illness, uncontrolled diabetes, heart disease, anemia, etc.) that increases surgical risks to unacceptable levels.  So put a hold on, let the patient recover, stabilize, benefit from further evaluation.

So when anesthesia asks to talk about my planned San Lucas surgery, it seemed routine.
"Do you have access to blood if a transfusion is needed?
"Do you have a specific (i.e., name and phone number) back-up for delayed postop complications?
"Do the sponsoring organizations know what you're doing?

These are valid issues for overseas medical missions and always play a role in patient selection, but I felt that I might as well have been asked, "Do you have a silver stake for the vampire?"

Bottom line: no gyn surgery.  I think the real issue was not wanting a gyn patient to bump a podiatry patient.  After all, this was podiatry mission, with four podiatrists and a team organized to support them; I was just an self-invited guest.  I'm okay with that. Just be open about it.

103. San Lucas: Fibroids

Fibroids, or leiomyomas, a common subject here.  Benign muscular tumors of the uterus. Ana, 36, Aura, 47, and Irma, 43, all have symptomatic fibroids.  Symptomatic means pain or abnormal bleeding.  No medical treatment for fibroids, just surgery, usually hysterectomy, which is usually not difficult but does have increased risk of bleeding (see previous post).  Ana and Aura have low blood count, so probably would do best taking iron supplements for a few months before any surgery.  But that leaves Irma (whose fibroid seems to be a pain issue), and Leticia, who has abnormal bleeding and an enlarged though non-fibroid uterus, as surgical candidates.  Two out of five, not bad, all things considered.

Enter anesthesia.

102. San Lucas: the Logistics of Care

Dr Tun had five San Lucas patients screened for possible gyn surgery:

Valeria, 67 has apparent cervical cancer with zero chance of getting the type of radiation, chemo and/or surgical treatment that would be standard in first world countries.  Would a "debunking" (i.e. removing as much of the cancer as possible, knowing that microscopic remnants would probably remain?) hysterectomy help?

But malignancy makes surgery more risky: life-threatening bleeding, pulmonary embolism, and injury to the urinary system, and so on. So I said I could not offer surgery, though the government hospital about 2 hours away by public transportation, might help her.  That would require multiple trips and blood donors.

Surgical patients at the government hospital are supposed to bring two blood donors (of the same blood type) in case they need a blood transfusion. Even if the surgery is unlikely to be associated with heavy blood loss--therefore the blood not needed--these donors will help replenish the hospital's blood bank. Apparently there are local biases against blood donation, such that many prospective surgical patients have to pay donors.

Chances are that the logistics of care away from San Lucas will prevent Valeria finding any care, unless symptoms such as bleeding increase, at which point any therapy would be less likely to help.

101. San Lucas: Tips for the Airport

Preparing for another overseas medical project (#10), to San Lucas, Guatemala, I was given advice that seems to go a bit more than the 3 ounce rule.  I've not had problem on previous trips, but on any particular day, a customs official can make life difficult.

"If you are carrying any medications, bury them at the bottom of the bags and keep a list with you.  If they find them, say that they are OTC [over the counter; i.e., nonprescription] meds and vitamins.  They are being very sticky about meds and anything out-of-date [i.e., "expired"].

The best thing to do when you get to the airport is to load our bags onto a card and walk toward the exit nonchalantly, looking straight ahead, walking out immediately.  Do not stand around waiting for someone to give you permission to leave.  Just keep walking out.

If they ask to see your bags, get your manifests and support letters and team roster list out and be prepared to answer their questions."

100. The Iron Lady

At 48, Vanessa continues satisfied with her decision to remain childless, but seeing friends unable to conceive, she wonders if she could be of help.  She reasons that a surrogate pregnancy with an implanted embryo, using either donated or anonymous sperm and ovum, would not only help friends, but would also provide her with a family of sorts.  Now caring for an aging mother, she is worried about becoming older without a family.

I told her that an IVF clinic would give her a better answer, but cautioned that she probably would not be accepted as a surrogate mother even with donated embryos.  There's too much at stake to risk the uncertainty of a 48-yr old uterus.

The film "Iron Lady" suggested to me that children or not, successful career or not, aging and loneliness are inextricably intertwined.

99. Hot Flashes

There's a connection between changing hormone levels and the body's heat regulation system.  So when there is a sharp decrease in estrogen level, the body's thermostat thinks that body is overheating, triggering perspiration and dilatation of superficial blood vessels.  The latter shunts blood to the skin, allowing heat to escape.  A perception of increased body temperature follows (though the core temperature has remained normal)--the classic menopausal hot flash (or a hot "flush," recognizing the skin's redness due extra blood near the surface).

48-year old Leeann tells me that she only experiences hot flashes when she's near her husband.  Apparently, there can be more to a hot flash than a malfunctioning thermostat.

98. Turf Wars

Medical turf wars usually involve stent-placing cardiologists up against bypass cardiac surgeons.  Or family practice docs performing colonoscopies that gastroenterologists want to keep as their own.  Or optometrists v ophthalmologists.  But here at StJ's we also fight over call rooms.  Call rooms are for hospital docs who don't need to be up all night but still want to be in the hospital for urgent calls.  Usually we think obstetricians and midwives, but others are involved, too.

StJ has 8 or so call rooms, with advance sign up sheets taped to each door.  Apparently someone has been  playing around with these sheets, to the ire of one doc who found his reservation crossed out.

So he posted this sign, naming the alleged offenders (before taking this pic, I blocked out the names) and this message: "Don't be DICKS and move out people who signed up for call rooms.  Our sleep is just as important as yours." Surprisingly this sign has stayed up for a couple of weeks.


It's a jungle out there.

97. My Husband Won't Let Me

Sandy is 25 with chronic pelvic pain and four kids.  Repeat evaluation over the years has not revealed any cause.  Last week she came in and asked for a hysterectomy; I hesitated because without diagnosed uterine pathology, the pain will likely continue after the surgery.

"Healthy Life Style"  That's what we propose for patients with chronic pain.  Sleep, nutrition, exercise.  Just a daily 20-30 walk outside can combine exercise and a meditation-like mind clearing.

"Do you have time for yourself?" I asked, hoping this would trigger a useful conversation.  Finding time (alone! --an exercise DVD won't work with a house full of kids) is the deal-breaker for many would-be home athletes.

Her reply:  "My husband won't let me."

With some prompting, she explained that he doesn't literally stand in the doorway keeping her homebound, but he refuses to take care of the kids. With no money for babysitters, he has effectively prevented her attempts to gain control of her health.  And I suspect that when someone has to be up at night with the kids, she's the one who loses sleep. Or she stays up late with laundry and other chores.

There's abuse and then there's abuse.

96. La Familia

Though childless at 51, Inez is not without family.  She came to the hospital with heavy bleeding, abdominal pain and just plain feeling terrible.  I've seen her several times--she's never been without family. There were six in the tiny ER exam room.  Two women sleep in her room.  This evening, I counted at least eight, of all ages.  You read a lot about the extended Hispanic family. It's one thing to read about it, another to see it in action.

95. Fate

At 90 Mildred is alert and independent.  She's in the hospital for complications of congestive heart failure: the heart doesn't pump as well as it should, blood and fluid back up in the circulatory system, leading to swelling in limbs and fluid in the lungs.  She needs meds (e.g., digitalis) to strengthen the heart, which should clear up her lungs, allowing for a discharge in a few days.

An abdominal CT scan (not too sure why that was obtained, but it's almost routine), incidentally showed an abnormal uterus, suspicious for cancer.  I recommended a uterine biopsy, to be done in the office after her discharge.  If it showed cancer, surgery might be recommended, or for a precancerous condition called hyperplasia, easy to take suppressive hormones (progesterone) could be recommended.  She said no thanks.

Her son was present and clearly wanted her to accept the biopsy.  A common theme. The kids want everything done for their parents, who often are satisfied to "let nature takes its course."  I argued for a middle ground:  do the biopsy (uncomfortable for a few minutes but no risk to health), then rethink.  She said she would consider but was inclined not to.

94. "Partner" part 2

Beth, 24, came in a few days before New Years' with a couple of issues, including refill of her birth control pills.  She mentioned that she would be leaving for California on Sunday but would be back in the spring. "Going back to school?" I asked.  "No, but my boyfriend is in divinity school there."

93. "Partner" part one

I'm rounding on a recently delivered 34 year I had not yet met.  The father asks if I will write a note excusing him from work for another week since she had an unanticipated cesarean delivery.  Sure, I said, and returned to the nursing station to write a note (most companies don't mind a hand-written note for this purpose; as long as there is some paper trail).

Then I realized I forgot his name--no problem, I'll just check the admission record; his name should be on it.  But no, for emergency contact, just her mother was listed.  Too bad because I had already started a note: "Please excuse [blank] from work until Jan 9th because his wife underwent an unexpected operative delivery."  When I wrote "wife" I had a fleeting thought--"maybe I should write 'partner.'" But that didn't seem right in this setting.  During that brief encounter, they seemed... well, like a married couple.

A recent analysis of census data shows that 51% of all adult Americans are married, an all-time low.   In my state about half of all deliveries are to unmarried women.  My own records over the past 15 years show that 70% of the woman whose deliveries I have attended are married.  That number will probably decline.

Anyway, I left the note as written, asking for and adding his name when I returned to give it to him.  I doubt that he or anyone reading it will give a second thought to my outdated social prejudices.