Clinic Vignette March 30th, 2006

driving in my car, i got a phone call from a distraught mom.

the question of doing "car medicine" with cell phones will be saved for another post, but the issues are seriuos - i wonder what the cost-benefit ratio is of "care given" vs auto accidents with cell phone use... would my car insurance count as liability insurance in that case? is there a special medicare billing modifyer that covers cell phone use but discounts for multi-tasking since likely you are talking on your own personal time? so many questions...

but back to the distraught mom. her son is a 40yo heroin user. still lives at home. he's been my patient trying to detox off heroin for a few months. over the past few days she reports that he is acting strange, hallucinating, disorganized, leaving the stove on and almost burning down the house with cigarettes. she had already tried unsuccessfully to convince him to get mental help, to enter a rehab facility, she had called the police to pick him up for his own safety (and hers), had called the mental health center twice seeking help. she was told repeatedly that since he is an adult, if he doesn't want to come in on his own, he doesn't have to, regardless of the fact that he is clearly incompetant to make that initial decision.

now i am all for personal autonomy, patient autonomy. but there is a line in our society between competancy and incompetancy. when someone is ill enough that they cannot care for themselves, that they are a danger to themselves or others, we respect the fact that they can be picked and evaluated by mental health experts. it's not jail. it's supposed to be done with good intentions, i.e. the express welfare of that person. and if the evaluation shows they are competant and perhaps the person calling is crazy or misguided, or trying to lock away someone they dislike, the system figures that out and lets the person go.

but why didn't our system, police or mental health, assist this woman with at least an evaluation? so there i am driving up 4th street on my way to pick up some pvc parts for a grey water system at 4pm and this mom is asking me to help her. my first step was to give her the special code words we use in healthcare - call the mental health center and say, "he is incompetant, he is hallucinating and is a danger to himself and others," don't focus on the drug use, heroin doesn't make you hallucinate. didn't work. she called me back and said they refused her concerns. next step was for me to fax the police dept with a "pick-up" order. that apparently is the right buracratic (side note - i am sick and tired of trying to remember how to spell bureacreaucy so from now on i'm going fenetic) form. i didn't have the form and it was 4 :30 and i'm now in the hardware store.

luckily, those guys are kinda cool and they let me fax off a prescription with the order. got a call back that the script wasn't adequate, couldn't i get the right form. NO! but thru some negotiations and begging, i convinced the police to at least send a cruiser by the house and look in on the situation. that way they could decide if he was a danger or not, at least. they went, thankfully, and actually took him in to the mental health center where he was evaluated.

the mom called me the next day to say thankyou. and then reported that they sent him home because he was an adult and didn't want to stay.

she heard my suggestion to call her county commissioners or the press, because what the heck else could she do? she hung up crying.

andru

Peanut Butter and Jelly sandwiches, the Web 2.o, and Blogging Health Justice

That's the title of a talk i'm giving at the National Physicians' Alliance conference this weekend in Chicago, which is happening back to back with the American Medical Student Association conference -- so yes, i get to go to both. sweet. I've never done a panel presentation before on this topic, and boy I'm no expert either, so we'll see how it goes. But i'm pumped about talking with graduating medical students and doctors about the potential of the web for expression/writing and also for organizing around health justice issues.

The PB&J in the title has to do with the progression of blogs from mundane personal expression (I had an amazing PB&J sandwich today) to reflective personal expression (Yummy PB&J sandwich today, and by the way it made me think about the incentives of the drug company that gives us these sandwiches free with our lectures) to community minded, organizing expression and discussion (I love me my PB&J sandwich, what if everyone had a right to PB&J sandwiches, how can we make that happen?). That's the general theme. I'll save this for another post, but I think, with the medical related blogs, we do the first two really well (especially the 2nd), which makes me really happy. But we're not yet at the third, and i'm pumped about being a part of developing the third in the coming months and years.

Lots of other talks. My co-intern and fellow past AMSA Jack Rutledge Fellow Casey's going to talk about sustaining activism during residency, and Andru (co-writer on this blog) is going to be talking at both the AMSA and NPA conference. He's popular, was asked to talk about public hospital and activism issues, as well as this fabulous topic and description:

"Brewing an Affordable Integrative Clinic for Poor and Uninsured Patients - Putting Care and Wonder Back into the Mystery of Health" will include a brief presentation on the creation process involved in birthing a new integrative clinic for uninsured patients in Albuquerque, NM, followed by group discussion of the various elements involved. Audience participation expected. Discussion to include all aspects of "practicing" medicine: team building, racism, pros and cons of insurance, business structure options, malpractice, labs/x-ray/specialist referral, patient advocacy, pharmacy, homeopathy, volunteers, donations, grants, politics, etc. We will discuss some of the laws that stand in the way of connecting good patient care to affordability and some ideas on how to overcome these limitations.

And that's just a snippet of the tons of other great interactive sessions, discussion groups, breakout sessions, and a rally, in the windy city. We'll report more when we're back. More about blogging health justice, the new and much needed National Physicians Alliance and updates from the NPA pow-wow, and other thangs in a few days... though i may need quite a few days to process the intravenous infusion of energy and discussion and building with dreamers, otherwise known as AMSA and NPA.

Over and out.

Clinic Stories - March 21st

today was a fascinating day in the clinic. we broke alot of social/medical rules but hopefully no true physiological laws in our practice of medicine.

we received a call from a local DOH office with an urgent referral of a hypertensive woman with chest pain, 180/110 blood pressure. she had the pain for over a month but it was getting worse. the woman is undocumented, uninsured and refused to go to the hospital for fear of a crushing bill. we agreed to do an initial assessment of her with our handy EKG and sensitive palpatory skills so they sent her on her way to see us. about 20 minutes later we get a call telling us she doesn't have a car so she's walking over!!!! at this point our awesome receptionist volunteered to go pick her up and transport her the 2 miles to our clinic. when she arrived, she looked sad, tired and was toting two young children. a quick EKG revealed Q-waves in two inferior leads (not reassuring) with no ST changes and a regular rhythm (reassuring). blood pressure of about 160/100 (not reassuring). and on top of it all, she's allergic to aspirin! (not good). what a day. she got metoprolol PO and some clinidine to control her BP, a GI cocktail which actually helped her chest pain alot (reassuring), and a physical exam which revealed reproducible mucsle pain along her sternum (reassuring). at this point we recommended her to the ER but she refused to go so we agreed to draw her blood and send off a STAT Troponin-I while she waited. Once again our receptionist volunteered to take the blood to the lab and amazingly enough, it came back FAST - completely normal value (very reassuring). we are bringing this woman back tomorrow to ensure her blood pressure is controlled and will do strong risk reduction counseling to ensure she minimizes her future potential for more heart attacks. the EKG findings could have been her baseline but i suspect that at some point in the past she lost a bit of heart function. she's had high blood pressure since she was a child.

what are you going to do? what would a court of law say? looking back with hindsight, if she was having an acute MI or if something happens to her tonight, it ain't going to look good for us. but from my perspective, we are honoring her wishes, and doing a good job within her means. it's a risk i'm willing to take.

we also saw a woman with bad cellulitis of her right hand secondary to injecting Crank (speed). she missed her vein and caused a serious bacterial infection to happen. we treated with a shot of ceftriaxone in the butt and a return visit tomorrow but she is right on the edge of needing hospitalization and possible surgery on her hand. she's another one who was mortified by the idea of entering the hospital, but for different reasons - she doesn't want anyone to know she is using drugs or else she'll lose her job.

another gentlman came in, alcoholic but recently quit, with a sebacious cyst right on his adams apple. i had cut it open a few days ago and drained out the cyst but it was in too delicate a place to remove it completely, so he was just back for followup wound care. he is going to have to try to get himself an appointment with a surgeon at the public hospital to have it removed. i'll let y'all know what that journey is like in a few months because that is likely how long it will take him to resolve this fairly simple problem.

andru

Clinic Vignettes - March 18th, 2006

The man with severe hypertension survived the night, is still alive, has reduced his tobacco intake, and is now at a level of Blood Pressure that is relatively controlled. i used a technique with him that i've been experimenting with for folks with high blood pressure. most folks cannot "feel" high blood pressure, it is a silent disease in many ways, until arteries start popping and people lose sight, kidney, heart or brain function. interestingly, many people claim their headaces are from high blood pressure related to stress but i am told by my medical colleagues in research that this isn't the case at all, that people cannot really feel high blood pressure.

so how can we help patients understand what is happening to them? what high blood pressure means and why it needs to be reduced?

this is my technique - while the cuff is inflated i hold the pressure at their systolic for a moment and ask them to feel that pressure on their arm, then i drop it to a normal systolic (120), let them feel that, then their diastolic for a moment, then a normal diastolic (70). then we have a conversation about fluid mechanics, pressure, and micro-arterial damage. once they feel the different pressures it is no longer an academic or intellectual exercise, nor is it faith or belief or trust in your doctor - it is REAL. it seems to be helping folks get a handle on why hypertension matters.

----------------------------

a musclebound weightlifter, Spanish speaking young guy came in the clinic the other day. he has had some issues with fungal skin infections that have responded well to diflucan. in the middle of our visit, something kinda cool happened. he asked me if i knew where he could find contemporary flute music. he had a shy look on his face and stated that he isn't like most other Mexican wieghtlifters who like ranchero or rock music. he's into the soft music of flutes. i found this to be so endearing and also insightful into the relaxed nature of the clinic, that a man could feel comfortable to ask his doctor to help him find flute music. i love that! i think part of the prompting came from the music we play in the reception area. it's an ipod loaded with lots of jazz, blues, some Mexican Indigenous flute music, Nora Jones, all the good stuff. turns out that Rasa, the naturopath, knows a couple yonung Mexican men producing their own flute music so we sent him in that direction. perhaps they will all click and the world will be a better place. :> here's to lots of broken stereotypes!

------------------------------------

a tile worker and her partner came in to the clinic with bad bronchitis bordering on pneumonia. fairly straightforward visit. towards the end of it, the patient asked me if she could help us finish our tiling in the bathroom. we are missing a transition piece that would act as a mini-ramp for a wheelchair, from the saltillo hallway to the slightly lower bathroom ceramic tile. i tried to barter her visit for the work but she and her partner refused, they paid the visit and once she is better, they will come back for the small volunteer job. they said were so happy to have found affordable, kind healthcare. and for them, it's only a few blocks away from where they live.

this past two weeks saw about four random and beautiful offers by patients to help us with various aspects of the clinic from finding new reception area chairs to the tiling to printing up more intake forms to helping us with our move to a new location, which will happen in about 3-6 months.

more than anything, these offers, and the continual small donations we get from our patients are the surest signs to me that we are on the right track, that we are offering something that really touches people, that inspires them to share a small part of their wealth, their skills, their time in helping us get even better.

andru

I am learning Spanish yesterday, es verdad!

I'm still quite embarassed at my spanish language skills these days. I'm finding myself confused by the tenses and using the present tense way too often. Working at an LA county hospital affords me the opportunity to work with many spanish-only speaking patients -- in the clinic, in the hospital -- and I've improved my Spanish immensely in the past few months. There's really nothing like immersion. But i'm just not nearly where I need to be. I used to be a pro -- I took 4 years of Spanish in high school and I was a conjugation and vocabulary rockstar, and a pronunciation queen. Then... I forgot everything. And now... it's coming back to me, but muy despacio.

Yesterday, I met a friend at a bookstore before we grabbed some dinner. I hunted down the Spanish language section, on a mission to find THE BOOK that would help me. Spanish for travelers? No. Spanish for lovers? Hmm, perhaps in the future, but not right now. Latino Slang for Gringos? what's this? here's a description:


I'll hold off on that item for now. Still lookin'....various spanish-english dictionaries of various mid-range pocket-fitting sizes. Do I want a dictionary? maybe. Do i want a 42,000 word one or a 100,000 word one that would take up my whole pocket? 42,000 words seems like it would be enough for me, really. Oh forget it, maybe i'll get a dictionary for my PDA instead of stuffing my pockets so much I can't close my white coat. What i'm looking for right now is a mastery of conjugation, not how to say "pencil sharpener" in spanish (try fitting "sacapuntas" in a conversation with a patient. Let me tell you, I've tried. You've gotta show you know some spanish, even if it's "your leg looks like it was eaten by a pencil sharpener. le duele?")

The various Spanish tenses are way back in the depths of my brain, and sometimes I recall them from my high school days. But the fact of the matter is, I only really have present-tense confidence right now: I'm still past tense shy, present progressive tense anxious and preterit tense scared-out-of-my-mind. I'm tired of using the present tense for everything:

Like: How much does that hurt you yesterday?
Or: I am going to will be in the future drew your blood in 5 minutes.

(ok really i'm not THAT bad). Well, my broken spanish gets me by, but would I want a doctor who talks like that? So anyway...still looking... looking for the right book for me. Thoughts go through my head as I pan my eyes over the rows and rows of Spanish learning tools. Wow, what a great industry, I think to myself. Books, dictionaries, audio CDs to distract you while driving, slang dictionaries, nicely dressed up and durable multi-colored plastic binding travel guides, etc. I even saw a Panjabi audio CD selling here -- I can't even imagine trying to learn Panjabi while driving in my car.

Oh wait, what's this?!? Complete Medical Spanish! Sweet! WITH tense explanations, vocabulary, AND only 280 small pages. Now I can add to my wealth of medical terminology...

So here I go, my friends. I bought the book. And it's so cute, the authors have thrown in cultural references to go with the grammar and vocabulary. I'm hoping they don't stereotype and make me cringe, but so far so good (as of page 2):

"One should shake hands with everyone to avoid being seen as extremely rude, cold, and uncaring. An even more kind, caring, and warm gesture is to cup your left hand over the hand you are shaking which conveys the feeling of trust (confianza). It is a quite comforting action seen from the Latin American point of view, and it tends to communicate the feeling that "You are in good hands now." It does not transmit the trite or paternalistic attitude that may be interpreted by U.S. Americans."

Sounds like a great way to shake hands with everyone, latino or not, paternalistic or not :> Mucho gusto, 'Complete Medical Spanish'. We're off to a good start.

(cross-posted at Los Anjalis)

Hypertension Crisis?

a 55yo gentleman came to the clinic yesterday. a smoker, he had known hypertension, untreated for 2 years from lack of funds and health insurance. he recently lost some vision in his right eye, a few weeks ago, which motivated him to find a doctor. he had the highest blood pressure i've yet seen in my career. 250/140. he was clear that he wouldn't go to the hospital, too expensive.

this raised ethical and legal questions for me. what is the right thing to do? he needs treatment, that is obvious, but where? in the clinic, in an ER, in a hospital setting? what does the research show? this is clearly a hypertensive urgency, perhaps even a hypertensive emergency (i would only know if i had more lab tools at my disposal). yet research is showing that if you drop the BP too fast, you place the patient at high risk of lots of complications, so outpatient treatment isn't necessarily wrong, it's just far from ideal. the benefit of the hospital is that you can monitor the patient, intervene immediately if he starts stroking or having a heart attack, you can monitor the blood for kidney function, etc. and all that costs thousands that this man doesn't have.

but what would a jury say if he stroked out overnight or had a heart attack? would they understand patient choice, system limitations, the role of a consulting doctor giving good information even if a bad outcome happened, the limitations of the patients resources? so many questions. would they understand that his high blood pressure is caused significantly by his own actions, smoking tobacco, taking in alot of caffeine? does any of that count? i believe it must so i will stand my ground, practicing medicine without mal-practice, even if it feels a little foolish now and then.

after counseling him on the importance of being in a hospital, i put him on norvasc 10mg daily and clonidine 0.1 mg three times a day, with a baby aspirin. i worried about this guy all night long. he was late to his clinic appointment today, making me more nervous. fortunately, he made it to the clinic, his BP was down to 200/135, he was feeling better, slept well, and is more committed to taking care of himself, now that he has an affordable option. he was still smoking though... i'll see him back on tuesday.

andru