My Gout is Getting Better – and Steroids are Interesting

I wrote a post the other day about diseases that present in strange ways.  It basically was about the pain in my toe from my gout. (http://dr-lasermed.blogspot.com/2012/01/stereotypes-and-diseases-only.html)

Hopefully you all will be happy to know that I’m finally getting better.  It has been an interesting journey.  I did all the usual stuff, even taking a medication that I hadn’t taken in 6 years (since the last really bad attack).  No luck.  Finally, I broke down and called my doctor. 

Gasps from my audience!  The doctor got a consult! 

Thank goodness my internist gave me his cell phone number, because something is going on at his office right now (details, folks when I get them) and I can’t get through to talk to or see him.

He told me that we might have to try steroids, since nothing else was working.  Steroids and I don’t get along very well.  I get lots of fun side effects.  Here’s a partial list of common side effects that I have run through in the last couple of days:

·         headache

·         vertigo

·         insomnia

·         nervousness

·         mood swings

·         edema

·         elevated BP

·         glucose intolerance

·         facial erythema

·         acne, dry skin, thinning skin, bruising or discoloration

·         dizziness, spinning sensation

·         nausea, stomach pain, bloating

I have gone from hardly being able to walk to feeling much better.  My toe is still purple, but it is almost normal size.  It only hurts a little bit.  Now if I could only sleep. 

But I am getting lots of work done. 

Stereotypes and diseases – only guidelines

Gout is that disease that old men who drink lots of wine get, right?  Their big toe gets sore and they get cranky.  It’s not supposed to run in families. 

I just love stereotypes.  My first gout attack happened in my early 40s.  I had switched some medications around and developed pain in one of my ankles.  I had no idea what this pain was.  I went to see my orthopedist about my knee.  I asked him about my ankle and, voila! A diagnosis of gout. 

Female

 Just barely in the age range (40-60)

Positive family history

Ankle

I get .25 out of 4.  But I still have the disease.

I learned about gout, which is controlled by diet mostly.  I behaved myself, and didn’t have another attack until I had an “indiscretion” around my 50^th birthday.  Everyone asked what I wanted for my birthday, and I answered “lobster”.  Not a good thing in my situation.

I have been really good since then.  The pain is so nasty that I’ll do anything to avoid it.  I have no idea why my MIDDLE toe turned red and got really sore a couple of weeks ago.  I thought I had an infection.  Gout never hit that joint before.  And I have been behaving myself.  Really.

Walking has been “exquisite pain”.  That’s a lovely doctor’s phrase.  I’ll let you all contemplate what that means.  I understand why the pictures have the old guy with his foot up.

Just remember, stereotypes don’t always fit the disease.  Remember that the disease doesn’t always manifest itself the same way every time. 

I’ll go heat my foot and take my new medicine.  Just contemplating going upstairs (ouch!)

“I’m on to you” – a patient who “only lied about one thing.”

“I’m on to you” – a patient who “only lied about one thing.”

Today I saw a young female patient with two children.  She supposedly has chronic pain after an accident. I "inherited" her after her last pregnancy. Her OB doctor maintained her on narcotics during her entire pregnancy, then discharged her. I have been seeing her for 5 months. She does have pain, but it is not pelvic.

Technically she should be seeing an orthopedist, but they won’t take her insurance. She has that "good insurance" (Medicaid). I don't participate anymore (you can all clap now) so she pays me CASH. I have been trying to get her to the University to see orthopedics since summer. She has had every excuse in the book.

She has been to the ER twice since she has been coming here. Both times there have been “issues”. The first time she was accused of child abandonment. Both times she was apparently inebriated.

Her story today about the injury that took her to the ER was different than what she told the staff and Doc there. I know for a fact that she was in jail for 7 days for domestic abuse since she was here. I had a call from child protective services yesterday about her.  They are concerned about her children and considering removing them from the home.

She has failed every urine drug screen since she has started here. On discussion today, she really doesn't like that Clonazepam. She just can't feel it. (She was on Xanax when she came here. I won't prescribe it to new patients). So she doesn't take it, and doesn't tell me she's not taking it. Her last two urine screens were negative for it. Others had other problems.  For non-medical people, Xanax is a medication that is used for “anxiety”.  It works fairly fast.  Apparently there is a good feeling with it.  Clonazepam is used for the same thing.  It is long acting, and has no rewarding “good feeling”.

I discharged her today in the office. Gave her 30 days of meds and sent her on her way.  My state requires 30 day notice before discharging a patient.  It’s a stupid rule in my opinion, but it’s the law.   She was shocked. "But I only lied to you about that one thing!" She tried to negotiate for staying without the Clonazepam. Then she wanted to stay "just one more month". Then she wanted to know if I would write her medications for her withdrawal when she got to the end of her prescriptions. 

I hate being manipulated and lied to.  She continued to try with a phone call about something after she left.  “I’m on to you!”

Pain Scale – Who made it up?

Ten is supposed to be the worst pain ever!

Sometime in the last few years, there appeared a new “vital sign”.  It’s called the pain scale.  We can’t measure this one with a thermometer or a sphygmomanometer.  This one is much more subjective.  In other words, we ask you to grade it yourself.  You will get asked “on a scale of 1 to 10, with 1 being no pain and 10 being the worst pain you can imagine, how much pain are you having now?”  At least that’s the plan.

I love to have people sitting quietly across my desk saying “8” or “9”.  Remember “10” is supposed to be the worst pain ever.  Like if you just got run over a truck, or stabbed 50 times, or….  You get the idea.  My doctor friends who have had kidney stones give them an “8”.

If you are fully conscious and well aware of your environment, it’s not a ten.  If you’re not crying or screaming, it’s not a nine.  If you can still breathe calmly, answer questions and remember your birthday and social security number, it’s not even an 8. 

Remember that the top number is 10.  Anyone that has a number greater than ten has obviously not listened to the question.  We hear “11” or “12” fairly frequently.  We also hear “20” and “30”, and occasionally “100”.  You don’t get any more credit for numbers over ten.  Really.  Except that the medical people taking care of you think you are stupid. 

You won’t get seen faster in the emergency room or the doctor’s office.  You won’t get any more pain medication.  In fact, you will probably get less pain medication, or none at all.  Those of us that do this for a living think that you are looking for pain medication, not really in pain if you say your pain is a “15”, but you can’t stop texting or talking on your phone.  Really.

A Rewarding Day at the Office

It’s Not What She Thought It Was

I saw a very nice woman today as a new patient.  She scheduled an appointment for “endometriosis problems”.  Since this can be tricky, I scheduled a long visit.  Good thing.

In my experience, patients with chronic pain tend to get frustrated.  They want to get their “side” of the story out before they think the doctor is going to stop listening.  This is because a lot of doctors DO stop listening and because CHRONIC problems tend to be very frustrating.  They go on and on….

I had to keep going back to her story.  It didn’t add up to endometriosis.  I reached into my magic left hand drawer (where I keep all the neat information sheets, forms, etc) and pulled out a questionnaire for a problem called “interstitial cystitis”.  This is a very painful condition of the bladder – which sits right in front of the uterus.  (The plot thickens, my friends)  Most people score under 10 on this “test”.  My lovely patient got a 27!

Her examination (yes, Virginia, I did one of those, too) showed that her bladder was tender – the cystitis thing – but her pelvic organs were totally not tender.  It’s hard to have endometriosis when none of the organs that usually have it are tender, and the time patterns just don’t fit.

I may not be the brightest bulb on the tree, but I was taught to take time and figure out what’s wrong with my patients.  There is a medicine that is specific for this condition.  It does not require surgery.  It should not require narcotics and muscle relaxers.  She was also on the wrong hormone treatment if she did have endometriosis. 

Could I do all this in 15 minutes?  No.  Do I want to practice 10-15 minute medicine?  No.  Was my day rewarding?  Absolutely!

Stumbled upon blog

Edwinleap.com

I stumbled upon this man’s blog through a physician’s web site called Sermo.  More about that another time.  This is from a post called: “ER: Theses for an Emergency (Medicine) Reformation”

 I’m certainly no Martin Luther, though I think he was a very cool guy. And in medicine, there’s now place to nail my theses, as Luther did in Wittenberg, and so spark a reformation. But if there were, here are a few of the things I’d say.

Physicians and nurses are weary of being the victims of assault and abuse at work, all the while perceiving that their hospitals and employers are more concerned with the rights and safety of the assailants. Shame on you, if you allowed your staff to be abused while you worried about the criminal who attacked them!

Thesis: Medical providers are under attack and need protection more than their attackers.

In all likelihood, physicians practicing full time emergency medicine don’t need to be recertified by board exams or anything else. And they may not even need documented CME. Actually practicing is its own education, day in, day out and year after year. They actually look things up and learn on the job.

Thesis: We practice medicine on real patients, and learn as we go. No more tests, no more hoops.

The pain scale, and the entire pain management culture, is (to quote my children) an ‘Epic Fail.’ It has led to addiction, abuse, dysfunction, disability, staggering cost in confabulated complaints and worst of all, unnecessary deaths from prescription medications. Regulatory panels and advisory groups need to stop wringing their hands and listen to the reality of people like us, who are asked, on every shift, ‘can I have more pain pills?’

Thesis: Narcotic abuse and addiction can start in the ED. The pain scale is worthless. The age of the ‘candy man’ must end.

The rest of medicine cannot abdicate its responsibilities, expecting emergency medicine to stand in the gap like Atlas, holding it up, so that they can avoid call, avoid poor patients, avoid drunks and have a comfortable life. Remember when they thought our speciality was inferior? Odd that we can now do anything.

Thesis: We cannot be all specialties to all people, and we cannot carry medicine for the convenience and economic prosperity of others.

EMTALA must be reformed. It has cost lives, jobs and entire facilities. And it has, like all entitlements, bred dependency, irresponsibility and abuse. Whatever benefits it accrued have been washed away by a tidal wave of reckless, uncaring misuse of the great gift the government gave the public…the gift of our productivity.

Thesis: EMTALA results in theft and abuse. It has to be reformed, or medicine as we know it will be finished in America.

Customer service has a place, but must be re-defined. A person who steals from you, abuses you and/or assaults you, knowingly, must cease to be a customer. Their satisfaction surveys should be stapled to them as they are escorted to the door.

To read the rest, go here:

http://edwinleap.com/blog/?p=1892

Medical Office Quandaries #3

You Have to TAKE the Medication

I really don’t understand a lot of patients.  The longer I do this, the more confused I get.  Maybe you can explain this to me:

I had a patient who came in recently with pelvic pain and period problems.  I’m sure she wanted narcotics.  I explained that she had to try other things first.  This ain’t my first rodeo, folks.  To make a long story short, I did the usual: a complete history and physical including Pap smear, sent for old records, gave her a prescription for birth control pills and for a NSAID (medications in the Motrin family). 

I also ran a urine drug screen on her.  I ask all the women I do this for EXACTLY what controlled substances I’m going to find in the urine.  I tell them not to lie to me, or they will not be able to get anything stronger than NSAIDS.  Do they listen? 

This patient’s urine had two drugs she had “forgotten” to tell me about.  Strike 1.

Her records didn’t exactly tell me the same story that she did.  She had gotten controlled substances at two of the places she had been before she came to me.  Strike 2.  She also has a low potassium level that could cause a heart irregularity.  This is in her records from an ER visit.  We tried to get in touch with her to tell her about this, but none of her phone numbers worked.  She gave us six numbers. 

When she came back for her follow-up visit, she said she gave her prescriptions to her mother to fill.  Her mother lost them, so she had not taken them.  Strike three. 

What did I do?

First, I gave her a lecture.  I was mad.  I gave her a list of high potassium foods and told her she needed to see her medical doctor.  I rewrote the prescriptions.  I explained that she had to take them and see what happened.  I refuse to “throw narcotics” at a problem that we have not defined.  Besides, she could have a major heart problem with the narcotics and the low potassium together. 

Do I think she will listen?  I doubt it.  She didn’t get what she wanted.  She got what she needed, but that doesn’t always matter to patients these days.

Kangaroo care

Something I learned today

I read an interesting article today while doing “continuing medical education” (CME).  I just wanted to share this one.  They studied kangaroo care and whether it helped reduce pain for procedures in premature infants.  Evidently they already know it works for term infants.  They also studied whether Moms or Dads worked better.

For those of you who don’t know, kangaroo care is a method of caring for infants involving skin to skin contact between the baby and the care giver.  The baby has a diaper on and is placed against Mom or Dad’s skin.  It is supposed to help with bonding, breast feeding, growth and development.

There were a lot of technical details in the article I read.  I won’t bore you with them.  If you want, you can refer to the article. The study was done by Johnston and colleagues and is reported in the September issue of the Archives of Pediatric and Adolescent Medicine. 

The results were interesting.  All the babies were comforted by being with their parents during the procedure.  The procedure was having their blood drawn from their foot – a “heel stick”.  They cried less, their heart rates went up less, and the heart rate returned to normal faster.  FYI, Moms did just a little bit better than Dads. 

I was impressed that we are studying ways to make painful procedures more comfortable for the little ones.  Aww….

You learn something new every day.