Approach to Chronic Illness

        I’ve promised y’all for a month I’d get around to an approach to chronic illness.  Oh well, I’ve never known a doctor to be on time, have you?

        Maybe it is appropriate that this is late, though, ’cause with chronic illness, you do have the luxury of a little more time.  If I’m sluggish about diagnosing a heart attack, I’ve got a problem.  (So does my patient.)  If I’m slow to figure out diarrhea is due to celiac disease, I have inconvenienced them.  If I am rude about it, I’ve hurt their feelings.  (I’m usually not, my scorecard is pretty good on that count.) 

        I never want to miss anything, but if I do on the first try in a chronic illness, I get a second chance.  But, at least I haven’t done ’em in.  If we can work together, we can live to fight another day, and might figure it out tomorrow.

        In this case I’ll tell you right up front I wasn’t brilliant, but I did turn up the right diagnosis.  I didn’t get it right off, but the outcome was good.  At least some of the credit goes to the patient, and she was patient and worked through the process.  

        As always, I have the permission of my families to use these vignettes. They feel their actions should be available for others to consider and also for the teaching points to be available to other docs.  After all, when you are dealing with doctors, you have your hands full, and the more you know about how doctors think, the better huh? 

        In spite of their kind permission the names have all been changed and specific identifying characteristics have been altered to render the cases unrecognizable other than to the people who were there.  (In fact they are often altered to be unrecognizable to even the patient.)  That way, as I said at the outset of this project, folks can maintain anonymity to any degree they choose.  And so can Dr. Bibey for that matter.  If some one says they think it was me, I can just say, “HUH?”

        So here we go.  A couple of years ago, I had a patient in her late 60s who was tired.  (When I was young, I would have described her as elderly, but I now know better.)  These can be tough cases- fatigue can wear you out and it ain’t easy on the patient either.

        The first order of business, as you guys now know, was to rule out anything acute.  Her E.K.G. was O.K., but more important she had had a nuclear stress test only six months back when her reflux became difficult and I got scared I was missing heart trouble.  Nothing had changed in her history, so I thought heart was unlikely.

        By the way, I remember when that little dark haired fellow who replaced Walter Cronkite came on national T.V. years ago and made the pronouncement that doctors were not aware that in middle aged women fatigue might be the only symptom of heart disease.

        I heard him say that, and turned to my Marfar.  “How come would they pay that man all those millions of dollars to say such a thing as that?  I’ve know that since I was a third year med student.”

        Marfar looked up from her knitting.  “It’s ’cause he’s better looking than you.”  End of that discussion.

        So without boring you with too many details, I went through the mental check list and came up blank for acute illness.  No aneurysm, no clots, etc.

        So, fatigue.  What to do?  It turned out she had a few red flags.  There was slight weight loss, and some night sweats.  I couldn’t find any enlarged lymph nodes, but the whole thing was suspicious for an underlying lymphoma. 

        I ran through some routine blood work and was not reassured.  She had a mild anemia, and a slightly elevated sed rate.  It was 65; I remember the number on the button.  After a few more tests and some x-rays, I had no answer.  She remained patient.

        You hate to call people and tell them you want to get a second opinion from a hematologist.  They ain’t dumb.  They know what you are looking for.

        I tried to reassure.  “I tell you, Ms. Smith, I don’t think there is any cancer, but I have to admit there is some chance- lets say one in ten- we gotta look into it.”  (I don’t know about you, but I don’t like those odds.)

        I sent her to my favorite hem/onc man at Sandhills U., Dr. Will Wilson.  After his evaluation he called and was worried, but unable to track down anything definite.  Another sed rate was 75.  Her hemoglobin had dropped more.  He was going to run a few more tests and get back with me.

        In these kind of cases, you have to expect that everyone and his brother is gonna give people advice.  “Well my uncle had this and the doctors didn’t know….”  You hear it all the time.  I never dismiss it.  Every once in a while you hear a clue that helps you make the diagnosis.

        In the middle of all that, I was riding down the road listening to my monthly continuing ed on the Scout’s cassette player.  

        I had a rule with my kids.  Home work first, music second.  “No tickee, no washee.”  I go by the same.  Until I finish my CME, I can’t listen to my music, and I don’t care if Blue Highway has a brand new disc on my desk. 

        All this does make for a strange family life- my kids made me eject my doctor cassettes before they would let their friends in the car- they didn’t want them to hear about irritable bowel syndrome or erectile dysfunction.  (That’s how I got  all the neighborhood kids hooked on Ralph Stanley instead of medical CME.)

        I remember right where I was when I heard the case presentation.  Elderly (excuse me- that’s a bad word) female, fatigue, suspected malignancy, tests all clean, high sed rate.  My ears perked up.  The lady on the cassette had an atypical presentation of polymyalgia rheumatica.  Eureka!  Why hadn’t I thought of it!!  I was gonna call her first thing in the morning.

      The next day when I got to the office there was a note on my desk to call Dr Wilson.  

        I dialed him up.  I couldn’t wait to tell him how smart I was.

        “Hey Will, Bibey here.”

         “Bibey.  Good to hear from you.  How’s the golf game?”

        “Fair to middling.  Better not give up my day job.  Hey, you remember Ms. Smith?”

       “Sure, she was here today.  All her studies are fine, except her sed rate is now 110.  What do ya think of polymyalgia rheumatica?”

        Shucks, he’d beat me to it.  Oh well, as long as the patient is O.K. that’s all that matters to me.  “Yeah, man I think she might have it, too.  110- probably so.  I gotta tell you though, when I was doing my CME yesterday, there was a case presentation that make me think of her- I guess we oughta get a biopsy.”  (Temporal artery biopsy for those interested in the details.)

        “I’ve already lined it up.”

       “Good, I think that is the right thing to do.  By the way, what made you think of it?”

        “NAP, (Bluegrass for not a problem) Bibey.  When she came in to get her test results she told me her hairdresser said her aunt had it, so I ran a third sed rate.”

        D***, scooped again.  You have to take those hairdressers seriously.  They have made more than one diagnosis for me over the years.

        Flatt and Scruggs immortalized their role in the song, “Rolling in my Sweet Baby’s Arms.”  It said, “Mother’s a beauty operator, sister can weave and can spin.”  Never, ever, underestimate a beauty operator in southern society- they are the source of considerable knowledge, power, and influence. 

        I guess I could give up my haircuts at the barber shop and go down to the California Unisex Hair Salon to get some kinda perm, but I haven’t gotten that modern yet.  I think an old bluegrass boy might be outta place there, anyway.

        Besides, I’ve got good contacts.  The grapevine has never let me down.  I can’t talk about my patients, but I can sure listen, and I’ve learned a lot through the years by doing so.

       I just finished my CME for the week, and that new Blue Highway CD is a killer.  Go see them and tell ’em Dr. Bibey sent you.  And if you’ve got a chronic illness give your doc a few tries, ’cause it can be hard to figure and often becomes more apparent over a period of time.  And, it is O.K. to take the hairdresser’s opinion under advisement.  They often turn up right.

        It’s another weekend in the Bibey household, and as usual me and Marfar are gonna take in a show.  When our youngest, my little Marie, left for school a few years back, I thought it was gonna break my heart.  I guess I’m old and soft hearted, but I cried for days over it.  Marfar and I stared at the walls a few weeks, then decided we were gonna have to make the best of it, and proceeded to take in every good show that drifted through the county.  It was the only way I could cope.  Marfar is tougher than I am, but I think she saw it the same way.  

         I remember one night we were watching the band Forth Time Around, and they were just a rockin’.  Marfar’s cell phone rang.  It was Marie.

        “Mother, where you have been?  I’m just worried sick over you, and …….”

        That Marie is a good’un.  She’s in grad school at Tobacco Triangle U.  Not only is she gonna be a fine professional someday, but I think she’s gonna be a good mama too, even without all the schooling.

        And when she is, it is gonna be O.K. for me to call her mama.

       See ya next time for more on chronic illness.

Dr. B

        

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