Archive for the ‘Advice- Five Cents’ category

Smarter ‘n a 5th Grader

April 21, 2008

        There is some show on T.V. these days called ‘Smarter Than a Fifth Grader.’  I have to confess I watch little television, so I haven’t seen it.  Maybe I need to watch, though.

        Not long ago I saw a patient with malignant hypertension.  I was very worried about her.  When we started out her BP was 240/120, and I was afraid she’d have a stroke before I got it under control.  It took some time, but I began to breathe a sigh of relief once we got down to the 150/90 range. 

        She was on two meds.  As much as I hated to do it, a third was indicated. 

        “Tell you what Ms. Little.  I hate to have you on so many pills, but we still need to be a bit lower.  You still following your diet?”

        “Yes, sir.  I ain’t had no salt a’tall.”

        “O.K.  Let’s add this- one twice a day.  I need to see back in two weeks.  We’re getting there, though.”

        When she returned in two weeks as instructed, she was weak and dizzy.  Her blood pressure was 90/50.  “Gee, Ms. Little.  I’m sorry.  I guess I overshot it, maybe we better cut this one pill down to one a day.”

        “Could my dog have anything to do with it?”

        “How’s that?”

        “My granddaughter said I needed to get a dog.  She said ever since her Paw-Paw died I ain’t got nobody to look after, and a dog would help me.  She read it on the Internet.”

         “Hm.  Well, I sure don’t see how it could hurt.  What kinda dog didja get?”

        “She’s a mutt.  A real sweetie, too.  I love that little dog, I tell ‘ya.”

         “Well, Ms. Little.  I do believe that is a good idea.  How old is your granddaughter?”

        “She’s in the fifth grade.” 

        Dang, scooped by a fifth grader.  Maybe I’d better watch more T.V.  “O.K. Ms. Little.  Tell you what.  You cut out that last medicine.  And hold onto that dog, too.”

        I saw her back in two weeks.  She is 118/74 and feels great.  From now on, I’m gonna remember two scripts and a dog might trump three meds and no pet therapy.  I can’t afford not to be as smart as a fifth grader.  It might be bad for my reputation.

Dr. B

         

       

 

 

The “Four A’s” of Medicine

April 14, 2008

        I saw a patient last month, and her situation reminded me of the four “A’s” of medicine.  The lady stopped me at the grocery store to ask a medical question.  She was not my regular patient, but had seen a Neuse River show, and knew I was a Doc.

        It took three sentences and four questions to know what she described had potential serious consequences.  For reasons I don’t understand her regular doctor could not see her for a month, even though she gave his staff the exact history she told me.  (They wouldn’t let her speak to the Doc or even give the message to the nurse- I promise you Lynn or Myrd woulda known exactly what to do.)  I was reminded of the old “Four A’s,” some of which I learned from my Dad.

        I suspect the “A’s” are also important in many other professions.  They are, and not necessarily in order of importance, Ability, Accessibility, Affordability, and Affability.

        I can only speak to being a general Doc with any authority, and I realize with different specialities the order of importance might change some.  We used to have a Neurosurgeon at the Medical Center who was gruff and bordered on mean, but the guy was such a good surgeon I didn’t care.  My patients would often complain, but I reassured them.  “Look, he’s there to take out your astrocytoma, and he is great at it.  Ya’ll don’t need a Family Neurosurgeon, he’ll turn you back over to me as soon as you are over the surgery.”  On the other hand, if your Family Doc ain’t at least somewhat of a friend, I’d think that over.

        I have one consultant, a lung specialist, who is notoriously difficult, and I use it to my advantage.  He is extra tough on the smokers, and if I can’t get someone to quit, I’ll threaten to send them to him.  “Now Ms. Smith, your lungs are getting worse.  If you can’t quit smoking, I might have to send you over to Dr. Rales for a pulmonary cussing out consult.”

        “Oh please don’t, Tommy.  I promise I’ll stop.  Give me a script for that Chantix you’ve been talking about.  I’ll see you next month.”  I try to give my folks good advice, but I never could bring myself to be mean about it- I left that to ones who did not deem all the “A’s” to be important.  

        It did occur to me with the grocery store case, though, that ability might not always be number one.  The Doc whose office turned her away is a very bright fellow.  I’m certain he knows the answer to the question at hand.  I bet he never knew anyone asked it.  (Of course, if every time his staff asks him to disrupt his appointment schedule he chews them out they might quit asking- I do not know the circumstances.)  But even if he is smarter than me, he sure missed the diagnosis, or even any chance to make it.  So, in this situation, accessibility trumped ability.

        I am a gregarious sort of fellow, and have more friends than any one man deserves, but I don’t rank affability that high.  I’ve had a number of people come to see me ’cause they like my mandolin playing, and that is an error.  If that were a good criteria, they should choose Darrell or Ben as their Doc, not me- I can not begin to approach their level of play.  This time the mandolin did come in handy, ’cause the woman felt comfortable enough to approach me at the dog chow aisle. 

        As far as affordability, with all the high tech demands we have now, I find it more difficult than ever, but I try to keep the costs down.  Most of patients think I’ve been fair enough, but sometimes when I see the bill they get I don’t know if I’d go see me for that!  Certainly for the indigent, or even the middle class folks with one serious illness and no insurance, the system is broken.

       Well, going back to my lady at the grocery store, she did fine.  The diagnosis was a TIA (trying to have a stroke) but she had some surgery and dodged it for now.  And to be honest, she might have been O.K. without intervention, but I wouldn’t have rolled the dice on my own people if they had her symptoms.  (Another rule I have: try to do for your patients like you truly believe you would do for your own family- can’t go wrong there.)

        Ya’ll think about those “A’s.”  I’m curious as to your perspective.  Which ones do you find important in your Doc and why?

        My agent said I was gonna learn a bunch from my readers.  So far, that has proved true, so I will be interested in your responses.

        And for mrschili, how the heck do you write the “A’s?”  Is that right?  I had no idea.

Dr. B

Office Brain Biopsy

April 11, 2008

        O.K. the title was just to get your attention.  We don’t have a code for office brain biopsies.  That is good ’cause I have no intention of ever doing one.

        Years ago, though, I coined the term to make a point.  I was cleaning out someone’s  ears and the young lady assistant stood on the other side of the patient.  For reasons I don’t understand, she decided the patients needed to have their head repositioned, and gave it a push in my direction.

        When you have a metal object down in someone’s ear canal it is not a good time to make such a maneuver.  I saw it coming, though, and took the cerumen spoon out pronto.  No harm was done.

        I was not happy.  More impulsive in my youth, I blurted out, “Young lady, this almost wasn’t an ear cleaning, but a brain biopsy!!”

        Of course she broke into tears, and quit in a few weeks.  Since those days, I’ve learned no one wants a smart @^^ for a boss or a doctor, and I’ve mended my ways.

        Nowadays, I would never correct an employee in front of a patient, (I don’t expect them to do that with me) but I still would find a way to tell them not to do that.

        These days, I’d probably pull them off to the side and say, “Look kid.  You gotta realize these old Docs might not be quick enough to anticipate everything you’re gonna do.  If you need to reposition the patient’s head, let the Doc know.  Some of ’em can be kinda dumb.  I don’t want to be doing no brain biopsies.”

          It’d go over better and the employee would still get the point, I just wouldn’t embarrass them.

         Either way, though, I’m against office brain biopsies.  One rule I have is if I ain’t done it by now I’m not gonna start at this age.  I’ll leave that to the young smart @^^es.  (as opposed to the old ones.)

Dr. B

The Lazy Musician

April 9, 2008

        Contrary to what many folks think, the musicians I know are far from lazy.  Most spent  hours every day in a endless quest for mastery of their art.  (Hence a saying we have: “Study your instrument.”)  So, you might be surprised to find that Ben, one of my mandolin gurus, wants me to be a bit more lazy.  

         Huh?  Don’t see how I could be.  After all, I only put in fifteen minutes to a half hour of practice a day.  How could I get any more lazy than that?

        Of course, that is not what he meant.  He wants me to to explore the fingerboard and become more economical with my left hand movements.  The exercise he has me doing is to work on the high octave of Manzanita (a tough Tony Rice number) and do it with three different fingerings.  It makes the point. As you get up to speed, method number three begins to emerge as superior.

        All this reminds me of a saying I heard from a jazz pianist.  “The amateur practices a piece until he/she can play it right.  The professional practices the piece until they can’t do it wrong.”  I tell you folks, Ben, like my buddy Darrell, can’t do it wrong.  They are pros.

        I am an amateur, but who knows?  At least if ain’t worried too bad over my patients this month, I might surprise Professor Ben, and get Manzanita down where I can’t do it wrong.  And right at the moment, I have all my folks tucked in good and figured out to suit me, so maybe I can study my instrument even a full hour a day.  But, if the sick ones take a turn for the worse and I lose my mandolin focus, I’ve always got next month.  At the level I play, there is always room to improve, and it gives me something to look forward to.  Hey, if I don’t get the tune down cold, I’ll just tell Ben I got a bit too lazy, and he’ll forgive me. 

        I guess it is like being a Doc.  If you only took care of folks who were perfect, there wouldn’t be anybody to help.  (And Doc would also have to go home with his own case of perfection deficiency.)  And if Ben and Darrell only had students as good as them they wouldn’t have anyone to teach, ‘cept they might be able to help each other, I guess. 

        My computer is on the blink, and going on the shop for a day or two.  (Even my boy couldn’t fix it, a sure sign of the need for a specialist.)  If I’m a bit late to answer your comments, forgive me.  I’ll either catch ’em on someone’s computer, or in a day or two on mine.

        Will be back soon.

Dr. B

A Wonderful Life

April 8, 2008

        I don’t know about y’all but I’m a sap for old Jimmy Stewart movies, especially ‘A Wonderful Life.’  As you get on towards the last leg of your journey on earth, there are times when you wonder how much difference you made.  For me, I wasn’t smart enought to figure out a cure for cancer, and I sure didn’t get rich or famous.  I pulled a few out of the fire along the way, and had a heck of a lot of fun with my music, but there are thousands of others who have toiled away at their daily routine, and many got a whole less credit than I did for it.

        Last night was one of those moments where things make sense, though.  We played music at one of the rest homes, and an aide stopped to speak to me.  She said she enjoyed the music, and I thanked her. 

         She went on to tell me I inspired her to study to get her degree and she became a nurse’s aide because of me.  It turned out I took care of her mother, who had a stroke years ago, and much difficulty swallowing afterwards.  As often is the case, the daughter was the only one who could get her to eat, and she fed her every day.  In the end, the patient aspirated one day, and died soon after from aspiration pneumonia.  One of the Docs (I remember the guy, he was a harsh rascal) came along and made the young woman feel guilty.

        I didn’t recall the precise moment, but she said I came by right after that, found her in tears, and heard out the story.  She said I patted her on the shoulder and told her mama would have never made it as long as she did if not for her feeding her every day.  (Which I am sure was true.)

        This was not a highly educated woman, or even one who was extremely bright, but she said it inspired her to go on.  Apparently she wanted to be a nurse’s aide and felt like she had a knack for it, but the first Doc made her feel like she wasn’t worthy.  I changed her mind.  That simple act, long forgotten by me, made her think again.

        She went on to proudly tell me she was the best one at the rest home, and when no one else could get a patient to eat, she was the one they called on.

        I patted her on the shoulder.  “I tell you what kid, I’m getting toward old.  I hope when I get here, you’ll be the one to take care of me.”

        “I will, Dr. Bibey.  You can count on it.”

         I figure that woman has had a wonderful life.  When you get down to the science of it, she has saved more lives than I have, and no one will ever hear of her, except on this little blog.

        Like I say, I’m an old sap, but I still think Jimmy Stewart had a few things to say we don’t need to forget.

Dr. B

       

 

A Heart Attack in the Mail Slot

April 4, 2008

        This post today goes out to Ms. Pande and Mr. Demonic, wherever my globe trotting pals might be at the moment.  Pande said she didn’t want me to forget to do some doctor posts, so I’ll dedicate this one to her and her hubby, Mr. Demonic, and their young’uns, the California girl and Pande’s violin.

        I saw a patient recently with a silent M.I.  (Heart attack without symptoms she didn’t know she’d had.)  Here’s how I found it.

       One day some blood work came across my desk. It was from another doc who was seeing one of my patients as a consultant.  It was a patient I had not seen in some time.  I noticed an abnormal test, a high CPK.  This could be a lot of things, but heart attack is on the list. 

        My nurse that day was Lynn O’Carroll, and I had her track down the patient.  Lynn was unable to convince her, and got me to come to the phone.  Given the patient had no symptoms, she was incredulous.

        “Whatda ya mean?  I ain’t had no heart attack.  I’m fine.”

        It took some kinda persuasion, but she did come in.  Her E.K.G. was abnormal, but the findings were subtle; only a few flipped T waves in the lateral leads.   She didn’t want to accept the possible diagnosis.  

        I began to get frustrated.  I mean, this was the same lady who read on the Internet a few years back about someone who developed a cough from an ACE inhibitor and called to yell at me for my choice of the medicine such as that.  (It was a side effect I was well aware of but one she did not tell me had developed in her case.)

        I almost pulled out the office policy manual- you know the rule I have quoted before- “sudden death is against office policy,” but I was able to convince her to see the cardiologist without all that drama.  Sure enough, she had a recent lateral M.I. and some intervention was indicated.  She’ll probably be fine.

        I’m glad my mama had me take that speed reading course, and thankful I read my mail, though I admit some of it is in a hurry.  I wish the patient had been more appreciative, but like my wife says, with some folks if you want gratitude you’d better look it up in the dictionary.

        Hey, don’t feel sorry for me though.  I love this job, and I’ve tried to my best on every encounter without fail.  For the most part I’ve been successful, and very lucky.  I have no regrets, even on the days when there is some verbal abuse.  I figure it comes with the territory.  I’m just glad the lady is O.K. 

        I suppose there is one lesson in this I do want patients to get.  Be sure all your blood work and tests are tracked down before you close the book on it.  Sometimes things can get lost or filed away without the Doc seeing the report.  (That is also against office policy, but I have seen it happen.)  Never assume no news is good news- it might be no news.

        Some of my folks want a copy, and that is O.K. with me as long as they promise to follow another office rule- “Don’t worry till Dr. Bibey says worry.”  (A variation of NTW.)

        If someone has some minor abnormalities, but they are O.K. in the context of the big picture, I don’t worry and try to reassure.

        However, if the abnormality seems minor but Dr. B says worry, I’d commence to doing just that till the thing is resolved.  The trick is learn to worry about the right things.  This patient got confused for a moment, but it worked out.  The Good Lord and mama’s speed reading course were looking out for her.  (Dr. B just happened to be there- it was pre-programmed.)

        Another rule I have is to always worry about the things that could do my patient in before I get another shot at it, so the stakes can be rather high.  (This is why I am not serious about golf, or even music, as much as I love it.)   

        So, if your Doc calls and says they’ve looked at your blood work and they are afraid you’ve had a heart attack, better take ’em seriously until you can prove them wrong.

        Even an old country Doc had better pay attention.  (As you get older, it is even more true, I’m not as quick as those young-uns.)  We don’t make the dignosis this way very often, but it is best to stay alert.  It ain’t every day a heart attack shows up in the mail slot.

Dr. B        

Advice Five Cents/Professional Courtesy Day

February 28, 2008

        Today I’d like get some advice from you guys.  I know medicine, and you folks know writers, so I hope you might trade out some ideas professional courtesy.  As always, my advice on the Net is free (watch out- you get what you pay for) and reading my blog costs the same, so I hope this is helpful.

        Along the way, I’ve written up a few posts that might help moms with young boys, so this one is for the girls.  And it might help the Dads too.  I have a little girl.  She’s grown up now, but I still understand the depth of that bond, and the desire to be protective.

        Probably most of y’all have heard of the Gardasil vaccine.  For girls from 9 to 26, this is a vaccine one should look into.  Without going into all the technical details it protects against infection from the virus that is associated with the development of cervical cancer later in life.  (Google their website- it is very detailed.)

        Given this is essentially a sexually transmitted disease, I realize some folks have trouble talking to their children about it.  Here’s how I sold one teenaged patient of mine on the idea.

         “Hey kid, you oughta take this Gardasil shot routine.  It is one of the few things in life that can keep you from getting cancer.”  (I took an early practice test on the subject and missed a question ’cause it was one of the few times the word ALWAYS was associated with the correct answer.  I’m sure it is not 100% but the Board was trying to make a point.  This thing works.) 

        “How does it keep you from getting cancer, Dr. Bibey?”

        “Well, cancer of the cervix is a female cancer, and it can come from having sex with a guy who has a certain kind of virus.  The vaccine can stop the virus from getting ahold of you.”

        “Dr. Bibey!  I ain’t having sex.  I don’t need it.  Don’t ya trust me?”  She was embarrassed.

        “Oh sure, kid.  I trust you.  It’s the rest of the world I don’t trust.  Someday down the road if you’ve got a husband with a wandering eye who runs around, this shot could protect you from some of what he is doing.  I’d go beat him up, but by then I’ll be over in the nursing home and too old to do it.”

        She laughed.  “O.K. Dr. Bibey.  If you think I need it I’ll take it.”  I think the image of old Dr. B duking it out with some young buck was what won her over.  You can only protect your people with the skills you possess.  Truth is it would have to be some kinda weakling of a twenty-five year old boy for me to whup nowadays, and it wouldn’t help her anyway. 

        Her mom agreed to the series, and we started that day.

        So y’all talk to your Docs about Gardasil for your young ladies.  Tell ’em Dr. Bibey sent you.

        Oh, yeah, I said this was professional courtesy day.  If y’all know of weblogs of Southern writers or humorists you think I should read, I hope you will let me know.  I have no idea what I am doing in this writer business, and I need all the help I can get.    

        In bluegrass we only steal from the best.  Don’t worry- I ain’t gonna plagiarize; it goes against everything I believe in, but I am curious about how other folks write.  My specific genre is Modern Medical Grit Lit, but I’d like to hear about any Southern Lit blogs you enjoy.  (For that matter if they write like my Northern friends, that is good too.)  If by chance you know of any other physician bluegrass fiction writers, that would be extra good.  I have a special interest in that area. 

        My agent has managed to get a few articles placed for me, and I figure the leads might give me a few other places to look into publication.  The 15% take for my agent is a bit slim, and I need to keep growing to keep him in the fold.  He’s got a young’un in college, and he has no choice but to be somewhat business-like.  (I drive him crazy with my meandering ways.) 

        Come to think of it, I believe his young’un is a girl.  If she’s in college she’s less than twenty-six years old.  I believe I’ll call him and offer them a free Gardasil shot- professional courtesy you know.  Every little bit helps.

        See ya this weekend.

Dr. B 

Up all Night

February 19, 2008

       Years ago I was up all night taking care of an elderly patient.  This was before we had full time cardiology consultation in town, much less hospitalists, so if you wanted it done, you did it yourself. 

        My patient was 81 years young, and had an inferior M.I. (heart attack in the bottom part of the heart.)  Of course, there are no good heart attacks, but as far as they go inferiors tend to do reasonably well most of the time.  Everything seemed to be going along O.K. till around midnight, when she had a burst of V. tach and a cardiac arrest.

        It was a long night.  After several more defibrillations, it was good to see the sun rise.  I was more than happy to call in reinforcements, and sent her down the road to Sandhills U.  Back then they did not do much high tech intervention in a cardiac patient that age, and they treated her about the same as we would have at home.  As it turned out the stay was uneventful, but it was still good to get second opinion.  In a few days she was safe to go home. 

        When the rescue squad boys took her out the door to go to Sandhills she said, “Tommy, I sure hated to keep you up all night, please apologize to your sweet wife for me.”

        “No problem, ma’am.  She’s given me permission to stay out all night with all the women I want to as long as they are older than 80.”  (Now that I am older, I suspect my wife would change her mind, the age limit, or both.)

          We teased about it for years, and I would tell her the two of us just couldn’t go out at night any more.  She was too wild; we’d have to meet at the office during daylight hours. 

        She was a sweetheart, and I’m proud to say she lived another dozen years.  She did quite well until her last eighteen months when age and heart failure finally caught up with her.

        I thought of her today when I saw her son for a physical.  There is a special bond in those all night-ers, and I’m still tight with the whole family.  Insurance chart guys, and sometimes young docs, often do not understand how we know so much about our people.  It’s ’cause we don’t have to ask the family history- we were there!

Dr. B

Golf Nut

February 15, 2008

        Golfers, like musicians, tend to trust docs involved in their genre, so I have a number of golfers in my practice.  A lot can transpire on the golf course.

        For the most part when we play golf the boys are about the game.  Who wants to talk about constipation when a fifteen dollar bet is on the line?  Early on one fellow did ask me about his prostate problems on number thirteen.  I told him I had a glove (and not a golf glove) in my bag, and if he’d pull down his pants, I’d be glad to check him.  I noticed after that, no one asked any medical questions unless it was urgent.

        One day a young fellow showed up for the Saturday choose-up.  He was underage, but the boys wanted to let him tee it up, ’cause then we’d have five foursomes instead of having one group be odd man out.

        I voiced my concern.  I sat on the Golf Course Board, and knew quite well if he gambled it was a violation of County High School team eligibility rules.  My arguments were to no avail, though.  The boy wanted to play, and everyone else wanted to let him.  On top of that he didn’t feel well, and had some cramping abdominal discomfort.  Intuition spoke and I didn’t like what I heard.

        He wasn’t febrile, at least to touch, and the history wasn’t consistent with an appendix.  Everyone was clamoring to tee off, so I decided to pay the kid’s fifteen bucks myself and declare him a “competing marker.”  It was a category I made up, and I hoped the ingenuity might save him trouble later.

        I pulled him aside.  “Look, Richard, don’t ever pull this again.  You’ve got a shot at college golf, and you don’t need to take any chances with it.”

        “Yes sir, Dr. Bibey.  I promise.”

        I knew the boy hated to back down after he’d promised to play, so I let it go.  He was in my group, and I’d keep an eye on things.

        We closed the front two under, not good enough to win the side, but were determined to make it up on the inward nine.  By twelve Ricky began to flag.  “Doc, I don’t feel so good, my nut hurts, and I mean bad.”

        Now, very little will bring the choose up to a halt, but all of sudden the boys were worried.  Not only were we contributing to the delinquency of a minor, but he was sick too. 

        Weasel was the most concerned.  It was his idea to invite the kid to play, and he worked for the boy’s dad down at the Purina plant.  Weasel began to foresee how this could play out.  He didn’t need to be out of a job.  

        “You better check him out, Doc.”  It had been their problem; now it was mine too.

        “Boys, dang it, this wasn’t my idea to start with.  Dadgum you rascals.  Come on Wease, you gotta be my chaperon.”  I doubt it was a customary role for the Weasel, but I wasn’t gonna drag this boy down in the woods and check him alone.  I knew everyone trusted me, but it didn’t seem proper.  Weasel protested, but gave in when I threatened to tell his boss this whole thing was his fault.  How did these boys get me into these situations?

        Well, we went down in the woods, and Ricky pulled down his pants for me to examine.  D^*#, this wasn’t epididymitis, but a torsion.  Exquisite tenderness, acute onset, horizontal position.  Why in the world did I let this boy play?  What was I thinking?!

        Wease took one glance and about fell out, (medical for near syncope) and Ricky and I had to catch him to keep him from going down.  Now here I was out in the woods with an under-aged boy I had involved in a golf match wager, and his pants down no less, with the two of us holding up a near comatose half drunk middle aged man.  Now I had two patients, one of who was near passed out.  This did not look good.  

         Ricky pulled up his britches and helped me triage the Weasel.  He was breathing O.K. and his pulse was strong.  I felt like he would be O.K., but we propped up his feet with an old log and whistled for help.  (Remember the old Boy Scout adage- in shock, face is pale, raise the tail.)

        By the time the boys got there, Wease was already coming around.  We had been walking, but the next group had a cart, and they donated it as an ambulance.  

        This was before the days of cell phones, so we had to get back to the golf shop to use the phone.  I caught the urologist at the office, and he heard out the story.

        “Damn, Bibey.  Really, you are gonna have to give up those house calls some day.”  He was getting a big laugh out of the situation, but he had me send the boy over the ER, where they confirmed the diagnosis.  He went to surgery and did well.

        Now I know you didn’t need to hear all that to make it through your day.  I tell the story to remind you with acute illness, you can’t be too careful.  Had I assumed epididymitis it would have been a big mistake.   

        I know many of my readers are parents, especially moms, so if your adolescent males turn up with acute pain in a testicle, I hope you remember this story and get ’em in to the doctor.  If it is a torsion (a twist) the chances of recovery lessen with each hour that goes by, and a few days is too long.

        Now you might say “Well what are the consequences of missing it?”  In truth, perhaps not much.  The Good Lord paired organs for a reason.  The boy would most likely get along O.K. without one testicle.  And, I’m sure to a lot of women we ain’t that much worse off for a minor reduction in the world’s testosterone level, but I figure the boy needs to be given a chance to make his decisions for himself.  If later he doesn’t behave properly ’cause of testosterone poisoning, it ain’t my fault.  We all are responsible for our own actions and all I can do is play his odds for him to his best advantage.    

        Even more important than one testicle, though, was his golf game.  Many a grown man would give up a testicle to play college golf, and this boy had some game.  After it was all over, my best advice to him was to not take any more chances with his scholarship odds.  He went on to play college golf on a full ride.  That was probably more important in his life than saving the testicle, at least to most of the golf nuts I know.  

        To all y’all in the frigid Arctic, golf season is might near here in N.C.  I’m off, and believe I’ll hit a few in the morning. 

Dr. B  

And the Winner Is….

February 12, 2008

        First of all the patient was the winner.  Like I said, I got a pound cake from her at Christmas so she is still O.K.  (I’m doing all right too- still getting pound cakes.)

        So, what did the x-ray show?  As crude as banjobilly was in his comment, he was on to a clue there.  What the x-ray showed, as billy had figured, was a CAMERA!  That thing was supposed to have come through a few days prior, and the fact it had not should have been my clue.  Not only did the x-ray show a camera, but  there were air fluid levels.  To a doc this means small bowel obstruction.  Now, there is an old saying in medicine, never let the sun set on a small bowel obstruction.  It isn’t always true, but I think it is fair enough to say a Family Doc should never let the sun set on a SBO without the blessings of a surgeon, so I knew a consult was in order before my patient left radiology.  Rocking Robert Linney came down and looked the situation over.

          “I’m willing to go get it Bibey, but I expect Sandhills would rather do the case since they are in the middle of it.”

        “Yeah, and I figure they might want their camera back, too.”

        “If they won’t take her, give me a holler, but I feel sure they will.”

        I got ahold of the intern and decided to have a bit of fun.  “Hey this is Dr. Tommy over in Harnett County.  How are y’all today?”

        “Good Dr. Bibey.”  Everyone down there knew me, not only was I a graduate but Neuse River was the go-to band for faculty pig-pickings.  (The Docs didn’t know much bluegrass, but could count on me to round up all the best without fail.)  “Whatcha got?”

        “I need to brag on Sandhills.  You know that new fangled camera you’ve got down in G.I.?”

        “Yes sir, sure.  I was on that rotation last month.”

        “Well tell ’em good ole Dr. Bibey said I sure am happy y’all got all that high tech down there, cause its sure enough made the  diagnosis for my patient.  I need to send her on.  She has a bowel obstruction, so she needs to go to the OR down there tonight, and not just me but Rocking Robert Linney thinks so too.”  Robert was well respected in the Eastern N.C. surgical community, and I knew his opinion would trump me, and more important, the intern.

        “Really, how’s that?”  

        “Son, I’m gonna make you a star today.  You tell ’em you talked to Dr. Bibey, and he was just a going in circles, but you extracted such a good history you know where to make an incision that guarantees the diagnosis, and you can do it without looking at the x-rays.”

        “How I am going to do that?”  I had him confused.

        “Don’t you worry about that.  When she gets there, you’ll understand.  Just tell him ’em Dr. Bibey knows and trusts his patients, and we’ve got ’em a diagnosis.  She’ll be NPO, and ready to go.”

        “I don’t get it.”

        “NTW, and lay money on it.”

        “O.K., Bibey, will do.  Send her on.”  I knew my patients, and he knew me.  He decided to have faith.

        I went back to my patient to break the news.  “Ms. Andrews, I think we are finally gonna resolve this thing.  Your camera is stuck, and I think whatever has it hung up is our problem.”

          “What do you think it is, Tommy?”

           “Well, I don’t know for sure, but I feel like we have to find out.  I’ve talked it over with Sandhills and they agree.  I’m sorry, but I think you need to go to surgery tonight.”

        “Do you think I’ll be alright?”  She seemed more relieved than worried.

        “Yes ma’am, I do.  One more thing.  You mind if I do a little art work on you?  I think it’ll help speed things up at the Medical Center.”

        “Sure, Tommy.  Anything you think that’ll help is O.K.”

        Well, I pulled out an erasable magic marker and drew an elaborate map right on her abdomen.  It was a beauty, complete with an arrow pointing to the spot which corresponded to the location of the camera on the x-ray.  Much like an anatomical treasure map, it was quite elaborate, and reminded me of the circuitous route I outlined in my high school English paper on the “Ryme of the Ancient Mariner.”  A prominent arrow pointed to a large ‘X” denoting the point of interest.   —> X- Albatross shot here. 

        In this case, the arrow pointed to the “X” and said, “Think carcinoid.” I signed off with “Bibey was here.”

        I kissed her on the forehead, and then tweaked her big toe.  “Good luck, kiddo.  You’re gonna be fine.  Come visit when you get back home.”  I read a long time ago about a patient who thought she was dying, but took heart ’cause a doc tweaked her big toe.  She figured no Doc would tweak her toe if she was doomed, and it encouraged her.  I’ve never admitted why I adopted the habit till today, but I always sensed some relief when I did so.  Besides, I reckon no Doc would draw a treasure map on your belly if they thought you weren’t gonna come home.  I think she got it, ’cause when they loaded her up in the ambulance she waved bye and promised me a pound cake.  

        Ms. Andrews went to surgery the same night, and as several of you guessed, had a carcinoid tumor just shy of her appendix.  They resected the tumor, and took her appendix out while they were there.  And, not just in this story, but in real life, the woman has sure enough lived happily ever after.

        The intern, by the way, followed instructions and won all his bets.

        Now for free tetanus shot contest.  Well, Ted and Irene were right.  Ted is a Professor, and like me, he tends to read a lot.  We have learned over the years not to let all that education get in the way of the simple truths of bluegrass music and its’ people.  He was afraid to ignore banjobilly’s homespun wisdom. 

        It’s sort of like the old saw about reading music.  A fellow asked a bluegrass man if he could read music, and he replied, “Well, a little, but not enough to hurt my playing.”

        Irene, as it turned out, had taken anatomy in college, so she was not relying solely on intuition.  She figured the camera was stuck, and came very close to the right location.  Ms. Susan also got it, though she came to her conclusion from a different angle- woman’s intuition re: the daughter in Tennessee.  mrschili, having studied Bibey’s peculiar writing style, figured it out from a literary point of view, and Dr. Bob knew all along but didn’t tell ’cause of HIPAA .  For that matter Ms. Pande was correct also; the thing was right near the appendix and it indeed had to come out pronto.  The fact the pathology did not end up as appendicitis is immaterial, ’cause Pande understood surgery was indicated that night.  Remember- she said, “Her appendix needs to come out, and don’t wait a day.”  

        Correctamongo.  Serendipity and the Good Lord have saved me before when I was not as close as she was pre-op, so I have to give her credit for a correct answer also.  When you think about it, the surgeons did not know for sure either prior to going in.  Sometimes knowing what you have do is more pressing than knowing why.  The situation had changed from chronic to acute.  I am thankful we didn’t stay in chronic illness mindset mode, and changed gears.

         banjobilly, crude as he is, made the right call.  One fellow wrote in and said, “I think banjobilly is right.  That woman has a camera problem.”  I asked billy what clued him in, and he said it was the one summer he worked as a plumber’s assistant, and had to fish all sorts of things out of septic tanks and toilets.  Like he said, “unless that woman has done s#&^ her a camera, she’s got a blockage somewheres.” 

        I’ve always liked banjobilly.  One should never discount folks ’cause of social status.  billy has virtually no book learning, yet he’s smarter than he looks, but the boy needs to work on that cussing of his.  I don’t want anyone to toss him out of bluegrass music.

         So, even though everyone thought about the problem their own way, in the end all my regular readers were right.  I guess they’ve been studying Bibey speak so long they are developing doctor intuition.

        Now all I gotta do is figure out how to explain all those free tetanus shots to Corporate.  I hope they ain’t gonna be mad.

        I know you wonder why I chose carcinoid.  Well, I have found through the years once you have gathered all your data, run all your tests, analyzed the thing from every scientific angle you can think of, and still have the diagnosis dangling in the wind, flip a coin and go with intuition.  The daughter from Tennessee thought carcinoid, so it was good by me.  And, I didn’t learn that from books, but from my wife, my daughter, and those office ladies.  They are the best.  To the patients’ daughters’ everlasting credit, she never said “I told you so” or complained I only made the diagnosis months after her.  She was just glad her mom was O.K.

        Gonna toggle back to music for a while, but I’m not done with chronic illness yet.

        If it don’t rain in the morning, I’m gonna tee it up with the choose-up boys.  Remind me to tell you about a golf tournament a buddy mine is trying to qualify for.  I’m not going to say much till I see if he gets in, but I’ll let you know.

Dr. B