Diary from a Week in Practice



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Am Fam Physician. 1998 Jul 1;58(1):85-86.

Monday

The last few weeks of pregnancy are often difficult for patients, especially if the pregnancy goes past the “due date.” TBS has heard of many unusual ways of inducing of labor from anxious moms-to-be and their families, such as walking, cleaning the house, herbal supplements, sexual intercourse, enemas, etc. Today, a couple who were seven days past their estimated due date came in for their appointment. Everything was going well, with no signs of preeclampsia or other complications, and the nonstress test was reactive. The husband then asked about a new method for bringing on labor that a friend of theirs had mentioned—eating macaroni and cheese with hot sauce. TBS did not think this sounded very appealing, but she told them there was no medical reason not to try it except for probable heartburn. Knowing that the patient would go into labor soon no matter what she eats, TBS reasoned that having something to do actively (even if it tasted bad) would help the couple feel as if they have some control over the situation. Teaching our patients to take control is part of the essence of being a family doctor.

Tuesday

Haven't we all heard that things seem to happen in threes? But sometimes it seems they can happen in fives or 10s or 20s. It appears there is an epidemic of tennis elbow here in Kissimmee. We routinely explain the pathophysiology and offer a variety of interventions ranging from the forearm brace to our favorite—the well-placed, carefully administered steroid and lidocaine injection. Even so, we always make sure that our patients understand that all lifting in the following week should be done “palms up” to unload the inflamed tendon. Nevertheless, JRH learned today that there are lots of things that don't lend themselves to being done in that way—brushing one's teeth, tying one's shoes and pulling up one's pantyhose were just a few suggested by our patients.

Wednesday

A 58-year-old woman with poorly controlled diabetes and diabetic neuropathy returned today happy that Dr. Walt's trick had dramatically reduced her neuropathic pain while she and WLL have been working on controlling her diabetes. What is the “trick”? Very simply, WLL had her apply OpSite polyurethane film over the unbroken skin of the anterior tibia, leaving it on for two weeks. WLL had read about this simple and safe treatment some time ago (Diabetic Medicine 1994;11:768–72). In this particular study, 33 patients with chronic diabetic neuropathy of the lower limbs applied OpSite to one of their legs for four weeks and then applied it to the other leg. Pain reduction was significantly greater in the limbs treated with OpSite than in the untreated limbs. In addition, the patients in this study, as well as our patient, reported improved sleep, mobility, mood and appetite.

Thursday

The process of taking care of patients is often one of transferring our relationship from doctor-to-patient into doctor-to-friend. JRH has taken care of one such couple for years and has supported them through a stroke, an ulcer, removal of a meningioma and removal of a cataract. More recently, the husband and wife have each developed diabetes, and this has proved to be most challenging. Educating, teaching, encouraging and even cajoling and bartering have been a part of forging a camaraderie among the threesome, who confidently call each other “friend.” True progress in controlling this disease seemed within sight. So imagine JRH's surprise when they arrived with a special gift for the doctor—a box of donuts.

Friday

While the debate over neonatal circumcisions continues, evidence supporting the use of anesthesia to provide better tolerance for the infant is accumulating. Not only that, researchers abandoned the randomized protocol during one recent study because the infants without anesthesia were having too much pain. In fact, the authors of this study, which was published in the December 1997 issue of JAMA, indicated that they now feel that performing a neonatal circumcision without anesthesia is unethical. Having performed dorsal penile blocks since his residency training, JSR noted some infant discomfort at the time of separation of the foreskin from the glans. Well, the JAMA study confirmed his observation in its comparison of dorsal penile blocks and penile ring blocks. Evidence of improved tolerance was found with both techniques, except at the time of separation of the foreskin from the glans, when the penile ring block proved to be more effective. A study on penile ring block was published in the September 1987 issue of Anesthesiology. After reviewing the article, WLL and JSR performed their first ring block. It was easy. Less than 1 mL of a 50:50 mixture of lidocaine and bupivacaine was injected subcutaneously in a “ring” around the midshaft of the penis. The baby slept through the procedure sucking on his pacifier.

Saturday/Sunday

An important part of being a family practice physician in a smaller town is community involvement. This weekend, SEF and TBS agreed to give lectures to the counselors of a local pregnancy center. Ten to 15 counselors arrived to hear talks on birth control and menopause. Both SEF and TBS had barely begun their separately prepared speeches when they were barraged with questions the counselors had all been holding back—questions they had always wanted to ask but never had the chance. The prepared speeches were shortened considerably, and the program became more of a question and answer session, in which the counselors asked questions not only about their clients' problems but also about many of their own problems. Both groups left the meeting satisfied that the clients of the pregnancy center would receive more informed advice and hoping the experience set a precedent for future interactions.

This is one in a series by Walter L. Larimore, M.D., John R. Hartman, M.D., Theresa B. Shupe, M.D., Stephanie E. Frisbie, M.D., J. Scott Ries, M.D., and Chad A. Griffin, M.D., six family physicians in private practice in Kissimmee, Fla.



Copyright © 1998 by the American Academy of Family Physicians.
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