Diary from a Week in Practice
Am Fam Physician. 1998 Nov 15;58(8):1762-1767.
While doing research for a presentation on removing foreign bodies from the ear and nose in children, WLL came across an old article in the May/June 1977 issue of the Annals of Otology, Rhinology and Laryngology (p.369) that described a “new” technique, using dental impression material for removing nonoccluding foreign bodies from the external ear canal. A semifluid dental impression material is injected into the external auditory canal, then removed after curing, with the foreign body attached. The technique was described as “a more pleasant experience,” for the patient and the doctor. WLL discussed the technique with a local dentist. She said that the appropriate material was like a dental amalgam, with two substances in separate tubes connected by a hand-held pump device and emptying into a single nipple. So, we waited for a good candidate. Today, a six-year-old came with left ear discomfort. A small bead was seen about half way into the external auditory canal. The eardrum was intact. The mom was told of WLL's desire to try this new “trick.” The child was cooperative while WLL slowly filled the ear canal with the substance and some was placed externally to create a “handle” to pull out the core after curing. After 15 minutes, the patient was allowed to pull out the “core.” Out it came, impression material and bead. It was painless, easy and fun! This technique should not be used with a tympanostomy tube in place.
Two weeks ago, JSR faced a difficult decision. One of his pregnant patients had a breech presentation with oligohydramnios, thus contraindicating an attempt at cephalic version. Obstetric consultation concurred that delivery should not be delayed. An elective cesarean section was scheduled for the next morning. The problem was that JSR was to leave that morning with his family on a vacation they had planned for some time. After much thought, JSR decided that this situation called for a practical demonstration to his wife and daughters of his commitment to his family over his occupation. When he carefully explained his predicament to the mother- and grandmother-to-be, they were disappointed but seemed to understand. CAG cheerfully filled in for his partner, assisted with the cesarean section and attended to the young infant. Today, JSR just happened to tune in to WLL's weekly radio broadcast and a familiar voice caught his attention. The caller was none other than the new grandmother, sharing with the listeners the joy of her new grandson and expressing thanks to JSR, CAG and their nurses for their loving care during her daughter's pregnancy. Hearing this live radio call provided a special sense of relief to JSR, who was grateful for having partners in whom he has full confidence to care for his patients. He was also reassured that this difficult decision, made in light of his priorities, values and goals, had been the correct one.
It never ceases to amaze us how strong and resolute some patients can be when faced with a crisis. Never is this more true than with issues of pregnancy and birth. Today, JRH handled the final details for an obstetric patient who is facing an arduous ordeal. She has learned in her 29th week of gestation that she will need complete bed rest for the remainder of her pregnancy and then face an elective cesarean section at 36 to 37 weeks, if all goes well. Many women confined to total bed rest during pregnancy become bored, frustrated and depressed. How these women cope with this, summoning a new type of strength and resolve to follow “doctor's orders” inspires JRH with awe. To make things just a little easier, JRH referred his patient to Sidelines, a national support network dedicated to women who need bed rest during their pregnancies. The address is P.O. Box 1808, Laguna Beach, CA 92652.
TBS has been following a 45-year-old man who previously weighed more than 300 lb. Before transferring to our practice, the patient had undergone gastric bypass surgery that had resulted in major complications and repeat operations. As a result of the surgery and a chronic pancreatic pseudocyst, he had lost over 150 lb and recently had difficulty maintaining his weight at 150 lb. Because of repeated illnesses, he had lost his job and subsequently his health insurance. The only medicine that had helped was octreotide acetate injections, which exert pharmacologic actions similar to those of the natural hormone, somatostatin, but this treatment was extremely expensive. Today, he came in for a follow-up visit and reported that in desperation he had tried smoking marijuana and had felt much better. His weight had increased 7 lb in one month, the biggest gain in over one year. TBS found it difficult deciding what to recommend to the patient. Was the patient telling the truth? Was the marijuana truly treating the nausea and abdominal pain? Or, was the marijuana helping the depression and anxiety that had resulted from the prolonged illness (although the patient is on antidepressant medication through his psychiatrist)? We hope the studies that are being done will help clear up the controversy of the “medicinal” use of its active component—tetrahydrocannabinol.
SEF treats many patients for depression and anxiety as well as their other medical problems. Today, a 56-year-old woman with a long history of depression presented with multiple somatic complaints including fever, headache, abdominal pain, nausea and urinary frequency. The routine urinalysis and focused physical examination revealed that she had a urinary tract infection, probably pyelonephritis. When the patient was told the diagnosis, she exclaimed, “Thank goodness! I'm so glad that something is actually wrong with me!” Because of her somatization associated with her psychiatric problems, her usual visit to the physician's office resulted in blame attributed to her depression. She thought she was having a flare-up of her depression and was very relieved to know that this was not the case. SEF prescribed the appropriate treatment, and the patient left the office already feeling better.
WLL has a friend in his church who has been living with multiple sclerosis for 25 years. During this time, she has developed some deep insights into living with a chronic disease and dealing with it emotionally. She shared her eight survival tips with WLL. They are: (1) Have faith in God. (2) Work as hard as you can to improve your physical condition. Although this won't cure the disease, great improvements can be achieved through physical conditioning. (3) Concentrate on the abilities you have, not on those you don't have. (4) Keep your sense of humor. If you have a sense of humor about your disability, the disease won't win, you will. (5) Find a support group with whom you can share ideas and experiences. (6) Allow yourself to be human. Even if you master the first five steps, there will be times when you “lose it.” On days when you are down, pamper yourself (e.g., eat dessert, listen to music, rent a movie). (7) Be sure to get counseling. (8) Always keep the faith. What wonderful lessons this “expert in the field” has taught WLL.
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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