Diary from a Week in Practice

Am Fam Physician. 1999 Oct 1;60(5):1367-1368.

Monday

“Dr. Hartman, will you see an emergency?” was the urgent request. “Sure, what is it?” JRH replied. “A young girl is wearing a ring, and the finger is starting to swell.” Thus began an interesting episode in the daily excitement of a family physician's office. The young girl, contrary to her mother's instructions, had placed her pinkie ring on her ring finger. Now she could not remove the ring, despite many frantic attempts. The more she tried to remove it, the more stuck it became. By the time she arrived at the office, her situation was desperate. Not wanting to pull out the ring cutter, JRH called for some string, but none was found. Instead, one of his staff had some dental floss. JRH used the technique of wrapping the floss around the finger from the distal end of the finger toward the ring and then unwrapping it proximal to the ring. When wrapping the string or the dental floss, be sure that each “wrap” lies next to the one before it, so that no skin can be seen. This takes a fair amount of string or floss. The theory is that this wrap compresses the edema under the ring so the ring can slide over the now “skinny” finger. The trick worked brilliantly. Soon the ring in question was safely past the knuckle, and the crisis was over.

Tuesday

We often seem to have patients wondering what they can do to reduce ear pain during air travel. WLL's advice for adults and children has been fourfold: (1) pseudoephedrine orally, (2) a nasal decongestant spray like Afrin, (3) hydration, and (4) swallowing during ascent and descent. Now, new evidence debunks his time-honored advice. A recent study in the pediatric literature shows that preflight use of pseudoephedrine does not reduce ear pain in children during flight; however, according to the report, it does make them drowsy (Arch Pediatr Adolesc Med 1999;153:466–8). This placebo-controlled, double-blind study involved 50 children, ages six months to six years. The researchers reported that use of pseudoephedrine did not prevent ear pain during either ascent or descent. At least the researchers confirmed, via literature research, that oral pseudoephedrine is effective in adults. The results of this study do not support the practice of administering oral pseudoephedrine to prevent ear pain associated with air travel in children. Now, will WLL follow this study or will he continue his anecdotal way, awaiting more research?

Wednesday

CAG saw a patient today who related an anecdote about her four-year-old son. The child had been eager to hold his new sister, but his mother had repeatedly told him, “You cannot pick up your sister because you are too little.” One day during nap time for her one-month-old daughter, the mother was in the kitchen when she was surprised to see her son standing in the doorway proudly holding his sister. He had climbed over the side of her crib and managed to pull the infant out and carry her across the house, with no outcry from the baby. His comment—“See, I can do it”—led to his first grammar lesson about the difference between “cannot” and “may not.”

Thursday

The more we get to know our patients, the more we share in their joys and sorrows. Today a young, adventurous grandmother arrived needing “the best help you've got, Doc.” The patient had struggled with plantar fasciitis, through treatment with non-steroidal anti-inflammatory drugs, heel cups and well-cushioned shoes, only to find out she was no better. To top things off, the “Great Raft Trip” with her grandson was coming up in one week and, according to the grandmother, “I'm going there with him and going through the Grand Canyon if it kills me.” So faced with this challenge, JRH proceeded to his two-pronged attack: (1) inject the heel with triamcinolone and lidocaine, and (2) fashion posterior splints to be worn at night. Two weeks later, the patient relayed her joy and her sorrow: the trip was fabulous and during the adventure she was pain free, but the plantar fasciitis had now returned.

Friday

JTL, perhaps not unlike other physicians, often looks forward to sharing the pleasurable (and sometimes painful) experiences associated with being a family physician when he arrives back home with his family each evening. Recently, while driving in the car with his wife and three daughters, JTL discussed with his wife just a few details about the infant he had delivered the previous night. Unbeknownst to him, JTL's eldest daughter, eight years of age, had been intently listening to the details of the somewhat prolonged second stage of labor. During a pause in the conversation, Annie flatly stated, “I don't like pushing. I want to adopt.” After an attempt to allay her anxieties about pushing, JTL vowed to be more cautious about having similar discussions in the presence of his children.

Saturday/Sunday

Family medicine is distinctive in its care of patients of all ages and all different life stages—“womb to tomb,” as our physicians often say. CAG experienced this range during his recent weekend on call. While working with two patients in labor and awaiting the birth of two infants, CAG also spoke repeatedly on the telephone with the wife of a hospice patient with terminal lung cancer, arranging narcotics for pain control. He then admitted a febrile neonate to the hospital, followed by the admission of an 84-year-old woman with dementia and a broken hip. He made and took telephone calls with a 39-year-old mother of three who had been diagnosed the day before with intraductal carcinoma of the breast and who was depressed and grieving. CAG found himself rejoicing with and reassuring new parents about their children, helping a spouse prepare for the possible loss of a loved one, caring for an elderly patient with dementia and encouraging a mother to prepare for a fight against breast cancer. CAG was thankful for his training as a family physician, knowing that no other specialty would have prepared him to meet the needs of such a wide range of patients.

This is one in a series by Walter L. Larimore, M.D., John R. Hartman, M.D., Chad A. Griffin, M.D., and John T. Littell, M.D., four family physicians in private practice in Kissimmee, Fla.


Copyright © 1999 by the American Academy of Family Physicians.
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