Diary from a Week in Practice



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Am Fam Physician. 2000 Aug 15;62(4):762-763.

Monday

WLL seems to find boric acid useful in various treatments. In one past “Diary” entry (June 1994), he told about using a supersaturated solution of boric acid to treat superficial onychomycosis and, in another (August 1994), he relayed how to make boric acid capsules for vaginal use to treat or prevent vaginal candidiasis. Physicians have gained more experience with these treatments, especially for acute or recurrent vaginal candidiasis. Now, the Vaginitis Committee of the International Society for the Study of Vulvovaginal Disease (ISSVDC) warns that boric acid is a potentially poisonous heavy metal (Family Practice News, Jan. 1, 2000, p. 19). It was reported that a 5- to 6-g oral dose is enough to kill an infant and that the chemical is not only easily absorbed when the skin is broken, but it can also be absorbed by intact skin. Therefore, powdering a baby with boric acid for monilial diaper rash could be fatal. In 1994, WLL had recommended 600 mg boric acid capsules intravaginally twice a day for up to 14 days. The ISSVDC says that this dose, via capsule, suppository or gel, should be “the absolute maximum dose.” They remind us, “There is a skull and crossbones on the box of boric acid. Never forget that.” So noted.

Tuesday

During the dry season here in Florida, it doesn't take long before everyone starts complaining about the lack of rain. The weather is on everyone's mind, but the tone becomes more serious when the dry spell is complicated by brush fires, as it was today. The telephones were busier, JRH and his partners saw more cases of wheezing, and the known patients with asthma were clearly in more trouble. Even the telephone requests for albuterol inhalers tripled from the usual rate. As we tried to render the best medical care we could offer, we realized a thorough prolonged rain would have been much better medicine. Clearly, what we do in our offices some days is “just a drop in the bucket!”

Wednesday

Treating depression during pregnancy pharmaceutically has always presented problems for WLL because of the scantiness of reliable information on the effects (or lack thereof) of antidepressants on the baby. This left WLL's maternity-care patients in the unenviable position of possibly having to choose their health over that of their baby's. Although most choose to continue their antidepressant, based on the best data available, WLL always remained nervous—at least until the normal child was born. Now, an excellent review article (JAMA 1999;282:1264–9) reports no increased risk for the unborn child in the mother who uses tricyclic antidepressants or selective serotonin reuptake inhibitors. Although this review of prospective data is useful and welcome, the authors still emphasize the need for more research, especially for fluoxetine (Prozac). They say fluoxetine is cleared so slowly from the body that the baby may have trouble clearing the drug. Because of this, the authors suggest that fluoxetine be stopped or tapered two weeks before the estimated date of birth.

Thursday

Harvey and Jean, who had been married for 53 years, came in today to see JTL for their medication checks. Not unlike many couples who JTL has cared for, Harvey and Jean seemed to share the same maladies, and even the same medications. After listening to Jean's heart, JTL tried to describe to Harvey what heart sounds were emanating from Jean's chest: “Har-vey, Har-vey, Har-vey.” JTL then placed his stethoscope against Harvey's chest and playfully remarked, “Lo-is, Lo-is, Lo-is.” Jean and Harvey seemed genuinely surprised, as Jean commented, “That was the name of his last girlfriend!” After a nervous chuckle, Jean added, “Well, at least I can tell you that she died years ago—so we all know what her heart is saying!” JTL figured that he'd better be careful in his kidding of patients in the future.

Friday

WLL has practiced and taught the use of alternating doses of acetaminophen and ibuprofen to treat fever in children. His practice was based on older studies showing that alternating aspirin and acetaminophen was more effective than single therapy. When aspirin use in children was recognized to be associated with Reye's syndrome, WLL began to recommend ibuprofen instead of aspirin. Apparently, this is a fairly common practice. Now, a report says this practice may cause harm (Pediatrics 2000;105:1009–12). This survey of 161 pediatricians indicated that 61.9 percent of respondents began antipyretic therapy at a temperature of 38.3C° (101°F), while 13 percent used patient discomfort as a benchmark to begin antipyretic therapy. With a temperature of 38.9° (102°F), 57 percent of the respondents recommended ibuprofen and 50 percent advised parents to alternate acetaminophen and ibuprofen. The report points out that both drugs act on prostaglandins through identical pathways so that those who advocate alternating the drugs are using therapy with the same mechanism. Further, say the researchers, “there's no scientific data that tells us that this is a good thing to do. There's data that tells us this is potentially a bad thing to do; kids can be harmed by this, certainly overdosed by this.”

Saturday/Sunday

While making rounds on Sunday mornings, JTL is frequently accompanied by his daughters, who enjoy going to “Daddy's big office” (his four-year-old's term for the hospital). While his daughters occupied themselves in the lounge, JTL visited with one of his patients in intensive care, Clyde, who had recently been diagnosed with non–small-cell cancer of the lung. Within seconds of JTL's arrival, Clyde developed acute respiratory distress, caused by tracheal compression from the large tumor. Fortunately, Clyde's family was present, and, after alerting respiratory therapy to prepare for mechanical ventilatory support, JTL quickly explained to them the need to make an important decision: whether or not to intubate Clyde and provide mechanical ventilation. JTL shared with the family his belief that Clyde, once intubated, may never get off the ventilator. Yet, everything had transpired so quickly, only one day after the diagnosis of cancer had been established. Knowing that they were religious, JTL then suggested, “Would you like to pray over this decision for a moment?” which was favorably received by the family. The decision was made to intubate Clyde and maintain him on mechanical ventilation. JTL found this an opportunity to reflect on the unique privilege that family physicians often have; that is, the privilege of assisting patients and their families in the dying process.

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



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