Diary from a Week in Practice



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Am Fam Physician. 2002 Sep 1;66(5):772-774.

Monday

In southern Illinois, hunting and fishing are more than popular pastimes. They are often a way of life. A retired veteran with diabetes, Leo Grakus epitomizes the deer hunters of our region. Today he recounted his latest adventure. “I was bow hunting and nailed a magnificent buck with a perfect shot. Although the arrow was embedded inches into its neck, the animal struggled to remove the arrow by grasping it in its mouth and eventually pulling it out. I followed the buck's trail of blood but never did find the wounded deer. What do you think, Doc? Did it escape or die in some secluded spot?” Without waiting for an answer, Grakus expounded on what I believe has been the story of his own life. “Remember, where there's a will, there's a way.” As he buttoned up his shirt, I noticed the scar on his neck from previous carotid endarterectomy surgery. The deer hunter had more on his mind. “People aren't so different than animals. We all want to live, no matter the cost.” I wondered if he realized what a powerful metaphor for survival his tale illustrated. Grakus quickly changed the subject. “Did I tell you about the fish I caught the other day?” The distance between his outstretched hands as he exaggerated the length of his prize catch was nearly matched by the width of his grin.

Tuesday

In our region, brown recluse spiders are both common and vexing. Charlotte, a 45-year-old woman, crept into the office grasping her right leg. Something had bitten her 24 hours earlier, and now she was experiencing burning pain and pruritus in her right anterior thigh. A small gray vesicle was surrounded by a zone of irregular erythema, and much of her upper leg had a morbilli-form rash. Cool compresses were recommended and dapsone was prescribed (after first checking for G-6-PD deficiency) along with an analgesic. A complete blood count and urinalysis were normal. Two weeks later, however, Charlotte returned to the office with a necrotic area on her leg. “I tried treating the bite myself,” she informed me. Charlotte had found a chat room for victims of brown recluse bites. She learned that some people treated their bites with low-voltage stun guns. Although treatment for these bites has at times included observation, steroids, dapsone, hyperbaric oxygen, colchicine, and surgical excision, I was stunned by her revelation. I advised Charlotte to have a plastic surgeon evaluate her leg. Today, two things made my skin crawl—the extensive tissue damage caused by a little spider, and the thought of a reasonable patient soliciting and following medical advice over the Internet.

Wednesday

Even on his best days, Alex could hardly catch his breath. The sum of 40 years of cigarette smoking, plus more than 30 years' working underground in the coal mines, added up to a 73-year-old man long on prescription medications, home oxygen, and nebulizer treatments but short on functioning alveoli. Alex was a tough guy and a straight shooter. “Do what you have to, Doc,” he told me on more than one occasion, “I may not like it, but I trust you.” In the past year alone, he had been in the hospital four times for acute exacerbations of chronic obstructive pulmonary disease, pneumonia, and congestive heart failure. Yet, no matter how awful he felt, Alex somehow always made everyone else feel better. He could be counted on for a smile, a joke, a kind word, or a generous act. I found caring for Alex to be a challenge and a privilege. Every encounter reminded me of the value and limitations of being a doctor. While eating lunch during his last hospitalization, Alex experienced respiratory failure. There was little choice but to put him on a ventilator. After days without improvement, his family agreed to take him off the respirator. As he was disconnected from the ventilator, I could not help but let out a long sigh for a patient I will truly miss and a man who was great in all the little ways that matter most.

Thursday

Pamela presented with a two-year history of back pain radiating to both upper legs that had gotten much worse in the past six months. “I'm taking eight ibuprofens a day,” said the 33-year-old woman, “and my back is still giving me fits.” Pamela was tender to palpation below her right ribs posteriorly and had a small, flat, brown skin lesion above her upper lip. Other than those findings, her physical examination was about as helpful as all the ibuprofen she had been taking every day. A magnetic resonance imaging (MRI) scan of the lumbosacral spine revealed an intradural mass at L1-L2 that was contiguous with a large right para-vertebral tumor and retroperi-toneal mass measuring 17 cm by 10 cm by 10 cm. The findings were suggestive of an intraspinal and extraspinal schwannoma. A neuro-surgeon recommended a two-stage tumor resection, but Pamela decided to pray for a cure instead. One month later she telephoned me and said, “My pain is 100 percent better. I believe I'm cured!” We repeated her MRI and found the large tumor unchanged. Three weeks later, she underwent an extensive surgery to resect the tumor. The operation was a complete success. Although she is relieved the surgery is behind her, I sense Pamela remains disappointed that her prayers did not result in a cure. I, on the other hand, believe that her prayers have indeed been answered, though not in the manner she expected.

Friday

From time to time, physicians receive small gifts from their patients. These presents often include artwork, books, handmade crafts, baked goods, and vegetables. There are rare occasions, however, when patients give me items that I really find it difficult to thank them for. In the middle of a routine office visit, a prim and proper elderly woman innocently handed me a small antique flask. “I brought this for you, doctor. Open it and tell me what you think.” Flattered, I accepted the gift from her. The exterior of the flattened bottle gave no clue as to what it might contain. Curiosity won over my better judgment. Removing the top of the flask, I inhaled deeply. What I smelled, however, was not the pleasant aroma of perfume or spice. The scent effusing from this bottle was no bouquet, but rather the foul odor of her recent diarrheal stool! After much throat clearing and a vigorous cough, I quickly transferred her stool specimen into a properly labeled container where it would no longer surprise anyone else. I passed it along to the microbiology lab, where I was certain it would be more fully appreciated. At times like these, I remind myself that there is no greater gift than the giving of oneself.

Saturday/Sunday

One of the pleasures of family practice is watching children grow and develop into healthy, happy, responsible, and ethical adults. Until my daughter's high school commencement three months ago, I never fully realized just how large my “extended family” had become or how very proud they all made me feel. The Benton High School gymnasium was packed that night. A few thousand people turned out to honor the graduating class of 2002. As I sat on the dais with other members of the Board of Education, I spotted my wife, two sons, parents, and in-laws in the crowd. I smiled at my daughter who sat almost exactly in the middle of the 135 graduating seniors. I calculated that I had seen one third of these young adults in my office, home, or both. I reminisced about their triumphs and tragedies—the girl who developed a cold sore the size of Rhode Island two days before the senior prom, the boy who expected me to cure his stress fracture one week before the conference track meet, and the young woman who awoke with laryngitis the morning of the school musical—and am reminded of my own inadequacies. I'm impressed by the resiliency of this group. Every time they've been knocked down, they've gotten back up. These are the faces of our future, and I'm convinced the future is in good hands. Congratulations gang, the world is yours for the taking and yours to take care of. I know you're up to the task.

In 1995, after 12 years in solo private practice, Dr. Tony Miksanek joined the St. Mary's Good Samaritan Hospital system. He is the medical director of, and sole physician in, the hospital's Benton, Illinois rural health clinic, which also employs a full-time physician assistant. Dr. Miksanek sees all kinds of patients, and many of them are elderly.

Address correspondence to Tony Miksanek, M.D., 712 Old Orchard Dr., Benton, IL 62812. Reprints are not available from the authors

In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.


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