Nov-Dec 2001 Table of Contents

PRACTICE DIARY

Chapter 30



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Fam Pract Manag. 2001 Nov-Dec;8(10):50.

Stress reaction

Isabel hung up the phone and rushed into my office to tell me that Matt, a patient of mine, had collapsed at home and was now in the ER. A moderately obese man of 56, Matt had multiple risk factors for coronary artery disease, and my first thought was that he had had an MI. But Gary, the ER doc, had found him to have a normal ECG and cardiac enzymes; however, he had guaiac positive stool and a hematocrit of 30. “Do you want me to put down a tube?” he asked.

“Call the surgeon on call,” I said. “Maybe they’ll go right to the scope.”

Matt’s bleed dovetailed nicely with the surgeon’s endoscopy schedule, and within an hour she had it done. “I didn’t see any ulcers or cancer,” she said, “but there were a lot of clots. I’d call it a hemorrhagic gastritis, probably brought on by stress.”

Matt certainly had enough stressors in his life. What he felt was an “Ozzie and Harriet” marriage had ended three years earlier with his wife walking out. He was putting two kids through college, had big alimony and mortgage payments, and had recently lost his job. He smoked two packs a day and was on two antidepressants. If anyone was going to have a stress bleed, it was Matt. He was textbook.

He remained stable on H2 blockers for a day and then dropped his hemoglobin two points. Thinking he was still equilibrating from his bleed, I transfused him three units. In the middle of the night, I received word that he had collapsed while walking to the bathroom and had to be resuscitated. His H/H showed no trace of the blood he had received because it had all gone into his stomach – his GI aspirate was grossly red.

I spent the next four hours at Matt’s bedside in the ICU lavaging him with ice water, pumping in blood faster than he was losing it and arranging for his transfer to a tertiary care facility. He was rescoped twice later that day. The first time, they thought they saw a diffuse gastritis, but after the clots cleared and they looked again, they found a benign erosive leiomyoma. Fooled again!

Networking

Last night, over dinner with friends, a patient’s wife paid me a marvelous compliment; she said I was a great networker. Her husband, Jonathan, had had open heart surgery 12 years ago for an extremely rare condition: a coronary artery fistula. An avid mountain biker, Jonathan had begun to experience extreme fatigue after arduous rides. It was the kind of complaint that wouldn’t have raised my eyebrow for most of my patients, but Jonathan was in great shape. His slow recovery, coupled with a newly perceived faint cardiac murmur, made me wonder if his fistula might have recurred.

I was able to track down his old cardiologist, who had since moved from Minneapolis to Milwaukee, and he thought the recurring fistula was a remote possibility. An Internet search yielded several articles suggesting procedures short of angiography that could be useful: a treadmill-Cardiolite scan and a stress echocardiogram. I referred Jonathan to a local cardiologist, who performed the stress echocardiogram, which showed no evidence of ischemia or the persistence of a coronary artery to pulmonary artery fistula. Jonathan was much relieved and his symptoms shortly abated.

I find myself increasingly involved in similar work, making connections for my patients with medical problems requiring special expertise. Seems to me that, in 21st century medicine, since we can’t treat all of our patients all of the time, we need to take pride in making great referrals. Sometimes, that’s all our patients really require of us.

Doctor cars

I drive a 1986 Ford LTD and love it. I bought it off an 86-year-old man who also loved it but couldn’t drive it any more. He was bed-bound and needed the money to pay for home care. “It kills me to do this,” he confessed to me as we made the sale. Three weeks later, he died.

The car had only 26,000 miles and was in pristine condition when I bought it five years ago. My son called it the “nark mobile,” and my daughter said it was an old man’s car and wouldn’t ride in it, but they couldn’t hurt my feelings. I got a terrific deal.

My last car was my late father’s 1984 Chevy Malibu, which I’d still be driving if a tree hadn’t crushed it during a winter storm. I like old cars in good condition. Besides, I don’t spend enough time driving to justify buying a high-performance automobile; I’d rather spend the money on something else. But lately I’ve been noticing that some of my patients don’t share my enthusiasm. In fact, they like to drive cars you’d normally associate with doctors. Aaron, a chiropractor and father of two young children, just drove up in a brand new Mazda Miata, not exactly a family car. Another patient, Sam, has a new Jaguar – and he’s only 35. But when Gordy, who’s 72 and on Social Security, showed up in his just-off-the-showroom-floor, powder blue BMW convertible, it was the last straw. “Maybe I’m missing something,” I thought, so I asked Gordy if I could take it for a spin.

I drove Gordy’s convertible around the hospital three times looking for some doctors to show it off to but returned to the office chagrined.

“Whadya think?” Gordy asked. “I didn’t see anyone,” I said, disappointed. “Great stereo system, though.”

I held back the suggestion that he let me borrow the car to go to the medical staff meeting that night.

Dr. Brown, a solo family physician living in Mendocino, Calif., is a contributing editor to Family Practice Management. These excerpts from his journal illustrate the many characters, stories and lessons family practice has to offer. No real patient names have been used.

Conflicts of interest: none reported.

Copyright © 2001 by the American Academy of Family Physicians.
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