On the medical front, good news and disappointments. A 79 year old man, who has been a patient for 13 years, was feeling weak and nauseated and had a change in his creatinine from 1.7 to 5.4, as measured by the assistant of a house call doctor with a bedside device. He was feeling too weak to come to the office and was availing himself of this house call service. To their credit, the abnormal value was called into the office and a nice message was written down for me, as though it were routine, by a new employee of the physician I share office space with. Mistake #1: Never trust an important message to the person who picks up a phone at the doctor's office! The message was left in a pile and I got to it Thursday at the end of office hours. I called the patient, spoke to his wife, found out that he was not urinating as often as normal, and knowing that he is a paraplegic, has a history of bladder stones, and didn't follow through on advice to see a vascular surgeon about an abdominal aortic aneurysm, I insisted that he needed to go to the emergency room and be admitted. Could it be acute renal failure due to the expanding aneurysm, or an obstruction? I phoned the ER, spoke to a nurse and relayed my concerns, and not wanting to take primary responsibility for the patient in the hospital, being the admitting physician, doing the admitting history and physical and the renal consultation for the same H&P fee, as well as handling first line calls, I asked that the patient be admitted to a hospitalist. Fine. Good insurance. He's there. I'm not. All the right heads-up, or so I thought. I even spoke to the hospitalist and told him the above. I didn't insist that he get a stat renal US. He looked at an elevated BNP, and a K+ of 5.7, and treated the minimal elevation of the K. The Creatinine was now 7.9. Self evident that first you rule out obstruction!
The next morning, at 8:30, while running from one dialysis unit to another, the nurse calls to inform me that the patient is putting out "much urine." Well, how much urine? "It's not recorded on the Intake and Output sheet." "Not much." Well what does the US show? "It's ordered for today." Well, get it stat and I'll be right there. (Nice to have a Porsche Turbo.)
On physical, no congestive heart failure. Smaller than expected left kidney, normal size right kidney. No obstruction. Aneurysm about the same size. BP good and not a lot of distress. So, we'll cautiously try a fluid challenge. A call today indicates that the creatinine is still in the 7's. The chart is with the patient who is getting a magnetic resonance arteriogram, with no iodine dye toxicity, so the vascular surgeon can see the extent of the aneurysm. As soon as he comes back, I'll examine him, determine the output and see if we can wait before dialyzing him. He may or may not allow me, just as he may or may not allow the vascular surgeon to repair the aneurysm. I know he's got the best surgeon available, that he's not obstructed, but I don't know about the renal arteries and the aorta. Dialysis will buy time. At least he's in the hospital! Interesting, to me anyway. No back pain, even in an acute dissection, which he probably doesn't have, because of the paraplegia.
And then there's Quicken! And a review of income tax, and no one wants to hear bad news. Anyway, on the basis of the pay, there has to be another reason for this stuff.... and there is, my Porsche, my employees, medical education in Hawaii, health insurance, and self-esteem. Still, my kind of medicine is only of historical interest, and the temptation grows all the time when I balance malpractice insurance and frustrations with the diminishing joys of practicing a profession that is increasingly being treated as a commodity. They don't get it, or I don't get it. Probably me. A good nurse practitioner armed with the right algorithm could do a better job for less money, and she would complain a whole lot less. I don't believe this for a moment! But, that's where we're headed. Doctors get paid for procedures, not for thinking or doing the right thing. That reward comes in heaven.... that place with the 72 virgins, I think. I don't know if that's a reward or a punishment.
Did you ever try to figure out how long your IRA will last and what life style sops you have to throw out and what family health factors encourage living in the now because the future is uncertain? None of this will buy my wife's health, and what really matters anyway? A wonderful wife, 7 kids, 9 grandchildren.... all that and the Porsche is back after a new alternator, a brake job, 2 new axles, etc, etc.... $4,900 worth of et ceteras! It's nice to work, have a job, a family and a Porsche. To try to understand it all, and to plan.
Oh, and of course I'm reading about Spitfires, and rereading old books! And hoping that old friends are well and happy, and that Democrts will put together a plan and send George into retirement. He doesn't feel he needs to obey the country's laws, and now he wants to recruit google to do his spying. And 2 of my sons are Republicans. Maybe, it's time to trade in the Porsche on an old Caddy with tail fins, learn to play bridge, and head for a condo in Florida. Not likely!