The chronicle of a lonely do-gooder family doctor who survived.

Friday, March 14, 2008

Poor prognostic signs

I was just finishing up my charting on a Friday evening and when I realized I was writing in volume IV of a patient's chart.

It's a poor prognostic sign when your medical chart is measured by volume number.

This got me thinking about other poor prognostic signs I'd seen recently.

It's a poor prognostic sign when your white blood cell count is greater than your hematocrit. It's an especially poor sign if your respiratory rate is greater than your heart rate.

We have health questionnaires that we send home to people to fill out before they come in for their preventative visit. Sometimes the forms come back after sitting at the patient's house, reeking of cigarette smoke. These forms then get filed in the patient's chart. It's a poor prognostic sign when your medical chart smells like cigarette smoke.

It's a poor prognostic sign when your doctor sends you to a zoo for anything.

"Doctor, I've lost 45 pounds and I've hardly had to change my diet at all!" is a poor prognostic sign.

Most people are familiar with the "O" sign; when a demented, dehydrated, and obviously ill elderly patient is transferred to the emergency room their lips are often drawn in and their mouth is fixed into the shape of an "O." A more grave sign is the dreaded "Q," when the tongue begins to hang out of the corner of the mouth. The O / Q shift is considered a poor prognostic sign.

An ER doctor is Arizona has worked out a calculation: Number of Tattoos/number of teeth in head X blood alcohol level. A number greater than 50 represents a 50% probability of being bitten by a snake.

There are a lot of poor prognostic signs based on weight. One of the most widely validated is IQ less than the weight of the patient in kilograms. That's a poor prognostic sign.

If the number of clinic visits per year is greater than two times the age of the patient, that's another poor sign.

One of the great things about being a doctor is that you get to peer into a world that is totally foreign to many Americans, a world populated by characters whose struggles are at once noble and pathetic. People go to doctors because we are both empathetic and clinically detached. It is this dance that I do with my patients that keeps medicine interesting for me and allows me to continue to be present in the lives of people whose concept of normalcy is so fascinatingly different from my own. Empathy tempered by objectivity.

With some patients the only empathetic response that would seem appropriate is despair. How else can you deal with a 400 pound person who cannot sit on a toilet who comes in because he has a bedsore that is infected with fecal bacteria? But if the doctor despairs, it denies the patient the objective consultation they deserve so we all have to figure out how to maintain our distance. Black humor is sometimes the only way to cope.

Tuesday, March 4, 2008

Seattle Driving

Ok, so I'm running at Green Lake yesterday and I come up to an intersection with a traffic light. The light changes red so I wait patiently, bouncing up and down on the corner. A car starts moving into the intersection, and in the middle of her own green light, she stops and waves at me to cross the street in front of her. Cars behind her are honking and I am using my most colorful language to remind her that she's come to a stop in the middle of an intersection. The light turns yellow and she can tell I am not going to cross in front of her, so she rolls down her window to give me this wounded look as if to say, "How could you refuse this beautiful act of kindness I have offered you" before driving off. Yeah, fuck you, lady.

Only Seattle.