OMM: When it works, it's great

I was a bit disappointed when I only saw one scheduled manip case today, but we ended up doing OMM on about five patients today. One lady came in complaining of LLQ pain; she had a colonoscopy done earlier this week which revealed the presence of diverticulosis. Her pain was typical of diverticulitis except she'd been taking medication for quite a while with no relief in sight. She'd had a hysterectomy so there was nothing else that could cause pain there. Except...a light bulb lit up and Dr. KB suggested that we diagnose her pelvis to see if everything was aligned. It wasn't; she had a left posteriorly rotated innominate (by one inch!) and a right anteriorly rotated innominate, which (naturally) jacked up her pelvis. Afterwards, she said the pain wasn't as bad as it used to be (probably pulled the psoas muscle), and I'm to follow up on her in a week to see if OMM fixed her pain. Similarly, another patient came in with chest pain; turns out her ribs were out of place. One of our last patients came in for back pain following a car accident (she had a LOT of ribs out of place), but when Dr. KB saw her name, she immediately asked Melanie, the PA, to see her and talk to her about taking low-dose cortisol for her RA and other things. "I have to get my cut after this and I'm already behind," said Dr. KB. Never mind that Melanie still had one more patient to see? Melissa, one of the MAs, asked Melanie why she agreed to see Dr. KB's patient for her just like that. "I don't know," was Melanie's reply. Probably because everyone always listens to the doctor. This is very different from Dr. P's office, where Dr. P's "girls" respect him and have a good rapport with him. Dr. KB is an excellent doctor to be sure, but very often she rubs on people the wrong way.

OMM: A lesson in cortisol

It's never fun when doctors get BFs (if you don't know what a BF is, refer to the movie White Chicks), even worse when the whole office is involved. Today Dr. KB and I fell way behind schedule (it doesn't help when the first patient arrives at 8:20 and isn't seen until 20 min later) so that we didn't finish seeing the morning patients until 1:20 (and afternoon hours begin at 1:40). The problem happens when patients have tons of problems and like to talk (I spent a good 20-30 minutes interviewing a 20-year-old girl who had all sorts of problems; it sounds like she has low thyroid and maybe low cortisol but gets hot flashes too; hopefully she's not going into ovarian failure), and Dr. KB will usually talk to them until they are reassured. Talking and listening are good traits in every doctor, but not when it cuts into another patient's time by a lot. Dr. KB had an appointment with her massage therapist (who comes here to treat patients as well), at 12:30; well as you can imagine, she had to reschedule. I asked Chris (the therapist) if she could just do a quickie massage on Dr. KB (who seemed very stressed and needed that massage), but Chris said it usually takes Dr. KB twenty minutes alone for her muscles to relax, so she needs a good hour. I'm hoping tomorrow we won't fall behind so much.

But because we did fall behind schedule, we didn't see the 1:40 patient until 2:00 (everyone had to eat lunch after all), and our second patient had no clue why she was even there. It said on the complaint sheet that she had a UTI, so I began interviewing her for that. Ten minutes into the interview, one of the MAs came in and told me that the patient wasn't here to discuss her UTI (she's already seeing a urologist for it), but to get some "energy treatment" (soft tissue?) Dr. KB came in and asked the patient whether she wanted to get her energy treatment or talk about her lab results, and the patient asked if they could do both. No, because it doesn't work that way. Meanwhile, the 1:40 patient was still at the front desk waiting for a prescription. Dr. KB barked at the MAs and me to write her prescription, but no one could find a prescription pad (we'd used the last sheet in the morning). Dr. KB stormed to her office, couldn't find a spare pad, then stalked back to the therapy room (where her energy tx patient was waiting), yelling, "Call it in!" over her shoulder. Poor Melissa, the MA she yelled at, just came in from lunch and had no clue what was going on (and why Dr. KB was so pissed off) Everyone gathered around to comment on Dr. KB's BF and what caused it, and the 1:40 patient offered to make things easier for us by calling the pharmacy herself (yes, even she was a witness to the BF) I think a combination of falling behind, not getting patients in and out fast enough, and no prescription pad (and no massage) contributed to the BF. Yikes...

My next patient was a woman named CD who ended up teaching me a lot based on her medical history alone. Several years ago she had a bad case of Graves disease (her TPO level was around 4500!), but managed to bring it down and control it symptomatically with exercise, diet, and "detox." This worked for seven years until suddenly, she had a flare-up that nearly killed her and she got her thyroid ablated. Even still, her TPO levels remained sky high, so she began doing some of her own research to see what she could do. She then came across the papers of one Dr. William Jeffries, who stated that most autoimmune diseases such as RA, Graves', psoriasis, fibromyalgia, and more can be treated with physiologic levels of cortisol since most patients with autoimmune diseases have lower levels or cortisol than normal, and the way to treat them is to replace the cortisol that is lost. Most professionals (med students included) are taught to have the mindset that all steroids are bad, when in fact the smallest dose of prednisone used pharmacologically (which may have side effects) has twenty times the amount of hydrocortisol that Dr. Jeffries treated HIS patients with just to boost their immune system. So once CD learned this information, she had to find a doctor who was willing to put her on hydrocortisone. Dr. KB was this doctor, and as a result CD's TPO levels fell all the way from 4500 to 1400 in a matter of months. Who knew? =) But because of this, Dr. KB has started treating many of her patients with autoimmune diseases with low-dose hydrocortisone if they have the signs and symptoms of adrenal failure, and many of them have done well as a result. I had to admit, I was impressed. There really is something to alternative medicine =)

OMM: Nonexistent punctuality

One thing I'll never get used to on these rotations is how far preceptors can fall behind schedule. With Dr. P, he scheduled 15 or 30 minute slots with each patient and did his best to see each one on time. Inevitably, there' d be overlap if a patient (or their spouse) had a lot of medical (or psych) issues to discuss and work with, but by the end of the day, we saw anywhere from 25-35 patients and were rarely more than one hour behind. Today, with Dr. KB, the last patient didn't leave until 6:30, and her scheduled appointment was around 4:20. The difference: Dr. KB sees only about 18-20 patients a day and schedules 20 minutes with each, but with the work she does (manip, hormone therapy, general family practice), it's very easy to fall behind. After seeing one patient together, I went to the manip room and spent 45 minutes treating a guy for back pain, and when I left to find her afterwards, she was still with the same patient...for a lab follow-up. This patient, however, was a sad case; she had interstitial pneumonitis and her lungs were infested with Aspergillus and Pseudomonas, but because her WBCs are too low due to chemo (what they use to treat pneumonitis), she can't fight off the infections. It's sad. Another time, Dr. KB spent about 20 minutes chatting with a patient (a nurse) about bio-identical hormone therapy (her specialty) and how she wants to educate others on that. A good goal, to be sure, but I couldn't help but think that while she was talking, others were waiting.

As far as manip goes, I'm still hesitant to use HVLA (and Dr. KB knows it; she has me pegged as the "muscle energy/indirect technique" type), but I'm getting better at it. With one tall guy today, I cracked his thoracics simply by pushing down on his back while he lay prone (a trick Miguel taught me when we were OMM partners) rather then use the Kirksville crunch. I've also gotten better and diagnosing the sacrum, but don't ask me to pop any OAs anytime soon. Everyone has their own way of doing the OA, so I'm a bit confused as to what's best for me. The bad news: no manip cases at all tomorrow. =/ Oh well. I'll just learn more about holistic medicine.

OMM: Afternoon at the PCC

Because Dr. KB doesn't work on Mondays, I went to the PCC for today's OMM rotation. To my surprise, the clinic had the morning off due to NBOME stuff, so I spent my morning going through OMM slides and looking at sample OMM papers. I can't believe some of the detail that a few students put into their papers; it was really like reading a journal article. I don't know how I'm going to be able to write something like that. =( Too out of practice.

With me included, there were seven medical students at the PCC today: three with Dr. G, three with Dr. W (me included), and a visiting med student from AZCOM with Dr. D. Our first patient was a couple in their 60s; Mrs. K had fibromyalgia and Mr. K had a history of a ruptured disc. Dr. W had all three of us working on the patients; one would be at the head doing soft tissue while the other two worked on the legs (interosseous membrane tx) Along the way, Dr. W pimped us on some basic anatomy and OMM (i.e. what percent of flexion/extension does the OA do? What muscles make up the hamstring?) and surprisingly, I knew most of the answers. Why didn't I know all this in first year when OMM was my worst subject? After that, we split up and went to see patients with Dr. W in twos. The other student stayed in the student charting room. The first time I stayed behind, I eavesdropped on Dr. D and Jim, the AZCOM student, as they talked about OMM, residencies (Dr. D doesn't think highly of neurology since neurologists can diagnose but not cure most of their patients), and more. In the middle of it, he got a call from one of the other OMM people about the first years; to his surprise, only one person failed the practical =P Interesting how little faith he has in us.

Dr. W is a lot of fun to work with. He likes to reminisce and talk about his father (who I presume is also a DO), his wife, and his "happy dog" Hosanna (there's a very cute pic of the two of them in one of the exam rooms). We get to learn a lot about him that way. So far, however, he hasn't let us see patients on our own. Dr. G has let his students see patients on their own (initially) to take a history and do some soft tissue (and attempt treatment) before he goes in. But I'm kind of glad for that; I like to make sure I'm doing something correctly. Today, for example, I found out that I did the CT HVLA completely wrong on a patient I saw at Dr. KB's last week. =( Fortunately Dr. KB followed up and did it correctly afterwards; otherwise I would have hurt the patient more. Tonight is for brushing up on more OMM because Dr. KB lets me work on my own, and I'd like to be able to do things correctly.

OMM: Intro to Holistic Medicine

Today I began my OMM rotation with a family doctor, Dr. KB, who specializes in naturopathic and holistic medicine. It didn't take me long to realize that she was not like most PCPs. The first few patients we saw were here for follow-up visits on bloodwork, focusing on hormones like testosterone (for libido), estrogen (for energy and others), pregnenelone (for memory), and adrenals (for cortisol production). We had one middle-aged man come with a testosterone level quadruple of what it should be (it's at a teenager's level), and he joked, "That's probably why I feel so good." We then had another lady come in for fibromyalgia that was not resolving with hydrocortisone; Dr. KB increased her dosage and recommended that she come back in 2 months. In the family medicine setting, Dr. KB rarely uses conventional medicines. If a patient shows up with high cholesterol, she prescribes red yeast rice instead of Lipitor because they have the same effect. If a patient can't sleep, she prescribes progesterone because it will also increase melatonin levels to help a patient sleep better. It's actually pretty interesting. Her clinic also offers something called "activated air" that ionizes air and helps treat all sorts of disorders (mainly asthma) as well as ionized foot soaks that supposedly detox the body. I'm not against natural medicine, but I got to admit it's all very new to me right now.

But I digress, this is an OMM rotation, and we did see a few manip cases today. The first patient had a clear-cut case of painful adhesive capsulitis, and I think I may use her case in my OMM paper. Another patient had a huge muscle knot running along her left side; I did muscle energy on her with no effect. Yet another patient had a major sacral shear that was giving her knee pain; we had to treat both her innominates and her shear. For another patient, I spent close to an hour on trying to diagnose and treat all her disorders (she had a right upslipped pelvis and was sidebent right all the way down her back), but ended up leaving her for Dr. KB to treat (while I was working on her, Dr. KB was next door talking to a disgruntled patient who had to wait an hour to see her and refused to talk to me b/c she "already did the student thing the last time"). Instead, Dr. KB referred me to see a 1st year med student who needed the 7 stages of Spencer done on him. This student, who I'll call T, was actually a postbac when I was a 1st year, and he'd wanted to attend our school but didn't meet the GPA requirement for automatic admission. He'd broken his clavicle in a motorcycle accident years ago, and the 7 stages helped his mobility a lot. He came to the clinic with his pregnant wife and expressed an interest in transferring to our school after 2nd year b/c all his family is here. I encouraged him to do so, since at least 2 people from other schools are now in my class (i.e. Wendy from TUCOM-NV).

I had nearly 90 min for lunch and drove to school to use the computer. There, I ran into Dustin N, who is doing ob-gyn and is on the Green team (he has 2 weeks of nights, too). I asked how how Dr. D and Dr. C were doing, and apparently his experiences have not been good ones. Dr. C has apparently become more uptight than usual, which doesn't bode too well. Dustin and Deanna have had no one to teach them since Drs C and D are always busy and they have two FP interns with them (no Dr. M to help out). Even though it's the 3rd week, Dustin hasn't been able to deliver a single baby (he only got 1-2 placentas) because the FP interns jump on every delivery to get experience and don't let the med students deliver. I was surprised when Dustin said that only the FP does postpartum checks and that he (Dustin) doesn't have to arrive until 6:30. What happened to all those mornings Anita and I had to arrive at 5:45?! They don't have to scrub in for all the C-sections, either, and the FP interns do most of the H&Ps or else take the med students' work. So according to Dustin, the OB rotation has been less than stellar (Dr. C has told him and Deanna that they weren't being proactive). Now I am really glad that Anita and I had Dr. B, Dr. K, and Dr. G to help us out when Dr. C and Dr. D didn't have time; they taught us enough to be more independent and probably look good in Dr. C's eyes. Also, apparently one of the previous students got Dr. C in trouble by letting it slip to one of our attendings (Dr. Ch____) that Dr. C had given them a day off, so he's afraid he won't get time off the 2nd week. If it was someone from the last rotation, then I have an idea who it is, but still...that stinks.

Thank goodness my OB rotation was a good one. And now...THANKSGIVING WEEKEND!

OMM: Orientation Day 1

OMM began today at the Research center at 8:00, but because Dr. W was in a meeting we didn't actually get started until around 8:45. Dr. W gave us a brief intro before one of the fellows, Ben W, came to give us a review about cephalgia, ribs, cervicals and thoracics. Between sections, we'd practice techniques on each other (or at least go through the motions). In the middle of some soft tissue, Anita hit a really painful spot on my left upper back (which was not the arm I'd been swinging the Wiimote with so it shouldn't have been sore) that made me say, "Ow," so Ben came over to see what was going on. Apparently my third rib was sticking out funny, so after confirming its location (like a wimp I screamed a little when he pressed on it b/c it really did hurt), Ben popped the rib back into place with HVLA and then let Anita float it. I don't know how you float a rib, but it did feel better afterwards =D At the end of the day Ben also spent about 5-10 minutes fixing Jason W's back pain, which has apparently been plaguing him for years. He did this in various ways, including sacral shear treatment (leg tug), psoas JSCS (Jason flinched bigtime when Ben pressed that tenderpoint), and others. Wonder if tomorrow will be as interesting.

PCP: Final Day

It was my last day at Dr. P's office, and to thank him and his staff for putting up with me for four weeks, I brought them a box of Ghiradelli chocolates. "My favorite," Chris, his manager, said, and Dr. P said the other girls will like them for sure. As usual, it was a busy Friday, and a drug rep brought lunch for us at around 10:30. We fell behind schedule again (sometimes Dr. P sees patients from church who like to chat with him about non-medical topics) and at one point overheard one woman say, "I'm about to go ballistic." I quickly ran to talk to her and her nephew after that one. He had a generalized rash that was brought about by amoxicillin; this was discontinued and changed to a Z-pak.

Then, while Dr. P and I were with one patient, the two MAs knocked on the door and said there was an emergency. I could hear what clearly sounded like a woman screaming and cryng in one of the other rooms. She was having a panic attack (funny enough, she came to the office for a follow-up visit on her anxiety) and had to be moved to a larger room. It didn't help that she'd brought her 2-year-old toddler with her, and when she started freaking out, her baby started crying too. What kid wouldn't be scared at the sight of Mommy screaming? Mommies are supposed to be stronger than that. She later got a shot to calm down, but dang...

At the end of the afternoon, Dr. P and I talked a little about what I learned and then parted on good terms. He invited me to come back at the end of my OMM rotation so I can find out about our patient with the testicular mass, whether it's cancer or not. I'll take him up on that.

PCP: Hard Lessons

This entry tells what happened yesterday. I forgot to update because it was the longest day ever. With only Dr. P and an NP named Angela (whom I've met previously) to care for about 35 patients, we didn't get out until after 6:00 pm. And although Angela had many years' experience as a nurse, she still had to run through her patients with Dr. P so he could sign off on prescriptions and approve her treatment plans. (One of her patients was the little boy with epididymitis that we saw the other day; he was placed on antibiotics and is doing much better. As for the man with the testicular masses, his sono came back suspicious for either lymphoma or metastasis. More workup must be done) Because of this, Angela took a very long time with her patients and was soon more than an hour behind schedule. The staff grumbled a bit about how she took too long, but they weren't the only ones. Most patients are allotted fifteen minutes' time with Dr. P, but the more complicated patients (the ones with multiple medical problems or counseling b/c they're depressed or newly diabetic) take way more time than that. Because of these lags, people get in later to see Dr. P. At one point we were nearly one hour behind schedule, and people in the waiting room were getting pissed. I asked one patient, a pediatric nurse, if the wait was that bad. She said no, but that non-medical people don't understand how it is. "It's like I tell my patients: if it were you with the doctor, wouldn't you want his undivided attention?" True that. Another time we could hear a patient in one of the waiting rooms loudly griping on the phone about how long he'd been waiting to see Dr. P, and Dr. P immediately went in to talk to him (and placate him)

One of the saddest cases I saw yesterday was a 74-year-old man named R with late-stage Alzheimer's disease. His MMSE (mini mental state exam) two years ago was 11/30 (pretty bad), so I knew when we saw him it would be much worse. He seemed friendly enough and said hello when Dr. P greeted him, but he didn't know Dr. P (or anyone else) by name. His wife (who came with him) told us that he was in Depends full-time and recognizes familiar faces but not names. Here's the result of Dr. P's version of his MMSE:

Dr. P: R, how many children do you have?
R:...I don't know
Dr. P: How many animals can you name off the top of your head?
R: Animals? I don't know.
Dr. P: How many colors can you name?
R: Colors? I...I can't think of any.
Dr. P: Where were you born, R?
R: ....
Dr. P: Did you grow up in a city or in the country?
R: I don't know.
Dr. P: Last year you told me you were born in Mississippi.
R: Yes! Yes, that's right!
Dr. P: And you grew up on a farm, is that correct?
R: Yes.

Later Dr. P told me that the last time he saw R, R kept repeating himself by telling where he was born and that he lived on a farm, but at least he could recall those long-term facts. Now he can't even remember those. This was my first time to see late-stage Alzheimer's up close and now I can really appreciate how hard Alzheimers' is on family members as well as patients. R's wife clearly loves him and is caring for him full-time, and he can't even remember who she is. I hope I never get Alzheimers. They say that if your mind is constantly active, you're less likely to get Alzheimers. So hopefully my love of Sudoku, my appreciation for the fine arts like dance and music, and my violin skills will save me from losing my mind.

PCP: Awkwardness

One of the first patients we saw this afternoon was a nineteen-old-girl and her mother for what sounded like a UTI (can't pee). When we first came to the room, the girl was curled in a ball on the bench. When we asked her when her symptoms started she said, "Something happened on Halloween." That was vague, so her mother tried to elaborate. "She was involved in, um, an activity (*sigh* what's so hard about saying the word sex?) with a male friend, and there was, um, some anal..." You get the idea. At this point the girl pipes up and said, "I didn't want him to do it, but he went in real fast, it was only about two seconds, and afterwards my butt hurt and there was some pinkish stuff oozing out." What got me was how the girl sounded totally clueless and matter-of-fact about it, considering this was her first sexual experience. Dr. P asked the mother if she's talked to her daughter about it, and she said, "Yes, and I'm disappointed that her first time turned out like this." This was in contrast to another case I saw yesterday, in which a girl raised by her trying-to-be-cool aunt was being pushed into being a singer, and her aunt said frankly, without worries, "She practices safe sex and only has one partner." Now I've heard of parents being open with their kids about sex, but seriously, how would a parent know whether or not their kid practices safe sex or how many partners s/he has? Sheesh.

We did not get out until 6:15 pm today, and the last patient was a woman who said she was sleeping too much, eating too little (gets full easily, no appetite), had a major case of fatigue, and could barely find strength to lift her purse. Now the wheels start turning, what could she possibly have? I contemplated MS or myasthenia gravis, as well as the obvious: depression (that's probably the most likely diagnosis). Dr. P asked me what tests I'd want to run. First: TSH (see if she's hypothyroid) and also CBC to look for anemia. And of course, a CMP to see electrolyte levels. Those were the big ones =)

Oh yeah, I also learned today that I can't tolerate Allegra-D. It does a good job of preventing congestion for sure, but now my nose is so dry it hurts.

PCP: Relapse

In my first week of my PCP, I met a patient named JF who presented in a state of opiate withdrawal in hopes of getting into Dr. P's suboxone program for treating opiate addiction. In the two followup visits since then, his mood was better and he seemed to be doing very well. But today, his urine tested positive for cocaine and opiates. Positive drug screens are a violation of the program, so Dr. P and I went to see what was going on. JF, to his credit, was honest with us and admitted that he'd taken some "Narco" for lupus-related neuralgia (one guy tested positive for cocaine and flatly denied it) but gave no reason for why he did cocaine (it wasn't his drug of choice). Dr. P asked what he was thinking, and JF said he didn't take the Narco for the sake of taking it (as most addicts do), he did it to treat his leg pain, which seems logical, right? Not for addicts in recovery. We also learned that JF has not thrown out all the opiates in his house; they're still sitting on his shelf, waiting to be taken. When asked why he's kept them, JF said it's fine b/c he's not taking them. JF did have good intentions, but the truth was that he was fooling himself into thinking it was okay to take Narco for pain when he shouldn't be near opiates at all. Well, he'll get a second chance to redeem himself, as long as he has outpatient treatment at a psych clinic as well. Dr. P has dismissed many suboxone patients in the past for falling off the wagon, but I'm still keeping the faith that JF will be one of the more successful patients.

As far as teaching cases go, we had a patient present for an ER follow-up after a bout of severe back pain and vomiting. She had no problem with range of motion, so the doctors were a bit confused until they ran a CK on her: it was very high, around 465. Also noteworthy was the fact that this woman had family hypercholesterolemia (her six-year-old has a cholesterol of 400 and is on Zetia) and was treated with statins. This was, in fact, a statin-induced myositis. But it's not a good idea to take her off statins for good, since they work so well on lowering LDL, so Dr. P is going to keep her on a low-dose statin.

In other news, the little boy yesterday was found to have bilateral epididymitis (rare in children), and once he was put on antibiotics he felt a whole lot better. We also saw a guy with his 6th MRSA infection (on his face no less) this year; I hope I never get one of those.