Busy, busy week ...

... and I'm not talking about the demise of Farrah, Ed and Jack-o; or the 3 ring reality show circus of 'Jon and Kate'. Life has been busy this week for us "real folks".

1) "crazies" - a non-flattering term that I use for all my mental health patients who got kicked out of their psychiatrists' or psychologists' offices only to land on my doorstep. Primary Care has been become the dumping ground for bipolars, schizophrenics, demented seniors, sociopaths, drug-seekers and borderline personalities. People that have fallen through (or in most cases, shoved through) the cracks by society and mental health specialists. Some well-meaning, low-paid and under-appreciated county worker rallies to get them medical insurance through MedicAid or Medicare and then sets them loose. They ricochet through ER's and 72 hour holds in the psych ward until some social worker gives them a piece of paper that says "Follow up with a primary care provider for refills on your medications". I have no problem treating their medical issues but I am NOT a psychiatrist or psychologist - If I wanted to be one, I could have gone into a Psych residency and ended up making more money with better hours. But I didn't, and I'd rather pluck out my eyelashes and eyebrows and eat them than deal with their psych issues.

Sorry, got caught up in a rant there for a moment. Anyway, this week sucked because all my worst head-cases came in to see me in a matter of a few days.

Some even came in twice.

2) the kid is all right - Peter had a cold (parents, you know what I'm talking about); and is officially doing fine; in fact, better than fine! That's all I'll say about that.

3) hypochondria solved - the problem with being a diagnostician and a closet realist is that you are going to be slightly hypochondriacal. The worse situation for a hypochondriac is when you're right - you are sick or have a disease.

I'm going to be a little vague here on purpose, but I was having a little problem, so of course I thought the worst, so I had a test and let's just say I got my "B-9" card punched. Whew.

4) the in laws are coming - Actually, they're here. Laura's parents are renting an apartment in St. Paul for a few months. They're escaping the oppressive heat of southwest Florida but are mainly here to see, spoil and spend time with the sole heir to the Mill's dynasty.

There's a saying about guests and fish after 3 days, but I'm glad they're here. My father-in-law helped me shovel about a ton of sand for Peter's new sandbox:



They also can watch Peter for a few hours and Laura can get some stuff done (like golf lessons, yay!) and de-stress a little. For everyone knows, if momma ain't happy, then nobody ain't happy.

I wanna keep momma happy.


5) my new toy - Well I finally go my new iPhone and it's pretty cool. One of the neat things I've done is downloaded an app that serves as my stroke coach and GPS on the water when I row. Here's my row in a double with Bruce this morning all mapped out:


View Larger Map

You should be able to zoom in and out. The breaks in the blue lines show when we stopped for water breaks, etc (it was pretty humid and hot even at 6:45 am). We only rowed about 5 miles because I had to go to a 8am meeting.

This really isn't a bad thing, but it's been keeping me busy. And I have to go to bed early in order to get up at 5:55am to row.



So, life goes on ... for most of us (sorry, Farrah and Jack-o). I just have to keep on reminding myself to stop and smell the roses. Some of them are pretty damn sweet ...

Hmmmm ...

... why is summer so busy?

I think it has to do with the 15 hours of sunlight up here in the northern climes.

"What's in a name? A rose is a ..."

"... is a rose is a rose."

True. A rose flower would still smell as sweet but I doubt it'd be as popular with gardeners and florists is it was called "sweaty butt muncher".

So I'm looking for a fitting name for my boat.

It nameless now, but it's generally considered bad luck not to re-christen a boat when it becomes yours. I don't think there's an accepted time-frame, but I'm arbitrarily calling it a year.

The relationship of man (or woman) with a boat is symbiotic. There's a lot of give and take. Well, mostly 'give'. I bought the damn thing. I transported it across the country. I pay to have it stored at my club's boat house.

And I just bought it this snazzy cover so it won't get all dinged up and covered with dead insects when I precariously strap it to the top of my car:



As far as the 'take', well, as I use it more ... I'm becoming pretty fond of quietly gliding across a nice lake at 6:40 in the morning with no one else around.

(Especially when I run into a dock! Like I did this morning; don't worry - no damage to me or the nameless boat.)

So, I'm taking this naming/re-christening kind of seriously. I've always wanted to try to be appropriate and right on the mark with this kind of thing. Hell, they were almost wheeling us out of the maternity ward before Laura and I settled on "Peter". We were seriously thinking that "baby boy Cytrynowicz" sounded OK, but we were worried we were limiting his future career choices.

We took a long time to name our cars, but "Bob" the CRV and "Miles" the Mazda are so ingrained into our vernacular to the point that we forget when we talk about them to non-family members.

I could go with something profound or moving, but that's not my style. I could just call it "Owen" as that's the name of the manufacturer, but I'm having trouble committing to that - it's kind of lazy.

I'm also contemplating "Minnesota Fugue" - ripping off the name of this blog - but that's too wordy. Maybe just "Fugue".

I don't want some corny, pun-ny phrase like "Myassis Dragon". Or something stoic like "Endeavor" or "Fortitude". However, "Sanity" is looking kind of good now.

A friend of mine has suggested the "Flying Wasp" and I'm considering it as an homage to my youth and one of the funniest movies ever made.

I also don't want to get too personal, but the "Bowlegged Sculler" keeps on percolating to the top of the list. I broke my right ankle in college and as a result my right knee wants to flail out on the recovery when I get tired. It's a definite technique "no-no" but maybe my boat name will let others know that, yes, I do know how to scull, I'm just not that good at it sometimes, so shut your pie hole.

Any name suggestions? The boat is red (my boat club already has a "Red Beaver"). It's old (made in 1988). And, it's helping me keep fit and healthy, physically and mentally.

I'll consider all - just as long as it doesn't contain any of the these words in any order: sweaty, butt, muncher.

"Hi, I'm a PC ... but I'd like to be a Mac" ...

Apple had their annual WWDC meeting yesterday.

I think it was held in a secret lair on Steve Job's island in the South Pacific that is uncharted and home of an immense energy source that can make time travel possible. Wait ... sorry, that's LOST.

Anyway, they announced the new iPhone yesterday - the 3GS. And it's cheaper than the previous model for the same amount of memory with new bells and whistles.

I have to admit it - I have Mac-envy. Especially every time my PC crashes at work. I was an early Mac follower - in fact, this is what I used in the 'computer labs' (remember them?) in college:



I love my first generation iPhone and I'd buy a mac computer if they weren't so expensive and/or my work would reimburse me. As of now, we're a PC-compatible company - so I'm stuck being a wannabe.

But, I'm going to pre-order the new 3GS phone. It's been a few years since I had a technology fix and I'm jonesing a little bit.

Plus, I need the 3G network so I can use my phone as a GPS on land and when I row - check out this app that I'm thinking of buying. It's a little spendy (as they say here in MN) but it's cheap compared to the real stroke coaches.

Hmm ... maybe I should learn how to row better before I worry about how fast and how far I'm going ...

"Ok, you're ugly too..."

... As a primary care doc, I see a myriad of ailments and complaints from a variety of people who are all shapes and sizes from all walks of life.

But there are a few common threads, observations, demands that pop up enough from my patients that merit some translation through my "Doc, what I'm really saying" translator (coming sooon as an app for your iPhone :)).

What they say: "I'm having trouble losing weight and I'm tired all the time, I'd like to have my thyroid checked out."
What it means: It usually comes from the 30 to 50 year old female wearing too much eyeliner and clothes that are 2 sizes too small - screaming kids are optional. They have a knock-off handbag that is filled with mentos and a 2 liter bottle of Mountain Dew. What she means is "I haven't exercised in years; I still eat like I did when I was a teenager; I like to drink and smoke .. alot. I'm starting to get fat and lonely and I want an easy solution that doesn't require any real work." Trust me, it's not your thyroid. Put down the twinkie and go for a walk.

What they say: "Your nurse said my temperature is 98 degrees; that's a fever to me because my temperature is usually 95 degrees."
What they mean: This usually comes from the mid 30's to mid 60's professional or soccer mom who looks pissed that they have to take a break from their busy day to see the doctor. They're not really that sick, but it usually means "This virus is annoying and disrupting my already too-hectic life. Write a prescription for an antibiotic, you little twit, so that mentally I'll feel better through the placebo effect. And no, I don't give a crap about causing community-resistance to common bacteria, I've got shit to do." Relax, take a day off of work, put your cell phone in a drawer, sit on the couch and eat chicken noodle soup and watch cartoons - the world and it's problems will still be there tomorrow. Yes, I will also validate your assertion, that because your "temperature is normally 95 degrees", you are unique and special.

What they say: "Tylenol and Ibuprofen don't seem to work for me."
What they mean: The patient will have some sort of pain complaint - twisted ankle, migraine headache and the classic, non-specific lower back pain. He or she is wincing and groaning and being incredibly histrionic - Emergency Room patient identification bracelet optional. Ocasionally will have rotten teeth and may actually be actively 'tweaking'. Their body language is screaming, "Give me oxycodone, hydrocodone, hydromorphone, morphine, tramadol, valium, horse tranquilizers, those frogs that you lick from the amazon-freekin-rainforest - anything that will get me high as a kite so I can get away from my miserable life for 10 minutes." I used to be sympathetic. Now, It just makes me sad.

What they say: "What? Hop along marietta beaver?"
What they mean: This is an elderly couple, usually in their 80's to 90's. She is deaf but refuses to wear hearing aids. He is pleasant but has dementia and always wears a baseball cap too high on his forehead. They are usually being seen for vague symptoms like fatigue, lightheadedness, insomnia and achey joints. This is usually the response to when I ask "How long have you had a fever?" What they really are saying is "We're old and tired and in pain. We want someone to listen to us and take us seriously. We know we're coasting into the 'beyond' but we want to enjoy the trip and remember the ride. Thanks for listening." Besides tweeking (not 'tweaking') their medications a little bit, that's all I usually do and it's that all they usually want.


Avoid saying any of the above and your doc may take you seriously the next time you're seen. Oh, never ask me for a 2nd opinion as you'll get the response (I can't help it) that's in the title ...

Like a (bad) rower to water ...

... I'm back on the Mississippi in the morning.

I'm going out with Bruce and Jim in doubles at 630am, sandwiched between the competitive team and the junior team. I didn't realize how much I missed it.

However, I'm ... sore.

It seems like the flexibility and the core strength that I built up all winter by going to the Y in the dark and frigid Minnesota mornings vanished in the 2 months of relative inactivity since my trip back east. Damn you, exercise physiology!

See you on the water, I'll be the guy in the annoying tshirt that's sweating twice as much as anybody else ...

MI's and Nursemaid elbows ...

... "So, Mr. Johnson, how's the chest pain, now?"

"Better, buckshot, better".

He was still ashen. I glanced over at the blood pressure monitor and it read 90/54. That's not too good. It was 130/80 before we gave him the sublingual nitroglyerin.

I looked at his EKG tracing that the lab tech just handed me. Something wasn't right. I couldn't put my finger on it but he definitely was NOT having an acute inferior or lateral wall myocardial infarction. There were no "tombstones" in the limb leads and V2-V6 looked normal as well.

Mr Johnson looked up at me and forced a wan smile. "Better, bucksot".

I smiled back. I don't know why he had chosen 'buckshot' as my nickname but it was congenial and sincere and seemed to make him feel better.

I felt my phone vibrate in my front pants pocket. I removed it and saw that Laura was calling me from her mobile. While I'll let other family members and friends go to voicemail, I always answer when she calls.

"Hey," I said as I turned my back on Mr. Johnson and the ekg tech and the RN who was getting a repeat BP reading, "Can I call you back in, oh, 10 minutes?"

Instead of the usual "sure thing, babe", Laura replied "Actually, no - Peter hurt his wrist or elbow somehow."

I started to feel as ashen as Mr. Johnson.

"Whaddya mean? did he fall? Is he bleeding, is he all right?". I gave the RN and Mr. Johnson a 'just a minute' index finger wave and stepped outside the surgical room.

I felt sick. My stomach was hollow, like when you take the first drop on a roller coaster.

Laura was talking quickly. "I have an appointment at the Saint Paul clinic at 11," it was 9:15am, "we are at art class and I was sitting on the floor and he came up behind me to give me a hug and he started to fall and he grabbed on to me but he jerked a little. He screamed but instead of shrugging it off after a few minutes, he's still whining and holding his arm funny. You know that's not like him."

My mind raced. Differntial diagnoses cycled through my mind. Fracture, dislocation, muscle or tendon tear. Thoughts grew deeper - Pathological fracture due to a carcinoma?

The RN came out into the hallway.

"Um, Dr. C, his BP is dropping - it's 80/40. We need you."

Shit. I have to triage, fast.

To the nurse - "ok". To Laura - "Um ... I'd take him to the ER; if there is a fracture or something, then they can do more than they can do at the clinic."

"Really?" pause. "OK."

I was worried about Peter but I knew that Laura's maternal instincts were kicking into overdrive. Mamma bear was going to take care of baby bear, no matter what. I trusted her to do the right thing.

"Love you," we said simultaneously.

Click. I slipped my phone back into my pocket.

I went back to Mr. Johnson's room. Still ashen, still hypotensive.

I picked up the EKG tracing again. I couldn't give him any more nitroglycerin with his blood pressure that low. He was defintely having a heart attack by clincal presentation, but the EKG wasn't telling me where.

Wait. V1 looked funny. The 'R' and 'S' spikes were reversed. That's it, he was having a posterior wall infarction.

It's rare type of heart attack that usually is fairly harmless as far as heart damage goes ... unless your right coronary artery is dominant or is the main supplier of blood to the back wall of the heart. Then it could be fatal because doctors do what I just did - treating it like a "normal heart attack". Instead of pushing fluids, I gave him nitroglycerin, causing his blood pressure to bottom out because his left ventricle fails to fill in time with blood - this makes the posterior wall becomes floppy and ineffective. The blood pressure continues to drop and the ventricle fibrillates and stops.

He needs fluids. Now.

I grabbed a liter of saline from the medicine closet and handed to the RN. "We need to hang this. Open it wide".

She was wide-eyed. "But he'll go into heart failure. Shouldn't we start a pressor like dopamine?"

I had to put on my 'hard-ass doctor look' I save for just the occasion. "No," pause for emphasis, "that will kill him. Hang the fluid."

She did. Within 10 minutes, the nitro had worn off and over half a liter was infused into Mr. Johnson's circulatory sysytem. His blood pressure had climbed to 97/60. He went from ashen to pale and he had stopped clutching his chest.

"Let's call 911 and get him to the ER with a stat Cardiology consult." He was doing better but wasn't out of the woods.

"What going on, buckshot?" Mr. Johnson looked a little worried.

"You were having a heart attack but it's going to be ok. We figured it out and stopped it from getting worse ... for now. We have to get you to the hospital to get is all settled down."

"I had faith in you, buckshot. Thank you." He was holding my hand firmly but gently. "Let my wife know what's going on - she'll like you, you're a handsome devil, buckshot."

"You're welcome, Mr. Johnson." Sometimes, I like my job.

I had to go back to my regular schedule of various ailments and personalities. Mrs. Franklin was getting a chest xray to rule out a possible pneumonina and Ms. Rodriguez was waiting in my other exam room - she thinks she has bugs in her rectum - last week it was people breaking into her apartment to rearrange her furniture. All the appointments were full for the rest of the morning.

Finally, at lunch I had time to plop down into my office chair and catch my breath. The RN from earlier poked her head in. "Just thought you'd want to know. Mr. Johnson had a 95% occlused right coronary artery. They were able to angioplasty and stent him open. The wife just called from the hospital, he's doing fine."

Yep, sometimes, things work out okay.

Then I had the sudden realization - "Shit!" - as I remembered Peter and Laura.

Laura picked up her mobile on the 2nd ring. I could hear Peter playing in the background.

"So? How is he?"

"He's great. He had a ... nursemaid's elbow? I think that's what it's called. Anyway, the people at Children's ER were great. He was seen by a Nurse Practicioner and a resident; the NP just popped the elbow back into place and He's been fine since. He yelped a little, but I go him ice cream on the way home. He's playing on the cube since we got home and is no worse for wear."

I was relieved. It's a relatively common injury in toddlers and with Peter being as active as he is, I'm not surprised. He'll be fine.

I'll be fine. Laura hung up and I got back to my charts.

Barely a minute later another one of the RN's poked her head into my office.

"Dr. C - we have another walk-in chest pain. She doesn't look too good."

I grabbed my stethoscope, took a swig of diet coke and raced down the hall ...