Residency was a difficult time for most young physicians.  But it was also a time that my family grew.  We got a dog named Murray.  He is a Shih Tzu that is 10 pounds with a Mo-Hawk.  He was named after a character from a television show on HBO called Flight of the Concords. 

In between long days of seeing patients Murray was always there to greet me at the door upon arrival home.  He never complained how much I worked and was always ready to cuddle.  We took long walks which were part of my attempt at preventing burnout. 

Since I have completed residency and I have now been an attending for over 12 years.  Murray has been here with me for many years.  I have learned about many medical conditions and illnesses.  Day after day treating humans does not always prepare one for the illnesses that may also happen to your animals.

Murray is 14 years old now.  His hearing and sight have diminished but the hardest part is seeing his spark dim.  He has been getting lost in our house.  He has forgotten how to get in and out of our home.  He does not even want to go for walks anymore.  I think he recognizes my smell and voice, but I am not sure.  He appears confused and I think he has dementia.

I have treated many patients with dementia but never an animal.  He did not get an MRI of his brain.  I did not do a Doggie Mini-Mental Status Exam.  He has not been prescribed Aricept or Namena.  But I know his memory is leaving his cute little body.  Just earlier today he got lost in the house he has lived for many years. 

Doggie Dementia is a real disease but it is actually called Canine Cognitive Disorder.  Canine Cognitive Disorder,  also know as Doggie Dementia presents with anxiety, failure to remember routines, decreased desire to play, confusion and dogs wandering aimlessly.  Murry has CCD.  Vets do tests to rule out other conditions and at times, actually do MRIs of dog’s brains. 

Some dogs are treated with Anipryl (generic selegiline) which in the human world we use to treat Parkinson’s.  But not for Murray.  I will carry him outside.  I will retrieve him from the corner and put him back in his bed if he gets lost.  I will continue to talk to him hoping that he recognizes my voice.  Murray is not the same dog that he was when he was a puppy, but he is still loved.  He may not have his memory, but he still has his Mo-Hawk. 

Not everyone has a favorite type of white blood cell, but I sure do.  Eosinophils have always been my favorite.  If I see them elevated on the differential, I am usually less worried than when there are other elevations in different types of white blood cells.  Neutrophils worry me about a significant infection and lymphocytes are even worse. 

Eosinophils help in many ways from trapping substances, killing cells, bactericidal activity and even anti-parasitic activity.  But usually, it just means that you are a highly allergic person.  Often these patients have 1 or all of the allergic triad.  The allergic triad consists of allergic rhinitis, asthma and atopic dermatitis.

I have had allergies for years and so I realize that my bone marrow is working hard right now making eosinophils.  Runny noses, sneezing, scratchy throat, itching eyes and post-nasal drip are all symptoms that may be coming from these eosinophils.  I cannot even spend time with someone that has cats due to my allergies.  They set my eosinophils on fire.  I once had to end a relationship with a girlfriend (that had a cat) over allergy issues. 

Asthma is a common respiratory condition that can be associated with eosinophils.  Asthma causes inflammation and bronchoconstriction in airways.  There are some new medicines that specifically treat allergic asthma.  These patients often have to get their IgE levels checked.  This is a way of checking your immunoglobulin levels associated with eosinophils.  Attacking the eosinophils has lead to big changes for some patients with asthma. 

Ivermectin has become an infamous medication over the past few months.  But it has been used in the past to treat certain parasites.  Both strongyloidiasis and river blindness are treated with ivermectin.  Why is this relevant?  Because parasites cause eosinophils to rise. 

But now we are seeing more eosinophilic esophagitis.  This is a condition that was first diagnosed in the 1980s.  This causes esophageal impaction, abdominal pain and even food refusal at times.  This has been diagnosed more and more over the past few years.  Patients with this condition often have food allergies that lead to this food impaction and gastrointestinal symptoms.  These classic symptoms along with more than 15 eosinophils per high power field is how the diagnosis is made. 

Now that I have thought about all the issues that are associated with eosinophils, I am going to rethink my favorite type of white blood cells.  Maybe it is time for me to move my love to monocytes.  But if not for eosinophils and the reaction I had to cats maybe I would not have met my wife.  Which lead to me having my children.  This is a thank you to my eosinophils.  If they were not as responsive in my life who knows where I would be in life.  Thank you Eosinophils. 

The Doc is In

I spend my days running from room to room seeing patients.  My weekends chasing my children.  While trying to sneak in time to exercise and improve my health.  And also time punishing my body with chips and occasional IPAs.

But you never see the change in your joints coming and then it is there.  I took a step.  Felt a shearing force in my knee.  I was not jumping or hurdling but something funny happened.  I continue my day and pretend that I am fine. 

Then the next day walking to a patient room I feel my knee give out.  Luckily my peripheral nerves, cerebellum and my vestibular center are still intact.  I do not fall.  Immediately I feel a click and realize that this joint is now swollen. Fluid pushing posteriorly.  There is no Baker’s cyst but I am sure that I have an effusion.

There is not pain but I realize that my knee has failed me.  I do not have my partner prescribe me Percocet.  I do not stop working.  I push through because that is what we are taught to do.  I ice my knee and use the occasional ibuprofen.  It is now 2 weeks later and I have still not had it examined.  I have been ignoring and hoping it will go away. 

I often am surprised when patients are not able to explain their pain.  I give them descriptive options if they cannot come up with a description on their own – sharp, achy, lancinating, burning, throbbing, crushing, gnawing, tingling, dull and more.  Yet I cannot even describe how my own knee feels.  It is not pain but discomfort.  Yet discomfort is a type of pain.  It feels tight.  I cannot feel tearing along my tibial plateau.  I cannot tell if it is patella vs medial. 

I worry that I have torn my meniscus.  I am a trained physician.  Yet all I can think about is how my body has failed me.  Will it heal on its own?  When do I get an MRI?  Will I ever play basketball again?  Should my weekend runs come to an end?  Was this an acute tear or degenerative?  Could I be that old that I have a degenerative meniscal tear?  I have started some PT and hope everyday that the effusion will have disappear.  But it has not. 

But if a patient came in with this complaint it would be a simple visit.  I could get a history, examine and create a plan in a few minutes.  I would ask the patient if they had any questions, while hoping the answer was no.  But I am the patient.  And it feels so different and yet it is not even a scary medical issue that I am dealing with.

If I feel this way, I cannot imagine how patients feel.  I realize I need patients to ask me more questions because they have them.  They have concerns and fears.  As do I.  Now that I have finished writing about my fears maybe it is time for me to see a doctor. 

The Doc Is In

Silly Rabbit. Trix are for kids. Growing up this was a cereal commercial.  It reminded us that this highly sugary cereal was meant for children.  Not a cereal for adults or rabbits, but kids.  Now the most common question I am getting is “Hey doc should my kids get a covid vaccine?”  Silly parents.  Vaccines are for kids. 

I think the best way to start the discussion about children getting vaccinated for covid is by realizing that it is normal for parents to be reluctant.  I think having a conversation about their concerns is a good place for us to get started. 

The Pfizer vaccine has now been approved for children aged 12-16 and it does look like the Moderna vaccine will be approved in the near future. 

Did the vaccine come out too quickly?  The answer to this question is both yes and no.  First I want to point out that the pandemic changed everyone’s lives including virologists, researchers and pharmaceutical companies.  Basically all of the scientists ever involved in vaccines stopped what they were doing to work on a vaccine.  The technology behind mRNA has been around for a while. 

What long term outcomes could happen from the vaccine?  Most vaccine issues happen within the first 42 days.  These vaccines do create quite an immune response but that happens right away.  At this point with adults, we have data almost a year out since the vaccine trials started in adults last summer.  We do not have many examples ever in the past of vaccines not causing immediate issues but then leading to long term negative outcomes. 

What did the kids trials show?  I think parents want real information.  So here it is.  They studied around 3,000 children aged 12-15 for over three months.  Of those that got the vaccine zero were infected with covid by the end of the trial.  And 18 in the placebo trial did get infected with covid.  Also those that were vaccinated were found to have strong immunity a month after the second dose. 

Could my child have side effects?  They can absolutely get an immune response.  Vaccines are not benign, but they can be life saving.  Side effects include redness, arm pain and achiness.  The rate of side effects in the children’s studies were the same as what has been found in adults.

But kids do not really get that sick?  This is true.  But there have been 130.000 hospitalizations in those under 18 in the past year.  I have taken care of many children that had covid.  None of them were critically ill.  But they got their parents sick.  They had to quarantine while they recovered.  There are many pockets of outbreaks from adolescents.  There is also a rare chance that children can develop Multisystem Inflammatory Syndrome in Children after getting COVID-19 infection. 

The world now has given almost 2 billion doses of covid vaccines.  Not all to children.  But at this time it is not experimental.  It is not new.  It is saving the world from a pandemic that would have gone on for many years without vaccines. 

I love well checks for children.  I get an update on what foods they like.  How much weight they have gained.  Whether or not they slept through the night.  I hold them and try to remember when my children were still that little.  Then I give them shots.  Lots of vaccines. At 2 months and 4 months and 6 months and 1 year and more.  Because as I said earlier – Silly parents.  Vaccines are for kids.  But on second thought we probably shouldn’t give Trix to kids. 

The Doc is In

Sometimes you can hear a “yelp” even before you enter a room.  You can hear them a few rooms away.  It may be kidney stones, a slipped disc or the gout.  This was the yelping I was ready for when I entered medical school.  Bringing a calm presence to the room so that I can evaluate and develop a plan.  Making sure that patients know we will have a plan to help decrease the acute pain that is providing a “yelp.”

But this is not the yelp that physicians now deal with.  Yelp is a public business founded in 2004 that publishes crowd-sourced reviews about businesses.  This has led to many different companies developing websites where patients can go to document both the good and bad about their physician experiences.  You can go to Health Grades or Vitals and basically write whatever you would like about your experience.

Who uses these apps?  Mostly 2 types of people.  Those that are appreciative of the care or super critical.  It seems that some people as a hobby enjoy pointing out everything that went wrong.  I feel worse for restaurants and hotels, but they are not quite as personal.  If you ever are feeling great about yourself take some time and google your name.  Every displeased patient has put to keyboard your deficiencies.  I use this as a time to fight back.

This is my time to push back on the things that are written about myself and others on the internet.  I am absolutely trying to improve as a physician. And I need constructive criticism but the amount of yelping is getting out of control.  Especially if you use this time to comment on physician’s physical appearance.  Yes.  I realize that since the pandemic started that I have not gotten a haircut.  And yes, I realize that I have a ponytail at this time but that does not affect the care given.  Please stop discussing my hair on the internet. 

Pain medicine.  There are debates about chronic pain medicine.  Currently my office has decided to not treat chronic pain with opiates.  There are pain management doctors that we can help with trying to control chronic pain.  Yet the most common complaint being yelped about is that the doctor allowed me to be in pain.  I first always try to acknowledge the experience pain patients are in and come up with a plan to try and overall reduce pain and functioning.  But it is time to stop yelping about doctors not giving the controlled medicines you ask for.

Wait times.  I get to work early.  Every physician is only one patient away from being behind.  Many patients come in with lists and then wonder why their appointment is not happening right on time.  Just an FYI for patients.  I got here early.  All of you are the reason that then I am running late.  I rarely turn away a patient for being late and it is time to stop posting about how long you waited to see me.

The honest truth is that most patients are writing very nice things on the internet.  But human nature makes us focus on the few negative things written.  I really try not to read all of them but I am human.  I have googled myself and my reviews.  I encourage the rest of you to try your best to avoid reading the reviews sent our way.  Also, I wish my mother and my aunt would stop googling my reviews.  My mom loves to tell me she read about how great my bedside manner is on the internet.  Also she asks me what my plan is to stay on time throughout the day.  After reading the internet my aunt and mother had been discussing ideas on how I could better stay on time.  Thanks yelp.  Thanks for nothing. 

The Doc is In