Mangled Care

Chapter 2

Chapter 2

Mrs. Joyce Tallman was a chronic headache sufferer. I had seen her, according to Giselle’s notes, about three years ago at the HMO.
“Oh, Dr. Stone, I was so happy to hear that I could see you again after I left that horrible HMO!”
I smiled and looked at her.
“So, Mrs. Tallman, what’s going on? How have you been?”
“Well, you remember you helped me get rid of my awful headaches. After I left the HMO, they came back. I’ve been to several doctors and nobody seems to be able to help me like you did.”
“Yes, well, as I recall, you did all the work. All I did was recommend some things for you to do.”
“You made me so much better! Can you do it again?”
“Well, I can try. Why don’t you tell me what’s gone on since I last saw you.”
Fifteen minutes later the diagnosis had become obvious. As obvious as the problems it would cause.
I asked Giselle to take Mrs. Tallman to the examination room and have her get into a gown.
After the ladies had left, I looked at my notes. I realized first that Mrs. Tallman should have been treated like a new patient, and had a regular 2 hour intake, or history, performed.
Secondly, her problem was iatrogenic in origin. That means the doctor did it.
Indeed, Mrs. Tallman had been seeing Dr. Katz, an older doctor, with a lot of clout in the medical community. I had met him several times, and encountered him on the phone when I worked at the HMO. On the phone, he was always calling to chew out a member of the medical staff. As Medical Director, it was my job to intercept those calls, if I could, and maintain the peace. He was correct, about half of the time I had spoken to him. The other times, he was just being obnoxious, trying to lord it over the physician drones at the HMO.
As was too often the case, as a doctor, he made a fine businessman. His practice, as he continually told everyone who would listen, was the most lucrative in the area. I have no problem with that. My problem was he obviously didn’t keep up with the medical literature. He was making sophomoric mistakes, the cynic in me felt, so that he could bill more money.
To treat Mrs. Tallman’s headaches, he had placed her on an absurd combination of drugs. Two different narcotics combined with several non-steroidal anti-inflammatories, all of which worked against Mrs. Tallman, by causing analgesic, or pain medicine induced rebound headache. This was caused by changes in the neurochemistry of the brain, which were being bombarded with pain medicines on a daily basis. According to Mrs. Tallman, she had been to see Dr. Katz once a month, regular as clockwork, to get new prescriptions for her medications.
I went in to examine Mrs. Tallman, with Giselle present as always. Her examination was neurologically normal, as I expected it would be. She had minimal signs of muscle spasm which would contribute to tension-type headache.
Her problem was her medications.
Upon her return to my office, I was still trying to decide the best way to broach the problem.
“Mrs. Tallman, the good news is that there is nothing neurologically wrong with you. Your headaches can be treated.”
I looked at her, expecting her to be happy.
She was.
“That’s wonderful, Dr. Stone. What should I do?”
“Well, we can stop the majority of your headaches by changing your medications. You are currently taking 8 to 10 percodan a day, which is a very strong narcotic. You are also taking Tylenol and codeine, 6 to 10 a day, ibuprofen 8 a day and you supplement all that with aspirin, up to 14 a day. You’ve been taking these medications like that for over a year. Am I correct?”
She looked at me, chewing on her lower lip for a moment. “Yes, that’s about right. But, you know I need that for my headaches. Dr. Katz told me that it was all right.”
Damn! I wanted to avoid that like the plague.
“I understand, Mrs. Tallman. However, if you want to get rid of your headaches, we will have to change your medications.”
“How will we do that?”
“The safest and most physiological method would be to put you in the hospital for three days, and give you intravenous medications to help stop the headache. I’ll also give you medication to help stop any signs of narcotic withdrawal. You’d just have to stop all your pain medications the night before we hospitalize you.
“That way, you should have very minimal discomfort. We’d then treat whatever headache problems you have left, once you are off the medications, here at the clinic.”
She looked stricken.
“Why do I have to stop my pain medications?”
“They are causing a separate type of headache called analgesic rebound headache, I told her. “Until we get rid of the medications, nothing we do will help your headaches.”
“Should I call Dr. Katz? He’s been giving me the medications.”
I shrugged. “Of course, you may do whatever you wish. All I am doing, all I can do, is make recommendations. Whether you choose to follow them is entirely up to you.”
“Well, I don’t know,” she said.
“I’d be happy to call Dr. Katz and explain to him what we have discussed,” I said.
“By the way, Mrs. Tallman, did Dr. Katz send you to see me?”
“No, I found out that you had left the HMO and decided to see you. I mean, you helped me so much before.”
She continued to chew on her lower lip.
“Well, those are my recommendations. Would you like us to arrange for your hospitalization?”
“I don’t know. I think I should talk to Dr. Katz first.”
“Mrs. Tallman, of course. I will also call him.”
“Do you think he’ll be mad at me for coming to see you?”
“Why would he be angry,” I asked her, “I’m sure he’s just interested in having your headaches stop.” As well as collecting a fee for seeing you every month to give you narcotic prescriptions, I added to myself.
“Look,” I continued, “Why don’t you think about it and call Giselle when you decide what you want to do.”
“OK, I’ll do that.”
She stood up and shook my extended hand.
“I hope I’ll see you again soon,” I said.
She left without another word.
Giselle said, “I have to take the new patient’s history. Ann will be with you until I’m done.”
“Fine,” I said. “See you in about an hour.”
I sat at my desk and looked disgustedly at the phone. I had to call Dr. Katz, sooner or later. I wanted to make it later, but I needed to settle the matter and dictate Mrs. Tallman’s consultation.
I looked up Dr. Katz’s phone number and dialed. His receptionist cracked her gum a couple of times after I asked to speak to the doctor.
“I’ll see if he’s free,” she said.
I held the phone and looked out my window at the traffic two stories below me.
“This is Dr. Katz. Who is this?”
“This is Jason Stone. One of your patients, Mrs. Joyce Tallman came to see this morning and I wanted to discuss my findings with you.”
Silence for a full minute.
“What’s the problem?” he asked, a bit cautiously I thought.
“It’s no big deal. As you know she has daily headache. Neurologically, she’s clean, no abnormalities on examination. Her main problem is analgesic rebound headache. I can deal with that easily.”
“How do you intend to do that?” he asked.
“I’ll hospitalize her for three days, beginning twelve hours after she stops her pain medications. She’ll receive intravenous medications to stop further rebound, and I’ll put her on medications to prevent her from feeling any symptoms of narcotic withdrawal.”
More silence from Dr. Katz.
“Then, I can deal with any problems with uncovered tension-type headache here at the clinic.
“There shouldn’t be any problems,” I finished.
“So,” Dr. Katz finally offered, “You want to stop her from taking her narcotics, huh.”
“No, I want to clear up the analgesic rebound headache. That involves the narcotics as well as the non-steroidal anti-inflammatory medications she’s taking.”
“You are new in practice, aren’t you,” he asked me, his voice accusatory.
“No, I was the Medical Director at the Big HMO for the last five years.”
“I mean you are new in private practice.”
“Yes, Sir, I am,” I told him.
“Then you should know better than to take away a patient’s pain medications, shouldn’t you?”
He was about to get me pretty pissed off.
“Actually, I know better than to over-prescribe narcotics. I also know how the brain works and what neurochemical dysfunctions the chronic use of narcotics as well as non-steroidals cause,” I told him.
“Are you sassing me, boy?”
“No, Sir, I am trying my best to have a discussion dealing with clinical issues, Dr. Katz.”
“Well, I’ve been a doctor for over twenty five years, and I’ve never heard of such a thing.”
“Dr. Katz, if you doubt what I am telling you, I’d be happy to fax you a copy of a paper I had published about the problem, last year, in the red pain journal.”
Silence again.
I didn’t want to play any more games with this joker, so I said, “I asked Mrs. Tallman to give you a call, Dr. Katz. You can feel free to discuss it with her.
“Good bye, doctor.”
I hung up the phone, angry at the way I had let him get to me. Damned idiot.
Well, either Mrs. Tallman would be back or she wouldn’t, and she would continue to get her narcotic supply filled monthly, along with a bill for an office visit.
It was her choice. She now had to make a decision as to which doctor to trust, Dr. Katz, who gives her pain medications, or me, who had helped her in the past, but who wanted to take her pain medications away.
To make things better for me on my first day in private practice, I had gone nose to nose with a big shot doctor.
Shit.
Ann came into the office and asked if I was ready to see the next patient. She is a physical therapy aide; the office was too new to have two nurses. I made it a practice never to meet with a patient alone. First, that way, there was someone else the patient could talk to about what was said. Secondly, I was never alone with a female patient.
That went back some years, to when I first started practice. I had a job with a doctor who was known as a specialist in pain. I worked for him for three months, until the day he entered my office and said, “God, Jason, I just got the best blow job from this patient!” I had placed my stethoscope on the desk and said, “OK, I’m out of here. When the crap hits the fan, I don’t intend to be here.” And I left my first paying job, with no place to go, and no source of income. Life wasn’t so good for a while, until I was able to re-establish myself.
Ethics were pretty important in medicine. I have never had a problem. I didn’t intend to ever have a problem like that. So I covered my ass. I would not allow myself to be alone with a female patient. Just in case one of them had a fit of imagination, creating a problem that was my word versus the poor female patient. Defensive medicine, to be sure.
I had a friend who was falsely accused by a female patient of fondling her during an examination. He almost lost his license. Locally, another doctor had been accused of propositioning a patient during a consultation. The price of a nurse or another office person being with me was a small price to pay for peace of mind.
I saw three more returning patients during the next hour or so. All expressed pleasure at being able to see me again. None had any major problems. It was a pleasant interlude.
Then Giselle came in with the history of the new patient, Mr. Tom Josephs. His PCP or primary care physician had referred Mr. Josephs from one of the smaller HMOs in town. We had to obtain special dispensation from the HMO to see him, as I was not a member of their panel. He was able to see me because he could prove that there were no pain specialists in his HMO, so they had to grant him the ability to see me, as they could not offer the necessary similar service.
As was my practice, I went over a summary of the patient’s old records, then the history he had given to Giselle, who used a fifteen page history form I had designed. When Mr. Josephs came in to the office, after we had greeted each other, I went over the history with him again.
I examined him and we then returned to the little round table.
“Well, Sir,” I began, “There are two problems. First, you have been taking 20 to 30 pain pills a day with fast acting barbiturates in them for over twenty years. That creates two problems. First is analgesic rebound headache.”
I explained it to him.
“Secondly, we have to use a hospital to safely take you off of the medicine.”
“Why is that, doc?” he asked.
“Narcotic withdrawal can be uncomfortable as hell, but not life threatening. Withdrawal from barbiturates can cause seizures and can be life threatening. You’ve been on enormous amounts of these medications for over two decades. We have to do this safely. I wouldn’t try it out of a hospital.”
He nodded to himself. “That’s essentially what my doctor at the HMO told me. I understand, and I want to do it.”
Mr. Josephs was a tall, lean man, in his late fifties, without a hint of pretension.
“Well, let’s do this,” I continued, “I’ll call Dr. Castro at the HMO, then we’ll have to get approval to hospitalize you and then treat you for your second problem.”
“What’s that?” he asked.
“You have a great deal of muscle spasm in your neck and shoulders. We need to do some work to get rid of these problems. By work, I mean some physical therapy and possibly biofeedback. The physical therapy will be used to break down the muscle spasm, and the biofeedback teaches you some ways to keep the muscles relaxed.
“We can do this as an outpatient here at the clinic after you get out of the hospital.”
“Well, that sounds mighty fine to me,” he said. “I want to get rid of these damn headaches.”
“No problem then, we’ll call for approvals and then let you know when we can get started.”
As soon as he had left my office I called Dr. Castro. After I introduced myself, I explained what I had found and what I wanted to do for her patients, Mr. Josephs.
“That’s what I had assumed,” Dr. Castro said. “I just inherited him and saw that he’d been taking the barbiturates for over twenty years. I hope you can help him.”
“I think he’ll be fine,” I told her. “I’ll have my office call for approval for the hospitalization and outpatient treatment.
“Also, thanks for sending him to see me.”
Dr. Castro laughed, a delightful female sound. “It’s my pleasure, Dr. Stone.”
“Jason, please,” I corrected her.
“Fine, Jason. You are welcome.”
“I’ll keep in touch regarding Mr. Joseph’s progress.”
“Great. Gotta go, a ton of patients to see,” Dr. Castro said.
“No problem. Thanks again.”
I hung up and thanked my lucky stars that doctors like Dr. Castro existed.
I looked at my patient list.
It was lunchtime
In honor of the offices’ opening, I had decided to have a pizza party in our conference room. By the time I got there, the pizza was almost gone. Sitting around the long rectangular table was my staff. I had a warm feeling of affection for them. They trusted me to give them a paycheck. I trusted them to deliver the finest in coordinated patient care.
I sat down at the head of the table and looked around me. I pounded on the table and said, “Ladies and germs, it’s a pleasure to share lunch with you all. Now will someone get me some pizza from down the other end of the table?”
Some laughter as the food got passed down to me.
“In the meantime, since some of you have worked with me before and some haven’t, why don’t we go around the room and have everyone introduce themselves.”
I motioned for Giselle, sitting next to me, to start. Giselle Stuart was a true find. She stood about five foot two and was willow slender. She was also smarter than the average nurse. She had quit the HMO to come with me, risking a weekly paycheck. I was really pleased that she had joined me, as I had spent a lot of time teaching her, and she knew more about pain and headache than the majority of physicians out there.
She introduced herself and explained how she had met me, and how her interests in chronic pain had grown. She said she was glad to be in the office.
Sitting next to her was Debra Jarvis, the physical therapist. Debra had also left the HMO to join me. She was an excellent therapist, one of the best I had ever worked with. She was also tough as nails and had a mouth that didn’t seem to know when to close itself. Debra was a blessing in disguise. I appreciated the clinical give and take I got from her. Unfortunately, many of the folk at the old HMO hadn’t been so pleased with her. That was their loss.
I listened with one ear to each of them speaking while I went over in my mind what I knew about the other folks working for me.
John Thomas, Ph.D. sat next to Debra. He was a neuropsychologist with the ego of a movie star. I had met John when I had brought him in on a consultation while I worked at the HMO. He was clinically excellent, but I didn’t think he had quite made up his mind as to where he stood regarding patients. Some psychologists look too much at test results and not enough at the patients themselves. Taking him on board was a possible mistake, but I hoped I could teach him how to best utilize his skills.
I had already told him, twice over drinks as we got to know each other, clinicians must treat patients, not test results. I wasn’t sure if he had begun to believe it yet.
The young, vivacious and certainly gorgeous woman sitting next to him was Susan Tunney, my receptionist, scheduler and so called secretary. I had hired her after interviewing a number of folk I found from an ad I had placed in the local paper. She was bubbly and seemed to have a warm feeling about the patients she dealt with on the phone and in person. In her younger twenties, Susan had a young son. She was a hard worker and seemed to want to get ahead. She had told me that she was taking a medical transcription course at night.
Across the table from Susan was Ann Smith, the physical therapy aid. Her job was to help Debra and, when she had time, help Susan. Ann was really laid back and seemingly nothing could bother her. She came from some place in California, and was the kind of woman who just seemed to ‘go with the flow’, and not allow herself to get upset by things. She dressed like a hippie from the sixties, but had the ability to put everyone with her at their ease.
George Hutt, the certified biofeedback therapist, sat next to Ann. George was a terrific guy and a fantastic find. He was a biofeedback therapist as well as a medical hypnotherapist and a computer maven. He liked being in the middle of ten things at once. As frenetic as he could appear, he could still teach the principles and practice of physical and mental relaxation to patients. A slightly overweight man on the wrong side of thirty-five, he was dying to get me into his office. He told me I needed to know how to relax, and I agreed with him. I just didn’t have the time.
Barbara “Babs” Tomero was the occupational therapist. She was a bit brawny, but that wasn’t noticed much after you got caught up in her smile. She was wonderful when dealing with patients with traumatic brain injury. She could help patients achieve mastery of the most basic things that their injury had taken away from them. The patients all loved her, as much for her sunny disposition as for her ability to make them work at achieving a goal that they had thought they couldn’t reach.
Kenesha Nichols was the other integral part of the traumatic brain injury treatment team. She was a speech and language pathologist, and as such would, according to the patients, torture them for hours at a time by teaching them how to reacquire attention and concentration as well as memory skills. A tall African American, her hair in dreadlocks, she joked about her Zulu background. It might have been funny until you saw the ferocious look on her face when a patient gave into the despair and feelings of helplessness and hopelessness that occurs when the brain stops being able to function normally. She was capable of bringing out the best work in her patients, who hated her and loved her at the same time. She was an incredible woman, and a hell of a therapist. She and Babs had both jumped ship from the HMO to my office.
Finally, sitting on my right was Tammy Sidel, Ph.D. Tammy didn’t work for me full time, at least not yet. She had her own private practice and was waiting to see how long it would take for me to give her a full time position. Until that time, Tammy was a consultant. She was one of the tiniest people I had ever met, at barely five feet in height and skinny as a rail. She was also a warm, caring, loving person, who made everyone feel at home with her, as if she was automatically his or her newest best friend. While careful not to cross any ethical boundaries, she achieved a close working relationship with her patients who then did their best to work towards a therapeutic goal to keep her approval. Best of all, they wanted to do it, as they felt that praise from Tammy was a hard won gift. She was one of the most effective clinical psychologists I had ever met. I was glad she wanted to work with my team. She made a wonderful addition to the group.
I focused my attention back to the team. I was gratified to see that the comradery they would need to work efficiently together was beginning to grow.
When it was my turn to speak again, I looked around the room at the members of my team. They were the instruments I needed to be able to provide the type of medical care my patients needed. I was pleased as hell that they were with me.
“All right, listen up! I have three things to say,” I told them.
“First, this is a big day for me, as you probably already know. I want to thank you all for being here with me and I look forward to working together and helping a lot of people.
“Secondly, I want to remind you that any difficulties you encounter need to come to me if you have problems dealing with them. My door is open to all of you, so make use of it.
“To make sure that we are all up to date, every Monday, prior to staffing meetings, we will have a little journal club, where one of you will present new information to the group about a topic in your field. I want everyone to know what everyone else is doing.
“Lastly, I want to say that we are going to kick some clinical ass! We will be the best at what we do, and I don’t doubt that for one moment.
“As you know, the patients we see are the hardest of all. They’ve been everywhere and done everything before showing up here. If it were easy, we wouldn’t have jobs.
“We will learn as much as we already know, and the patients will teach us as much as we can teach them.
“So, let’s get going! First staffing is next Monday.
“And, thanks again.”
They all filed out of the room, some patting me on the shoulder. Kenesha and Tammy kissed me on the cheek. I watched the last of the team leave the room and shook my head.
We were ready to deal with whatever problems the patients threw at us. We were good enough, experienced enough and, I hoped, tough enough to make it.
I was glad that I didn’t know what the afternoon had in store for me. I might have bolted and found an island somewhere to camp out on.