But No One Told me I am Diabetic, Doc!

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Hi. It’s Dr. Louella in a sombre mood today. I keep thinking about this patient I had today in chronic disease clinic; a young guy in his thirties.

No drama here. I started off with my usual verification of what the patient suffers with. I’ve been doing that a while now, since discovering that patients attend our clinics for years with only a vague idea of what they’re being treated for.

I don’t know if it’s a Trinidadian thing with the responses I receive but I’ve asked this question so many times that I’m no longer surprised…

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‘What are you suffering with sir/madame?’

Some patients get offended. They start to stammer that I am the doctor and therefore I should know. So I let them know it’s a big file (we use handwritten patient notes) and we would move a lot faster if they tell me rather than me having to go through all these notes.

Furthermore I remind them that they are the patient. It is their health and their responsibility to know what they are afflicted with.

‘So, would you like to tell me, sir/madame, what are you suffering with?’

There are other patients who begin everything with ‘they say’. For example that, ‘They say I have diabetes’. When I try to confirm that they mean that they have been diagnosed with diabetes, they respond consistently, ‘So they say’. So in my estimation, they are in huge denial!

Sometimes I would make a check in the notes only to find that they have had this said to them for five years or more. I let them know that ‘they’ say it only because it is true and it’s very important they learn to accept it and deal with it.

Then there are those patients who try to respond correctly but leave out diagnoses. When I check the notes there may be an additional diagnosis such as ischaemic heart disease or chronic kidney disease that they are clueless about and which they sometimes deny vehemently.

So then I need to backtrack to find out where that came from, if they were diagnosed at hospital or presumed to have the disorder or what. I need to know if a diagnosis is true or not to convey this to the patient sitting in front of me.

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Finally there are patients who give additional diagnoses to what are documented. Something may have happened since the last visit or more likely they had been suffering with some disorder and didn’t think it necessary to inform us.

Our patients attend several different doctors, clinics and institutions simultaneously. Very little official information is shared between these groups.

It is often up to the patient to let us know what is going on. To some of them it is a secret. Others forget or don’t think it relevant. Me, I grab up this stuff, because I want to know everything.

I use the diagnosis as a starting point to inform and educate the patient. It’s not that you maybe sometimes could probably have hypertension. You HAVE it and you need to deal with it. It’s not about a bunch of numbers but really debilitating complications that you could get but we are trying to prevent.

Getting back to the case at hand… When I had my usual discussion with this young man about his diagnoses today, I was a bit thrown. He knew he was overweight and had elevated cholesterol but knew nothing about having had diabetes.

But it was staring at me in his notes! He was newly diagnosed as a diabetic on the previous visit. Apparently he had not been told. Oops! That was a problem. And he seemed intelligent enough that he would have remembered.

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I proceeded to take the time to double check his blood investigations. Those results pointed to pre-diabetes, which as I explained to him, was in between ‘normal’ and ‘diabetic’. He was becoming diabetic. Steps had to be taken to try to prevent, or at least delay, full blown diabetes.

(The term ‘Impaired Glucose Tolerance’ is an older term that was and is still used for this condition. I much prefer the simpler ‘pre-diabetes’ when dealing with patients as ‘pre-‘ indicates ‘before’.)

While advising the patient about his condition, I needed to reassure him as well. He had been started on the appropriate medication (metformin). I actually increased his meds for now because his glucose level was high.

I advised him strongly about weight loss, that that in itself may reverse his condition and referred him to the dietitian (they make our life so much easier).

I spoke a lot about exercise because I know that if you’re not into it, it could take you a while to get started. I wanted to get him thinking that this thing was doable.

I threw out different ideas of different types of exercise he could attempt and explained how the day-to-day routine he described was physical activity but not intense enough to be classed as exercise. And he had the size to show for it.

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In the end he was really grateful for the information. But of course, other patients were waiting.

I really feel passionate about helping younger patients prevent and manage chronic diseases. That’s why I spend extra time with them.

It is often more difficult for them to come to terms with their illnesses than older adults. They want to enjoy their youth and do not want to be saddled with strict diets and medication.

I let them see that I take their health seriously and they should too. But I also try to inspire hope within them because without it they wouldn’t even try.

I will continue to ask patients the question ‘What are you suffering with’ or seek verification from the patient as to his/her diagnoses because it is important. It is only when people properly understand what is going on with them can they make informed decisions and live healthier lives.

I feel better now that I’ve shared that. I’d like to think I am making a difference in this world, one dot at a time. Dr. Louella is out!!!

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Once I Had a Naked Patient

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Hi. It’s Dr. Louella on a Saturday afternoon. I just remembered this doctor-patient story. It is a classic and I love to tell it.

I was at work in a rural health centre in deep south Trinidad. I had only worked in the community about two years then.

I was attending to patients, when the nurse called me, for some emergency I presumed. I started to grab my stethoscope. She said I wouldn’t be needing that but refused to say what the problem was.

Of course, I became suspicious, but not for long. As soon as I stepped out my door and unto the corridor I saw a naked female  in the waiting area.

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I looked again. Yes! There was a young woman in her forties of African descent butt naked, as they say, standing among the seated patients in the health centre!

So naturally I was shocked and disturbed and thinking, oh my God, what am I supposed to do? The doctor is always in charge, right?

The history was that of a mentally in female walking in off the streets without any clothes. The only real experience I had had with psychiatric patients was in medical school. Mentally ill patients were seen in a separate clinic at another centre.

Ok, so we had to do something. All the other patients were staring and it was causing quite a commotion.

All the clothes we had were on our back but nurse got a yellow surgical gown. It was a task to convince the patient to put it on but eventually she complied. What a relief! Remember, everyone was watching and listening and commenting.

We decided that she needed to be taken to hospital. We would call the ambulance but she had to be sedated first. Another task!

We got her to go with us into the treatment room. I had researched how much CPZ (chlorpromazine) to give. We used 100 mg and thankfully she fell off to sleep.

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She reached her destination but unfortunately it was said that she jumped out the ambulance and ran off into the town as soon as she did. I didn’t give enough CPZ! Hopefully she kept the gown on.

All that drama took a while but of course I had to resume seeing patients. I will never forget one of them, this elderly gentleman, smiling from ear to ear saying that he enjoyed the show. Dirty old man!

One has such amazing experiences as a doctor! Trouble is you are usually the one expected to fix the situation. I do it. With all the terror inside, I still do it.

Enjoy the rest of the day folks. This has been Dr. Louella down memory lane and back. Laterrrr!

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Ew! Sometimes It’s Yucky Being a Doctor!!!

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IMG-20140910-WA014Hi! It’s Dr Louella again on a cool Thursday evening (at least with the a/c on) here in our beautiful island of Trinidad. I want to recount this story from work because it definitely impacted me. It entailed basic medicine, yet it was quite unique and reminded of how unglamorous a doctor’s job often is.

This was about a week ago, in a clinic dedicated to children at the health centre. My morning had been busy, because there was an asthmatic emergency, along with routine cases and those without appointments.

The asthmatic was not settling down and needed transferral to the emergency centre. Securing an ambulance is not easy nowadays and we were relieved to get one and send her off.

There was a lull as clinic was almost over. I thought I’d grab a quick lunch in the kitchen.

Some nurse or other had tried to tell me about an adult patient they wanted seen, an amputee. Honestly, I did not pay much attention at the time because I was tired. But as I picked up my lunch bag I knew I would have to assess the situation before settling down so I went in search of the patient.

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She was easy to find. The female patient was seated on a wheelchair just outside the screening room. She was in fact a double amputee and had only two stumps without knees. She was flapping here arms up and down. One female relative beside her was panicking.

I identified myself and tried to bring some order to the situation. I enquired as to why they had brought her. There was a bit of rambling but from what I could decipher the elderly wheelchair-bound patient was well the day before but started shaking violently today.

Then I heard the word ‘fever.’ I was very glad that I did. I asked the nurse to include a temperature with the screening and explained to the relative that if she indeed had a fever then this would most likely be chills she was having.

Of course, she wanted to know why she would have a fever. I explained that a simple viral illness (or ‘the virus’ as we say it in Trinidad) could be the cause but when I attend to her I would be looking for a source of infection to make sure that is not the cause.

Whilst having lunch they gave me her temperature as 39 degrees Celsius. That was pretty high so she did have a fever. I ordered two Paracetamol (acetaminophen) for her and said I would see her shortly. I could not order a cold shower.

fever-thermometer-11947388While still eating I found out that this patient’s relatives had been trying to accost the ambulance attendants for our asthmatic patient to take their mother down to the emergency facility even before she had been seen by a doctor.

It seemed quite strange to me that they would behave so desperately. I was glad I had taken a little time to explain to them that it was most likely something minor.

I didn’t spend any extra time in the lunch room that day. But now I wish I had. I went to the office, called the patient and they wheeled her into my office.

The door was still open as they were positioning her wheelchair when she lurched forward in what I thought was a sneeze. Then I felt wet stuff on both my forearms. I flew out of my seat and sprinted to the wash basin about 5 feet away.

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I could not help it. I got into protect-me mode. I continued scrubbing my forearms intently until I felt clean again. I did not pay any attention to the patient and the relatives at this point. I had heard them mentioning something about vomit.

When I returned to my seat there it was. The old lady had vomited all over her clothes, the wheelchair handle, the wheel and the floor. They had a vomit bag for her. They had gotten it from the nurses when I was busy cleaning myself.

I quickly realized that I could not continue this consultation with things in this state. The wheelchair was rolling in vomit. I excused myself to find one of the cleaners.

Well I found them, but both cleaners were having their lunch in the kitchen. One asked me to relocate because they would not be coming right away. I had no choice. I could not talk to these people while staring at and smelling vomit.

(It is only when everything was over and I was recounting the events to some nurses later that they pointed out to me a few spots of vomitus on my pants. Of course I was disgusted and did a make-shift cleaning. I couldn’t wait to fling those filthy trousers to be washed.)

At the time I felt all clean, though. But I had to ask someone to leave a room for me to use it. A clerk was using one of the doctors’ offices as we are short of doctors this month so I borrowed that room and the relatives wheeled the patient over.

I understood from one daughter that it was whilst the patient was being bathed that morning that she began complaining of feeling cold and started to shake. The shaking grew worse as the day progressed. With the vomiting she was now convinced that it could be “the virus”.

The patient had had one leg amputated earlier this year and one three years prior. They were all properly healed and there were no signs of infection on the stumps. She was diabetic of course.

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Examination was otherwise normal, including the chest. I confirmed my presumptive diagnosis of a viral illness and gave her medication for vomiting (“Gravol” – dimenhydrinate), rehydration salts (Gesol) and more Paracetamol. I advised on increased fluid intake.

I was pleased with my management of the patient but I still felt a little shaken. It reminded me of other exposures I have had from one of the fattest needles ever going straight through my finger; to a needle stick injury with a confirmed HIV infected needle and my developing a fungal rash on the forehead from being kicked by a baby’s booty.

But what can I say? Every day is not the same. This one could not have been prevented but we take precautions whenever we can. Importantly, I was able to bring some assurance to this family.

I will bring you more interesting cases as I explain the some of the medicine behind it as well as the social aspects.

Life is still more than good. It is great and terrific and we must ever have gratitude that we live! Catch you later… Dr. Louella!!!

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Doctor advise us! This man’s blood pressure is very low!!!

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Hi. It’s Dr Louella. I had an awesome time dancing in church today. I promised to tell you about a sweet elderly gentleman in “Caring for others more than they care for themselves part II.” Well this is it, but with a different title.

The new title reflects how they bombarded me that day, as soon as I dropped my bags in my office. When I walked into the screening room last Wednesday, I was accosted by nurses.

They were sorry to disturb me so early but they wanted advice on an elderly man with a very low pressure. Now we hardly ever get patients with low blood pressure as a problem; unless they are in heart failure or it is from blood or fluid loss or a severe allergy.

This old timer was a regular, they said. He had been seen for low blood pressure before and had already been  referred to hospital. I looked at the BP. It was for real, 59/35. That’s quite low. I looked at the man. He looked terrible, really sunken in temples and cheeks. He looked like a homeless person.

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He was not out cold so he could speak. He complained of dizziness and some weakness. Said he was 72 years old. First thing that came to mind is if he had had breakfast. Yes he did, was the reply, after I had identified myself. He had had a coconut water. (Ok, so now I knew he did not have breakfast).The nurses had started giving him water to drink. I said, “Let’s get this man something to eat”. All we had were his crackers and my slice of chocolate cake (my lovely cake that I had baked from scratch and brought to have as a snack).

We moved him to the treatment room and gave him these things to eat. I proceeded to find out what his normal diet was like. Turns out he was married, his wife died and he lived with three subsequent women after that, all of whom had died. He has eleven children, who visit him from time to time but he lives alone. He drives his own vehicle.

He often neglected his meals now that there was no one to care for him and did not go through the trouble of preparing anything. He drank about quarter of a 1.5 litre water bottle a day. He sometimes felt weak when going to his garden.

So I was wrong about one thing. Here was no homeless person but a gentleman with the means to take care of himself but not the will to do so. I stressed the importance of regular meals and lots of water and asked if he wouldn’t mind a visit with our dietitian to advise him on meal planning.

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Water is needed for blood. It makes up about 50% of it. When we are dehydrated the blood volume decreases and there is less blood for the heart to pump so blood pressure drops. Eating helps the water to remain in the circulation by providing salt.

I explained that he found difficulty going to the garden because his muscles were weakened by old age and without eating and drinking he would feel much weaker. He was interested in avoiding that.

As soon as he had eaten the snacks he wanted to leave. I had to say “Slow down pappy. That food is not digested so it cannot benefit you as yet”. He himself admitted to still feeling somewhat ill.

I realised that with all this talk I did not do a physical exam on this man. When I did, I found him to have a bradycardia, an unusually slow heart rate. His was 48 while the normal heart beats between 60 and 100 beats per min.

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Here was another cause of a low blood pressure. I ordered an electrocardiogram (ECG or EKG), or heart tracing. It was normal except for a heart rate of 54. He was not on any medication.

I was now able to explain to him that his slow heart rate was most likely responsible for his low blood pressure. But this becomes exacerbated when he is dehydrated. Also when he does not eat, there is less salt to keep liquid in the circulation.

I explained that if his heart rate decreased further to the point where he could not support a decent blood pressure he would need a pacemaker inserted in his heart. He reacted strongly to that because in no way did he wish to go to hospital.

After a couple hours I felt pleased to see our elderly gentleman walking out of the centre, looking and feeling much improved, and with a blood pressure of 105/65. I’m sure that he would now be more empowered to manage such episodes. I’m also sure we’ll be seeing him again, if even for an update.

My next case will be what the doctor does when threatened by someone else’s body fluids. Does she save herself or play the brave doctor? My next post will tell. Bye for now! Dr Louella.

 

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Caring for Others More Than They Care for Themselves Part 1

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Hi folks. Dr Louella is back after a long break!!! I was busy getting married and settling into this new phase of my life (at this age).

I’ve always been looking for a new approach to this blog and I finally hit upon it. I plan to use my numerous unique patient experiences to teach about medicine, and by extension, life.

I have two interesting, touching cases to bring to you to demonstrate the title of this post and the medicine that goes along with it. The second case will be in the following post.

Now the part of medicine that I really enjoy is relating with the patients. I am different in this regard from many doctors I know. I take the time to find out about my patients and work with their situation. That’s one of the reasons why I am such a good family doctor.

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Just yesterday (Oct 6, 2015) we had a chronic disease clinic on work. Clinic was practically over when a nurse came to ask me to re-write an insulin prescription for a diabetic patient. She was an amputee. He husband had broken her insulin vial. He had also put her out of the house and she was staying with a cousin.

I was about to re-write it when she also revealed that the patient had missed her appointment and had come to get a new one. She was in the car.

Well, I thought that the only humane thing to me was for me to attend to her one time. But it was not that easy because this patient believed herself to be inappropriately dressed and refused to get out of the car.

To speed things up I said I would go outside and have a look at what she was wearing. I thought it was fine, a dress with a tube top, and reassured her.

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