Tuesday, September 25, 2012

A Nurse Manager

I was sitting next to my gastroenterology clinic nurse reviewing a couple of patient phone calls and what they needed, so my assigned nurse could take care of them.  As we were finishing up the last patient contact, when in walked the clinic nurse manager, Kate. 
Kate leaned up against a desk close-by and waited for my clinic nurse and myself to finish our conversation over the last patient contact. Then she asked, “Sharon, what causes leg pain when I’m out walking my dog?”
I had a quizzical look on my face as I turned to face Kate.  “What do you mean by leg pain, Kate?”
Kate replied, “Well when I’m out walking my dog every morning and after I get home at night I’m able to walk about 3-4 blocks before I have to sit down somewhere and rest my legs, they become heavy and my lower legs just hurt.  I rub them which helps, and after a few minutes I’m able to stand back up and walk home at which time my legs hurt again.”
“Kate, that sounds like you could have some peripheral vascular disease.  What’s your family history, is there any cardiovascular disease in your family members?”
“Yeah, my younger brother is 53 and he’s had a heart attack, a subsequent surgery to have a quadruple bypass.  My dad died from a heart attack when he was 60.  My mom is in her 80’s and has congestive heart failure due to long standing hypertension (high blood pressure).”
“Okay, that’s a rather positive family history for cardiac disease.  When was the last time you had your lipids checked?”
“I haven’t had them checked.”
“Well, then I would make an appointment with your primary care provider pronto, let him know what your symptoms are, make sure to get your lipid levels drawn and ask him to send you to an interventional cardiologist who can assess your vascular structures in your legs, you’ll probably end up with having either stents placed or the cardiologist will do a balloon angioplasty based on how extensive your disease is.  The cardiologist will also send you to a cardiac rehab program so you can be involved in a supervised exercise program.”
“You think my problem with my legs is due to a lack of blood flow?”
“That’s what it sounds like.  I seem to also recall that you used to be a smoker and quit about 10 years ago, right?”
“Yeah, that’s right.”
“Well, that’s another risk factor for peripheral vascular disease.  So if I were you, go make that phone call to your primary care provider.  In the meanwhile, you can take a baby aspirin every day until you complete your work-up, that will help your platelets to not stick to each other.”
“Thanks for the info, Sharon.  I’ll start the aspirin today and go call my primary care provider.”
“Let me know what happens, Kate, good luck.”
“Sure thing.”

Peripheral vascular disease, is a disease of the lower limbs where they have atheroslerotic plaques within the blood vessels.  Peripheral vascular disease is very similar to coronary artery disease, where there is plaque formations in the coronary arteries.  As just like in the coronary arteries, which have plaque formations with patient’s having angina (chest pain) due to not enough blood flow being presented to the heart muscle, the same thing happens in the legs.  The plaque formations prevent an adequate amount of blood flow from getting to the legs/muscles.  When this happens patients end up with leg pain.
The risk factors for peripheral vascular disease include: 1) hypertension, 2) hypercholesterolemia (high levels of blood lipids or fats), 3) history of smoking, 4) diabetes.
Most patients also have a family history of cardiac disease, which Kate’s family had. 
Patients can present to their clinician with symptoms (as in Kate’s case) or be asymptomatic.  20-50% of patients will be asymptomatic, 40-50% of patients will have atypical leg pain, 10-35% will have classic claudication symptoms, and 1-2% will have critical limb ischemia (totally impaired lack of blood flow).    

I didn’t follow-up with Kate for several weeks, due to a busy clinic seeing patients.  One day in clinic I was sitting at my clinic nurse’s desk, signing some prescriptions for patients that needed to be faxed off.  Kate just happened to walk by my clinic nurse’s desk and I called out her name. 
“Kate, hey what happened about your leg pain?”
Kate turned around and seeing that there wasn’t anyone else in my clinic nurse’s office, she walked in and sat down. 
“Sharon, I saw my primary care physician a few days after we talked about a month ago.  He ordered my lipid panel and it came back with high levels, so I’m on 40 mgs of lipitor.  He also listened to what I had told you and immediately sent me off to the cardiologist over at the University who specializes in peripheral vascular disease.”
Kate continued, “I saw the University cardiologist, and he ordered an arteriogram of my lower legs.  They found quite a bit of atherosclerotic plaque in both legs.  So, as you probably know I was gone on Friday, that’s when the interventional cardiologist went in and did a balloon angioplasty on one of the lesions and put in a long stent into another lesion in my leg.  Both of the lesions were up in my femoral arteries.  I’m still a little sore from the procedure site today.  I’ve been referred to the cardiac rehab program and I’m supposed to start it later this week.  But the one good thing is that I’ve been walking my dog and my leg pain is gone.  So now every day I’m having to take two medications, the lipitor and cilostazol, which is supposed to help with my intermittent claudication.”
“Oh, Kate I’m so glad you got everything worked up.  Is your cardiologist going to order any additional testing on your heart, like looking at your coronory vessels to assess for plaque there?”
“Yes, I’m scheduled for that in about 3 weeks.  The cardiologist told me that he can only give me so much dye in one sitting, so that’s why he did my legs first, seeing that I was symptomatic from my legs.  He told me that I could have some plaque that needs to be taken care of in my coronary arteries, so I’m scheduled for a coronary CT calcium scan in about 3 weeks.  He told me that based on my test result, he may have to go in and do a coronary angioplasty on any plaque found there.”
“Well, I’m glad that you are getting everything taken care of.”
“Well, I owe you a big thank you, had you not told me what it was I would have just continued to ignore it.  It was a wake up call for me.  I knew my brother and dad had coronary heart disease, I just never thought I would have it.  I thought I was taking care of everything by quitting my cigarette smoking and keeping my blood pressure under control by keeping weight off and walking my dog every day.  So thanks.”
“You’re welcome.  Talk to you later, I have to get going, I’ve got some work to do back in my office.”

Prevalence of peripheral vascular disease increases with age.  For those over age 50 the prevalence is 2.5% in the general population, for those over age 60 the prevalence is 4.7%, and for those over age 70 the prevalence is 14.5%. 

A quick and easy way to determine whether a person has peripheral vascular disease is to do take a blood pressure reading of the patient’s ankle vs. their brachial artery.  The two systolic pressures are compared.  If the pressures are the same, i.e. comparison is 1 to 1, then this is considered a normal test.  If the pressures are different, i.e. less than 1 to 1, ankle systolic pressure less than the brachial pressure, <.9 then this is considered a positive test and the patient most likely has peripheral vascular disease.

Patients are treated for peripheral vascular disease based on how extensive the plaque formations are.  Type A formations usually show only a single formation.  Type B is multiple plaques.  Type C is multiple, long lesions.  Finally, Type D is lesions which are 20 cms or longer.  Based on the type of lesions patients have they receive either medical intervention (balloon angioplasty, stent placements) or surgical intervention (arterial bypass, i.e. some type Cs and all type Ds).  

Thursday, September 20, 2012

A "Skunk Whisperer"

Recently, I was doing some temporary locums work as a PA in an occupational medicine clinic.  This type of clinic is for employees who have been hurt on the job, and their employer sends them into be seen by us, for medical treatment.

I knocked on the exam room door and walked in to be greeted by a women in what looked to be a police uniform.  The patient’s name was Anita.  After introducing myself, I began asking her some questions as to what happened that brought her to our office. 

Anita replied, “I was retrieving a skunk this morning,  which had wandered into a guy’s kitchen.   In trying to remove the little critter, I snagged him with my long nosed skunk handler.   I then flung the skunk a short distance out the open back door, and into the guy’s back yard.  Using the long nosed handler allows the skunk to go airborne for a short distance.   So I aimed my fling for a pile of dead leaves where I knew the skunk would land and then wander away, like it should.  Well, the skunk landed in the pile of leaves, then  shook his head and slowly walked off.  The only problem was in my using the long nosed handler, my finger got caught in the hand gripper and now it hurts.  So I need you to take a look at it.”

All the while, Anita was telling me this, my eyes were getting wider and wider, and my jaw was beginning to drop.  My facial expression went from a quiet content, listening to a patient’s story, to one of ‘no way, did you just do that!”

“Ok, Anita, I’ve heard of ‘dog whisperers, horse whisperers,’ but never a ‘skunk whisperer.’  How many times have you been sprayed by them?”
“Never?  Like zilch, never?”
“That’s right.”
“How many times do you have to go out and deal with a skunk?”
“About 3-4 times a week.”
“And you’ve never been sprayed?”
“Okay, now I have to know, how do you manage that?”
“I just understand skunks.  I know what they’re going to do, and I use my long nosed handler in such a way that it doesn’t hurt the skunk and they can’t spray me.”
“Amazing!  I’ve now met my first ‘skunk whisperer.”

“Even my boss is amazed that I’ve never been sprayed.  Many of the other animal control officers get sprayed every once in a while, but not me.”
“You know you could open your own business and become the ‘skunk whisperer’ consultant.  There’s probably money in that somewhere.”
“Yeah, but I like working where I’m at right now.  So I don’t see a need to change anything.”
“Suit yourself.  Alright, well then, let me see your finger.”

Anita extended out her right hand and showed me her second finger which was by this time beginning to ooze some blood, close to her palm.  I cleaned the wound, and as it was small enough to only need some steri-strips on it, I applied them.  I then put a clean bandage on her finger.  The medical assistant gave Anita a tetanus vaccine because she couldn’t remember the last time she had received one.

“Alright, Anita, I want you to keep an eye on this minor wound, if it starts to swell up, turn red around the edges or drain excess fluid from it, get right back in here and let us take a look at it.  Also, if you start to run a fever, get back into us.  Otherwise, get into the shower starting tomorrow, take the outside bandage off, keep the two steri-strips on, let warm soap and water run over the area, pat it dry, put  some neosporin ointment on it and then put a clean band-aid on it.  The steri-strips will come off on their own in about 5-6 days, just let them.  This wound should be healed up in about a week, so we’ll see you then, just to make sure everything is fine.”

“Okay, thanks a lot.”
“You’re welcome.  Oh, and no more skunks for a little while, let your finger heal up before you use your long nosed skunk handler again.”
With that I went to go see the next patient who was waiting.