Bryson City Tales — Lessons in Daily Practice (Part 3)

This is from the fourteenth chapter from my best-selling book, Bryson City Tales. I hope that you’ll enjoy going back to Bryson City with me each week, and that if you do, you’ll be sure to invite your friends and family to join us.

Screen Shot 2016-03-13 at 3.12.40 PM

LESSONS IN DAILY PRACTICE (PART 3)

The office calls during my first year in practice continually gave me a chance both to teach and to be taught.

Ray approached me in the hall one afternoon about a patient with a skin problem—chronic urticaria, which is doctor-talk for hives. Ray had done the extensive laboratory tests recommended by an Asheville dermatologist he had called—and the lab tests were entirely normal. The medications he’d prescribed had either caused side effects or had had no effect. He and the patient were frustrated, and he was considering sending the fellow off for further treatment. But before doing so, he asked for a second opinion.

I wasn’t sure I had a single thing to offer, but I did see the patient and spent some time taking an elaborate history—just like a detective looking for the perpetrator. But none was found. For some reason, toward the end of the interview, I remembered Terry Kane, M.D., my chief while I was in training at Duke University, who used to say, “You can take all the history you want, but when all is said and done, you gotta take their clothes off and look!”

Although the young man was already clad in his briefs, and although his skin, hair, and nails appeared normal, I had him pull down first his briefs and then his socks. And there, underneath the socks that had never been removed before, at least in our office, was a rip-roaring case of tinea pedis and onychomycosis— doctor-talk for athlete’s foot and athlete’s toenails. Ray and I exchanged knowing glances. We both realized, instantly, that this was a likely cause for the hives, since a fungal infection of the skin can result in recurrent hives in a susceptible person.

“Jim, you ever notice this rash before?” I asked.

“Oh yeah, Doc. Been there off and on most of my life.”

I took an ophthalmoscope off the wall and turned it on. The ophthalmoscope is designed to help a doctor look into the eye—especially at the retina. However, because its light is bright and because it magnifies the view manyfold, it can be an excellent tool for examining the skin.

“Yep,” I commented. “I thought so.”

“What is it, Doc?” asked a now worried Jim.

“Infection looks deep, Jim. I’m suspecting it and the hives are connected. Tell you what, if you’re willing to take a little pill four times a day for the next three months, I believe we might just whip this thing.”

“Don’t know if I can remember.”

“Don’t worry about it, Jim. You just have your lovely wife, Elaine, do the remembering for you.”

He smiled, “That she can do, Doc. That she can do.”

That wasn’t the last time that day I used the ophthalmoscope trick. In fact, the next patient was a little girl who had suffered an insect bite on her wrist while working in the garden the pre- vious weekend. The girl’s severe pain caused her mom to bring the little one to the emergency department twice—each time for an injection for pain.

To the naked eye, the skin looked almost normal, except for a small red line. However, under ophthalmoscopic magnification I could see two tiny parallel rows of red raised lesions—almost like two dotted lines lying together like a railroad track. I knew instantly what it was—a classic case of “caterpillar dermatitis.” Once I knew what it was, treating the pain required merely removing the tiny toxin-containing stingers embedded in the lit- tle girl’s skin.

I had Gay get me a piece of ordinary Scotch tape. As the mom gently held her daughter’s arm in place, I stuck the tape to the lesions, rubbing the tape onto the skin. Then I carefully removed the tape, which had all of the little caterpillar hairs stuck to it. The pain relief for my little patient was almost immediate.

This is one of those treatments that always makes the doctor look wise—instantly. I, for one, was glad that the tape worked in this prickly situation.

One of the lifelong joys of family practice is that we family physicians can fill in our basic training with a day-to-day training that continues for the rest of our professional lives. For instance, one morning a six-year-old patient who had shingles came to the office for a follow-up. I had done the original exam and had made the diagnosis, even before the rash broke out. Today the mother and child were seeing Mitch for the follow-up. Apparently the mother had told him about my “hitting the nail on the head by using the Kleenex test.”

A few days earlier she’d brought in her child, who was complaining of having “funny-feeling skin” that felt like it was burn- ing, even though there was no rash whatsoever. I had learned the Kleenex test from cardiologist E. Harvey Estes during my residency. All the doctor had to do was gently pull a tissue, hanging loosely from his or her fingers, over the affected skin. If the sensation was painful to the patient, it served to predict the characteristic shingles rash that would follow. Mitch had never heard of such a thing and continued to brag about my lesson all afternoon. I, of course, was elated to be the one who earned his praise.

Toward the end of the day he had a chance to return the favor. A lumberman came in for a last-minute visit to have his hand sewed together with Dr. Mitchell’s “cut glue.” I examined the man’s hands and fingers, which were thickly calloused from his daily labor. It was not unusual, he said, for these calluses to crack open at the beginning of autumn when the air became cooler and drier. Needless to say, these cracks, as they tried to scab and then were broken open again and again, resulted in a fair amount of pain. The problem was apparent, but I had no idea what he meant by the “cut glue” treatment.

I left the room to find the maestro. “Walt,” explained Mitch, “this is a fairly recent trick of mine. You just fill the cracks with Super Glue.”

“Super Glue?” I half-asked and half-repeated—with more than a trace of doubt in my voice.

“Yep. Although application of the glue will sting like the dickens for a few minutes, the stinging stops quickly and the wound seems to heal faster than on its own. Not only will the Super Glue hold the cracks shut, it’s the only ‘bandage’ I’ve found that will stick to a sweaty palm. Then you just have the patient use a file or a pumice stone every night to keep those calluses a bit thinner. That will prevent further cracking.”

The lumberman hated the actual cut-glue treatment but loved the result—his cracked fingers and palms were sealed and pain free.

UPDATE: It is now known that over-the-counter “super glue” can be harmful to skin. The medical version, Dermabond, is safe and effective, but much more expensive. You can read more about the difference here.

(TO BE CONTINUED NEXT FRIDAY)

PAST STORIES


© Copyright Walter L. Larimore, M.D. 2016. This blog provides a wide variety of general health information only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment from your regular physician. If you are concerned about your health, take what you learn from this blog and meet with your personal doctor to discuss your concerns.