My life had been so out of whack

I flew cross the sea

From Barrow to Leigh

Now I’m home and it’s good to be back.

I received an email from a doc who went walkabout to New Zealand for a good deal longer than I had, and asked me questions about my reintegration.  I asked for permission to post the original missive, but three weeks later haven’t heard back.

I replied: 

It’s interesting that you emailed me six months to the day after I started back into work here in the States, and if it’s OK with you I’ll use your email and this return as a post.

I’ve enjoyed reintegrating to US society and the medical care system.  I’m back doing hospital work, which, strangely, I really enjoy.   I know my consultants on a first-name basis and I like the camaraderie in the hospital.

It helps that I’m working for a Community Health Center.  For a lot of reasons, our patient population gets sicker earlier.  The pathology load weighs heavy on them.  At any one time, half of our twenty to thirty hospital patients also appear on the nephrologists’ list because of chronic renal failure and dialysis.  Usually we have three people in active DT’s and three others in liver failure. 

I have had to get used to the paranoid reality of defensive medicine.  Our patient population has made the transition easier because many have no money and no insurance and hence can’t pay for procedures that probably weren’t needed in the first place.

For those with insurance, I worry that I overuse medical technology.

Getting labs back the same day, like glycohemoglobin and TSH, makes patient management easier, as does having in-house x-ray.  

I liked MedTech32, the electronic medical record (EMR) system that makes documentation so easy throughout New Zealand, and the hardest part of coming home has been dealing with Centricity, whose software engineers remain isolated from any contact with this particular end user; for example, I have to click through five data fields to make a back to work/school slip and I have no way to fix it.  My productivity has gone way down; eleven patients in a morning or afternoon taxes my resources; not that I spend more time with each patient but I spend more time fighting the computer to enter data.  And about half the problems could be fixed easily.

I miss the way I always started on time in New Zealand because I brought my own patients back from the waiting room, and I miss the way the patients (mostly) respected my time.  In my current situation I limit the patients to three problems per visit.

Narcotics seeking remains a problem here as well as everywhere.  I’m building up a reputation in the street-drug community here, just like I did in the South Island, as parsimonious with opiates and benzodiazepines. 

Still, my practice swells with new patients every day.  I like pediatrics, and I find that a new practice attracts young people and young families, even with an old practitioner.

In the long run, most people either fit into the category of wanderers or homebodies, and I am definitely a homebody. 

But man, did I have a great time.

Here is the year in review

Some of my readers

Worried about bleeders

But over all, quite a nice crew.

The WordPress.com stats helper monkeys prepared a 2011 annual report for this blog.

Here’s an excerpt:

The concert hall at the Syndey Opera House holds 2,700 people. This blog was viewed about 15,000 times in 2011. If it were a concert at Sydney Opera House, it would take about 6 sold-out performances for that many people to see it.

Click here to see the complete report.

Though free time can be quite a perk

     Away I did roam

     And now I’m back home

Tomorrow I start back to work.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  During my year-long sabbatical, while I danced back from the brink of burnout and my non-compete clause expired, I traveled, had adventures, and wrote.  Tomorrow I start regular work again at the Sioux City Community Health Center. 

When we left Sioux City for New Zealand we hadn’t cleared things up from our stay in Alaska.  In the process of packing, editing, and repacking, I left disordered mounds of clothes, crammed drawers, and messy floors. 

I forgot about them while we were gone.  We found the house orderly when we returned, but I keep coming across things that need revising, drawers that need setting in order, and things that need to get divested.  My long underwear alone I found in three different drawers and on two different horizontal surfaces.

I’ve been whittling away at my mail since we got back; I try to get rid of at least two magazines a day but the pile of unread journals remains daunting.

Jet lag has improved, and I slept through the night last night.  I still get sleepy most afternoons and the occasional morning but nap duration has returned to my previous 18 minute specials.

The fact that I start back to work tomorrow excites me at the same time it feels like I’ll be, well, working.  After all, from May 21, 2010 to June 20, 2011 it felt like vacation even when I spent sixty-three hours a week on the job.

Sleeping in our own bed ranks as a euphoric experience, and planting my garden marks a return to reveling in the sequence of seasons.  Abruptly changing from long, cool New Zealand nights to the long, hot humid Iowa days has jarred our systems.  It reminds why I spent last summer in Alaska.

I have returned refreshed and optimistic.  Even though I’ll go back to a job tomorrow I have set things up so I’ll have enough time to write, garden, exercise, play music, hunt, read recreationally, and breathe.

Contrasts strike me every hour of every day.  I drive on the right down broad lanes with quiet pavement.  Home smells like home, gas and food come cheap, Iowans weigh a lot more than Kiwis, haze hangs in the air.  When we play Scrabble we have dictionaries ready to hand.   We don’t struggle to understand the Kiwi accent.  We haven’t seen a single sheep since we arrived, and corn fields dominate the landscape. 

Underlying the upbeat mood of our homecoming runs the town’s worry about flood from the Missouri River.  The Dakota Dunes community, displaced from upscale homes between the Missouri and Big Sioux Rivers, has moved into Sioux City and snapped up real estate and rentals.  The water, high when we arrived, has continued to rise.  Interstate off ramps have morphed into boat ramps. 

We have all considered worse case scenarios, where abrupt snow melt and heavy rains trigger domino-like dam failures all the way down the Missouri and the Fort Calhoun nuclear plant, sixty miles south, goes critical.  Yet the town keeps an optimistic mood while we fill sandbags and take the weather seriously.

A blog sure isn’t a tome

     This thing they call jet lag

     Comes out to big drag

But happiness is being back home.

Synopsis:  I’m a family practitioner from Sioux City, Iowa. I took a sabbatical to dance back from the brink of burnout.  While my one-year non-compete clause ticked away, I worked in Alaska, Iowa, Nebraska, and Alaska.  I had a lot of adventures working in out-of-the-way places.  Now I’m back home, getting ready to start my new job.

When is a trip home like a spider?  When it has eight legs. 

Our trip home lasted thirty-eight hours and left us with the worst jet lag we’ve ever had.  We slept badly even before boarding the plane in Dunedin.  From Dunedin to Christchurch to Wellington to Auckland (thirteen hours) we might have napped on the plane, but we didn’t get restorative sleep. 

Turbulence, related to the recent Chilean volcanoes, dominated the twelve hours spent flying to Los Angeles.  I ignored the bucking airplane and watched three movies, and didn’t sleep. 

By the time we deplaned in Phoenix’s late afternoon the temperature exceeded anything we’d experienced in New Zealand. 

Omaha at midnight had darkness and thick, sweet summer air.  Long detours necessitated by the Missouri River flooding added an extra forty-five minutes to the drive home.  By the time we actually walked into the house the clock came close to 3:00 AM.  Our trip had lasted thirty-eight hours, if you don’t count the travel from Bluff to Dunedin. 

Jet lag hit us hard in LA and didn’t get better as we progressed.  Both aware that neither of us could process information well, we showed immense patience with each other; I doubt either of us could have negotiated the trip home alone.

We suffer not just from the time difference but also from the abrupt change of season.  We departed for New Zealand near the equinox, when day and night all over the planet approached twelve hours, but we returned home just before the solstice.  Dunedin’s shortest day would coincide with Sioux City’s shortest night a mere eight days after we landed.

Our body clocks have been thrown into chaos.  I have been on the ground for three days and only now am I starting to write again.  I awaken at about 4:00AM and crash hard at one in the afternoon.

Of course I went to my new work place less than twenty-four hours after I arrived; I needed to discuss my upcoming schedule.

Unlike a lot of the family practitioners these days I enjoy hospital work, rubbing elbows with the specialists and providing continuity of care.  My new routine will start with hospital rounds for the group Monday, Tuesday, and Wednesday.  If things go according to plan, after lunch those days I’ll do clinic, and I’ll have an evening clinic on Mondays.   Those twenty-eight hours, combined with my share of a one-in-eight call rotation, add up to 45.7 average hours per week, which, for a doctor, means part-time work.

 
Synopsis: I’m a family practitioner from Sioux City, Iowa. On sabbatical to dance back from the verge of burnout, I’m having adventures and working in out-of-the-way places. We’re touring after a month-long assignment an hour outside of quake-stricken Christchurch, in New Zealand’s South Island. We’ll be back home, Good Lord willing and Missouri River behaves, in a day and a half.

 
The ferry brought us from Oban on Stewart Island to Bluff as the sun set; we stayed the night at the outskirts of town.
We drove the next morning from to Dunedin, coming in from the south, and plotted our departure day moves. The airport sits thirty kilometers from the city center; we checked with the rental car office about dropping the Hyundai off early.
In the city center we enquired at the I-Site for penguin viewing, and booked a guided tour on the Otago Peninsula.
With plenty of time, we set out using the low-detail map from the tourist center, but having no directions to Penguin Place. In Portobello, faced with a Y intersection, we made the mistake and took the literal high road. The name Highcliff Road should have tipped me off.
I think the world of Kiwis but hold low opinions of their roads. Highcliff Road, winding sharply high above steep drop-offs, would have been bad enough. Younger men with no trauma experience might find the drive exhilarating; I found it terrifying. With loose gravel, grossly inadequate lane width, and no barriers, I soon found myself straddling the white line, until it gave out and, without the option of turning around, I continued on asphalt narrower than the infamous Oil Strip of the Nebraska Sandhills. At one point I faced an oncoming Mercedes, with a driver either overconfident from untreated mania or just careless because he had the inside lane. With my outside wheels on the ten-centimeter shoulder, I cleared his rearview mirror by millimeters.
We finally descended to sea level. At Penguin World we met eleven other tourists from New Zealand and Asia. We got a look in the penguin hospital, and we went out to the viewing area to see the wild yellow-eyed penguins.
At this time of year, when the short days limit the amount of time the aquatic birds can spend fishing, they leave land early in the morning, eat all day, and return in the evening. We walked the trail through the replanted native bush, and saw a little blue penguin (the smallest species) in its burrow and not looking well. Without moving, we saw two fur seals lounging on the dune grass, and the yellow-eyed penguins coming onto the beach with the waves.
Our guide discussed the seasonal mate selection process of penguins, and called the gathering in the surf a “beach party.” First three, then six stood on the beach just at the high edge of the waves, representing one percent of the earth’s total of yellow-eyed penguins.
Penguins mate monogamously but divorce; the rate runs much higher in the emperor penguins in Antartica, which maintain closer contact because of the cold. The yellow-eyed penguins spend less time together and have a lower divorce rate. They sometimes form same-sex unions.
I suppose there’s a lesson about human behavior, but I’m not sure what it is.

We arrived and longed for the prairie

     From New Zealand to Nome

     There’s no place like home

We’ll fly with no help from a fairy.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to dance back from the verge of burnout, I’m having adventures and working in out-of-the-way places.  We’re touring after a month-long assignment an hour outside of quake-stricken Christchurch, in New Zealand’s South Island.

We drove south from Paparoa and Bruce Bay, along New Zealand’s southwest coast, down the loneliest stretch of highway either of us could remember.  So little traffic passed we saw no other cars for thirty minutes at a stretch.  Two sheep wandered outside their paddocks in evident safety.

Despite Southern Hemisphere’s  fast-pproaching  wnter, though we drove further south than Minneapolis lays north, the temperature stayed above freezing.  We filled the tank in Haast at the slowest pump I can remember, requiring a quarter-hour for six gallons (twenty-four liters) while I swatted at biting black flies.

Rains forests require rain which biting insects love; no surprise that flying blood suckers abound in the environment.  They’re just doing their job.

Further south we lunched in Queenstown, a mountain resort that reminded Bethany us of the tourist glitz in Keystone, Colorado, complete with a huge lake.

On south we went, further south than either of us had ever been before, and stopped in Kingston, the only guests at a motel that would have charmed if we hadn’t had to wrap ourselves in blankets to play Scrabble.  New Zealanders don’t think much of central heating; during the few cold months many heat with wood, a few with coal, but hostelry relies on space heaters. 

Further south yet, through Invercargill to Bluff, the southern tip of the South Island and famous for its oysters.  We walked from the Drunken Sailor car park further south, to the point, and looked across the water to Stewart Island.

The author inspects a sign post in the parking lot of the Drunken Sailor

We took the afternoon ferry there, landing at sunset.  The usually laid-back Kiwi attitude slows to the speed of the tides on Stewart Island and outside the tourist season they really relax.  One shop turned on its lights during the posted store hours of 1:00 to 3:00 but didn’t unlock its doors till 1:30.

Oban remains as the sole town on the island, with a year-round population of 600.  The rest of the island hosts the southernmost wild whitetail deer population in the world.  I briefly contemplated the irony and absurdity of leaving Iowa to hunt the same species that browses in my back yard.

Two hours before sunrise we awoke at the South Seas Hotel and walked out to Ackers Point in hopes of seeing little blue penguins, the smallest species.  Having made a mistaken detour into a sheep paddock in the darkness despite the use of the clip-on headlight I bought in Barrow, we arrived too late to see the raft depart.

We walked around town after breakfast, then went back to the hotel to sit in the midday sun, never more than halfway from the horizon.

“I’m ready to go back,” Bethany said.

“So am I,” I said, standing, closing my eyes and clicking my heels three times.  “There’s no place like home”.  I opened my eyes.  “We’re not in Kansas!”

“Nor in Iowa,” Bethany said.  “We still have to drive to Dunedin, fly to Christchurch to Wellington to Auckland to LA to Phoenix to Omaha and drive to Sioux City.”

 
Synopsis: I’m a family practitioner from Sioux City, Iowa. On sabbatical to dance back from the verge of burnout, I’m having adventures and working in out-of-the-way places. We’re touring after a month-long assignment an hour outside of quake-stricken Christchurch, in New Zealand’s South Island.

 
Tourist destinations outside the tourist season have a special mood. The crowds gone, the ratio of locals to outsiders improves. Lonely staffers seem glad to have company.

Sometimes, prices go down.

The transient crowds shrink.

Franz Josef, on the South Island, ranks as New Zealand’s most visited glacier, but we bypassed it for the next glacier south, Fox. The two maintain the distinction of being the only glaciers in the world next to rain forests. Huge snowfalls in the Southern Alps feed the rivers of ice that drop almost to sea level; the same forces that bring the heavy snows bring rains of Biblical proportions to the lowlands.

Thrilled by the vista in the car park as I exited the rental car, I started snapping digital photos that cannot hope to capture to emotional impact of looking across a desolate quarter mile of glacial debris and three hundred feet up a sheer cliff.

I donned my jacket and gloves to ward off biting black flies. We left the car park just as a tour busload walked back from the end of the glacier. Most looked tired; the children and adolescents appeared sullen and irritated.

Bethany and I walked across the lifeless, boulder-strewn valley bottom, tracks the glacier had left in retreat. The approach path used stepping stones across two creeks. When I arrived, I had the glacier face to myself.

On the way back we crossed paths with another busload of tourists, this bunch happier than the last, small children holding parents’ hands and asking unending questions.

Down the coast, the highway runs under treetop canopy blotting out the sun.

At Bruce Bay, I slowed the car and stopped to look at the surf of the Tasman Sea.

I motioned Bethany into the rain, to join me.

All up and down the verge between the highway and the beach, people had piled stones and driftwood. Bethany noticed before I did.

Human hands had jammed driftwood vertically between boulders, and stacked rounded rocks, one on top of the other. Flecks of gold glittered in the granite, and writing graced some of the cobbles; people left names, dates, and messages with permanent marker on the smooth white marble.

We had found a moraine of the universal human urge to travel and see and leave evidence of their passing, along a lonely stretch of highway, order imposed on chaos for two kilometers.

We are tourists in the off-season.

For jewelry, for bowls, or for blades

     What it looked so official,

     Just like my initial

Was the thing that the artist had made.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to dance back from the verge of burnout, I’m having adventures and working in out-of-the-way places.  We’re touring after a month-long assignment an hour outside of quake-stricken Christchurch, in New Zealand’s South Island.

This morning we got off to a leisurely start to the Paparoa National Park, famous for pancake rocks and blow-holes. 

The mood of the beaches of the South Island’s West Coast differs from the beaches of the East Coast, where we started our New Zealand odyssey, as much as Big Sur differs from New Jersey.  The Tasman Sea, which separates New Zealand and Australia, generates much bigger surf than the Pacific. 

We found the East Coast rainy, but the West Coast, where parts flow with 3 meters (ten feet) of rain in an average year, makes all that greenery look positively drought-stricken.

We took the short Truman Walk down to the beach north of Punkaiki proper as the tide rose. We entered the cool zone of the rain forest and followed the path downhill out into the open where trees give way to New Zealand flax, then down the rocks to the sand.  Bethany found a piece of jade.

“Look how gorgeous this is,” she said, “and with the main attraction by the visitor’s center, I’ll bet almost no one comes here.”

In fact, the number of tourists at the Pancake Rocks increased steadily as high tide approached.  We went out on the path across the rocks and looked over the eroded, layered dolomite, feeling the ground shake as the waves pounded through the grottos under our feet.  A brief rain made me zip up my duck-hunting jacket and drove the other tourists away.  When the number of smokers reached critical mass, we left.

An easy afternoon’s drive through driving rain, past brooding mountains with low hanging clouds brought us to Hokitika, famous for greenstone and jade.

The Maori prized greenstone for its beauty and utility, and grew ceremony and custom to go with it.  Found nowhere else in the world, greenstone jewelry finds favor with Maori and Pakeha alike, and two years ago attained recognition as a gemstone separate from jade.  You don’t find the greenstone, the Maori say, the greenstone finds you; never purchased for oneself, it should only be bought as a gift.

The local Maori iwi owns the only privately held river in the country; they find jade and greenstone in the bed, and carve it for market at their shop in Hokitika. 

We walked in, and as I looked through the display case, the goose bumps hit.

Fifty years ago I combined my first and last initial into a monogram; it evolved as I finished medical school and started signing things hundreds of times a day.  Not particularly legible, but consistent and distinctive, the center resembles a treble clef.

I called Bethany over and pointed; she gasped.  The piece could pass for my signature.  The greenstone had found me, but Bethany would have to make the actual purchase.

The Maori clerk, a nurse, also works full-time at the Greymouth hospital, and in short order we fell to talking about medicine.

Their hospital has lab and x-ray.  Depending on who has the duty, surgery can be performed there, but complicated fractures get flown to Christchurch on weekends.  A top-heavy administration uses resources to make rules for the sake of rules, while such facilities as an Alzheimer’s unit lack the money for beds.

I told her that, outside the specialty hospitals, the same problems crop up in American facilities. Here, as in the US, rural areas and small towns have problems recruiting doctors.

I explained the Medical Council of New Zealand’s rules for provisional licensure the first year; the registration comes tied to a specific location, and the doc has to notify the Council before any practice move.  My registration expired yesterday, I told her, and I smiled.

Synopsis: I’m a family practitioner from Sioux City, Iowa. On sabbatical to dance back from the verge of burnout, I’m having adventures and working in out-of-the-way places. I’ve just finished a month-long assignment in New Zealand’s South Island, just outside of earthquake stricken Christchurch.

Saturday Bethany and I traveled into Christchurch and with some inhabitants who discussed their quake experiences.

The city has turned into a community of applied seismologists. Everyone knows an S-wave from a P-wave. They have embraced with understanding the geologic map under their homes and businesses.

Their vigilance doesn’t stop; they keep waiting for the next shock. The sleep deprivation has added into the post-traumatic stress. I talked about the mental health problems I’d seen amongst the relocated, the surprising and terrible amount of bipolar disorder unmasked by the ongoing stress.

After the experience, they cannot enter a room without looking for a place to duck into if a temblor hits; they want to know the location of the nearest table or door frame. They don’t like being in a room with glass or china in cupboards or breakfronts. They like to get heavy, precious, or dangerous things down on the floor where they can do the least damage and get damaged the least. They don’t like libraries, where books become deadly missiles.

And so many people have left; we had all talked with those who, having left, will never return to their home.

Yet as we sat down at a nice lunch the mood stayed light-hearted. We heard about a young man who ran out of the house when the quake started, then ran right back in because the bricks from the chimney had flown at him; the story-teller’s delivery came perfectly timed with a riotous punch line, and we all laughed.

New Zealand has earthquake building codes. Whereas Wellington builds to 1.4 of the quake-proofing standards, Christchurch, thought to be much more stable, built to a factor of .8.

The city’s inhabitants want to know two things about a quake now: the Richter scale and the depth. Each parameter holds a separate emotional connotation.

Around the table each person recounted where they’d been during the quake and what they’d done. They talked about how things had changed in the city, and they didn’t mind getting local junk mail advertising services.

Most everyone had insurance, we learned, but no company will insure the work done to repair the earthquake damage.

They told us about townhouses that collapsed the entire ground floor, but have two good-looking levels above ground.

Politics and personal grudges have delayed the rebuilding of the Art Center, an important social focus. Yet people now know their neighbors in a way they never had before.

I mentioned America’s New Madrid quake in the early 1800’s. I soon learned the difference between quakes between plates, such as in New Zealand, and those that happen within a plate, such as the one in Missouri.

In an earthquake zone, they said, watch out for underground streambeds. Build your house of wood, not brick, with foundations anchored on bedrock.

The Three Little Pigs had it wrong.

I tell you I’m learning but slow

     If the patient’s deranged

     Their mind can’t be changed

But I’m starting now to say no.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to dance back from the verge of burnout, I’m having adventures and working in out-of-the-way places.  Right now I’m living in Amberley, and just finished working a four-week assignment in Waikari, less than an hour from quake-stricken Christchurch, in New Zealand’s South Island. 

I worked this last month so the regular doctor could go back to the UK to get married; I wanted to leave an orderly desk so I arrived early.

The office staff booked me light for my last day.

In midmorning a patient came in for the first time since November requesting prescription refills.    When a person has press of speech, flight of ideas, over-detailing, and tangential associations, the differential diagnosis (the list of possible diseases) narrows down to mania, hyperthyroidism, and abuse of drugs like speed.  I told the patient my concerns, politely declined to renew his prescriptions, and sent him across the hall to get his blood drawn.

After lunch I stopped at the hospital on the way back to the clinic.  I signed off medications and drew blood.  The charge nurse told me there’d been a glitch in getting a patient transferred from Christchurch, and wouldn’t I be happy to do the admission?

I firmly and politely declined twice, but third and fourth time I said no I quit smiling.  So, she asked, should I phone them and tell them not to send the patient?

I wrestled with that one.  I could have succumbed to the guilt tripping.  But I didn’t.  I nodded.

Even though with the long holiday weekend, the Queen’s Birthday and all, she won’t get here till Tuesday?

I nodded again, and this time I smiled.

The afternoon went well.  I had breaks between patients.  The last person had eye irritation from a phlyctenule (she gave her permission to use this information).   I’ve written before about this rare eye disorder that comes from an infection in another part of the body.  I explained the problem, phoned the ophthalmology resident in Christchurch and wrote a prescription.

I had my computer shut off, my coat on and my hand on the doorknob when the receptionist stopped me with a message from the patient whose refills I’d declined.

I had a bad feeling about the call, but said yes.

His already rapid speech had accelerated; he made his anger clear, and held me responsible for his problems.  I walked across the corridor to the nurse and held the phone up so she could listen to him ramble.  After two minutes of non-stop diatribe, on her advice I said, “If you don’t let me speak I’ll terminate the call.”

Never argue with a crazy person, a drunk, or a woman in labor.  Pointing out logical inconsistencies to a person out of touch with reality does no good.  After interruptions and threats to ring off, I pointed out that he could talk to his regular doctor next week.

By the last minute of the conversation his mood had changed to friendly, he wished me well six or seven times.

I added unstable mood to the list of findings, but it didn’t help me make the diagnosis.