A fast 3 weeks vacation

February 14, 2019

In Denver we sat down for a meal,

To talk of how people heal.

We were shooting the breeze

Speaking medicalese

It’s just our typical spiel.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and Canada. I took three weeks’ vacation between assignments.

Three weeks’ vacation went fast. We had enough time for laundry and almost enough time for mail before we visited our (physician) daughter, her (physician) husband and their two children in Texas.  Not surprisingly, dinner conversation included medical topics as common as B12 deficiency and as esoteric as clivochordoma (a ridiculously rare sort of brain tumor).  But we also talked about normal stuff like the grandchildren developing, the political situation, physician career development (for all 3 of us doctors) and the progress of my Texas medical license , which I started back in May.

Some states make licensing easier than others, and I wondered out loud who oversees licensing authorities to make sure they act in the State’s best interests.

Bethany and I stayed 2 days with the 2 grandchildren (who between them don’t have 4 calendar years) listening to the pounding of the Galveston surf and watching squadrons of pelicans fishing in knee-deep water.

We flew directly from Houston to Denver. Our youngest daughter and her husband came to Colorado to touch base with family and friends before a planned move to Israel.  Three of my 6 sib, along with spouses and children, live in Denver.

We met in a Persian restaurant for supper.

Medicine has warped our conversations and vocabularies, starting with our internist/cardiologist/Emergency physician father who dropped the words “myocardial infarction” (heart attack) at least six times a meal.

When I had young children, and even after, I literally brought my work home with me, sometimes attending patients in the basement and usually dictating office notes after supper. When I had call, I took the kids with me to the hospital starting, before the first one could walk to when the youngest one hit puberty.  Of course family meals included discussions of the drama and irony my work.

Our youngest daughter married the youngest son of my former medical partner. One of my Denver sisters, an interpreter for the deaf, has been through veterinary school 3 times, and she does a lot of ER interpreting.  Her son, just done with premed, is in the process of studying for the MCAT (Medical College Aptitude Test).  My Denver brother, a paramedic for decades, will apply to PA school within the year.

My other Denver sister has a PhD, arguably the more normal sort of doctor.

The family’s way-off-the-wall sense of humor dominated the evening. At the end of the meal we had a short hands-on colloquium on OMT, or, in common English, back cracking.

 

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Saxophone and life lessons

February 3, 2019

In Memoriam

Diane G.

March 28, 1960- January 24, 2019

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. Just back from my 4th Canadian assignment, I’m taking some time off in the States

After a miraculous, 15 year fight with cancer, Diane, my friend and saxophone teacher, died last week. I was with her when she passed, not as her physician but as her friend.  Bethany was there as a friend as well, and to support me.

She died surrounded by the love of her friends and her family.

Diane had to see other physicians while I went locum tenens, but I never found another music teacher. Thursdays when in town meant life lessons along with music.  She would not accept money, so I brought chicken soup.

At her urging, and with her permission, I wrote about her in 2011. I have included the post word-for-word below.

We count good moments, not years

When we don’t give in to our fears

     I once went with a hunch,

     It helped my patient, a bunch.

And she looks good in front of her peers.

My patient, Diane, has given me permission to use this information in my blog.

She taught my three children instrumental music; she came to me as a patient more than a decade ago.

Six years ago a cough brought her in.  As with all health professionals doing their job with a woman between ten and sixty, I asked if there were any chance she was pregnant.

“No,” she said.

Sometimes I get a hunch and a long time ago I learned to trust that tingling at the back of my brain; in this case it told me not to believe her.

“Well,” I said, “Just lay back on the exam table while I check your tummy.”

I plainly felt the top of her uterus higher than her belly button, but I couldn’t find a heartbeat with the Doppler.

I pled urgency with an OB-Gyn and got her an appointment within the hour.   The ultrasound showed her womb had turned into a malignancy the size of a soccer ball.

A few weeks later, she came, in her words, to a “critical decision that I make a ‘leap of faith’ in action right before surgery, because I knew in order to live I had to not be afraid to die.”

The pathology report said leiomyosarcoma, a cancer of the uterine muscle.  In later years she said, “I was always a survivor from the beginning.  I was born C-section at 7 mo.[ 3.5 lbs] in 1960.  I had no idea how having ‘faith’, ‘letting go’ of past hurts, and learning to trust others would change my life all for the better.”

It helped that she had never been a bitter person.

I coordinated her care as she went from specialist to specialist.  So rare a tumor had no chemotherapeutic experience.  With a paucity of clinical evidence, I gave advice from my heart.

“The worst day of my life wasn’t when you called and told me it was in my lungs,” she said.  “Not even close.  I’ve had more good days since my diagnosis than I had in my entire life combined.”

The next summer Bethany and I met Diane and her husband on their way out of the movie theater.  She’d been carded trying to get into an R rated movie.  Her skin had the clear glow of a teenager and her hair shone in the sun.  She walked with a bounce befitting a sophomore.

The spring after that she sat in the waiting room of the Cancer Center before a radiation treatment.  The other cancer patients turned to her. “You’re not here for radiation,” they said, “you’re just another representative. What do you represent?”

“I represent hope,” she said.

My middle daughter fell rock climbing three years ago; in the aftermath of ICU’s and neurosurgeons and months of not knowing I learned a great deal.  Diane and I have discussed these truths: Time comes to us in moments, some good, some bad, most neutral; if you let the bad moments contaminate the neutral you give them too much power and if you let the bad soil the good you’re missing the point; embracing the uncertainty of not knowing bad news makes your day better.

When I made my decision to slow down back in February I also decided to bring music back into my life and buff up my saxophone skills by doing lessons with Diane.  On my last clinic day, she and her husband and my office nurse gave me a soprano sax.

(see my post https://walkaboutdoc.wordpress.com/2010/05/23/can-a-soprano-beat-a-naked-lady/)

Over the course of ten surgeries, seventy-nine radiation treatments, fifteen hospitalizations, and thirty-eight CTs, Diane continues to look younger and younger.  She serves as a beacon of light and hope to all who know her.

 

 

 

A Full BC license

February 1, 2019

A full license the College did grant

I could work elsewhere, but I shan’t

At home, with a friend

I saw a Parkinson’s trend

A tremor, and a walk with a slant

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. Just back from my 4th Canadian assignment, I’m taking some time off in the States

Much has happened in the two weeks since I last posted.

I got my full BC license on January 17th. Up to now I’ve been working with a provisional license, which requires that I have supervision and work in 3 month blocks.  The licensing authority waived the requirement that I be a permanent BC resident.  Technically I now can work in other parts of the province.  Still, I would have to ask myself why I would want to go anywhere other than the most functional medical community I’ve ever experienced.

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We got back to the States on the 20th.  The mountain of unread mail made procrastination unfeasible.  I sorted it into piles of WILL READ and RECYCLING.  Having been gone for the December holidays, we also had a few gifts.

At this stage of my career, having accumulated too much, we need very little. So if someone wants to buy a present, we’ve taken to saying it should be expendable, negotiable, edible, biodegradable, or inheritable.  Imagine our surprise when we got a really nice cutting board.  Which, strangely, we can use.

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I have noted an alarming increase in Parkinson’s in the general public. When I finished med school, the vast majority of Parkinson’s disease came from the Great Influenza of 1918.  In the ‘80s you could pick it out in a crowd just on the basis of age and gait.  Than generation has passed.  Saturday, at a social gathering, I glanced at a friend’s hand resting on a lectern, and spotted the characteristic tremor of her right hand.  Over the decades I’ve known her, I failed to note the gradual loss of facial expression.  When quizzed she confirmed anosmia (loss of sense of smell), micrographia (shrinking handwriting), bradyphrenia (slowed thinking), and loss of balance.  She also gave me permission to write about her in my blog.

And from time to time, in an airport or grocery store, I’ll point out to Bethany the telltale leaning, shuffling gait, and blank stare.

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My wife and I do better with cold than heat. We flew to Texas to visit our (doctor) daughter, her (doctor) husband and their children.  We left Omaha at a temperature of 1F (-17C) and arrived in Houston to 47F (8C).  We happily walked around in our shirt sleeves while the locals wore parkas, ski caps, and mittens.  Two days later, I reverted to wearing my winter jacket, but not my long underwear.

Contrast remains the essence of meaning.

I’m the doctor. You need the dentist.

January 15, 2019

It doesn’t take much of a sleuth

When it comes to a pain in the tooth

In the head, but not mental

Those problems are dental

They start in the mouths of the youth

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

 

Canada’s recognition of care as a right means that cost comes out of everyone’s taxes, and, in that sense, everyone has health insurance.

(Actually, they don’t. The Mennonites, for example, do not have to pay those taxes.  And I ran into a young man with such massive self-defeating behaviors that he procrastinated getting his insurance card for 4 years.)

The mainstream plan does not cover dental work.

The bigger employers offer dental insurance, but, like the US dental insurance, it has a high deductible and large copay. Thus people tend to ignore their teeth.

I see between two and four patients a day with dental problems; a higher percentage when I’m on call. About a quarter of those who come in with toothaches have never visited our facility before.

If people didn’t hurt a lot, if they could get in to a dentist close by, they wouldn’t come in to ER with dental pain. When they open their mouths, I see decades of procrastination and neglect.  Broken teeth, teeth rotted to the gum line, teeth worn out from the clinching that methamphetamine brings.

I can’t actually fix the problem. I can give antibiotics and pain relief.  Amoxicillin remains the standard in dental infection.   For analgesia, I have the nurse administer ketorolac (Brand name, Toradol) 30 mg as an injection, and I give the same medication as a pill for 5 days.

If time permits I show the patient ho-ku acupressure, squeezing a point in the muscle between the thumb and forefinger, which relieves head and neck pain.

But I have to urge them to get into the dentist as soon as possible. For those who can’t afford to pay, I give them information on the free dental clinic held twice monthly in Prince George.  Staffed by volunteers, they rarely have time to do anything besides pull the offending tooth.

I suppose I could learn to do dental extractions. If I did, in short order I’d be doing almost nothing else.

Some of the patients don’t have a problem till they’re about to head into the wilderness for work for a few days; I generally give them a longer prescription of Amoxicillin, but I don’t give out pain pills that would make them dangerous around machinery, or driving to Prince George.

Confronting a smoker with a heart attack

January 13, 2019

 

When it comes to attacks of the heart

Please listen, you docs who are smart

Whenever the bloke

Steps out for a smoke

Don’t yell, and keep your words smart.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

Though the patient gave me permission to write about him, I won’t say when this incident happened.

He came in with chest pain. As per protocol, I did the electrocardiogram which strongly resembled previous tracings.  But I also asked for and obtained a blood test for troponin, which rises only when heart muscle has sustained damage.  It came back normal.

But we have learned that sometimes the damage doesn’t show up on the initial blood work, so I ordered the same tests 4 hours later.

I read the second ECG with alarm: a sag in the line connecting the wave representing the heart’s contraction, with the deflection of the heart’s electrical preparation for the next beat. I sat down with the patient and discussed the situation.  In the middle of a heart attack, I had to make arrangements for more specialized care.  He would require a cardiologist and a catheterization, perhaps stents or a cardiac bypass graft.

I started the complicated business of sending the patient to a higher level of care while the snow fell hard enough to make the task impossible. I repeated the same story on the phone, each time emphasizing that the patient remained pain-free and with normal blood pressure and pulse.

The snow eased my emotional frustration. No medevac helicopters fly in this health district.  I only ask for fixed-wing transfer when justified by the distance to the facility, and the weather throughout the province assured that the small planes involved in medical transfer could neither take off nor land.  Still, the decision-making came at day’s end.  Vancouver’s cardiologists had no beds, we would have to keep the patient.

As I finished the hospital admit process, the nurse said, “You know, don’t you, that he stepped outside for a smoke.”

No, I hadn’t known. I confess I lost my temper.  I slammed my pen on the desk and stormed out to the front entrance.

I confronted the patient.

Those who have known me the longest will confirm that when I get angry I get articulate, but I rarely raise my voice. I don’t have to.

What I said boiled down to, “You have a beautiful young wife and a son. There are a lot of people who love you, and we’re worried about you.”  But I said it, angrily, about 6 times.

I care about my patients, but I haven’t expressed that kind of fury for years. Maybe I’d worked too many hours with too much noise.  I finished more fatigued, and I felt worse for hours.

The next day the patient thanked me, as did his family. He felt better, the best he’d felt in a year.

Outside, the snow fell thick for the next five days, when, finally, we got word we could transfer.

New Year’s lacerations

January 3, 2019

I said to my very next case

With a cut so bad on his face

He got from a grinder

Do you suppose that it’s kinder

To use stitches to close up the space?

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

I approached the third laceration patient of New Year’s Day on call. Lacking a bolt cutter, the patient had been using a power tool called a grinder to cut a bolt for a friend.  Living flesh suffered in the slip that followed.  The wound gaped straight down the midline of the chin and onto the upper part of the neck.

I said, “You got two choices. The risks of the procedure include infection, bleeding, pain, and the certainty of a scar.  The risks of not doing the procedure include infection, bleeding, pain, and the certainty of a scar.  Your choice.  Shall we proceed?”  The patient agreed.   While the patient’s wife took cell phone pictures, I cleaned and numbed the area, then held the wound open for the camera.

“Is this already on Facebook?” I asked. The patient and wife both laughed.  I said, “Then if it’s already on Facebook, is it OK if I write about it on my blog?”  They both agreed.

I put on my headlamp, slipped off my glasses, slipped on my gloves, and started stitching. Suturing fell into a rhythm: sew, tie, cut.  Between the cut and placing the next stitch, I would ask a question and the patient would reply.

We talked about ice fishing and the discomfort inherent in the activity. I made the comment that I’d been out on the ice while others fished, but, aside from the Inuit, it seemed like beer constituted the main reason to bring poles and bait outside.

We all laughed, and I said, “Ten thousand comedians out of work, and you got one with a stethoscope.”

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Bad call put my senses into a time warp. This morning I awakened thinking I had call again, not realizing till almost 9:00AM that I had clinic.

My morning’s highlight, which put a bounce back in my step, came when I met with a man I’d diagnosed with Parkinson’s last month (and who gave me permission to write about him). His stiffness melted, leaving behind a more fluid gait, clearer speech, a mobile face, and better balance.

He’d had a stroke a couple of years ago, and in the aftermath he started having auditory and visual hallucinations. The rehab staff told him that, 9 times out of 10, nursing home placement follows one spouse finding out the other hears and sees things that aren’t there.  So he’d kept his hallucinations to himself.  But they’d stopped right after he started carbidopa/levodopa (trade name, Sinemet) that I prescribed for his Parkinson’s.

Even though in the last year I’ve helped dozens of similar patients, each one reminds me of why I’m a doctor.

 

Diagnosing a broken toe with a headlight

December 25, 2018

In a flash, I brought out my light,

With a beam that’s ever so bright

That, what do you know,

I can see through a toe.

Can it show me a break? Well, it might.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

About a year ago I replaced my head lamp. The old one had no problems but it carried the logo of an outdoor outfitter and required 3 AA batteries about once a month.

The new one throws a much brighter, whiter beam. It has a lithium battery that runs 120 hours on a charge.  Of course I use it diagnostically, to look into throats, noses, and other body cavities.  Then I started to use it during procedures such as stitches and cerumen removal.

About a month ago, though, I figured out the light has the intensity to shine through (in medicalese, transilluminate) fingers. I used it to remove a splinter.

Last week, a patient came in with a painful, bruised little toe (and gave me permission to write about it) suffering from that eternal truth of one of Newton’s law: two objects cannot occupy the same place at the same time.

In a flash (pun intended) of inspiration, I turned out the lights and brought out my head lamp. Holding it on the other side of the toe, shielding the light from coming through the edges with my fingers, the toe glowed red in the darkness.   I clearly saw not just the bone but the arteries and veins.

And sure enough, a dark line ran across the base of the toe bone closest to the foot, a piece broken into two, but still well aligned.

With the exception of the big toes, we treat toe fractures the same: we tape the broken toe to the next toe, a maneuver called “buddy splinting.”   Thus many times we don’t x-ray toes suspected of fractures, we just treat them and tell the patient to keep the toes taped together till it feels better without the tape than with.

I couldn’t correlate the head lamp image with the gold standard of the x-ray, because toes do not warrant x-rays.

But fingers do. And I will undoubtedly transilluminate the next finger if I think there’s a fracture.

Was it just giardia?

December 25, 2018

I admit I didn’t know why

But I thought to give it a try

That parasite

An intestinal blight

Under the scope has always been shy

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

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Watching a couple lay foundations of abuse

December 17, 2018

I know it’s just not my place

To go and get in the face

Of the emotionally unstable

At the next table

They’re just not my clinical case

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

 

The last to arrive, I got the seat at the end of the table. We gathered to celebrate the final day of work for a Family Practice resident who had come for a rural experience.

I sat down just after the waiter came with my pre-ordered sandwich. I found my colleagues wondering about me.  I explained I missed catching a ride to care for a last-minute patient, and I enjoyed the exercise of a snowy kilometer’s walk.

The conversation centered at the other end of the table, I reveled in the leisurely meal and watched the dynamics around the room.

I can write about these things because they happened in a public place.

A young woman tried to distance herself from the affections of a young man. She leaned away from him, he put his arm around her shoulder, she resisted his efforts to pull her closer.  He scooted in, she leaned further.  He tried to put his head on her shoulder, she did push him away but her posture told me she did not welcome the closeness.

The young man clearly did not understand, and did not want to understand.

I watched a couple lay the foundations of an abusive relationship. The courtship’s emotional intensity stems from the amount of work one party has to put into getting the other party’s attention.

I could read immaturity in the young man’s body language; he acted like a 15-year-old in a 25-year-old’s body. The resistance to his advances would strengthen his interest, leading to a pathologically intense courtship.  Once locked into a love interest, he would lose perspective and sensitivity.

I have seen the consequences of such scenarios at various stages of development. Pathologic fixation on another person with inevitable human imperfections gives rise to uncertainties, then disappointments, then hurt, then abuse.  The young woman may court intensely; the abuse may flow emotionally, verbally, or psychologically.  It rarely flows one direction, and always spills out of the home, rippling through families and communities.  I see the physical impact clinically.  People get sick as an end result of such courtship, sometimes generations and continents away.

I want to go over and tell the young man to grow up, and tell the young woman that if she cares at all for him, she should drop him now and not lead him down the path of destructive love that will crush both their souls and mangle their bodies in the process.

But I don’t. I sit in a public place and watch people who aren’t my patients while I munch my crispy chicken sandwich and make small talk with a colleague.

Eye color change, addicts with insight

December 11, 2018

A change in the color of eyes?

It comes as quite a surprise

It can happen, it’s rare

It’s more common in hair

Don’t count on it for a disguise

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

I found myself on call this morning, glad that it came as a surprise so I didn’t have the anticipatory anxiety the night before.

I recognized a person who came in accompanying an ER patient, but I had problems with the appearance.

I had seen the patient weeks before, with a very puzzling physical finding, and tonight I got permission to blog about it.

Presenting complaint: eye color change. I hadn’t heard of such a thing, and I hid my skepticism.  But I did ask for the driver’s license, which confirmed eye color as hazel.  Yet the patient, without a doubt had blue-grey eyes.  I posted an inquiry on a doctors-only clinical social media website.  About half the responses derided the very idea.  But one ophthalmologist offered an erudite discussion and attached a link.

Indeed, eye color can change.

So I thought it over. Eye color depends on little packets of pigment called melanosomes.  I already knew that some unfortunate people can lose color from patches of their skin in a process called vitiligo (two prominent examples include Michael Jackson and the Pied Piper of Hamlin).  And if a person loses a patch of hair to alopecia areata but the hair grows back, it will usually grow back white, due to a loss of melanosomes.

So, if that can happen in the skin, when not the eye?

The patient’s eye color had since darkened, now having bits of brown and green, enough to throw off the appearance.

I said that discussing such a rare finding would come close to identifying a patient.

The person happily gave permission for me to write about the incident in my blog, and talked about running into others who similarly had seen their irises go from dark to light.

Eye color change happens little more rarely than addicts acquiring insight, yet for the 7th time in a week an addict came to clinic knowing change was needed, having started the change, and requesting counseling.

Note: this post made it into the draft queue and marinated there for more than a week.  Since then I’ve had 5 more addicts come in with insight, requesting counseling.  Some have already started going to meetings.