A quick week close to home

October 11, 2021

If a person wants to legally drive,

To go out and come back alive

Everywhere they must be

6 months seizure-free

As all epileptics should strive.

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 further travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.   I did 10 months of telemedicine in my basement, followed by 5 months staffing a COVID-19 clinic in Iowa.  After a 1 week assignment in person not far from home, I plan on relaxing and exercising and working a few hours daily in remote medicine.

I had a great time working a combination of outpatient, inpatient, ER, and telemedicine for the last week. 

In that time, I saw 5 patients from a correctional facility, handled 8 telemedicine calls, admitted 2 patients, and transferred 2 patients to specialists with whom I have long-standing relationships. 

I ask all patients older than 12 if they use tobacco.  For those that do, I ask if they want to quit.  Most have ambivalence about their addiction, but a few actively want to stop.

The patient involved gave permission to discuss his responses.  We talked about therapies for nicotine dependence.  He failed with the patches.  He got mean when he went cold turkey.  Bupropion (Wellbutrin/Zyban) gave him a fuzzy brain.  So I brought up varenicline (Zyban).

It works better in real life than it did in the research studies.  Almost everyone gets vivid dreams, I said, as REM (dream sleep) rebound comes after nicotine stops suppressing it.  But 5% of the population have nightmares, a legit reason to stop the drug.

Except that this patient likes photography and he likes horror movies, and he finds little difference between his usual dreams and his favorite cinematic fare.  If he had a scary dream, he said, he’d just wake up in the morning satisfied and be good to go. 

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People should learn from other people’s mistakes; antivaxxers tend to run in groups.  If one person in the group dies from COVID, the rest generally get vaccinated. 

And if people hear about someone being hanged by their seatbelt in a car accident, they quit wearing seatbelts.  I doubt the veracity of the story as I cannot imagine the geometry of how that could happen.  Yet those people who believe it, despite the inability to give an exact mechanism, cannot be shaken from their belief.

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Across the country, uncontrolled seizures legally interrupt driving privileges.  If such a person comes to the attention of a doctor, however, only six states mandate that the physician notify the state.  Iowa does not have such a mandate.  

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We drove to and from the small town down county and Iowa state roads.  Harvest has started.  In a few places, it finished long ago enough that the first green of the cover crops has peeked through. 

Patients: face-to-face and remote

October 5, 2021

Telemed patients, 1 in 3,

Have a problem when it comes to their pee

It’s not quite an emergency

That terrible urgency

And in person I don’t have to see.

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 further travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.   I did 10 months of telemedicine in my basement, followed by 5 months staffing a COVID-19 clinic in Iowa.  I plan on spending this month relaxing and exercising and working a few hours daily in remote medicine.

Bethany and I took a leisurely, perfect weather drive away from Sioux City.  Corn fields, green mottled with yellow 3 weeks ago, have turned light tan, soybeans the same color. 

Despite the pandemic and poor rain, the crops did OK but not great.  About 10% of the fields have already been harvested.

This marks my 4th trip to this particular facility.  It feels familiar, it feels like home.  But roadwork forced a detour, and we came down paved county roads we’d never seen before, through municipalities we’d never considered. 

The few white wind turbines, the ones that marked the skyline as if to say, “Almost there,” have multiplied.  The wind farm now stretches further than the eye can see. 

The subculture here embraces the virtues of sobriety, tobacco avoidance, monogamy, and hard work.  I will be attending an aging, vigorous, active population.  The people have very long, fascinating life stories. 

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Today I attended 6 patients, 3 by telephone, and 3 in person. 

We all face gravity, those who do not die young will age, and people who age will face the deaths of the people they love.  Thus the problems that brought the 3 face-to-face patients. 

I got to make one patient better before departure.  I also got to start medication that will certainly bring visible improvement, but I won’t be here to see the results when the patient returns in 2 weeks for dose adjustment.

The facility has also embraced telemedicine.

I have been doing telemedicine since May of 2020, working for an outfit with a slick, functional EMR system integrated with a video platform so that almost anyone with a smart phone can access medical services.  I have to tell about 25% of those that their problems demand in-person medical examination and treatment.

Painful urination prompted about 1/3 of those patients to seek attention.  Really, such patients need no more examination than a quick thump on the back to rule out serious kidney infection; patients can do that to themselves while I watch.  I can treat those folks just as well remotely as in person as long as they get a urinalysis.  And I can arrange for that test to be done at Quest or LabCorp facilities. 

Here, we do not have video capabilities.  We have well-defined criteria for COVID testing.  And COVID, dominating the US medical scene, dominated my telehealth experience as well.   

Based loosely on reality

October 4, 2021

I know nothing about writing a script

How’s this for a bit of a clip?

For a doctor show series

As this pandemic wearies

And the COVID tightens its grip.

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 further travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.   I did 10 months of telemedicine in my basement, followed by 5 months staffing a COVID-19 clinic in Iowa.  I plan on spending this month relaxing and exercising and working a few hours daily in remote medicine.

How would this be for a scene in a doctor series show?

External shot:  rural hospital surrounded by cornfields.  Drone camera comes to a side entrance marked:  COVID CLINIC ENTRANCE.

Interior shot:  3 TV-gorgeous female house staff physicians wearing gowns and hoods over hospital scrubs and white coats.  One each redhead, African American, and Asian American. 

Opening shot:  They doff their personal protective equipment (PPE) at the negative pressure COVID clinic interface to the hospital.  BACKGROUND: older, white-haired white-bearded white-coated white male attending physician, bent over a computer.

Residents: “We’re going to lunch, Dr. Killdare.”

He waves.  A heart beat, slow, starts under the chat of the resident, talking about COVID, spike proteins, monoclonal antibodies. 

CAMERA FOLLOWS RESIDENTS DOWN THE HALL 

Heart beat sounds louder as they walk, drowning out the chat. 

CAMERA FOCUSES ON REDHEAD’S FACE, heart beat suddenly speeds from 60 to 180 per minute.  Redhead looks puzzled, worried.  She squeezes her shoulder blades together and slow her walking.

Other two residents: “Are you OK?”

RH: “Um, I just lost my appetite.  You guys go ahead.”

AA resident; “You don’t look so good.  Are you sure you’re ok?”

RH resident: “I just lost my appetite.  Really.  I promise.”

Asian American resident: “Can we bring you something from the cafeteria?”

Camera zooms to RH’s eyes, racing heartbeat sounds louder.

Cutaway shot, RH trying to make herself look well.  “Yeah, I could use some tea.  With honey, no sugar, if you don’t mind.  You guys go ahead.  I’m going to catch up on my documentation.”  Turns, going back down the hall. 

“You’re sure?”

(Over her shoulder) “I’m sure.  Sally, I’ll even do that whole last note.” Heart beat takes over sound track.

Heartbeat stops.

Moments later.  In the deserted COVID clinic office.

KILLDARE, looking at electrocardiogram.  “OK, abrupt onset of malaise, tachycardia, myalgias, anosmia, headache, photophobia, and nausea?”

Redhead nods, putting on white coat.

KILLDARE: “Chest pain?”

Redhead: “None.”

KILLDARE: “Diarrhea?”

Redhead shakes her head.

KILLDARE: “Rash?”

Redhead nods vigorously.  “It’s just burning between my shoulder blades.”

KILLDARE:  “Well, let’s have a look.  Slip your lab coat off again.”

Redhead nods, takes off white coat, turns around. Without showing any skin, we see elbows and redhair from behind, implying the back of a scrub shirt has been raised.  Killdare leans in.  “Hand me your phone.”

Takes a flash picture of rash and hands phone back. 

KILLDARE: “OK, doctor, describe the rash.”

Redhead: “Well demarcated, red, non-dermatomal, macular, not raised, symmetric.”

KILLDARE:  “OK, what’s on your differential?”

Redhead:  “Viral exanthem, Dr. Killdare.”

KILLDARE (sarcastic):  “Call a rash a virus and you’re going to be right 90%.  Which virus?”

Redhead looks shamefully at floor.  “COVID-19?”

KILLDARE:  “Very good, doctor.  What about the tachycardia?  Pulse of 180.  Look at the EKG.  Tell me what you see.”

Redhead: “It’s the S1Q3T3 pattern,”

KILLDARE: “Very good.  Classic McGinn-White sign.  You know we really haven’t seen any severe breakthrough COVID-19 here in the fully vaccinated.  Only about 6000 cases nationwide.  Which vaccine did you get?  We’ll need to report this.”

Redhead (staring at floor) :  mumbles

KILLDARE: “I didn’t hear that.”

Redhead: (looking up)  I said I didn’t get any vaccine.”

KILLDARE (angry): “What?  You’re staffing a COVID clinic, you’ve been unmasked half the time you’ve been in my space.  When you know I’m living with a neuro-endocrine malignancy?”

Redhead (staring at floor) nods, sniffles.

KILLDARE: “You’ve got hereditary coproporphyria!  You’re putting your best friends and the only attending who’s got your back at risk.  Catherine is pregnant.  And you’ve been exposing your patients for the last week.  What were you thinking?”

Redhead: “Oh, I didn’t have time to get down to Employee Health.  And it’s so new.  And I just figured I’d wait till I came down with COVID and then I’d get the shot.”  (sobs) “That sounds so stupid when I say it out loud.”

KILLDARE hands her a box of tissues.  “It certainly does.”  (gets out a giant syringe with a long needle) Well, let’s not let this go any further.  Let’s get you some monoclonal antibodies.  Then let’s get you down to CT and make sure you don’t have a pulmonary embolism.”

Redhead:  (weeping harder)  “I can’t do that!  I don’t have insurance!  And with these crushing debts I’ve got from medical school, I just can’t afford it!”

KILLDARE: “No vaccination and no insurance?  It’s exactly the kind of thing we’re going to face until we nationalize health care.”

All the medical jargon and case details are real.  I won’t say where or when the above scene didn’t exactly happen.  I made up a fraction.  You get to guess which fraction.

Not working, still a doc

September 24, 2021

Sometimes I just need to speak

When I noticed a mole on the cheek

Of an undergrad friend

I just had to send

An email, saying: BIOPSY SEEK!

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 further travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.   I did 10 months of telemedicine in my basement, followed by 5 months staffing a COVID-19 clinic in Iowa.  I plan on spending this month relaxing and exercising and working a few hours daily in remote medicine.  Any identifiable patient information has been included with permission. 

The Yale I attended from 1968 to 1972 had high admission standards, and raised them in 1969 when the College started accepting women.  I don’t know that I would be accepted by current criteria.

All of us easily rated the term brilliant.

I got assigned to Morse College, one of the then-12 residential colleges that housed the undergrads.  Coming up to our 50th reunion, some of us have started bi-weekly Zoom meetings.  Attendance varies, rarely more than 10 at a time.

Four of us went into medicine.  The others took a straight course; I stagnated for a year before 3 pre-med years at a commuter college. 

(In all fairness, the other docs have held prestigious positions. I have not.)

A couple of months ago, I sent an email to one of my Saturday Zoom friends, worried about a mole on his left cheek.  I had no idea mine would not be the only one.

Today I got word that the biopsy showed melanoma but it had not spread, and those of us who had raised the alarm got credit for saving our cohort’s life.

When I read the email to Bethany, her eyes glistened with pride. 

Such triumphs constitute the high points of a doctor’s day, but in the final analysis, it’s what we do.

The news came when the day’s original agenda included exercise, continuing medical education (CME), and struggling with my Canadian work permit.

We hired a long-time (decades) friend with a window-cleaning business. In the course of the morning he and I struck up a conversation.  I did what I do well: I listened.

Fatigue set in about 2 years ago (he gave me permission to include more information than I have), and he got very little satisfaction from his interactions with the medical profession. 

During my private practice years, I said, I saw a lot of people who just didn’t feel well, and I ran a lot of lab.  For a golden 18 months, 50% of the time I found problems I could do something about, but I knew that no population of patients is so sick nor is any doc so good that that yield would continue.

I know his primary care doc to be a solid physician with both feet on the ground, who doesn’t mind patient requests within reason.  (If you must know, for everyone with fatigue, I like to get CBC, ESR/CRP, CHEM 14, TSH, FE/ferritin/transferrin, Hep C, B12/folate; for those with a Y chromosome I will almost always get testosterone, free and total.  Many times, not always, I recommend ruling out sleep apnea.)

Then, to my regret, I stopped listening and started to talk about myself.  It’s a failing that I have made progress on, but not enough.      

From my basement to Alaska and Texas

September 14, 2021

In Alaska we call it remote

When you arrive by plane or by boat

For the distance is far

You can’t get there by car.

Did you bring a very warm coat? 

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 further travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.   I did 10 months of telemedicine in my basement, followed by 5 months staffing a COVID-19 clinic in Iowa.  I plan on spending this month relaxing and exercising and working a few hours daily in remote medicine.

We remodeled our basement over the summer, and during that time I lacked proper set-up for telehealth.  After the contractors finished the walls and floors, I could deploy my desk and chair in front of a scholarly-looking bookcase, open up the curtains, and take care of patients from Texas to the Arctic. 

I wear a nice shirt and a white lab coat, and I spread an exquisite Navajo rug for my feet, but I can wear shorts or sweatpants if I choose. 

COVID-19’s 4th wave has come smashing across the unvaccinated parts of the country, in particular, Texas. 

Most of the traffic over two hours came evenly divided between Alaska and Texas.  

I got used to remote medicine during my jobs in Alaska, starting in 2010.  Alaska Natives populate the coastline in small villages, and each village has a relationship to a regional hospital.  In that situation, “remote medicine” means that the doc sits in comfort in Kotzebue or Nome or Barrow, and talks to someone from the Community Health Aid Program (CHAP).  The CHAP has been trained to do a physical exam, and frequently can start IVs or draw blood.  But the last time I did traditional Alaska remote care, the system lacked video capability.

I reveal nothing about the patient if I say the call came from a remote location in Alaska, nor if I say that a paramedic accompanied the patient.  I can say that without the paramedic I would not have been able to make the diagnosis.  This time of year the sun sets late there, and I got treated to a beautiful view of clear blue skies and white clouds, at a time long after sunset in Iowa.

After the patient visit, we talked about coming capabilities for diagnosis, including Bluetooth stethoscopes, digital otoscopes, and point-of-care ultrasound. 

I even got to mention my anthropology degree from Yale.

People have called from WalMart break rooms, behind liquor store counters, back yards, and front yards.  But for the first time I got a call from someone while fishing, and I can say that without disclosing anything about the patient.  After all, Alaska and Texas are our two largest states. 

Note from COVID-19 clinic (out of sequence)

September 13, 2021

The stethoscope made a small crack

And the spring, of a sudden, went slack

The needs of my ears

Made me shift gears

So I used a manual hack.

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 further travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  During COVID-19, I did telemedicine, got COVID-19 and then the vaccinations, and a week of in-person medicine close to home.  My current Iowa gig works me 2 weeks on/1 week off; I took some time off to attend my beloved stepmother’s funeral.  Any identifiable patient information, including that of my wife, has been used with permission.

Respiratory illness dominated the clinical day.  Of 12 COVID-19 tests, only one came back positive. 

I continue to ask patients why they haven’t had the COVID vaccination.  The reasons have shifted to the more rational; no one in the last week has mentioned control, tracking, or microchips.  The most common answer involved having gotten COVID-19 and recovered fully. 

Three adult patients came in with their parents.  Each family situation revolved on a unique center and had a fascinating back story. 

Long-term smokers should have low-dose CT scans yearly to screen for lung cancer.  None of my previous venues offered this option, and until this year few tobacco addicts would accept the procedure, but as the 4th wave of Corona smashes against the population, more people have decided to take my advice.

I have a very good stethoscope that mostly makes up for my hearing loss.  More and more I find myself asking if the patient knew they had a heart murmur, and about half did.  The other half get sent for an echocardiogram, an ultrasound of the heart.  But no matter how good the equipment, sooner or later it will fail.  Stethoscopes have a spring (usually metal) that connects the two ear pieces; after tens of thousands of times flexing, that metal piece broke with a subtle but sickening crack as I put it to my ears.  It continued to function but I had to manually jam the ear pieces home and hold them there.  The replacement sits on my desk hundreds of miles away.  Until I get it, I will make do or perform a complicated series of clicks to blue tooth the signal to my cellphone thence to my hearing aids.  The electronics worked just fine.

Our facility has a deserved reputation for organized, quality care, and people will drive past other clinics and hospitals to come here, some close to an hour.  But we also offer same-day appointments, and frequently people can finish their medical care hours or days before they could elsewhere, closer to home. 

Another last day

September 12, 2021

Just like a river must flow round a bend

Another gig has come to an end.

Part gratifying

And part satisfying,

And I watched the pandemic trend.

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 further travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  During COVID-19, I did telemedicine, got COVID-19 and then the vaccinations, and a week of in-person medicine close to home.  My current Iowa gig works me 2 weeks on/1 week off; I took some time off to attend my beloved stepmother’s funeral.  Any identifiable patient information, including that of my wife, has been used with permission.

I have worked this particular job since March.  I have not worked at a better organized facility.  Two top-notch RNs call patients in follow-up.  The clinic manager, a nurse, used decades of experience to solve small problems and prevent big ones.

My job consisted mostly of caring for people with symptoms related to COVID-19, thus most came unvaccinated and a few had legitimate reasons.  I watched the disease shift from the lungs to the gut; in the end, patients had more diarrhea than cough.

Other patients came as well.  I got to diagnose some of my favorite problems: 14 cases of B12 deficiency, 4 cases of Parkinson’s, 2 cases of folate deficiency, 3 cases of low thyroid, 8 cases of polymyalgia rheumatica (PMR, an arterial inflammation that responds to steroids like prednisone). 

I had to learn about mycoplasma, the smallest free-living germ.  It infects people, pigs, and cattle.  Because the lab has the capability of running the right test, I could make the diagnosis accurately. 

But I delivered bad news in the wake of CT scans or MRIs.  The patients received the reports with courage and dignity. 

The set-up offered the immediate gratification of Urgent Care, and the deeper satisfaction of following patients with treatable, longer-term problems.

I had the weekends free.  Bethany and I drove to Fairfield, home of Maharishi International University.  A couple of times we went to Kirksville, the home of Osteopathy.  And we got to the Davis County Rodeo.  We toured one of the county courthouses, but we missed the oldest continuously used courthouse west of the Mississippi (and the second oldest continuously used courthouse in the country). 

My last morning, I attended 6 patients; the last afternoon, 3.  The only positive COVID-19 test came in the first part of the morning. 

The final patient visit ran long, at a time when I had to turn in my key and get final clearance from Health Information Management before I left.  I regret I had to interrupt the patient at the very last, and plead for leave to take care of the final administrative clearance. 

I had almost nothing left in my office except my ball cap and my raincoat, which I needed for the drizzle as we left town.   

COVID-19 surging and mucus poetry

August 31, 2021

Of disaster we’re right on the brink.

If you ask me “What do you think?”

When it comes to rejection

Of Covid injection

I’d say that the thought process stinks.

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 further travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  During COVID-19, I did telemedicine, got COVID-19 and then the vaccinations, and a week of in-person medicine close to home.  My current Iowa gig works me 2 weeks on/1 week off; I took some time off to attend my beloved stepmother’s funeral.  Any identifiable patient information, including that of my wife, has been used with permission.

Today I attended 16 patients, all but 4 for respiratory or gut problems requiring COVID testing. 

Of the 12 COVID tests, 6 came back positive.

Another COVID patient from last week came in with complications.

Of the 6 new COVID patients, 4 had not been vaccinated.  More than one had had COVID before.  Most needed back-to-work slips.  None expressed contentment about the length of time the CDC recommends for quarantine. 

But the nature of my set-up brings in a disproportionate number of those who remain unimmunized.  If I don’t remember that, I will get a warped view of my clientele. 

I took care of three children, and got out my yoyo for all 3.  Gloves make some string tricks difficult and others impossible.  Still the kids didn’t mind that I couldn’t do The Matrix or Rock the Baby On the Flying Trapeze.  Even the one with a fever smiled. 

One of the mothers used a term so poetic, evocative, and memorable that I requested (and received) permission to write about it in my blog.  She described the kiddy’s nasal projectiles from sneezing as “snot rockets.”

The region has a long-term care facility (LTCF).  A person who probably knows asserted that very few of the staff have had their injections, but almost all the residents have.  I look forward to the enforcement of the recent Executive Order, requiring COVID immunizations for LTCFs receiving federal funds. 

I continue in my information-gathering about why people don’t get COVID shots.  The most common answer: “I don’t know.”  The second most common: “It’s too new.”  The third most common: “We don’t know all the side effects.”

I do my best not to argue against the illogic.  I do my best to just take the information in and repeat it, using the patient’s own words. 

But twice today I just couldn’t help myself.  I said, “You know all the risks of smoking, and you continue to smoke.  And you think there might be risks from the COVID shot so you won’t get it.  Do I have that right?”

I hope I get them to think.

After 52 years, a shave

August 29, 2021

Since the 60s I didn’t shave

And a couple of months I did save

But here is the deal

The mask wouldn’t seal

Now my wife thinks I’m handsome and brave

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 further travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  During COVID-19, I did telemedicine, got COVID-19 and then the vaccinations, and a week of in-person medicine close to home.  My current Iowa gig works me 2 weeks on/1 week off; I took some time off to attend my beloved stepmother’s funeral.  Any identifiable patient information, including that of my wife, has been used with permission.

Internet access problems resulted in some non-sequential posts.

I cut myself shaving 7 times on August 11, 1969.  At the time I used a straight razor.  My summer job, bank management trainee, required shaving and prohibited long hair.

I worked in airconditioned comfort all summer and hated it.  I resented the distance from nature.  The predatory paths that lead to banks’ financial stability disgusted me.  The structure rubbed me the wrong way.

My beard lacked density then.  Two weeks after I folded my straight razor for the last time, no one had noticed that I had quit shaving.

My teenage acne stopped abruptly and I started smiling.

For the next 52 years I didn’t shave.

Untrimmed and untamed, I kept my beard up with a bobby pin. 

The Navajo called me Hosteen Daghaa, which can be translated variously as The Man With A Beard or Mister Whiskers.

By the turn of the century few could truthfully say they remembered me without a beard.  Only a few of my close friends knew that my beard without the bobby pin would reach my belly button.

Bethany had many times expressed a wish to see my face.  My usual reply ran along the lines of “Don’t hold your breath.”

But the pandemic changed a lot of things.

N95 masks don’t seal around facial hair.  Working a COVID clinic during the rise of the Delta variant made me uneasy about my vaccination effectiveness.

Then an unvaccinated coworker, used to sitting close to me, came down with the Corona virus. 

Two weeks ago I had Bethany take off my beard with the hair cutting kit.  One of our daughters made a video. 

Now my wife can’t seem to take her eyes off me. Everyone tells me I look younger and more attractive without the beard.  Every mirror shows me a stranger.

I resent shaving’s daily 5-minute waste of time.  In retrospect, 4 shaves a week times 5 minutes per shave times 52 years comes to over 900 hours, or 37.5 entire days.  Which amount to 56 days of being awake for 16 hours.  But realistically shaving takes more than 20 minutes per week.  I don’t want to figure the expense. 

Now I have to shave every work morning because even one day’s stubble becomes intensely itchy under the N95 mask. 

All in all, I can’t wait for this pandemic to end. 

Treatment for the morphing COVID

August 25, 2021

This news from the great FDA,

After a 5-month delay

The vaccine adviser

Gave the vaccine from Pfizer

Authorization that goes all the way

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 further travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  During COVID-19, I did telemedicine, got COVID-19 and then the vaccinations, and a week of in-person medicine close to home.  My current Iowa gig works me 2 weeks on/1 week off; I took some time off to attend my beloved stepmother’s funeral.  Any identifiable patient information, including that of my wife, has been used with permission.

Internet access problems resulted in some non-sequential posts.

In the last two days I’ve seen more confirmed cases of COVID-19 than I have in the month preceding.  Those with viral symptoms compose the majority of my workload so far this week, and those with positive COVID-19 tests outnumber the ones with negative tests. 

In the last month the disease symptoms morphed from primarily respiratory (cough, sore throat, runny nose) to mostly gut dominant (diarrhea, fever, aching, headache). 

I can offer treatment to those with risk factors for having complications: obesity, emphysema, diabetes, high blood pressure, immunosuppressive drugs, or impaired immune function. 

The FDA granted Emergency Use Authorization for Regeneron’s RegenCov, lots easier to say than casirivimab/imdevimab.  Most people with the novel Corona virus just want to feel better, some just want a back to work slip.  If they want treatment, I have to explain antibodies and discuss the risks and benefits of the treatment.  I mention that Trump got the earlier version of the therapy when he contracted COVID-19.  Insurance coverage runs 100% but someone paying out-of-pocket can drop $650 in less than an hour. 

For those who don’t have risk factors, I detail colchicine, a plant extract in use for about 3000 years.  We have one good study that lacks replication, I say, and it costs more than it should, but I haven’t seen side effects from the dosage that I recommend. 

About half the people who got COVID either had the virus earlier or had the vaccine. 

Those who didn’t get the vaccine have given me increasingly rational reasons: history of certain rare, bad neurologic disease (specifying the condition risks identifying the patient), breast feeding mothers, upcoming mammograms, found too long a line at the pharmacy, took time off work but the pharmacy ran out. 

The Pfizer vaccine got FDA approval this week, and more patients have said they’ll get vaccinated in the near future. 

Only one person gave me a completely irrational reason. 

But I didn’t argue with anyone.  Making them state the rationale out loud makes them think, and getting them to think works better than lecturing. 

Lecturing doesn’t work, anyway.  And it takes up too much of my energy.