Not our first rodeo

July 13, 2021

The kiddies, oh how they tried

To stay on for an 8-second ride

The artists of rope

Who have skill and have hope

For the calves they’ve thrown and tied.

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.  Any identifiable patient information, including that of my wife, has been used with permission.

Internet access problems resulted in some non-sequential posts.

Bethany and I headed to the Davis County fairgrounds in Bloomfield for the rodeo on July 4th weekend. 

We met in 1979 in Casper, Wyoming, the home of the Natrona County Fair and Rodeo.  At the time, the town shut down for the Parade Day that kicked off the festivities.  And the rodeo itself went for close to a week.  Talent came from all over North America.

I got chute seats for my first rodeo because I and one of my instructors constituted medical help.  We sat directly over the place where violent bulls and horses got mounted by cowboys who wanted to stay with the animal for 8 seconds.  We got such a choice point of view with the expectation that we’d leap 12 feet down to the arena if someone got hurt. 

I had never been so close to an animal so angry and so large. A riled-up Brahma bull compares well to a rabid freight train.

I also provided medical talent at the National All-Indian Rodeo in Albuquerque one year past residency.  The worst injury I cared for consisted of a badly fractured wrist, but the rider refused transport for care as he came from Canada,  didn’t have medical insurance, and didn’t qualify for the Indian Health Service .    

Both those rodeos ran all day for several days.  The riders all wore long-sleeved white Western shirts, blue jeans, white hats, and no protective equipment.

Now the riders wear protective vests and any color shirt or hat they choose.  Some wore helmets. 

This time we went with the understanding that we’d leave early enough to get back for a good night’s rest.  None of the men’s events drew more than 8 riders; one night 6 of the 7 bull riders didn’t show (I can’t say I blame them).  The women’s barrel racing had the most competitors with roughly a dozen.

Baxter Black, the cowboy poet, noted that the bull doesn’t like the rider and the rider doesn’t like the bull but one without the other doesn’t have a job.

Children had a chance to get some action: trying to stay on a running sheep for 8 seconds, trying to take a piece of tape from the back of a skittish calf, or, for the very young, racing 30 yards to hunt up a shoe and run to the finish line. 

The sun set and the temp cooled while we watched, grateful that none of the events drew more than 8 competitors. 

At the end, we wandered looking for the car in the dark, when the fireworks started. 

We found the car and I enjoyed gawking at disorganized pyrotechnics; in this case I couldn’t keep track of all the stuff getting launched from a half-dozen spots in a radius of less than a mile.  After a half-hour we had seen so many spectacular detonations that we lost interest.  Contrast remains the essence of meaning.

We left before the end, and all the way back we had rockets on both sides. 

Playing with frightened toddlers

July 6, 2021

It’s harder to fight than to play

Although at first it makes a delay

The resulting efficiency

From today’s time deficiency

Rewards gentle, this doctor’s 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.  Any identifiable patient information, including that of my wife, has been used with permission.

Internet access problems resulted in some non-sequential posts.

Monday brought a rush of patients.  Respiratory illness dominates the clinical picture, though today the percentage of positive COVID results decreased radically.  We still maintain a policy of testing everyone with any COVID symptoms as, nationwide, a few people have gotten infected despite full vaccination along with previous infection. 

I had cared for 3 of the day’s 14 patients before, some carry serious psychiatric diagnoses and all with back stories full of drama and irony. 

I like to show off my keyboarding skills by typing notes while the patient talks.  But sometimes the history comes with such a rush of detail that I can’t keep up and I just listen.  And sometimes the patient just needs someone who listens. 

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I attended 9 patients Tuesday morning.  I spend 4 minutes per patient putting on personal protective equipment (PPE): gown, gloves, and mask.  I also spend 2 minutes going between office and exam room.  In the days of paper medical records and transcriptionists, I established a drop-down desk in the hallway between two exam rooms, dictating between patients.  In those non-pandemic days, I could see 36 patients per day, but the efficiency came at a terrible emotional price. 

I took care of a toddler today (and received permission from the mother to write more than I have).  When I entered the exam room, the patient sat frightened, clinging to his mother.  I got out my yoyo and started to play while I stood next to the door, as far from the patient as the room permitted.  He watched the spinning metal toy, and, bit by bit forgot to be afraid.  I brought the otoscope over to the mother, instructed her to use it in play with the patient, and stepped out of the room for 3 minutes.

With 20 minutes of patience and play, I got a good look into the ears without using force.  During my private practice days when time equaled money, I found that investing extra moments for patience and play on the first pediatric visit constituted a sound investment in the future.  Establishing trust and rapport with preverbal children gave me more energy at the end of the day and made future visits more efficient.  

The ease with which I can invest extra time in the future comes in direct proportion to the flexibility of the schedule. 

Wednesday and Thursday

July 5, 2021

You know,  I said with a drawl,

I’m now back to taking some call

For a hospital admission

I needed permission

To leave town and get to the mall.

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.  Any identifiable patient information, including that of my wife, has been used with permission.

Internet access problems resulted in some non-sequential posts.

Wednesday

For the first time since January, 2020, I admitted a patient to the hospital, but not for anything related to COVID-19.

With my inpatient duties I have a return of vigilance after hours.  Indeed, I got a call about the patient around 9:00 PM. 

The cell phone revolution has changed the way that call works.  I have to stay within reasonable distance in case something changes with the patient, but “reasonable” does not carry the same 20-minute designation I’ve grown used to. 

Thus I started the day with hospital rounds, found the patient had improved greatly, and spent most of the rest of the day trying to generate documentation and enter orders. 

Against all expectations, the pace of my clinic work slowed. 

I found no one in the outpatient area when I arrived, and only one patient in the queue for 2:00PM.  (Spoiler alert: things didn’t stay that quiet; I ended up with six patients on the schedule before the day ended.)  I got a 90-minute lunch break, and time to talk with a pharma rep touting a new inhaler. 

Every trip between outpatients and inpatients involved a half-mile walk.

I had to call IT several times.  Most of the problems amounted to chair-ware, but some will remain inexplicable if transient mysteries. 

No new cases of COVID-19 today.

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Thursday

Seven patients today, 5 COVID tests, none positive.  One no-show.

My inpatient got discharged.  I spent several hours today learning how to use the inpatient version of the Electronic Medical Record; it resembles one I used in the last 3 years.

Some parents with appointments bring their children.  Well-behaved kids present no problem.  I can manage most of the others by doing a couple of yoyo tricks, then promising more if the child doesn’t interrupt.  Today a young person played quietly, but I had my yoyo in my pocket and at the end of the visit I did a couple of tricks. 

I always ask patients about tobacco use.  And if they smoke or chew I ask if they’re ready to quit.  Any expressed ambivalence I address with a question about the good parts of nicotine.  My approach usually generates dialogue, but occasionally sends a smoker flying off the handle.

We have had wonderful rains and some spectacular clouds.  I like the clouds, but wet streets keep my bicycle in the garage.  Most days, though, I ride to work, and park my bike in the ambulance bay.

Medical professionals talk about the medical problems of people they know and love.  Today I heard of a person (not my patient, and not in this county) with widely metastatic pancreatic cancer who stabilized abruptly after getting COVID-19 vaccination.  The story came with so many details and numbers that I tend to believe it. 

This corona virus becomes its designation as novel.  We don’t understand more than we do, and the vaccine will teach us many lessons.  

Masking: an aid to non-traumatic peds exam.

July 4, 2021

If a 10-month-old comes in sick

I can clue you into a trick

Is it too much to ask

To put on a mask?

You’ll make friends, ever so quick

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.  Any identifiable patient information, including that of my wife, has been used with permission.

Internet access problems resulted in some non-sequential posts.

To accomplish the desired goal of playing, rather than fighting, with children to get a good look in their ears, my own children taught me some maneuvers, I figured others out on my own, and I picked up some tricks by reading. 

The age of ten months holds a particular problem.  People at this age have stranger anxiety, a consequence of attaining mobility and learning to recognize family from non-family.  (Such was not the case in the two Keresan-speaking Pueblos I worked with in the 80s, Acoma and Laguna, where the “family” consisted of the entire village, and where children constantly received play, attention, warmth, love, and food from hundreds of different people.)  But not until age 15 months do they get really good at imitation. 

Medical school and residency taught us how to use the parents to restrain children who didn’t want examination.  Tears, unhappiness, and fear of the medical profession followed. 

Though kids at 10 months can recognize strangers, they haven’t completely learned how to organize visual information, thus they think that if they haven’t seen your eyes that they remain hidden.

My usual approach involves keeping a barrier between my eyes and the patient’s eyes, turning my back to the patient facing sideways on the parent’s lap, then rotating towards the patient’s back, so I can get in with the otoscope to examine the ears without making eye contact. 

This last week, though, coming to my first 10-month-old in 2 years, I forgot to put the barrier up, and only realized my error after I’d made direct eye contact. 

The pandemic still requires masking.

I sat a foot outside of normal conversational distance and chatted with the parent, waiting for the child to signal the wish to engage. 

In less than a minute, the infant smiled at me and extended a hand.  I ignored the first two signals, then raised my eyebrows, and touched my forefinger briefly to the offered palm, which start a quick game of touch-my-hand. 

The ear exam, the hardest part of the pediatric physical, went well, without restraint or force or tears or coercion. 

I think the presence of the mask prevented the patient from figuring out my non-family status. 

Just one more trick to put in the bag.

Super spreader to spreader max

June 11, 2021

The cows have calves, the pigs shoats

You feed them corn, grass and oats

And then there are horses

Which provide motive forces

And capricious are the ways of the goats.

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 gig is a 2 week on/2 week off position in Iowa.  Identifiable patient information, including that of my wife, has been used with permission.

Internet access problems resulted in some non-sequential posts.

After a very long Monday, administration and I devised a plan to give me a 90- minute lunch.  It works well for me: it gives my day a sanity break, and it keeps me from going into overtime.  We also agreed that I can leave early if we have no patient flow. 

Normal high school events spawned a sequence of super spreader events, culminating in a spreader-max event the weekend before I returned.  Sure enough, the sick ones started coming in Wednesday.  In one day we had 8 out of 10 Covid tests come up positive.  About half of those patients looked sick.  I could offer some monoclonal antibody treatment (no longer the bamlanivimab, now casirivimab and imdevimab…hey, they didn’t hire me to name those drugs).  Most accepted.

But I could only offer that treatment to those patients with risk factors for developing severe disease, such as obesity, hypertension, diabetes, emphysema, immunocompromise whether by disease or medication, alcoholism, or age greater than 65.

To those with a positive test but none of those risk factors, I could offer general supportive measures like acetaminophen, honey, and fluids, and I could mention the single study showing colchicine decreases the severity of illness.  So far, that study, however well-designed and -executed, has not been replicated.   

Despite the rages of the pandemic, I have to continue vigilance about other diseases.  Strep has started to creep through the community.  We have a virus circulating that gives abrupt onset of diarrhea lasting about 24 hours.  A different virus gives anosmia (loss of sense of smell), fever, and cough but the COVID-19 test consistently comes up negative.  So far none of those have progressed to severe disease.   

I have yet to confirm a case of influenza since 2019.

About half the population spends time with livestock.  The Amish use horses for work and transport.  The area raises a lot of pork, mostly in hog confinements.  Cattle husbandry falls into four segments: feed lots where cattle eat to contentment till they reach slaughter weight, cow-calf operations which supply feed lots, dairy farms, and show cattle. Those who know tell me Guernsey provides the best-tasting beef, even from a cow milked to old age.

The people who keep goats love them, but with ambivalence.  Goats think independently and like to play, giving rise to our word capricious

The ripples of a murder

June 10, 2021

Perhaps your job you might lose

Perhaps your ego will bruise

But the right thing to do

And is done by but few

Report the kid’s burn or the bruise.

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 gig is a 2 week on/2 week off position in Iowa.  Identifiable patient information, including that of my wife, has been used with permission.

Internet access problems have resulted in some non-sequential posts.

No one can argue that the US has no firearms violence problem.  Despite the fact that the number of deaths by handgun and rifle have decreased steadily for the last 30 years, the media would have us believe that things are getting worse.  Every day for the last three weeks the net has splashed large headlines about mass shootings.

Yet the bulk of those bullet-related murders, on the order of 400 weekly, happen to inner city males, age 15 to 25, in the course of minority-on-minority violence.  The fact that the media ignores so much blood on the streets in favor of white shooting deaths, could by itself provide convincing evidence of systemic racism. 

The problem does not stop with one person’s mortality, because everyone comes from a family context.  Both victim and perpetrator have relatives, and as the shock of the death ripples through the population, just the family but the friends and neighbors, illness results. 

This last week I cared for a patient from another county for PTSD related to a murder hundreds of miles distant.  The ramifications will impact lives in family after family and community after community for at least two generations.

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One of my patients, who gave me permission to write a good deal more than I have, worked as a kindergarten paraeducator for behaviorally difficult students in another county during a different decade.  The adult reported several attacks by the most disturbed child, and administration took no action.  Against the rules, the teacher removed the student’s shirt, promptly reported multiple healing cigarette burns, and child protective services took no action.  But administration warned the teacher that reporting a major injury to the sheriff would bring immediate dismissal.  The teacher, again against the rules, went to the student’s dwelling, found horrible conditions, and reported them to child protective services, who again did nothing.  Shortly after, a pencil stabbing got reported to the sheriff.  My patient got dismissed, but the child got removed from the abusive parents, and now continues to thrive.  “It was worth it,” the patient said.  I had to agree.  Sometimes a person has to do the right thing even at the expense of a job.

Difficult patient? Easier than difficult computer.

June 9, 2021

To physicians under attack

There is a way to fight back

The IT tech? Don’t dispute her

On changing out your computer

Or warning you of a bad hack.

(Sorry, the IT tech was in fact male, but I needed the rhyme.) 

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 gig is a 2 week on/2 week off position in Iowa.  Identifiable patient information, including that of my wife, has been used with permission.

Internet access problems resulted in some non-sequential post publication.

After a two-week hiatus, I had a rough first day back.

While the facility’s electronic medical record (EMR) system doesn’t rank as the best I’ve worked with, it certainly outshines the worst.  Still, I had problems early in the day.  Whenever I call Information Technology (IT) with a problem, they always tell me to restart my computer.  I called IT at 10:00 AM and said, “I’ve restarted my computer now 6 times and it’s still freezing up.” 

Fast forward to 3:00 PM when the nice IT guy handed over my third computer of the day.  It worked after that. 

To my regret, my three years with Community Health destroyed my patience for balky computer systems.  These days I complain early in the process but I tend to sulk if design flaws stop my progress and patients stack up as a result.

Today I got plenty of warning from coworkers about a “difficult” patient.  As it turned out, shared commonalities established a solid basis for communication.  I recognized a human being in distress, and I listened and I didn’t interrupt.  I found working with the “difficult” patient easier than working with the difficult computer.

The pandemic continues to dominate the schedule.   We ran a lot of tests today but only one came back positive.  But a person in another state died of COVID-19, the effects rippled throughout our social structure, and a patient came to me, sick, as a result. 

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I conversed with another clinician today about infectious disease and bipolar illness.  We see depressed people with pneumonia all the time, I said, but we never see anyone in the manic state with any infections at all.  Indeed, neither of us could come up with an exception. 

Yet we know that 2.3 million Americans have bipolar illness, and each one of those spends, on average, between 13 and 26 weeks per year in the manic phase. Thus in a pandemic, the chance that the bipolar patient will encounter the virus while feeling invulnerable comes to about 1 in 4. 

Which leaves me wondering about those who survived other plagues.  Did typhus, bubonic plague, yellow fever and the Great Influenza confer a selective advantage on the genes that lead to mania? 

For that matter, we know that massive sociologic upheaval (such as with the Christchurch earthquake in New Zealand) can precipitate mania in those who have the tendency, but who would otherwise live their lives without suffering.  

Return after a fornight, capsaicin for shingles

May 31, 2021

From experience, here is my scheme:

Get capsaicin that comes in a cream,

For the pains and the tingles

That follow-up shingles

The relief comes close to a dream.

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 gig is a 2 week on/2 week off position in Iowa.  Identifiable patient information, including that of my wife, has been used with permission.

Internet access problems resulted in some non-sequential post publication.

I took two weeks off to return home.  When we arrived, we found the cherry trees had set a good crop and we found no surprise in the peach tree’s barrenness. 

Cold temps and rain kept me from road cycling for several days. 

Warm weather came late and abruptly.   Thus not getting the garden planted till the third week of may didn’t set production back to speak of. 

We got out to the movies, and half the time found ourselves the only ones in the theatre.

Our favorite Thai chef has reopened in a new location, and we stopped there for a snack. 

Bethany had her second new knee installed last week.  She doesn’t realize the speed of this recovery compared to the last one.  She swapped the walker for a cane at the end of the first week.

On the way back to work today we stopped by a friend’s house. 

Because I did no physical exam at all, it didn’t qualify as a medical visit.  I asked for and received permission to write about our friend’s problem and treatment: post-herpetic neuralgia, the pain that comes after shingles and can last a lifetime.  The oldest patients run the most risk of this most feared complication. 

Many years ago, an undergrad friend who turned into a real scientist gave me the run-down on capsaicin, the active ingredient in hot peppers such as jalapenos.  It only takes a handful of molecules of the stuff to convince certain cells responsible for transmitting chronic pain to quit, sometimes permanently.  Red-pepper liniments preceded the Civil War, and for good reason.  Now we have creams with standardized doses.  Non-prescription capsaicin cream constituted the first really effective treatment for post-herpetic neuralgia.

Most who try to start with a whole dose on a large area experience such an unpleasant burning that they refuse to continue.

I offer advice based on personal experience: start with a pea-sized amount of (non-prescription) low-potency, generic capsaicin cream, spread over a silver-dollar sized area, three times daily till the burning stops.  Then gradually increase the dose.

With decreased pain comes improved sleep, and our friend looked a lot better. 

Thinking about self-defeating behaviors

May 20, 2021

Some people smoke, and they drink,

They teeter, sometimes, at the brink.

Down, they can’t cut.

Really, anything but.

I’m just trying to get them to think.

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.  A month ago, I started a 2 week on/2 week off position in Iowa.  Identifiable patient information, including that of my wife, has been used with permission.

Internet access problems resulted in some posts’ non-sequential publication.

We had a day with a reasonable patient flow.  We didn’t have to turn anyone away.  I got to spend time with patients coming to insight about self-defeating behavior, and to talk about things that work and that don’t work.

A lot of my patients who smoke tell me they’re “cutting down.” I point out that cutting down invariably fails because those who do so haven’t made the emotional commitment to quit.  I have a standing offer:  find me one person who has quit smoking by cutting down and stayed quit for a year, come find me, and I’ll take you both out to lunch.  In thirty years I have not had a single taker.  I tell people who want to quit smoking to wait till they’re ready to quit, and then to quit.  But not to torture themselves before then.

Most people who use too much alcohol tell me they’ve cut way back.  I nod my head and I listen, and by listening I encourage them to talk, and at a particular juncture I ask, “So, how’s that working for you?”  If I time it right, the person starts to think.  And much more change comes from people thinking than from doctors lecturing.  Or preaching.  Or judging. 

I attended two “healthy” patients with no respiratory symptoms at all.  But in the course of the day we ran 5 COVID-19 tests, of which one returned positive. 

We already know of two super spreader events, where one person infected many.  And today we found out we might be looking at a third.  The nurses got out the calendar, pointed out specific dates associated with specific events.  We can follow with alarm the trail of disease, just like a fuse leading to a powder keg. 

The facility did a marvelous job of setting up a clinic to deal with the pandemic: the parking lot replaced the waiting room, people with COVID-19 symptoms come and go by a separate door. 

But mask-, distancing-, and separation-fatigue set in.  People have gotten careless. 

We anticipate the disease will return, this time with a vengeance, before everyone has been completely immunized. 

The facility shifted personnel around, and set up a mass screening that keeps people in their cars. 

My preparation?  Get a good night’s sleep. 

Super spreader events, unapproved colchicine use

May 19, 2021

When it comes to the pandemic scene,

It’s a nightmare, it isn’t a dream

The young dance and sing

And spread COVID-19

All I can offer is just colchicine.

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.  A month ago, I started a 2 week on/2 week off position in Iowa.  Identifiable patient information, including that of my wife, has been used with permission.

Internet access problems resulted in non-sequential publication of this post.

As India’s death toll soars, as British Columbia wrestles with the balance between flattening the curve and keeping the society running, we have had our own “super spreader” event here. 

A person with COVID-19 passes on the virus best in the first three days of infection, before any symptoms appear.  The country’s current most common variant of the novel corona virus spreads less well than influenza; on average one infected person sheds enough virus to infect one other person.  When people mask and distance, when they keep the contacts short, that number goes down.  If they unmask, crowd, sing, and stay in each other’s company for longer, that number goes up. 

A super spreader event usually happens when one infected person with no signs of illness stays in close company with the unvaccinated.  The bigger the crowd, the louder that people talk (or sing), the longer the party, the more droplets and illness spread.

At one event (not here, in a case published by the CDC) one person infected hundreds. 

In spring, high school and college students graduate, dance, and perform.  Normal people this age feel invulnerable and immortal, and resent being told what to do.  They doff their masks at celebrations and gatherings.  All this when we lack the vaccine, infrastructure or will to immunize the young. 

We had two super spreader events during the last two weeks, one leading to the other, in a population with a lot of vaccine hesitance and refusal.

Today we had 6 out of 9 COVID-19 tests come back positive. 

If a person has risk factors which make severe infection likely, when the infection is mild and early, we can give monoclonal antibodies such as the bamlanivimab that I received in November. 

I cannot offer any FDA-approved treatment to the healthy young with mild disease.

But I can offer colchicine, a centuries-old plant extract used mostly for gout.  If I do, I discuss unapproved uses of approved drugs.  I detail the single double-blind, placebo- controlled study with 4000 patients, which showed a shortened illness, about 50% reduction in risk of hospitalization and the need for oxygen, and a smaller improvement in risk of death. 

I keep my pitch firmly to the spinless truth. 

Less than half the patients request the drug. 

I look forward to the time when I have more data, and more options to offer the patient.  But by then, I suspect we’ll have fewer patients vulnerable to the disease.