An Abnormal MRI, too close to home

July 13, 2016

We’re doing the best that we can

To follow an abnormal scan

The rumor was tumor

But the answer was no cancer

And the treatment’s a flash in the pan.

 

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, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. All our plans have been put on hold pending resolution of my wife’s brain tumor.  Any identifiable patient information has been included with permission. 

Three weeks ago on Tuesday my wife, Bethany, awakened with severe vertigo. She couldn’t get out of bed without vomiting.  Over-the-counter meclizine helped but little.  I posted the case on a physician’s chat site the next day, and got the recommendation for the Transderm Scop patch (she had one left over from a recent trip).  It helped but the problem persisted.

I don’t like to be my family’s doctor, so that Friday morning we went to the Clinic Formerly Known As Mine. Bethany’s doctor found horizontal nystagmus (a twitching gaze), when looking to the right, and ordered an MRI with contrast.

Chaos dominates Friday afternoons, thus Friday’s MRI happened without contrast.

I have the training and education to imagine a large collection of really bad things, and by now I’ve learned that the awful moments in life come to us unanticipated. So I went through my catastrophic catalog and felt better for having done so.  My phone went off while I was gardening.

In general, you don’t want your doctor to have bad news, especially not on Friday afternoon.

The MRI showed a 2.2 centimeter something behind the left eye. The original report mentioned possible glioma with the strong recommendation for a contrast study.  The thing’s location didn’t account for the dizziness.

With advances in imaging, we have had to come up with a term that means an abnormal finding found by coincidence; we call it an incidentaloma.

I called my locum tenens recruiter to say I had put all plans on hold; she relayed the information to those facilities expecting me in Nebraska and Alaska. Bethany phoned our daughter to say she wouldn’t be coming to help with the new grandson.

That night I read Bethany the Wikpedia article on glioma: 1/3 benign, 2/3 cancer.

Bethany’s cousin’s first wife died three weeks after getting her glioma diagnosed; she only had time to pick out her husband’s next wife, and say a loving goodbye to her family. In the ‘80’s I had a patient with a glioma who lived for less than 100 days after diagnosis.

We didn’t talk about those things.

Bethany took the information in stride, with understated courage. I focused on the moment with the joy of uncertainty that gives hope.  I embraced not knowing and did my best to focus on the moment: stripping the last tart cherry tree of its fruit, bringing in the first green chiles from the garden. I clung to things precious for their normality.

We suffered through the next four days, our plans shredded, as Bethany’s dizziness faded and her balance improved.

With her vertigo improved and her calm unruffled, Bethany went in for the contrast MRI the Tuesday morning before July 4. In the afternoon our fax brought the new diagnosis of meningioma, a well-behaved tumor with little if any malignant potential.

Relief of a magnitude that brings tears defies description.

I relied on my status as a physician and on friendship to get us an appointment with a neurosurgeon the next morning.

He explained the choices: leave it alone, open surgery, or radiation. He said if it were his tumor, he’d prefer the radiation.  He also showed us the MRI image, with a bright cylinder an inch long and half-inch wide growing up from the floor of the skull just behind the left eye.

He doesn’t do that procedure, but his partner does. And that partner wouldn’t be back in the office till Tuesday the following week.

Basking in the light of a better diagnosis while marinating in the darkness of an upcoming brain procedure, we went about our business. We had ice cream with our neighbors, and friends over for dinner on Friday.

Yesterday we met with the neurosurgeon, who explained stereotactic radiosurgery. And today we met with the radiation oncologist.

The actual treatment consists of focusing a radiation beam on the tumor, zapping the same way sunlight, focused with a lens, burns one point.

The next step, the 3D MRI, remains unscheduled.

 

 

Colleagues, vitamin D, and statin myopathy

June 20, 2016

There once was a doc from Manhattan

One day we just fell to chattin’

I asked, “What would it take

Besides a muscular ache

To get someone off of a statin?”

 

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, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter found me working in western Nebraska and, later, in coastal Alaska.  After the birth of our first grandchild, I have returned to Nebraska. Any identifiable patient information has been included with permission.

 

Merkin’s Law states that any patient given a high enough dose of a statin for a long enough time will eventually hurt so badly exercise becomes impossible.

We call the drugs statins now because the generic names all end with those two syllables, but when they first came out we called them HMG coA reductase inhibitors. We used those drugs for years to lower cholesterol, in the hopes of decreasing risk of heart attack and stroke.

More than 20 years ago, though, a cynical doctor at the back of a lecture hall questioned the utility of that class of drugs if we got no net benefit in all-cause mortality. It seems, he said, that for every life saved from heart attack or stroke, one was lost to homicide, suicide, car accidents or respiratory infections.  The crowd laughed at the litany of diseases.  A year later, at the same Continuing Medical Education event, we chuckled when the same scene played, and a year after that, nobody laughed.  Aggressive drug company marketing fueled the cholesterol hysteria but I never developed a passion for treating cholesterol numbers.

My wife, after 3 years of statin therapy, over the course of 5 days developed such severe aches that her Tae Kwon Do class missed her black belt till she quit the med and recovered. Such circumstances did not endear that bunch of drugs to my heart.

Still, in context, I have the obligation to give my patients standard of care. I tell them about diet and exercise almost to the point of nagging, then I start the statin, and I warn them about side effects.

In the last two years, we have gotten convincing evidence that high-dose statins, regardless of cholesterol numbers, improve the outlook for those at high risk of heart attack and stroke.

Still if a statin patient hurts for no good reason, I tell them to stop the med, but I also test the blood for creatine phosphokinase (abbreviated to CPK or CK).

I outlined my personal algorithm to my colleague, and described my strategy of stop and rechallenge, and, if need be, use of coenzyme Q10.

He told me, gently, that coQ10 does no good, but switching to a lipid soluble statin does.

I found the discussion so constructive I went online, and found, to my chagrin, that he was right, and my past experience with coQ10 relied on the placebo effect.

I stuck my head in his office, and told him he was right. But I also told him I learned to check the thyroid and the vitamin D in those cases.  He looked at me with the same amazement I felt when I’d read about lipid-soluble statins.

We both emerged from the experience better doctors.

Transferring a complicated patient 3 hours away

June 6, 2016

I handled the case presentation

With the addition of great complication

Planned down to the comma

This tale of drama

Ran a full minute’s narration.

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, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter found me working in western Nebraska and, later, in coastal Alaska.  After the birth of our first grandchild, I have returned to Nebraska. Any identifiable patient information has been included with permission.

On Friday a patient and I walked down the hallway. I said, “I write a blog.  Now I won’t write your gender, age, race or diagnosis, but I’d like to write that I took care of a very complicated, sick patient requiring lots of lab and x-ray and referral to a higher level of care than we can give you here.”

“Yeah, OK,” the patient said, and looked sideways at me.

I called the referral hospital, 3 hours away, and presented the case to the ER physician.

I do case presentations the way I used to do radio commercials in the early 70’s, during my college radio years at WYBC. If I can’t say it in less than 60 seconds, I need to reorganize.  This subgenre of the short story, when done well, presents human drama condensed down to the density of gold.  The very fact of doctor talking to doctor about a patient means that something important happened.  In a sense, it’s short play to a small audience.

I presented the story according to the conventional order: age, gender, race, presenting complaint, history of presenting illness, past medical history, social history, physical exam, lab, x-ray, EKG, and my working diagnosis, followed by the request, “Will you accept the transfer?”

“Yes,” the other doc said, “Of course. This is a very sick patient, but, I don’t quite understand, are you in the ER?”

No, I replied, I’m a locums. They send me the walk-ins.  Essentially, I’m doing Urgent Care, with benefits.

“You mean you did all THAT in Urgent Care?” she asked, flabbergasted.

I cared for 8 patients that day, the youngest 15, the oldest 95; 2 inpatients, 6 outpatients. I only wrote 3 new prescriptions but I stopped two others.

Though I used to look at a clinic day of 32 patients as nerve-wracking light, and 36 per day as perfect, I felt good when I left at 5:30. Learning a new EMR system takes weeks.

And towards the end of the day my ability to send prescriptions electronically directly to pharmacies suddenly stopped. While I saw the last patient, of course more complicated than anticipated, a team of 4 figured out that restoring that ability couldn’t happen, and set up my machinery to print prescriptions to be faxed.

But Bethany and I left the hospital behind, and drove to Denver, arriving after sunset, for a family gathering.

 

An afternoon with 3 patients

June 2, 2016

This afternoon, I was happy to see

Patients, but really just three

I couldn’t send the prescription

Without a description

Of where the button happened to be.

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, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter found me working in western Nebraska and, later, in coastal Alaska.  After the birth of our first grandchild, I have returned to Nebraska. Any identifiable patient information has been included with permission.

No work for me on this last Monday because of the holiday; I spent Tuesday getting trained for the new EMR. The Basic Life Support (BLS) class took up most of Wednesday, and I left without seeing a single patient.

This morning I looked in on two hospitalized patients that I’ll care for on Friday.

Then I listened to jackhammers outside my office window for the rest of the morning while I did more BLS instruction on line. After all, hospitals only finish up their construction when they die.

My afternoon included 3 patients, scheduled at the rate of one per hour to allow me to figure out the new system. Two came from my generation, one from my parents’ generation.  The first I treated by taking away a medication.  The second, with a very complicated history and a long med list, I treated with gravity.  The EMR guru, sent by the vendor to help the transition, and living away from home for months, gently and patiently talked me through the documentation.  Then, after hours, he needed to leave for family business.

I had to prescribe a medication for the last patient, something I’d not done so far. My nurse, a stranger my end of the EMR, couldn’t help me with a very confusing task.  At that point, late in the afternoon, all the other providers had gone home.  One other remaining nurse stood over my shoulder, and told me what to do.

She had me click on an ellipsis, and then clicked her tongue and said, “Well, I’ve never seen that before.”  Fifteen minutes later, we resorted to calling the prescription in.

It reminded me of the time when the airline scanner wouldn’t take my boarding pass and my name ended up hand-written on the passenger manifest.

At the end of the day, Bethany picked me up. We stepped into an afternoon with a light breeze and a perfect temperature.  Atypical rains have left the sky clear blue and the countryside lush green.

I regretted keeping her waiting when all I’d done was take care of three patients.

Return to Nebraska

May 31, 2016

I wonder what could be cuter

Than an easy to use computer

But here is the deal

For the ones that are real,

You need a professional tutor.

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, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter found me working in western Nebraska and, later, in coastal Alaska.  After the birth of our first grandchild, I have returned to Nebraska. Any identifiable patient information has been included with permission.

 

Western Nebraska has greened up since I left in January. The temperatures hover near a perfect 66F.  But the same pure white clouds scud across the same clear blue sky.  I walked into the hospital where I worked last winter.

I called it the most reasonable job I’d ever had. One Saturday clinic every 4 weeks, no nights, always finished before 6:00PM and almost always before 5:30PM.

A lot of people grinned when they saw me.

I heard about two of my patients, one with a neurologic problem and one with a chemical problem, who had started to improve with my care and had done very well since.

I also heard about the transition to a new EMR, so that the outpatient and inpatient sides could talk to each other. And, indeed, my task to day consisted of learning the new system.

Superficially, it looked familiar, but I have learned 11 new EMR systems in the last 18 months. I try not to get whiney about quirks that impede work flow and make no sense; I just try to master the task at hand.  However, RPMS, the system I used in Alaska from February through April, made the most sense, and I found it the easiest to use.

I got back my old office here, but the temporary CT scanner trailer outside the window has left, giving me a very nice view of the sky.

I spent more time with Continuing Medical Education (CME) than on computer training in the last year and a half, but not by much. The worst training was from a person who wanted to get her 15 students out early and went way too fast, the best was from a gifted teacher who worked one-on-one with me for three days, combining orientation and EMR.

Today I sat in front of a computer screen and talked to a trainer in Arizona over a speaker phone. Parts of the system looked familiar, most didn’t.  Real fluency and economy of motion will take time, but I have to start somewhere.

In small towns like this, the sound of a helicopter means someone’s serious illness. I heard the unwelcome thwap thwap thwap of the rotor blades while I talked to the Arizona trainer about some of the fine points of documentation for billing purposes.

I prefer taking care of patients to dealing with computers, but here I found myself torn: my favorite patients have problems where I get to think, I don’t find them on the brink of death.

The chopper landed just outside my window. I had to ask for half a minute of quiet at the peak of the landing noise.  Then, while unspeakable drama ran rampant elsewhere in the hospital, I went back to the intricacies of an Electronic Medical Record system.

 

Of Red Tide and dead walrus

April 16, 2016

We went for a very short ride

And found acres exposed by low tide

Which brought within reach

Clams of the beach

And other things people eat fried

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, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. After two months each in Western Nebraska and the West Coast of Alaska, I’m now in Southeast Alaska.  Any specific patient information has been included with permission.

An intestinal virus with violent vomiting and profuse watery diarrhea has dominated my clinical work for the last week. It hits the toddler-to-middle school age range disproportionately, but it still struck a lot of adults, and struck them hard. I can’t do anything for the basic disease process; people tend to heal on their own. But if dehydration sets in, I have developed a routine that calls for 2 liters of IV fluids (if you must know, Normal Saline, the same as 0.9% Sodium Chloride) and 8 mg of ondansetron (trade name, Zofran).

When I hear of vomiting and diarrhea starting at the same time, I tend to think of food poisoning. But food poisoning will strike a household all at once, where this virus hits family members in sequence.

I had to consider, also, the shellfish problem.

The people on an island with 25-foot tides like to go out at low tide for mussels, clams, cockles, whelks, abalone, crabs, and octopus.

When the water ebbed out 3 feet lower than average this weekend, Bethany and I went to explore the beach.

We found the water’s edge a hundred yards past where logs drifted onto beach grass mark the high tide line, on a beach of whispering tranquility, surrounded by towering evergreens. We picked up a dead sand dollar, and saw holes where a clam spade would have brought a tasty morsel. A mother with her two children came out exploring. The adults had a delightful conversation, and one of the kids picked up an abalone. I had never seen a live one before.

Which prompted me, the next day at rounds, to ask my colleague about the posters we’d seen warning of Paralytic Shellfish Poisoning. He explained that some algae contain a toxin that filter feeders, like clams and mussels, concentrate, and which, if consumed, cause a very ugly paralysis. Those algae blooms, known as the Red Tide, in the warm weather, especially in El Nino years, and more often when the temperature goes up.

I asked about walrus, the sea mammal that eats mostly clams. I recalled the large walrus skull I saw on the wall of friends who live in Southwest Alaska. While out sport flying, they spotted a walrus carcass on the beach, landed, and wrestled the ivory-bearing head into the plane.

While the algae blooms won’t happen for another month, some bivalves, like mussels, retain the toxin for years after a bloom.

First day in Metlakatla

April 12, 2016

I set off in the down-pouring rain

To the clinic, a small House of Pain

I started up with a smile,

Because that’s my style

And it’s easy for me to sustain.

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, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. After two months each in Western Nebraska and the West Coast of Alaska, I’m now in Southeast Alaska.  Any specific patient information has been included with permission.

On Sunday we took the ferry from Ketchikan to Annette Island, a ride of 45 minutes. We arrived in a pouring rain.

People call this area of Alaska the Panhandle, it juts southeast along the Pacific coast. It receives an average of over 100 inches of precipitation yearly.

About 2000 souls reside in Metlakatla, the town on the west part of the island. WWII brought an influx of defense personnel, who did not leave until late in the 20th Century; the majority of the inhabitants are Natives. As Alaska’s only Indian Reservation, license plates and driver’s licenses are optional, and ATVs run street legal.

The clinic assigned us to a cozy apartment less than a half-mile walk from the clinic, and I did my initial morning commute on foot in a torrential rain.

My first day on the job here started with morning rounds.

Talk of tides and fishing dominated the conversation before the clinical discussion. I mentioned the poster warning of paralytic fish poisoning I’d seen on the front door, and those present assured me that the problems wouldn’t start for a month or so.

The doc who had call opened the discussion with a rundown of the weekend ER patients.

I spent the morning in orientation and getting my ID badge and entry card, and I took care of four patients in the afternoon. I used RPMS, an Electronic Medical Record (EMR) system developed by the Veteran’s Administration.  Far from perfect, I find it the best one of the 9 I’ve learned in the last 14 months.

I talked to a relative of the first Native to be drafted by the NBA (that unique individual has a lot of relatives on the island).

I saw the first of what would be a string of patients with violent vomiting and diarrhea, ranging from infant to middle age. Almost certainly viral, we have no treatment aside from oral rehydration, or, in extreme cases, IV rehydration.

But we are a clinic with an ER and no hospital; we don’t keep patients overnight. I will have to weigh the risks of a boat ride if I consider sending a patient for further diagnosis or treatment.

At the end of the day, we arrived back at the apartment dripping from a walk in the driving rain.

Well, if you can’t take the rain, stay out of the Panhandle.

Ketchikan to Metlakatla

April 12, 2016

We came across on the ferry

At leisure, and then we could tarry.

Some food we bought more

With a trip to the store

And we found some good prices on dairy.

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, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. So far this year I worked assignments in western Nebraska and southwestern Alaska; I just arrived in southeast Alaska.  Any specific patient information has been included with permission.

We took the ferry from Ketchikan to Annette Island, the only Indian Reservation in Alaska. In 1887 an Anglican missionary, motivated by doctrinal differences, led a thousand Canadian Tsimtshians on a search for a new home.  They found this island, moved legally, and in 1906 petitioned for, and received, reservation status from Congress.

Fortunate enough to have no mineral wealth that economic interests wanted to steal, they maintained their reservation more or less inviolate until WWII, when they got an air base, and a promise to build a road to the other side of the island so as to link up with the Alaska Marine Highway system. The road took eleven years to build and finished 8 years ago.

We learned these things from the Security guard who drove the 15 miles from the clinic to pick us up, and also took us on a tour of the town.

Falling timber prices shut down the logging and sawmill operations.  The salmon cannery, the casino, the school, and the clinic provide the most jobs.

We passed the gas station, the schools, the churches, but no bars or liquor stores.

Perhaps because of fewer freeze-thaw cycles, perhaps because of better maintenance, the roads lack the crater-grade potholes we find back home in the spring.

The guard helped us drag the luggage up the stairs to the apartment. We unpacked briefly.  We ate the snack that Bethany had the foresight to bring, then we walked to the grocery store.

We hadn’t expected a well-maintained, well-stocked, brightly-lit facility.  The prices, a big higher than Ketchikan’s, didn’t look so bad compared to what we’ve paid for the last two months.

Then we settled in. We tried the TV and found no service, and we had no idea whom to call about the Internet password.  We played Scrabble, ate some salmon we’d brought, and found ourselves exhausted when the sun went down.

In the same time zone, but we definitely faced jet lag.

Overnight in Ketchikan

April 10, 2016

Up here, it’s one of the sights

When present it cheers up the nights

I regretted quite loudly

That the sky was too cloudy

To see the great Northern Lights.

 

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, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. After 2 months in western Nebraska, then two months in coastal Alaska, I’m now in the Alaska Panhandle.  Any specific patient information has been included with permission.

 

After an overnight in Anchorage, we arrived in Ketchikan, Alaska’s first city and never Alaska’s capitol.

Contrast is the essence of meaning, and Alaska’s hugeness makes for a lot of contrasts. After overlooking an arm of the Bering Sea from a coastal plain with mountains 30 miles distant, mountains here rise abruptly from the salt water, with not a single swath of tundra to be seen.

Technically in the same time zone, we crossed 24 degrees of longitude to get here, as many as you cross getting from New York to Chicago.

Ketchikan built its airport on an island, and, I suspect, built the island for the airport. One takes a ferry to town.  Anticipating problems with luggage, transitions, and inadequate support for the profession of skycap, the airport offers free luggage carts.

We found Ketchikan’s mood much like other tourist towns in the off season. The gold rush over and the timber prices low, tourists won’t start arriving by the literal boatload till May.  The other industry, salmon canning, stays small to stay sustainable.

The town features large on cruises of Alaska’s Inside Passage, and last year more than a million tourists filtered through.

We stashed our cooler full of salmon in the Best Western’s freezer space. The hotel’s service amenities include a van that drives people around town.

We went grocery shopping, knowing the high prices found on any island, especially an Alaskan island. We walked back to the hotel because we needed the exercise, exploring the Marina and the parking lots off Tongass Avenue, the main drag.

On the advice of a ferry passenger, we went out to the Lodge at Cape Fox, a first class restaurant run by a Native Corporation.  We enjoyed a spectacular view of the harbor and Halibut Olympia, while we discussed a weight loss strategy for our upcoming stay.

The news predicted great Northern Lights. After dark, I went outside to look up and find dense cloud cover.

Easter Sunday in the ER

April 10, 2016

Readers:  Connectivity problems slowed the flow of posts.  To preserve the sequence, this is a week late.

It could have been nothing at all

With the cold and a sudden snow fall

I thought I would try it

It was 6 hours of quiet

This Easter when I took ER call

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, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

When the Russians took possession of the part of North America we now call Alaska, they enslaved the indigenous people but had more interest in furs than in land. But they brought their religion, and it stayed when they left. Thus this town celebrates Easter at two different times. And this year the Orthodox Easter comes almost a month after the Catholic Easter.

If one of my colleagues celebrates a religious holiday that I don’t, I do my best to take call for that person, thus I find myself this morning in the Emergency Room.

0750AM: Arrived in ER to find no one here. I sat down in the doctor’s corner, fired up my computer, and started looking through the inpatient census.

0800: Spoke with a helicopter pilot in follow up and got to quizzing about the other professional’s job. I learned about darting wolves and moose. I found out what can happen when a compressor goes out and the engine fails between 60 and 600 feet up, what the helicopter pilots call the death curve. At such altitudes the helicopter can fall hard enough to kill, but can’t build speed enough to use the rotor as a brake. The problem being, of course, that most helicopter work involves just those altitudes.

Spoke with the doc who had taken call for the 12 hours previous. Not much to report.

0830: Started inpatient rounds on three patients. I can’t write about individuals, and, in this case, writing about disease states might identify people who didn’t give their permission.  But I can say that I dealt with the respiratory system and the gastrointestinal system.

Newton’s laws of physics don’t account for certain large parts of the universe, but one of those laws says two things can’t be in the same place at the same time. And human bodies suffer in consequence. If the person damaged by that inescapable reality lives in a small village accessible only by air or water, the consequent injurious effects ripple throughout the community.

10:00 AM Heavy snow fall started. Nap time.

10:20 AM One of the inpatients worsened. I got information and facts straight before I called the consultant at Alaska Native Medical Center (ANMC) in Anchorage. The light-hearted interaction brought me new information. The decision to send a patient out in a Medevac plane brings risks, especially in a snow storm.

11:00: Watched YouTube videos on Eskimo Scouts, racist Cold War Propaganda, but sympathetic to the people of Shishmaref outside of Nome.

11:45AM Called my wife to meet me for lunch in the cafeteria. The soup was excellent.

1230: Phone call requesting a medication refill. I said yes to a blood pressure medication with multiple uses and no resale value. I put a note in the electronic health record, but didn’t see the patient face to face.

13:00: Colleague called. Church finished. Take your time, I said.

14:00:  Colleague arrived.  Left in a slush flurry.


Follow

Get every new post delivered to your Inbox.

Join 56 other followers