Mud pit volleyball

August 3, 2016

After rounds, we went to the fair.

Who knew what we’d find there!

But a volleyball flood

Made a pit full of mud

There was plenty of fun to spare.

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. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

 

I made Saturday hospital rounds on three patients, discharging one, getting another ready for discharge, and continuing treatment for rather serious illness in a third.

We went over to the Farmer’s Market. We arrived too late to get the tomatoes that we crave, and our current cooking facilities (a microwave oven) wouldn’t let us take advantage of the good ranch chickens on sale, but we bought a cantaloupe driven in from Rocky Ford in Colorado.

Afterwards, Bethany and I headed out to a nearby (a relative term in western Nebraska) county fair.

A county with a small population holds a small county fair, one which we can circumnavigate on foot with no problem. We saw prize-winning cattle, sheep, goats, pigs, and rabbits.  We took in the exhibit hall and learned about elk and the importance of solitary bees.

Despite seeing a lot of mounted people and we arrived too early for rodeo.

But we found a couple of volley ball games in full swing.

As near as I can tell, there are three kinds of volleyball: indoor, beach, and mud pit. And I hadn’t known about mud pit volleyball before today.

Imagine a beach volleyball court excavated to a depth of 5 feet and filled knee deep with water. Participants might wear sneakers or they might go barefoot.  As the event progresses, the water gets muddier and the bottom gets more slippery and uneven.  Those inherent difficulties of trying to move radically change the character of the game, and Newton’s Laws bring a comic flavor.  Diving doesn’t work, and only the foolhardy jump.  If the ball comes to you, great, and if it doesn’t you don’t have a lot of choices.  I saw a lot of unintended slapstick comedy, including an all-out pratfall with both feet off the ground, a short-lived full water clearance, and a high-splash back-flop (like a belly flop but on the other side).  Eventually, those at the sides of the pits started to slide towards the middle.  The wind, always a factor on the Great Plains, gave a distinct advantage to one side. 

They say that the more seriously you take something, the less fun you have doing it. And I think those teams who lost had just as much fun as those who won.

 

Sports physicals and good horses

July 30, 2016

Out here they have nothing to hide

They think it’s important to ride

The unified force

Comes down to a horse

They’re cowboys and cowgirls, bona fide.

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. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

Thursday the construction noise had become intolerable. I put on my shooting muffs, and stepped out the side door.  The worker operated an electric jackhammer, not a drill, detaching a concrete lip from the foundation.  I waited till he had hacked off a chunk, stopped his machine, and repositioned.

“Excuse me,” I said, “Um, any idea how much longer you’re going to be?”

“Almost done, probably by lunch,” he said.

“Do you have hearing protection?”

“Yeah, “he said, “In the truck.”

“Take it from me,” I said, “If you want to be able to hear the voice of your grandchildren, protect your ears.”

I had a productive day, between outpatient and inpatient I attended 14 people.

Sports physicals, required by school districts, don’t save lives and don’t prevent injuries. On average, less than once every two years I detect a problem during a pre-participation exam that I can do something about.  Still, the visit goes quickly, and I get to educate the kids.  As the athlete sits on the exam table I ask what sports.

Here in western Nebraska a lot of the students start their list with rodeo. Ranching and wheat dominate the agricultural sector.  People rely on horses for work and for play.  Ranch work goes much easier with a good horse and good roping skills.  People favor quarter horses for their intelligence and speed.  So when the kid says rodeo, I ask, “Do you have a good horse?”

Sometimes the face lights up and the grin follows, and I infer, that, indeed the horse is a quality animal. And sometimes the answer comes back, “Pretty good.”

Patient flow slowed to a negligible trickle on Friday; I attended three times more people in the hospital than in the clinic, where I only saw one.

I greatly enjoyed that patient, who gave me permission to write that I diagnosed piriformis syndrome (see my post from 2010), one of my favorite problems because I can fix it before the person leaves.

The insurance credentialing process has cleared me for 4 insurances but not for the majority. I do not understand why, because I had full credentials when I worked here in January.

So I had a slow week, and I would have preferred more patients. All in all, I saw entirely too much drama and irony in for form of patients paying the ultimate piper for their dance with tobacco.

 

A single digit error explains low patient flow

July 27, 2016

I said to the front office clerk

I hope I’m not being a jerk

Someone who works in hive

Wrote  seven, not five.

Now will you please just send me more work?

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. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

After two months of no patient care I returned to work three days ago. Patient flow crept in the single digits daily.

Still I had bloggable moments.

We dealt with a cardiac arrest the first day. Doing CPR constitutes a valid workout, and people fatigue so quickly that the guidelines call for a change of personnel every 2 minutes.  My turn came, and the hospital CEO followed me.

For different people with different problems that day I advised drastic alcohol reduction, complete tobacco elimination, good hydration, sleep prioritization, regular exercise, and a return to counseling. I pointed out that marijuana aggravates anxiety, deepens depression, brings on paranoia, and sabotages life goals.

Yesterday we watched through my office window as the crane lowered a new installation, really a prefabricated building with very expensive equipment, into place. The machine, worth dozens of millions of dollars, came down slowly, guided by men in hard hats with ropes.  I recalled my days in construction, when I swept the concrete footing furiously just before the crane lowered the form.  I looked at the odd clods of dirt on the footing and shook my head.  The stucco wall now sits three feet outside my office window, completely obstructing the view, and reflecting the heat from the sun.  I’ve quipped it’s a monochrome mural by a noted abstract artist titled Beige Wall, and offered to forge a Salvador Dali signature on it.

I performed my version of a complete neurologic exam on 4 different patients yesterday; all completely normal. I deal with a lot of patients with headaches, migraines and others.

But I also took care of a very sick patient. At the end of the day, I ordered a lot of lab work, all of which got sent to a reference lab an hour away.  I left my phone number with the techs, telling them that they could text me results without violating HIPAA as long as they didn’t attach a patient name.  And I could do so safely because I only had one patient hospitalized.

Today the low patient flow continued. The new installation required lots of drilling through my office wall.  I fled the intolerable noise to chat with a colleague.  But I also passed a front office staffer at a critical time.  She asked me my UPIN.

Various entities have assigned me various unique identifying numbers, starting with my 9 digit Social Security number. The longest one, with 14 digits, comes from Canada. I gave her the 10 digit number, flippantly, ending with 365.  She frowned.  The one she had on file ended with 367.

That one digit error resulted in no insurance credentialing for 5 companies. The clinic administration worked hard much of the afternoon to try to set things right.

While the drilling in the wall continued.

I thought about the Bob Dylan song, Lily, Rosemary and the Jack of Hearts.

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.


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