Misnomers, eponyms, and radio traffic

February 12, 2016

We started out doing rounds

Exploring our intellectual bounds

It’s not a misnomer

To call a vomer a vomer,

No matter how silly it sounds.

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.

Yesterday before 10:00 AM I had to research two diseases I’d never heard of before, and I didn’t attend a patient with either.

Medicine uses its own language. Some nouns, like vomer (the midline bone in the nose) have no other synonym.  Ideally one could discern the nature of a disease by its name; viral hepatitis, for example, means liver inflammation caused by a virus.  But if we call a malady by someone’s name, such as Parkinson’s disease or Lou Gehrig’s disease, we say that we use an eponym.  And we call it a misnomer if the disease isn’t what we call it, for example, a pyogenic granuloma is neither pyogenic nor a granuloma.

Another provider held up an x-ray report and pointed to a term, asking if I’d ever heard of it. I chuckled and asserted that surely the transcriptionist meant either fracture or infarction instead of what appeared in black and white, infraction.  So I looked up the eponym, only to find that the transcriptionist had typed correctly.

The other term, including an Alaskan place name, got thrown around during rounds. I had heard of the body of water, but not the syndrome.

The medical staff gets together every morning, much as we did in Barrow and each meeting makes me a better doctor. We talk about admissions, births, deaths, and interesting cases.

For the second time this week, we threw the term Wernicke-Korsakoff around without making that diagnosis.

When we talk about what might be wrong with a person, we use the term “differential diagnosis,” meaning the things that could give rise to a particular clinical picture. In conversation, we shorten it to “differential.”  In the process of dialogue, we draw on each other’s experiences and knowledge at the same time we go through our reasoning process.

After rounds I nipped out to the airport to pick up Bethany, then I came back to find that I had drawn the position of second call: help out the first call doc if overwhelmed, and take care of radio traffic.

The term radio traffic qualifies as a misnomer because we use telephones where previously radios had done the job. Dozens of villages look to the town as their hub for business, health, and air travel. Every village has a clinic staffed by a Community Health Aid or a midlevel practitioner. Each permanent doc serves as consultant for more than one village, but the second call physician converses with the clinic when the assigned doctor goes on vacation.  And right now the hospital finds itself short-handed.

I sat in the medical staff office. I cleared up documentation and read through the scores of emails that had arrived before I did.  I looked at the corporate website, and checked weather reports.  I read through some informative threads on Sermo.com, a doctors-only website.  At noon I went to a Continuing Medical Education lecture on diabetes and the new class of drugs, incretin analogs.

At one I had a few phone calls, and I phoned around to a dozen clinics.

And I drew on my experience with game theory to make decisions based on incomplete and imperfect information.

I did a necessary job, but I prefer face-to-face human contact.

 

 

Back in Alaska

February 8, 2016

On a flight I was lucky to get

I left Omaha on a jet

And then I flew far

To learn a new EMR

America’s most sensible yet

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.

Leaving Omaha last week on Alaska Airlines included more difficulties than anticipated, mostly at the gate.  The bar code scanner flashed red three times and made an ominous noise with 20 minutes to take off.  At 16 minutes to take off the gate agent phoned for help.  Four minutes later the third, Millennial gate agent, despite obvious computer expertise, said, “I’ve been working here two and a half years and I’ve never seen this error message before.”  Four minutes before the doors closed a couple caught the plane because my computer glitch prevented an early departure.  I told the fourth gate agent I had a credit card, I knew how to use it, and sick natives awaited me where cars cannot go.  With a minute to spare I got on the plane; the airline staff resorted to hand writing my name on the manifest.  I didn’t say anything about what happens in medicine when we lose the paper option and can’t free text.

Alaska is a very big place, with roads going to only a few population centers.  A nice overnight motel in Anchorage brought little sleep.

The airport I came into has no jet way or luggage carousel, but unloading baggage involved little chaos.

The nice lady from Medical Staff who picked me up started my orientation on the drive from the airport, explaining the road system in 3 minutes.  You can’t get lost, she said, just keep walking and you’ll get there.

Few Americans can name any of the 7 states that border Iowa, but most people here can, and a surprising number have been through Sioux City.

I went through a compressed, simplified orientation.  Maybe because it’s simple and not geared towards billing, and maybe because I’ve learned 8 new ones in the last 14 months, but the electronic medical record (EMR) system didn’t need much introduction.

With no internet connection or TV at my apartment, in desperation for something to do I turned to reading the orientation materials.

Then I had to brush up on botulism, paralytic shellfish poisoning, amnestic shellfish (domoic acid) intoxication, scombroid fish poisoning, glanders, and  melioidosis.

 

 

 

 

 

 

 

 

 

 

Discharge summaries

January 30, 2016

I can’t believe how the time flies

We’ve already said our goodbyes

I got into the groove

And now we must move

And drive east into the sunrise.

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. I just finished two months in western Nebraska. Any patient information has been included with permission.

 

Friday dawned clear, cool and bright. We got up early for the finishing touches on moving out.

The townhome the agency rented for us surpassed all expectations with cathedral ceilings, hardwood floors, good construction, comfortable mattress, serviceable equipment, and a killer view. I moved stuff out the front door to the walk by the car while Bethany packed. We left notes for the landlord and the neighbor.

We stopped at the hospital. I had forgotten one bit of documentation when I discharged a hospital patient on Wednesday.

The discharge summary recounts what happened during a patient’s hospital stay. When I finished residency, I would go through the whole chart from the first day, giving lab values, reading x-ray and consultation reports, and recounting vital signs in detail.  Later I learned to dictate my hospital notes so I could do the discharge summary from them.  Later still, I changed my model to answer the question: What does the next doctor need to know?

In the 80’s I deliberately waited two weeks after discharge to do the summary, because vitamin B12 levels and thyroid functions could take that long to come back. Paper charts in those days dominated the doctors’ lounge; you couldn’t get your coffee without being reminded you needed to clean up your paperwork.  And you could see everybody else’s backlogs.  I’d clean things out once or twice a month.

By the last half of the first decade of this century I had started to dictate the discharge summary at time of discharge, so I could have a copy when the patient came to see me a week later.

Some attending physicians pay residents, Physician Assistants, or Nurse Practitioners to do the discharge summaries.

Now the hospital’s Electronic Medical Record puts in all the lab values, discharge medications, and x-ray reports. I summarized 11 days of hospital care with 4 sentences typed into the middle of the document under the heading Hospital Course.  The next doc will have to scan through pages of note bloat to get to the part that he or she will need to know.

With all the documentation done, we drove the loaded car through town to a chain diner.

Over a luxury breakfast out, we talked about how fast the time had gone. It hardly seems two months since we arrived.

I found 4 new cases of Parkinson’s disease, 2 new cases of hypothyroidism, and 1 case of vitamin B12 deficiency. I referred people with, variously, a hernia, a hot gallbladder, and a bad appendix to the surgeon.

When major trauma cases came in I kept things moving in the outpatient clinic.

On the weekends when we didn’t go to Denver, visit a niece in Wyoming, or go shopping at Cabela’s, I made rounds in the hospital.

We went to the movies three times; the tickets cost less than half of what we usually pay.

We ate at every Chinese restaurant in town at least once. We saw eagles, deer, jackrabbits, migrating ducks and geese.

After breakfast, we started east down the highway, under clear blue skies with the wind at our back.

Winding down in Nebraska

January 28, 2016

I started out making rounds

As my current assignment winds down

Right now it’s Nebraska

Next week, it’s Alaska

On Friday I’ll be homeward bound 

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 the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

At the end of Monday inpatient rounds I found one patient on my afternoon schedule, and when I finished I had seen 11. The age range falls heavily on the extremes: most patients either of preschool or Social Security age.  Despite the fact that the US has the lowest rate of smokers in the industrialized world, tobacco related illness accounted for more than half of those patients.

I discharged one of my two hospitalized patients. I try my best to be a good hospitalist, and I tried to call the attending physician at an office a half-hour away, instead I reached the nurse.  The patient would follow-up there for monitoring lab values.  I passed on a consultant’s recommendations.

Here, as everywhere, the geographic imperative impacts my approach to patient care.  Back home  I don’t even consider risk when asking a consultant to stop by a patient’s room, but here I have to think about the hazards of putting the patient on an ambulance for an hour, or going three hours for testing to a major medical center.

Sometimes the people who live here talk about “Radio Free Nebraska,” where the search function on the car radio may fail to find anything for the rest of the trip. Still, each village or town has its unique specialty; a tree nursery and sawmill here, a bridal boutique there.

Before I tell a patient to make a follow up appointment, I ask how far away they live, and I have to take time, winter highway danger, and the cost of travel into account. For anyone who lives outside of town, I say, “Don’t come if it’s snowing, call.”

In the afternoon on Tuesday I picked up another hospital patient. The Emergency doc had done the admission and put in the original orders.

At the end of the day I faced a room full of patients, some of whom had appointments and some of whom didn’t. As I went through each person’s history, the family’s background emerged, shards of tragedy, accident, desertion and betrayal against a backdrop of economic trends, population shifts and changing social expectations. People’s bodies can be impacted by germs, as well as laws of physics, or history.

I have limited ability in such cases to fix the basic problem. But I can only do four things: medicate, operate, manipulate, or educate.  Sometimes the human capacity to love leaves me thrilled, and sometimes people’s capacities for perfidy astounds.

Today, Wednesday, I discharged both of my hospital patients. I called the attending physicians.  I dealt with an EMR system that sometimes turns orders into vapor.  Getting a patient out of the hospital generates a flurry of activity, proof that all change generates chaos.

My first and last outpatients of the day required surgical consultation. I walked three steps across the hall, presented the case, and got things ready for both.

I had plenty of time to clear up my documentation and to clean my desk. The staff held a potluck in honor of my next-to-last day.

 

 

 

 

 

 

Shingling me out

January 24, 2016

It has to do with our skins

And it started with needles and pins

After six weeks of tingles,

I came down with the shingles

But it hasn’t cut down on my grins.

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 the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

This case concerns a 65 year old male with shingles.

I’ve seen two other patients with shingles here in western Nebraska so far. I started both on Valtrex during the first visit.  Easy diagnosis, any rash that follows the path of a skin nerve (dermatomal distribution) names the process.  Therapy of the immediate, acute phase of this problem is straightforward.

With this disease, I worry the most about post-herpetic neuralgia, which can happen after shingles. It happens mostly in the elderly, and sometimes they hurt till they die.  During my training, we had no good treatment.  Narcotics work for no more than a few weeks.  We didn’t know at the time that capsaicin cream and seizure medications work, and work well; although we had the tools available we didn’t know how and when to use them.  Generalists who tried to treat a patient with hopeless, severe pain would either burn out and retire or move, or send the patient to the neurologist, who would either burn out, retire, or move.  Now I only refer the patient out if I fail under my “3 strikes and I’m out” policy or if the patient requests.

If a patient, after shingles, shows up with pain where they had the rash, despite rash improvement, I will lightly stroke the area involved, and ask if it hurts. A positive finding, allodynia, pretty much cinches the diagnosis.  I like to start with capsaicin cream; available without a prescription, it depletes the structures of a particular part of the nervous system called the dorsal root ganglion of the chemical needed to transmit chronic pain signals.  If that doesn’t work,  I skip on to the anti-epilepsy drugs Depakote or gabapentin.

I can write publicly about this patient because I’m writing about me. Over the last six weeks I’ve had a tingling sensation, paresthesias, on the right side of the back of my neck.  Always worse under stress or time pressure, it came and went, and I ignored it.  I’d had something similar over the summer.  I consulted by phone with my doctor, who agreed that it could have been the prodrome, or warning signs, of shingles.  I took Valtrex and the rash never appeared.

This time, I decided to test the hypothesis, by ignoring the pins-and-needles that would crop up for no reason from time to time, last a minute or so, then disappear for no reason.

Last night, we were coming home from the movies when I noticed two sore spots on my neck, just the size of chickenpox. This morning, on rounds, I pulled my colleague into a room and showed him my rash.  He looked where I pointed at the front of my neck, followed  around to the back of my neck, confirmed my suspicion, and advised Valtrex.

Of course, a few milligrams of prevention is worth kilos of treatment, and the shingles vaccine, Zostavax, is a really good idea for anyone on Medicare. I plan to get mine when I visit the VA next week.

 

It’s harder to keep the patients alive after they’re dead

January 20, 2016

The question came up to me

About patients, who number three.

Should we try to restart

A non-beating heart?

Or perhaps just them 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 am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

Today I wrote Do Not Resuscitate orders for 3 hospital patients.

Television and movies thrive on the tension of cardiopulmonary resuscitation (CPR): doctors shout, orders fly through the air, the seconds tick while a life hangs in the balance, and in the end the dead come back to life. In Hollywood, CPR always works.

In real life, CPR patients rarely make it out of the hospital. The ones who have the best chance are the ones who didn’t have much wrong to start with: the young, the athletic.  Those with a tenuous hold on life, the ones most likely to have their hearts stop, do not do well.  Perhaps a third of those with cardiac arrest survive what the doctors call the code.  Most live long enough to generate six- or seven-figure medical bills, but die before they leave the hospital.  And lack of oxygen leaves many survivors with permanent brain damage.

New Zealand’s national policy, when I worked there in 2010, held that age greater than 75 constituted an absolute contraindication to CPR.

Now when I have an end-of-life conversation with a patient or a medical Power of Attorney (POA), I ask, “If your heart stops beating, do you want us to try to restart it?” always prepared for a long answer. Nobody gets to the end without a really great backstory; those who love the frail unambivalently need much less time than those with mixed emotions, and the human condition results in contradictory feelings.

A negative answer comes rolled in with long justification.

For a positive answer I have to explain what CPR and shocks do.

The act of pressing on the chest to keep the blood circulating breaks ribs in everyone over the age of 30, and almost everyone over the age of 20. Electric shocks hurt, and the shock of the defibrillator hurts worse than any shock the average American has ever felt.

Then I get to the question of the tube in the windpipe, which requires unconscious ness and eventually a ventilator.

Few of those born before WWII who retain all their faculties choose resuscitation after my discussion.

None of the patients during today’s discussions wanted CPR. Each conference took a long time.  But trying to rush such a talk is rude and disrespectful, and hurrying it can obscure patients’ real wishes.

So I gave my complete attention, easy when listening to wonderful tales, stuff I couldn’t make up.

 

A movie, an owl, and patient getting worse.

January 19, 2016

 

Last night we went out to a flick

It got prizes for being so slick

But a hoot from an owl

Who was out on the prowl

Warned of patients, who got desperately sick

 

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 the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

Last night Bethany and I went to the two-screen theater in town and saw The Revenant, an Academy Award winning movie.

On the way out of the theater, I got a call from the hospital; one of my inpatients requested a sleeping pill. Hospitals thwart the sleep that healing requires, and I gave the order over the phone

We talked about the film on the way back. It featured a lot of action, it got some bits of woodcraft and history right, and a lot wrong.  I enjoyed the Shawnee and Arikara dialogue.  We agreed that we could have done without so much gratuitous violence.  Bethany asked some medical questions, and we tried to figure out at what point the French traders stole Powaqa.

On the net, researching the real story of Hugh Glass that served as the basis for the film, I heard an owl hoot 4 times outside the north part of our townhouse. I glanced out the sliding doors to the deck, but saw nothing.

In my years with the Indian Health Service, I learned that most Native Americans regard owls as terrible omens, bringers of bad luck and death, and the sound chilled me. The film had brought memories of working in a tribal context, bringing that milieu back into my consciousness.

But I slept soundly, because call here means nothing. The doc covering the ER handles problems in the hospital as they arise.  Thus finding a “missed call” message from the hospital from 1:00AM brought alarm.  The voice mail asked me to call back immediately.

When I got to the hospital, I found that my patient, the one who had requested the sleeper, had just been transferred out. After the ironic decision to change after decades of bad health decisions, the dramatic payment to the piper came, and the patient’s fast glissade downhill started about the time I heard the owl.  His medical needs exceeded our capabilities.

And despite all the right decisions and all the right medications, just like Humpty Dumpty, some things can’t be repaired.

But the clinic patients started well and got better. One of the follow-up patients looked and felt dramatically improved on a scheduled dose reduction.  Two people had ear infections.  Nobody quit smiling when I wouldn’t give antibiotics for colds.  I had time to do some online research about testing for cystic fibrosis, and I caught a power nap over the lunch break.

The pace picked up in the afternoon. I got to speak Spanish, and I used the osteopathic part of my training to make a person well before departure.

Without the gloom of the first part of the morning, the rest of the day wouldn’t have gone so sweetly. Contrast is the essence of meaning.

 

Coming back from New Year’s Day

January 16, 2016

When it comes to the question of pot

And all the supporters it’s got

It just doesn’t makes sense

Because now evidence

Shows that good for depression it’s not

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 the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

I’ve listened to Audio Digest Family practice for 37 years. In the beginning, my aging Karmann Ghia had no place for the tape cassettes. I wore out a tape machine about every 7 years.  Last century I upgraded my vehicles and started listening over the car stereo system.  Now that cars don’t have tape cassette decks, I get the programs on CD.

Yesterday we drove east through the flat Colorado wheat country after spending the holiday with family and friends, listening to an educational CD about medical marijuana on the car stereo.

The lecturer talked slowly, leading me to wonder about his firsthand experience with the drug.

Good evidence supports the use of medical marijuana for AIDS wasting syndrome (hardly ever seen anymore) and the nausea from cancer chemotherapy. After that the quality of research falls off with small studies and poor design.

I know a doc from Colorado who supports use of medical marijuana, and points out that the sativa variety has more THC, the stuff that gets people high, whereas indica plants have more cannabidiol. He asserts that the cannabidiol has the medicinal properties.

Even the pro-pot lecturer said that all the commercial products come from hybrids.

I put marijuana’s long tenure as an herbal remedy at the same level as Teddy Roosevelt’s touting the unique properties of champagne for dysentery and brandy for everything else. Alcohol turns out to be alcohol and while it may have a number of physiologic properties, it comes in last place as a pharmacologic agent because it doesn’t make anything better.

Marijuana does not relieve anxiety; quite the contrary, it brings paranoia. Nor does it relieve pain though it interferes with the ability to reason through questions about the 10-point pain scale.  It predictably drives down the level of testosterone for both genders which leads to terrible sexual dysfunction.  Eventually, it makes people depressed.  It might help some sleep, but they don’t rest.

Yet I would agree that the FDA needs to take it off Schedule 1 so that we can start doing decent research on it.   The plant makes hundreds of compounds that can stimulate receptors throughout our bodies, and its potential remains basically untapped.

I ask everyone past the age of puberty about use of tobacco, alcohol, marijuana, and other drugs. While most people at my current assignment avoid excesses, those who don’t account for a disproportionate share of the ones who need medical help.  If someone uses marijuana, I ask how much, and whether they’re using legal stuff from across the border or the illegal weed purchased locally.  I hope that the Colorado product has fewer adulterants, but it remains largely unregulated.

Today I attended a patient with chronic pain (and a number of other problems); two weeks ago we decided gradually decreasing the morphine dose would be a good first step towards returning functionality. You could see the improvement from across the room, and we talked about the increasing exercise tolerance.  I let the patient decide on the pace of treatment, and two weeks from now we will look for more progress after another dosage reduction.

As always, I heavily recommended exercise.

Christmas? Easy. The day after? Difficult transport

December 27, 2015

For ambulances, we have only two.

The blizzard came out of the blue

It stormed and it snowed

All the way down the road

That’s the reason that nobody flew.

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 the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

Christmas went quietly, and I only write that after the fact because I don’t want to jinx myself by saying good or bad when people ask me how the call is going. I always say, ask me when it’s over.

I used to work at a place which regarded the holiday as lasting 5 days, with me on the hook for 120 continuous hours. The second year I started with a census of 38 hospital patients  At the end, with a grand today of 20 hours of sleep, my work quality had degraded significantly in that I had quit caring.  The following year I absolutely refused to carry the beeper for more than 72 hours.  Management voiced their objections, which I noted, and used the phrase “patient safety” in my reply.

I don’t work there now.

So far here in Nebraska I haven’t worked more than 50 hours a week. When I go home, I go home.  The term “call” carries no meaning; I have no beeper and they expect me to turn my phone off at night.

I finished my Christmas work before noon, went to the gym, and got back home in time for lunch.

This morning, the day after Christmas, I went in to make hospital rounds and staff the Saturday clinic. I crept down icy asphalt, a strong north wind threatened to blow me off the road.  Just as I pulled into the parking lot snow started in earnest.

I can’t talk about individual patients but I can speak to the aggregate: all could remember the start of World War II, and all could remember the Armistice Day Blizzard of 1940.

One patient had improved enough for discharge.

The medical end of the discharge process came easier than the EMR. I ran into a 16 item set of blocks requiring responses.  I clicked in a couple of places, got no response, muttered in Navajo (the only per se taboo words have to do with the government), clicked again and nothing happened.  Eventually I asked for a consult from the ER doc.  By the time help arrived I figured out that my computer had locked up and needed restarting.

One patient, having failed to respond, required transport to Omaha, but the weather had worsened to blizzard conditions and no one would fly. The town has two ambulances, one had yet to return from a transport in the wee hours.  So my patient’s transfer would have to wait for a loaner from another community or the return of our other ambulance.

I looked outside at the whiteout, and I thought of Barrow, where weather prevented flying an average of 1 day out of 3, and the flight would last a minimum of 5 hours. The ground transport to Omaha would last a fraction of that, with several other hospitals along the way if the conditions worsened.

Saturday clinic welcomes walk-ins but has no appointments. I saw my first patient at 10:15AM.  I have gotten enough fluency with NextGen that the documentation flowed.  I took care of 5 out patients.  One had an alarming physical finding I’d never seen before.

At the end of clinic I bought delivery pizza for the skeleton crew. We usurped the conference room and chatted.  When I walked out, the snow had stopped but the wind, if anything, had freshened.

I didn’t have to scrape the windows.

 

Christmas Eve, finishing at noon.

December 26, 2015

I don’t mind that the other docs leave
A balance I hope to achieve
And they’re closing at noon
The time off is a boon,
I’m happy to work Christmas Eve

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 the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

I work the holiday weekend because I don’t celebrate the holiday and I want those who do to have the time with their families. With two exceptions, I’ve done so every Christmas since 1975. Our facility made the decision to close at noon on 12/24/15. One of the permanent docs has already left for vacation.
I came in a bit early to care for a patient admitted yesterday through the ER.
Then I went back to my office to find no one on the schedule until 10:00.
I waded through a backlog of documentation that preceded my entry into the EMR here, NextGen. After two weeks in the system, I got full access this week.
I took the delay with equanimity. If I can’t get a piece of information or do a particular task, then I can’t. Management treats me very, very well here, and hasn’t overloaded me. If I eventually need to stay late to play with the semi-conductors, I get paid.
NextGen has a particular button to push, called PAQ. Because no one seems to know what that stands for, I’ve started calling it Pheasants and Quail, and until Tuesday, every time I clicked it a message appeared saying the provider was disabled, good for a few jokes. Yesterday the button started to function for me, giving me 118 of my own documents, plus x-rays, lab tests, letters, and consultations to approve.
As with most EMRs, NextGen has its share of irrational quirks. I don’t know another system that makes the doctor approve his or her own document twice.
With exactly one patient on my schedule, I cheerfully took another provider’s patient who showed up 45 minutes late. I had a good time talking with the patient and the family; we developed a plan and I completed the electronic paperword about the time the next patient, in the pediatric age range, got through screening.
I carry a yoyo because I take care of children; a really spiffy one because I can. I did a few tricks, involving a couple of mistakes, but impressed the family and the patient. At the end I said, as I usually do, “If you don’t smoke, drink, or use drugs, you can afford any yoyo you want.” I see it as a way to guide concrete-thinking children towards good lifestyle decisions.
A family member held up a thick envelope, expressed frustration that nationally recognized experts hadn’t helped, and requested I take the case.
I said I’d be happy to, but the more doctors that failed before me, the smaller the chance that I would succeed. “Make an appointment,” I said.
That documentation finished at noon, I went back down the hallway to the hospital and conferred with the patient and family. Terms like the 2 midnight rule and the 3 day stay rule flew back and forth. Eventually I said, “I understand the synthesis of porphyrins, but I haven’t been able to grasp the insurance company’s rules. Because they don’t want their rules to be understood. There is no transparency.” And I left the question up to the nurse who would talk to experts working Somewhere Else.
Bethany waited for me in my office when I returned. We sweated in the gym for an hour and went out to lunch.


Follow

Get every new post delivered to your Inbox.

Join 55 other followers