Writers conversing over coffee

January 22, 2020

Some of us just need to write

As an outlet, it’s just a delight

The whole and the part

Please write from the heart

Insomnia?  Do it at night.

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia, and vacations in Israel and San Francisco. I have now returned to Iowa.   Any identifiable patient information, including that of my wife, has been used with permission.

I sat in a popular Sioux City coffee shop with Kevin to talk about writing. Though we have a mutual friend, John, we hadn’t met before.

Kevin has a great story to tell.  In his duties as a policeman, he was shot in the head and survived.  He wants to write about it.

I gave full disclosure.  I write a blog but I’ve never been published (almost true, but medical journal snippets, blog posts, and online articles aren’t books).  I enjoyed writing my 9 novels but I don’t relish the thought of promoting them.

In the US there only a few hundred people who make a living writing books.  I met one, Win Blevins, during my Wyoming Residency.  He said that the people who should write are the ones who have to write.  And I’m one of those.  I find the physical act of writing pleasurable, if not a  compulsion.  I write because I would be less of a person if I didn’t. It gives my imagination an outlet.

In The Snows of Kilimanjaro,  Hemingway’s protagonist, dies of a stinking infection, rotting from the inside out, what Hemingway would have been if he hadn’t written the story.

Kevin continued police work for a couple of years.  He enjoys his current retirement but knows that he owes it to himself to do more.

Do you enjoy writing? I asked.

He does.

I gave tips: don’t start with a description of the weather.  Active voice is stronger than passive voice. Death to the adverbs: no more than 2 per page, because modifiers weaken the writing. Litoties (example: not infrequently) are the weakest.  Avoid the use of the verb to be.  White space is important: don’t use too much or too little.  For non-fiction, publishers want to see four chapters and an outline.

We talked about how the strength of true crime stories takes away the pressure to write well.

By the end of the conversation I had referenced Isaak Denison (aka Karen Blixen), Hemingway, Melville, 1001 Arabian Nights, Out of Africa, The Snows of Kilimanjaro, Umberto Ecco, The Name of the Rose, Dangerous Visions, and Moby Dick.

I should have referenced Beryl Markham and Samuel Clemens. Unschooled in writing, they didn’t have to think outside the box because they didn’t know about boxes.

Also, write from the heart.  If you don’t put yourself emotionally into your work, your audience knows and they won’t want to read.

I endorsed the single throwaway page.  Write it first and keep it but keep it out of the final version.

Many people work better from an outline, and, if not from an outline, from chapter cards.

At the end I realized I have read a lot of books despite not doing any recreational reading for 30 years.

And perhaps I should think about promoting my work instead of just letting it sit in my computer.

 

Another month in review

January 18, 2020

This month, I made a good call.

Had a great time overall.

You know what I did?

I delivered a kid.

Because I just couldn’t stall. 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia, and vacations in Israel and San Francisco. I have now returned to Iowa.   Any identifiable patient information, including that of my wife, has been used with permission.

I had another good month in British Columbia, returning home on the 8th day of the year. This time I entered through Edmonton, and they didn’t ask for my work permit.

I started 3 people on vitamin B12 injections.  While I love making the diagnosis of B12 deficiency, I don’t mind poaching: someone else ordered the test but went on vacation. I got to start the patient on therapy.

I adjusted thyroid doses on 4 different patients.

I had 4 admissions for 3 patients.  I sutured one laceration and applied one cast.  Half the ER patients who needed follow up ignored the advice to do so.

I made a couple spectacular diagnoses. One, a disease in a young person that, if ignored would take 20 years of productive life away, and but if treated would make no impact at all.  I made that diagnosis almost by accident, in a flurry of lab tests for vague symptoms I happened to order the right one.

The other triumph I claim only because I paid attention to the patient and ignored the demographics.

Four more people with addictive disorders came to insight and asked for help.  They arrived at a pinnacle of personal responsibility (or you could say they hit rock bottom) with no help from me.  And that fact carries a lesson for me in terms of educating patients.  While I have a moral obligation to tell them to quit tobacco, alcohol, and marijuana, I have no such obligation to nag them. Perhaps if I don’t nag them, they have a better chance of figuring things out.

The economy of the town and the region impacted patient care.  Mining interests remain the stable factor in an economy dominated by uncertainty.

And I can tell the economy has tanked because the number of cocaine abusers decreased.

I took call again for Christmas Eve and Christmas, but this time I also drew New Year’s Day.

I delivered a baby, only because if I hadn’t, the baby would have come during transport.

I had the easiest patient transfer I’ve ever had from a rural facility.

If I, as a locum, order lab or x-ray, I have to designate one of the permanent docs as a recipient for the result.  On 2 occasions, as I filled out the form I asked the patient who their regular doc is.  The puzzled response came back, “Well, you are.”

40 years of change: hits and misses

January 17, 2020

I talked of the changes I’ve seen

And the medical places I’ve been

Today, for sure,

There’s more chance of a cure,

I love now, I embrace the serene.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia, and vacations in Israel and San Francisco. I have now returned to Iowa.   Any identifiable patient information, including that of my wife, has been used with permission.

I talk about myself too much, a failing that I’m improving.  Still, the invitation to be the subject of a podcast proved too much.

I told my story.  An undergrad anthropology degree led me to medicine as a way to fix problems rather than just identify them.

I glossed over my 3 years with the Navajo and 2 years with the Winnebago.  And the 23 years in private practice got no more than a sentence or two.

I remembered as a med student watching a manic surgeon brutalize a terminally ill teenager.  I spoke from the heart to a digression.  When I stopped I listened to the smy interviewers’ shocked silence .

They asked about the changes I’d seen in medicine.  I got part of it right.

New immunizations made 90% of my inpatient peds training obsolete, but forgot to mention the unintended consequence that ear infections disappeared.

I talked a lot about the feminization of medicine.  When the barriers to women in medicine came down, the applicant pool doubled, raising the bar to admission and improving the quality of the student body.  That demographic shift gentled and enlightened medicine’s culture.

I missed the changes in diagnostics: MRIs, PET scans, better CTs, DNA. Biomarkers for blood clots, heart attacks, seizures.

I mentioned TXA (slows bleeding) changed trauma management.  Non-addictive ketorolac replaced most injectable narcotics.  Proton pump inhibitors  (example, Prilosec) did away with perforated ulcers. The biologics, like Remicade, revolutionized rheumatology but at breath-taking expense.

I forgot to mention therapeutic advances for hepatitis, diabetes, asthma, depression, smoking, vascular disease, prostate enlargement, erectile dysfunction (yes, there was a world before Viagra), sleep, post-herpetic neuralgia, menstrual disorders, and some cancers.

I neglected the 5 antihistamine classes I had to memorize in 1980.  Two generations, each an improvement, replaced them.

I gave unfortunate short shrift to evidence-based medicine as a way to tell us if interventions do more good than harm.

My lab coat pocket exemplifies the progress in data access: from the Washington Manual, to the PDR as a dedicated E-book, thence to the Palm PDA, and now access to the world’s largest library on my smart phone.

A lot of bad things escaped my attention.  Insurance has hijacked the profession, and we spend more and more time with prior authorizations.  Government has used the electronic medical record as a tool to force doctors to do a lot of work that has nothing to do with patient care.  And the new diseases, from HIV to Lyme.

I regret I didn’t say, in these words, that I have no urge to go back in time; I prefer today over any day in the past 40 years as a time when the patient has the best chance of survival.

Not that anyone has a choice.

 

 

 

 

 

Old technology: it works till it doesn’t

January 10, 2020

The technology I’ll grant you is old,

But pneumonia clearly it showed

When the treatment it failed

Then reason prevailed

And the patient got sent down the road.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia, and vacations in Israel and San Franciso. I have now returned to Iowa.   Any identifiable patient information, including that of my wife, has been used with permission.

During my most recent assignment in British Columbia, I made the diagnosis of pleural effusion twice, and received permission to write about one of the cases.

The lungs reside in a double membrane; the pleurae (the plural of pleura is pleurae), the shiny coverings of the lungs and the lining of the chest, give their name to the painful condition pleurisy, which happens when a rough spot develops.  Liquid on the inside of that double layer constitutes a pleural effusion.  The lungs can’t exchange gases unless they actually get air, and they can’t underwater.

The patient came in the first time to the Emergency Room, looking sick, with cough and fever.

I turned to very old technology, the stethoscope, and couldn’t hear breath sounds over the left lower lobe.  I went to even older technology, percussion, thumping my right middle finger on my left, which I placed on the patient’s chest.

Percussion, highly developed two centuries ago when doctors used sets of tiny hammers (plexors) striking tiny anvils (pleximiters) placed against chests and abdomens.  They listened to the echoes, and could tell a good deal about the cavity’s contents.  The technique faded with the development of x-rays.  Ultrasounds use the same principle.

In fairness, med students now learn to use ultrasounds as part of routine physical diagnosis.  You can get apps for your cell phone.

Few physicians in training bond with outdated technology, even in my generation.  But I learned on myself, when, in my first year of medical school, my liver swelled due to an hereditary blood disease. (If you must know, hereditary spherocytosis.  Go look it up.) I practiced percussion on myself, and I got good at it.

The patient’s findings came clear even to my aging ears, even to everyone in the room.

So I could diagnose pneumonia, and start antibiotic treatment without radiation, and make everyone happy in the process.

The patient improved rapidly, but five days later the fever and cough returned while I covered the ER, again.

The old technology had failed, and we all knew it.  The chest x-ray showed fluid inside the chest and outside the lung, illness severe enough to justify referral to Prince George, down snowy, moose-infested roads.

Sick people get stressed, stressed people get sick.

December 31, 2019

On Christmas, with light patient flow

I went back and forth in the snow

Illness comes when we’re stressed

Because with love we are blessed

They’re mortals, those people we know

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia, to which I have returned after visits to Israel and San Francisco   Any identifiable patient information, including that of my wife, has been used with permission.

I took call again this Christmas, as I have for almost every Christmas since 1979.  Though I don’t celebrate the holiday  I feel strongly that people who do should have the chance to spend it with their families.

Most of the time taking call on Christmas includes Christmas Eve. (In Utqiaviq call never meant anything other than 12 hours, but I never worked there in December.)  This year I cared for 4 patients on the 24th and 3 on the 25th.

In general, alcohol, tobacco, and drugs account for about 70% of my medical work load, but 30% of the time illness comes to my patients gratuitously. For these two days, 100% of those I attended suffered from the ills of just being human.  I saw one pediatric patient, and two over age 70.

The majority have such healthy lifestyles I couldn’t even ask them to exercise more.  Only one patient takes more than 3 regular medications.

With the luxury of light patient flow I could take the time and listen to people’s stories.  One patient confessed feeling a bit unnerved by a doctor who didn’t interrupt.

I ran into one challenging mystery.  After the patient and I agreed on a plan for the evening, I handed her a lab slip to bring in after Boxing Day, explaining the tests I ordered.

The natural tendency of people to love constitutes a force comparable to gravity.  However perfect that force, it applies to humans, subject to growth and decay and the vagaries of genetics, time, gravity, and mortality.  Thus the wonder of the human universe operates against us when those we love fall prey to the inevitabilities of existence.  Such stress accounted for half the people who came to see me.

During these 48 hours of call, no one wanted to interrupt the celebration by coming to the hospital.  For every person I attended I received an apology for bringing me in, and to each I gave assurances that I didn’t mind.

I ordered injectable medication three times.

At 1:00 PM on Christmas the hospital staff, Bethany and I sat down to eat lunch. The nurses brought prawns, wings, veggies with dip, crackers and cheese.  My contribution consisted of fried potato wedges from the convenience store, brought in by my wife.  I binged on the holiday chocolates.

Snow fell off and on through both days.  At night, driving in, I spotted tracks of a 4-legged animal right outside the hospital, most likely a coyote or wolf.  The snow blurred the details.

 

 

 

If only Sam Clemens had duct tape

December 18, 2019

The patient looks up and he snorts

When discussing the treatment of warts

You’re in no better shape

Using duct tape

Than liquid nitrogen.  We buy it in quarts

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia, to which I have returned after visits to Israel and San Francisco   Any identifiable patient information, including that of my wife, has been used with permission.

I had a great day in clinic.  I took care of a follow-up from the weekend that had me genuinely worried.  I saw a couple more cases that could end up being infectious mononucleosis.  I dealt quickly with some administrative visits, and others just needing refills.

Though the patient gave permission to write in specifics, I’ll keep to some general principles.  Migraine can mean very different things to very different people.  For example, I get retinal migraines, with intriguing flashing lights but no headache.  Thus if a person has a recurrent neurologic problem that comes and goes, with months between clusters or swarms, a doctor should consider a migraine variant, even without pain, flashing lights, nausea, aggravation by bright lights or loud noises.  Still I knew that the more doctors the patient sees before they get to me the smaller the chance I have of making a difference.

Another patient showed me a cluster of warts.

I gave full disclosure.  Mark Twain in Tom Sawyer, I said, gave a recipe for wishing warts away that works about half the time.  These days I can’t offer anything better than 60%.  In other words, every therapeutic option carries a 40% risk of recurrence.  And if we do nothing, 90% will disappear in less than 2 years. 

Then I gave the options: duct tape at home, liquid nitrogen, or wait another year.

His facial expression said, “Duct tape??!! Are you serious?”

Yes.  A person puts a small piece of duct tape over the wart (colored duct tape works best), removing it ever 2 or 3 days and filing the wart down with an emery board till it hurts or bleeds.  It carries the same success rate as liquid nitrogen, used to bring frostbite to the wart.

Then I went on a bit of a rant.  The last 20 years have brought so many game-changing medications and treatment, from hepatitis C to testicular cancer, but when it comes to warts we’re still stuck in the 1800’s.

He said, “But they didn’t have duct tape back then.” 

I broke out laughing.  I asked for, and received, permission to write about the interchange and quote him on my blog.

Emergency obstetrics only

December 17, 2019

The last time, in the land of the corn

I dealt with an afterbirth torn.

I’m not keeping score,

But perhaps just one more.

I’ll help a baby be born

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia, to which I have returned after visits to Israel and San Francisco   Any identifiable patient information, including that of my wife, has been used with permission.

In my first year of residency I conversed with an attending Family Physician who grinned widely when he announced he’d turned 60 and stopped delivering babies.  “I feel like I’ve retired,” he said.

 

At the time I felt he’d betrayed the profession.  After all, Family Practice by definition involves families.

I delivered babies in the Indian Health Service.  In New Mexico we had a program at the non-IHS hospital in Grants.  I delivered a couple more in Winnebago, though the hospital lacked the equipment and the staff training.  Better to deliver in a hospital than in an ambulance.

 

To finish my IHS contract I returned to the Southwest and delivered more than 50 babies in Tuba City, AZ.  I refreshed my skills so I could join a Family Practice group in Sioux City and share full call.  Even back then, 1987, I knew that I would stop OB on my 60th birthday.

 

My last two deliveries in private practice had frightening complications, one involving a torn placenta, and cemented my resolve to give up that part of medicine.

 

Before that, three of my partners stopped delivering babies.  Without the young families and a new generation, their pediatrics practices withered and geriatrics took over.

 

I’ve declined jobs with OB, saying, “My 60th birthday present to myself was stopping OB and I’m not giving it back.”

 

A doctor has to work hard to deliver babies.  They can come at any time.  For a quarter-century I had at least one patient past 36 weeks gestation, set to deliver at any moment.  The vigilance murdered sleep. And, indeed, when I stopped obstetrics, I felt like I’d retired.

 

OB here has the same uncertainty that OB has everywhere, and my first obligation remains doing what is right for the patient.  On Saturday, my day on call, I requested back up when a patient in labor arrived.  In the hallway we conferred and divided duties.  My colleague would take care of the baby, I would handle the delivery.

 

The mechanics of my role have not changed in the last 9 years.  My colleague clued me in on standard procedures, that were once considered trendy.

 

In the middle of the action I realized I’d forgotten to put on a gown.

 

The closest that we come in this life to perfection can be found in the peace and stillness after a normal delivery.

 

It was wonderful.

 

Afterwards, the patient gave me permission to write that I’d delivered her baby.

 

I still don’t want to give back my 60th birthday present to myself.

 

Dancing with ambivalence

December 12, 2019

There’s a place in the wrist called a tunnel

Where nerves and their friends face a tunnel

And by the ankle as well

If things start to swell

The pressure the nerve will disgruntle

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia, to which I have returned after visits to Israel and San Francisco   Any identifiable patient information, including that of my wife, has been used with permission.

My mood lifted as I returned to Canada. It helps that Canadians have a well-deserved world wide reputation as friendly and polite. I sang when no one listened and danced when no one looked.

But I sang and danced with ambivalence.  My wife stayed in Sioux City; the radiation treatment for thyroid cancer demands that she stays isolated for the better part of a week, and I miss her.

I left Omaha at 8:00 AM and landed in Prince George at 8:00 PM, having crossed two time zones in 4 planes.  For the first time, I flew through Edmonton.

To avoid the drive north in the cold and dark I stayed over in Prince George, where, despite a great hotel, I slept as poorly as if I’d been driving.  In the last month I’ve crossed 22 time zones, and not spent more than 12 days in any one.  I don’t expect to sleep well for a couple of months.

My first day back in clinic I cared for 16 patients.  I knew half of them.  Despite my intermittent presence here I seem to have established a practice.

A pinched nerve causes a lot of pain.  “Carpal tunnel syndrome” has become part of modern American English vocabulary because the median nerve has to run through an enclosed space to get from the arm to the hand.  Any pressured nerve brings pain that burns or shoots or stabs, and runs both directions away from the pinch point.

One of my patients, who gave permission to write this, had to give up an exciting job in demolitions due to pain from a nerve pinched just behind her inside ankle bone in the tarsal tunnel.  I have not seen the problem before, nor can I remember where I learned about it.  But I had to preface the visit with full disclosure: the chance that I’ll help you is inversely proportional to the number of doctors who failed.  We await diagnostic confirmations.

Twenty-five percent of my patients qualified as pediatrics, the same percentage born outside Canada, and the same percentage who abuse marijuana.

The trend of substance abusers coming to insight without any input from me continued today; I could step around the corner to dialogue with counselors, who, unfortunately, had stepped away.

I stayed late finishing up my documentations, loathe to go back to an empty hotel room, but finally I stepped out into the darkness relieved by hard points of stars.  For the first time since our Alaska adventure, I felt the frost condense in my beard.  I called Bethany.  She had radioactive iodine, I 131, for her thyroid cancer today.

 

Conversations with a saxophonist

December 1, 2019

The conversation soon got to brass tacks

As I failed to gather the facts

I talked too much of me

When I found out, you see,

We both are players of sax.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia.  Back from two weeks in Israel, I visited my sister in San Francisco.   Any identifiable patient information, including that of my wife, has been used with permission.

Jumping 9 time zones in 72 hours will ruin my sleep for weeks. Despite a great bed at a quiet hotel, I had trouble keeping to my resolve of never leaving bed before 4:00AM. I arrived at SFO 3 hours early.

I stretched my breakfast time, eating slowly and savoring my food. Paying on the way out, I noticed an instrument case next to a woman waiting for her meal.

“Saxophone?” I asked. She answered in the affirmative. As usual when I speak English (but not when I speak Spanish) I started to show off. I asked if she’d heard of Theo Wanne mouthpieces. She had but she hadn’t tried one.

As it turned out, we had seats on the same flight to Chicago, and continued our conversation in the boarding lounge.

In addition to playing for hire, she teaches instrumental music, frequently to Native American youth. We have a commonality in experience with Navajo, Hopi, and Tuba City.

I talk about myself too much, a failing I’m improving slowly by writing this blog. But I fell to my old habits. I recounted my Indian Health Service experience early in my career and my adventures since 2010. But because I did the talking, I failed to detail her story. Still, I discovered that she is en route to Maryland. She has a daughter who works as a family therapist. We both have low serial number Selmer Mark VI saxophones.

Modern technology has improved almost everything but so far that sax remains the best.

She got hers when the people who hired her band brought a saxophone down from the attic and asked if that would settle the account for the entertainment. I can imagine her surprise and the trouble she took to nuance her facial expression when she opened the case, raised her chin, and nodded. I can picture her shutting the case and saying, yes, this will do just fine, and I can just hear the passion that particular victory added to the way the band played.

During the conversation, I realized that the threads of saxophones and music have wandered through this blog for the last 9 years.

I haven’t played my horn with the delightful mouthpiece since my teacher, Diane, died. I have had a lot of excuses: difficulty traveling with a horn and living in hotels where other people pay to not listen to my music. But in the end, those remain just excuses. I have the ultimate saxophone with arguably the ultimate mouthpiece, and I have let them and my meager musical talent languish. My teacher would never have approved. It’s time to stop grieving.

 

More street side diagnosis

November 28, 2019

The stuff you diagnose on the street

With the people you see and you meet

Forget confidential

Just note evidential

And hope that the homeless can eat.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia.  After less time off than I planned, I did some more hospital work and vacationed in Israel and San Francisco.   Any identifiable patient information, including that of my wife, has been used with permission.

Confidentiality does not apply to people who are not my patients, nor to what I can observe on the street.

The country’s homeless problem worsened in the wake of the mass mental hospital closings, an example of shameful bipartisan cooperation.

They comprise a heterogeneous group.  One summer I derived my income from my music and I made enough to eat but not pay rent; during that time I was homeless, and I found the lifestyle seductive.

Those homeless by choice, though, comprise a minority.  Most homeless have major mental problems.  No one can usefully separate schizophrenic from bipolar or addict; the Venn diagram has too much overlap.

Wonderful climate attracts not only the yuppies but the homeless, and every trendy city has plenty of both.  Alaska, where the homeless comprise part of the food chain, has a very small summer problem and in the winter almost none.

No surprise then that the homeless gravitate towards the West Coast and the Sun Belt.

I walked out onto Mission in San Francisco and observed what I could observe.

It doesn’t take Sherlock Holmes to diagnose heroin addiction in a grimy young man with a sleeping bag who injects himself on a sidewalk and nods off before he can get his syringe into the soft drink bottle he uses for needle disposal.

You don’t need much training to diagnose full-blown mania in the thin man talking fast to anyone he saw (including those invisible to others) and moving quickly without stopping.  You wouldn’t need much more to call schizophrenic the people talking to themselves and watching things only they could see.

It took much more clinical experience to diagnose rheumatoid arthritis in the twisted fingers of the man in the wheelchair who accepted a quarter from me.

On the bus, although the man tried to hide it by drumming his fingers, I saw the intermittent, asymmetric pill-rolling hand tremor and I matched it with a blank facial expression to come up with Parkinson’s.

On the street I saw a man walking with a bilateral foot drop: with every step his toes touched before heels, and he had to pick his feet up higher than normal.  I knew that he had long-track disease: something had happened to the nerve bundles running down the back of his spinal cord.  But without lab and imaging I couldn’t tell syphilis from Lyme from B12 or folate deficiency, or a mechanical lesion pressing on the spine.

Females comprised less than 10% of the homeless I saw though statistically the genders have an equal burden of schizophrenia and bipolar.  I wondered where they had gone.