The thrills of cerumen and B12 deficiency

April 23, 2017

Real flu has cough, fever, and ache

And I know just the pill you can take

And then there’s the test,

It’s good but not best

But a decision it sure helps me make.

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. 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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

I had a good week in Clarinda.

Orientation on the new job went well; I found it well-organized and well-planned.

The facility not only assigned me a scribe but also a cracker-jack Electronic Medical Record superuser to train me on the 14th new EMR I’ve learned in the last 28 months.

Recognizing the problems of learning a new system, my patients have come no more often than every ½ hour.

Thursday morning went well; I had the immediate gratification of curing the first patient by removing ear wax and the second with osteopathic manipulation.   Close to noon I received lab results on tests ordered earlier in the week, including three vitamin B12 levels.  Two borderline numbers (between 211 and 400) require further testing, and one came in frankly low, less than half the lower limit of normal.  That bit of information made my day; I can save the patient’s life with a simple injection once a week for 12 weeks, then once a month.

Bethany met me for lunch in the hospital cafeteria: well-prepared, healthy food at insanely low prices. I told about how I found my morning not only gratifying but satisfying.

Influenza dominated the afternoon. We have the clinical experience to predict that the annual flu epidemic starts in the north and works its way south, with 90% of the cases in any one location occurring in the course of 3 weeks.  I enjoy taking care of influenza; we have a clear-cut, good but not perfect, lab test and two effective drugs.  The older the patient, the more likely my prescription will prevent death.  Most of my patients here are over the age of 70 with several in their 90s.

The problem with taking care of old people is that I don’t get enough time to talk to them. I could easily spend a morning or afternoon just listening to one patient.  A person can’t get to advanced age without acquiring a large stock of really great stories.

Thanks to a light patient load and a scribe, I finished at 6:00PM. I walked out of the hospital at sunset, ten minutes across dry winter grass and quiet back streets.  We decided to drive back to Sioux City and our own wonderful bed.  We packed the car in less than 20 minutes.  The sky darkened as we traversed two-lane county roads through the rolling hills and farm country. We detoured to Trader Joe’s in Omaha, but missed a turnoff, adding an hour to the trip.

 

 

 

I take call and end up a patient.

April 23, 2017

At the end, it wasn’t a stroke

It was gone when I awoke

The symptoms were brief

Avoiding much grief

And I got to tell a crude joke.

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. 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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

 

Tuesday evening while on call, I got up to play Scrabble and I couldn’t make my right leg work. It didn’t feel heavy, numb or weak; it felt too light so that any effort to move it got exaggerated.   I sat down to do a neurologic exam on myself.  I found nothing other than my right leg ataxia.  I called Bethany from the next room, and told her the situation.  She helped me dress, and drove me to the ER.

The ARNP covering the ER did the same neuro exam I did, which wasn’t impressive until I demonstrated my gait.

She did all the right tests. The first EKG showed an old heart attack, which disappeared with proper lead placement.

She also found a heart murmur.  It hadn’t been present 5 years ago, but the PA at the VA found it a couple of months ago, and I called her attention to it.

My blood work had no surprises. She offered me the choice of staying in Clarinda or going into Council Bluffs, and I chose to go.  In terms of game theory, if something happened in the middle of the night, I wanted to be close enough for timely intervention.

In the process I had to make arrangements for someone else to take call.

I napped off and on for the ambulance ride, which almost got derailed twice by herds of deer. I bypassed the ER at Jennie Edmundson Hospital.  At 2:00 AM I had gotten settled, my IV had given me a couple of quarts, the second set of labs had come back and I’d had a good visit with the hospitalist ARNP.  Just before being tucked in, I offered the nurses a choice between a clean joke, a clean joke with a bad word, or a dirty joke.  They chose the last option, and I gave them the funniest crude joke in my large arsenal.

I don’t get to tell that joke as a physician, no matter how funny it is. But, as a patient, I can get away with it.  The punch line drew gales of laughter.

By then, motor control of my right leg was functioning at about 90%.

I slept for a couple of hours and had breakfast.

The neurologist arrived, and with economy of motion, did a thorough exam. He advised an aspirin a day and starting a low dose migraine medication.

The morning parade of tests started. By the time Bethany arrived I had done the basic neurologic exam six times and the symptoms had resolved except for the funny feeling inside my head.

I had an ultrasound of my neck, a consultation with the dietician (whom I amazed with my six pieces of fruit a day and my two ounces of salmon at breakfast), a consultation with the Occupational Therapist, and then the Piece de Resistance, the MRI. In between, I napped because I’d slept so lousy.

The hospital feeds its patients on the room service system; I ordered a lunch of soup, sandwich, and fruit, and within a half hour a young Guatemalan arrived with the food. We had a brief conversation in Spanish, I introduced my wife.

And we waited. The hospitalist came back, and went over the results.  Ultrasound demonstrated clean carotids (neck arteries).   The MRI didn’t show anything conclusive.  He also recommended an aspirin a day.

We waited for echocardiogram results. The hospital public address system announced a severe thunderstorm warning, and then a tornado watch in effect till 10PM.  The internet and the TV weather agreed that severe weather approached from the west.  At 4:45PM we decided to leave before the storm arrived, without the echocardiogram results.  We didn’t want to spend the night in the hospital, nor did we want to risk hitting deer on the way back to Clarinda.

Bethany drove. We enjoyed dramatic skies and listened to a Continuing Medical Education CD.  We ate at Clarinda’s premiere restaurant, J Bruner’s, ordering off the appetizer menu.

I returned to work the next day, the episode completely resolved, making it a transient ischemic attack (TIA), also call a reversible ischemic neurologic event (RIND).  Except I noticed my handwriting was much clearer.

I don’t think anyone else noticed.

Have imagination, will catastrophize. Professionally.

April 16, 2017

Here’s a subject in which I’m well-versed,

And for 40 years I’ve been immersed

When it comes to the best

I’ll just keep it in jest.

I’m paid to think of the worst.

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. 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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

Some people have a thought process that involves using their imagination to the worst possible effect. They think of all the things that can go wrong, and, sooner or later, they run into health consequences from dwelling on negative things that haven’t happened.  The medical profession has a term for this phenomenon; we call it catastrophizing.   As time goes on, the catastrophizer dreams up more horrible scenarios; they come to my attention when they develop insomnia, depression, and other problems.

I try to point out to the person in question that they couldn’t have anticipated the 10 worst moments of their lives, and that none of last 10,000 terrible “what ifs” they imagined came to pass. Therefore, it follows, that just by dreaming up negative scenarios, they prevented them.  Mostly, they don’t listen.

In the daily course of my work I think about the worst things I can imagine. I’m good at it, I’m a pro.  I have talent, training, and experience.  I can think of really terrible things.

Of course, like the experience of any catastrophizer, most of the really bad things I think of never come to pass. The thought doesn’t quite cancel out the possibility; I run the diagnostic tests.  At the end of the visit I frequently say, “You want me to be wrong.  You want to walk away from the tests shaking your head and complaining about what an alarmist your doctor is.”

A patient (who gave me permission to write this) came in with terrible pain in her hands. I thought of Lyme disease and rheumatoid arthritis, and ordered appropriate tests, but I also examined her med list and decided to at least temporarily remove the most likely candidate, her statin.  A week later, the pain is gone, and she feels better.

I also did not diagnose cancer, Lyme disease, syphilis, B12 deficiency, lead poisoning, measles, sepsis, and meningitis. Despite of string of previous successes, I also failed to find folic acid deficiency and polymyalgia rheumatic.

But I went looking for them. In my case, imagining the scenario doesn’t prevent it.  But, then again, I’m a pro.

 

 

Measles, a word the 7-year-olds haven’t heard

April 9, 2017

Here’s a contagious word to the wise

If there’s rash and runny eyes

With a cough, I suppose

Look! How runny the nose!

And it’s MEASLES! The CDC cries!

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. 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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

About 3 weeks ago I received an email from the Iowa Department of Public Health about a case of measles. The person (age and gender not given) had been in the Omaha airport on March 12.  Diagnosis of measles had come on March 15, after visiting 3 different healthcare facilities.

So I was on the lookout for a disease I hadn’t seen for 30 years.

Finishing my Indian Health Service contract in 1987 at the Tuba City, Arizona Indian Health Service Hospital, I saw hundreds of cases, and I had to learn about the disease. Measles discussions center on the 3 c’s: cough, conjunctivitis (runny eyes), and coryza (runny nose); the patient looks sick, and has a fever.  The rash starts on the face, and in the next three days works down the body, concentrating in the midline, armpits, and groin.  The 3-day or German measles has a similar looking rash that also starts on the face and spreads down, but people don’t get nearly as sick.

At the time, that reservation had an immunization rate close to 100%, but when the dust settled, the case count came very close to a 5% vaccine failure rate. Since then, the MMR has gone to a two-dose immunization schedule.

With the alert fresh in my mind, I had reason to think of the things I learned and saw so many decades ago. Working a game of incomplete and imperfect information, I called the state Department of Health.  Connecting eventually with an expert who had never seen the disease, but knew what to order, I heard for the first time of a viral transport medium called M4.  And I learned to use a culturette or a Dacron swan, not cotton and certainly not wood.

We still have no treatment for the disease. And with the illness almost extinct, we probably won’t invent one.  Yet measles still runs into complications in almost 10% of those who have it.

Exposure confers lifelong immunity, and only humans can get measles. Thus as an undergrad in anthropology, in one class we did calculations based on 2 week contagion, 3 week incubation, and generation length of 20 years to figure out how what size population can support the disease.  We decided, eventually, that measles couldn’t be more than 50,000 years old.

Measles remains contagious in the air for 2 hours after a person with an active infection leaves a closed room. Thus the case that triggered the alert, arriving on an airplane, exposed a lot of people.

I want to know about that case. What irony or drama surrounds the circumstances of inadequate vaccination?  Who did the exposing, and how sick did that patient get?  Where was the exposure, and was it linked to the Disneyland outbreak?

I never had measles as a child. The son of a physician, I served as a test patient when I was 14 for the first measles vaccine that only served to deplete what my meager natural immunity.  I had to wait till middle age to get an effective vaccine.

Later that day I asked a 7 year old if he’d ever heard the word, measles. “No,” he said, “What are they?”

The antivax movement makes no sense. Mercury has been removed from the vaccine, and all the evidence linking MMR to autism was fabricated by one researcher who has since owned up to his deception, yet that myth persists.

I fear that the antivaxxers may get enough traction to let the genie back out of the bottle, and that the word, measles, may once again become part of the language.

Weekend call: nature abhors a vacuum

March 27, 2017

I took the weekend on call

I started with no patients at all

But I fixed that up quick

With the ill and the sick

The thin and the fat, the short and the tall.

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. 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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

 Perfect people don’t come to see me. When I find a patient who has to face the music and pay the piper, I do my best not to judge.  Strangely, when I can condense my approach to, “You’ve made mistakes in the past, let’s move forward,” I find it easy to establish rapport.  I like to think that the rapport brings better chance of patient cooperation in lifestyle modification.  At the very least I have more energy at the end of the day.

In residency and in private practice, when I would take sign-out for weekend call, I would look first at the gross number. Of course we like it when no-one occupies a hospital bed.  But if the number came in really low, I’d shudder and remember the adage, “Nature abhors a vacuum.”

This weekend, I started call on Friday afternoon with a census of 0. By the time Saturday morning dawned, the census had climbed to 5.  Most, not all, had pneumonia.  Most, not all, sickened from a combination of tobacco damage and the aftermath of the influenza. I went into a rhythm of admission history and physical.

I dictate with sophisticated software. Still, sometimes I get so frustrated that I use my well-honed keyboarding skills.  For example, dictating a list gets me correct numbers except “4” which prints out as “for.”

And beneath the commonalities of fever, cough, and wheeze, each patient has a unique circumstance, a story of drama and irony that brought them to illness. And almost all have come at a time of stress in their lives.

Nothing is 100% in my business. A very few patients sickened gratuitously.  A genetic accident should not constitute a death sentence.

I enjoy talking with the patients. I ask them what they do in their spare time if they haven’t told me before I get to the question.  Over the years I’ve acquired enough vocabulary to speak meaningfully about a wide range of subjects.  Particularly in rural America, being able to talk about farming, crop yields, soil management, firearms, archery, and hunting gives me credibility.

Here in Clarinda, close to St. Joseph, Missouri, I ask people my age and older if they remember the Jerome Hotel.

It belonged to my grandfather. I drop his name.

 

 

 

What does “call” mean? Don’t look in the dictionary

March 26, 2017

Consider the places I’ve been

Then tell me, what does “call” mean?

For sometimes the word “call”

Means nothing at all

And sometimes it can make me turn green

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. 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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

People can use the same word to mean different things, and the same person can use a word at different times to mean different things.

For example, when I worked in the Indian Health Service, “call” started at 4:30PM and lasted until 8:00AM. Weekend call started on Friday afternoon and lasted till Monday morning.

In my years of private practice, it started at 5:00PM and went till 7:00AM. The doc who took Friday evening call worked the clinic on Saturday from 9:00AM till 2:00PM.  The physician with weekend call started Saturday as early as he or she wanted, rounded on the patients in the hospital, and took care of admissions till 7:00 Monday morning.  For a long time we saw the patients who came to the ER, but that faded over the years.  The on call doctor did the obstetrics over the weekend.

Call in Barrow (now called Utqiavik) never meant anything other than 12 hours, weekend, weekday, or holiday.

In Petersburg, the physician on call also covered the emergency room.

In western Nebraska, being on weekend call meant doing a Saturday clinic till noon, rounding on patients Saturday and Sunday, and admitting patients from the ER.

In Metlakatla, where we had no hospital beds, the two main ER nurses had excellent clinical skills. I could rely on them to know when I needed to come in and when I could safely wait to see the patient in the morning.

I have call this weekend, starting at 8:00AM on Thursday and going to 8:00AM on Monday. During that time, I’ll round on the hospitalized patients.  But someone else will work the Emergency Room.  If a patient needs admission, the Emergency doc does an admit note and writes admitting orders.  If a patient needs me to come in and see them before morning, they generally need to be at a larger facility.

I have had two nights of call so far. The first one passed without my phone going off, not even once.  The second time I worked steadily till 9:00PM stabilizing a very ill patient for transport.

But what does call really mean, here, this weekend?

I can tell you on Monday.

And I can guarantee it won’t mean the same thing a month from now.

Finishing early=playing hookey

March 22, 2017

The morning went just a bit slow

And I left with an hour to go                                              

But with the time I had freed

I got in some read

And enlarged the stuff that I 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. 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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

Last night Bethany and I had the chance to tell my story to a housemate. Coming up to my 60th birthday I knew if I didn’t slow down I’d burn out.  But I had a one-year, 30 mile non-compete clause.  That’s when I went to Barrow, Alaska, the northernmost place in the US.

Bethany recounted the time I called her to say that I had put in 63 hours that week, but I had time for the gym, playing my sax, participating in a jazz group, recreational reading and writing, socializing and watching TV. I initially attributed the extra time to commute reduction and other factors inherent in living in a small community, but then I applied the same criteria to what I’d been doing in private practice and came up with a conservative estimate of 84 hours a week, not counting obstetrics work.

Nowadays, any work week shorter than 60 hours feels like vacation. And when I walk into the clinic on Mondays, my steps bounce and I grin because I love the work.

I love it passionately up to about 50 hours, and after that my enjoyment starts to decay.

And I think my patients can tell when I get excited about a diagnosis. And when the patient makes my day, I tell them so.

Since I got here I’ve been able to radically help about a dozen patients with either Parkinson’s (involving tremor and stiffness) or PMR, polymyalgia rheumatic (an inflammation of the arteries).

But as influenza season wanes, so does the patient flow. This morning I had no inpatients at all.  Of my two scheduled morning patients, the first one showed on time at 9:00 and the second at 9:30.

I used the hours to read up on PMR . It overlaps with giant cell arteritis (GCA) and temporal arteritis (TA).  Because it comes in clusters, some authorities think it might be viral, and, indeed, if a biopsy of the temporal artery (which runs from right in front of the ear up into the scalp on the side of the head) shows TA, 3 times out of 4 it has the chickenpox virus in it.

Bethany met me for lunch.

In the afternoon I did some more work on my Canada license. I read up on Parkinson’s disease.  I saw 4 patients and finished their documentations.  Throughout the clinic, calm and low patient flow prevailed.  I got permission to leave at 430PM.  Bethany picked me up outside the front entrance, with a stiff March breeze blowing.  She took one look at me.  “Feel like you’re playing hookey?”  she asked.

I nodded. I had only worked 9 hours.

Six clinical triumphs and a tornado

March 17, 2017

I had me a wonderful day

I was keeping the blindness at bay

And I helped stop the shakes

Oh, the difference it makes!

To start steroids without a delay.

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. 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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

I can’t write about particular patients but I can write about clinical trends.

Sometimes I suspect Parkinson’s in the first 60 seconds after I meet a patient. I note a shuffling gait with arms that don’t swing, a face with limited movement, and a quiet voice lacking in music.  After the patient finishes their concerns,  I ask about shrinking handwriting size and loss of sense of smell.  Then, if the patient lacks the characteristic resting tremor, I’ll hold the patient’s hand.  If I feel the muscles between the thumb and forefinger quivering, I strongly suspect the disease.

No single sign or symptom serves as a gold standard. Without a lab test for Parkinson’s, the diagnosis frequently relies on response to the medication Sinemet, (levodopa and carbidopa).

Parkinson’s always progresses, but the rate varies. No matter what stage I find the patient in, I tell them that we have no medication that will slow disease progression, but we have a whole sequence of drugs for the symptoms.  Most elect to try the meds, a few don’t.

I love seeing a person in the hour or two after their first Sinemet dose, especially if I find the family close at hand. It really deserves the term, awakening, the title of the Oliver Sachs book and Robin Williams movie about the development of the drug.

I have picked up more than one case per week here.

I’m also finding an inordinate number of people with polymyalgia rheumatica (PMR), also called giant cell arteritis or temporal arteritis. For unknown reasons, worse with advancing age, occasionally a person’s body will attack the arterial lining with very large immune cells.  As a result, people feel terrible, lose strength in their shoulders and hips, and get severe morning stiffness lasting more than an hour.  The symptoms can sneak up over the course of months, or ambush over the course of days.  I ask if their jaw gets tired while chewing.  I feel the arteries over the temples; once in a while I feel hot, ropey spots on the scalp, where the blood vessel pulses .  We use two non-specific blood tests, the C-reactive protein (CRP) and the erythrocyte sedimentation rate (sed rate or ESR), which help make the diagnosis.  The conclusive test is the temporal artery biopsy, but only if it’s positive, which it never is.

Blindness ranks as the most feared complication of the untreated PMR; the artery that supplies the retina can clot off. Thus if I have strong suspicion I start steroid therapy promptly.  A quick response helps make the diagnosis.

Last Tuesday I had the wonderful experience of seeing more than one Parkinson’s patient and more than one PMR patient in their initial positive response to therapy.   Bethany picked me up at the hospital, and in the time it took for me to walk out the front door and get into the car the sky darkened so fast that the street lights came on.  As we drove to the gym I started to recount my day full of successes, but halfway there our phones interrupted with the announcement of a tornado warning.  We continued on, but the noise of the hail drowned out my words.  Three blocks later we arrived at the gym just as the tornado sirens started.

We sat on a bench inside and watched the vacant pool while I finished recounting my 6 clinical triumphs in one day.

Admit ignorance: practice it, get good at it.

March 13, 2017

If you don’t know a yes from a no,

And if you can’t tell the fast from the slow

Listen up, please,

For I can do it with ease,

Just say out loud, “I don’t 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. 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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

Over the weekend I observed the anniversary of my graduation from medical school. I remember the night well; I went out to the Chinese restaurant in East Lansing (at that time, there was one) with my father and my brother.  My fortune cookie said, “You will have great power over women.  Use it wisely.”

Before and after I have heard many commencement speakers, but the only one I remember was the one from March 11, 1979. “When you get up in the morning,” he said, “First thing, look in the mirror and say, ‘I don’t know.’  Practice it.  Get good at it.”  I remember a good deal more of that speech, but that particular commandment came to my mind this morning.

The patient came in for follow-up of cough. He had had all the right treatments before he got to me, but he wasn’t getting better.  I repeated the chest x-ray and didn’t see pneumonia.  Antibiotics, steroids, breathing treatments helped but not nearly enough, and he felt worn out from the cough bothering his sleep.  I said, “I don’t know what’s wrong, but, clearly, something is wrong.  And I know exactly what to do when I don’t know what to do, and that’s to send you to someone who knows more than I do.  Because I’m the world’s final authority on nothing.”  We were lucky to get him a follow-up appointment with the pulmonologist in a week.

But at the end of the visit I told him about my medical school commencement speaker, and how good I’d gotten at saying, “I don’t know.” And then I asked permission to write about him in my blog.  “I won’t say name of course, or age, or gender, but…”

“Doc,” he said, “You can tell ‘em my name is ### and I’m ## years old and I’m ### for all I care. Especially if it’ll teach other doctors to admit when they don’t know.”

I can hope.

An awful lot has changed in medicine since 1979. We don’t use penicillin for pneumonia any more, and rarely do we bring out the digitalis.  But doctors still have to admit when they don’t know.  It’s one of the rules of the game.

 

 

The blizzard to home

March 1, 2017

There’s the net, and we know what we know,

But if something’s uncertain, it’s snow

Is it foolish or bold,                                       

To make a trip in such cold?

Or just plan on making it slow?

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. 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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

I kept an eye on the internet weather predictions on Thursday preparatory to the drive back to Sioux City, and I could see snow predicted for the evening, but the really hard snow wouldn’t start till after midnight. Bethany and I talked about the trip over lunch.  We decided to try to get as far as we could, and, if necessary, stay the night in a motel in Onawa, about 50 miles from home.  We left in light rain mixed with sleet.  Our neighbors called before we reached Omaha.  The blizzard had engulfed our destination.

We talked it over some more. We decided that even if we could get to Onawa, a closed Interstate at that point would mean full motels.

If we’re going to get stuck, we said, we’d rather get stuck in a town with a variety of good restaurants and an overabundance of rooms.

We dined at the Jaipur, and while we tried a couple of dishes we’d never had before, the snow-covered the car to a depth of 3 inches.

We crept down icy streets to a nearby motel.

We hadn’t even brought a change of clothes, but the front desk had toothbrushes with tiny tubes of toothpaste.

We slept hard and deep and awakened rested to find, after breakfast, the car encrusted with ice and coated with heavy, wet snow. The trunk, frozen shut, required a good deal of coaxing to open.

As I pulled onto the Interstate in Omaha, a car intending to take the same ramp from the other direction spun out while I watched.

Between the two of us, my driving talent lies with traffic, and Bethany’s with snow and mountains. I got us out of Omaha and headed north on I-29.  At the first rest area we changed drivers.

On the way to Sioux City we saw two more spin outs and a half-dozen cars off the road, one on its roof.

The drive took twice as long as usual. But we arrived, safe and grateful.

It snowed and it blew but the cold didn’t approach the negative double digits we’d planned on in Fairbanks. Still it’s all part of the adventure.