Speechless during a speech

February 20, 2018

I stood up to give a talk

And then a Canadian doc

Said “You may want to switch

To a province less rich.

It might be a bit of a shock.”

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. I’m taking some time off after a month of part-time (48 hours per week) work in northern Iowa. Any identifiable patient information has been included with permission.

I originally went to work in Canada to learn about the medical system first hand. Of course I want to share the knowledge, and I put together a half-hour lecture for the County Medical Society.

I managed to arrive at this late date without learning Power Point. But having adapted to 15 electronic medical record systems in the course of 3 years, I figured that putting together a PP presentation couldn’t be very difficult. And, indeed, in less than an hour I found myself creating slides and downloading images from the Internet.  My brother, an accomplished graphic artist, provided me with two illustrations.

American physicians do not want to hear that the current Canadian system is better for the doctors than the American system, especially not the ones who came from Canada. I hasten to say that the systems now are not what they were 20 years ago or even 10 years ago.

Still, a Canadian ex-pat pointed out that I had chosen Canada’s most prosperous province (which I hadn’t realized), and that least-prosperous Nova Scotia might have given me a different view-point.

Over the next 3 days, I talked to 3 American doctors far from burnout. Two of them, both in their 60s, have refused to acquire electronic medical record systems.  One refuses to take insurance.

A week and a half later, I gave a slightly different version of the same talk to first- and second-year medical students in Des Moines. The audience’s palpable idealism impressed me, and I pitched my presentation to those struggling with the basic sciences.  I advised them that burnout is a very real problem.

The early warnings about burnout happened early in my medical school career. The dean of the med school, in the first week, told us that if we didn’t take care of ourselves eventually we’d be of no use at all in the medical system.  I don’t think he could have foreseen the escalation of burnout now threatening the system, nor that it would come not from emotional exhaustion, but from frustration with electronic medical record systems and overreach by management and government.

Twenty minutes into my talk, my phone gave me a text chirp. I ignored it and kept talking.

At the end, I took questions. One of which, almost word for word, got asked at the County Medical Society meeting:  What one single, practical thing can be done to improve our system?

Go to a single level of service, I said, instead of the 5 that we have now.

I got four questions from the audience, three others on 3×5 cards, and five more as the students exited on their way to the next class, snagging leftover pizza.

Then I looked at my phone. My physician daughter had given birth to her second child, a daughter.

And then, for about five minutes, I was speechless.

It doesn’t happen often.

 

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I got a call from the state

February 13, 2018

Amanda, she works for the state.

She called one morning at eight

“You haven’t reported!”

“I’m a locums!” I snorted

Things resolved when she gave me the date.

 

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. I’m taking some time off after a month of part-time (48 hours per week) work in northern Iowa. Any identifiable patient information has been included with permission.

A week after I finished up my most recent assignment the phone rang. Most of the calls I get these days come from robots, so I stopped answering with my name and title.  The voice at the other end said, “Excuse me, I was trying to reach the hospital.”

Thirty seconds later the phone rang again, the same caller, trying to reach the hospital. So I identified myself.

Amanda, calling on behalf of the Iowa State Health Department, wanted to know why I hadn’t reported a reportable illness.

The law says that physicians, on making certain specific diagnoses, have to notify the Department of Public Health. I approve of the law in its concept and reasonable enforcement and application.  But I hadn’t seen any patients for a week.

Amanda named the patient but not until she gave the date could I place the case as having happened the last day of that assignment. She wanted to know if I worked in that hospital.

Well, yes I had, but that locum tenens assignment had finished.

Then I had to explain locum tenens: temporary doctoring. (Nomad with a stethoscope, perhaps more poetic, carries less accuracy.)

On another locum tenens job in Pennsylvania, I’d learned a good deal about the disease: infectious but not contagious, treatable and curable, but with a very narrow window to start medication and avoid lifelong consequences. And it pleased me to no end that I’d made the diagnosis, just by being thorough and remembering lessons from past assignments.  I told Amanda she’d made my day, but she’d have to call the facility to get details about the patient’s symptoms. At the end of the call I asked for and received permission to recount the conversation and use her name.

So I walked around for the rest of the day with a big grin.

I don’t want to do straight ER or Urgent Care and miss out on moments like those.

But there followed emotional ups and downs. My college friend, Bob died of consequences of the medical problems I wrote about in October 2010, see https://walkaboutdoc.wordpress.com/2010/10/13/of-long-awaited-punch-lines-rolling-stones-and-fresh-faced-volunteers/

With the miracles of modern connectedness, I located other college friends who knew and loved Bob. One, also a physician, continues to love his work while most American doctors hit burnout.  He doesn’t have an electronic medical record, and he doesn’t care that the government will penalize him for mouse click deficiency.

In the midst of our grief, we talked about how much joy we get from patient care. We both want to continue as long as we can.

Sense of humor restored

January 25, 2018

 

Thinks of all the calls that I dial

And the round trips I make by the mile

And the hours on hold

Can leave my humor just cold

But it got restored with the sight of a smile.

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia, and now I’m living at home and working 48 hours/week in rural Iowa. Any identifiable patient information has been included with permission.

I go out of my way to keep a sense of humor. But I’m only human.

I had 8 patients on the morning clinic schedule. I cured the first patient of the morning and sent him on his way.  I returned to a clipboard with 4 sheets of redundancy inherent in a government-based workman’s compensation case.

About 11:00AM nurses told me of an arriving ambulance. By that time I had 5 undictated charts.

The hundred paces to the ER disappeared rapidly under my shoes. I took the history, ordered the CT scan and some blood work, and quick-stepped back to the clinic.  I knew I faced a serious, complicated case which would require a transfer and demanded prompt action.  I finished the last three morning patients and retreated to the break room to listen to the drug rep pitch very expensive asthma drugs and bolt Chinese food.

At 12:45PM I returned to ER just as the patient got back from CT. I finished the history and physical, and awaited the radiologist’s call.

I started with a call to the transfer operator, and the basic clinical picture. Then to the hospitalist, who accepted the transfer.  I started typing up the history and physical and was 75% finished when the hospitalist called back, clarifying some historical details.  Is the patient OK for MRI?

Trips back and forth from my work area to the ER. Calls to a specialist in Minneapolis.  Holding for 10 minutes at a time, while patients waited in the clinic and the piles of unfinished documentation fermented.

No, the specialist said, not a candidate for MRI.

On hold for another 10 minutes with the hospitalist. Do not send patient without speaking with neurosurgeon.

Twenty minutes later the neurosurgeon, dithered for 5 minutes and refused the transfer, and recommended Mayo clinic.

I considered how badly things could go during the hours necessary to get to Rochester.

The nurses recommended a competing Sioux Falls hospital. I announced that my sense of humor was weakening.

Another 5 minutes on hold. The hospitalist accepted the transfer graciously.

I gave the history and physical last-minute revisions to reflect the past two hours of clinical and clerical actions.

With the paperwork all packaged, I went back to the clinic. After 3 hours of the drama, irony, and frustration inherent in trying to be two places at once; after all the tension built into a system of inefficiencies dedicated not to patient care but to the cash flow generated thereby; after literal miles of fast walking hospital hallways, I stepped into the exam room.

The patient whom I started on Parkinson’s medication last week beamed at me when I walked in. The very small doses of a very old drug had done their job; the patient (who gave permission to write more than I have) bloomed.  Now the smile went all the way to the eyes, the speech had music, and the expressions danced on the face.

In less time than it took to shake hands, my sense of humor returned.

Yes, emergency work brings me challenging cases, but I do not want to give up the satisfaction and gratification that comes with patient follow-up.

Spanish, spinal manipulation, and zoonoses

January 24, 2018

The patients come in, I’m a doc,

And I ask, Are you working with stock?

Do the animals thrive?

Are they even alive?

How big is your herd or your flock?

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia, and now I’m living at home and working 48 hours/week in rural Iowa. Any identifiable patient information has been included with permission.

(Post generated week of 1/15 and held till now.)

I faced subzero temps and 40 MPH winds on the drive into work today. Still I came in to find my morning schedule full.

Which conflicted with a complicated ER patient, requiring hospitalization, and, eventually, a very complex transfer. So today I started counting the steps between my clinic work area and the Emergency Department.

The steps added up to 100 each way, but I lost track of the number of times I made the round trip.

Midway through the morning, I noted a holster with a pair of pliers on a patient’s belt. Obviously a quality piece of leather, and just as obviously worn daily for many years, I made the observation that even an American-made pair of pliers has a finite life expectancy if used often, and asked how many pairs of pliers he’d been through.  He chuckled.  He’d been through three pairs so far, and the holster had been custom-made for him.  He gave me permission to recount our conversation.

A lot of farmers and other agricultural workers come to see me. The rules on antibiotic stewardship do not apply to people who work with livestock.  I have concerns not only with zoonoses (diseases acquired from animals) but with the hazard to the animals if the patient transmits microbes.   I generally don’t give out antibiotics for respiratory infections under 5 days duration, but I make exceptions, for example, for those who have just removed thousands of dead or dying pigs from a hog confinement. So along with asking if a person uses tobacco, or if a woman might be pregnant, I ask, “Do you work with livestock?”

Today was a good day for speaking Spanish, relieving suffering among patients from teenagers to septuagenarians just with my fluency. I fielded the usual question:  Where did you learn Spanish (high school, but I’ve been practicing for 50 years), and also, Are you Cuban?  (no).

At one point a non-physician clinician needed an interpreter while I worked my way through clinic, and the nursing staff activated a video service. When I returned 40 minutes later I immediately recognized an accent from Spain, but I did not get a chance to chat up the interpreter.

By the end of the morning, I had cured three patients before they left (ear wax removal for one, and spinal manipulation for two). But the ER patient would stay another 3 hours until transfer could be arranged.

I left in the dark, in subzero temperatures, ferocious winds, and a light snow.

Getting a ride from the Sheriff

January 23, 2018

In Alaska in a blizzard we grinned

But here, with the howling wind

Good sense made me balk

At taking a walk

While the blades in the wind turbine spinned

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia, and now I’m living at home and working 48 hours/week in rural Iowa. Any identifiable patient information has been included with permission.

I watched the incoming weather most of the weekend, and decided Bethany and I should drive to work the night before, rather than possibly face blizzard conditions, and we set a depart time of 3:00PM. Two hours before, I got a call from the clinic manager asking if I would mind terribly coming in early.  I didn’t have to think twice.  We’d already be in the hotel, and I might as well get paid for it.

We found the drive windy but otherwise pleasant, and, looking at the clear, dry landscape, we couldn’t imagine that the weather would change radically.

But we awoke in the morning to find that it had, indeed, changed, and more radically than we could have imagined. We couldn’t see out windows covered with blown snow, and really couldn’t tell if that side of the hotel had drifted over.

I scraped the car while the wet flakes covered my glasses. On the way to the hospital, the wind drove the snow so thick and hard that only after a half-mile did I realize that my windshield had fogged up.  Even with defrosted glass I still had to creep.

I bought pizza for the clinic crew for lunch, and the manager closed the clinic. I could stay, she said, or I could go.

I went, figuring that snow this hard would act as an effective patient repellant. But the wind drifted the snow so deep I got stuck at the parking lot exit.  I got pushed out by a woman half my age.  With visibility less than 20 feet, I inched back to the hotel.  I got stuck again.  I rocked the car, but, in the end, the 50 MPH wind blew me out.

I got called back to the ER. I had to ask the Sheriff to give me a ride; my front wheel drive Avalon doesn’t have nearly the clearance I need.

Then I faced a case where, in the usual course of events, I would get lab and x-ray.   Not positive of the diagnosis, though, I had to consider that bringing techs from their homes to the hospital would endanger lives.  I explained the situation to the patient and spouse, and they agreed.  Then the story behind the illness unfolded, a wonderful tale of lasting love and dedication that held me spellbound till the nurse came in, and told them they’d better get to the pharmacy, which would close early.

More real emergencies came in. I spoke with consultants in Sioux Falls, who cheerfully accepted referrals and gave good advice, mostly to do with delaying transfer till the weather cleared.

But one transfer could not be put off. The nurses worked magic to arrange snowplows to precede the ambulance, county by county, and across state lines.

Then the call to the Sheriff’s Office. I rode with the same deputy.  He told me the weather had closed the highway, and that law enforcement had given out a “no tow” order.

Harrowing transfers

January 14, 2018

It’s the time of year for the flu

If it’s that, we know what to do

But in transferring out

We have without doubt

The stressors come out of the blue.

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia, and now I’m living at home and working 48 hours/week in rural Iowa. Any identifiable patient information has been included with permission.

With bad weather promised in the forecast, I decided to drive to work the evening before rather than the morning of. Fog shut down visibility and I crept the last few miles into town and hotel to await the impending major winter storm.

Overnight the temps plummeted to double negative digits, and the wind rattled the windows. I awoke to a scene of a blowing snow, but the worst of the wind had passed and the gusts stayed under 40 miles per hour.

Not surprisingly, clinic load dropped with the mercury. Through the day I cared for people with the problems of abdominal pain, a cold, a rash, another cold, the flu, a cough, another cold, ankle pain, yet another cold, and an irritated eye.  Two of the patients spoke Spanish; one of them first spoke an indigenous dialect before he started to learn Spanish at 15, thus making us equally Hispanic.

At the end of the day one of the permanent docs and I went to the Mexican restaurant. We talked a lot  about hunting and Alaska and the pragmatic parts of medical practice.

I had almost 45 seconds at the hotel before the call summoned me back to the ER to care for another person with a respiratory infection.

I took care of 3 more patients before midnight, one psychiatric and two respiratory. I did not ask for permission to write about any of them.

But I can write about the problems inherent in rural practice. Small hospitals lack the resources to deal with life-threatening problems.  Whether in Iowa, Canada, or Alaska, patient transfers can be the most harrowing part of the job: you don’t have to send well patients to referral centers.

Here I have to do a complete history and physical, just as if I intended hospitalization. I get the basic labs, and, if necessary, x-rays.  I ask the nurses where to best send the patient.

Sometimes neither nearest nor best-equipped means the same as best.

Then I make the first call. Sometimes a secure video link, much like Skype, opens up.  I generally have to go through a nurse to get to the doctor, who has final authority to say, Yes or No to the transfer.

Depending on the context, ambulance and/or law enforcement personnel need to be enlisted.

Then the harrowing wait begins. The helicopter, airplane or ambulance never shows until I have hit the outskirts of emotional exhaustion.

When the patient leaves, I start keyboarding my history and physical into the computer as fast as I can. I hand the printed copy to the nurse with the request to fax it to the accepting physician.

Then I dictate the same information into the dictation system.

I got back to the hotel shortly after midnight, too wound up to sleep. I studied for an hour and a half.  I slept surprisingly well before going back to the clinic to discuss legal threats with the manager.

The last week of the year

January 5, 2018

The Canadians were boxing that day

The 26th is a time that they play

But I took the call

Which was not rushed at all

But was long. What can I say?

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. A month in the Arctic followed a month in Iowa followed 3 months in British Columbia, to which we have returned. Any identifiable patient information has been included with permission.

Much has happened in the last week.

Sunday: I don’t celebrate Christmas, I support my colleagues who do and go out of my way to take call on 12/24 and 12/25. But this year, I had to compete with two colleagues who don’t celebrate either, and for the 3rd time since the 70’s I didn’t work the holiday.  Bethany and I went cross country skiing.

Monday: We rented waxless skis from one of the hospital staff. I wore most of my clothing, including seal skin mittens and a beaver fur hat purchased in Alaska.

Bethany and I hadn’t cross-country skied together so far this century. The last time I went out on skis, waxless skis had just come out. I still ran then, compulsively, and I had some flexibility left, and my hair and beard had yet to turn the color of snow.

We went out for 3 kilometers, not far as cross-country skiing goes. I didn’t fall till the very last, and had to clip out of my skis in order to stand up.

Tuesday: I celebrated Boxing Day for the first time.  One of my Canadian patients explained the holiday:  “You stay in your pajamas all day and eat left overs and play with your toys.”  Of course I thought that kind of celebration laudable and wondered why it would only come once a year.   But I had volunteered for call that day, giving it to the Canadians who celebrate the holiday, and who couldn’t imagine that an entire country wouldn’t.  Steady patient flow, about one per hour, let me pay enough attention to each patient without rushing.  But it kept up till just shy of midnight.

Wednesday: ER patient at 3:00AM, requiring lots of ER care. In the middle, I returned to the room, showered, and changed. Back at the hospital an hour before dawn, the sky brightening in the east.  I faced the coldest temperature of the year thus far, -25 Celsius (-18Fahrenheit).  The new snow squeaked in protest as I stepped.  I worked the walk-in clinic, despite assurances I could take the morning off after a hard call.  I lunched back at the hotel, napped marvelously, and walked back to finish the afternoon.  I didn’t want to drive; scraping car windows inside and out takes more time. I did, however, drink a cup of coffee.

Thursday: after caffeine ruined a good night’s sleep I returned to clinic early to finish the inevitable odds and ends that come at assignment’s termination.   Unable to enter the dictation system for a discharge summary, I sighed, sent an email, and moved on.  I cleaned out my electronic queues of lab and x-ray reports, and consultations. I had 500 items, of which two made me exclaim out loud, not because I had been wrong, but because I had been right.

Friday: We scraped the car windows, put the heat on full blast, and packed.  At the clinic we said good byes and snapped pictures.  On the drive to Prince George any outside temp less than -19C iced our breath inside the glass.

Saturday: Getting to the airport 30 minutes before boarding gave us plenty of leisure.  I pointed out my multi-tool to the airport security personnel.  She told me Canada approves blades less than 5 cm, but I would lose it in the States.  It doesn’t have a blade but I didn’t argue.  We left in the dark and the snow, and 18 hours later landed in the dark and the snow in Sioux City (and temperatures of -26F/-33Celsius, even colder than Canada) after two long layovers separating three boring flights.  The best kind.

 

A Tale of Two ER Patients

December 27, 2017

The blood came gush from the nose

Staining the floor and the clothes

But a Merocel pack

Slid from front to the back

Brought a stop to the flood, I suppose.

 

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. A month in the Arctic followed a month in Iowa followed 3 months in British Columbia, to which we have returned. Any identifiable patient information has been included with permission.

A tale of 2 ER patients.

I find the process of transferring patients out daunting and frustrating. The remoteness of the community demands stewardship of the two ambulances with their crews.  Thus, when possible, I send  patients to Prince George via POV (privately owned vehicle).

Even then, the process of stabilize-and-transfer can involve an hour or two of ER time when I get to chat with a patient.

I got to talk with a chef, who gave me permission to write a good deal more than I have. His camp, with 120 workers, employs three cooks, each responsible for one meal a day.  We had a great time talking about gravy; we agreed that corn starch beats flour for thickener, and that a good broth or stock means more to the sauce than the drippings.

*-*-*-

 

I gave a different ER patient the reverse of my usual dietary advice. Eat three scoops of premium ice cream at bed time, I told her.  Don’t drink water, always make sure your beverage has calories, especially high fructose corn sweetener.  I described how the Iowa beef industry uses it to accelerate fat gain in cattle.   I told her not to eat anything without gravy, mayo, or a sauce.

At the end, I said, “I write a blog. I won’t mention name, diagnosis, or age, but I’d like to write about the eating plan I gave you, the opposite of what I usually give out, how poison for one person is life-saving for another.”

She waved her hand and said, “You can use my name if you like.”

 

*-*-*-

During my IHS time in New Mexico, I saw 2 or 3 major nose bleeds a week for 18 months.  In that time, I became skilled at packing the front part of the nose to stop the bleeding.  Most times I could get the stanch the flow, and when I couldn’t, I knew what to do to get the patient to specialist care.

But since then the nose bleeds I’ve seen were simple, easy to stop temporarily followed immediately by a touch with a silver nitrate stick for permanent resolution. .

But the problem of serious epistaxis (bleeding from the nose) relies heavily on equipment, and the equipment has changed in the last 30 years. Our hospital has specialized catheters with inflatable balloons (the Rapid Rhino), and sponges made of material that promotes clotting (Merocel).  We also have tranexemic acid, unknown in the 20th century

For the time frame involved, I’ve seen more than my share of complicated nosebleeds this trip. I discovered that the closest Ears, Nose, Throat specialist doesn’t take call, and that most of the ER docs cheerfully confer by phone.

Croup treatment has and hasn’t changed

December 21, 2017

With a cough like the bark of a seal
And the kiddy so good doesn’t feel
There’s no way to avoid
A dose of steroid
Croup must be treated with zeal.


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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. A month in the Arctic followed a month in Iowa followed 3 months in British Columbia, to which we have returned. Any identifiable patient information has been included with permission.
I had cause to contemplate how things do and don’t change in medicine. Consider, for example, croup. If a virus swells a child’s narrow airway, a barking cough, much like a seal asking for a fish, follows. Death can ensue if the airway narrows to the point of closing, or if the child stops breathing out of exhaustion.
The pediatric ward in the hospital where I did my residency had two outdated features for treating croup when I arrived.
One consisted of a tiled room that could be filled with water vapor; a large cloud chamber that could sleep 8. During my tenure its only use was storage.
But the spacious balcony on the other side of the nurses’ station told a different story. It had sliding glass doors and space for 6 cribs. In a bad croup year, the nurses bundled the children up, to sleep with their faces uncovered in the cold, dry Wyoming air.
It worked for most of the kids, and I still recommend that strategy, saying, “Now if the spasm of croup doesn’t clear in 3 breaths you’re already headed to the ER.”
Treatments have come and gone and come back. Antibiotics, we found, did no good. Theophylline (a close cousin of caffeine, and found in pharmacologic amounts in chocolate) helped, but not much, and had a lot of side effects so has since been completely displaced by the albuterol (in Canada, salbutamol) updraft.
Every winter, during the peak croup season, I’d ask my pediatrician friends if we’d gotten anything new for croup, and every winter they’d shake their heads.
We used to use inhaled adrenaline (also called epinephrine). It has come and gone in five year cycles. A year and a half ago I thought for sure that I’d never use it again when I heard a study showed it did no better than inhaling saline (salt water).
We used steroids a lot and stopped for a while in the 90s, started again just before the millennium, and continue to this day. Controversy remains regarding dose, and method of administration.
But croup has changed. The really, really bad version, where the epiglottis (the flap valve between the airway and the swallow tube) swells has disappeared with modern immunizations for diphtheria and Hemophilus influenza. And with the decreasing smoking rates we don’t see nearly as much as we used to.
I had cause to research croup treatment recently, finding, to my surprise, that all my internet sources recommend inhaled epinephrine and steroids. Just like 1982.

I joined NIRD

December 20, 2017

I think that what you have heard

Could be boiled down to a word

The truth I must face,

And even embrace

Is the fact that I’m really a nerd.

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. A month in the Arctic followed a month in Iowa followed 3 months in British Columbia, to which we have returned. Any identifiable patient information has been included with permission.

No one called me “nerd” in high school, only because the word hadn’t come into currency. I belonged in the clique of intellectuals that didn’t have a clique. I figured out pretty early that I’d rather study than party, read a dictionary than drink, and find a movie’s logical inconsistencies and anachronisms than sit back and enjoy it.   By the time I could relax and embrace my nerdiness, I knew how to find groups that valued and even revered book learning.

So I jumped at the chance to join Northern Interior Rural Division of Family Practice, or NIRD and the chance it offered for a Christmas party and an opporutnity to get together with other rural docs. I even ignored the misspelling.

True to my inner nerd, I got us to the party on time at 11:00AM, and before anyone else.

Most physicians brought their families and most of the kids were younger than 12. I probably graduated from med school before half the docs were born.

I gave a yoyo demo. Bethany and I repaired an 11-year-old’s yoyo, I gave him a new string and taught him how to wax it to improve the sleep time.

The docs from our clinic, with spouses and kids, settled at one table. To my surprise and delight, we didn’t discuss patients.

We had a great meal, centered on turkey but with plenty of vegetables. We didn’t rush dessert, and chatted on after everyone else had left.

At 3:00PM, little daylight remained. Bethany and I picked out a movie, but couldn’t find the theater in the dark despite 3 GPS units.

We stayed overnight in a rather nice hotel room. I’d never seen glass interior walls that opacified for privacy.

The next day we bought groceries at Costco and Real Canadian Super Store, which vies with Costco for great prices but offers a better selection.

Without the rampant Canadian politeness, we probably wouldn’t have escaped from the parking lot of either store before closing time.

We had a beautiful drive back, with clear skies and bright sun, and fine, gleaming white frost on the trees.