An Icon Tried to Avoid Being an Icon

October 13, 2019

The thyroid, that excellent gland

Got removed via scalpel in hand

The rumor was tumor

The answer was cancer

A cure, we think, would be grand.

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.  I am currently taking some time off.   Any identifiable patient information, including that of my wife, has been used with permission.

Three weeks after her thyroid surgery, Bethany is recovering well and doing OK with an adjusted thyroid replacement dose.

In this country, anything removed from a patient gets sent to a pathologist.  Bethany’s thyroid had definitively turned against her.  The cancer was fully contained on the left but had come to edges (perhaps further) on the right.

Aside from minor fluid accumulation at the site of the surgery requiring drainage 3 times, her recovery has gone according to plan.

Sioux City has been through a sequence of endocrinologists, subspecialists caring for people with hormonal problems.  Sometime during one of my absences a very good one moved away.

Friday morning we set out for Sioux Falls.  While the dark and the chill reminded us of our fishing trips from Soldotna to Homer (Alaska) last spring, the experience had a decidedly different mood.  Wind whipped the car, we drove on divided highway with traffic, and we didn’t play at counting roadside moose.  In Alaska, we stayed close to the 60 MPH speed limit, but South Dakota lets Interstate traffic go 80; with a 35 MPH headwind we had noise we hadn’t dealt with last spring.

We’ve known the endocrinologist, Dr. Oppenheimer, socially, for decades.  He has an independent practice close to an I-229 exit.

The visit proceeded as expected: history, physical, then education.

Bethany will go off her levothyroxine, a generic T4, and onto Cytomel, a brand name T3.  (There are two active thyroid hormones.  T4 has 4 iodines and lasts for weeks; T3 has 3 iodines, is 6 times more potent, and lasts for hours.)  After a month, she’ll be off thyroid supplements completely for two weeks.  When her tsh (thyroid stimulating hormone) rise reflects an adequate loss of thyroid hormone, she’ll get radioactive iodine, I-131.  And then she’ll need to be isolated for several days.

Dr. Oppenheimer showed us around his clinic.  He has a room dedicated to ultrasound, and another for telemedicine.  He has a good deal of artwork in which he takes justifiable pride.

But I stopped and my jaw dropped at a framed letter.

The letter, addressed to Dr. Oppenheimer’s father (also an endocrinologist), dated 1947, entirely in German, bore the signature of Albert Einstein.  The iconic physicist declined to give the elder Dr. Oppenheimer an interview because he did not want to become an icon.

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My beloved’s thyroidectomy

September 22, 2019

It’s OK for preserving the life

Of your lover, your friend, your wife

We’d like to avoid

A malignant thyroid

And so she went under the knife. 

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.  Last week a colleague’s illness necessitated my return to hospital work.   Any identifiable patient information, including that of my wife’s, has been used with permission.

Yesterday I drove my wife, Bethany, to the surgical hospital.  Our family doctor, on routine exam, found a tiny thyroid lump, leading to an inconclusive thyroid needle biopsy.

Thyroid disease comes as common as rain.  With the advent of iodized salt and the food globalization, the “goiter belt” I learned about in med school disappeared 70 years ago, yet a cold climate forces thyroid glands to work harder and wear out faster.  But it doesn’t cause cancer.

Amongst ourselves, docs would choose thyroid cancer over any other.  Slow growing, if it spreads, the cancerous tissue stays so functional that it continues to hog the body’s iodine, including radioactive iodine (I 131), which turns the remaining thyroid tissue into a microwave oven.

This problem comes when I have, in the adolescent idiot’s sense of the term, fallen in love with my wife, who has been blessed till now with wonderful health. On top of deep, mature love from 40 years together, for the last couple of years I have experienced, again, the young man’s sense of wonder, seeing in every act a reason for integrity that would make my beloved proud of me.  I felt like a teenager seeing their first love go under the knife.  I know everything that could go wrong.

We arrived at noon.  At 1:30 PM she walked down the hall to the operating room.  I sat with other families awaiting their loved ones.  I used our phones to text and call our children and my sisters-in-law about start of surgery, end of surgery, and exit from the recovery room.

I spoke with the surgeon as soon as he’d finished.  Colleagues for decades, I know him and trust him.  The frozen section, what the pathologist does during surgery, came indeterminant: a follicular lesion; neither conclusively malignant nor benign.  Final result expected next Wednesday.

I worried about the parathyroids, the tiny glands sitting at the 4 corners of the thyroid’s H.  They regulate calcium; one functions as well as 4 but none lead to lifelong problems.

I longed to see her and to be near her, but getting from recovery room to settled in bed took aching hours.

I waited in the family lounge with my computer, finding writing a soothing balm for my feelings.

From behind me I heard, “Doctor Gordon?”  I turned my head to see a comely young woman.  “You delivered me,” she said.

She told me one of my former patients, a relative, had a joint replacement, and gave me the room number.  In the conversation I found a distraction from my worry, and went to visit.

I code shifted, English/Spanish, with my patient.

Yes, the patient said, “You delivered her 27 years ago. You look great.  You look younger!“  I didn’t mention that quick arithmetic showed me the delivery came the year my OB practice peaked.

Nor did I mention running into a hospital staffer who recognized me 3 minutes before I recognized her; I also delivered her babies.

Bethany looked pale and felt nauseated and high.  We dozed together without the TV.  At 10:00 PM I left for home, not wanting to be away from her at a vulnerable time.

I drove through the dark, watching the Big Sioux and Missouri Rivers threatening their banks, flooding for the 3rd time this summer.

 

 

 

Some diagnoses considered and rejected

September 21, 2019

My colleague, it seems, came down sick

It happened, I fear, rather quick

Then I got the call

To pick up the ball

To save someone’s life is a kick.

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.  Despite intention to take some time off, I did a couple of days of hospital work this week.  I really do intend to take a couple of weeks off.   Any identifiable patient information has been used with permission.

It doesn’t take Sherlock Holmes to predict that if 8 docs work 14 hours daily two weeks running in a facility crawling with germs, that sooner or later someone will get sick.

I got a call on Monday to come back to work in the hospital, one of the other docs had taken ill abruptly.  I said yes.

I like hospital work.  I get to rub elbows with docs who know more than I do.  And I like working in one of my old hospitals, I get to see my old buddies.

Adequate restrictions on tobacco and alcohol would have robbed me of half my work.  Each person came with a back story of drama and irony, of love and regrets and unfinished business.

Sometimes I find myself the least knowledgeable person on the team.  Thus I walked into the ICU, introduced myself as the generalist.  I told the family and patient my job consisted mainly serving as an English translator of the situation, and what to expect.

But every once in a while I find myself adding substantially to the patient’s care.

Potentially my most valuable contribution this week caused me to remember my experience with Wernicke-Korsakoff, which I’ve written about before.

httpIs://walkaboutdoc.wordpress.com/2015/12/15/double-vision-remembering-wernickes-without-korsakoff/

https://walkaboutdoc.wordpress.com/2010/06/18/wernicke-without-the-korsakoff-dont-hold-the-thiamine/

I think back to those two experiences and to a third patient who didn’t get his thiamine in time and got trapped in a summer’s day in the first decade of this century.

Few lab findings make me dance, among them a low vitamin B12 level and a high TSH (thyroid stimulating hormone); in both cases I get to save the patient’s life for pennies a day.

But I came across another lab finding that required I call the hematologist (blood specialist), who, in our culture, is the oncologist (cancer specialist).

Of the 20 patients I saw each day, six had cirrhosis of the liver, but not all from alcohol.  Two had liver cancer resulting from cirrhosis.  I overlapped with the nephrologist (kidney specialist) on six more.  Four others got stuck in a holding pattern until insurance would agree to pay for rehabilitation placement.

A physician should always keep in mind the possibility of Munchausen’s syndrome: the patient purposely makes the symptoms happen.  A rare problem, to be sure, but a good deal more common than a dozen others I considered and rejected.  And the patient involved almost always knows more about the disease than the doctor does.

 

 

A dual-purpose dental visit

September 14, 2019

When I had a bad pain in my jaw

It turned out that the dentist I saw

Had sciatica pain

From an infrequent bane

A piriformis muscular flaw.

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 now I’m taking a few weeks off.   Any identifiable patient information has been used with permission.

 

I have sleep apnea but I have so far avoided the dreaded CPAP machine by using a dental device called the TAP.  It works well enough but over the last three months, with increasing frequency the right side of my jaw will get stuck if I chew something that’s too tough.  What that happens I have trouble opening my mouth all the way.  Up till now the problem has resolved itself in a matter of hours, generally with a soft but satisfying pop as that joint slides back into place.

Yesterday it happened and all my maneuvers failed to put things back into line.

I refuse to be my own doctor, so I called the dentist who fit me with the device.

He got me in promptly, and reassured me my problem boiled down to a sprain.  He advised ibuprofen.

I had to stop all non-steroidal anti-inflammatory drugs, I said, because of kidney damage from taking indomethacin, naproxen, Vioxx, and others for a couple of decades.

He ran through an impressive list of herbal anti-inflammatories, and gave his experience with them.  He’s had terrible problems with sciatica, despite getting state-of-the-art diagnostics and therapeutics.  I listened, I nodded, and didn’t say anything till he mentioned piriformis syndrome, a problem I’ve written about before: https://walkaboutdoc.wordpress.com/2010/12/24/piriformis-syndrome-a-curable-pain-in-the-buttock/.  And then I couldn’t help myself.

He understood all the jargon having to do with isometric contraction away from the barrier to range-of-motion, including fooling the gamma efferent into providing reflex inhibition of the antagonist groups.  On the floor of his office I showed him how to relax the piriformis, a muscle that both externally rotates and extends the hip, with an osteopathic technique called muscle energy (he gave me permission to include more information than I have).

I explained that I have an MD, not a DO, but I went to Michigan State where the two schools share classes, and I learned manipulation.  I stumbled across this piriformis syndrome treatment by accident as a first-year med student.  Two or three times a year, I said, a patient will limp in and strut out.

Sometime during the last 9 years, to avoid hurting my back, I quit manipulating the patient and I started showing them how to manipulate themselves.

At the end of the visit I mentioned my plan to get acupuncture, and named the same chiropractor he goes to for that service.  He asked me to send his regards.

 

Collegial colloquium at Sam’s

September 12, 2019

 

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 now I’m taking a few weeks off.   Any identifiable patient information has been used with permission.

My 24-hour homeward journey from Canada has acquired a familiar flavor.  I recognized the black bear on the road to Prince George by the white patch over his sternal notch. Sooner or later I may get to know the Customs and Border Protection people on a first-name basis.

The morning after my return I ran into a friend and colleague at Sam’s Club.

Less than a minute into the conversation I showed off the picture of Bethany and me with our 92-pound halibut.  I talked about our travels, which brought the conversation around to the generalized wonder that 21st century North America has become.

I missed the chance to gesture around at the Sam’s Club environment and assert that monarchs 100 years ago could not access what exists in just one store in one small city in the middle of the US.

Instead, I asked about his family

A pediatric cardiologist married to a family practitioner, the couple have 4 sons, three in medical school and one studying for the MCATs (Medical College Admission Test).

He recently spoke to his oldest son.  As a 3rd year medical student he admitted a patient in his 90s with a terminal diagnosis and a request for a Do Not Resuscitate (DNR) status.  The student and the patient bonded during the hospital course which ended with the patient’s death, leaving behind a family at peace and a grief-stricken student.  The son wept as he recounted the experience to his father.

Father to son, the older doctor gave consolation and support and the advice to never stop feeling.

I didn’t recount one of my experiences earlier this year, with a 98-year-old patient I admitted to the hospital with a list of diagnoses that included heart, kidneys, lungs, and metastases.  I followed my routine at the end of the history and physical: I explained the clinical situation, discussed treatment options, clarified the patient’s goals, and asked the last question of the interview: if your heart stops beating, do you want us to try to restart it?

She did not hesitate, and said, “I’m ready to die.”

Writing months later, I still find myself pausing like I paused when I sat down to do the admission orders.  I thought about life and death and mortality and the unique place a physician holds in the orderly circle of life. In a space away from the noise of the nurses’ station I paused before I checked the DNR box, then I burst into tears.

.

 

Labour Day Weekend Call: Real Time.

September 5, 2019

You’ll find at the end of the day

If you call the tune up to play

You can say it’s no fair

And I don’t mean to scare

But the piper you will have to pay

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 Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, South Central Alaska.  After two weeks vacation and 5 weeks as a hospitalist in my home town, I have found my way back to British Columbia. Any identifiable patient information has been used with permission.

They spell Labour Day differently here than in the US but it remains the same day: the first Monday in September, a day to not work.

I have call.

I slept in, not arising till 6:30 AM, ate a leisurely breakfast, and went back to bed.

At 9:30 AM I got a call for the first morning patient, followed quickly by the second morning patient, both on-the-job injuries from the same plant.  One injury resulted from safety features gradually disabled over the last 40 years, the other from safety features that should have been in place 40 years ago.,

The plant is in the process of closing down.  Economic downturns, a decrease in the demand for forestry products, outdated technology, and changes in the transportation network have resulted in shuttering plants processing trees all over the province.

Noon:  That piece of glass didn’t belong there.  I removed it from a person moving ahead with hopes and aspirations.

12:15 PM:  A patient with a straight forward infectious problem arrived with a family context.  The children enjoy a few yo-yo tricks.

1300:  In an over-resourced system this patient would have a CT scan regardless of age or concern for late effects of radiation.  I exercised clinical judgment involving a trip to Prince George for more sophisticated diagnostics.

1330:  I slipped out of the hospital to the convenience store to buy lunch for the crew.  Not mandatory, but certainly appreciated.  Originally intending to just get wedges and wings, I found samosas and egg rolls.  While I’ve had better samosas, I haven’t had many, and certainly not at this price.

1345: In Canada a doctor can be a locum tenens only for a specific physician for a defined time period.  The US has a much more flexible view of locum tenens, and I have worked in facilities where temporary physicians provide most of the care, with permanent docs found in administration.  My current position requires review of lab, x-ray, and consults that come in under the name of the doc I substitute for.  With the vast majority normal, the remainder bring messages of drama and irony, from gratuitous bad luck to the piper demanding a long overdue accounting.  In the last week I’ve checked off more than 1100 items.

1500: Another patient with job uncertainty because of plant closings.  Your problem is not imaginary, I explained; stressed people get sick.

1630:  If you call the tune, sooner or later you pay the piper.  This patient, like so many others, knew the diagnosis even without having an extensive medical vocabulary.  I listened, I gave choices, and we agreed on the treatment.

1715:  Another person called the tune, and had to pay the piper.

1930:  Another piper-patient payment.

2100:  Trying to warn an intoxicated patient of the inevitable piper’s payment does no good.

2200: Back in my room, I sleep poorly.

Cardiac treatments: when less is more

August 29, 2019

When it comes to attacks of the heart

You can choose what to do a la carte

Use statistics and math

Before you order a cath

And say less is more when it’s smart.

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 Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, South Central Alaska.  After two weeks vacation and 5 weeks as a hospitalist in my home town, I have found my way back to British Columbia. Any identifiable patient information has been used with permission. 

The US medical system, bloated and over-resourced, does not get quite as good results as the much leaner, under-resourced Canadian system.

Consider the problem of chest pain.  In 21st Century North America, doctors will suspect heart attack if anyone complains of pain between the diaphragm and the neck.  The investigation starts with a simple blood test (troponin) and a tracing of the heart’s electrical activity (electrocardiogram or ECG).  (In the 20th century we looked at the ECG and the CK-MB, a slower, less accurate test.) A low risk patient with 2 normal tests gets sent home; higher risk patients with normal tests gets kept for at least three hours for repeat testing.  Mild heart attacks may show a rise in the troponin with a normal ECG (medicalese: NSTEMI).  But if an abnormal troponin accompanies an abnormal ECG, we make the diagnosis of a much more serious heart attack and we call it a STEMI.

British Columbia has no cath lab north of the Vancouver area.  Realistically the patient doesn’t get definitive treatment for 4 days.  Yet the Canadian patients do slightly better than those in the States.  Here in the North we know how to stabilize and hold patients because we do it a lot.  One nurse told me she hadn’t seen the more serious STEMI for 9 years.

The improved outcomes may be due to chance or to different statistical methods, but real reasons remain a possibility

Canada has done very well fighting tobacco.  The same pack that goes for $3 in Missouri costs $10 here.   The pharmacies sell nicotine patches and gum without a prescription at subsidized prices.  The tobacco settlement money, originally earmarked for prevention campaigns, got hijacked into the various States’ general funds; Canada has vigorous and effective anti-smoking advertisements.

Thus the US has a slightly higher rate of smoking than Canada.

Very good research has enabled us to differentiate which patients will do better with medication vs. surgery.  Canada does well at using that information to prioritize treatment.  In my experience, though, Americans, given the choice (and gray areas predominate over black and white) demand more treatment even when an alternative exists.

I suspect but cannot prove that keeping patients close to their support systems improves outcomes.

Vancouver Work Permit Pickup

August 19, 2019

I need a permit for work.

I struggle against being a jerk

A reasonable fate

Is a reasonable wait.

I’ll try to make friendly my quirk

 

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 Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, South Central Alaska.  After two weeks vacation and 5 weeks as a hospitalist in my home town, I have found my way back to British Columbia.

At 2:00PM I walk into the Immigration section of the Vancouver airport, for the 4th time since 2017.  The layout has changed a little, and today I waited in line just to get in the room, chatting with a young woman from the Czech Republic.

The youthful Canadian Immigration Services officer wears a Glock and Kevlar.  I hand her my passport and a thick stack of papers: LMIA, job offer, proof of qualification, police statement, physical exam, etc., etc., etc.  She looks at them briefly, and hands me a tab with the number 757, points to the almost empty half of the room and politely tells me to wait over there till my number is called.

I wait and I read as I sit close to a bank of 4 other Immigration Services officers, working full tilt with computers and phones.  Pretty soon one calls number 342.

Thirty minutes later another officer calls 343.  I look at my tab and do some arithmetic and decide at this rate, if the officers work 24 hours a day, I’ll get my work permit in 8.6 days.  I expect my papers to take not minutes, but hours or a day, certainly not days.

At 4:00PM I look up from my book with alarm and realize all the officers have left.  When a straggler passes at 4:10PM, I politely express concern that my plane leaves in an hour, and it’s only fair to inform WestJet.

In the US, I must confess I would have been more urgent and abrupt, perhaps even sarcastic.  In fact, back home I would not have walked away from my passport so blithely.  But Canadian society qualifies as more polite and friendly than the US and I don’t want to slip into the stereotype of the loud, brash, demanding American.

With casual friendliness he goes through a door I can’t and returns with the news that my papers are being processed.  Ten minutes later, I get my work permit.

I land in Prince George in the late afternoon, the air cool and wet with a gentle rain.  While waiting for my luggage I rent my car.  The young man looks at my driver’s license and says, “Iowa.  What country is that?”  Of course I say the US, but I don’t admit that most Americans don’t know the difference between Iowa and Idaho, and certainly don’t know the location of either.  I ask if he’s from Vancouver, but, no, he’s from Prince George.

With weather and mechanical delays, I have to wait 4 hours for Bethany’s arrival.  I check into the hotel, have Tibetan dumplings at a restaurant across the street, and watch TV movies on a large flat screen till almost midnight.

At the airport, I make friendly small talk till Bethany’s plane comes in, and then I can not help but jump to my feet, smiling.

 

Pulling a Sherlock Holmes at a Motel

August 16, 2019

You know, I said to the clerk,

I hope I’m not being a jerk

It seems like a trifle

To guess your cartridge or rifle

I’d say, for you, shooting’s a perk.

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 Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, South Central Alaska.  After two weeks vacation and 5 weeks as a hospitalist in my home town, I am on my way back to British Columbia

Checking out of a motel in Boise, Idaho, I decided to do my best imitation of Sherlock Holmes and I addressed the clerk.  “I’ve been reading Arther Conan Doyle lately,” I said, “And I’d like to make a guess, if you don’t mind.”  He nodded.  “Are you a recreational shooter?”

I find a really nuanced double-take much more satisfying than a heavy-handed startle or exaggerated head shake.  It’s the same kind of double-take that I get when I speak Spanish to a patient who doesn’t expect it.  And this time, I got a good one.  Of course he asked me how I knew.

I admitted I didn’t know, that I guessed.  And I based the guess on a well-healed, subtle, curved scar on the forehead.  Shooters call them a lot of things, including the ought-six hickey and the Leupold laceration; but he referred to it as a scope check.

As it turned out that scar came from a different sport that he didn’t name.  He’d gotten scope-checked before, he said, on the other side.

That’s where Sherlock Holmes went wrong, I replied.  He got hung up on cause and effect: OK as far as it goes but fails to take into account a larger pattern, and I related a different case.

At another time, in another state, an African American came in for his executive physical, and I spotted a distinctive flat, ovoid scar on the shoulder.   I asked if he did a lot of bicycling, and, indeed, he had.  And he wanted to know why I would guess that; at the time he did not fit the demographic.

As it turned out he had gotten his scar at his other favorite sport, tennis.

And then I explained to the clerk about the Calvary Cross tattoo as an indicator of incarceration, though the person almost never gets that tattoo while behind bars.

I also gave out my blog address, and asked for, and received, permission to write about our conversation.

I gave into a hunch and guessed, correctly, his favorite caliber: the .308.  I based my guess on patterns observed in other.308 shooters.  Later, if asked, I would have said that his athletic build and his age tipped me off, but, really, I have gotten good at guessing.

On my way to my car, though, I went one step further.  His bolt action rifle, I decided, comes from either Remington or Savage.  But I didn’t turn around to ask.

 

5 Weeks of Hospital Ended

August 12, 2019

I turned and returned the page

These words are wise and they’re sage

Slow elevators? No glares

I went up and down stairs

It’s the chaos, it can’t be  my age.

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 3 years’ Community Health Center work I returned  traveling and adventures in temporary medical positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, most recently, south central Alaska.  After 2 weeks’ vacation and a wedding, I just finished a 5-week stint in hospital medicine in my home town.

Forty-eight hours after I finished my most recent assignment, I sat down to lunch with a friend.

“So, what did you learn?” he asked.

I learned a lot.

By exhausting my vocabularies in Greek, Hochungra, Umaha, and Lakota, I learned that not only do I still retain random words in other languages but using them can seriously lighten the mood of the room

I learned that not all Dineh languages are the same, and that being friendly in one might be perceived badly in another.

I learned that my version of the law of unintended consequences remains true:  from change comes chaos; the bigger the change the greater the chaos.

I learned that I can handle 13 hours of orderly work a lot easier than 12 hours of chaos, and I can handle 14 hours of order a lot easier than 12 hours of order followed by one hour of chaos.

I learned that taking a break to have dinner with my wife brought an enormous boost to my morale.

I learned that hospital work involves so much walking that losing 3 pounds a day came easily.  Especially if time pressure made me choose stairs over elevators.

I learned that while a generalist among specialists might occasionally look superfluous, finding a couple of cases of B12 deficiency or starting Parkinson’s medication can still make me dance.

I learned that whining about a bad electronic medical record wastes my time and emotional energy, but embracing it and calmness work together.

I learned that if it takes the help desk a half hour to get back to me, I can generally find the solution. Before they call.

But I also learned to give up defective software right when I when I find out it’s defective.  Complaining to someone with a financial interest in a task made impossible by the tools at hand works a lot better than not speaking up.

I learned that a clock in a doctor’s lounge will go for months with a dead battery unless I take it upon myself to fix it.

I learned that everything in the real world, even medical care, carries a degree of geographic imperative.

I learned that staying friendly in the face of internal anger gets me further than expressing that anger.

I learned that despite my insight and learning, I could backslide down the slippery slope of workaholism right to the knife edge of burnout.

I learned that a stressful, chaotic work environment changes me physically, from my gut to my body odor to my rate of hair and nail growth.

I learned that I’m a much better husband if I don’t work 12 hours days 3 in a row.

I learned that a 12-hour day rarely ends at 12 hours.

I learned that mission creep is inevitable.

I learned that nurses who say, “Don’t bring chocolates,” don’t mean it.

I looked at my fork, then at my friend, and I said, “I’m not 65 anymore.”