Of Red Tide and dead walrus

April 16, 2016

We went for a very short ride

And found acres exposed by low tide

Which brought within reach

Clams of the beach

And other things people eat fried

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. After two months each in Western Nebraska and the West Coast of Alaska, I’m now in Southeast Alaska.  Any specific patient information has been included with permission.

An intestinal virus with violent vomiting and profuse watery diarrhea has dominated my clinical work for the last week. It hits the toddler-to-middle school age range disproportionately, but it still struck a lot of adults, and struck them hard. I can’t do anything for the basic disease process; people tend to heal on their own. But if dehydration sets in, I have developed a routine that calls for 2 liters of IV fluids (if you must know, Normal Saline, the same as 0.9% Sodium Chloride) and 8 mg of ondansetron (trade name, Zofran).

When I hear of vomiting and diarrhea starting at the same time, I tend to think of food poisoning. But food poisoning will strike a household all at once, where this virus hits family members in sequence.

I had to consider, also, the shellfish problem.

The people on an island with 25-foot tides like to go out at low tide for mussels, clams, cockles, whelks, abalone, crabs, and octopus.

When the water ebbed out 3 feet lower than average this weekend, Bethany and I went to explore the beach.

We found the water’s edge a hundred yards past where logs drifted onto beach grass mark the high tide line, on a beach of whispering tranquility, surrounded by towering evergreens. We picked up a dead sand dollar, and saw holes where a clam spade would have brought a tasty morsel. A mother with her two children came out exploring. The adults had a delightful conversation, and one of the kids picked up an abalone. I had never seen a live one before.

Which prompted me, the next day at rounds, to ask my colleague about the posters we’d seen warning of Paralytic Shellfish Poisoning. He explained that some algae contain a toxin that filter feeders, like clams and mussels, concentrate, and which, if consumed, cause a very ugly paralysis. Those algae blooms, known as the Red Tide, in the warm weather, especially in El Nino years, and more often when the temperature goes up.

I asked about walrus, the sea mammal that eats mostly clams. I recalled the large walrus skull I saw on the wall of friends who live in Southwest Alaska. While out sport flying, they spotted a walrus carcass on the beach, landed, and wrestled the ivory-bearing head into the plane.

While the algae blooms won’t happen for another month, some bivalves, like mussels, retain the toxin for years after a bloom.

First day in Metlakatla

April 12, 2016

I set off in the down-pouring rain

To the clinic, a small House of Pain

I started up with a smile,

Because that’s my style

And it’s easy for me to sustain.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. After two months each in Western Nebraska and the West Coast of Alaska, I’m now in Southeast Alaska.  Any specific patient information has been included with permission.

On Sunday we took the ferry from Ketchikan to Annette Island, a ride of 45 minutes. We arrived in a pouring rain.

People call this area of Alaska the Panhandle, it juts southeast along the Pacific coast. It receives an average of over 100 inches of precipitation yearly.

About 2000 souls reside in Metlakatla, the town on the west part of the island. WWII brought an influx of defense personnel, who did not leave until late in the 20th Century; the majority of the inhabitants are Natives. As Alaska’s only Indian Reservation, license plates and driver’s licenses are optional, and ATVs run street legal.

The clinic assigned us to a cozy apartment less than a half-mile walk from the clinic, and I did my initial morning commute on foot in a torrential rain.

My first day on the job here started with morning rounds.

Talk of tides and fishing dominated the conversation before the clinical discussion. I mentioned the poster warning of paralytic fish poisoning I’d seen on the front door, and those present assured me that the problems wouldn’t start for a month or so.

The doc who had call opened the discussion with a rundown of the weekend ER patients.

I spent the morning in orientation and getting my ID badge and entry card, and I took care of four patients in the afternoon. I used RPMS, an Electronic Medical Record (EMR) system developed by the Veteran’s Administration.  Far from perfect, I find it the best one of the 9 I’ve learned in the last 14 months.

I talked to a relative of the first Native to be drafted by the NBA (that unique individual has a lot of relatives on the island).

I saw the first of what would be a string of patients with violent vomiting and diarrhea, ranging from infant to middle age. Almost certainly viral, we have no treatment aside from oral rehydration, or, in extreme cases, IV rehydration.

But we are a clinic with an ER and no hospital; we don’t keep patients overnight. I will have to weigh the risks of a boat ride if I consider sending a patient for further diagnosis or treatment.

At the end of the day, we arrived back at the apartment dripping from a walk in the driving rain.

Well, if you can’t take the rain, stay out of the Panhandle.

Ketchikan to Metlakatla

April 12, 2016

We came across on the ferry

At leisure, and then we could tarry.

Some food we bought more

With a trip to the store

And we found some good prices on dairy.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. So far this year I worked assignments in western Nebraska and southwestern Alaska; I just arrived in southeast Alaska.  Any specific patient information has been included with permission.

We took the ferry from Ketchikan to Annette Island, the only Indian Reservation in Alaska. In 1887 an Anglican missionary, motivated by doctrinal differences, led a thousand Canadian Tsimtshians on a search for a new home.  They found this island, moved legally, and in 1906 petitioned for, and received, reservation status from Congress.

Fortunate enough to have no mineral wealth that economic interests wanted to steal, they maintained their reservation more or less inviolate until WWII, when they got an air base, and a promise to build a road to the other side of the island so as to link up with the Alaska Marine Highway system. The road took eleven years to build and finished 8 years ago.

We learned these things from the Security guard who drove the 15 miles from the clinic to pick us up, and also took us on a tour of the town.

Falling timber prices shut down the logging and sawmill operations.  The salmon cannery, the casino, the school, and the clinic provide the most jobs.

We passed the gas station, the schools, the churches, but no bars or liquor stores.

Perhaps because of fewer freeze-thaw cycles, perhaps because of better maintenance, the roads lack the crater-grade potholes we find back home in the spring.

The guard helped us drag the luggage up the stairs to the apartment. We unpacked briefly.  We ate the snack that Bethany had the foresight to bring, then we walked to the grocery store.

We hadn’t expected a well-maintained, well-stocked, brightly-lit facility.  The prices, a big higher than Ketchikan’s, didn’t look so bad compared to what we’ve paid for the last two months.

Then we settled in. We tried the TV and found no service, and we had no idea whom to call about the Internet password.  We played Scrabble, ate some salmon we’d brought, and found ourselves exhausted when the sun went down.

In the same time zone, but we definitely faced jet lag.

Overnight in Ketchikan

April 10, 2016

Up here, it’s one of the sights

When present it cheers up the nights

I regretted quite loudly

That the sky was too cloudy

To see the great Northern Lights.

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. After 2 months in western Nebraska, then two months in coastal Alaska, I’m now in the Alaska Panhandle.  Any specific patient information has been included with permission.

 

After an overnight in Anchorage, we arrived in Ketchikan, Alaska’s first city and never Alaska’s capitol.

Contrast is the essence of meaning, and Alaska’s hugeness makes for a lot of contrasts. After overlooking an arm of the Bering Sea from a coastal plain with mountains 30 miles distant, mountains here rise abruptly from the salt water, with not a single swath of tundra to be seen.

Technically in the same time zone, we crossed 24 degrees of longitude to get here, as many as you cross getting from New York to Chicago.

Ketchikan built its airport on an island, and, I suspect, built the island for the airport. One takes a ferry to town.  Anticipating problems with luggage, transitions, and inadequate support for the profession of skycap, the airport offers free luggage carts.

We found Ketchikan’s mood much like other tourist towns in the off season. The gold rush over and the timber prices low, tourists won’t start arriving by the literal boatload till May.  The other industry, salmon canning, stays small to stay sustainable.

The town features large on cruises of Alaska’s Inside Passage, and last year more than a million tourists filtered through.

We stashed our cooler full of salmon in the Best Western’s freezer space. The hotel’s service amenities include a van that drives people around town.

We went grocery shopping, knowing the high prices found on any island, especially an Alaskan island. We walked back to the hotel because we needed the exercise, exploring the Marina and the parking lots off Tongass Avenue, the main drag.

On the advice of a ferry passenger, we went out to the Lodge at Cape Fox, a first class restaurant run by a Native Corporation.  We enjoyed a spectacular view of the harbor and Halibut Olympia, while we discussed a weight loss strategy for our upcoming stay.

The news predicted great Northern Lights. After dark, I went outside to look up and find dense cloud cover.

Easter Sunday in the ER

April 10, 2016

Readers:  Connectivity problems slowed the flow of posts.  To preserve the sequence, this is a week late.

It could have been nothing at all

With the cold and a sudden snow fall

I thought I would try it

It was 6 hours of quiet

This Easter when I took ER call

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

When the Russians took possession of the part of North America we now call Alaska, they enslaved the indigenous people but had more interest in furs than in land. But they brought their religion, and it stayed when they left. Thus this town celebrates Easter at two different times. And this year the Orthodox Easter comes almost a month after the Catholic Easter.

If one of my colleagues celebrates a religious holiday that I don’t, I do my best to take call for that person, thus I find myself this morning in the Emergency Room.

0750AM: Arrived in ER to find no one here. I sat down in the doctor’s corner, fired up my computer, and started looking through the inpatient census.

0800: Spoke with a helicopter pilot in follow up and got to quizzing about the other professional’s job. I learned about darting wolves and moose. I found out what can happen when a compressor goes out and the engine fails between 60 and 600 feet up, what the helicopter pilots call the death curve. At such altitudes the helicopter can fall hard enough to kill, but can’t build speed enough to use the rotor as a brake. The problem being, of course, that most helicopter work involves just those altitudes.

Spoke with the doc who had taken call for the 12 hours previous. Not much to report.

0830: Started inpatient rounds on three patients. I can’t write about individuals, and, in this case, writing about disease states might identify people who didn’t give their permission.  But I can say that I dealt with the respiratory system and the gastrointestinal system.

Newton’s laws of physics don’t account for certain large parts of the universe, but one of those laws says two things can’t be in the same place at the same time. And human bodies suffer in consequence. If the person damaged by that inescapable reality lives in a small village accessible only by air or water, the consequent injurious effects ripple throughout the community.

10:00 AM Heavy snow fall started. Nap time.

10:20 AM One of the inpatients worsened. I got information and facts straight before I called the consultant at Alaska Native Medical Center (ANMC) in Anchorage. The light-hearted interaction brought me new information. The decision to send a patient out in a Medevac plane brings risks, especially in a snow storm.

11:00: Watched YouTube videos on Eskimo Scouts, racist Cold War Propaganda, but sympathetic to the people of Shishmaref outside of Nome.

11:45AM Called my wife to meet me for lunch in the cafeteria. The soup was excellent.

1230: Phone call requesting a medication refill. I said yes to a blood pressure medication with multiple uses and no resale value. I put a note in the electronic health record, but didn’t see the patient face to face.

13:00: Colleague called. Church finished. Take your time, I said.

14:00:  Colleague arrived.  Left in a slush flurry.

March 23, 2016

When it came to the blackened entrée

I hardly knew what to say

The salmon’s the surf

But the moose is the turf

And the wind blew the high heat away

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

Friday we drove out to a potluck at the house of one of the other docs. I brought an Asian salad, Bethany made bread.  Other treats included sweet potato casserole, Spam fried rice, Philippine corn nuts and peanuts and pork rinds, bean salad, potato salad.

While the temperatures this winter have hovered around freezing, the mercury started to plunge last week, into the single digits. The Bay froze over, and the wind picked up.

The host faced a culinary challenge: cooking outdoors when the wind chill sucked so much heat that he had to construct a windscreen.

The entrée consisted of the unique surf and turf of this area of Alaska: blackened moose and salmon. At the end of the party I asked for and received tips on the process of blackening.

Monday the snow fell and fell hard, and I had something I very rarely have, a slow day. I perused my email.  I did some online CME, but mostly I sat.  My tally for the entire day stayed in the single digits.

Today during rounds I heard a doctor referred to a patient as a “high liner.” Too much of an outlander to have heard the term, I waited till I cared for a commercial fisherman later in the day to ask, and I learned the term refers to the best commercial fishermen, the ones who consistently bring in large catches.

One of the first patients of the day came in with a neck lump. In short order I diagnosed a sebaceous cyst, a collection of cheesy, smelly material that happens when one of the skin oil glands gets plugged.  With an apparently open schedule, I agreed to cut it out right then.  We gathered the gear, I wiped the area with alcohol, prepped it with Betadine, and draped it with a sterile towel.  Then I couldn’t find it, nor could the patient, nor the resident.  David Copperfield could duplicate the trick, but I had to repeatedly plead that I had no idea what I’d done.

In the afternoon, a young patient arrived to follow up on a shoulder injury, and I very quickly found range of motion loss. In a culture such as this, where everyone hunts and fishes,  incapacity of a shoulder can have terrible consequences.  After the x-ray, while I awaited contact with the specialist, I used an osteopathic technique called muscle energy.  I brought the arm to the barrier, and using my own muscle power had the patient perform an isometric contraction away from the barrier for 5 seconds.  I instructed in a relaxing breath, got 10 degrees more of motion, and repeated the process.  Then I showed the patient how to do it without me.  That person left with better range of motion, and I finished the day euphoric from making two people better before they left.

They both gave permission to publish more information than I have.

 

Mail the patient in a cardboard box.

March 15, 2016

The ER doc said with a growl

“Should I cry fish, fair or foul?’

For after the collision

How do I make a decision

About a Boreal Owl?”

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

 

At morning rounds on Monday we gathered to go over the cases from Friday and the weekend. Including the doctors and the representatives from Mental Health, Pharmacy, Nursing, Physical Therapy, and Social Services, I counted 15.

Drama and irony run rampant in those stories, and, as always, drugs and alcohol provided the majority of the good stuff. But the best patient had been brought in after a collision with a car, and still had a pulse, and was eventually identified (with the help of the internet) as a Boreal Owl.  The calls flew back and forth, and the experts agreed that the best course of action included punching holes in a cardboard box and send the owl via mail.  Which is perfectly legal.

I hope HIPAA doesn’t apply to wild animals.

In general I don’t like prescribing controlled substances, and, when I do, I prescribe in small numbers. Though I dislike the benzodiazepines (a family which includes Valium, Xanax, Ativan, Miltown, and Klonipin) the most, I acknowledge they have their uses.  In fact, I would have difficulty caring for inpatient alcohol withdrawal without them.  I find few other uses for them, such as claustrophobia for an MRI or fear of flying, but I in fact found a reason to prescribe 6 pills of one (but I won’t say for what or for whom).

I decided a long time ago that I’m a lousy judge of character. Too many people have fooled me too many times.  So I ask for a urine drug screen on everyone who asks me for a controlled substance, and even a few who don’t.  I find about 50% surprises.

As everywhere, drug seekers come to the facility hoping to get substances with which to get high or to resell. As it turned out today I did a lot of physical exams for people wanting to get into drug or alcohol rehab, and I was able to pick the diagnosis of Health Seeking Behavior.

And today the people wanting to quit tobacco outnumbered the ones who wanted to continue.

Athabascan languages and radio traffic

March 11, 2016

Today’s limerick at the bottom.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

I learned to speak Navajo in the early 1980’s in Canoncito, New Mexico. My teachers asserted ability I didn’t feel and made me speak for myself.  My first sentences stumbled at two words in length.  The language has 32,000 tenses and no regular verbs; I pretty much kept to the simplest of the present tenses.  I could make myself understood, and the people showed great generosity in their tolerance.  Despite my lack of grammar and vocabulary I had good pronunciation.  Sometimes my patients or the staffers would burst out laughing because, they said, “You sound just like a real person.”

Navajo language belongs to the Athabascan family. Those cultures call themselves Naa Dine (or something very close), meaning People.  The men practice mother-in-law avoidance.  Women run the society. They potlatch: every few years those who can throw a massive party for the purpose of redistribution of wealth.   Those peoples mostly call the North Pacific area home.  Anthropologists have a lot of interesting theories about why the Navajo and the closely related Apache live so far from other Dine.

The area of my current assignment includes several villages of Athabascan speakers who call themselves Denaina. Today I asked a Denaina speaker if the language were close to Navajo.  “We have a lot of the same words,” the person said, “but they mean different things.”  Struck by the universal truth of the statement, I laughed out loud and asked to use the quote in my blog.

***

The Alaska State Legislature is currently debating Bill #98 to regulate telemedicine. Docs out here in the wilderness have been doing telemedicine for decades under the old law, which demanded an examination before any prescription.  The remote hospitals trained Community Health Aides (CHAs) to do examinations and dialogue with doctors via radio.  Now with good telephones connections  and cell phones we still call talking with the CHAs “radio traffic.”  At this hospital, each physician has an ongoing relationship with a number of villages.  And every village has a clinic with a limited pharmacy.

The new law lacks consideration for good patient care and the reality of life in villages accessible only by air or by water. One of our docs went to Anchorage to testify against the bill, and I wrote him this limerick:

We work in places remote

You can to by plane or by boat

We rely on description

To make our prescription

Please, for this bill, do not vote.

 

Nobody in the audience laughed.

 

 

March 7, 2016

We went out on a fine day

At the checkout we were ready to pay

When down went the power

For less than an hour

And then we went on our way.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

We went grocery shopping today, and got to two of the three food stores in town.

Most calories consumed by the2500 city residents and 5000 villagers get into the neighborhood by swimming or walking. Without salmon, moose, and caribou, we would face widespread starvation.  Flying foodstuffs in costs a lot of money.  Eggs run $6.00 a dozen, milk is $10.00 a gallon.  Nonetheless one can find oranges, apples, nectarines, pears, lettuce, and bag salad; we inhale deeply and try not to look at the price.

We stood in the checkout line, ready to pay, when the lights went out.

Power outages come regularly here, sometimes several times a day. The hospital has a backup generator, and well they should as just Friday they lost power 4 times.

People stayed cheerful in the dark. I switched on the lithium flashlight I keep clipped to the brim of my ball cap.  We joked.  Eventually the people in the parking lot turned off their engines.  The lights flickered, five minutes passed.

I talked about my friend whose start-up company provides solar cell and battery backup electricity to hog confinements, where pigs suffocate without adequate ventilation. It wouldn’t take much, I said, to make sure the registers didn’t stop working.

It wouldn’t take much, the clerk said, to power the whole building.

The lights flickered again, and then, 8 minutes later, came on and stayed on.

When I worked an outlying Navajo clinic in the early 80’s we rarely had continuous power for more than an hour. Existing technology at the time would face complete computer memory loss with each outage, so computerization didn’t attain viability.

I failed to appreciate the efficiency of the paper system at the time. In fact I complained frequently that I couldn’t dictate my notes.

In the late afternoon, we went to the only Chinese restaurant in town. We faced high prices for reasonably-sized portions.  Two entrees, soup, and tip came to $65, more than 3 times what we would pay in Iowa.  But in Iowa we wouldn’t overhear a phone conversation in Athabascan in a Chinese restaurant run by Koreans, watch planes take off and land, and run into a Coast Guard Rescue Team coming up the stairs as we left.

 

 

Referrals to Anchorage and Rembrance of Reye’s

March 6, 2016

We’re much further out than is rural

Logistics would make your hair curl

I don’t know the choice

But there’s burnout in voice

When I need to make a referral

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

Medicine has always been a team sport, none of us alone is smarter than all of us put together. Our profession has always relied on specialists.

You can’t drive to where I work from anywhere but here. Nonetheless, 21st century American medicine requires referral to specialist from time to time.  They come here on regularly.  Ears, nose, throat (ENT), for example, flies in for a week every two months and has a packed schedule.  Cardiology comes four times a year.

We have a system for getting referrals down to Alaska Native Medical Center (ANMC), which starts with a simple call to a Case Manager, always a Registered Nurse (RN). All three RN nurse managers have a firm grasp of realities of Alaska life and the way inherent logistic problems color the provision of medical care.  Occasionally, the problem at hand demands a close time frame, which is when I have to speak doctor to doctor.

On two occasions so far I have made such calls. The neurosurgeon spoke from or past the brink of burn out; he would not yield to any attempts at cheeriness or optimism.  The cardiologist’s voice showed more resilience.

I remembered another Indian hospital, in another state, in another century. The adoloscent came in with intractable vomiting and personality change; I needed less than 5 minutes to make the diagnosis of Reye’s syndrome, a malady that disappeared when we got out the message not to give children aspirin. But we didn’t know the link then; we knew the liver turned to mush and the brain swelled and sometimes the child died, and we didn’t have much in the way of treatment.

After the first five minutes, I had to call the lab tech in, and midnight came and went while I awaited biochemical proof. Once I had the diagnosis solidly confirmed, I called the University medical center an hour away and started working my way up the hierarchical ladder.  I presented the case to the student, intern, and resident.  By the time I got to the chief resident at 3:00AM I could deliver the presentation in less than a minute, but my nerves had started to fray.

I could hear the chief resident’s heart break in the sigh and the pause. Clearly overworked and sleep deprived, he sounded cornered when he said, “Well, I guess you’ve got to send the patient down.”

I can look back on my own burnout and I can empathize with the other doctors, but I don’t have a solution when we cannot make enough doctors to staff the system without working most of them more than 60 hours a week.

The neurosurgeon probably works more.


Follow

Get every new post delivered to your Inbox.

Join 58 other followers