Hot job, hot office

July 12, 2018

In my office I might take a seat

Depending on the degree of the heat

I’ll tell you, no fooling

I don’t get the cooling

And it’s hot enough to cook meat

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. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

Summer in Iowa brings sun, heat and humidity. The closer the temp gets to 85 degrees, the faster the corn grows; 2 degrees higher and the growth stops.  If the night fails to dip below 85 degrees the corn loses energy trying to keep cool.

You can find old farmsteads by their wood lots, 1-2 acre stands of trees that shaded a house from the sun in the summer, blocked the wind and snow in the winter, and provided fuel close to home.

Towering shade trees don’t fit in with 21st century American hospitals’ parking lots and helipads.  Air conditioning provides the necessary climate control.

(Last century, when I visited Cuba, I found hospitals, that depended on open architecture, breezeways, ventilation, and shade trees. But for obvious reasons, they don’t need parking lots.  And I visited in February.)

My clinic office has a great location on the west side of the building. Of all the rooms in the outpatient department, mine alone has no air conditioning.  More accurately, it has air conditioning but it doesn’t work.  On a good, hot, muggy day, I get some cool air in from the corridor in the morning, but as the afternoon wears on, my outside wall takes a beating from the sun, heats up, and radiates into the room.  And as the corn grows, I start to sweat.

Fans help by evaporative cooling. I got an aging tower fan that doesn’t work nearly as well as the desk fan Bethany bought at a hardware store on the square.  If I sit at my desk, the breeze on my face helps.  If anyone seeks to have a conversation with me after 3:00PM, I have to turn the fan so that they don’t suffer too much.  But then, I do.

When I worked in Barrow (now Utqiavik) in the winter of 2011, the hospital hadn’t had the heating updated since construction in 1964. Though the outside temp ran to -40, the clinic area stayed oven hot.  Entering a room, I opened by saying , “You can have privacy or you can have ventilation, but you can’t have both.  Door open or closed?”  And the patients always wanted the door open.  I could  stand by the window that no one ever closed, or I could even go outside without a coat.  Environmental services assured me they could not fix the system.  At the time, with the new hospital under construction, they weren’t about to try.

In New Mexico, my humble clinic’s windows always worked but the electricity didn’t. If the power went off, we opened the windows.  If the power went off in the winter, we kept on our coats.

The patient care here takes place in very comfortable surroundings, but I do my dictations and paperwork in the high 80’s.

Not surprisingly, I find myself spending more time with the patients, and trying to spend less time in my office.

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A weekend call full of chest pain

July 9, 2018

This weekend I was hard pressed

And, as always I worried my best

The lilt in my song

Comes when I’m wrong

About the cause of pain in the chest.

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. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

I took ER and hospital call this weekend.

The chaos that suffused my time came as no surprise, but the consistent theme of the people seeking my services, chest pain, did.

The area involved can be anywhere between the diaphragm and the jaw. The complaint doesn’t have to include pain; so often the person says, “It’s not a pain, really, more of a discomfort.”  And, sometimes the patient doesn’t feel discomfort at all, but shortness of breath, or nothing more than fatigue.

Of course I worry about the heart. If the body’s main pump runs out of blood carrying vital oxygen, it can’t pause to rest, and parts of the heart muscle die.

But I also have to consider the possibility of pulmonary embolism (blood clot in the lungs), pericarditis (inflammatory fluid around the heart), aortic aneurysm (where the aorta, the main artery coming from the heart falls apart), cancer, broken ribs, pleurisy (an inflammatory roughness of the smooth shiny membrane that lines the chest), or esophageal spasm (a cramp in the in the swallow tube).

By the end of the weekend, the nurses had gotten used to my routine: an aspirin, chewed, and a nitroglycerin pill slipped under the tongue, both while obtaining an electrocardiogram and getting blood drawn for a series of tests. Sometimes I asked for chest x-ray, sometimes a CT of the chest to rule out pulmonary embolism.

Sometimes the studies revealed the problem, sometimes not. I saw a good cross-section of diagnoses including the profoundly serious and the mundane.  I sent patients out by ambulance and by car, and I kept a couple in the hospital for observation.

(Everyone in town knows the helicopter came and went; for reasons of confidentiality I will neither confirm nor deny it had anything to do with a patient I attended.)

I took care of patients from the age of 13 to the age of 88. I enjoyed talking to two consultants I knew from my private practice and Community Health days.

But the highlights of the weekend had to do with me thinking of serious pathology and being wrong.

 

Once a patient, always a patient

July 8, 2018

The story came as a surprise,

Perfidy, adultery, and lies.

Misuse of narcotics

And antibiotics.

And names I wouldn’t surmise.

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. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

I don’t have to know everything in the business; I have to know when I don’t know. I usually know who knows more than I do.

At my graduation from medical school, the speaker (so effective I still remember large portions of the address) told us to look in the mirror every morning and say, “I don’t know.” It took a few years but I got good at it.  Admitting ignorance does not bruise my medical ego anymore because reality has humbled me so often I don’t have one left.

Halfway through a laceration repair yesterday, I realized the wound went much deeper than I thought. I stopped immediately, doffed my surgical gloves, and called for help.

I put the call through a hospital operator who asked me to spell my name, which I did. Then I commented that she knew me but I hadn’t been around for a few years.  I could hear the smile spring back to her voice.

I had to re-introduce myself to the consultant, and, again, the telephone connection could not interfere with the smile.

Earlier in the day I needed to talk to a cardiologist regarding the proper time frame for a referral. I ran into that on-call doc at a dinner conference the week before.  He, too, smiled.

Still, medical communities qualify as living things: doctors come and doctors go. Change is inevitable.  I had a conversation this last week with a member of the Iowa Board of Medicine, and got access to some really juicy stories.  I cannot give the details here but I can give the moral lessons:  doctors should not have sexual relations with patients (and, once a patient, always a patient), they should not write narcotics prescriptions if they intend to use the narcotics for themselves, they should not misuse their position of power for financial gain.

None of those stories related to the local physicians, though some related to changes in the Sioux City medical community. Most came as complete surprises.

Most, but not all.

Looking for things I don’t want to find

July 1, 2018

Pessimism is my inspiration

When I’m testing for inflammation

Sometimes we’re stuck

With a run of bad luck

I’m hoping for no information.

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. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

I make my living by thinking up worst case scenarios. As my knowledge and experience grows, I can dream up increasingly horrific things to rule out.

A lot of people, for example, just plain don’t feel good. I listen to the story, I take all the details seriously, I try to figure out the context, and then I go looking for diseases.  My favorites are the ones I can cure without specialist consultation, intrusive interventions, or expensive drugs.  I don’t like to find conditions that will last for the rest of the patient’s life, disrupting the plans of friends and family, misery that echoes down the generations.

Most disease, about 70%, comes to us directly from our choices: nicotine, alcohol, recreational drugs, overindulgence, and exercise avoidance.

But a sizeable portion of my work has to do with bad luck.

No matter what the source of the problem, my task is to make the patient better, and help the patient meet their goals.

But to get to that point I have to listen to the patient.

I listen a lot. I think pessimistically, and I run a lot of tests.

I use two particular assays, the C-reactive protein (CRP), and the erythrocyte sedimentation rate (ESR or sed rate) to make a major division in my lines of inquiry. Both seek to confirm or deny inflammation throughout the body, and two normals mean I can rule out a lot of illnesses. A high number in either parameter means I have to keep seeking till I find an answer, and, generally, an answer I don’t want to find.

Too many times this week I’ve looked at a lab sheet and used words unbecoming to a professional vocabulary.

At this point in my career, I shouldn’t take an abnormal lab test personally. I can either handle the patient’s treatment or I can find someone who knows more than me.

I look at the consequences of illness not just to the patient, but to the surrounding community. Every one of my patients exists in a context, and, just as the patient cannot be understood without understanding the context, the context cannot be understood without understanding the patient.

I shouldn’t take an abnormal lab test personally, but I do. Every patient is part of my context.

Hardware, software, and chairware

June 24, 2018

A problem is found, tell me where?

Is a problem that’s not the software

I said to IT

Perhaps it is me.

Is the answer to be found in the chair?

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. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

Eight years ago I took a course for doctors who want to be writers. Don’t use the word suddenly, they said, and never write, “All hell broke loose.”

I suppose all writing has rules, yet I haven’t figured out all the rules for effective blogging.

But I find myself enjoying this gig. A small hospital is an efficient hospital; one doesn’t waste a lot of steps.  Consider the context:  a functional Iowa town just big enough to have a hospital.  In two weeks I’ve dealt two marijuana users, and no drug seekers.  Every urine drug screen has come back clean.  Fewer than 10% of the patients smoke.

And I have time to spend with the patients. I listen attentively, I don’t interrupt.  I get to dictate my progress notes, and I can enter my hospital inpatient orders on paper.

I haven’t figured out how to use the Emergency Room EMR, not quite the same system as the inpatient program. I just couldn’t get it to turn on.

Today the Information Technology person asked me to show her the problem; I signed on and got a nice border on an otherwise blank screen.

“Is it the hardware?” I asked

She shook her head.

“The software?”

Headshake.

“The chairware?”

She looked at me, left eyebrow crowding the right.

“You know, the person in the chair?”

She burst out laughing, and told me she’d get back to me.

Despite cool, rainy weather, the clinic overheated. We got out the fans.  I sweated.  For the first time I realized that my large flat screen monitor produces a huge amount of heat.

The morning went at a reasonable pace. Online research, signing my dictations, reviewing labs.  Then at 11:00, suddenly, all hell broke loose.  The surgeon and the nephrologist each asked me for consultations.  The radiologist called from Orange City.  The neurologist called from Sioux City.  Two non-English speakers turned out to have a much more complicated clinical picture than we could have imagined.

I worked through lunch; the nurses and I did not get a chance to eat.

In the course of 4 hours I read 4 electrocardiograms, ordered 4 sets of labs and admitted 2 patients. I accommodated a walk-in.

I worked hard to replace my fluids lost to sweat.

And just as suddenly, things went quiet at 4:15PM. I finished with the two hospitalized patients at 5:00PM on the dot.  Food became my next priority.

 

Weekend call: lunch at the gas station or the country club?

June 20, 2018

You won’t believe what the ER nurse said

The patient came in on a wagon that’s red

Then later, for grub

We went down to the club

And on burgers and fries we were fed.

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. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

I took call last Wednesday, worked the clinic 8 hours on Thursday, then took call again Friday, Saturday, and Sunday. Bethany came up for company on the weekend, by coincidence the town’s annual summer festival.

I had two patients in the hospital on Sunday, and after leisurely rounds we wondered about lunch. Neither the bar nor the Pizza Ranch would open before supper.  Which left two choices.

I asked Bethany, “Where would you rather go, the gas station or the country club?” We laughed, and decided on the country club.  I got out Google Maps, and checked the route.

Not wanting to be more than 20 minutes in case I got called back, we drove, but we could have walked the 5 blocks. The only customers in the middle of the afternoon, we ordered burgers and fries.  I ate with the relish and tension that lunch on Sunday call brings: savoring every bite knowing that I could be called away at any time.

Not a fancy lunch, but very tasty.

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In Emergency Department linguistic convention, the nurse will present the patient’s name, age, and gender, brief condition, and how that person arrived. Mostly I hear that the person “presented ambulatory via privately owned vehicle” or “presented on stretcher via ambulance.”  But people have also come in by boat, snow machine, bicycle, and ATV.  This weekend, for the first time, I cared for an adult patient who arrived on a Radio Flyer red wagon.

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In the last week I have had to do a lot of research. I can’t talk about the cases that inspired the research, nor whether related directly to a patient or not, but I learned a lot. Borrelia burdorferi causes Lyme disease, but the cork-screw shaped bacterium has a couple of cousins that can cause problems as well, and they can slip right past the standard Lyme disease test.  Provoked small rodent bites carry so little risk of rabies that the Iowa Hygienic Lab recommends neither treatment nor testing.  Twenty percent of the 20,0000 Americans bitten by rats last year developed rat bite fever, a disease easy to cure with penicillin.  To diagnose Legionnaire’s disease, run a test on the urine.

 

High School Reunion 3: the Beatles Suite, no Scotch or cigars

June 19, 2018

The supper we passed bite by bite

As the party went into the night

The smoke was too risky

To go out for some whiskey

And some of us still have to write.

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. After some part-time work in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, I am taking a break from Sioux City for my 50th High School reunion.  Any identifiable patient information has been included with permission.

One of my classmates had the terrific generosity to buy a crowd of 25 a very nice meal at a landmark Denver restaurant, the Brown Palace. The talk ran to careers and retirements.

Most of my classmates remembered my days with the Navajo and the Indian Health Service. More than half find themselves in some phase of retirement.

I announced my intention to keep going till 2035 as much from sincerity as for the shock value.

After dinner our host showed us his room, the hotel’s Beatles Suite, where the Fab 4 stayed during their Red Rocks performance in 1964. We talked about music.

Jimi Hendricks, Vanilla Fudge and Soft Machine played at the venue in 1969 with an opening band called Eire Apparent. The number of my classmates attending astounded me, equally that I had seen none of them there.

I would assert, and many would agree, that popular music reached a zenith between 1964 and 1975. Well trained musicians broke with musical conventions, tweaking formulae, and writing poetry that may yet stand the test of time.

I can’t overstate the importance of music to my generation. In the days before digital recording devices, when music came pressed onto vinyl or magnetized onto tape, a person’s record collection and how they cared for it served as a personality thumbprint as well as a financial barometer.

Two of us had been in the Preps, the school’s instrumental group who played Big Band numbers. One had his own rock band, playing significant gigs in Denver and Boulder even before he was 18.  I still play sax, and I mentioned my time playing professionally in Barrow, Alaska in 2010.

Another classmate, a former Glee Club member, still composes and sings.

Our host suggested Scotch and cigars; I declined as my distaste for smoke far outweighs my appreciation of fine distilled spirits.

I caught a ride back to my sister’s house with a chum I’d first met in September 1963 when we started into 7th grade; I collided with him again during my pre-med years at University of Colorado at Denver.

We both write. I mentioned my 9 novels.  I have nothing published and haven’t had an agent since the first one.

I told him I blog, and he asked, “How often do you feed the dragon?”

I like a turn of phrase so good it gets a lot of play without being trite, and even better for application outside of its usual ball park.

While I work, I said, 4 or 5 posts a week. His face showed both shock and amazement.

Not everyone writes. Those of us who write do so because we have to, not because we think we’ll get paid.

Call, Storm, Flood, and Nursing Home Rounds

June 19, 2018

Bad sleep when on call is the norm

Made all the worse by the storm

Far from a dud

It gave us a flood

But incidentally watered the corn.

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. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

The call from the ER at 5:00AM didn’t exactly wake me. The thunder did that hours before, and I tried dozing after.  But I never sleep well on call, and the lightning flashes came through my eyelids, strobe lights through a red curtain.

I should have slept well. My clinic day segued directly into ER call at 5:00PM.  One patient, of my generation, came in with a dramatic history, full of the ironic pains that only the power of human love mixed with inevitable human fallibility can bestow.  Stressed people get sick, sick people get stressed, and I needed 21st century technology, from CT scans to telemedicine. In the end, we finished with a mystery, a neurologic conundrum we do not understand but Hollywood loves and misrepresents.

I still have a lingering feeling that I shouldn’t complain when I have a 12-hour day; earlier this decade I had harder 38-hour days in much more hostile environments, and I kept going.

Still I could have used another couple of hours between the sheets. At the guest house door I looked across the parking lot to the hospital.  With no hat, my white lab coat, more sponge than tarp, offered no protection from the wet.

Damp but not soaked after 50 paces in the rain, I arrived in the ER seconds before the patient.

The presenting problem required much lab and x-ray. I called a fellow ER doc in another city for reality testing.  A subtle but definite physical finding that many would not have noticed complicated the diagnostic picture; a solid, sharp patient with a strong sense of reality clarified it with declarations of no heroics and no surgery. Later, a medically literate relative helped to enforce the decisions.

With the patient tucked into a hospital bed at 7:00 AM, I found the cafeteria had run out of eggs, and I returned through a light rain to the guest house, to make breakfast, and take a too-short nap.

At 9:00AM the clinic manager and I drove 15 miles out to a neighboring town with a nursing home. The cornfields, run emerald riot with perfect temperature and generous rains, had low spots turned to streams and rapids by 6 inches of precipitation in 3 hours.

In the course of the morning I cared for 10 patients. I stopped 4 medications, and started 2 but left orders to stop 3 more.  I had the honor of attending 3 people who had survived the 1918 influenza epidemic. I ordered lots of lab, with little hope of more than a 10% pick-up rate.

I look forward to my next visit, when I’ll be able to see the effects of adjusting some neurologic meds, and I’ll get to talk some more to alert, sharp people born before the Depression.

I hope I get to their age with their faculties.

New Job, First Week

June 13, 2018

I laughed, and said with a snort

In the square of the town there’s a court

You could call the town small

There isn’t a mall

And friendly comes by the quart

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. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

I saw a distressing number of serious pneumonia cases during my first week on the new job. Each patient presented differently, each brought in a life story from a family context.  And each challenged me in a different way.

We have exceptional pneumonia vaccines that don’t prevent pneumonia nearly as well as they prevent death from pneumonia.

In the last 40 years the disease has changed a good deal, and we’ve reduced the death rate, but not nearly enough.

The history and physical make the diagnosis more than anything. We listen for a crackling sound as the patient breathes in, but mostly we listen to the patient’s narrative.  Still we get blood counts, blood cultures, chest x-rays, and occasionally CAT scans.  A new blood test, pro-calcitonin, helps a lot but hasn’t made an appearance in any facility where I’ve worked.

I disappointed several patients by not finding ear wax.

I have acquired a minimalist approach to medication at this stage in my career, an approach that many of my patient appreciate. I especially enjoy stopping statins, a class of cholesterol-lowering drugs that can stop heart attacks and strokes, but will not prevent a first one after the age of 65.

The facility has a small staff and a small footprint. I counted 36 steps from my office to the ER, and 6 steps from ER to radiology.

I get a steep discount on meals, reasonable cooking served in reasonable portions.

Various licensing details have insulated me from the worst of the Electronic Medical Record (EMR) headaches, and I get to dictate my notes.

A small parking lot separates my accommodations from the ER; a landline assures good communications in the unlikely event of a sound night’s sleep.

I haven’t run into marijuana problems yet. Smokers constituted a surprisingly small proportion of the patients.  Not surprisingly, binge drinkers here, as everywhere, have difficulty with insight.

The facility has a gym, a CAT scanner, anesthesia, and a surgery program. I worked with two of the nurses here during my days in private practice, and I established a relationship with the radiologist during one of my other assignments.

Most of the referral traffic will go to Sioux City, where I still know many consultants.

And there’s an absolutely first class pizzeria about 20 minutes away.

 

Paper Order Joys and Outpatient Dictation

June 7, 2018

If it helps to make a decision

We like a CAT scan’s precision

It sure made my day

When in truth I could say

It looks like you’ve dodged an incision.

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. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

I arrived 15 minutes early for a brand-new gig. I started the usual orientation: meeting a lot of people whose names I forget and shuffling around a confusing geographic set-up.

No one expects me to remember everything the first day, but much like any other human learning endeavor, one has to find a starting point,

The facility has three EMRs, one each for the hospital, the clinic and the ER. The ER and hospital systems communicate with and resemble each other, but do not qualify as twins.  And I’ve used the hospital system before, in Nome and in western Nebraska.

The outpatient system, however, looks like nothing I’ve ever seen.

For reasons I don’t completely understand, my schedule keeps changing, and I covered an outlying clinic in the afternoon.

I cared for 5 patients, including 2 children, both of whom I mesmerized with my yoyo. I managed to not increase anybody’s prescription burden, recommending only agents available over-the-counter.

Not a single patient came to the ER that night, yet the vigilance of call kept me up.

I only attended 8 outpatients and an inpatient the next day, yet high-stakes clinical material dominated the landscape. I sent two patients to the CT scanner down the hall.  Surprisingly, the results swayed the decision-making process in both cases.  Neither went to surgery nor to inpatient.

A different patient became my first admission to the hospital. The wonderful nurses gave me the choice of writing my orders or entering them into the computer system.  Grinning, I took the hand-written option, and later watched a new-hire nurse struggling through an unintuitive system.

The glitch that prevents me from using the outpatient system for entering lab and x-ray orders or for electronic prescribing continues to defy resolution. The management here lets me write my orders on plain paper and have the nurse enter them into the computer. I dictate my notes.

And I finished on time. For whatever reasons, for the time being I can enjoy slow patient flows.

The patients have already started asking if I’ll move here. Forever.  I thank them, but I decline; Bethany and I still have more adventures to look forward to.