Archive for May, 2010

Life is full of tradeoffs: travelling light is expensive

May 30, 2010

I’m working too hard to get packed

My complacence is coming up cracked.

     It’s a bit of a fight

     But I can’t travel light

To Barrow for months, that’s a fact.

When I started moonlighting in 1980 I learned to pack fast and travel light.  When I would get off of work on Friday afternoon, I’d go home, pack for a three-day trip, and jump in the car.  I never exceeded the speed limits like most Wyoming drivers, but I knew I wouldn’t start getting paid till I arrived. 

In residency at the time,  I learned more and earned more moonlighting than I did during the program proper.  Fifteen dollars an hour, compared to what I’d earned in the past, seemed a very large amount of money.  I came to view material goods in terms of what a weekend of work could buy.

I had to hurry to both ways.  After a few trips, I learned how to pack efficiently.

I can ready myself for most vacations in less than a half hour without trying. 

A hunting trip takes a lot more time because one must bring a wide variety of clothing.

Today, I spent most of the afternoon and evening packing. 

I have never packed for a two month trip before.  It may turn into a three-month trip with possible hunting at the end. 

In medical school when I did externships I didn’t pack for one month trips so much as I moved, and every time I moved, I moved fewer things.

Now part of the establishment, my clothes reflect my position.  I have proper business attire for 8 days.  An Alaska destanation demands cold weather gear.  Because I’m going to Barrow I can’t rely on availability of consumer goods when I arrive.

Travel in the information age demands a computer, a camera, a Palm, and iPod and all the cords and impedimenta that go along with them.

Previously proud of traveling light, I look at my luggage pile with embarrassment.

One cannot go to discover new adventures without leaving home; one must weigh mobility against cost.

Life is full of tradeoffs.

Jet lag is avoidable

May 29, 2010

The problem is common, not cheap

So here’s some advice you can keep:

     Television

    Interferes with life’s mission

And steals hours of sleep.

At a social gathering today I was once again called on for medical advice.

Abrupt onset of vomiting and diarrhea is usually food poisoning, best managed with oral rehydration fluids like Pedialyte, Gatorade, and agua horchata (a sugared Mexican rice-based beverage).

Itchy, watery eyes with itchy watery nose and volley sneezes, without fever, indicate allergies, best managed with over- the-counter cetirizine or loratidine.

And a lot of people sleep poorly.  In short order I found myself lecturing an audience of seven about basic sleep management: nicotine, caffeine, alcohol, move the TV out of the bedroom, don’t exercise or use a computer within two hours of retiring, keep regular hours.  Don’t think your internal clock has more flexibility than it does.

The adolescents in the group do what adolescents in our culture usually do: stay up late and try to sleep in.  Things like work and school interfere with the lateness of how long they can sleep, so that, in the real world, they go around chronically sleep deprived.

Teenagers effectively move to a different time zone so they don’t have to deal with adults; no wonder they love vampire novels and films.

I explained that the internal clock can be reset forwards 2 hours a day but can only be reset back ½ hour a day.  Then I started to get to time management; the television for most Americans has taken a higher priority than sleep.

Nothing on TV merits the time it takes to watch it.  History and Discovery shows teach in an hour what can be learned in ten minutes of reading.  A half hour news show has 12 minutes of commercials and six minutes of news; weather and sports take the rest of the program .  In the final analysis if a person doesn’t have time to stay in bed till awakening rested, that person doesn’t have time for television.

I recommended two alarm clocks, one to go to sleep and one to get up.

The conversation turned to jet lag.  What should a person do who’s flying across an ocean?

Jet lag is a problem I’m really good with.  Give me the time the person takes off, the time they land, the flight duration and the time difference, and I can recommend a sequence of melatonin, zaleplon, Provigil, caffeine, hydration, exercise and meals that synchronizes the person’s internal clock with destination time within twenty-four hours of arrival. 

Four  years ago I went to Israel with a tour group.  The day after we arrived the rest of the group crashed before sundown, but, good to go, I went for a walk on the banks of the Jordan and heard the wolves howling in the Golan.  It was an intense solo experience but I would have preferred company.

Thyroid, not phosgene, and other non-compete delights

May 27, 2010

This insomnia’s got out of hand!

I think it might be a gland,

     It might come as a shock

     I can’t be your doc,

But I can certainly tell you who can.

 

Four days of being unemployed, I have the electric fence up and the vegetable garden in.  A soaker hose and planter paper to discourage weeds will keep it low maintenance. 

I met with the Care Initiatives Hospice staff to get my computer set up to Skype, so I can attend meetings without being present.  Much remains to be done to ready the computer; I have to finalize Skype, add Palm and Epocrates and transfer documents.

My office stuff is gradually coalescing into one section of the basement. I still have seven stethoscopes, a personal stereo amplifier, three headlamps and a lot of things from the walls.

My seven medical licenses (Iowa, Wisconsin, South Dakota, Nebraska, New Mexico, Colorado, and Wyoming) and the professional certificates take up more room than the framed photographs and artwork put together.  There are two boxes of books and three of files; one full head mount of an antelope, and set of antelope horns.

They wait in limbo till I have my next office.

My contract says that for the next year I can’t enter into competition as a family practitioner with my parent organization in Sioux City or for a 30-mile radius.  Without  that clause I wouldn’t be having nearly as much fun as I am; I would have made a hurried transition to another venue.  As it is I’m having a fabulous time and I’m building leisure skills.

Still, the mysteries find me.

While I was cycling at the gym I got a call from a friend living in a community just barely inside the 30 mile limit, who has never been my patient, concerned about insomnia.  Could phosgene, a common agricultural chemical, cause that problem?

I didn’t know, I said, could I find out more? 

Working with equipment fumigated with phosgene, the patient said, in a closed area, and just couldn’t sleep for the last three or four days.

Phosgene?  I asked.  Are you sure?

Yeah, phosgene.  Been working with it for years.

I don’t know much about phosgene, I said, but I’ll look it up.  Then I thought back to when my thyroid betrayed me, and I asked if there had been heat intolerance, heart racing, fatigue without being able to sleep, weight loss, and no sense of inner peace.

Well, yeah, the person said, all those things.  How did you know?

You need your thyroid checked, I said.  Who’s your doctor?

I don’t have one.

I said, You need one, not me, I’ve got this contract…

Yeah, I know, but who do you recommend?

I named three doctors in the system, paying attention to location. 

Later on I called again while looking at Wikipedia.  Are you sure it’s phosgene? I asked.

Yeah, positive.

Not possible, I said, you shouldn’t have phosgene anywhere outside a chemical plant.  And phosgene causes cough.

Well, maybe it’s phosphine.

I keyed that molecule’s name in and got a fumigant.  I believe you’ve been exposed to phosphine, but I’m sure it won’t give you insomnia.  Phosphine will interrupt  your lungs pretty bad before it hits your brain, and if it affects your brain it’ll put you to sleep, it won’t keep you up.  And if there’s that much phosphine, you should notice insect life dying off.

No, the person said, the bugs are doing just fine.

We hashed out what to expect from getting the thyroid checked, and the need to find a doctor soon.

The patient thanked me profusely and wanted to know what I was owed.

I didn’t want to take anything, and I used the non-compete clause as an excuse.

Most weeks don’t have three sundays

May 25, 2010

Let me tell you about the week’s game

No two days are the same

Monday brings stress,

And Friday’s a mess,

With the worried, the well and the maimed

For a long time, my weeks fell into a rhythm. Monday mornings brought stacks of paper work, with lab and x-ray results, in addition to reviewing documents about what had happened in the ER and hospital over the weekend. Monday afternoons predictably brought chaos; people who had been sick on Saturday and Sunday wanted to see their doctor, and really didn’t want to wait till Thursday. After work Bethany and I would spend half an hour at a nursing home, and after that I went to the gym.

Tues was calmer. The drug rep brought breakfast rather than lunch. The noon hour became the noon hour and a half so that the docs could meet, making the afternoon thirty minutes half an hour shorter. The flood of paperwork from Monday had slowed to a trickle. I exercised on my way home.

Wednesday I took call, and the pace quickened. In our group the doc on call takes care of the phone messages for the docs who have the afternoon off or who go on vacation. For years there I had hospital work to do on the way home and phone calls through the night, and I missed my gym session. Vigilance murdered my sleep.

For the last year and a half I took Thursday off. I started early with a radio show about 6:45. Once a month I would have a Credentials Committee meeting at the hospital at 7:00 and once a month I would have Quality Assurance meeting at the nearby nursing home. During hunting season I would take to the field for the afternoon. Outside of hunting season my agenda included cycling, target archery, a trip to the bank, and a stop at the Mexican grocery store.  After I came home I’d log onto the office computer and take care of messages, lab, x-ray and scanned documents.

After a reasonable Friday morning, Friday afternoon brought more chaos: people getting sick and didn’t want to face the weekend with an illness, and really needed treatment. The afternoon usually went long and when I arrived home I had documentation to complete. (For a very long time I brought home a microcassette recorder and a milk crate full of charts. When we made our records electronic, homework got much easier.

I did my best to take Saturday off completely and not do anything productive; unless I had call I didn’t turn my computer on at all. I usually awakened Saturday morning late (frequently after 7:00) and well rested. Which didn’t keep me from napping on Saturday afternoon.

Sunday, in season, I went hunting early before teaching Sunday School, and again afterwards. For most months, though, I exercised early, and Bethany and I would go to the movies in the afternoon. No two days in a row the same, I never had a boring day but Mondays and Fridays carried more stress. Today, Tuesday, my second real day of unemployment, has me feeling deliciously like I’m on my third Sunday in a row.  Bethany’s birthday, we gardened for 4 hours in the morning, planting tomatoes, chiles, and cucumbers. We did a matinée movie, a very nice dinner out, and another movie in the evening (we now both qualify as Seniors).

What a fabulous day. Bethany calls it pure decadence.

Non-compete clause and doctor’s karma

May 24, 2010

I am a respecter of laws.

I keep my word, just because

     The reason for smiles

     Thirty good miles

And a standard non-compete clause

 

In December of 1978 I went out to Mongolian Barbeque with Lynne, one of my medical school classmates in Saginaw, Michigan. 

“It’s funny, you know, this karma happens when you get into med school,” she said as we sat in a booth.  “I noticed as soon as we started clinical rotations that people would just start opening up about their medical problems.”

The waitress brought the hot and sour soup and egg rolls.  As two women sat down at the next booth one of them started talking about her rheumatoid arthritis.  Lynne and I shot each other looks.  While paying our tab, the two men in front of us talked about their blood pressure.

Thus it has continued ever since.  People who don’t know my profession, people who don’t even know I’m listening, talk to me about their medical problems or talk about their medical problems within in earshot.  I doubt people talk more about their health now than they did during my musician days.

While eating nachos at a friend’s restaurant this afternoon, another restaurateur walked in.  He’d never met me, he didn’t know my profession.  While he mixed himself a Keystone and Clamato he pulled up his pant leg and showed me the bruise and swelling of his knee.  He’d fallen from a boom truck onto the point of the knee.  I resisted the urge to tell him what to do for his problems, starting with alcohol abstinence.

The non-compete clause of my contract went into force today and I have no intention of violating it.

I am a man of my word. 

It also gives me another reason to go walkabout. 

I met with the insurance agent today, finalizing details of my medical malpractice insurance; it will cost me about a month’s earnings. 

I went to the office and took down some pictures I had forgotten.  I also took my photographic portrait that had hung in the front.

My office manager asked me about keeping my name on the glass door.  Did I want to keep my name up?  Did I want to put the word “Retired” after it?

I admit I had to think.

“Take it down,” I said.  “I’m not retired and I don’t work here anymore.  I don’t want to mislead people with false advertising.”

I stopped into the break room and had a piece of cheese pizza from the stack of sixteen pizzas, brought in by the pharmaceutical manufacturer’s rep.

He came in while I munched and listened to the staff’s conversation.  I’d not met him before.  I dressed in shorts and a button-down shirt, certainly not what a working doc would wear.

He didn’t introduce himself, and I didn’t have to sit still for a sales pitch.

***

I got a lot done today: I cooked Bethany and me breakfast, cleaned the kitchen, spaded up the garden, exchanged my computer at Best Buy, bought reeds and miscellaneous for my new sax, met with the insurance rep, stopped at the office, went grocery shopping, dropped in on friends, bought plants for my garden, led religious services, and exercised at the gym. 

But I didn’t rush through it.

Can a soprano beat a Naked Lady?

May 23, 2010

My spirits soar to the max

Here are a few of the facts:

     What gives me a lift

     Is the receipt of a gift,

A brand new soprano sax.

On my last afternoon of my last day of my last job my last patient, Diane, gave me permission to write about her.

We have known each other for decades.  She taught my oldest daughter trombone, my middle daughter saxophone, and my youngest daughter flute.  She has retired from her job as instrumental music teacher in the Sioux City Public School system.  To properly explain our relationship I would have to start with my music history.

When I graduated high school forty-two years ago and drove away, vowing never to return again, and sure to become a musician and composer, I could not have imagined a career besides music.

Passions die hard.  Two years later I embraced the conclusion that I had neither the talent to make my living that way nor the inclination to put up with the requirements of the job: chaos, salesmanship, and artistic compromise.

Proper attention to the craftsmanship of music, sometimes called practice, would have developed my marginal talent to the point where I could have made a marginal living. 

But I kept my saxophones.  I knew that my alto, a Selmer Mark VI, carried much more valuable than what I paid for it, but I had no idea about my tenor.

From time to time I brought my horns out when I needed to play, but I quit composing.

When my middle daughter, Chaya, entered in middle school and started instrumental music, she usurped my tenor sax.  On the first day of band, Diane heard snickering in the corner, and went to see what the fuss was about.

Chaya was showing off the engraving of a topless woman on the bell of the saxophone.  The teacher immediately recognized the instrument as a Naked Lady Conn, the jazz equivalent of a Stradivarius.

(At the risk of too many coincidences, my mother grew up in Elkhart, Indiana, where the instrument was manufactured.)

Chaya was bursting with the news over dinner.

I had no idea of the value of the horn, my grandmother purchased it for my at a pawn shop when I was 13; it took Diane’s knowledge to inform me.

I saved her life about six years ago by finding leiomyosarcoma, a malignancy so rare that it has no chemotherapy experience.  She has been teaching me a great deal about the nature of healing ever since.

When Chaya fell climbing three years ago, I discovered the value of embracing uncertainty.  Diane and I talk frequently about the things we do to live in the moment, about savoring the positive moments through the neutral moments, and not letting the negative moments last.

We speak often of the need to write her story into a screenplay; I become George Clooney, she becomes Nicole Kidman, and the surgeon at Mayo becomes Danny DaVito for comic relief.

Diane’s survival exceeds all expectations.  The quality of her life sines as a beacon to those who know her.  (Bethany and I ran into her and her husband, Lynn, at the movies the summer after her diagnosis; at age 45 she had been carded trying to get into an R-rated film.)  She and Cheryl, my office nurse for 20 years, have become close friends. 

When I made my career decision I decided to bring music back into my life and I asked Diane for saxophone lessons; she was going through a career change at the same time.  I still have the passion for the music but my expectations of being a star have faded.  I like playing scales, I don’t need fame.  But I couldn’t bring the instrument with me to the northern end of the continent.

Diane booked the last appointment of the day, to follow-up blood in the urine.

I relish the treat of finding a simple problem with a great patient at the end of a Friday afternoon, the cherry on an ice cream sundae.  When I walked into the exam room at 4:25, I found the dipstick urinalysis in the result cue of my computer.

We had chatted about the good news for a couple of minutes when Cheryl knocked on the door and entered, carrying a box with a card.

Of course it was a surprise. 

“Can I open it now?” I asked.

“The card,” they said, “Read the card now.”

ACHIEVEMENT started the platitudes on the front of the card.  I opened it and Pomp and Circumstance came out.  It was a graduation card.  We laughed.  Do great moments get better than this?

I used my key chain pocketknife to slit the tape on the blue wrapping paper.  I looked onto the top of the cardboard under the paper, and read the word Soprano.

Yes, great moments can and do get better, and sometimes they get so much better we have no imagination of it, and they become astounding moments. 

Cheryl, Diane, and Lynn had bought me a new B flat soprano sax.  Struck speechless and tearless, I stared.

I had wanted a soprano for forty-two years.  I didn’t buy one back then because I didn’t have the money, and when I had the money I didn’t have the time to play it.

Now I have time and money and an instrument small enough to put in my luggage.

I opened the case and the new brass and mother-of-pearl gleamed at me against the plush lining.

Diane walked me through the proper assemblage, how to put the reed in the mouthpiece and the mouth piece on the neck. 

I looked into the hallway.  Patients still here, rats!  No playing in the hallway. 

I shut the door and played a piece I’d written in 1970, forty years ago to the day.

Surrounded by measles, I turn in my beeper and my key doesn’t work

May 21, 2010

Could my happiness ever run deeper?

Could a thrill come any cheaper?

     I took the thing from my belt,

    Oh, the joy that I felt!

Today, I gave up my beeper.

 

I slept very badly my last night on call, from vigilance rather than need.

Thursday dawns cloudy, windy, and cool as I drive down Pierce Street for my radio segment.

I discussed measles.

During my childhood everyone knew what the word measles meant, though common knowledge didn’t help distinguish between the hard measles, the three-day measles, or the German measles.  Now measles is so rare that most docs in town have never seen a case.

If I hadn’t worked Tuba City, Arizona in the spring of 1987, I wouldn’t have seen measles at all.

A terrible disease, I announced to the radio audience, with high fever, a rash, and the three C’s: cough, conjunctivitis (runny eyes), and coryza (runny nose).  I remembered vividly the epidemic in the Navajo and Hopi patients at Tuba City and the distinctive rash: deep red and bumpy, heaviest in the midline and the armpit and groin creases.

One MMR injection confers 80% immunity and two gives 99%.  The Indians I worked with in Arizona had a very high single immunization rate, but the current standard demands two shots.  The vaccination protects so well that most nine-year-olds have never even heard the word measles, let alone mumps or rubella.

Four measles outbreaks surrounded Iowa as I spoke.

I enjoyed the show and the repartee with the DJ before, during and after my microphone time.  I stepped out to the parking lot, into the wind and the fresh air. 

I drove to St. Luke’s and parked under the portico by the valet, assuring him I won’t be but 30 seconds. 

The two phone operators work just inside the front doors of the hospital.  At 7:02 I handed my beeper over, explaining that as I have just finished my last night on call I won’t be needing it again.

Perhaps the beeper only weighed three ounces, but it felt like I’d carried a 60 lb albatross on my neck for the last 23 years and I had just put it down.

I turned and I took a step towards the electric door and then I couldn’t help dancing, kicking high, into the driveway, past the valet to my parked car.

I walked the way I walked in May 1972 when I finished my last exam over a very good demographics course, taught by Henry Harpending (still a distinguished academic who makes an occasional appearance on The History Channel) which forever changed the way I view politics and social trends.  I finished early and turned in my blue book to the professor seated at the front of the room. I slapped high fives with every student still writing in the first row, and strode out into a hazy, warm spring day.

But it wasn’t my last exam.  Eight months later I decided to become a doctor, and for the next seven years I kept taking tests.  When I took the last examinations in med school in 1979, I wrote my mother a letter that started, “It is the end of an era.  I have taken my last exam.”

Except that wasn’t my last exam, either.  All the tests I took were merely exercises before the three-day monster called the FLEX.  I did well on it in 1979 and I got my license.

Nowadays I just have one six-hour test every seven years.

And it wasn’t my last night on call,  just the last night on call till I start my next job in Barrow.

I don’t have to but I drive out to the clinic in the early afternoon.  The lock has been changed and my key doesn’t open the door.  The artwork has been taken off the walls in my office, and boxed up.

A little premature, but I don’t mind.

A day and half in the life

May 19, 2010

A day and a half I’m on call

I know I can’t do it all 

     I take wax from the ears

     I give Kleenex for tears

And then I just hit the wall.

My long day on call grows no shorter as I write.

I get to the office most days before 7:30; I review lab results and scanned documents, and I read a medical journal.  Patients start at 8:30.

A reasonable morning opens with a sequence of 5 diabetics in several linguistic and ethnic groups.  I do a lot of tearful goodbyes.

A thank-you note and card comes from an Hispanic family;  the note verbatim reads Para: Dr. Gordon.  De familia (family name deleted) le deseamos mucha suerte en este nuevo camino que enpieza Gracias por todo lo que nos alludo en nuestra salud.  Lo vamos a extranar.

The few brief sentences carry much warmth.

A patient, whom I have known for many years, comes in with arm pain and no trauma.  I get an x-ray on a hunch; most times such studies yield little information but this time the pattern of light and dark suggests something very unusual and much deeper.  I show the films to my partners, we nod and say, “periosteal elevation.”  I arrange for a CT of the arm for the next day.

Urgent Care calls me about noon to ask if I’ll work there; illness disrupted regular coverage.  I can’t say no because of my job description.

The drug rep brings lunch and after my sandwich and chips we chat, mostly about my future.

The afternoon stars six people with earache.  Four have normal eardrums, and, speaking from personal experience, I ask them if the short, sharp, stabbing pain, severe enough to make them wince, comes at random intervals.  I explain the problem with temporal-mandibular joint dysfunction, I get to the bottom of the problem, and treat without medication. 

Two of the people with ear pain have ear wax stuck, hard, in the ear canals, and I have the satisfaction of curing the patient before they leave.

At five Bethany shows up and I let her know about my late shift.  We go across the street to the grocery store for Chinese food.

We get the Senior Two Entree Special (I’m 60 now), an enormous amount of food, and two sets of chopsticks.  We sit in the corner dining area and share the small intimacies of our days.

Back at the office, I finish my documentation from the afternoon, and at 6:00 the first of the evening patients arrives.

I move quickly while the dusk gathers outside.  I speak Spanish and English to the patients, some of them my regular clinic patients who couldn’t get in to see me on a timely basis or who can’t take time away from work.  I send a patient with puzzling abdominal pain and chest pain to the hospital for consults with specialists, and I wonder what I would do with that patient in Barrow with the nearest surgeon 800 miles away. 

Three more patients with ear pain: one with TMJ problems, one with wax packed hard enough to have turned to stone, and one with an actual ear infection. 

I face the dilemma of treating smokers for cough.

At 8:23 I go back to my office and I try to finish my afternoon’s documentation.  I answer and dispose of email.  At 8:58 I shut down my computer, hoping to  leave promptly at 9:00

But I find the fourteenth and last patient ready at 8:59.

At 9:10 I walk out of the clinic, into the deepening night, and I smell spring running riot.  My back hurts, not as bad as it did 20 years ago. My feet hurt, but they hurt worse 30 years ago because now I have rigid orthotics. I’m tired, but not like I was tired 15 years ago; within striking distance of the end and I have slept much better since I gave up OB.  I walk straighter and stand straighter than I did when I was half my age.  Even when I’m tired.

I miss my workout at the gym, the hour and a half to sweat and watch TV.

At home I take care of more ework and roll into bed at 10:30.

In the middle of the night I take a call from the nursing home about a patient with a significant change in condition since striking their head in a fall a few hours earlier; I instruct the nurse to send the patient to the ER.

At 5:55 I get an alarmed call from St. Luke’s Labor and Delivery: come for a STAT C-section.  I am dressed and brushing my teeth in the car 4 minutes later.  I exceed the speed limit.

I arrive just as the crew gets into position, and I have time to pull on booties and scrubs before the actual surgery starts. 

With a very good obstetrician at the helm, I have absolute confidence as the secondary member of the team, and the baby arrives in short order but distressed.  Stabilized in less than 10 minutes and up to the NICU, we sit down to debrief at the nurse’s station at 6:30. 

We discuss inexplicable physical findings during the labor.  “I want to know why,” the OB says.  Then, “God humbles me weekly.  If not daily.”

I talk about how every day I see something I’ve never seen before.

When I get home at 6:50 in the morning Bethany has my lunch packed and is finishing breakfast.  I shower, eat, leave the house half an hour later than usual and have to face traffic.  My commute takes 18 minutes instead of 13 and I arrive at the office sleep deprived with hoarse voice and a sense of humor even weirder than usual. 

More people with ear problems, and the nurse and I marvel at how many of those I’ve seen in the last few dozen hours.

Gridlock seizes my rooms from 10:40 to 11:25.  A patient with chest pain needs x-ray and EKG; a patient with pain on urination needs a urinalysis; and a patient on Coumadin for a blood clot needs a protime.  I feel trapped with both lab and x-ray backed up.  The people in the waiting room get angrier and angrier. I twiddle my thumbs, powerless.

The CT scan results come back for the patient with the arm pain from yesterday; non specific abnormalities can only be elucidated with MRI, which I order.

Then the lab and x-ray start to move again and by neglecting my documentation I manage to get the last morning patient out by 12:10 PM.

By that time day has gotten longer and my voice has deepened into the subwoofer range. 

Chinese food comes to the break room courtesy of a drug rep who doesn’t even stay to pitch his product.  I eat too much of it and then I eat the fabulous sandwich Bethany has sent me (green chile, avocado, artichoke heart and baked chicken on fresh chipotle baguette).  Fatigue drives my appetite runs out of control.

I power nap for 20 minutes, then I go back to my documentation.

The afternoon brings more earaches, loss of hearing, and dizziness.  I take out plugs of wax as big as the patient’s little finger. 

A patient with broken ribs contracts pneumonia.

My tongue sticks to the roof of my mouth as I feel dehydration set in, but I can’t slow down long enough to get to the water cooler.

A bipolar alcoholic patient with migraines, and a problem of just not feeling right also has chest pain, a main complaint that can’t be delayed.  The amount of clinical material exceeds any reasonable time limits for one visit.

Patients with borderline personality have limited emotional resilience and come  at a time in my day when I am pressured, fatigued and running behind.  That patient wants to get everything taken care of right now, and when I resist, threatens to leave without being seen.

Which, of course, is a ploy.  If not a short timer, I would grit my teeth, get through the visit, and send a termination letter while I still upset.  I let the patient manipulate me.  I don’t have long to go and I don’t have to fire anyone. 

Sore throat, cough, and two well-child checks. 

The Hispanic well-child checks constitute a problem; a lot of the parents don’t speak English, and none of my partners speak Spanish.  Like all my patients since February, I have to arrange for follow-up after my departure.  I send a lot of the children to a pediatrician who speaks Spanish well. 

After I finish documenting the last visit, I walk out of the back door into the sunshine and an absolutely perfect afternoon, and I drive through the spring warmth to the gym for a workout.  I lose myself on the elliptical machine and the stationary cycle, sweating out the exhaustion.

Party medicine and the three week rule

May 18, 2010

At parties they come up to me,

For advice that I give out for free.

     The elbow from tennis,

     That overuse menace

Comes up at week number three.

 

I cannot go to a party without being asked for medical advice.

Sometimes a person will approach me and, smirking, say, “I’m gonna hit you up for some free medical advice.”

My usual reply is, “I’ll give you the advice.  If you take it, it’s free, and if you don’t take it, I expect to be paid.”  Which is another way of saying that I enjoy my work, but I don’t like being jerked around.  Then, frequently, I’ll launch into my standard recommendations about nicotine, caffeine, alcohol, diet, exercise, sleep, and seatbelts.

I don’t mind the intrusions for the most part, I see it as part of the job, part of the warped perspective you get on life from going to med school. 

Actually, it goes back further than that.  People have always turned to my for advice.  Probably just as well; I give out much better advice now than I did  before I got my degree.

In 1993,  mourning my mother’s death and short on sleep, when a person approached me at a gathering.  I lost my temper.  I said, “I’ve just been up for 36 hours, I’m up to my neck in grief, and you’re the fifth person tonight who just can’t seem to get to the office.   I’m telling you no.  No free medical advice at a party.”  Then I stalked away.

It’s the only time I can remember being rude about it.

One of the many physicians I’ve admired over the years said, “Anyone who asks for medical care in the hallway deserves what they get.”

Party medical complaints are pretty mundane for the most part but occasionally you get the really great stories.

Tennis elbow comes up a lot.

I have seen a lot of tennis elbow, but I have not seen a single case of tennis elbow that came from playing tennis.  I’ve seen it from weight lifting, excessively heavy purses, computer/mouse use, meat-packing, baseball, gardening, carrying a shotgun, swinging a hammer, paddling a kayak, martial arts, archery, musicianship, and bass fishing.  It’s an overuse injury, and like most overuse injuries, it starts about three weeks after the onset of activity or increase in frequency, duration, or intensity.  Symptoms can be improved with ice, compression, and elevation, but resolution depends on decreasing the stress by a third (whether duration or intensity) for three weeks, then increasing ten percent per week, but no faster.

Not surprisingly, when we did a lot of workman’s compensation medicine we saw a lot of overuse injuries.  Back when Aalf’s, a local industrial concern, made blue jeans for Levi’s, I would regularly see tennis elbow three weeks after they started sewing size 54’s.  Packing plant new hires would come in three weeks after they started on the job.

The three-week rule applies to the immune system, as well as well as the neurological system.  Thus people are most likely to get an infectious disease, or to trip and fall three weeks after making a change.

I’ll have to keep that in mind for myself.

A very long first step

May 17, 2010

I am as free as a sparrow

And it thrills me down to the marrow

     As I venture forth,

    I’m going up north

To the arctic village of Barrow.

 

If you go north in the US you’ll get to Alaska, a very big place.  Anchorage, the biggest city, has the largest airport.  Go eight hundred miles north out of Anchorage, stop just before you fall into the Arctic Sea, and you’ll get to Barrow.

I have a friend who lived in Barrow a long time ago.  He took some time off from Yale and worked at the Naval Arctic Research Lab.  He also went to Antarctica.  We met on his return to New Haven in the fall of 1969.  We have been friends since. 

Barrow is the northernmost place in the United States.  Three hundred miles inside the Arctic Circle, day is synonymous with summer.

When the opportunity came to me from a locum tenens recruiter, I looked it up on the net.

Barrow has access only by air and by sea.  Two commercial flights daily supplement the yearly summer cargo barge.  It has 4500 inhabitants.  The hospital also serves as the base for medical care for four villages that are even more remote.

Barrow is as far as I can go from Iowa and still be in the US, as big a first step in the next phase of my career as I can make.

I had two phone interviews, one with the clinical director and one with one of the locum tenens docs.

From the tenor of my conversations, the docs at the hospital in Barrow have excellent collegiality.

They also said I have an impressive Curriculum Vitae.

I never thought my CV anything special with the exception of my linguistic achievements (English and Spanish fluently; ASL, Navajo and Hebrew roughly).  Bethany thinks the impressive part is Yale.

I suppose an anthropology degree might come in handy in Barrow.

I have spent untold hours this last week getting my paperwork filled out, and I’m making an average of eight phone calls a day to manage the transition. 

Back when I started with the Indian Health Service in 1982 I snickered at the idea that I had to be fingerprinted.  Since then, identity theft has become a national problem, and I appreciate the fact that due diligence must be exercised, especially in the realm of health care.

I don’t know why one institution would need the day, month and year of my starting and stopping dates, and why another would just need the month and year.  I can see why a different body would want to know my professional society memberships and the years associated with them, but I don’t see why I should have to send the address for the Woodbury County Medical Society, Iowa Medical Society, American Medical Association, and American Academy of Family Practice.  After all, anyone can find those on the net.

I also had to get certified in Basic Life Support (done on Thursday), and I have yet to get a current certification in Advanced Cardiac Life Support.

But I also had to make copies of my seven medical licenses and certified copies of my medical school diploma and my residency completion certificate.  

I wouldn’t have thought that in the digital age hard copies would have counted for anything.

So I’ve got my application for an Alaska license in, along with paperwork for the hospital in Barrow. 

Life carries few certainties, especially when it comes to the future.  My first step in my Walkabout will probably be Barrow, Alaska.