Archive for January, 2011

Returning to Barrow

January 17, 2011

This trip is a bit of a lark,

Not exactly a walk in the park

     Where the polar winds blow,

     Making blizzards from snow,

Up north, where it’s cold and it’s dark.

Our friends gave us a going away party Friday night, or maybe we gave them a party; either way we had a great dinner.

It was an extension of our Friday night potlucks, which will continue in our absence.  With an original head count of nine for sure and four maybes, I made a boeuf burguignon. 

Having seen the movie, Julie and Julia, I picked up two tips for the recipe: dry the beef on paper towel before putting it in to brown, and don’t crowd the mushrooms in the pan.  From the net I learned to make a roux to thicken it. 

While constructing the main dish, I put together guacamole, using six avocados and four fresh roasted Poblano peppers.  I thawed out the fillet from Bethany’s huge ling cod, caught last August during our dream fishing trip on Alaska’s Prince William Sound.

Head counts at potlucks run notoriously inaccurate till the last-minute.  Eventually, twenty-one guests arrived, and as always, we had too much food:  fresh-baked challah, green salad, squash and asparagus salad, cut fruit, sweet potato casserole, chips, salsa, noodles, angel food cake with strawberries, bread, beef and fish.

The conversation didn’t stop with the eating; clean up continued after the meal.  Three of us sipped at Crown Royal while we washed and dried dishes and put away leftovers.  I distributed the rest of the cod to people who promised to cook and eat it within twenty-four hours.  Our last guests left about 10:30, and Bethany and I rolled into bed, congratulating ourselves on a first-class dinner.

I hadn’t finished packing, but our schedule was flexible enough to permit items be put into luggage in the morning.  At the last minute we remembered to bring exercise bands, a portable telephone for the landline, my electronic tuner, batteries, books, and CDs. 

John, our good friend, will be house sitting while we’re gone.  (He has a fifth degree black belt and he knows how to shoot.)

As I write, Bethany and I are en route to Alaska for a winter adventure, back to Barrow for the end of the sixty-three day Arctic night.  She plans to work as a substitute teacher and I’ll be back working at the hospital.

We stayed in Anchorage Saturday night and Sunday, visiting our friends Les and Beth, whom we’ve known since Wyoming.  Les and I discussed the fine points of vitamin D, calcium, and phosphorus metabolism, along with genetics, skin color, and astronomy, in relation to one of his current pediatrics cases.  We fried potato pancakes (latkes) and ate salmon we caught in August and had smoked. 

Later, the group enlarged, the erudition base broadened, and the discussion ran from the Constitution to free trade (as defined in 1775), free trade (as defined in 2011), economics, the gold and silver standard, the process of Constitutional amendments, the price of manufactured goods, the Swedish Empire, freedom of religion, and excesses of monarchs.


Allergy masquerades with joint pain

January 16, 2011

If it comes with an itch or a sneeze

Or a rash or even a wheeze

     It could be joint pain

     Or even a migraine

The diagnosis might be allergies

  One April day long ago (I won’t say where), a young woman came to see me with joint pain of two weeks duration.  She had the characteristic history items that went along with rheumatoid arthritis: swollen joints,  morning stiffness lasting two hours, gelling (stiffening up if she sat for more than half an hour), and fatigue and malaise.  I ran all the right blood work, and when we met the next week I assured her the results had come back normal.  I prescribed a non-steroidal anti-inflammatory drug (NSAID) for her joint pains, and I didn’t see her till she returned a year later.  The joint pains had lasted, she said, six weeks after she’d seen me, the NSAID didn’t help, and now the joint pain had returned.  I ran the right blood work again, and again she returned to normal results a week later, and got a prescription for a different NSAID.

Thus we met every spring for seven years, and six NSAIDs didn’t help.  I said, “Look, I can see you’re miserable, and because of personal experience I have real sympathy, but the blood work has all come up normal.  I’ve looked through your chart, and, give or take ten days, you’re here every April.  Even though the symptoms look like arthritis, the timing looks like allergy.  Let’s see how you do with an antihistamine.”  I gave her a prescription for Seldane (since removed from the market because of some nasty complications).

She called three hours later to announce her joint pain had completely resolved.

Since May I’ve run into a couple of other patients who have had arthritis-like symptoms but whose clinical progress has been less than satisfactory.  One has done reasonably with a change of diet based on a theory I can’t support. 

I’ve had some of them try Zyrtec, an over-the-counter antihistamine.

(When Zyrtec, or certrazine, went over-the-counter, my summer allergy business disappeared.  Instead of taking care of hundreds of patients with itchy, watery eyes, itchy, watery nose, and volley sneezes, from May through September, I might take care of a dozen; usually the few who do not respond to Zyrtec.)

Allergies can behave strangely.  Though I’ve never seen a case, fixed drug eruption occurs when a few square centimeters of body surface have an allergy to a medication.  I’ve seen documented cases in the literature where people have had a rash in reaction to tap water.

We can take away several morals:

You can’t have good medical care without good medical records.

Anyone can have any reaction to any drug.

Allergies don’t always involve sneezing.

Common things happen more commonly than uncommon things, but uncommon things still happen.

If the patient gets better as a result of a crackpot theory, don’t write off the theory

Twenty years of minutes

January 14, 2011

Complacence can creep in so slow

It wouldn’t be something you’d know

     But it’s there after years

     In lots of careers

When you just kind of go with the flow.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I’m slowing my career down, and while my one-year non-compete clause ticks away, I’ve gone walkabout, travelling, working, and visiting family and friends.

My twenty-year tenure as Medical Director of Touchstone Living Center (previously known first as Indian Hills Care Center, then as Indian Hills Nursing and Rehabilitation Center) has come to end during these months of going walkabout. 

I came on board in 1990 as a result of the Omnibus Budget and Reconciliation Act, and I found a lot of complacency.  I worried then that I wouldn’t know when the same problem would overtake me.

At the first Quality Assurance meeting I established an agenda: falls, pressure ulcers, deaths, hospitalizations, infections, physical plant problems, and personnel problems.  At the second QA meeting we discussed the sixty-three falls from the previous month; we looked took a hard look at the five patients with the most falls.  I recommended physical therapy, changes in their medication regimen, and changing their rooms.  Bit by bit, the number of falls slowly decreased.

I went out of my way to include housekeeping and maintenance in the monthly meetings, and in return received the two biggest pieces of progress.  By moving all the patients out of one wing every day, and opening the windows for two hours, we cut in half the number of respiratory infections.  By removing the carpeting from one hall, where the patients tripped going out of their rooms, we did away with half the falls.

Over the years, I’ve seen eleven administrators come and go; none of the nursing staff present at the first meeting works there currently.  I’ve had excellent working relationships with the staff pharmacist and the Directors of Nursing.

I never thought to ask for a raise, but I received a couple of them anyway.  On a few occasions I realized I hadn’t gotten a check for a few months, but it came promptly once I asked.

Influenza struck hard in 1993, with patients dying less than an hour after developing symptoms.  Even in retrospect we could have done nothing to prevent the terrible mortality that year.  By the end of the flu season, neither love nor money could have bought you amantadine, rimantidine, or a flu test kit.  The staff morale plummeted.  I hope I never see a flu season that bad again.

The Assisted Living movement cut into the Nursing Home business, and the facility re-invented itself as a rehab facility with one Hospice wing and one Alzheimer’s wing.  Over the years, the patients have progressively averaged more severe problems.  Still, the number of falls has continued to decrease until some months we applauded single digits.  The count of pressure ulcers starting or worsening in-house has dropped, most months to zero.

The death rate continues, not surprising for the patients and diagnoses involved.

My original contract stipulated that I keep minutes of the QA meetings.   After roughly 250 meetings, I had a pile of paper a foot thick.  I took it to the administrator’s office today and dropped it off. 

I know the doc taking over as Medical Director to be solid and sensible, with both feet on the ground.  I suspect he will bring a fresh approach to certain problems.

I hope he doesn’t find I’ve been too complacent.

Forgetting phones, Pad Thai, and making overseas plans

January 13, 2011

Today we went out to eat Thai

At a place where they know how to fry

     But out in the cold

     Where the frost has its hold

We quickly were kissing good-bye

Bethany and I went to a Thai restaurant for lunch today.

During my lens’s accommodation to indoor light, I thought I might have seen a colleague, but he left before I got a chance to say hi.  While Bethany and I looked at the menu, the owner of the restaurant walked out of the door, and came back in with a white coat in his hand.

I named the doctor, asking if the coat belonged to that person.

Yes, it did, he said, and he would call the doctor’s office. 

Such things happen.  Years ago, one particularly busy weekend on call I arrived at a Japanese restaurant for lunch.   Bolting the food between phone calls, I missed the subtlety and complexity of flavors.  I left and started back to a hospital ER.

I hadn’t gotten six blocks when my beeper sounded.  I pulled to the curb and called the number of the Japanese restaurant.  I had forgotten my credit card.

I navigated the one-ways, double-parked in front of the restaurant, ran in, got my card, and ran out.

I can’t think of a restaurant in town that wouldn’t do the same thing; I love living in a small town.

Bethany and I enjoyed very good Pad Thai and pumpkin curry.  While blasts of arctic-temperature air arrived every time the door opened, I told her about progress I’d made trying to get work for ten or twelve weeks outside the country.  I’m dealing with a couple of recruiters.

I get an average of five calls a day, looking for doctors to fill locum tenens positions.  I listen politely, tell them I have no availability, and invite them to send me an email, so that if things don’t work out and I have to put my lines back in the water I know where to locate them.  I have even put a partition in my saved email called “locum tenens.”

More than eighty agencies in this country try to place doctors into temporary assignments, but both doctors and potential employers run into what the economists call “opportunity friction.”  Since I started into this year of going walkabout, I have said yes to seventeen different jobs, and all but four fell through.  I enjoyed every place I went, and I can’t stop saying great things about each one.  But the level of professionalism on the part of the recruiters and agencies varies.  If my foreign plans don’t materialize, I will probably throw myself on the mercy of the three recruiters whom I trust.

We took our time with our meal.  We stopped, full, before we finished the food, and boxed the leftovers.

Outside, in the bizarre contrast of sub-zero air temperatures with bright sun on the south side of a building, we briefly talked about plans for the rest of the day.  We’d just kissed good-bye when the owner hurried out the door to give Bethany her telephone.  She’d forgotten it on the table.

Outdoor winter workouts: low-impact, high-intensity

January 11, 2011

For cold, we’ve got Barrow beat,

A strong wind will steal your heat.

     Despite what I ate,

     In the cold I lose weight,

But sure it’s a harsh way to cheat.

I’ve been following the weather on the internet. Ten days ago, the temperature in Barrow, Alaska ran twenty degrees colder than Sioux City.  For the last four days Sioux City has shivered ten to fifteen degrees colder than Barrow. 

I went out for a walk this morning in the frigid air, the house thermometer reading in the negative double digits.  With official wind gusts of thirty miles per hour, I put on two layers below the belt and four above.  Hat, mittens, neck warmer and hood, I figured, would be warm enough.

But for the wind blasting my face, I was right.  I turned back after two hundred yards.  I rummaged in my hunting gear till I found a mask. 

Of course the problem that developed once I went back outside had to do with my glasses.  While the wind in my face cleared frost well, when I turned around the polycarbonate iced over, then fine crystals blew in from the back. 

Winter workouts have advantages.  Walking in snow makes for a high-intensity, low-impact workout.  Breathing cold air burns a lot of calories.  I get the chance to see wildlife at a season when most people don’t venture out.

Four winters ago I walked every morning between 5:30 and 6:15.  As the winter progressed I followed the fortunes of the animals.  Two hen turkeys with three chicks roosted in trees a quarter-mile from the house; as time went by I noted their mortality, one by one, by tracks in the snow.  Here the signs of struggle, there a pile of feathers.  A fox got them, I could tell from footprints.   I knew where he lived, and I knew his ambush points by the number of turkey kills.  I found the breast bone of the last survivor, picked clean, on top of the snow in February. 

All active animals in winter need more calories.  When I shiver in a deer blind, I remind myself that I burn calories at the same rate I used to when I ran.  Even when I don’t shiver, I burn energy just by breathing.

In the evening, Bethany and I went out to a dinner seminar; the temp hovered at zero, and  20  MPH winds howled across the landscape. 

We arrived late, and missed the hors d’oeuvres.  I had been ready to write about the irony of eating large meals while listening to lectures about weight loss.  In an uncharacteristic burst of sanity, the food stopped with the appetizers.

When we got home, we found it too late to eat.

Just as well, Bethany and I both need to lose weight.

Even doctors have to wait to see the doctor

January 10, 2011

I don’t have a diagnosis or why,

As the tears run out of my eye.

     It’s just the creation

     Of a foreign body sensation

I’m really not one to cry.

I went to the Clinic Formerly Known As Mine as a patient today.  Despite a steady snowfall on top of six inches accumulation from yesterday, I went out into the cold, with the mercury here in Iowa reading two degrees colder than in Barrow, Alaska.

Two days ago my left eye started feeling scratchy, and I woke in the middle of the night to put in Celluvisc eye drops, which have worked well in the past.  They helped for a short time, then the sensation that I had a boulder stuck between my upper lid and my eyeball increased until, I was sure, the Rock of Gibraltar had taken up new residence.

I don’t mind waiting for my doctor.  In years past I have found a few minutes of peace and the chance to read a magazine in physician’s waiting rooms.  But today I sought relief from major, immediate physical discomfort.

During her examination the numbing drops from my doctor came as a wonderful relief, which I knew would only last twenty minutes.  The flourescein drops showed a small corneal abrasion.  My doctor inverted my upper lid but found nothing stuck there.

On the way out I received many hugs and questions about my upcoming plans.  I hope all patients are treated so warmly, especially on so cold a winter’s day.

You can’t call it a blizzard unless wind combines with cold and snow, but the white stuff has continued to fall for a day and a half and slippery doesn’t even come close to describing the roads.

On a day when going to the doctor carries significant risk, I drove to the drug store, fearing its closure.

I bought my prescriptions, and I also bought more Celluvisc.

I first made my acquaintance with this very soothing eye drop twenty-five years ago, and have recommended it frequently since.  If the problem went away in less than twenty-four hours with Celluvisc, it did not warrant a visit to the doctor. 

I broke open one of the single use units in the car before I drove away from the pharmacy, dropping the soothing artificial tears into my eye.  I waited to get home before using the antibiotic and the anti-inflammatory.

Continuing pain demanded more Celluvisc, a couple of Tylenol, and recumbent position with my eyes closed.  Two hours later, I called my friend, the ophthalmologist.  Two hours after that, he has not called me back yet. 

Just as well, most of the pain has gone.

Even doctors have to wait to see the doctor.

Fanfaron: Spanish for “show-off”

January 9, 2011

The Hospice nurse phoned in late,

But I made good use of the wait

      The stranger did vanish

      When I slipped into Spanish

And the form I helped her translate.

I met with the Care Initiatives Hospice nurse at a nearby nursing home; as I walked in she called to tell me she’d be twenty minutes late.

As I’m working with a more flexible schedule, I told her, “No problem.”

Sitting by the door were a woman with a clipboard, another woman in white pants and a nursing smock, and a receptionist.  Closing my phone, I looked at the woman with the clipboard, and I furrowed my eyebrows.

One cannot tell by the face what language the mouth has, but I went out on a limb and said, “Te conozco?” (“Do I know you?”)

“Yes,” she answered in Spanish, “Doctor?  I heard you retired.”

Then we struck up a lively conversation.   I gave her my synopsis, and told her I came to care for dying patients.  She nodded, and asked about my Christmas.  Soon food dominated our conversation.  After five minutes or so I turned to the receptionist, and in English announced my name and my purpose and why I would be starting late.

I turned back to the woman with the clipboard.  “I’m embarrassed to ask,” she said, in Spanish, “but would you help me fill out this form?  I don’t have enough English.”

I sat down with her and soon realized that, however well I can discuss pathophysiology, pharmacology, and disease states, I have never translated an employment application.  The woman, who has above average inherent intelligence but less than a high school education from a third-world country, had been working in the USA for years but had always found help when seeking work.

I did the best I could.  She had documentation of her ability to work legally.

But she had little English.  I told her how my wife and daughter had been teaching English as a Second Language at Western Iowa Tech; she was familiar with the institution and wanted to learn English but she was too busy working to get to classes.  I expounded the virtues of Rosetta Stone.

I had gotten the education and recent work history sections filled out for her when the Deb, the Care Initiatives nurse, walked in out of the cold.  I excused myself and we went to round on two patients.

Some people approach the end of life with awareness and wisdom, some with fear, some without input of their senses or the ability to understand. 

Great stories fill every nursing home.  One doesn’t traverse decades without experiencing fascinating slices of reality.

An hour later, our work finished, we came back past the receptionist.  The woman I had helped had left. 

The Spanish word for show-off is fanfaron.

Housecalls to drama and irony

January 8, 2011

In time, all will come to an end,

And be mourned, if at least by a friend

      Don’t bring on your death    

      With tobacco or meth,

There’s no need to hurry a trend.

Every hospice program has to have a medical director; I took on the responsibility for Care Initiatives Hospice in Sioux City a year ago.  The patient load doesn’t justify a full-time physician; in general I work for them eight hours a month.  My duties include attending a weekly meeting, signing papers, and taking phone calls from the nurses when patients come on to the program or die.

As of this year, 2011, if a patient has survived on Hospice for more than six months, the doctor has to visit the patient face-to-face.  I called on such patients Thursday.

Because of confidentiality, I cannot write about details of patient cases, nor where they live.

Some of those born long ago approach their finality without vision or hearing or awareness; some have all their faculties.  Those over ninety who maintain clear contact with the world as we know it rarely object to their demise. 

Few half that age come to hospice with equanimity. 

I entered houses where death will soon visit.  Each person has uniqueness and I cannot write about identifying details.  I can mention a clock that plays Amazing Grace at noon.  Or the beautiful grandfather clock which has not been wound, next to a table supporting a very good dry wall hammer; I did not ask what repairs were underway.

 I can write about alcohol, drugs, anger, grief, and the natural tendency people have to love.

I have a few words in a lot of esoteric languages, and I used all of my vocabulary in one of them. 

If a person dies at a young age because of bad decisions, the people who love him or her will suffer from a large emotional backlog of unfinished business.  The grief stemming from the time during and after death will ripple through the family and community and bring unintended effects.

Even under the best of circumstances, when a parent dies the children find a rift.  I have seen otherwise sane people use the smallest of excuses so that one thing leads to another until both sides nurture a grudge so bitter that it justifies silence for decades, or forever.

Long ago I invented the acronym DOCS, the Distant Obstreperous Child Syndrome.  When the death of a parent nears, the offspring who has been the most distant geographically (and, hence, emotionally) will focus the most anger at the healthcare team.

Drama and irony weave in and out of the human condition, and the ultimate drama comes with the ultimate irony.  We will all come to an end; no one gets out of this game alive.  Some approach finality at half the years of others; some of those held the self-destruct button down too long, some had plain bad luck.

Of leisure skills, Hospice, coq au vin, Barrett, Ellington, and drug reps

January 7, 2011

I sent patients from Hospice alive,

I visited my old clinic hive.

     So that I’m not alone

     I got a new phone,

And served dinner at fifty past five.

I started my day by getting a new phone.

I had to replace the old one with a smart phone that would let me use a drug database.  It can also function as a camcorder, take excellent pictures, act as a GPS, remember more music than I’ve had time to listen to in my life, and browse the net.  I rate it Pretty Miraculous, but I realize I’m starting at the bottom of the learning curve and that it can do a lot more.  I’ve missed every call I’ve gotten so far today because I changed my ringtone.

I did well at my saxophone lesson.  My teacher, Diane, and I played some pretty great music; we did a duet by Barrett and it came out well.  Then we jammed some Ellington.  I allowed my analytic hemisphere rest and I let the horn find the notes.

My teacher continues to be a beacon of life lessons.

I stopped by the Clinic Formerly Known As Mine, I got lots of hugs and told my tales.  I also ate the lunch the pharmaceutical manufacturers’ representative brought, but I didn’t talk to the rep, and as I walked away from the clinic I realized that in the last eight weeks, the amount of time I hadn’t spent talking to drug reps totaled forty hours.   On the other hand I know of four new drugs on the market that I need to learn about, possibly more.

I’m still the Medical Director at Care Initiatives Hospice; while on my epic road trip I attended meetings by Skype.  Today I enjoyed having a real meeting.  I feel we do a good job; we let another patient out of Hospice alive.  We cut dosage or eliminated a medication six times.  A Hospice meeting brings lessons in the human condition, eternal verities about drama and irony, and, as always, great stories.  I won’t write those stories because demented people cannot give their permission.

Back at home I cut up chicken hindquarters.  I poured tablespoons of garlic salt and black pepper into half a cup of flour.  After dredging the chicken in the flour, the pieces browned nicely in canola oil at the bottom of a Dutch over.  I took the pieces out and dumped in a pound of sliced Portobello mushrooms  and two chopped white onions.  After sautéing those till the onions were translucent I put the chicken back in, dumped in a bottle of white wine, and pressed in a dozen cloves of garlic. The covered pot went into a 350 degree oven.  Two hours later the house smelled lovely; by then I had two loaves of take-and-bake baguette bread ready, and the rice cooker had done its job.

Our friends, Dolf and Mercedes and their children came over for dinner.  They talked about the Florida adventure they’d just been on and I told about my 6000 mile, 7 week road trip.

Dolf has a strong work ethic but he also possesses an enviable set of leisure skills.  About a year ago I went to him for advice in that realm.  He said, “I got one word for you:  practice.”

I’m taking his advice.

Thirty-eight CT scans later, life’s lessons from a musician and a teacher

January 6, 2011

We count good moments, not years

When we don’t give in to our fears

     I once went with a hunch,

     It helped my patient, a bunch.

And she looks good in front of her peers.

My patient, Diane, has given me permission to use this information in my blog. 

She taught my three children instrumental music; she came to me as a patient more than a decade ago.

Six years ago a cough brought her in.  As with all health professionals doing their job with a woman between ten and sixty, I asked if there were any chance she was pregnant. 

“No,” she said.

Sometimes I get a hunch and a long time ago I learned to trust that tingling at the back of my brain; in this case it told me not to believe her. 

“Well,” I said, “Just lay back on the exam table while I check your tummy.” 

I plainly felt the top of her uterus higher than her belly button, but I couldn’t find a heartbeat with the Doppler.

I pled urgency with an OB-Gyn and got her an appointment within the hour.   The ultrasound showed her womb had turned into a malignancy the size of a soccer ball.

A few weeks later, she came, in her words, to a “critical decision that I make a ‘leap of faith’ in action right before surgery, because I knew in order to live I had to not be afraid to die.”

The pathology report said leiomyosarcoma, a cancer of the uterine muscle.  In later years she said, “I was always a survivor from the beginning.  I was born C-section at 7 mo.[ 3.5 lbs] in 1960.  I had no idea how having ‘faith’, ‘letting go’ of past hurts, and learning to trust others would change my life all for the better.”

It helped that she had never been a bitter person.

I coordinated her care as she went from specialist to specialist.  So rare a tumor had no chemotherapeutic experience.  With a paucity of clinical evidence, I gave advice from my heart. 

“The worst day of my life wasn’t when you called and told me it was in my lungs,” she said.  “Not even close.  I’ve had more good days since my diagnosis than I had in my entire life combined.”

The next summer Bethany and I met Diane and her husband on their way out of the movie theater.  She’d been carded trying to get into an R rated movie.  Her skin had the clear glow of a teenager and her hair shone in the sun.  She walked with a bounce befitting a sophomore.   

The spring after that she sat in the waiting room of the Cancer Center before a radiation treatment.  The other cancer patients turned to her. “You’re not here for radiation,” they said, “you’re just another representative. What do you represent?”

“I represent hope,” she said.

My middle daughter fell rock climbing three years ago; in the aftermath of ICU’s and neurosurgeons and months of not knowing I learned a great deal.  Diane and I have discussed these truths: Time comes to us in moments, some good, some bad, most neutral; if you let the bad moments contaminate the neutral you give them too much power and if you let the bad soil the good you’re missing the point; embracing the uncertainty of not knowing bad news makes your day better.

When I made my decision to slow down back in February I also decided to bring music back into my life and buff up my saxophone skills by doing lessons with Diane.  On my last clinic day, she and her husband and my office nurse gave me a soprano sax.

(see my post

Over the course of ten surgeries, seventy-nine radiation treatments, fifteen hospitalizations, and thirty-eight CTs, Diane continues to look younger and younger.  She serves as a beacon of light and hope to all who know her.