Archive for March, 2013

Is mole (moe lay) chili?

March 18, 2013

Where we live the country is hilly

And people might think that it’s silly

With no burger nor bean

Whether it’s red or it’s green

To call my recipe chili.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

I made my second foray into competitive cooking today at the clinic’s annual chili cook-off.

My first experience came while still working at the Clinic Formerly Known As Mine.   I had a dynamite recipe, inherited from my mother; it brings consistent accolades when I serve it to guests.  But in accepting corporate sponsorship, I accepted the mandate to make the product heart healthy.  Perhaps my sponsors didn’t mean vegan.  I definitely do not qualify as a vegan.  But I decided to make a vegan chili.

I considered the basic recipe, and after a couple of false starts, decided on ground roasted pumpkin seeds as the substrate.  Once a week over a twelve week summer, I produced another batch, each time fine tuning the mixture of spices.

Simple arithmetic scales a recipe easily; if I put 12 cloves of garlic into a recipe that produces 4 quarts, I need to use 120 cloves of garlic if the rules say I need to produce 10 gallons.  I did the math, I prepped the ingredients, and on the day of competition I arrived early.  With the help of a friend and my wife, we cooked for four hours.  The chili came out absolutely delicious.

The contest awarded a total of 30 prizes to a total of 27 competitors. I won none.  Of the 10 gallons of chili I made, we brought home 9.

In the end, I decided that entering a vegan chili in an Iowa chili cook-off made as much sense as bringing a knife to a gun fight.  Even if every bunch of hungry firemen and ER staff we gave the leftovers to loved it.

The tastes of cocoa and tomato disappear and a distinctive savor that the Mexicans call mole (pronounced moe lay), replaces them both.  Finding the correct balance is very difficult.  My mother got a recipe out of the newspaper, and in an uncharacteristic move, followed it to the letter, nailing a culinary conundrum the first time out.

I took the recipe to college and refined it.  I adapted it from chicken to hamburger, and eventually to deer, elk, and aoudad.  I decided that the meat didn’t matter with a sauce that good.

Which brings up the question:  What is chili?  Growing up it meant browned ground beef, canned tomato, and beans.  When we lived in New Mexico, it usually included meat, rarely tomatoes, never beans, but always chiles, whether green or red. 

This time I used dark meat of turkey as the base; I would rate the result as exquisite.

I wanted to win the contest but I didn’t want the prize, a gift certificate to a faux Mexican food chain.  Bethany and I know we don’t like their food because we ate what drug reps gave us. 

Five cooks entered the contest.  I didn’t place in the top three.  I suspect I came in last.

I came away a trifle disappointed, but I really liked having one of my favorite dishes as a hot lunch. 

Enjoying your own cooking ranks as more important than a prize in a chili cook-off.

Maybe I would have won if I had used beef instead of turkey.  Maybe I would have won if my entry had less heat. 

Maybe mole isn’t really chili.

Next year I might try doing a Pueblo Indian-style beef red chile, something that I’ll work on this summer, with chunked chuck and cascabel chiles.

If I win, I hope I like the prize.

Chicken Mole

3 pound chicken, cut up

Olive or corn oil

1 large green pepper, chopped coarse

1 large onion, chopped medium

28 oz can crushed tomatoes

12 ounce can tomato paste

7 rounded teaspoons cocoa

2 ½ tablespoons ground cumin

Ground chile, chile molido puro, powdered chile, jalapenos, or crushed red pepper; the inherent heat will dictate the amount.  I use 2 ½ tablespoons of a medium hot ground chile.

Garlic to taste

Water as needed.

In a heavy pot, brown the chicken and remove.  Sautee the pepper and onion.  Add tomato paste and crushed tomatoes, thin with ½ cup water, and add cocoa.  (The balance can be so close that scavenging the fugitive bits of tomato paste left in the can make the difference between success and failure; the result should taste neither of tomato nor cocoa).  Press in the garlic.  Add the cumin and the chile, stir in ½ cup water, add the chicken.  Bake covered at 350 degrees for 90 minutes.  Serve with soft corn tortillas and/or rice.  Serves six.

Bits and pieces, clinical and otherwise

March 13, 2013

After shaving off all the head’s hair,

My patient said, “What is this there?

For my scalp is so sore

I can’t touch anymore

And the smallest exertion’s a chore.”

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

I met a person with the last name of Jeffords. 

“Any relation to Tom Jeffords?” I asked.

Yes, came the reply. 

Tom Jeffords carried US mail in Arizona Territory back when the Apaches didn’t hesitate to expend ammunition when showing disapproval of the new invaders.  After the Chiricahua killed a couple of his carriers, he rode his horse into Geronimo’s camp and demanded the depredations cease.  Geronimo, impressed at the personal courage and straightforward approach, agreed, and the mail went through unmolested.  The two men became fast friends.  When his Apaches went to their new reservation, Geronimo requested Jeffords as his agent, Jeffords accepted, and, to the best of my knowledge, became the only Indian Agent to remain uncorrupted by his position.

I knew the story in far greater detail than the Jeffords I talked to.  Tom Jeffords still holds my admiration for personal courage and integrity; we agreed that such characteristics come rarely and we wished we could find men like Tom Jeffords in prominent positions in our government.

++++

Today I took care of a patient who noticed tenderness in the scalp after shaving (in the 21st century, make no assumptions about age or gender of the patient).   This unusual complaint puzzled me, but remembering the adage, “When all else fails, examine the patient,” I reached out to the touch the indicated area and found it warm and swollen but not red.  I looked at one side then the other, and realized that the temporal artery stood out on the right.

Temporal arteritis remains a mysterious disease; for unknown reasons the arteries throughout the body become inflamed.  As a result those afflicted feel run down, have morning stiffness, and lose strength in their shoulders and hips.  As I queried my way through the list of symptoms the patient became more and more puzzled that I would even ask such questions (the patient also gave me permission to include a great deal more information than I have).  Front line docs don’t see a lot of it, maybe a case every couple of years, and we usually refer to a rheumatologist if available.  Head-shaving, increasingly popular through many segments of the population, occurred rarely during my training years; it made the physical finding visible which before were only tactile.

+++

I started early without trying this morning at 6:15AM, and finished my share of hospital rounds at 8:15.  While I could have conceivably taken the morning off, I used the windfall hours to catch up on hospital documentation.  At 10:30 I had made great progress and went over to the office and worked on my paperwork backlog till patients started at 1:00PM.  For some unknown reason one hospital began sending me lab summaries from patients hospitalized as far back as last July. 

I can pull up the patient’s electronic chart and see if the information has already been downloaded, but given the peculiarities of our system, it goes faster to sift through the data as if I’d never seen it.  Not to say it goes fast.  It doesn’t. 

 

The doctor takes the wrong end of the scalpel

March 4, 2013

In the head there’s this thing called a brain.

Where we feel our pride and our pain

But when the cutting is done

Are narcotics just fun?

Or the source of some ill-gotten gain?

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

Recovering from surgery cuts into the desire to write, but I’m doing better now.

Even doctors must have doctors; the internal dialogue that leads us to minimize contact with our own profession has gradually led us to healthier life styles.  Few doctors smoke in the 21st century; most of us exercise regularly.  While no doctor should prescribe for him or herself, neither should any patient completely abrogate self-advocacy nor decision-making. 

I won’t dwell on the circumstances that led me to a repeat surgery; denial worked for a long time but eventually failed.  Thus on Valentine’s Day I sat in our local specialized surgical center, hungry and thirsty waiting for anesthesia.

The procedure started on time, but went long, only because of the nature of the problem.

A lightweight when it comes to most medications, I dozed off and on for the rest of the day.  When it came time to leave, I adamantly refused a prescription for a popular narcotic.  The exchange with the nurse went several rounds and finished with her tearing the slip to bits and putting it in a small plastic envelope designated for that purpose.

All narcotics slow the gut and suppress the cough reflex.  I feared constipation (after a major abdominal procedure) and pneumonia more than I feared pain.   Nor would my marginal kidney function permit me the usual pain relief of the NSAIDs (a drug class that includes Ibuprofen, Alleve, Toradol, diclofenac, and 28 others).

Which left humble acetaminophen, also known as Tylenol.

If we assign post-operative pain a range of 1 to 10, we know that the much-abused oral opiates like Percodan and Norco can bring the pain down by 2.7 points in the same study where an inactive pill will bring it down by 2 points and Tylenol by 2.1 points.

(Interestingly, propoxyphene, the active ingredient in Darvon, now removed from the market, would decrease it by 1.7, which means that despite bringing euphoria, a drug could aggravate acute pain; a phenomenon we see with marijuana and chronic pain.)

I have spent most of the last 5 days asleep, but today I’m coming around.  My appetite and my sense of humor have palpably improved through the day.  I still fear coughing but I do it anyway. 

I didn’t actually need the narcotics.

When I talk to my non-drug abusing patients after a surgery, most of them didn’t, either.

Weekend Call: transitional chaos, a colleague retires, and another teaches.

March 3, 2013

The hospital’s making a switch,

The electronics are finding a niche

I don’t think it’s strange

I was there for the change

Unexpected is always a glitch

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

I agreed to take call this weekend to help out a colleague and coworker.  Had I thought ahead I might not have.

One of our hospitals made the shift from paper to electronic medical records (EMR) at midnight between Saturday and Sunday.  Only the Wednesday before the switch, when I had already committed to taking call, did I realize I would be on board for the transition.

All change inherently involves chaos; nothing ever works out the way you planned.  The greater the change or the faster the change, the more that the Law of Unintended Consequences applies. 

One of my colleagues, an emergency physician with whom I have worked for the last two decades, chose this time to retire; he didn’t see a future on the far side of the learning curve.  At 5:30 in the morning he called me about a patient needing an admission.  I listened to his presentation, accepted the admission, and asked if it constituted the last admit of his career.  (It doesn’t make a difference, but the clinical problems included diabetes, dehydration, and diarrhea.)

It had.  A small silence passed between us, memories filled with drama and irony.  I recalled my year of walkabout and the last day I spent at the clinic.  Much was said and little spoken.  “Well, it’s been an honor,” I told him.

I could hear his smile in his pause.  “Thanks, Steve,” he said.

An hour later, with my unfamiliar-looking census in hand, I arrived at the 6th floor ICU to spend 15 minutes with the patient and the next 45 minutes doing the documentation.   To my regret I stooped to occasional truculence and sarcasm aimed at the nice lady who wore the fluorescent yellow vest of a super-user, someone educated enough in the system to help those just starting.  I pointed out that I had 15 patients on my list and at that speed I wouldn’t get home till ten in the evening.

The next floor down presented compound problems of two new admits and two other patients in the surrounding context of rampant chaos.  

I found Dr. Tan (who gave me permission to write this) in the position of super-user.  We have worked together for close to 20 years.  With a background of a great working relationship based on clinical respect and trust, she gently ushered me into esoteric information pathways.  My second patient took me 45 minutes and my third patient took me 30. 

Our practice has too many hospital patients for one doctor to round on through the weekend.  One doctor takes call and sees patients at one hospital; the other doctor rounds at the other hospital, then goes home.  I take pride in being able to finish at one place and help out the other doc across town, but noon today found me done with the 6th and 5th floors and the rest of the hospital to go.  Knowing I wouldn’t possibly finish in a reasonable time frame, I broke for lunch. 

No food today graced the doctors’ lounge, but the cheerful mood verged on hypomanic.  Contrast those smiles to the last time I saw a hospital go digital and grim faces drip frustration.

At home I relaxed my way through soup and a nap. 

I finished the 4th floor and arrived in the Newborn Nursery at 3:00 PM.  Immediately confronted by logistic problems involving ordering things for circumcision, I glowered.   In 30 years I had never had to do such a thing, only with the current new digital system.  I expressed a desire to be done with the procedure by 5:00.  Better to be happy than right. I finished half an hour later.

On the way out I reported a large number of computers on the second floor incompatible with the new system.  Or so the nurses thought.

All in all, I had had the best day to transition, not the worst.