Archive for March, 2014

Another last day

March 27, 2014

My month now draws to an end
What a great way my vacation to spend
I might be a geezer
Enjoying his leisure
But I’m sure enjoying the trend.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, sold my share of a private practice, and, honoring a 1-year non-compete clause, went to have adventures in Alaska, Nebraska, Iowa, and New Zealand. I returned to take a part-time position with a Community Health Center, now down to 40 hours a week from 54. Right now I’m in Petersburg, Alaska, on a 1 month working vacation.

The month of March flew by in Southeast Alaska. This trip’s last day passed in a leisurely fashion.

I cared for 8 patients in the course of both sessions and none in the last two hours of the afternoon.

Confidentiality limits what I can say about patients, but I can write about clinical matters. When all else fails, examine the patient, even the hard-to-examine autistic. Meatal stenosis (a narrowing of the hole through which the urine passes) requires a surgery so simple that I could probably do it. Phyctenular keratoconjunctivitis, an unusual cause of a red eye, comes no more commonly than rosacea of the conjunctiva. Allodynia (where light touch produces pain), unusual to start with and even less common as back pain, demands more than symptomatic treatment. If the original plan fails to fix the patient, the three most important steps are re-evaluate, re-evaluate, re-evaluate. Hemoptysis (coughing up blood) in a former smoke demands a chest x-ray, even if the smoking stopped ten years ago.

I got the chance to speak Spanish; I told a joke involving a pun involving ratito meaning both a small period of time and a diminutive rodent.

In the middle of the morning I stopped into the lab to get my PPD (TB skin test) read. Every health care institution demands periodic testing for tuberculosis among its workers in 21st century America and my previous test lapsed a little over two weeks ago. The small geographic size of the operation here made getting the poke in the forearm much easier than such a test at home. After all, it takes 14 steps to get from my office to the lab, and at home I would have to drive to my doctor’s office.

I ate lunch down the hill at Coastal Sea Foods, deep-fried halibut and fries. A construction worker shared my table and we talked a lot about the vagaries of the weather in the Alaska Panhandle. The place filled up during our discussion, and I finished my meal surrounded by commercial fishermen.

In the last half of the afternoon I cleaned up both my physical and electronic desktops. I tried to log in to the provider portal at my clinic back home. When the request came to change my password because of brevity, I fired off a quick note saying that 9 characters had sufficed for 3 months, and I wouldn’t accede to a request for more.

My sojourn here coincided with a family emergency for one of the full-time permanent doctors who returned today. I expressed gratitude that I could help.

I had a good time. If all works well, I go fishing tomorrow.

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Memories of March 11. 1979

March 14, 2014

Three decades ago I did walk
How fast move the hands of the clock!
My life rearranged
As a man I was changed
And I remember the speaker’s fine talk.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, sold my share of a private practice, and, honoring a 1-year non-compete clause, went to have adventures in Alaska, Nebraska, Iowa, and New Zealand. I returned to take a part-time position with a Community Health Center, now down to 40 hours a week from 54. Right now I’m in Petersburg, Alaska, on a 1 month working vacation.

The anniversary of my medical school graduation arrived with snow and rain in southeast Alaska.

March 11, 1979 remains a date burned into my personal calendar. I had hitchiked back from Montana, my 4th move in 5 months. I stayed with friends in Saginaw and East Lansing the few days till graduation.

My father and brother flew out from Denver.

The graduation speaker did an effective job; I still remember what he said: There aren’t very many true emergencies. Write down what you need to know for each one on 3×5 cards and carry them around till memorized. Every morning, first thing, look in the mirror and say, “I don’t know.” Get good at it. Medicine is a jealous mistress with a cruel embrace.

He spoke for about 20 minutes. His exact words probably reside somewhere in the archives, but I carry the most important parts in my memory.

Michigan State at that time and to this day keeps the med students in East Lansing for the two preclinical years; after that the College of Human Medicine sends the students off to the five clinical campuses around the state. Those clinicals years constitute the crucible that makes a doctor. We saw people born and die; we delivered babies. We received praise and verbal abuse. We listened to attending physicians expound wisdom and acclaim outright lies. And for our last year, most of us travelled.

We lost track of each other. Some slowed their program from four to five years, some longer. Some dropped out. For the next three years we focused on our post graduate training, and for the next thirty years we focused on our careers.

But most of us walked across the stage that cold and snowy night in East Lansing.

I almost didn’t.

While I stood in line I started to panic. I had been a student for 24 years at that point, and without a school and a program, I had no identity. With only two classmates ahead of me, I turned to my one time roomate, who, fortunately, came right behind me alphabetically. “I can’t do this,” I said, “I’m a student. I don’t know how to be anything else.”

He said, “Be quiet. Turn around and graduate.” Which I did.

In that short walk across the stage I underwent a metamorphosis. I walked off the stage gripping a faux parchment (not the diploma; they had handed me a note that promised my diploma would be mailed to me), a changed man. The change, of course, had built over the three years of premed and the four years of medical school, but those few steps brought me past the tipping point.

Yes, I had lost an identity and in doing so acquired another.

My classmates and I milled around in euphoria and then we prepared to leave.

My father and brother and I went out to the Chinese restaurant afterwards. My fortune cookie said, “You will have great power over women. Use it wisely.”

What “weekend on call” means here

March 11, 2014

What does call mean, can you tell?
A 3 day or 12 hour spell?
Does it make me a cynic
To see folks in the clinic?
The sick along with the well.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, sold my share of a private practice, and, honoring a 1-year non-compete clause, went to have adventures in Alaska, Nebraska, Iowa, and New Zealand. I returned to take a part-time position with a Community Health Center, now down to 40 hours a week from 54. Right now I’m in Petersburg, Alaska, on a 1 month working vacation.

Different people can use the same word and mean different things, and the same word used by one person can mean different things at different times.

At the Practice Formerly Known As Mine, “weekend call” meant from Saturday at 8:00AM to Monday at 8:00AM; it included seeing patients in the ER, rounding in the hospital, and delivering babies.

In Barrow, “on call” always meant 12 hours, covering the ER and caring for the patients in the hospital.

At the Community Health Center where I now have my main part-time gig, before December 1 “weekend call” meant Friday 8:00AM to Monday 8:00AM, no ER, and responsibility for 20 to 40 hospitalized patients. Now, with the same time parameters, the hospital census seldom exceeds 8, all of them children. Interactions with the ER come only with pediatric admissions.

Here in Petersburg, “weekend call” starts at 8:00AM Saturday, ends 8:00AM Monday. It includes a Saturday morning walk-in clinic and scheduled afternoon patients. If someone comes to the ER, the on call doctor goes in to see them, but most of the hospitalized patients will see the doctor who admitted them. When a patient in long-term care (much like a nursing home) needs to see a doctor, they see the doctor on call.

On Saturday call I saw a number of cases involving infectious diseases. We have strep making the rounds of the school system, and an epidemic of hand, foot, and mouth disease (a viral illness causing (blisters on the palms and soles and in the mouth) in the day care system. In the wake of a respiratory virus, lungs compromised by years of smoking develop problems. Commercial fishing brings its own set of medical risks, complicated by the vagaries of being away from port for days to weeks, as well as port changes. The Forest Service employs about 50 people, making it one of the larger employers; those workers have medical problems associated with spending protracted time in the wilderness. But we also have people who work desk jobs and run into overweight, diabetes, high blood pressure and high cholesterol as a result.

And sometimes I see the worried well along with the well children.

Most cannery workers left before the end of September, but some remain for the halibut, crab, and shrimp season.

Where people walk on ice, the doctors can count on seeing slip-and-fall injuries.

But in such a small village most people walk most places. In a town where people observe the posted speed limits of 15 and 20 MPH I get little motor vehicle collision work. And the school system teaches water safety conscienctiously and effectively.

Still part of the US, we have our share of problems stemming from meth, heroin, prescription pain relievers, marijuana, tobacco, and alcohol.

Decompression: not to be confused with mania

March 9, 2014

It came, this feeling sublime,

With the freeing up of my time.

Don’t get in a panic,

I haven’t turned manic

But boy, this place is just prime.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa.  In 2010 I danced back from the brink of burnout, sold my share of a private practice, and, honoring a 1-year non-compete clause, went to have adventures in Alaska, Nebraska, Iowa, and New Zealand.  I returned to take a part-time position with a Community Health Center, now down to 40 hours a week from 54.  Right now I’m in Petersburg, Alaska, on a 1 month working vacation. 

Two weeks after I left the Practice Formerly Known as Mine, I called my doctor from Alaska.

Me:  I’m so euphoric I’m afraid I’m having my first manic episode.

My doctor:  So you’re feeling good?

Me:  Yeah.  Really, really good.

My doctor:  Are you doing anything impulsive ?

Me:  Like?

My doctor:  Like spending money?

Me:  Does paying arctic prices for a pint of Ben and Jerry’s count?”

My doctor:  No.  Or gambling?

Me:  No

My doctor:  Doing anything risky?

Me:  Like going out on the sea ice?  Absolutely not.

My doctor:  How are you sleeping?

Me:  Fantastic!  Eight solid hours a night and waking up rested without an alarm.

My doctor:  You’re not manic, you’re just happy that you’re decompressing.

That same euphoria washed over me in waves while I walked around Petersburg the day I arrived, just an overall sense of happy.  Yes, the blue sky and the dramatic mountains could take the breath away from a fish, but it takes more than good weather to bring happiness.  I suspect I’d be this happy if I wandered around Pittsburgh (I won’t write off that possibility).  I think it has to do more with freeing up of time constraints than with scenery or a new place.

***

I left for work back home on a Wednesday with the thermometer firmly at 7 below zero; I got off the plane in Petersburg, Alaska at 45 degrees, and the air, compared to Sioux City, smelled like spring.  I ran around in shirt sleeves till the sun went down.

***

First thing off the plane I went to the clinic, where, since I left in August, a new electronic medical record (EMR) system has taken hold, though the reasons remain unclear to me.  Sleep deprived and jet lagged (the trip lasted 28 hours), my brain fails to consolidate the lessons.  Yet I observe that if it takes me 3 tries to learn something, I might as start that day  and have my first failures out of the way.

***

Second day of clinic I find I learned more than I thought.  As with any complex computer system, I run into some transient functionality problems.  Because I can’t talk about patients, I’ll talk about the disease states I encountered:  sore throat, cough, back pain, laceration, and neuropathy.   I saw four patients (if you do the math you’ll see at least one patient had more than one  diagnosis) at the rate of one per hour, and for Monday I have the confidence to handle one every 45 minutes.

I seem to learn quickly.

Enjoying my time on hold: A terrible double murder, a rocky coast, and the US Marshalls

March 7, 2014

Here’s an idea that’s bold:

A thing you can do while on hold

Instead of music to hear

That will bore you to tears

Listen to the story that’s told.

 

SYNOPSIS:  I’m a Family Practitioner from Sioux City, Iowa.  In 2010 I danced back from the brink of burnout, sold my share of a private practice, and, honoring a 1-year non-compete clause, went to have adventures in Alaska, Nebraska, Iowa, and New Zealand.  I returned to take a part-time position with a Community Health Center, now down to 40 hours a week from 54.  Right now I’m in Petersburg, Alaska, on a 1 month working vacation. 

I won’t dwell on the details of the case, or the drama and irony that unfolded as I watched the dancer pay the piper.  The bottom line came when the patient requested a referral to the Native Hospital on Sitka. 

I go out of my way to expedite referrals, consultations, and second opinions; I have never regretted doing so.  In this case, protocol required I call the physician on call at the referral hospital.

I got put on hold.

I have spent a lot of my life on hold; in 1990 my frustration with the insurance companies’ abuse of my time led me to put a yoyo in my pocket (which relieved tension and brought me to a degree of proficiency I could not have imagined).  I now do my best to leave my name and cell phone number rather than wait; I can get work done if not distracted by the hold music or the canned ads that impose on a captive audience.  The phone system at Mount Edgecome didn’t play music or ads. Instead, I listened to a Native story teller.  He had a good story and he told it well, drawing pictures with words, of a terrible double murder and a difficult bureacracy. 

My fascination brought me to another place, a stormy, rocky coast under gloomy skies.  Had I sat in his audience, my legs would have fallen asleep before I noticed.  I really could have listened to him all day.  And just as he got to the part where the US Marshalls discovered the bodies, the other doc picked up the phone. 

Her voice came through, clear and chipper and professional.  We exchanged pleasantries.  I told her about the case, and what we’d done so far.  She asked an incredibly insightful question about substance abuse, and 45 seconds into the conversation we poised ready to ring off.  But I had to tell her how much I had enjoyed the time on hold.  The hospital, she said, had recently changed the tape; I told her it was a great idea.

A musician in the audience

March 7, 2014

With a fiddle, a guitar, and bass,

The auditorium served up the space

You couldn’t go wrong

With a fine blue grass song

And the mandolin followed the trace

SYNOPSIS:  I’m a Family Practitioner from Sioux City, Iowa.  In 2010 I danced back from the brink of burnout, sold my share of a private practice, and, honoring a 1-year non-compete clause, went to have adventures in Alaska, Nebraska, Iowa, and New Zealand.  I returned to take a part-time position with a Community Health Center, now down to 40 hours a week from 54.  Right now I’m in Petersburg, Alaska, on a 1 month working vacation. 

Thursday clinic went a little long, but I finished documentation by 530.  Tired, sleepy and hungry, I shopped the grocery store with a bias towards instant gratification, then came home and bolted cheese, garlic toast, artichoke hearts and sun-dried tomatoes.  Then I drove back to the high school.

I haven’t seen much of Petersburg High School besides the auditorium.  It serves as the movie theater for the island, but it also serves as the venue for live music.

I arrived while the opening act finished their first number.  I took a seat at the back.

Double Rock Band performs bluegrass locally.  Three siblings play, respectively, fiddle, mandolin, and guitar; a fourth woman plays string bass.  The oldest has not yet attained the age of 16.  They played well, they even sang with Appalachian accents.  If an opening act or back up group functions mainly to make the headliner look good, Double Rock Band will never succeed; they perform too well.  Even if their showmanship hasn’t acquired polish their musicianship shines and they play from the heart.

After four numbers, they left the stage and they left the audience fully impressed.

The audience conversation buzz filled the room while the stage made minimal changes.  I saw half a dozen people I’d seen in clinic.  In a town this size, everybody knows everybody.

I napped.

I suppose lessons in the performing arts start with making the audience wait, and by the time the Ruth Moody Band came on stage I had come to appreciate Double Rock’s lack of polished showmanship. 

Ruth Moody played two sets.  Billed as a bluegrass band, in the 60s I would have called them folk.  While most of the audience just enjoyed the music, I noted the bass and the fiddle had fantastic coordination.  Ruth herself sang well and with passion.  From time to time I slipped into the moment and I just listened.

When I played with Synergy in Barrow (see entries this blog from the summer of 2010) I lived in the moment while the music rolled out of my saxophone.  I find it harder to get into the moment while listening.  But the last number, Troubles and Woes, brought me there.  Justifiably, it brought down the house.  They saved the best for the last. 

Then came the predictable standard standing ovation and the encore.

Outside, the night had warmed and smelled like snow coming.  More tired than hungry now, I dropped into bed before 10:00.

35,000 feet with no bandage scissors or silver nitrate

March 5, 2014

I decided to help just because

After an adequate pause

The person in need

Had a bit of a bleed

That I fixed  with a cork screw and gauze
SYNOPSIS:  I’m a Family Practitioner from Sioux City, Iowa.  In 2010 I danced back from the brink of burnout, sold my share of a private practice, and, honoring a 1-year non-compete clause, went to have adventures in Alaska, Nebraska, Iowa, and New Zealand.  I returned to take a part-time position with a Community Health Center, now down to 40 hours a week from 54.  Right now I’m in Petersburg, Alaska, on a 1 month working vacation. 

I might take a vacation but I never stop being a doctor.

On a long, late flight west I saw a passenger approach a flight attendant, then watched the flight attendant retrieve a white plastic box.  They retreated  the beverage and food service alcove.  I hung back for as long as I could, catching busy glimpses of them.  When I couldn’t take the suspense any more I approached.

“Need a doctor?”  I asked.

Yes, they did.

The passenger had cut her hand several hours before, leaving a flap of skin and a wound that kept bleeding intermittently.

Local pressure stops bleeding, I explained.  Even if you have a hole in your aorta, you can stop the red tide if you can put the pressure on the right spot.  Then I had the passenger raise her hands above her head.  To keep track of the discomfort I put her through, I adopted the same posture.

The flight attendant rummaged through the first aid kit, looking for a bandage the right size and something to make it stay in the right spot.  All the while I dug into ingenuity to make up for lack of equipment.

I could have uses a silver nitrate stick; it looks like a fireplace match with a spot of dark chemical at the end.  Exposed to water, either from the tap or from body fluids, it generates nitric acid, which, in turn, coagulates blood. Widely used for nosebleeds, canker sores, and other miscellaneous projects, I have plenty back at the office.  And none at 35,000 feet.

The smallest bandage in the kit came to twice a useable size.  And in the 21st century you can’t find any cutting instrument on an airplane.

The flight attendant use the point of the cork screw to tear the bandage.  I put the truncated gauze between the fingers and buddy taped them, putting pressure on the wound.  I warned the patient to take the tape off if her fingers went numb.

I asked for, and received permission, to talk about the incident on my blog, and she revealed she writes a blog as well.  We exchanged blog addresses and when I read it out loud she revealed her cancer survivorhood.  The University of Nebraska published her book.  We talked about Bernie Segal’s book, Love, Medicine and Miracles, and I told about my patient miraculously 8 years past a 90-day prognosis.

Then turbulence hit and I had to return to my seat and buckle up, and we never got a chance to talk about writing.