Archive for January, 2015

Learning curves and light days: notenoughworkosis

January 21, 2015

Some say that I’m a quick learner
I know I’m an EMR spurner
But I’m feeling much fresher
With a little time pressure
And the EMR they call Cerner

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Right now I’m in Nome, Alaska.

Any introduction to a new system involves a learning curve, involving time necessary to acheive fluency and efficiency. The overall system here involves little difficulty outside of the electronic medical record (EMR) systme). I had a passing acquaintance with Cerner, the product they use here,back home, where I hated, loathed and despised it.

I try my best not to fight it. All EMRs are built by people who don’t talk to doctors, and are purchased by people who don’t take care of patients. The ideology that gave us the Palm Pilot could give us better systems.

But the administration here, recognizing the EMR’s steep learning curve, scheduled me very light for the first couple of weeks, about one patient an hour. I’ve preogressed enough that in the last two days I have had double-bookings once an afternoon, and even asked my nurse to start poaching patients out of ER and the Fast Track.

My first afternoon patient didn’t show, nor did my second. I said to my nurse, “When too many patients have noshowitis I get notenougworkosis.”

I looked forward to my last three patients. I taught myself how to put a lab order into the computer before the patient arrives. Sure enough, the result came back abnormal enough to justify hospitalization just as the nurse readied the other two patients (family members).

I had to learn the process for admiiting patients, even more Byzantine than the usual order process, and I had to do it while the other two patients waited. So I had time pressure for the first time since October 2.

I called the computer trainer, who walked me through the process. Even though he got hung up a couple times and, at the end, we encountereed a task, that, if I had done it today would have saved me time. But such couldn’t happen till next Wednesday, though that did not become clear until the trainer and I had run a number of microchip laps.

During the process, one of my colleagues, frustrated by the anti-ergonomics, fumed that seeing the patient took 15 minutes but putting the orders into the computer took 45. And I couldn’t quarrel with him. We talked about opening up a practice with paper records and charging $50 a call.

Eventually, I got the sick patient admitted, the order into the computer, and the other two patients seen. I put lab orders in for both the inaptient and outpatient side. At the end, 3 patients took me 90 minutes. And trying to get three people taken care of simultaneously stressed me out. But I liked it a lot more than the thumb twiddling I’d done in the beginning of the afternoon.

A musk ox butchery

January 15, 2015

I helped the cutting of meat
Up here where muskox is a treat
I took a small share
I hear it’s great fare
Though the hunting’s not a hard feat.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Right now I’m in Nome, Alaska.

Community colleges form a part of the American landscape; they constitute educational institutions close to the people who want to learn. Administrators time courses to suit the needs of students who also need to work, and demand dictates academic choices.

The Northwest Campus in Nome published its spring semester catalogue. Along with the usual courses of Human Anatomy and Physiology, Basic Excel, Elementary Algebra, and Preparatory College Writing, I found 4 courses on beading, 5 on ceramics, 2 on birding, and one each on Snow Machine Maintenance and Repair, Arctic Survival, Subarctic Horticulture, Conversational Inupiaq, Qiviiut Lace Knitting, and Working With Qiviut: harvesting, processing, and knitting.

Qiviut comes from the muskox; these holdovers from the Ice Age grow an under layer in the winter and shed it in the summer. The only mammalian fiber with no scales and hence impervious to felting, it has unique insulating characteristics and rates as the warmest yarn in the world.

The demand for meat in Alaska’s gold rush wiped out the native muskox; the current herd descends from a dozen animals imported from Greenland in the 30’s. Late last century musk ox hunting only happened when individuals strayed onto sea ice floes and faced certain death. Since then they have done well, and now have a population large enough to sustain hunting. Because of the high value of the qiviut, domestic muskox husbandry has become economically feasible.

These shaggy, short-tempered animals roam wild in the Nome area and sometimes stray into town. The Nome Nugget (Alaska’s oldest newspaper) carried two stories this last year concerning the conflict between the local muskox and the local sled dogs; both times the dogs lost.

Yesterday afternoon, I held a discussion with the most seriously ill patient I’ve seen since my arrival. I can’t give details about the case or the demographics; though I can write my words :”Weight loss in the US in the 21st century is not normal,” a point on which we agreed. After I proposed a diagnostic plan, I asked some geographic questions, and in the process revealed my fondness for hunting. Which led to a discussion of local hunting, which led to a mention of muskox, and I expressed my eagerness to try the meat. The patient told me to go ask a (specific) dentist, who had gotten one just outside town two days ago.

When my clinic work finished, I ascended the thrillingly beautiful front staircase while the subarctic sunset blazed in the south over the Bering Sea, announced myself at the dental reception desk, found the dentist and offered to help with the meat cutting. Above all, I said, I can keep the knives sharp using nothing else but the back of a china plate.

He pointed me to the dentist two cubicles over. I repeated my offer.

That evening the crowd gathered. The dentists had already broken the carcass into primal cuts.

This bull muskox compared favorably to the largest elk I’ve taken in terms of size. Over the next three hours two dentists and I cut the meat, while the spouses wrapped and labelled. We talked about our backgrounds and our back stories. Hunting stories flew thick as mosquitos in spring. I got to recount the 70’s and even told of my jail time served for the crime of illegal pedestrian. I made good on my boast of knife sharpening.

At the end, I trimmed the meat from the two hind shanks, and gratefully took it for myself. With very large animals so abundant here, hunters usually give that cut to the dogs. I talked about the joys of braising the tough cuts, especially the shanks.

But generosity didn’t end there; I also got a couple of back strap steaks, and the promise of burger after grinding,

I have heard it said that a hunter’s emotional attachment to the meat varies inversely with the time from the kill, but here the willingness to share seems to start as soon as the animal hits the ground. The first dentist had taken a few pieces and passed the rest on to the second dentist, who passed much of it on to friends, coworkers, and me.

Before I left, I got to see two tanned musk ox hides and three brown bear rugs.

Tomorrow I’ll cook musk ox meat for the first time.

Getting around town in the subarctic

January 12, 2015


Why would I want a car
In a town where no one goes far
And a four-dollar taxi
Has a speed that is maxi
If you’re just going from here to thar.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Right now I’m in Nome, Alaska.

When I accepted the assignment here in Nome, I told the recruiter I didn’t need a car. Googlemaps revealed a town small enough that walking would suffice. Yes, from time to time I expected bad enough weather to make the half mile walk to work dangerous, and for that I requested taxi vouchers. Nome has more car traffic than Barrow did and a lot fewer people walk. The snow machines, Gators, ATVs pedestrians and fat-tire bikes still rule the snow-packed streets. And, because of connection with the Nome-Teller highway, a road maintained by the state in the summer, vehicles need current registration and drivers need licenses.

On Wednesday, the Norton Sound Health Corporation issued me a corporate vehicle. The Nice Lady in Administration stood on the 3rd floor and pointed out the window. “See that white Ford next to that pickup parked nose out?” she asked, and handed me the key.

After finishing electronic documentation for the only 4 afternoon patients, I approached the aging SUV.

By the time I got 3 blocks from the hospital, I had discovered: 1) It takes longer to warm it up than it does to scrape a light layer of frost from the glass. 2) The left side dash lights don’t work and the only way to visualize the gas gauge is with a flashlight. 3) The Check Engine light functions as an eternal beacon. 4) The oil pressure gauge stays pinned on zero. 5) You can use a Bic pen top as a radio knob. 6) You can’t tell the difference between the Overdrive and windshield wiper controls without a really good flashlight. 7) Neither fob nor the driver’s side power lock button will unlock the doors.

I turned around, put the Ford in its place, and walked back to the apartment.

Next day I told the Nice Lady in Administration about the oil pressure gauge and the Check Engine light.

In the afternoon an employee from maintenance brought me the keys and assured me nobody could find anything wrong with the engine. The oil gauge needle, stuck on the wrong side of the E pin, wouldn’t function in the foreseeable future.

Three days after receiving the keys, I have scraped frozen rain from the glass twice, and used the Ford to buy groceries twice. I remain unconvinced that vehicle possession advantages outweigh the disadvantages. I’ll still walk to work.

January 7, 2015

If you’re walking around in the snow
Be careful of where you might go
We can’t be assured
That the Nome Musk Ox herd
Will watch for pedestrian flow

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Right now I’m in Nome, Alaska.

Getting up before dawn doesn’t mean much in Nome in the winter.  But I arose early and walked 14 minutes through near zero temperature to the hospital.  I have adapted quickly to the cold; I worked up a sweat though my clothing didn’t change from yesterday.

I came in through the ER entrance, up the spectacular main staircase, to the third floor conference room for orientation.

The employees here get great benefits: pension plan, very low cost health insurance, low cost meals at the cafeteria, free admission to the gym, and work comp insurance.  I miss out because of my contractor status; I (nominally) work for myself.

After the benefits rundown, we got the briefest synopsis of the employee handbook.  We watched DVDs about blood borne pathogens, fire extinguishers, and HIPAA.  Security took our pictures, and made us ID badges.  We got a tour of the hospital, with an emphasis on how to evacuate for a fire.

Another DVD showed us how to walk on ice so we don’t fall; I discovered the hospital has an office where one can buy outdoor safety equipment.

The cultural presentation surprised me.  I hadn’t known that Nome serves as economic and medical hub for 17 villages with a total population almost  as large as the city  itself.

We trooped to the  cafeteria at noon, just as the sun came up.  The hospital paid for our lunch, but not for chips, candy, or soda.  We ate while watching another DVD about harassment in the workplace; whether from the cooking or from the  less than stellar video, I couldn’t bring myself to finish the chicken fried steak.

The end of the day, with the red sun setting south across the Bering  Sea found me at the information services office getting my email account set up.

With no clinical work expected for another 48 hours I found 136 emails in my inbox, dating from 12/25. About 10% carried holiday greetings, and another 30% had to do with usual hospital business like  cars scratched in the parking lot, lost earrings, and “I will be gone from my desk until…”

The best email read:
You may have noticed we have Musk Ox hanging around the Hospital. Mostly north of the hospital around QCC and the smoking area near the BIG rock. At times, they could get somewhat get a little to close for comfort.
A freindly reminder:
Please use caution and keep your eyes open when outside around the Hospital. Generally, the Musk Ox are first to move away and stay to themselves. One only knows they could have a change in mind. Having said that, please be safe outside and enjoy the rest of your glorious day and week. Happy Holidays from the Security Department.

First impressions of Nome

January 4, 2015

I came from the land of the brome
To the subarctic city of Nome.
Where the story is told
Of how they dredge up the gold
But the weather is warmer than home

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Right now I’m in Nome, Alaska.

Nome, Alaska sits 102 miles south of the Arctic Circle. The 161 mile distance prevents seeing Russia from here, even on a clear day. As I write, the Nome thermometer at 9 degrees registers 10 degrees warmer than my home town’s current temp.

Before the gold rush, Natives had temporary habitation here. But the yellow metal brought 20,000 people to Nome in 1899. The placer gold ran so rich through the beach that the extracted mineral depressed worldwide gold prices. Wyatt Earp came here to “mine the miners;” making money at gambling and alcohol, and left a rich man, in 1906.

The 100 year storm washed away most of the beach gold early last century. Dredging the Bering Sea bottom for that gold continues as a major economic activity here. The newspaper, the Nome Nugget (Alaska’s oldest newspaper) this week carries ads for 3 competing gold buyers.

At one time Alaska’s largest city, Nome now has 4500 inhabitants, about half Native. Correctly observing the pejorative nature of the term Eskimo, they prefer the word Inuit, Inupiat, or Yupik, depending on their language.

Perhaps owing to the recent passage of the Christmas holiday, the mood here contrasts with that of Barrow (see previous posts from 2010 and 2011). Nome feels more economically active and commercial. Barrow’s heart beats to the rhythm of the whaling seasons.

In town only 48 hours now, I’ve been to been to two grocery stores and two restaurants. Koreans run both eateries, but one touts its Japanese menu and the other its Chinese fare and its pizza.

I’ve also learned about the polar vortex.

Fluids of different densities, like air of different temperatures, mix poorly. As the air near the pole, in the polar vortex warms and loses its contrast to the air further south, it mixes better, and the warm air can travel north and the cold air can travel south. Thus the recent violent storms attributed to the “polar vortex” really find their cause in the weakening polar vortex. And the temp at home frequently exceeds the temp in Nome.

I declined my agency’s offer of a rental car. My apartment sits over a garage half a mile from the hospital and a mile from the furthest grocery store. I walked around Nome yesterday and the day before, getting my bearings, and breathing in the mood of the city. The commercial district, Front Street, features a lot of liquor stores, most of them closed. But I also found a theater, several restaurants, a couple of stores selling native art work, and a couple of churches. Despite the above 0 temperature, the wind made me glad of my long underwear and my Arctic grade parka with the wolverine ruff.