Archive for February, 2015

A fund raising auction at the Convention Center

February 18, 2015

The city of Nome has a flag

They imprinted it all over some swag

Just for the kiddos

I made the right bid-do

On a bucket, a bottle, and bag

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 one says Convention Center in a town the size of Nome, one means a building with less floor space but better acoustics than the high school gym.  Adequate for the Nome Preschool annual fund-raiser, it seats about 200.

I bought tickets for the evening’s raffle last week, and, in the spirit of supporting community institutions, walked over to check out the auctions.

I bypass the home-baked desserts and chili, browsing items on the silent auction table.  With no interest in cosmetics, fragrances, and home-made garments, I note winter clothing bearing logos for telephone, construction, and fuel companies.  I discard the idea of a wrench set, or anything else difficult to transport.  I consider the knife and flashlight sets.

I find an item entitled City of Nome Swag: a plastic bucket holds a Frisbee, T-shirt, fabric shopping bag, water bottle, and ball cap.

I like to bring back small stuff from my travels, an ivory polar bear from Barrow, a ball cap from Waikiri.  And this batch would suit my purposes.  Especially the water bottle.

I sit with a PA and a CMA from work.  We swap stories about Alaska.  I learn about an island where statute prohibits locking the car or the outer door of one’s arctic entry, because bears regularly harass the population and people need to have shelter in a hurry.  We talked about Adak Island, I hear about being stuck for two weeks because of winds.

The live auction list reveals a lot about the location and the town’s values.  The Natives invented the ulu, a kind of knife very useful for dressing hides, and the program sports three of them, one for sewing.  I find a half-dozen kuspuks, an ornate, hand tailored upper garment with a hood and an elaborate kangaroo pocket.

The auctioneer pitches tryouts for the Community Theater, and emphasizes that we have gathered to raise funds.  He chants through pieces of local art, a home dog grooming kit, and a toddler’s Ski-Doo jacket.  The first item that holds an interest for me, dinner at every restaurant in town and movie tickets for two, also catches the crowd’s fancy; the bidding passes the triple digit mark and keeps going.  In the course of the evening, the other items that fetch the highest prices include 100 pounds of air freight (three different airlines), 10 pounds of crab (three lots each), a one night fishing getaway to Niukluk river, a helicopter sightseeing tour for 3, an hour of bluegrass music from Landbridge Tollbooth (a local group), Nome Discovery Tour for 4, 100 gallons of fuel, and 40000 frequent flyer miles with Alaska Air.

Every 15 items, the action stops.  A child picks a door prize ticket (cash), and the MC reads the names of successful silent auction bidders from two or three tables.

I outbid everyone for the Bucket of Nome Swag.

In the third round I buy a dog sled ride. My bid goes over the triple digit mark.  Later I find out the musher, the District Attorney, qualified for next year’s Iditarod.

I look forward to the conversation as much as the ride.

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Aching and waiting for the CT scan

February 17, 2015

It starts with a drip from the nose

And progresses with an ache to your toes

What should you do

When contracting the flu

While waiting for the clinic to close?

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.

My nose starts dripping at 4:00PM, while finishing a visit with a patient with a knee problem. I blow my nose, wash my hands, and apologize. A vague sensation of not feeling quite right accompanies an explanation of how to apply a cold, not frozen, can, not bottle, of regular, not diet soda to an area of overuse.

I exit the room, have my nurse print the patient’s depart papers, and ask about the afternoon’s first patient.

I started with that patient on time at 1:00PM. While I washed my hands, I noticed shortness of breath. I listened to the account of all the things that had happened since a recent surgery. After examination, I told that person my concern for a possible blood clot in the lungs, then started in the process of ordering a CT of the chest (and, because of other problems, other places).

The welcome assignment to Same Day duty brought my most intense day since arriving in Nome. Starting with an empty schedule, the morning filled with people who had sickened or worsened in the last 72 hours. I moved efficiently, discharging the last morning patient promptly at noon. I bolted up the stairs to the cafeteria, inhaled lunch, and descended to finish the morning’s documentation. With satisfaction every time I hit the SIGN box, I started the afternoon with no morning leftovers.

Nothing happened quickly for that first afternoon patient. While I cared for others with respiratory infections, orthopedic problems, rashes, and psychiatric conditions, complicated by betrayal, bitterness, and overwhelmed emotional resilience, we had delays getting the lab to draw the blood, and delays getting the results.

The nurse tells me that the patient hasn’t yet gotten the IV for the contrast.

However late, we need the result before the patient can leave.

I start with my 4:00 PM patient at 4:05. At the end I discuss the difference between sinusitis and the common cold. I describe the relationships between stress, alcohol, marijuana, tobacco, and the immune system, and make recommendations.

I sit down at the computer and I start the depart orders for that patient: diagnoses, medication reconciliation, follow-up, and patient education.

I wait for the CT scan to start while I start the afternoon’s documentation. At 5:00 my nose has gone from dripping to running and I worsen. My forehead warms my palm, but I keep keyboarding.

At 5:15 I ask the nurse for a portable thermometer and receive, to my surprise, real mercury in real glass.

The patient enters the CT scan while I mutter that I don’t feel good; at three minutes the thermometer reads 99.0. The glass bulb stays under my tongue.

Long ago I learned to keep the thermometer in till it quit going up. I keep computing, checking the silver line every three minutes, till 5:45. The worst of the documentation ended, I await the viral onslaught with a near fever, 99.5.

At 6:10 I can tell the patient, “You have no blood clot in your lungs, and the rest of the studies showed no surprises.”

At 6:15 I walk out, feeling even worse. The dry, hacky cough (confirming my diagnosis of influenza) starts while I crunch across crusted, packed snow in the gathering subarctic, subzero gloom. The half-mile back to my lodging takes me 15 minutes. After 2 acetaminophen, a Tamiflu and a liter of fluids, I crawl into bed and don’t crawl out till morning.

Feeling much better, I walk back to hospital in 10 minutes, arriving before business hours. Funny lab results bring me to research multiple myeloma until 8:30 when I call the infection control nurse. She comes to my cubical.

My story recounted, I ask, “Do you or don’t you want me seeing patients today?”

“What would you tell a colleague?” she counters.

To answer a question with a question constitutes a dodge, but, in this case, a legitimate one.

I said, “Generally I send folks back to work when fever free for 24 hours, and I never actually ran a fever.”

And in fact the worst part of my contagiousness happened in the 24 hours before my nose started to drip.

Old patients with old ATV, delusions of a hypothyroid, improving patient flow, what people here want to win, and Eskimo salad

February 8, 2015

Here is a word to the wise,

The thing for which everyone tries

When it comes to the raffle

The stuff shouldn’t baffle

When it appears as a winnable prize

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.

The closer I get to Medicare age, the nicer I treat those over 70. I quit trying to push them around years ago; it doesn’t do any good. So I don’t tell them when to come back, I ask them when they want their next appointment. A 76 year old patient today considered the question. “My ATV’s old and hard to start,” he said, “I had to use a hot water bottle to get it started today.” Which I took for a polite way of saying he didn’t want to come back till spring.

***

During residency one of the recently minted Family Pratitioners told us 14 patients a day covered his overhead. During my quarter century of private practice, 32 a day was light, 36 just right and 40 left me frustrated and rushed. I spent many years trying to squeeze too many patients into too little time. After the installation of this electronic medical record (EMR) system, the administration here in Nome recognized inherent slowness and lowered the expectations to 12 patients a day for the experienced docs and 8 for those just learning the system. One month into my time in Nome has left me begging for more patient flow. And yesterday I had the great good fortune to be placed on the Same Day duty: I would start with no appointments and see those people who needed care that day. Dermatology occupied half my case load, I saw 11 patients and got through with documentation at 5 sharp. I had a psychiatric patient whom I could rate as either difficult or impossible due to delusions but really had a great time treating their dramatically dysfunctional thyroid. I know the patient’s contact with reality will improve when those medical problems get handled, but I don’t know how much.

***
People don’t buy raffle tickets unless they want to win something on the list of prizes, thus such lists speaks volumes about what people want. Nome’s preschool will have their annual fund raiser this Saturday and I’ll attend the silent and regular auction.
Prizes Include:
1. Weekend Getaway – 2RT tickets, OME-ANC w/3 nights @ Captain Cook + $1,000 spending cash (Q-Trucking)
2. Two Round Trip Tickets, system-wide (Alaska Airlines)
3. Two Round Trip Tickets (Bering Air)
4. One Round Trip Ticket (Rav’n Alaska)
5. One Hundred Gallons of Fuel (Bonanza Fuel)
6. Ruger 10/22 and Smith & Wesson 22A (Charley & Jennifer Reader)

***

Highlight of the intranet email today:

Eskimo salad for sale: includes Reindeer meat, walrus meat, smoked fish, imitation crab, green and red peppers, onion, carrots, seaweed and greens mixed in seal oil. $20.00

Due to the fog today, flights are being canceled. If you had hotel reservations, please call the hotel you were booked at and reschedule your stay or NSHC will be charged for a no-show. Thanks

Doing the best for a difficult patient

February 2, 2015

Sometimes it’s almost a test
The inappropriate narcotic request
If it’s bad that I judge
I just will not budge
For the patient I’ll do what is best

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.

Confidentiality limits what I can say about my patients, and what I write here may or may not relate to a particular patient or a composite of patients.
Our country has a major problem with prescription narcotics or opiates, painkillers with significant feel-good potential. I find them useful in terminal conditions with long term pain, like cancer, and in short term conditions like kidney stones, fractures, and burns. When I get to a new location, patients frequently flock to me to see if I’ll generously dole out the prescriptions. The word leaks into the drug-abusing community very early that those who seek from me come away disappointed.
I worked the patient in on request from an ancillary service, on short notice so as get the patient to the scheduled commercial flight in time.
Most of what a doctor knows comes from what the patient says, physical exam, lab, and x-ray account for less than 10% of medical decision making. This particular patient couldn’t come up with a straight story.
After twenty minutes of rambling, I made the Time Out signal and said, “Do you know that you interrupted me every time I tried to ask a question?”
No, the patient hadn’t realized it. And I had made clear that I would not prescribe the narcotics so stridently demanded.
After all, if the patient had asked for anything else inappropriate and dangerous, say, plutonium or a whole vial of Botox, I wouldn’t prescribe it, either.
The doctor always wants to know these things about the pain: context, quality, intensity, location, duration, modifying factors, and timing pattern. In short order, I figured out the patient really couldn’t answer the questions. So I would have to guess, and my best efforts would have to be at the veterinary level. I proposed an x-ray.
The patient emphasized the request for pain pills and needed to get to the airport. And wouldn’t I please call the airline and have them hold the plane?
I could have someone do that, I said, and I can do a lot of things for chronic pain, and I really like normalizing a restorative sleep pattern.
The patient didn’t want the sleeping pills but the pain pills, but then let slip the 23 pound weight loss, that had occurred but she couldn’t recall the time interval.
I knew right then the patient couldn’t make the plane. And I said so, noting the slack flesh and wrinkled facial skin.
I have to work harder for some patients than for others; I find those who require more intelligence or persistence. My job is always to do the best thing for the patient, no matter how difficult, demanding, or inappropriate.
I ordered the x-ray, blood count, chemistry panel, sedimentation rate, and thyroid/diabetes/B12 and folate tests. Then I started slogging through old records.

Waking up to a phone consult, a new hat, a fire drill

February 1, 2015

I said yes right off the bat
For a warm, soft qiviut hat
I didn’t ask why
The price was so high
The musk-ox don’t like to chat.

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.

From time to time different organizations need physician expertise outside of patient care. Occasionally I receive emails requesting an hour of phone time and promising 3 times my usual hourly rate. Apparently the outfit had a hard time rounding someone up, and on less than 24 hours notice I received a call before I left my bed. We discussed opiates for chronic pain relief, medication for high blood pressure, and the problem of attention deficit disorder. I gave my strong opinions in all three areas, mostly against controlled substances, probably not encouraging the development of new products. But I spoke from the position of both professional and personal experience for chronic pain and attention deficit. I enjoyed the discussion, appreciated bringing in data the interviewers hadn’t known, and finished at 8:00AM.

Since my arrival in Nome I’ve awakened very early, with plenty of time for email and breakfast, but this time I had to move efficiently. Thirty-six minutes later, showered and breakfasted, I stepped briskly into the subzero darkness and hurried to the hospital.

Mid-morning on my in-house email I read of a qiviut hat for sale. musk-ox live here; they shed their unique undercoat, qiviut, in the spring. Gathered by the locals, carded and spun into the world’s warmest yarn, some people bring in a secondary income from knitting. Despite a breathtaking cost, I found the knitter, tried on the hat, and bought it. I promptly sent my wife a selfie featuring my new headgear, warm and soft beyond words.

After lunch the fire alarm went off. The PA announced evacuation, and, not knowing drill vs. real, I grabbed my parka and new hat and walked quickly to the nearest exit. Hundreds of people streamed out of the hospital into the bright sun and an ambient temperature of 6 degrees below zero. Most had good quality coats and hats, one stood wrapped in a hospital blanket, and a few had no outer wear at all. My mittens stayed behind and I kept my hands firmly in my pockets. After chilling for 15 minutes the all-clear sounded and we trooped back in, some of us shivering, but most of us ironically grateful for the break in routine.

Despite clear conditions in Nome, snow and wind dominated out in the villages; one of my emails announced the closure of the Wales clinic due to winds, another announced the reopening when the wind dropped to 60 MPH. A lot of my afternoon patients, scheduled for pre-endoscopy history and physical, couldn’t make it in from outlying communities because weather grounded air traffic, and the afternoon passed without a time crunch.