Archive for September, 2015

Denver Panhandlers, Then and Now.

September 28, 2015

On the street they reach their hand out

It’s money they’re talking about

If the world is a stage,

They’re here to beg,

They have problems, of that there’s no doubt

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. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, and two weeks a month working Urgent Care in suburban Pennsylvania. I’m attending a medical conference in Denver.  Any patient information has been included with permission.

Most docs finish med school with crushing debts, I finished with great poverty skills and a 2 year obligation to the Indian Health Service (I stayed 5).

I did my pre-medical education at University of Colorado at Denver, at the time a commuter college with no dorms and no parties.  Paying for your own education brings out the student’s motivation.  My classmates had other employment and wanted better.

Lower downtown Denver at the time had just renovated its Skid Row around Larimer Street with specialty shops, but the bums, drunks, and prostitutes still frequented the neighborhood, occasionally drifting away from the pawn shops to the campus.

In those years I rode my bicycle everywhere, and I confronted panhandlers only when my bike broke down and I had to take the bus.

I returned to Denver for the American Academy of Family Practice’s  FMX, a convention for continuing medical education (CME).  We drove in from Iowa over the weekend.  We visited family.  The classes start tomorrow.

We walked from a very nice hotel to a silversmith’s on Larimer Square.  I’ve known the owner for 40 years now.  We walked down the 16th street Pedestrian Mall, past the panhandlers.

During my pre-med days a lot of young people found themselves on the streets because of lousy economic opportunities and generational alienation, they had good mental health.  They figured that the difference between no pay and minimum wage didn’t justify 40 hours of structure.

But at the time a lot of Indians came off the reservation to drink heavily in Denver (the sober ones, the vast majority, stayed on the reservation, giving the non-Indians in Denver a false impression of Indian alcoholism).  One afternoon I found myself walking down 15th Street when a Crow Indain confronted me.  “I’m just got into town,” he said, “I’m trying to get together enough for a bottle.  Can you help me out?”

He had caught me at a bad time.  I had much to learn about softening my words.  “You want me to help you out?”  I exploded.  “I’ve got a quarter in my pocket and I don’t have enough to buy a patch for my bicycle tire because I used the last one this morning and I got another flat this afternoon.  I haven’t eaten since 6 this morning and I don’t have enough for the bus.  No, I can’t help you out.”

He was taken aback and reached into his pocket, offered me half of what he had.

Humbled, I took enough to buy myself a new patch kit.

The street people look better fed but less washed than they did 40 years ago, and not an Indian among them.  My years in the Community Health Center softened my reaction to those who beg for money.  I have treated so many mentally ill that I appreciate the overlap between bipolar, schizophrenia, and substance abuse.  Most but not all the people I saw asking for money had the bizarre affect of schizophrenia and the twitchy gait of the overmedicated.

I gave some money, I didn’t give to others.

I can afford it a good deal more than the Crow who helped me buy a patch kit.

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September 20, 2015

When it comes to care of the heart

The doctor must always play smart

Though I’m working for free

I’ve no EKG

And Urgent Care only offers a start

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. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania, where I’m working for an Urgent Care company. Any patient information has been included with permission.

I carry my stethoscope in my car for a reason.

In a town where I’ve been a medical community fixture for more than a quarter-century, people frequently seek my advice, whether or not I have an office

At a place of business which I visit weekly on average,  the person at the counter asked me to help someone.

The patient opened up with, “I don’t know, I just can’t describe it.”  It took skills honed over 30 years to develop a useful history, always the first step to making a diagnosis.

After a good discussion and a brief exam, I could definitely not make a diagnosis.  But I could say, especially from recent experience, that cardiologic problems don’t belong in Urgent Care.  Diagnostic options there include the essential electrocardiogram.  If abnormal, the patient needs to go to the ER.  But a normal EKG doesn’t mean the patient shouldn’t go to the ER; it means that more investigation must follow, and the ER uniquely has the tools to take the process further.

Urgent Care does a lot of things well, but Urgent Care needs to leave heart problems alone.  Since the summer began, I’ve sent all patients with chest pain to the ER.  Along with those who called their chest pain “back pain” or “abdominal pain.”

I phoned a longtime colleague at the ER, gave the condensed history and saved him the use of an interpreter.

I also spared the patient a useless trip to Urgent Care, but I fear I didn’t do much more.  Still the store owner insisted on comping my purchase; I insisted on not making a charge.

I thoroughly enjoyed using my medical and linguistic skills.

When I arrived home, my email included a note from Canada; I will not possibly start working till December.  This information comes as no surprise.

Bethany and I talked it over, and in the course of less than a minute decided to go back to Navajoland, but this time to the western part of the Reservation, so as to be reasonably close to our daughter in Prescott.

Finding and losing the rhythm

September 16, 2015

Air conditioning sure kept us cold

While outside the hottest weeks rolled

The corn grew so tall

We’re coming up on the fall

But I’ve put the rhythm on hold

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. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania, where I’m working for an Urgent Care company. Any patient information has been included with permission.

This phase of my career has fallen into a rhythm.   Two weeks in Pennsylvania followed by two weeks at home.  Packing now takes 20 minutes, unpacking, whether at home or at the hotel takes 5.  Leaving Pennsylvania comes on the heels of a long day at the end of a 48 hour work week.

I try to sleep late the departure morning, I rarely stay in bed past 7:30.  Then we do breakfast, a drive of an hour or two, fueling at the Sunoco, dropping the rental car, shedding boots for security, and the wait in the boarding lounge.

We know our way around the airport in Pittsburgh.  We know when to stop trusting the GPS, pull over and get out the map.

We have learned the relevant sections of Chicago O’Hare, and have gotten past that one section of bad signage.

If we arrive in Iowa in the daylight, we marvel at the growth of the corn and soybeans, now, respectively 10 feet and chest high.

As soon as we walk in the door at home, we unpack and attack the mail.  With the exception of three magazines and four professional journals, I put everything exclusively addressed to me in the recycling.   If we’ve made it home in the daylight, we pick tomatoes and green chiles from the garden.  I roast the chiles over charcoal.  Bethany checks the voice mail on our machine.

At the same time I have found the rhythm between home and Pennsylvania I have lost the rhythm of the week.  The predictable patient flow pattern of the week in private practice, or even in the outpatient section of Nome, just doesn’t happen in Urgent care.  It doesn’t help that I rarely start my work week on Monday and I never work Friday.

By the same token the shift in climate inherent in jet travel shattered the flow of the season.  I catch the progress of the corn and soybeans between the airport and home, but two-week gaps account for a lot of change.

Working 12 to 14 hours a day with enthusiastic air conditioning removed most of the sense of summer.

In the meantime, work continues on my Canadian license, but very slowly.  I finally got the College of Physicians and Surgeons to accept my $600.  My residency program faxed my records but they haven’t made it to the right person’s desk.

Kung Pao unrushed

September 10, 2015

A leisurely lunch can’t be beat
A time to savor, to rest, and to eat
With minutes to burn
And a good chance to learn
And send patients, fast, down the street.

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. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania, where I’m working for an Urgent Care company. Any patient information has been included with permission.

The Urgent Care concern I work for has many locations, and each has a unique flavor. The spot I worked at last week and most of this week, for example, maintains a reasonable patient flow and rarely gets too busy; my experience over the holiday weekend qualifies as the exception. I had 40 hours in by the time I walked out Tuesday night.

Today I worked at a different site famous for its triple digit days.  Last month I had intense experiences here, which, all in all, I would prefer not to repeat.  I arrived with my metaphorical flak jacket on.

To everyone’s surprise, light patient flow graced the morning, and after the first four hours we all expressed disbelief. But a mood of tension enveloped us, in anticipation of really bad stuff.

At 11:00 I placed an order for Chinese food delivery; it arrived at noon and I got to eat it hot.

More than just food, lunch needs to be a time when the stress ceases.  In the last 35 years I bolted the vast majority of my mid-day nutrition, rarely tasting the food and certainly not resting.  Today I ate egg drop soup leisurely, then turned my fork on the Kung Pao chicken.

Things slowed down after lunch but the tension didn’t stop. I caught up on my email, finding the latest snag in my quest for a Canadian license.  My Community Health Center asked me to cover Christmas.

The number of people who came in with colds but who didn’t want antibiotics surprised and pleased me.

I saw a person with alopecia areata, a patchy loss of hair, usually on the scalp. It can happen anywhere on the body, but people notice it most where they have the most hair. When it regrows, which it does most of the time, the result is a white patch. I’ve known a handful of people with white eyelashes on one side. Today I had the time to go look it up; I hadn’t seen a case this century. In the Information Age, I could find out how little of what I remembered has stayed true. Topical steroid treatment, once controversial but now the standard of care, combines with minoxidil, the hair restoring agent now available over the counter.

Business picked up shortly after supper while rain beat heavily on the roof.  I remarked to several patients that I felt flattered by the confidence they showed, but, under the circumstances, the diagnostic capabilities of Urgent Care don’t measure up to those of an ER.  More than one needed CT scanning, ultrasound, and extensive diagnostic blood work.

Some problems don’t belong in Urgent Care at all.  People with chest pain, vigorous bleeding, major trauma, shortness of breath, and major neurologic changes, for example, belong in the Emergency Room (multiple examples of each have come my way in the last three months).  Yet I understand the tendency to come to us because of the horrendous wait elsewhere.  Yesterday, when I called ahead to the hospital regarding a life-threatening case, I learned that 94 people sat stacked up in their Urgent Care section.

I miss not learning the follow-up on the cases I sent out.  We can’t learn from experience without feedback.

Pie, ice cream, and click-and-wait

September 7, 2015

Oh no, please.  Not again

The problems with ICD-10

It makes us all late,

The darned click-and-wait

Why can’t we go back to the pen?

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. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

I have just finished a 14 hour day.

I haven’t worked many Labor Days, so I have little basis for comparison.  But the day started slow, I didn’t see any patients till almost 9:00AM.

The crew brought food to share.  Light-hearted banter echoed through the clinic.  I read my email, went to a doctors’ social media site, and read Wikipedia about things medical and literary.

I introduced the PA to the wonders of Zanfel, an over-the-counter agent that can take the poison ivy resin out of the skin.

Bethany brought ice cream, pie, and a rotisserie chicken over at 11:00AM.  I didn’t want to jump the gun on lunch.  But a few patients trickled in and about 1:00 I ate.  I texted Bethany to come over in the early afternoon.  The PA left at 2:00PM.

The pace picked up to reasonable and stayed there till about 5:30, when the patients started signing in at the rate of 6 per hour, and it got really hectic.  Twelve patients signed in during the last hour.

A distressing number of x-rays in Urgent Care show fractures, certainly a better yield than when I worked in private practice.  We see more abnormal chest x-rays as well,  but most of the problems related to asthma or acute infection.

The poison ivy patients made a resurgence, probably because overall high numbers.  Skin and soft tissue infections remain important.

Lyme disease stays a concern.  Twenty percent of the ticks carry the disease.  Any tick on long enough to become engorged, or  present for at 24 hours demands presumptive treatment with a very short course of antibiotics (200 mg single dose of doxycycline).  I have seen an inordinate number of the “bull’s-eye rash” (erythema chronica migrans) of early Lyme.

I also see too many people, convinced they have chronic Lyme, on long courses of dangerous antibiotics.  And anyone with any heart problem at all gets a test for Lyme.

At the end, with incomplete documentation stacking well into the double digits, despite fatigue. I did OK with the challenging patients.  I kept my cool saying “no” to inappropriate medication requests, I maintained patience with difficult children.  All in all, I did well with the people.

But last week’s shift from ICD-9 to ICD-10, intended to bring more specificity to the diagnostic process, has not settled well.  So, for example, for a foreign body I can easily specify which side and whether it’s the first or subsequent visit, but it took me 10 minutes to specify the correct organ afflicted.

I did not do well with the click-and-wait problems.

I finished with the last patient just before 9:00PM, and started on my 14 unfinished records.  The staff left.  While the cleaning crew went about their duties I sat in the quiet and relived the experiences.  I put down accurate descriptions of wounds, x-rays, and histories.  But I didn’t comment on the human cost of the disease, or what the injury meant to the patient.  Somewhere during the day, the headache and gut discomfort that followed me since Saturday, faded into the business.

When Bethany came to pick me up, in the warm late-summer darkness, I was pretty wired.

On seasonality of medical care

September 6, 2015

Here’s a thing I have come to know

It’s September, before the first snow

There must be a reason

For the pace of the season

For the flow of the woe to be slow.

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. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

In the days when I owned part of a clinic, we noted a definitely seasonality.  Cold and strep season started up as the weather chilled, six weeks after school started.  That business increased at Thanksgiving, with a big jump after Christmas.  Influenza generally provided a lot of work till spring, when the athletic injuries started up and would last most of the summer.  School physical season would start about July and ran through August..

But things slowed down in September.  Warm weather, open houses, outdoor activities, and sunshine discourage the spread of respiratory infections.

For years I worked long hours in the summer while my partners vacationed, but I went on hunting trips during the slow business month.

People don’t come in at nearly as brisk a pace now, as summer slows into September.  The school sports physical season has almost finished.  We see a good number of those with sore throats, but the people with “summer colds” (really allergies) have diminished in number.  Folks suffering from poison ivy, half my business in June and July, now show up about once a day, and not nearly as severe as before.

I didn’t have a chance to care for a patient till after 9:30 this morning.  We got in a good number of people needing drug screens for their employment.

The memorable patients today (more than one) had heart problems, thankfully, not requiring ambulance transport.  I explained several times that the way a person’s hand describes the pain provides a valuable diagnostic clue.  The open hand next to the breast bone more often describes heartburn or anxiety, but the closed fist or clawed fingers usually describes blocked arteries.

But two-thirds of the electrocardiograms told alarming stories of drama and irony in squiggling lines.  For all three patients I made calls to facilities with expertise and options outside our Urgent Care scope of practice.

In the middle of the day, with plenty of time permitting, I took a chair out the back door and ate lunch al fresco.

Through the day I kept wondering when I’d see something I’d never seen before.  Because it happens every time I see patients.  Seven patients checked in after 7:35PM.  Closing time came and went.  Staff, understandably, wanted to go home.The PA and I slogged our way through.

Then, the very last patient had a physiologically inexplicable finding.  The PA had never seen anything like it, either.

Two cups of coffee after a bird strike.

September 2, 2015

A bird sure made our plane late

We missed by a hair at the gate

So a bit of caffeine

Kept my wit keen

With a steady patient flow rate.

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. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

The smallest bird striking the largest commercial aircraft in the US in the 21st century demands an airframe inspection.  The regional jet coming into Sioux City ruined the day of a dove.  And so we sat in the departure lounge for a couple of hours till the inspection and the inevitable paperwork.

In medicine, the documentation takes as long as the visit, and I would imagine in aviation it takes longer.  I napped and I read.

Late to leave, late to arrive, we got to Gate H1 in Chicago O’Hare just after the flight closed.  The gate agent took care of the rebooking cheerfully and professionally.  He gave us meal vouchers and better seats.  We strolled the airport for a while, I got a torta and guacamole.  We settled down in the seats designed for discomfort.  I napped and I read some more.  We took off on time and got into Pittsburgh just past midnight.

I had slept much of the day at that point.  Connie, the GPS, took us on slow back roads that would enhance a leisurely Sunday afternoon, but doubled the drive time.  We wasted no time at check in but didn’t roll into bed till 2:00AM.

I had not one but two cups of coffee with breakfast.

It doesn’t sound like much but, outside of chocolate, my body doesn’t see much caffeine.  Thus a little goes a long ways.

I nearly fell asleep before the first patient arrived at 9:30.  After that a steady, reasonable pace kept me awake and engaged and despite my initial dread I found myself grinning in the afternoon.  The PA arrived at 2:00, and the reasonable pace continued.  We took care of 48 patients in the 12 hours.  I got to speak Spanish with 2 (though both spoke English well).

This late in the summer, poison ivy continues to bring misery to multiple patients per day.

Sometimes patients with chronic pain ask for opiates, drugs in the same class as morphine.  But as time has gone on we’ve found that while such medications can ease pain in the short-term, in the long run they fail to relieve pain and they ruin functionality.  Frequently the patient will say in one breath that they need more of a drug that doesn’t work.

I wrote a prescription for a 5 day supply of hydrocodone for a person with a broken bone.  I hadn’t needed my DEA number for more than six weeks.

I give a lot of warmth and understanding to the people who have chronic pain at the same time I explain why opiates are a bad idea.  I print off a copy of my post, https://walkaboutdoc.wordpress.com/2012/12/09/pills-and-skills-you-need-a-tool-set-to-deal-with-chronic-pain-caution-longer-than-average/.  I get mixed reactions.  Those serious about pain management read it carefully, those serious about just getting the drugs pitch a fit and stomp out.  And I can’t predict who will do what before hand.

I left the clinic at 8:37, ready for bed.

If you use caffeine rarely, it will serve you as an ally.  If you use it habitually you will be its slave.