Archive for March, 2016

March 23, 2016

When it came to the blackened entrée

I hardly knew what to say

The salmon’s the surf

But the moose is the turf

And the wind blew the high heat away

 

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 (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

Friday we drove out to a potluck at the house of one of the other docs. I brought an Asian salad, Bethany made bread.  Other treats included sweet potato casserole, Spam fried rice, Philippine corn nuts and peanuts and pork rinds, bean salad, potato salad.

While the temperatures this winter have hovered around freezing, the mercury started to plunge last week, into the single digits. The Bay froze over, and the wind picked up.

The host faced a culinary challenge: cooking outdoors when the wind chill sucked so much heat that he had to construct a windscreen.

The entrée consisted of the unique surf and turf of this area of Alaska: blackened moose and salmon. At the end of the party I asked for and received tips on the process of blackening.

Monday the snow fell and fell hard, and I had something I very rarely have, a slow day. I perused my email.  I did some online CME, but mostly I sat.  My tally for the entire day stayed in the single digits.

Today during rounds I heard a doctor referred to a patient as a “high liner.” Too much of an outlander to have heard the term, I waited till I cared for a commercial fisherman later in the day to ask, and I learned the term refers to the best commercial fishermen, the ones who consistently bring in large catches.

One of the first patients of the day came in with a neck lump. In short order I diagnosed a sebaceous cyst, a collection of cheesy, smelly material that happens when one of the skin oil glands gets plugged.  With an apparently open schedule, I agreed to cut it out right then.  We gathered the gear, I wiped the area with alcohol, prepped it with Betadine, and draped it with a sterile towel.  Then I couldn’t find it, nor could the patient, nor the resident.  David Copperfield could duplicate the trick, but I had to repeatedly plead that I had no idea what I’d done.

In the afternoon, a young patient arrived to follow up on a shoulder injury, and I very quickly found range of motion loss. In a culture such as this, where everyone hunts and fishes,  incapacity of a shoulder can have terrible consequences.  After the x-ray, while I awaited contact with the specialist, I used an osteopathic technique called muscle energy.  I brought the arm to the barrier, and using my own muscle power had the patient perform an isometric contraction away from the barrier for 5 seconds.  I instructed in a relaxing breath, got 10 degrees more of motion, and repeated the process.  Then I showed the patient how to do it without me.  That person left with better range of motion, and I finished the day euphoric from making two people better before they left.

They both gave permission to publish more information than I have.

 

Mail the patient in a cardboard box.

March 15, 2016

The ER doc said with a growl

“Should I cry fish, fair or foul?’

For after the collision

How do I make a decision

About a Boreal Owl?”

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 (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

 

At morning rounds on Monday we gathered to go over the cases from Friday and the weekend. Including the doctors and the representatives from Mental Health, Pharmacy, Nursing, Physical Therapy, and Social Services, I counted 15.

Drama and irony run rampant in those stories, and, as always, drugs and alcohol provided the majority of the good stuff. But the best patient had been brought in after a collision with a car, and still had a pulse, and was eventually identified (with the help of the internet) as a Boreal Owl.  The calls flew back and forth, and the experts agreed that the best course of action included punching holes in a cardboard box and send the owl via mail.  Which is perfectly legal.

I hope HIPAA doesn’t apply to wild animals.

In general I don’t like prescribing controlled substances, and, when I do, I prescribe in small numbers. Though I dislike the benzodiazepines (a family which includes Valium, Xanax, Ativan, Miltown, and Klonipin) the most, I acknowledge they have their uses.  In fact, I would have difficulty caring for inpatient alcohol withdrawal without them.  I find few other uses for them, such as claustrophobia for an MRI or fear of flying, but I in fact found a reason to prescribe 6 pills of one (but I won’t say for what or for whom).

I decided a long time ago that I’m a lousy judge of character. Too many people have fooled me too many times.  So I ask for a urine drug screen on everyone who asks me for a controlled substance, and even a few who don’t.  I find about 50% surprises.

As everywhere, drug seekers come to the facility hoping to get substances with which to get high or to resell. As it turned out today I did a lot of physical exams for people wanting to get into drug or alcohol rehab, and I was able to pick the diagnosis of Health Seeking Behavior.

And today the people wanting to quit tobacco outnumbered the ones who wanted to continue.

Athabascan languages and radio traffic

March 11, 2016

Today’s limerick at the bottom.

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 (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

I learned to speak Navajo in the early 1980’s in Canoncito, New Mexico. My teachers asserted ability I didn’t feel and made me speak for myself.  My first sentences stumbled at two words in length.  The language has 32,000 tenses and no regular verbs; I pretty much kept to the simplest of the present tenses.  I could make myself understood, and the people showed great generosity in their tolerance.  Despite my lack of grammar and vocabulary I had good pronunciation.  Sometimes my patients or the staffers would burst out laughing because, they said, “You sound just like a real person.”

Navajo language belongs to the Athabascan family. Those cultures call themselves Naa Dine (or something very close), meaning People.  The men practice mother-in-law avoidance.  Women run the society. They potlatch: every few years those who can throw a massive party for the purpose of redistribution of wealth.   Those peoples mostly call the North Pacific area home.  Anthropologists have a lot of interesting theories about why the Navajo and the closely related Apache live so far from other Dine.

The area of my current assignment includes several villages of Athabascan speakers who call themselves Denaina. Today I asked a Denaina speaker if the language were close to Navajo.  “We have a lot of the same words,” the person said, “but they mean different things.”  Struck by the universal truth of the statement, I laughed out loud and asked to use the quote in my blog.

***

The Alaska State Legislature is currently debating Bill #98 to regulate telemedicine. Docs out here in the wilderness have been doing telemedicine for decades under the old law, which demanded an examination before any prescription.  The remote hospitals trained Community Health Aides (CHAs) to do examinations and dialogue with doctors via radio.  Now with good telephones connections  and cell phones we still call talking with the CHAs “radio traffic.”  At this hospital, each physician has an ongoing relationship with a number of villages.  And every village has a clinic with a limited pharmacy.

The new law lacks consideration for good patient care and the reality of life in villages accessible only by air or by water. One of our docs went to Anchorage to testify against the bill, and I wrote him this limerick:

We work in places remote

You can to by plane or by boat

We rely on description

To make our prescription

Please, for this bill, do not vote.

 

Nobody in the audience laughed.

 

 

March 7, 2016

We went out on a fine day

At the checkout we were ready to pay

When down went the power

For less than an hour

And then we went on our way.

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 (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

We went grocery shopping today, and got to two of the three food stores in town.

Most calories consumed by the2500 city residents and 5000 villagers get into the neighborhood by swimming or walking. Without salmon, moose, and caribou, we would face widespread starvation.  Flying foodstuffs in costs a lot of money.  Eggs run $6.00 a dozen, milk is $10.00 a gallon.  Nonetheless one can find oranges, apples, nectarines, pears, lettuce, and bag salad; we inhale deeply and try not to look at the price.

We stood in the checkout line, ready to pay, when the lights went out.

Power outages come regularly here, sometimes several times a day. The hospital has a backup generator, and well they should as just Friday they lost power 4 times.

People stayed cheerful in the dark. I switched on the lithium flashlight I keep clipped to the brim of my ball cap.  We joked.  Eventually the people in the parking lot turned off their engines.  The lights flickered, five minutes passed.

I talked about my friend whose start-up company provides solar cell and battery backup electricity to hog confinements, where pigs suffocate without adequate ventilation. It wouldn’t take much, I said, to make sure the registers didn’t stop working.

It wouldn’t take much, the clerk said, to power the whole building.

The lights flickered again, and then, 8 minutes later, came on and stayed on.

When I worked an outlying Navajo clinic in the early 80’s we rarely had continuous power for more than an hour. Existing technology at the time would face complete computer memory loss with each outage, so computerization didn’t attain viability.

I failed to appreciate the efficiency of the paper system at the time. In fact I complained frequently that I couldn’t dictate my notes.

In the late afternoon, we went to the only Chinese restaurant in town. We faced high prices for reasonably-sized portions.  Two entrees, soup, and tip came to $65, more than 3 times what we would pay in Iowa.  But in Iowa we wouldn’t overhear a phone conversation in Athabascan in a Chinese restaurant run by Koreans, watch planes take off and land, and run into a Coast Guard Rescue Team coming up the stairs as we left.

 

 

Referrals to Anchorage and Rembrance of Reye’s

March 6, 2016

We’re much further out than is rural

Logistics would make your hair curl

I don’t know the choice

But there’s burnout in voice

When I need to make a referral

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 (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

Medicine has always been a team sport, none of us alone is smarter than all of us put together. Our profession has always relied on specialists.

You can’t drive to where I work from anywhere but here. Nonetheless, 21st century American medicine requires referral to specialist from time to time.  They come here on regularly.  Ears, nose, throat (ENT), for example, flies in for a week every two months and has a packed schedule.  Cardiology comes four times a year.

We have a system for getting referrals down to Alaska Native Medical Center (ANMC), which starts with a simple call to a Case Manager, always a Registered Nurse (RN). All three RN nurse managers have a firm grasp of realities of Alaska life and the way inherent logistic problems color the provision of medical care.  Occasionally, the problem at hand demands a close time frame, which is when I have to speak doctor to doctor.

On two occasions so far I have made such calls. The neurosurgeon spoke from or past the brink of burn out; he would not yield to any attempts at cheeriness or optimism.  The cardiologist’s voice showed more resilience.

I remembered another Indian hospital, in another state, in another century. The adoloscent came in with intractable vomiting and personality change; I needed less than 5 minutes to make the diagnosis of Reye’s syndrome, a malady that disappeared when we got out the message not to give children aspirin. But we didn’t know the link then; we knew the liver turned to mush and the brain swelled and sometimes the child died, and we didn’t have much in the way of treatment.

After the first five minutes, I had to call the lab tech in, and midnight came and went while I awaited biochemical proof. Once I had the diagnosis solidly confirmed, I called the University medical center an hour away and started working my way up the hierarchical ladder.  I presented the case to the student, intern, and resident.  By the time I got to the chief resident at 3:00AM I could deliver the presentation in less than a minute, but my nerves had started to fray.

I could hear the chief resident’s heart break in the sigh and the pause. Clearly overworked and sleep deprived, he sounded cornered when he said, “Well, I guess you’ve got to send the patient down.”

I can look back on my own burnout and I can empathize with the other doctors, but I don’t have a solution when we cannot make enough doctors to staff the system without working most of them more than 60 hours a week.

The neurosurgeon probably works more.

Interesting morning rounds: botulism, alcohol, and narcotics.

March 3, 2016

The problems our doctors have faced!

The Natives have developed a taste

For foods they call stink

And eat with a wink

And can’t be prepared in great haste.

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 (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

This morning the main topic of rounds continued to center on botulism.

Alaskan Natives have a taste for fermented foods. The proper way to prepare whale, I learned in Barrow, is to put the meat and blood in 5 gallon buckets in the living room and to stir it every day for 6 weeks.   In some parts of southern Alaska, the locals bury a burlap bag of salmon heads at high tide line and come back a week later.  Other meats, such as beaver tail, walrus fin, or seal blubber, get placed in a grass-lined hole in the ground, covered with dirt, and consumed when the fermentation process goes to completion.  Those who grow up with these foods regard the flavor as intense and incomparable.

Plastics food containers exclude oxygen, allowing the formation of botulism toxin, the most powerful poison known.

I don’t know why this area owns most of the country’s botulism when so many people in the rest of this very large state prep similar foods in a similar manner, but it presents so much of a problem that the hospital stocks the anti-toxin.

We have had three outbreaks since I arrived.

In fact, without alcohol, narcotics, and botulism, morning rounds would be done in ten minutes rather than an hour.

I keep learning more about botulism. The poison irreversibly binds to the connection between the nerve and the muscle (neuro-muscular junction, or NMJ) and prevents the nerve from triggering a muscular response.  Things don’t start to work again till the NMJ regenerates, which can take 6 to 12 weeks.  Those who have respiratory paralysis spend that time on a ventilator.

If the gut loses the NMJ, swallowing becomes difficult, vomiting ensues because the stomach doesn’t empty, and the small intestine blows up as if obstructed because it doesn’t move. People will complain about dry mouth first; the experienced docs here don’t wait for double vision or respiratory weakness.

Some of the patients have insurance, some of the insurance companies don’t want to pay for 10 days observation. Today the discussion centered on how to get past Those Who Serve Only To Deny.  “If you get a doctor on the phone,” I said, “Point out that no one in the country has had as much experience with botulism as we have, and that the insurance company’s doctor has never seen a case.”

Spring has come early. We have been slogging through mud for the last week when we go outside.

I got a chance to talk with a wildlife biologist who specializes in walrus. A nearby beach draws males who haul out of the water on average of a day and a half out of 5.  Walrus cams placed at the beach take pictures every hour, and revealed that some of the walrus go to the top of a bluff to look out over the sea, forget they’ve reached a height, and move straight to the water, taking a fatal plunge in the process.  The biologists regularly police the area to remove ivory so that the Natives don’t come by in skiffs for the same purpose.  The US Fish and Wildlife Service sells the ivory regularly to coastal Natives, who carve it for sale, mostly to non-Natives.

I found the conversation fascinating.