Archive for August, 2016

Underworked and overpaid

August 30, 2016

The setting in Alaska was pretty

Near eagles and bear’s there’s a city

With specialists plural

You can’t call it rural.

And it paid really well. What a pity.

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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

I worked a week in a city in Alaska.

Alaska doesn’t have many cities, but it has more than one.

They put me up in a very nice hotel, walking distance from the workplace.

Medicare pays doctors very poorly in rural areas, so badly that a doctor cannot cover overhead if the practice includes too large a percentage of elderly. So a lot of private practitioners refuse to see new Medicare patients, and some will terminate care on the patient’s 65th birthday.

Massachusetts attacked the problem by making Medicare participation mandatory for licensure. The doctors responded by moving away.

(Canada’s system pays a premium to rural practices, but they still don’t have enough rural doctors.)

So in this particular city one of the larger institutions put together a clinic for the elderly to take the burden off the Emergency Rooms. Salaried physicians see Medicare patients; the clinic depends on grant monies to continue operation.  The model lacks sustainability.

But the docs still need vacations.

I confess I said yes to the job because of ego; I liked the idea that they would fly me to Alaska, and put me up, for a week’s work.  I had hoped to work for a week a month and get in some fishing before my return, and I would have, if paperwork hadn’t moved at a glacial pace and my wife hadn’t come down with a benign brain tumor.

So on a beautiful Monday morning, I got two interviews, a name tag, and a couple of pamphlets by way of orientation, and started to work in a large hospital complex.

My previous experience with their electronic medical record (EMR) system came in handy despite the major differences between versions.

With not much on the schedule, I sat down with the first patient and said, “Tell me about your problem.” I listened without interrupting till the word flow stopped, and said, “Tell me more.”  At the next long pause I asked, “What else?”

With never more than 7 patients on a days’ schedule, I could take a lot of time with each patient. I enjoyed listening to the Alaska pioneer stories.  One 72-year-old male patient gave me permission to write that he had biceps a 16-year-old would envy.

Most of the patients of both genders have hunted, many still hunt, and I enjoyed discussion of moose and caribou weapons.

I could access specialty services, including ER, quickly, but, as easy as it made my job, it didn’t fit with my conception of Alaska as the ultimate in rural experience.

And, for me, rural makes the adventure.

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My wife had stereotactic radiosurgery

August 29, 2016

The computer would focus the beam,

And I would doze, perchance I would dream.

And turn after turn

The tumor would burn

Ramsay Hunt wasn’t part of the scheme. 

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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

Bethany had her stereotactic radio surgery on schedule. Even though the tumor involved no malignancy, the procedure took place at the June Nylen Cancer Center and involved a radiation oncologist.  The festivities started off with the neurosurgeon using 4 screws to affix a frame to her head.  Then followed a CT scan of the head, and three hours wait.  When all was ready I walked Bethany to the linear accelerator, which didn’t make much of a visual impact.   The frame screwed to my wife’s head got bolted to the table under the linear accelerator.  I made a small contribution by suggesting a couple of rolled towels under her shoulders would favorably change the angle of her neck.

Then I walked back to wait. They said it would be an hour, and I thought about going out for lunch, but I stayed around, and twenty minutes later we walked out into the heat.

The next twenty-four hours went well but then the full impact of the radiation hit with nausea and vomiting. A couple of quick calls brought a prescription for Zofran which helped a lot.

Bethany seemed to have bounced back well, and she drove me to Omaha on a Saturday to catch a plane to Alaska very early the next day.

I brought a cooler full of 50 pounds of sweet corn to friends who live in Anchorage, before I started work on Monday.

By the time I’d landed, blisters had broken out on the left side of Bethany’s hard and soft palate; her description brought shingles to mind.

A while ago, leafing through a free medical journal called a “throw away” for good reason, I came across a photo quiz which showed zoster inside the mouth. I flipped the page to find the diagnosis of Ramsay Hunt Type 2.  I scoffed, figuring if I hadn’t seen something like that in 30 years I probably wouldn’t ever.  But three weeks later I looked in the mouth of a patient complaining of a “sore throat” and found exactly that.

I posted a poll on my favorite doctor’s social media site, and found that 80% of physicians haven’t heard of Ramsay Hunt Type 2, but 10% have seen it.

But it was the weekend. I told Bethany to schedule with her physician, and by the time she got an appointment she’d broken out with the worst cold sores she’d ever had, on the left side of her nose.

The viral culture eventually showed Herpes 1 (cold sores), not its cousin, the varicella zoster virus, or shingles.

Valcyclovir will treat both, but shingles requires a much higher dose.

And I can’t say I’ve seen two cases of Ramsay Hunt Type 2.

Mud pit volleyball

August 3, 2016

After rounds, we went to the fair.

Who knew what we’d find there!

But a volleyball flood

Made a pit full of mud

There was plenty of fun to spare.

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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

 

I made Saturday hospital rounds on three patients, discharging one, getting another ready for discharge, and continuing treatment for rather serious illness in a third.

We went over to the Farmer’s Market. We arrived too late to get the tomatoes that we crave, and our current cooking facilities (a microwave oven) wouldn’t let us take advantage of the good ranch chickens on sale, but we bought a cantaloupe driven in from Rocky Ford in Colorado.

Afterwards, Bethany and I headed out to a nearby (a relative term in western Nebraska) county fair.

A county with a small population holds a small county fair, one which we can circumnavigate on foot with no problem. We saw prize-winning cattle, sheep, goats, pigs, and rabbits.  We took in the exhibit hall and learned about elk and the importance of solitary bees.

Despite seeing a lot of mounted people and we arrived too early for rodeo.

But we found a couple of volley ball games in full swing.

As near as I can tell, there are three kinds of volleyball: indoor, beach, and mud pit. And I hadn’t known about mud pit volleyball before today.

Imagine a beach volleyball court excavated to a depth of 5 feet and filled knee deep with water. Participants might wear sneakers or they might go barefoot.  As the event progresses, the water gets muddier and the bottom gets more slippery and uneven.  Those inherent difficulties of trying to move radically change the character of the game, and Newton’s Laws bring a comic flavor.  Diving doesn’t work, and only the foolhardy jump.  If the ball comes to you, great, and if it doesn’t you don’t have a lot of choices.  I saw a lot of unintended slapstick comedy, including an all-out pratfall with both feet off the ground, a short-lived full water clearance, and a high-splash back-flop (like a belly flop but on the other side).  Eventually, those at the sides of the pits started to slide towards the middle.  The wind, always a factor on the Great Plains, gave a distinct advantage to one side. 

They say that the more seriously you take something, the less fun you have doing it. And I think those teams who lost had just as much fun as those who won.