Archive for September, 2016

Free treatment for bleeding and glucose monitor

September 8, 2016

The patient, a he or a she,

At a party came up to me

Whilst I was feeding

I was stopping the bleeding

Performing a treatment for free.

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. Getting my wife’s (benign) brain tumor treated took a large part of the summer, then a week each in urban Alaska, Pittsburgh with family, and western Nebraska.  Any identifiable patient information has been included with permission. 

I was seated at a catered social event enjoying a turkey sandwich when one of the staff approached me, saying, “I need you to be a doctor in the kitchen.”

Without hesitation I left my lunch.

Firmly entrenched in Sioux City Society, I have friends and patients amongst employers and employees wherever I go.

Most kitchen cuts happen to the non-dominant hand, and the patient (who gave me permission to write this) had cut the left ring fingertip half-an-hour before. The bleeding hadn’t stopped. In similar situations I have used Superglue with good effect, but in this case the knife had completely detached a couple millimeters of skin, leaving nothing to glue together.

I applied pressure to the fingertip with my thumb and forefinger and a generous helping of paper towel, holding the patient’s arm extended straight overhead. I made small talk and cracked few jokes.  The internal blood pressure at the wound, weakened by gravity, could not exceed the external pressure applied by my pinch.  After 10 minutes, I brought the hand down and, sure enough, the bleeding had stopped.  I applied a Band-Aid tightly, held it in place with aging, weak adhesive tape, and had the patient put on a plastic food service glove.

Then I went back to my sandwich, sitting between a board-certified hand surgeon and my wife. Of course we discussed the case, talking about therapeutic use of superglue, the generic version of the much more costly Dermabond.

I won’t send a bill, I didn’t even get the patient’s name. I’m pretty sure Good Samaritan rules apply.

At another event, I fixed someone’s home glucose monitor, and four days later, I attended a sick child at my house.

I explained that in the absence of fever or severe pain, use of antibiotics for a one sided ear infection (in a patient over 18 months age) wouldn’t change the course of the disease, and wouldn’t increase or decrease the chance of complications. Acetaminophen and ibuprofen would do just as good a job.  We discussed alarm signs along with the importance of fluticasone (brand name, Flonase) and a Neti pot for allergies.

I won’t send a bill for that patient, either. With no prescription to write, I didn’t generate a note.

While in private practice, a parent would frequently ask me to check the ears of a patient’s sibling. I would smile, and to establish boundaries, I would say, “A normal ear exam is free.”

In the era of evidence-based medicine, sometimes an abnormal ear exam is free. I love the work and good Samaritan rules apply.  I couldn’t send a bill if I wanted to.

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Leaving Nebraska. For now.

September 6, 2016

On the plains I worked for a week

The enjoyment was close to my peak

A lot of folks I befriended

But then the need ended

And new work I’ll now have to seek.

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. Getting my wife’s (benign) brain tumor treated took a large part of the summer, then a week each in urban Alaska, Pittsburgh with family, and western Nebraska.  Any identifiable patient information has been included with permission. 

 

A week passed quickly on the plains of Western Nebraska.

A respiratory virus, looking for all the world like influenza, with fever, cough, and ache, but also with runny nose, and lasting the better part of a week, provided 1/6th of my clinical material.  I really didn’t do anything for those patients except recommend Tylenol, fluids and rest.

Seasonal respiratory allergies accounted for an equal number. My two favorite drugs in that regard, Zyrtec and Flonase, now available without a prescription, have high quality evidence to support their use.  Still I gave instruction on how to use Flonase based on personal experience.

I took care of a patient with an agricultural injury, and, in the process, learned about Stewart’s Wilt, an important corn disease, which originated not far from where I worked.

I sent two patients to the new MRI, and, surprisingly, both scans picked up significant pathology.

I didn’t get a chance to take care of any hospitalized patients, but I did get the chance to talk to a couple of new doctors with a passion for rural medicine.

I had a wonderful conversation with an Army linguist, and found Arabic has 3 Hs. I got to talk about how Navajo has the only click outside of Africa (the initial consonant in string and goat, the middle consonant in blue).  We had a marvelous time tossing jargon back and forth and singing praises of Rosetta Stone.

I used my massage skills to make one of my patients better before leaving the clinic.

I started a complicated endocrine investigation, and will probably not know the results.

I kept at least one patient out of the hospital with Gatorade.

One twelfth of the patients came in with dermatologic problems. I recounted the remarkable experience my son-in-law, my daughter and I had at a Continuing Medical Education event in Pittsburgh, where the lecturer announced that we can now treat pityriasis rosea (with the same antivirals we use on herpes viruses).  He went over his daughter’s experience with a red rash in a “Christmas tree” distribution just before her wedding, with no time to change her backless, strapless wedding gown.  He told her nothing could be done; twenty smart phone minutes later she showed him his error.

All in all, I took care of 36 patients, the same number I used to consider optimal for a day’s work in private practice. In those days clinic hours went 9 to noon and 1:00 to 4:30, with two hours dictation after supper.

I had a great time. I bonded well with staff and patients, but, towards the end, though the installation might invite me back when one of their docs takes a vacation, I realized they don’t need my full-time services now.  My experience exemplified the success of the locum tenens concept.

I even got out a couple of hours early. On a Friday afternoon.

 

 

 

 

Chain Hotels: tasteful, but no local flavor

September 4, 2016

I came, I worked, and got paid

I left as twilight did fade

I did well to cheat

My exposure to heat

And in a nice hotel I stayed.

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. Getting my wife’s (benign) brain tumor treated took a large part of the summer. I worked a week in urban Alaska before heading to Pennsylvania to our married daughters and our grandson.  Any identifiable patient information has been included with permission. 

 

I stayed in a very nice hotel in Alaska, with a hot breakfast every day and tasteful décor.  I walked to the clinic in the mornings, lunched in the Doctors’ Lounge, walked back in the evenings, and watched first-run movies on the TV.  After a week, I checked out of the hotel, and met up with a longtime friend in Anchorage.  We spent a morning scouting for moose.  About sunset, I headed back to the airport where you can spot the fisherman by the coolers and the cylindrical fishing rod cases. With day faded into the subarctic’s midnight twilight, I boarded the jet and sleep poorly all the way to Chicago O’Hare.

I left Alaska under clear skies with ideal temperature and deplaned in Chicago in stifling humidity and heat. My flight from Chicago to Pittsburgh got cancelled, due to “air traffic congestion.”

I had never heard of such a thing.

I approached the ticket agent with cheery patience. Actually, I was determined to be so sweet she’d get diabetes from talking to me.  While she tapped furiously at her keyboard, I said, “Look, it’s rare in my life that this happens, but today I’m just about as flexible as can be, and these folks behind me, they just want to get onto the plane.  So go ahead and take care of them, and after they take off, you can see if you can help me.”

Jet-lagged and sleep-deprived, I slouched into a deliberately uncomfortable chair and snoozed. When the crowd cleared out I approached the podium.  The agent booked me to Pittsburgh the next day with a flight through Charlotte, NC.

I very politely asked for a hotel voucher. She looked at me for a moment, and then said that she almost never gets anyone nearly so calm as me and she would see what she could do.  I watched her take her case to her boss at the next gate, and she came back with a voucher.

I stepped outside the air conditioned airport into the heat and waited for the shuttle. I went directly into the cool of the hotel and checked in.  The clerk, finding I had no food voucher, comped me a bag of snack mix from the in-house mart.

I haven’t always gone out of my way to avoid the heat. In the summer of 1972 a college buddy and I rode our bicycles from Connecticut to Denver.  One hundred-mile day in Ohio we each drank 3 gallons of fluids and urinated not a drop.  By the end of the trip, entry into normal climate-controlled businesses felt uncomfortably cold.  Till two summers ago I wouldn’t use the car AC in town.  As time has gone on, though, I find the cold easier to tolerate than the heat.

The next day I flew into Pittsburgh. My oldest daughter picked me up.  I didn’t discourage use of the Honda’s air conditioner.

I checked into a hotel of the same chain I had in Alaska. It had the same hot breakfast and tasteful décor.  Nice, but no local flavor.