Archive for October, 2016

Chinese moose parfait

October 27, 2016

I said to my friend, “Make me, please,

Some dishes with moose, but Chinese

The meat from the shoulder,

And a flavor much bolder

With mushrooms, or orange, or snow peas

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, traveled 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. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  I just returned from a moose hunt in Canada.  Any identifiable patient information has been included with permission. 

Twenty years ago when I took my bow to Alberta after moose for the first time, the road trip became the highlight of the odyssey.  With enough time to avoid rushing, we found Chinese restaurants attached to every tiny gas station.  I found that “almond chicken” can mean a lot of things, and a person eating their way across Canada can order that one dish and never have the same thing twice.

I like Chinese food, a lot, ever since childhood.  When we lived in New Mexico we tried to eat at every Chinese restaurant in Albuquerque, but in 3 years we only managed to hit 17 out of 23.  At a more prosperous stage in my career, I managed to eat at every Chinese restaurant in Barrow, Dillingham, Nome, and Petersburg in Alaska.

I had the best sesame chicken of my life in Grundy Center, Iowa.  I ate my most memorable chicken foo young overlooking the Arctic Ocean in Barrow, Alaska

Karma being karma, what goes around comes around.  At one point during my 23 years in private practice I could count as patients half the Chinese restaurant owners in town.  I learned much about the business, but I would have liked to have learned more.   For example, the wait staff has to learn Spanish because the cuisine is so popular with the Mexicans and Guatemalans.

Time has moved on, those owners no longer come to me for medical care, but I count a number as friends.  And I asked a friend a favor.  Could you, I asked, take this 4 pound frozen hunk of moose chuck (if you really want to know, the subscapularis, part of the shoulder), and turn it into Szechuan moose, Mongolian moose, orange moose, snow pea moose, and mushroom moose?

He smiled.  For you, yes.

On other occasions, other Chinese restaurant owners have made me deer curry, or other ethnic dishes having nothing to do with mainland China and everything to do with the large Chinese diaspora around the Pacific Rim.  Actually, what we conceive of as Chinese food here in the US has little to do with what Chinese people eat, and those venison dishes gave me a startling culinary glimpse into a world of ethnic cooking at whose dimensions I can only wonder.

This time my selections came from the menu.  And they were fabulous.

This moose tastes like very good, very lean, very tender beef.  And the sauces brought out the best in the meat.

Our daughter, Aliya, used the fried rice and leftovers to make a Chinese moose parfait.  Which I have never had before.

Now I have to figure out a suitable gift for my friend.

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An encounter with a fellow wordsmith

October 26, 2016

A lexicon connoisseur’s a nerd

The electoral choices absurd

But I went out to vote

And met someone to note,

A fellow smither of words.

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. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  I just returned from a moose hunt in Canada.  Any identifiable patient information has been included with permission. 

Bethany and I went to vote early, as my work will take us out of town on Election Day.

No one I know, conservative or liberal, likes the presidential choices. I have made jokes about needing to take Zofran (a powerful anti-vomiting drug) before casting my ballot.

Though late in the season, construction still dominates Downtown, with the Courthouse parking blocked off by heavy equipment.

Two deputies manned the metal detector and access to the polling place. They found and held the discreet 1- inch pocket knife on my key chain.  I didn’t give them a hard time, though I thought such a precaution silly.

With one exception, I didn’t like any of the choices on the ballot. But I found the name of a former patient, someone I know to have personal integrity and strength of character, and I blackened that circle with sincerity.

When I turned in my ballot, I looked at the desk in front of the poll watcher.

“It’s not very often you see print dictionaries, anymore,” I said.

I like dictionaries. I have a lot of them, more than a dozen, some better than others.  The elite, the Oxford English Dictionary, stands as a paragon of scholarship but even the microprinted edition weighs 25 pounds.  I will use it, if allowed, in a knock-down, drag-out Scrabble or Boggle game, though the people who have played with me bar such reference material.   If someone wants to play a word game with me and specifies a dictionary, I check it for two words.

A zarf is a cup holder; silver in ancient Persia, and plastic in Mr. Coffee installations. The f word, arguably the harshest verb and most overused pragmatic particle in our language, sits as a glaring black mark on our linguistic landscape.  If I use a dictionary, I want it to have a bigger and more honest vocabulary than I do.  If it lacks those two words, I do not recognize its validity.

I didn’t check her dictionary. But I asked if she needed it for her poll registration work.

No, she said, she’s writing a poem. She has a lot of dictionaries, including rhyming dictionaries and thesauri.

I told her I write limericks, and she looked impressed. I’ve written so many by now, I told her, that sometimes I speak in limericks.  And I asserted that limericks don’t qualify as poetry.  I didn’t mention that I’ve developed a rhyming algorithm so that I don’t use a dictionary to help me.

Poetry, the language of indirection, says something by saying something else. Limericks exist for wit and involve cleverness rather than real word artistry.  In a hurry, I can produce a limerick in less than a minute, and I never need more than five.  A good poem, however, will take me at least an hour and involve physical sweat.

But we had a lively discussion on wordsmithing, and what it means to be a writer. I invited her to read my blog, and asked her permission to write about the conversation.

In the end I told her I show kindness to my readers: I keep my posts to about 500 words, I treat modifiers with an ax, and I eschew the passive voice.

And she understood me.

Apology and an abnormal thyroid

October 25, 2016

A veteran I might legally be

Does it feel like that?  Not to me

I sure owe a debt

To the Viet Nam vet

Without any PTSD  

 

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. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  I just returned from a moose hunt in Canada.  Any identifiable patient information has been included with permission. 

I cleared out most of the month to take some holidays, but I accepted a couple of days’ work in a rural clinic not far from home.

I didn’t get formal training on the Electronic Medical Record. It turned out it didn’t take much to get me going.  They let me dictate my notes and they let me work with a nurse who knows her way around.  It doesn’t hurt that I’ve learned 12 new systems in the last 24 months.

I made that observation to a colleague involved in the residency, who noted that our Family Practice residents have to deal with 7 different systems.

The first day I worked in the new venue, I massaged away the headaches of two patients, and helped two others by taking out ear wax. In the evening, I saw three patients in the ER, two of whom required hospitalization and consultation the next day.

The pace of work went well that next day, and I drove home in a reasonable time frame.

Bethany came with me when I returned at the end of last week, driving past corn and soybean fields in the early stages of harvest.

Doctors can take some pretty rough verbal treatment, and an apology first thing in the morning made my day.

I did several pre-op evaluations. In one case, my findings came so markedly unexpected I had to call the surgeon to formulate a plan.

I cared for a Viet Nam combat vet with no Post Traumatic Stress Disorder. I told him how highly I regard the VA.  I see him as a Real Veteran but I don’t see myself that way.  He reassured me that anyone who has to put up with owning a uniform, and having a rank in a system with bad pay and bad management  qualifies as a Real Veteran.  We had a good discussion about emotional resilience and how it plays a big factor in PTSD.  He gave me permission to write about more than I have.

Even if I can’t write about people, I can write about medical conditions. I really like finding abnormal thyroid results.  Because a thyroid gland, either over- or under-active, can cause a lot of different symptoms.  When my thyroid went into overdrive, I could not sleep, I lost weight, I had no inner peace, and I couldn’t sit still.  I know that, sooner or later, my thyroid will quit working and I’ll need to take replacements.  And at the end of the day, the nurse handed me a slip of paper with an abnormal thyroid result, which explained a lot but not all of the patient’s symptoms.

 

 

 

Reverse Snowbirds

October 19, 2016

North we are planning to go

For the experience, not for the dough

If we prefer cold to heat

Can Alaska be beat?

We’ll wait for the dark and the snow.

 

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. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  I just returned from a moose hunt in Canada.  Any identifiable patient information has been included with permission. 

Yesterday featured a volley of emails and phone calls to Canada.

American liberals love the Canadian medical system; American doctors love to hate the Canadian system. Neither side understands it.  I want to experience it firsthand.  To that end I’ve been working on getting a Canadian license.

Rural areas in both the US and Canada face terrible shortages of medical personnel. Even doctors willing to work in small communities have to overcome enormous hurdles for licensure if they come from out of the country.  In the US, physicians and other skilled workers from other countries bring diversity to the hinterlands.

I wouldn’t bring much diversity to Canada.

After quite a saga, I’ve gotten to the point of talking with a facility in northern British Columbia. They need me, I’d like to work for them, but I have no intention of immigration (though the social fallout from the election could change that).  After I get a formal job offer, the facility needs to file a Labour Market Impaction Application (LMIA) with Immigration.

Yesterday I learned that a realistic time frame for having Immigration review the LMIA and act on it would be six months. I had planned a mid-January start date.

So Bethany and I sat at the table and asked, Where do we want to go?

It took about ten minutes to decide to go back to Alaska, where we have had such wonderful experiences. And, because the window would come smack in the middle of the winter, we decided on the interior, far from the moderating effects of the ocean, where we’ll face cold more intense than Barrow.  Bethany specified she didn’t want to get in a small plane to get there.

I put several items on my original walkabout agenda back in 2010, among them the Veterans’ Administration, because they’ve been so good to me. I let my fingers do the walking through the Internet.

I introduced myself to the clinic manager and asked if she needed any locums. The sunshine in her voice radiated through my cell phone when she said “Yes.”

I specified the agencies I’ve worked with, emailed my CV, and set up a phone interview with the Chief of Staff.

On the phone today I found out that they need me enough to consider working around the lack of authority to make a contract for a locum tenens.

I usually say yes to 6 assignments for every one that actually happens, and I have come to embrace the uncertainty.

Hearing loss and moose hunt

October 15, 2016

There’s a ringing I have in my ears

I sure hope that it clears

Perhaps on its own

Or with prednisone

For deafness is one of my fears

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. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  I just returned from a moose hunt in Canada.  Any identifiable patient information has been included with permission. 

We first spotted the moose on a hill about 170 yards from the lakeshore. He moved just before I pulled the trigger.  The guide started to call, and the moose came to us, his antlers swinging at the level of the boreal forest tree tops.

With my crosshairs on the bull’s sternum, I pulled the trigger when the distance closed to 60 yards, and my ears started to ring.

Age-related hearing loss runs in my family. My mother and her mother needed hearing aids before they reached my age.  But neither of them stood in front of the drummer playing sax for an R and B band, hung out in discos, nor had anything to do with firearms.  I could still hear bats at the age of 26, but the highs gradually faded.  I started hunting in my 30’s and after the first few years of firearms use I got conscientious about hearing protection.  Later I bought occlusive hearing aids with a limiter circuit, so I could hear a pheasant taking off or a deer approaching, but nothing louder than 85 db would transmit to my ears.  The devices worked fine hunting pheasants in January.

But they failed to protect my ears from the blast of a 7mm Remington Magnum.

The death of an animal, even a mouse in a trap, always hits me spiritually. I have never killed a moose before, and when he crumpled he left a palpable hole in my universe.

When the moose stopped moving I found my hearing had fled.

Over the next couple of days my hearing improved. As soon as I got home I contacted the audiologist.  He found I’d lost 20 db on the left and 10 on the right.   He adjusted my hearing aids and talked to me about vitamins.

Luckily, I’d already ordered an electronic stethoscope.

The next day I went for acupuncture. But on a physician’s social media site, I posted a question about treatment for acute noise-induced hearing loss.  More than one doc said it served me right for killing such a majestic creature, a thought I had already had.  But a few mentioned steroids.

I never self-prescribe; I called my ENT, and I started steroids today.

I hope they work. I’m not done listening.

Aging truckers and doctors

October 13, 2016

In the land of the poplar and spruce

I saw the eagle, the crow and the goose

I cooled my seat

While they processed the meat

That came from a 30-inch moose

 

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. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  I just returned from a moose hunt in Canada.  Any identifiable patient information has been included with permission. 

 

I went moose hunting in Manitoba, and shot a young bull at about 60 yards. (For the firearms enthusiasts, I used 175 grain bullets in a Weatherby Vanguard 7mm Remington Magnum.)  To paraphrase Jose Ortega y Gassett, eating justifies the kill, the kill justifies the hunt.  I really had no idea of the enormity of the northern Canadian wilderness.

I drove north out of Sioux City through Winnipeg to Thompson, about 16 hours. Past Thompson, one can drive east or west but no further north.  An hour by float plane put me onto a lake where the living moose have seen humans only for two weeks last year.

The camp consisted of a wall tent with a wood floor, big enough to sleep two hunters and a guide comfortably.

We hunted by boat, cruising the shore line. I shot the third moose we saw, three days into the hunt.  After that we took care of the meat, went fishing, and loafed.  With no internet, I didn’t post anything though I continued to write.

After the hunt I stayed in Thompson getting the meat processed and frozen. In the Days Inn that Saturday I struck up a conversation with a married trucking couple.  They drive separate rigs together in Canada, and his engine needed work for a day or two.

They love their work, but, in his early 60’s, he’s looking forward to retiring. Over-regulation has robbed the job of much joy.  He finds it no longer feasible to drive in California because a drop of oil onto a white sheet of paper results in a fine and in turning back at the border.  That state stringently enforces emission rules, mostly in the form of expensive inspection stickers.  Log books, now electronic, can no longer be juggled.  While Canada permits a solo driver 13 driving hours per day, the US only permits 10, and he finds it difficult to make driving in the States profitable.

He could diagnose and fix almost anything wrong with a truck made before 1995, but since then computers have taken over the engines. A mechanic needs certification, with a week update training every 2 months.

I sympathized. Doctors, I said, have seen regulation erode earning potential.  Clinical improvement justifies about 10% of those regulations, and the rest just take more time.  Recertification, a hot button issue, occupies more time and energy than it deserves.

Both fields have changed markedly in the course of our careers. The older generation, voting with their feet, is retiring earlier than they had intended because of the problems.

But autonomous big rig trucks will replace human drivers in the next 20 years. Every society needs doctors.  At least for the foreseeable future.