Archive for December, 2016

Working the 4-day holiday weekend

December 28, 2016

The continuous days I worked: 4

And had I wanted I could have had  more

With a wink and a scoff

I took the day off.

Cause it was offered.  Oh, what a score!

 

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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

I had call for the 4-day holiday weekend.  It went well, as such things go.  Always alert to the chance of call back, I napped wholeheartedly at every opportunity but slept fitfully during the night. I didn’t set an alarm, but lived with the fear that the hospital-issued phone would run out of charge or otherwise fail.

Patients came in a reasonable flow.  Late morning and midafternoon brought one or two people to our ER.  In a town such as this, where everyone lives walking distance from the clinic, our nurses can make house calls.  They draw blood, and can run a few tests on the weekends.

Our clinic boasts very high quality ER nurses, tough and experienced.  They’re not afraid to make a decision about what can wait till tomorrow and what can’t.  They have good clinical judgment, and I can trust them.

I didn’t have to call staffers for lab or x-ray, but when a patient’s illness exceeded our resources, I had to call the transport team.  Interestingly, the patient’s illness exceeded the resources in Ketchikan as well.

I didn’t see more than 5 patients a day.  On two of the call days I had work between 11PM and 8AM.  Every patient, if not downright polite and respectful, was doing the best with what they had.  They mostly suffered respiratory issues.  Two had run into  trauma, there was no interpersonal violence.  Everybody came in sober.

On Tuesday morning I trudged through the rain to the clinic for Morning Report.  I discussed the patients I’d seen.  I got a lot of sympathy for taking 4 continuous days of call, and made haste to say that it really hadn’t been at all bad.

Then I got an unexpected day off.  The weather didn’t get any better, under leaden skies the rain either spit or poured, driven by winds remarkable for inconsistency.  Still, Bethany and I went walking around town, to the grocery store and the Post Office.  I marveled at foot traffic and the scenic beauty, things I’m not used to seeing because I spend the day inside.

If you can’t have a good time in bad weather, you need more practice.

 

 

 

 

 

Christmas 2016 on call

December 25, 2016

When it comes to Christmases all,

I’ll consistently take all the call

The 25th of December

Is a time to remember

Saving lives in a hospital’s hall

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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

I take call for the Christmas holiday; with two exceptions I’ve worked every December 25th since 1973.

Friday night we had company for supper. I got called to ER, but took care of the patient and the paperwork and made it back to the apartment in time.

As a village with a maritime orientation, the town has a tradition of decorating boats for Christmas, and Friday launched an aquatic parade, complete with fireworks when the night got good and dark. We enjoy the seasonal lights, and the spectacle moved across the water, bringing a new appreciation, punctuated by occasional fireworks.  As we watched, I thought to myself that where people have seasonal recreation, injuries will follow, and I wondered what I’d seen in the ER.

If I had thought hard, I might have predicted the hurt that brought me back to the clinic a few hours later. As with most trauma, I advised the RICE protocol:  rest, ice, compression, and elevation.  But I also did a good deal of therapeutic listening.

In the run up to the holiday I read my posts from previous Decembers, and thought back to other Christmases working.

The urge to talk about the bad calls tempts me, but I’ll have more energy at the end of the post if I don’t. One of my patients asked me how many lives I’d saved on Christmas.  I hadn’t thought about it till she asked, but, in fact, I’ve saved a lot.

And I saw really interesting pathology, stuff I’ve not seen before or since (I can list the diagnoses without designating time or place). Q fever.  Duodenal atresia.  Leiomyosarcoma.  Dermatomyositis.  Plague.  Hypernephroma.

In the early morning hours today I took care of a patient for problems that had nothing to do with his recent survival of being in a plane struck by lightning.

Right after that I took care of another Christmas-related injury.

For both those patients, I carried on wonderful conversations with the people who accompanied them. I exchanged views on firearms and deer hunting.  I bragged about missing a deer at 6 yards with my bow.  And  I showed off my knowledge of chiles: if you want the hottest pepper possible, restrict the water supply in an area with cool nights, and, after roasting and peeling, freeze and thaw the chile.

 

First week back in Metlkatla

December 22, 2016

With parents, so strong, warm and brave

To them the praises I gave

Imagine the joys

In a room with 3 boys

And all of them stay well-behaved.

 

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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

MONDAY

Normally, I cruise right through jet lag, but with plane delays, sleep disruption on the way here shattered my usual techniques. The schedule wisely gave me Monday morning to get up to speed with the EMR, but no one to help me.   I used this system here and elsewhere in Alaska before.  Open –sourced from the Veteran’s Administration, it has functioned well for the last couple of decades.

The sun rises late and sets early here, short days mean I walk to and from work in the dark. I wake up early, more or less at the time I got up in Iowa.  But my office and the exam rooms have windows giving onto spectacular views, with evergreens and towering, snow-capped mountains.  Sometimes, during an examination, I ask patients whether they get tired of the scenery.  Uniformly, they don’t.  People move back from the cities to live here.

TUESDAY

Our clinic does a lot of treatment with nebulized albuterol, IV fluids and Zofran (ondansetron), a potent anti-vomiting drug. So far everyone needing albuterol smokes or is exposed to smoke.  Dehydration,  with the need for IV fluids, can come from a number of sources.  I get a charge when a patient feels better because of fluid replacement or breathes better because of albuterol.

Wednesday

I’ve given out a lot of Zofran since I started here three days ago; I enjoy the change on patients’ faces when the drug takes away the nausea..

Today I have call.  With the upcoming holidays and a number of permanent staff on vacation, the usual Wednesday afternoon meetings got postponed, and no one bothered to reschedule patients.  I didn’t want to face an afternoon with no work, and, as it turned out, I didn’t have to.

We have limited diagnostic and therapeutic capabilities here, and I don’t mind. With no CT, very limited lab chemistries, and no ultrasound, we send a lot of blood tests out.  If time frame permits, we make arrangements for transport by ferry for specialist consults.  But more than one person so far has required Medevac via boat to Ketchikan

THURSDAY

More permanent staffers have left on vacation. Mostly I do Urgent Care with a chance of follow-up, but sometimes I take care of people with long-term problems.

Today a family came in, both parents and three sons under the age of 10. The boys stayed well-behaved and quiet, without interruption, during the entire visit.  When not watched, the oldest took the opportunity to hug his brother.  I saw similar patterns of behavior in other families with three sons when I worked here in April: oldest hugs middle, middle hugs youngest.  At the end of the visit, I thanked the parents for the treat of caring for their children.

I didn’t say, but I wanted to: “It’s a pleasure to work in a community where families maintain such a high level of functionality.”

 

.

December 19, 2016

Too many the tales of woe
That result when the fall of the snow
Stop the traffic by air
And it hardly seems fair
When you’ve thousands of miles to go.

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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of gigs in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

I met Bethany in Omaha as the temp hovered near freezing.  With no break between assignments, in the hotel we packed for 3 weeks in Alaska as, outside, ice encrusted the car. In the morning, we took more time on the ground in Denver then we did in the air getting there, as the blizzard turned the runways into a winter wonderland of snowy jets.
Weather delay horror stories come cheap, most of us can tell them. While the wind whipped plumes of snow across the airport campus, the day came and went, we missed connections and got lied to.  Lines moved like depressed, hypothyroid glaciers.

Twelve hours later, as we boarded the plane for Seattle, the gate agent warned about the cold jet way, exhorting us to don coats and move quickly.  I found the walk cold, but not cold enough to frost my beard.

Rain dominated the scene in Seattle with people wearing down jackets and complaining of the cold. I thought the temp relatively gentle.

We slept four hours and got up to face the security delays.  I dodged giving a TSA agent medical advice for a relative, directing her to my blog.   I won’t include the marvelous short conversation because I didn’t ask permission.  Even if she didn’t know I’m a doctor.

We landed in fog and driving rain in Ketchikan, the weather we expected, with the mercury in the low 40’s and vicious wind.  We took our time lunching at the Best Western, delaying the short, soaking walk to the ferry terminal.

The late-model vehicles, all in good shape, had to back down the ramp to park on the ferry deck.  I watched the drama and irony as the sea birds struggled not to get blown away.

The last time we made the passage, in April, we sailed on calm waters, but this time we faced white caps and significant chop.

We got a text from a friend at home just as we landed; the temperatures there plunged to the negative double digits.

As ironic as it sounds, we dodged cold winter weather by coming to Alaska.

 

 

 

 

Vicodin found on a plane

December 18, 2016

You wouldn’t believe the stuff that I’ve found

On the road, the sidewalk, or ground

But it gave me a chill

When I picked up a pill

That was tan, not square, and not round

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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of gigs in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

During my med school years at Michigan State, the student paper carried a piece written by a runner. He kept a journal not only of his mileage, but of the money he found.  The piece pointed out that as time progressed and the value of the dollar decreased, he found more and more change.

I read that before I knew about complex systems, and while I took his point, now I realize that as time went on, he probably improved his money finding skills.

I find money, too, but I don’t run any more. And the amounts that I find progress with the years, so that what I found this summer, in the triple digits, stands as my all-time record.

I’ve also found gold and diamonds, but so rarely I can tell you the weather on those days.

Cycling or strolling, I find tools, as well. I pick them up because I usually end up needing them.  An acquaintance says I find things because I’m a hunter.

Getting onto the plane in Omaha, I found a pill on the floor. It didn’t require a lot of skill; the tan color didn’t match the blue carpet.  After we settled into our seats, I pulled out my smart phone and used the Epocrates pill ID app.  I entered the imprint and the shape and discovered I’d picked up a Vicodin HP, containing 300 mg of acetaminophen (also called Tylenol) and 10 mg of hydrocodone.

We have a nationwide epidemic of opioid addiction; the government has acknowledged that fact to the tune of billions of dollars of funding. Hydrocodone is one of the most popularly abused drugs.  Physicians, pushed by the Pain, the 5th vital sign initiative, and driven by patient-satisfaction survey-driven reimbursement, bear most of the responsibility for this epidemic.

I had to wonder about the person who lost the Vicodin. Was it the one it was prescribed for?  Did they want it medically or recreationally?  What did the patient say to the doctor to get the original prescription, and how many times did that particular pill get remarketed? What drama and irony went into the backstory?

I hope that the fact of finding that pill doesn’t signal the ease with which doctors prescribe such meds, but I suspect it represents the inflation of the supply side of the abusable drug market in this country.

December 15, 2016

I sure there’s a talent I own

But of those there’s many a clone

And when I read the news

Of the ultimate dues

I think that I’m just a drone.

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. After a moose hunt in Canada, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

A doctor of my acquaintance, since retired, started at 6:00AM, went full speed till 2:00AM, never lost his sense of humor or his smile, never yelled at a nurse, knew everything and didn’t act like it. Every physician in town knew that he was the best doctor.  We were keenly aware that more docs like him could put the rest of us out of a job.

During my training, one of the best docs amongst the house staff would say of himself, “I’m just a drone,” meaning that, as a physician, he represented nothing outstanding. While I would agree that I have a few talents (I listen well, have a gift for languages, and establish rapport with children easily) I don’t see myself as anything special as a doctor.

Yet daily I face pressure from patients, staff, and management to relocate. Or at least make a long-term commitment.

During our lunch conference today I received subtle hints along with a very good program about pertussis, and what to do during an outbreak.

Shortly after lunch, though, a memo circulated. One of the consulting surgical specialists came to the ultimate drama and irony, dying unexpectedly overnight.  Arrangements would be made for alternative care.

While I stared at the sheet of paper, unbidden, the faces of 8 patients I’d referred to him in the last two weeks came to mind, some straightforward and some mysteries to be unraveled. For two I just wanted reassurance that nothing more remained to be done.

When I first started into private practice, I had to listen to a series of practice management lectures on cassettes. One of the aphorisms that stuck with me went something like, If you think you’re irreplaceable, check your appointment book for the week after your funeral.

It’s true I made some good pickups today. Because of plural occurrences, I can talk about pre-op history and physicals where I uncovered statin-induced joint pain because I asked every question the computer listed.  Or the thyroid disease I found, or the folic acid deficiencies.  I can talk about how my time in western Pennsylvania helped me interpret the Lyme disease serologies, how my experience in the infectious mononucleosis epidemic of 1990 helped more than one patient this month, or how my habit of always touching the patient where they hurt brought about the diagnosis.

But in the final analysis, I don’t think of myself as anything special. I’m just a drone.  When I leave here, the patients will do fine.

 

December 14, 2016

Is it the crud, or is it the croup?

Is there ought that beats chicken soup?

Get my advice in

Azithromycin

Will stop the cough that’s a whoop.

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. After a moose hunt in Canada, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

When I went to med school I had my father’s microscope cleaned and refurbished. He’d gotten it during his education, and used it in his office to run diagnostic tests on his patients.  I hoped to avoid the microscope rental fee.

I shouldn’t have bothered. By the time I started, Michigan State didn’t demand proficiency in microscope use, because little remained in the practicing physician’s purview that demanded a microscope.  Even in the 70’s, most lab work got sent to hospitals.

Forty years later, we have the slow growth of CLIA (Clinical Laboratory Improvement Act) waived Point of Care testing: we can run pregnancy tests, urinalyses, urine drug screens, strep tests, and influenza tests so quickly and accurately that we don’t need a federal inspection sticker to do so. We send the rest on to a hospital.  But the hospital relies on a reference lab for assays run infrequently or requiring more sophisticated equipment.

Yesterday I got three low folic acid levels in a row, leading me to question the accuracy of the test, so I started the day with a trip to the lab. The director agreed with my skepticism.  By the sheerest of coincidences he knew that the reference lab had just changed their methodology, and agreed to call them.

Pertussis, or whooping cough, has reared its ugly head here recently. At one time I read that the Chinese name for the disease is Cough of a Thousand Days.  It starts with a runny nose and progresses to a brassy cough that doesn’t get worse at night.  The disease doesn’t threaten adults or even older children, but it can kill infants when the airway swells shut.  I learned of my exposure this week, and I have to start treatment with an antibiotic in the macrolide class, which includes erythromycin, clarithromycin, azithromycin, the notorious Zpack, , and Biaxin.

Employers would cover the cost of the medication as part of Worker’s Compensation, but I am an independent contractor, and, as such, I carry my own WC insurance. Compared to the hours and hassles of filing, the cost of the medication seems small indeed.  When the head of Infection Control for the hospital offered to have the institution cover the cost of the antibiotic, I refused.

The most important thing you can take into or out of a bank is a clean conscience.

Folic acid levels and unicorn sightings

December 12, 2016

My schedule was a basic mistake

The day off I just didn’t take

But abnormals times three?

It just couldn’t be

What kind of sense does that make?

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. After a moose hunt in Canada, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

 

I had a speaking engagement in Sioux City, when it got rescheduled to January I forgot to change my calendar. Thus I came in at 8:00AM to an empty schedule.  It didn’t stay empty long.

Most of my patients had respiratory problems, and most had coughs with runny noses and a tobacco problem. I enjoyed making the children smile with my yoyo tricks, but finding a toddler with not one but two infected ears made my morning.

Despite a leisurely start, morning patients didn’t finish till after the noon hour.

The cafeteria here does a good job. Reasonable prices, reasonably sized portions, and very decent cooking put it in the top 10% of hospital food services.

I don’t know that I helped the last patient of the afternoon, but as I wrapped up, I asked about her work. Though she gave me permission to write more, I will say I learned about secondary distance learning in Iowa, and may have found Bethany some work. In the long run, I suspect the networking will bring more value to our interaction than the medical care.

I sat down to my lab results queue. I found a case of a vaccine-preventable illness, and we’ll soon have an epidemic here, but the notification came in after the Health Department had closed for the day.  I’ll end up taking medication for a few days because of the exposure.  It goes with the territory, but as a self-employed physician, turning it into Worker’s Compensation makes no sense.

The next lab number just about knocked my socks off, a low folic acid level. Folic acid and Vitamin B12 work together to repair DNA, keep the marrow producing blood, and the nervous system from deteriorating.  They work together; an excess of one can hide a deficiency of the other; thus you can’t buy a folic acid pill more than 400 micrograms without a prescription.  But 15 years ago the FDA mandated folic acid supplementation in our flour supply.  The deficiency of that vitamin, never common to start with, just about evaporated.  Up to now I’ve not seen more than a half-dozen cases.

So finding one really put the music into the end of the day. I called the patient, discussed the problem, fiddled with the computer, sent the prescription, and opened the next set of lab results.

My jaw dropped. Could it be?  Two folic acid deficiencies in a row?  And there it was.  Lower limit of normal 7.1.  Patient’s level 3.9.  Yep.  What a rush!

Another enthusiastic call to a patient, another prescription sent at the speed of light to the pharmacy. And on to another lab result.

Wait a minute.

Three folic acid deficiencies in a row defy credibility.

If you see a unicorn, you get bragging rights, and if you see two in an afternoon, you get big bragging rights. But if you see three, you need to get your eyes checked.  Tomorrow I’ll have a talk with the lab.

Horse collisions, running eyes, and my best work

December 8, 2016

During the rut, if it’s too late to veer

You might run into a deer

But more serious of course

To run into a horse

Which is even worse than a steer.

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. After a moose hunt in Canada, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

I went to bed early last night. Aching at the end of a day marked by my left nostril plaguing me with a clear but slimy river and launching attack after attack of violent sneezes, I took Tylenol and slept fitfully.  I awoke with my left eye stuck shut.  I applied hot compresses, and, two hours later, strode a couple blocks to the hospital.  Until noon I worked in fear that my eye would start to run again and I’d have to go rest.  But it didn’t.

***

Most of this country suffers from too many whitetail deer, and their bodies litter the highways, especially during this, their breeding season. Mention a deer collision, then sit back and enjoy to the flurry of stories.  Sometimes the deer hits the car.  Sometimes, on a two lane road, a deer struck by one vehicle flies across the pavement and into the path of an oncoming vehicle.

Most people survive collisions with deer and antelope, and, for that matter, cattle. Horses and moose, however, stand higher and tend to come up through the windshield.  Moose stray but rarely this way, but horses remain a fact of life, and terrible damage results when they wander onto a roadway.

I cared for such a patient this week, and a very subtle neurologic finding prompted an investigation.

***

Today I ran into the first drug seeker I’ve seen here, and a reputation that keeps them away speaks well of the docs. The literature can give you plenty of red flag clues that the patient might want drugs for other than medical purposes: geographic instability, getting care from multiple providers, symptoms not objectively verifiable.  The research has yet to define the speech pattern that rings my alarm bells, but when a person talks like other addicts I’ve known I get suspicious.

I listen carefully even to stories with obvious contradictions. I sort data based on experience, knowing that I play a game of incomplete and imperfect information.  At the end of the day, as I clicked my way to the bottom of my electronic messages, I came across lab results so startling that I swore.

Perfect people don’t come to see me. Those with psychiatric problems, low intellect, poor social skills, inadequate education and unhealthy lifestyle decisions get sicker than others.  And all of them deserve my best work, every time.

Chicken and noodles over click-and-wait

December 8, 2016

They come in, the sneezers and chokers

The sick, the depressed, and the jokers.

It would be nice

If they’d take my advice

But alas, they want to stay smokers.

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. After a moose hunt in Canada, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

Seventeen patients came for help from me today.

More than half will get better on their own. I found adverse drug reactions in two of them; all I needed to do was stop the drug.

With one of them I drew on my own migraine experience.

While the US has the lowest rate of smoking among the industrialized countries at 15%, 53% of my patients got the diagnosis of tobacco addiction. I gently asked if they wanted to quit, 6 said “no.”  I hold no illusions that the others will quit soon.

One patient turned out much more complicated than anyone could have foreseen, my staff took care of setting up studies and getting pre-authorization. Still, these things take time.  I sat down to discuss results and make recommendations at noon.

Two of the nurses kindly asked if they could bring me lunch from the cafeteria, and I graciously accepted the offer. I inhaled the chicken and noodles they brought to me while I struggled to document a pre-operative history and physical that had come in on an ASAP basis.  Tap, tap, spoon, tap, tap, chug some water, tap, tap, spoon.  All in all, I can say I got nutrition but I can’t say I got a lunch break.  At quarter to one, my computer froze.

But I didn’t realize the problem for about three minutes. I attributed the delay in response to the click-and-wait feature that so many systems have.  I reached a particular part of the documentation process, and I knew the computer would have to think about things for a while, so I wolfed more food, and even took my eyes off the screen.  When I looked back, nothing had changed.  When I tried to click out of the field, nothing happened.

I will admit my tolerance for computer glitches runs thin. I think my fuse shortened during time when the frozen system ate two hours a day.  Those prone to bad puns say I’m wired a little tight when it comes to stuff like that.

I restarted my computer, came back to the time-sensitive document, only to have the computer tell me I’d locked it.

Normally annoyingly cheerful, I came perilously close to a normal mood when I couldn’t take a lunch break and the computer stopped responding.

I used my pediatric exam skills to examine four sick young kids without the use of force. Yesterday, for the first time in 9 months, I failed in the task; the child started crying when I came into the room.  So like every other person who cares for toddlers, I had the parent restrain the patient so I could look in the ears.  Today I applied extra patience because I didn’t want to have to admit I had failed twice in a calendar year.

And, really, patience invested now brings dividends of time saved during later examinations.