More Like Have a Nice Vacation Than Saying Goodbye

If not normal, what could it be?

I can think of a horror or three.

I don’t try very hard

And those thought I discard

But this time, I know what I see.

 

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.

 

Between patients my nurse asked, “Did you see that outside?”

I looked out the window. “It’s snowing,” I said.  “In January.”

“But it never snows here!” she said. Indeed, this island in the Japan Current rarely gets so cold that the precipitation falls as a solid.

I have come to another last day of an assignment. I worked here in April, and enjoyed it.  But they only needed me this time for their holiday vacation coverage.

The upcoming Tribal Council Inauguration had shifted the clinic routine, with the last patient scheduled at noon today. But the Council postponed the ceremonies out of respect for the family of a suicide.  That tragic event got splashed across Facebook.  I know no more than the general public knows about the case, and, considering a few insiders, I know a good deal less.  I won’t write about it.

But in a community this small, where everyone knows everyone, I started to see the medical fallout within 48 hours. Two of my 9 patients today would not have gotten sick but for the stresses and chaos from that suicide.

The island has a strep epidemic going. We now have clinical criteria, the Centor Score, which takes into account age, fever, tonsillar exudate (if you prefer, pus), enlarged lymph nodes, and absence of cough.  I have asked for rapid strep tests on my sore throat patients, but, after examination, if the patient has fever, big lymph nodes near the jaw, pus on the tonsils, and no cough I prescribe penicillin (to the non-allergic) no matter what the test shows.  Our facility ran out of injectable penicillin, though, a week ago.  But as I read up on the subject last night, the main preventable complication of strep, rheumatic heart disease, dropped below less than one case in a million 20 years ago, and the CDC stopped keeping statistics on it.

Four of my 9 patients had sore throats today. More had coughs.  Towards the end, people start wishing me well, but it felt more like telling me to have a nice vacation than saying good-bye.  I’d like to come back again.

I make a living out of thinking of the worst thing possible.  It’s something I do with every patient.  Mostly I delete the catastrophic stuff from my consideration, but today I went ahead and got an x-ray which should have had a low chance of being productive.  I waited as long as I could for the radiologist’s report, but as the hum of the clinic faded to a whisper, I went ahead and ordered the MRI because I couldn’t deny I’d seen a shadow where I shouldn’t have.

I put on my jacket and slipped the cleats onto my boots. I stepped out into the driving snow.  As the fat, wet flakes melted on my face, I hoped I was wrong.

Tags: Centor Score, Japan Current, penicillin, snow, strep epidemic, strep throat, Tribal Council Inauguration