Archive for October, 2017

A procedure I couldn’t talk the patient out of

October 29, 2017

I looked down at the big toe

To see how the nail did grow

It sure wasn’t right

And it hurt day and night

So I fixed it, but not for the dough.

 

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I have returned to the Arctic.  Any identifiable patient information has been included with permission.

Medical school and residency merely start the process of lifelong learning required of my profession.

In residency, I saw one ingrown toenail removal before I did three under supervision. In the Indian Health Service, a podiatrist said, “This is the procedure that’s going to put your kids through college!” and gave me some tips on speed.  In the 90’s I did quite a few, but by the time the century turned, despite a large financial motivation to the contrary, I figured out how to get the patient taken care of without shedding blood.  A bit of cotton, an orange stick (a wood implement widely used to rearrange cuticles) and a bit of povidone dione (marketed most commonly as Betadine), with patience and about a week, can usually move the flesh away from the nail a millimeter a day.

Over the summer, researching the problem while in Canada, I came across the concept of a nail spreader, which can flatten out a curved nail over the course of several months.

But the patient yesterday (who gave permission to write more than I have) had already tried everything I had to offer, yet the problem persisted.  And I couldn’t talk  the patient out of the procedure.

Finding the right equipment takes up more than half the time of an office surgery when neither the physician nor the nurse knows where anything is.

I got trained to not only take out the nail plate, but scrape away germinal matrix (the tissue that makes the nail) down to the bone with an instrument called a curette, then apply a chemical, phenol, so destructive to human tissue that the nail would, hopefully, never grow back.

We had no curette, and no phenol, and I didn’t mind: less work for me and a good deal less blood loss.  At the end, I used a stick coated with silver nitrate to burn the heaped-up inflammatory tissue growing over the nail.

During the procedure we talked about high school sports (very important in small-town America) and music while outside, the gentle snow fell.

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6 afternoon patients and an evening power failure.

October 22, 2017

With a light do you send out a scout

To see what the problem’s about?

For it gets pretty dark

And the prospects are stark

Up here when the power goes out.

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I have returned to the Arctic.  Any identifiable patient information has been included with permission.

On my first Friday back in the Arctic, I got to talk with a Native about village life.  After getting through the medical agenda, I asked about fishing.

The village in question right now does it a lot.  And, with freeze up coming, the Natives are working the set nets.  Soon the caribou migration will start.

But the whaling grabbed my attention.  We talked about a village that brought in their entire quota of 10 bowheads last spring; in times past the villagers sometimes had to make do with as few as 4.  In the process, we talked about making the bombs necessary for the complicated harpoon that the Natives use.

***

I had the thrill of making two people better before they left.  One I helped with massage and spinal manipulation, one with an exercise I saw on YouTube.  “YouTube?”  the patient exclaimed, “You mean I could be a doctor from YouTube?”

I said, “You want to learn to put in a chest tube or do a cricothyrotomy?  Go to YouTube.”  And, in fact, you can find instructions on almost any procedure.

***

Still learning, or relearning, the Electronic Medical Record system here, I only had 6 patients scheduled for the day, 2 in the morning and 4 in the afternoon.  I’m just getting the hang of sending the prescription to the pharmacy before the patient leaves, and finishing the remaining documentation later.

The docs here meet with staffers for morning report, much like we did during my time in Barrow (now called Utqiavik).  Shortly before the meeting started, I realized I’d brought the wrong cell phone, the one with no local signal.  Yet, wonder of wonders, I had two bars of service and updated email.  I texted Bethany to not text me on either phone, attributing the miracle to sun spot activity.  She didn’t get the message; I have no idea if solar flares were responsible.

***

We had settled in for the night when the power failed, and moonless Arctic nights have a deep, Stygian darkness.  We have had power failures everywhere we’ve gone, and for the most part we can laugh it off as part of the adventure.  But our all-electric housing has no alternative to combat the cold, and while I searched out flashlights and head lamps (a total of five) I started to worry about making it through the night.  While the hospital has emergency power and we have long underwear, here we lack the cold weather sleeping bags and tents residing comfortably in our basement in Iowa.

The words power outage take on new meaning in an unforgiving climate.

This year’s first Arctic day seeing patients

October 22, 2017

The one forty-five didn’t show

Perhaps the wind and the snow

Made him think twice

About going out on the ice

Where a fall can be the stop of your 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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I have returned to the Arctic. Any identifiable patient information has been included with permission.

I started in to seeing patients this morning after rounds. The first patient of the day would have presented more difficulties if I didn’t speak Spanish with considerable tolerance for dialectic variation.
I got a chance to write when my 1:45PM patient didn’t show.
In less than 72 hours the weather went from overcast and rainy to snowy, then clear. When snow falls, people become the unwilling slaves to Newton’s 3 laws: A body in motion remains in motion absent external force, a body at rest remains at rest absent external force, and for every action there is an equal and opposite reaction. Friction can conceal those laws from our consciousness, but put dry powder snow onto black ice, and people slip, slide and fall. And then they come to see me.
The real heart of a medical visit, though, lies in evaluating what the illness means to the patient. And each patient so far today arrived with unique circumstances with a fascinating back story.

Consider the overall Alaska picture.  Natives have seen tremendous change, and many have been engulfed by linguistic upheavals.  In the memory of people younger than me were the trips onto the winter sea ice, camping in igloos to hunt seal with harpoons, using dogs to find the holes in the ice where the seal come to breathe.  Most non-Natives moved here from somewhere else, and each one finds themselves in the middle of a personal odyssey.  Of the small number of non-Natives, born here, most have moved around, a lot.  Each move has its own tale of motivations, losses, and gains.

Those, like me, who keep coming back to the 49th state, have their own epics.  This time I’ve found two people I’ve worked with before in other places on the Alaska coast, and a third is soon to arrive.

Back in the Arctic

October 17, 2017

We ignored the things with the wheels

We set out with our toes and our heels

In the wind and the rain

The pleasure to gain

From watching the antics of seals.

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I have returned to the Arctic.  Any identifiable patient information has been included with permission.

I am back on the fringe of the 21st century, in a town considerably closer to Russia than to the state capital, inside the Arctic Circle.  You can get here by air. If you come by land, you’d better come in the winter via dog sled or snow machine.  If you come by sea, you’d better come during the summer.

Alaska Natives, Inuit and Yupik, comprise the majority of the population. Most of the calories come from hunting and fishing.

Town life has centered on the waterfront for millennia; boats full of fish or beluga hauled out to start the drying process. But with the passage of time came automobiles, ATVs and motorcycles, and with vehicles came dust, so that food preservation moved away from town.  (A similar problem happened in Barrow, and now most summer fish and game drying takes place in Old Barrow, about 5 miles outside of town.)

Now some of the streets are paved, the water comes right to the sea wall, with a generous sidewalk for pedestrians.

The town has plenty of stop signs and no stop lights. Pedestrians move constantly.  With traffic this thin, people think nothing of stopping in the middle of the road to converse with a friend.

We landed in the early morning dark in a combi, a jet that has cargo in the front and passengers in the back. We walked across the tarmac with the wind and the rain cold in our faces, and listened to people talking about how warm the weather has been the last dozen years.  At the hospital we met two of the doctors and had a small breakfast.  By the time that the black night sky started to gray, we settled into the hotel to nap.

We are so far north and so far west that the sun doesn’t come up till 10:00AM and doesn’t go down till 7:00PM.

We took advantage of the hotel Sunday brunch, looking out over an arm of the Arctic Ocean. We watched seals playing and hunting; I had a cup of caffeinated coffee to help me past the ravages of jet lag.

At 1:00PM I put my sweater on under my waterproof camo jacket and we went out on foot. We timed the walk to the hospital, and we found the Chinese restaurants, grocery store, cell phone shop, post office, police station, and the apartment building where we’ll stay.  We walked in the wind and the rain along the pedestrian path overlooking the water so that we could watch the seals.

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

Fixing a calf cramp

October 9, 2017

Type and cross has a 2 hour lead

So if a transfusion the patient might need

Stay 2 units ahead

So they don’t end up dead

If the gut gives rise to a bleed

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 traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed. I just finished 3 months in northern British Columbia, getting a first-hand look at the Canadian system. I’m now back picking up an occasional shift in northwest Iowa.  Any identifiable patient information has been included with permission.

“Always stay 2 units ahead of a GI bleeder,” they said in med school and again in residency. Many years and much experience has not diminished that truism, which to this day shines as an example of game theory.  It means that when a patient loses blood from anywhere in the gut, from the esophagus (swallow tube) to the rectum, that the physician must stay prepared to transfuse 2 units (a liter, close to a quart) of blood.

One can’t transfuse blood without first typing and cross-matching the blood, a complicated lab procedure that takes 2 hours. (For one extreme trauma patient in another country, I ordered the hospital’s entire stock of 5 units of O negative blood, the so-called universal donor type.  But that country has a very different legal climate, and I had no other options.)  You can lose the patient in the time it takes to do the test.

This weekend, I had a patient come in with profuse painless blood in the stool. My small rural hospital has a very limited blood bank, and the ride to the referral hospital realistically takes 2 hours.  I explained to the patient that transferring a stable patient beats transferring an unstable patient, and asked for permission to write about the case from the perspective of how doctors make decisions.  She gave me permission to publish the entire case, and pointed out that Facebook would probably have her room number before she arrived at the referral center.

(Her family history has a disease so rare that to name it would name the patient.)

The mathematical discipline of game theory has a whole branch dealing with games of incomplete and imperfect information. The real world of medicine deals with those circumstances.  I have to live with the limit of what can be known in the time allotted in the place where I work.  I know I never have the whole story and that patients never give a completely accurate history.  I have to work with what I get.

Thus I deal with the certainty of uncertainty.  I can’t know if the patient’s bleeding will worsen or stop by itself, nor if problems will arise during transport.  I have to look at probabilities ranging from worst to best case scenarios.

The paramedics arrived, and greeted the patient by name. Everyone knows everyone here.  As the patient shifted from the gurney to the stretcher, a cramp seized her leg, and she asked the paramedic to massage her calf.

“I can make that cramp go away,” I announced, perhaps with too much assurance. But I took the outside of the middle of the patient’s upper lip as close to the nose as I could, between my thumb and forefinger, and squeezed.  Fifteen seconds later, her calf cramp disappeared.

I think that I unduly impressed the nurses and paramedics,

I learned that acupressure trick early in my career, but I don’t remember where or when. Probably before I learned to stay 2 units ahead of a GI bleeder.