Archive for January, 2018

Sense of humor restored

January 25, 2018

 

Thinks of all the calls that I dial

And the round trips I make by the mile

And the hours on hold

Can leave my humor just cold

But it got restored with the sight of a smile.

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. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia, and now I’m living at home and working 48 hours/week in rural Iowa. Any identifiable patient information has been included with permission.

I go out of my way to keep a sense of humor. But I’m only human.

I had 8 patients on the morning clinic schedule. I cured the first patient of the morning and sent him on his way.  I returned to a clipboard with 4 sheets of redundancy inherent in a government-based workman’s compensation case.

About 11:00AM nurses told me of an arriving ambulance. By that time I had 5 undictated charts.

The hundred paces to the ER disappeared rapidly under my shoes. I took the history, ordered the CT scan and some blood work, and quick-stepped back to the clinic.  I knew I faced a serious, complicated case which would require a transfer and demanded prompt action.  I finished the last three morning patients and retreated to the break room to listen to the drug rep pitch very expensive asthma drugs and bolt Chinese food.

At 12:45PM I returned to ER just as the patient got back from CT. I finished the history and physical, and awaited the radiologist’s call.

I started with a call to the transfer operator, and the basic clinical picture. Then to the hospitalist, who accepted the transfer.  I started typing up the history and physical and was 75% finished when the hospitalist called back, clarifying some historical details.  Is the patient OK for MRI?

Trips back and forth from my work area to the ER. Calls to a specialist in Minneapolis.  Holding for 10 minutes at a time, while patients waited in the clinic and the piles of unfinished documentation fermented.

No, the specialist said, not a candidate for MRI.

On hold for another 10 minutes with the hospitalist. Do not send patient without speaking with neurosurgeon.

Twenty minutes later the neurosurgeon, dithered for 5 minutes and refused the transfer, and recommended Mayo clinic.

I considered how badly things could go during the hours necessary to get to Rochester.

The nurses recommended a competing Sioux Falls hospital. I announced that my sense of humor was weakening.

Another 5 minutes on hold. The hospitalist accepted the transfer graciously.

I gave the history and physical last-minute revisions to reflect the past two hours of clinical and clerical actions.

With the paperwork all packaged, I went back to the clinic. After 3 hours of the drama, irony, and frustration inherent in trying to be two places at once; after all the tension built into a system of inefficiencies dedicated not to patient care but to the cash flow generated thereby; after literal miles of fast walking hospital hallways, I stepped into the exam room.

The patient whom I started on Parkinson’s medication last week beamed at me when I walked in. The very small doses of a very old drug had done their job; the patient (who gave permission to write more than I have) bloomed.  Now the smile went all the way to the eyes, the speech had music, and the expressions danced on the face.

In less time than it took to shake hands, my sense of humor returned.

Yes, emergency work brings me challenging cases, but I do not want to give up the satisfaction and gratification that comes with patient follow-up.

Advertisements

Spanish, spinal manipulation, and zoonoses

January 24, 2018

The patients come in, I’m a doc,

And I ask, Are you working with stock?

Do the animals thrive?

Are they even alive?

How big is your herd or your flock?

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. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia, and now I’m living at home and working 48 hours/week in rural Iowa. Any identifiable patient information has been included with permission.

(Post generated week of 1/15 and held till now.)

I faced subzero temps and 40 MPH winds on the drive into work today. Still I came in to find my morning schedule full.

Which conflicted with a complicated ER patient, requiring hospitalization, and, eventually, a very complex transfer. So today I started counting the steps between my clinic work area and the Emergency Department.

The steps added up to 100 each way, but I lost track of the number of times I made the round trip.

Midway through the morning, I noted a holster with a pair of pliers on a patient’s belt. Obviously a quality piece of leather, and just as obviously worn daily for many years, I made the observation that even an American-made pair of pliers has a finite life expectancy if used often, and asked how many pairs of pliers he’d been through.  He chuckled.  He’d been through three pairs so far, and the holster had been custom-made for him.  He gave me permission to recount our conversation.

A lot of farmers and other agricultural workers come to see me. The rules on antibiotic stewardship do not apply to people who work with livestock.  I have concerns not only with zoonoses (diseases acquired from animals) but with the hazard to the animals if the patient transmits microbes.   I generally don’t give out antibiotics for respiratory infections under 5 days duration, but I make exceptions, for example, for those who have just removed thousands of dead or dying pigs from a hog confinement. So along with asking if a person uses tobacco, or if a woman might be pregnant, I ask, “Do you work with livestock?”

Today was a good day for speaking Spanish, relieving suffering among patients from teenagers to septuagenarians just with my fluency. I fielded the usual question:  Where did you learn Spanish (high school, but I’ve been practicing for 50 years), and also, Are you Cuban?  (no).

At one point a non-physician clinician needed an interpreter while I worked my way through clinic, and the nursing staff activated a video service. When I returned 40 minutes later I immediately recognized an accent from Spain, but I did not get a chance to chat up the interpreter.

By the end of the morning, I had cured three patients before they left (ear wax removal for one, and spinal manipulation for two). But the ER patient would stay another 3 hours until transfer could be arranged.

I left in the dark, in subzero temperatures, ferocious winds, and a light snow.

Getting a ride from the Sheriff

January 23, 2018

In Alaska in a blizzard we grinned

But here, with the howling wind

Good sense made me balk

At taking a walk

While the blades in the wind turbine spinned

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. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia, and now I’m living at home and working 48 hours/week in rural Iowa. Any identifiable patient information has been included with permission.

I watched the incoming weather most of the weekend, and decided Bethany and I should drive to work the night before, rather than possibly face blizzard conditions, and we set a depart time of 3:00PM. Two hours before, I got a call from the clinic manager asking if I would mind terribly coming in early.  I didn’t have to think twice.  We’d already be in the hotel, and I might as well get paid for it.

We found the drive windy but otherwise pleasant, and, looking at the clear, dry landscape, we couldn’t imagine that the weather would change radically.

But we awoke in the morning to find that it had, indeed, changed, and more radically than we could have imagined. We couldn’t see out windows covered with blown snow, and really couldn’t tell if that side of the hotel had drifted over.

I scraped the car while the wet flakes covered my glasses. On the way to the hospital, the wind drove the snow so thick and hard that only after a half-mile did I realize that my windshield had fogged up.  Even with defrosted glass I still had to creep.

I bought pizza for the clinic crew for lunch, and the manager closed the clinic. I could stay, she said, or I could go.

I went, figuring that snow this hard would act as an effective patient repellant. But the wind drifted the snow so deep I got stuck at the parking lot exit.  I got pushed out by a woman half my age.  With visibility less than 20 feet, I inched back to the hotel.  I got stuck again.  I rocked the car, but, in the end, the 50 MPH wind blew me out.

I got called back to the ER. I had to ask the Sheriff to give me a ride; my front wheel drive Avalon doesn’t have nearly the clearance I need.

Then I faced a case where, in the usual course of events, I would get lab and x-ray.   Not positive of the diagnosis, though, I had to consider that bringing techs from their homes to the hospital would endanger lives.  I explained the situation to the patient and spouse, and they agreed.  Then the story behind the illness unfolded, a wonderful tale of lasting love and dedication that held me spellbound till the nurse came in, and told them they’d better get to the pharmacy, which would close early.

More real emergencies came in. I spoke with consultants in Sioux Falls, who cheerfully accepted referrals and gave good advice, mostly to do with delaying transfer till the weather cleared.

But one transfer could not be put off. The nurses worked magic to arrange snowplows to precede the ambulance, county by county, and across state lines.

Then the call to the Sheriff’s Office. I rode with the same deputy.  He told me the weather had closed the highway, and that law enforcement had given out a “no tow” order.

Harrowing transfers

January 14, 2018

It’s the time of year for the flu

If it’s that, we know what to do

But in transferring out

We have without doubt

The stressors come out of the blue.

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. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia, and now I’m living at home and working 48 hours/week in rural Iowa. Any identifiable patient information has been included with permission.

With bad weather promised in the forecast, I decided to drive to work the evening before rather than the morning of. Fog shut down visibility and I crept the last few miles into town and hotel to await the impending major winter storm.

Overnight the temps plummeted to double negative digits, and the wind rattled the windows. I awoke to a scene of a blowing snow, but the worst of the wind had passed and the gusts stayed under 40 miles per hour.

Not surprisingly, clinic load dropped with the mercury. Through the day I cared for people with the problems of abdominal pain, a cold, a rash, another cold, the flu, a cough, another cold, ankle pain, yet another cold, and an irritated eye.  Two of the patients spoke Spanish; one of them first spoke an indigenous dialect before he started to learn Spanish at 15, thus making us equally Hispanic.

At the end of the day one of the permanent docs and I went to the Mexican restaurant. We talked a lot  about hunting and Alaska and the pragmatic parts of medical practice.

I had almost 45 seconds at the hotel before the call summoned me back to the ER to care for another person with a respiratory infection.

I took care of 3 more patients before midnight, one psychiatric and two respiratory. I did not ask for permission to write about any of them.

But I can write about the problems inherent in rural practice. Small hospitals lack the resources to deal with life-threatening problems.  Whether in Iowa, Canada, or Alaska, patient transfers can be the most harrowing part of the job: you don’t have to send well patients to referral centers.

Here I have to do a complete history and physical, just as if I intended hospitalization. I get the basic labs, and, if necessary, x-rays.  I ask the nurses where to best send the patient.

Sometimes neither nearest nor best-equipped means the same as best.

Then I make the first call. Sometimes a secure video link, much like Skype, opens up.  I generally have to go through a nurse to get to the doctor, who has final authority to say, Yes or No to the transfer.

Depending on the context, ambulance and/or law enforcement personnel need to be enlisted.

Then the harrowing wait begins. The helicopter, airplane or ambulance never shows until I have hit the outskirts of emotional exhaustion.

When the patient leaves, I start keyboarding my history and physical into the computer as fast as I can. I hand the printed copy to the nurse with the request to fax it to the accepting physician.

Then I dictate the same information into the dictation system.

I got back to the hotel shortly after midnight, too wound up to sleep. I studied for an hour and a half.  I slept surprisingly well before going back to the clinic to discuss legal threats with the manager.

The last week of the year

January 5, 2018

The Canadians were boxing that day

The 26th is a time that they play

But I took the call

Which was not rushed at all

But was long. What can I say?

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. A month in the Arctic followed a month in Iowa followed 3 months in British Columbia, to which we have returned. Any identifiable patient information has been included with permission.

Much has happened in the last week.

Sunday: I don’t celebrate Christmas, I support my colleagues who do and go out of my way to take call on 12/24 and 12/25. But this year, I had to compete with two colleagues who don’t celebrate either, and for the 3rd time since the 70’s I didn’t work the holiday.  Bethany and I went cross country skiing.

Monday: We rented waxless skis from one of the hospital staff. I wore most of my clothing, including seal skin mittens and a beaver fur hat purchased in Alaska.

Bethany and I hadn’t cross-country skied together so far this century. The last time I went out on skis, waxless skis had just come out. I still ran then, compulsively, and I had some flexibility left, and my hair and beard had yet to turn the color of snow.

We went out for 3 kilometers, not far as cross-country skiing goes. I didn’t fall till the very last, and had to clip out of my skis in order to stand up.

Tuesday: I celebrated Boxing Day for the first time.  One of my Canadian patients explained the holiday:  “You stay in your pajamas all day and eat left overs and play with your toys.”  Of course I thought that kind of celebration laudable and wondered why it would only come once a year.   But I had volunteered for call that day, giving it to the Canadians who celebrate the holiday, and who couldn’t imagine that an entire country wouldn’t.  Steady patient flow, about one per hour, let me pay enough attention to each patient without rushing.  But it kept up till just shy of midnight.

Wednesday: ER patient at 3:00AM, requiring lots of ER care. In the middle, I returned to the room, showered, and changed. Back at the hospital an hour before dawn, the sky brightening in the east.  I faced the coldest temperature of the year thus far, -25 Celsius (-18Fahrenheit).  The new snow squeaked in protest as I stepped.  I worked the walk-in clinic, despite assurances I could take the morning off after a hard call.  I lunched back at the hotel, napped marvelously, and walked back to finish the afternoon.  I didn’t want to drive; scraping car windows inside and out takes more time. I did, however, drink a cup of coffee.

Thursday: after caffeine ruined a good night’s sleep I returned to clinic early to finish the inevitable odds and ends that come at assignment’s termination.   Unable to enter the dictation system for a discharge summary, I sighed, sent an email, and moved on.  I cleaned out my electronic queues of lab and x-ray reports, and consultations. I had 500 items, of which two made me exclaim out loud, not because I had been wrong, but because I had been right.

Friday: We scraped the car windows, put the heat on full blast, and packed.  At the clinic we said good byes and snapped pictures.  On the drive to Prince George any outside temp less than -19C iced our breath inside the glass.

Saturday: Getting to the airport 30 minutes before boarding gave us plenty of leisure.  I pointed out my multi-tool to the airport security personnel.  She told me Canada approves blades less than 5 cm, but I would lose it in the States.  It doesn’t have a blade but I didn’t argue.  We left in the dark and the snow, and 18 hours later landed in the dark and the snow in Sioux City (and temperatures of -26F/-33Celsius, even colder than Canada) after two long layovers separating three boring flights.  The best kind.