Archive for March, 2018

What not to do for bite wounds

March 24, 2018

I’m at leisure, but I’m not at rest

And I always still try my best

By day or by night

Don’t sew up a bite

Just leave it cleaned up and dressed.

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. After a month of part-time in northern Iowa, I’m taking a break to welcome a new granddaughter, deal with my wife’s (non-malignant) brain tumor, and attend a friend’s funeral.  Any identifiable patient information has been included with permission.

 

Even without a regular office or practice site, people ask for my expertise. I can’t discuss the people without their permission, but I can discuss, in general, certain medical conditions.

Dogs, cats, and humans inflict the vast majority of bites in 21st Century USA, not surprising as these comprise the species with the most human contact.  Cat bites almost always cause infection, and human bites, though less dangerous than cat bites, carry large amounts of really nasty bacteria.  Dog bites carry less than half the risk of infection of the other two, but still deserve a good course of antibiotics.  I prefer amoxicillin/clavulinate for bite wounds.  I always have to consider if the bite was provoked, and, in the case of pets, the vaccination status.  Running tap water and soap cleanses wounds as well if not better than sterile water or peroxide, and drug stores sell the best dressing supplies.

(In Africa, the most common fatal bites come from hippopotami).

I don’t suture gaping skin wounds from bites unless on the face or genitals; I advise the patient they’ll have a scar. Sewing the wound predisposes to having a wound infection, and having that infection turn ugly.

When I treat overuse athletic injuries (including workman’s compensation cases) I rarely recommend complete cessation of the activity, partly because athletes won’t listen. I advise decreasing the stress (whether by duration or intensity) by 1/3 for 3 weeks, then increasing by 10% or less per week.  Perhaps those under 18 can bounce back faster, but mostly I deal with the others, the ones who comprise the “aging athletes.”

Then comes the eternal RICE protocol: Rest, Ice, Compression (such as an Ace bandage), and elevation. For cooling, I prefer a cold (not frozen) can (not bottle) of regular (not diet) soda.

The medical profession has used those principles for 40 years, they still work and have few side effects.

Several decades ago I completely some surveys (really, very thinly disguised marketing ploys) and in return received, as compensation vouchers for medical equipment. I now own seven stethoscopes, four head lamps, and two splinter removal kits.  Those kits have extremely sharp tweezers, which make extracting slivers of wood from the skin much quicker than using a hypodermic needle.  Which I can use, in a pinch.

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Yoyo memories at the meat counter

March 21, 2018

For a child hiding under a chair,

A technique that I use with much flair,

With the yoyo, a trick

For the well and the sick

The resistant are ever so rare.

 

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. After a month of part-time in northern Iowa, I’m taking a break to welcome a new granddaughter, deal with my wife’s (non-malignant) brain tumor, and attend a friend’s funeral.  Any identifiable patient information has been included with permission.

Bethany and I went grocery shopping and stopped at the meat counter for lamb shanks. The butcher who served us recognized me immediately as his former physician (and gave permission to recount the interaction).  After he took our order he recounted with delight how I could soothe his children with my yoyo tricks.  I reached into my pocket and brought out the toy.

Of course the string had tangled in my pocket, and I had to disassemble the yoyo to straighten things out. To my horror, the bearing dropped off the axle and went rolling across the floor.

Even to the best eyes on the planet, finding an object as small as a yoyo bearing (about 5mm) on a place as big as a grocery store floor come with difficulty, and I don’t have the best eyes on the planet. Bethany and I looked, and then encouraged a couple who just wanted to buy meat to engage the butcher.  When I had given up, I found the shiny metal piece on the linoleum, reassembled the yoyo, and wound the string.  By then my audience included the butcher, my wife, and the other couple.

I chose my single most elaborate (not most difficult) trick: Around the world sideways twice followed by double or nothing.  A great visual but not as hard as it looks, I do it with my eyes closed and invariably draw applause; in this case small applause from a small audience.

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Over the years I developed a system to establish rapport with children, eventually I figured out how to do so even with the sick ones. After 1991, the yoyo found a key place in my armamentarium.

Many children come to me after bad interactions with the health care profession, whether dentists or other docs or nurses, and many of those hide under chairs before I walk in. Generally, I just get out my yoyo and play with it and talk to the parent until the kid gets curious.  Regretfully, once or twice a year a child arrives so traumatized that my best tricks don’t work.

At a funeral I ran into a parent of one of the many children I charmed out from under a chair.

 

A friend’s death 5: leaving

March 17, 2018

With one exception, when I wrote about the death of my brother-in-law, I have opened these posts with a limerick.  Understandably, until now.

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. After a month of part-time in northern Iowa, I’m taking a break to welcome a new granddaughter, deal with my wife’s (non-malignant) brain tumor, and attend a friend’s funeral.  Any identifiable patient information has been included with permission.

 

Paul, Bob’s son, and Paul’s wife, Cara, do some marvelous cooking with beautiful presentation, and made a wonderful breakfast.

I did a lot of cooking during the two years Bob and I lived under the same roof in the early 70’s. At the time, most considered cooking to be women’s work.  But I, like many in my generation, questioned pre-defined gender roles.

In later years cooking became a major part of our connection. The winter he lived in Minneapolis he visited most weekends.  Once, when my wife and children went visiting elsewhere, Bob and I thawed some wild ducks and prepared them according to Russ Chatham’s Great Duck Misunderstanding.  The end product was seared on the outside, rare in the middle and topped with a sauce to die for.

I recounted the story over breakfast.

But, mostly, we talked about Bob, his upbringing, and his life. We agreed he would have made an excellent internist, but taking premed courses at Yale discouraged a lot of would-be physicians.

(I did my premed at University of Colorado at Denver, a commuter college, after I finished at Yale. I don’t think I would have gotten adequate grades in physics, chemistry, and calculus if I had tried at an Ivy League institution.)

Bob had some trouble with the law, and never shared the details with his family. I revealed the secrets, which I won’t relate here.  At his sentencing, Bob shocked his lawyer by speaking out of turn, taking responsibility for the crime, and getting his co-defendant a much reduced sentence.  Bob got 60 days in a half-way house and a year’s probation; the other guy got 6 months’ probation.  But Bob figured things out on a moral basis, and took personal responsibility for his life.  Without doing a 12-step program, he did the 12 steps on his own, right down to living a day at a time.

The codefendant never reached Bob’s level of understanding, and, no matter what the death certificate says, went on to die of amorality.

After I’d finished the story I looked at the clock and knew I needed to leave.

As I merged into the eternally frenetic South California traffic, I turned the radio on, then turned it off to think about writing.

Bob and I shared an acquaintance with a real author, with dozens of books in print, who said that the people who write are those who have to write, a piece of wisdom that still rings true. I’m one of those who has to write.

When Bob wrote, he wrote well. His exposition came clear, articulate, and well-structured.  He lamented his inability to write fiction, but enjoyed my novels.  He served as an unfailingly accurate sounding board, his criticisms brought depth.

That resource is now gone.

Still, when I write, I write from the heart. This series, since Bob’s death, has been the hardest since I started my blog.

 

A friend’s death 4: Playing poker

March 15, 2018

With one exception, when I wrote about the death of my brother-in-law, I have opened these posts with a limerick.  Understandably, until now.

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. After a month of part-time in northern Iowa, I’m taking a break to welcome a new granddaughter, deal with my wife’s (non-malignant) brain tumor, and attend a friend’s funeral.  Any identifiable patient information has been included with permission.

 

Sunday evening after the service we sat down to play poker.

Bob loved to play poker, and I never knew. When his family cleared out his apartment they found literally dozens of decks of cards, and encouraged those at the service to help themselves.  I took a deck.

I do well at Draw and poorly at Stud and Hold ‘Em.

I told the story of how, in my premed days during a minimum wage seasonal job involving travel my coworkers started a penny ante game of 5 Card Draw, and I couldn’t lose. I knew the dangers of winning at gambling, and I started drawing to inside straights and keeping ace kickers, and I still couldn’t lose.  When we got back to Denver, I had won $3.50, close to two hours wages at the time.

I played poker a few times in med school and residency, but always penny ante. No one could get hurt badly, I figured, if the bag of chips cost more than the pot.

I introduced my friends to the game of 7 card Pass The Trash, a game I learned from my father, but have not heard of before nor since.

Each player gets 7 cards, keeps 4 and passes 3 to the left. Then each player selects the best poker hand of 5 cards, turning each over in succession, with a round of betting at every card turn.  We played for toothpicks, ketchup packets, and coffee creamers, valued at 1, 5, and 10 respectively.

With a table of 5 players, a pat hand (straight, flush, or full house) usually takes the pot. Betting strategy involves a lot of skill and nuance; each player knows three cards that the person to their left might have.  The order in which one reveals one’s cards takes particular importance.

We could not have played poker with more passion if we had played for money, because we were playing so that we could be near each other.

Eventually three players ran out of tokens and we started to play hearts, a game I hadn’t played since high school. I didn’t do badly, I don’t think, but we didn’t keep score.

The conversation over the cards included the game, as well as market forces, macro and micro economics, polyester, history, and the humanity of the deceased.

Through it all I realized the conversation and the game didn’t matter.

The presence of those who loved Bob was the closest we would ever get to having Bob with us again, and because we loved him, we didn’t want to let go, and we didn’t want to stop playing.

A friend’s death 3: the service.

March 14, 2018

With one exception, when I wrote about the death of my brother-in-law, I have opened these posts with a limerick.  Understandably, until now.

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. After a month of part-time in northern Iowa, I’m taking a break to welcome a new granddaughter, deal with my wife’s (non-malignant) brain tumor, and attend a friend’s funeral.  Any identifiable patient information has been included with permission.

Saturday we headed into El Cajon for the service at the Ronald Reagan Center. I was honored and flattered that the family asked me to officiate.

Mostly agnostic, in adulthood Bob identified with Judaism because of the institutionalized tolerance of dissent; absence of dogma makes heresy almost impossible. His agnosticism softened during his last year.

The service thus didn’t feel like a religious service.

In attendance were those who had known Bob before college, and some of those who had known Bob after he moved to assisted living in the wake of his spinal disaster.

When we had gathered, after I introduced myself, I started with, “Who is wise? Someone who can learn from anyone.  This comes to us from a body of Jewish wisdom called Pirkei Avot.  That was Bob, wasn’t it?  He had a vast wealth of knowledge, but when he talked to you, no matter who you were, he could find out what you knew about more than he did, and he would listen to you while he got you to talk about it.  And he would remember what you said.  In a lot of ways, he was a wisdom vampire.

“According to another body of Jewish wisdom, the Mishnah, we should not concern ourselves with anything than happens before or after this life, because to do so takes away from, in the parlance of the decade, being in the moment. As the years went by, I got more and more religious, and Bob never let that get in the way of our friendship.”

Then followed a photo collage video put together by Bob’s son, Paul.

Afterwards, I said, “Now we all have a Bob story, how we met, something he taught us, how he changed our lives, and I’m going to open it up to anyone who wants to talk. But I ask you to speak from the heart, and speak the truth.  It’s what Bob would have wanted.”

I sat down. I had caught my breath a couple of times to hold back the tears, and I thought I had the situation under control.  Then the first person started to reminisce, and I started to cry.  I couldn’t stop the tears.  I covered my face and I wept.  I tried to do so silently.

Bob’s friends, his three children, and his wife spoke. Recurrent themes included his ability to listen empathetically, the pureness of his heart, his immense fund of knowledge, and his complete lack of meanness.

One of the last to speak did so reluctantly. He and Bob had met through a National Science Foundation program that got promising high school students into genuine scientific research.  A Professor Moriarty (for real, and nothing to do with Sherlock Holmes) mentored them, even after that program had finished and they’d both gone on to Arctic and Antarctic adventures.  To my great surprise, a man I thought incapable of tears couldn’t hold his back, either.

He triggered for me a whole new wave of sobs.

The family had followed Bob’s wishes for cremation; each child got a portion of his ashes.

I was honored with some of his ashes, as well, in a laminated wooden cylinder.

I object to cremation because it doesn’t leave a place for the living to visit and remember.

Sooner or later I’ll come to a place to leave his ashes.

It might be in Barrow.

A friend’s death 2: massage

March 13, 2018

With one exception, when I wrote about the death of my brother-in-law, I have opened these posts with a limerick.  Understandably, until now.

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. After a month of part-time in northern Iowa, I’m taking a break to welcome a new granddaughter, deal with my wife’s (non-malignant) brain tumor, and attend a friend’s funeral.  Any identifiable patient information has been included with permission.

Physician is a large part of my identity. I observe people wherever I go, I note physical findings.  A stiff gait, poor arm swinging, and a face that doesn’t move normally indicates Parkinson’s disease, even before the tremor.  I call that airport neurology.

In any social gathering, people will come to me for medical advice, and I don’t even try to dodge. Lack of a state medical license limits what I can do out-of-state.  I listen sagely and say the 7 things the doctor always says: nicotine, caffeine, alcohol, overweight, exercise, sleep, and seatbelts.  And, these days, I recommend vitamin D.

None of those who gathered for my friend’s service uses nicotine. Most caffeine users expressed a willingness to taper down to zero and stay caffeine free for two weeks as long as they could do a full dose rechallenge.  Almost all get regular exercise and about half do yoga.  None are overweight, all have conscientious diets, and most do not sleep well.

In our college years, Bob and I hung out in a social group where we did a lot of back rubs; one of us went on to become a licensed massage therapist.

I can feel other people’s pain by touch. Such a talent has a surprisingly wide distribution: almost all massage therapists and chiropractors.  Bob taught me a good deal about finding hot spots in other people’s backs, and what to do about those spots.

I remember early in our friendship, as he leafed through a Playboy magazine, he said something like, “If she doesn’t get that T6 adjusted she’s going to get an ulcer.” I looked, he pointed at the photo of a good-looking young woman’s naked back.  “You look for the ridge-valley sequence,” he said, “And where there’s an interruption, there’s a problem.”

He taught me how to adjust the spine, from the critical vertebra at the base of the skull to the place where the pelvis joins the lumbar spine.

I shudder now to think that I acquired the tools before learning when to use and when not to use them, comparable to giving a 3rd grader a chain saw.  But acquire those tools I did, and when I took the osteopathic manipulative therapy course in med school I had close to a decade of experience.

Over the last 30 years I developed a routine for relaxing the muscles in the upper back and neck, and for most the routine takes 3 minutes. A couple of years ago, at a clinic I will not name, a teenager’s neck muscles (trapezii and paracervicals) melted when I touched them in the initial tactile scouting expedition, cutting 2 minutes and 50 seconds off the routine.

This last weekend, the people I massaged, Bob’s friends and family, relaxed very easily. When I demonstrated the way to relax the muscles without help, I had an audience of half a dozen.

A friend’s death 1

March 12, 2018

RMB sketch sfg with sax 1970

With one exception, when I wrote about the death of my brother-in-law, I have opened these posts with a limerick.  Understandably, until now.

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. After a month of part-time in northern Iowa, I’m taking a break to welcome a new granddaughter, deal with my wife’s (non-malignant) brain tumor, and attend a friend’s funeral.  Any identifiable patient information has been included with permission.

 

I wrote about my friend Bob in this blog starting October 10, 2010. A disc exploded in his mid-back, he had severe medical problems in the aftermath of his surgery.

Bob and I met in the fall of 1969 at Yale. He came fresh from trips to Antarctica and Barrow where he worked with the Naval Arctic Research Lab.  We lived in the same house off-campus my junior and senior years. We saw each other through the roller-coasters of college dating, and the difficult years of career takeoffs.  He provided a shoulder to weep on during the emotional case-hardening of medical school; I danced at his first wedding.  When I graduated I visited him and his wife in the east, and he gave me my first car.  He danced at my wedding, too, and I supported him through the agony of both his divorces.

We kept in contact over the years; I visited in the east when I went for continuing medical education, he visited me several times in New Mexico and Iowa. One year we hunted ducks in the Yucatan together.

Our kids regard us as uncles.

Bob’s health never recovered from his spinal accident. After years of repeated hospitalizations, he died about a month ago.  The family held a small, private gathering at the time of his cremation, and last weekend I traveled out to California for the more public service.

Bob had an enormous intellect and a fund of knowledge that rivaled Wikipedia. But no matter who he talked to, he could find out what that person knew more about than he did, and he would listen and learn while he made the other person talk.  Bob never succumbed to the arrogance that wide knowledge can bring.   He listened whole heartedly and empathetically.

When outsiders heard the two of us converse, they would erroneously infer constant one-upping and miss the joy of learning that we volleyed back and forth.

Of course all heroes must have a flaw. I am among the many both drawn by Bob’s brilliance and charisma, and frustrated by his sense of time.

He also had talents I didn’t realize.

I didn’t realize he loved to play poker.

In the ‘60’s he turned down an acting scholarship.

I had forgotten he could sketch, and his family gave me a copy of a page they’d found in one of his sketch books.

 

The caption:  “Bag the words.  Steve Gordon and secondarily his axe.  10/9/1970”

 

 

 

March 1, 2018

From Galveston we drove in the rain

To discuss a tumor of brain.

To our great relief

And we love the belief

That surgery would be in vain.  

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. I’m taking some time off after a month of part-time (48 hours per week) work in northern Iowa. Right now we’re in Texas visiting our married daughter, her husband and their new baby. Any identifiable patient information has been included with permission.

MD Andersen could lay claim to the title of America’s Premier Cancer Hospital. The exam room at the Brain and Spine Center on the 7th floor of Building 3 held more than a century of education.

I have had 27 years of formal education; my wife has 20 years of schooling including a bachelor’s, a master’s, a year for her Certified Medical Assistant, and another for advanced educator training; our oldest daughter, a Family Physician in her own right, has 23 years. The two neurosurgeons have at least 27 years each.  Including Anya, our 12 day old granddaughter, the average number of years in school came to 21.

But the two neurosurgeons spoke directly to the patient, my wife Bethany. A routine MRI in the summer of 2016 found a meningioma, a non-malignant thumb-sized brain tumor growing out of the floor of the skull just behind the left eye.  She had radiation therapy that August and has remained symptom free since.

But follow-up MRI in Sioux City showed mistiness suggesting possible tumor growth, and we came to Houston for another opinion about proposed treatment.

Actually, we came to Texas to visit the new grandchild. Jesse arranged for a consultation and drove us through the pouring South Texas rain, up from Galveston.

I listened in while the neurosurgeons explained the findings on the scans. The tumor itself shows a clear-cut outline or capsule; the haziness around it does not connect with the meningioma proper, and probably represents radiation necrosis, that is, death of brain tissue from the radiotherapy.

To our great relief, they strongly recommended against surgery, and prescribed a quartet of drugs: steroids to take down inflammation, Vitamin E as an antioxidant, pentoxifylline to make the blood less viscous, and pantaprazole to prevent an ulcer from the steroids.

We all felt relief flood the room. And I’m sure little Anya, who knows nothing cognitively but stays locked to her mother’s emotions, felt it too.

I had my work calendar cleared out because of worst case scenarios. That night, while thunder rolled over the Gulf of Mexico, Bethany I and snuggled in the darkness and talked about Where To Go Next.