Archive for July, 2018

Hot job, hot office

July 12, 2018

In my office I might take a seat

Depending on the degree of the heat

I’ll tell you, no fooling

I don’t get the cooling

And it’s hot enough to cook meat

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, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

Summer in Iowa brings sun, heat and humidity. The closer the temp gets to 85 degrees, the faster the corn grows; 2 degrees higher and the growth stops.  If the night fails to dip below 85 degrees the corn loses energy trying to keep cool.

You can find old farmsteads by their wood lots, 1-2 acre stands of trees that shaded a house from the sun in the summer, blocked the wind and snow in the winter, and provided fuel close to home.

Towering shade trees don’t fit in with 21st century American hospitals’ parking lots and helipads.  Air conditioning provides the necessary climate control.

(Last century, when I visited Cuba, I found hospitals, that depended on open architecture, breezeways, ventilation, and shade trees. But for obvious reasons, they don’t need parking lots.  And I visited in February.)

My clinic office has a great location on the west side of the building. Of all the rooms in the outpatient department, mine alone has no air conditioning.  More accurately, it has air conditioning but it doesn’t work.  On a good, hot, muggy day, I get some cool air in from the corridor in the morning, but as the afternoon wears on, my outside wall takes a beating from the sun, heats up, and radiates into the room.  And as the corn grows, I start to sweat.

Fans help by evaporative cooling. I got an aging tower fan that doesn’t work nearly as well as the desk fan Bethany bought at a hardware store on the square.  If I sit at my desk, the breeze on my face helps.  If anyone seeks to have a conversation with me after 3:00PM, I have to turn the fan so that they don’t suffer too much.  But then, I do.

When I worked in Barrow (now Utqiavik) in the winter of 2011, the hospital hadn’t had the heating updated since construction in 1964. Though the outside temp ran to -40, the clinic area stayed oven hot.  Entering a room, I opened by saying , “You can have privacy or you can have ventilation, but you can’t have both.  Door open or closed?”  And the patients always wanted the door open.  I could  stand by the window that no one ever closed, or I could even go outside without a coat.  Environmental services assured me they could not fix the system.  At the time, with the new hospital under construction, they weren’t about to try.

In New Mexico, my humble clinic’s windows always worked but the electricity didn’t. If the power went off, we opened the windows.  If the power went off in the winter, we kept on our coats.

The patient care here takes place in very comfortable surroundings, but I do my dictations and paperwork in the high 80’s.

Not surprisingly, I find myself spending more time with the patients, and trying to spend less time in my office.

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A weekend call full of chest pain

July 9, 2018

This weekend I was hard pressed

And, as always I worried my best

The lilt in my song

Comes when I’m wrong

About the cause of pain in the chest.

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, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

I took ER and hospital call this weekend.

The chaos that suffused my time came as no surprise, but the consistent theme of the people seeking my services, chest pain, did.

The area involved can be anywhere between the diaphragm and the jaw. The complaint doesn’t have to include pain; so often the person says, “It’s not a pain, really, more of a discomfort.”  And, sometimes the patient doesn’t feel discomfort at all, but shortness of breath, or nothing more than fatigue.

Of course I worry about the heart. If the body’s main pump runs out of blood carrying vital oxygen, it can’t pause to rest, and parts of the heart muscle die.

But I also have to consider the possibility of pulmonary embolism (blood clot in the lungs), pericarditis (inflammatory fluid around the heart), aortic aneurysm (where the aorta, the main artery coming from the heart falls apart), cancer, broken ribs, pleurisy (an inflammatory roughness of the smooth shiny membrane that lines the chest), or esophageal spasm (a cramp in the in the swallow tube).

By the end of the weekend, the nurses had gotten used to my routine: an aspirin, chewed, and a nitroglycerin pill slipped under the tongue, both while obtaining an electrocardiogram and getting blood drawn for a series of tests. Sometimes I asked for chest x-ray, sometimes a CT of the chest to rule out pulmonary embolism.

Sometimes the studies revealed the problem, sometimes not. I saw a good cross-section of diagnoses including the profoundly serious and the mundane.  I sent patients out by ambulance and by car, and I kept a couple in the hospital for observation.

(Everyone in town knows the helicopter came and went; for reasons of confidentiality I will neither confirm nor deny it had anything to do with a patient I attended.)

I took care of patients from the age of 13 to the age of 88. I enjoyed talking to two consultants I knew from my private practice and Community Health days.

But the highlights of the weekend had to do with me thinking of serious pathology and being wrong.

 

Once a patient, always a patient

July 8, 2018

The story came as a surprise,

Perfidy, adultery, and lies.

Misuse of narcotics

And antibiotics.

And names I wouldn’t surmise.

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, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

I don’t have to know everything in the business; I have to know when I don’t know. I usually know who knows more than I do.

At my graduation from medical school, the speaker (so effective I still remember large portions of the address) told us to look in the mirror every morning and say, “I don’t know.” It took a few years but I got good at it.  Admitting ignorance does not bruise my medical ego anymore because reality has humbled me so often I don’t have one left.

Halfway through a laceration repair yesterday, I realized the wound went much deeper than I thought. I stopped immediately, doffed my surgical gloves, and called for help.

I put the call through a hospital operator who asked me to spell my name, which I did. Then I commented that she knew me but I hadn’t been around for a few years.  I could hear the smile spring back to her voice.

I had to re-introduce myself to the consultant, and, again, the telephone connection could not interfere with the smile.

Earlier in the day I needed to talk to a cardiologist regarding the proper time frame for a referral. I ran into that on-call doc at a dinner conference the week before.  He, too, smiled.

Still, medical communities qualify as living things: doctors come and doctors go. Change is inevitable.  I had a conversation this last week with a member of the Iowa Board of Medicine, and got access to some really juicy stories.  I cannot give the details here but I can give the moral lessons:  doctors should not have sexual relations with patients (and, once a patient, always a patient), they should not write narcotics prescriptions if they intend to use the narcotics for themselves, they should not misuse their position of power for financial gain.

None of those stories related to the local physicians, though some related to changes in the Sioux City medical community. Most came as complete surprises.

Most, but not all.

Looking for things I don’t want to find

July 1, 2018

Pessimism is my inspiration

When I’m testing for inflammation

Sometimes we’re stuck

With a run of bad luck

I’m hoping for no information.

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, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

I make my living by thinking up worst case scenarios. As my knowledge and experience grows, I can dream up increasingly horrific things to rule out.

A lot of people, for example, just plain don’t feel good. I listen to the story, I take all the details seriously, I try to figure out the context, and then I go looking for diseases.  My favorites are the ones I can cure without specialist consultation, intrusive interventions, or expensive drugs.  I don’t like to find conditions that will last for the rest of the patient’s life, disrupting the plans of friends and family, misery that echoes down the generations.

Most disease, about 70%, comes to us directly from our choices: nicotine, alcohol, recreational drugs, overindulgence, and exercise avoidance.

But a sizeable portion of my work has to do with bad luck.

No matter what the source of the problem, my task is to make the patient better, and help the patient meet their goals.

But to get to that point I have to listen to the patient.

I listen a lot. I think pessimistically, and I run a lot of tests.

I use two particular assays, the C-reactive protein (CRP), and the erythrocyte sedimentation rate (ESR or sed rate) to make a major division in my lines of inquiry. Both seek to confirm or deny inflammation throughout the body, and two normals mean I can rule out a lot of illnesses. A high number in either parameter means I have to keep seeking till I find an answer, and, generally, an answer I don’t want to find.

Too many times this week I’ve looked at a lab sheet and used words unbecoming to a professional vocabulary.

At this point in my career, I shouldn’t take an abnormal lab test personally. I can either handle the patient’s treatment or I can find someone who knows more than me.

I look at the consequences of illness not just to the patient, but to the surrounding community. Every one of my patients exists in a context, and, just as the patient cannot be understood without understanding the context, the context cannot be understood without understanding the patient.

I shouldn’t take an abnormal lab test personally, but I do. Every patient is part of my context.