Archive for September, 2018

Another going away lunch

September 30, 2018

The problem the town now must face

Is to get a doc to replace

My predecessor and me

But I think we agree

That for change, like a storm, we must brace.

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, my 50th High School reunion, I just finished an assignment in northwest Iowa.  Any identifiable patient information has been included with permission

I have ankylosing spondylitis, an auto-immune disease related to rheumatoid arthritis but hitting the spine harder than the limb joints.

The first patient of my last clinic day has a closely-related disease, and gave permission to write more than I have. He talked about his joint pains,  reminding me how I felt during my many bad days and worse nights with morning stiffness, sleep disturbance and skin problems.  We agreed on specialist referral.

Follow-ups dominated the morning, with a lot of fallout from the recent flooding.

At noon Bethany and I went to the hospital for my going-away lunch, cooked nicely by a nurse brought in from retirement by the dietician’s sudden illness. We chatted over grilled chicken breasts, Asian salad, and apple pie.

My predecessor gave decades of high-quality medical care. Despite much pressure to stay as his replacement, I point out my age.  The town really needs a younger permanent doc.

In the afternoon I strode back and forth between the clinic, with a swelling patient roster, and the ER’s frightening variety of serious illness. With every transition I got 9 steps outside, in the fall sunshine with a brisk cool breeze.

At one point 4 people stacked the CT queue, looking for, variously, blood clots in the lung, skull fracture, brain damage, or appendicitis.

All the scans came back normal.

The day’s final frenzy finished, and documentation’s slow-receding tide left two patients with IVs running. As the sun set I stepped over to the doctor’s quarters, and Bethany and I went out for pizza.  Off and on till after 10:00 PM I went back and forth to the hospital, till the patients hydrated and improved adequately for discharge.

Law enforcement brought a patient, as it turned out, my last patient of the assignment. Trained in medicine and not law, I don’t need to know about the conflict of my patient with society, I just work on fixing medical problems.

Up early, Bethany and I breakfasted at the gas station café. While she packed the car, I came back to sign off dictations and results from the previous day.

We left town later than planned. The fields I passed in June with the barest fringe of green against the brown of the soil, now stood with dead foliage, yielding to the harvest.

 

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No man is an island. But a town might be.

September 25, 2018

There is no testing

When you look and you see there’s a flow
Of water cross the road you should know
And ask yourself why
Cross that flow you would try
To drive, and not another way 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. 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

 

After a 5 day weekend I headed back to work in a driving rain, leaving early enough to arrive on time despite slowing for wet roads.

The summer has waned. In June I left home more than an hour after sunrise.  Today, I rolled down my driveway under a canopy of jet black wet felt.

Off on a county road I crested a hill and could see water flowing across the road at the bottom. I turned around at the barricade.

GPS and cell phone navigation apps can’t possibly advise on a problem related northwest Iowa’s rolling hills’ wet spots.   So I called my office manager, who grew up here watching flood waters rise and recede.

I used her directions and a dated paper map. I pulled into the hospital parking lot 30 minutes behind schedule to find I had an unscheduled patient ready and a flash flood warning on my phone.

Within 30 seconds of starting the interview I knew the most likely diagnosis justifying the patient’s early, unannounced arrival. With the glorious speed of a small facility, I had the lab and CT back in less than 40 minutes.  By that time, the problem had progressed in the right direction and I could see the patient’s improvement.

I like helping patients, but I like it more when they get better on their own.

I had a full morning, caring for 8 patients, and clearing paperwork accumulated in my absence.

The weather kept some staffers home, others took their lives in their hands driving through flowing waters.

At day’s end I had attended 4 different people with flooded basements. None had insurance to cover the damage.

My office manager, who had given me such wonderful directions, could not remember when the rain had fallen so hard. For a short time, the town qualified as an island.

After clinic, I drove out to a nursing home. I evaluated the patient, gathering information I could not possibly have gotten without physical presence.

I glanced out the window at torrents of rain while I listened for telltale heart sounds with my stethoscope. I accelerated the pace of the visit because the trip back had two low spots where the road could flood, and I had a responsibility to cover the ER.

I got back OK.

Telemedicine is lower-quality medicine. But in bad weather it’s safer for the doc.  And it’s probably inevitable.

 

And sometimes, it’s about me

September 24, 2018

It shouldn’t be all about me

It’s about the people I see.

And the good that I do

The what for the who,

And occasionally, a day that is free.

 

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 did nursing home rounds on Thursday.   Patients come to long term care facilities because of long-term problems.  In the absence of cure, the medical profession settles for treatment.  Thus, in general, I find patients don’t have much in the way of future plans there.

My general approach to smoking relies on hope. I ask, “Do you want to still be smoking in 5 years?”  Most smokers say ‘no’.  Nursing home smokers usually shake their heads, grin sheepishly, and say that they hope they live that long.

This particular facility’s specialty caters to a population that develops incurable diseases at a younger age than the general population. Still, I cared for 9 patients.  I had the pleasant surprise of seeing improvement in 6 and being able to trim the med list of 2.

When I started morning rounds my afternoon schedule had 3 patients; when I got back from the nursing home at 11:45AM I had 4. I rather enjoyed the fact that I could squeeze in 5 more unscheduled patients after lunch.

For the second time since I started here in June, I had documentation and other tasks that kept me working till 6:10PM, a far cry from my usual routine 9 years ago. At that time I started at 7:30AM, sprinted till 5:00 or 6:00, and faced an hour or two of documentation after supper.

Between the nursing home and the clinic, I saw 3 improving Parkinson’s patients.

I had one evening call that involved law enforcement. It went well.

Friday morning I came into clinic and signed in to the computer system. I reviewed labs and answered questions until one of the nurses pointed out that my name didn’t appear on the schedule, and I had no patients for the day.

Five minutes later I had the choice of staying with no scheduled patients or taking the day off.

With so much leisure I drove without exceeding the speed limit, between corn fields turning brown and soybean fields mottling from green to yellow, reflecting on my clinic day.

I felt great. I had seen patient improvement, and had fixed the bleeding and the broken.

Yet my work shouldn’t be about me, it should be about the patients, but confidentiality limits what I can write about them.

Still, my day off was about me.

 

 

 

Bad Call Night, a House Call, a Doctor’s Moment

September 7, 2018

A change in the dose might be small

But to keep myself on the ball

It’s not about me

It’s rewarding, you see

Going out to make a house call

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.

Last night I had the only really bad call night so far this assignment, not bad for a gig that started in June. Called to the ER just after brushing my teeth at 10:30PM, I stayed till after midnight.  I can’t give the details of the case that brought me in at 2:30AM, except to say that a very sick patient needed more resources than we have after hours, and left at 3:30AM with follow ups scheduled along with my exhortation to read Beryl Markham’s West With the Night.

Sleep deprivation hits me harder than it did 30 years ago. I try not to show fatigue around patients and staff, but I felt my steps dragging when I started this morning.

I prioritize ER patients when on call, even when scheduled to simultaneously make nursing home rounds. This morning the inherent conflict resulted in my delayed arrival at a nearby Long Term Care Facility (LTCF).  About half the patients didn’t note my tardiness to a place where one can so easily lose track of time.

When I finished long-term patient care early, I begged the nurse to leave me alone in the exam room for a power nap. Elbows on desk, head propped on my hands, I hit REM sleep in less than a minute and awoke 6 minutes later feeling better.  Not well, but certain I could make the 8 mile drive without falling asleep.

Another true emergency dominated the lunch hour as the afternoon schedule swelled from 3 patients to 8. I bolted lunch and squeezed in another 4 minute nap.  I started into afternoon clinic on time but feeling my years.

At 2:00PM I left with nurses for a house call, and fell asleep on the 5 minute drive.

The first house call to this patient found little hope, the second progress. This time the trip rewarded me with a physician’s moment, the gratification of seeing the effects of improved human health and function rippling through the family in front of my eyes.

Back at the clinic, I stepped out of the car with a bounce in my step I didn’t have before I left. I faced a packed afternoon schedule, behind on documentation and still a bit hungry, but full of energy and the joy of having the best job in the world.

 

ATLS: because real emergencies don’t give you time for an open-book test

September 5, 2018

 

Between the chest and the lung there is air

You don’t have an hour to spare

To consider the drama

Brought on by trauma

One must think, in spite of the scare

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

Friday I attended the Advanced Trauma Life Support (ATLS) refresher course in Lincoln, Nebraska.

The summer showed signs of drawing to a close on the trip down.

The geese, having spent the spring mating and then hatching, and the summer nurturing, flew training flights with their broods. The mass migrations south won’t come till later.

The corn, which shot up so green against the brown earth in June, has come to the end of its life cycle; some fields losing their green at the edges, and a few already dead and drying down for harvest.

The ATLS requires renewal every 4 years; I decided to go a year early.

I hadn’t forgotten as much as I’d thought. The morning lecture went quickly.

I chatted with my colleagues at lunch. On my left, a doc married to a doc plans to retire as soon as he can but doesn’t have an idea about what he’ll do then.

On my right, a well-preserved physician declared that she does locums to ease into retirement. We asked each other about ultimate plans but neither had a good answer.

The written test preceded the skills station.

Anyone who finishes med school excels at written tests. All the homework, papers and exams of secondary and higher education just prepared me for the next 40 years.  Every day I write (or dictate) essays.  Last year’s 200 Continuing Medical Education (CME) hours involved lectures, reading, and quizzes.

The real world gives open-book tests. Most of my daily clinical challenges give me time to look up answers. Real emergencies don’t, and the ATLS prepares the student to keep cool thinking in times of terrible crisis.

I proceeded on to the clinical simulation; the examiner sat on a chair and presented a scenario: alcohol-mediated single car crash with victim ejected and now in my ER with low blood pressure and oxygen, distended neck veins, and no right-sided breath sounds. The model victim, a live person, lay on a simulated gurney.

“Tension pneumothorax! Needle thoracostomy!” I cried, because doctors talking to doctors can’t say “Collapsed lung!  Run a needle over the top of the 2nd rib to release air so it re-inflates.”

The rest of the case came frighteningly close to a blend of the two trauma cases that inspired me to take the course early.

I was the last to finish my clinical simulation, but still 2 hours earlier than planned. Which gave Bethany and I time to do some leisurely grocery shopping in Omaha on the way home.