Archive for December, 2018

Diagnosing a broken toe with a headlight

December 25, 2018

In a flash, I brought out my light,

With a beam that’s ever so bright

That, what do you know,

I can see through a toe.

Can it show me a break? Well, it might.

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, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

About a year ago I replaced my head lamp. The old one had no problems but it carried the logo of an outdoor outfitter and required 3 AA batteries about once a month.

The new one throws a much brighter, whiter beam. It has a lithium battery that runs 120 hours on a charge.  Of course I use it diagnostically, to look into throats, noses, and other body cavities.  Then I started to use it during procedures such as stitches and cerumen removal.

About a month ago, though, I figured out the light has the intensity to shine through (in medicalese, transilluminate) fingers. I used it to remove a splinter.

Last week, a patient came in with a painful, bruised little toe (and gave me permission to write about it) suffering from that eternal truth of one of Newton’s law: two objects cannot occupy the same place at the same time.

In a flash (pun intended) of inspiration, I turned out the lights and brought out my head lamp. Holding it on the other side of the toe, shielding the light from coming through the edges with my fingers, the toe glowed red in the darkness.   I clearly saw not just the bone but the arteries and veins.

And sure enough, a dark line ran across the base of the toe bone closest to the foot, a piece broken into two, but still well aligned.

With the exception of the big toes, we treat toe fractures the same: we tape the broken toe to the next toe, a maneuver called “buddy splinting.”   Thus many times we don’t x-ray toes suspected of fractures, we just treat them and tell the patient to keep the toes taped together till it feels better without the tape than with.

I couldn’t correlate the head lamp image with the gold standard of the x-ray, because toes do not warrant x-rays.

But fingers do. And I will undoubtedly transilluminate the next finger if I think there’s a fracture.

Was it just giardia?

December 25, 2018

I admit I didn’t know why

But I thought to give it a try

That parasite

An intestinal blight

Under the scope has always been shy

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, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

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Watching a couple lay foundations of abuse

December 17, 2018

I know it’s just not my place

To go and get in the face

Of the emotionally unstable

At the next table

They’re just not my clinical case

 

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, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

 

The last to arrive, I got the seat at the end of the table. We gathered to celebrate the final day of work for a Family Practice resident who had come for a rural experience.

I sat down just after the waiter came with my pre-ordered sandwich. I found my colleagues wondering about me.  I explained I missed catching a ride to care for a last-minute patient, and I enjoyed the exercise of a snowy kilometer’s walk.

The conversation centered at the other end of the table, I reveled in the leisurely meal and watched the dynamics around the room.

I can write about these things because they happened in a public place.

A young woman tried to distance herself from the affections of a young man. She leaned away from him, he put his arm around her shoulder, she resisted his efforts to pull her closer.  He scooted in, she leaned further.  He tried to put his head on her shoulder, she did push him away but her posture told me she did not welcome the closeness.

The young man clearly did not understand, and did not want to understand.

I watched a couple lay the foundations of an abusive relationship. The courtship’s emotional intensity stems from the amount of work one party has to put into getting the other party’s attention.

I could read immaturity in the young man’s body language; he acted like a 15-year-old in a 25-year-old’s body. The resistance to his advances would strengthen his interest, leading to a pathologically intense courtship.  Once locked into a love interest, he would lose perspective and sensitivity.

I have seen the consequences of such scenarios at various stages of development. Pathologic fixation on another person with inevitable human imperfections gives rise to uncertainties, then disappointments, then hurt, then abuse.  The young woman may court intensely; the abuse may flow emotionally, verbally, or psychologically.  It rarely flows one direction, and always spills out of the home, rippling through families and communities.  I see the physical impact clinically.  People get sick as an end result of such courtship, sometimes generations and continents away.

I want to go over and tell the young man to grow up, and tell the young woman that if she cares at all for him, she should drop him now and not lead him down the path of destructive love that will crush both their souls and mangle their bodies in the process.

But I don’t. I sit in a public place and watch people who aren’t my patients while I munch my crispy chicken sandwich and make small talk with a colleague.

Eye color change, addicts with insight

December 11, 2018

A change in the color of eyes?

It comes as quite a surprise

It can happen, it’s rare

It’s more common in hair

Don’t count on it for a disguise

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, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

I found myself on call this morning, glad that it came as a surprise so I didn’t have the anticipatory anxiety the night before.

I recognized a person who came in accompanying an ER patient, but I had problems with the appearance.

I had seen the patient weeks before, with a very puzzling physical finding, and tonight I got permission to blog about it.

Presenting complaint: eye color change. I hadn’t heard of such a thing, and I hid my skepticism.  But I did ask for the driver’s license, which confirmed eye color as hazel.  Yet the patient, without a doubt had blue-grey eyes.  I posted an inquiry on a doctors-only clinical social media website.  About half the responses derided the very idea.  But one ophthalmologist offered an erudite discussion and attached a link.

Indeed, eye color can change.

So I thought it over. Eye color depends on little packets of pigment called melanosomes.  I already knew that some unfortunate people can lose color from patches of their skin in a process called vitiligo (two prominent examples include Michael Jackson and the Pied Piper of Hamlin).  And if a person loses a patch of hair to alopecia areata but the hair grows back, it will usually grow back white, due to a loss of melanosomes.

So, if that can happen in the skin, when not the eye?

The patient’s eye color had since darkened, now having bits of brown and green, enough to throw off the appearance.

I said that discussing such a rare finding would come close to identifying a patient.

The person happily gave permission for me to write about the incident in my blog, and talked about running into others who similarly had seen their irises go from dark to light.

Eye color change happens little more rarely than addicts acquiring insight, yet for the 7th time in a week an addict came to clinic knowing change was needed, having started the change, and requesting counseling.

Note: this post made it into the draft queue and marinated there for more than a week.  Since then I’ve had 5 more addicts come in with insight, requesting counseling.  Some have already started going to meetings.

Vice-Grips as a surgical tool

December 10, 2018

He came in with a tree in his heel

I didn’t ask, How do you feel?

But I got a good grip

At the end of the stick

And yanked.  And I did it with zeal.

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, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

People sustain damage in such unlikely ways I would be ashamed to write them into a script. The young man involved gave me permission to tell his story.

Working in wilderness areas where bears and wolves constitute more of usual hazard than anything on the ground, he stepped off a log onto another, not realizing that a dead branch projected directly into his landing zone. The sharp piece penetrated the industrial-rated sole of a new boot in good condition, into the foot just in front of the heel bone, and exited right next to the outside ankle bone (lateral malleolus, if you must).  He crawled 300 meters (three football fields with end zones).  His boss drove him 4 ½ hours to our facility.

The thick end, about half an inch around, stuck out half an inch from the skin.

Of course I called for help. The orthopedist in Prince George advised us to remove it, give the patient antibiotics and pain pills, and make sure he arrived ready and in time for surgery the next morning at 8:30AM.

I know a lot about procedural sedation, but I’ve not done one, so I called for more help.

While I waited, I got to thinking about exactly how to grasp the spear at its base. I located the biggest needle driver and the toughest-looking Allis clamp, but neither appeared up for the task and I wished out loud for a pair of Vice-Grips.

Check Maintenance, the nurses said.

Finding the Maintenance door locked, I discovered to my amazement that my key for the Doctors’ Lounge opened it. From the drawer marked PLIERS I extract a Vice-Grips, a Channellocks, and a pair of industrial-grade Stanley pliers, thinking that all those years as a bicycle mechanic finally paid off.

My colleague graciously came in, talked me through the anesthesia set-up, and watched as I administered fentanyl (a powerful, short-acting narcotic), and propofol (a general anesthetic). When the patient quit answering questions, using my experience with Vice-Grips and metal, I got a loose fit, tightened the locking pliers half a turn, grasped the projecting end of the stick and yanked.  The stick exited cleanly though blood-covered, just a bit longer than my palm’s-width.

Despite heavy anesthesia, the patient sat up and talked without making sense, then after 15 seconds lay back down. When the general anesthetic wore off, he did not remember.

I brought the tools back to Maintenance, and took a good look at their tool drawer.

tool drawer december 2018

Note the needle driver, hemostat, and surgical scissors juxtaposed with Vice-Grips, Channellocks, wire strippers, and tin snips.

Contrast is the essence of meaning, especially in a hospital maintenance department.

Gentle cold and frustrated pagophilia

December 4, 2018

So rare has the story been told

You can ask, is it fool or bold?

Those pagophiles

Travel thousands of miles

Trekking north to seek out the cold

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, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

A thermophile, one who loves warmth, doesn’t deliberately head north after the autumnal equinox. In fact, such a person would go south in the winter.  The language has acquired a term, snow bird, to refer to the millions who yearly flee the snows of the north.

So rarely does the opposite migration happen that I didn’t come across the proper term, pagophile (a person or thing who loves cold), until a few months ago, in a book describing people who deliberately set out to experience the Polar Regions in the winter.

Bethany and I discovered our pagophilia in the winter of 2011, when we landed in Barrow (now Utqiavik) a week before sunrise.

We arrived here in northern British Columbia in October, and though we had a dusting of snow early on, gentle cold has prevail with the temperature has hovered around freezing for the last couple of weeks. We’ve had some more snow, but we’ve also had rain.

In the last four days I’ve enjoyed the plunging mercury, finally in the negative double digits Celsius (about 14 Fahrenheit). Snowflakes fall dry, but I’ll have to wait for colder weather to frost my beard.

We’re still sleeping with the heat off and the window opened a crack.

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A lot of Americans complain about the US Postal Service, but in fact the US delivers packages reliably in less than a week. Even during the December retail madness, a slow package arrives in 2 weeks.

Canada mail moves slower, perhaps because of greater distances, sparser population density, or less well-developed roads. Or maybe we have a distorted view because the mail has to go about 500 miles from Vancouver to Prince George, (about the same distance as Sioux City to Dallas) before it can get loaded onto trucks for delivery out to the smaller towns.

Right now Canada Post faces a “rolling strike” by workers in 4 major cities, Victoria, Edmonton, Halifax, and Windsor. Theoretically, the workers only strike 24 hours at one of those centers before moving on to the next, but in fact the work stoppage has slowed parcel delivery down from its usual laid-back stroll to a crawl.  People talk about ordering from Amazon, prepared to email pictures of presents.

Of course, any package attempting to cross the border will run into a time warp worth of a science fiction story.