Archive for February, 2019

Teaching 3 things I didn’t learn in med school

February 26, 2019

The student might have thought I was mad

When I lit up an alcohol pad

And then used that fire

To heat up a wire

But then I made happy the sad.

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 Canada. After 3 weeks’ vacation in Texas and Denver, I have returned to northern British Columbia.

Some of the docs here have decided to split weekend call so as to avoid working 72 continuous hours, a step I regard as so healthy that I volunteered for Saturday call last weekend. I had the chance to teach a medical student, Dyon, who intends to do a Family Practice residency.

All patients mentioned gave permission to write about their cases.

The first patient came in with a subungual hematoma, or blood clot under the finger or toe nail. A very painful problem, but one easy to cure by putting a hole into the nail.

The nurses couldn’t find the usual tool, an electrocautery, which looks like a disposable electric soldering iron.

I taped an unfolded paper clip to a tongue depressor with 3cm of wired extending past the end. In the absence of a Bunsen burner, I turned an alcohol pad into an alcohol lamp by tearing a corner from the foil packet and lighting it with the patient’s cigarette lighter.  The student, in his capacity as fireman, held the flame close at hand.  I kept the paper clip tip in the hottest part of the flame till it glowed, and applied it to the nail.  It sizzled nicely but cooled too quickly to go all the way through.  The first “alcohol lamp” burnt out before resolving the problem.  Then the patient volunteered to keep his lighter burning.  On the 3rd try, the glowing metal melted the nail, and close to half a teaspoon of dark red blood spurted free.  The patient, like most in his situation, had such relief that he started to chuckle, probably from endorphin rebound.

In short order we faced an 11-month-old, and another chance to teach. When babies, about 10 months old, distinguish family from non-family, they fear strangers.  While humans can see from birth, it takes till age 9 to fully organize the information coming from our eyes.  Thus, if you don’t make eye contact with a 10-month-old patient, you can examine the ears without force or trauma; they think if they can’t see you, then you can’t see them.  The trick worked on the 11-month-old.

About an hour after, an adolescent arrived with a toothache. Standard treatment consists of pills for pain and infection; in addition I showed the student, the patient, and the parent how to find the acupuncture point that the Chinese call Ho-Ku and that Western anatomists call the branching point of the superficial radial nerve.

For all three patients I got to show off knowledge acquired outside of medical school.

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Taking Call: the best reality show

February 24, 2019

I volunteered to take call

And it wasn’t a wonder at all

For no Valentine’s date,

I’m missing my mate

And hanging out in the hospital’s hall.

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 Canada. After 3 weeks’ vacation in Texas and Denver, I have returned to northern British Columbia.

The US had President’s day while Canada celebrated Family Day. I took call Sunday.

In truth, I don’t like call. But while Bethany visits her sisters in Arizona, hospital duty beats sitting and watching TV.

Over the course of 24 hours I cared for 12 people, half before noon. I called in x-ray twice and lab once.

I told two patients that I couldn’t possibly give better advice than their 12-step programs.

Several people required prescriptions, but the pharmacies here would stay closed 2 days running. Like most Emergency Departments, ours houses a limited number of drugs that can be dispensed until the drugstores open up.  For three of those patients, I wrote standing orders: they could receive, for example, injected or inhaled medications till Tuesday

One patient needed an x-ray, but, as the problem had been present for 2 weeks, I gave a splint and a requisition for the study on Wednesday.

One person’s repeated denials of domestic violence failed to convince me, and the spouse’s behavior raised further suspicions.

But like my patients who drink to excess and smoke things they shouldn’t, my good advice only goes so far, and if I try to push good advice, I risk alienating the person. I get more patients to change by building rapport.

I had attended 4 people before, and they greeted me warmly.

Half the patients came in before noon. For the rest of the day, they arrived singly or in pairs.  I never fell too far behind in my documentation.

The last patient arrived by ambulance an hour and a half before midnight. Over the course of the day the mercury had gone from -12C to -20C (single digits to 0 Fahrenheit).  I kept driving back and forth rather than walking, not so much because of the cold but because the air is so dry the windshield didn’t need scraping.

That last patient proved quite complex, needing IV treatments and both lab and x-ray evaluation.

I left the hospital about 1:00AM, reasonably tired.

A long day working, certainly. But right now, with Bethany visiting her sisters in Arizona, hanging out with patients and nurses at the Hospital constitutes a better reality show than anything on TV.

A fast 3 weeks vacation

February 14, 2019

In Denver we sat down for a meal,

To talk of how people heal.

We were shooting the breeze

Speaking medicalese

It’s just our typical spiel.

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 Canada. I took three weeks’ vacation between assignments.

Three weeks’ vacation went fast. We had enough time for laundry and almost enough time for mail before we visited our (physician) daughter, her (physician) husband and their two children in Texas.  Not surprisingly, dinner conversation included medical topics as common as B12 deficiency and as esoteric as clivochordoma (a ridiculously rare sort of brain tumor).  But we also talked about normal stuff like the grandchildren developing, the political situation, physician career development (for all 3 of us doctors) and the progress of my Texas medical license , which I started back in May.

Some states make licensing easier than others, and I wondered out loud who oversees licensing authorities to make sure they act in the State’s best interests.

Bethany and I stayed 2 days with the 2 grandchildren (who between them don’t have 4 calendar years) listening to the pounding of the Galveston surf and watching squadrons of pelicans fishing in knee-deep water.

We flew directly from Houston to Denver. Our youngest daughter and her husband came to Colorado to touch base with family and friends before a planned move to Israel.  Three of my 6 sib, along with spouses and children, live in Denver.

We met in a Persian restaurant for supper.

Medicine has warped our conversations and vocabularies, starting with our internist/cardiologist/Emergency physician father who dropped the words “myocardial infarction” (heart attack) at least six times a meal.

When I had young children, and even after, I literally brought my work home with me, sometimes attending patients in the basement and usually dictating office notes after supper. When I had call, I took the kids with me to the hospital starting, before the first one could walk to when the youngest one hit puberty.  Of course family meals included discussions of the drama and irony my work.

Our youngest daughter married the youngest son of my former medical partner. One of my Denver sisters, an interpreter for the deaf, has been through veterinary school 3 times, and she does a lot of ER interpreting.  Her son, just done with premed, is in the process of studying for the MCAT (Medical College Aptitude Test).  My Denver brother, a paramedic for decades, will apply to PA school within the year.

My other Denver sister has a PhD, arguably the more normal sort of doctor.

The family’s way-off-the-wall sense of humor dominated the evening. At the end of the meal we had a short hands-on colloquium on OMT, or, in common English, back cracking.

 

Saxophone and life lessons

February 3, 2019

In Memoriam

Diane G.

March 28, 1960- January 24, 2019

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. Just back from my 4th Canadian assignment, I’m taking some time off in the States

After a miraculous, 15 year fight with cancer, Diane, my friend and saxophone teacher, died last week. I was with her when she passed, not as her physician but as her friend.  Bethany was there as a friend as well, and to support me.

She died surrounded by the love of her friends and her family.

Diane had to see other physicians while I went locum tenens, but I never found another music teacher. Thursdays when in town meant life lessons along with music.  She would not accept money, so I brought chicken soup.

At her urging, and with her permission, I wrote about her in 2011. I have included the post word-for-word below.

We count good moments, not years

When we don’t give in to our fears

     I once went with a hunch,

     It helped my patient, a bunch.

And she looks good in front of her peers.

My patient, Diane, has given me permission to use this information in my blog.

She taught my three children instrumental music; she came to me as a patient more than a decade ago.

Six years ago a cough brought her in.  As with all health professionals doing their job with a woman between ten and sixty, I asked if there were any chance she was pregnant.

“No,” she said.

Sometimes I get a hunch and a long time ago I learned to trust that tingling at the back of my brain; in this case it told me not to believe her.

“Well,” I said, “Just lay back on the exam table while I check your tummy.”

I plainly felt the top of her uterus higher than her belly button, but I couldn’t find a heartbeat with the Doppler.

I pled urgency with an OB-Gyn and got her an appointment within the hour.   The ultrasound showed her womb had turned into a malignancy the size of a soccer ball.

A few weeks later, she came, in her words, to a “critical decision that I make a ‘leap of faith’ in action right before surgery, because I knew in order to live I had to not be afraid to die.”

The pathology report said leiomyosarcoma, a cancer of the uterine muscle.  In later years she said, “I was always a survivor from the beginning.  I was born C-section at 7 mo.[ 3.5 lbs] in 1960.  I had no idea how having ‘faith’, ‘letting go’ of past hurts, and learning to trust others would change my life all for the better.”

It helped that she had never been a bitter person.

I coordinated her care as she went from specialist to specialist.  So rare a tumor had no chemotherapeutic experience.  With a paucity of clinical evidence, I gave advice from my heart.

“The worst day of my life wasn’t when you called and told me it was in my lungs,” she said.  “Not even close.  I’ve had more good days since my diagnosis than I had in my entire life combined.”

The next summer Bethany and I met Diane and her husband on their way out of the movie theater.  She’d been carded trying to get into an R rated movie.  Her skin had the clear glow of a teenager and her hair shone in the sun.  She walked with a bounce befitting a sophomore.

The spring after that she sat in the waiting room of the Cancer Center before a radiation treatment.  The other cancer patients turned to her. “You’re not here for radiation,” they said, “you’re just another representative. What do you represent?”

“I represent hope,” she said.

My middle daughter fell rock climbing three years ago; in the aftermath of ICU’s and neurosurgeons and months of not knowing I learned a great deal.  Diane and I have discussed these truths: Time comes to us in moments, some good, some bad, most neutral; if you let the bad moments contaminate the neutral you give them too much power and if you let the bad soil the good you’re missing the point; embracing the uncertainty of not knowing bad news makes your day better.

When I made my decision to slow down back in February I also decided to bring music back into my life and buff up my saxophone skills by doing lessons with Diane.  On my last clinic day, she and her husband and my office nurse gave me a soprano sax.

(see my post https://walkaboutdoc.wordpress.com/2010/05/23/can-a-soprano-beat-a-naked-lady/)

Over the course of ten surgeries, seventy-nine radiation treatments, fifteen hospitalizations, and thirty-eight CTs, Diane continues to look younger and younger.  She serves as a beacon of light and hope to all who know her.

 

 

 

A Full BC license

February 1, 2019

A full license the College did grant

I could work elsewhere, but I shan’t

At home, with a friend

I saw a Parkinson’s trend

A tremor, and a walk with a slant

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. Just back from my 4th Canadian assignment, I’m taking some time off in the States

Much has happened in the two weeks since I last posted.

I got my full BC license on January 17th. Up to now I’ve been working with a provisional license, which requires that I have supervision and work in 3 month blocks.  The licensing authority waived the requirement that I be a permanent BC resident.  Technically I now can work in other parts of the province.  Still, I would have to ask myself why I would want to go anywhere other than the most functional medical community I’ve ever experienced.

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We got back to the States on the 20th.  The mountain of unread mail made procrastination unfeasible.  I sorted it into piles of WILL READ and RECYCLING.  Having been gone for the December holidays, we also had a few gifts.

At this stage of my career, having accumulated too much, we need very little. So if someone wants to buy a present, we’ve taken to saying it should be expendable, negotiable, edible, biodegradable, or inheritable.  Imagine our surprise when we got a really nice cutting board.  Which, strangely, we can use.

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I have noted an alarming increase in Parkinson’s in the general public. When I finished med school, the vast majority of Parkinson’s disease came from the Great Influenza of 1918.  In the ‘80s you could pick it out in a crowd just on the basis of age and gait.  Than generation has passed.  Saturday, at a social gathering, I glanced at a friend’s hand resting on a lectern, and spotted the characteristic tremor of her right hand.  Over the decades I’ve known her, I failed to note the gradual loss of facial expression.  When quizzed she confirmed anosmia (loss of sense of smell), micrographia (shrinking handwriting), bradyphrenia (slowed thinking), and loss of balance.  She also gave me permission to write about her in my blog.

And from time to time, in an airport or grocery store, I’ll point out to Bethany the telltale leaning, shuffling gait, and blank stare.

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My wife and I do better with cold than heat. We flew to Texas to visit our (doctor) daughter, her (doctor) husband and their children.  We left Omaha at a temperature of 1F (-17C) and arrived in Houston to 47F (8C).  We happily walked around in our shirt sleeves while the locals wore parkas, ski caps, and mittens.  Two days later, I reverted to wearing my winter jacket, but not my long underwear.

Contrast remains the essence of meaning.