Archive for May, 2019

More fishing

May 31, 2019

The strength and the time that it took,

With a denizen firm on the hook,

Adventure was fetching

The fish we were catching,

Were halibut, we’re planning to cook.

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 have now returned to southern Alaska. Any identifiable patient information has been used with permission.

When I took this assignment I specified Fridays off, mostly for fishing.  We found a fishing charter captain, Keith Kalke of the Ocean Hunter,  whom we get along with well, and this Friday we got up at 430 for the drive down to Homer.

We arrived at the same time as Larry and Judy (who gave permission to write about our adventure). We come from the same generation.

The morning gave us winds and waves worse than NOAA predicted, at the fine far edge of comfort.  Bethany’s scopolamine patch (TransDerm Scop) prevented sea sickness, and I watched the far horizon as much as I could.

After a no-catch morning we moved, the wind abated and waves weakened.  Keith set us up with circular halibut hooks, 2 and 3 pound sinkers, and bait fish big enough to be considered dinner in Iowa. We dropped our lines into 190 feet of water.

Judy brought up a respectable 30-inch halibut.  After Larry’s rod tip shook a few times, Keith instructed him to lift his fishpole and start reeling.

From the beginning he knew he had a big one.  Larry used good technique, lifting the rod tip to the vertical and then winding while lowering it.

Three of us kept hold of poles while the drama of a fish’s struggle for life played out at the end of 190 feet of fishing line.

We didn’t realize the size of the fish until we saw it, about 15 feet down.  Keith, who has experience with very large halibut, went forward and returned with a shotgun, taking a cartridge out of a small blue box..

Salmon, rock fish, greenling, and smaller halibut can be dispatched with a blow to the head, halibut large enough to be dangerous on deck cannot.

Keith’s onboard halibut weapon, a.410 gauge, single-shot, break action, 18 ½ inch barrel, loaded with birdshot, it represents the minimalist’s shotgun: a danger to fish but not to the boat.

Larry held the struggling fish with his rod.  I put on my noise-cancelling muffs and protected Bethany’s ears with my hands while we watched.  Keith gaffed the fish with one hand and administered the coup de grace with the other.

When finally aboard we gasped at the size

(Keith has brought in halibut more than 6 times bigger.)

We went back to fishing.  Bethany hooked one well, and reeled till she fatigued.  I took over and brought in a respectable 31” fish.

I seized the moment when the rod tip jiggled.  Working the reel I brought the fish up by degrees.  A couple of times it dove, and I quit trying to work the line flying out against the drag.  I brought in 50 feet before I had to rest for the first time, holding the rod with my right hand while blood flow returned to my left.  As the fish ascended my rest stops grew more frequent, each a mandatory 8 count.

Bethany asked, “What are you doing?”

“Regenerating my creatine phosophokinase,” I answered.  “It takes 8 seconds.”

I worked the reel crank by crank and my rests grew closer together.  Finally I asked Bethany to take over.

Neither of us at our age have hand stamina adequate for bringing in a big fish from a long way off, and we have learned how to relay.

Bethany brought the fish close enough to the surface for Keith to gaff.  A respectable fish, about 50 pounds coming out of the water, too small to shoot but big enough to club.

With 4 halibut in the boat, we started back to Homer.  Larry’s left hand cramped, and I volunteered to massage it.

“Why does it do that?” he asked.

“It cramps because it’s fatigued,” I said, and I could tell he wanted more of an answer.  “You ran out of creatine phosphokinase, the enzyme that keeps the muscle from cramping.”

The cramps came from the forearm muscles which provide the main grip strength as well as from the hand’s own muscles that let us squeeze our fingers together.

It wasn’t really medical care; I learned more sophisticated massage techniques in undergrad dorm rooms.  Still, I made him feel better.

In Homer, we took pictures.   I had to get Bethany to help me raise our fish, even though it was smaller than Larry’s.

halibut photo 2019 26May

Larry hoisted his fish and his hand fatigued and cramped again.  I helped again with massage and showed him a few simple exercises.

Halibut x4 2019 26May

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How can you tell the south Alaska winter is over?

May 21, 2019

These could be signs of the spring

The grass coming up soft and green

And though you look twice

You’ll find no piles of ice

And moose moms get protective and mean.

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 have now returned to southern Alaska. Any identifiable patient information has been used with permission.

In the lower 48 people look for signs of spring in the first robin or crocus, or the appearance of morel mushrooms in the woods, or the sound of wild turkeys gobbling.

With Alaska’s furthest north point, Utqiavik (formerly Barrow) as far north from here as Windsor, Ontario is from Atlanta, people look for different things to show that winter ended.  In Utqiavik, for example, they look for the last sunset.

How do you know that the southern Alaska spring arrived?

Wearing long underwear makes you overheat on your way to work.

No ice on your windshield in the morning.

The last snow pile at the edge of the parking lot melts.

You hear reliable rumors of King salmon swimming upstream in the Kasilof.

You can tell male moose from female moose:  the bulls have their first antler buds covered in velvet, and you can see the fetuses kicking the sides of the females.

Clouds of mosquitoes come after you when you get out of the car.

The bait fish, the hooligan and the needle fish, go into spawning frenzy, the sea gulls dive head first from 30 feet up, and the King salmon you catch in Cook Inlet looks like he’s been sitting at the football team’s training table.  Because he’s been eating hooligan and needlefish.

You don’t see floating cakes of ice in the rivers, estuaries, or bays.

You don’t gasp at produce prices at the grocery store.

Traffic on the Alaska Route 1 gets louder and louder, and the people who live here all winter complain about the RV traffic.

The snow birds return with Arizona tans and Mexico t-shirts.

The tourist attractions on Homer Spit open up.

If your recipe says to let something set up overnight you have to start before sunset and let it go after sunrise.

Nights don’t get dark enough to see stars, twilight lasts all night, which isn’t very long.

You have to start worrying about bears.

Of hearing aids and tremors.

May 15, 2019

She didn’t hear well, I suppose

For the wax that clogged the holes

Of the aids for her hearing

With the brush I went clearing

And she left with so rosy a glow.

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 have now returned to southern Alaska. Any identifiable patient information has been used with permission.

I won’t write about what the patient came in for, because I didn’t ask for or get permission to write about that, but I asked for and received the go ahead to write about the rest.

I followed my usual approach and didn’t interrupt until she had told her story.  Then I started to  question.  At the third question, she furrowed her brows, apologized for not understanding me as her hearing aids weren’t working.

Despite new batteries, they didn’t help at all.  After her appointment, her husband would come back from fishing and they’d spend the rest of the afternoon driving to the Costco in Anchorage.

Let me have a look, I said.

I hated near sightedness as a kid, but now I find it a gift: to see very small things as I push 70, all I have to do is take off my glasses.

I stepped out of the exam room and retrieved my hearing aid case and its tiny tool.  I slipped off the tulips, the part that goes into the ear.  The ear wax packing the miniscule opening came out easily with the plastic thread, about the same diameter as fishing leader.  With my hearing aid brush I swept out the debris clogging the microphone holes and handed the hearing aids back to the patient.

I drew great satisfaction from her smile, even more so because I knew she wouldn’t be facing 7 hours on hazardous roads.

She explained that her tremor kept her from doing things like cleaning her hearing aids.

I confirmed I saw her hands shaking while I was working on her hearing aids, despite the fact that she kept her left hand hidden.

Then I did my Parkinson’s diagnostic test:  I held her hands, encouraged her to relax and I listened.  As she relaxed, the tremor in her left hand got worse and the muscle in her right hand, between her thumb and forefinger, started to quiver.

I asked my usual Parkinson’s questions: loss of balance and sense of smell, shrinking handwriting; she answered yes to some and no to others.

I diagnosed Parkinson’s disease.  Treatment helps symptoms, I said, but that medication doesn’t slow the disease progression.

Since her tremor started decades ago, she’d seen lots of docs, including neurologists, all of whom agreed she didn’t have Parkinson’s but benign familial tremor.

Perhaps she had that, too, but I knew for sure today she had Parkinson’s and I could probably help her.

She confirmed her current medications didn’t help much, if at all.

We set up a plan to start Parkinson’s medications at very low dose.  As I’ll be leaving in less than a month, some other doc will have the pleasure of seeing her blossom with Sinemet, the later the tedious but rewarding process of deprescribing several medications.

But I had a great time fixing her hearing aids.

Lunch at a senior center, this time as a senior.

May 15, 2019

We have now come around to that age

Where we work, but not for the wage

While the winds went to whirling

We set off for Sterling

A decision we found rather sage.

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 have now returned to southern Alaska. Any identifiable patient information has been used with permission.

With terrible weather forecast for Cook Inlet, Friday we avoided fishing and went to the Senior Center in Sterling; we had heard they serve exception burgers on alternate Fridays.

We found two raffles, one for a very large, beautiful quilt, and one for a .22 rifle.  Both of us bought tickets and neither complained about gender specificity. Neither of us expect to win the raffle, both regard the purchase of the ticket as a donation, and neither could predict what we’d do if we did win.

About 30 people occupied the hall, including a surprising number of children exhibiting varying degrees of truculence sitting with their apparent grandparents.

Neither of us had ever been to a Senior Center as a Senior before.  But now we have reached the age where we can benefit from Senior programs.

We both had our burgers with caramelized onions, sautéed mushrooms, onion rings, and French fries with a side of beef chili and chips.  The grand total, $15 for the two of us, stands out as a Best Buy for an Alaskan lunch out.

Around the room I could diagnose emphysema, depression, alcoholism, and Parkinson’s with certainty, along with probable diabetes, hypertension, heart attacks, and stroke.

The day before I had 3 patients, all male, and none more than 10 months different in age from me.  The number of diagnoses I had in common with them gave me credibility, and I established rapport by talking about fishing.  I continue to learn from my patients.

I have cared for a surprising number of fishing guides and commercial fisherman, at varying stages of retiring, from a week before the sale of a business to a month after, through the pain of the first season not fishing, to never wanting to quit.

Most, not all, people in my age bracket who still work do so because they want to.  Between savings, Social Security, inheritances, and cashing out businesses, they have enough money to live comfortably till it runs out.

Some don’t.  Alcohol, tobacco, drugs, gambling, and divorce account for much financial insecurity; but those who arrive at old age with money problems have dealt with such problems most of their lives.

The few who have experienced long periods of leisure seem to do the best as seniors.  They know how to spend their time and their money.

 

 

 

 

 

 

 

Perfect people don’t come to see me.

May 1, 2019

When it comes to the way patients flow,
You could call this gig a bit slow.
But the patients expressed
They’ve been pretty impressed
At the warmth that I can show.

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 have now returned to southern Alaska. Any identifiable patient information has been used with permission.

I currently deal with low patient flow on a daily basis. Yesterday I had, for the second time, 5 patients in one day; all the other days have gone more slowly. Yet with 5 patients, each scheduled for ½ hour appointments, I kept busy. My electronic inbox never gets to empty. I review lab work and incoming consultation results. In fact, my in box would keep me busy for about 2 hours a day whether or not I saw patients. Thus the electronic version of paperwork flows so fast that it has acquired a life of its own.
Still I have a good amount of time to spend with each patient. I impressed each one so far with my patience. I nod, I listen, I take notes. I get to ask the patient their agenda. The vast majority have been over the age of 70; the youngest so far this week was 48.
But I interrupted one patient. Within 2 minutes, I knew my trouble following his story came from his shifting focus. The numbers in his narrative didn’t add up. After a while I asked if he were having trouble focusing, which he was. Eventually, that one piece of information, more than any data from the telling, gave me the diagnosis.
One patient, who gave me permission to write this, has ankylosing spondylitis, a disease I myself have struggled with since 1967 (or maybe 1963). The best I could do during that visit came down to running a chronic pain support group with two people. We turned out to have a lot in common.
Addicts lie. This truth comes so consistently that, when I find a liar, I look for an addiction. However fun and charming the addict, their words cannot be trusted, especially when it comes to what drugs they use. I have not yet found a way to figure out when an addict stops lying.
But I listen to the addicts and alcoholics as patiently as I listen to the overeaters and the smokers. Perfect people do not come to see me. Everyone who brings illness through the front door comes with a back story of drama and irony, and I have the time here to dig for the patient’s agenda.
The patient’s agenda always wins. Asking what they want in 5 or 10 years uncovers that agenda better than anything else, but does not do so perfectly. Some people don’t know what they want. But asking what they want makes them think.