Archive for August, 2019

Cardiac treatments: when less is more

August 29, 2019

When it comes to attacks of the heart

You can choose what to do a la carte

Use statistics and math

Before you order a cath

And say less is more when it’s smart.

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 Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, South Central Alaska.  After two weeks vacation and 5 weeks as a hospitalist in my home town, I have found my way back to British Columbia. Any identifiable patient information has been used with permission. 

The US medical system, bloated and over-resourced, does not get quite as good results as the much leaner, under-resourced Canadian system.

Consider the problem of chest pain.  In 21st Century North America, doctors will suspect heart attack if anyone complains of pain between the diaphragm and the neck.  The investigation starts with a simple blood test (troponin) and a tracing of the heart’s electrical activity (electrocardiogram or ECG).  (In the 20th century we looked at the ECG and the CK-MB, a slower, less accurate test.) A low risk patient with 2 normal tests gets sent home; higher risk patients with normal tests gets kept for at least three hours for repeat testing.  Mild heart attacks may show a rise in the troponin with a normal ECG (medicalese: NSTEMI).  But if an abnormal troponin accompanies an abnormal ECG, we make the diagnosis of a much more serious heart attack and we call it a STEMI.

British Columbia has no cath lab north of the Vancouver area.  Realistically the patient doesn’t get definitive treatment for 4 days.  Yet the Canadian patients do slightly better than those in the States.  Here in the North we know how to stabilize and hold patients because we do it a lot.  One nurse told me she hadn’t seen the more serious STEMI for 9 years.

The improved outcomes may be due to chance or to different statistical methods, but real reasons remain a possibility

Canada has done very well fighting tobacco.  The same pack that goes for $3 in Missouri costs $10 here.   The pharmacies sell nicotine patches and gum without a prescription at subsidized prices.  The tobacco settlement money, originally earmarked for prevention campaigns, got hijacked into the various States’ general funds; Canada has vigorous and effective anti-smoking advertisements.

Thus the US has a slightly higher rate of smoking than Canada.

Very good research has enabled us to differentiate which patients will do better with medication vs. surgery.  Canada does well at using that information to prioritize treatment.  In my experience, though, Americans, given the choice (and gray areas predominate over black and white) demand more treatment even when an alternative exists.

I suspect but cannot prove that keeping patients close to their support systems improves outcomes.

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Vancouver Work Permit Pickup

August 19, 2019

I need a permit for work.

I struggle against being a jerk

A reasonable fate

Is a reasonable wait.

I’ll try to make friendly my quirk

 

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 Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, South Central Alaska.  After two weeks vacation and 5 weeks as a hospitalist in my home town, I have found my way back to British Columbia.

At 2:00PM I walk into the Immigration section of the Vancouver airport, for the 4th time since 2017.  The layout has changed a little, and today I waited in line just to get in the room, chatting with a young woman from the Czech Republic.

The youthful Canadian Immigration Services officer wears a Glock and Kevlar.  I hand her my passport and a thick stack of papers: LMIA, job offer, proof of qualification, police statement, physical exam, etc., etc., etc.  She looks at them briefly, and hands me a tab with the number 757, points to the almost empty half of the room and politely tells me to wait over there till my number is called.

I wait and I read as I sit close to a bank of 4 other Immigration Services officers, working full tilt with computers and phones.  Pretty soon one calls number 342.

Thirty minutes later another officer calls 343.  I look at my tab and do some arithmetic and decide at this rate, if the officers work 24 hours a day, I’ll get my work permit in 8.6 days.  I expect my papers to take not minutes, but hours or a day, certainly not days.

At 4:00PM I look up from my book with alarm and realize all the officers have left.  When a straggler passes at 4:10PM, I politely express concern that my plane leaves in an hour, and it’s only fair to inform WestJet.

In the US, I must confess I would have been more urgent and abrupt, perhaps even sarcastic.  In fact, back home I would not have walked away from my passport so blithely.  But Canadian society qualifies as more polite and friendly than the US and I don’t want to slip into the stereotype of the loud, brash, demanding American.

With casual friendliness he goes through a door I can’t and returns with the news that my papers are being processed.  Ten minutes later, I get my work permit.

I land in Prince George in the late afternoon, the air cool and wet with a gentle rain.  While waiting for my luggage I rent my car.  The young man looks at my driver’s license and says, “Iowa.  What country is that?”  Of course I say the US, but I don’t admit that most Americans don’t know the difference between Iowa and Idaho, and certainly don’t know the location of either.  I ask if he’s from Vancouver, but, no, he’s from Prince George.

With weather and mechanical delays, I have to wait 4 hours for Bethany’s arrival.  I check into the hotel, have Tibetan dumplings at a restaurant across the street, and watch TV movies on a large flat screen till almost midnight.

At the airport, I make friendly small talk till Bethany’s plane comes in, and then I can not help but jump to my feet, smiling.

 

Pulling a Sherlock Holmes at a Motel

August 16, 2019

You know, I said to the clerk,

I hope I’m not being a jerk

It seems like a trifle

To guess your cartridge or rifle

I’d say, for you, shooting’s a perk.

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 Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, South Central Alaska.  After two weeks vacation and 5 weeks as a hospitalist in my home town, I am on my way back to British Columbia

Checking out of a motel in Boise, Idaho, I decided to do my best imitation of Sherlock Holmes and I addressed the clerk.  “I’ve been reading Arther Conan Doyle lately,” I said, “And I’d like to make a guess, if you don’t mind.”  He nodded.  “Are you a recreational shooter?”

I find a really nuanced double-take much more satisfying than a heavy-handed startle or exaggerated head shake.  It’s the same kind of double-take that I get when I speak Spanish to a patient who doesn’t expect it.  And this time, I got a good one.  Of course he asked me how I knew.

I admitted I didn’t know, that I guessed.  And I based the guess on a well-healed, subtle, curved scar on the forehead.  Shooters call them a lot of things, including the ought-six hickey and the Leupold laceration; but he referred to it as a scope check.

As it turned out that scar came from a different sport that he didn’t name.  He’d gotten scope-checked before, he said, on the other side.

That’s where Sherlock Holmes went wrong, I replied.  He got hung up on cause and effect: OK as far as it goes but fails to take into account a larger pattern, and I related a different case.

At another time, in another state, an African American came in for his executive physical, and I spotted a distinctive flat, ovoid scar on the shoulder.   I asked if he did a lot of bicycling, and, indeed, he had.  And he wanted to know why I would guess that; at the time he did not fit the demographic.

As it turned out he had gotten his scar at his other favorite sport, tennis.

And then I explained to the clerk about the Calvary Cross tattoo as an indicator of incarceration, though the person almost never gets that tattoo while behind bars.

I also gave out my blog address, and asked for, and received, permission to write about our conversation.

I gave into a hunch and guessed, correctly, his favorite caliber: the .308.  I based my guess on patterns observed in other.308 shooters.  Later, if asked, I would have said that his athletic build and his age tipped me off, but, really, I have gotten good at guessing.

On my way to my car, though, I went one step further.  His bolt action rifle, I decided, comes from either Remington or Savage.  But I didn’t turn around to ask.

 

5 Weeks of Hospital Ended

August 12, 2019

I turned and returned the page

These words are wise and they’re sage

Slow elevators? No glares

I went up and down stairs

It’s the chaos, it can’t be  my age.

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. After 3 years’ Community Health Center work I returned  traveling and adventures in temporary medical positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, most recently, south central Alaska.  After 2 weeks’ vacation and a wedding, I just finished a 5-week stint in hospital medicine in my home town.

Forty-eight hours after I finished my most recent assignment, I sat down to lunch with a friend.

“So, what did you learn?” he asked.

I learned a lot.

By exhausting my vocabularies in Greek, Hochungra, Umaha, and Lakota, I learned that not only do I still retain random words in other languages but using them can seriously lighten the mood of the room

I learned that not all Dineh languages are the same, and that being friendly in one might be perceived badly in another.

I learned that my version of the law of unintended consequences remains true:  from change comes chaos; the bigger the change the greater the chaos.

I learned that I can handle 13 hours of orderly work a lot easier than 12 hours of chaos, and I can handle 14 hours of order a lot easier than 12 hours of order followed by one hour of chaos.

I learned that taking a break to have dinner with my wife brought an enormous boost to my morale.

I learned that hospital work involves so much walking that losing 3 pounds a day came easily.  Especially if time pressure made me choose stairs over elevators.

I learned that while a generalist among specialists might occasionally look superfluous, finding a couple of cases of B12 deficiency or starting Parkinson’s medication can still make me dance.

I learned that whining about a bad electronic medical record wastes my time and emotional energy, but embracing it and calmness work together.

I learned that if it takes the help desk a half hour to get back to me, I can generally find the solution. Before they call.

But I also learned to give up defective software right when I when I find out it’s defective.  Complaining to someone with a financial interest in a task made impossible by the tools at hand works a lot better than not speaking up.

I learned that a clock in a doctor’s lounge will go for months with a dead battery unless I take it upon myself to fix it.

I learned that everything in the real world, even medical care, carries a degree of geographic imperative.

I learned that staying friendly in the face of internal anger gets me further than expressing that anger.

I learned that despite my insight and learning, I could backslide down the slippery slope of workaholism right to the knife edge of burnout.

I learned that a stressful, chaotic work environment changes me physically, from my gut to my body odor to my rate of hair and nail growth.

I learned that I’m a much better husband if I don’t work 12 hours days 3 in a row.

I learned that a 12-hour day rarely ends at 12 hours.

I learned that mission creep is inevitable.

I learned that nurses who say, “Don’t bring chocolates,” don’t mean it.

I looked at my fork, then at my friend, and I said, “I’m not 65 anymore.”