Archive for December, 2019

Sick people get stressed, stressed people get sick.

December 31, 2019

On Christmas, with light patient flow

I went back and forth in the snow

Illness comes when we’re stressed

Because with love we are blessed

They’re mortals, those people we know

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 further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia, to which I have returned after visits to Israel and San Francisco   Any identifiable patient information, including that of my wife, has been used with permission.

I took call again this Christmas, as I have for almost every Christmas since 1979.  Though I don’t celebrate the holiday  I feel strongly that people who do should have the chance to spend it with their families.

Most of the time taking call on Christmas includes Christmas Eve. (In Utqiaviq call never meant anything other than 12 hours, but I never worked there in December.)  This year I cared for 4 patients on the 24th and 3 on the 25th.

In general, alcohol, tobacco, and drugs account for about 70% of my medical work load, but 30% of the time illness comes to my patients gratuitously. For these two days, 100% of those I attended suffered from the ills of just being human.  I saw one pediatric patient, and two over age 70.

The majority have such healthy lifestyles I couldn’t even ask them to exercise more.  Only one patient takes more than 3 regular medications.

With the luxury of light patient flow I could take the time and listen to people’s stories.  One patient confessed feeling a bit unnerved by a doctor who didn’t interrupt.

I ran into one challenging mystery.  After the patient and I agreed on a plan for the evening, I handed her a lab slip to bring in after Boxing Day, explaining the tests I ordered.

The natural tendency of people to love constitutes a force comparable to gravity.  However perfect that force, it applies to humans, subject to growth and decay and the vagaries of genetics, time, gravity, and mortality.  Thus the wonder of the human universe operates against us when those we love fall prey to the inevitabilities of existence.  Such stress accounted for half the people who came to see me.

During these 48 hours of call, no one wanted to interrupt the celebration by coming to the hospital.  For every person I attended I received an apology for bringing me in, and to each I gave assurances that I didn’t mind.

I ordered injectable medication three times.

At 1:00 PM on Christmas the hospital staff, Bethany and I sat down to eat lunch. The nurses brought prawns, wings, veggies with dip, crackers and cheese.  My contribution consisted of fried potato wedges from the convenience store, brought in by my wife.  I binged on the holiday chocolates.

Snow fell off and on through both days.  At night, driving in, I spotted tracks of a 4-legged animal right outside the hospital, most likely a coyote or wolf.  The snow blurred the details.

 

 

 

If only Sam Clemens had duct tape

December 18, 2019

The patient looks up and he snorts

When discussing the treatment of warts

You’re in no better shape

Using duct tape

Than liquid nitrogen.  We buy it in quarts

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 further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia, to which I have returned after visits to Israel and San Francisco   Any identifiable patient information, including that of my wife, has been used with permission.

I had a great day in clinic.  I took care of a follow-up from the weekend that had me genuinely worried.  I saw a couple more cases that could end up being infectious mononucleosis.  I dealt quickly with some administrative visits, and others just needing refills.

Though the patient gave permission to write in specifics, I’ll keep to some general principles.  Migraine can mean very different things to very different people.  For example, I get retinal migraines, with intriguing flashing lights but no headache.  Thus if a person has a recurrent neurologic problem that comes and goes, with months between clusters or swarms, a doctor should consider a migraine variant, even without pain, flashing lights, nausea, aggravation by bright lights or loud noises.  Still I knew that the more doctors the patient sees before they get to me the smaller the chance I have of making a difference.

Another patient showed me a cluster of warts.

I gave full disclosure.  Mark Twain in Tom Sawyer, I said, gave a recipe for wishing warts away that works about half the time.  These days I can’t offer anything better than 60%.  In other words, every therapeutic option carries a 40% risk of recurrence.  And if we do nothing, 90% will disappear in less than 2 years. 

Then I gave the options: duct tape at home, liquid nitrogen, or wait another year.

His facial expression said, “Duct tape??!! Are you serious?”

Yes.  A person puts a small piece of duct tape over the wart (colored duct tape works best), removing it ever 2 or 3 days and filing the wart down with an emery board till it hurts or bleeds.  It carries the same success rate as liquid nitrogen, used to bring frostbite to the wart.

Then I went on a bit of a rant.  The last 20 years have brought so many game-changing medications and treatment, from hepatitis C to testicular cancer, but when it comes to warts we’re still stuck in the 1800’s.

He said, “But they didn’t have duct tape back then.” 

I broke out laughing.  I asked for, and received, permission to write about the interchange and quote him on my blog.

Emergency obstetrics only

December 17, 2019

The last time, in the land of the corn

I dealt with an afterbirth torn.

I’m not keeping score,

But perhaps just one more.

I’ll help a baby be born

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 further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia, to which I have returned after visits to Israel and San Francisco   Any identifiable patient information, including that of my wife, has been used with permission.

In my first year of residency I conversed with an attending Family Physician who grinned widely when he announced he’d turned 60 and stopped delivering babies.  “I feel like I’ve retired,” he said.

 

At the time I felt he’d betrayed the profession.  After all, Family Practice by definition involves families.

I delivered babies in the Indian Health Service.  In New Mexico we had a program at the non-IHS hospital in Grants.  I delivered a couple more in Winnebago, though the hospital lacked the equipment and the staff training.  Better to deliver in a hospital than in an ambulance.

 

To finish my IHS contract I returned to the Southwest and delivered more than 50 babies in Tuba City, AZ.  I refreshed my skills so I could join a Family Practice group in Sioux City and share full call.  Even back then, 1987, I knew that I would stop OB on my 60th birthday.

 

My last two deliveries in private practice had frightening complications, one involving a torn placenta, and cemented my resolve to give up that part of medicine.

 

Before that, three of my partners stopped delivering babies.  Without the young families and a new generation, their pediatrics practices withered and geriatrics took over.

 

I’ve declined jobs with OB, saying, “My 60th birthday present to myself was stopping OB and I’m not giving it back.”

 

A doctor has to work hard to deliver babies.  They can come at any time.  For a quarter-century I had at least one patient past 36 weeks gestation, set to deliver at any moment.  The vigilance murdered sleep. And, indeed, when I stopped obstetrics, I felt like I’d retired.

 

OB here has the same uncertainty that OB has everywhere, and my first obligation remains doing what is right for the patient.  On Saturday, my day on call, I requested back up when a patient in labor arrived.  In the hallway we conferred and divided duties.  My colleague would take care of the baby, I would handle the delivery.

 

The mechanics of my role have not changed in the last 9 years.  My colleague clued me in on standard procedures, that were once considered trendy.

 

In the middle of the action I realized I’d forgotten to put on a gown.

 

The closest that we come in this life to perfection can be found in the peace and stillness after a normal delivery.

 

It was wonderful.

 

Afterwards, the patient gave me permission to write that I’d delivered her baby.

 

I still don’t want to give back my 60th birthday present to myself.

 

Dancing with ambivalence

December 12, 2019

There’s a place in the wrist called a tunnel

Where nerves and their friends face a tunnel

And by the ankle as well

If things start to swell

The pressure the nerve will disgruntle

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 further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia, to which I have returned after visits to Israel and San Francisco   Any identifiable patient information, including that of my wife, has been used with permission.

My mood lifted as I returned to Canada. It helps that Canadians have a well-deserved world wide reputation as friendly and polite. I sang when no one listened and danced when no one looked.

But I sang and danced with ambivalence.  My wife stayed in Sioux City; the radiation treatment for thyroid cancer demands that she stays isolated for the better part of a week, and I miss her.

I left Omaha at 8:00 AM and landed in Prince George at 8:00 PM, having crossed two time zones in 4 planes.  For the first time, I flew through Edmonton.

To avoid the drive north in the cold and dark I stayed over in Prince George, where, despite a great hotel, I slept as poorly as if I’d been driving.  In the last month I’ve crossed 22 time zones, and not spent more than 12 days in any one.  I don’t expect to sleep well for a couple of months.

My first day back in clinic I cared for 16 patients.  I knew half of them.  Despite my intermittent presence here I seem to have established a practice.

A pinched nerve causes a lot of pain.  “Carpal tunnel syndrome” has become part of modern American English vocabulary because the median nerve has to run through an enclosed space to get from the arm to the hand.  Any pressured nerve brings pain that burns or shoots or stabs, and runs both directions away from the pinch point.

One of my patients, who gave permission to write this, had to give up an exciting job in demolitions due to pain from a nerve pinched just behind her inside ankle bone in the tarsal tunnel.  I have not seen the problem before, nor can I remember where I learned about it.  But I had to preface the visit with full disclosure: the chance that I’ll help you is inversely proportional to the number of doctors who failed.  We await diagnostic confirmations.

Twenty-five percent of my patients qualified as pediatrics, the same percentage born outside Canada, and the same percentage who abuse marijuana.

The trend of substance abusers coming to insight without any input from me continued today; I could step around the corner to dialogue with counselors, who, unfortunately, had stepped away.

I stayed late finishing up my documentations, loathe to go back to an empty hotel room, but finally I stepped out into the darkness relieved by hard points of stars.  For the first time since our Alaska adventure, I felt the frost condense in my beard.  I called Bethany.  She had radioactive iodine, I 131, for her thyroid cancer today.

 

Conversations with a saxophonist

December 1, 2019

The conversation soon got to brass tacks

As I failed to gather the facts

I talked too much of me

When I found out, you see,

We both are players of sax.

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 further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia.  Back from two weeks in Israel, I visited my sister in San Francisco.   Any identifiable patient information, including that of my wife, has been used with permission.

Jumping 9 time zones in 72 hours will ruin my sleep for weeks. Despite a great bed at a quiet hotel, I had trouble keeping to my resolve of never leaving bed before 4:00AM. I arrived at SFO 3 hours early.

I stretched my breakfast time, eating slowly and savoring my food. Paying on the way out, I noticed an instrument case next to a woman waiting for her meal.

“Saxophone?” I asked. She answered in the affirmative. As usual when I speak English (but not when I speak Spanish) I started to show off. I asked if she’d heard of Theo Wanne mouthpieces. She had but she hadn’t tried one.

As it turned out, we had seats on the same flight to Chicago, and continued our conversation in the boarding lounge.

In addition to playing for hire, she teaches instrumental music, frequently to Native American youth. We have a commonality in experience with Navajo, Hopi, and Tuba City.

I talk about myself too much, a failing I’m improving slowly by writing this blog. But I fell to my old habits. I recounted my Indian Health Service experience early in my career and my adventures since 2010. But because I did the talking, I failed to detail her story. Still, I discovered that she is en route to Maryland. She has a daughter who works as a family therapist. We both have low serial number Selmer Mark VI saxophones.

Modern technology has improved almost everything but so far that sax remains the best.

She got hers when the people who hired her band brought a saxophone down from the attic and asked if that would settle the account for the entertainment. I can imagine her surprise and the trouble she took to nuance her facial expression when she opened the case, raised her chin, and nodded. I can picture her shutting the case and saying, yes, this will do just fine, and I can just hear the passion that particular victory added to the way the band played.

During the conversation, I realized that the threads of saxophones and music have wandered through this blog for the last 9 years.

I haven’t played my horn with the delightful mouthpiece since my teacher, Diane, died. I have had a lot of excuses: difficulty traveling with a horn and living in hotels where other people pay to not listen to my music. But in the end, those remain just excuses. I have the ultimate saxophone with arguably the ultimate mouthpiece, and I have let them and my meager musical talent languish. My teacher would never have approved. It’s time to stop grieving.