To stitch or not to stitch.

Lacerations rarely come planned

When it comes to a cut on the hand

With fibroblast zeal

The deep part will heal

But the outside will gap, on demand. 

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,, followed by vacations in Israel, San Francisco, Iowa, and now Texas, visiting our oldest daughter and her family.   Any identifiable patient information, including that of my wife, has been used with permission.

My daughter and son-in-law had friends over, one of whom came with a finger laceration.

In a room crowded with physicians and advanced degrees, I volunteered to answer the question of to stitch or not to stitch.

Inspection of the wound on the thumb-side of the middle finger tip, diagonal and clean, with no bleeding.

I advised against sutures.  As a group, we showed off the healed consequences of our collective experiences cooking.  All the lacerations happened to the thumb side of the last joint of our middle or index fingers; all were diagonal.

Then we had a colloquium about tetanus shot.  Quite some time ago (perhaps as recently as the Pleistocene) I read that no one who had had 3 tetanus shots had ever had tetanus, but none of my younger colleagues could confirm or deny that assertion.  And none of us had had a patient with tetanus, though I had heard of a case of an unvaccinated child dying from the disease.

The tetanus bacterium belongs to the same genus that includes botulism.  Those germs produce spores that can be killed with cooking under pressure but not with ordinary boiling.  They are common soil organisms, but tetanus only contaminates dirt by way of ungulate feces.

One of the other docs said, “Ungulate? I haven’t heard that word since undergrad!”

Yes, I overuse long words.  I could have said horse droppings.

We also had a super-glue (chemically the same as DermaBond) colloquium.

The finger has since healed well without stitches. Fortunately I warned that the dermis, the inner growing layer, would heal but the outer dead layer, the stratum corneum, would not.

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The VA sent out a wonderful video featuring one of the Navajo Code Talkers who had been at Iwo Jima.  He gave an example of one of the messages in Navajo, a language I spoke in the 80s.  Just for fun, I hit pause, and listened to the exact message before translation.  Sheep eye nose deer destroyer tea mouse turkey onion sick horse 3 6 2 bear.  I missed destroyer, tea, mouse, and onion because I’d never needed those words clinically.

What it meant was “send demolition team to hill 362B.”

Even a Navajo speaker could not understand the message, because the system was dual-coded.  And each English word could be one of 3 Navajo words.  The program stood as a paragon of efficiency by bypassing a couple layers of bureaucracy.  Two code talkers could relay a message in 20 seconds where as the standard machine code/decode sequence would take 30 minutes.

It seems obvious that person-to-person communication beats reliance on technology in terms of clarity and efficiency without compromising security.  A lesson I’d like to see applied in the health-care setting.

10 years, 150,00 views, and 80 thousand visitors

You know we’re having a blast

For the decade that’s now almost past

I call Walkabout

My wandering route

I was saving the best for the last

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, and vacations in Israel, San Francisco, and Iowa. Now currently on vacation in Texas, visiting our oldest daughter and her family.   Any identifiable patient information, including that of my wife, has been used with permission.

Tomorrow marks the 10^th anniversary of my blog.

I am a better writer for the 845 posts, but I am also 10 years older.

Reading back the first 4 months, I can feel how close to burnout I’d come.  Bethany knew it, but I didn’t.  And then I can read the euphoria of the decompression.

I have used this written record over and over, to reconstruct my movements, especially when applying for new positions.  I keep recommending my post on my personal experience with chronic pain to my patients, but my piece about gravity drainage for sinusitis remains the most popular.

I have had more than 150,000 views from more than 80,000 visitors.

In the beginning I would sit down to write and before I knew it I’d put down a thousand words.  Then, to keep my posts in the 500-600 word range, I’d have to edit down.  Somewhere along the line I started to edit as I wrote, and I can tell where my writing lacks exuberance.

Initially I had a lot to learn about negotiation and uncertainty.  Eventually I learned I’d say yes to 6 jobs for every one that came through.  That ratio of the first year has held since.

Learning lots of new electronic medical record systems got me over my fear of computers but not over my resentment at how poorly they function.  I have come to acceptance.

I’ve also come to accept the inevitable hiccups that derail plans.  Unplanned things happen and I shrug and grin and say, “It’s all part of the adventure.”

And what adventures my wife and I have had.  New Zealand, Canada, 7 different Alaska locations.  Gems in Iowa, Nebraska, and Pennsylvania we never would have known about if I hadn’t gone Walkabout.  Seeing the drama of the human condition up close enough to smell the pheromones of irony.

Of course the world has changed.  As American medicine deteriorates before my eyes and physicians burn out earlier and earlier, new diseases arise and new treatments get invented.  Tobacco continues to slide to its logical conclusion, but even if the last cigarette had been smoked yesterday, I’ll have work from its last gasp for another 10 years.  Marijuana legalization will give us consequences to deal with for generations.  As a country we have started dealing appropriately with opioids, using laws and prescription tracking.  Cocaine and meth seem to have been eclipsed by heroin.   Alcohol has never gone out of fashion; I do not see an end to its days as a killer and disabler.

My locum tenens years now constitute more than 20% of my professional career since finishing residency in 1982.

I’m trying out an extended vacation, with my wife, our oldest daughter, and her family in Texas.  I miss patient care, but tomorrow Bethany and I will go fishing.