Archive for the ‘Adventures in Iowa’ Category

Fixing a calf cramp

October 9, 2017

Type and cross has a 2 hour lead

So if a transfusion the patient might need

Stay 2 units ahead

So they don’t end up dead

If the gut gives rise to a bleed

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 three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed. I just finished 3 months in northern British Columbia, getting a first-hand look at the Canadian system. I’m now back picking up an occasional shift in northwest Iowa.  Any identifiable patient information has been included with permission.

“Always stay 2 units ahead of a GI bleeder,” they said in med school and again in residency. Many years and much experience has not diminished that truism, which to this day shines as an example of game theory.  It means that when a patient loses blood from anywhere in the gut, from the esophagus (swallow tube) to the rectum, that the physician must stay prepared to transfuse 2 units (a liter, close to a quart) of blood.

One can’t transfuse blood without first typing and cross-matching the blood, a complicated lab procedure that takes 2 hours. (For one extreme trauma patient in another country, I ordered the hospital’s entire stock of 5 units of O negative blood, the so-called universal donor type.  But that country has a very different legal climate, and I had no other options.)  You can lose the patient in the time it takes to do the test.

This weekend, I had a patient come in with profuse painless blood in the stool. My small rural hospital has a very limited blood bank, and the ride to the referral hospital realistically takes 2 hours.  I explained to the patient that transferring a stable patient beats transferring an unstable patient, and asked for permission to write about the case from the perspective of how doctors make decisions.  She gave me permission to publish the entire case, and pointed out that Facebook would probably have her room number before she arrived at the referral center.

(Her family history has a disease so rare that to name it would name the patient.)

The mathematical discipline of game theory has a whole branch dealing with games of incomplete and imperfect information. The real world of medicine deals with those circumstances.  I have to live with the limit of what can be known in the time allotted in the place where I work.  I know I never have the whole story and that patients never give a completely accurate history.  I have to work with what I get.

Thus I deal with the certainty of uncertainty.  I can’t know if the patient’s bleeding will worsen or stop by itself, nor if problems will arise during transport.  I have to look at probabilities ranging from worst to best case scenarios.

The paramedics arrived, and greeted the patient by name. Everyone knows everyone here.  As the patient shifted from the gurney to the stretcher, a cramp seized her leg, and she asked the paramedic to massage her calf.

“I can make that cramp go away,” I announced, perhaps with too much assurance. But I took the outside of the middle of the patient’s upper lip as close to the nose as I could, between my thumb and forefinger, and squeezed.  Fifteen seconds later, her calf cramp disappeared.

I think that I unduly impressed the nurses and paramedics,

I learned that acupressure trick early in my career, but I don’t remember where or when. Probably before I learned to stay 2 units ahead of a GI bleeder.

 

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The impossibility of scheduling call

September 27, 2017

We know that it’s always our fate,

When the call makes us work late

And our faculties sour

Because of the hour

And it’s really the call that we hate.

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 three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed. I just finished 3 months in northern British Columbia, getting a first-hand look at the Canadian system. I’m now back picking up an occasional shift in northwest Iowa.  Any identifiable patient information has been included with permission.

I took call yesterday. The ER load included 7 patients, all of them legitimately ill.  The five who came after clinic closed arrived at intervals of 2-3 hours.

One patient ended up in surgery.

One, so ill as to necessitate transfer to a higher level of care, needed my presence in the ER as the evaluation proceeded.  While the steady rain fell, the hours clicked off from 3:00 till 6:00, and the results came back from lab and x-ray, I chatted with patient and family members.

One family member (not the patient) told me about breaking her pelvis barrel racing, a women’s rodeo event involving riding a horse as fast as possible around three barrels set in a triangle in a rodeo arena. From my experience in western Nebraska, I already knew that the more time a person spends around horses, the more bones break.  But then she revealed she stayed in the saddle.  “They called it an ‘open-book’ type fracture,” she said, and pulled a copy of the x-ray up on her phone.  The g-forces involved in a tight circle had ripped the bones asunder.  I asked about osteoporosis, and she shook her head, producing another cell phone image showing her on her horse, her face distorted in agony.  When I handed the device back, she pushed a few buttons more and showed me the post-operative x-ray, which included hardware sufficient to stabilize a brick building in an earthquake zone.

I told her I write a blog, noted that as she wasn’t the patient that HIPAA didn’t apply, but nonetheless I wouldn’t write about her without her permission. “Go ahead,” she said, “I’m already a case study at the University of Iowa.”

When I compiled all the result, the subsequent transfer process went well with the patient leaving less than two hours after I asked for the lab tech to be called back in.

In a situation where doc-to-doc communication can mean the difference between life and death, and with an approaching shift change, I had to generate a note to go with the patient, and, in this case, it had to be a Word document. My usual stellar typing performance deteriorates with sleep deprivation, and proofreading showed I’d dropped about half my t’s.

Another patient came in with ten minutes left on my shift, again needing lab and x-ray. Not used to handing patients off, I met with the doc coming on.  We had a passionate discussion about how we love our work, but we hate call.

And really, without call the facility probably wouldn’t need me. The average patient flow in the ER doesn’t justify the expense of a dedicated ER staff.  Game theory predicts the impossibility of scheduling with imperfect and incomplete information. Nonetheless, illness doesn’t punch a time clock.

Shipping a patient: difficult, not impossible

September 22, 2017

There’s a thing or two that I’ve found

By plane, by chopper, or ground,

To move a patient who’s sick

I prefer it be quick

So as to arrive safe and sound.

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 three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed. I just finished 3 months in northern British Columbia, getting a first-hand look at the Canadian system. I’m now back picking up an occasional shift in northwest Iowa.  Any identifiable patient information has been included with permission.

3:00PM: within 30 seconds of meeting the patient I know he’s sicker than he thought, and within a minute and a half I know he belongs not in the clinic, but in the ER. (He gave me permission to write the information in this blog.)

Then I think to ask the nurse, “Wait. I’m on call.  Which means that I’m covering ER, right?”  She nods.

In the current jargon of real-world medicine, the word “dump” means transferring a patient to another service without proper work-up. In this case, though,  I can’t call it a dump if I hand off to myself.

While I wait for the ER gurney I finish my exam, and get as much history as I can.

Two nurses, pulled from the inpatient service to ER, arrive to transport the patient. I hand them a list of lab and x-ray requests and IV orders, and return to the other walk-in patients on my schedule.

3:40 PM: I quick step to radiology to look at images.  In the ER the nurses hand me copies of the lab results, giving me the start of a diagnosis and confirming that the patient needs an ICU.  I discuss findings with the patient and family.  I strongly recommend transfer.  They request a hospital 3 ½ hours distant.

4:00 PM: I weave through the hospital switchboard and phone tree to the consultant’s phone crew, who use a handset that renders speech almost unintelligible.  The consultant is not available.  Would I prefer to wait for the nurse, to leave a voice mail, or to provide a call back number?  I ask for the nurse.

4:10 PM: I run through the case with the nurse, who puts me on hold.

4:20PM PM: I present the patient to the consultant.  I run through the presentation, context, past medical history, lab, x-ray, and my working diagnosis.  I finish with a request to transfer the patient, and the consultant agrees.

In 21st century USA, a doctor cannot legally transfer a patient without a physician accepting the transfer.

4:30 PM: back in the ER to get consent-to-transfer signed.

4:50 PM: the accepting hospital calls to tell us they won’t have a bed available till tomorrow.

The nurses tell me if the patient needs fluids during transfer, we’ll need a Paramedic crew out of Sioux City, because no nurse can’t be found to accompany the patient.

I think that they want me to back off on the IV fluids, but I can’t.

Return to ER: I advise a transfer a hospital two hours closer. The patient and family agree.

5:00 PM: I have the hospital operator put my call-back number into the consultant’s pager, asking how long I should wait before calling back.  The hospital operator assures me she rechecks every 15 minutes.

The nurses point out that if I ask for a helicopter I can get the patient to the destination a lot faster. I look at the ground-transport time from Sioux City (90 minutes) and then the time to hospital, 1 1/2 to 3 1/2 hours.  I agree to the helicopter.

5:10 PM: The closer consultant calls.  My cell phone has enough signal strength to ring but not enough to keep from terminating the conversation.  The nurses usher me to a spot by a window, and I call the consultant back.

5:15 PM: I reach the consultant, who agrees transfer is appropriate, but tells me I have to call the hospitalist.

I call the hospital back to try for the hospitalist.

I didn’t ask for the helicopter lightly.  In this case the geography and gravity of the situation changes the risk/benefit ratio.

5:20 PM: the hospitalist picks up. I make my presentation, with updated vital signs and report on response to treatment.  He accepts the transfer.

5:30 PM: in the ER with the patient (who looks better but not well) and family again, I outline the progress and have them sign an updated consent-for-transfer specifying a new accepting physician and hospital.

I make small talk in the ER, then wander back to the nurses’ station.

5:45 PM: I ask, “When is the chopper due?”

The nurse shrugs. “They said 20 minutes 25 minutes ago.”

5:50 PM: the helicopter crew arrives, with a small bag of Dove chocolates.

I make sure they take the necessary papers with them.

At five minutes to six, the sweet thump-thump of the rotors reaches my ears. In less than twenty minutes, I know, the patient will have access to the personnel and services he needs.

The nurses note that I don’t look upset.  I tell them it might have taken 3 hours, but I’ve seen worse.

How did those samples find me?

May 11, 2017

The samples can help people quit
Without the nicotine fit
Tobacco detox
In a little brown box
Came free, and it made quite a hit.

 

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 three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

 

About ten days ago I found a box on my desk, sturdy cardboard, about 6 inches on a side. It held Chantix samples from Glaxo, Smith, Kline.
I hadn’t asked for the samples, I’d signed no papers for them, and I have no idea how GSK knew where I am. After all, I’ve only been here since February.
And they were the right samples to treat exactly one patient: a starter pack, because abruptly starting full dose Chantix risks major side effects, and two months follow-up therapy. Chantix turns out to work better in real life than it did in the lab; it works more consistently than anything besides quitting cold turkey.
The first patient of the day came in for other things (and gave me permission to write what I’ve written). But just like I do for everyone else, I asked if he smoked.
And, indeed he does.
I used to lecture people on the evils of smoking. By now, though, everyone already knows all the bad things about tobacco. Lecturing only brings antagonism into the relationship; “educating” the patient can thinly mask judging the patient.
These days I use a script from Motivational Interviewing, a technique that capitalizes on ambivalence. I hold my two forefingers a foot apart, and I ask, “On a scale of 1 to 10, where 1 means you’re not ready to quit, and 10 means you’re ready right now, how ready are you to quit?” If they say 1 or 10, I stop. For any other number, I ask, “Why not 2?” Mostly the smokers don’t get the question, and will tell me the bad things about tobacco. I interrupt them, explain that they weren’t ready for the question, and ask them the 3 best things about tobacco. When the patient understands what I’m asking, they mostly talk about stress relief, anxiety, and habit. A few talk about taste. One said “Breakfast, lunch, and dinner.” After they tell me their favorite things about tobacco, I give them a blank stare for 3 seconds, then change the subject. The idea of Motivational Interviewing is to get the patient to think.
But this patient gave me an enthusiastic 10. I don’t get many of those, just like I don’t get many 1s. And he’d done well with Chantix in the past. In fact, he wanted me to give him a prescription for Chantix. “I’ll do better than that,” I said, “I will give you the Chantix.” And 90 second later I reappeared with the samples.
He already knew how to use them, and he already knew about side effects.
I couldn’t think of a more appropriate way to use the samples. Tobacco makes any other medical problem worse.
I enjoy helping people, but certain parts of my work bring me disproportionate pleasure. A low B12, a high TSH, or curing someone by stopping their statin makes my day.
This one came close.

Reflections on medical frauds

May 8, 2017

The system is inherently flawed

They want me to sign and to nod

They have no excuse

It’s all billing abuse

And I’ll say to their face, “You’re a fraud.”

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 three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

Sunday I visited a web site that promised to cure my tinnitus. It had all the marks of snake-oil fraud: heavy reliance on testimonials, repeated themes that the establishment didn’t want the product to succeed, recounting hard-to-believe medical horror stories for those that relied on established medical practice, and at the end the assertion that the narrator didn’t want to make money, he only wanted to do good for the world but mainstreamers would soon make him take down his website because of jealousy over his success.  Those tools exist because they work, and they nearly worked on me.  I wanted to believe.  But I knew if the narrator really just wanted to help people, he would have made the audio download available for nothing, and relied on contributions to keep the website up.

Towards the end of the video the phone rang. I listened to the robot,  pressed one, and told the live operator, “Your prerecorded announcement said I got the call because I’d responded to a TV back brace commercial.  Is that right?”

“Yeah.”

“How can that be? I don’t have a television.”

The line went dead.

This morning when I dove into my IN box  I found 4 faxes from a physical therapy operation in a nearby town, wanting me to sign off on very general orders for patients that I didn’t know and certainly hadn’t examined. I called the number at the bottom of the sheet, and spoke with a secretary who explained that the firm had a direct access program.  I tried to explain, in turn, that I could not in good conscience sign off on a patient with whom I had had no contact.  But as Mark Twain observed, it is difficult to get people to understand if their jobs depend on them not understanding.  I turned the papers over to our clinic manager.

Yet I also got a similar order sheet for medical supplies, and I checked with the staff; the doc whose place I’m holding indeed orders those supplies yearly, and I signed.

Our country has an enormous amount of medical fraud; vendors interested more in profit than patients buy a lot of late-night TV commercial time, and some people call in to get scooters and other durable medical goods. Over the years I had a lot of requests to sign off on knee, back, elbow and shoulder braces, none were needed.

Yet a few vendors offer diabetic supplies at greatly reduced cost. So I can’t just shred all the requests.  I have to read each one.  After all, the fraudsters only copy successful business models.

 

Have imagination, will catastrophize. Professionally.

April 16, 2017

Here’s a subject in which I’m well-versed,

And for 40 years I’ve been immersed

When it comes to the best

I’ll just keep it in jest.

I’m paid to think of the worst.

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 three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

Some people have a thought process that involves using their imagination to the worst possible effect. They think of all the things that can go wrong, and, sooner or later, they run into health consequences from dwelling on negative things that haven’t happened.  The medical profession has a term for this phenomenon; we call it catastrophizing.   As time goes on, the catastrophizer dreams up more horrible scenarios; they come to my attention when they develop insomnia, depression, and other problems.

I try to point out to the person in question that they couldn’t have anticipated the 10 worst moments of their lives, and that none of last 10,000 terrible “what ifs” they imagined came to pass. Therefore, it follows, that just by dreaming up negative scenarios, they prevented them.  Mostly, they don’t listen.

In the daily course of my work I think about the worst things I can imagine. I’m good at it, I’m a pro.  I have talent, training, and experience.  I can think of really terrible things.

Of course, like the experience of any catastrophizer, most of the really bad things I think of never come to pass. The thought doesn’t quite cancel out the possibility; I run the diagnostic tests.  At the end of the visit I frequently say, “You want me to be wrong.  You want to walk away from the tests shaking your head and complaining about what an alarmist your doctor is.”

A patient (who gave me permission to write this) came in with terrible pain in her hands. I thought of Lyme disease and rheumatoid arthritis, and ordered appropriate tests, but I also examined her med list and decided to at least temporarily remove the most likely candidate, her statin.  A week later, the pain is gone, and she feels better.

I also did not diagnose cancer, Lyme disease, syphilis, B12 deficiency, lead poisoning, measles, sepsis, and meningitis. Despite of string of previous successes, I also failed to find folic acid deficiency and polymyalgia rheumatic.

But I went looking for them. In my case, imagining the scenario doesn’t prevent it.  But, then again, I’m a pro.

 

 

Measles, a word the 7-year-olds haven’t heard

April 9, 2017

Here’s a contagious word to the wise

If there’s rash and runny eyes

With a cough, I suppose

Look! How runny the nose!

And it’s MEASLES! The CDC cries!

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 three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

About 3 weeks ago I received an email from the Iowa Department of Public Health about a case of measles. The person (age and gender not given) had been in the Omaha airport on March 12.  Diagnosis of measles had come on March 15, after visiting 3 different healthcare facilities.

So I was on the lookout for a disease I hadn’t seen for 30 years.

Finishing my Indian Health Service contract in 1987 at the Tuba City, Arizona Indian Health Service Hospital, I saw hundreds of cases, and I had to learn about the disease. Measles discussions center on the 3 c’s: cough, conjunctivitis (runny eyes), and coryza (runny nose); the patient looks sick, and has a fever.  The rash starts on the face, and in the next three days works down the body, concentrating in the midline, armpits, and groin.  The 3-day or German measles has a similar looking rash that also starts on the face and spreads down, but people don’t get nearly as sick.

At the time, that reservation had an immunization rate close to 100%, but when the dust settled, the case count came very close to a 5% vaccine failure rate. Since then, the MMR has gone to a two-dose immunization schedule.

With the alert fresh in my mind, I had reason to think of the things I learned and saw so many decades ago. Working a game of incomplete and imperfect information, I called the state Department of Health.  Connecting eventually with an expert who had never seen the disease, but knew what to order, I heard for the first time of a viral transport medium called M4.  And I learned to use a culturette or a Dacron swan, not cotton and certainly not wood.

We still have no treatment for the disease. And with the illness almost extinct, we probably won’t invent one.  Yet measles still runs into complications in almost 10% of those who have it.

Exposure confers lifelong immunity, and only humans can get measles. Thus as an undergrad in anthropology, in one class we did calculations based on 2 week contagion, 3 week incubation, and generation length of 20 years to figure out how what size population can support the disease.  We decided, eventually, that measles couldn’t be more than 50,000 years old.

Measles remains contagious in the air for 2 hours after a person with an active infection leaves a closed room. Thus the case that triggered the alert, arriving on an airplane, exposed a lot of people.

I want to know about that case. What irony or drama surrounds the circumstances of inadequate vaccination?  Who did the exposing, and how sick did that patient get?  Where was the exposure, and was it linked to the Disneyland outbreak?

I never had measles as a child. The son of a physician, I served as a test patient when I was 14 for the first measles vaccine that only served to deplete what my meager natural immunity.  I had to wait till middle age to get an effective vaccine.

Later that day I asked a 7 year old if he’d ever heard the word, measles. “No,” he said, “What are they?”

The antivax movement makes no sense. Mercury has been removed from the vaccine, and all the evidence linking MMR to autism was fabricated by one researcher who has since owned up to his deception, yet that myth persists.

I fear that the antivaxxers may get enough traction to let the genie back out of the bottle, and that the word, measles, may once again become part of the language.

Weekend call: nature abhors a vacuum

March 27, 2017

I took the weekend on call

I started with no patients at all

But I fixed that up quick

With the ill and the sick

The thin and the fat, the short and the tall.

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 three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

 Perfect people don’t come to see me. When I find a patient who has to face the music and pay the piper, I do my best not to judge.  Strangely, when I can condense my approach to, “You’ve made mistakes in the past, let’s move forward,” I find it easy to establish rapport.  I like to think that the rapport brings better chance of patient cooperation in lifestyle modification.  At the very least I have more energy at the end of the day.

In residency and in private practice, when I would take sign-out for weekend call, I would look first at the gross number. Of course we like it when no-one occupies a hospital bed.  But if the number came in really low, I’d shudder and remember the adage, “Nature abhors a vacuum.”

This weekend, I started call on Friday afternoon with a census of 0. By the time Saturday morning dawned, the census had climbed to 5.  Most, not all, had pneumonia.  Most, not all, sickened from a combination of tobacco damage and the aftermath of the influenza. I went into a rhythm of admission history and physical.

I dictate with sophisticated software. Still, sometimes I get so frustrated that I use my well-honed keyboarding skills.  For example, dictating a list gets me correct numbers except “4” which prints out as “for.”

And beneath the commonalities of fever, cough, and wheeze, each patient has a unique circumstance, a story of drama and irony that brought them to illness. And almost all have come at a time of stress in their lives.

Nothing is 100% in my business. A very few patients sickened gratuitously.  A genetic accident should not constitute a death sentence.

I enjoy talking with the patients. I ask them what they do in their spare time if they haven’t told me before I get to the question.  Over the years I’ve acquired enough vocabulary to speak meaningfully about a wide range of subjects.  Particularly in rural America, being able to talk about farming, crop yields, soil management, firearms, archery, and hunting gives me credibility.

Here in Clarinda, close to St. Joseph, Missouri, I ask people my age and older if they remember the Jerome Hotel.

It belonged to my grandfather. I drop his name.

 

 

 

What does “call” mean? Don’t look in the dictionary

March 26, 2017

Consider the places I’ve been

Then tell me, what does “call” mean?

For sometimes the word “call”

Means nothing at all

And sometimes it can make me turn green

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 three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

People can use the same word to mean different things, and the same person can use a word at different times to mean different things.

For example, when I worked in the Indian Health Service, “call” started at 4:30PM and lasted until 8:00AM. Weekend call started on Friday afternoon and lasted till Monday morning.

In my years of private practice, it started at 5:00PM and went till 7:00AM. The doc who took Friday evening call worked the clinic on Saturday from 9:00AM till 2:00PM.  The physician with weekend call started Saturday as early as he or she wanted, rounded on the patients in the hospital, and took care of admissions till 7:00 Monday morning.  For a long time we saw the patients who came to the ER, but that faded over the years.  The on call doctor did the obstetrics over the weekend.

Call in Barrow (now called Utqiavik) never meant anything other than 12 hours, weekend, weekday, or holiday.

In Petersburg, the physician on call also covered the emergency room.

In western Nebraska, being on weekend call meant doing a Saturday clinic till noon, rounding on patients Saturday and Sunday, and admitting patients from the ER.

In Metlakatla, where we had no hospital beds, the two main ER nurses had excellent clinical skills. I could rely on them to know when I needed to come in and when I could safely wait to see the patient in the morning.

I have call this weekend, starting at 8:00AM on Thursday and going to 8:00AM on Monday. During that time, I’ll round on the hospitalized patients.  But someone else will work the Emergency Room.  If a patient needs admission, the Emergency doc does an admit note and writes admitting orders.  If a patient needs me to come in and see them before morning, they generally need to be at a larger facility.

I have had two nights of call so far. The first one passed without my phone going off, not even once.  The second time I worked steadily till 9:00PM stabilizing a very ill patient for transport.

But what does call really mean, here, this weekend?

I can tell you on Monday.

And I can guarantee it won’t mean the same thing a month from now.

Finishing early=playing hookey

March 22, 2017

The morning went just a bit slow

And I left with an hour to go                                              

But with the time I had freed

I got in some read

And enlarged the stuff that I 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. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

Last night Bethany and I had the chance to tell my story to a housemate. Coming up to my 60th birthday I knew if I didn’t slow down I’d burn out.  But I had a one-year, 30 mile non-compete clause.  That’s when I went to Barrow, Alaska, the northernmost place in the US.

Bethany recounted the time I called her to say that I had put in 63 hours that week, but I had time for the gym, playing my sax, participating in a jazz group, recreational reading and writing, socializing and watching TV. I initially attributed the extra time to commute reduction and other factors inherent in living in a small community, but then I applied the same criteria to what I’d been doing in private practice and came up with a conservative estimate of 84 hours a week, not counting obstetrics work.

Nowadays, any work week shorter than 60 hours feels like vacation. And when I walk into the clinic on Mondays, my steps bounce and I grin because I love the work.

I love it passionately up to about 50 hours, and after that my enjoyment starts to decay.

And I think my patients can tell when I get excited about a diagnosis. And when the patient makes my day, I tell them so.

Since I got here I’ve been able to radically help about a dozen patients with either Parkinson’s (involving tremor and stiffness) or PMR, polymyalgia rheumatic (an inflammation of the arteries).

But as influenza season wanes, so does the patient flow. This morning I had no inpatients at all.  Of my two scheduled morning patients, the first one showed on time at 9:00 and the second at 9:30.

I used the hours to read up on PMR . It overlaps with giant cell arteritis (GCA) and temporal arteritis (TA).  Because it comes in clusters, some authorities think it might be viral, and, indeed, if a biopsy of the temporal artery (which runs from right in front of the ear up into the scalp on the side of the head) shows TA, 3 times out of 4 it has the chickenpox virus in it.

Bethany met me for lunch.

In the afternoon I did some more work on my Canada license. I read up on Parkinson’s disease.  I saw 4 patients and finished their documentations.  Throughout the clinic, calm and low patient flow prevailed.  I got permission to leave at 430PM.  Bethany picked me up outside the front entrance, with a stiff March breeze blowing.  She took one look at me.  “Feel like you’re playing hookey?”  she asked.

I nodded. I had only worked 9 hours.