More Like Have a Nice Vacation Than Saying Goodbye

If not normal, what could it be?

I can think of a horror or three.

I don’t try very hard

And those thought I discard

But this time, I know what I see.

 

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 a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

 

Between patients my nurse asked, “Did you see that outside?”

I looked out the window. “It’s snowing,” I said.  “In January.”

“But it never snows here!” she said. Indeed, this island in the Japan Current rarely gets so cold that the precipitation falls as a solid.

I have come to another last day of an assignment. I worked here in April, and enjoyed it.  But they only needed me this time for their holiday vacation coverage.

The upcoming Tribal Council Inauguration had shifted the clinic routine, with the last patient scheduled at noon today. But the Council postponed the ceremonies out of respect for the family of a suicide.  That tragic event got splashed across Facebook.  I know no more than the general public knows about the case, and, considering a few insiders, I know a good deal less.  I won’t write about it.

But in a community this small, where everyone knows everyone, I started to see the medical fallout within 48 hours. Two of my 9 patients today would not have gotten sick but for the stresses and chaos from that suicide.

The island has a strep epidemic going. We now have clinical criteria, the Centor Score, which takes into account age, fever, tonsillar exudate (if you prefer, pus), enlarged lymph nodes, and absence of cough.  I have asked for rapid strep tests on my sore throat patients, but, after examination, if the patient has fever, big lymph nodes near the jaw, pus on the tonsils, and no cough I prescribe penicillin (to the non-allergic) no matter what the test shows.  Our facility ran out of injectable penicillin, though, a week ago.  But as I read up on the subject last night, the main preventable complication of strep, rheumatic heart disease, dropped below less than one case in a million 20 years ago, and the CDC stopped keeping statistics on it.

Four of my 9 patients had sore throats today. More had coughs.  Towards the end, people start wishing me well, but it felt more like telling me to have a nice vacation than saying good-bye.  I’d like to come back again.

I make a living out of thinking of the worst thing possible.  It’s something I do with every patient.  Mostly I delete the catastrophic stuff from my consideration, but today I went ahead and got an x-ray which should have had a low chance of being productive.  I waited as long as I could for the radiologist’s report, but as the hum of the clinic faded to a whisper, I went ahead and ordered the MRI because I couldn’t deny I’d seen a shadow where I shouldn’t have.

I put on my jacket and slipped the cleats onto my boots. I stepped out into the driving snow.  As the fat, wet flakes melted on my face, I hoped I was wrong.

The Risks of Patient Transport: playing games of imperfect and incomplete information

Blog 2017 January 5, 2017

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 a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

In private practice last century, I got a call from a mother of a sick child late in the afternoon. Despite a tight schedule, I told her to bring the kid up, now, and I would attend to the problem.  In a hurry, and in traffic, her car collided with another.  No injuries resulted, but since then I have always kept in mind the risk of patient transport.

Many Alaskans live in places inaccessible by road. You can get there by plane, train, or boat, or, in winter, by snow machine.  Rivers thus become highways, not barriers.  The geographical imperative colors medical decision making.

Game theory forms the basis for making a lot of choices, and medicine becomes a microcosm of the human condition. Any course of action carries a risk, and, at the same time, not taking that action carries a risk.  As physicians, we deal with the real world when we play games with incomplete and imperfect information.

Consider, for example, a hypothetical patient in alcohol withdrawal. At first evaluation, I would generate a CIWA (Clinical Institute Withdrawal Assessment) score based on temperature, blood pressure, pulse, sweating, agitation, irritability, restlessness, memory, and overactive sensations of touch, hearing, and sight.  In Iowa, where transport to the hospital carries almost no risk, a score above 8 would mean hospitalization.  But here, a score of 25 would make me consider sending the patient to Ketchikan by boat.

Not so fast. If the wind keeps the floatplane from flying, it whips up whitecaps on the water.  I would have to consider the risk of drowning 5 people.

I also have to consider the risk that the patient, once stabilized in the Ketchikan ER to a score less than 8, might be discharged to the streets.

In such a case, I would do as much as I could (in this example, fluids, vitamins, and sedatives in the family that includes Valium, Xanax, and Ativan), keep the patient in my ER, and, if I could get the CIWA score under 8, get twice daily follow ups for a couple of weeks.

When we refer patients out, they usually go to Ketchikan, but our obstetrics patients go to Sitka. Major illness requiring subspecialists could go to Seattle or Anchorage.  And every transport carries a risk.

Chickenpox, and cannabis hyperemesis syndrome

The patient came down with some spots

All over, in multiple crops.

So I called up the State

To tell them this date

To watch out for chickenpox.

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 a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

I saw a patient with chickenpox today (and received permission to mention it and more in my post). Though outbreaks came a couple of times a year last century, the varicella vaccine has made the diagnosis a rarity.

The characteristic lesion starts out as a red bump. The bump grows a blister, characterized by the poetic catch-phrase “dew drop on a rose petal.”  Then follows a pimple (doctors say pustule), which collapses in on itself (medicalese=umbilication because it looks like a belly button), and scabs over.  To make the diagnosis, the patient has to have multiple crops of lesions, coming successively over the course of several days, visible in various stages of healing.

A very small proportion of those vaccinated, less than 1%, will develop the disease from the shot, sometimes a year afterwards. Among the vaccinated, 5% will get chickenpox if exposed to the wild virus, but the infection may be so light as to be unrecognizable.

Still my strong suspicion and the public health laws made me call the Alaska State Epidemiologist, and I found out that, in fact, the illness is currently circulating. In the end, I based my decision not to medicate on the number of days elapsed since onset and the desire for the treatment not to be worse than the disease.

I saw two cases of cannabis hyperemesis syndrome today; if a person smoke a large amount of weed for a long enough time, they start to vomit and very little can help them besides stopping the marijuana. I went to my favorite physician’s social media site, Sermo, to research the problem and found, to my surprise, the tendency of those so afflicted to crave hot showers and baths.

I saw two men with astonishingly similar injuries from astonishingly similar circumstances.

One patient came to me after a specialist work-up and MRI and many, many primary docs over the years failing to help. I listened without interrupting. I came to a much different conclusion, and advised that the dentist had a better chance than anyone of fixing the problem.  At which point the patient told me the diagnosis.  Not in medical terms, but in plain English.

 

Working the 4-day holiday weekend

The continuous days I worked: 4

And had I wanted I could have had  more

With a wink and a scoff

I took the day off.

Cause it was offered.  Oh, what a score!

 

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 a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

I had call for the 4-day holiday weekend.  It went well, as such things go.  Always alert to the chance of call back, I napped wholeheartedly at every opportunity but slept fitfully during the night. I didn’t set an alarm, but lived with the fear that the hospital-issued phone would run out of charge or otherwise fail.

Patients came in a reasonable flow.  Late morning and midafternoon brought one or two people to our ER.  In a town such as this, where everyone lives walking distance from the clinic, our nurses can make house calls.  They draw blood, and can run a few tests on the weekends.

Our clinic boasts very high quality ER nurses, tough and experienced.  They’re not afraid to make a decision about what can wait till tomorrow and what can’t.  They have good clinical judgment, and I can trust them.

I didn’t have to call staffers for lab or x-ray, but when a patient’s illness exceeded our resources, I had to call the transport team.  Interestingly, the patient’s illness exceeded the resources in Ketchikan as well.

I didn’t see more than 5 patients a day.  On two of the call days I had work between 11PM and 8AM.  Every patient, if not downright polite and respectful, was doing the best with what they had.  They mostly suffered respiratory issues.  Two had run into  trauma, there was no interpersonal violence.  Everybody came in sober.

On Tuesday morning I trudged through the rain to the clinic for Morning Report.  I discussed the patients I’d seen.  I got a lot of sympathy for taking 4 continuous days of call, and made haste to say that it really hadn’t been at all bad.

Then I got an unexpected day off.  The weather didn’t get any better, under leaden skies the rain either spit or poured, driven by winds remarkable for inconsistency.  Still, Bethany and I went walking around town, to the grocery store and the Post Office.  I marveled at foot traffic and the scenic beauty, things I’m not used to seeing because I spend the day inside.

If you can’t have a good time in bad weather, you need more practice.

 

 

 

 

 

Christmas 2016 on call

When it comes to Christmases all,

I’ll consistently take all the call

The 25^th of December

Is a time to remember

Saving lives in a hospital’s hall

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 a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

I take call for the Christmas holiday; with two exceptions I’ve worked every December 25^th since 1973.

Friday night we had company for supper. I got called to ER, but took care of the patient and the paperwork and made it back to the apartment in time.

As a village with a maritime orientation, the town has a tradition of decorating boats for Christmas, and Friday launched an aquatic parade, complete with fireworks when the night got good and dark. We enjoy the seasonal lights, and the spectacle moved across the water, bringing a new appreciation, punctuated by occasional fireworks.  As we watched, I thought to myself that where people have seasonal recreation, injuries will follow, and I wondered what I’d seen in the ER.

If I had thought hard, I might have predicted the hurt that brought me back to the clinic a few hours later. As with most trauma, I advised the RICE protocol:  rest, ice, compression, and elevation.  But I also did a good deal of therapeutic listening.

In the run up to the holiday I read my posts from previous Decembers, and thought back to other Christmases working.

The urge to talk about the bad calls tempts me, but I’ll have more energy at the end of the post if I don’t. One of my patients asked me how many lives I’d saved on Christmas.  I hadn’t thought about it till she asked, but, in fact, I’ve saved a lot.

And I saw really interesting pathology, stuff I’ve not seen before or since (I can list the diagnoses without designating time or place). Q fever.  Duodenal atresia.  Leiomyosarcoma.  Dermatomyositis.  Plague.  Hypernephroma.

In the early morning hours today I took care of a patient for problems that had nothing to do with his recent survival of being in a plane struck by lightning.

Right after that I took care of another Christmas-related injury.

For both those patients, I carried on wonderful conversations with the people who accompanied them. I exchanged views on firearms and deer hunting.  I bragged about missing a deer at 6 yards with my bow.  And  I showed off my knowledge of chiles: if you want the hottest pepper possible, restrict the water supply in an area with cool nights, and, after roasting and peeling, freeze and thaw the chile.

 

First week back in Metlkatla

With parents, so strong, warm and brave

To them the praises I gave

Imagine the joys

In a room with 3 boys

And all of them stay well-behaved.

 

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 a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

MONDAY

Normally, I cruise right through jet lag, but with plane delays, sleep disruption on the way here shattered my usual techniques. The schedule wisely gave me Monday morning to get up to speed with the EMR, but no one to help me.   I used this system here and elsewhere in Alaska before.  Open –sourced from the Veteran’s Administration, it has functioned well for the last couple of decades.

The sun rises late and sets early here, short days mean I walk to and from work in the dark. I wake up early, more or less at the time I got up in Iowa.  But my office and the exam rooms have windows giving onto spectacular views, with evergreens and towering, snow-capped mountains.  Sometimes, during an examination, I ask patients whether they get tired of the scenery.  Uniformly, they don’t.  People move back from the cities to live here.

TUESDAY

Our clinic does a lot of treatment with nebulized albuterol, IV fluids and Zofran (ondansetron), a potent anti-vomiting drug. So far everyone needing albuterol smokes or is exposed to smoke.  Dehydration,  with the need for IV fluids, can come from a number of sources.  I get a charge when a patient feels better because of fluid replacement or breathes better because of albuterol.

Wednesday

I’ve given out a lot of Zofran since I started here three days ago; I enjoy the change on patients’ faces when the drug takes away the nausea..

Today I have call.  With the upcoming holidays and a number of permanent staff on vacation, the usual Wednesday afternoon meetings got postponed, and no one bothered to reschedule patients.  I didn’t want to face an afternoon with no work, and, as it turned out, I didn’t have to.

We have limited diagnostic and therapeutic capabilities here, and I don’t mind. With no CT, very limited lab chemistries, and no ultrasound, we send a lot of blood tests out.  If time frame permits, we make arrangements for transport by ferry for specialist consults.  But more than one person so far has required Medevac via boat to Ketchikan

THURSDAY

More permanent staffers have left on vacation. Mostly I do Urgent Care with a chance of follow-up, but sometimes I take care of people with long-term problems.

Today a family came in, both parents and three sons under the age of 10. The boys stayed well-behaved and quiet, without interruption, during the entire visit.  When not watched, the oldest took the opportunity to hug his brother.  I saw similar patterns of behavior in other families with three sons when I worked here in April: oldest hugs middle, middle hugs youngest.  At the end of the visit, I thanked the parents for the treat of caring for their children.

I didn’t say, but I wanted to: “It’s a pleasure to work in a community where families maintain such a high level of functionality.”

 

.

Too many the tales of woe
That result when the fall of the snow
Stop the traffic by air
And it hardly seems fair
When you’ve thousands of miles to go.

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 a couple of gigs in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

I met Bethany in Omaha as the temp hovered near freezing.  With no break between assignments, in the hotel we packed for 3 weeks in Alaska as, outside, ice encrusted the car. In the morning, we took more time on the ground in Denver then we did in the air getting there, as the blizzard turned the runways into a winter wonderland of snowy jets.
Weather delay horror stories come cheap, most of us can tell them. While the wind whipped plumes of snow across the airport campus, the day came and went, we missed connections and got lied to.  Lines moved like depressed, hypothyroid glaciers.

Twelve hours later, as we boarded the plane for Seattle, the gate agent warned about the cold jet way, exhorting us to don coats and move quickly.  I found the walk cold, but not cold enough to frost my beard.

Rain dominated the scene in Seattle with people wearing down jackets and complaining of the cold. I thought the temp relatively gentle.

We slept four hours and got up to face the security delays.  I dodged giving a TSA agent medical advice for a relative, directing her to my blog.   I won’t include the marvelous short conversation because I didn’t ask permission.  Even if she didn’t know I’m a doctor.

We landed in fog and driving rain in Ketchikan, the weather we expected, with the mercury in the low 40’s and vicious wind.  We took our time lunching at the Best Western, delaying the short, soaking walk to the ferry terminal.

The late-model vehicles, all in good shape, had to back down the ramp to park on the ferry deck.  I watched the drama and irony as the sea birds struggled not to get blown away.

The last time we made the passage, in April, we sailed on calm waters, but this time we faced white caps and significant chop.

We got a text from a friend at home just as we landed; the temperatures there plunged to the negative double digits.

As ironic as it sounds, we dodged cold winter weather by coming to Alaska.

 

 

 

 

Uncertainty usually strikes at least twice

Only a second was I left perplexed

And then with the changes I flexed

I know what to do

When the plans all fall through

I ask, What shall we do next?

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. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  Just back from a Canada moose hunt, I’ve worked a couple of days in northern Iowa, and I’m taking a few days off.  Any identifiable patient information has been included with permission.

I have been working on practicing in Canada for 20 months. Six weeks ago I thought I was within 2 months, then 3 weeks ago learned that my case would have to go through immigration because I have no plans to immigrate.  And that their review would take 6 months.

OK, I know how to deal with uncertainty. Bethany and I talked for about 10 minutes, with the unspeakable luxury of discussing, Where shall we go next?

If I had the chance to tell me as a teenager what life would look like 50 years in the future, I would not have believed me saying that such freedom could exist in the real world. We decided on interior Alaska for the winter.  And I decided I wanted to work for the Veterans’ Administration, because they have been so very good to me.

I got on the net, I plugged my headphones into my cell, and I started the process. VA facilities run shorthanded chronically, but the one in Fairbanks no longer works with agencies.  And they are willing to work with me directly.

Over the next couple of days I got emails from several people in the institution with a far warmer and friendlier tone than I expected.

Last week I started the credentialing process. I put in a mere 7 hours, finishing yesterday with a trip to FedEx.

Because I cut the agency out, I’ll have to arrange my own housing and vehicle.

Tonight I talked with a man who specializes in selling cars to seasonal Alaska workers and buying them back when the jobs are done. I’ll wait till things have firmed up till I start contacting real estate agents and other housing mavens.

Yesterday I learned that that my putative Canadian gig had found permanent recruits and wouldn’t need me.

Uncertainty, part of the human condition, runs rampant in the locum tenens business, and struck again in less than a week. Yet from experience I know if something falls through, I generally end up having a better time with my second, third or fourth choice than I would have with my first.

I got out my 3×5 cards and started making notes as I cruised Googlemaps and Wikipedia.

I read stuff to Bethany, and we talked. She doesn’t want to go anywhere reachable only by small plane or snow machine, or that has under 1000 people.  I, in turn, define my professional zone of comfort as less than 2 hours from the nearest surgeon.

We have to have indoor exercise facilities for both of us, internet access, and at least one grocery store. Nice options would include a cinema, indoor archery range, and recreational fishing.  I would like to walk to work, and Bethany would like to be able to get work as a teacher.

We’re looking forward to the next adventure.

 

 

Chain Hotels: tasteful, but no local flavor

I came, I worked, and got paid

I left as twilight did fade

I did well to cheat

My exposure to heat

And in a nice hotel I stayed.

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, travelled 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. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska. Getting my wife’s (benign) brain tumor treated took a large part of the summer. I worked a week in urban Alaska before heading to Pennsylvania to our married daughters and our grandson.  Any identifiable patient information has been included with permission. 

 

I stayed in a very nice hotel in Alaska, with a hot breakfast every day and tasteful décor.  I walked to the clinic in the mornings, lunched in the Doctors’ Lounge, walked back in the evenings, and watched first-run movies on the TV.  After a week, I checked out of the hotel, and met up with a longtime friend in Anchorage.  We spent a morning scouting for moose.  About sunset, I headed back to the airport where you can spot the fisherman by the coolers and the cylindrical fishing rod cases. With day faded into the subarctic’s midnight twilight, I boarded the jet and sleep poorly all the way to Chicago O’Hare.

I left Alaska under clear skies with ideal temperature and deplaned in Chicago in stifling humidity and heat. My flight from Chicago to Pittsburgh got cancelled, due to “air traffic congestion.”

I had never heard of such a thing.

I approached the ticket agent with cheery patience. Actually, I was determined to be so sweet she’d get diabetes from talking to me.  While she tapped furiously at her keyboard, I said, “Look, it’s rare in my life that this happens, but today I’m just about as flexible as can be, and these folks behind me, they just want to get onto the plane.  So go ahead and take care of them, and after they take off, you can see if you can help me.”

Jet-lagged and sleep-deprived, I slouched into a deliberately uncomfortable chair and snoozed. When the crowd cleared out I approached the podium.  The agent booked me to Pittsburgh the next day with a flight through Charlotte, NC.

I very politely asked for a hotel voucher. She looked at me for a moment, and then said that she almost never gets anyone nearly so calm as me and she would see what she could do.  I watched her take her case to her boss at the next gate, and she came back with a voucher.

I stepped outside the air conditioned airport into the heat and waited for the shuttle. I went directly into the cool of the hotel and checked in.  The clerk, finding I had no food voucher, comped me a bag of snack mix from the in-house mart.

I haven’t always gone out of my way to avoid the heat. In the summer of 1972 a college buddy and I rode our bicycles from Connecticut to Denver.  One hundred-mile day in Ohio we each drank 3 gallons of fluids and urinated not a drop.  By the end of the trip, entry into normal climate-controlled businesses felt uncomfortably cold.  Till two summers ago I wouldn’t use the car AC in town.  As time has gone on, though, I find the cold easier to tolerate than the heat.

The next day I flew into Pittsburgh. My oldest daughter picked me up.  I didn’t discourage use of the Honda’s air conditioner.

I checked into a hotel of the same chain I had in Alaska. It had the same hot breakfast and tasteful décor.  Nice, but no local flavor.

 

 

Of Red Tide and dead walrus

We went for a very short ride

And found acres exposed by low tide

Which brought within reach

Clams of the beach

And other things people eat fried

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, travelled 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 am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. After two months each in Western Nebraska and the West Coast of Alaska, I’m now in Southeast Alaska.  Any specific patient information has been included with permission.

An intestinal virus with violent vomiting and profuse watery diarrhea has dominated my clinical work for the last week. It hits the toddler-to-middle school age range disproportionately, but it still struck a lot of adults, and struck them hard. I can’t do anything for the basic disease process; people tend to heal on their own. But if dehydration sets in, I have developed a routine that calls for 2 liters of IV fluids (if you must know, Normal Saline, the same as 0.9% Sodium Chloride) and 8 mg of ondansetron (trade name, Zofran).

When I hear of vomiting and diarrhea starting at the same time, I tend to think of food poisoning. But food poisoning will strike a household all at once, where this virus hits family members in sequence.

I had to consider, also, the shellfish problem.

The people on an island with 25-foot tides like to go out at low tide for mussels, clams, cockles, whelks, abalone, crabs, and octopus.

When the water ebbed out 3 feet lower than average this weekend, Bethany and I went to explore the beach.

We found the water’s edge a hundred yards past where logs drifted onto beach grass mark the high tide line, on a beach of whispering tranquility, surrounded by towering evergreens. We picked up a dead sand dollar, and saw holes where a clam spade would have brought a tasty morsel. A mother with her two children came out exploring. The adults had a delightful conversation, and one of the kids picked up an abalone. I had never seen a live one before.

Which prompted me, the next day at rounds, to ask my colleague about the posters we’d seen warning of Paralytic Shellfish Poisoning. He explained that some algae contain a toxin that filter feeders, like clams and mussels, concentrate, and which, if consumed, cause a very ugly paralysis. Those algae blooms, known as the Red Tide, in the warm weather, especially in El Nino years, and more often when the temperature goes up.

I asked about walrus, the sea mammal that eats mostly clams. I recalled the large walrus skull I saw on the wall of friends who live in Southwest Alaska. While out sport flying, they spotted a walrus carcass on the beach, landed, and wrestled the ivory-bearing head into the plane.

While the algae blooms won’t happen for another month, some bivalves, like mussels, retain the toxin for years after a bloom.